Prophylactic Extended-field Irradiation Research Articles

Efficacy and side effects of modern radiotherapy in prophylactic extended field irradiation for locally advanced cervical cancer: A systematic review and meta-analysis (307)

Objectives: For locally advanced cervical cancer (LACC) patients without para-aortic lymph node metastasis, the standard treatment is pelvic radiotherapy plus concurrent chemotherapy. After standard treatment, 7-15% of patients had a recurrence in para-aortic lymph nodes. The present study aimed to evaluate the efficacy and side effects of modern radiotherapy in prophylactic extended field irradiation (EFI) for locally advanced cervical cancer (LACC). The present meta-analysis has been registered in PROSPERO (no. CRD42020167302). Methods: A systemic review and meta-analysis of recent studies retrieved from PubMed, EMBASE, and Cochrane databases from the establishment of the database to March 2021 was performed. All LACC patients with negative para-aortic lymph nodes received concurrent chemoradiotherapy. The experimental group consisted of patients undergoing pelvic irradiation plus prophylactic EFI, but the control group was undergoing pelvic irradiation. The primary outcomes were overall survival (OS) and para-aortic control. The secondary outcomes were: disease-free survival (DFS)/progression-free survival (PFS), distant metastasis, pelvic control, and toxicities. The quality of RCT was evaluated by the Cochrane bias risk tool. The quality of the retrospective study was evaluated by the Newcastle Ottawa scale (NOS). Revman5.3 software was used for statistical analysis. Results: A total of 180 studies were evaluated and six literatures met the inclusion criteria. Prophylactic EFI significantly improved 5-year OS (HR: 0.36 [0.22-0.59], p <0.0001) and DFS (3-year: HR: 0.53 [0.32-0.87], p=0.01; 5-year: HR: 0.45 [0.27-0.77], p=0.004). Prophylactic EFI reduced the rate of para-aortic failure (3-year: OR: 0.09 [0.01-0.70], p=0.02; 5-year: OR: 0.09 [0.03-0.30], p<0.0001) and distant metastasis (3-year: OR: 0.22 [0.11-0.45], p <0.0001; 5-year: OR: 0.53 [0.33-0.87], p=0.01). EFI did not increase the gastrointestinal toxicities (acute: OR: 1.94 [0.59-6.35], p=0.27; chronic: OR: 1.24 [0.65-2.40], p=0.51) and acute hematotoxicities (leukopenia: OR: 1.59 [0.98-2.59], p=0.06; thrombocytopenia: OR: 2.81 [0.87-9.03], p=0.08). Conclusions: The results of the present study suggested that prophylactic EFI using modern radiation techniques is beneficial for patients with LACC. Because five out of six pieces of literature included in our study are retrospective studies, prospective, large sample, and multicenter clinical trials are needed to further verify the impact of prophylactic EFI. Objectives: For locally advanced cervical cancer (LACC) patients without para-aortic lymph node metastasis, the standard treatment is pelvic radiotherapy plus concurrent chemotherapy. After standard treatment, 7-15% of patients had a recurrence in para-aortic lymph nodes. The present study aimed to evaluate the efficacy and side effects of modern radiotherapy in prophylactic extended field irradiation (EFI) for locally advanced cervical cancer (LACC). The present meta-analysis has been registered in PROSPERO (no. CRD42020167302). Methods: A systemic review and meta-analysis of recent studies retrieved from PubMed, EMBASE, and Cochrane databases from the establishment of the database to March 2021 was performed. All LACC patients with negative para-aortic lymph nodes received concurrent chemoradiotherapy. The experimental group consisted of patients undergoing pelvic irradiation plus prophylactic EFI, but the control group was undergoing pelvic irradiation. The primary outcomes were overall survival (OS) and para-aortic control. The secondary outcomes were: disease-free survival (DFS)/progression-free survival (PFS), distant metastasis, pelvic control, and toxicities. The quality of RCT was evaluated by the Cochrane bias risk tool. The quality of the retrospective study was evaluated by the Newcastle Ottawa scale (NOS). Revman5.3 software was used for statistical analysis. Results: A total of 180 studies were evaluated and six literatures met the inclusion criteria. Prophylactic EFI significantly improved 5-year OS (HR: 0.36 [0.22-0.59], p <0.0001) and DFS (3-year: HR: 0.53 [0.32-0.87], p=0.01; 5-year: HR: 0.45 [0.27-0.77], p=0.004). Prophylactic EFI reduced the rate of para-aortic failure (3-year: OR: 0.09 [0.01-0.70], p=0.02; 5-year: OR: 0.09 [0.03-0.30], p<0.0001) and distant metastasis (3-year: OR: 0.22 [0.11-0.45], p <0.0001; 5-year: OR: 0.53 [0.33-0.87], p=0.01). EFI did not increase the gastrointestinal toxicities (acute: OR: 1.94 [0.59-6.35], p=0.27; chronic: OR: 1.24 [0.65-2.40], p=0.51) and acute hematotoxicities (leukopenia: OR: 1.59 [0.98-2.59], p=0.06; thrombocytopenia: OR: 2.81 [0.87-9.03], p=0.08). Conclusions: The results of the present study suggested that prophylactic EFI using modern radiation techniques is beneficial for patients with LACC. Because five out of six pieces of literature included in our study are retrospective studies, prospective, large sample, and multicenter clinical trials are needed to further verify the impact of prophylactic EFI.

