Pelvic Fields Research Articles

Safety and efficacy of nimotuzumab and concurrent intensity-modulated radiation therapy and chemotherapy for locally advanced cervical squamous cell cancer.

5532 Background: To evaluate the safety and efficacy of nimotuzumab plus concurrent intensity-modulated radiation therapy (IMRT) and chemotherapy for the treatment of locally advanced cervical squamous cell cancer (LACSCC). Methods: From December 2013 to March 2017, 31 patients with stage (FIGO 2009) IB2-IVA cervical squamous cell cancer were enrolled in this single-arm clinical trial at an academic medical center and received concurrent chemoradiotherapy plus nimotuzumab. All patients underwent at least 1 year of follow-up. The prescription radiation dose was 50.4 Gy/28 F on the pelvic field with or without extended-field radiation. An additional 30-36 Gy to Point A was delivered with high-dose-rate techniques. Cisplatin 40 mg/m2 and nimotuzumab 200 mg were infused intravenously once weekly during radiotherapy. The main and secondary outcome measures were toxicity evaluated using CTCAE 4.0., and the short-term outcome evaluated by RECIST 1.1. Results: The median follow-up duration was 29.7 months (13.3-61.2 months). All patients received external beam radiotherapy, brachytherapy, and nimotuzumab six times. Twenty-seven patients received six cycles of chemotherapy while four received only 4-5 cycles. There was no life-threatening toxicity. The incidence of acute grade 3 bone marrow depression was 51.6% (16/31) and grade 3 gastrointestinal tract reaction was 9.7% (3/31). The incidence of late toxicities was 22.6% (7/31), and these included vaginal-rectal fistula, intestinal obstruction, rectal hemorrhage, hematuria, and vaginal stenosis. Complete response was achieved in 30 cases (96.8%). The 1-year disease-free survival (DFS), local progression-free survival (LPFS), and overall survival (OS) rates were 87.1%, 90.3%, and 100%, respectively. The corresponding 3-year values were 74.8%, 90.3%, and 86.7%. Conclusions: Nimotuzumab plus concurrent IMRT and chemotherapy may represent a well-tolerated and effective treatment regimen in patients with LACSCC.

IMRT pelvic radiotherapy with simultaneous integrated boost in high-risk prostate cancer: Results after 10 years.

5084 Background: To report 10 year results after image guided intensity-modulated radiotherapy (IMRT) with hypofractionated simultaneous integrated boost (SIB) in high-risk prostate cancer. Methods: Between 2007 and 2009, 97 patients with an estimated risk of lymph node metastases above 15% (Roach equation) were prospectively included in a phase II study. Patients were treated with 2-2.7 Gy to the prostate, vesicula seminalis and elective pelvic field in 25 fractions over 5 weeks with androgen deprivation therapy for 2 years. Toxicity was scored according to RTOG criteria and biochemical free survival (BFS) using the Phoenix definition. Patients were divided into three groups; very high-risk patients (VHR) according to NCCN 2015 criteria (n=50), high-risk patients (HR) (n=32), and patients with N+ disease and/or pretreatment s-PSA ≥100 (n=15). Differences were examined using Kaplan Meier estimates with log rank test. Results: Ten year BFS in the entire cohort was 63%. Metastasis-free survival (MFS) was 77% and prostate-cancer-specific-survival (PCSS) 88%. Overall survival (OS) was 69% and local failure rate was 11%. VHR vs. HR subgroups had significant different BFS; 58% vs 84% (p=0.01) respectively. MFS and PCSS in the VHR group compared to the HR group was 78% vs 91% (p=0.108) and 86% vs 97% (p=0.157) respectively. Patients with N+ and/or PSA>100 had worse outcome compared to the HR/VHR groups, but not all had treatment failure. BFS was 33% vs 68% (p=0.001), MFS 47% vs 83% (p=0.000) and PCSS 73 % vs 90% (p=0.04), respectively. Patients who reached a PSA nadir value below 0.1 (n=80) had significant better outcomes, with PCSS 93% vs 65% (p= 0.001) and BFS 74% vs 12% (p=0.000), respectively. Acute gr 2 GI and GU toxicity was observed in 27% and 40%, gr 3 GI and GU toxicity in 1% and 3%. Late gr 2 GI and GU toxicity at 3 years appeared in 3% and 4% with no gr 3 toxicity. Conclusions: High-risk prostate cancer patients treated with IMRT with SIB obtained favorable outcomes with few serious side effects. There were significant better results in the HR versus the VHR group, both better than the N+/PSA≥100 group.

