1. THREE OR FOUR FRACTIONS PER WEEK IN POSTOPERATIVE HIGH DOSE RATE BRACHYTHERAPY (HDRBT) FOR ENDOMETRIAL CARCINOMA (EC).
Rovirosa A1, Vargas M1, Ascaso C2, Sánchez-Reyes A3, Martinez F1, Herreros A1, Francisco R1, Piñeiro M2, Arenas M4, Biete A1.
1- Radiation Oncology Dpt., Hospital Clinic i Universitari, Barcelona. 2- Public Health Dpt,
University of Barcelona. 3- Radiation Oncology Dpt, Hospital Platón, Barcelona. 4- Oncology Dpt., Hospital Sant Joan Reus, Tarragona. SPAIN.
PURPOSE: To evaluate the HDRBT in postoperative treatment of EC using a schedule of 3 or 4 fractions / week.
PATIENS AND METHODS
89 PATIENS (pts) Between June 2003 and December
2006. Mean follow-up 31 months (6 to 70 months).
AGE: median 69 years (y), range between 38 and 89 y.
SURGERY: 30/89 Vaginal hysterectomy + bilateral
salpingo-Ooforectomy (HTSO) & laparoscopic pelvic +/-
para-aortic lymphadenectomy; 30/89 abdominal HTSO
& pelvic lymphadenectomy; 20/30 abdominal HTSO,
lymphadenectomy & omentectomy, 7/89 vaginal
HTSO and 2/789 abdominal HTSO lymphadenectomy
+ omentectomy.
FIGO STAGE: 24 IB, 45 IC, 4 IIA, 6 IIB, 4IIIA, 1 IIIB, 5 IIIC.
PATHOLOGY: 77 Endometrioid, 6 Serous, 2 Clear
cell, 3 mixed types, 1 miscelaneous.
17G1, 43G2, 29G3
RADIOTHERAPY: TWO GROUPS
GROUP 1: 67/89 PTS
11 IB, 37 IC, 4 IIA, 5 IIB, 4 IIIA, 1 IIIB, 5 IIIC
26/67 Grade 3 (13 IC, G3)
EXTERNAL BEAM IRRADIATION (EBI)
Linac of 6-18 MV. Median dose 45Gy, range 44 to
50 Gy, 1.8-2Gy/day.2 to 4 pelvic fields (para-aortic
lymph nodes included when necessary) . If N+:
boost with small fields until 50 to 60 Gy.
HDRBT 3 fractions of 4 to 5 Gy.
GROUP 2: 22/89 PTS
13 IB, 8 IC, , 1 IIB. 3/22 Grade 3 (1IC,G3)
HDRBT alone: 6 fractions of 4 to 5 Gy.
BRACHYTHERAPY
3 to 4 fractions per week when possible.
I192 HDR, MicroHDR afterloading system (Nucletron®)
Technique: 6/89 colpostats, 83/89 cylinders (1/83 2cm,
8/ cm, 33/83 3 cm, 41/ cm). Median treated
length 3 cm.
OVERALL TREATMENT TIME
GROUP 1 (3 FRACTIONS). 32/ 67 pts ≤ 5 DAYS
(median 5 days, range 3 to 5 days). 35/67 pts > 5 DAYS
(median 7 days, range between 6 and 23 days).
GROUP 2 (6 FRACTIONS). 11/22 pts ≤ 5 DAYS (median
14 days, range 9 to 15 days). 11/22 pts > 15 DAYS
(median22 days, range 16 to 28 days).
TOXICITY
Rectum and bladder: RTOG
Late Vagina. G1: Telangiectasia without
bleeding, slight pigmentation change, vaginal
scar fibrosis. G2: Telangiectasia with bleeding,
dryness, slight atrophy, ulceration, partial
synechiae, marked pigmentation change,
symptomatic fibrosis. G3: Stenosis, complete
synechiae, intermitent bleeding. G4: Obliteration,
fistulae, Diffuse atrophy, persistent bleeding,
total dysfunction.
BED vaginal surface dose Study
STATISTICS
Non parametric ANOVA, Chi-square & ROC
curves
RESULTS
FIG. 1
GROUP 2
1/89 Vaginal relapse and died at 1 y. 1/89 was lost
in follow-up at 50 months. 4 patients died at 16 and
37 months without relationship with EC.
Early Toxicity was resolved in all de pts. in 2 months.
Vagina (8/89, 9%): 91% G0, 8% G1, 1% G2. No
relationship with BED at vaginal surface. Rectum
2/89 G1( 2%), 1/89 (1%)G2. Bladder 5/89 (5.5%) had
G1 urinary problems.
Late Toxicity appeared in 13/89 (14%). Rectum 2/89
pts (2%): 2 G1. Bladder 4/89 pts (4%): 2G1, 2 G2.
Vagina 11/89 pts (12%): 7G1, 3G2, 1G4 (obliteration).
BED vaginal mucosa. Group 1: Mean 63 Gy (41-
146Gy). Group 2: Mean 120 Gy, range 82 to 188 Gy.
The relationship between BED and late toxicity
is shown in Fig. 1 for Group 1 and 2.
Overall interval time. No differences in toxicity were
found in Group 1 for ≤ 5 days or > 5 days, and in
Group 2 for ≤ 15 days or > 15 days.
GROUP 1
BED VAGINAL
SURFACE DOSE
AND LATE TOXICITY
FOR GROUPS 1 & 2.
CONCLUSIONS
1- 3 FRACTIONS OF 4 TO 5 Gy IN 3 TO 5
DAYS AFTER EBI OR 6 FRACTIONS IN
LESS THAN 15 DAYS SEEMS A SAFE
TREATMENT IN RELATION TO TOXICITY
AND LOCAL CONTROL IN HDRBT FOR EC.
2- CASES WITH G2 LATE VAGINAL
TOXICITY SHOWED VAGINALSURFACE
BED HIGHER THAN 60 Gy AFTER EBI OR
MORE THAN 120 GY FOR HDRBT ALONE.