Radiation Oncology/Cervix/Radiation Technique
Overall treatment time
- Total treatment time (EBRT + brachy) should not exceed 8 weeks; target 85 Gy to Point A. However, concurrent chemotherapy may negate this time effect
- University of Wisconsin; 2013 PMID 23561652 -- "Effects of treatment duration during concomitant chemoradiation therapy for cervical cancer." (Shaverdian N, Int J Radiat Oncol Biol Phys. 2013 Jul 1;86(3):562-8. doi: 10.1016/j.ijrobp.2013.01.037. Epub 2013 Apr 2.)
- Retrospective. 372 patients (RT 206, CRT 166). Median F/U 4.2 years
- Outcome: Treatment duration RT 55 days versus CRT 51 days (SS). In RT cohort, treatment duration ≥ 62 days trended to worse DFS (HR 1.4, p=0.08). No difference for treatment duration in CRT cohort
- Conclusion: With addition of concomitant chemotherapy, extended TD has no effect on treatment efficacy
- Washington University; 1995 (1959-89) PMID 7635767, 1995 -- "Carcinoma of the uterine cervix. I. Impact of prolongation of overall treatment time and timing of brachytherapy on outcome of radiation therapy." Perez CA et al. Int J Radiat Oncol Biol Phys. 1995 Jul 30;32(5):1275-88.
- Usual treatment including EBRT and 2 intracavitary insertions lasts 42-48 days (less than 7 weeks). For Stage IB, the cause specific survival was 86% for 7 weeks or less, 78% (7-9 weeks), and 55% (>9wks). For IIA, 73% / 41% / 43%. For Stage III (and dose >=85), 46% for <9 wks vs 38% for longer. No effect of treatment time for Stage IB tumors < 3 cm (IB1).
- Patterns of Care; 1993 (1973-1978) PMID 8436516, 1993 -- "The influence of treatment time on outcome for squamous cell cancer of the uterine cervix treated with radiation: a patterns-of-care study." (Lanciano RM, Int J Radiat Oncol Biol Phys. 1993 Feb 15;25(3):391-7.)
- Retrospective. 837 patients. Time bins <6 weeks, 6-8, 8-10, >10 weeks
- Multivariate for in-field recurrence: stage, total treatment time, age (50)
- Stage III cancers: total treatment time independent predictor; not in Stage I-II
- Conclusion: Significant adverse effect in Stage III patients
- Gustave-Roussy; 1993 (France)(1973-1983) PMID 8262826 -- "Overall treatment time in advanced cervical carcinomas: a critical parameter in treatment outcome." Girinksy T et al.
- Retrospective. 386 patients. Stage IIB and III. Loss of local control and overall survival when treatment extended beyond 52 days. 1% loss of LC and OS per day.
- Princess Margaret; 1992 PMID 1480773 -- "The effect of treatment duration in the local control of cervix cancer." (Fyles A, Radiother Oncol. 1992 Dec;25(4):273-9.)
- Retrospective. 830 patients.
- Loss of control: 1% per day beyond 30 days, predominately in Stage III/IV
Classic pelvic fields
- Fox Chase; 1996 PMID 12118547 — "Bony landmarks are not an adequate substitute for lymphangiography in defining pelvic lymph node location for the treatment of cervical cancer with radiotherapy." Bonin SR et al. Int J Radiat Oncol Biol Phys. 1996 Jan 1;34(1):167-72.
- Used lymphangiograms to determine the adequacy of lymph node coverage by standard GOG pelvic fields.
- Great variability in lymph node location. Bony landmarks are a poor substitute for lymph node location. Poor coverage of lateral external iliac lymph nodes.
Target Volume Delineation
- Gyn IMRT Consortium: Definitive Treatment; 2011 PMID 20472347 -- "Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy for the definitive treatment of cervix cancer." (Lim K, Int J Radiat Oncol Biol Phys. 2011 Feb 1;79(2):348-55. Epub 2010 May 14.)
- Guidelines for CTV definition in definitive therapy setting
- Gyn IMRT Consortium: Postoperative Treatment; 2008 PMID 18037584 -- "Consensus guidelines for delineation of clinical target volume for intensity-modulated pelvic radiotherapy in postoperative treatment of endometrial and cervical cancer." (Small W, Int J Radiat Oncol Biol Phys. 2008 Jun 1;71(2):428-34. Epub 2007 Nov 26.)
