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Robotic radiosurgery as an alternative to brachytherapy for cervical cancer patients

Robotergestützte Radiochirurgie als eine Alternative zur Brachytherapie bei Patientinnen mit Zervixkarzinom

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Abstract

Background and purpose

To compare MRI-guided brachytherapy (BT) and two different dose prescriptions for robotic radiosurgery (RRS) in locally advanced cervical cancer.

Methods and materials

Eleven patients with FIGO stage IIB–IIIB cervical cancer underwent RRS instead of BT for various reasons. A total dose of 30 Gy was administered in five fractions. The maximum dose was chosen such that the prescribed dose was 70 % of the maximum dose (RRS70). To simulate BT more closely, additional plan calculations were carried out for a higher maximum dose with the same enclosing dose of 30 Gy being now 25 % of the maximum dose (RRS25). BT plans were calculated for the same patients (BTRRS). Finally, the resulting three sets of treatment plans were compared with 38 other patients treated with MRI-guided BT and the same dose prescription (BTref). Plan comparisons were performed based on DVH parameters with regard to target coverage (V100), conformation number (CN), and sparing of the organs at risk (OARs).

Results

The best coverage of V100 = 100 ± 0 % was obtained with RRS25, followed by RRS70 with 97.1 ± 2.7 %, BTref with 90.9 ± 8.9 %, and the intraindividual BTRRS with 80.6 ± 6.4 %. The sparing of OARs was associated with D0.1 cc, D2 cc, and D5 cc to the rectum, sigmoid, and bladder walls. OAR doses were compliant with the GEC-ESTRO guidelines and comparable among RRS70, RRS25, BTRRS, and BTref. By contrast, RRS25 could not fulfill these guidelines, exceeding considerably the tolerable dose constraints for the walls of the critical OARs.

Conclusion

Despite of the excellent coverage and higher maximum dose, the unacceptably high exposure to the OARs disqualified RRS25 as an alternative for BT in cervical cancer patients. By contrast, RRS70 offered the best protection for the OARs, comparable to BT, and even better target coverage and conformity than BT.

Zusammenfassung

Hintergrund und Ziel

Vergleich der MRT-basierten Brachytherapie mit zwei unterschiedlichen Dosisverschreibungen der robotergestützten Radiochirurgie (RRS) bei Patientinnen mit lokal fortgeschrittenem Zervixkarzinom.

Material und Methoden

Insgesamt 11 Patientinnen mit Zervixkarzinomen im Stadium FIGOIIB–IIIB erhielten aus verschiedenen Gründen statt der Brachytherapie eine RRS. Die Gesamtdosis von 30 Gy wurde in 5 Einzeldosen appliziert. Die Maximaldosis wurde so gewählt, dass die verschriebene Dosis 70 % (= 6 Gy) der Gesamtdosis (RRS70) entsprach. Als Planvergleich diente die Verschreibung von 25 % der Maximaldosis (= 6-Gy-Einzeldosis; RRS25), um eine der brachytherapieähnliche Verschreibung mit höheren Maxima im Tumor zu simulieren. Es erfolgte ein intraindividueller Planvergleich mit Hilfe der Brachytherapie (BTRRS). Die resultierenden drei Planvergleiche wurden in einem Kollektiv mit identischer Fraktionierung der MRT-basierten Brachytherapie (BTref, n = 38) auf Grundlage der Dosis-Volumen-(DVH-)Parameter bzgl. „Coverage“ (V100), „Conformation number“ (CN) und Schonung der Risikoorgane (OARs) verglichen.

Ergebnisse

Die beste Abdeckung mit einer V100 von 100 ± 0 % erzielte die RRS25, gefolgt von der RRS70 mit einer V100 von 97,1 ± 2,7 %, und der BTref mit 90,9 ± 8,9 % sowie der intraindividuell geplanten BTRRS mit nur 80,6 ± 6,4 %. Die Schonung der Risikoorgane wurde mit Hilfe der Subvolumina D0,1 cc, D2 cc, and D5 cc der Rektumwand, Sigmoid und der Harnblase evaluiert. Die OAR-Dosen wurden auf der Basis der GEC-ESTRO-Guidelines gewählt und verglichen (RRS70 vs. RRS25 vs. BTRRS vs. BTref). Im Gegensatz zu allen gewählten Techniken, konnten mit Hilfe der RRS25 die Dosisbeschränkungen der OARs nicht eingehalten werden.

Schlussfolgerungen

Trotz der exzellenten Abdeckung und der hohen Tumordosen war die RRS25 als Alternative zur Brachytherapie inakzeptabel bezüglich der Belastung der Risikoorgane. Hingegen zeigte die RRS70 die beste Schonung der umliegenden OARs verbunden mit einer besseren Abdeckung des Tumors im Vergleich zur BT.

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Acknowledgments

We thank D. Schaal, Etienne Lessard, and Mikhail Gezginci for discussing and reviewing the manuscript.

Compliance with ethical guidelines

Conflict of interest

O. Neumann, A. Kluge, O. Lyubina, W. Wlodarczyk, U. Jahn, C. Köhler, V. Budach, M. Kufeld, and S. Marnitz state that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Radiation Oncology, Charité University Hospital, Charitéplatz 1, 10117, Berlin, Germany

    Oliver Neumann, Anne Kluge Ph. D., Olga Lyubina M. D., Waldemar Wlodarczyk Ph. D., Ulrich Jahn Ph. D., Volker Budach M. D. & Simone Marnitz M. D.

  2. Department of Gynecology, Charité University Hospital, Berlin, Germany

    Christhardt Köhler M. D.

  3. Charité CyberKnife Center, Berlin, Germany

    Markus Kufeld M. D.

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  1. Oliver Neumann
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  2. Anne Kluge Ph. D.
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  5. Ulrich Jahn Ph. D.
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Correspondence to Simone Marnitz M. D..

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Neumann, O., Kluge, A., Lyubina, O. et al. Robotic radiosurgery as an alternative to brachytherapy for cervical cancer patients. Strahlenther Onkol 190, 538–545 (2014). https://doi.org/10.1007/s00066-014-0614-4

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  • DOI: https://doi.org/10.1007/s00066-014-0614-4

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