Validation of Animal Model of Pelvic Radiation Induced Female Sexual Dysfunction and Cystitis [35D

INTRODUCTION: Women receiving radiation therapy (RT) for cervical and endometrial cancers experience injury and fibrosis to surrounding healthy tissues leading to genitourinary dysfunction, specifically vaginal atrophy, dyspareunia and radiation cystitis. METHODS: Adult female Sprague-Dawley rats were separated into three groups (n=7-8/group): control, 4-week RT, and 9-week RT. RT rats received a single 20Gy dose of cervical x-ray irradiation. In vivo, pelvic nerve electric field stimulated (EFS) increases in vaginal blood flow were measured using a laser Doppler probe. Ex vivo tissue bath experiments assessed vaginal adrenergic and cholinergic contractions. Bladder cholinergic contractions were measured in the presence or absence of muscarinic inhibition. Internal and external urethral sphincter contractions to cholinergic agonists and caffeine were measured. EFS neurogenic contractions were evaluated in all tissues. Experiments were conducted in accordance with the East Carolina University Institutional Animal Care and Use Committee. RESULTS: Pelvic RT caused a decrease in vaginal blood flow and less cholinergic vaginal contraction 4-weeks post-RT. Following 9-weeks RT, vaginal blood flow normalized; however, adrenergic-mediated vaginal contraction remained elevated. In both RT groups, EFS neurogenic-mediated bladder contractions were reduced. No changes were observed in internal urethral sphincter contractility. In contrast, external urethral sphincter contractions to EFS and caffeine were elevated at 4 and 9-weeks post-RT. CONCLUSION: This pelvic RT model demonstrated impaired sexual arousal and increased vaginal contractility. Similar to previous RT studies, the bladder developed decreased neurogenic contractions; a symptom of radiation cystitis. Using our female pelvic RT model, we can begin to understand the pathophysiology of RT-induced sexual dysfunction and cystitis.

A Minor Adaptation in the Houdek Gynecological Applicator for Limited Intracavitary and Interstitial HDR Brachytherapy for Vault Cancers

The standard treatment for isolated vaginal vault recurrences post-surgical cervical and endometrial cancers, in previously unirradiated patients, is radio(chemo) therapy including brachytherapy (BT) boost. Radiation therapy would include standard external beam pelvic fields followed by BT boost depending on the residual disease. BT boost is challenging and depends on the residual disease and vault thickness. The vault disease usually has a supra-vaginal component which cannot be treated adequately with a simple intracavitary vault BT. These case scenarios would require interstitial BT. The classical interstitial approach includes the use of perineal templates (MUPIT, Syed Neblett etc.) which involves need of experience, increased number of needles and association with a learning curve. We attempted a minor adaptation in an existing Houdek Applicator (used for simple Intracavitary Vault BT) by introducing an acrylic cap fitted over the ring with multiple holes drilled for provision to introduce straight needles (18 Gauge stainless steel needles) through the cap as shown in figure 1. (Clockwise from top: 1. Central tandem and ring. 2. Acrylic caps 3. Ring fitted with the cap with needles) In addition to the tandem and ring channel, we made a customized acrylic cap to adapt to different ring diameters and drilled array of holes for central tandem and 2 circular planes of needles. After commissioning and dosimetric review, we evaluated its applicability. The assessment of technical feasibility, dosimetric parameters, and preliminary clinical outcome forms the basis of this report.

EP-1478 Adjuvant small pelvic field radiotherapy in cervical cancer with intermediate risk factors

EP-1478 Adjuvant small pelvic field radiotherapy in cervical cancer with intermediate risk factors

Plasma citrulline levels as a biomarker for bowel toxicity in prostate stereotactic radiotherapy with or without pelvic nodal radiation.

73 Background: Plasma levels of citrulline, an amino acid, are derived mainly from small bowel enterocytes. Decreased levels occur in a range of bowel conditions and citrulline has been proposed as a biomarker of bowel toxicity in pelvic radiotherapy. In a prospective study, we identify no correlation between plasma citrulline and toxicity in men receiving prostate stereotactic radiotherapy randomized to receive either pelvic nodal irradiation or not. Furthermore, citrulline levels were not significantly different between these two groups. Methods: As part of an approved clinical trial, men with intermediate to high risk prostate cancer were randomised 1:1 to prostate only or prostate + pelvic nodal radiotherapy, delivered with a rectal spacer gel in situ. The prostate and proximal seminal vesicles received 40 Gy in 5 fractions. Those randomised to the pelvic nodal arm also received 25 Gy in 5 fractions to pelvic nodes. Citrulline was measured at 10 points during treatment – consent, before fraction 1, 1 and 24 hours following fraction 1, prior to each fraction 2 – 5 and at 6 weeks’ and 3 months’ follow up. Bowel toxicity was measured by EPIC patient reported scores. Results: 16 men with follow up of at least 3 months (median 9, maximum 18 months) were analysed. Reported toxicity was significantly higher in the prostate and pelvis arm: 5 of 9 men showed a decrease in EPIC bowel domain summary score of 10 points or more compared to 0 of 7 in the prostate-only arm (p = 0.0337, two tailed Fisher’s exact test). No significant correlation between toxicity and citrulline levels was seen, nor did citrulline vary significantly between arms or fall as treatment progressed. Data analysis for a further 8 men already recruited to the study is ongoing. Conclusions: Toxicity was more commonly reported by men randomised to receive pelvic radiotherapy, suggesting that the small bowel irradiated in pelvic fields plays a role in bowel toxicity experienced during stereotactic radiotherapy. Citrulline levels showed no significant correlation with toxicity or radiation dose to small bowel. We propose that citrulline is not a useful biomarker of small bowel toxicity in this setting. Clinical trial information: NCT03253978.

