Lymph Node-Directed Simultaneous Integrated Boost in Patients with Clinically Lymph Node-Positive Cervical Cancer Treated with Definitive Chemoradiation: Clinical Outcomes and Toxicity

Jethwa, Krishan R.; Jang, Seok Won; Gonuguntla, Karthik; Evans, J. D.; Block, Michael S.; Kumar, Amit; Langstraat, C.L.; Whitaker, Thomas J.; Day, Courtney N.; Deufel, Christopher L.; Haddock, Michael G.; Petersen, Ivy A.

doi:10.1016/j.ijrobp.2018.07.1710

Cited by 4 publications

(9 citation statements)

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“…An important result from this study is the finding that toxicity is not increased over that in a control cohort when SIB is used. No ≥ grade 3 toxicities in terms of acute and late GI/GU, fatigue, lymphoedema and pelvic fracture were found in our SIB cohort which is similar to other published studies [ 15 – 18 ]. Grade 3 vaginal stenosis was seen in 1 patient in both the control and the SIB group.…”

Section: Discussionsupporting

confidence: 91%

“…As shown in Table 3, 16/23 (70%) of the SIB cohort were staged with 18 All treated patients in the SIB cohort showed complete radiological response at the primary site on follow-up CT at 3 months. When considering the lymph nodes 83% of them had complete response three months after treatment and 13% showed partial response (> 50% regression).…”

Section: Resultsmentioning

confidence: 97%

“…All patients were staged with a pelvic multiparametric MR scan and computed tomography (CT) scans of the chest, abdomen and pelvis. For patients showing equivocal node status on CT, 18 FDGPET was performed. Radiologically abnormal lymph nodes were identified on the planning CT scans and a separate clinical target volume (CTV) defined which was expanded by 5 mm globally to form the planning target volume (PTV).…”

Section: Methodsmentioning

confidence: 99%

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High dose simultaneous integrated boost for node positive cervical cancer

2021

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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.

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Section: Discussionsupporting

confidence: 91%

Section: Resultsmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

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High dose simultaneous integrated boost for node positive cervical cancer

2021

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“…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.…”

Section: Discussionmentioning

confidence: 99%

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

Cheung,

Law,

Fung

et al. 2023

Cancers

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This study retrospectively evaluates clinical outcomes of dose escalation to involved nodes using volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) for node-positive locally advanced cervical cancer (LACC) at a single institution. Consecutive patients with node-positive LACC (FIGO2018 IIIC1-IVA) who received definitive chemoradiotherapy by VMAT 45 Gy in 25 fractions with SIB to 55–57.5 Gy, followed by magnetic resonance image-guided adaptive brachytherapy (IGABT) between 2018 and 2022 were identified. A standardized strategy regarding nodal boost delivery and elective para-aortic (PAO) irradiation was employed. Primary endpoints were involved nodal control (INC) and regional nodal control (RNC). Secondary endpoints were pelvic control (PC), locoregional control (LRC), disease-free survival (DFS), overall survival (OS), failure pattern, and radiotherapy-related toxicities. A total of 234 involved nodes (182 pelvic and 52 PAO) in 54 patients, with a median of 3 involved nodes per patient (range 1–16), were analyzed. After a median follow-up of 19.6 months, excellent INC was achieved, with four (2%) boost-volume failures occurring in three patients. The 2-year actuarial RNC, PC, LRC, DFS, and OS were 93%, 87%, 87%, 78%, and 85%, respectively. Adenocarcinoma histology was associated with worse RNC (p = 0.02) and OS (p = 0.04), whereas the primary tumor maximum standardized uptake value (SUVmax) was associated with worse PC (p = 0.04) and LRC (p = 0.046) on univariate analysis. The incidence of grade ≥3 acute and late radiotherapy-related toxicity were 2% and 4%, respectively. Treatment of node-positive LACC with VMAT with SIB allows safe and effective dose escalation. The 5-year local experience demonstrated excellent treatment outcomes without additional toxicity.

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“…This trial also examined the value of PET-based IG-IMRT and found that patients treated with IG-IMRT had a significantly lower incidence of acute grade !3 neutropenia. Doses to the primary tumour and grossly involved lymph nodes can be boosted relative to elective nodal regions via the use of a simultaneous integrated boost technique, which has been shown to be well tolerated with encouraging control rates [35].…”

Section: Intensity-modulated Radiation Therapymentioning

confidence: 99%

Advances in External Beam Radiation Therapy and Brachytherapy for Cervical Cancer

et al. 2021

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The standard of care for the definitive treatment of locoregionally advanced cervical cancer is external beam radiation therapy (EBRT) with concurrent chemotherapy followed by a brachytherapy boost. Historically, EBRT was delivered via a two-dimensional technique based primarily on bony landmarks. This gave way to three-dimensional conformal radiation therapy, which allows for dose calculation and adjustment based on individual tumour and patient anatomy. Further technological advances have established intensity-modulated radiation therapy (IMRT) as a standard treatment modality, given the ability to maintain tumoricidal doses to target volumes while reducing unwanted radiation dose to nearby critical structures, thereby reducing toxicity. Routine image guidance allows for increased confidence in patient alignment prior to treatment, and the ability to visualise the daily position of the targets and organs at risk has been instrumental in allowing safe reductions in treated volumes. Additional EBRT technologies, including proton therapy and stereotactic body radiation therapy, may further improve the therapeutic index. In the realm of brachytherapy, a shift from point-based dose planning to image-guided brachytherapy has been associated with improved local control and reduced toxicity, with additional refinement ongoing. Here we will discuss these advances, the supporting data and future directions.

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Lymph Node-Directed Simultaneous Integrated Boost in Patients with Clinically Lymph Node-Positive Cervical Cancer Treated with Definitive Chemoradiation: Clinical Outcomes and Toxicity

Cited by 4 publications

References 0 publications

High dose simultaneous integrated boost for node positive cervical cancer

High dose simultaneous integrated boost for node positive cervical cancer

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

Advances in External Beam Radiation Therapy and Brachytherapy for Cervical Cancer

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