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Techniques of Radiation
Outline
Introduction
Cervical Caner Treatment
Definitive Treatment
Postoperative Treatment
Addition of Chemotherapy
Locally Advanced Cervical Cancer
Radiation Technology
Treatment Delivery
3D Conformal Radiation
IMRT
Brachytherapy
Conclusion
Radiation or Hysterectomy
Landoni F et al. Lancet. 1997 Aug23;350(9077):535-40
343 patients with stage IB-IIA (IB1 61%, IB2 27%, IIA 12%). Treated with radical
hysterectomy vs. radical RT. Median F/U 87 mo.
63% of pts in surgery arm received RT.
5-year outcome: no difference; OS surgery 83% vs. RT 83% (NS), DFS surgery
74% vs. 74% (NS).
AdenoCA: significantly better outcomes with surgery; OS (70% vs. 59%), DFS
(66% vs. 47%).
Complications (Grade 2-3): Surgery 28% vs RT 12%. Severe leg edema - surgery
0%, RT 1%, surgery + RT 9%.
Conclusion: Surgery and RT are both acceptable treatments for early stage
cervical ca; (for bulky tumors, primary surgery a less good option).
277 pts randomized, stage IB, node negative, but with high estimated risk of recurrence (from
GOG 49) s/p radical hysterectomy and lymphadenectomy randomized to +/- adjuvant pelvic
XRT 46-50.4 Gy.
Included pts with: 1) LVSI, deep 1/3 stromal invasion, any size; 2) LVSI, middle 1/3 invasion,
size >= 2cm; 3) LVSI, superficial 1/3 invasion, >= 5 cm; or 4) no LVSI, deep or middle 1/3
invasion, >= 4 cm.
These pts were estimated to have a 31% recurrence at 3 yrs.
Recurrences in 15% (RT) vs 28% (no RT).
2-year recurrence free rate 88% vs 79%. Hazard ratio=0.53. Grade 3/4 adverse effects were
6% vs 2.1%.
Distant metsases 2% (RT) vs 7% (no RT).
2006 Update - decreased rate of recurrence by 46%; local recurrence 13.9% (RT) vs 20.7% (no
RT), distant 2.9% vs 8.6%. Improved PFS by 42%. Decreased death rate by 30% (28.6% vs
19.7%) but not SS (p=0.07). RT has improved benefit for adenocarcinoma or adenosquamous
histologies (8.8% vs 44% recurrence).
LVSI
+
+
+
--
Stromal invasion
Deep 1/3
Middle 1/3
Superficial 1/3
Deep or middle 1/3
Need 2 of 3 features
Tumor size
Any
> 2cm
> 5cm
> 4cm
403 pts. Stage IIB-IVA, or Stage IB-IIA with >5cm tumor, or LN+.
2) 45 Gy to pelvis alone plus 3 cycles 5-FU and cisplatin concurrent with RT.
Intracavitary RT given in both arms.
Chemotherapy was cisplatin (75 mg/m2) on Day 1 and 5-FU (4 g/m2 96-hr
infusion,Days 1-5), repeated q3w.
Estimated 5-year outcome: DFS RT alone 40% vs CRT 67% (SS); OS 58% vs
73% (SS).
Chemotherapy
Radiation Techniques
The Generation of Photons
Computing and
robotic advances have
allowed for
sophisticated and
precise control of
photons for
radiotherapy delivery.
vs. X-Rays
Now therapeutic
X-rays can have
different energies,
different
intensities, and
gaiting to account
for respiratory
motion.
In addition, CT
imaging can be
used for targeting
of tumors and
normal tissues.
IMRT Rationale
PET/CT Fusion
Improved Targeting
Brachytherapy
From the Greek Root Short
Brachytherapy
HDR Brachytherapy
High Dose Rate irradiation uses an Ir132 source
embedded in a wire.
HDR Brachytherapy
Uterine Cervix Applicators
HDR Brachytherapy
Uterine Cervix Smit Sleeve
HDR Brachytherapy
Uterus
Brachytherapy is Necessary
4 Yr Pelvic Control
Lanciano JROBP 20:95, 1991
4 Yr Survival
Lanciano JROBP 20:95, 1991
Local Control
Montana Cancer 57:148, 1986
External Beam
EB + Brachytherapy
45%
67%
19%
46%
40%
52%
Brachytherapy vs IMRT
Brachytherapy
IMRT
Conclusions