Short-course PET based simultaneous integrated boost for locally advanced cervical cancer

Background Patients with large, locally advanced cervical cancers (LACC) are challenging to treat. The purpose of this work is to use 18F-FDG PET as planning basis for a short-course simultaneous integrated boost (SIB) in external beam radiotherapy of LACC in order to increase tumour shrinkage and likelihood of local control. Methods Ten previously treated patients with LACC were included, all with pre-treatment FDG PET/CT images available. The FDG avid tumour volume, MTV50, was dose escalated in silico by intensity modulated radiotherapy from the standard 1.8 Gy to 2.8 Gy per fraction for the 10 first fractions; a short-course SIB. For the 18 remaining external fractions, standard pelvic treatment followed to total PTV and MTV50 doses of 50.4 Gy and 60.4 Gy, respectively. Photon and proton treatment were considered using volumetric modulated arc treatment (VMAT) and intensity-modulated proton therapy (IMPT), respectively. All treatment plans were generated using the Eclipse Treatment Planning System (TPS). The impact of tumour shrinkage on doses to organs at risk (OARs) was simulated in the TPS for the SIB plans. Results Dose escalation could be implemented using both VMAT and IMPT, with a D98 ≥ 95 % for MTV50 being achieved in all cases. The sum of the 10 fraction short-course SIB and subsequent 18 standard fractions was compared to the standard non-SIB approach by dose volume histogram (DVH) analysis. Only marginal increase of dose to OARs was found for both modalities and a small further increase estimated from tumour shrinkage. Most DVH parameters showed a mean difference below 2 %. IMPT had, compared to VMAT, reduced OAR doses in the low to intermediate dose range, but showed no additional advantage in dose escalation. Conclusions Planning of dose escalation based on a FDG avid boost volume was here demonstrated feasible. The concept may allow time for enhanced tumour shrinkage before brachytherapy. Thus, this strategy may prove clinically valuable, in particular for patients with large tumours

Self-reported cognitive impairment in cervical cancer survivors: A cross-sectional study

Objective Cancer-related cognitive impairment (CRCI) is a major obstacle for cervical cancer survivors, preventing the return to their social life. This study assessed the prevalence of CRCI in cervical cancer survivors and studied the association of self-reported cognitive impairment with treatment regimen and the quality of life (QoL) domains depression, anxiety, and fatigue. Methods Six hundred twenty one cervical cancer survivors, treated with combined chemo-radiotherapy (CCRT) (n = 458) or surgery only (n = 163) were invited in this cross-sectional study. Self-reported cognitive function was assessed using the Functional Assessment of Cancer Therapy-Cognitive Function (FACT-Cog). Fatigue and psychological distress were assessed using EORTC-QLQ C30 and Hospital Anxiety and Depression Scale (HADS). Results Data of 254 women (40.9%) was available for the analysis. Of those, 204 (80.3%) women had received CCRT and 50 (19.7%) surgery only. In the whole cohort, 42.5% reported significant cognitive impairment. In both treatment groups cognitive complaints were significantly associated with anxiety, depression, and fatigue (all p < 0.001). CCRT was strongly associated with increased risk of CRCI (OR = 4.02, 95% CI = 1.57–10.25). Anxiety, depression, and fatigue increased the risk of CRCI by 13% (OR: 1.13, 95% CI 1.03–1.23), 16% (OR 1.16, 95% CI 1.04–1.28) and 2% (OR 1.02, 95% CI 1.00–1.03), respectively. Conclusion Almost half of the cervical cancer survivors after CCRT report significant cognitive impairment. CRCI is associated with other indicators of poor QoL, such as depression, anxiety and fatigue. An increased understanding of the specific cognitive domains affected and of the associated late effects like fatigue is crucial to customize successful interventions

Distress, problems and unmet rehabilitation needs after treatment for gynecological cancer

Introduction The prevalence of distress, problems and need for rehabilitation among women treated for gynecological cancer is largely unknown. The aims of this study were to examine the prevalence of distress, problems and unmet rehabilitation needs in the first years after treatment for gynecological cancer. Material and methods Women treated for gynecological cancer within the last 2 years were invited. Participants responded to the National Comprehensive Cancer Network Distress Thermometer and Problem List measuring distress and problems. They also answered a questionnaire regarding physical endurance, muscle strength, and need for rehabilitation services. Results Of 114 eligible women, 92 (81%) agreed to participate. Mean time since last treatment was 7.6 months (range 0–24.5 months). A total of 57% of the participants reported distress. The four most common problems reported were fatigue (58%), tingling in hands/feet (54%), worry (53%), and problems with memory/concentration (50%). Problems associated with distress were: dealing with partner, all emotional problems (i.e. depression, fears, nervousness, sadness, worry, and loss of interest in usual activities), appearance, memory/concentration, pain, sex, sleep, and problems with physical endurance and muscle strength. Fifty-two per cent reported unmet needs for rehabilitation services. Women with distress reported more unmet rehabilitation needs than those in the non-distressed group. Conclusions The prevalence of distress in this population of women treated for gynecological cancer was high. Having a high number of problems and having unmet needs for rehabilitation services were both associated with distress. Hence, measurement of distress seems to be helpful when assessing the need for rehabilitation services

