Adjuvant Pelvic Radiotherapy Research Articles

Treatment results of adjuvant pelvic radiotherapy after radical hysterectomy for low-risk Stage IB1-IIA cervical cancer.

The aim of the present retrospective analysis was to determine the effectiveness of pelvic radiotherapy (RT) as postoperative adjuvant therapy for low-risk cervical cancer. Between June 2003 and April 2011, the clinical data of 225 International Federation of Gynecology and Obstetrics (FIGO) Stage IB1-IIA cervical cancer patients with low-risk factors were retrospectively reviewed, to analyze the relationship between adjuvant pelvic RT after radical hysterectomy and tumor recurrence or the patients' survival. The 5-year overall survival (OS) of 225 patients was 91.2% and 5-year disease-free survival (DFS) was 84.5%. The 5-year DFS and local regional disease-free survival was significantly better for patients in the RT group compared with that in the non-RT group (5-year DFS, 91.2% vs. 77.1%, P = 0.006; 5-year local regional disease-free survival 94.6% vs. 79.0%, P = 0.001). There were no statistically significant differences in the 5-year OS (92.9% vs. 89.4%, P = 0.371) and distant metastasis-free survival (96.4% vs. 96.5%, P = 0.887) between the two groups. Grade 3-4 treatment-related acute and late toxicities were not significantly different between the two groups. Subgroup analysis shows the 5-year DFS of RT alone, chemotherapy (CT) alone, non-RT/CT, RT and CT was, respectively, 90.5%, 62.9%, 81.4%, 92.5% separately (P = 0.002). The 5-year OS was not significantly different (91.6% vs. 78.2% vs. 92.9% vs. 96.9%, P = 0.887) between the four groups. Performing univariate analysis, postoperative CT was the only significant risk factor for DFS. Our results indicate that postoperative adjuvant pelvic RT has a tendency to improve DFS especially local regional disease-free survival for FIGO Stage IB1-IIA cervical cancer patients with low-risk factors, without increased Grade 3-4 treatment-related acute and late toxicities, but non-standard CT is harmful to the prognosis (DFS) of these patients.

Adjuvant Small Pelvic Radiotherapy in Patients with Cervical Cancer Having Intermediate Risk Factors Only - Is It Sufficient?

Background: We sought to determine the outcomes of adjuvant small pelvic external beam radiotherapy (EBRT) and prognostic factors for survival and disease control. Patients and Methods: We retrospectively evaluated 113 cervical cancer patients treated with postoperative median 50.4-Gy small pelvic EBRT. We treated the surgical bed, bilateral parametria, paravaginal soft tissues, upper third of the vagina, and presacral lymphatics. Results: Median follow-up of all patients and survivors was 58 and 67 months, respectively. The 2- and 5-year overall survival (OS) and disease-free survival rates were 91 and 82%, and 85 and 74%, respectively. The locoregional failure rate was 10%. Age was a significant predictor for OS and distant metastasis-free survival (DMFS) on univariate analysis. The number of dissected lymph nodes being < 30 negatively affected the pelvic recurrence-free survival. The only independent predictor on multivariate analysis was older age for DMFS. Although no severe acute toxicity was observed, late grade ≥ 3 toxicity developed in 8 patients. Conclusion: Small pelvic EBRT produces satisfactory survival and locoregional control with acceptable toxicity, and can be an alternative to whole pelvic EBRT in selected cervical cancer patients.

