IMRT and cervical cancer

[CUBuffsgrad98]

Anyone using IMRT in advanced cervical CA? I know there is RTOG data for post op. If so, what dose do you go to for pelvic sidewall involvement?

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[Palex80]

If not doing brachy, we give 59.4 Gy with chemo. In advanced cases small bowel comstraints usually become the restricting factor in my opinion.

 

[CUBuffsgrad98]

If doing Brachy do you still use IMRT? If so, do you boost the side wall (for those with extension) with IMRT?

 

[medgator]

If not doing brachy, we give 59.4 Gy with chemo. In advanced cases small bowel comstraints usually become the restricting factor in my opinion.

When would you NOT do brachy assuming no surgery? Palliation of advanced-stage disease? The data for brachy as part of definitive Tx of intact cervix is pretty strong (at least stateside): http://www.redjournal.org/article/S0360-3016(13)00595-6/abstract

I do IMRT post-op, 3D definitive.

 

[Neuronix]

Anyone using IMRT in advanced cervical CA? I know there is RTOG data for post op. If so, what dose do you go to for pelvic sidewall involvement?

IMRT to GTV/CTV including pelvic nodes to 45 Gy followed by brachytherapy. If pelvic sidewall is involved, interstitial brachytherapy is indicated, and if necessary it should be referred out to someone who does it.

3D-CRT is fine also. I justify IMRT due to less acute and late bowel toxicity from http://www.redjournal.org/article/S0360-3016(03)00325-0/fulltext and http://www.redjournal.org/article/S0360-3016(01)02785-7/fulltext. In my (limited) experience with pelvic malignancies, we get a lot more small bowel sparing above the bladder with IMRT, especially Tomo. For the details I generally like the INTERTECC trial protocol.

 

[thesauce]

Anyone using IMRT in advanced cervical CA? I know there is RTOG data for post op. If so, what dose do you go to for pelvic sidewall involvement?

We'd probably do 45Gy IM-WPRT with boost to 54Gy to pelvic sidewall. Brachy to 85-90Gy to point A.

 

[Palex80]

When would you NOT do brachy assuming no surgery? Palliation of advanced-stage disease? The data for brachy as part of definitive Tx of intact cervix is pretty strong (at least stateside): http://www.redjournal.org/article/S0360-3016(13)00595-6/abstract

I do IMRT post-op, 3D definitive.

Actually there are only two cases, when I won't do brachy:

1. When I won't be able to get inside the uterus. There are always patients with advanced primaries, when you won't be able to insert your applicator even after EBRT.

2. When the tumor has extensive invasion of rectum & bladder. Most of the patients with such advanced disease are actually palliative anyway, although some can be cured with RCT. The problem with HDR-brachy here is that by giving high doses you can induce a lot of fistulas. I tend not to do extensive brachy in these patients.

 

[medgator]

Actually there are only two cases, when I won't do brachy:

1. When I won't be able to get inside the uterus. There are always patients with advanced primaries, when you won't be able to insert your applicator even after EBRT.

2. When the tumor has extensive invasion of rectum & bladder. Most of the patients with such advanced disease are actually palliative anyway, although some can be cured with RCT. The problem with HDR-brachy here is that by giving high doses you can induce a lot of fistulas. I tend not to do extensive brachy in these patients.

Got it. Both situations make sense.

 

[Neuronix]

Actually there are only two cases, when I won't do brachy:

1. When I won't be able to get inside the uterus. There are always patients with advanced primaries, when you won't be able to insert your applicator even after EBRT.

2. When the tumor has extensive invasion of rectum & bladder. Most of the patients with such advanced disease are actually palliative anyway, although some can be cured with RCT. The problem with HDR-brachy here is that by giving high doses you can induce a lot of fistulas. I tend not to do extensive brachy in these patients.

I think in the case of such bulky tumors, your only choices for cure are going to be chemoRT including HDR brachytherapy or pelvic exenteration. EBRT is typically not going to deliver sufficient dose while meeting normal tissue constraints to cure bulky cervical cancer. So we routinely treat cases like #1 and #2, though we are a referral center for this and have a very active HDR program. For the scenarios above:

1. This doesn't seem particularly common to me. Under anesthesia it seems like we can dilate them open. Worst case, you could probably use a MUPIT or Syed-Neblett and still treat with interstitial applicators.

2. We go for cure in these patients, with the patient understanding that she could need exenteration later if she fails treatment or has a problematic fistula (and we quote up to 50% fistula rates depending on the case). Even patients who have a fistula at presentation would rather take their chances that the fistula could worsen rather than undergoing exenteration up front.

 

[Mr RADical]

I think in the case of such bulky tumors, your only choices for cure are going to be chemoRT including HDR brachytherapy or pelvic exenteration. EBRT is typically not going to deliver sufficient dose while meeting normal tissue constraints to cure bulky cervical cancer. So we routinely treat cases like #1 and #2, though we are a referral center for this and have a very active HDR program. For the scenarios above:

1. This doesn't seem particularly common to me. Under anesthesia it seems like we can dilate them open. Worst case, you could probably use a MUPIT or Syed-Neblett and still treat with interstitial applicators.

2. We go for cure in these patients, with the patient understanding that she could need exenteration later if she fails treatment or has a problematic fistula (and we quote up to 50% fistula rates depending on the case). Even patients who have a fistula at presentation would rather take their chances that the fistula could worsen rather than undergoing exenteration up front.

Similar practice at our institution. Everyone gets brachy unless they are purely palliative from the start. To get around #1 our attendings use HDR interstitial but it doesn't seem to happen that often. For patients with extensive locally advanced disease we consel them up front for the very real possibility of creating or worsening a fistula. Most of our patients seem to still want to undergo everything they can to avoid an exent.

 

[medgator]

Upcoming Red Journal article.... didn't realize it was this bad in the community. Brachy usage wasn't as big of an issue as much as protracted treatment and no chemo apparently

http://www.redjournal.org/article/S0360-3016(13)03589-X/abstract

The use of high-dose-rate brachytherapy sharply increased, particularly in small nonacademic facilities. Overall, patients treated in nonacademic facilities were more likely to have incomplete or protracted treatment; 43% of patients treated in small nonacademic facilities did not have treatment completed within 10 weeks. Also, patients treated in facilities that treated 3 or fewer eligible patients per year were significantly less likely to receive concurrent chemotherapy than were patients treated in other facilities.

 

[OTN]

Good article, MedGator. Crazy to think that patients didn't get chemo and/or were treated with such a protracted course. I'm happy to say I'm in a community non-academic practice and very much have my patients treatments completed well under 10 weeks (7, actually) and with concurrent chemo.

 

[Gfunk6]

Part of the problem with advanced cervical cancer is hospitalizations during treatment. At academic centers (with an attached hospitals) this is less of a problem.

 

[CUBuffsgrad98]

Interestingly enough, in my community non academic practice (with participation in open national studies), this woman probably will not have chemo, nor a protracted treatment. Despite multiple calls and urging, she started off refusing chemo and then never showed up for her radiation. Every now and then we get a call that she is ready to start, we reschedule her, and then she doesnt show up. Skews the numbers a bit I suppose

 

[clinonc]

Don't think IMRT adds much when you're giving definitive RT. In most cases, by the time you've included the whole uterus in the CTV (as we do in the UK) and added a margin for organ motion, the ability to spare additional bladder or small bowel is minimal. Therefore agree with mediator: IMRT for postop, 3D

 

[clinonc]

I mean 'medgator'