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Routine use of Intraoperative Ultrasound Guidance during Intracavitary Tandem Placement in Cervical Cancer: The University of Alabama at Birmingham Experience
I. J. Radiation Oncology d Biology d Physics
S372
Volume 75, Number 3, Supplement, 2009
Conclusions: Adjuvant therapy with carboplatin/paclitaxel chemotherapy and radiotherapy is well-tolerated and provides favorable disease-free survival in advanced UPSC. Radiotherapy provides good local control. A significant number of patients will still relapse distantly suggesting a need for improved systemic therapy. Author Disclosure: D. D’Souza, None; K. Lupe, None; J.S. Kwon, None; E. Wiebe, None; F. Whiston, None; M. Carey, None.
2425
Routine use of Intraoperative Ultrasound Guidance during Intracavitary Tandem Placement in Cervical Cancer: The University of Alabama at Birmingham Experience
P. E. Schaner, J. J. Caudell, S. Shen, J. F. DeLos Santos, S. S. Spencer, R. Y. Kim University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): Intracavitary brachytherapy (ICBT) is an essential component of definitive radiation therapy (RT) for cervical cancer. Proper applicator placement improves local control and reduces complication rates. However, without image guidance intrauterine tandem insertion is essentially a blind procedure. Previous studies found up to 30% suboptimal tandem placement and 10% uterine perforation by post-insertion imaging. In order to optimize tandem placement, intraoperative abdominal ultrasound (US) has been standard at UAB since 1999. The objective of this study is to evaluate outcomes in relation to US guided tandem placement. Materials/Methods: Between 1999 and 2008, 244 cervical cancer patients [FIGO I (57), IIA (23), IIB (104), IIIA (2), IIIB (47), IV (11)] underwent intraoperative US guided tandem placement for definitive RT. 140 patients received low dose rate (LDR) and 104 received high dose rate (HDR) brachytherapy. In general, two ICBT insertions were performed for LDR and three to five ICBT insertions were done for HDR. All LDR brachytherapy tandem placements were performed with US guidance, but only the first tandem placement for HDR brachytherapy utilized US. Subsequent tandem placements were done without US guidance. The bladder was filled with 180 cc of normal saline to improve visualization of the uterus. On US visualization, if the tandem was not centered in the uterine cavity it was removed and reinserted immediately using US guidance. Before 2007, postoperative CT imaging was obtained only with difficult tandem placements in order to assess tandem position. Since 2007, all patients have received postoperative CT imaging for treatment planning. A total of 120 US were done for HDR and 236 US were done for LDR. Results: 356 consecutive tandem placements were performed in 244 patients under US guidance. All patients completed ICBT. US enabled direct visualization of the uterine canal, and facilitated selection of a suitable tandem length and curvature; no suboptimal placements requiring return to the operating room occurred (excluding perforation). The incidence of uterine perforation was 1.4% (5/356): 1 patient was perforated in the anterior wall, 1 patient in the posterior wall, and 3 patients in the lateral wall. All 5 of these patients underwent successful tandem insertion on the second attempt, and no side effects of perforation were noted. Conclusions: Intraoperative US is a readily available and inexpensive imaging modality. In this large series, US guidance significantly diminished the rate of uterine perforation and suboptimal device placement relative to historical controls. Use of US guidance should strongly be considered when performing operative intrauterine tandem placement. Author Disclosure: P.E. Schaner, None; J.J. Caudell, None; S. Shen, None; J.F. DeLos Santos, None; S.S. Spencer, None; R.Y. Kim, None.