Efficacy and Toxicity of IMRT-Based Simultaneous Integrated Boost for the Definitive Management of Positive Lymph Nodes in Patients with Cervical Cancer.

Background: The optimal radiotherapy regimen for treating metastatic lymphadenopathy in patients with locally advanced cervical cancer remains controversial. This study aimed to investigate the clinical outcomes, as well as associated toxicities, of intensity-modulated radiotherapy (IMRT) with a simultaneous integrated boost (SIB) for pelvic and para-aortic lymph nodes (LNs).Methods: Between 2011 and 2015, 74 patients with 2014 International Federation of Gynecology and Obstetrics stage IIB-IVB cervical cancer exhibiting pelvic or para-aortic LN involvement were examined. The pelvic field planning dose was 45-50 Gy in 25 fractions, and an SIB of 62.5 Gy in 25 fractions was delivered to positive LNs. Next, CT-guided brachytherapy was performed 24 Gy in 3 fractions to 42 Gy in 6 fractions once or twice weekly.Results: The median follow-up duration was 36 (range: 3-62) months. The 3-year local control, distant metastasis-free survival, and overall survival rates were 91.7%, 75.7%, and 71.4%, respectively. No residual or recurrent LNs were detected. Six patients developed grade 3 acute gastrointestinal (GI) toxicity. Twenty-nine (39.2%) and 3 (4.1%) patients developed grade 3 and 4 hematological toxicities, respectively. Twenty patients (28.5%) developed grade ≥2 chronic GI toxicity. Only 1 patient (1.4%) experienced a grade 4 rectovaginal fistula, and 3 patients (4.2%) developed grade 2 genitourinary toxicities. SIB to the LNs did not influence acute or chronic toxicity rates.Conclusions: Our findings demonstrate that a dose of 62.5 Gy to positive LNs using the IMRT with SIB method can achieve excellent clinical outcomes with acceptable toxicity.

Prospective, Multisite, International Comparison of 18F-Fluoromethylcholine PET/CT, Multiparametric MRI, and 68Ga-HBED-CC PSMA-11 PET/CT in Men with High-Risk Features and Biochemical Failure After Radical Prostatectomy: Clinical Performance and Patient Outcomes

A significant proportion of men with rising prostate-specific antigen (PSA) levels after radical prostatectomy (RP) fail prostate fossa (PF) salvage radiation treatment (SRT). This study was done to assess the ability of 18F-fluoromethylcholine (18F-FCH) PET/CT (hereafter referred to as 18F-FCH), 68Ga-HBED-CC PSMA-11 PET/CT (hereafter referred to as PSMA), and pelvic multiparametric MRI (hereafter referred to as pelvic MRI) to identify men who will best benefit from SRT. Methods: Prospective, multisite imaging studies were carried out in men who had rising PSA levels after RP, high-risk features, and negative/equivocal conventional imaging results and who were being considered for SRT. 18F-FCH (91/91), pelvic MRI (88/91), and PSMA (31/91) (Australia) were all performed within 2 wk. Imaging was interpreted by experienced local/central interpreters who were masked with regard to other imaging results, with consensus being reached for discordant interpretations. Expected management was documented before and after imaging, and data about all treatments and PSA levels were collected for 3 y. The treatment response to SRT was defined as a reduction in PSA levels of >50% without androgen deprivation therapy. Results: The median Gleason score, PSA level at imaging, and PSA doubling time were 8, 0.42 (interquartile range, 0.29-0.93) ng/mL, and 5.0 (interquartile range, 3.3-7.6) months. Recurrent prostate cancer was detected in 28% (25/88) by pelvic MRI, 32% (29/91) by 18F-FCH, and 42% (13/31) by PSMA. This recurrence was found within the PF in 21.5% (19/88), 13% (12/91), and 19% (6/31) and at sites outside the PF (extra-PF) in 8% (7/88), 19% (17/91), and 32% (10/31) by MRI, 18F-FCH, and PSMA, respectively (P < 0.004). A total of 94% (16/17) of extra-PF sites on 18F-FCH were within the pelvic MRI field. Intrapelvic extra-PF disease was detected in 90% (9/10) by PSMA and in 31% (5/16) by MRI. 18F-FCH changed management in 46% (42/91), and MRI changed management in 24% (21/88). PSMA provided additional management changes over 18F-FCH in 23% (7/31). The treatment response to SRT was higher in men with negative results or disease confined to the PF than in men with extra-PF disease (18F-FCH 73% [32/44] versus 33% [3/9] [P < 0.02], pelvic MRI 70% [32/46] versus 50% [2/4] [P was not significant], and PSMA 88% [7/8] versus 14% [1/7] [P < 0.005]). Men with negative imaging results (MRI, 18F-FCH, or PSMA) had high (78%) SRT response rates. Conclusion: 18F-FCH and PSMA had high detection rates for extra-PF disease in men with negative/equivocal conventional imaging results and rising PSA levels after RP. These findings affected management and treatment responses, suggesting an important role for PET in triaging men being considered for curative SRT.

