Long term experience with 3D image guided brachytherapy and clinical outcome in cervical cancer patients

Background and purpose: To report our 10 years' experience and learning curve of the treatment of cervical cancer patients with chemo radiotherapy and MRI (or CT in 9 selected patients) guided brachytherapy using pulsed dose rate (PDR) brachytherapy (BT). Methods and materials: Hundred and seventy consecutive patients with cervical cancer FIGO stage IB-IVB (without metastases beyond the para-aortic nodal region) were treated in our institute between 2002 and 2012. Patients received external beam radiotherapy (nodal boost to the lymph nodes positive at diagnosis) +/- chemotherapy followed by a pulsed or low dose rate brachytherapy boost. MRI (or CT) images were taken with the applicator in situ. The first 16 patients were treated according to X-ray-based plans, optimized on MRI. High-risk CTV, intermediate-risk CTV, bladder, rectum and sigmoid were retrospectively contoured according to the GEC-ESTRO recommendations. In all other patients, treatment plans were optimized after delineation of the target volumes and organs at risk at MRI (or CT). Doses were converted to the equivalent dose in 2 Gy (EQD2) by applying the linear quadratic model. The median age of the patients was 55 years (range 16-88). 41% had stage III or IV disease. Of the 170 patients, 91 patients had on imaging metastatic lymph nodes at diagnosis (62 patients pelvic lymph node involvement and 29 para-aortic). In 27 (16%) patients the intracavitary technique was combined with interstitial brachytherapy. Results: The mean D90 and D100 for the high-risk CTV were 84.8 +/- 8.36 Gy and 67.5 +/- 6.29 Gy for the entire patient group. Mean D90 and D100 values for the IR CTV were 68.7 +/- 5.5 Gy and 56.5 +/- 6.25 Gy. There was an important learning curve between both patient groups, with an increase in mean D90 of 75.8 Gy for the first 16 patients compared to 85.8 Gy for the second group. At the same time, the mean dose to 2 cm(3) of bladder and sigmoid decreased from 86.1 Gy to 82.7 Gy and from 70 Gy to 61.7 Gy, respectively. At a median follow-up of 37 months (range 2-136 months), local control rate for all patients was 96%, the regional control (pelvic and para-aortic) rate 81% and crude disease free survival rate 55%. The overall survival at 5 years is 65%. The higher dose to the target volume resulted in an increase in local control from 88% in the first 16 patients compared to 97% in the second patient group. Regarding late toxicity, 21 patients (12%) presented grade 3-4 late morbidity. Rectal, urinary, sigmoid and vaginal morbidity was 5%, 6%, 2% and 5%, respectively. A correlation between rectal D2 cm(3) >65 Gy and grade >3 late morbidity was found (p = 0.006). Conclusion: Although the majority of the patients presented with locally advanced carcinoma, excellent local and regional control rates were achieved. Rectal, urinary, sigmoid and vaginal grade 3-4 morbidity was 5%, 6%, 2% and 5%, respectively. A correlation between rectal D2 cm(3) >65 Gy and grade >3 late morbidity was found (p = 0.006). (C) 2016 Elsevier Ireland Ltd. All rights reserved.