1. Comparative Results of Vaginal Relapses and Toxicity of Three 192-Ir HDR brachytherapy (BT) Schedules in Postoperative Endometrial Carcinoma (EC).
Rovirosa A 1,2, Cortes KS I, Ascaso C 3, Herreros A 1, Sánchez J4, Arenas M5, Sabater S6, Rios I1,7, Sola J1, Agusti E1, Huguet J1, Garrido S1, Lloret A1, Castro C1, Escudero E1, Molina MD1, Arnau O1, Torne A2.
1- Radiation Oncology Dpt. and 2-Functional Gynecological Cancer Unit. Hospital Clinic, University of Barcelona. 3- Public Health Dpt. University of Barcelona. 4- Economics Dpt. Hospital Clinic Universitari, Barcelona. 5- Radiation Oncology Dpt. Hospital Sant Joan de Reus, Tarragona. 6- Radiation Oncology Dpt, Hospital General de Albacete, Albacete. SPAIN. 7- Radiation Oncology Dpt. Centro Imbanaco, Cali, Colombia
INTRODUCTION
RESULTS
SUMMARY / CONCLUSION
The best fractionation schedule is not established in Postoperative brachytherapy for endometrial carcinoma.
Considering the results of the present analysis, treatment with 7Gy after EBI and 6Gy x 3 fractions daily in exclusive treatment was the best regime in postoperative EC.
No differences were found in VCR and in vaginal, rectal and bladder toxicities between the 3 BT schedules. No vaginal relapses were found in patients receiving BT alone.
Tables 2 and 3 show the characteristics and distribution of each group by stage, mean follow-up, (Mf-u), median overall BT treatment time (MBTT) and vaginal-cuff relapses (VCR). (Group 1&3: EBI+BT; Group 2&4: BT alone). The mean age of patients in schedule 1 was 66 years (38-89), 64 years (39-90) in schedule 2, and 66 years (39-90) in schedule 3. Table 4 show late toxicity results.
VCR of the entire series 1.4%: 0% BT alone group and 2.0% in the EBI+BT group
AIM
To analyze the toxicity and vaginal control of three short brachytherapy (BT) schedules after surgery for endometrial carcinoma from 2003 to 2014.
Table 2 (a,b and c).
Table 2a:Group 1 (125p) Table 2b: Group 3 (94p) Table 2c: Group 3 (74p)
Mean F-up
(months)
Stage
Nºp
MBTT
(days)
VCR 95
(11-153)
IA * 29 5
(3-23)
1.7% 3p
2-IB,
1-IIIC1
IB * 61 II
IIIA 10
IIIB 2
IIIC1 9
IIIC2 2
Mean F-up (months)
Stage
Nºp
MBTT
(days)
VCR
nºp 67
(12-112)
IA * 5 2
(2-12)
2.1% 2p
(2-IB)
IB * 45 II
IIIA 13
IIIB 2
IIIC1 10
IIIC2 5
Mean F-up
(months)
Stage
Nºp
MBTT
(days)
VCR 38
(10-67)
IA * 13 1
0.9% 1p
IB * 28 II
IIIA 4
IIIB 1
IIIC1 8
IIIC2 5 IV
MATERIAL & METHODS
421 patients with endometrial carcinoma (EC) staged after surgery as 2009-Figo I-IVB underwent radiotherapy from 2003 to 2014 using 3 different BT schedules.
Table 1 shows patients (p) distributed into 4 groups (1 to 6) according to the number of patients, period of treatment and corresponding EBI+BT and BT alone schedules.
* Presence of pathological type other than endometrioid, vascular and lymphatic space invasion and/or tumor size >3cm.
Table 1:
Schedule & period
Number of p
Treatment schedule
f / w: Fraction/week.
Schedule 1: 2003 to 2007
(166p)
Group 1: 125p
4-6Gy in 3 f/w of after EBI
Group 2: 41p
4-6Gy in 6 f/2w BT alone
Schedule 2: 2007 to (153p)
Group 3: 94p
5-6Gy in 2f/w after EBI
Group 4: 59p
5-6Gy in 4f in BT alone
Schedule 3; 2011 to 2014
(102p)
Group 5: 74p
Group 6: 28p
7Gy in 1 fr after EBI
6Gy x 3fr, daily in BT alone
Table 3(a, b and c).
