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Outcome of Patients with Early-Stage Cervical Cancer Treated with Preoperative Image-Guided Pulse-Dose Rate Brachytherapy Followed by Surgery
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Abstracts / Brachytherapy 15 (2016) S21eS204
PO66 The Use of a Savi Strut-Based Device in the Boosting of a Stenotic Distal Vagina Serban Morcovescu, MS, Jeffery D. Morton, MD. Texas Oncology Denton, Denton, TX, USA. Purpose: To report our clinical experience on the use of a SAVI8þ1 strutbased device on boosting a distal vagina carcinoma. Methods: A 80-year-old white female with T2 N1b M0 FIGO grade 3 squamous cell carcinoma of the vulva extending into the distal vagina was recently treated at our facility. Following a standard course of treatment using intensity modulated radiation therapy up to 45 Gy, we elected to deliver an interstitial implant boost treatment of 20 Gy at 1cm depth into the vaginal wall, in 10 daily fractions of 2 Gy/fx via a SAVI8þ1 device. Only the two (2) most posterior catheters of the device, in partial expansion, were actually loaded. The smallest available vaginal cylinder of 2.0cm diameter in our applicator library was not possible to use due to the extreme narrowing of a stenotic vagina subsequent of IMRT treatments. Four fiducial markers were placed around the residual tumor in the posterior lower vaginal/introitus area, in order to locate the tumor radiographically. A simple, in-house modular clamping device was designed in order to assist with the reproducibility of the treatment setup. Results: A PTV volume was contoured using the implanted fiducial markers. The PTV coverage for V100 was 99.6%. Maximum bladder dose was 18.2 cGy (9.1% of the prescription dose), maximum rectal/anal dose was 79.6 cGy (39.8% of the prescription dose) and maximum small bowel dose was 5.4 cGy (2.6% of the prescription dose). We were able to excellently cover the PTV volume while sparing adjacent critical organs. Conclusion: This study demonstrates the clinical versatility of the strutbased brachytherapy device. It can be successfully used for other clinical applications than the ones originally intended for (mainly breast APBI), providing excellent dosimetric results and adaptability.
Purpose: To report the clinical outcome of early and less than 4cm cervical cancer patients treated according to a multimodality approach based on a preoperative pulse-dose-rate brachytherapy (PDR-BT) followed by surgery. Materials and Methods: We examined the clinical records of patients treated in our institution and undergoing a preoperative image-guided PDR-BT between August 2004 and May 2013 for an early stage cervical cancer with risk factors (lymphovascular embols and/or tumor greatest dimension O 2cm). PDR-BT was performed using the vaginal mold technique and dosimetry was based on a three-dimensional imaging. Treatment aimed at delivering 60 Gy to 100% of the intermediate risk clinical target volume, given in one fraction at a dose rate not exceeding 0.55 Gy per hour to the critical organs (rectum, bladder, sigmoid). PDRBT was followed 6 weeks later by a radical hysterectomy/bilateral salpingo-oophorectomy plus pelvic node dissection (extended to the paraaortic area in case of positive pelvic nodal metastases at frozen section examination). Patient outcome was examined for patterns of relapse, survival and side effects. Results: A total of 82 consecutive patients were identified. Mean age was 47.1 years (ranging from 11.7 to 77.6 years). Seventy-six patients (92.7%) were stage FIGO IB1 and 6 patients (7.3%) IIA1. Histology was squamous cell carcinoma for 57 patients (69.5%) and adenocarcinoma for 25 patients (30.5%). Mean tumor size was 2.4 cm (ranging from 0 to 3.8 cm). All patients received 60 Gy PDR-BT. Surgery was performed within a median time interval of 58 days (from 33 to 109 days). Twenty-five patients (30.5%) presented a residual tumor but only four patients (4.9%) had a viable tumor residuum $ 1 cm. Fifteen patients (18.3%) had histological evidence of pelvic nodal metastases, including three patients (3.6%) with para-aortic nodal metastases. Fourteen patients (17.0%) had chemo-radiotherapy with a median shield (one with metastases at the time of surgery had only first line chemotherapy regimen). With a median follow-up of 48.4 months, the 2- and 5-year overall survival (OS) rates were 94.2% and 83.1% respectively. The 2- and 5-year disease-free survival (DFS) rates were 91.2% and 79.4% respectively. A total of 11 relapses (13.4%) were reported, including only two (2.4%) local recurrences. At univariate analysis, one factor was correlated with a poorer DFS: the presence of nodal metastases at time of surgery (9.7 years versus 5 years, p 5 0.001). Two factors were associated with a poorer OS: the presence of nodal metastases at time of surgery (10.1 years versus 5.3 years, p 5 0.001) and the time interval O 63 days between PDR-BT and surgery (9.9 years versus 4.5 years, p 5 0.01). Given the low number of events, multivariate analysis was not performed. Nodal metastases at histological examination were found in 5/20 patients (25%) with a time interval O 63 days, versus 10/62 (16.1%) in the group of patients with a time interval less than 62 days. The difference did not reach statistical significance. Acute toxicities were reported in 17 (20.7%) patients with 2 pyelonephritis and 1 peri-rectal abscess. Most late toxicities were mild to moderate, mainly represented by urinary (16.9%) and vaginal (20.5%) toxicities. Grade 3-4 delayed toxicities were encountered by 5 patients (6.1%): 1 urethral stenosis and 4 sexual toxicities. Conclusions: Imagedguided preoperative PDR-BT in early stage cervical cancer patients was found well tolerated and effective for ensuring longterm local control. Nodal metastases were strong prognostics factors for the overall survival and the disease-free survival. Time interval between PDR-BT and surgery O 63 days is a strong prognostic factor for overall survival. Although underlying causes should be further investigated, an increasing time interval between BT and surgery could be correlated with an increasing risk of nodal extension.
