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Is there a role of radiation in
management of recurrent cervical
cancer??
Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB, UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow
Recurrent cervical cancer
 Pelvic relapse rates* in definitively treated
patients: 20-40%
 Approximately 60-80% are pelvic failures
 Approximately 80% are in the irradiated field
and 20% outside this
 Treatment is very challenging, limited
options
 Limited literature and ultimate outcome of is
poor.
*Andreu Martinez FJ et al. Clin Transl Oncol 2005;7:323-331
Treatment options
 Surgery, radiotherapy, systemic therapy,
Palliative care
 Patient`s suitability
 Performance status
 Symptomatolgy
 Previous treatment
 Toxicities of previous therapy
 Present disease extent
 Patient selection remains the key
Recurrent Cervical
Cancer
Local recurrence
•Central
•Lateral pelvic wall
•Both
•+/- Nodal
Distant
metastasis
•Para-aortic
alone
•Other sites
Local plus
distant
metastasis
Recurrent cervical cancer
After definitive
surgery
√
No prior
radiotherapy
After prior
radiotherapy
With or without
surgery
Recurrence after surgery with no
prior RT
 Explore surgery for very limited disease
 Usually a combination of EBRT and Brachytherapy
 Brachytherapy (Interstitial) recommended for
patients with >5 mm thickness of recurrence
 Concurrent chemotherapy should be combined in
suitable patients
Recurrence after prior RT
 Surgery
Central limited
volume disease
 Reirradiation
 Systemic therapy
Lateral pelvic wall recurrences
Reirradiation: Which patients??
 Central recurrences* (inoperable/unwilling for
surgery)
 Volume of disease**: <2-4 cm, <100 cc
 Disease free interval**
 Longer the better
 At least > 6-12 month; >2 years
 Squamous histology
 Non-para-aortic location
 Good KPS with limited toxicities from prior RT
*Mahantshetty U. Brachytherapy 2014
**Zolciak Sivinska. Gynec Oncol 2014
Re-irradiation: What Technique??
 Brachytherapy (ICRT/ISBT) +/- EBRT
 Interstitial brachytherapy alone
 External beam radiotherapy (EBRT)
 IORT
Role of radiotherapy in recurrent carcinoma cervix
Role of radiotherapy in recurrent carcinoma cervix
 52 patients treated with HDR-
ISBT based Reirradiation
 Local control rate: 76%
 Grade ¾ toxicities: 25%
 Tumour size (>4 cm) and DFI (<6
months) important prognostic
factors
Image guided HDR ISBT in PIRCC
 AIIMS experience of 23 recurrent patients
 N=33; recurrent=23 and residual=10
 1 or 2 session of ISBT was done with a dose of 8 Gy/# followed by
EBRT depending upon the interval of recurrence,
total 52 procedures
 2 year pelvic disease control rate 63%
 Grade ¾ complication rates: 6%
Sharma DN; RSNA 2008; Oral abstract
 Indiana university experience of 19
patients (6 cervix patients)
 Median RT dose=50 Gray
 Median tumour volume=3.3 cm3
 2 year local control rates=52.6%
 N=50
 3 year OS and loco-regional
control: 56% and 59%
 Median RT dose=50 Gray (45-64
Gray)
 No Grade 3 or greater acute
GI/GU
 Grade 3 late toxicity <10%
 Poorer OS for DFI <2 years and
non-squamous histology (p<0.05)
Patients Rectum-4, Anal canal-6,
Cervix-4, Endometrium-
1, UB-1
All patients previously
treated with RT
Median previous RT
dose- 45 Gy
36 Gy/ 6 fractions in 3
weeks
Median FU- 11 months
LR- 51 %, Median DFS-
8 months
One year OS- 46%
No grade 3 acute
toxicity
Role of radiotherapy in recurrent carcinoma cervix
Role of radiotherapy in recurrent carcinoma cervix
Isolated Para aortic recurrence
Re-irradiation: What Technique??
 Minimize volume of irradiation: Conformal
 Avoid OARs
 Brachytherapy preferred for central, accessible site
 EBRT for very lateralized disease/para-aortic
 IORT for patients suitable for surgical salvage
Radiation: What doses??
 Without prior RT
 EBRT 45-50 Gray + Brachytherapy (total EQD2
65-75 Gray)
 For ReRT
 EBRT
IMRT/3DCRT: 40-50 Gray (20-25#)
SBRT: 20-36 Gray in 3-6 fractions
 Brachytherapy alone
20-25 Gray HDR in 4-5 fractions BID
 IORT: 10-30 Gray
 For palliative RT
 20-30 Gray in 5-10 fractions
Clinical outcome after RT
 Local control
Interstitial Brachytherapy= 25-80%
EBRT + Brachytherapy =40-80%
IORT + Surgery=20-70%
EBRT=50-60%
 3-5 year Overall survival: 30-70%
Morbidities and toxicities: RT
 Interstitial brachytherapy:
Grade 2 toxicities 5-10%
Earlier series: Grade 3-4 toxicities15-25%
 EBRT: Grade 3 toxicities 5-10%
 IORT + Surgery: Grade 2-3 toxicities 25-30%
(higher with higher doses)
Take home message!!
 Radiation therapy yields descent outcomes in
recurrent cervical cancer patients naïve to RT
 Reirradiation has become less morbid with better
outcomes owing to technological advancement in RT
 Conformal techniques like brachytherapy with or
without EBRT should be used
 IMRT/SBRT should be used when using EBRT alone
 Role of concurrent chemotherapy is not well defined
 Patient selection remains the key for optimizing the
best outcomes
Thank you!!