2426
The Percentage of Positive Lymph Nodes is a Predictor of Survival in Uterine Papillary Serous Carcinoma
L. J. Lee1, D. Schultz2, C. Tanaka3, A. N. Viswanathan3 Harvard Radiation Oncology Program, Boston, MA, 2Millersville University, Wickersham, PA, 3Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
1
Purpose/Objective(s): To analyze the importance of lymph node ratio (the percentage of positive nodes [%LN+]) as a predictor of progression-free (PFS) and overall (OS) survival in uterine papillary serous carcinoma (UPSC). Materials/Methods: We retrospectively identified 89 patients with UPSC who underwent TAH/BSO and lymph node sampling/ dissection at Brigham and Women’s Hospital/Dana Farber Cancer Institute from 1983 to 2006. The FIGO stage distribution was 1A–1C (31), II (8), IIIA (23), IIIB (1), IIIC (20), IVA (5) and IVB (1). Adjuvant RT was delivered to the pelvis (31), whole abdomen (23) or vaginal vault only (6). 46 patients received adjuvant chemotherapy, most commonly carboplatin (41), taxol (42) and/ or doxorubicin (16). Kaplan-Meier PFS and OS rates were compared using the log–rank test. Cox multivariate regression (MVA) was used to analyze predictors of survival. The median follow-up time was 17.1 months for all patients and 22.7 months for survivors. Results: The median age was 68 years (range, 53–84); median tumor size, 3 cm (range, 0–12); and median depth of myometrial invasion, 25% (range, 0–100%). Lymphovascular invasion (LVI) was present in 33 patients (38%) and positive peritoneal cytology in 27 (31%). The median number of recovered nodes was 4 (range, 1–30). A total of 63 patients had no LN+, 11 had between 1 and 50% LN+, and 15 patients had .50% LN+. The 5-year PFS rates for 0%, 1%–50%, and .50% LN+ were 46%, 47%, and 13% (p = 0.018). The corresponding 5-year OS rates were 62%, 44%, and 17% (p = 0.005). On univariate analysis, stage, LVI and %LN+ were significant predictors of OS. On MVA, having .50% LN+ was the only independent predictor of overall survival compared to the node-negative group (HR 3.6, p = 0.003). Age, use of radiation, and adjuvant chemotherapy did not predict either PFS or OS. Grade 3 GI toxicity was reported in 2 patients who received whole abdomen RT. Conclusions: UPSC is an aggressive subtype of uterine cancer that portends a poor prognosis. Patients with more than 50% positive nodes have a 5-year overall survival rate that is significantly lower than that of node-negative patients and those with \50% positive nodes. The percentage of positive lymph nodes, or lymph-node ratio, is an important prognostic factor among patients of all stages with UPSC. Author Disclosure: L.J. Lee, None; D. Schultz, None; C. Tanaka, None; A.N. Viswanathan, None.
S372
Volume 75, Number 3, Supplement, 2009
Conclusions: Adjuvant therapy with carboplatin/paclitaxel chemotherapy and radiotherapy is well-tolerated and provides favorable disease-free survival in advanced UPSC. Radiotherapy provides good local control. A significant number of patients will still relapse distantly suggesting a need for improved systemic therapy. Author Disclosure: D. D’Souza, None; K. Lupe, None; J.S. Kwon, None; E. Wiebe, None; F. Whiston, None; M. Carey, None.
2425
Routine use of Intraoperative Ultrasound Guidance during Intracavitary Tandem Placement in Cervical Cancer: The University of Alabama at Birmingham Experience
P. E. Schaner, J. J. Caudell, S. Shen, J. F. DeLos Santos, S. S. Spencer, R. Y. Kim University of Alabama at Birmingham, Birmingham, AL Purpose/Objective(s): Intracavitary brachytherapy (ICBT) is an essential component of definitive radiation therapy (RT) for cervical cancer. Proper applicator placement improves local control and reduces complication rates. However, without image guidance intrauterine tandem insertion is essentially a blind procedure. Previous studies found up to 30% suboptimal tandem placement and 10% uterine perforation by post-insertion imaging. In order to optimize tandem placement, intraoperative abdominal ultrasound (US) has been standard at UAB since 1999. The objective of this study is to evaluate outcomes in relation to US guided tandem placement. Materials/Methods: Between 1999 and 2008, 244 cervical cancer patients [FIGO I (57), IIA (23), IIB (104), IIIA (2), IIIB (47), IV (11)] underwent intraoperative US guided tandem placement for definitive RT. 140 patients received low dose rate (LDR) and 104 received high dose rate (HDR) brachytherapy. In general, two ICBT insertions were performed for LDR and three to five ICBT insertions were done for