cervix brachytherapy

1. NCI Workshop on Advanced
Technologies in Radiation Oncology:
Cervix
December 1, 2006
David Gaffney MDPhD
Huntsman Cancer Hospital
University of Utah

2. Radiotherapy for Cervix Cancer:
An Important Paradigm
• Cure very large tumors with RT alone
– Local control correlates with survival
• Brachytherapy permits very high dose to tumor
– Requisite component of successful treatment
• Morbidity is high (dose to bladder and rectum)
• Concurrent Chemotherapy improves LC and
DMFS
• Modern Imaging (MRI and PET ) provides
superior pre-Tx evaluation and treatment

3. Radiotherapy for Cervix Cancer:
An Important Paradigm
• Cure very large tumors with RT alone
– Eifel PJ, et al Time course and outcome of central recurrence after
radiation therapy for carcinoma of the cervix. Int J Gynecol Cancer
2006;16:1106–1111.
5% of patients received chemotherapy

4. Radiotherapy for Cervix Cancer:
An Important Paradigm
• Local control remains a clinical
problem (ASTRO 2006)
–RTOG 0128: 2 yr DFS is 69%
–2 yr Local Regional Failure is 26%
–55% of first sites of recurrence included
a local-regional component

5. • Brachytherapy permits very high dose to tumor,
and minimized complications
– FIGO IIIB squamous cell carcinoma of the cervix: an analysis of
prognostic factors emphasizing the balance between external beam
and intracavitary radiation therapy
Logsdon and Eifel IJROBP 43(4):763, 1999.
Pt A 85 Gy,
VSD 110 Gy,
Cervical os 150-200 Gy

6. Radiotherapy for Cervix Cancer: An
Important Paradigm
• Dose Limiting toxicity
– Small Bowel: < 45 Gy
– Rectum: < 75 Gy
– Bladder: < 75 Gy

7. Chemo?
• Chemotherapy improves DMFS and LC!
• Neoadjuvant chemo has not worked in multiple
randomised trials
• NCI 1999: 5 randomised trials
– All improved local control
– 2 improved DMFS
• Other chemo showed same benefit as CDDP
(IPD Meta-analysis Tierney IGCS 2006)
• Extended adjuvant chemo may have benefit
(IPD Meta-analysis Tierney IGCS 2006)

8. Radiotherapy for Cervix Cancer: An Important Paradigm
• Imaging is better now: PET
Grigsby et al IJROBP 59(3):706, 2004
Pelvic Nodes Para-aortic nodes

9. Imaging is better now: PET
5/132 with PET + Pelvic LN’s failed. 1/33 with PET + PA LN’s failed.
“Lymph node recurrence as the only site of failure occurred in
<2% of our patients…To resect or not to resect enlarged lymph
nodes or to increase the irradiation dose to toxic levels in all
patients is not the clinically relevant issue.“

10. Radiotherapy for Cervix Cancer:
An Important Paradigm
• Tumors regress rapidly: shrinking GTV, poorly defined CTV--
-effect of endometrial extension is not clear
SUV t1/2 20 days or 25 Gy t1/2 21 days or 31 Gy
Rapid involution and mobility of carcinoma
of the cervix, Lee et al IJROBP 58(2):625, 2004
Sequential FDG-PET brachytherapy
treatment planning in carcinoma of the cervix
Lin et al IJROBP 63:1494, 2005

11. Radiotherapy for Cervix Cancer:
An Important Paradigm
• FDG-PET imaging for the assessment of physiologic
volume response during radiotherapy in cervix cancer
Lin et al IJROBP 65(1):177, 2006
RFS by PET

12. Cervix Cancer
• Cervix/Vagina is mobile
• Variable filling of bowel and
bladder
• ITV used in post hysterectomy
setting in RTOG 0418
Lee et al IJROBP 2004

13. Cervix:
Stereotactic RT
No Randomized Trials!

14. Cervix: IMRT/IGRT
No Randomized Trials!
1. Promising Single Institutional Data
-AJ Mundt MD U of Chicago/UCSD
-bone marrow sparing
-less GI and hemetologic toxicity
2. Prospective RTOG phase II trial: 0418

