Pelvic Fields Research Articles

Key issues in diagnostic accuracy of sentinel lymph node biopsy in early-stage ovarian cancer: systematic review and meta-analysis

ObjectiveSentinel lymph node (SLN) mapping may reduce the morbidity of lymphadenectomy while maintaining diagnostic accuracy. Nevertheless, SLN mapping in epithelial ovarian cancer is still under investigation. This systematic review and...

Assessing the Adequacy of Traditional Vertebral Landmarks as Upper Border of Whole Pelvic Radiotherapy Field for Stage IB2-IIB Cervical Cancer.

This study investigates the impact of insufficient common iliac lymph node (CIN) irradiation on treatment outcomes in patients with stage IB2-IIB cervical cancer receiving concurrent chemoradiotherapy (CCRT). We retrospectively analyzed 68 patients with Federation of Gynecology and Obstetrics stage IB2-IIB, treated with weekly cisplatin-based CCRT from 2008 to 2018. Patients received external-beam whole pelvic radiotherapy (WPRT) and concurrent cisplatin chemotherapy, followed by high-dose-rate brachytherapy. The WPRT upper border was at L4-5 in 61 patients and L3-4 in 7 patients. Thirty-seven patients had the CIN area fully included (full-CIN group), while 31 had partial inclusion (partial-CIN group). Recurrence rates and survival outcomes were analyzed over a median follow-up of 111 months. Patient characteristics and the irradiated dose were comparable. Treatment failure occurred in three patients (8.1%) in the full-CIN group and in six patients (19.4%) in the partial-CIN group, with CIN and para-aortic lymph node recurrence in two and one patients, respectively. The 5-year cumulative recurrence rate was 0% for the full-CIN group and 11.4% for the partial-CIN group (p = 0.04). Cause-specific survival was 100% vs. 87.1% (p = 0.025), and the overall survival was 94.3% vs. 87.1% (p = 0.44). Fully including the CIN area in WPRT is crucial for stage IB2-IIB cervical cancer. Vascular anatomical margins should be considered over vertebral landmarks.

Training Postural Balance Control with Pelvic Force Field at the Boundary of Stability.

This study characterizes the effects of a postural training program on balance and muscle control strategies in a virtual reality (VR) environment. The Robotic Upright Stand Trainer (RobUST), which applies perturbative forces on the trunk and assistive forces on the pelvis, was used to deliver perturbation-based balance training (PBT) in a sample of 10 healthy participants. The VR task consisted of catching, aiming, and throwing a ball at a target. All participants received trunk perturbations during the VR task with forces tailored to the participant's maximum tolerance. A subgroup of these participants additionally received assistive forces at the pelvis during training. Postural kinematics were calculated before and after RobUST training, including (i) maximum perturbation force tolerated, (ii) center of pressure (COP) and pelvic excursions, (iii) postural muscle activations (EMG), and (iv) postural control strategies (the ankle and hip strategies). We observed an improvement in the maximum perturbation force and postural stability area in both groups and decreases in muscle activity. The behavior of the two groups differed for perturbations in the posterior direction where the unassisted group moved towards greater use of the hip strategy. In addition, the assisted group changed towards a lower margin of stability and higher pelvic excursion. We show that training with force assistance leads to a reactive balance strategy that permits pelvic excursion but that is efficient at restoring balance from displaced positions while training without assistance leads to reactive balance strategies that restrain pelvic excursion. Patient populations can benefit from a platform that encourages greater use of their range of motion.

Treatment Outcomes of Simultaneous Integrated Boost to Intraprostatic Lesions with External Beam Radiotherapy in Localized Prostate Cancer Patients.

