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Role of radiotherapy in recurrent carcinoma cervix

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While the role of radiation therapy in carcinoma cervix management is undauntable for all stages. Recurrent carcinoma cervix need a lot of personalisation

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Role of radiotherapy in recurrent carcinoma cervix

  1. 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. 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. 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. 4. Recurrent Cervical Cancer Local recurrence •Central •Lateral pelvic wall •Both •+/- Nodal Distant metastasis •Para-aortic alone •Other sites Local plus distant metastasis
  5. 5. Recurrent cervical cancer After definitive surgery √ No prior radiotherapy After prior radiotherapy With or without surgery
  6. 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. 7. Recurrence after prior RT  Surgery Central limited volume disease  Reirradiation  Systemic therapy
  8. 8. Lateral pelvic wall recurrences
  9. 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. 10. Re-irradiation: What Technique??  Brachytherapy (ICRT/ISBT) +/- EBRT  Interstitial brachytherapy alone  External beam radiotherapy (EBRT)  IORT
  11. 11.  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
  12. 12. 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
  13. 13.  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%
  14. 14.  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)
  15. 15. 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
  16. 16. Isolated Para aortic recurrence
  17. 17. 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
  18. 18. 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
  19. 19. 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%
  20. 20. 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)
  21. 21. 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
  22. 22. Thank you!!

While the role of radiation therapy in carcinoma cervix management is undauntable for all stages. Recurrent carcinoma cervix need a lot of personalisation

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