Department of Radiotherapy, IEO, European Institute of Oncology IRCCS, Milan, Italy.
Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy.
Int J Gynecol Cancer. 2020 May;30(5):607-612. doi: 10.1136/ijgc-2019-000735. Epub 2020 Mar 17.
Standard treatment in locally-advanced cervical cancer is external beam radiotherapy concomitant with platinum-based chemotherapy, followed by brachytherapy. The goal of our study was to determine whether an intensity modulated radiation therapy (IMRT) boost is feasible in patients unfit for brachytherapy.
We retrospectively analyzed data of 25 patients unfit for brachytherapy with median age 55 years (range, 30-82) with locally-advanced/metastatic cervical cancer who underwent external beam radiotherapy to pelvis ±para-aortic lymph nodes and sequential IMRT boost between July 2014 and December 2017. Total dose of 45-50.4 Gy in 25-28 fractions (1.8 Gy/fraction) was administered to the cervix, uterus, parametria, ovaries, vaginal tissues (based on vaginal extension), involved lymph nodes, or relevant draining lymph-nodal groups. Para-aortic nodes were included if involved at radiological staging or if common iliac nodes were positive. The IMRT boost included all residual tumor after external beam radiotherapy identified on MRI. The Kaplan-Meier method was used to calculate 2 years' overall survival, 2 years' progression-free survival, and 2 years' local control. Overall survival- and progression-free survival were calculated considering the starting of radiotherapy or neo-adjuvant chemotherapy if prescribed, while local control was calculated from the end of radiotherapy.
Median radiation dose to pelvis ±para-aortic lymph nodes was 50.4 Gy (45-50.4), boost treatment was homogeneously performed to a total dose of 25 Gy in five fractions every other day.After a median follow-up of 26 months (range, 4-77), tumor persistence at cervix at 6 months from the end of radiotherapy or local recurrence occurred in five women (20%), eight (32%) experienced a further distant progression (two of them had also tumor persistence). Two-year local control and overall survival rates for all stages were 78% and 67%, respectively. According to Common Terminology Criteria for Adverse Events v.4 scoring criteria, 10 patients experienced gastrointestinal and/or genitourinary grade G1-2 acute toxicity. G2 rectal late toxicity requiring laser-coagulation was registered in two patients, there were no gastrointestinal and/or genitourinary acute or late toxicities≥G3.
The combination of external beam radiotherapy and brachytherapy remains the standard of care, however our preliminary data show the feasibility of IMRT boost in terms of toxicity with promising results in terms of local control and overall survival.
局部晚期宫颈癌的标准治疗方法是外照射放疗联合铂类化疗，随后进行近距离放疗。我们的研究目的是确定对于不适合近距离放疗的患者，调强放疗（IMRT）加量是否可行。
我们回顾性分析了 2014 年 7 月至 2017 年 12 月期间 25 名年龄 55 岁（范围，30-82 岁）的局部晚期/转移性宫颈癌且不适合近距离放疗的患者数据。这些患者接受了盆腔±腹主动脉旁淋巴结外照射放疗，并在 25-28 个分次（1.8Gy/分次）中进行序贯 IMRT 加量治疗。宫颈、子宫、宫旁组织、卵巢、阴道组织（根据阴道扩展范围）、受累淋巴结或相关引流淋巴结组给予 45-50.4Gy 的总剂量。如果影像学分期提示存在腹主动脉旁淋巴结受累或同侧髂淋巴结阳性，则包括腹主动脉旁淋巴结。IMRT 加量包括外照射放疗后 MRI 上识别的所有残留肿瘤。采用 Kaplan-Meier 法计算 2 年总生存率、2 年无进展生存率和 2 年局部控制率。如果患者接受了放疗或新辅助化疗，则将总生存率和无进展生存率从放疗开始或新辅助化疗开始时计算，而局部控制率则从放疗结束时计算。
盆腔±腹主动脉旁淋巴结的中位放疗剂量为 50.4Gy（45-50.4），每日一次给予 5 次 25Gy 的等剂量 boost 治疗。中位随访时间为 26 个月（范围，4-77 个月），5 名女性（20%）在放疗结束后 6 个月时出现宫颈肿瘤残留，8 名（32%）出现进一步的远处进展（其中 2 名也存在肿瘤残留）。所有分期的 2 年局部控制率和总生存率分别为 78%和 67%。根据不良事件通用术语标准第 4 版评分标准，10 名患者发生胃肠道和/或泌尿生殖系统 1-2 级急性毒性。2 名患者发生直肠 2 级晚期毒性需要激光凝固治疗，无胃肠道和/或泌尿生殖系统急性或晚期毒性≥3 级。
外照射放疗联合近距离放疗仍是标准治疗方法，然而我们的初步数据显示，在毒性方面，IMRT 加量是可行的，并且在局部控制和总生存率方面具有良好的效果。