To evaluate the treatment outcomes and toxicity of definitive radiotherapy (RT) for prostate cancer (PC) patients using the simultaneous integrated boost (SIB) technique to intraprostatic lesion (IPL). All the patients received 78 Gy for their prostate ± seminal vesicles and 86 Gy for the IPL using the SIB technique. High-risk patients received pelvic nodal irradiation. The pelvic lymphatic field received 46-54 Gy of radiation. Univariable and multivariable analyses were conducted of the prognostic factors for freedom from biochemical failure (FFBF), progression-free survival (PFS), and PC-specific survival (PCSS) of 619 PC patients who received definitive RT between September 2012 and August 2021. Predictors of late Grade ≥ 2 genitourinary (GU) and gastrointestinal (GI) toxicities were also identified using logistic regression. The median age of the entire cohort was 69 years (range, 47-89 years). Most of the patients (82.7%) had tumors with a GS of 6 or 7, 134 (21.6%) had PC with a GS of 3 + 4, 126 (20.4%) had PC with a GS of 4 + 3, and only 9% had clinical nodal metastasis. The median follow-up time for the entire cohort was 68.5 months (95% CI, 64.4-72.6 months). The 5-year FFBF, PFS, and PCSS rates were 93.2%, 83.2%, and 98.6%, respectively. They were predicted by the serum prostate specific antigen (PSA), Gleason score (GS), clinical nodal stage, and D'Amico risk group. Only 45 patients (7.3%) developed disease recurrence 41.9 months after RT. Of these patients, 12 (1.9% of the total) had BF only, 31 (5.3%) had both BF and distant metastasis, and 2 (0.3%) had distant metastasis only. The 5-year FFBF rates for low-, intermediate-, and high-risk disease were 98.0%, 93.1%, and 88.5%, respectively (p < 0.001). The 5-year PFS and PCSS rates according to risk groups were 91.0%, 82.1%, and 77.4% (p < 0.001), and 99.2%, 96.4%, and 95.9% (p = 0.03), and respectively. GS > 7 and lymph node metastasis negatively predicted FFBF and PCSS in multivariable analysis. Lymph node metastasis was associated with poor PFS, but only marginally (p = 0.06). Ninety (14.6%) and 44 (7.1%) patients had acute Grade ≥ 2 GU and GI toxicities, respectively, and 42 (6.8%) and 27 (4.4%) patients had late Grade ≥ 2 GU and GI toxicities, respectively. Diabetes (OR = 2.61; 95% CI = 1.29-5.26; p = 0.007) and transurethral resection of prostate (OR = 6.75; 95% CI = 3.37-13.54; p = 0.001) independently predicted late Grade ≥ 2 GU toxicity, but no significant predictor of late Grade ≥ 2 GI toxicity was found. Localized PC was effectively and safely treated with definitive RT using the SIB technique to deliver 86 Gy to the IPL in 39 fractions without severe late toxicity. This finding must be validated with long-term results.

Proton Radiation Therapy for Stage IIA/IIB Testicular Seminoma.

Testicular seminoma affects young men and is associated with very favorable prognosis. The evolution in treatment paradigm has focused on minimizing acute and especially late toxicities. Following orchiectomy, while surveillance is favored in Stage I patients, radiotherapy (RT) is a standard treatment option for de novo or relapsed stage IIA or select non-bulky stage IIB disease. Despite low doses, standard RT fields to paraaortic and pelvic lymphatics using x-rays exposes a large volume of uninvolved normal tissue/viscera to excess dose. This young patient population is especially vulnerable to risks of late RT toxicities including secondary malignancy. Proton beam therapy (PBT) has dosimetric advantage over x-ray-based RT due to lack of exit dose, and comparative dosimetric/modeling studies show significant sparing of uninvolved abdominal/pelvic organs. However, there is scant reported clinical data at this time for PBT. We review our early institutional outcomes with PBT for testicular seminoma. Single institution retrospective review from a tertiary care center of patients treated with PBT from 2013-2022 for testicular seminoma. Recurrence free (RFS) and overall survival (OS) were calculated from the completion of PBT. Toxicities were graded (Gr) using CTCAE v5.0. Four patients underwent PBT, median age 39 (range 36-47). All were Stage I at diagnosis (pT1b n = 3; pT2 n = 1) and were treated for recurrent stage II disease (IIA n = 3; IIB n = 1) at a median of 34 months from orchiectomy (range 3 - 74 months). Nodal extent included 2 with multiple paraaortic nodes, 1 with solitary paraaortic node and 1 with solitary pelvic node. PBT was delivered with pencil-beam scanning, treating paraaortic + ipsilateral pelvic fields (20 Gy in 10 fractions), then sequential boost to involved nodes (10 -16 Gy in 5-8 fractions). Typically, PA or posterior oblique fields were used to minimize dose to out-of-field abdominal/pelvic viscera. Treatment was well tolerated with minimal acute toxicities: fatigue Gr 1 (n = 3), nausea Gr 1 (n = 3). No Gr 2 or higher acute toxicities or significant late toxicities were observed. At median follow up of 30 months (range 3 - 54), no recurrences were observed, and RFS and OS were 100%. Two patients are without evidence of disease > 4 years post-treatment. In this case series, PBT for retroperitoneal and pelvic metastases in Stage IIA/IIB testicular seminoma was associated with oncologic efficacy with minimal toxicity. PBT reduces unnecessary dose to abdominal/pelvic organs compared to x-ray techniques, which is advantageous in young patients who have anticipated long-term survival. This is one of the few series reporting clinical outcomes of PBT in the management of seminoma. Randomized comparisons with x-ray approaches are impractical given the relatively low volume of patients receiving RT in modern seminoma management, so it is essential to report and track longitudinal outcomes across institutions to validate this approach.

