S. Gouy

Accuracy of Magnetic Resonance Imaging in Predicting Residual Disease in Patients Treated for Stage IB2/II Cervical Carcinoma With Chemoradiation Therapy Correlation of Radiologic Findings With Surgicopathologic Results

The evaluation of residual disease (RD) after chemoradiation therapy (CRT) in stage IB2/II cervical carcinoma conventionally is based on a clinical examination and magnetic resonance imaging (MRI) performed 3 to 8 weeks after the end of treatment. Very few studies have correlated MRI and histologic findings specifically in cervix cancer. This was the objective of the current study.

Post radiation hysterectomy in locally advanced cervical cancer: Outcomes and dosimetric impact.

PURPOSESnFirstly, to evaluate the impact of completion hysterectomy after chemoradiation and image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer. Secondly, to assess a potential differential dose-effect relationship for the rectum and bladder according to the realization of hysterectomy.nnnMATERIAL AND METHODSnTwo cohorts of patients were identified, differing by the realization of completion hysterectomy. Inclusions were limited to FIGO stage I-II, with no para-aortic involvement. All patients received a combination of pelvic chemoradiation followed by IGABT. Their outcomes and morbidity were reviewed. Log-rank tests were used to compare survivals. Probit analyses were performed to study dose-volume effect relationships.nnnRESULTSnThe two cohorts comprised 54 patients in the completion surgery group and 157 patients in the definitive radiotherapy group. They were well balanced, except for the mean follow-up, significantly longer in the post hysterectomy cohort and the use of PET-CT in the work-up, more frequent in the definitive radiotherapy cohort. Although less local relapses were reported in the hysterectomy group, the 5-year disease-free and overall survival did not differ between groups. The cumulative incidence of severe late morbidity was significantly increased in the hysterectomy cohort: 22.5% versus 6.5% at 5years (p=0.016). Dose-volume effects were observed for the bladder, with the D2cm3 corresponding with a 10% probability of late severe morbidity urinary events (ED10) of 67.8Gy and 91.9Gy in the hysterectomy and definitive radiotherapy cohorts, respectively. A D90 CTVHR of 85Gy (planning aim) corresponded with a 93.3% rate of local control in the definitive radiotherapy cohort whereas it corresponded with a 77.3% chance to have a good histologic response (complete response or microscopic residual disease) in the hysterectomy group.nnnCONCLUSIONnNo benefit from completion hysterectomy in terms of overall or disease-free survival rates was observed, which was moreover responsible for an increase of the severe late morbidity. The realization of post-radiation hysterectomy resulted in a shift of the ED10 of 24.1Gy.

Brachytherapy as part of the conservative treatment for primary and recurrent vulvar carcinoma

PURPOSEnThere are only scarce data on the place of brachytherapy (BT) for treatment of vulvar carcinoma. Our institutional experience of interstitial BT for vulvar carcinoma patients is reported.nnnMETHODS AND MATERIALSnClinical records of patients receiving low-dose-rate or pulsed-dose-rate BT as part of the primary treatment for primary/recurrent vulvar squamous cell carcinoma or as part of postoperative treatment between 2000 and 2015 were included. Patients, tumors, and treatment characteristics as well as clinical outcome were examined.nnnRESULTSnA total of 26 patients treated with BT were identified. BT was delivered as part of primary intent treatment for locally advanced/recurrent cancer in 11 patients and as part of postoperative treatment in 15 patients. Median age at time of BT was 63xa0years (range, 41-88xa0years). Pulsed-dose-rate and low-dose-rate were used in 15 patients and 11 patients, respectively. BT was performed as a boost to the tumor bed following external beam radiotherapy (nxa0= 13) or as the sole irradiation modality (nxa0= 13). Total median dose at the level of primary tumor was 60 GyEQD2 (range, 55-60 GyEQD2). With mean followup of 41xa0months (range, 5xa0months-11.3xa0years), 11 patients experienced tumor relapse, and in two of them, site of relapse was only local. Three-year estimated disease-free survival and overall survival rates were 57% (95% confidence interval: 45-69%) and 81% (95% confidence interval: 72-90%), respectively. All toxicities were Grade 2 or less.nnnCONCLUSIONSnInterstitial BT used as part of the primary or postoperative treatment of vulvar carcinoma is feasible with a satisfactory toxicity profile. Prognosis remains, however, dismal, with a high frequency of failures in patients with locally advanced tumors.

