Abstract
BACKGROUND AND PURPOSE
Ureteral stenosis (US) is an underreported complication of brachytherapy (BT) for
cervical cancer (CC), with limited data on toxicity risk reduction. A previous study
demonstrated ureter EQD2 D0.1cc > 77 Gy correlated with US development. We sought
to assess feasibility of this constraint while maintaining similar HR-CTV coverage.
MATERIALS AND METHODS
Patients with locally advanced CC treated with EBRT plus HDR MRI-based brachytherapy
boost without hydronephrosis at diagnosis and with ureter dose EQD2 D0.1cc > 77 Gy
were included. Replan was attempted to achieve HR-CTV D90 ≥ 80–85 Gy and ureter dose
reduction. Ureter distance from lateral margin of HR-CTV and tandem was recorded.
t-test was performed to compare ureteral dose and HR-CTV D90.
RESULTs
Of 25 patients were identified. Hundred percent received 45 Gy in 25 fractions to
the pelvis ± paraaortic lymph nodes and 80% receiving median additional parametrial
dose of 5.4 Gy. Replan meeting ureteral dose of ≤77 Gy was feasible in 18 of 25 patients,
with a reduction in median ureter D0.1cc from 82.3 to 76.8 Gy (p < 0.001). Median HR-CTV D90 was similar (84.7 vs. 85.0 Gy). Replan achieved D0.1cc
≤77 Gy in 56% of patients who experienced US. All unilateral US cases occurred in
the ureter closest to HR-CTV.
CONCLUSIONS
Optimization to reduce ureter dose to ≤77 Gy is feasible when ureters are visible
and contoured. Ureters may be considered as potential OAR during MRI-based brachytherapy
treatment. Reduced ring to tandem total reference air kerma (TRAK) ratio may provide
an additional metric by which to lower US risk.
Keywords
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References
- Global Cancer Facts & Figures.3rd Edition. American Cancer Society, Atlanta2015 (Available at:) (Accessed June 5, 2021)
- Trends in cervical cancer incidence rates by age, race/ethnicity, histological subtype, and stage at diagnosis in the United States.Prev Med. 2019; 123 (Epub 2019 Apr 16. PMID: 31002830): 316-323https://doi.org/10.1016/j.ypmed.2019.04.010
- Analysis of outcomes of microinvasive adenocarcinoma of the uterine cervix by treatment type.Obstet Gynecol. 2010; 116 (PMID: 20966701): 1150-1157https://doi.org/10.1097/AOG.0b013e3181f74062
- Surgical treatment of early-stage cervical cancer.Oncol Res Treat. 2016; 39 (Epub 2016 Aug 22. PMID: 27614875): 508-514https://doi.org/10.1159/000448794
- Concurrent cisplatin-based radiotherapy and chemotherapy for locally advanced cervical cancer.N Engl J Med. 1999; 340: 1144-1153
- Pelvic irradiation with concurrent chemotherapy versus pelvic and para-aortic irradiation for high-risk cervical cancer: an update of radiation therapy oncology group trial (RTOG) 90–01.J Clin Oncol. 2004; 22: 872-880
- Carcinoma of the cervix: patterns of care studies: review of 1978, 1983, and 1988–1989 surveys.Int J Radiat Oncol Biol Phys. 1995; 32: 1481-1486
- Pretreatment and treatment factors associated with improved outcome in squamous cell carcinoma of the uterine cervix: a final report of the 1973 and 1978 patterns of care studies.Int J Radiat Oncol Biol Phys. 1991; 20: 667-676
- Brachytherapy in the treatment of cervical cancer: a review.Int J Womens Health. 2014; 6: 555-564
- Improved survival of patients with cervical cancer treated with image-guided brachytherapy compared with conventional brachytherapy.Gynecol Oncol. 2014; 135: 231-238
- Image-based brachytherapy for cervical cancer.World J Clin Oncol. 2014; 5: 921-930
- MRI-guided adaptive radiotherapy in locally advanced cervical cancer from a Nordic perspective.Acta Oncol. 2013; 52: 1510-1519
- Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cance.Oncologist. 2013; 18: 415-422
- Magnetic resonance imaging-guided intracavitary brachytherapy for cancer of the cervix.Int J Radiat Oncol Biol Phys. 2009; 74: 1157-1164
- Clinical outcome and dosimetric parameters of chemo-radiation including MRI guided adaptive brachytherapy with tandem-ovoid applicators for cervical cancer patients: a single institution experience.Radiother Oncol. 2013; 107: 69-74
- Image guided adaptive brachytherapy with combined intracavitary and interstitial technique improves the therapeutic ratio in locally advanced cervical cancer: analysis from the retroEMBRACE study.Radiother Oncol. 2016; 120: 434-440
- CT or MRI for image-based brachytherapy in cervical cancer.Jpn J Clin Oncol. 2012; 42: 309-313
- Late urological complications and malignancies after curative radiotherapy for gynecological carcinomas: a retrospective analysis of 10,709 patients.J Urol. 1997; 158: 814-817
Same-institution author, 2020. Censored to preserve blind review.