Concurrent intensity-modulated radiation therapy and chemotherapy plus nimotuzumab for locally advanced cervical squamous cell cancer: A long-term follow-up result

The study aimed to evaluate the safety and efficacy of concurrent intensity-modulated radiation therapy (IMRT) and chemotherapy plus nimotuzumab for the treatment of locally advanced cervical squamous cell cancer (LACSCC). From December 2013 to March 2017, 34 patients with stages IB2&amp;ndash;IVA (FIGO 2009) cervical squamous cell cancer were enrolled and received concurrent chemoradiotherapy plus nimotuzumab. The prescription radiation dose was 50.4 Gy/28 F on the pelvic field with or without extended-field radiation. An additional 30&amp;ndash;36 Gy to Point A was delivered with high-dose-rate brachytherapy. Cisplatin 40 mg/m2 and nimotuzumab 200 mg were infused intravenously weekly. The main and secondary outcome measures were toxicity evaluated using common terminology criteria for adverse events 4.03. and the outcome evaluated using response evaluation criteria in solid tumors 1.1, respectively. The median follow-up duration was 66 months (13 &amp;ndash; 98 months). All patients received 6 times of IMRT, brachytherapy, and nimotuzumab. Among them, 24 received six cycles of chemotherapy, while 11 received 4&amp;ndash;5 cycles. No life-threatening toxicity was found. The incidence of acute Grade 3 bone marrow depression was 52.9% (18/34), and Grade 3 gastrointestinal tract reaction was 8.8% (3/34). The incidence of late toxicities was 58.8% (20/34), including vaginal-rectal fistula, intestinal obstruction, rectal hemorrhage, hematuria, vaginal stenosis, and paresthesia. About 90% of those were Grades 1&amp;ndash;2. Complete response was achieved in 33 cases (97.1%). The 3-year disease-free survival, local progression-free survival (LPFS), and overall survival rates were 79.4%, 91.2%, and 82.4%, respectively. The corresponding 5-year values were 79.4%, 91.2%, and 79.3%. In conclusion, concurrent IMRT and chemotherapy plus nimotuzumab may represent a well-tolerated and effective treatment regimen in patients with LACSCC.

Efficacy and Safety of Bladder Preservation Therapy in Combination with Atezolizumab and Radiation Therapy (BPT-ART) for Invasive Bladder Cancer: Interim Analysis from a Multicenter, Open-label, Prospective Phase 2 Trial

To evaluate the safety and pathological complete response (pCR) rate of radiotherapy with atezolizumab as bladder-preserving therapy for invasive bladder cancer. A multicenter, phase II study was conducted with clinically T2-3 or very high-risk T1 bladder cancer patients who were poor candidates for or refused radical cystectomy. Here, we report our interim analysis of pCR as a key secondary endpoint ahead of the progression-free survival rate primary endpoint. Radiotherapy (41.4 Gy to the small pelvic field and 16.2 Gy to the whole bladder) was given plus 1200 mg intravenous atezolizumab every 3 weeks. After 24 treatment weeks, response was assessed after transurethral resection and tumor programmed cell death ligand-1(PD-L1) expression was assessed using tumor-infiltrating immune cell scores. Forty-five patients enrolled from January 2019 to May 2021 were analyzed. The most common clinical T stage was T2 (73.3%), followed by T1 (15.6%) and T3 (11.1%). Most tumors were solitary (77.8%), small (<3 cm) (57.8%), and without concurrent carcinoma in situ (88.9%). Thirty-eight patients (84.4%) achieved pCR. High pCR rates were achieved in older patients (90.9%) and in patients with high PD-L1-expressing tumors (95.8% vs. 71.4%). Adverse events (AEs) occurred in 93.3% of patients, with diarrhea being the most common (55.6%), followed by frequent urination (42.2%) and dysuria (20.0%). The frequency of grade 3 AEs was 13.3% while no grade 4 AEs were observed. Combination therapy with radiotherapy and atezolizumab provides high pCR rates and acceptable toxicity, indicating it could be a promising option for bladder preservation therapy.

PO46 Presentation Time: 4:45 PM: MRI-Guided Adaptive External Beam Radiotherapy for Cervical Cancer

Cervical cancer is the fourth most common cancer in women worldwide. Traditionally, bulky cervical tumors or those with clinical nodal involvement are treated with definitive chemoradiation therapy. Pelvic or extended field radiation has traditionally been delivered using 3-dimensional conformal radiotherapy with fields that are not altered during treatment. However, there is an emerging role for intensity modulated radiotherapy as well as adaptive planning. Although MRI-based linear accelerators have recently been used for image guidance during brachytherapy, to our knowledge, there are no reports of adaptive planning for cervical cancer cases using MRI-based linear accelerators. We present a case of a postpartum patient with a bulky cervical adenocarcinoma who underwent replanning twice during treatment due to uterine and tumor shrinkage. The use of a MRI-based linear accelerator facilitated both replanning and tumor assessment.

