Association Between Thyroid Radiation Dose and Hypothyroidism in Breast Cancer Patients Undergoing Volumetric Modulated Arc Therapy for Regional Nodal Irradiation.

BACKGROUND/AIM: To investigate the association between the thyroid dysfunction and thyroid radiation dose in regional nodal irradiation (RNI) using volumetric modulated arc therapy (VMAT) for breast cancer. PATIENTS AND METHODS: We reviewed medical data of 67 patients with breast cancer who underwent curative surgery followed by adjuvant radiotherapy, including RNI using VMAT, between 2018 and 2021. All patients had normal thyroid functional test results, including thyroid stimulating hormone (TSH), T3, and free-T4. We defined subclinical hypothyroidism as increased TSH with or without decreased levels of free-T4 and T3 after the completion of VMAT. We calculated dose-volume histogram parameters (DVHPs), including the mean dose and relative thyroid volume receiving at least 10, 20, 30, and 40 Gy. RESULTS: The median follow-up time was 23.2 months. The 3-year locoregional failure-free survival, progression-free survival, and overall survival rates were 96.3%, 94.7%, and 96.2%, respectively. The mean thyroid dose was 21.4 Gy (range=11.5-29.4 Gy). Subclinical hypothyroidism was noted in 14 patients (20.9%) and the median time to the event was 4.1 months. Among the DVHPs, the relative volume receiving ≥20 Gy (V20Gy) was associated with subclinical hypothyroidism. The 2-year rates of subclinical hypothyroidism were 24.8% and 59.1% in patients with V20Gy ≤46.3% and >46.3%, respectively. CONCLUSION: A significant proportion of patients with breast cancer developed subclinical hypothyroidism after undergoing VMAT for RNI. Our findings highlight the importance of considering the thyroid as an organ at risk for VMAT planning, and suggest that V20Gy could be a useful dose-volume constraint.

Effects of Radiation Dose on Liver After Free-breathing Volumetric Modulated Arc Therapy for Breast Cancer.

BACKGROUND/AIM: To evaluate the early effect of radiation dose on liver function in breast cancer patients undergoing free-breathing volumetric modulated arc therapy (FB-VMAT). PATIENTS AND METHODS: Medical records of 125 patients with breast cancer who underwent curative surgery followed by postoperative radiotherapy using FB-VMAT during 2018-2021 were reviewed. Results of the liver function test (LFT), performed within 1-week before and 6-months after radiotherapy, were collected and compared. The LFTs analyzed albumin, total and direct bilirubin, aspartate transaminase, alanine transferase, and alkaline phosphatase levels. The mean dose and relative liver volume receiving at least 10 Gy, 20 Gy, or 30 Gy were calculated. RESULTS: Median follow-up time was 21.4 months. One patient experienced locoregional and distant failures. The mean liver irradiation dose was 325.9 centigray (cGy) for all patients. The liver irradiation dose was higher in patients with right breast cancer than in those with left breast cancer (mean, 434.1 cGy vs. 260.6 cGy, p<0.001). Direct bilirubin and aspartate transaminase levels showed significant differences after FB-VMAT. LFT results outside normal limits were noted in 31 patients at follow-up, but nobody met the criteria of radiation-induced liver disease. Underlying liver disease, breast laterality, systemic treatment, or dose-volume histogram parameters were not associated with abnormal LFT results. CONCLUSION: FB-VMAT can deliver radiation doses safely without adversely affecting the liver. The mean dose ≤4 Gy could be a useful dose criterium of the liver for FB-VMAT plans.

Ultra-low-dose radiation treatment for early-stage ocular adnexal MALT lymphoma.

PURPOSE: To investigate the long-term outcomes of ultra-low-dose (4 Gy) radiation treatment (RT) in patients with early-stage ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma. METHODS: This retrospective case series includes eight patients with ocular adnexal MALT lymphoma who received ultra-low-dose RT at a single tertiary referral center between March 2016 and February 2018. Response to treatment and the time taken to respond were analyzed. RESULTS: Of the eight patients (three men, five women), seven patients had conjunctival lymphoma (T1N0M0), and one patient had orbital lymphoma (T2N0M0). Six patients with T1 disease showed complete response (CR), and the median time to CR was 4.5 months (range 2-5). Partial response was achieved in the remaining two patients (one each with T1 and T2). During the median follow-up period of 44 months (range 30-54), none of the patients had a relapse or needed additional treatment. RT was well-tolerated in all patients with no ocular complications, including cataracts and dry eye. CONCLUSION: This case series suggests that ultra-low-dose RT is effective and well-tolerated in patients with early-stage ocular adnexal MALT lymphoma. Further studies with a larger sample size and long-term follow-up are needed to evaluate the local control rate and disease-free survival precisely.

