High dose simultaneous integrated boost for node positive cervical cancer

Abstract

Introduction Lymph node metastases presenting with locally advanced cervical cancer are poor prognostic features. Modern radiotherapy approaches enable dose escalation to radiologically abnormal nodes. This study reports the results of a policy of a simultaneous integrated boost (SIB) in terms of treatment outcomes. Materials and methods Patients treated with radical chemoradiation with weekly cisplatin for locally advanced cervical cancer including an SIB to radiologically abnormal lymph nodes were analysed. All patients received a dose of 45 Gy in 25 fractions and a SIB dose of 60 Gy in 25 fractions using intensity modulated radiotherapy/volumetric modulated arc therapy, followed by high dose rate brachytherapy of 28 Gy in 4 fractions. A control cohort with radiologically negative lymph nodes was used to compare impact of the SIB in node positive patients. Treatment outcomes were measured by overall survival (OS), post treatment tumour response and toxicities. The tumour response was based on cross sectional imaging at 3 and 12 months and recorded as local recurrence free survival (LRFS), regional recurrence free survival (RRFS) and distant recurrence free survival (DRFS). Results In between January 2015 and June 2017, a total of 69 patients with a median follow up of 30.9 months (23 SIB patients and 46 control patients) were identified. The complete response rate at 3 months was 100% in the primary tumour and 83% in the nodal volume receiving SIB. The OS, LRFS, RRFS and DRFS at 3 years of the SIB cohort were 69%, 91%, 79% and 77% respectively. High doses can be delivered to regional pelvic lymph nodes using SIB without excessive toxicity. Conclusion Using a SIB, a total dose of 60 Gy in 25 fractions chemoradiation can be delivered to radiologically abnormal pelvic nodes with no increase in toxicity compared to node negative patients. The adverse impact of positive nodal status may be negated by high dose deposition using SIB, but larger prospective studies are required to confirm this observation.

Clinical research of the value of high-risk CTV setting on intensity-modulated radiotherapy for stage IIB-IVA cervical cancer

“…Patients with locally advanced cervical cancer were treated with a combination of IMRT/VMAT (45 Gy/25f), weekly cisplatin chemotherapy, and pushes to LNM (60 Gy/25f), followed by ICRT(28 Gy/4f). The 3-year OS rate, local recurrence-free survival rate, regional recurrence-free survival rate, and distant recurrence-free survival rate were 69%, 91%, 79%, and 77% in 23 patients, not statistically significant when compared to patients without LNM [ 27 ]. In a prospective study by Beriwal et al, 36 patients with stage IB2-IVA cervical cancer were treated with IMRT and concurrent cisplatin chemotherapy.…”

Simultaneous Integrated Boost for Dose Escalation in Node-Positive Cervical Cancer: 5-Year Experience in a Single Institution

“…With the paradigm shift towards MR-based IGABT in the past decade achieving excellent local control, there is a pressing demand to address regional and systemic disease control, especially in patients with node-positive disease [ 10 ]. One of the attractive strategies is dose escalation to involved nodes, which has demonstrated encouraging outcomes [ 18 , 35 , 36 , 37 ]. However, the dose–response relationship for nodal control has not been clearly defined, thus consensus on the optimal dose prescription is lacking.…”

“…However, the dose–response relationship for nodal control has not been clearly defined, thus consensus on the optimal dose prescription is lacking. In clinical practice, SIB is commonly prescribed in the range of 55–60 Gy in 25 fractions [ 18 , 36 , 37 ]. Bacorro et al [ 38 ] suggested that increasing the total nodal dose from 50 Gy to 60 Gy EQD2 could significantly improve nodal control, especially for bulky nodes.…”

Toripalimab combined with concurrent platinum-based Chemoradiotherapy in patients with locally advanced cervical Cancer: an open-label, single-arm, phase II trial

“…75 patients from EMBRACE study received a median nodal boost dose of 62 Gy EQD2, only six patients recurred in boosted nodes with a median follow up of 30 months [ 30 ]. Jayatilakebanda, et al delivered a total dose of 60 Gy in 25 fractions to radiologically abnormal pelvic nodes by SIB technique and found no increase in toxicity compared to node negative patients [ 29 ]. Based on these results, we adopted SIB-IMRT technique in our trial and designed a 53.50–59.92 Gy /25–28 fractions boost protocol.…”