Upfront Boost Followed by Elective Node Radiation [UBER] for Treatment of Locally Advanced Cancer of the Vulva in Older (> 70 years) Women

<h3>Purpose/Objective(s)</h3> Three key radiation metrics identified for optimizing treatment of cancer (ca) of the vulva include: completion of ≥ 20 fractions, overall treatment duration of < 8 weeks (56 days), and <1 week treatment break. Among older women (≥ 66 years) compliance to all 3 metrics is noted only 50% of the time.¹ Our study aims to evaluate treatment metrics of a radiation sequence that delivers upfront boost to the primary and positive inguinal nodes followed by adding a pelvic field for elective regional node radiation [UBER]. We reasoned that by initially targeting the highest risk volume of disease, and delaying the onset of acute (gastrointestinal, hematologic) toxicity generally associated with pelvic field radiation we may observe better compliance to RT delivery metrics in older women. <h3>Materials/Methods</h3> From September 2019 to October 2021, we identified 5 patients over the age of 70 years diagnosed with ca of the vulva and treated with radiation using the UBER sequence. All 5 patients had locally advanced clinical stage (cT3/T4 and/or node positive). Three patients received primary RT+ weekly cisplatin, 1 patient each received primary RT, and adjuvant RT alone. The RT dose/ fractionation prescribed was at the discretion of the treating physician, and 4/5 patients were treated using IMRT plans. <h3>Results</h3> The median age is 79 years [73-88 years]. The upfront boost dose delivered to the primary and positive inguinal nodes ranged from 900cGy to 2400cGy. The larger pelvic field including the primary, inguinal and pelvic nodes received a dose that ranged from 3420cGy to 4500cGy. The composite RT dose/ fractions ranged from 4320cGy/ 24 fractions to 6480cGy/36 fractions delivered over an average of 54 elapsed days [range: 37 to 69 days]. The average treatment break was 4 days [range: 0 to 6 days]. Two of the 3 patients received all 6 cycles of concomitant weekly cisplatin, and 1/3 patients received 5 cycles. Patient status at median follow up of 6 months (range: 3 to 22 months) is: 2 alive with no evidence of disease, 1 alive with partial response, 1 alive with disease progression, and 1 died of disease. <h3>Conclusion</h3> Early experience with the UBER sequence suggests high compliance to clinically important RT delivery metrics i.e., completion of > 20 fractions, average overall treatment time of < 8 weeks with < 1 week treatment break. Additionally, patients were able to receive 5-6 cycles of concomitant weekly cisplatin. In a particularly challenging older patient population with ca of the vulva further study of the UBER sequence is warranted. ¹ Swanick CW et al: Gynecol Oncol 146:87, 2017

The Outcomes of Definitive Radiotherapy in Patients with Prostate Cancer Using Simultaneous Integrated Boost Technique

<h3>Purpose/Objective(s)</h3> Previous studies had shown a dose-response relationship in prostate cancer during radiotherapy (RT). The clinical outcomes of prostate cancer patients treated with definitive RT using the simultaneous-integrated boost (SIB) technique were investigated in this study. <h3>Materials/Methods</h3> The clinical data of 556 prostate cancer patients who underwent RT using the SIB technique between September 2012 and September 2021 were retrospectively analyzed. In 39 fractions, patients received 78 Gy to the entire prostate±seminal vesicles and 86 Gy to the intraprostatic lesion (IPL). In addition, high-risk patients received 54 Gy pelvic field irradiation. Diffusion-weighted magnetic resonance imaging was used to define the IPL. Failure from biochemical failure (FFBF) and prostate-cancer specific survival (PCSS) were the primary endpoints. Secondary endpoints were progression free survival (PFS) and toxicity. <h3>Results</h3> The median age of the population was 69 years (range: 47–89 years). According to D'Amico risk categories, there were 175 patients (31.5%) classified as low risk, 186 patients (33.4%) classified as intermediate risk, and 195 patients (35.1%) classified as high risk. 253 patients (54.5%) received androgen deprivation therapy. The median duration of follow-up was 58.2 months (range, 4.7–126.8 months) for the entire cohort. The 5-year FFBF, PCSS, and PFS rates were respectively 93.3%, 98.5%, and 84.1%. In 40 patients (7.2%), progression was observed as biochemical failure in 16 patients, distant metastasis in 2 patients, and both biochemical failure and distant metastasis in 22 patients. Only four patients (0.7%) had a local recurrence. Univariate analysis revealed that the pretreatment PSA value, T and N stages, ISUP score, and D'Amico risk groups were all significant prognostic factors for FFBF and PCSS. PSA levels higher than 20 ng/mL [HR=3.39 (95% CI, 1.28–8.94); p=0.01], nodal metastasis [HR=4.03 (95% CI, 1.61–10.03); p=0.003], high risk disease [HR=6.66 (95% CI, 1.72–25.77); p=0.001], and higher ISUP scores [HR=2.31 (95% CI, 1.53–3.49); p<0.001] were all independent predictors of worse FFBF. In multivariable analysis, the significant predictors of worse PCSS were high risk disease [HR=8.96 (95% CI: 2.13–19.71; p=0.01] and a higher ISUP score [HR=12.21 (95% CI: 1.70–87.74; p=0.004]. Acute gastrointestinal (GI) and genitourinary (GU) system toxicities of grade 2 or greater were observed in 7.4% and 14.0% of patients, respectively. Late GI and GU toxicities of grade 2 or greater were observed in 5.3% and 6.9% of patients, respectively. <h3>Conclusion</h3> The treatment strategy of 78 Gy delivered to the entire prostate with a boost dose of 86 Gy to IPL was effective and safe, with excellent biochemical control and PCSS, and very low toxicity rates. Longer follow-up and randomized trials are needed to validate our findings.

Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AimsRisk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume ‘mini-pelvis’ radiotherapy fields, were evaluated in a population-based study. Materials and methodsAll patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed. ResultsIn total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy. ConclusionRisk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.

Radiation therapy for pelvic recurrent colorectal or gynecological cancer: is whole pelvic irradiation necessary?

Preoperative whole pelvic radiation therapy (RT) is used commonly for rectal cancer and is the standard field postoperatively in gynecological cancer. However, the ideal field (local vs. whole pelvis) has not been determined for local recurrence of these cancers. We retrospectively reviewed the data for 52 patients who developed local tumor recurrence of rectal or gynecological cancer treated from 2013 to 2021. The initial treatment for all patients was total excision of the primary tumors without radiation therapy. Radiation therapy targets were surgical stumps, perianastomosis sites, and pelvic lymph nodes, classified according to the pelvic nodal volume atlas for radiation therapy. Patients were divided into the local recurrent tumor only radiation therapy group and the whole pelvis radiation therapy group. Whole pelvis radiation therapy included the common iliac lymph nodes or prophylactic lymph nodes below the L5/S1 junction. We recorded second recurrence after RT and the affected site(s) in each group. We also compared disease-specific survival using uni- and multivariate analyses. We found no significant differences between the groups regarding second recurrence or regarding the site(s) of recurrence. We also found no significant differences in disease-specific survival between the two RT groups. However, patients who did not receive chemotherapy after the initial surgery and before RT had significantly longer survival (P=0.015). In patients with locally recurrent rectal or gynecological cancer, we found no significant difference in second recurrence or survival between the local tumor only RT field and the whole pelvic RT field.

MP13-13 ASSOCIATION BETWEEN COMPLEXITY OF PELVIC SURGICAL FIELD AND OUTCOMES OF RADICAL CYSTECTOMY WITH URINARY DIVERSION

You have accessJournal of UrologyCME1 May 2022MP13-13 ASSOCIATION BETWEEN COMPLEXITY OF PELVIC SURGICAL FIELD AND OUTCOMES OF RADICAL CYSTECTOMY WITH URINARY DIVERSION Leilei Xia, Raju Chelluri, Ruchika Talwar, Daniel Lee, and Thomas Guzzo Leilei XiaLeilei Xia More articles by this author , Raju ChelluriRaju Chelluri More articles by this author , Ruchika TalwarRuchika Talwar More articles by this author , Daniel LeeDaniel Lee More articles by this author , and Thomas GuzzoThomas Guzzo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002542.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical field can be complicated by prior pelvic surgery or radiation for patients undergoing radical cystectomy (RC) with urinary diversion (UD). However, whether the complexity of pelvic surgical field leads to worse perioperative outcomes is not well reported in the literature. METHODS: Patients who underwent RC and UD were identified from the 2019 National Surgical Quality Improvement Program (NSQIP) database. Pelvic surgical field complexity was categorized into 4 groups based on prior history of pelvic surgery and/or radiation: no pelvic surgery or radiation (n=893), pelvic surgery only (n=807), pelvic radiation only (n=73), pelvic surgery and radiation (n=147). Outcomes of interest were derived from NSQIP outcomes within 30 days from surgery and included: any complications, major complications, prolonged operative time (pOT, ≥400 min), prolonged length of stay (pLOS, ≥9 d), discharged to continued care, and unplanned readmission. RESULTS: A total of 1,920 patients (ileal conduit=1,628, neobladder=292) were included; 22.9% had robotic approach and 36.4% had preoperative chemotherapy. Overall complication rate in the cohort was 59% and major complication rate was 25.8 %. The outcomes stratified by the complexity of pelvic surgical field are shown in the Figure. Multivariable logistic regression showed that compared with no pelvic surgery or radiation, pelvic surgery only (odds ratio [OR]=1.43, 95% confidence interval [CI]=1.13-1.81, P=0.003) and pelvic radiation only (OR=1.98, 95%CI=1.13-3.46, P=0.016) were associated with higher odds of pOT but not other outcomes. Pelvic surgery and radiation group was associated with higher odds of major complications (OR=1.47, 95%CI=1.00-2.16, P=0.052), pOT (OR=1.84, 95%CI=1.22-2.77, P=0.004), and pLOS (OR=1.49, 95%CI=1.00-2.24, P=0.049). CONCLUSIONS: This is the first national study focusing on the complexity of pelvic surgical field and outcomes of RC. This NSQIP study, although limited by sample size, showed increased complexity of pelvic surgical field was associated with longer OT, longer hospital stays, and likely higher complication rates. Our study will add to literature improving patient counseling for a group of challenging bladder cancer patients who had prior history of pelvic surgery and pelvic radiation, especially those who had both. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e226 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Leilei Xia More articles by this author Raju Chelluri More articles by this author Ruchika Talwar More articles by this author Daniel Lee More articles by this author Thomas Guzzo More articles by this author Expand All Advertisement PDF DownloadLoading ...

