Abstract
BackgroundPurpose of this study was to identify predictors of vaginal ulcer after CT based three-dimensional image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for gynecologic malignancies.MethodsRecords were reviewed for 44 female (14 with primary disease and 30 with recurrence) with gynecological malignancies treated with HDR-ISBT with or without external beam radiation therapy. The HDR-ISBT applicator insertion was performed with image guidance by trans-rectal ultrasound and CT.ResultsThe median clinical target volume was 35.5 ml (2.4-142.1 ml) and the median delivered dose in equivalent dose in 2 Gy fractions (EQD2) for target volume D90 was 67.7 Gy (48.8-94.2 Gy, doses of external-beam radiation therapy and brachytherapy were combined). For re-irradiation patients, median EQD2 of D2cc for rectum and bladder, D0.5cc, D1cc, D2cc, D4cc, D6cc and D8cc for vaginal wall was 91.1 Gy, 100.9 Gy, 260.3 Gy, 212.3 Gy, 170.1 Gy, 117.1 Gy, 105.2 Gy, and 94.7 Gy, respectively. For those without prior radiation therapy, median EQD2 of D2cc for rectum and bladder, D0.5cc, D1cc, D2cc, D4cc, D6cc and D8cc for vaginal wall was 56.3 Gy, 54.3 Gy, 147.4 Gy, 126.2 Gy, 108.0 Gy, 103.5 Gy, 94.7 Gy, and 80.7 Gy, respectively. Among five patients with vaginal ulcer, three had prior pelvic radiation therapy in their initial treatment and three consequently suffered from fistula formation. On univariate analysis, re-irradiation and vaginal wall D2cc in EQD2 was the clinical predictors of vaginal ulcer (p = 0.035 and p = 0.025, respectively). The ROC analysis revealed that vaginal wall D2cc is the best predictor of vaginal ulcer. The 2-year incidence rates of vaginal ulcer in the patients with vaginal wall D2cc in EQD2 equal to or less than 145 Gy and over 145 Gy were 3.7% and 23.5%, respectively, with a statistically significant difference (p = 0.026).ConclusionsRe-irradiation and vaginal D2cc is a significant predictor of vaginal ulcer after HDR-ISBT for gynecologic malignancies. Three-dimensional image-guided treatment planning should be performed to ensure adequate target coverage while minimizing vaginal D2cc in order to avoid vagina ulcer.
Highlights
High-dose rate intracavitary brachytherapy (HDR-Intracavitary brachytherapy (ICBT)) is an established method in the management of gynecological malignancies, especially in cervical cancer
Patients with superficial vaginal disease with thickness less than 5 mm were treated with HDR-ICBT and did not treated by HDR-interstitial brachytherapy (ISBT); these patients were not included in this analysis
HDR-ISBT was not applied for those patients who had distant metastasis or for those patients with far advanced tumors which had not responded to external beam radiation therapy (EBRT) performed before HDR-ISBT
Summary
High-dose rate intracavitary brachytherapy (HDR-ICBT) is an established method in the management of gynecological malignancies, especially in cervical cancer. In patients with a narrow vagina, short uterine cavity, distal vaginal extension, and bulky tumors in which the optimal dose distribution cannot be obtained by intracavitary during brachytherapy tough it is adjacent to target volume and radioactive sources [8]. The purpose of this study was to retrospectively analyze the incidence of vaginal morbidities after HDRISBT for gynecological cancers and to find clinical and dosimetric factors which affect the incidence of the vaginal morbidities. Purpose of this study was to identify predictors of vaginal ulcer after CT based three-dimensional image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for gynecologic malignancies
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