Pelvic Radiotherapy For Cervical Cancer Research Articles

Insights into pelvic insufficiency fracture following pelvic radiotherapy for cervical cancer: a comparative review

BackgroundRadiotherapy (RT)-induced pelvic insufficiency fractures (PIF) are prevalent in patients with cervical cancer. Inconclusive studies on PIF after cervical irradiation create uncertainty. This review examined PIF after RT in cervical patients, including its pathobiology, likely locations of fractures, incidence, clinical symptoms, and predisposing factors. We further discussed study limitations and therapeutic possibilities of PIF.MethodsThe following online resources were searched for relevant articles: Google Scholar and PubMed. The keywords ‘pelvic insufficiency fractures’, ‘cervical carcinoma’ and ‘cervical cancer’, as well as ‘chemoradiotherapy’, ‘chemoradiation’, and ‘radiotherapy’, were some of the terms that were used during the search.ResultsPatients with PIF report pelvic pain after radiation treatment for cervical cancer; the incidence of PIF ranges from 1.7 to 45.2%. Evidence also supports that among all patients treated with pelvic radiation, those who experienced pelvic insufficiency fractures invariably had at least one sacral fracture, making it the most frequently fractured bone in the body. Menopausal status, weight, BMI, age, and treatments and diagnosis modalities can influence PIF during radiotherapy.ConclusionsIn conclusion, our comparative review of the literature highlights significant heterogeneity in various aspects of PIF following radiation for patients with cervical cancer. This diversity encompasses prevalence rates, associated risk factors, symptoms, severity, diagnosis methods, preventive interventions, and follow-up periods. Such diversity underscores the complexity of PIF in this population and emphasizes the critical need for further research to elucidate optimal management strategies and improve patient outcomes.

Comparison of photon energies and field techniques for ovarian dose reduction in volumetric modulated arc therapy

For fertility preservation in young female patients undergoing pelvic radiotherapy for cervical cancer, lateral ovarian transposition (LOT) is a procedure that moves the ovaries away from the radiation field. However, it is still challenging to fully protect the ovaries from radiation damage in volumetric modulated arc therapy (VMAT). In this study, we optimized VMAT techniques and simulated the effect of the LOT position on the ovarian dose. Ten cervical cancer patients who received pelvic radiotherapy after LOT were retrospectively analyzed. A restricted arc plus split field technique, which incorporated beam avoidance sectors, split field, fixed jaw, and orthogonal collimator orientation with 10 MV energy (rasf-10MV-VMAT), was designed to minimize the dose to the ovaries. This technique was compared with dual-arc conventional VMAT (dac-6MV-VMAT) and restricted arc and field VMAT (raf-6MV-VMAT) techniques with 6 MV energy. Ovarian dose, target coverage, and organs at risk (OAR) sparing were compared. The location of the ovaries in the anterior-posterior and superior-inferior directions was changed to simulate the effect of the LOT position on the ovarian dose. Compared to dac-6MV-VMAT and raf-6MV-VMAT, rasf-10MV-VMAT decreased the ovarian dose significantly more, especially for a low-dose volume. Both ovaries, received a 44.0–52.1 % lower volume of >3 Gy dose, and (0.5–1.9 Gy) lower maximum and mean doses with rasf-10MV-VMAT (p < 0.05). Rasf-10MV-VMAT also improved target conformity and coverage more than raf-6MV-VMAT (p < 0.05) and reduced the bladder mean dose more than dac-6MV-VMAT (p < 0.05). The ovarian dose decreased with the distance from the target contour, and placing the ovaries near the mid-frontal plane or as high as possible after the LOT lowered ovarian exposure. This technique, using 10 MV photon energy combined with field technique optimization, reduced the ovarian dose, particularly by decreasing the low-dose exposure of ovarian tissue and improving the target conformity simultaneously. The ovarian dose could be minimized by a proper LOT position. This optimized technique could enhance ovarian protection and fertility preservation for young female survivors of cervical cancer.

A machine learning model for grade 4 lymphopenia prediction during pelvic radiotherapy in patients with cervical cancer.