The international penile advanced cancer trial (InPACT): The first phase III trial for squamous carcinoma of the penis with regional lymph node metastases.

TPS7 Background: Penis cancer is a rare but potentially fatal disease. A limited body of evidence exists on which to base the majority of management decisions for patients with regional nodal metastases. Five-year survival for patients with a single involved inguinal lymph node treated with surgery alone is approximately 80%, whilst it ranges from 0 to 12% for patients with pelvic node involvement (N3). Additional strategies are required for the management regionally-advanced disease. InPACT (NCT02305654) aims to determine prospectively the relative benefits and sequencing of surgery, chemotherapy, and chemoradiotherapy in the management of patients with penis cancer who present with palpable or radiologically evident inguinal lymph node metastases. InPACT addresses the following questions: Is there a role for neoadjuvant therapy and, if so, which of the two options (chemotherapy or chemoradiotherapy) before surgery gives superior outcomes? Among patients whose inguinal node histology predicts a high risk of recurrence, does prophylactic pelvic lymph node dissection (PLND) plus chemoradiation to the inguinal and pelvic fields improve survival compared to chemoradiation alone? Methods: A Bayesian trial design aims to include a wide population of patients and incorporates two randomisations: InPACT-neoadjuvant and InPACT-pelvis. Participants are stratified by disease burden (extent of nodal involvement), by the presence or absence of high-risk radiological features, and by GFR. Participants with high disease burden where neoadjuvant treatment is thought to be indicated are randomised to neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy. Participants with intermediate disease burden are randomised to one of 3 arms: Surgery alone or neoadjuvant chemoradiotherapy followed by surgery, or neoadjuvant chemotherapy prior to surgery. Participants in the low-burden group proceed directly to surgery. Participants with postoperative inguinal node pathology that shows high-risk features may then proceed to InPACT-pelvis where randomisation is between adjuvant chemoradiotherapy ± PLND for those not previously treated with chemoradiotherapy &amp; between PLND &amp; observation for those previously treated with neoadjuvant chemoradiotherapy. The study aims to recruit 200 participants. The primary outcome measure is overall survival, with secondary outcome measures of disease-specific survival, disease-free survival, and freedom from locoregional recurrence and distant metastasis. Feasibility, toxicity, the type/extent of surgical complications, and quality of life will be assessed as secondary endpoints for all the InPACT treatment arms. To October 2021, 65 participants have been recruited with centres open in the UK, US and Canada. Clinical trial information: NCT02305654.

Evaluating dosimetric parameters predictive of hematologic toxicity in cervical cancer patients undergoing definitive pelvic chemoradiotherapy.

We performed aretrospective study of cervical cancer pelvic radiotherapy plans to explore dosimetric parameters predictive of hematologic toxicity (HT), with specific interest in evaluating metabolic parameters and identifying the best predictive model. Active marrow was retroactively contoured as pelvic bone with SUV > mean on 18F-FDG-PET. "Highly active" marrow was contoured as the hottest 10-14% volume of active marrow. Pelvic bone contour was segmented into lumbosacral, iliac crest, and lower pelvis. Predictors of HT were evaluated using logistic regression and repeated measures modeling. One hundred women were evaluated from 2009 to 2020. The plurality/majority had stage IIIC1 disease (38%) and underwent IMRT (88%) with pelvic field alone (72%). The majority received weekly cisplatin (78%), and 82% completed at least five cycles. The most common HT was leukopenia (grade2+: 68%). Predictors of grade2+ and3+ HT were baseline WBC (p < 0.001), and 10-and 20-Gy dosimetric parameters to the active marrow, highly active marrow, and pelvic bone. The best predictive model of leukocyte trajectory included baseline WBC (p < 0.001), highly active marrow V20 (p < 0.001), and interactions of baseline WBC with time (p < 0.001) and highly active marrow V20 (p < 0.001), such that those with low baseline WBC experienced the greatest impact of highly active marrow V20. Baseline WBC was highly predictive of HT; dosimetric predictors included dose to the active marrow, highly active marrow, and pelvic bone, with the greatest impact from V20 to the highly active marrow, particularly in women with low baseline WBC. Future studies should consider incorporating baseline WBC and limiting dose to the most highly active marrow.

