High Dose Rate Vaginal Brachytherapy Research Articles

Comparison of Two Different Adjuvant High Dose Rate Vaginal Brachytherapy Fractionation Regimens in Early-Stage Endometrial Cancer

Adjuvant vaginal brachytherapy (VBT) as monotherapy is commonly used as treatment for early-stage uterine cancer following hysterectomy. No ABS guidelines existed at the onset of our institution's high dose rate (HDR) brachytherapy program, so a regimen of 30 Gy in six fractions was adopted in this setting. Due to the COVID pandemic in 2020, we implemented the use of 22 Gy in four fractions as our primary regimen to reduce overall treatment duration and healthcare exposure risks. In this analysis, we seek to compare outcomes and toxicities between the two treatment regimens. This is a single institution retrospective review of patients with Stage I-II endometrial cancer who received adjuvant VBT as monotherapy between 1998 and 2022. HDR VBT was delivered via a vaginal cylinder prescribed to a depth of 5 mm, to a dose of 22 or 30 Gy in four or six fractions, respectively. We evaluated maximum acute and chronic toxicities, defined as ≤6 months and ≥ 6 months following treatment completion, respectively. Toxicities were assessed using the Common Terminology Criteria for Adverse Events (CTCAE) criteria. We evaluated clinical outcomes including local recurrence (LR), distant metastasis (DM), cause-specific survival (CSS) and overall survival (OS). P-values <0.05 were considered significant. A total of 270 patients were included in our analysis, with a median follow up of 4.98 years (7.7 and 1.3 years for six-fraction and 4-fraction regimen, respectively, p<0.001). The median age at the time of treatment was 66 (range 31-89). 195 patients (72.2%) were treated with six fractions and 75 (27.8%) were treated with four fractions. There was significantly less chronic vaginal dryness (p = 0.017) and vaginal stenosis (p<0.001) with the four-fraction compared to the 6-fraction regimen. There was no difference in acute toxicity (p = 0.468). There were no grade ≥3 toxicities in either group. The 2-year LR, DM, CSS, and OS rates for four/six fractions were 2.4%/3.7%, 6.8%/3.7%, 95.8%/97.9%, and 95.8%/95.8%, respectively. There were no significant differences in outcomes between the two groups. Our experience supports that VBT in four fractions is well tolerated with minimal acute and chronic toxicities. When comparing to our institution's historical data for a six-fraction regimen, the use of a four-fraction regimen resulted in less chronic vaginal dryness and stenosis, supporting its continued use. The clinical outcomes have been similar thus far. Further analysis with a longer follow-up duration and a match-pair analysis is warranted.

Do Radiotherapy Planning Factors Influence Para-Aortic Recurrence in IIIC1 Cervical Cancer Patients?

