skip to main content
OSTI.GOV title logo U.S. Department of Energy
Office of Scientific and Technical Information

Title: Patterns of Regional Recurrence After Definitive Radiotherapy for Cervical Cancer

Abstract

Purpose: To determine the patterns of regional recurrence in patients treated with definitive radiotherapy (RT) for cervical cancer. Methods and Materials: The records of 198 patients treated with definitive RT for cervical cancer between 1980 and 2000 who experienced a regional recurrence without a central or distal vaginal recurrence were reviewed. All patients received a combination of external-beam RT and intracavitary brachytherapy. In the 180 patients with a documented location of regional recurrence, the relationship between the recurrence and the radiation fields was determined. Results: The median time to regional recurrence was 13 months (range, 2-85 months). Of the 180 patients who had an evaluable regional recurrence, 119 (66%) had a component of marginal failure; 71 patients recurred above-the-field, 2 patients occurred in the inguinal nodes, and 2 patients recurred above-the-field and in the inguinal nodes. In addition, 105 patients (58%) had a component of in-field failure; 59 patients recurred in-field only, 39 patients recurred in-field and above-the-field, 2 patients recurred in-field, above-the-field, and in the inguinal nodes, and 5 patients recurred in-field and in the inguinal nodes. The median survival after regional recurrence was 8 months (range, 0-194 months). Conclusions: Most regional recurrences after definitive RT for cervical cancermore » include a component of marginal failure, usually immediately superior to the radiation field. These recurrences suggest a deficiency in target volume. Recurrences also occur in-field, suggesting a deficiency in dose. Developments in pretreatment staging, field delineation, dose escalation, and posttreatment surveillance may help to improve outcome in these patients.« less

Authors:
; ;  [1];  [2];  [1]
  1. Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX (United States)
  2. Department of Gynecologic Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX (United States)
Publication Date:
OSTI Identifier:
21372204
Resource Type:
Journal Article
Resource Relation:
Journal Name: International Journal of Radiation Oncology, Biology and Physics; Journal Volume: 76; Journal Issue: 5; Other Information: DOI: 10.1016/j.ijrobp.2009.04.009; PII: S0360-3016(09)00565-3; Copyright (c) 2010 Elsevier Science B.V., Amsterdam, The Netherlands, All rights reserved.
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; BRACHYTHERAPY; NEOPLASMS; UROGENITAL SYSTEM DISEASES; DISEASES; MEDICINE; NUCLEAR MEDICINE; RADIOLOGY; RADIOTHERAPY; THERAPY

