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Treatment results of radical radiotherapy of carcinoma uterine cervix using external beam radiotherapy and high dose rate intracavitary radiotherapy  [cached]
Azad S,Choudhary V
Journal of Cancer Research and Therapeutics , 2010,
Abstract: Aim: To report the outcome of carcinoma cervix patients treated radically by external beam radiotherapy and high dose rate intracavitary radiotherapy. Material and Methods: From January 2005 to December 2006, a total of 709 newly diagnosed cases of carcinoma cervix were reported in our department. All cases were staged according to the International Federation of Gynecologist and Oncologist staging system. Out of 709 cases, 342 completed radical radiotherapy and were retrospectively analyzed for the presence of local residual disease, local recurrence, distant metastases, radiation reaction, and disease free survival. Results: There were 11(3.22%), 82(23.98%), 232(67.83%), and 17(4.97%) patients in stages I, II, III, and IV, respectively. The median follow up time for all patients was 36 months (range 3 -54 months). The overall treatment time (OTT) ranged from 52 to 69 days (median 58 days). The 3 year disease free survival rate was 81.8%, 70.7%, 40.08%, and 11.76% for stages I, II, III, and IV, respectively. There were 91 (26.6%) cases with local residual diseases, 27(7.9%) developed distant metastasis, and 18(5.26%) pts had local recurrence. Discussion: The results of this study suggest that radical radiotherapy with HDR brachytherapy was appropriate for the treatment of early staged cancer of uterine cervix. For locally advanced cancer of cervix addition of concurrent chemotherapy, higher radiation doses, reduction of overall treatment time to less than 8 weeks, and use of latest radiotherapy techniques such as IMRT is recommended to improve the results.
Treatment Planning Methods in High Dose Rate Interstitial Brachytherapy of Carcinoma Cervix: A Dosimetric and Radiobiological Analysis  [PDF]
Surega Anbumani,Pichandi Anchineyan,ArunaiNambiraj Narayanasamy,Siddanna R. Palled,Sajitha Sathisan,Punitha Jayaraman,Muthu Selvi,Ramesh S. Bilimagga
ISRN Oncology , 2014, DOI: 10.1155/2014/125020
Abstract: Treatment planning is a trial and error process that determines optimal dwell times, dose distribution, and loading pattern for high dose rate brachytherapy. Planning systems offer a number of dose calculation methods to either normalize or optimize the radiation dose. Each method has its own characteristics for achieving therapeutic dose to mitigate cancer growth without harming contiguous normal tissues. Our aim is to propose the best suited method for planning interstitial brachytherapy. 40 cervical cancer patients were randomly selected and 5 planning methods were iterated. Graphical optimization was compared with implant geometry and dose point normalization/optimization techniques using dosimetrical and radiobiological plan quality indices retrospectively. Mean tumor control probability was similar in all the methods with no statistical significance. Mean normal tissue complication probability for bladder and rectum is 0.3252 and 0.3126 ( ), respectively, in graphical optimized plans compared to other methods. There was no significant correlation found between Conformity Index and tumor control probability when the plans were ranked according to Pearson product moment method ( ). Graphical optimization can result in maximum sparing of normal tissues. 1. Introduction Cervical cancer is a major cancer burden which constitutes number one among Indian women with relative survival rate of 48.7% [1]. EBRT followed with brachytherapy (BT) is the standard of care and an integral part of local control of the disease. Cervix carcinoma has been treated with HDR BT for more than 30 years. It has advantages in terms of local recurrence, mortality, and late complications for the clinical stages I, II and III, similar to those of Low Dose Rate therapy [2]. The present standard of care using concomitant chemotherapy and radiotherapy has resulted in 80–90% local control rates for early stages [3–5]. But a decline of about 67–75% is noted for advanced stages because of the local failure due to inadequate dose coverage [6–8]. Interstitial brachytherapy (ISBT) is best suited for the patients with anatomy not allowing for standard intracavitary application and wherein the disease could not be encompassed in the standard ICBT application. It can improve the dose coverage with various normalization and optimization techniques. Improved planning strategies and dose optimization can reduce normal tissue complications rate without compromising local control of the disease [9]. Clinical investigations and dosimetric comparisons in the evaluation of interstitial implants are
Does Change in the Effect of Source Strength of the High Dose Rate 192Iridium Radio-Isotope on Local Control and Late Normal Tissue Toxicity (Bladder and Rectum) in the Treatment of Carcinoma Cervix  [PDF]
K. Sudhakar, K. Gunaseelan, K. S. Reddy, K. Saravanan, N. V. Vinin
International Journal of Medical Physics,Clinical Engineering and Radiation Oncology (IJMPCERO) , 2014, DOI: 10.4236/ijmpcero.2014.34027
Abstract: Aim: To analyse and assess the effect of dose rate of 192ir-source strength on late complications and local control rate during treatment of carcinoma cervix. Materials and Methods: One hundred and two cases of carcinoma cervix were included in the study. All patients were treated with a curative intent with radical dose of radiation as per the department protocol. All patients were treated with both EBRT plus Brachytherapy with Inj. Cisplatin 40 mg/m2 weekly. Patients were divided into 2 groups based on activity i.e. group A (10-6Ci) and group B (5-2Ci). After brachytherapy, point doses were analysed based on ICRU 38 recommendations. During follow up, morbidities were evaluated using RTOG grading system. Results: There was no difference in local control and distant metastasis in both groups after six months of follow up. Late Complications were comparable in both groups irrespective of source strength. Bladder complications were minimal with no significant difference in both study groups. Further Patients were divided into four groups i.e. BED of ICRU rectal point (<100 Gy3 and ≥100 Gy3) and source strength (10-6Ci and 5-2Ci), when BED was >100 Gy3 resulted in higher late rectal complication rate (P < 0.05) compared to BED < 100 Gy3. Conclusion: This study suggests that change in source activity did not make a difference in local control, late rectal and bladder morbidities at 6 months of follow up. Longer follow up is required to assess long term results and morbidities.