Background/purposeSevere lymphopenia during pelvic radiotherapy (RT) predicts poor survival in patients with cervical cancer. However, the risk of severe lymphopenia has not been well predicted. We developed a machine learning model using clinical and dosimetric information to predict grade 4 (G4) lymphopenia during pelvic RT in patients with cervical cancer.MethodsThis retrospective study included cervical cancer patients treated with definitive pelvic RT ± induction/concurrent chemotherapy. Clinical information and a set of dosimetric parameters of external beam radiotherapy plan were collected. G4 lymphopenia during RT, which was also referred to as G4 absolute lymphocyte count (ALC) nadir, was defined as ALC nadir <0.2 × 109 cells/L during RT according to Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Elastic-net logistic regression models were constructed for the prediction of G4 lymphopenia during pelvic RT using a repeated cross-validation methodology.ResultsA total of 130 patients were eligible, and 43 (33.1%) patients had G4 lymphopenia during RT. On multivariable analysis, G4 ALC nadir was associated with poor overall survival (OS) [hazard ratio (HR), 3.91; 95% confidence interval (CI), 1.34–11.38, p = 0.01]. Seven significant factors [Eastern Cooperative Oncology Group (ECOG) performance score, pre-RT hemoglobin, pre-RT lymphocytes, concurrent chemotherapy, gross tumor volume of regional lymphadenopathy (GTV_N volume), body volume, and maximum dose of planning target volume receiving at least 55 Gy (PTV_5500 Dmax)] were obtained by elastic-net logistic regression models and were included in the final prediction model for G4 ALC nadir. The model’s predicting ability in test set was area under the curve (AUC) = 0.77 and accuracy = 0.76. A nomogram of the final predicting model was constructed.ConclusionsThis study developed and validated a comprehensive model integrating clinical and dosimetric parameters by machine learning method, which performed well in predicting G4 lymphopenia during pelvic RT for cervical cancer and will facilitate physicians to identify patients at high risk of G4 lymphopenia who might benefit from modified treatment approaches.

Pelvic radiotherapy for cervical cancer affects importantly the reproducibility of cytological alterations evaluation

Backgroundto evaluate the intraobserver and interobserver reproducibility of cervical cytopathology according to previous knowledge of whether patients received radiotherapy (RT) treatment or not.MethodsThe study analyzed a sample of 95 cervix cytological slides; 24 with cytological abnormalities (CA) and presence of RT; 21 without CA and presence of RT; 25 without CA and without previous RT; 25 with CA and without previous RT. Two cytopathology (CP) evaluations of the slides were carried out. For the first CP re-evaluation, the cytotechnologist was blinded for the information of previous RT. For the second CP re-evaluation, the cytotechnologist was informed about previous RT. The results were analyzed through inter and intraobserver agreement using the unweighted and weighted kappa.ResultsPost radiotherapy effects were identified in 44.4% of cases that undergone previous pelvic RT. The agreement for RT status was 66.32% (unweighted K = 0.31, 95%CI: 0.13; 0.49, moderate agreement). The intraobserver agreement, regarding the cytological diagnoses, regardless of radiotherapy status, was 80.32% (weighted K = 0.52, 95%CI: 0.34; 0.68). In no RT group, the intraobserver agreement was 70% (weighted K = 0.47, 95%CI: 0.27;0.65) and in patients that received RT, the intraobserver agreement was 84.09% (unweighted K = 0.37, 95%CI: 0.01;0.74). The interobserver agreement between cytopathology result (abnormal or normal) in the group with RT, considering normal and abnormal CP diagnosis was 14.0% and 12.5%, respectively. There was no association between the cytological alterations and the median time between the end of RT and the cytological diagnosis.ConclusionThis study showed that RT has an important impact in CP diagnosis because the agreement, also in interobserver and intraobserver analysis, had high discrepancy in patients that received RT. Also, demonstrated that it is difficult to recognize the presence of RT in cytological slides when this information is not provided.

Tumor-specific outcome of metachronous uterine malignancy after pelvic irradiation for cervical cancer

ObjectiveTo examine survival of women who develop metachronous uterine malignancy after definitive pelvic radiotherapy for cervical cancer. MethodsThis retrospective observational study examined the Surveillance, Epidemiology, End Results Program between 1973 and 2013. Women with cervical cancer who received definitive radiotherapy without hysterectomy were examined for the diagnosis of metachronous uterine malignancy (n = 5277). Survival was compared between metachronous and non-metachronous uterine malignancies according to tumor factors. ResultsThe 10- and 20-year cumulative incidences of metachronous uterine malignancy were 0.6% and 1.2%, respectively. When compared to non-metachronous uterine malignancy, metachronous tumor were more likely to be non-endometrioid and advanced-stage (both, P < 0.001). As a whole cohort, metachronous uterine malignancy was significantly associated with decreased overall survival (OS) compared to non-metachronous tumors (hazard ratio [HR] 4.22, P < 0.001). OS was significantly worse in metachronous compared to non-metachronous malignancies, although the magnitude of statistical significance was greater for endometrioid tumors (HRs for endometrioid versus non-endometrioid: 6.17 versus 1.92). For grade 1–2 endometrial cancer, metachronous cases had significantly decreased OS compared to non-metachronous cases, a larger difference than that seen in higher grade tumors (HRs for grade 1–2 versus 3: 7.79 versus 2.15). Similarly, in early-stage endometrial cancer, metachronous cases had significantly decreased OS, with a greater HR compared to advanced-stage disease (HRs for stage I–II versus III–IV: 5.29 versus 2.29). ConclusionRadiotherapy-associated metachronous uterine malignancy after cervical cancer is rare but commonly presents with aggressive tumor characteristics. The impact on survival is considerably high when metachronous uterine malignancy is endometrioid, low-grade, and early-stage.