Citation Formats

Beadle, Beth M., Jhingran, Anuja, Yom, Sue S., Ramirez, Pedro T., and Eifel, Patricia J., E-mail: peifel@mdanderson.or. Patterns of Regional Recurrence After Definitive Radiotherapy for Cervical Cancer. United States: N. p., 2010. Web. doi:10.1016/j.ijrobp.2009.04.009.
Beadle, Beth M., Jhingran, Anuja, Yom, Sue S., Ramirez, Pedro T., & Eifel, Patricia J., E-mail: peifel@mdanderson.or. Patterns of Regional Recurrence After Definitive Radiotherapy for Cervical Cancer. United States. doi:10.1016/j.ijrobp.2009.04.009.
Beadle, Beth M., Jhingran, Anuja, Yom, Sue S., Ramirez, Pedro T., and Eifel, Patricia J., E-mail: peifel@mdanderson.or. 2010. "Patterns of Regional Recurrence After Definitive Radiotherapy for Cervical Cancer". United States. doi:10.1016/j.ijrobp.2009.04.009.
@article{osti_21372204,
title = {Patterns of Regional Recurrence After Definitive Radiotherapy for Cervical Cancer},
author = {Beadle, Beth M. and Jhingran, Anuja and Yom, Sue S. and Ramirez, Pedro T. and Eifel, Patricia J., E-mail: peifel@mdanderson.or},
abstractNote = {Purpose: To determine the patterns of regional recurrence in patients treated with definitive radiotherapy (RT) for cervical cancer. Methods and Materials: The records of 198 patients treated with definitive RT for cervical cancer between 1980 and 2000 who experienced a regional recurrence without a central or distal vaginal recurrence were reviewed. All patients received a combination of external-beam RT and intracavitary brachytherapy. In the 180 patients with a documented location of regional recurrence, the relationship between the recurrence and the radiation fields was determined. Results: The median time to regional recurrence was 13 months (range, 2-85 months). Of the 180 patients who had an evaluable regional recurrence, 119 (66%) had a component of marginal failure; 71 patients recurred above-the-field, 2 patients occurred in the inguinal nodes, and 2 patients recurred above-the-field and in the inguinal nodes. In addition, 105 patients (58%) had a component of in-field failure; 59 patients recurred in-field only, 39 patients recurred in-field and above-the-field, 2 patients recurred in-field, above-the-field, and in the inguinal nodes, and 5 patients recurred in-field and in the inguinal nodes. The median survival after regional recurrence was 8 months (range, 0-194 months). Conclusions: Most regional recurrences after definitive RT for cervical cancer include a component of marginal failure, usually immediately superior to the radiation field. These recurrences suggest a deficiency in target volume. Recurrences also occur in-field, suggesting a deficiency in dose. Developments in pretreatment staging, field delineation, dose escalation, and posttreatment surveillance may help to improve outcome in these patients.},
doi = {10.1016/j.ijrobp.2009.04.009},
journal = {International Journal of Radiation Oncology, Biology and Physics},
number = 5,
volume = 76,
place = {United States},
year = 2010,
month = 4
}
  • Purpose: Locoregional control is associated with breast cancer-specific and overall survival in select women with breast cancer. Although several patient, tumor, and treatment characteristics have been shown to contribute to locoregional recurrence (LRR), studies evaluating factors related to radiotherapy (XRT) technique have been limited. We investigated the relationship between LRR location and XRT fields and dose delivered to the primary breast cancer in women experiencing subsequent locoregional relapse. Methods and Materials: We identified 21 women who were previously treated definitively with surgery and XRT for breast cancer. All patients developed biopsy-result proven LRR and presented to Emory University Hospital betweenmore » 2004 and 2010 for treatment. Computed tomography (CT) simulation scans with XRT dose files for the initial breast cancer were fused with {sup 18}F-labeled fluorodeoxyglucose positron emission tomography (FDG PET)/CT images in DICOM (Digital Imaging and Communications in Medicine) format identifying the LRR. Each LRR was categorized as in-field, defined as {>=}95% of the LRR volume receiving {>=}95% of the prescribed whole-breast dose; marginal, defined as LRR at the field edge and/or not receiving {>=}95% of the prescribed dose to {>=}95% of the volume; or out-of-field, that is, LRR intentionally not treated with the original XRT plan. Results: Of the 24 identified LRRs (3 patients experienced two LRRs), 3 were in-field, 9 were marginal, and 12 were out-of-field. Two of the 3 in-field LRRs were marginal misses of the additional boost XRT dose. Out-of-field LRRs consisted of six supraclavicular and six internal mammary nodal recurrences. Conclusions: Most LRRs in our study occurred in areas not fully covered by the prescribed XRT dose or were purposely excluded from the original XRT fields. Our data suggest that XRT technique, field design, and dose play a critical role in preventing LRR in women with breast cancer.« less
  • Purpose: To ascertain the adequacy of radiotherapy (RT) margins by studying the relapse patterns after definitive chemoradiotherapy for carcinoma of the esophagus. Methods and Materials: We performed a retrospective study assessing the first site of disease relapse after definitive chemoradiotherapy that included four 3-weekly cycles of cisplatin and continuous infusion 5-fluorouracil, with conformal RT (50 Gy in 25 fractions) concurrent with Cycles 3 and 4. The RT planning target volume was the endoscopic ultrasonography/computed tomography-defined gross tumor volume with 1.5-cm lateral and 3-cm superoinferior margins. Results: A total of 145 patients were included. Their average age was 65.4 years, 45%more » had adenocarcinoma, 61% had lower third esophageal tumors, and 75% had Stage III-IVA disease. After RT, of 142 patients, 85 (60%) had evidence of relapse at a median follow-up of 18 months. The relapse was local (within the RT field) in 55; distant (metastatic) in 13, and a combination of local and distant in 14. The local relapse rates were not influenced by tumor stage, lymph node status, or disease length. Three patients developed a relapse in regions adjacent to the RT fields; however, it is unlikely that larger field margins would have been clinically acceptable or effective in these cases. The median overall survival was 15 months. Conclusion: The gross tumor volume-planning target volume margins in this study appeared adequate. Future efforts to improve outcomes using definitive chemoradiotherapy should be directed toward reducing the high rates of in-field and distant relapses.« less