PO67 Outcome of Patients with Early-Stage Cervical Cancer Treated with Preoperative Image-Guided Pulse-Dose Rate Brachytherapy Followed by Surgery Alexandre Escande, MD1, Cyrus Chargari, MD1, Pierre Maroun, MD1, Renaud Mazeron, MD, PhD1, Isabelle Dumas, MS1, Pauline Castelnau-Marchand, MD1, Georges Fahra, MD1, Sebastien Gouy, MD2, Philippe Morice, MD2, Eric Deutsch, MD, PhD1, Christine Haie-Meder, MD1. 1Radiotherapy, Brachytherapy Service, Gustave-Roussy, Cancer Campus, Villejuif, France; 2Gynaecological surgery, Gustave-Roussy, Cancer Campus, Villejuif, France.
PO68 An Analysis of Image Guided Intact Cervical Cancer (ICC) Hdr Brachytherapy (HDR-BT) and the Relationship between Overall Treatment Time (OTT), Brachytherapy Technique and Partial Bladder Filling Technique on Local Control and Toxicity Patrizia Guerrieri, MD, MS1, Bryan C. Coopey, MS1, Michael Tassotto, PhD1, Fredric V. Price, MD2. 1Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA; 2Gynecology Oncology, Allegheny Health Network, Pittsburgh, PA, USA.
Abstracts / Brachytherapy 15 (2016) S21eS204
PO66 The Use of a Savi Strut-Based Device in the Boosting of a Stenotic Distal Vagina Serban Morcovescu, MS, Jeffery D. Morton, MD. Texas Oncology Denton, Denton, TX, USA. Purpose: To report our clinical experience on the use of a SAVI8þ1 strutbased device on boosting a distal vagina carcinoma. Methods: A 80-year-old white female with T2 N1b M0 FIGO grade 3 squamous cell carcinoma of the vulva extending into the distal vagina was recently treated at our facility. Following a standard course of treatment using intensity modulated radiation therapy up to 45 Gy, we elected to deliver an interstitial implant boost treatment of 20 Gy at 1cm depth into the vaginal wall, in 10 daily fractions of 2 Gy/fx via a SAVI8þ1 device. Only the two (2) most posterior catheters of the device, in partial expansion, were actually loaded. The smallest available vaginal cylinder of 2.0cm diameter in our applicator library was not possible to use due to the extreme narrowing of a stenotic vagina subsequent of IMRT treatments. Four fiducial markers were placed around the residual tumor in the posterior lower vaginal/introitus area, in order to locate the tumor radiographically. A simple, in-house modular clamping device was designed in order to assist with the reproducibility of the treatment setup. Results: A PTV volume was contoured using the implanted fiducial markers. The PTV coverage for V100 was 99.6%. Maximum bladder dose was 18.2 cGy (9.1% of the prescription dose), maximum rectal/anal dose was 79.6 cGy (39.8% of the prescription dose) and maximum small bowel dose was 5.4 cGy (2.6% of the prescription dose). We were able to excellently cover the PTV volume while sparing adjacent critical organs. Conclusion: This study demonstrates the clinical versatility of the strutbased brachytherapy device. It can be successfully used for other clinical applications than the ones originally intended for (mainly breast APBI), providing excellent dosimetric results and adaptability.
