1Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
2Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Korea
3Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
4Institute of Radiation Medicine, Seoul National University College of Medicine, Seoul, Korea
5Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Korea
6Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
7Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
Copyright © 2023 by the Korean Cancer Association
This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Ethical Statement
This study was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB No. H-2204-055-1314) before collecting patient information. Informed consent was waived due to its retrospective nature.
Author Contributions
Conceived and designed the analysis: Lee TH, Kang HC.
Collected the data: Lee TH, Kim KS, Kim HJ, Choi CH, Kang S, Kang HC.
Contributed data or analysis tools: Kim HJ, Eom KY, Wee CW, Song YS, Park NH, Kim JW, Chung HH, Kim HS, Lee M, Kang HC.
Performed the analysis: Lee TH, Kim KS, Choi CH, Kang S, Kang HC.
Wrote the paper: Lee TH, Kim KS, Kang HC.
Conflicts of Interest
Conflict of interest relevant to this article was not reported.
Characteristic | Image-guided brachytherapy (n=50) | Conventional brachytherapy (n=54) | p-value |
---|---|---|---|
Age at diagnosis (yr) | 49.5 (31–80) | 59 (27–88) | < 0.001 |
FIGO stage | |||
I | 0 | 3 (5.6) | 0.263 |
II | 8 (16.0) | 12 (22.2) | |
III | 38 (76.0) | 34 (63.0) | |
IV | 4 (8.0) | 5 (9.3) | |
Pathology | |||
Squamous cell carcinoma | 40 (80.0) | 42 (77.8) | 0.869 |
Adenocarcinoma | 9 (18.0) | 10 (18.5) | |
Others | 1 (2.0) | 2 (3.7) | |
Parametrial invasion | |||
Yes | 41 (82.0) | 42 (77.8) | 0.771 |
No | 9 (18.0) | 12 (22.2) | |
Pelvic lymph node metastasis | |||
Yes | 38 (76.0) | 33 (61.1) | 0.156 |
No | 12 (24.0) | 21 (38.9) | |
Paraaortic lymph node metastasis | |||
Yes | 7 (14.0) | 12 (22.2) | 0.406 |
No | 43 (86.0) | 42 (77.6) | |
Pelvic organ invasion | |||
Yes | 3 (6.0) | 3 (5.6) | > 0.99 |
No | 47 (94.0) | 51 (94.4) | |
Distant metastasis | |||
Yes | 1 (2.0) | 2 (3.7) | > 0.99 |
No | 49 (98.0) | 52 (96.3) | |
Initial tumor size (cm) | 5.4 (2.4–9.6) | 5.2 (2.5–11.5) | 0.757 |
Brachytherapy dose prescription (Gy) | 30 (25–30) | 27.5 (20–30) | < 0.001 |
Brachytherapy fractions | |||
4 | 6 (12.0) | 2 (3.7) | 0.258 |
5 | 43 (86.0) | 50 (92.6) | |
6 | 1 (2.0) | 1 (2.0) | |
EBRT technique | |||
IMRT | 44 (88.0) | 40 (74.1) | 0.121 |
3D-CRT | 6 (12.0) | 14 (25.9) | |
EBRT pelvic dose fractionation | |||
45.0 Gy/25 fractions | 48 (96.0) | 41 (75.9) | 0.013 |
50.4 Gy/28 fractions | 2 (4.0) | 10 (18.5) | |
Others | 0 | 3 (5.6) | |
EBRT nodal boost | |||
Yes | 37 (74.0) | 36 (66.7) | 0.547 |