PROSEDUR TERAPI RADIASI EKSTERNA PADA PASIEN KANKER KANDUNG KEMIH DENGAN METASTASIS ARTICULATIO COXAE

ABSTRACT&#x0D; Background: It has been conducted research about external radiation therapy technique of bladder cancer with articulatio coxae metastasis at Dr. Moewardi Hospital Surakarta in order to explain the procedure of external radiation therapy in bladder cancer with articulatio coxae metastasis and the purpose of asymmetric radiation field that used in external radiation therapy of bladder cancer with articulatio coxae metastasis.&#x0D; Methods: The type of research conducts is an observational research with case report approach conducted by using direct observation method, interview with radiation oncologist and radiation technologies as well as documenting the data about external radiation therapy of bladder cancer with articulatio coxae metastasis.&#x0D; Results: From the research result, it is obtained the data that external radiation therapy technique of bladder cancer patient with articulatio coxae metastasis is used asymmetric whole pelvic field where right border more wide than left border. The purpose of using asymmetric field is to reach articulatio coxae metastasis in radiation field, to decrease skin dose and time efficiency of radiation therapy.&#x0D; Conclusions: From a technical point of view, for time efficiency by considering many patients, there is only one plane therapy and the plane can be carried out in an asymmetrical field between the right and left. While the goal from a clinical perspective is to reach the articulatio coxae into the radiation field and reduce the dose received by the skin.

A Prospective Study of a Resorbable Intravesical Fiducial Marker for Bladder Cancer Radiation Therapy

PurposeWe conducted a prospective pilot study to evaluate safety and feasibility of TraceIT, a resorbable radiopaque hydrogel, to improve image guidance for bladder cancer radiation therapy (RT). Methods and MaterialsPatients with muscle invasive bladder cancer receiving definitive RT were eligible. TraceIT was injected intravesically around the tumor bed during maximal transurethral resection of bladder tumor. The primary endpoint was the difference between radiation treatment planning margin on daily cone beam computed tomography based on alignment to TraceIT versus standard-of-care pelvic bone anatomy. The Van Herk margin formula was used to determine the optimal planning target volume margin. TraceIT visibility, recurrence rates, and survival were estimated by Kaplan-Meier method. Toxicity was measured by Common Terminology Criteria for Adverse Events version 4.03. ResultsThe trial was fully accrued and 15 patients were analyzed. TraceIT was injected in 4 sites/patient (range, 4-6). Overall, 94% (95% confidence interval [CI], 90%-98%) of injection sites were radiographically visible at RT initiation versus 71% (95% CI, 62%-81%) at RT completion. The median duration of radiographic visibility for injection sites was 106 days (95% CI, 104-113). Most patients were treated with a standard split-course approach with initial pelvic radiation fields, then midcourse repeat transurethral resection of bladder tumor followed by bladder tumor bed boost fields, and 14/15 received concurrent chemotherapy. Alignment to fiducials could allow for reduced planning target volume margins (0.67 vs 1.56 cm) for the initial phase of RT, but not for the boost (1.01 vs 0.96 cm). This allowed for improved target coverage (D95% 80%-83% to 91%-94%) for 2 patients retrospectively planned with both volumetric-modulated arc therapy and 3-dimensional conformal RT. At median follow-up of 22 months, no acute or late complications attributable to TraceIT placement occurred. No patients required salvage cystectomy. ConclusionsTraceIT intravesical fiducial placement is safe and feasible and may facilitate tumor bed delineation and targeting in patients undergoing RT for localized muscle invasive bladder cancer. Improved image guided treatment may facilitate strategies to improve local control and minimize toxicity.

Dosimetric and Metabolic Parameters Predictive of Hematologic Toxicity in Cervical Cancer Patients Undergoing Definitive Chemoradiotherapy

In cervical cancer, adding concurrent chemotherapy to definitive radiotherapy bestows a clear survival benefit, but the combination increases acute hematologic toxicity, potentially resulting in chemotherapy interruption or discontinuation. We performed a single institutional retrospective study of pelvic radiotherapy plans and FDG-PET/CT of cervical cancer patients to explore dosimetric parameters predictive of grade 3+ hematologic toxicity, with particular interest in evaluating metabolic (SUV) parameters and identifying the best predictive model. We hypothesize that metabolic metrics will be more predictive than bone metrics.Patients were included if they underwent definitive pelvic chemoradiotherapy, and the following information were available: (1) radiotherapy plan in MIM Radiation Oncology software, (2) diagnostic or treatment planning FDG-PET/CT, (3) baseline and serial CBCs. Pelvic bone and active marrow contours were retrospectively contoured by one radiation oncologist for uniformity. Active marrow was contoured as pelvic bone with SUV greater than mean pelvic bone SUV. Highly active marrow was contoured as the 10-14% volume of pelvic marrow with the highest SUV. Differences in toxicity were evaluated using logistic regression and linear mixed effects modeling.One hundred women from 2009 to 2020 were evaluable. The majority had FIGO stage (2018) IIIC1 disease (38%) and underwent IMRT (88%) with pelvic field alone (72%), prescribed to a mean dose of 48 Gy; 77% received a nodal boost to a mean dose of 58 Gy. The majority received weekly cisplatin (78%), and 82% (64/78) completed at least 5 cycles. The most common hematologic toxicity was leukopenia, grade 2 (41%, n = 41), then grade 3 (25%, n = 25). Significant predictors of grade 3+ hematologic toxicity were baseline WBC (P < 0.001), and 10 and 20 Gy dosimetric parameters to the active marrow, highly active marrow, and pelvic bone (specifically lumbosacral and lower pelvis subsites), all P-values < 0.050. Mixed model analysis demonstrated that the best predictive model of leukocyte and neutrophil trajectory were baseline WBC (P < 0.001), highly active marrow V20 (P < 0.001), and interactions between baseline WBC and time (P < 0.001) and highly active marrow V20 and baseline WBC (P < 0.001), such that patients with low baseline WBC experienced the greatest impact of highly active marrow V20.Baseline WBC was highly predictive of grade 3+ hematologic toxicity; dosimetric predictors included low dose (10 and 20 Gy) to the active marrow, highly active marrow, and pelvic bone (specifically lumbosacral and lower pelvis subsites), with potentially the greatest impact from V20 to the highly active marrow, particularly in women with low baseline WBC. Future studies should further evaluate optimal metabolic metrics incorporating baseline WBC to determine ideal radiotherapy plan parameters, and potentially better sparing of the highly active marrow in this population.E. Rahimy: None. R. Von Eyben: None. J. Lewis: None. D.H. Hristov: None. E.A. Kidd: Advisory Board; Varian Brachytherapy Advisory Board.

