Intracavitary Irradiation Research Articles

Comparison between weekly two times and three times high dose rate (HDR) intracavitary radiotherapy (ICR) for uterine cervical cancer treated with radiotherapy alone

Comparison between weekly two times and three times high dose rate (HDR) intracavitary radiotherapy (ICR) for uterine cervical cancer treated with radiotherapy alone

Vaginal lymphatic duct location and implication on intracavitary brachytherapy radiation treatment

Vaginal lymphatic duct location and implication on intracavitary brachytherapy radiation treatment

Vaginal lymphatic duct location and implication on intracavitary brachytherapy radiation treatment

Vaginal lymphatic duct location and implication on intracavitary brachytherapy radiation treatment

External-beam boost is an equivalently effective alternative to intracavitary radiotherapy in cervical cancer patients with involved vaginal resection margin after radical hysterectomy

External-beam boost is an equivalently effective alternative to intracavitary radiotherapy in cervical cancer patients with involved vaginal resection margin after radical hysterectomy

Analysis of the survival rate with cervical cancer using137Cs and192Ir afterloading brachytherapy

OBJECTIVE TO analyze and compare the surwval rate for stages II and III cervical cancer treated by external irradiation plus ~TCs or l~lr. METHODS The patients with cervical cancer were treated by external ~rradiat~on plus ~3:Cs (group A, 427 patients) or plus ~921r (group B, 156 patients). There were 170 stage II cases and 413 stage III cases. The number of cancer types were as follows: squamous cell carcinoma, 524; adenocarc~noma, 34; and adenosquamous cell carcinoma, 25. The two groups received the same external irradiation using 8 or 10 MV of X-ray. After the whole pelvis received 25-35 Gy, the focus was given a total of 45-55 Gy by four divided fields. Intracavitary irradiation was performed with one fraction of 6-7 Gy in reference dose at A point every week and a total dose of 40-60 Gy with 6-8 fractions for group A; every fraction of 5-6 Gy in reference dose of A point and total dose of 30-42 Gy with 5-7 fractions for group B. RESULTS The 5-year survwal rate of stage II and III, and total were 82.9%, 62.2%, and 67.2% for group A respectively and 85.1%, 61.5% and 69.2% for group B respectively. There were significant differences between stage II and Ill in each group (P 0.05). The late complications of the therapy were rectitis and urocystitis and with an incidence rate of 7.3% and 6.3% for group A and 9.6% and 9.0% for group B ( P > 0.05). CONCLUSION The long-term survival rate and complications of stages II andIll cerwcal cancer are similar when treated with external irradiation plus '3:Cs or plus le2ir.

Management of cystic craniopharyngiomas with phosphorus-32 intracavitary irradiation.

The efficacy of stereotactic intracavitary irradiation with phosphorus-32 ((32)P) for patients with cystic craniopharyngiomas was assessed on the basis of patient survival, tumor control, and visual and endocrinological function before and after treatment. Limited data are available regarding long-term outcomes. Forty-nine patients were treated with stereotactic (32)P intracavitary irradiation. Of these, 25 had had no prior treatment as the primary treatment, and 24 were treated for residual or recurrent tumor cysts. At the time of (32)P intracavitary irradiation, 34 of the patients were adults, and 15 were children younger than 16 years of age. The mean cyst volume was 13 ml. The radiation dose varied from 189 to 250 Gy to the cyst wall during five half-lives of the isotope (mean, 224 Gy). The mean follow-up periods were 7 years after diagnosis and 4 years after (32)P treatment. The actuarial survival rates were 90% at 5 years after the diagnosis and 80% at 10 years. The actuarial tumor cyst control rates were 76% at 5 years and 70% at 10 years after the diagnosis. After treatment, 9 (23%) of 40 patients who underwent preoperative and postoperative visual testing were found to have delayed worsening in visual function, 6 as a result of tumor progression and 3 attributed to irradiation. Nineteen patients (48%) had improved visual function. Of 17 patients who had normal preoperative pituitary function or stalk effect, 12 (71%) had preserved and 5 (29%) had worsened visual function. No complications other than visual or endocrinological deterioration occurred in these patients. For patients with cystic craniopharyngiomas, (32)P intracavitary irradiation proved effective, with a low risk of complications, for the control of tumor cysts but not of solid tumor components.

Postoperative radiotherapy for uterine cervical cancer: results of the 1995-1997 patterns of care process survey in Japan.