Brachytherapy for cervix cancer: low-dose rate or high-dose rate brachytherapy – a meta-analysis of clinical trials
Gustavo A Viani, Gustavo B Manta, Eduardo J Stefano, Ligia I de Fendi
Journal of Experimental & Clinical Cancer Research , 2009, DOI: 10.1186/1756-9966-28-47
Abstract: A meta-analysis of RCT was performed comparing LDR to HDR brachytherapy for cervix cancer treated for radiotherapy alone. The MEDLINE, EMBASE, CANCERLIT and Cochrane Library databases, as well as abstracts published in the annual proceedings were systematically searched. We assessed methodological quality for each outcome by grading the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. We used "recommend" for strong recommendations, and "suggest" for weak recommendations.Pooled results from five randomized trials (2,065 patients) of HDR brachytherapy in cervix cancer showed no significant increase of mortality (p = 0.52), local recurrence (p = 0.68), or late complications (rectal; p = 0.7, bladder; p = 0.95 or small intestine; p = 0.06) rates as compared to LDR brachytherapy. In the subgroup analysis no difference was observed for overall mortality and local recurrence in patients with clinical stages I, II and III. The quality of evidence was low for mortality and local recurrence in patients with clinical stage I, and moderate for other clinical stages.Our meta-analysis shows that there are no differences between HDR and LDR for overall survival, local recurrence and late complications for clinical stages I, II and III. By means of the GRADE system, we recommend the use of HDR for all clinical stages of cervix cancer.Intracavitary radiation in the form of low-dose rate (LDR) brachytherapy has been in use for the treatment of cervical cancer for nearly a century, although the method has been greatly refined. High-dose rate (HDR) brachytherapy for carcinoma of the cervix has been in use for over 30 years. LDR is defined as a dose of 0.4–2 Gray (Gy)/h, and HDR is defined as a dose of >12 Gy/h [1]. HDR is widely used throughout Asia and Europe, and its use is steadily increasing in North and South Americas [2]. The Patterns of Care Studies show that, in the United States, the use of HDR for the treatme
Radical radiotherapy treatment (EBRT + HDR-ICRT) of carcinoma of the uterine cervix: Outcome in patients treated at a rural center in India  [cached]
Jain Vandana,Singh Kailash,Shrivastava Rajeev,Saumsundaram K
Journal of Cancer Research and Therapeutics , 2007,
Abstract: Aim: To report the outcome of carcinoma of the uterine cervix patients treated radically by external beam radiotherapy (EBRT) and high-dose-rate (HDR) intracavitary radiotherapy (ICRT). Materials and Methods: Between January 1997 to December 2001, a total of 550 newly diagnosed cases of carcinoma of the uterine cervix were reported in the department. All cases were staged according to the International Federation of Gynecologists and Oncologists (FIGO) staging system, but for analytical convenience, the staging was limited to stages I, II, III, and IV. Out of the 550 cases, 214 completed radical radiotherapy (EBRT + HDR-ICRT) and were retrospectively analyzed for presence of local residual disease, local recurrence, distant metastases, radiation reactions, and disease-free survival. Results: There were 7 (3.27%), 88 (41.1%), 101 (47.1%), and 18 (8.4%) patients in stage I, II, III, and IV, respectively. The median follow-up time for all patients was 43 months (range: 3-93 months) and for patients who were disease free till the last follow-up it was 59 months (range: 24-93 months). The overall treatment time (OTT) ranged from 52 to 73 days (median 61 days). The 5-year disease-free mean survival rate was 58%, 44%, 33%, and 15%, with 95% confidence interval of 48 to 68, 37 to 51, 24 to 35, and 6 to 24 for stages I, II, III, and IV, respectively. There were 62 (28.97%) cases with local residual disease, 35 (16.3%) developed local recurrence/distant metastases, 17 (7.9%) developed distant metastases, and 9 (4.2%) had local recurrence as well. Discussion and Conclusion: The overall outcome was poor in advanced stage disease, but might be improved by increasing the total dose, decreasing overall duration of treatment, and by adding chemotherapy in patients with disease limited to the pelvis.