- Feasibility of ureter delineation and dose recording in the assessment of ureteric stenosis during brachytherapy for cervical cancer.Brachytherapy. 2021; 20 (Epub 2021 Apr 26. PMID: 33926834): 755-764https://doi.org/10.1016/j.brachy.2021.03.007
- Risk Factors for Ureteral Stricture After Radiochemotherapy Including Image Guided Adaptive Brachytherapy in Cervical Cancer: results From the EMBRACE Studies.Int J Radiat Oncol Biol Phys. 2019; 103 (Epub 2018 Nov 10. PMID: 30419309): 887-894https://doi.org/10.1016/j.ijrobp.2018.11.006
- Prophylactic urethral stenting with Memokath® 028SW in prostate cancer patients undergoing prostate 125I seed implants: phase I/II study.J Contemp Brachytherapy. 2011; 3 (Epub 2011 Mar 31. PMID: 27877196; PMCID: PMC5108832): 18-22https://doi.org/10.5114/jcb.2011.21038
- Total reference air kerma can accurately predict isodose surface volumes in cervix cancer brachytherapy. A multicenter study.Brachytherapy. 2017; 16 (Epub 2017 Sep 1. PMID: 28867617): 1184-1191https://doi.org/10.1016/j.brachy.2017.05.011
- Hybrid (CT/MRI based) vs. MRI only based image-guided brachytherapy in cervical cancer: dosimetry comparisons and clinical outcome.Brachytherapy. 2016; 15 (Epub 2015 Oct 23. PMID: 26602964): 40-48https://doi.org/10.1016/j.brachy.2015.09.002
- Feasibility of ureter delineation and dose recording in the assessment of ureteric stenosis during brachytherapy for cervical cancer.Brachytherapy. 2021; (S1538-4721(21)00056-8Epub ahead of print. PMID: 33926834)https://doi.org/10.1016/j.brachy.2021.03.007
- Comparison of computed tomography and magnetic resonance imaging in cervical cancer brachytherapy target and normal tissue contouring.Int J Gynecol Cancer. 2010; 20 (PMID: 20130502): 47-53https://doi.org/10.1111/IGC.0b013e3181c4a627
- Total reference air kerma is associated with late bowel morbidity in locally advanced cervical cancer patients treated with image-guided adaptive brachytherapy.J Clin Med. 2019; 8 (PMID: 30669569; PMCID: PMC6352249): 125https://doi.org/10.3390/jcm8010125
- Dose-effect relationship and risk factors for vaginal stenosis after definitive radio(chemo)therapy with image-guided brachytherapy for locally advanced cervical cancer in the EMBRACE study.Radiother Oncol. 2016; 118 (Epub 2016 Jan 9. PMID: 26780997): 160-166https://doi.org/10.1016/j.radonc.2015.12.025
Article info
Publication history
Published online: December 31, 2021
Accepted:
November 8,
2021
Received in revised form:
November 4,
2021
Received:
August 9,
2021
Footnotes
Disclosure: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Identification
Copyright
© 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
