Radiation Oncology/Palliation/Pelvic

Palliation of Pelvic Malignancies

• RTOG 85-02 (1985-89) - Phase II-III
  • Gynecologic (40%), colorectal (28%), genitourinary (25%), and miscellaneous (7%)
  • 3.7 Gy BID x 2 days (14.8Gy), total of 3 courses for 44.4 Gy. Interval between courses 4 weeks; later randomized to 2 vs 4 wks.
  • 151 pts on pilot study (variable rest interval). 144 pts on randomized study.
    • PMID 8083097, 1994 — "Late effect of multiple daily fraction palliation schedule for advanced pelvic malignancies (RTOG 8502)." Spanos WJ Jr et al. Int J Radiat Oncol Biol Phys. 1994 Jul 30;29(5):961-7.
      • 6.9% late complications at 18 months (Grade 3+). No pts receiving < 30 Gy (fewer than 3 courses) developed late toxicity.
    • PMID 7679668 (1993) — "Effect of rest interval on tumor and normal tissue response--a report of phase III study of accelerated split course palliative radiation for advanced pelvic malignancies (RTOG-8502)." (Spanos WJ Jr, Int J Radiat Oncol Biol Phys. 1993 Feb 15;25(3):399-403.)
      • Trend toward increase acute toxicity for shorter interval but no difference in late toxicity. No significant difference in tumor response (CR+PR 34% vs 26%). More pts in 2-wk group completed all 3 fractions; pts completing 3 courses had higher overall response rate (42% vs 5%).
    • PMID 2476426, 1989 — "Phase II study of multiple daily fractionations in the palliation of advanced pelvic malignancies: preliminary report of RTOG 8502." Spanos W Jr et al. Int J Radiat Oncol Biol Phys. 1989 Sep;17(3):659-61.
  • Conclusion: Safe regimen with effective palliation of symptoms.

• RTOG 79-05 (1979-82) - 10 Gy x 3
  • 46 pts, Phase I/II. RT 10 Gy (single fraction), repeated at 4-wk intervals for total of 3 fx. Misonidazole prior to RT
  • Of pts completing 3 fractions (n=37) - 6 with CR(16%), 10 PR(27%), minimal response(19%), no response (32%)
  • High rate of late complications (45% at 1 yr; crude 11% Grade 3 and 19% Grade 4)
  • PMID 2442127, 1987 — "Palliation of advanced pelvic malignant disease with large fraction pelvic radiation and misonidazole: final report of RTOG phase I/II study." (Spanos WJ Jr, Int J Radiat Oncol Biol Phys. 1987 Oct;13(10):1479-82.)
  • Conclusion: high rate of late complications. Followed by RTOG 85-02

• UNC; 1986 (1980-1986) PMID 2429945 -- "1000 cGy single dose palliation for advanced carcinoma of the cervix or endometrium." (Halle JS, Int J Radiat Oncol Biol Phys. 1986 Nov;12(11):1947-50.)
  • 42 pts. 9 pts in Group I (localized disease, but palliation recommended due to other medical factors), 19 pts in Group II (locally advanced), 11 pts in Group III (distant metastatic), and 3 pts with advanced recurrent disease. Treated with 1000 cGy per fraction. 25 pts received one course, 15 two courses (at monthly intervals), 2 patients received three courses (1000 x 2 then 700 x 1). 38 of 42 pts presented with bleeding; 11 pts presented with pain.
  • Pain: Of 9 pts evaluable, 2 had complete resolution, 2 had partial resolution. Bleeding: of 30 pts evaluable, 18 (60%) had complete resolution, 9 (30%) had partial resolution. 8 pts (27%) remained permanently free of bleeding. Tumor response: of 28 pts evaluable, 7 (25) had CR, 8 (28%) PR.
  • Toxicity: 5 pts with serious complications
  • Conclusion: "We conclude that 1000 cGy single-fraction whole pelvis treatment can be an effective means of palliating advanced gynecologic cancer provided the patient has a life expectancy of less than 1 year. Patients with a longer life expectancy are at risk for both recurrence of symptoms and for treatment related complications."

Definitive Treatment in Metastatic Setting

• University of Tennessee; 2018 (2004 - 2014) PMID 30054609 -- "Association of Definitive Pelvic Radiation Therapy With Survival Among Patients With Newly Diagnosed Metastatic Cervical Cancer." (Wang Y, JAMA Oncol. 2018 Jul 26. doi: 10.1001/jamaoncol.2018.2677. [Epub ahead of print])
  • Retrospective. NCDB review, 3169 women with metastatic cervical cancer, treated with chemotherapy with RT (n=2361) or without RT (n=808). Median F/U 13 months.
  • Outcome: Overall survival better if chemoRT than chemo alone (HR 0.65, SS). On propensity matching, median OS chemoRT 14.4 months vs chemo 10.6 months. Benefit across all subgroups, including distant node-only mets and organ-only mets. By dose, median OS >45 Gy was 18.5 months vs <45 Gy was 10.2 months (SS). Similar benefit to adding brachytherapy (27.5 months vs 12.9 months, SS).
  • Conclusion: ChemoRT results in substantially longer survival. Prospective trials are warranted.

• Split; Croatia PMID 15032295 -- "Long-lasting complete remission of a patient with cervical cancer FIGO IVB treated by concomitant chemobrachyradiotherapy with ifosfamide and cisplatin and consolidation chemotherapy--a case report." (Vrdoljak E, Eur J Gynaecol Oncol. 2004;25(2):247-9.)
• Case report. 63 year old with cervical cancer and ovarian met, treated with chemo-RT and consolidative chemotherapy. NED 35 months later