Extended-field radiotherapy for locally advanced cervical cancer

Extended-field radiotherapy for locally advanced cervical cancer

What are the Optimal Radiation Fields for FIGO IIIC Endometrial Cancer? A Multi-Institutional Study

In GOG-258, rates of pelvic & para-aortic (PA) nodal failure were lower with the addition of adjuvant radiation (RT) compared to chemotherapy alone, although details on RT fields have not yet been reported. In patients with node positive endometrial cancer, the selection of pelvic (PRT) vs. extended field RT (EFRT) has yet to be defined. This study evaluates outcomes and sites of failure in patients with FIGO stage IIIC endometrial cancer treated with PRT vs. EFRT. In a multi-institutional retrospective cohort study, we identified 143 patients with FIGO IIIC endometrioid endometrial cancer s/p surgical staging who received adjuvant RT from 1/2000-12/2016. RT fields were reviewed and categorized as EFRT if the superior field border included the renal hilum or PRT if below. Baseline characteristics & outcomes were compared by stage (IIIC1 vs. IIIC2) and RT type (PRT vs. EFRT). Actuarial estimates of RFS & OS were calculated by Kaplan-Meier & compared by logrank. Sites of failure were reported as local (vaginal), regional (pelvic or PA nodal) or distant, & within or outside the RT field. Median follow-up was 59.3 months. Clinical and treatment characteristics for 3 treatments groups are described in Table 1: pelvic node positive (IIIC1) & elective EFRT, pelvic node positive (IIIC1) & PRT, and PA node positive (IIIC2) & EFRT. Recurrence rates were lowest for patients with IIIC1 EFRT (5-year RFS 78.9%), but did not significantly differ from IIIC1 PRT (72.5%) or IIIC2 EFRT (69.3%, p =0.44). The 5-year OS rates were similar by group: 91.7% for IIIC1 EFRT, 86.5% for IIIC1 PRT, and 84.9% for IIIC2 EFRT (p=0.65). Of 31 patients with recurrence, most had distant relapse outside the RT field (16, 52%). In-field recurrences were local (3, 13%), regional (13%) or both (1, 3%). Of 78 IIIC1 patients treated with PRT, 7 patients (9%) had PA failure. Most patients with PA relapse had LVI (86%), ≥50% MMI (71%), & grade 3 disease (57%). Adjuvant RT results in excellent survival outcomes for patients with FIGO IIIC endometrial cancer. For patients with positive pelvic nodes, further study is warranted to determine if those with LVI, deep MMI & grade 3 disease benefit from EFRT.Abstract TU_21_3531; Table 1Patient CharacteristicsIIIC1 EFRTIIIC1 PRTIIIC2 EFRTp-value∗Wilcoxon rank sum, Kruskal-WallisN=32 (22.4%)N = 78 (54.5%)N = 33 (23.1%)Median Age (Range)57.5 (33-84)60.5 (41-78)57 (44-74)0.20Grade1238 (25.0)18 (56.3)6 (18.8)23 (29.5)33 (42.3)22 (28.2)11 (33.3)12 (36.4)10 (30.3)0.58LVI25 (78.1)53 (69.7)23 (71.9)0.77MMI ≥50%23 (71.9)49 (62.8)28 (84.8)0.16Gross residual diseaseInvolved LN VaginalOther01 (3.1)01 (1.3)0012 (36.4)01 (3.0)<.0001Median LNs dissected (Range)11.5 (2-46)13 (1-55)12 (0-39)0.99Median LNs involved (Range)1 (1-5)1 (1-10)3 (0-19)0.59Median EBRT dose in Gy (Range)45 (45-50.4)45 (45-56)45 (21.6-54)0.1Systemic Chemotherapy29 (92)63 (81)33 (100)∗ Wilcoxon rank sum, Kruskal-Wallis Open table in a new tab

