cervical brachytherapy acute side effects

1. Acute Side Effects with High
Dose Rate CT Guided 3D
Brachytherapy in Ca Cervix
Presented by
Dr. Sadia Sadiq
SMO,INMOL

2. Cervical Cancer:
4th most common malignancy in women
Number of new cases in 2018,Females

3. Globocan 2018: Pakistan Statistics

4. Age Standardized Incidence & Mortality

5. INMOL Statistics
Year Total No of Pts.
Ca Cervix
N (%Age)
2011 4087 121 (2.96%)
2012 3755 122 (3.24%)
2013 4179 163 (3.90%)
2014 4722 158 (3.34%)
2015 4994 201 (4.02%)
2016 4890 248 (5.07%)
2017 5311 305 (5.7%)
2018 5760 344 (5.9%)

7. TREATMENT SUMMARY
Stage Treatment
I A1,IA2 Radical Surgery + PLND/ RT
IB1,IIA1 Radical Surgery + PLND/ CCRT
IB2,IIA2 CCRT/ Radical surgery + PLND
IIB,III,IVA CCRT
IVB Palliation

8. Survival Rates

9. Radiation Therapy:Ca Cervix
EBRT Brachytherapy

10. Brachytherapy
• Internal radiation treatment achieved by implanting radioactive
material directly into the tumor

11. Conventional Brachytherapy Technique

12. Conventional 2D Treatment Planning
conventional 2D treatment plan may result in either under-coverage
of the tumor extent or unnecessary dosage to the surrounding normal
tissues.

13. Image Guided Brachytherapy (IGBT)
• Data acquisition using 3D imaging and treatment planning of
brachytherapy implants
• Slice-by-slice delineation of targets, applicators, and organs at risk
• 3D reconstruction of tumor volumes and OARs
• Evaluation of treatment plan via isodose curves, isodose surfaces or
dose volume histograms

14. IGBT Steps

15. Literature Review
• A study describing acute side effects with CT based 3D brachy could
not be found.
• So, a pilot study was conducted on 10 patients.
RESULTS:
• Grade 0, 1, 2, 3, 4 Vaginitis was found in 0, 0, 60, 20 and 20% patients
respectively.
• Grade 0,1, 2, 3 ,4 lower GIT side effects were observed in 30, 40, 20,
10 and 0%patients and
• Grade 0, 1, 2, 3, 4 Genitourinary (GU) side effects were experienced by
0, 80, 20, 0 and 0% patients respectively.

16. Background
• 2D brachytherapy is being practised in many centres
• The lack of CT simulation,cost and expertise are main barriers
in initiation of 3-D brachytherapy
• INMOL started IGBT in 2015
• Learning curve

17. Purpose
• To facilitate the treatment delivery with safer techniques
• To evaluate the frequency and grades of acute side effects
with 3D brachytherapy using RTOG Scoring Criteria
• Multivariate analysis of age, stage and tumor size and their
correlation with toxicities

18. Study Design:
• Descriptive Case series
Setting:
• Department of Radiotherapy, INMOL Lahore
Study Duration:
• 11th July 2016 to 30th September 2017

19. Statistical Description
Sampling Technique
• Non-probability, consecutive sampling
Sample size
• 55 cases were evaluated with 95% confidence interval, 8% margin of
error and taking expected percentage of grade 3 Gastrointestinal
toxicity i.e.10% (least among all acute side effects).

20. Inclusion Criteria
• Women aged 16-70 years
• Biopsy proven SCC of the Cervix
• FIGO stage IB-IVA
Exclusion Criteria
• Patients with uncontrolled diabetes
and HTN
• H/O previous pelvic RT
• Inflammatory bowel diseases &
fistula
• Presence of simultaneous
malignancies

21. Treatment Protocol
• Informed consent was taken
• EBRT 45 Gy/25 # with or without parametrial boost of 15 Gy/8 # with
concomitant cisplatin weekly followed by ICBT 28 Gy (7 Gy x 4#)

