Clinical Outcomes of Intensity-Modulated Pelvic Radiation Therapy for Carcinoma of the Cervix

doi:10.1016/j.ijrobp.2010.04.041

International Journal of Radiation OncologyBiologyPhysics

Volume 80, Issue 5, 1 August 2011, Pages 1436-1445

Presented at the 51st Annual Meeting of the American Society of Radiation Oncology, Chicago, IL, November 1–5, 2009.

https://doi.org/10.1016/j.ijrobp.2010.04.041 Get rights and content

Purpose

To evaluate disease outcomes and toxicity in cervical cancer patients treated with pelvic intensity-modulated radiation therapy (IMRT).

Methods and Materials

We included all patients with Stage I–IVA cervical carcinoma treated with IMRT at three different institutions from 2000–2007. Patients treated with extended field or conventional techniques were excluded. Intensity-modulated radiation therapy plans were designed to deliver 45 Gy in 1.8-Gy daily fractions to the planning target volume while minimizing dose to the bowel, bladder, and rectum. Toxicity was graded according to the Radiation Therapy Oncology Group system. Overall survival and disease-free survival were estimated by use of the Kaplan-Meier method. Pelvic failure, distant failure, and late toxicity were estimated by use of cumulative incidence functions.

Results

The study included 111 patients. Of these, 22 were treated with postoperative IMRT, 8 with IMRT followed by intracavitary brachytherapy and adjuvant hysterectomy, and 81 with IMRT followed by planned intracavitary brachytherapy. Of the patients, 63 had Stage I–IIA disease and 48 had Stage IIB–IVA disease. The median follow-up time was 27 months. The 3-year overall survival rate and the disease-free survival rate were 78% (95% confidence interval [CI], 68–88%) and 69% (95% CI, 59–81%), respectively. The 3-year pelvic failure rate and the distant failure rate were 14% (95% CI, 6–22%) and 17% (95% CI, 8–25%), respectively. Estimates of acute and late Grade 3 toxicity or higher were 2% (95% CI, 0–7%) and 7% (95% CI, 2–13%), respectively.

Conclusions

Intensity-modulated radiation therapy is associated with low toxicity and favorable outcomes, supporting its safety and efficacy for cervical cancer. Prospective clinical trials are needed to evaluate the comparative efficacy of IMRT vs. conventional techniques.

Introduction

Over the past decade, interest in intensity-modulated radiation therapy (IMRT) for gynecologic malignancies has grown considerably (1). Multiple studies have shown that IMRT reduces bowel, rectal, bladder, and bone marrow (BM) dose 2, 3, 4 and is associated with lower rates of gastrointestinal (GI), genitourinary (GU), and hematologic toxicity compared with conventional techniques 5, 6, 7, 8. Optimizing IMRT plans may further reduce toxicity 9, 10, 11, 12 and/or permit higher target doses 13, 14, 15, thereby improving the therapeutic ratio of radiation therapy (RT).

Despite promising results with IMRT for gynecologic cancer, outcomes data remain limited. Moreover, the application of IMRT in cervical cancer, particularly for women with an intact uterus, remains controversial. Among the factors contributing to this controversy are the increased complexity of IMRT, potential for underdosing target because interfraction and intrafraction motion 16, 17, 18, 19, 20, and debate regarding optimal pelvic IMRT techniques, including target definition 21, 22, 23, normal tissue dosimetric constraints 10, 12, and magnitude of planning margins required (24). The comparative effectiveness of IMRT vs. conventional pelvic RT techniques for cervical cancer therefore remains unknown.

Studies reporting long-term outcomes in cervical cancer are needed to help provide benchmark results for prospective clinical trials. We began using IMRT in 2000 at the University of Chicago, with favorable early treatment results 5, 6, 25, 26, and have subsequently collected data in a large cohort of women treated at several different medical centers. Here, we report our findings on acute and late GI and GU toxicity and disease outcomes for this cohort.

Section snippets

Patients

All patients with International Federation of Gynecology and Obstetrics Stage I–IVA cervical cancer treated with IMRT between 2000 and 2007 at the University of Chicago, University of Illinois at Chicago, and University of California, San Diego were included. Patients with synchronous malignancies, positive para-aortic lymph nodes or distant metastases, or treatment with extended-field radiation therapy (EFRT), conventional RT techniques, or palliative intent were excluded. The study was

Patients

Of the 141 patients screened, 111 met the inclusion criteria. The reasons for exclusion included the use of EFRT (n = 13), initial treatment with conventional RT (n = 11), palliative intent (n = 4), concurrent treatment for lung cancer (n = 1), and missing records (n = 1). Of the patients, 63 (57%) had Stage I–IIA and 48 (43%) had Stage IIB–IVA disease (Table 1). Two women with Stage IA2 disease who were not candidates for surgery were treated with RT alone. Of the patients, 22 (20%) were

Discussion

The use of IMRT for gynecologic malignancies has increased during the past decade (1), despite limited data on long-term toxicity or disease control. Currently, the only completed prospective trial of IMRT in cervical cancer has been in the postoperative setting (43). Long-term outcomes data remain limited, particularly for women with intact cervical cancer. This study represents the largest analysis of cervical cancer patients treated with IMRT to date. We found that IMRT was associated with

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: Supported by National Institute of Health Grants L30 CA135746-01 and T32 RR023254.

: Conflict of interest: none.

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Clinical InvestigationClinical Outcomes of Intensity-Modulated Pelvic Radiation Therapy for Carcinoma of the Cervix

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Patients

Patients

Discussion

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Gynecol Oncol

Int J Radiat Oncol Biol Phys

Gynecol Oncol

Am J Obstet Gynecol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Clinical Investigation
Clinical Outcomes of Intensity-Modulated Pelvic Radiation Therapy for Carcinoma of the Cervix