Concomitant chemoradiotherapy with high dose rate brachytherapy as a definitive treatment modality for locally advanced cervical cancer
T Refaat, A Elsaid, N Lotfy, K Kiel, W Small Jr, P Nickers, E Lartigau
Alexandria Journal of Medicine , 2011,
Abstract: Purpose: This study aims to report the incidence of treatment-induced acute toxicities, local control and survival of patients with cervix cancer treated by external beam radiotherapy (EBR) and high-dose-rate (HDR) brachytherapy concomitant with weekly Cisplatin chemotherapy. Methods: Forty patients with FIGO Stages IB2 and II were treated. The mean age was 48.49 years. EBR to the whole pelvis TO 45 Gy in 25 fractions was given to all patients. Aparametrial boost was given in 60% of patients, to a median dose of 9 Gy. Brachytherapy with HDR was performed during or after completing EBR with a dose of 24 Gy in four fractions of 6 Gy delivered weekly to point ‘‘A’’ or in some patients who were planned on MRI image guided brachytherapy with dose prescribed to high risk clinical target volume (CTV). Patient age, tumor stage, and presence or absence of comorbid conditions as diabetes mellitus, ischemic vascular disease and collagen disease and total dose to right and left point ‘‘A’’ were variables analyzed for treatment induced toxicities, survival and local control. Cumulative biologic effective dose (BED) at rectal and bladder reference points were correlated with treatment complications in these organs. Results: The most common acute toxicities included grade 1 and 2 fatigue (30%), diarrhea (25%), decreased neutrophil count (25%) and anemia (22.5%). Only 5% of the patients developed grade 3 rectal complications (proctitis and rectal bleeding) and 10% developed grade 1 or 2 rectal complications. Regarding urinary complications, 12.5% developed grade 1 or 2 toxicities. Mean follow-up time was 20 months. Overall survival, disease-free survival, and local control were 100%, 92.5 %, and 95%, respectively. One patient developed bone metastases and two patients developed local relapse. Conclusion: This study suggests that concomitant chemoradiotherapy with 45 Gy to the whole pelvis concomitant with cisplatin chemotherapy and four fractions of 6 Gy to point ‘‘A’’ with HDR brachytherapy is an effective and tolerable fractionation schedule in the treatment of Stages IB2 and II cervix cancer.
COMPLICATIONS AT THE OPERATIVE TREATMENT OF THE INVASIVE CERVIX UTERI CARCINOMA
Vekoslav Lili?,Radomir ?ivadinovi?,Milan Vukeli?
Acta Medica Medianae , 2002,
Abstract: In the period from 1997 to 2001 at the Clinic for Gynecology and Obstetrics of the Clinic Center, Nis, there were 140 treated patients suffering from the cervix uteri carcinoma in I-B and II-A stadiums according to the FIGO classification. In 16 (11,42%) patients there was modified radical hysterectomy (class 11) done while in 124 (88,57%) the Wertheim-Meigs hysterectomy (class III) done. Inter operative complications (lesions) were recorded in 8 (5,69%) patients, namely, urinary tract lesions in 4 (2,85%) while blood vessel ones in 3 (2,13%) patients. The obturator nerve is cut in 1 (0,71%) patient. Immediate postoperative complications were recorded in 56 (39,96%) patients. Most often they are infection-induced. Urinary infections were noticed in 25 (17,85%) patients, febrility in 22 (15,71%) and infections of the operative wound in 3 (2,14%) patients. Later complications of the operative cervix treatment were noticed in 37 (26,42%) patients. Their emergence depends on the fact whether the patient was radiated before or before and after the operation. Most often later complications emerge in the patients that undenvent, after the operation, brachytherapy and transcutaneous radiotherapy (27 or 19,28%); the least frequent were in only 3 (2,14%) of the operated patients. The most frequent later complications are those of the urinary tract (fistulas, cystitis) in 11 (7,83%) patients as well as changes upon the last part of the gastrointestinal tract, namely, hemorrhage colitis in 9 (9,28%), late ileus in 3 (2,14%) and rectovaginal fistula in 3 (2,14%) patients. Hydronephrosis was recorded in 7 (5,00%) patients. There were no lethal cases. All the patients are still living.
