Positron Emission Tomography-Guided Bone Marrow-Sparing Radiation Therapy for Locoregionally Advanced Cervix Cancer: Final Results From the INTERTECC Phase II/III Trial

Williamson, Casey W.; Sirák, Igor; Xu, Ronghui; Portelance, Lorraine; Wei, Lichun; Tarnawski, Rafał; Mahantshetty, Umesh; Heide, Elena S.; Yashar, Catheryn M.; McHale, Michael; Bosch, Walter; Lowenstein, Jessica; Saenz, Cheryl C.; Plaxe, Steve; Eskander, Ramez N.; Einck, John; Mundt, Arno J.; Mayadev, Jyoti; Mell, Loren K.

doi:10.1016/j.ijrobp.2021.08.019

Cited by 19 publications

(22 citation statements)

References 49 publications

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“…Additionally, data from the INTERTECC study suggest the possibility of using lumbar spine and pelvic bone FDG uptake to identify the most active bone marrow to spare with intensity modulated radiation therapy planning. In a select group of patients, treatment with this bone marrow sparing intensity modulated radiation therapy approach showed significantly lower grade 3 neutropenia without any significant increase in gastrointestinal or other toxicity 23. This finding is being further evaluated in NRG-GYN006.…”

Section: Cervix Cancermentioning

confidence: 81%

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Imaging to optimize gynecological radiation oncology

Kidd

2022

Int J Gynecol Cancer

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Gynecological cancers have particularly benefited from the increasing use of imaging to guide radiation treatment planning for both external beam radiation and brachytherapy. While the different gynecological cancers have varying use of imaging, certain trends predominate. CT represents an economical choice for evaluating initial disease extent or potential metastasis at follow-up, particularly for endometrial and ovarian cancers. F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is particularly useful for assessing the initial disease extent and longer term treatment response of squamous predominant cancers, including cervical, vaginal, and vulvar cancers. With its excellent pelvic soft tissue discrimination, MRI provides the greatest assistance in evaluating the local extent of gynecological tumors, including initial evaluation for non-operative endometrial and vulvar cancer, and assessment before, after and during brachytherapy for cervix, locally recurrent endometrial, and primary vaginal cancers. With more limited availability of MRI, ultrasound can also help guide brachytherapy, particularly during procedures. The benefits of using imaging to better spare bone marrow or earlier assessment of treatment response are topics still being explored, in particular for cervical cancer. As imaging along with radiation oncology technologies continue to evolve and develop, such as with MRI-linacs and ultra high dose rate (FLASH) radiation, we may continue to see increasing use of imaging for advancing gynecological radiation oncology.

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Section: Cervix Cancermentioning

confidence: 81%

“…In a select group of patients, treatment with this bone marrow sparing intensity modulated radiation therapy approach showed significantly lower grade 3 neutropenia without any significant increase in gastrointestinal or other toxicity. 23 This finding is being further evaluated in NRG-GYN006.…”

Section: Fdg-pet/ct Mri and Prognosismentioning

confidence: 94%

Imaging to optimize gynecological radiation oncology

Kidd

2022

Int J Gynecol Cancer

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“…Bone marrow sparing (BMS) radiotherapy reduces G2 + HT by approximately 70%, particularly leukopenia and neutropenia [2]. BMS-IMRT could reduce the volume of bone marrow receiving high-dose irradiation while maintaining the target coverage, resulting in fewer HT and potentially limiting the suppressive effect on immune responses [19][20][21]. Some retrospective studies have reported that low-dose irradiation of PBM was significantly associated with HT events [22,23].…”