Patients with locally advanced cervical cancer are at higher risk of para-aortic lymph node recurrence, however, the addition of prophylactic para-aortic irradiation is still controversial. The aim of this study was to evaluate prognostic factors related to para-aortic recurrence in patients with cervical cancer and pelvic lymph node metastasis (2018 FIGO Stage IIIC1).A retrospective cohort analysis was conducted with patients with cervical cancer and pelvic lymph node metastasis (2018 FIGO Stage IIIC1), that were treated with primary or adjuvant chemoradiotherapy from 2007 to 2018 at a single tertiary cancer center. Clinical and pathological variables were evaluated, as well as radiological and radiotherapy planning factors. Kaplan-Meier method was used to calculate survival and survival comparison between groups with log-rank method. Statistically significant was defined as P ≤ 0.05.Seventy-two patients were included: 56 (77.8%) had primary chemoradiotherapy and 16 (22.2%) adjuvant chemoradiotherapy after radical hysterectomy and lymph node staging. 58 (80.5%) underwent 3D-conformal, 14 (19.5%) intensity-modulated radiotherapy, and 67 (93%) also had high dose rate vaginal brachytherapy. Only 1 patient did not receive concomitant chemotherapy. Staging PET-CT was available in 23 (31.9%) cases and the remaining ones were staged with MRI or CT scans, Surgical para-aortic staging was not performed. The median follow-up was 42 months (range, 5 to 144 months). Overall, 27 (37.5 %) patients recurred during follow-up, and 7 (26 %) had isolated para-aortic lymph-node recurrence. Distant metastasis and pelvic recurrence were found in 12 (45 %) and 8 (29 %) cases, respectively. Median overall survival, disease free survival, distant metastasis free survival, loco-regional free survival and para-aortic free survival were 56, 52, 52, 51 and 42 months, respectively. In univariate analysis, PET SUV in pelvic lymph nodes higher than 10.2 (P = 0.02) and positive lymph nodes in the left common iliac station (P = 0.05) were identified as predictive factors for isolated para-aortic recurrence. We also identified positive lymph node in the common iliac station as a predictor for distant recurrence (P = 0.002). Tumor size larger than 66 mm (P = 0.046) and positive lymph node in the left common iliac lymph node station (P = 0.02) as predictors for pelvic recurrence. Lymph node > 24 mm was the only prognostic factor associated with overall survival (P = 0.012).In this retrospective cohort, radiological and radiotherapy planning factors as high lymph node's PET SUV and proximal location of positive pelvic lymph nodes were prognostic for para-aortic recurrence in IIIC1 cervical cancer patients. Further prospective and randomized studies are required to validate those risk factors as well as to determine if prophylactic para-aortic irradiation would improve outcomes in these patients.P.J. Pinto: None. S.L. Favareto: None. C.F. Souza: None. G. Baiocchi: None. A.A. da Costa: None. A.C. Pellizon: None. C. Abrahao: None. D.G. Castro: None. G.R. Gondim: None. H. Ramos: None. E. Santos Neto: None. R.C. Fogaroli: None. M.G. Silva: None. M.J. Chen: None.

Comparaison entre Stump Cylinder et moule personnalisé, effet de la forme de l’applicateur sur la distribution de dose

PurposeThe purpose of this study was to compare the efficacy of two applicators used in high dose rate vaginal brachytherapy. The first is the Stump Cylinder used in the “brachycenter” department at the Middle East Institute of Health in Lebanon and the second is the custom mold used in the radiotherapy department at Tenon Hospital in France. Materials and methodA comparison of the clinical target volume and the doses received by the rectum and bladder was performed in order to determine the best method of treatment and to optimize the dose distribution. 95 patients were treated in both departments. ResultsThe average values of the D95% dose received by the CTV were respectively 89.43% for the Stump Cylinder and 110.16% for the custom mold. The conformity index was 0.84 for the Stump Cylinder while it was 0.97 for the custom mold, which ensures a better dose distribution. For the rectum, the maximum dose D2cc taken by volume was 71.23% for the Stump Cylinder and 79.51% for the custom mold. The bladder was better protected with Stump Cylinder with a D2cc value of 65.81% against 94.88% for the custom mold. ConclusionThe underdosing obtained using the Stump Cylinder was due to the shape of upper part of the cylinder which was not conform with the shape of the vaginal vault in women. A better protection of the organs at risk was observed with the Stump Cylinder since the dose taken by the rectum and bladder using a custom mold can reach the tolerance limits.