A Novel Risk Factor for Para-Aortic Lymph Node Recurrence After Definite Pelvic Radiotherapy in Stage IIIB Cervical Cancer.

Background: Studies determining which patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB disease benefit from prophylactic extended-field irradiation (EFRT), which can reduce para-aortic lymph node (PALN) failure rates, are limited. The study was designed to evaluate the value of the controlling nutritional status (CONUT) score as a risk factor for predicting PALN recurrence and identifying potential indications of prophylactic EFRT. Methods: From 2010 to 2015, a retrospective review was conducted among patients with FIGO stage IIIB cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy. We analyzed para-aortic lymph node metastasis-free survival (PALNMFS) using Kaplan-Meier curves. Multivariate analyses were performed using Cox regression models. Results: A total of 116 patients with FIGO stage IIIB cervical cancer were included in the study and the median follow-up was 42.2 months (range: 3.5-104.2 months). Multivariate analysis revealed that the CONUT score (HR: 3.141; 95% CI: 2.321-5.436; P < .001) and ≥3 pelvic lymph node metastases (HR: 2.235; 95% CI: 1.428-11.242; P < .001) were independent risk predictors of PALNMFS. Compared with the low CONUT group (score<3), the high CONUT group (score≥3) was associated with a significantly worse 3-year disease-free survival rate (46.9 vs 69.5%, P = .001), a significantly lower 3-year overall survival rate (68.5 vs 79.7%, P = .016) and a significantly lower PALNMFS rate (74.8 vs 96.4%, P < .001). Conclusions: A high CONUT score (score≥3) and ≥3 pelvic metastatic lymph nodes were significant predictors of PALNMFS after pelvic radiation in FIGO stage IIIB cervical cancer patients. Patients with these risk factors might benefit from prophylactic EFRT.

A modified delineation method of para-aortic nodal clinical target volume in patients with locally advanced cervical cancer.