To determine the average national practice of postoperative radiotherapy for uterine cervical cancer in Japan. The Japanese Patterns of Care Study (PCS) reviewed the process of care employed for 455 uterine cervical cancer patients who were treated with surgery followed by postoperative radiotherapy (RT) during 1995-1997. Cases with missing data were excluded from calculations of percentage and significance for each of the surveyed items. According to FIGO stages, 198 patients (45%) were in stage I, 52 patients (12%) were in stage IIA, 146 patients (33%) were in stage IIB and 46 patients (10%) were in stage III/IVA. The most common surgical procedure among the patients was radical hysterectomy (73%). Three hundred and seventy patients (82%) were treated with external beam RT (ERT) alone, and 74 patients (17%) were treated with a combination of ERT and intracavitary RT (ICRT). A midline block was used for the pelvic field in 63 patients (14%). Only seven patients (2%) were treated with extended field ERT. Pelvic ERT was most often performed using AP-PA opposed fields for 431 patients (97%). A majority of the patients (312 patients, 70%) were treated with a total dose of 45.0-50.4 Gy for ERT. Chemotherapy (CT) was administered to 178 patients (40%), neoadjuvant preoperative CT was administered to 80 patients (22%) and concurrent CT with postoperative RT was administered to 29 patients (8%). This PCS established the national practice average of postoperative RT for uterine cervical cancer. Follow-up studies need to be conducted to determine whether the observed differences in treatment processes affect outcomes.

Increased Incidence of Symptomatic Venous Thrombosis in Patients With Cervical Carcinoma Treated With Concurrent Chemotherapy, Radiation, and Erythropoietin

Obstetrical & Gynecological Survey: January 2004 - Volume 59 - Issue 1 - p 34-35 doi: 10.1097/01.OGX.0000103403.79267.07

Prognostic significance of c-erbB-2/HER2 expression in advanced uterine cervical carcinoma with para-aortic lymph node metastasis treated with radiation therapy

This paper looks at whether c-erbB-2/HER2 expression in uterine cervical carcinoma before treatment is a predictive parameter of prognosis in patients with para-aortic lymph node metastasis (PALN) in advanced disease after treatment with radiation therapy (RT). Twenty-one patients with PALN at the first visit and/or during follow-up and treated with RT for PALN lesions were studied. Their clinical stages were IIIB or greater and they were referred to the National Institute of Radiological Sciences Hospital for RT between 1987 and 1995. They consisted of 12 patients with PALN detected at the first visit and nine with PALN detected during the follow-up period. All patients had no distant metastasis except PALN. They were treated with a combination of external whole pelvis and intracavitary irradiation to the primary pelvic lesions. The PALN was treated with external irradiation alone with anterior-posterior parallel opposed fields and anterior oblique fields or anterior-posterior parallel opposed oblique fields. The average total dose to PALN was 53.3 Gy (40–61Gy). Tissue samples were obtained from cervical tumors (primary lesions) before RT. Immunohistochemical staining was performed using anti-c-erbB-2/HER2 monoclonal antibody for conventional paraffin sections. c-erbB-2/HER2 positive staining was observed in cancer membrane and cytoplasm. Nine specimens were positive for c-erb-B2/HER2 and the total positive rate was 43%. The 5-year survival rate was 38% for all patients. The 5-year survival rate of the c-erbB-2/HER2 positive patients was 28%, representing a trend toward poorer prognosis than the 52% of negative patients (P=0.10). Multivariate analysis using Cox proportional hazards model showed that c-erbB-2/HER2 was an independent prognostic factor (P= 0.024). The present study suggests that c-erbB-2/HER2 expression of cervical tumors might be a predictive parameter of prognosis after radiation therapy for PALN of very advanced uterine cervical carcinoma patients.

Custom step wedge blocking using dynamic multileaf collimation for parametrial pelvic boost irradiation following brachytherapy for carcinoma of the cervix.

Carcinoma of the cervix is typically treated with a combination of intracavitary brachytherapy and external beam radiation. The external beam dose is delivered with whole pelvis fields followed by split fields that protect midline organs at risk (bladder and rectum) while treating the parametria. Three approaches have been developed to shield midline structures: a simple rectangular block, a block customized to a single brachytherapy isodose line, and a step wedge filter constructed to conform to multiple brachytherapy isodose lines. A customized step wedge filter has the potential to produce a more homogeneous dose distribution but has not achieved widespread use due to labor intensive construction. We have developed a simple, novel method to produce a custom midline step wedge using dynamic multileaf collimation (dMLC). A comparison of film measurements in a phantom with the dose calculated by a commercial treatment planning system demonstrated agreement within 3% or 3 mm. The technique requires delivery times comparable to conventional techniques.

