Radiation Oncology/Endometrium/Definitive RT


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Definitive Radiation Therapy (Inoperable Patients)

Brachytherapy applicator types:

  • Standard tandem & ovoid
  • Rotte applicator (HDR) - Y-shaped device for maximizing uterine coverage
  • Simon-Heyman capsules - Intrauterine sources

Brachytherapy aloneEdit

  • PMID 3698503, 1986 (1965–70) — "Results of intracavitary radium treatment for adenocarcinoma of the body of the uterus." Jones DA et al. Clin Radiol. 1986 Mar;37(2):169-71.
    • Non randomized. 160 pts. LDR intracavitary radium alone. Either two insertions (75 Gy over 10 days) or one insertion (50 Gy over 4 days).
    • Primary tumor control 77% (two insertions) vs 67% (one insertion). 5-yr and 10-yr OS 73%/62% vs 58%/34%.
  • MDACC, 1993 (1960–86) - PMID 8244810 — "Treatment of endometrial carcinoma with radiation therapy alone." Kupelian PA et al. Int J Radiat Oncol Biol Phys. 1993 Nov 15;27(4):817-24.
    • Retrospective. 152 pts. 116 with brachytherapy alone, the rest with tele + brachy.
    • 5-yr disease-specific survival was 87% for Stage I, 88% Stage II, 49% for Stage III-IV. Worse outcome for papillary serous, 43% for Stage I-II.
    • Patients were twice as likely to die from intercurrent illness than from uterine cancer at 10 years.
  • Vienna, 1997 (1981–92) - PMID 9069308 — "Primary treatment of endometrial carcinoma with high-dose-rate brachytherapy: results of 12 years of experience with 280 patients." Knocke TH et al. Int J Radiat Oncol Biol Phys. 1997 Jan 15;37(2):359-65.
    • 280 pts. 8.5 Gy x 4-5 fractions (intrauterine) weekly and 7 Gy x 1-2 (vaginal cylinder).
    • Mean f/u 55 mo. 5-yr OS 52%, DSS 76%, LC 75%.

External Beam RT + brachytherapyEdit

  • Washington U., 1987 - PMID 3558039 — "Medically inoperable stage I adenocarcinoma of the endometrium treated with radiotherapy alone." Grigsby PW et al. Int J Radiat Oncol Biol Phys. 1987 Apr;13(4):483-8.
    • 69 pts. Stage I. BT alone in 11, BT + low dose EBRT in 9, and "definitive" BT + high dose EBRT in 49.
  • France, 1988 (1975–84) - PMID 3182345 — "Radiation therapy alone for medically inoperable patients with adenocarcinoma of the endometrium." Taghian A et al. Int J Radiat Oncol Biol Phys. 1988 Nov;15(5):1135-40.
    • 104 pts
  • PMID 8226152, 1993 — "Primary radiation therapy for endometrial carcinoma: a case controlled study." Rose PG et al. Int J Radiat Oncol Biol Phys. 1993 Oct 20;27(3):585-90.
    • Retrospective. 64 pts. Stage I+II. 10 had brachytherapy alone, the rest had tele + brachy.
    • No difference in survival between these pts treated with primary radiotherapy and surgically-treated case controls.
  • France, 1993 (1967–86) - PMID 8491680 — "Exclusive radiation therapy in endometrial carcinoma." Rouanet P et al. Int J Radiat Oncol Biol Phys. 1993 May 20;26(2):223-8.
    • Retrospective. 250 pts. All pts treated with 45 Gy EBRT followed by BT.
    • 5-yr OS 58%, DFS 55%.
  • Washington U, 1996 (1965–90) - PMID 12118561 — "Medically inoperable stage I endometrial carcinoma: a few dilemmas in radiotherapeutic management." Chao CK et al. Int J Radiat Oncol Biol Phys. 1996 Jan 1;34(1):27-31.
    • 101 pts, clinical Stage I. EBRT only in 3 pts, brachy only in 26, EBRT + BT in 10, and whole pelvis with midline shield + BT in 62. Brachytherapy consisted of tandem + colpostats + Simon-Heyman capsules.
    • Median f/u 6.3 yrs. 5-yr pelvic control 88-100%.
    • Conclusion: radiation therapy should be continued regardless of a negative D&C specimen at the time of the 2nd intracavitary implant.
  • Yale, 1996 (1975–92) - PMID 8626131 — "Radiation therapy as exclusive treatment for medically inoperable patients with stage I and II endometrioid carcinoma with endometrium." Fishman DA et al. Gynecol Oncol. 1996 May;61(2):189-96.
    • 54 pts.
    • Inoperable patients who did not die from intercurrent disease had a median 5-year survival which approaches that of operable patients
  • McGill University, 2005 (1984–2003) - PMID 16099598 — "Long-term results of high-dose-rate brachytherapy in the primary treatment of medically inoperable stage I-II endometrial carcinoma." Niazi TM et al. Int J Radiat Oncol Biol Phys. 2005 Nov 15;63(4):1108-13.
    • 38 pts. 76% clinical Stage I. Treatment: HDR brachy alone in 79%, EBRT+BT in 21%. Brachytherapy technique: tandem alone, biconcave butterfly tandem, or tandem + colpostats (in Stage II pts). Median dose 24 Gy, in 3 fractions 1 week apart. Dose prescribed at 2 cm from central axis or at uterine surface (if using MRI). EBRT: median dose 42 Gy. Brachytherapy dose same if EBRT given.
    • Median f/u 57 mo. 22 deaths (32% died of disease, 68% from other causes). 29% experienced failure.