Low-Dose Adjuvant Cylinder Brachytherapy for Endometrioid Endometrial Cancer

PurposeOur purpose was to evaluate outcomes and sites of failure for women with early stage endometrial adenocarcinoma treated with adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) with a low dose scheme. Methods and MaterialsRetrospective review identified 318 patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-II endometrioid endometrial cancer who received adjuvant HDR VB to a dose of 24 Gray (Gy) in 6 fractions from 2005 to 2017. Patients with <6 months follow-up were excluded. Dose was prescribed to cylinder surface and computerized tomography (CT) imaging was performed before each fraction to assess cylinder placement. Rates of vaginal relapse (VR), pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were calculated by Kaplan-Meier method. Univariate analysis was performed by log rank test or Cox proportional hazards. Pretreatment CT images were analyzed for patients with VR. ResultsMedian follow-up was 42 months for 243 patients. The 3-year rates of VR, pelvic nodal relapse, distant metastasis, recurrence-free survival, and overall survival were 1.9%, 1.5%, 4.3%, 94.1%, and 98.9%, respectively. The 3-year VR rates by Gynecologic Oncology (GOG)-99 risk groups were 0%, 1.4%, and 3.2% for low risk, low-intermediate risk, and high-intermediate risk (HIR) disease (P = .5). By Post-operative Radiation Therapy in Endometrial Carcinoma (PORTEC) risk stratification, 3-year VR rate was 1.3% for HIR disease. On review of pretreatment CT images of the 6 patients with VR, 3 patients had relapse at the introitus outside of the treated vaginal length, and 3 had in-field recurrence at the vaginal apex. Higher body mass index (BMI) was associated with VR, with a 14% increase in risk per BMI unit (kg/m2, P = .02). There were no reported grade 2 GI or any grade 3 toxicities. ConclusionsAdjuvant HDR VB with a low-dose regimen results in excellent clinical outcomes for patients with early stage endometrioid endometrial cancer. Patients with higher BMI may be at increased risk of VR, and additional study is needed to optimize brachytherapy treatment parameters.

Preliminary epi-diode characterization for HDR brachytherapy quality assurance

High Dose Rate vaginal brachytherapy for endometrial cancer has evolved from simple single-channel (i.e. cylindrical applicator) deliveries to treatments involving several channels (i.e. multichannel applicator) for the radiotherapy source to dwell, increasing the complexity of the dose distribution, and allowing more space for potential errors. For this reason real-time treatment verification has gained a greater importance than ever before, and more methods need to be developed in order to provide assurance that the dose delivery has been carried out as intended by the hospital staff. P-type silicon epi diodes have been designed at the Centre for Medical Radiation Physics (CMRP) in Australia to suit the specific needs of HDR BT, and characterized in the clinical BT facility of the Fondazione IRCCS (INT) in Italy. They have shown great potential for BT treatment verification in real time due to their radiation hardness, dose rate independence, flexibility in physical design, and ability to monitor the treatment at a 1-kHz readout frequency. Their dynamic range has been determined as ±17 to ±20 mm and dwell time calculation accuracy of > 0.1 s has been shown. If placed on the same longitudinal plane of a treatment accessory, these detectors would enable coverage of about 40 mm for source position and dwell time tracking. Respective detector positioning at (0, +3, −3 mm) would extend this range to 45-50 mm, depending on the catheter location, proving to be sufficient for the majority of treatment cases. Further studies are encouraged to develop diodes with a wider dynamic range.

EROS study: evaluation between high-dose-rate and low-dose-rate vaginal interventional radiotherapy (brachytherapy) in terms of overall survival and rate of stenosis.

PurposeTo compare the survival and toxicity outcomes in patients with endometrial cancer treated with either high-dose-rate (HDR) or low-dose-rate (LDR) vaginal brachytherapy (VBT) following external beam radiotherapy (EBRT).Material and methodsFrom January 2000 to December 2014, patients with endometrial cancer after radical hysterectomy with/without pelvic and/or para-aortic lymphadenectomy were treated with adjuvant EBRT (45 Gy, 1.8 Gy/day to the whole pelvis) and subsequent VBT boost (HDR dose of 7 Gy in one fraction or LDR VBT dose of 25 Gy). The dose was prescribed at 0.5 cm from the surface of the applicator and the proximal half to two-thirds of the vagina was irradiated. The outcomes of patients were evaluated in terms of local control (LC), overall survival (OS), and rates of adverse events.ResultsWe analyzed data of 200 patients treated with EBRT followed by HDR VBT boost in 78 patients and LDR VBT boost in 122 patients. With a median follow-up of 25 months (range, 6-163), 5-year OS was 98% and 97% in the LDR and HDR groups, respectively (p = 0.37). The 5-year LC was similar (93% in both groups) (p = 0.81). In multivariate analyses, none of the factors assessed (age, stage, grade) impacted OS (p = 0.37) or LC (p = 0.81). Patients treated with LDR VBT after EBRT had higher rates of acute gastrointestinal toxicity. No differences were found in acute genitourinary or hematological toxicities. Late toxicity such as vaginal stenosis was registered during regular follow-up visits and was similar in the two groups (p = 0.67).ConclusionsIn our analysis, there were no differences in terms of OS and late toxicity outcomes for patients receiving LDR or HDR VBT. HDR VBT is a safe technique in comparison to LDR VBT.