Factors associated with changes in vaginal length and diameter during pelvic radiotherapy for cervical cancer.

This study reports the incidence and factors associated with vaginal stenosis and changes in vaginal dimensions after pelvic radiotherapy for cervical cancer. A descriptive longitudinal study with 139 women with cervical cancer was conducted from January 2013 to November 2015. The outcome variables were vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE v3.0) and changes in vaginal diameter and length after the end of radiotherapy. Independent variables were the characteristics of the neoplasm, clinical and sociodemographic data. Bivariate analysis was carried out using χ 2, Kruskal-Wallis and Mann-Whitney's test. Multiple analysis was carried out using Poisson regression and a generalized linear model. Most women (50.4%) had stage IIIB tumors. According to CTCAE v3.0 scale, 30.2% had no stenosis, 69.1% had grade 1 and 0.7% had grade 2 stenosis after radiotherapy. Regarding changes in vaginal measures, the mean variation in diameter was -0.6 (±1.7) mm and the mean variation in length was -0.6 (±1.3) cm. In the final statistical model, having tumoral invasion of the vaginal walls (coefficient +0.73, p<0.01) and diabetes (coefficient +1.16; p<0.01) were associated with lower vaginal stenosis and lower reduction of vaginal dimensions. Advanced clinical stage (coefficient +1.44; p=0.02) and receiving brachytherapy/teletherapy (coefficient -1.17, p<0.01) were associated with higher reduction of vaginal dimensions. Most women had mild vaginal stenosis with slight reductions in both diameter and length of the vaginal canal. Women with tumoral invasion of the vagina have an increase in vaginal length soon after radiotherapy due to a reduction in tumoral volume.

Radiothérapie et dispositifs médicaux implantables : exemple des pompes diffuseurs

Indication for radiotherapy is often questioned for patients equipped with implantable medical devices like infusion pumps as the radiation tolerance is poor or not known. We report here on the case of a patient who we treated with pelvic radiotherapy for cervical cancer and who had an infusion pump in iliac fossa. We conducted a series of tests on five identical pumps that insured that the treatment protocol is harmless to the implanted device.

Pelvic Insufficiency Fracture After Pelvic Radiotherapy for Cervical Cancer: Analysis of Risk Factors

To investigate the incidence, clinical characteristics, and risk factors of pelvic insufficiency fracture (PIF) after pelvic radiotherapy (RT) in cervical cancer. Medical records and imaging studies, including bone scintigraphy, CT, and MRI of 557 patients with cervical cancer who received whole-pelvic RT between January 1998 and August 2005 were reviewed. Eighty-three patients were diagnosed as having PIF after pelvic RT. The 5-year cumulative incidence of PIF was 19.7%. The most commonly involved site was the sacroiliac joint. Pelvic pain developed in 48 patients (57.8%) at diagnosis. Eleven patients (13.3%) needed admission or narcotics because of severe pain, and others had good relief of symptoms with conservative management. In univariate analysis, age>or=55 years (p<0.001), anteroposterior/posteroanterior parallel opposing technique (p=0.001), curative treatment (p<0.001), and radiation dose>or=50.4 Gy (p=0.005) were the predisposing factors for development of PIF. Concurrent chemotherapy (p=0.78) was not significant. Multivariate analysis showed that age>or=55 years (p<0.001), body weight<55 kg (p=0.02), curative treatment (p=0.03), and radiation dose>or=50.4 Gy (p=0.04) were significant predisposing factors for development of PIF. The development of PIF is not rare after pelvic RT. The use of multibeam arrangements to reduce the volume and dose of irradiated pelvic bone can be helpful to minimize the risk of fracture, especially in elderly women with low body weight.

Pelvic Insufficiency Fractures After Pelvic Radiotherapy for Cervical Cancer: Analysis of Risk Factors

Pelvic Insufficiency Fractures After Pelvic Radiotherapy for Cervical Cancer: Analysis of Risk Factors

Lateral ovarian transposition before radiation treatment of Hodgkin disease

Preservation of ovarian function by repositioning the ovaries out of the irradiation field is suggested in women of reproductive age before pelvic radiotherapy for cervical cancer or Hodgkin disease. In women with Hodgkin disease this is usually done at the time of staging laparotomy. A 21-year-old woman with stage IIIa Hodgkin disease underwent repositioning of the ovaries during staging laparotomy, but before planned irradiation therapy it was noted that the ovaries were back in their normal anatomic position. Outpatient laparoscopic lateral transposition of the ovaries was performed without complication. Five years after pelvic irradiation she still has normal ovarian function. In selected women with malignancy and planned irradiation therapy, laparoscopy is an alternative to laparotomy to preserve ovarian function by lateral ovarian transposition.