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Role of radiotherapy in recurrent carcinoma cervix

  • 1. Is there a role of radiation in management of recurrent cervical cancer?? Dr Ajeet Kumar Gandhi MD (AIIMS), DNB, UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  • 2. Recurrent cervical cancer  Pelvic relapse rates* in definitively treated patients: 20-40%  Approximately 60-80% are pelvic failures  Approximately 80% are in the irradiated field and 20% outside this  Treatment is very challenging, limited options  Limited literature and ultimate outcome of is poor. *Andreu Martinez FJ et al. Clin Transl Oncol 2005;7:323-331
  • 3. Treatment options  Surgery, radiotherapy, systemic therapy, Palliative care  Patient`s suitability  Performance status  Symptomatolgy  Previous treatment  Toxicities of previous therapy  Present disease extent  Patient selection remains the key
  • 4. Recurrent Cervical Cancer Local recurrence •Central •Lateral pelvic wall •Both •+/- Nodal Distant metastasis •Para-aortic alone •Other sites Local plus distant metastasis
  • 5. Recurrent cervical cancer After definitive surgery √ No prior radiotherapy After prior radiotherapy With or without surgery
  • 6. Recurrence after surgery with no prior RT  Explore surgery for very limited disease  Usually a combination of EBRT and Brachytherapy  Brachytherapy (Interstitial) recommended for patients with >5 mm thickness of recurrence  Concurrent chemotherapy should be combined in suitable patients
  • 7. Recurrence after prior RT  Surgery Central limited volume disease  Reirradiation  Systemic therapy
  • 8. Lateral pelvic wall recurrences
  • 9. Reirradiation: Which patients??  Central recurrences* (inoperable/unwilling for surgery)  Volume of disease**: <2-4 cm, <100 cc  Disease free interval**  Longer the better  At least > 6-12 month; >2 years  Squamous histology  Non-para-aortic location  Good KPS with limited toxicities from prior RT *Mahantshetty U. Brachytherapy 2014 **Zolciak Sivinska. Gynec Oncol 2014
  • 10. Re-irradiation: What Technique??  Brachytherapy (ICRT/ISBT) +/- EBRT  Interstitial brachytherapy alone  External beam radiotherapy (EBRT)  IORT
  • 13.  52 patients treated with HDR- ISBT based Reirradiation  Local control rate: 76%  Grade ¾ toxicities: 25%  Tumour size (>4 cm) and DFI (<6 months) important prognostic factors
  • 14. Image guided HDR ISBT in PIRCC  AIIMS experience of 23 recurrent patients  N=33; recurrent=23 and residual=10  1 or 2 session of ISBT was done with a dose of 8 Gy/# followed by EBRT depending upon the interval of recurrence, total 52 procedures  2 year pelvic disease control rate 63%  Grade ¾ complication rates: 6% Sharma DN; RSNA 2008; Oral abstract
  • 15.  Indiana university experience of 19 patients (6 cervix patients)  Median RT dose=50 Gray  Median tumour volume=3.3 cm3  2 year local control rates=52.6%
  • 16.  N=50  3 year OS and loco-regional control: 56% and 59%  Median RT dose=50 Gray (45-64 Gray)  No Grade 3 or greater acute GI/GU  Grade 3 late toxicity <10%  Poorer OS for DFI <2 years and non-squamous histology (p<0.05)
  • 17. Patients Rectum-4, Anal canal-6, Cervix-4, Endometrium- 1, UB-1 All patients previously treated with RT Median previous RT dose- 45 Gy 36 Gy/ 6 fractions in 3 weeks Median FU- 11 months LR- 51 %, Median DFS- 8 months One year OS- 46% No grade 3 acute toxicity
  • 20. Isolated Para aortic recurrence
  • 21. Re-irradiation: What Technique??  Minimize volume of irradiation: Conformal  Avoid OARs  Brachytherapy preferred for central, accessible site  EBRT for very lateralized disease/para-aortic  IORT for patients suitable for surgical salvage
  • 22. Radiation: What doses??  Without prior RT  EBRT 45-50 Gray + Brachytherapy (total EQD2 65-75 Gray)  For ReRT  EBRT IMRT/3DCRT: 40-50 Gray (20-25#) SBRT: 20-36 Gray in 3-6 fractions  Brachytherapy alone 20-25 Gray HDR in 4-5 fractions BID  IORT: 10-30 Gray  For palliative RT  20-30 Gray in 5-10 fractions
  • 23. Clinical outcome after RT  Local control Interstitial Brachytherapy= 25-80% EBRT + Brachytherapy =40-80% IORT + Surgery=20-70% EBRT=50-60%  3-5 year Overall survival: 30-70%
  • 24. Morbidities and toxicities: RT  Interstitial brachytherapy: Grade 2 toxicities 5-10% Earlier series: Grade 3-4 toxicities15-25%  EBRT: Grade 3 toxicities 5-10%  IORT + Surgery: Grade 2-3 toxicities 25-30% (higher with higher doses)
  • 25. Take home message!!  Radiation therapy yields descent outcomes in recurrent cervical cancer patients naïve to RT  Reirradiation has become less morbid with better outcomes owing to technological advancement in RT  Conformal techniques like brachytherapy with or without EBRT should be used  IMRT/SBRT should be used when using EBRT alone  Role of concurrent chemotherapy is not well defined  Patient selection remains the key for optimizing the best outcomes