Tailoring Adjuvant Radiotherapy in Endometrial Cancer

The aim of this study was to examine the patterns of failure following adjuvant radiotherapy in patients with endometrial cancer according to: (a) the extent of the disease present at the time of primary surgery, (b) according to risk groups as agreed upon in the ESMO–ESGO–ESTRO consensus conference on endometrial cancer (Colombo et al. in Int J Gynecol Cancer Off J Int Gynecol Cancer Soc 26:2–30, 2016). One thousand two hundred and seven newly diagnosed endometrial cancer patients with endometrioid/serous, clear cell and serous histology, treated by primary surgery and presented to The Peter MacCallum Cancer Centre, between January 1996 and December 2014 for adjuvant radiotherapy, were analysed for patterns of any failure to study the efficacy of adjuvant radiotherapy. Nine hundred and eight (75%) patients were alive at the last observation date, 826 without any evidence of disease. Two hundred and sixty-one patients have died, 147 (12%) from recurrent cancer. The median follow-up time was 5.4 years. 53% patients had LVSI, and 18% patients had positive nodes. 19% patients developed metastases. Pelvic, para-aortic and distant relapses were observed in 13, 11 and 8.5%, respectively. Vaginal vault brachytherapy was a very efficient form of radiotherapy that provided 99% control of disease at the vaginal vault in intermediate- and high-intermediate-risk patients in FIGO stages 1 and 2. In stage 3 and 4 patient, adjuvant pelvic radiotherapy and extended field radiotherapy provided a good pelvic and para-aortic control. Patients with lymphovascular space invasion recur more diffusely and at multi-sites.

Adjuvant pelvic radiation is associated with improved survival and decreased disease recurrence in pelvic node-positive penile cancer after lymph node dissection: A multi-institutional study

PurposeFew studies have examined the role of radiation therapy in advanced penile squamous cell carcinoma. We sought to evaluate the association of adjuvant pelvic radiation with survival and recurrence for patients with penile cancer and positive pelvic lymph nodes (PLNs) after lymph node dissection. Materials and methodsData were collected retrospectively across 4 international centers of patients with penile squamous cell carcinoma undergoing lymph node dissections from 1980 to 2013. Further, 92 patients with available adjuvant pelvic radiation status and positive PLNs were analyzed. Disease-specific survival (DSS) and recurrence were analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards model. Results43% (n = 40) of patients received adjuvant pelvic radiation after a positive PLN dissection. Median follow-up was 9.3 months (interquartile range: 5.2–19.8). Patients receiving adjuvant pelvic radiation had a median DSS of 14.4 months vs. 8 months in the nonradiation group, respectively (P = 0.023). Patients without adjuvant pelvic radiation were associated with worse overall survival (hazard ratio [HR] = 1.7; 95% CI: 1.01–2.92; P = 0.04) and DSS (HR = 1.9; 95% CI: 1.09–3.36; P = 0.02) on multivariable analysis. Median time to recurrence was 7.7 months vs. 5.3 months in the radiation and nonradiation arm, respectively (P = 0.042). Patients without adjuvant pelvic radiation was also independently associated with higher overall recurrence on multivariable analysis (HR = 1.8; 95% CI: 1.06–3.12; P = 0.03). ConclusionsAdjuvant pelvic radiation is associated with improved survival and decreased recurrence in this population of patients with penile cancer with positive PLNs.

Adjuvant pelvic radiation sandwiched between paclitaxel/carboplatin chemotherapy in women with completely resected uterine serous carcinoma (USC): A prospective phase II trial update

Adjuvant pelvic radiation sandwiched between paclitaxel/carboplatin chemotherapy in women with completely resected uterine serous carcinoma (USC): A prospective phase II trial update

Dose-volume correlation of cumulative vaginal doses and late toxicity after adjuvant external radiation and brachytherapy for cervical cancer

PurposeTo investigate dose-response relationship between vaginal doses and long-term morbidity. Methods and MaterialsPatients receiving adjuvant pelvic (chemo) radiation and brachytherapy for cervical cancer from January 2011 to December 2014 were included. Baseline vaginal length was determined clinically and from imaging at BT planning. Dose points were defined along mucosa and at 5 mm depth at 12, 3, 6, and 9 ‘o’ clock positions at every 2 cm from apex to introitus. Cumulative equivalent doses in 2 Gy were calculated. Vaginal stenosis was reported in reference to baseline length according to CTCAE version 3.0. Receiver operator characteristics curve was used to identify dose thresholds for univariate and multivariate analysis. ResultsOverall, 78 women with median age of 49 (32–71) years were included. The median dose at vaginal apex mucosa and 5 mm depth was 118 Gy3 (78–198) and 81 Gy3 (70–149) respectively. At median follow-up of 36 (18–60) months, vaginal stenosis ≥25%, and grade ≥ II telangiectasia was observed in 33.3% and 45.7%, respectively. On receiver operator characteristics analysis, apical mucosal dose >142 Gy3 and recto-vaginal point dose >86 Gy3 predicted for stenosis on univariate (p = 0.02, p = 0.06) and multivariate analysis (p = 0.04). The probability of stenosis increased from 32% at 70 Gy3, 38% at 80 Gy3, and 45% at 90 Gy3 rectovaginal point dose. No correlation was observed between vaginal doses and telangiectasia and vaginal stenosis and sexual quality of life. ConclusionVaginal apex mucosal dose >142 Gy3 independently predicts for vaginal stenosis.

