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Helical Tomotherapy in Cervical Cancer Patients

Simultaneous Integrated Boost Concept: Technique and Acute Toxicity

Tomotherapie in der Therapie des Zervixkarzinoms. Simultanes integriertes Boostkonzept: Technik und Akuttoxizität

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Abstract

Purpose:

To evaluate the acute toxicity of simultaneous integrated boost (SIB) technique for dose escalation with helical tomotherapy (HT) in patients with locally advanced cervical cancer.

Patients and Methods:

20 patients (FIGO IB1 pN1-IIIB) underwent primary chemoradiation. Prior to chemoradiation, a laparoscopic pelvic and para-aortic lymphadenectomy was performed. A boost region was defined using titanium clips during staging for planning target volume (PTV-B). Patients were treated with five weekly fractions of 1.8 Gy to a total dose of 50.4 Gy to the tumor region and the pelvic (para-aortic) lymph node region (PTV-A), and five weekly fractions of 2.12 Gy to a total dose of 59.36 Gy to the PTV-B. Chemotherapy consisted of weekly cisplatin 40 mg/m2. 19 patients underwent brachytherapy. Dose-volume histograms were evaluated and acute gastrointestinal (GI), genitourinary (GU), and hematologic toxicity were documented (CTCAE v3.0).

Results:

Pelvic and para-aortic lymph node metastases were confirmed in nine and four patients, respectively. Five patients refused laparoscopic staging. The mean volume of PTV-A and PTV-B was 1,570 ± 404 cm3and 341 ± 125 cm3, respectively. The mean dose to the bladder, rectum, and small bowel was 47.85 Gy, 45.76 Gy, and 29.71 Gy, respectively. No grade 4/5 toxicity was observed. Grade 2/3 hematologic toxicity occurred in 50% of patients and 5% experienced grade 3 diarrhea. There was no grade 3 GU toxicity. 19 patients underwent curettage 6–9 weeks after chemoradiation without any evidence of tumor.

Conclusion:

The concept of SIB for dose escalation in patients with locally advanced cervical cancer is feasible with a low rate of acute toxicity. Whether dose escalation can translate into improved outcome will be assessed after a longer follow-up.

Zusammenfassung

Ziel:

Die Akuttoxizität der simultanen integrierten Boost-(SBI-)Technik der helikalen Tomotherapie (HT) in der primären Radiochemotherapie bei Patientinnen mit lokal fortgeschrittenen Zervixkarzinomen wurde untersucht.

Patienten und Methodik:

20 Patientinnen mit Zervixkarzinomen (FIGO IB1 pN1-IIIB) erhielten nach laparoskopischer transperitonealer pelviner und paraaortaler Lymphonodektomie eine primäre Radiochemotherapie. Unter Einschluss der pelvinen/paraaortalen Lymphknoten und der Tumorregion (PTV-A [Planungszielvolumen]) wurden die Patientinnen mit fünf wöchentlichen Einzeldosen von 1,8 Gy bis 50,4 Gy bestrahlt. Eine standardisierte Boostregion wurde mit Hilfe von Titanclips (PTV-B) markiert. Simultan betrug hier die Einzeldosis im PTV-B 2,12 Gy, die Gesamtdosis 59,36 Gy. Eine simultane Chemotherapie (40 mg/m2 Cisplatin wöchentlich) wurde appliziert. 19 Patientinnen erhielten zusätzlich eine intrazervikale Brachytherapie. Die Dosis-Volumen- Histogramme wurden ausgewertet und akute gastrointestinale (GI), urogenitale (GU) und hämatologische Toxizitäten dokumentiert (CTCAE v3.0).

Ergebnisse:

Pelvine und paraaortale Lymphknotenmetastasen wurden bei neun und vier Patientinnen gesichert. Fünf Patientinnen hatten das laparoskopische Staging abgelehnt. Das mittlere Volumen von PTV-A bzw. PTV-B betrug 1 570 ± 404 ml bzw. 341 ± 125 ml. Die mittlere Dosis von Blase, Rektum und Dünndarm lag bei 47,85 Gy, 45,76 Gy und 29,71 Gy. Es trat keine Grad- 4/5-Toxizität auf. Hämatologische Toxizität Grad 2/3 entwickelten 50 % der Patientinnen, 5 % wiesen eine Grad-3-Diarrhö auf. GU-Toxizität Grad 3 trat nicht auf. Die Abrasio 6–9 Wochen nach Therapieende zeigte bei 19 Patientinnen keinen vitalen Resttumor.

Schlussfolgerung:

Das SIB-Konzept ist mittels HT in der primären Radiochemotherapie durchführbar. Insgesamt sind niedrige Raten höhergradiger Toxizität beobachtet worden. Ob die Dosiserhöhung zu einer verbesserten lokalen Kontrolle führt, muss evaluiert werden.

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Authors and Affiliations

  1. Department of Radiooncology, Charité – University Medicine, Berlin, Germany

    Simone Marnitz MD, Carmen Stromberger, Michael Kawgan-Kagan, Waldemar Wlodarczyk, Ulrich Jahn & Volker Budach

  2. Department of Gynecology, Charité – University Medicine, Berlin, Germany

    Achim Schneider & Christhardt Köhler

  3. Department of Gynecology and Obstetrics, Martin Luther Hospital, Berlin, Germany

    Uwe Ulrich

  4. Department of Radiooncology, Charité – University Medicine, Charitéplatz 1, 10117, Berlin, Germany

    Simone Marnitz MD

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  1. Simone Marnitz MD
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  2. Carmen Stromberger
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Correspondence to Simone Marnitz MD.

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Marnitz, S., Stromberger, C., Kawgan-Kagan, M. et al. Helical Tomotherapy in Cervical Cancer Patients. Strahlenther Onkol 186, 572–579 (2010). https://doi.org/10.1007/s00066-010-2121-6

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  • DOI: https://doi.org/10.1007/s00066-010-2121-6

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