Rebuttal to Drs. Good, Lalondrelle, and Blake

Abstract

The arguments brought forward by Drs. Good, Lalondrelle, and Blake in favor of parametrial boost (PMB) by external beam radiotherapy (EBRT) brilliantly display the many dilemmas facing the proponents of this technique. Unfortunately, solutions to the problems are not provided. Avivid anatomical description of the parametrium as an open landscape ready to be swept by the attacking malignant cells breaking through the cervix is used to promote the use of EBRT to boost the parametrium to a higher EBRT dose than used to ‘‘at-risk nodal areas.’’ However, we are still left in the dark with regard to the central questions of when, where, and how much. Is PMB to be delivered routinely by EBRT to all patients with breach of the cervical stroma? Should we apply PMB unilaterally or bilaterally and what total dose of EBRT (50 or 62 Gy) is necessary to control microscopic disease in the parametrium? The intermediate-risk target concept from the Groupe Europ een deCurieth erapie-EuropeanSociety forTherapeutic Radiology and Oncology (GEC-ESTRO) recommendations is used as an argument in favor of treating the parametrium to 60 Gy by EBRT. However, the intermediate-risk target concept is a four-dimensional brachytherapy (BT) target concept defined at the time of BT and aimed for treating the path of the regressing primary tumor with an intermediate dose of radiationprovided byBTon topofwhole pelvicEBRT dose (usually about 45 Gy) (1). Apart from distal vaginal involvement, this goal is achieved almost automatically when a dose O85 Gy is obtained in the high-risk clinical target volume (2). The most recent clinical data from Vienna demonstrate the superior results that can be obtained by applying image-guided adaptive brachytherapy (IGABT) and refraining fromPMBbyEBRT (3). Thepaper byLogsdon and Eifel (4) based on clinical data obtained even before the modern BT target concept was conceived, also emphasize the importance of aggressive intracavitary BT and that the