cervical cancer

[meemee2016]

hi i have a patient with stage IIb cervical cancer and has underwent subtotal hysterectomy. i have already given her external beam radiotherapy till 46 Gy. kindly advise whether she would benefit from brachytherapy with two ovoids or should i continue the treatment with EXTERNAL beam radiotherapy only till 60 Gy?

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[hot sauce]

What was taken with the surgery? I am a little confused as to what the surgery was and what was left behind. Is there gross disease still present? The full pathology report would be helpful to determine the optimum treatment.

What are you planning on boosting if you use EBRT to 60 Gy?

I assume that she is getting concurrent chemotherapy as well.

 

[Gfunk6]

Multiple attempts have been made to replace brachytherapy with different forms of external radiation including stereotactic platforms, all have failed. Therefore, I would start by saying that whatever external beam dose you give, it cannot replace brachytherapy. Second, tandem/ovoids cannot reach the parametrium so she should really receive an interstitial component of brachytherapy. If latter not possible, consider boost to parametrium to 54 Gy or so (or whatever you can achieve to prevent overdose of bowel) followed by intracavitary brachy boost.

 

[juliet2009]

I don't think subtotal hysterectomy or even a radical surgery, was suitable for stage IIB . The post-operation treatment depends on the pathology and a thorough evaluation including pelvic MR or PET/CT.
Dose of external beam pelvic radiation generally 50Gy, if lymph nodes positive or tumor residue, locally boost. Vaginal cuff bachytherapy is necessary, 5Gy *2, if margin positive 5Gy*4. She also needs concurrent chemotherapy.

 

[Reaganite]

hi i have a patient with stage IIb cervical cancer and has underwent subtotal hysterectomy. i have already given her external beam radiotherapy till 46 Gy. kindly advise whether she would benefit from brachytherapy with two ovoids or should i continue the treatment with EXTERNAL beam radiotherapy only till 60 Gy?

Depends....were parametrial margins microscopically positive or is there gross residual disease? If microscopic, focally or widespread?

 

[meemee2016]

thanks for your reply. Surgery was surely inappropriate in this case and uterus was removed but part of cervix has been left behind. The pathology is a squamous cell carcinoma. When she came to me she had gross disease in the remnant cervix and involving the medial one third of parametrium and i started her on concurrent cisplatin weekly with EBRT.i have finished 46GY EBRT. I am going to shield midline and give 50Gy to her parametrium with EBRT and the put to ovoids with LDR brachytherapy to give a total dose of 60Gy. What is your opinion?

 

[Neuronix]

I don't usually do this, but I'm going to come out and use my moderator powers to say this poster is not posting from the first world.

Is this all 2D planned? What energy?

If there is still gross disease out in the parametrium at this point, in the first world we'd want to get 3D imaging and consider interstitial implant or a few interstitial needles (a "hybrid applicator"). This may not be possible here.

46 Gy whole pelvis is reasonable, but I'd recommend a total dose of 54 Gy to the parametria. LDR boost point A to a total dose of 85-90 Gy (just as a starting point in the USA check out: https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf)

 

[meemee2016]

Hi. yes i used 2D planning because i do not have 3D RT at my center. and we just have LDR brachytherapy. Since patient has subtotal hysterectomy no tandem can be used. only ovoids.

 

[Reaganite]

If significant gross residual disease and no ability for interstitial, I'd argue you're better off using definitive chemo RT to 60+ Gy as opposed to taking the pelvis to 45 with chemo and then sticking in some ovoids which aren't going to give you much depth dose. Have the patient fill the hell out of their bladder and hope all the bowel gets lifted out of the field. Maybe do a small bowel follow through and confirm on simulator (?) that bowel is out of the high dose area?

 

[thecarbonionangle]

do you have access to radioactive old school wire?