FIGO stage IB1 cervical carcinoma: Place and principles of brachytherapy

The treatment of cervical cancers according to FIGO staging is well defined. For FIGO stage IB2 or more, chemoradiotherapy followed by uterovaginal brachytherapy boost is the standard treatment. Surgery is the preferred choice for less advanced tumors. However, most French institutions propose preoperative brachytherapy followed by hysterectomy with pelvic lymphadenectomy for FIGO stage IB1 tumors over 2cm. Brachytherapy is also used for the boost after adjuvant pelvic external beam radiotherapy. Tridimensional dosimetry with optimization allows better treatment planning, delivering high doses to target volumes with limited irradiation to the organs at risk. We will discuss the indications of brachytherapy for FIGO stage IB1 tumors and the principles of pulsed-dose rate and high-dose rate techniques.

Impact of adjuvant treatment on oncologic outcomes in patients with stage I leiomyosarcoma of the uterus.

This study aimed to evaluate the role of adjuvant therapy for stage I uterine leiomyosarcoma (LMS). Clinicopathological data of cases of stage I uterine LMS from 1998 to 2015 were retrieved from the computerized database of Hacettepe University Hospital. The Kaplan-Meier method was used to estimate survival and progression-free survival, and survival differences were analyzed by log-rank test. Cox regression analysis was performed to account for the potential influence of confounding factors. We evaluated the outcomes of 35 patients with histologically proven stage I LMS. The median age at diagnosis was 50 years. All patients underwent surgical treatment and 20 patients (57.1%) received adjuvant therapy. Twelve of these patients (34.3%) received adjuvant chemotherapy, 3 (8.6%) received adjuvant pelvic irradiation, and 5 (14.2%) received adjuvant chemotherapy with pelvic irradiation. The median follow-up duration was 34 months (range: 3-231 months). Twenty-three (65.7%) patients had a recurrence during follow-up. Adjuvant therapy did not significantly improve median progression-free survival or median overall survival. Cox regression analysis did not demonstrate any significant impact of the factors studied, including age, menopausal status, tumor size, mitotic count, staging surgery, or adjuvant therapy. Adjuvant therapy for surgically treated stage I uterine LMS did not improve oncologic outcomes.

Identifying risk factors for occult lower extremity lymphedema using computed tomography in patients undergoing lymphadenectomy for gynecologic cancers

ObjectiveTo identify risk factors for lower extremity lymphedema (LEL) using computed tomographic (CT) scan in patients undergoing lymphadenectomy for gynecologic cancers. MethodsWe retrospectively reviewed 511 consecutive gynecologic cancer patients undergoing lymphadenectomy. Mean difference (3.77±3.14mm) of subcutaneous layer thicknesses between preoperative and postoperative 1-year CT scans of 106 patients with clinical LEL was used as an objective criterion for regrouping all the patients into those with mean difference >3.77mm and ≤3.77mm. Risk factors for clinical LEL and significant increase of subcutaneous layer thickness on CT were evaluated using a logistic regression model. ResultsA total of 106 (20.7%) patients were clinically diagnosed with LEL by a physician. Total number of lymph nodes (LNs) retrieved >30 (Odds ratio [OR] 3.2; 95% Confidence interval [CI] 1.94–5.32; p<0.001) and adjuvant pelvic radiotherapy (OR 3.1; 95% CI 1.75–5.52; p<0.001) were risk factors for clinical LEL. One hundred-nineteen (23.3%) had subcutaneous layer thickness increase of >3.77mm. In addition to number of LNs retrieved >30 (OR 2.3; 95% CI 1.40–3.74; p=0.001) and adjuvant pelvic radiotherapy (OR 1.7; 95% CI 1.01–2.74; p=0.046), open surgery (OR 1.8; 95% CI 1.01–3.11; p=0.045), long operation time (OR 1.7; 95% CI 1.05–2.83; p=0.032), and no use of intermittent pneumatic compression (IPC) (OR 2.1; 95% CI 1.06–4.16; p=0.034) were risk factors for thick subcutaneous layer on postoperative CT. ConclusionsIn addition to high LN retrieval and adjuvant pelvic radiotherapy, open surgery, long operation time, and no IPC use could be risk factors for occult LEL after lymphadenectomy in gynecologic cancers.

