Use of Specific Duodenal Dose Constraints During Treatment Planning Reduces Toxicity After Definitive Paraaortic Radiation Therapy for Cervical Cancer

Overview

Journal Pract Radiat Oncol

Publisher Elsevier

Specialties Oncology
Radiology

Date 2021 Dec 27

PMID 34958984

Citations 1

Authors

David S Lakomy

Juliana Wu

Bhavana V Chapman

Zhiqian Henry Yu

Belinda Lee

Ann H Klopp

Anuja Jhingran

Patricia J Eifel

Lilie L Lin

Affiliations

Soon will be listed here.

Abstract

Purpose: This study aimed to validate the safety of paraaortic nodal (PAN) radiation therapy (RT) for patients with cervical cancer when the duodenal dose is limited to V < 15 cm and V < 2 cm.

Methods And Materials: A total of 97 patients who were treated with RT for cervical cancer between 2010 and 2018 received at least 56 Gy to grossly involved PANs. Patients were treated with concurrent chemoradiation (n = 88; 91%), with 93% of patients (n = 90) receiving intensity modulated RT to the initial PAN field and 98% (n = 95) receiving intensity modulated RT to a sequential PAN boost. The V < 15 cm and V <2 cm criteria were implemented in 2014. Normal tissues were contoured on computed tomography (CT) simulation data sets, and the duodenum was contoured from the gastric outlet to the duodenojejunal flexure. Sixty-six patients (68%) had a resimulation scan after approximately 20 fractions. Composite duodenal doses were calculated using the initial CT scan for 50 patients (52%) and the resimulation CT scan for 47 patients (48%) depending on the anatomic changes throughout treatment.

Results: The median duodenal V was 3.5 cm (interquartile range [IQR], 0.2-8.1 cm) and the median V was 0.3 cm (IQR, 0.0-1.8). Constraints were exceeded in 18 patients, of whom 16 patients (89%) had been treated before 2014. Treatment for the 2 patients treated after 2014 was complicated by significant weight loss and reduced anterior-posterior diameter, which likely overestimated the true dose on the composite plan. Only 1 patient experienced grade 3 duodenal toxicity (stricture requiring endoscopic balloon dilation 3 months after treatment); however, the stricture was outside of the high-dose boost volume, and the patient had a history of gastritis. Six patients (6%) had a first recurrence within the PAN region.

Conclusions: Limiting the duodenal dose to V < 15 cm and V < 2 cm for patients with cervical cancer and PAN involvement is feasible, and minimizes duodenal toxicity while maintaining acceptable local control rates.

Citing Articles

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References

Yoon H, Cha J, Keum K, Lee H, Nam E, Kim S . Treatment outcomes of extended-field radiation therapy and the effect of concurrent chemotherapy on uterine cervical cancer with para-aortic lymph node metastasis. Radiat Oncol. 2015; 10:18. PMC: 4311470. DOI: 10.1186/s13014-014-0320-5. View

Varia M, Bundy B, Deppe G, Mannel R, AVERETTE H, Rose P . Cervical carcinoma metastatic to para-aortic nodes: extended field radiation therapy with concomitant 5-fluorouracil and cisplatin chemotherapy: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys. 1998; 42(5):1015-23. DOI: 10.1016/s0360-3016(98)00267-3. View

Kwak Y, Lee S, Kay C, Park H . Intensity-modulated radiotherapy reduces gastrointestinal toxicity in pelvic radiation therapy with moderate dose. PLoS One. 2017; 12(8):e0183339. PMC: 5573121. DOI: 10.1371/journal.pone.0183339. View

Piver M, Barlow J, Krishnamsetty R . Five-year survival (with no evidence of disease) in patients with biopsy-confirmed aortic node metastasis from cervical carcinoma. Am J Obstet Gynecol. 1981; 139(5):575-8. DOI: 10.1016/0002-9378(81)90519-6. View

Du X, Sheng X, Jiang T, Yu H, Yan Y, Gao R . Intensity-modulated radiation therapy versus para-aortic field radiotherapy to treat para-aortic lymph node metastasis in cervical cancer: prospective study. Croat Med J. 2010; 51(3):229-36. PMC: 2897095. DOI: 10.3325/cmj.2010.51.229. View

Zhang G, Fu C, Zhang Y, Wang J, Qiao N, Yang Q . Extended-field intensity-modulated radiotherapy and concurrent cisplatin-based chemotherapy for postoperative cervical cancer with common iliac or para-aortic lymph node metastases: a retrospective review in a single institution. Int J Gynecol Cancer. 2012; 22(7):1220-5. DOI: 10.1097/IGC.0b013e3182643b7c. View

Bae S, Kim M, Cho C, Kang J, Lee S, Lee K . Predictor of severe gastroduodenal toxicity after stereotactic body radiotherapy for abdominopelvic malignancies. Int J Radiat Oncol Biol Phys. 2012; 84(4):e469-74. DOI: 10.1016/j.ijrobp.2012.06.005. View