INDIVIDUALIZED TREATMENT OF PREINVASIVE LESIONS OF THE CERVIX  [cached]
Neacsu Dorin,Eduard Crauciuc,Oviviu Toma,Dragos Crauciuc
Analele ?tiin?ifice Ale Universit??ii Alexandru Ioan Cuza din Ia?i,Sectiunea II A : Genetica si Biologie Moleculara , 2010,
Abstract: The management of cervical preinvasive lesions in primary medical practice is characterized by a wide variety of attitudes, objectives and therapeutic decisions. The purpose of the study. To supply new landmarks referring to the preinvasive lesions of cervical cancer from the perspective of the clinician. Materials and methods. The study was made on a number of 16732 patients who were monitored comparatively in the Family Planning offices in the counties of Ia i and Buz u, between 2007 and 2011. Results and discussions. The treatment was applied according to the type of the lesion. Conclusions. The individualized treatment of the preinvasive lesions of the cervix targeted the destruction of the pathogenic agent and the infected tissues and caused a fibroblast proliferation and re-epithelisation
Uterine cervix carcinoma: pathologic characteristics, treatment and follow-up evaluation
Amouzegar Hashemi F,Esmati E,Kalaghchi B
Tehran University Medical Journal , 2008,
Abstract: Background: Carcinoma of the uterine cervix is the sixth most common malignant neoplasm in women. Early stage diagnosis of uterine cervix carcinoma increases the cure rate of disease. Radiotherapy, with or without concurrent chemotherapy, is one of the most effective treatment modality in cervical carcinoma. After radiotherapy, accurate and regular follow-up results in early diagnosis and effective treatment of recurrence. The aim of this study is the assessment of the pathologic characteristics, setting and indications for postoperative radiotherapy and outcome of patients at the last follow-up.Methods: In this retrospective study, we evaluated 346 cases of cervical carcinoma had received radiotherapy in radiation oncology department of the Cancer Institute of Imam Khomeini Hospital, Tehran, Iran, from 1995 to 2001.Results: The age of the study group ranged from 26 to 78 years (mean=50.5, SD=11). Of these patients, 30.4% were in the early stage and 69.6% had advanced stage disease. Squamous cell carcinoma comprised 92.2% of the cases and 6.4% adenocarcinoma. Radical radiotherapy was the most frequent radiotherapy setting and adjuvant radiotherapy (post-op) was the second. A considerable number of patients did not come back for follow-up, and 43.7% were followed for a short time.Conclusion: Accurate presurgical clinical staging and surgical treatment by an expert gynecologic oncologist can reduce expose the patients to risks of two modality treatments (surgery and radiotherapy). According to our results, patients do not pay enough attention to disease follow-up. An acceptable training plan with emphasis on regular follow-up, is recommended.
Brachytherapy for stage IIIB squamous cell carcinoma of the uterine cervix: survival and toxicity
Zuliani, Antonio Carlos;Cunha, Maércio de Oliveira;Esteves, Sérgio C. B.;Teixeira, Júlio César;
Revista da Associa??o Médica Brasileira , 2010, DOI: 10.1590/S0104-42302010000100013
Abstract: objective: to compare survival and toxicity of three different treatments for stage iiib cervix cancer: low-dose-rate (ldr), high-dose-rate (hdr) brachytherapy and association of hdr and chemotherapy. methods. between 1985 and 2005, 230 patients with figo stage iiib squamous cell carcinoma of the uterine cervix received 4-field pelvic teletherapy at doses between 40 and 50.4 gy, with a different complementation in each group. the ldrb group, with 42 patients, received one or two insertions of ldr, with cesium-137, in a total dose of 80 to 100gy at point a. the hdr group, 155 patients received hdr in 4 weekly 7 gy fractions and 9 gy to 14.4 gy applied to the involved parametria. the cht group, 33 patients, were given the same treatment as the hdr group and received 5 or 6 weekly cycles of cisplatin, 40 mg per m2. results: the five-year progression-free survival (pfs) was 60% for the hdr group and 45% for the ldr group, and the two-year pfs for the cht group was 65% (p = 0.02). the five-year overall survival (os) was 65% for the hdr group and 49% for the ldr group. the two-year os was 86% for the cht group (p = 0.02). rectum toxicity grade ii was 7% for the ldr group, 4% for the hdr group and 7% for the cht group that had one case of rectum toxicity grade iv. conclusion: patients that received hdr had better os and pfs. the chemotherapy-hdr association showed no benefit when compared to hdr only. toxicity rates showed no difference between the three groups.
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