Cancers du col utérin : nouveautés dans la prise en charge en oncologie radiothérapie

During the recent past years, the therapeutic management of locally advanced cervical cancer patients has consistently improved, with the integration of image guided brachytherapy and dose escalation strategies leading to an improvement of local control rates. In parallel, the evolution of external beam radiotherapy techniques and the better control of organs at risk doses in brachytherapy have contributed to decrease the probability of severe normal tissue complication. In case of advanced disease, patients prognosis remains however marked by a high risk of distant failure, and this finding has encouraged the assessment of various research pathways in order to better predict and/or prevent tumor relapse. Major studies are being conducted or have been published, and the place of chemoradiation and brachytherapy has been confirmed as first intent treatment in case of locally advanced disease. Numerous prospective or retrospective data, few of which are reviewed there, have been integrated as part of a strategy aimed at being more and more personalized. Next steps of therapeutic optimization will include the assessment of multiparameters radiological tools, but will also rely on a better understanding of radiobiological pathways involved in local or systemic response to irradiation, and the most promising of those is probably the anti-tumor immune response.

Image-guided adaptive brachytherapy in primary vaginal cancers: A monocentric experience

PURPOSEnPrimary vaginal cancer is a rare disease for which treatment has been modeled based on cervical cancer. We report our experience in the use of image-guided adaptive brachytherapy (IGABT) in this indication.nnnMETHODS AND MATERIALSnPatients treated for vaginal cancer with a combination of external beam radiation therapy and IGABT were identified through electronic search. The Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology recommendations for cervical cancer have been extrapolated with the definition of two clinical target volumes (CTVs) corresponding to the residual disease after external beam radiation therapy (CTVBT), assessed from clinical and imaging findings, and the so-called CTVi, comprising the CTVBT with directional margins and at least the initial disease at diagnosis.nnnRESULTSnTwenty-seven patients were identified. MRI was used for brachytherapy guidance in 82% of the cases. An interstitial component was used in 59% of the cases. The D90 CTVBT and D90 CTVi were 73.1xa0±xa012.8xa0Gy and 66.6xa0±xa06.7xa0Gy, respectively. After a median followup of 40.1xa0months, nine recurrences in 8 patients were observed of which four were local. Local relapses occurred within the CTVBT. Three-year local control and disease-free rates were 82% and 65%, respectively. At 2xa0years, the Grade 2-4 gastrointestinal or urinary morbidity accrual rate was 9%. Twelve patients experienced late sexual morbidity, including three patients with Grade 3xa0stenosis.nnnCONCLUSIONnIGABT is feasible in vaginal cancer with promising outcomes. Harmonizing the definition of CTVs is required to allow comparisons between experiences and to perform multicenter studies.

Hystérectomie de clôture dans les cancers du col utérin localement évolués : résultats cliniques et impact dosimétrique

Objectif de l’etude Evaluer l’impact de l’hysterectomie de cloture apres chimioradiotherapie et curietherapie adaptative guidee par l’image dans les cancers du col uterin localement evolues. Etablir des relations dose-effets pour le rectum et la vessie en fonction de la realisation ou non d’une hysterectomie. Materiel et methode Deux cohortes de patientes prises en charge par chimioradiotherapie pelvienne suivie d’une curietherapie adaptative guidee par l’image ont ete identifiees, differant par la realisation d’une hysterectomie. Les inclusions etaient limitees aux tumeurs de stade, selon la classification de la Federation internationale de gynecologie obstetrique (Figo)xa0I–II. Des tests du Log-rank ont ete utilises pour comparer les survies et des analyses probit pour etudier les relations dose-effet. Resultats Les deux cohortes comprenaient respectivement 54xa0patientes dans le groupe ayant eu une hysterectomie et 157xa0patients dans le groupe exclusivement irradie. Elles etaient bien equilibrees, sauf pour le suivi, plus long dans la cohorte ayant eu une hysterectomie et le recours a la TEP-scanographie dans le bilan initial, plus frequent dans la cohorte exclusivement irradiee. Bien que les rechutes locales aient ete moins frequentes dans le groupe exclusivement irradie, les taux de survie sans maladie et globale a 5xa0ans ne differaient pas. Le taux d’incidence cumulee de morbidite severe tardive a 5xa0ans etait significativement superieur dans la cohorte ayant eu une hysterectomiexa0: 22,5xa0% contre 6,5xa0% (pxa0=xa00,016). Des effets dose-volume ont ete observes pour la vessie, avec une difference de 24xa0Gy entre les seuils correspondant a une probabilite de morbidite severe de 10xa0%. L’objectif de planification de 85xa0Gy correspondait a un taux de controle local de 93,3xa0% dans la cohorte exclusivement irradiee et a une probabilite de 77,3xa0% d’obtenir une bonne reponse histologique dans le groupe ayant eu une hysterectomie. Conclusion L’hysterectomie de cloture a ete responsable d’une augmentation de la morbidite tardive severe sans benefice en termes de taux de survie globale ni sans recidive. Sa realisation desequilibre la relation dose-effet etablie de la vessie.