PurposeTo validate the nodal center coverage (NCC) of the three mainstream delineation methods of para‐aortic nodal clinical target volume (CTV) and propose a modified delineation method of para‐aortic nodal CTV in prophylactic extended‐field irradiation (EFI) of cervical cancer.MethodsA total of 106 patients with para‐aortic lymph nodes (PALNs) identified on PET/CT were included at Peking Union Medical College Hospital between 2011 and 2020. PALNs were classified as left lateral para‐aortic (LLPA), aorto‐caval (AC), and right para‐caval (RPC). Distances from the nodal center to the aorta and inferior vena cava (IVC) were measured. The NCC of the three mainstream delineation methods of para‐aortic nodal CTV (CTV‐K, CTV‐S, and CTV‐D) and a modified CTV (CTV‐M) was calculated. Radiotherapy plans were created based on 4 CTVs for 10 selected patients who received prophylactic EFI. The chi‐squared test and the Student's t‐test were performed.ResultsWe identified 344 PALNs (216 LLPA, 101 AC, and 27 RPC) in 106 patients. Mean distance from the nodal center to the aorta was 9.6 mm in the LLPA and 7 mm in the AC and from the nodal center to the IVC was 5.6 mm in the AC and 5.6 mm in the RPC. CTV‐D improved the NCC of 98% compared with 92% for CTV‐K (p = 0.002) and 95% for CTV‐S (p = 0.046). CTV‐M provided the same satisfactory NCC as CTV‐D (97% vs. 98%, p = 0.485). The V50Gy to the duodenum, the Dmean to the bilateral kidneys, and the V45Gy to the small bowel were significantly lower on the CTV‐M‐based plan than on the CTV‐D‐based plan (p = 0.001, 0.011, and 0.001, respectively).ConclusionCTV‐D provided more satisfactory NCC than CTV‐K and CTV‐S. CTV‐M provided the same satisfactory NCC as CTV‐D and reduced the dose to the critical structures.

A Prediction Model for Para-Aortic Lymph Node Metastasis in Cervical Cancer by Radiomics Analysis Using Pre-Treatment MRI Images of the Primary Tumor

Whole pelvis irradiation (WPI) is the standard radiation technique for locally advanced cervical cancer without para-aortic lymph node (PALN) metastasis. PALN is one of the most common late failure sites in patients treated with WPI. Although there are several reports about the utility of prophylactic extended-field irradiation (EFI), it is still controversial which patients benefit from prophylactic EFI. If we could predict a PALN metastasis from pre-treatment imaging data, it might help patients to select prophylactic EFI. This study aimed to construct a predictive model for the PALN metastasis in patients with cervical cancer by radiomics analysis using pretreatment magnetic resonance imaging (MRI) of the primary tumor.Data of 94 patients with cervical squamous cell carcinoma who underwent radiotherapy between 2003/10 and 2018/2 were split into two sets: 66 patients for the training/validation and 28 patients for testing. The PALN status was classified into two groups (positive or negative). Both the synchronous and metachronous PALN metastasis was classified as PALN positive. A total number of 9394 radiomics features per a patient image were extracted from T1- and T2-weighted MRI images. The set of candidate predictors were selected with the least absolute shrinkage and selection operator (LASSO) logistic regression and build predictive models with neural network classifiers were used. The precision, accuracy, and sensitivity by generating confusion matrices and the areas under the receiver operating characteristic curve (AUC) for each model were evaluated.By the LASSO analysis of the training/validation data, we found 9 radiomics features from T1-weighted MRI image and 61 radiomics features from T2-weighted MRI image for the classification. The accuracy, specificity, sensitivity, and AUC of the prediction model for the dataset in testing group were 67.9 %, 91.0%, 10.0%, and 0.60 with T1-weighted MRI image, 95.7%, 97.0%, 92.5%, and 0.98 with T2-weighted MRI image, 96.4%, 99.0%, 90.7%, and 0.99 with the combination of T1 and T2-weighted MRI images, respectively.We constructed a model to predict the PALN metastasis in patients with cervical cancer using pre-treatment MRI image-based radiomics and machine learning. The model based on T2-weighted image or combination of T1 and T2-wighted MRI image showed promising prediction accuracy. This model may be useful to select patients who benefit from prophylactic EFI.I. Nishibuchi: None. D. Kawahara: None. M. Kawamura: None. K. Kubo: None. N. Imano: None. Y. Takeuchi: None. A. Saito: None. Y. Murakami: None. Y. Nagata: None.

Potential Indications of Prophylactic Extended-field Irradiation

Potential Indications of Prophylactic Extended-field Irradiation

Prophylactic Extended-Field Irradiation in Patients With Cervical Cancer: A Literature Review.

