Li-Tee Tan1, Richard Pötter2, Alina Sturdza3, Lars Fokdal4, Christine Haie-Meder5, Maximilian Schmid2, Deborah Gregory1, Primoz Petric6, Ina Jürgenliemk-Schulz7, Charles Gillham8, Eric Van Limbergen9, Peter Hoskin10, Ekkasit Tharavichitkul11, Elena Villafranca12, Umesh Mahantshetty13, Christian Kirisits2, Jacob Lindegaard4, Kathrin Kirchheiner2, Kari Tanderup4. 1. Department of Oncology, Addenbrooke's Hospital, Cambridge University Hospitals, United Kingdom. 2. Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria. 3. Department of Radiation Oncology, Comprehensive Cancer Center, Christian Doppler Laboratory for Medical Radiation Research for Radiation Oncology, Medical University of Vienna, Vienna, Austria. Electronic address: alina.sturdza@akhwien.at. 4. Department of Oncology, Aarhus University Hospital, Aarhus, Denmark. 5. Radiotherapy Department, Brachytherapy Unit, Gustave Roussy Cancer Campus, Villejuif, France. 6. Department of Oncology, Aarhus University Hospital, Aarhus, Denmark; Institute of Oncology, Division of Radiotherapy, Ljubljana, Slovenia; National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar. 7. Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands. 8. Department of Radiation Oncology, St Luke's Hospital, Dublin, Ireland. 9. Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium. 10. Mount Vernon Cancer Center, Northwood, United Kingdom. 11. Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. 12. Department of Radiation Oncology, Hospital of Navarra, Pamplona, Spain. 13. Department of Radiation Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, India.
Abstract
PURPOSE: Image guided adaptive brachytherapy (IGABT) for cervical cancer improves pelvic control and survival across all stages. Improvement in pelvic control is larger in advanced stages, but improvement in survival is similar across stages. This paper analyzes the patterns of failure in the RetroEMBRACE cohort to investigate this discrepancy. METHODS AND MATERIALS: 731 patients from 12 institutions treated with chemoradiation therapy and magnetic resonance imaging or computed tomography-based IGABT were evaluated. The pattern of failure at time of first relapse was analyzed. RESULTS: Three hundred twenty-five failures (single and synchronous) occurred in 222 of 731 patients (30%). Among the 325 failures, 9% were local and 6% regional. Pelvic (local or regional) failures made up 13%, paraaortic node (PAN) 9%, systemic 21%, and distant (systemic + PAN) 24%. Of the 222 patients with treatment failure, 21% had pelvic failure alone, 57% had distant failure alone, and 23% had both pelvic and distant failure. Of all failures that occurred, 40% to 50% occurred in the first year, with a further 20% to 30% occurring in the second year. Although local, regional, and PAN failure tended to plateau after year 3, systemic failure continued to occur up to year 10. CONCLUSIONS: Implementation of IGABT has changed the patterns of relapse after chemoradiation therapy for cervical cancer. The predominant failure after IGABT is systemic, whereas the predominant failure with conventional brachytherapy is pelvic. Effective treatments to eradicate micrometastases in PAN and distant organs are needed in addition to IGABT and chemoradiation therapy to maximize local, regional, PAN, and systemic control and improve survival.
PURPOSE: Image guided adaptive brachytherapy (IGABT) for cervical cancer improves pelvic control and survival across all stages. Improvement in pelvic control is larger in advanced stages, but improvement in survival is similar across stages. This paper analyzes the patterns of failure in the RetroEMBRACE cohort to investigate this discrepancy. METHODS AND MATERIALS: 731 patients from 12 institutions treated with chemoradiation therapy and magnetic resonance imaging or computed tomography-based IGABT were evaluated. The pattern of failure at time of first relapse was analyzed. RESULTS: Three hundred twenty-five failures (single and synchronous) occurred in 222 of 731 patients (30%). Among the 325 failures, 9% were local and 6% regional. Pelvic (local or regional) failures made up 13%, paraaortic node (PAN) 9%, systemic 21%, and distant (systemic + PAN) 24%. Of the 222 patients with treatment failure, 21% had pelvic failure alone, 57% had distant failure alone, and 23% had both pelvic and distant failure. Of all failures that occurred, 40% to 50% occurred in the first year, with a further 20% to 30% occurring in the second year. Although local, regional, and PAN failure tended to plateau after year 3, systemic failure continued to occur up to year 10. CONCLUSIONS: Implementation of IGABT has changed the patterns of relapse after chemoradiation therapy for cervical cancer. The predominant failure after IGABT is systemic, whereas the predominant failure with conventional brachytherapy is pelvic. Effective treatments to eradicate micrometastases in PAN and distant organs are needed in addition to IGABT and chemoradiation therapy to maximize local, regional, PAN, and systemic control and improve survival.
Authors: Junzo Chino; Christina M Annunziata; Sushil Beriwal; Lisa Bradfield; Beth A Erickson; Emma C Fields; KathrynJane Fitch; Matthew M Harkenrider; Christine H Holschneider; Mitchell Kamrava; Eric Leung; Lilie L Lin; Jyoti S Mayadev; Marc Morcos; Chika Nwachukwu; Daniel Petereit; Akila N Viswanathan Journal: Pract Radiat Oncol Date: 2020-05-18