15. Cervix: Image Guided Brachytherapy
RX to HR-CTV by MR, not point A
No Randomized Trials!
• Single Institution Experience: Univ of
Vienna
• RTOG 0417 -secondary endpoint: develop
dose volume library to correlate with
toxicity

16. Cervix: Protons
No Randomized Trials!
– High-energy proton beam radiation therapy
for gynecologic malignancies. Potential of
proton beam as an alternative to
brachytherapy. Arimoto et al Cancer 68:79-83, 1991.
– N=15, 1983 to 1987
– Particle Radiation Medical Science Center
– Local Control 14/15.
– Radiation-induced proctitis (n=2, neither of which required surgical
treatment) were the only complications despite a dose > 80 Gy in
most cases.
– “The results suggest that sharply localized, high-dose proton beam
RT can produce an antitumor effect equivalent to that of conventional
brachytherapy.”

17. Cervix: Neutrons
Yes! Randomized Trials!
Neutron therapy in cervical cancer: results of a
phase III RTOG Study. Maor MH et al IJROBP 14:885, 1988
-n=156 patients
-(50 Gy in 25 fractions over 5 weeks plus intracavitary applications or external-beam boost)
or mixed-beam radiotherapy (2 fractions a week of neutrons, 3 fractions a week of photons
to a total RBE-adjusted dose of 50 Gy plus intracavitary applications or external mixed-
beam boost).
-The % of patients undergoing intracavitary applications was 50% on mixed beam and 75%
on photons (p < 0.01).
-Tumor clearance was 52% and 72% for mixed beam and photons, respectively (p<0.03).
-Median survivals were 1.9 years on mixed beam and 2.3 years on photons.
-Severe complications occurred in 19% and 11% in mixed beam and photons
respectively (p<0.13). The inferior outcome with neutron therapy in this study
may have resulted from the use of horizontal neutron beams of varying energy
and penetration.

18. Neutrons: Randomized Brachy Trial
• 252Cf vs conventional gamma radiation in the brachytherapy of advanced
cervical carcinoma long-term treatment results of a randomized study. Tacev
et al Strahlenther Onkol 179:377, 2003
– N=227, 40 Gy-eq via brachy in first week, 16 Gy photon
brachy week 5, ext beam 40 Gy/20 fractions, pt A 85 Gy
– 19% increase in OS and LC for 252Cf, p<0.003
Promising phase II experience
at Univ of Kentucky by
Maruyama et al.
Sources now at Tufts.

19. Neutrons/Photons vs Photons

20. Neutrons/Photons vs Photons

22. Hyperthermia: Two Ongoing
Randomized Trials
• Dutch Trial
– RT and hyperthermia +/- chemo
• Ellen Jones MDPhD Duke PI
– ChemoRT +/- hyperthermia (q week)

23. Promising Technologies in Cervix Cancer
• Image Guided Brachy: MR-Based (RTOG 0417)
– Point A was not designed for dose prescription
Dimoupoulos et al IJROBP
66(1):83, 2006

24. Promising Technologies in Cervix Cancer
• Improved imaging (ACRIN/GOG study: Correlate
surgical findings with MR and PET)
• Improved imaging (ACRIN/RTOG proposed study:
MR and PET; Correlate imaging with response, pre,
during and post Tx, identify poor responders)
• GOG/RTOG have performed trials previously in
Cervix and Endometrium successfully +/- RT: GOG
92 and 99 (Reminiscent of success of RTOG
0413/NSABP B39)
• IMRT (RTOG 0418) Stratification factor in GOG
trials
• Image Guided Brachytherapy (MRI)

25. Promising Technologies in
Cervix Cancer
• Better Radiosensitizers: In Meta-analysis:
other chemo had same survival benefit as
CDDP (Tierney et al IGCS 2006)
• Extended Adjuvant chemo in LN + patients
• Personalized Tx eg microarray gene
expression analysis (permit dose
escalation, choice of chemo?)

26. Promising Technologies in Cervix Cancer
• Hyperthermia (mult adv may make this more
attractive)
• High LET Brachytherapy program
– Positive trial with Cf252
– Limited institution
• Proton beam
– For Intact Cervix: Adaptive RT and IGRT required
– Lymph node boosts
– Recurrent disease
– Poorly responding advanced stage disease