23. Grades of Toxicity
Toxicity G 0 G 1 G 2 G 3 G 4
Mucous
membrane
No change Injection/mild pain Patchy
Mucositis/Moderat
e pain
Confluent
fibrinous
mucositis
Ulceration,hemor
rhage and
necrosis
Lower GI No change Change in bowel
habits not requiring
medication
Diarrhea requiring
medication
Diarrhea
requiring
parenteral
support/severe
mucous /blood
discharge
Acute /sub acute
obstruction,Fistul
a,perforation,GI
bleeding
requiring
transfusion
Genitourinary No change Frequency/Nocturia
twice pretreatment
habit
Dysuria,Urgency,
Bladder spasm
Urgency,Nocturia
hourly
Gross hematuria
Hematuria
requiring
transfusion,Ulcer
ation,Necrosis
Acute Side Effects were defined according to the RTOG criteria. It included those adverse
events that occurred from day 1 through day 90 after start of RT.

24. Data Analysis
• SPSS version 20
• Descriptive statistics applied
• Stratification of outcome variable with pre-treatment
radiological size of tumor, stage at diagnosis and performance
status of the patient was done to control the effect modifiers.
• P value of less than or equal to 0.05 was considered as
statistically significant.

25. RESULTS

26. Patient Characteristics
Characteristics Frequency Percentage (%) p Value
Mean age: 47.09 + 13.09 (Range:21-68)
<40.0 Years 22 40.0
0.178
>40.0 Years 33 60.0
Mean Tumor Size: 3.67 + 1.47 (Range: 1.0-6.0)
<3.0 cm 24 43.6
0.418
>3.0 cm 31 56.4
Time to presentation: 5.65 + 2.32 (Range:1.0-11.0)
<6.0 months 34 61.8
0.106
>6.0 months 21 38.2

27. Contd…..
Characteristics Frequency Percentage (%) p Value
Disease Stage
Stage I 9 16.4
0.375
Stage II 13 23.6
Stage III 18 32.7
Stage IV 15 27.3
Performance Status
ECOG-0 12 21.8
0.064
ECOG-1 17 30.9
ECOG-2 20 36.4
ECOG-3 6 10.9

28. Results:Toxicity Profile
Acute Toxicities G-0 G-1 G-2 G-3 G-4 P Value
Genitourinary Toxicity 1 (1.8%) 43(78.2%) 9(16.4%) 2(3.6%) 0% <0.001
Lower Gastrointestinal
toxicity
21(38.2) 30(54.5) 3(5.5) 1(1.8) 0 <0.001
Vaginal Toxicity (Mucous
membrane)
1(1.8) 4(7.3) 29(52.7) 16(29.1) 5(9.1) <0.001

29. Multivariate analysis of age, tumor size
and stage with toxicities

30. GU Toxicities

31. Lower GI Toxicities

32. Vaginal Toxicities

33. Discussion
• MRI based IGBT : Gold standard….CT : Frequent
• Limited data on Rx outcome and acute toxicities in CT based 3D
Brachytherapy of cervical cancer.
• We have observed that the 3D brachytherapy is safe and effective in
treatment of cervical cancer patients.

34. Limitations
 No comparative study available for acute side effects of 2D vs 3D
brachytherapy Ca Cervix
 Hematological toxicities are not assessed
 CT based planning rather than standard MRI based treatment
planning
 Limited No. of patients
 Single institution Study

35. Conclusion
3D brachytherapy in ca cervix is a safe and tolerable procedure with
minimal acute side effects

36. Recommendations
• Efforts needed to treat more patients with 3D brachytherapy.
• Early referral
• Financial considerations
• Patient support programs
• Awareness in society
• Cervical Screening & Vaccination

37. MRI Based IGBT:1st Case at INMOL,Feb,2019

38. Future Directions
• Design and conduct A Multicenter Study
• To evaluate
1. acute & late toxicities
2. treatment outcome including DFS and OS
using 3D brachytherapy in Carcinoma of Cervix
MRI Based IGBT : Implementation and improvement

39. Acknowledgment
• Dr. Abubaker Shahid, Director INMOL
• Dr.Misbah Masood, HOD Oncology INMOL
• Dedicated Oncology Department INMOL
• Determined Physics Department INMOL
• My Family & Friends
• Patients with their attendants