Clinical outcomes following 3D image-guided brachytherapy for vaginal recurrence of endometrial cancer

Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA. Electronic address: .
Gynecologic Oncology (Impact Factor: 3.77). 09/2013; 131(3). DOI: 10.1016/j.ygyno.2013.08.040
Source: PubMed


To evaluate clinical outcomes for women with recurrent endometrial cancer treated with 3D image-guided brachytherapy Methods and Materials 44 women received salvage RT for vaginal recurrence from 9/03-8/11. HDR or LDR interstitial brachytherapy was performed under MR or CT guidance in 35 patients (80%); 9 (20%) had CT-guided HDR cylinder brachytherapy. The median cumulative dose in EQD2 was 75.5Gy. Actuarial estimates of local failure (LF), DFS and OS were calculated by Kaplan-Meier.
Histologic subtypes were endometrioid (EAC, 33), papillary serous/clear cell (UPSC/CC, 5) and carcinosarcoma (CS, 6). The 2-year DFS/OS rates were 59%/72% overall, 75%/89% for EAC, and 11%/24% for UPSC/CC/CS (both p<0.01). On MVA, high tumor grade was associated with recurrence (HR 3.2 for grade 2, 9.6 for grade 3, p<0.01). The cumulative incidence of LF at 2years was 12%; median cumulative dose for patients with LF was 66.2Gy and 73.9Gy for those without LF (p=0.02). When excluding 13 patients who had prior RT, the 2-year LF rate was 4%. Patients who had prior RT received lower cumulative doses at recurrence (66.5Gy vs. 74.4Gy, p<0.01). Four patients (9%) experienced grade 3 late toxicity, including 3 of 13 (23%) in the re-irradiation setting and 1 if 31 (3%) with no prior radiotherapy.
3D image-guided brachytherapy results in excellent local control for women with recurrent endometrial cancer, particularly with cumulative EQD2 doses greater than 70Gy. Successful salvage of vaginal recurrence is strongly related to tumor grade and histologic subtype.

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    ABSTRACT: Purpose Data for salvage radiotherapy for recurrent endometrial cancer are limited especially in the era of modern radiotherapy including IMRT and 3-dimensional image-based HDR brachytherapy. Theoretically, modern radiotherapy reduces the dose to critical organs-at-risk and maximizes dose to the target volume, possibly decreasing morbidity and increasing tumor control. Materials and methods Forty-one patients completing definitive salvage radiotherapy for vaginal recurrence of endometrial cancer from June 2004 to December 2013 were retrospectively reviewed. HDR Brachytherapy was completed using image-based planning with contouring/optimization with each fraction to a median dose of 23.75 Gy in 5 fractions. HDR brachytherapy was preceded by external beam radiotherapy predominately using an IMRT technique (90%) to a median dose of 45 Gy in 25 fractions. Toxicity was reported according to CTCAEv4. Results At a median follow-up of 18 months (range: 3–78), the clinical complete response rate was 95%. The 3-year local control, distant control, recurrence free survival, and overall survival were 95%, 61%, 68%, and 67%. Significant predictors of both distant failure and overall survival were primary prognostic factors of depth of myometrial invasion, FIGO stage, and FIGO grade. There was no grade 3+ acute toxicity; the 3-year rate of grade 3+ late toxicity was 8%. Conclusions Salvage IMRT plus 3-dimensional image-based HDR brachytherapy shows excellent tumor control and minimal morbidity for vaginal recurrence of endometrial cancer. Anticipated salvage rates must be taken in the context of primary risk factors including depth of myometrial invasion, FIGO stage, and FIGO grade.
    Radiotherapy and Oncology 09/2014; 113(1). DOI:10.1016/j.radonc.2014.08.038 · 4.36 Impact Factor
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    ABSTRACT: Purpose To evaluate clinical outcome and feasibility of a four-dimensional image-guided adaptive brachytherapy concept in patients with locally recurrent endometrial cancer. Methods and Materials Forty-three patients with locally recurrent endometrial cancer were included. Treatment consisted of conformal external beam radiotherapy followed by a boost using pulsed-dose-rate brachytherapy (BT). Large tumors were treated with MRI-guided interstitial BT. Small tumors were treated with CT-guided intracavitary BT. The planning aim (total external beam radiotherapy and BT) for high-risk clinical target volume was D90 > 80 Gy, whereas constraints for organs at risk were D2cc ≤ 90 Gy for bladder and D2cc ≤ 70 Gy for rectum, sigmoid, and bowel in terms of equivalent dose in 2 Gy fractions. Results Median high-risk clinical target volume was 18 cm3 (range, 0–91). D90 was 82 Gy (range, 77–88). D2cc to bladder, rectum, and sigmoid were 67 Gy (range, 50–81), 67 Gy (range, 51–77), and 55 Gy (range, 44–68), respectively. Median followup was 30 months (6–88). Two-year local control rate was 92% (standard error [SE], 5). Disease-free survival rate and overall survival rate was 59% (SE, 8) and 78% (SE, 7), respectively. Patients with low- to intermediate-risk for recurrence had a 2-year disease-free survival rate of 72% (SE, 9) compared with 42% (SE, 12) in patients with high risk for recurrence (p = 0.04). Late morbidity Grade 3 was recorded in 5 (12%) patients. Conclusions Four-dimensional image-guided adaptive brachytherapy is feasible in locally recurrent endometrial cancer. Local control rate is good. Systemic control remains a problem in patients with high risk for recurrence.
    Brachytherapy 11/2014; 13(6). DOI:10.1016/j.brachy.2014.06.004 · 2.76 Impact Factor
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    Brachytherapy 11/2014; 14(1). DOI:10.1016/j.brachy.2014.10.001 · 2.76 Impact Factor
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