PURPOSE: Brachytherapy is critical for the curative treatment of locally advanced cervical cancer. Although brachytherapy use is declining in the United States (U.S.), novel interstitial or intracavitary applicators and advances in image guidance for applicator placement and treatment planning have allowed for tumor dose escalation while reducing normal tissue toxicity. Recent survey data have suggested insufficient brachytherapy training for radiation oncology trainees in the United States. This study aimed to address these gaps by developing and piloting a simulationbased education (SBE) workshop for MR-guided cervical cancer brachytherapy. METHODS AND MATERIALS: An SBE workshop was developed for graduate medical education (GME) trainees focusing on MR-guided brachytherapy for cervical cancer. Four hands-on stations, simulating aspects of the procedure, were led by a team of gynecological brachytherapy experts. The learners were radiation oncology residents and fellows in a U.S. GME training program. The primary outcome was feasibility, assessed by completion of the workshop within the time constraints of the curriculum. Learners completed preworkshop and postworkshop surveys to provide information on efficacy. RESULTS: The workshop was successfully completed in a 1-h block of GME didactic time. Ten trainees completed all four stations, and all completed preworkshop and postworkshop surveys, which showed improvements in knowledge and technical proficiency. Feedback was positive, and trainees requested additional learning opportunities. CONCLUSIONS: This study showed that GME-focused SBE in MR-guided cervical cancer brachytherapy was feasible. SBE provided a nonclinical environment in which to practice aspects of MR-guided brachytherapy. Ongoing work includes collaboration with other U.S. institutions. Future studies should focus on international adaptation.
ObjectiveThe aim of this study was to evaluate recurrence patterns and survival outcomes for patients with early-stage non-endometrioid endometrial adenocarcinoma treated with adjuvant high-dose rate vaginal brachytherapy with a low-dose scheme.MethodsA retrospective review was performed of patients with International Federation of Gynecology and Obstetrics (FIGO) stage I–II non-endometrioid endometrial cancer who received adjuvant vaginal brachytherapy with a low-dose regimen of 24 Gy in six fractions from November 2005 to May 2017. All patients had >6 months of follow-up. Rates of recurrence-free survival, overall survival, vaginal, pelvic, and distant recurrence were calculated by the Kaplan–Meier method. Prognostic factors for recurrence and survival were evaluated by Cox proportional hazards modeling.ResultsA total of 106 patients were analyzed. Median follow-up was 49 months (range 9–119). Histologic subtypes were serous (47%, n=50), clear cell (10%, n=11), mixed (27%, n=29), and carcinosarcoma (15%, n=16). Most patients (79%) had stage IA disease, 94% had surgical nodal assessment, and 13% had lymphovascular invasion. Adjuvant chemotherapy was delivered to 75%. The 5-year recurrence-free and overall survival rates were 74% and 83%, respectively. By histology, 5-year recurrence-free/overall survival rates were: serous 73%/78%, clear cell 68%/88%, mixed 88%/100%, and carcinosarcoma 56%/60% (p=0.046 and p<0.01). On multivariate analysis, lymphovascular invasion was significantly associated with recurrence (HR 3.3, p<0.01). The 5-year vaginal, pelvic, and distant recurrence rates were 7%, 8%, and 21%, respectively. Vaginal and pelvic recurrence rates were highest for patients with carcinosarcoma, lymphovascular invasion and/or FIGO stage IB/II disease. At 5 years, vaginal and pelvic recurrence rates for patients with lymphovascular invasion were 33% and 40%, respectively. Patients with stage IA disease or no lymphovascular invasion had 5-year vaginal recurrence rates of 4% and pelvic recurrence rates of 6% and 3%, respectively.ConclusionsAdjuvant high-dose rate brachytherapy with a low-dose scheme is effective for most patients with early-stage non-endometrioid endometrial cancer, particularly stage IA disease and no lymphovascular invasion. Pelvic radiation therapy should be considered for those with carcinosarcoma, lymphovascular invasion and/or stage IB/II disease.
Purpose To evaluate MRI characteristics in vaginal recurrence of endometrial cancer (EC) including tumor volume shrinkage during salvage radiotherapy, and to identify imaging features associated with survival. Methods Patients with vaginal recurrence of EC treated with external beam radiotherapy (EBRT) followed by brachytherapy (BT), and with available pelvic MRI at two time points: baseline and/or before BT were retrospectively identified from 2004 to 2017. MRI features including recurrence location and tissue characteristics on T2-and T1-weighted images were evaluated at baseline only. Tumor volumes were measured both at baseline and pre-BT. Survival rates and associations were evaluated by Cox regression and Fisher's exact test, respectively. Results Sixty-two patients with 36 baseline and 50 pre-BT pelvic MRIs were included (24/62 with both MRIs). Vaginal recurrence of EC was most commonly located in the vaginal apex (27/36, 75%). Tumors with a post-contrast enhancing peripheral rim or low T2 signal rim at baseline showed longer recurrence-free survival (RFS) (HR 0.2, 95% CI 0.1-0.9, P < 0.05 adjusted for histology; HR 0.2, 95% CI 0.1-0.8, P < 0.05, respectively). The median tumor shrinkage at pre-BT was 69% (range 1-99%). Neither absolute tumor volumes nor volume regression at pre-BT were associated with RFS. Lymphovascular space invasion (LVSI) at hysterectomy and adjuvant RT were associated with recurrence involving the distal vagina (both P < 0.05). Conclusion Vaginal recurrences with rim enhancement at baseline MRI predicted improved RFS, while tumor volume shrinkage at pre-BT did not. Distal vaginal recurrence was more common in patients with LVSI and adjuvant RT at EC diagnosis.
