Intraoperative Electron Beam Radiation Therapy (IOERT) in the Management of Locally Advanced or Recurrent Cervical Cancer

Abstract

Purpose/Objective(s)To report our institutional experience, including clinical outcomes and toxicity, for women with locally recurrent or advanced cervical cancer who received IOERT as a component of cancer therapy.Materials/MethodsFrom 1983 to 2010, 89 patients with locally recurrent (n = 74, 83%) or primary locally advanced (n = 15, 17%) cervical cancer received IOERT following maximal surgical resection. IOERT fields included the hemipelvis (n = 60, 67%), aortic bifurcation (n = 14, 16%), paraortic area (n = 13, 15%), and inguinal region (n = 2, 2%). The median IOERT dose was 15 Gy (range, 6.25-25 Gy). In addition to surgery + IOERT, 62 patients (70%) also received perioperative external beam radiation therapy (EBRT) ± brachytherapy; 46 (74%) before surgery, 14 (23%) after surgery, and 2 (3%) both before and after surgery. The median total perioperative dose was 45 Gy (range, 19.8-83 Gy). Forty-two patients (47%) also received perioperative chemotherapy. All patients were followed from the date of IOERT for clinical outcomes and toxicity.ResultsThe median follow-up time for surviving patients was 2.7 years (range, 0.1-25.5 years). Thirty-six patients (40%) underwent an R0 resection prior to IOERT; the remaining 53 patients had R1 (n = 32, 36%) or R2 (n = 21, 24%) resections. The 3-year Kaplan-Meier estimate of local control was 59%, and central control (within the IOERT field) was 70%. The 3-year freedom from distant relapse was 48%. Median survival was 15 months, and the 3-year Kaplan-Meier estimates of cause-specific and overall survival were 31% and 24%, respectively. Late toxicity potentially related to IOERT occurred in 33%, consisting most commonly of peripheral neuropathy (n = 17), ureteral stenosis (n = 4), and bowel fistula/perforation (n = 4). Twelve of 17 patients with neuropathy required long-term pain medication; however, 8 of these 12 also experienced local disease relapse, making it difficult to establish a definitive causal relationship between IOERT and neuropathy in these patients.ConclusionsCombined modality therapy including IOERT is feasible for locally recurrent or advanced cervical cancer. Long term survival in a significant number of patients is observed. The most common pattern of relapse is distant, yet a significant number of patients also experience local progression in spite of aggressive local treatment. Careful patient selection and consideration of disease- and treatment-related morbidity is essential. Purpose/Objective(s)To report our institutional experience, including clinical outcomes and toxicity, for women with locally recurrent or advanced cervical cancer who received IOERT as a component of cancer therapy. To report our institutional experience, including clinical outcomes and toxicity, for women with locally recurrent or advanced cervical cancer who received IOERT as a component of cancer therapy. Materials/MethodsFrom 1983 to 2010, 89 patients with locally recurrent (n = 74, 83%) or primary locally advanced (n = 15, 17%) cervical cancer received IOERT following maximal surgical resection. IOERT fields included the hemipelvis (n = 60, 67%), aortic bifurcation (n = 14, 16%), paraortic area (n = 13, 15%), and inguinal region (n = 2, 2%). The median IOERT dose was 15 Gy (range, 6.25-25 Gy). In addition to surgery + IOERT, 62 patients (70%) also received perioperative external beam radiation therapy (EBRT) ± brachytherapy; 46 (74%) before surgery, 14 (23%) after surgery, and 2 (3%) both before and after surgery. The median total perioperative dose was 45 Gy (range, 19.8-83 Gy). Forty-two patients (47%) also received perioperative chemotherapy. All patients were followed from the date of IOERT for clinical outcomes and toxicity. From 1983 to 2010, 89 patients with locally recurrent (n = 74, 83%) or primary locally advanced (n = 15, 17%) cervical cancer received IOERT following maximal surgical resection. IOERT fields included the hemipelvis (n = 60, 67%), aortic bifurcation (n = 14, 16%), paraortic area (n = 13, 15%), and inguinal region (n = 2, 2%). The median IOERT dose was 15 Gy (range, 6.25-25 Gy). In addition to surgery + IOERT, 62 patients (70%) also received perioperative external beam radiation therapy (EBRT) ± brachytherapy; 46 (74%) before surgery, 14 (23%) after surgery, and 2 (3%) both before and after surgery. The median total perioperative dose was 45 Gy (range, 19.8-83 Gy). Forty-two patients (47%) also received perioperative chemotherapy. All patients were followed from the date of IOERT for clinical outcomes and toxicity. ResultsThe median follow-up time for surviving patients was 2.7 years (range, 0.1-25.5 years). Thirty-six patients (40%) underwent an R0 resection prior to IOERT; the remaining 53 patients had R1 (n = 32, 36%) or R2 (n = 21, 24%) resections. The 3-year Kaplan-Meier estimate of local control was 59%, and central control (within the IOERT field) was 70%. The 3-year freedom from distant relapse was 48%. Median survival was 15 months, and the 3-year Kaplan-Meier estimates of cause-specific and overall survival were 31% and 24%, respectively. Late toxicity potentially related to IOERT occurred in 33%, consisting most commonly of peripheral neuropathy (n = 17), ureteral stenosis (n = 4), and bowel fistula/perforation (n = 4). Twelve of 17 patients with neuropathy required long-term pain medication; however, 8 of these 12 also experienced local disease relapse, making it difficult to establish a definitive causal relationship between IOERT and neuropathy in these patients. The median follow-up time for surviving patients was 2.7 years (range, 0.1-25.5 years). Thirty-six patients (40%) underwent an R0 resection prior to IOERT; the remaining 53 patients had R1 (n = 32, 36%) or R2 (n = 21, 24%) resections. The 3-year Kaplan-Meier estimate of local control was 59%, and central control (within the IOERT field) was 70%. The 3-year freedom from distant relapse was 48%. Median survival was 15 months, and the 3-year Kaplan-Meier estimates of cause-specific and overall survival were 31% and 24%, respectively. Late toxicity potentially related to IOERT occurred in 33%, consisting most commonly of peripheral neuropathy (n = 17), ureteral stenosis (n = 4), and bowel fistula/perforation (n = 4). Twelve of 17 patients with neuropathy required long-term pain medication; however, 8 of these 12 also experienced local disease relapse, making it difficult to establish a definitive causal relationship between IOERT and neuropathy in these patients. ConclusionsCombined modality therapy including IOERT is feasible for locally recurrent or advanced cervical cancer. Long term survival in a significant number of patients is observed. The most common pattern of relapse is distant, yet a significant number of patients also experience local progression in spite of aggressive local treatment. Careful patient selection and consideration of disease- and treatment-related morbidity is essential. Combined modality therapy including IOERT is feasible for locally recurrent or advanced cervical cancer. Long term survival in a significant number of patients is observed. The most common pattern of relapse is distant, yet a significant number of patients also experience local progression in spite of aggressive local treatment. Careful patient selection and consideration of disease- and treatment-related morbidity is essential.