Currently, the standard radiation field for locally advanced cervical cancer patients without evidence of para-aortic lymph node (PALN) metastasis is the pelvis. Due to the low accuracy of imaging in the diagnosis of PALN metastasis and the high incidence of PALN failure after pelvic radiotherapy, prophylactic pelvic and para-aortic irradiation, also called extended-field irradiation (EFI), is performed for patients with cervical cancer. In the era of concurrent chemoradiotherapy, randomized controlled trials are limited, and whether patients with cervical cancer can benefit from prophylactic EFI is still controversial. With conformal or intensity-modulated radiation therapy, patients tolerate prophylactic EFI very well. The severe toxicities of prophylactic EFI are not significantly higher than those of pelvic radiotherapy. We recommend delivering prophylactic EFI to cervical cancer patients with common iliac lymph nodes metastasis. Clinical trials are needed to investigate whether patients with ≥3 positive pelvic lymph nodes and FIGO stage IIIB disease can benefit from prophylactic EFI. According to the distribution of PALNs, it is reasonable to use the renal vein as the upper border of the radiation therapy field for patients treated with prophylactic EFI. The clinical target volume expansion of the node from the vessel should be smaller in the right para-caval region than in the left lateral para-aortic region. The right para-caval region above L2 or L3 may be omitted from the PALN target volume to reduce the dose to the duodenum. More clinical trials on prophylactic EFI in cervical cancer are needed.

Risk factors associated with Para-Aortic Lymph Node Failure after pelvic irradiation in patients with Cervical Cancer.

Objective: Previous studies have shown that prophylactic extended-field irradiation can reduce para-aortic lymph node failure (PALNF) rates in patients with cervical cancer. As such, this type of irradiation may particularly benefit patients with a high risk of PALNF. In the present study, we analyzed the risk factors for PALNF in patients with cervical cancer treated with pelvic irradiation in order to identify potential indications of prophylactic extended-field irradiation.Methods: We evaluated patients with 2018 FIGO stage IB3-IIIC1 cervical cancer who were treated with definitive pelvic radiotherapy or concurrent chemoradiotherapy at our institution between 2011 and 2014. Univariate and multivariate analyses were performed to identify risk factors for PALNF.Results: We included 572 patients in the study. The median follow-up period was 37.9 months. Eighteen patients (3.1%) first site of tumor relapse was the para-aortic lymph nodes, and thus showed PALNF. Using multivariate Cox regression analysis, we identified two significant risk factors for PALNF: tumor extension to the pelvic wall (hazard ratio, HR 3.60, p=0.026) and ≥ 2 pelvic MLNs (HR 5.30, p=0.005). For patients with and without risk factors, the 3-year overall survival, disease-free survival, and PALNF rates were 77.3% and 90.1% (p<0.001), 56.4% and 83.1% (p<0.001), and 12.0% and 2.3% (p<0.001), respectively.Conclusion: Tumor extension to the pelvic wall and ≥ 2 pelvic MLNs are positively associated with PALNF after pelvic irradiation in patients with cervical cancer. Further trials will be required to validate whether patients with these two risk factors may benefit from prophylactic extended-field irradiation.

Evaluation of the efficacy of prophylactic extended field irradiation in the concomitant chemoradiotherapy treatment of locally advanced cervical cancer, stage IIIB in the 2018 FIGO classification

BackgroundThe new staging system of cervical cancer issued in 2018 by the International Federation of Gynecology and Obstetrics (FIGO), calls for a new evaluation of the efficacy of prophylactic extended field irradiation (EFI) in the concomitant chemoradiotherapy/brachytherapy treatment of locally advanced cervical cancer patients (stage IIIB).MethodsWe performed a retrospective study consisting of 133 FIGO IIIB cervical cancer patients treated in the Peking Union Medical College Hospital from 2002 to 2010. The patients were distributed in two groups depending whether they were treated with EFI or pelvic only irradiation. The therapeutic efficacy, toxicity and prognostic factors of EFI were evaluated in the frame of the new FIGO staging system.ResultsWhen compared to patients who received pelvic only irradiation, patients who received prophylactic EFI showed significantly less distant metastasis and a significant improvement in their 5 years overall survival (OS), disease free survival (DFS), out of field recurrence free survival (OFRFS) and para-aortic lymph node metastasis free survival (PALNMFS). Multivariate analysis revealed that EFI is an independent prognosis factor for DFS, OFRFS and PALNMFS. Finally, although more acute complications were observed in the EFI group, there is no significantly worst acute toxicity in the EFI group.ConclusionOur retrospective analysis supports the prophylactic effect of EFI in the concomitant chemoradiotherapy treatment of IIIB patients and suggests that this prophylactic effect is associated with a clear improvement in 5-years OS, DFS, OFRFS and PALNMFS. Consequently, EFI appears to be a very valid treatment option for FIGO IIIB cervical cancer patients.