Primary Penile Cancer: The Role of Adjuvant Radiation Therapy in the Management of Extranodal Extension in Lymph Nodes

BackgroundIn head and neck cancer, the presence of extranodal extension (ENE) in lymph nodes (LNs) has been shown prospectively to require adding chemotherapy to postoperative radiation therapy (RT). Limited data exist regarding ENE in LNs from primary penile cancer (PeCa). ObjectiveTo determine the association of RT and ENE in PeCa. Design, setting, and participantsWe retrospectively analyzed the outcomes of 93 patients with pT1–4 N3 M0 (American Joint Committee on Cancer 7th edition) squamous cell carcinoma of the penis across four international centers. InterventionIf the inguinal nodal specimen had ENE or two or more positive inguinal LNs, RT was delivered to an ipsilateral inguinal field. An ipsilateral pelvic field was added for positive pelvic LNs on dissection. The delivered dose was usually 50Gy in 25 daily fractions. Outcome measurements and statistical analysisClinical and demographic characteristics of relapse-free (RFS), disease-specific (DSS), and overall (OS) survival were compared by ENE status and receipt of adjuvant RT. Results and limitationsSeventy-two percent of patients had inguinal ENE, and 49% had pelvic ENE. On multivariable analysis (MVA) of ENE-negative patients, an OS benefit was noted with postoperative chemotherapy (p=0.038) and inguinopelvic RT (p=0.037). RFS suffered with worsening grade of the lesion (moderately: p=0.027; poorly: p=0.038), but was improved with groin (p=0.016) and inguinopelvic (p=0.006) RT. On MVA of patients with ENE, inguinopelvic RT was associated with better DSS (p=0.041). Grade impacted DSS (moderately: p=0.043; poorly: p=0.033), and poorly differentiated lesions impacted RFS (p=0.013). ConclusionsInguinopelvic RT may benefit regional control in PeCa patients with positive pelvic LNs, but this appears to be limited to those without ENE. Patient summaryFor patients with penile cancer and positive pelvic lymph nodes, postoperative radiation therapy was found to decrease the likelihood of disease recurrence in the groin or pelvis only if extranodal extension was absent.

Evaluation of applying Kinesio taping in children with urinary incontinence

Physiotherapeutic methods, used in patients with urinary incontinence, are recommended and acknowledged treatment methods. They include pelvic floor muscle exercises, electrical stimulation, magnetic field, acupuncture, and biofeedback. However, the influence of Kinesio taping (KT) applications is not known. The aim of this work was to assess the influence of the KT method on the number of incontinence incidents in children. Additionally, children included in the research were given a depression level test to assess their mental state and how it is influenced by incontinence. The study included 62 children (37 boys and 25 girls), aged 7-14 years, diagnosed as having night urinary incontinence and frequent daytime incontinence (daytime wetting). Study participants were randomly allocated to the research group, in which KT was applied, or the control group in which a placebo was used. The main outcome measure was the number of incontinence incidents. The analysis of study results indicated that there was a statistically significant decrease (p<0.001) in the number of incontinence incidents after KT was applied among children in the research group compared with those in the control group. After 4 days of KT application the number decreased by half within 24h (Figure). As can be seen from the analysis of the literature on urinary incontinence therapy, several physiotherapeutic methods are described. They are not merely based on a single strategy but include combinations of methods. To our knowledge, the method described in our work is a pioneer method, previously not applied on its own. It is, however, limited by a relatively small number of research participants, although it took 29 months to gather the group for the research. Additionally, the research based on the principle that children with up to threw incontinence episodes per day were given KT applications every 3 days (72h per session), whereas children with more frequent incontinence episodes were given KT applications every day (24h per session). It seems that the principle should be that all children are given KT applications with the same frequency. Perhaps it could be interesting to compare the effects between groups with different frequency. Nevertheless, we believe that the results obtained in this research are of interest in the context of possibility to use KT for urinary incontinence in children. The KT method may serve as an effective complementary form of physiotherapy for children with urinary incontinence.

A retrospective study of stage IB node-negative cervical cancer treated with adjuvant radiation with standard pelvic versus central small pelvic fields

Objective: To compare two types of postoperative radiation therapy (PORT) in early-stage, node-negative cervical cancer treated at Groote Schuur Hospital, Cape Town, South Africa.Materials and meth...

A Robust and Affordable Table Indexing Approach for Multi-isocenter Dosimetrically Matched Fields.