Uterine Adenosarcoma: a Review.

Adenosarcomas are rare malignancies of the female genital tract, accounting for approximately 5% of uterine sarcomas. Occasionally, adenosarcoma occurs in the ovaries or in extra-uterine tissue, which may be related to endometriosis. These tumors are characterized by benign epithelial elements and a malignant mesenchymal component. Pathologic diagnosis is dependent on the identification of the characteristic morphologic features. The most common immunohistochemical markers for adenosarcoma are CD10 and WT1, but these are not specific. The most frequent presenting symptom is abnormal uterine bleeding. The majority of patients present with stage I disease, with a 5-year overall survival of 60 to 80%. Survival is influenced by the presence of myometrial invasion, sarcomatous overgrowth, lymphovascular invasion, necrosis, and the presence of heterologous elements including rhabdomyoblastic differentiation. Patients with sarcomatous overgrowth have significantly increased risk of recurrence 23 versus 77% and decreased 5-year overall survival 50 to 60%. Standard of care treatment is total hysterectomy with bilateral salpingo-oophorectomy without lymphadenectomy, as the incidence of lymph node metastasis is rare. Retrospective data does not support the use of adjuvant pelvic radiotherapy in uterine adenosarcomas as no survival benefit is seen. Insufficient data exists to recommend routinely neoadjuvant or adjuvant chemotherapy for uterine adenosarcomas. Limited evidence exists for the role of hormonal therapy in uterine adenosarcomas. The PIK3/AKT/PTEN pathway is mutated in ∼70% of adenosarcomas, and this may represent a possible therapeutic target. This article reviews the current state of knowledge concerning uterine adenosarcoma and discusses the management of this rare tumor.

Adjuvant Small Pelvic Radiation Therapy in Cervical Cancer Patients With Minor Risk Factors

Adjuvant Small Pelvic Radiation Therapy in Cervical Cancer Patients With Minor Risk Factors

Adjuvant Pelvic Radiation Therapy±Vaginal Brachytherapy in Patients With High-risk Stage I or Stage II Uterine Papillary Serous, Clear Cell, and High-grade Endometrioid Carcinoma.

Radiation therapy (RT) for stages I-II uterine papillary serous carcinoma (UPSC), clear cell (CC), and high-grade endometrioid (HGE) carcinoma present a treatment challenge. Regimens include external beam radiotherapy (EBRT) with or without brachytherapy. We examine the use of these radiation modalities in these endometrial cancers (EC) with respect to cause-specific survival (CSS). The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with AJCC stages I-II UPSC, CC, or HGE cancer treated with hysterectomy and RT between 1998 and 2008. Patients who did not receive adjuvant RT or received brachytherapy alone were excluded. CSS was evaluated by the Kaplan-Meier survival analysis and the log-rank test was used to compare CSS. Multivariate analysis was performed using the Cox proportional hazards regression model. Adjusted hazard ratios (HR) were calculated for risk of EC death. There were 1653 patients included in this analysis. The overall 100-month CSS for the entire cohort was 81.0%. The 100-month CSS was 85.3% for EBRT alone and 86.5% for EBRT+brachytherapy (P=0.72). Stage IC/IIA/IIB patients had a greater risk of EC death compared with stage IA/IB patients (adjusted HR=2.39; P<0.0001). Patients with UPSC and CC had a slightly higher risk of EC death compared with HGE (adjusted HR=1.01 [P=0.97] and 1.42 [P=0.02], respectively). On subset analysis, there was no difference in CSS with the addition of brachytherapy for UPSC (P=0.37), CC (P=0.27), or HGE cancer patients (P=0.42). Patients treated with brachytherapy in addition to EBRT did not demonstrate a reduced adjusted risk of EC death compared with EBRT alone (P=0.38). The addition of brachytherapy to adjuvant EBRT in stages I-II UPSC, CC, and HGE cancer did not demonstrate superior CSS. Thus, patients may not benefit from the addition of brachytherapy to EBRT.