Dose planning variations related to delineation variations in MRI-guided brachytherapy for locally advanced cervical cancer

Purpose: To examine the variability in prescribed dose due to contouring variations in intracavitary image-guided adaptive brachytherapy for cervical cancer. To identify correlations between dosimetric outcomes and delineation uncertainty metrics. Methods and materials: A data set from an EMBRACE sub-study on contouring uncertainties was used, consisting of magnetic resonance images of six patients with cervical cancer delineated by 10 experienced observers (target volumes and organs at risk). Two gold standard contours were generated, an expert consensus and the simultaneous truth and performance level estimation. Plans were individually optimised to all of the contour sets (12 in total). Plans were applied to the gold standard contour sets, and dose volume histogram parameters including D90, D98 and D2cm3 were determined. The variability between plans was assessed. Dose volume histogram parameters and delineation uncertainty metrics were correlated using the Spearman's non-parametric rank correlation. Results: There is a dosimetric variability between observers, patients and the gold standard contour used for analysis. Approximately 3 Gy D90 EQD210 variability (SD) was observed for the CTVHR and 1.2-3.6 Gy D2cm3 EQD23 for the organs at risk. The maximum geometric dimensions of the delineations are most commonly correlated with dosimetry changes. Although the correlations are similar across gold standards, the direction of these correlations differs, indicating that the dosimetric outcomes are dependent on the contour that the plan is optimised to. Conclusion: This study highlights the dosimetric differences interobserver uncertainty in contouring can have for cervical cancer brachytherapy. The importance of carefully choosing a gold standard from which to benchmark is reiterated

Salvage radiation for pelvic relapse after surgically treated endometrial cancer

(1) Background: This study evaluated the clinical outcome after salvage radiotherapy for first pelvic relapse after endometrial cancer (EC). (2) Methods: This multicenter retrospective study included EC patients with first central pelvic relapse without lymph node involvement treated with curative intent. Progression-free (PFS) and overall survival (OS) were calculated with the Kaplan–Meier method and possible predictive factors for risk of relapse and mortality were identified using the Cox model. (3) Results: We included 139 patients with median EQD2 (Equivalent Dose in 2 Gy fractions) to the clinical target volume of 70.0 Gy. During follow up of median 6.66 years, 39.6% patients developed a second relapse. Risk group classification at primary diagnosis based on histology, grading and FIGO stage and how the pelvic tumor boost was administered were independently associated with PFS and OS. Five-year OS was 68% (95% CI (59–75)) for the whole cohort. Five-year OS was 88% (95% CI (75–94)), 72% (95% CI (55–84)) and 38% (95% CI (15–60)) for the stage I low-, intermediate- and high-risk group, respectively. (4) Conclusions: The majority of central pelvic recurrences in RT-naive EC women can be successfully salvaged with radiotherapy. However, survival in patients with high-risk disease remains poor and warrants a more individualized approach to optimize outcome

Salvage Radiation for Pelvic Relapse after Surgically Treated Endometrial Cancer

(1) Background: This study evaluated the clinical outcome after salvage radiotherapy for first pelvic relapse after endometrial cancer (EC). (2) Methods: This multicenter retrospective study included EC patients with first central pelvic relapse without lymph node involvement treated with curative intent. Progression-free (PFS) and overall survival (OS) were calculated with the Kaplan–Meier method and possible predictive factors for risk of relapse and mortality were identified using the Cox model. (3) Results: We included 139 patients with median EQD2 (Equivalent Dose in 2 Gy fractions) to the clinical target volume of 70.0 Gy. During follow up of median 6.66 years, 39.6% patients developed a second relapse. Risk group classification at primary diagnosis based on histology, grading and FIGO stage and how the pelvic tumor boost was administered were independently associated with PFS and OS. Five-year OS was 68% (95% CI (59–75)) for the whole cohort. Five-year OS was 88% (95% CI (75–94)), 72% (95% CI (55–84)) and 38% (95% CI (15–60)) for the stage I low-, intermediate- and high-risk group, respectively. (4) Conclusions: The majority of central pelvic recurrences in RT-naive EC women can be successfully salvaged with radiotherapy. However, survival in patients with high-risk disease remains poor and warrants a more individualized approach to optimize outcome