Comparing organ-at-risk doses for high-dose-rate vaginal brachytherapy between three different planning workflows

PurposeThe aim of this study was to compare the organ-at-risk doses to the rectum and the bladder in postoperative endometrial cancer patients who receive high-dose-rate vaginal brachytherapy (HDR-VB), when using three different methods of treatment planning: (Workflow A) individualized treatment planning before every fraction, (Workflow B) individualized treatment planning for first fraction only), and (Workflow C) using a template plan based on applicator choice and prescription specifics without patient-specific imaging or planning (standardized template approach). Methods and MaterialsAlternative plans were retrospectively created using workflows B and C for 22 patients who previously received postoperative HDR-VB using a vaginal cylinder and planned using Workflow A for endometrial cancer. The rectum and bladder were contoured on the CTs used for each fraction for dose comparison between the three methods. D50, D2cc, D1cc, D0.1cc, and V100 of the bladder and the rectum were compared using the two-sided Wilcoxon signed-rank test. ResultsA total of 123 fractions were available for comparison. For Workflow A vs. Workflow B, there was no significant difference for any rectal or bladder dosimetric parameter. For Workflow A vs. Workflow C, Workflow A delivered a significantly higher median dose to the rectum than Workflow C for D50, D2cc, D1cc, and V100. Workflow C delivered a significantly higher dose to the bladder than Workflow A: D2cc, D1cc, D0.1cc, and V100. However, the magnitudes of the differences were small; the dose index difference was >75 cGy for only two fractions. ConclusionPlan standardization in HDR-VB may result in considerable time and cost savings with minimal organ-at-risk dose differences.

PO-1020: High-dose rate vaginal brachytherapy in early stage endometrial cancer

PO-1020: High-dose rate vaginal brachytherapy in early stage endometrial cancer

Sequential versus “sandwich” sequencing of adjuvant chemoradiation for the treatment of stage III uterine endometrioid adenocarcinoma

ObjectiveTo compare the efficacy and tolerance of adjuvant chemotherapy and radiotherapy delivered in sequential (chemotherapy followed by radiation) versus “sandwich” fashion (chemotherapy, interval radiation, and remaining chemotherapy) after surgery in patients with FIGO stage III uterine endometrioid adenocarcinoma. MethodsFrom 2004 to 2011, we identified 51 patients treated at our institution fitting the above criteria. All patients received surgical staging followed by adjuvant chemoradiation (external-beam radiation therapy (EBRT) with or without high-dose rate (HDR) vaginal brachytherapy (VB)). Of these, 73% and 27% of patients received their adjuvant therapy in sequential and sandwich fashion, respectively. ResultsThere were no significant differences in clinical or pathologic factors between patients treated with either regimen. Thirty-nine (76%) patients had stage IIIC disease. The majority of patients received 6cycles of paclitaxel with carboplatin or cisplatin. Median EBRT dose was 45Gy and 54% of patients received HDR VB boost (median dose 21Gy). There were no significant differences in the estimated 5-year overall survival, local progression-free survival, and distant metastasis-free survival between the sequential and sandwich groups: 87% vs. 77% (p=0.37), 89% vs. 100% (p=0.21), and 78% vs. 85% (p=0.79), respectively. No grade 3–4 genitourinary or gastrointestinal toxicities were reported in either group. There was a trend towards higher incidence of grade 3–4 hematologic toxicity in the sandwich group. ConclusionAdjuvant chemoradiation for FIGO stage III endometrioid uterine cancer given in either sequential or sandwich fashion appears to offer equally excellent early clinical outcomes and acceptably low toxicity.

