High Control Rate for Lymph Nodes in Cervical Cancer Treated with High-dose Radiotherapy using Helical Tomotherapy.

Technol Cancer Res Treat. 2013 Feb;12(1):45-51.

Yeon-Joo Kim, M.D., Joo-Young Kim, M.D., Seung Hoon Yoo, Ph. D., Byung Jun Min, Ph. D., Kwangzoo Chung, Ph.D., Sang-Soo Seo, M.D., Sokbom Kang, M.D., Myong Cheol Lim, M.D., Jong-Ha Hwang, M.D., Heon Jong Yoo, M.D., Sang-Yoon Park, M.D.

 

Research Institute and Hospital, National Cancer Center

809 Madu 1-dong, Goyang-si, Gyeonggi-do, 411-769, South Korea.

 

Abstract

The purpose of this study was to evaluate whether bulky lymphadenopathy located in the abdominopelvic cavity in cervical cancer can be controlled without severe toxicity by increasing radiation dose using helical tomotherapy. From January 2007 to December 2010, 26 patients with cervical cancer with metastatic lymph nodes (LNs) having at least one short diameter > 1.5 cm were treated with helical tomotherapy. A total of 58 LN sites were treated and the largest LN of each site was evaluated for response. Median follow-up time was 28 months (4–50 months). Median short diameter of the LNs was 1.7 cm (0.7–4.2 cm) with median radiation dose of 62.6 Gy10 in 2 Gy equivalent dose (53.3–77.9 Gy10). Initial LN response was evaluated on imaging obtained within 4 months after radiotherapy. Initial complete response (CR), partial response (PR), and stable disease (SD) were observed in 54, 2 and 2 lesions, respectively. Recurrence occurred in two with CR and progression in one with PR. Therefore, final CR, PR, SD, and progression of disease were observed in 52, 1, 2, and 3, respectively. Actuarial 3-year LN progression-free survival and overall survival (OS) were 63% and 65%, respectively. Multivariate analysis revealed final LN response (CR vs. non-CR) as a strong prognostic factor for OS (p=0.016). Radiation Therapy Oncology Group grade 2 or more acute and late toxicity was observed in 8 and 1 patients, respectively. The treatment of bulky lymphadenopathy using helical tomotherapy in advanced cervical cancer is highly effective and has acceptable toxicity.

 

Yeon-Joo Kim-1

Figure 1. (A) FIGO IIB patient with right internal iliac LN (2.4 x 2.1 cm). This patient was treated with EBRT (41.4 Gy/23 fractions) with tomotherapy boost (30 Gy/10 fractions) and ICR (24 Gy/6 fractions). The large bowel (colored blue) was located away from the LN and the fraction size to PGTV-LN was 3 Gy (red, LN; blue, large bowel; green, sigmoid colon; yellow, small bowel; cyan, bladder). She experienced acute RTOG grade 1 lower gastrointestinal toxicity (diarrhea). The treated lymphadenopathy showed complete response. She had no evidence of disease at follow-up of 40 months.

(B) FIGO IVB patient with right internal iliac LN (1.5 x 1.2 cm), left internal iliac LN (2.6 x 2.1 cm), PAN (2.1 x 1.2 cm), and ING (1.6 x 1.2 cm). This patient was treated with EBRT (39.6 Gy/22 fractions) with tomotherapy boost (20 Gy/10 fractions) and ICR (25 Gy/5 fractions). The right internal iliac LN was close to the bowel and the fraction size was 1.5 Gy in this case. The left internal iliac LN was located slightly away from the bowel and was larger in size; the fraction size was 2 Gy per fraction to PGTV-LN (red, right internal iliac LN; pink, left internal iliac LN; yellow, small bowel; cyan, bladder). She also had SCN initially and it was treated with opposite two fields of EBRT (60 Gy/24 fractions). She experienced acute RTOG grade 1 lower gastrointestinal toxicity (diarrhea). Complete response was achieved in all treated lymphadenopathies. However, 5 months after RT, bone metastasis were found at T and S spines and she died 1 year later.

(Abbreviations: FIGO, International Federation of Gynecology and Obstetrics (FIGO) staging system; LN, lymph node; EBRT, external beam radiotherapy; fractions, fraction; ICR, intracavitary radiotherapy; PGTV-LN, planning target volume of LN for tomotherapy boost; RTOG, the Radiation Therapy Oncology Group; PAN, para-aortic lymphadenopathy; ING, inguinal lymphadenopathy; SCN, supraclavicular lymphadenopathy)

Yeon-Joo Kim-2

Figure 2. Scatter diagrams of (A) tomotherapy fraction size and (B) total 2 Gy equivalent dose (EQD2) according to lymph node (LN) size. Linear regression analysis of radiation dose against LN size yielded R2 values of 0.292 and 0.352, respectively.

Yeon-Joo Kim-3

Figure 3. (A) Survival curves showing actuarial 3-year lymph node (LN) progression-free survival (LNPFS) and overall survival (OS) of 63% and 65%, respectively. (B) OS curve according to LN response. Three-year OS was 73% in patients with complete response (CR); three patients who did not show CR died at 26 months of follow-up (p = 0.005).

 

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