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85 Survey of brachytherapy practice for carcinoma of the cervix in the united states — A report of the american brachytherapy society
$22 85
86
SURVEY OF BRACHYTHERAPY PRACTICE FOR CARCINOMA OF THE CERVIX IN THE UNITED STATES - A REPORT OF THE AMERICAN BRACHYTHERAPY SOCIETY
AMBIGUITIES IN DOSE PRESCRIPTION IN HAEMOSTATIC BRACHYTHERAPY FOR CARCINOMA OF UTERINE CERVIX.
Subir Nag, Colin Orton, Dotm Young, Beth Erickson, for the American Brachytherapy Society, Reston, VA
Sharma DN, Sarkar B, Chander S, Ganesh T, Rath GK. Institute Rotary Cancer Hospital, AliMS, New Delhi, INDIA
PURPOSE: To survey the patterns of care in brachytherapy of cervical cancer in the United States. METHODS: The Clinical Research Committee of the American Brachytherapy Society (ABS) surveyed the physicians of the ABS and American Society of Therapeutic Radiologist and Oncologists (ASTRO) regarding the treatment of patients of carcinoma of the cervix by brachytherapy in 1995. RESULTS: A total of 521 responses were received. Of these responders, 206 (40%) did not perform any brachytherapy for carcinoma of the cervix in 1995. Of the other 315 responders reporting a total of 4,892 patients treated in 1995, 88% used low-dose-rate (LDR) while 24% used high-dose-rate (HDR). For LDR treatments, the median total external beam radiation therapy (EBRT) dose was 45 and 50 Gy for early and advanced cancers, respectively. The total LDR dose to point A or equivalent was 42 and 45 Gy for early and advanced cancers, respectively. For HDR treatments, the median EBRT dose was 48 and 50 Gy for early and advanced cancers, respectively. The median HDR dose to point A was 29 and 30 Gy for early and advanced cancers, respectively. The median dose per fraction was 6 Gy. Interstitial brachytherapy was used by 21% of responders. Very few responders treated with pulsed or medium dose-rates. CONCLUSION: A baseline pattern of care regarding cervical cancer brachytherapy has been established and this can serve as a guide for clinicians.
Patients with advanced carcinoma of uterine cervix often presents with profuse vaginal bleeding and require hemostatic radiotherapy (RT). The dose of hemostatic external RT ranges from 6-20 Gy in 2-6 fractions (higher dose per fraction). Altsrnative|y, hernostatlc brachytherapy may be tried wtth a single application of either standard ICRT (if possible) or wRh intravaginal ovoids. A dose of 20-40 Gy Is prescribed at the tumor surface when ovoids ere used. Though rectum might receive a significant proportion of the prescribed dose, traditionally this hemostatic dose Is disregarded from the cumulative dose calculation when curative treatment Is offered subsequently. Such patients have higher risk of developing radiation morbidity. Should we continue ignoring this dose since ICRti-38 provides no guidelines regarding consideration or abondonmont of this dose? We have analysed 20 such patients (treated from 1990 to 1994at our centre) to assess the stoppage of haomorrhage, tumor control & radiation morbidity (especially the rectal complications). The age of peUents ranged from 27 to 62 yTs (median 42 yTs). Stagewlse (FIGO) distribution was : liB, 3 pts; IliA, $ pts; ilIB 11 pts. Median hemostatlc surface dose of 25 Gy (LDR, Selectron) by ovoids was followed by curative RT (external RT + ICRT). Vaginal bleeding stopped In 14 pts within 24 hrs and all pts within 48 hrs. Four pts had grade 3, and 2 pts had grade 2 radiation procUtls. Fourtuen pts had local or distant failure with 24 months follow up. In view of the higher rectal morbldify (30'/.) in our study, we suggest that the hemostatic dose may not be totally disregarded In every pt since this dose might add to rectal complications. The decision should be indlvldualised according to the bulk of the disease and doslmetrlc calculations with computarlaed treatment planning sustsm. Simultaneously, ICRU-38 needs to be revised to incorporate the guldllnes regarding various aspects of hemostatic brachytherapy.
87
88
P R E O P E R A T I V E LDR T E C H N I Q U E S OF BRACHYTHERAPY IN PATIENTS W I T H EARLY CERVICAL CANCER.