Adjuvant Chemotherapy After Radical Cystectomy for Urothelial Bladder Cancer: Outcome and Prognostic Factors for Survival in a French Multicenter, Contemporary Cohort

BackgroundIn the past decade, adjuvant chemotherapy (AC) after radical cystectomy (RC) was preferred worldwide for patients with muscle-invasive urothelial bladder cancer. In this study we aimed to determine the outcome of patients who received AC and evaluated prognostic factors associated with survival. Patients and MethodsWe retrospectively analyzed 226 consecutive patients treated in 6 academic hospitals between 2000 and 2009. Multivariate Cox proportional hazards regression adjusted for center to estimate adjusted hazard ratios (HRs) with 95% confidence intervals were used. ResultsThe median age was 62.4 (range, 35-82) years. Patients had pT3/pT4 and/or pN+ in 180 (79.6%) and 168 patients (74.3%), respectively. Median lymph node (LN) density was 25% (range, 3.1-100). Median time between RC and AC was 61.5 (range, 18-162) days. Gemcitabine with cisplatin, gemcitabine with carboplatin, and MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) regimens were delivered in 161 (71.2%), 49 (21.7%), and 12 patients (5.3%) of patients, respectively. The median number of cycles was 4 (range, 1-6). Thirteen patients (5.7%) with LN metastases also received adjuvant pelvic radiotherapy (ART). After a median follow-up of 4.2 years, 5-year overall survival (OS) was 40.7%. In multivariate analysis, pT ≥3 stage (HR, 1.73; P = .05), LN density >50% (HR, 1.94; P = .03), and number of AC cycles <4 (HR, 4.26; P = .001) were adverse prognostic factors for OS. ART (HR, 0.30; P = .05) tended to provide survival benefit. ConclusionClassical prognostic features associated with survival are not modified by the use of AC. Patients who derived benefit from AC had a low LN density and received at least 4 cycles of treatment.

Impact of paraaortic lymphadenectomy for endometrial cancer with positive pelvic lymph nodes: A Korean Radiation Oncology Group study (KROG 13-17)

AimWe investigated the role of paraaortic lymph node dissection (PALND) in patients with stage IIIC1 endometrial carcinoma after surgery followed by adjuvant radiotherapy (RT) alone or chemoradiotherapy (CTRT). MethodsWe performed a subgroup analysis in 151 patients treated with adjuvant pelvic RT. Paraaortic-recurrence free survival, disease-free survival (DFS) and overall survival (OS) were analyzed. ResultsIn adjuvant RT alone, PALND was significantly related to reduced risk of paraaortic recurrence (0% vs. 17.1%) and distant metastasis (4.5% vs. 19.5%) compared with the no PALND group. PALND affected 5-year DFS (90.2% vs. 58.9%, p = 0.016) and OS (100% vs. 83.1%, p = 0.022). For the CTRT group, the paraaortic recurrence rate was 19.5% for the no PALND group and 12.8% for the PALND group (p = 0.682). Of patients who underwent PALND in the CTRT group, less extensive PALND was significantly related to increased paraaortic recurrence (≤10 vs. >10 dissected LNs, 17.1% vs. 0%). In the no PALND group (n = 82), 5-year paraaortic-recurrence free survival was 79.4% for the CTRT group and 76.2% for the RT alone group (p = 0.941). In multivariate analysis, PALND was significantly associated with reduced risk of disease-specific death (HR, 0.50; 95% CI, 0.26–0.96; p = 0.037). ConclusionPALND provided excellent paraaortic control and improved outcome in stage IIIC1 endometrial cancer with favorable tumor features treated with adjuvant RT alone. Less extensive PALND was associated with significantly increased paraaortic recurrence in patients with advanced tumor features treated with adjuvant CTRT. Combined CTRT did not affect disease control in the paraaortic region compared with RT alone.