High-dose rate versus low-dose rate intracavitary radiotherapy in the treatment of cervical carcinoma: a meta-analysis

Purpose/Objective: Controversy still persists regarding the clinical efficacy of high dose rate (HDR) intracavitary radiotherapy (ICR), which was introduced in early 1960s, compared with conventional low dose rate (LDR) ICR in the treatment of cervical carcinoma. We performed meta-analysis to determine the effectiveness of HDR ICR compared to LDR ICR for overall survival, disease free survival, local recurrence, and complication rate of rectum and bladder in the treatment of cervical carcinoma.

498 High-dose rate versus low-dose rate intracavitary radiotherapy in the treatment of cervical carcinoma: a meta-analysis

Spinal cord arteriovenous malformations (AVM) are rare lesions associated with recurrent hemorrhage and progressive ischemia. Occasionally a favorable location, size or vascular anatomy may allow management with endovascular embolization and/or microsurgical resection. For most, however, there is no good treatment option. Between 1997 and 2014, we treated 37 patients (19 females, 18 males, median age 30 years) at our institution diagnosed with intramedullary spinal cord AVM (19 cervical, 12 thoracic, and six conus medullaris) with CyberKnife (Accuray, Sunnyvale, CA, USA) stereotactic radiosurgery. A history of hemorrhage was present in 50% of patients. The mean AVM volume of 2.3 cc was treated with a mean marginal dose of 20.5 Gy in a median of two sessions. Clinical and MRI follow-up were carried out annually, and spinal angiography was repeated at 3 years. We report an overall obliteration rate of 19% without any post-treatment hemorrhagic events. In those AVM that did not undergo obliteration, significant volume reduction was noted at 3 years. Although the treatment paradigm for spinal cord AVM continues to evolve, radiosurgical treatment is capable of safely obliterating or significantly shrinking most intramedullary spinal cord AVM.

The trail of the development of high-dose-rate brachytherapy for cervical cancer in Japan.

The differences in radiotherapeutic treatment systems for cervical cancer between the United States and Japan can be attributed either to the tolerance of high-risk organs, or dosimetry itself. High-dose-rate (HDR) brachytherapy is the standard treatment for uterine cervix carcinoma in Japan. In addition, HDR Co-60 afterloading machines have been gradually replaced with Ir-192 micro-source afterloading machines during the past ten years. This implies that it has now become impossible to conduct a prospective comparative study of HDR versus low-dose-rate (LDR) brachytherapy for cervical cancer in Japan. An examination of the history of HDR intracavitary radiotherapy for uterine cervix carcinoma in Japan led us to the conclusion that HDR intracavitary brachytherapy for the treatment of cervical cancer is as effective as LDR intracavitary brachytherapy in terms of both survival and complications. In Japan, studies on the former can be drawn from a long experience of more than 35 years.

Measurement of serum squamous cell carcinoma antigen levels as a predictor of radiation response in patients with carcinoma of the uterine cervix.

Optimal timing of the measurement of serum squamous cell carcinoma (SCC) antigen during radiation therapy (RT) and its significance for predicting the response of cervical carcinoma patients as early as possible remain unknown. Sixty-three patients with SCC of the uterine cervix who received RT only were studied. Patients were treated with a combination of external beam irradiation and high-dose rate intracavitary irradiation. The serum SCC antigen level was measured before, every 2 or 3 weeks during, and 1 or 2 months after RT. Clinical outcome was divided into complete response and incomplete response. Forty-seven patients (74.6%) had serum SCC antigen levels 1.5 ng/mL (the reference value) before RT. Normalization of serum SCC antigen levels at the end of RT were found to be significantly correlated with complete response in the SCC-positive patients. It was especially noted that in patients with serum SCC levels between 5-30 ng/mL before RT, a > 70% decrease in the serum SCC antigen level at 4 weeks was correlated significantly with complete response. In this group, a significant correlation also was found between a > 70% decrease in serum SCC level at 4 weeks and the normalization of SCC at the end of RT. The current study data suggest that the serum SCC antigen level not only before, but also during and at the end of RT can predict the response of patients with cervical carcinoma and help in identifying those patients who are at high risk of local recurrence and/or distant metastasis.