Purpose Radiotherapy treatment planning of extended volume typically necessitates the utilization of multiple field isocenters and abutting dosimetrically matched fields in order to enable coverage beyond the field size limits. A common example includes total lymphoid irradiation (TLI) treatments, which are conventionally planned using dosimetric matching of the mantle, para-aortic/spleen, and pelvic fields. Due to the large irradiated volume and system limitations, such as field size and couch extension, a combination of couch shifts and sliding of patients are necessary to be correctly executed for accurate delivery of the plan. However, shifting of patients presents a substantial safety issue and has been shown to be prone to errors ranging from minor deviations to geometrical misses warranting a medical event. To address this complex setup and mitigate the safety issues relating to delivery, a practical technique for couch indexing of TLI treatments has been developed and evaluated through a retrospective analysis of couch position.MethodsThe indexing technique is based on the modification of the commonly available slide board to enable indexing of the patient position. Modifications include notching to enable coupling with indexing bars, and the addition of a headrest used to fixate the head of the patient relative to the slide board. For the clinical setup, a Varian Exact CouchTM (Varian Medical Systems, Inc, Palo Alto, CA) was utilized. Two groups of patients were treated: 20 patients with table indexing and 10 patients without. The standard deviations (SDs) of the couch positions in longitudinal, lateral, and vertical directions through the entire treatment cycle for each patient were calculated and differences in both groups were analyzed with Student's t-test.ResultsThe longitudinal direction showed the largest improvement. In the non-indexed group, the positioning SD ranged from 2.0 to 7.9 cm. With the indexing device, the positioning SD was reduced to a range of 0.4 to 1.3 cm (p < 0.05 with 95% confidence level). The lateral positioning was slightly improved (p < 0.05 with 95% confidence level), while no improvement was observed in the vertical direction.ConclusionsThe conventional matched field TLI treatment is error-prone to geometrical setup error. The feasibility of full indexing TLI treatments was validated and shown to result in a significant reduction of positioning and shifting errors.

PD26-07 URETHRAL DIVERTICULA IN WOMEN ARE ASSOCIATED WITH INCREASED URETHRA-SPHINCTER COMPLEX VOLUMES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Non-neurogenic Voiding Dysfunction II1 Apr 2017PD26-07 URETHRAL DIVERTICULA IN WOMEN ARE ASSOCIATED WITH INCREASED URETHRA-SPHINCTER COMPLEX VOLUMES Eskinder Solomon, Sahar Naseeri, Sachin Malde, Mahreen Pakzad, Rizwan Hamid, Jeremy Ockrim, and Tamsin Greenwell Eskinder SolomonEskinder Solomon More articles by this author , Sahar NaseeriSahar Naseeri More articles by this author , Sachin MaldeSachin Malde More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Rizwan HamidRizwan Hamid More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1215AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The aetiology of urethral diverticula in women is unknown. Blockage of drainage and subsequent infection of paraurethral glands have been suggested but the primary initiating pathology remains to be elucidated. We have postulated that functional obstruction secondary to a high-tone non-relaxing sphincter may be the primary initiating pathology leading to the formation of a proximal to mid-urethral diverticulum (UD). As urethral pressure profilometry is unreliable in a urethra with a diverticulum, the urethra-sphincter complex volume may be used as a proxy for the maximal urethral closure pressure. We assessed whether urethra-sphincter complex volumes in female patients with proximal to mid-UD are higher than those without. METHODS The clinical and MRI data of 17 women with a mean age (± SD) of 49.4 years (±13.2) with the ostium of the diverticulum at or proximal to 2/3 the length of the urethra were reviewed. A consultant uro-radiologist outlined the urethra-sphincter complex using pelvic axial small field of view T2-weighted MRI sequences with 3 mm slices. OsiriX© was used to determine the urethra-sphincter complex volume. The findings were compared with a control group consisting of 24 age matched women of mean age 50.8 years (± 11.2 years) having MRI for unrelated conditions. RESULTS The mean urethra-sphincter complex volume for the UD group was 10.01 cm3 (±6.97 cm3). The mean urethra-sphincter volume of the control group was 3.92 cm3 (± 1.60 cm3). This difference was statistically significantly (p = 0.01). CONCLUSIONS Women with proximal-urethral diverticulum have significantly higher urethra-sphincter complex volumes than those who do not. This finding suggests that high pressure in the proximal urethra during a void secondary to a high-tone non-relaxing sphincter may contribute to the formation of a urethral diverticulum. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e508-e509 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Eskinder Solomon More articles by this author Sahar Naseeri More articles by this author Sachin Malde More articles by this author Mahreen Pakzad More articles by this author Rizwan Hamid More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Patterns of lymph node positivity on 11C-acetate PET imaging in correlation to the RTOG pelvic radiation field for prostate cancer