Vaginal brachytherapy for early stage uterine papillary serous and clear cell endometrial cancer

ObjectiveTo report clinical outcomes following adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) for early-stage uterine papillary serous (UPSC) and clear cell (CC) endometrial cancer. MethodsA retrospective study of Stage I and II papillary serous and clear cell endometrial cancer treated with post-operative HDR VB between October 2005 and May 2012 was performed. A total of 37 patients were identified, 26 with UPSC, 9 with CC and 2 with mixed UPSC/CC. After total hysterectomy and bilateral salpingo-oophorectomy, VB was administered without external-beam radiation with a dose of 24Gy in 6 fractions prescribed to the vaginal surface. Chemotherapy was given to 30 patients (75%). ResultsThe median follow up time was 24.8months (range, 2.0 to 71.5months). Four patients relapsed, 2 with UPSC and 2 with CC. The initial site of relapse was concurrent vagina, pelvic/para-aortic nodes and abdominal wall (1), pelvic/para-aortic nodes (1) and para-aortic nodes alone (2). The 2-year vaginal-control rate was 96.8%. The pelvic-control rate including vaginal and nodal relapse was 93.5%. The 2-year disease-free and overall survival rates were 89.3% and 100%, respectively. ConclusionHDR VB as the sole adjuvant treatment modality for early-stage UPSC/CC is associated with a low rate of vaginal relapse and excellent survival outcomes. This novel low-dose regimen for VB is safe and effective.

Endometrial cancer recurrence: Adjuvant high-dose rate vaginal brachytherapy (HDR) versus HDR with whole pelvic radiation.

e15504 Background: Investigators hypothesize that patients with endometrioid carcinoma of the endometrium treated with adjuvant high-dose-rate vaginal brachytherapy (HDR) alone vs. HDR with whole pelvic radiation (WPXRT) have similar recurrence patterns. Methods: Patients reated with any adjuvant HDR between March 2005 and January 2011 were included retrospectively. Demographic, pathologic and treatment data was extracted from the medical record. These clinical data were compared among subjects receiving HDR only vs. HDR with 4500 cGy whole pelvic radiation using t-tests, Mann-Whitney tests, and chi-square analyses as appropriate. Results: One hundred eighty-six patients received adjuvant HDR. Fifty eight were excluded from analyses (46 based on non-endometrioid histology; 12 lost to follow-up). Among the sample of 128 subjects, 56 were treated with HDR only vs. 72 with HDR and WPXRT (43.8% vs. 56.2%, respectively). Subjects were similar in age, body mass index, and the existence of medical co morbidities. Of the 72 patients receiving HDR and WPXRT, 28 (38.9) were staged IA-IC, 28 (38.9) were staged as IIA-IIB, 11 (15.4%) were staged as IIIA-IIIC, 1 was staged as IVA-IVB (1.4%) and 4 (5.5%) was unstaged at diagnosis. Complications were similar between the groups. A total of 5 subjects experienced a recurrence, 1 who received HDR only vs. 4 who received HDR and WPXRT (1.8% vs. 5.6%, respectively, p=0.27). The subject treated with HDR was diagnosed with a grade 1 endometrioid carcinoma and had recurrence in the lung. Of the 4 subjects treated with HDR and WPXRT, 3 had recurrence in the vaginal cuff and 1 had recurrence in the peri-aortic lymph nodes. Conclusions: Recurrence was low among all subjects and did not differ among those who received HDR therapy only compared to HDR therapy with whole pelvic radiation. Investigators plan to conduct additional studies with a larger sample size to determine whether a difference in recurrence exists while adjusting for disease stage and total treatment dosage. If such confirmatory evidence is found, HDR brachytherapy alone may be a viable alternative to the additional radiation exposure of WPXRT in treating patients with endometrioid carcinoma of the endometrium.