Author's Reply

The exact role of transition zone (TZ) biopsy in predicting the extent of local pathological stage is yet to be determined. In the present study, two cores of TZ biopsies were added to the systematic sextant biopsy technique and the results were compared with the histopathological data from the radical retropubic prostatectomy (RRP) specimens. The analysis of clinical and biopsy (peripheral zone [PZ] and TZ) features revealed that although TZ biopsy provided some valuable information (e.g. very good agreement between the positive TZ biopsy side and extraprostatic extension [EPE] side) it was not superior to the percentage of positive PZ cores for the prediction of EPE. This result does not necessarily mean that TZ biopsy is useless for the prediction of EPE. An increased number of cores from the TZ can certainly provide better information. However, there is no agreement on the optimum number of TZ cores that should be taken for this purpose. Kojima et al. took four TZ cores and compared their results with RRP specimens in only 14 of their patients.1 Chang et al. performed systematic sextant biopsy of the TZ. However, this study did not provide information on prostatectomy results.2 Liu et al. took four to 10 TZ cores, depending on the size of the prostate.3 They also did not provide information on pathological stage. It should also be noted that patient tolerance considerably drops when the number of TZ biopsies is increased. Both Kojima et al. and Chang et al. used some form of regional anesthesia to perform prostate biopsies.1,2 Thus, we suggest that the relationship between TZ involvement and prediction of EPE should be further investigated in prostatectomy specimens. In addition, increased number of TZ cores should be taken using regional anesthesia. The technique used by Kojima et al., which utilized intracavitary radiotherapy templates for transperineal prostate biopsy,1 is an interesting approach, but whether it is superior to the standard transrectal technique should be well documented before such an invasive approach can be recommended for routine use.

Radiation therapy with and without extrafascial hysterectomy for bulky stage IB cervical carcinoma: a randomized trial of the Gynecologic Oncology Group☆

Objective To evaluate, in a randomized clinical trial, the role of adjuvant hysterectomy after standardized radiation in improving progression-free survival and survival for patients with “bulky” stage IB cervical cancer. Methods A total of 256 eligible patients with exophytic or “barrel” shaped tumors measuring ≥4 cm were randomized to either external and intracavitary irradiation (RT, N = 124) or attenuated irradiation followed by extrafascial hysterectomy (RT + HYST, N = 132). Twenty-five percent of patients had tumors with a maximum diameter of ≥7 cm. Results Tumor size was the most pronounced prognostic factor followed by performance status 2 and age at diagnosis. Hysterectomy did not increase the frequency of reported grade 3 and 4 adverse effects (both groups, 10%). The majority of these adverse effects were from the gastrointestinal or genitourinary tracts exclusively. There was a lower cumulative incidence of local relapse in the RT + HYST group (at 5 years, 27% vs. 14%). There were no statistical differences in outcomes between regimens except for the adjusted comparison of progression-free survival, although all indicated a lower risk in the adjuvant hysterectomy regimen (unadjusted relative risk [URR] of progression, 0.77, P = 0.07; URR of death, P = 0.26, both one tail). Conclusion Overall, there was no clinically important benefit with the use of extrafascial hysterectomy. However, there is good evidence to suggest that patients with 4-, 5-, and 6-cm tumors may have benefitted from extrafascial hysterectomy (URR of progression; 0.58; URR of death, 0.60).

The role of stereotactic radiosurgery for low-grade astrocytomas

This study was conducted to examine the role of radiosurgery in the management of patients with recurrent or unresectable low-grade astrocytomas. During a 13-year interval, 49 patients underwent stereotactic radiosurgery as part of multimodal treatment of their recurrent or unresectable low-grade astrocytomas. Thirty-seven of these patients (median age 14 years) harbored pilocytic astrocytomas and 12 patients harbored World Health Organization (WHO) Grade II fibrillary astrocytomas (median age 25 years). Tumors involved the brainstem in 22 cases, cerebellum in four, thalamus in six, temporal lobe in five, frontal lobe in four, and parietal lobe in three, as well as the hypothalamus, corpus callosum, insular cortex, optic tract, and third ventricle in one patient each. Each diagnosis was confirmed with the aid of stereotactic biopsy sampling in 17 patients, open biopsy sampling in five, partial resection in 13, and near-total resection in 14. Multimodal treatment included fractionated radiotherapy in 14 patients, stereotactic intracavitary irradiation in five, chemotherapy in two, cyst drainage in eight, ventriculoperitoneal shunt placement in five, and additional cytoreductive surgery in five. Tumor volumes ranged from 0.42 to 45.1 cm3. The median radiosurgical dose to the tumor margin was 15 Gy (range 9.6-22.5 Gy). After radiosurgery, serial neuroimaging demonstrated complete tumor resolution in 11 patients, reduced tumor volume in 12, stable tumor volume in 10, and delayed tumor progression in 16. No procedure-related death was encountered. Forty-five of 49 patients are alive at a median follow-up period of 32 months after radiosurgery and 63 months after diagnosis. Sixteen patients participated in follow-up review for more than 60 months. Three patients died of local tumor progression. Stereotactic radiosurgery is a potential alternative or adjunctive intervention in the management of selected patients with pilocytic or WHO Grade II fibrillary astrocytomas, usually performed for small-volume tumors in an attempt to avoid larger-field fractionated radiotherapy.