Reduction of dose to duodenum with a refined delineation method of Para-aortic region in patients with locally advanced cervical Cancer receiving prophylactic extended-field radiotherapy

BackgroundTo compare irradiation dose to the second and third portions of duodenum (Duo2 and Duo3) with a new refined and old delineation method of para-aortic region for patients with locally advanced cervical cancer (LACC) receiving prophylactic extended-field radiotherapy (EFRT).MethodsTwenty consecutive patients with LACC were treated with prophylactic EFRT from January 2016 to January 2017 at our institute. Two delineation methods of para-aortic region were designed for each patient, the old delineation method ensured a full coverage of aortic and inferior vena cava, while the right paracaval region above L3 was omitted from CTV in the new delineation method. Patients received a dose of 50.4Gy in 28 fractions for PCTV and a dose of 60.2Gy in 28 fractions for PGTV with volumetric-modulated arc therapy (VMRT). The dose delivered to Duo2 and Duo3 with these two delineation methods were compared.ResultsAll treatment plans achieved excellent target volume coverage with 95% of PCTV receiving 50.4Gy and 95% of PGTV receiving 60.2Gy. There was no difference between delineation methods in low dose level (V5, V10, V15, V20, V25) for Duo2 and Duo3. The V30, V35, V40, V45, V50, Dmax, Dmean and D2cc for Duo2 with the new and old delineation methods were 55.76% vs 80.54% (P = 0.009), 34.72% vs 70.91% (P < 0.001), 18.69% vs 55.46% (P < 0.001), 8.20% vs 41.49% (P < 0.001), 1.86% vs 21.60% (P < 0.001), 49.58Gy vs 52.91Gy (P = 0.002), 30.38Gy vs 39.22Gy (P = 0.001) and 37.90Gy vs 48.64Gy (P < 0.001) respectively. For Duo3, the new delineation method achieved significant advantages in V30, V35, V40, V45, V50 and Dmean over the old one (96.82% vs 99.25%, P = 0.021; 89.65% vs 97.21%, P = 0.001; 79.50% vs 93.18%, P < 0.001; 65.63% vs 82.93%, P < 0.001; 43.39% vs 65.60%, P < 0.001; 46.09Gy vs 49.24Gy, P < 0.001), no deference was observed regarding D2cc and Dmax with these two delineation methods.ConclusionWith the new delineation method of para-aortic area in prophylactic EFRT, significant reduction of irradiation dose to the second and third portions of duodenum in high dose area was obtained. This may further lower the incidence of duodenal toxicity when performing prophylactic EFRT for patients with LACC.

Prophylactic Extended Field Radiotherapy Can Improve The Survival of Stage IIIB Cervical Cancer According to The Updated FIGO Staging

Prophylactic Extended Field Radiotherapy Can Improve The Survival of Stage IIIB Cervical Cancer According to The Updated FIGO Staging

Which Patients with Cervical Cancer Could Benefit from Prophylactic Extended-Field Irradiation?