No | 13 (26.0) | 18 (33.3) | |
EBRT parametrial boost | |||
Yes | 26 (52.0) | 7 (13.0) | < 0.001 |
No | 24 (48.0) | 47 (87.0) | |
EBRT cervical tumor boost | |||
Yes | 3 (6.0) | 4 (7.4) | > 0.99 |
No | 47 (94.0) | 50 (92.6) | |
Duration of radiation therapy (day) | 54 (47–63) | 53.5 (45–67) | 0.345 |
Concurrent chemotherapy regimen | |||
Weekly cisplatin | 40 (80.0) | 53 (98.1) | 0.007 |
Tri-weekly cisplatin | 10 (20.0) | 1 (1.9) | |
Pelvic lymph node surgery | |||
Dissection | 6 (12.0) | 1 (1.9) | 0.010 |
Sampling | 4 (8.0) | 0 | |
None | 40 (80.0) | 53 (98.1) | |
Paraaortic lymph node surgery | |||
Dissection | 1 (2.0) | 1 (1.9) | 0.188 |
Sampling | 3 (6.0) | 0 | |
None | 46 (82.0) | 53 (98.1) | |
Positive pathological lymph node | |||
Yes | 6 (12.0) | 1 (1.9) | 0.019 |
No | 5 (10.0) | 1 (1.9) | |
Not observed | 39 (78.0) | 52 (96.3) | |
Additional treatment after brachytherapya) | |||
Yes | 2 (4.0) | 1 (1.9) | 0.946 |
No | 48 (96.0) | 53 (98.1) |
Values are presented as median (range) or number (%). 3D-CRT, 3-dimensional conformal radiation therapy; EBRT, external beam radiotherapy; FIGO, International Federation of Gynecology and Obstetrics; IMRT, intensity-modulated radiation therapy.
a) Consolidative immunotherapy administered by other prospective trial was excluded.
Patient characteristics and treatment specifics
Characteristic | Image-guided brachytherapy (n=50) | Conventional brachytherapy (n=54) | p-value |
---|---|---|---|
Age at diagnosis (yr) | 49.5 (31–80) | 59 (27–88) | < 0.001 |
FIGO stage | |||
I | 0 | 3 (5.6) | 0.263 |
II | 8 (16.0) | 12 (22.2) | |
III | 38 (76.0) | 34 (63.0) | |
IV | 4 (8.0) | 5 (9.3) | |
Pathology | |||
Squamous cell carcinoma | 40 (80.0) | 42 (77.8) | 0.869 |
Adenocarcinoma | 9 (18.0) | 10 (18.5) | |
Others | 1 (2.0) | 2 (3.7) | |
Parametrial invasion | |||
Yes | 41 (82.0) | 42 (77.8) | 0.771 |
No | 9 (18.0) | 12 (22.2) | |
Pelvic lymph node metastasis | |||
Yes | 38 (76.0) | 33 (61.1) | 0.156 |
No | 12 (24.0) | 21 (38.9) | |
Paraaortic lymph node metastasis | |||
Yes | 7 (14.0) | 12 (22.2) | 0.406 |
No | 43 (86.0) | 42 (77.6) | |
Pelvic organ invasion | |||
Yes | 3 (6.0) | 3 (5.6) | > 0.99 |
No | 47 (94.0) | 51 (94.4) | |
Distant metastasis | |||
Yes | 1 (2.0) | 2 (3.7) | > 0.99 |
No | 49 (98.0) | 52 (96.3) | |
Initial tumor size (cm) | 5.4 (2.4–9.6) | 5.2 (2.5–11.5) | 0.757 |
Brachytherapy dose prescription (Gy) | 30 (25–30) | 27.5 (20–30) | < 0.001 |
Brachytherapy fractions | |||
4 | 6 (12.0) | 2 (3.7) | 0.258 |
5 | 43 (86.0) | 50 (92.6) | |
6 | 1 (2.0) | 1 (2.0) | |
EBRT technique | |||
IMRT | 44 (88.0) | 40 (74.1) | 0.121 |
3D-CRT | 6 (12.0) | 14 (25.9) | |
EBRT pelvic dose fractionation | |||