Clinical Investigations Dosimetry and toxicity outcomes in postoperative high-dose-rate intracavitary brachytherapy for endometrial carcinoma

PurposeThe optimal dosimetric parameters and planning techniques for high-dose-rate vaginal brachytherapy (HDR-VB) are unclear. Our aim was to evaluate the utility of bladder and rectal dosimetry for patients receiving HDR-VB for postoperative treatment of endometrial carcinoma.Material and methodsPatients with endometrial cancer who underwent postoperative HDR-VB from January 1, 2004 through December 31, 2010 were included. All patients underwent primary surgery consisting of total hysterectomy and bilateral salpingo-oophrectomy (TH-BSO) with or without lymph node dissection and were treated with HDR-VB without pelvic external beam radiotherapy (EBRT) or chemotherapy. Demographic, pathologic, dosimetric and clinical data were collected.ResultsOne hundred patients were identified with the majority of patients receiving HDR-VB in 700 cGy × 3 fractions (45%) or 550 cGy x 4 fractions (53%). No plan was altered based on bladder dosimetry at the time of planning. The rate of acute urinary reactions (< 90 days from beginning of RT) grades 1 and 2 were 14% and 2%, respectively. The rate of late urinary reactions (> 90 days after RT) grades 1 and 2 were 7% and 3%, respectively. Dose to the bladder point did not correlate with urinary toxicity. No rectal toxicity was reported by patients receiving HDR-VB.ConclusionsIn the setting of HDR-VB without EBRT, the measured dose to the bladder point does not predict urinary toxicity and is very unlikely to indicate the need to change the treatment plan. The treatment of endometrial carcinoma utilizing HDR-VB alone is associated with very low rates of high-grade acute or late bladder toxicity.

Measuring The Interfraction Variation In Dose To The Rectum And The Bladder Using CT-based Treatment Planning For Postoperative High Dose Rate Vaginal Brachytherapy In Women With Endometrial Cancer

To determine the interfraction changes in dose to the rectum and the bladder in patients receiving high dose rate vaginal brachytherapy (HDR-VB) using CT-based dosimetry for post-operative endometrial cancer patients.

Recommendations to Perform Bladder Dosimetry for Patients With Endometrial Carcinoma Receiving Adjuvant Intracavitary High-Dose-Rate Brachytherapy

Purpose: To evaluate the need for bladder dosimetry prior to initiating postoperative high-dose-rate (HDR) intracavitary brachytherapy to the vaginal cuff. Materials and Methods: All patients treated at a single institution for FIGO Stage IA-IIIC grade 1–3 endometrial adenocarcinoma between 2004 to 2010 were reviewed. Patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy with or without lymph node dissection followed by HDR intracavitary brachytherapy using a vaginal cylinder without external beam radiation. Radiotherapy dose was either 7 Gy x 3 fractions or 5.5 Gy x 4 fractions. Reference isodose was 0.5 cm from the cylinder surface. Orthogonal radiographs were acquired and used for 2D planning. A foley catheter was placed in the bladder and filled with 5 cc of radioopaque contrast for visualization. A bladder reference point was identified according to ICRU recommendations. Equivalent doses for acute and late effects of the bladder were calculated and expressed as if given as fractionated irradiation at 1.8 Gy/fraction with alpha/beta ratios for acute and late effects as 10 and 3, respectively. Urinary symptoms were assessed prior to each HDR procedure and at all subsequent followup visits. The severity of urinary symptoms was coded using the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 chart. Patients were followed every 3 months for 2–3 years and every 6 months thereafter. Results: Eighty-eight patients were treated during the specified time period, 89% of whom received formal bladder dosimetry. The bladder point dose per HDR fraction was 487.11 cGy (ranging from 203.65 to 899.81 cGy). Mean treatment equivalent doses for acute and late effects of the bladder were 21.98 (2.93 to 47.59) and 29.10 (2.53 to 71.76) Gy. The rate of acute urinary reactions (<90 days from beginning of HDR therapy) Grade 1 and 2 were 13.6% and 2.2%. The rate of late urinary reactions (>90 days after HDR therapy) Grade 1 and 2 were 5.6% and 3.4%. No Grade 3 or higher urinary toxicities were observed. No treatment plans were altered on the basis of bladder dose. Recurrences were seen in 5 patients (5.6%), none of which were at the vaginal cuff. Conclusions: In this series, bladder toxicity after vaginal cuff radiotherapy was minimal, and no treatment plan was altered based on bladder dose. The use of routine foley catheter placement prior to postoperative HDR vaginal brachytherapy seems unwarranted. The acquisition of rectal dosimetry alone prior to adjuvant vaginal cuff HDR brachytherapy may be sufficient.