To identify the potential indication of prophylactic extended-field irradiation therapy (EFRT) in cervical cancer patients treated with concurrent chemotherapy. We reviewed patients with 2018 FIGO stage IB3-IIIC1 or IVA cervical cancer and treated with definitive pelvic radiation therapy (PRT) or prophylactic EFRT combined with concurrent chemotherapy in our institute between 2011 and 2014. The upper border of PRT was at the levels of aortic bifurcation and the superior border of prophylactic EFRT was at the level of T12 or renal vessel. A dose of 50.4Gy in 28 fractions was delivered to the target volume with intensity modulated radiation therapy. Cisplatin was conducted weekly during radiotherapy. To select high-risk patients, the DFS rates of patients in some potential subgroups were compared between two radiation fields. For the selected high-risk patients, overall survival (OS), DFS, distant failure and para-aortic lymph nodes failure (PALNF) rates were compared between patients treated with PRT and EFRT. A total of 726 patients were included into this study, with 573 patients treated with PRT and 175 patients treated with EFRT. Analyze in subgroups revealed that prophylactic EFRT had the trend to improve the DFS of patients with pelvic MLNs ≥ 2, diameter of pelvic MLNs ≥1.5cm and pelvic wall involvement. Patients with these three factors were selected as high-risk patients. Of the 206 high-risk patients, 99 patients were treated with PRT and 107 patients were treated with EFRT. Patients in prophylactic EFRT group trend to have more advanced disease. For high-risk patients treated with PRT and prophylactic EFRT, the 3-year OS, DFS, distant failure and PALNF rates were 78.2% and 78.6% (p=0.585), 57.2% and 75.9% (p=0.023), 32.1% and 13.9% (p=0.034), 12.6% and 1.0% (p=0.006), respectively. After Multivariate analysis, prophylactic EFRT was significant in predicting DFS (p=0.002), distant failure (p=0.003) and PALNF(p=0.026). It was not an independent factor of OS (p=0.107). The incidences of ≥ grade 3 complications in high-risk patients treated with PRT and prophylactic EFRT were 3.0% and 8.4%(p=0.099), respectively. Compared with PRT, prophylactic EFRT could improve the DFS, distant failure, and PALNF in cervical cancer patients with pelvic MLNs ≥ 2, pelvic MLNs ≥ 1.5cm, or pelvic wall involvement. The present study contributed direct evidence on the indication of prophylactic EFRT for patients with cervical cancer.

Escalated radiation and prophylactic extended field nodal irradiation are beneficial for FIGO IIIB cervical cancer patients\u2019 prognosis

BackgroundCurrently, the standard treatment for locally advanced cervical cancer patients is concurrent chemoradiotherapy. Here we aim to evaluate therapeutic efficacy, treatment failure, toxicity and prognostic factors for FIGO IIIB cervical cancer patients.MethodsA comprehensive retrospective analysis was performed to understand various factors which contribute to IIIB cervical cancer prognosis. In total 223 well defined patients were assigned according to their pathological subtype, age, pre-treatment HGB level, tumor size, pelvic lymph node (LN) metastasis, para-aortic LN metastasis as well as external irradiation technologies, treatment duration, point A EQD2 dose and concurrent chemotherapy cycles. We then performed correlation studies of these factors and OS, DFS, LCR, DMFS using univariate and multivariate analysis respectively.ResultsWe managed to achieve 207 (92.8%) complete response (CR) and 16 (7.2%) partial response (PR) with acceptable adverse effects. Notably, the 5 years OS, DFS, LCR, DMFS for these patients were 61.1, 55.2, 83.6 and 66.4% respectively. Importantly, our studies suggest that escalated point A EQD2 can significantly improve OS, DFS and LCR for FIGO IIIB cervical cancer patients, furthermore, patients without para-aortic LN metastasis who received prophylactic extended field irradiation have significant survival advantage for DFS and a tendency to improve OS and DMFS.ConclusionsOur results suggest that FIGO IIIB cervical cancer patients should receive higher EQD2 (≥98Gy10) radiotherapy, moreover, patients without para-aortic LN metastasis should receive prophylactic extended field nodal irradiation to improve prognosis.