Stereotactic Management of Craniopharyngiomas

Eleven patients with craniopharyngiomas underwent 13 stereotactic procedures (intracavitary irradiation, n = 7; radiosurgery, n = 6). Nine patients (82%) had recurrent tumors after prior surgery (median, 2 operations). The median patient age was 50 years (range, 6–63 years). At a median follow-up of 38 months (range, 24–102 months), no patient had progression of the treated tumor component. Two patients developed new cysts, so the actuarial 2- and 4-year progression-free survival rates were 91 and 73%, respectively. Visual function improved in 3 patients, remained stable in 6 patients, and worsened in 1 patient. Two patients (both without prior surgery) not having diabetes insipidus pre-operatively continued to have normal posterior pituitary function. Stereotactic techniques should be considered for patients with craniopharyngiomas, especially those who have failed prior surgical resection.

Stereotactic Radiosurgery for Well-Circumscribed Fibrillary Grade II Astrocytomas: An Initial Experience

Objective: To examine the role of stereotactic radiosurgery in the management of patients with progressive, well-circumscribed grade II fibrillary astrocytomas. Methods: During a 13-year interval, 12 patients (median age: 25 years) required multimodality management for recurrent or unresectable World Health Organization (WHO) grade II fibrillary astrocytomas. Tumors involved the brainstem (n = 4), thalamus (n = 1), cerebellum (n = 1), frontal lobe (n = 4), temporal lobe (n = 1), and parietal lobe (n = 1). Diagnosis was confirmed by stereotactic biopsy (n = 5), partial resection (n = 5), and near total resection (n = 2). Multimodality management of patients prior to radiosurgery included fractionated radiation therapy (n = 4), stereotactic cyst drainage (n = 1), and ventriculoperitoneal shunt placement (n = 2). Tumor volumes varied from 1.2 to 45.1 cm³. The median radiosurgical dose to the tumor margin was 16 Gy. Results: After radiosurgery, serial imaging showed complete tumor resolution in 1 patient, reduced tumor volume in 4, stable tumor volume in 3, and delayed tumor progression in 4 (3 patients with increase in cyst size only). Therapy after radiosurgery included additional cytoreductive surgery (n = 1) for recurrence of a higher grade tumor, stereotactic cyst aspiration (n = 1), and stereotactic intracavitary irradiation (n = 1). All patients were alive at a median follow-up of 52 months after radiosurgery and 103 months after diagnosis. In 8 patients, follow-up lasted more than 60 months. Conclusion: Stereotactic radiosurgery is a potential alternative or adjunctive strategy in the management of selected patients with WHO grade II fibrillary astrocytomas.

Long-term results of proton beam therapy for carcinoma of the uterine cervix

Purpose To determine the role of proton therapy in patients with carcinoma of the uterine cervix. Methods and materials Between 1983 and 1991, 25 patients with squamous cell carcinoma of the uterine cervix (stages IIB–IVA) were treated with a curative intent by external photon irradiation to the pelvis, followed by proton irradiation to the primary tumor, delivering a median total tumor dose of 86 Gy (range 71 Gy/26 Fr–101 Gy/46 Fr), and were followed for a median period of 139 months (range 11–184 months). Results Ten-year overall survival rates for stages IIB and IIIB/IVA patients were 89% and 40%, respectively. Five-year local control rates for stages IIB and IIIB/IVA patients were 100% and 61%, respectively. Four percent of patients experienced severe (Grade 4 or more) late complications in the intestine or urinary bladder at 5 years. Conclusions External photon and proton therapy is effective for those who are not eligible for intracavitary irradiation, and who otherwise have a poor prognosis. The results show that tumor control, survival, and morbidity are similar to those after conventional therapy.