Purpose: To report the clinical outcome of early and less than 4cm cervical cancer patients treated according to a multimodality approach based on a preoperative pulse-dose-rate brachytherapy (PDR-BT) followed by surgery. Materials and Methods: We examined the clinical records of patients treated in our institution and undergoing a preoperative image-guided PDR-BT between August 2004 and May 2013 for an early stage cervical cancer with risk factors (lymphovascular embols and/or tumor greatest dimension O 2cm). PDR-BT was performed using the vaginal mold technique and dosimetry was based on a three-dimensional imaging. Treatment aimed at delivering 60 Gy to 100% of the intermediate risk clinical target volume, given in one fraction at a dose rate not exceeding 0.55 Gy per hour to the critical organs (rectum, bladder, sigmoid). PDRBT was followed 6 weeks later by a radical hysterectomy/bilateral salpingo-oophorectomy plus pelvic node dissection (extended to the paraaortic area in case of positive pelvic nodal metastases at frozen section examination). Patient outcome was examined for patterns of relapse, survival and side effects. Results: A total of 82 consecutive patients were identified. Mean age was 47.1 years (ranging from 11.7 to 77.6 years). Seventy-six patients (92.7%) were stage FIGO IB1 and 6 patients (7.3%) IIA1. Histology was squamous cell carcinoma for 57 patients (69.5%) and adenocarcinoma for 25 patients (30.5%). Mean tumor size was 2.4 cm (ranging from 0 to 3.8 cm). All patients received 60 Gy PDR-BT. Surgery was performed within a median time interval of 58 days (from 33 to 109 days). Twenty-five patients (30.5%) presented a residual tumor but only four patients (4.9%) had a viable tumor residuum $ 1 cm. Fifteen patients (18.3%) had histological evidence of pelvic nodal metastases, including three patients (3.6%) with para-aortic nodal metastases. Fourteen patients (17.0%) had chemo-radiotherapy with a median shield (one with metastases at the time of surgery had only first line chemotherapy regimen). With a median follow-up of 48.4 months, the 2- and 5-year overall survival (OS) rates were 94.2% and 83.1% respectively. The 2- and 5-year disease-free survival (DFS) rates were 91.2% and 79.4% respectively. A total of 11 relapses (13.4%) were reported, including only two (2.4%) local recurrences. At univariate analysis, one factor was correlated with a poorer DFS: the presence of nodal metastases at time of surgery (9.7 years versus 5 years, p 5 0.001). Two factors were associated with a poorer OS: the presence of nodal metastases at time of surgery (10.1 years versus 5.3 years, p 5 0.001) and the time interval O 63 days between PDR-BT and surgery (9.9 years versus 4.5 years, p 5 0.01). Given the low number of events, multivariate analysis was not performed. Nodal metastases at histological examination were found in 5/20 patients (25%) with a time interval O 63 days, versus 10/62 (16.1%) in the group of patients with a time interval less than 62 days. The difference did not reach statistical significance. Acute toxicities were reported in 17 (20.7%) patients with 2 pyelonephritis and 1 peri-rectal abscess. Most late toxicities were mild to moderate, mainly represented by urinary (16.9%) and vaginal (20.5%) toxicities. Grade 3-4 delayed toxicities were encountered by 5 patients (6.1%): 1 urethral stenosis and 4 sexual toxicities. Conclusions: Imagedguided preoperative PDR-BT in early stage cervical cancer patients was found well tolerated and effective for ensuring longterm local control. Nodal metastases were strong prognostics factors for the overall survival and the disease-free survival. Time interval between PDR-BT and surgery O 63 days is a strong prognostic factor for overall survival. Although underlying causes should be further investigated, an increasing time interval between BT and surgery could be correlated with an increasing risk of nodal extension.
PO67 Outcome of Patients with Early-Stage Cervical Cancer Treated with Preoperative Image-Guided Pulse-Dose Rate Brachytherapy Followed by Surgery Alexandre Escande, MD1, Cyrus Chargari, MD1, Pierre Maroun, MD1, Renaud Mazeron, MD, PhD1, Isabelle Dumas, MS1, Pauline Castelnau-Marchand, MD1, Georges Fahra, MD1, Sebastien Gouy, MD2, Philippe Morice, MD2, Eric Deutsch, MD, PhD1, Christine Haie-Meder, MD1. 1Radiotherapy, Brachytherapy Service, Gustave-Roussy, Cancer Campus, Villejuif, France; 2Gynaecological surgery, Gustave-Roussy, Cancer Campus, Villejuif, France.
PO68 An Analysis of Image Guided Intact Cervical Cancer (ICC) Hdr Brachytherapy (HDR-BT) and the Relationship between Overall Treatment Time (OTT), Brachytherapy Technique and Partial Bladder Filling Technique on Local Control and Toxicity Patrizia Guerrieri, MD, MS1, Bryan C. Coopey, MS1, Michael Tassotto, PhD1, Fredric V. Price, MD2. 1Radiation Oncology, Allegheny Health Network, Pittsburgh, PA, USA; 2Gynecology Oncology, Allegheny Health Network, Pittsburgh, PA, USA.