  • Purpose: To evaluate patterns of locoregional failure, and predictors of recurrence and survival in patients treated with chemoradiation for anal cancer. Methods and Materials: Between September 1992 and August 2004, 167 patients with nonmetastatic squamous cell anal carcinoma were treated with definitive chemoradiation. The median dose of radiotherapy was 5500 cGy. Concurrent chemotherapy was given with 5-fluorouracil and cisplatin in 117 patients, 5-fluorouracil and mitomycin C in 24 patients, and other regimens in 26 patients. Results: The estimated 3-year rates of locoregional control, distant control, disease-free survival, and overall survival were 81%, 88%, 67%, and 84%, respectively. Multivariate analysis showedmore » that higher T stage and N stage independently predicted for a higher rate of locoregional failure; higher N stage and basaloid subtype independently predicted for a higher rate of distant metastasis; and higher N stage and positive human immunodeficiency virus status independently predicted for a lower rate of overall survival. Among the patients who had locoregional failure, 18 (75%) had failure involving the anus or rectum, 5 (21%) had other pelvic recurrences, and 1 (4%) had inguinal recurrence. The 5 pelvic recurrences all occurred in patients with the superior border of the radiotherapy field at the bottom of the sacroiliac joint. Conclusions: Trials of more aggressive and innovative locoregional and systemic therapies are warranted in high-risk patients, based on their T and N stages. The majority of locoregional failures involve the anus and rectum, whereas inguinal recurrences occur rarely. Placing the superior border of the radiotherapy field at L5/S1 could potentially reduce pelvic recurrences.« less
  • Purpose: To discuss the implications of three examples of periparotid recurrence after definitive intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC). Methods and Materials: We present 3 patients with HNC who underwent definitive IMRT with concurrent chemotherapy and later had treatment failure in or near a spared parotid gland. Two patients had bilateral multilevel nodal disease, and all had Level II nodal disease ipsilateral to the site of recurrence. The patients were treated using dose-painting IMRT with a dose of 70 Gy to the gross tumor volume and 59.4 Gy or 54 Gy to the high-risk or low-risk clinicalmore » tumor volume, respectively. The parotid glands were spared bilaterally. The patients had not undergone any surgical treatment for HNC before radiotherapy. Results: All patients had treatment failure in the region of a spared parotid gland. Failure in the 2 patients with bilateral multilevel nodal involvement occurred in the periparotid lymph nodes. The third patient developed a dermal metastasis near the tail of a spared parotid gland. On pretreatment imaging, the 2 patients with nodal failure had small nonspecific periparotid nodules that showed no hypermetabolic activity on positron emission tomography. Conclusion: For HNC patients receiving definitive IMRT, nonspecific positron emission tomography-negative periparotid nodules on pretreatment imaging should raise the index of suspicion for subclinical disease in the presence of multilevel or Level II nodal metastases. Additional evaluation of such nodules might be indicated before sparing the ipsilateral parotid gland.« less
  • Purpose: Positron emission tomography/computed tomography (PET/CT) is commonly used for nodal staging in locally advanced cervical cancer; however the false negative rate for para-aortic disease are 20% to 25% in PET-positive pelvic nodal disease. Unless surgically staged, pelvis-only treatment may undertreat para-aortic disease. We have treated patients with PET-positive nodes with extended field intensity modulated radiation therapy (IMRT) to address the para-aortic region prophylactically with concomitant boost to involved nodes. The purpose of this study was to assess regional control rates and recurrence patterns. Methods and Materials: Sixty-one patients with cervical cancer (stage IBI-IVA) diagnosed from 2003 to 2012 withmore » PET-avid pelvic nodes treated with extended field IMRT (45 Gy in 25 fractions with concomitant boost to involved nodes to a median of 55 Gy in 25 fractions) with concurrent cisplatin and brachytherapy were retrospectively analyzed. The nodal location was pelvis-only in 41 patients (67%) and pelvis + para-aortic in 20 patients (33%). There were a total of 179 nodes, with a median number of positive nodes of 2 (range, 1-16 nodes) per patient and a median nodal size of 1.8 cm (range, 0.7-4.5 cm). Response was assessed by PET/CT at 12 to 16 weeks. Results: Complete clinical and imaging response at the first follow-up visit was seen in 77% of patients. At a mean follow-up time of 29 months (range, 3-116 months), 8 patients experienced recurrence. The sites of persistent/recurrent disease were as follows: cervix 10 (16.3%), regional nodes 3 (4.9%), and distant 14 (23%). The rate of para-aortic failure in patients with pelvic-only nodes was 2.5%. There were no significant differences in recurrence patterns by the number/location of nodes, largest node size, or maximum node standardized uptake value. The rate of late grade 3+ adverse events was 4%. Conclusions: Extended field IMRT was well tolerated and resulted in low regional recurrence in node-positive cervical cancer. The dose of 55 Gy in 25 fractions was effective in eradicating disease in involved nodes, with acceptable late adverse events. Distant metastasis is the predominant mode of failure, and the OUTBACK trial may challenge the presented paradigms.« less