Nomogram for predicting para-aortic lymph node metastases in patients with cervical cancer

Some patients with cervical cancer may benefit from prophylactic extended-field radiotherapy (EFRT). However, the indications for prophylactic EFRT were unclear. In this study, we constructed a nomogram to predict para-aortic lymph node (PALN) metastases in cervical cancer. Between January 2011 and June 2017, 1903 patients with stage IA-IVA cervical cancer received definitive radiotherapy. Patients who were diagnosed during 2011-2015 were assigned to a model development cohort (n = 1193) and others were assigned to a validation cohort (n = 710). Possible predictors were analysed using logistic regression models with model development cohort. A nomogram based on this work was constructed and validated. A total of 130 patients (6.8%) suffered from PALN metastases, with 81 patients (6.8%) in the model development cohort and 49 patients (6.9%) in the validation group. Multivariate analysis of the model development cohort demonstrated that histology, tumour size, bilateral pelvic lymph node (PLN) metastases, common iliac lymph node metastases and PLN convergence or muscle involvement were significant predictive factors of PALN metastases. The nomogram including these five factors showed good predictive accuracy (concordance index 0.916, 95% confidence interval, CI 0.881-0.952) in the model development cohort. In the validation cohort, the nomogram showed good discrimination (concordance index 0.949, 95% CI 0.911-0.988) and the predicted probability was close to the actual observed outcome. We have developed a robust tool that is able to predict PALN metastases in patients with cervical cancer. The nomogram could help physicians to decide whether prophylactic EFRT should be performed for patients with cervical cancer patients.

Prognostic analysis of extended field intensity-modulated radiation therapy for cervical cancer

In recent decades, accurate radiotherapy has developed rapidly, and the application of intensity-modulated radiation therapy (IMRT) in gynecologic malignancies has increased gradually in the past ten years. Many studies have shown a high rate of occult abdominal aortic lymph node metastasis in patients with advanced cervical cancer, while pelvic and abdominal aortic lymph node status are important prognostic factors in cervical cancer patients. Conventional prophylactic extended field radiotherapy has the characteristics of severe gastrointestinal side effects, and synchronic chemotherapy is also controversial. The optimal dose of radiation therapy for metastatic pelvic and abdominal aortic lymph nodes is still controversial. This paper mainly analyzed the effect of prophylactic extended conformal radiotherapy with concurrent chemotherapy on the prognosis of cervical cancer and the dose-effect relationship of lymph node positive region. Key words: Cervical neoplasm/intensity modulated radiation therapy; Extended field radiotherapy; Concurrent chemotherapy; Lymph node; Survival rate

Prophylactic extended-field irradiation with concurrent chemotherapy for pelvic lymph node-positive cervical cancer.

PurposeThis study aimed to evaluate whether prophylactic extended-field pelvic radiotherapy (EF-PRT) yields better results than standard whole pelvic radiotherapy (WPRT) in patients with pelvic lymph node-positive cervical cancer treated with concurrent chemoradiotherapy (CCRT).Materials and MethodsA total of 126 cases of stage IB-IVA cervical cancer that had pelvic lymph node involvement in magnetic resonance imaging and were treated with CCRT between 2000 and 2016 were reviewed. None of the patients had paraaortic lymph node (PALN) metastases. The patients were classified to two groups, namely, those treated with EF-PRT, including prophylactic para-aortic radiotherapy, and those treated only with WPRT. The median dose to the PALN area in patients treated with EF-PRT was 45 Gy. All patients received concurrent cisplatin-based chemotherapy.ResultsOverall, 52 and 74 patients underwent EF-PRT and WPRT, respectively. Patient characteristics and irradiated dose were not significantly different, except the dose to the para-aortic area, between the two groups. The median follow-up period was 75.5 months (range, 5 to 195 months). The 10-year cumulative recurrence rate of PALN for EF-PRT vs. WPRT was 6.9% and 10.1% (p = 0.421), respectively. The 10-year disease-free survival and overall survival for EF-PRT vs. WPRT were 69.7% vs. 66.1% (p = 0.748) and 71.7% vs. 72.3% (p = 0.845), respectively. Acute gastrointestinal complications were significantly higher in EF-PRT (n = 21; 40.4%) than WPRT (n = 26; 35.1%) (p = 0.046). Late toxicities were not significantly different in both groups.ConclusionIn this study, prophylactic radiotherapy for PALN does not have an additional benefit in patients with pelvic lymph node-positive cervical cancer treated with CCRT.