Section: Discussionmentioning

confidence: 99%

Functional MRI radiomics-based assessment of pelvic bone marrow changes after concurrent chemoradiotherapy for cervical cancer

et al. 2022

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Objectives To quantify the dose-response relationship of changes in pelvic bone marrow (PBM) functional MR radiomic features (RF) during concurrent chemoradiotherapy (CCRT) for patients with cervical cancer and establish the correlation with hematologic toxicity to provide a basis for PBM sparing. Methods A total of 54 cervical cancer patients who received CCRT were studied retrospectively. Patients underwent MRI IDEAL IQ and T2 fat suppression (T2fs) scanning pre- and post-CCRT. The PBM RFs were extracted from each region of interest at dose gradients of 5–10 Gy, 10–15 Gy, 15–20 Gy, 20–30 Gy, 30–40 Gy, 40–50 Gy, and > 50 Gy, and changes in peripheral blood cell (PBC) counts during radiotherapy were assessed. The dose-response relationship of RF changes and their correlation with PBC changes were investigated. Results White blood cell, neutrophils (ANC) and lymphocyte counts during treatment were decreased by 49.4%, 41.4%, and 76.3%, respectively. Most firstorder features exhibited a significant dose-response relationship, particularly FatFrac IDEAL IQ, which had a maximum dose-response curve slope of 10.09, and WATER IDEAL IQ had a slope of − 7.93. The firstorder-Range in FAT IDEAL IQ and firstorder-10Percentile in T2fs, showed a significant correlation between the changes in ANC counts under the low dose gradient of 5–10 Gy (r = 0.744, -0.654, respectively, p < 0.05). Conclusion Functional MR radiomics can detect microscopic changes in PBM at various dose gradients and provide an objective reference for bone marrow sparing and dose limitation in cervical cancer CCRT.

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“…Although there are currently no randomized data suggesting the routine use of intensity-modulated radiation therapy for the external beam phase of intact locally advanced cervical cancer, a preponderance of evidence suggests that intensity-modulated radiation therapy may reduce bowel toxicity and, potentially, bone marrow toxicity 23 24. Recently, an international study showed that intensity-modulated radiation therapy can reduce acute grade 3 neutropenia, but not treatment-related lymphopenia 25. In the IntErnational study on MRI-guided BRAchytherapy in CErvical cancer (EMBRACE-1) prospective clinical trial, approximately 40% of patients were treated with intensity-modulated radiation therapy and 60% with three-dimensional conformal radiation 26.…”

Section: Locally Advanced Cervical Cancermentioning

confidence: 99%

“…23 24 Recently, an international study showed that intensity-modulated radiation therapy can reduce acute grade 3 neutropenia, but not treatment-related lymphopenia. 25 In the IntErnational study on MRI-guided BRAchytherapy in CErvical cancer (EMBRACE-1) prospective clinical trial, approximately 40% of patients were treated with intensity-modulated radiation therapy and 60% with three-dimensional conformal radiation. 26 This approach resulted in 90% local control and high rates of nodal control and set new benchmarks for both local control, as well as morbidity reduction with combined modality external radiotherapy and brachytherapy.…”

Section: Locally Advanced Cervical Cancermentioning

confidence: 99%

The role of proton therapy in gynecological radiation oncology

Taunk

2022

Int J Gynecol Cancer

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Proton beam therapy is an external beam radiotherapy modality that offers potentially similar efficacy and reduced toxicity compared with photon radiotherapy due to little to no exit dose of radiation beyond the intended target. Improvements in radiotherapy from two-dimensional, to three-dimensional, to intensity-modulated radiation therapy have offered comparable to improved efficacy of radiation therapy with progressive reductions in toxicity. Proton beam therapy may offer further improvements, with multiple dosimetric studies demonstrating potential reductions in exposure of normal tissue to radiation, particularly bowel and bone marrow. Proton beam therapy offers avenues for dose escalation or re-irradiation, which were previously not feasible with photon radiotherapy. Although early clinical data generally demonstrate safety, feasibility, and efficacy in a few series, prospective clinical trials are limited and needed to better define who might benefit from proton therapy. In this review, we discuss the history, dosimetry, available clinical data, and technical needs to deliver high-quality proton therapy.

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Positron Emission Tomography-Guided Bone Marrow-Sparing Radiation Therapy for Locoregionally Advanced Cervix Cancer: Final Results From the INTERTECC Phase II/III Trial

Cited by 19 publications

References 49 publications

Imaging to optimize gynecological radiation oncology

Imaging to optimize gynecological radiation oncology

Functional MRI radiomics-based assessment of pelvic bone marrow changes after concurrent chemoradiotherapy for cervical cancer

The role of proton therapy in gynecological radiation oncology

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