Objectives: The objective of this study was to determine if deficiency of mismatch repair (dMMR) proteins in patients with early-stage favorable endometrial cancer treated with vaginal brachytherapy (VB) is associated with increased recurrence. Materials and Methods:A multi-institutional retrospective cohort study of 141 patients with stage I to II grade 1 and 2 endometrioid adenocarcinoma treated with surgery and adjuvant VB was performed to compare recurrence risk in dMMR (n = 41) versus MMR-preserved (pMMR) (n = 100). Additional clinical and pathologic risk factors were also collected. Univariate analysis and multivariable analysis Cox regression analysis was performed to identify factors associated with any recurrence. Kaplan-Meier method and log rank test were used to compare recurrence free survival and overall survival (OS).Results: Median follow up was 42 months. Forty-one patients (29%) were dMMR. There were 7 recurrences (17%) in dMMR versus 4 recurrences (4%) in pMMR (P = 0.009). On univariate analysis of any recurrence, both dMMR (hazard ratio: 5.3, P = 0.008) and stage (hazard ratio: 3.8, P = 0.05) were statistically significantly associated with time to first recurrence. The 5-year recurrence free survival was 90% (95% CI: 73%-96%) in pMMR versus 61.0% (95% CI: 19%-86%) in dMMR (P = 0.003). Five-year OS was 96% (95% CI: 76%-99%) in pMMR versus 86% (95% CI: 62%-95%) in dMMR (P = 0.03).Conclusions: MMR deficiency in stage I to II grade 1 to 2 endometrial cancer patients treated with adjuvant VB alone was associated with statistically significant increased risk for any recurrence and worse OS. MMR status may be an important prognosticator in this cohort of patients warranting adjuvant treatment intensification in the clinical trial setting.
The prognostic impact of number of dissected and metastatic lymph nodes, the lymph node metastasis ratio in stage IIIC endometrium cancer is not well-studied. Thus, the purpose of this retrospective multicentric study is to investigate the prognostic value of the number of dissected (LNC) and positive nodes (pN) with the value of the lymph node ratio (LNR) in FIGO stage IIIC endometrial cancer patient who received postoperative radiotherapy with or without chemotherapy. Materials/Methods: From January 2001 to December 2016, a total of 180 stage IIIC endometrial cancer patients who were treated with surgery and adjuvant postoperative radiotherapy (RT) (51 patients, 28%) or radiotherapy and chemotherapy (RT-CT) (129 patients, 72%) were retrospective analyzed. The LNR was defined as the number of positive lymph nodes divided by the total number of lymph nodes dissected. The endpoints were overall survival (OS) and progression-free survival (PFS). Results: The median age and follow up times for entire cohort were 60 years (range 36 e 88 years) and 50.5 months (range 2.8 e 199.2 months), respectively. The median dissected and metastatic lymph node numbers were 36 (range 5 e 34) and 2 (range 1 e 45), respectively. The receiveroperating characteristic (ROC) analysis identified 36 [AUCZ0.390 (% 95CI; 0.304-0.476); pZ002] as cutoff value for LNC, with 53% sensitivity and 53% specificity. For LNR, the cutoff value determined in ROC analysis was 10% [AUCZ0.636 (%95CI; 0.548 e 0.725), pZ0.001] with 60% sensitivity and 60% specificity. In univariate analysis, patients with an LNC 36 and LNR value less than 10% had better 5-year OS (68% vs 54% pZ0.04; %76.0% vs.45.0%, p < 0.001 respectively), 5-year PFS rates (67% vs 48% pZ0.01; 74% vs. 41%, p<0.001 respectively). Multivariate analysis only revealed that LNR was an independent prognostic factor for OS (hazard ratio [HRZ2.06 (95% CI; 1.26-3.36); pZ0.004) and PFS [HRZ1.83 (95%CI; 1.16-2.88; p Z 0.001)]. Additional analyses revealed grade I-II histology, receiving adjuvant chemotherapy showed better OS and PFS than counterpart groups (pZ0.02, p<0.001 and pZ0.04 and p<0.001 respectively). Conclusion: More than 10% LNR and high grade (grade III) histology are an important prognostic factors for OS and PFS in stage IIIC endometrial carcinoma patients. Our findings suggest that addition of chemotherapy to RT should be the preferred adjuvant treatment strategy for patients with stage IIIC endometrial cancer with higher grade disease and high lymph node metastasis ratio.
V45 for bladder from 110 to 126 cc (mean 117 AE 6.3 cc), and V45 for rectum from 35 to 38 cc (mean 36 AE 1.4 cc). For dataset B, the V45 for bowel space ranged from 109 to 449 cc (mean 237 AE 120 cc), V45 for bladder from 95 to 122 cc (mean 122 AE 9.0 cc), and V45 for rectum from 17 to 19 cc (mean 17.6 AE 0.8 cc). Variations in normalized means of V45 from dataset A were significantly greater for bowel space when compared to bladder (pZ0.02) and rectum (pZ0.01). Similarly, significantly greater variation in V45 was observed for bowel space compared to bladder (pZ0.01) and rectum (p<0.01) for dataset B. Conclusion: Significant variability exists in how the bowel space OAR is practically delineated during treatment planning for gynecologic cancers. These discrepancies may potentially result in misleading radiation dose and volume assessments for the small bowel. The clinical impact of these findings warrant further study.
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