Prophylactic irradiation of para-aortic lymph nodes for patients with locally advanced cervical cancers with and without high CA9 expression (KROG 07-01): A randomized, open-label, multicenter, phase 2 trial

Background and purposeThe efficacy of prophylactic extended-field irradiation (EFI) plus concomitant cisplatin in patients with locally advanced uterine cervical cancer (LAUCC) is unknown, nor is it known whether tumor carbonic anhydrase IX (CA9) expression level, a hypoxia marker, influences survival outcome. Material and methodsWe recruited patients with UCC, FIGO stage IB1 with pelvic lymph node (LN) metastases to IVA with negative para-aortic LN on PET/CT. CA9 expression was examined and patients were randomized to either EFI or pelvic only radiotherapy (PRT) in each CA9 group. The primary outcomes were para-aortic recurrence-free survival (PARFS) and disease-free survival (DFS). ResultsBetween 2006 and 2011, 79 patients with CA9-positive and 37 with CA9-negative tumors were enrolled, respectively. The median follow-up period was 69.2months (range 6.8–102.1). For CA9-positive patients, 5-year PARFS was 100% and 81.7% for those receiving EFI and PRT (p=0.007), respectively. DFS was 78.6% for EFI and 71.3% for PRT patients (p=0.353). For CA9-negative patients, 5y PARFS was 100% and 94.1% for EFI and PRT (p=0.317), respectively. DFS was 100% for EFI and 70.7% for PRT (p=0.018). ConclusionEFI significantly reduced recurrences in PAN in patients with CA9-positive tumors, but survival outcome was not improved, due to high local recurrence and high distant metastases rates. This study indicates the necessity for new therapeutic strategies for LAUCC patients whose tumors show high CA9 expression.

Five-year outcome of concurrent radiotherapy and chemotherapy in Saudi women with locally advanced cervical cancer: single-institution experience

BACKGROUND AND OBJECTIVESWe aimed to evaluate long-term treatment outcomes and toxicity profile of combined radiotherapy and chemotherapy in Saudi women with locally advanced cervical cancer.DESIGN AND SETTINGSRetrospective study in a tertiary care cancer center in Riyadh, Saudi Arabia.METHODS AND MATERIALSThe medical records of patients with histopathologically proven, locally advanced cervical cancer were analyzed. These patients received three-dimensional conformal radiotherapy with concurrent chemotherapy followed by high dose rate brachytherapy in our center between July 2007 and April 2012. The data regarding the safety profile, response rates, occurrence of locoregional or distant failure, disease-free survival, and overall survival rates were recorded.RESULTSThe median follow-up period was 60 months (range, 8–66) for 74 patients. The median age of study population was 52.3 years (32–78), and the stage IIB was the predominant stage (49 patients [66.2%]). A total of 45 patients (60.9%) had radiologic-positive pelvic ± para-aortic lymphadenopathy. The 5-year locoregional and distant control rates were 84.3% and 78.5%, respectively. The 5-year disease-free and overall survival rates were 75.7% and 64.5%, respectively. Stage, nodal status, and hemoglobin levels were found to be important prognostic factors for locoregional and distant control. Acute grade 3 hematological and nonhematological toxicities were seen in 4 (5.4%) and 4 (5.4%) patients. Late toxicities were mild, and only 1 (1.4%) patient presented with subacute intestinal obstruction.CONCLUSIONConcurrent chemoradiation in Saudi women with locally advanced cervical cancer showed better locoregional and distant control and survival rates with minimal toxicity.

Prophylactic extended-field irradiation of para-aortic lymph nodes in stages IIB and bulky IB and IIA cervical carcinomas. Ten-year treatment results of RTOG 79-20

Prophylactic extended-field irradiation of para-aortic lymph nodes in stages IIB and bulky IB and IIA cervical carcinomas. Ten-year treatment results of RTOG 79-20