Ferioli Martina, Macchia Gabriella, Cilla Savino, Malizia Claudio, Perrone Anna Myriam, Tagliaferri Luca, Buwenge Milly, Deodato Francesco, Galietta Erika, Donati Costanza M, Zamfir Arina A, Strigari Lidia, Cammelli Silvia, Iaco Pierandrea De, Morganti Alessio G
Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy.
Radiation Oncology, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy.
J Contemp Brachytherapy. 2024 Oct;16(5):383-389. doi: 10.5114/jcb.2024.145274. Epub 2024 Nov 14.
This systematic review aimed to assess the feasibility, safety, and efficacy of using modern external beam radiotherapy (EBRT) techniques, such as intensity-modulated radiotherapy (IMRT), volumetric modulated arc therapy (VMAT), and stereotactic body radiotherapy (SBRT) as alternative approaches to brachytherapy (BRT) in adjuvant treatment of endometrial cancer (EC).
A systematic review was conducted following PRISMA guidelines. The research question was framed using the PICO method, focusing on patients with EC [P] and comparing modern EBRT techniques (IMRT, VMAT, SBRT) [I] vs. BRT [C], to evaluate their feasibility, safety, and effectiveness, particularly in terms of tumor local control (LC) [O]. Both planning and clinical outcomes, including acute toxicity, late side effects, and LC were analyzed with quality assessments performed using the GRADE framework and ROBINS-I tool.
Planning studies revealed that while IMRT and VMAT provided comparable or improved target coverage and dose homogeneity compared with BRT, brachytherapy was associated with lower doses to critical organs. Post-operative SBRT and SIB-VMAT studies reported high LC rates (up to 100%) with minimal acute toxicity. However, the overall quality of evidence was low to very low, with significant risks of bias, mainly related to participant selection.
This review highlights that, although modern EBRT techniques, such as IMRT and VMAT are feasible alternative approaches to BRT for post-operative vaginal cuff irradiation, the current evidence does not support their superiority over BRT. Brachytherapy remains a highly effective treatment modality with well-established benefits. Future research should focus on more robust comparisons between EBRT and BRT, considering not only local control and toxicity, but also psychological impact and quality of life, especially in low-resource settings, where access to BRT may be limited.
本系统评价旨在评估使用现代外照射放疗（EBRT）技术，如调强放疗（IMRT）、容积调强弧形放疗（VMAT）和立体定向体部放疗（SBRT）作为子宫内膜癌（EC）辅助治疗中近距离放疗（BRT）替代方法的可行性、安全性和有效性。
按照PRISMA指南进行系统评价。使用PICO方法构建研究问题，聚焦于EC患者[P]，比较现代EBRT技术（IMRT、VMAT、SBRT）[I]与BRT[C]，以评估其可行性、安全性和有效性，特别是在肿瘤局部控制（LC）方面[O]。使用GRADE框架和ROBINS-I工具进行质量评估，分析计划和临床结果，包括急性毒性、晚期副作用和LC。
计划研究表明，与BRT相比，IMRT和VMAT提供了相当或更好的靶区覆盖和剂量均匀性，但近距离放疗对关键器官的剂量较低。术后SBRT和同步整合加量VMAT研究报告了高LC率（高达100%）且急性毒性最小。然而，证据的总体质量低至极低，存在显著的偏倚风险，主要与参与者选择有关。
本评价强调，尽管现代EBRT技术，如IMRT和VMAT是术后阴道残端照射中BRT的可行替代方法，但目前的证据不支持它们优于BRT。近距离放疗仍然是一种具有公认益处的高效治疗方式。未来的研究应侧重于EBRT和BRT之间更有力的比较，不仅要考虑局部控制和毒性，还要考虑心理影响和生活质量特别是在资源匮乏地区，那里获得BRT的机会可能有限。