Curiethérapie postopératoire du fond vaginal de haut débit de dose dans le cancer endométrial

Purpose This study aimed at analyzing the evolution and type of recurrence in patients treated for stage I endometrial carcinomas, in order to define the respective roles of adjuvant radiotherapy and brachytherapy. Patients and methods This monocentric retrospective study was conducted at Centre Alexis-Vautrin, Nancy, France, between January 1995 and December 2000 on all the patients surgically treated for an endometrial cancer, and then treated with high dose rate vaginal brachytherapy. The brachytherapy was delivered in two or three fractions of 7 Gy at 5 mm from the applicator. Results In the good prognosis group, the specific and overall survivals at 5 years were respectively 96.5 and 94.2% with no local recurrence demonstrated. In the intermediate prognostic group, the specific and overall survivals at 5 years were respectively 88 and 85%, with six locoregional recurrences observed among those who did not undergo lymphadenectomy; the overall survival at 5 years was significantly decreased in the absence of external radiation. In the group of poor prognosis (stages II and III), the specific survival at 5 years was respectively 72.8 and 67 %, and the overall survival at 5 years 66.7 and 56.4%. Conclusion Results for local control and survival as well as for tolerance were good. So we have decided to deliver high rate brachytherapy for all intermediate or poor prognosis patients and we have abandoned pelvic radiotherapy for good prognosis tumours (stages IA: no myometrium invasion with grade 3 and >50% of myometrium invasion with grades 1 and 2), whatever the lymph nodes surgery they had. We now propose pelvic radiotherapy only for intermediate prognosis tumours (such as IA > 50% of myometrium invasion with grade 3 and IB stages), if patients did not have any lymphatic surgery, or for bad prognosis tumours.

A cost-effective analysis of adjuvant therapies for the treatment of stage I endometrial adenocarcinoma

Objectives. Recent surveys have indicated that four alternatives are employed for adjuvant treatment of stage I endometrial adenocarcinoma: observation (OBS), high dose rate vaginal brachytherapy (VB), whole pelvic external beam radiotherapy (EBRT), or a combination of pelvic external beam with vaginal brachytherapy (COMB). Our goal was to evaluate the cost-effectiveness of these alternatives for management of stage I endometrial adenocarcinoma. Methods. We designed a decision analysis model comparing the four possible treatments in terms of their utility and cost. We reviewed the existing literature and utilized published data to estimate complication and recurrence rates from each treatment option. We obtained cost data from a chart review of patients treated with each approach at a single institution between 1995 and 2005. Results. OBS yielded the lowest expected cost, $437 million per 100,000 women. COMB yielded the highest cost, at $2.93 billion per 100,000 women. VB yielded the highest 5-year quality adjusted survival, 86%. In a population of 100,000 women, VB would result in an additional 8200 quality adjusted survivors compared to OBS, at a cost of $65,900 per survivor. In contrast, EBRT and COMB result in either fewer survivors and/or greater costs when compared to OBS or VB. Conclusion. Routine use of adjuvant EBRT or COMB in the management of surgical stage I endometrial adenocarcinoma is not cost-effective. Compared to OBS, post-operative VB improves survival at a cost of $65,900 per survivor, supporting further investigation of this adjuvant therapy.