HDR. All LDR brachytherapy tandem placements were performed with US guidance, but only the first tandem placement for HDR brachytherapy utilized US. Subsequent tandem placements were done without US guidance. The bladder was filled with 180 cc of normal saline to improve visualization of the uterus. On US visualization, if the tandem was not centered in the uterine cavity it was removed and reinserted immediately using US guidance. Before 2007, postoperative CT imaging was obtained only with difficult tandem placements in order to assess tandem position. Since 2007, all patients have received postoperative CT imaging for treatment planning. A total of 120 US were done for HDR and 236 US were done for LDR. Results: 356 consecutive tandem placements were performed in 244 patients under US guidance. All patients completed ICBT. US enabled direct visualization of the uterine canal, and facilitated selection of a suitable tandem length and curvature; no suboptimal placements requiring return to the operating room occurred (excluding perforation). The incidence of uterine perforation was 1.4% (5/356): 1 patient was perforated in the anterior wall, 1 patient in the posterior wall, and 3 patients in the lateral wall. All 5 of these patients underwent successful tandem insertion on the second attempt, and no side effects of perforation were noted. Conclusions: Intraoperative US is a readily available and inexpensive imaging modality. In this large series, US guidance significantly diminished the rate of uterine perforation and suboptimal device placement relative to historical controls. Use of US guidance should strongly be considered when performing operative intrauterine tandem placement. Author Disclosure: P.E. Schaner, None; J.J. Caudell, None; S. Shen, None; J.F. DeLos Santos, None; S.S. Spencer, None; R.Y. Kim, None.
2426
The Percentage of Positive Lymph Nodes is a Predictor of Survival in Uterine Papillary Serous Carcinoma
L. J. Lee1, D. Schultz2, C. Tanaka3, A. N. Viswanathan3 Harvard Radiation Oncology Program, Boston, MA, 2Millersville University, Wickersham, PA, 3Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
1
Purpose/Objective(s): To analyze the importance of lymph node ratio (the percentage of positive nodes [%LN+]) as a predictor of progression-free (PFS) and overall (OS) survival in uterine papillary serous carcinoma (UPSC). Materials/Methods: We retrospectively identified 89 patients with UPSC who underwent TAH/BSO and lymph node sampling/ dissection at Brigham and Women’s Hospital/Dana Farber Cancer Institute from 1983 to 2006. The FIGO stage distribution was 1A–1C (31), II (8), IIIA (23), IIIB (1), IIIC (20), IVA (5) and IVB (1). Adjuvant RT was delivered to the pelvis (31), whole abdomen (23) or vaginal vault only (6). 46 patients received adjuvant chemotherapy, most commonly carboplatin (41), taxol (42) and/ or doxorubicin (16). Kaplan-Meier PFS and OS rates were compared using the log–rank test. Cox multivariate regression (MVA) was used to analyze predictors of survival. The median follow-up time was 17.1 months for all patients and 22.7 months for survivors. Results: The median age was 68 years (range, 53–84); median tumor size, 3 cm (range, 0–12); and median depth of myometrial invasion, 25% (range, 0–100%). Lymphovascular invasion (LVI) was present in 33 patients (38%) and positive peritoneal cytology in 27 (31%). The median number of recovered nodes was 4 (range, 1–30). A total of 63 patients had no LN+, 11 had between 1 and 50% LN+, and 15 patients had .50% LN+. The 5-year PFS rates for 0%, 1%–50%, and .50% LN+ were 46%, 47%, and 13% (p = 0.018). The corresponding 5-year OS rates were 62%, 44%, and 17% (p = 0.005). On univariate analysis, stage, LVI and %LN+ were significant predictors of OS. On MVA, having .50% LN+ was the only independent predictor of overall survival compared to the node-negative group (HR 3.6, p = 0.003). Age, use of radiation, and adjuvant chemotherapy did not predict either PFS or OS. Grade 3 GI toxicity was reported in 2 patients who received whole abdomen RT. Conclusions: UPSC is an aggressive subtype of uterine cancer that portends a poor prognosis. Patients with more than 50% positive nodes have a 5-year overall survival rate that is significantly lower than that of node-negative patients and those with \50% positive nodes. The percentage of positive lymph nodes, or lymph-node ratio, is an important prognostic factor among patients of all stages with UPSC. Author Disclosure: L.J. Lee, None; D. Schultz, None; C. Tanaka, None; A.N. Viswanathan, None.