Purpose11C-acetate positron emission tomography (PET) imaging allows for the detection of occult metastatic disease that may otherwise go undetected with standard imaging for prostate cancer (PCa). The aim of this study was to evaluate lymph node coverage of the standard Radiation Therapy Oncology Group (RTOG) whole pelvic radiation therapy (WPRT) field in patients found to have node-positive PCa determined by 11C-acetate PET imaging. Methods and materialsA retrospective analysis was conducted on 125 PCa patients who underwent 11C-acetate PET scans at our institution between 2007 and 2014. Patients were included if they had evidence of nodal disease without distant metastatic cancer. Individual lymph nodes were characterized by location, size, and relationship to the RTOG WPRT field. ResultsA total of 55 11C-acetate PET scans (from 54 men) met criteria for inclusion in the study. Median age at diagnosis was 61 years. Median prostate-specific antigen values at diagnosis and at the time of the scan were 9.2 and 8.1 ng/mL, respectively. A total of 159 positive lymph nodes were identified, 78% of which were smaller than 1 cm. The most frequently involved lymphatic regions were the external iliacs (38.4%), para-aortics (19.5%), and common iliacs (16.3%). Additionally, 10.1% of positive nodes were identified as nodes of Cloquet. Of the positive nodes, 51.6% were determined to reside outside of the radiation field and, of those, the most common sites were para-aortic (36.9%), proximal common iliac (17.8%), distal external iliac (17.8%), and nodes of Cloquet (17.8%). ConclusionsBased on 11C-acetate PET imaging in patients with PCa, the standard RTOG WPRT field may miss more than one-half of all positive lymph nodes. Clinicians should be aware of the potential for insufficient nodal coverage when using the standard RTOG WPRT field in patients with node-positive PCa. 11C-acetate PET imaging may be useful in defining target volumes for these patients.

Patterns of relapse and second malignancy after adjuvant external beam radiation therapy for stage I-II seminoma.

428 Background: To determine relapse rate, patterns of relapse and risk of second malignancy (SM) from a large single institution experience of adjuvant external beam radiation therapy (RT) for stage I-II seminoma. Methods: 463 patients with clinical stage I (n = 339) and II (n = 124) seminoma underwent adjuvant RT (median 25.5Gy) between 2/1990 and 11/2015. Data was gathered by retrospective chart review. Patients with &gt; 5 years of follow-up (n = 312) were included in analysis of SM risk. Of stage II patients, 72% (89/124) received a boost to gross disease (median 4.5Gy). Field design was para-aortic nodal region only (n = 96), para-aortic and ipsilateral pelvic nodal region (n = 351) or para-aortic and bilateral pelvic nodal region (n = 8). Field design was not available for 8 patients. Patients were followed with clinical exam, serial imaging, and tumor markers. Relapse and SM were confirmed pathologically. Results: At median follow-up of 7.9 years, there were 20 relapses (median 13.2 months; range 2.5-55.3 months). There were 9 and 11 relapses in stage I and II patients, respectively, with 7/20 (35%) occurring &gt; 2 years after RT. Relapses were identified by clinical symptoms (n = 7), imaging (n = 9), or elevated serum markers (n = 4). Sites of relapses included the lung/mediastinum (n = 10), retroperitoneum/pelvis (n = 5), bone (n = 3) and inguinal nodes (n = 2). 15 (3 pelvic) occurred after para-aortic and ipsilateral pelvic lymph node RT, while 5 (2 pelvic) occurred after para-aortic RT alone. 19/20 patients received cisplatin-based chemotherapy for relapse and were without evidence of disease at last follow-up (median 123 months). Of 35 total non-testicular SM (33 patients), 17 (48.6%) were in the RT field, 4 (11.4%) were marginal and 14 (40%) were out of field. Common SM were prostate (10), lymphoma (4), bladder (3) and kidney (3). The 5 and 10 year overall survival for the cohort is 99.2% and 97.9%, respectively. Conclusions: Stage I-II seminoma patients have a low risk of relapse and SM following adjuvant RT. Relapse is less common in patients treated with para-aortic and pelvic fields. More than 1/3 of relapses occur more than 2 years after adjuvant RT, necessitating long term clinical, radiographic and biochemical follow-up.

Reduced pelvic field sparing anastomosis for postoperative radiotherapy in selected patients with mid-upper rectal cancer.

The aim of this study was to report the clinical results of reduced pelvic field radiotherapy (RT), excluding the anastomotic site, after total mesorectal excision in selected patients with rectal cancer. Between 2011 and 2014, 99 patients underwent upfront surgery for clinically less-advanced tumors but were finally diagnosed as pT3/N+. Among them, 50 patients with mid–upper rectal cancer who received postoperative RT with a reduced pelvic field were included in this retrospective review. This group was composed of patients with high seated tumors, complete resection with a clear circumferential resection margin, and no complication during surgery. We investigated treatment outcomes, toxicity and the effect of RT-field reduction on organs-at risk in 5 randomly selected patients. During the median follow-up period of 42 months (range: 15−59 months), tumors recurred in 9 patients (18%). The 3-year overall and disease-free survival were 98% and 81%, respectively. Distant metastasis was the dominant failure pattern (n = 8, 16%), while no recurrences occurred at or near anastomotic sites. No anastomotic complications were found on pelvic examination, images and/or colonoscopy. Reported acute and late RT-related toxicities were mostly mild to moderate, with only small numbers of Grade 3 toxicities. None of the patients developed Grade 4−5 acute or late toxicity. With a caudally reduced field, 64% reduction in absolute anastomotic exposure at the maximum dose was achieved compared with the traditional whole-pelvic field (P = 0.008). The reduced pelvic field RT was able to minimize late anastomotic complication without increasing its recurrence in selected patients with mid–upper rectal cancer in the postoperative setting.