Adjuvant pelvic radiotherapy in patients with stage IVA rectal adenocarcinoma.

711 Background: For patients with stage IVA rectal cancer with liver metastases treated with curative-intent chemotherapy and surgery, the role of adjuvant pelvic radiotherapy (RT) is unclear. The purpose of this study was to evaluate the impact of pelvic RT on oncologic outcomes in this patient population. Methods: We retrospectively reviewed medical records of all patients with stage IVA rectal adenocarcinoma with liver metastases treated with curative-intent resection of the primary tumor and all liver metastases at our institution between 1991 and 2010. Patient and treatment characteristics were compared between patients who did or did not receive pelvic RT using chi-square and unpaired ttests. Survival and recurrence estimates were calculated from date of initial diagnosis using the Kaplan-Meier method. Local recurrence (LR) was defined as recurrence in the pelvis occurring at or before distant recurrence (DR). Cox regression was used to compare rates of freedom from LR (FFLR), freedom from DR (FFDR), and overall survival (OS) between patients who did or did not receive pelvic RT. Results: The analysis included 65 patients. Median patient age at diagnosis was 59 years (range, 27-87). Tumor stage was T2 (n = 4), T3 (n = 53), or T4 (n = 8). The median number of liver metastases was 2 (range, 1-14). Surgery was low anterior resection (n = 54) or abdominoperineal resection (n = 11). All patients received perioperative fluoropyrimidine based chemotherapy. Pelvic RT was administered to 35 patients (54%), either preoperatively (n = 22) or postoperatively (n = 13). Median RT dose was 50.4 Gy (range 25-58). Patient characteristics were similar for those who did or did not receive pelvic RT. Median follow-up was 3.7 years. The 3-year estimates of FFLR, FFDR and OS were 81% vs 58% (p =.056), 35% vs 29% (p =.75), and 66% vs 71% (p =.81) for RT vs no RT, respectively. Conclusions: In this analysis of patients with stage IVA rectal cancer with liver metastases undergoing curative intent therapy, pelvic RT (vs. no pelvic RT) was associated with a trend to lower rates of LR and similar rates of DR and OS.

Adjuvant pelvic radiotherapy for pathological high-risk muscle-invasive bladder cancer: A multicenter retrospective study.

369 Background: Radical cystectomy (RC) and pelvic lymph-node dissection (PLND) are standard procedures in the management of non-metastatic muscle invasive bladder cancer (MIBC). Loco-regional recurrence (LRR) is a common early event associated with a poor prognosis. The aim of this study is to evaluate adjuvant radiotherapy (RT) for pathological high-risk MIBC. Methods: We retrospectively reviewed data from patients treated by RC from 3 institutions. Inclusion criteria were MIBC, histologically proven urothelial carcinoma treated by RC and adjuvant RT. Patients with conservative surgery were excluded. LRR free-survival, overall survival (OS) and metastasis-free survival (MFS) were evaluated. Acute toxicities were recorded according to CTCAE V4.0 scale. Results: Between January 2000 and December 2013, 57 patients with a median age of 66 years (45-84) were included. Post-operative pathological staging was pT2, pT3 and pT4 in 16%, 44%, and 39%, respectively. PLND revealed 28% of pN0, 26% of pN1 and 42% of pN2. For 2 patients, no PLND was performed. Median number of lymph-nodes retrieved was 10 (2-33). Forty-eight patients (84%) received platin-based chemotherapy, 7 in neo-adjuvant and 41 in adjuvant setting. For RT, clinical target volume 1 (CTV 1) alwyas encompasses pelvic lymph nodes and cystectomy bed for 37 patients (65%). Median dose for CTV 1 was 45 Gy (4-50). Dose complement of 16 Gy (5-22) corresponding to CTV 2 was achieved in 53 of cases, depending on pathological features. Intensity Modulated RT was performed in one third of patients. With a median follow-up of 40.4 months, LRR occurred in 8 patients (14%). Three-year loco-regional free survival, MFS and OS were 45% (IC 95%: 0.30-0.60), 39% (IC 95%: 0.25-0.52) and 49% (IC 95%: 0.33-0.63), respectively. Acute grade ≥ 3 toxicities were observed in 5 patients (9%). One patient died with intestinal fistula in septic context. No survival or toxicity predictive factor was identified. Conclusions: Adjuvant radiotherapy for pathological high-risk MIBC is safe and may have oncological benefits. Thus, new prospective trials evaluating this approach with modern RT techniques should be undertaken.

