Kasri Abdul Rahim
Department of Radiation Oncology, Royal Adelaide Hospital
Clinical research fellow

Raghu Gowda
Radiation Oncologist
Royal Adelaide Hospital

Scott Carruthers
Radiation Oncologist
Royal Adelaide Hospital

Braden Higgs
Radiation Oncologist
Royal Adelaide Hospital

Wendy Phillips
Radiation Oncology Medical Physicist
Royal Adelaide Hospital

Angelo Katsilis
Senior Radiation Therapist
Royal Adelaide Hospital

Purpose:

To analyse early clinical outcomes with CT based imaged guided adaptive HDR brachytherapy combined with EBRT+chemotherapy for locally advanced cancer of cervix.

Materials and Methods:

Between June 2013 and Aug 2016, 52 consecutive patients with locally advanced cancer of cervix were treated with EBRT (45Gy/25F) +chemotherapy using IMRT followed by 3 fractions of 8-8.5Gy HDR brachytherapy over 3 weeks with HR CTV concept (EMBRACE trial). CT based planning and US confirmation was used for 1st fraction and US based confirmation only for 2nd and 3rd fractions. Dose volume adaptation was performed with the aim of dose escalation in large tumours ( D90 >85Gy). Interstitial needles were used as per clinicians’ discretion. Dose volume constraints ( D2cc) were <75Gy for rectum and sigmoid and <95Gy for bladder.

Patients were prospectively followed up for efficacy (Imaging PET or clinical assessment) and Grade 3/4 toxicity mainly (modified RTOG – bowel/bladder toxicity scores).

Results

52 patients ( median age 51.9 years) with cervix cancer FIGO IB- IVA were treated with definitive intent. Histology was Squamous Cell Carcinoma in 44 ( 85 %) , tumours size was > 5cm in 22 (43 %), LN involvement 24(46%).

Median follow up was 20.9 months (minimum 3months). Mean OTT was 55.1 days (range 38-76). 73% completed 4 cycles of chemotherapy.

19 % patients developed Grade 3 neutropenia and one patient (2%) had a grade 4 neutropenia.

Interstitial needles were used in addition to intracavitary brachytherapy in 24 (46 %). Total prescribed mean dose (D90) was a 90.14 Gy, D2cc bladder 87.5 Gy,D2cc Rectum= 64.46Gy and D2cc Sigmoid= 76.35Gy.

PET was done in 44% . Overall LC was 94 (%)

79% are disease free. 21% had relapsed – majority were distant (outside radiation field- sites)

There were total of 4 cases with Grade III/IV toxicity (GI/GU) – Entero- enteric fistula requiring stoma. Grade 3 GU toxicity ( haemorrhagic cystitis)was seen in two patient (4%), and radiation induced necrosis of vagina in another patient (2%). All three patients require HBO2.

Conclusions:

Early follow up data with IMRT and CT based image guided brachytherapy for locally advanced cervix cancer shows good local control and acceptable toxicity. Using interstitial needles is associated with superior D90 especially in those who still have bulky residual disease at the time of brachytherapy. DM is the main site of relapse


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