Table 3a:Group 2 (41p) Table 3b: Group 4 (59p) Table 3c: Group 4 (28p)
ACKNOWLEDGEMENTS
Mean F-up
(months)
Stage
Nºp
MBTT
(days)
VCR 88
(16-143) IA 13
(8-28) IB II
Mean F-up
(months)
Stage
Nºp
MBTT
(days)
VCR 75
(21-127)
IA 33 6
(4-15)
IB 24 II
Mean F-up
(months)
Stage
Nºp
MBTT
(days)
VCR 41
(11-73)
IA 17 3
(3-5)
IB 11 II
GRANT:
SPANISH ASSOCIATION AGAINST CANCER (AECC) FOUNDATION
Previous Surgery:
Schedule 1: Vaginal hysterectomy + bilateral salpingo-oophorectomy and pelvic with or without paraaortic lymphadenectomy by laparoscopy: 37.8%; Abdominal hysterectomy + bilateral salpingo-oophorectomy and pelvic lymphadenectomy: 36.6%; Other: 25.5%.
Schedule 2: Vaginal hysterectomy + bilateral salpingo-oophorectomy and pelvic with or without paraaortic lymphadenectomy by laparoscopy 42.5%; Abdominal hysterectomy + bilateral salpingo-oophorectomy and pelvic lymphadenectomy: 26.8%; Other: 30.7%.
Schedule 3: Laparoscopic-assisted vaginal histerectomy plus bilateral oophorectomy (HBO) and pelvic plus para-aortica lymphadenectomy 32.3%, abdominal HBO and pelvic lymphadenectomy in 21.6%, vaginal HBO in 9.8%, abdominal HBO plus pelvic and para-aortic lymphadenectomy in 8 (7.8%) and ommentectomy in 7 (6.8%); Other:29.5%.
Chemotherapy (CT).
CT was administered in high risk and advanced cases when performance status and comorbidities allowed: 17p in schedule-1, 26p in schedule-2 and 20 in schedule-3 received 4-6 cycles of carboplatin and paclitaxel.
Radiotherapy
External beam irradiation (EBI) plus BT was considered for high risk and stages II-III p and BT alone for those with intermediate risk (but 3 stage II patients received exclusive BT). Two different BT schedules were used during this period of analysis.
The mean EBI dose in Groups 1 and 3 was 44Gy ( ).
BT was performed mainly using vaginal cylinders in 309 p and colpostats in 10p. The median active length of BT treatment was 2.5cm (2-4). The mean and median cylinder size was 3.5cm. for the two BT schedules (2-3.5cm).10Ci HDR 192-Iridium source.
Toxicity evaluation.
Toxicity was prospectively evaluated using the RTOG score for the rectum and bladder and objective criteria of LENT-SOMA for the vagina.
Statistical analysis. Chi-square and Fisher’s exact tests. .
Table 4. Late toxicity in Organs at Risk
LATE TOXICITY
VAGINA
BLADDER
RECTUM
GROUP-1
21.6%
9G1,16G2,1G3,1G4
1.6%
1G1,1G3
6.4%
5G1,2G2,1G3
GROUP-2
29.9%
8G1,4G2
2.4%
1G2 0%
GROUP-3
28.7%
7G1,19G2,1G4
4.3%
1G1,1G2
8.5%
1G1,6G2,1G3
GROUP-4
33.9%
11G1,9G2
1.7%
1G1
GROUP-5
35.1%
5G1,21G2
2.7%
2G1
6.6%
3G1
GROUP-6
21.4%
3G1,2G2,1G3
P-VALUE
0.378
0.514
0.113
REFERENCES
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Harkenrider MM, Block AM, Alektiar KM, et al. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for earlys-stage endometrial cancer: A comprensive review. Brachytherapy. 2017; 16(1):
Small W, Beriwal S, Demanes J, et al. American brachytherapy society consensus guidelines for adjuvant vaginal cuff brachytherapy after hysterectomy. Brachytherapy 2012;11:58-67.
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