Effects of prescription depth, cylinder size, treatment length, tip space, and curved end on doses in high-dose-rate vaginal brachytherapy

To determine the effects of the prescription depth, cylinder size, treatment length, tip space, and curved end on high-dose-rate vaginal brachytherapy (HDR-VBT) of endometrial cancer. Treatment plans were prescribed and optimized based on points at the cylinder surface or at 0.5-cm depth. Cylinder sizes ranging from 2 to 4 cm in diameter, and treatment lengths ranging from 3 to 8 cm were used. Dose points in various depths were precisely defined along the cylinder dome. The given dose and dose uniformity to a depth of interest were measured by the mean dose (MD) and standard deviation (SD), respectively, among the dose points belonging to the depth. Dose fall-off beyond the 0.5 cm treatment depth was determined by the ratio of MD at 0.75-cm depth to MD at 0.5-cm depth. Dose distribution varies significantly with different prescriptions. The surface prescription provides more uniform doses at all depths in the target volume, whereas the 0.5-cm depth prescription creates larger dose variations at the cylinder surface. Dosimetric uncertainty increases significantly (>30%) with shorter tip space. Extreme hot (>150%) and cold spots (<60%) occur if no optimization points were placed at the curved end. Instead of prescribing to a depth of 0.5 cm, increasing the dose per fraction and prescribing to the surface with the exact surface points around the cylinder dome appears to be the optimal approach.

American Brachytherapy Society survey regarding practice patterns of postoperative irradiation for endometrial cancer: Current status of vaginal brachytherapy

To survey the current postoperative recommendations for radiotherapy (RT) in patients with endometrial cancer, with an emphasis on vaginal brachytherapy (VBT). In August 2003, a 32-item questionnaire was mailed to a random sample of 2396 members of the American Society for Therapeutic Radiology and Oncology and the American Brachytherapy Society. The sample excluded members-in-training, physicists, and non-U.S. members. A follow-up mailing was conducted in November 2003. Those who had not treated any patient in the previous year for endometrial carcinoma were instructed to indicate so at the beginning of the questionnaire and return it without responding to any other item. Responses were tabulated to determine the relative frequency distribution. of the 2396 surveys sent out, 757 were returned, for a response rate of 31.6%. Of those who responded, 551 (72.8%) had performed postoperative irradiation for endometrial cancer and were included in this study. Of the 551 respondents, 99.8% had delivered external beam RT to some endometrial cancer patients. An increasing trend was found toward referrals for VBT; 91.5% of those who treated endometrial cancer performed VBT. The vaginal target most often irradiated was the upper vagina in 40.7%, upper 4-5 cm in 54.5%, and the entire vagina in 4.9%; 21.3% placed clips at the vaginal apex for applicator verification. The maximal dose to the bladder and rectum was recorded in 78.3% and 80.2% of patients, respectively. Of the respondents, 40% did not use low-dose-rate (LDR) VBT. The two most common LDR applicators were Delclos cylinders (29.7%) and Fletcher colpostats (29.3%). The mean boost dose delivered with LDR VBT when prescribed to the surface was 29.9 Gy and when prescribed to 0.5 cm was 23.8 Gy. When LDR therapy was used without external beam RT, the mean dose when prescribed to the surface was 56.8 Gy and when prescribed to 0.5 cm was 47.9 Gy. In 2002, 69.1% of respondents treated patients with high-dose-rate (HDR) VBT. Of the respondents, 90.6% used a single-channel vaginal cylinder, and 83.3% of cylinder users followed the curve of the cylinder to optimize dose, 67.9% adjusted the applicator position based on localization films, and 47% adjusted the applicator to be horizontal. The most common fractionation scheme when using HDR VBT as a boost was 5 Gy in three fractions prescribed to 0.5 cm (42.9%). The most common fractionation scheme used with HDR without external beam RT was 7 Gy in three fractions prescribed to 0.5 cm (41.8%). VBT is a common recommendation for postoperative adjuvant therapy for endometrial cancer. HDR appears to be the most popular approach, with a wide variety of dose fractionation schemes reported. Additional study is warranted to help define the ideal use of VBT.

Vaginal brachytherapy alone: An alternative to whole pelvis radiation for early stage endometrial cancer

Vaginal brachytherapy alone: An alternative to whole pelvis radiation for early stage endometrial cancer

26 oral High dose rate vaginal brachytherapy in the management of stage I-II endometrial cancer after complete surgical staging

26 oral High dose rate vaginal brachytherapy in the management of stage I-II endometrial cancer after complete surgical staging