EARLY RESULTS OF EXCLUSIVE RADIOTHERAPY WHICH WAS GIVEN ACCORDING TO ICRU 3 8 IN ADVANCED STAGE CERVICAL CARCINOMA
Sobotkowski J., Grzelak M., Pietraszek A., Kordek P. WSZ im. M. Kopemika, Lodz. Poland
M.N. And~eu. A.Saran, H. Edlnsel, F. Alloglu, T. Turgay Anke.ra Oncology Hospital, Ankara, Turkey
In 1994 authors started to use a combined modality of cervical cancer treatmenl. It consists of brachytherapy followed by radical hysterectomy and lymphadenectomy. 45 patients had initial diagnosis of IB and IIA stage of carcinoma colli uteri. To attain precise staging they were subjected to proper diagnostic procedures including US and MRI. To undergo combined treatment patients had to fulfil some rigorous conditions described in the paper. So only 36 patients qualified to this method. Authors used modified Paris radium method in II women and in 25 - afterloading caesium 137 with Selectron LDR (Nucletron). Summarized doses at A point were about 60 Gy. After 4 weeks operations m/o Wenheim were performed in operative gynecology Institutes in Lodz. Generally in 89% of patients postoperative pathologic examination has not revealed neoplastic infiltration. Remaining women underwent external radiotherapy with dose of 44 Gy. Early and late radiation morbidity assessed as good or very good according to RTOG/EORTC scale. This mode of treatment gives a chance for some patients with this diagnosis to avoid external irradiation and its complications. To strict assessment of treatment efficacy longer duration of observation is necessary.
Purpose : The aim of the study Is report our Initial experience about hrac~herapy which was applied according to ICRU 38 recommendations. Materials and Methods : From June 1994 to June 1997 80 cases of cervicad carcinoma were treated by combined external beam radiotherapy (EBRT) and MDR brachytherapy (BT). The average age of patients was 54. The stage distrubitlon according to F~'GO classification was: 2 were stage llA; 46 were stage lIB; 12 were stage IliA: 15 were stage [lIB and 5 were Stage IVA. EBRT doses were changing between 46 to 52 Gy and all of the patients received 2 fractions of MDR brachytherapy I to 15 days aRer the and of EBRT. BT was applied according to ICRU 38 and totally 60 Gy was given to the chosen referance isodose. Between two fractions of BT an additional dose of EBRT between 8-14 Gy was given as parametrlai boost. Results : 76,3 % complete rcmisston a~d 23,7 % partial remission were obtained. 6 paUents, who were completely cured, bad local recurrens and distant metastasis occured in 12 patients. 3 years survlvals for stage II. Ill and IV were 7 1 % , 56 % and 50 % respectively. Grade I[I compllcatlons were occured in 8 patients (I0 %}. 6 had scwere rectltls, 2 had lleus and l patient had rectovaglnal fistula. Conclusion : Even if it was difficult for us to decide to the fractlonatl~on schedule and close for the BT plans, as there have not been too many examples about ICRU 38 method used with HDR, the results seem to be in accordance ~vlth the literature. But. of course. LI lutlg ternl Ibllow tip IS necessary for evaluation of survtvals and cspecially Ior late complications.
86
SURVEY OF BRACHYTHERAPY PRACTICE FOR CARCINOMA OF THE CERVIX IN THE UNITED STATES - A REPORT OF THE AMERICAN BRACHYTHERAPY SOCIETY
AMBIGUITIES IN DOSE PRESCRIPTION IN HAEMOSTATIC BRACHYTHERAPY FOR CARCINOMA OF UTERINE CERVIX.
Subir Nag, Colin Orton, Dotm Young, Beth Erickson, for the American Brachytherapy Society, Reston, VA
Sharma DN, Sarkar B, Chander S, Ganesh T, Rath GK. Institute Rotary Cancer Hospital, AliMS, New Delhi, INDIA
PURPOSE: To survey the patterns of care in brachytherapy of cervical cancer in the United States. METHODS: The Clinical Research Committee of the American Brachytherapy Society (ABS) surveyed the physicians of the ABS and American Society of Therapeutic Radiologist and Oncologists (ASTRO) regarding the treatment of patients of carcinoma of the cervix by brachytherapy in 1995. RESULTS: A total of 521 responses were received. Of these responders, 206 (40%) did not perform any brachytherapy for carcinoma of the cervix in 1995. Of the other 315 responders reporting a total of 4,892 patients treated in 1995, 88% used low-dose-rate (LDR) while 24% used high-dose-rate (HDR). For LDR treatments, the median total external beam radiation therapy (EBRT) dose was 45 and 50 Gy for early and advanced cancers, respectively. The total LDR dose to point A or equivalent was 42 and 45 Gy for early and advanced cancers, respectively. For HDR treatments, the median EBRT dose was 48 and 50 Gy for early and advanced cancers, respectively. The median HDR dose to point A was 29 and 30 Gy for early and advanced cancers, respectively. The median dose per fraction was 6 Gy. Interstitial brachytherapy was used by 21% of responders. Very few responders treated with pulsed or medium dose-rates. CONCLUSION: A baseline pattern of care regarding cervical cancer brachytherapy has been established and this can serve as a guide for clinicians.