A postoperative scoring system for distant recurrence in node-positive cervical cancer patients after radical hysterectomy and pelvic lymph node dissection with para-aortic lymph node sampling or dissection

ObjectiveTo identify risk factors for distant recurrence in node-positive cervical cancer patients who underwent radical hysterectomy and pelvic lymph node dissection (PLND) with para-aortic lymph node sampling (PALNS) or para-aortic lymph node dissection (PALND). MethodsA total of 299 patients in whom lymph node metastasis was confirmed after radical surgery at Asan Medical Center for stage IA2 to IIB cervical cancer from February 2001 to December 2012 were identified. In all, 72 (24.1%) patients underwent PLND only and 227 (75.9%) underwent PLND with PALNS or PALND. Four patients were excluded due to diagnosed with small cell carcinoma. The clinicopathologic data of 223 patients were retrospectively analyzed. Distant recurrence was defined as recurrence at a site over the pelvic radiation field. ResultsAmong all 223 study patients, the mean number of positive lymph nodes was 4.46. There were 54 (24.2%) patients with distant metastasis. Multivariate analyses using the Cox proportional hazards model showed that histologic types (HR=3.031, P≤0.001 for adenocarcinoma, HR=2.302, P=0.066 for adenosquamous carcinoma), number of positive lymph nodes (HR=1.077, P≤0.001), and surgical stage (HR=1.264, P=0.022) were independent risk factors for distant recurrence of cervical cancer. A scoring system for the prediction of distant recurrence was generated by incorporating these factors and showed good discrimination and calibration (concordance index of 0.753). In an internal validation set, this scoring system showed good discrimination with a C-statistics of 0.777. According to the Hosmer-Lemeshow test, the chi-square was 0.650 and the P-value was 0.723. ConclusionsWe have developed a robust scoring system that can predict the risk of distant recurrence in node-positive cervical cancer patients after radical operation. This scoring system was used to identify a group of patients who required systemic control of distant micrometastasis. This group of patients is an appropriate target for consolidation chemotherapy after concurrent chemoradiation therapy.

Patterns of Recurrence After Postprostatectomy Fossa Radiation Therapy Identified by C-11 Choline Positron Emission Tomography/Computed Tomography

To evaluate C-11 choline positron emission tomography/computed tomography (CholPET) in staging and determining patterns of recurrence in prostate cancer patients with rising prostate-specific antigen levels after prostatectomy radiation therapy (RT). The study includes patients with biochemical failure after postprostatectomy RT who underwent CholPET between 2008 and 2015. Patient and disease characteristics were examined in relation to sites of recurrence. All RT dosimetry records were reviewed, and recurrences were mapped on a representative computed tomography dataset with their relationship relative to the irradiated fossa field as out of field (OOF), edge of field (EOF; recurrence within <45-Gy isodose lines), or in field (IF; recurrence within ≥45-Gy isodose lines). Forty-one patients were identified with 121 sites of recurrence (median 2 sites; interquartile range [IQR], 1-4). The median prostate-specific antigen level at CholPET was 3.1 (IQR, 1.9-5.6) ng/mL. Median interval from RT to biochemical failure was 24 (IQR, 10-46) months, with recurrence identified on CholPET at a median of 15 (IQR, 7-28) months from biochemical failure. Histologic confirmation of recurrence was obtained in 20 patients (49%), with the remainder confirmed by treatment response. Five patients (12%) had IF recurrences, 10 patients (24%) had EOF recurrences (median dose 10Gy; IQR, 5-30Gy), and 36 patients (88%) had OOF recurrences. Ten patients had combination failures: 6 (15%) EOF/OOF and 4 (10%) IF/OOF. Fifty-seven recurrences (47%) were pelvic nodal sites inferior to the L5-S1 interspace, of which 52 (43%) were within a pelvic RT field. Eighty-one recurrences (67%) were nodal and inferior to the aortic bifurcation. Using CholPET, we found that the majority of patients evaluated for biochemical failure recurred outside of the postprostatectomy RT field. Furthermore, most recurrence sites were nodal and inferior to the aortic bifurcation. These results provide data that may be useful for examining strategies that include elective lymph node irradiation in postprostatectomy patients.