Osborne E, Klopp A, Jhingran A, Meyer L, Eifel P . Impact of treatment year on survival and adverse effects in patients with cervical cancer and paraortic lymph node metastases treated with definitive extended-field radiation therapy. Pract Radiat Oncol. 2016; 7(3):e165-e173. DOI: 10.1016/j.prro.2016.09.003. View

Beriwal S, Gan G, Heron D, Selvaraj R, Kim H, Lalonde R . Early clinical outcome with concurrent chemotherapy and extended-field, intensity-modulated radiotherapy for cervical cancer. Int J Radiat Oncol Biol Phys. 2007; 68(1):166-71. DOI: 10.1016/j.ijrobp.2006.12.023. View

10.

Marnitz S, Wlodarczyk W, Neumann O, Koehler C, Weihrauch M, Budach V . Which technique for radiation is most beneficial for patients with locally advanced cervical cancer? Intensity modulated proton therapy versus intensity modulated photon treatment, helical tomotherapy and volumetric arc therapy for primary radiation.... Radiat Oncol. 2015; 10:91. PMC: 4404108. DOI: 10.1186/s13014-015-0402-z. View

11.

Grigsby P, Lu J, Mutch D, Kim R, Eifel P . Twice-daily fractionation of external irradiation with brachytherapy and chemotherapy in carcinoma of the cervix with positive para-aortic lymph nodes: Phase II study of the Radiation Therapy Oncology Group 92-10. Int J Radiat Oncol Biol Phys. 1998; 41(4):817-22. DOI: 10.1016/s0360-3016(98)00132-1. View

12.

Kidd E, Siegel B, Dehdashti F, Rader J, Mutic S, Mutch D . Clinical outcomes of definitive intensity-modulated radiation therapy with fluorodeoxyglucose-positron emission tomography simulation in patients with locally advanced cervical cancer. Int J Radiat Oncol Biol Phys. 2009; 77(4):1085-91. DOI: 10.1016/j.ijrobp.2009.06.041. View

13.

Stacey R, Green J . Radiation-induced small bowel disease: latest developments and clinical guidance. Ther Adv Chronic Dis. 2014; 5(1):15-29. PMC: 3871275. DOI: 10.1177/2040622313510730. View

14.

Deng X, Han C, Chen S, Xie C, Yi J, Zhou Y . Dosimetric benefits of intensity-modulated radiotherapy and volumetric-modulated arc therapy in the treatment of postoperative cervical cancer patients. J Appl Clin Med Phys. 2017; 18(1):25-31. PMC: 5689869. DOI: 10.1002/acm2.12003. View

15.

Poorvu P, Sadow C, Townamchai K, Damato A, Viswanathan A . Duodenal and other gastrointestinal toxicity in cervical and endometrial cancer treated with extended-field intensity modulated radiation therapy to paraaortic lymph nodes. Int J Radiat Oncol Biol Phys. 2012; 85(5):1262-8. DOI: 10.1016/j.ijrobp.2012.10.004. View

16.

Cihoric N, Tapia C, Kruger K, Aebersold D, Klaeser B, Lossl K . IMRT with ¹⁸FDG-PET\CT based simultaneous integrated boost for treatment of nodal positive cervical cancer. Radiat Oncol. 2014; 9:83. PMC: 4014138. DOI: 10.1186/1748-717X-9-83. View

17.

Wharton J, Jones 3rd H, Day Jr T, RUTLEDGE F, FLETCHER G . Preirradiation celiotomy and extended field irradiation for invasive carcinoma of the cervix. Obstet Gynecol. 1977; 49(3):333-8. View

18.

Lin A, Kidd E, Dehdashti F, Siegel B, Mutic S, Thaker P . Intensity Modulated Radiation Therapy and Image-Guided Adapted Brachytherapy for Cervix Cancer. Int J Radiat Oncol Biol Phys. 2018; 103(5):1088-1097. PMC: 7065668. DOI: 10.1016/j.ijrobp.2018.11.012. View

19.

Pair M, Du W, Rojas H, Kanke J, McGuire S, Lee A . Dosimetric effects of weight loss or gain during volumetric modulated arc therapy and intensity-modulated radiation therapy for prostate cancer. Med Dosim. 2013; 38(3):251-4. DOI: 10.1016/j.meddos.2013.02.004. View

20.

Lei C, Ma S, Huang M, An J, Liang B, Dai J . Long-Term Survival and Late Toxicity Associated With Pelvic Intensity Modulated Radiation Therapy (IMRT) for Cervical Cancer Involving CT-Based Positive Lymph Nodes. Front Oncol. 2019; 9:520. PMC: 6593063. DOI: 10.3389/fonc.2019.00520. View