Non-standard fractionation:

  • U.Pittsburgh, 2006 - PMID 16644466 — "Twice-daily high-dose-rate brachytherapy for medically inoperable uterine cancer." Gerszten K et al. Brachytherapy. 2006 Apr-Jun;5(2):118-21.
    • 22 pts. Twice-daily HDR in 5 fractions over 3 days. Pts received EBRT + HDR or HDR alone (favorable pts). Rotte applicator. Post-implant imaging with prescription dose covering "uterine points" based on CT imaging (not 3D planning). 4 Gy x 5 (if EBRT given) or 7 Gy x 5 (HDR alone).
    • No significant acute complications. 2 of 22 with Grade 1 proctitis.

Summary of doses used: [1]

  • EBRT + brachytherapy:
    • EBRT + 4700 mgh [2]
    • EBRT 45 Gy + 30 Gy LDR at 1.5–2 cm [1]
    • ABS recommendations (PMID 11020575) - 45 Gy EBRT + HDR 8.5 Gy x 2, 6.3 Gy x 3, or 5.2 Gy x 4 (all at 2 cm)
  • Brachytherapy alone:
    • LDR 65 Gy (2 insertions of 32.5 Gy - at 1.5 cm lateral to the tandem) [3]
    • LDR 60 Gy (2 x 30 Gy - at 2.0 cm) [4]
    • LDR 72 Gy (2 x 36 Gy - at Point A) [5]
    • LDR 80 Gy [6]
    • LDR 3600 mgh x 2 (Kupelian, IJROBP 1993)
    • LDR 4000 mgh x 2 (Bond, Clin Oncol 1997)
    • HDR 10 Gy x 5 at 2 cm (Herbolsheimer, Endocuriether Hypertherm Oncol 1992)
    • HDR 8.5 Gy x 4 at 2 cm (Knocke, IJROBP 1997)
    • HDR (6 Gy x 5) x 2 (Bond, ibid.)
    • ABS recommendations (see above) - HDR 8.5 Gy x 4, 7.3 Gy x 5, 6.4 Gy x 6, or 5.7 Gy x 7 (all at 2 cm)

Treatment complications:

  • Washington U, 1995 (1965–91) - PMID 7995766 — "Brachytherapy-related complications for medically inoperable stage I endometrial carcinoma." Chao CK et al. Int J Radiat Oncol Biol Phys. 1995 Jan 1;31(1):37-42.
    • 96 pts. Tandems + ovoids + Simon-Heyman capsules in all pts.
    • Morbidity rate: 4% (4 pts - 2-MI, 1-CHF, 1-PE), Mortality rate: 2% (2 pts - 1-MI, 1-PE).
    • Acceptable morbidity and mortality for high risk pts.

ReferencesEdit

  1. a b Adapted from PMID 16344259 — "Image-based intracavitary brachytherapy in the treatment of inoperable uterine cancer: individual dose specification at specific anatomical sites." Kim RY et al. Brachytherapy. 2005;4(4):286-90.
  2. PMID 3558039 (Grigsby, IJROBP 1987)
  3. PMID 14272522 (Strickland, Clin Radiol 1965)
  4. PMID 5822722 (Badib, Radiology 1969)
  5. PMID 3698503 (Jones, Clin Radiol 1986)
  6. PMID 1752489 (Lehoczky, Gynecol Oncol 1991)
Last modified on 27 October 2012, at 22:32