Uterine Transposition after Radical Trachelectomy for Fertility Preservation: Step By Step of the Surgical Technique.

<h3>Study Objective</h3> To demonstrate the technique of a laparoscopic uterine transposition for fertility preservation in a patient with a previous radical trachelectomy. <h3>Design</h3> A technical video showing step-by-step a laparoscopic uterine transposition. <h3>Setting</h3> A tertiary referral hospital in Argentina. For surgery, the patient was placed in a dorsal modified lithotomy position. During the pelvic part of the procedure, the surgeon was on the patient's left side, the first assistant on the right, and the second assistant between the patient's legs. When working in the upper abdomen the surgeon moved to the patient's right side, the first assistant was between the patient's legs, and the second assistant to the left side. <h3>Patients or Participants</h3> A 27-year-old woman with a FIGO stage IB1 squamous cell cervical carcinoma who had had a radical trachelectomy, and after histopathological assessment fulfilled the criteria for pelvic external radiation therapy. <h3>Interventions</h3> This intervention for fertility preservation consists of three main steps. During the first one, a minimally invasive surgery is performed to detach the uterus and adnexa from the vagina and to place them in the right upper abdomen, out of the pelvic radiation field. Afterwards, the patient is able to start the radiotherapy without delays, and after finishing it, the last step is to reposition the uterus and adnexa in the pelvis with a laparoscopic approach. <h3>Measurements and Main Results</h3> Two months after surgery, the patient has regular uterine bleeding with oral contraceptives. A transvaginal doppler ultrasound shows normal blood flow to the uterus, and the cervix exhibits a normal appearance on physical examination. <h3>Conclusion</h3> Uterine transposition is a feasible surgery, and it should be considered as an alternative for fertility preservation in women who have a pelvic tumor and require pelvic radiation therapy.

Clinical Observation of Prophylactic Extended-Field Intensity-Modulated Radiation Therapy with Synchronous Chemotherapy in Locally Advanced Cervical Cancer.

BackgroundWe aimed to evaluate the value of prophylactic extended-field intensity-modulated radiation therapy (IMRT) in the treatment of locally advanced cervical cancer with multiple pelvic lymph node metastases (≥2) and negative common iliac and paraaortic lymph nodes.Material/MethodsThirty-four patient with newly diagnosed cervical cancer (IB1-IVA) and multiple pelvic lymph node metastases (≥2) confirmed by computed tomography and magnetic resonance imaging were randomly divided into an extended-field group (17 patients) and a pelvic-field group (17 patients). In the extended-field group, we added the drainage area of paraaortic lymph nodes on the pelvic field. The pelvic field was administered Dt 45.0 to 50.4 Gy, while the drainage area of paraaortic lymph nodes was administered Dt 40.0 to 45.0 Gy. Both groups were given IrI92 intracavitary radiotherapy after 3 weeks of external irradiation. The total dose of point A was 25.0 to 30.0 Gy, fractional 6.0 to 7.0 Gy. All patients had concurrent platinum-based chemotherapy once weekly until the end of radiotherapy.ResultsNo paraaortic lymph node metastasis was found in the extended-field group (P=0.0184), and disease-free survival (DFS) was prolonged (P=0.0286). Adverse effects in patients with III–IV degree myelosuppression were increased in the extended-field group (P=0.0324). However, all patients recovered after symptomatic treatment.ConclusionsProphylactic extended-field IMRT with chemotherapy reduced the metastasis rate of paraaortic lymph nodes and prolonged the DFS in patients with locally advanced cervical cancer and multiple pelvic lymph node metastases (≥2), while the toxic adverse effects were tolerated.