- Guidelines for CTV definition in postoperative therapy setting
- RTOG Atlas
- Batticoloa, Sri Lanka; 2012 PMID 23027037 -- "Reviewing the role of parametrial boost in patients with cervical cancer with clinically involved parametria and staged with positron emission tomography." (Rajasooriyar C, Int J Gynecol Cancer. 2012 Nov;22(9):1532-7. doi: 10.1097/IGC.0b013e31826c4dee.)
- Retrospective. 193 patients, locoregionally advanced cervical cancer. Whole pelvis 40 Gy, PET positive nodes boosted to 46-50 Gy, no parametrial boost. Group A (IB-IIA) versus Group B (IIB-IIIB)
- Outcome: No difference in pelvic failure or extrapelvic failure between Group A and Group B. Pelvic failure predicted by tumor volume, extrapelvic failure predicted by nodal disease. Parametrial involvement with no parametrial boost not related to either pelvic or extra-pelvic failure. No isolated pelvic nodal failures
- Conclusion: Cervical cancer with clinical parametrial involvement can be adequately treated without parametrial boost. Dose 46-50 Gy adequate to avoid isolated pelvic nodal failure
Para-aortic Lymph Nodes
- UC San Diego; 2013 (2003-2010) PMID 23262521 -- "Outcomes for patients with cervical cancer treated with extended-field intensity-modulated radiation therapy and concurrent cisplatin." (Jensen LG, Int J Gynecol Cancer. 2013 Jan;23(1):119-25. doi: 10.1097/IGC.0b013e3182749114.)
- Retrospective. 21 patients. treated with EFRT IMRT and concurrent weekly cisplatin. Positive PA nodes in 14, positive pelvic nodes in 20. Median F/U 22 months
- Outcome: 18 month OS 60%, DFSS 43%. LR 9%, DM 43%.
- Toxicity: Grade 3+ GU 5% and GI 0%
- Conclusion: Low rates of late toxicity; high rates of distant failure
- Shadong University, China; 2012 PMID 22854654 -- "Extended-field intensity-modulated radiotherapy and concurrent cisplatin-based chemotherapy for postoperative cervical cancer with common iliac or para-aortic lymph node metastases: a retrospective review in a single institution." (Zhang G, Int J Gynecol Cancer. 2012 Sep;22(7):1220-5. doi: 10.1097/IGC.0b013e3182643b7c.)
- Retrospective. 58 patients, EF-IMRT and concurrent cisplatin. Median F/U 2.8 years
- Outcome: in-field recurrence 3.4%, distant recurrence 31%
- Toxicity: Late grade 3 toxicity 5%; 77% of patients with ovarian transposition maintained ovarian function
- Conclusion: Concurrent cisplatin with postoperative ER-IMRT is safe; locoregional control rates are hopeful, but distant metastases the primary mode of failure
- Patterns of Care Study, 1991 - PMID 2004942
- Dose response demonstrated only for Stage III with improved conrol with Pt A dose of 85 Gy.
- Lucknow, India -- morning RT vs evening RT
- Randomized. 229 patients, cervical CA. Arm 1) morning (8-10 AM) vs Arm 2) evening (6-8 PM) RT. Primary outcome mucositis
- 2010 PMID 20162717 -- "Circadian variation in radiation-induced intestinal mucositis in patients with cervical carcinoma." (Shukla P, Cancer. 2010 Feb 16. [Epub ahead of print])
- Outcome: Overall diarrhea AM 87% vs PM 68% (SS), Grade 3-4 diarrhea 14% vs 5% (SS)
- Conclusion: Significant difference between morning and evening arms suggest influence of circadian rhythms
- Image-guided brachytherapy working group
- 2004 PMID 15519788 — "Proposed guidelines for image-based intracavitary brachytherapy for cervical carcinoma: Report from Image-Guided Brachytherapy Working Group." Nag et al. Int J Radiat Oncol Biol Phys. 2004 Nov 15;60(4):1160-72.