45.0 Gy/25 fractions | 48 (96.0) | 41 (75.9) | 0.013 |
50.4 Gy/28 fractions | 2 (4.0) | 10 (18.5) | |
Others | 0 | 3 (5.6) | |
EBRT nodal boost | |||
Yes | 37 (74.0) | 36 (66.7) | 0.547 |
No | 13 (26.0) | 18 (33.3) | |
EBRT parametrial boost | |||
Yes | 26 (52.0) | 7 (13.0) | < 0.001 |
No | 24 (48.0) | 47 (87.0) | |
EBRT cervical tumor boost | |||
Yes | 3 (6.0) | 4 (7.4) | > 0.99 |
No | 47 (94.0) | 50 (92.6) | |
Duration of radiation therapy (day) | 54 (47–63) | 53.5 (45–67) | 0.345 |
Concurrent chemotherapy regimen | |||
Weekly cisplatin | 40 (80.0) | 53 (98.1) | 0.007 |
Tri-weekly cisplatin | 10 (20.0) | 1 (1.9) | |
Pelvic lymph node surgery | |||
Dissection | 6 (12.0) | 1 (1.9) | 0.010 |
Sampling | 4 (8.0) | 0 | |
None | 40 (80.0) | 53 (98.1) | |
Paraaortic lymph node surgery | |||
Dissection | 1 (2.0) | 1 (1.9) | 0.188 |
Sampling | 3 (6.0) | 0 | |
None | 46 (82.0) | 53 (98.1) | |
Positive pathological lymph node | |||
Yes | 6 (12.0) | 1 (1.9) | 0.019 |
No | 5 (10.0) | 1 (1.9) | |
Not observed | 39 (78.0) | 52 (96.3) | |
Additional treatment after brachytherapy |
|||
Yes | 2 (4.0) | 1 (1.9) | 0.946 |
No | 48 (96.0) | 53 (98.1) |
Values are presented as median (range) or number (%). 3D-CRT, 3-dimensional conformal radiation therapy; EBRT, external beam radiotherapy; FIGO, International Federation of Gynecology and Obstetrics; IMRT, intensity-modulated radiation therapy.
a)Consolidative immunotherapy administered by other prospective trial was excluded.
Dosimetric parameters of brachytherapy
Parameter | Dose (Gy) |
---|---|
Image-guided brachytherapy | |
HR-CTV D90% | 31.6 (25.1–35.0) |
Cumulative EQD210 | 87.1 (75.7–93.9) |
HR-CTV D98% | 26.4 (19.7–29.4) |
Cumulative EQD210 | 78.2 (69.8–84.0) |
IR-CTV D90% | 25.4 (17.5–29.9) |
Cumulative EQD210 | 76.2 (67.6–84.0) |
IR-CTV D98% | 20.5 (9.7–25.3) |
Cumulative EQD210 | 68.3 (53.9–75.9) |
Bladder D2cc | 23.3 (9.5–40.9) |
Cumulative EQD23 | 78.8 (52.5–134.8) |
Rectum D2cc | 25.6 (17.8–42.7) |
Cumulative EQD23 | 66.8 (49.4–80.2) |
Sigmoid D2cc | 17.3 (7.8–24.5) |
Cumulative EQD23 | 66.0 (50.3–81.9) |
Conventional brachytherapy | |
A point (left) | 27.9 (19.2–33.1) |
Cumulative EQD210 | 82.5 (67.9–90.1) |
A point (right) | 28.3 (20.8–31.5) |
Cumulative EQD210 | 83.0 (70.6–89.5) |
B point (left) | 7.4 (4.8–9.4) |
Cumulative EQD210 | 51.8 (48.7–57.6) |
B point (right) | 7.7 (5.6–9.4) |
Cumulative EQD210 | 51.9 (49.6–57.6) |
Bladder point | 17.2 (6.7–35.3) |
Cumulative EQD23 | 67.9 (49.6–114.1) |
Rectal point | 25.6 (17.8–42.7) |
Cumulative EQD23 | 85.6 (66.6–143.7) |
Values are presented as median (range). EQD2n, equivalent dose in 2 Gy per fraction with α/β of n; HR-CTV, high risk clinical target volume; IR-CTV, intermediate risk clinical target volume.