Dosimetric comparison of different treatment planning techniques with International Commission on Radiation Units and Measurements Report-83 recommendations in adjuvant pelvic radiotherapy of gynecological malignancies.

The study evaluates the different treatment planning techniques according to three recommendation levels of the International Commission on Radiation Units and Measurements Report-83 in gynecologic cancer patients treated with adjuvant pelvic radiotherapy (APR). Computerized tomography images of ten endometrial and cervical cancer patients who were treated with APR were assessed. For each patient, five different treatment plans were created. One homogeneity index and four different conformity indexes (CIs) were calculated for three-dimensional conformal radiotherapy (3D-CRT), field-in-field (FIF), seven-field intensity modulated radiotherapy (7-IMRT) with two different degrees beginning (7A-IMRT, 7B-IMRT) and 9-IMRT treatment plans. Dose volume histogram parameters and normal tissue complication probability (NTCP) were compared for organs at risk (OAR). The CI values of the IMRT were closer to 1 with respect to other plans (P < 0.05). The rectum and the bladder volumes which received more than 40 Gy were decreased with IMRT compared to 3D-CRT (P < 0.05). Doses received by the 195 cc volume of the small intestine and NTCP values were significantly decreased with IMRT (P < 0.05). IMRT provided more protection than FIF plans at high dose volumes of the OAR; however, it did not show any superiority at low-dose volumes. The NTCP results supported IMRT for only small intestine protection. Because IMRT is increasingly used clinically, the comparison of NTCP will become more common in the near future. Therefore, new prospective studies with sufficient number of patients and appropriate NTCP models are needed for this treatment modality.

The Outcomes of Ultralow Anterior Resection or an Abdominoperineal Pull-Through Resection and Coloanal Anastomosis for Radiation-Induced Recto-Vaginal Fistula Patients

PurposeThe purpose of this study was to evaluate the outcomes of patients who underwent colorectal resections and coloanal anastomosis for radiation-induced recto-vaginal fistulas (RVFs). The effect of the surgical treatment technique on bowel function, fecal continence, and quality of life of patients was also evaluated. MethodsTwenty-one female patients, who received adjuvant chemotherapy and external beam pelvic radiation for cervix carcinoma after radical hysterectomy + pelvic/paraaortic lymph node dissection, having RVF but without tumor recurrence, were included. All patients underwent an ultralow anterior resection (n = 11) or an abdominoperineal pull-through resection and straight coloanal anastomosis (n = 10). A bowel functions questionnaire and a Fecal Incontinence Quality of Life (FIQLI) questionnaire were applied to patients pre-operatively and also 6 months after the ileostomy closure procedures. ResultsNo recurrent RVF was observed in a mean follow-up period of 20 months after ostomy reversal procedures. The FIQLI depression, lifestyle, and embarrassment scores were significantly improved on the follow-up questionnaire. The mean pre- and post-operative incontinence scores were not significantly different. ConclusionsThe spontaneous closure rate after a simple diverting stoma is quite low and local repair procedures usually result in failure. In selected patients, performing a nearly total rectum resection and maintaining the intestinal continuity with a coloanal anastomosis may be accepted as a safe and curative option. Recurrence-free outcome and the improvement of the quality of life of the patients represent the efficiency of this treatment modality.