Patients with advanced carcinoma of uterine cervix often presents with profuse vaginal bleeding and require hemostatic radiotherapy (RT). The dose of hemostatic external RT ranges from 6-20 Gy in 2-6 fractions (higher dose per fraction). Altsrnative|y, hernostatlc brachytherapy may be tried wtth a single application of either standard ICRT (if possible) or wRh intravaginal ovoids. A dose of 20-40 Gy Is prescribed at the tumor surface when ovoids ere used. Though rectum might receive a significant proportion of the prescribed dose, traditionally this hemostatic dose Is disregarded from the cumulative dose calculation when curative treatment Is offered subsequently. Such patients have higher risk of developing radiation morbidity. Should we continue ignoring this dose since ICRti-38 provides no guidelines regarding consideration or abondonmont of this dose? We have analysed 20 such patients (treated from 1990 to 1994at our centre) to assess the stoppage of haomorrhage, tumor control & radiation morbidity (especially the rectal complications). The age of peUents ranged from 27 to 62 yTs (median 42 yTs). Stagewlse (FIGO) distribution was : liB, 3 pts; IliA, $ pts; ilIB 11 pts. Median hemostatlc surface dose of 25 Gy (LDR, Selectron) by ovoids was followed by curative RT (external RT + ICRT). Vaginal bleeding stopped In 14 pts within 24 hrs and all pts within 48 hrs. Four pts had grade 3, and 2 pts had grade 2 radiation procUtls. Fourtuen pts had local or distant failure with 24 months follow up. In view of the higher rectal morbldify (30'/.) in our study, we suggest that the hemostatic dose may not be totally disregarded In every pt since this dose might add to rectal complications. The decision should be indlvldualised according to the bulk of the disease and doslmetrlc calculations with computarlaed treatment planning sustsm. Simultaneously, ICRU-38 needs to be revised to incorporate the guldllnes regarding various aspects of hemostatic brachytherapy.
87
88
P R E O P E R A T I V E LDR T E C H N I Q U E S OF BRACHYTHERAPY IN PATIENTS W I T H EARLY CERVICAL CANCER.
EARLY RESULTS OF EXCLUSIVE RADIOTHERAPY WHICH WAS GIVEN ACCORDING TO ICRU 3 8 IN ADVANCED STAGE CERVICAL CARCINOMA
Sobotkowski J., Grzelak M., Pietraszek A., Kordek P. WSZ im. M. Kopemika, Lodz. Poland
M.N. And~eu. A.Saran, H. Edlnsel, F. Alloglu, T. Turgay Anke.ra Oncology Hospital, Ankara, Turkey
In 1994 authors started to use a combined modality of cervical cancer treatmenl. It consists of brachytherapy followed by radical hysterectomy and lymphadenectomy. 45 patients had initial diagnosis of IB and IIA stage of carcinoma colli uteri. To attain precise staging they were subjected to proper diagnostic procedures including US and MRI. To undergo combined treatment patients had to fulfil some rigorous conditions described in the paper. So only 36 patients qualified to this method. Authors used modified Paris radium method in II women and in 25 - afterloading caesium 137 with Selectron LDR (Nucletron). Summarized doses at A point were about 60 Gy. After 4 weeks operations m/o Wenheim were performed in operative gynecology Institutes in Lodz. Generally in 89% of patients postoperative pathologic examination has not revealed neoplastic infiltration. Remaining women underwent external radiotherapy with dose of 44 Gy. Early and late radiation morbidity assessed as good or very good according to RTOG/EORTC scale. This mode of treatment gives a chance for some patients with this diagnosis to avoid external irradiation and its complications. To strict assessment of treatment efficacy longer duration of observation is necessary.
Purpose : The aim of the study Is report our Initial experience about hrac~herapy which was applied according to ICRU 38 recommendations. Materials and Methods : From June 1994 to June 1997 80 cases of cervicad carcinoma were treated by combined external beam radiotherapy (EBRT) and MDR brachytherapy (BT). The average age of patients was 54. The stage distrubitlon according to F~'GO classification was: 2 were stage llA; 46 were stage lIB; 12 were stage IliA: 15 were stage [lIB and 5 were Stage IVA. EBRT doses were changing between 46 to 52 Gy and all of the patients received 2 fractions of MDR brachytherapy I to 15 days aRer the and of EBRT. BT was applied according to ICRU 38 and totally 60 Gy was given to the chosen referance isodose. Between two fractions of BT an additional dose of EBRT between 8-14 Gy was given as parametrlai boost. Results : 76,3 % complete rcmisston a~d 23,7 % partial remission were obtained. 6 paUents, who were completely cured, bad local recurrens and distant metastasis occured in 12 patients. 3 years survlvals for stage II. Ill and IV were 7 1 % , 56 % and 50 % respectively. Grade I[I compllcatlons were occured in 8 patients (I0 %}. 6 had scwere rectltls, 2 had lleus and l patient had rectovaglnal fistula. Conclusion : Even if it was difficult for us to decide to the fractlonatl~on schedule and close for the BT plans, as there have not been too many examples about ICRU 38 method used with HDR, the results seem to be in accordance ~vlth the literature. But. of course. LI lutlg ternl Ibllow tip IS necessary for evaluation of survtvals and cspecially Ior late complications.