Patterns of recurrence
Type of recurrence | Image-guided brachytherapy (n=50) | Conventional brachytherapy (n=54) | p-value |
---|---|---|---|
Local recurrence | 3 (6.0) | 5 (9.3) | 0.799 |
Regional recurrence | 8 (16.0) | 11 (20.4) | 0.747 |
Pelvic lymph node only | 7 (14.0) | 2 (3.7) | 0.129 |
Paraaortic lymph node only | 1 (2.0) | 3 (5.6) | 0.666 |
Pelvic and Paraaortic lymph node | 0 | 6 (11.1) | 0.045 |
Distant metastasis | 6 (12.0) | 14 (25.9) | 0.121 |
Values are presented as number (%).
Toxicity profile
Late toxicity | Image-guided brachytherapy (n=50) | Conventional brachytherapy (n=54) | p-value |
---|---|---|---|
Urinary toxicity (highest grade) | |||
Grade 1 | 1 (2.0) | 1 (1.9) | 0.375 |
Grade 2 | 5 (10.0) | 7 (13.0) | |
Grade 3 | 0 | 3 (5.6) | |
Grade 4 | 0 | 1 (1.9) | |
Hematuria | |||
Grade 1 | 2 (4.0) | 0 | 0.042 |
Grade 2 | 1 (2.0) | 7 (13.0) | |
Urinary tract infection | |||
Grade 2 | 1 (2.0) | 0 | 0.969 |
Dysuria | |||
Grade 1 | 3 (6.0) | 2 (3.7) | 0.930 |
Urinary frequency | |||
Grade 2 | 3 (6.0) | 6 (11.1) | 0.564 |
Urgency | |||
Grade 2 | 1 (2.0) | 0 | 0.969 |
Urinary obstruction | |||
Grade 2 | 0 | 1 (1.9) | > 0.99 |
Urinary incontinence | |||
Grade 1 | 0 | 1 (1.9) | 0.389 |
Grade 3 | 0 | 1 (1.9) | |
Urinary fistula | |||
Grade 3 | 0 | 2 (3.7) | 0.239 |
Grade 4 | 0 | 1 (1.9) | |
Lower gastrointestinal toxicity (highest grade) | |||
Grade 1 | 5 (10.0) | 4 (7.4) | 0.104 |
Grade 2 | 4 (8.0) | 0 | |
Grade 3 | 3 (6.0) | 7 (13.0) | |
Grade 4 | 0 | 2 (3.7) | |
Rectal/Colonic hemorrhage | |||
Grade 1 | 4 (8.0) | 5 (9.3) | 0.209 |
Grade 2 | 4 (8.0) | 0 | |
Grade 3 | 3 (6.0) | 3 (5.6) | |
Diarrhea | |||
Grade 1 | 1 (2.0) | 0 | 0.969 |
Ileal perforation | |||
Grade 3 | 0 | 1 (1.9) | 0.239 |
Grade 4 | 0 | 2 (3.7) | |
Colonic perforation | |||
Grade 4 | 0 | 1 (1.9) | > 0.99 |
Rectal fistula | |||
Grade 3 | 0 | 3 (5.6) | 0.269 |
Values are presented as number (%).
Values are presented as median (range) or number (%). 3D-CRT, 3-dimensional conformal radiation therapy; EBRT, external beam radiotherapy; FIGO, International Federation of Gynecology and Obstetrics; IMRT, intensity-modulated radiation therapy. Consolidative immunotherapy administered by other prospective trial was excluded.
Values are presented as median (range). EQD2n, equivalent dose in 2 Gy per fraction with α/β of n; HR-CTV, high risk clinical target volume; IR-CTV, intermediate risk clinical target volume.
Values are presented as number (%).
Values are presented as number (%).