Adjuvant Small Pelvic Radiation Therapy in Cervical Cancer Patients With Minor Risk Factors

To retrospectively evaluate the efficacy of adjuvant small pelvic radiation therapy (RT) in cervical cancer patients with minor risk factors after radical surgery. Seventy-six patients with at least 2 minor risk factors (tumor size > 4cm, lymphovascular space invasion (LVSI), deep stromal invasion (DSI) and adenocarcinoma histology) after surgery were treated with small pelvic RT from January 2001 through April 2013 in our department. None of the patients received concomitant chemotherapy. Median age was 54 years (range, 34-70 years). Surgery was in the form of type 3 in 72 (95%) and type 2 radical hysterectomy in 4 (5%) patients. The mean number of dissected lymph nodes (LN) was 47 (13-120). Vaginal surgical margin was positive in 4 patients (5%) and closer than 0.5cm margin in 4 (5%) patients; in addition, carcinoma in situ was detected on the surgical margin in 3 patients (3.9%). From 2001 through 2007, pelvic RT was administered as 2-dimensional RT with field borders between L5-S1 in superior, below obturator foramens in inferior and bony pelvis in lateral directions. After 2007, pelvic RT was in the form of 3-dimensional conformal RT, and the clinical target volume included primary tumor bed, proximal vagina, parametrial bed, and presacral lymphatic region as defined by RTOG. External RT was performed to small pelvis, which comprised surgical bed and presacral LNs. The median fraction dose was 1.8 Gy (range, 1.8-2 Gy), and the median total dose was 50.4 Gy (range, 45-50.4 Gy). In 9 (12%) patients with surgical margin positivity or close surgical margins, a total median dose of 21 Gy (range, 15-28 Gy) of additional brachytherapy (BRT) was also performed with median 7 Gy (range, 5-7 Gy) fraction doses. Median follow-up time was 78 months (range, 4-169 months). Local recurrence, regional recurrence or distant metastasis developed in 6 (7.9%), 3 (3.9%), and 4 (5%) patients, respectively. Median local recurrence-free survival (LRFS) was 76 months (range, 4-169 months), regional recurrence-free survival (RRFS) was 76 months (range, 4-169 months), and distant metastasis-free survival (DMFS) was 78 months (range, 4-169 months). Five-year cancer specific survival (CSS) rate was 94%; disease-free survival (DFS) rate was 86%; LRFS rate was 92%; RRFS rate was 96%; DMFS rate was 94%, respectively. In multivariate analysis, no statistically significant factor was found for CSS and DFS; however, the presence of LVSI was found significant for LRFS (P=.017). Following RT, rectovaginal fistula in 1 patient after 5 months, enterovesical fistula in 1 patient after 35 months, and rectovesical fistula in 1 patient after 40 months were observed. Our results confirmed us that small pelvic RT in patients with minor risk factors after definitive surgery is highly effective treatment strategy with high local and regional control, and DFS rates with low toxicity profile.

Assessing the Quality of Life in Patients With Endometrial Cancer Treated With Adjuvant Radiotherapy.

The current study evaluates long-term quality of life (QOL) and sexual function of patients with endometrial cancer who received adjuvant pelvic external beam radiotherapy (EBRT) and/or vaginal brachytherapy (BRT). One hundred forty-four endometrial cancer survivors who were treated between January 2000 and December 2009 in our department were included in this study. Median follow-up was 79 months (range, 31-138 months). Fifty-two patients were treated with 45 to 50.4 Gy EBRT, 76 were with BRT, and 16 were with both EBRT and BRT. Brachytherapy was in the form of vaginal cuff BRT with 5 × 550 cGy high dose rate BRT, prescribed to the first 4 cm and whole wall thickness of vagina. Quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and subscales from the supplemental 24-item Cervical Cancer Module. Vaginal BRT patients reported better physical functioning (P = 0.01), role functioning (P = 0.03), and sexual enjoyment (P = 0.01) compared to EBRT group. Symptom score (P = 0.01), lymphedema (P = 0.03), pain (P = 0.02), and diarrhea (P = 0.009) scores were also higher with EBRT. Vaginal BRT did not worsen symptom scores or sexual functions when added to EBRT. Obese patients experienced higher rates of lymphedema (P = 0.008). Cognitive and role functioning scores were significantly higher in patients with normal body mass index. External beam radiotherapy negatively affects long-term QOL and sexual functions in endometrial cancer survivors. Vaginal BRT provides higher QOL. Patients with body mass index within normal limits have improved QOL.