Neutrophil-to-Lymphocyte Ratio After Definitive Concurrent Chemoradiotherapy Predicts Survival in Patients With Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: Lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio represent systemic immune-inflammatory responses. We evaluated the association between immune-inflammatory cell ratios and prognosis in esophageal squamous cell carcinoma (ESCC) patients who underwent definitive concurrent chemoradiotherapy (dCCRT). PATIENTS AND METHODS: Medical records of 68 ESCC patients in three institutions who underwent dCCRT between 2006 and 2017 were reviewed. The immune-inflammatory cell ratios were calculated before and after dCCRT. RESULTS: The median follow-up time was 11.4 months. The 3-year overall survival (OS) rate was 21.6%. Among the immune-inflammatory cell ratios, lower post-dCCRT neutrophil-to-lymphocyte ratio (NLRpost) was associated with better OS (median 15.2 vs. 9.7 months, p=0.030). Patients with lower NLRpost had more improved OS when adjuvant chemotherapy was administered following dCCRT (median 16.6 vs. 4.8 months, p<0.001). CONCLUSION: NLRpost may be useful in predicting OS in ESCC patients after dCCRT. Furthermore, NLRpost might play a role in establishing adjuvant therapy plans following dCCRT.

Adjuvant Chemotherapy and Dose Escalation in Definitive Concurrent Chemoradiotherapy for Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: To validate the effect of treatment intensification on survival in esophageal squamous cell carcinoma (ESCC) patients undergoing definitive concurrent chemoradiotherapy (dCCRT). PATIENTS AND METHODS: We reviewed the medical records of 73 ESCC patients who underwent dCCRT between 2006 and 2017 in 3 institutions. RESULTS: The median follow-up time was 13.3 months. The median overall survival (OS) and locoregional recurrence-free survival (LRFS) were 13.3 and 11.2 months, respectively. The median radiotherapy dose was 55.8 Gy, and the median biologically effective dose (BED) was 65.8 Gy. Chemotherapy was given in all patients during dCCRT, and adjuvant chemotherapy was administered in 56 patients (76.7%). Adjuvant chemotherapy improved OS (3-year, 24.2% vs. 11.8%, p=0.004). Higher BED ≥70 Gy improved LRFS (3-year, 41.7% vs. 23.6%, p=0.035). CONCLUSION: The addition of chemotherapy after dCCRT improves OS. A higher radiotherapy dose improved LRFS, but not OS. Adjuvant chemotherapy should be considered after dCCRT for better outcomes.

Survival outcomes after adjuvant radiotherapy for aggressive fibromatosis depend on time frame and nuclear ß-catenin.

PURPOSE: To identify prognostic factors influencing progression-free survival (PFS) of aggressive fibromatosis (AF) after postoperative radiotherapy (PORT) and assess correlations between immunohistochemistry (IHC) features of ß-catenin/smooth muscle actin (SMA) and PFS. MATERIALS AND METHODS: Records of 37 patients with AF treated by PORT from 1984 to 2015 were retrospectively reviewed. Fifteen patients underwent wide excision for AF and 22 patients received debulking operation. The median total dose of PORT was 59.4 Gy. IHC staining results of ß-catenin and SMA were available for 11 and 12 patients, respectively. RESULTS: The median follow-up duration was 105.9 months. Five-year PFS rate was 70.9%. Tumor size or margin status was not related to PFS in univariate analysis (p = 0.197 and p = 0.716, respectively). Multivariate analysis showed that increased interval from surgery to PORT (>5.7 weeks) was a marginal risk factor for PFS (p = 0.054). Administration of PORT at the initial diagnosis resulted in significantly improved PFS compared to deferring PORT after recurrence (p = 0.045). Patient with both risk factors of deferring PORT after recurrence and interval from surgery to PORT >5.7 weeks had significantly lower 5-year PFS than patients without risk factor (34.1% vs. 100.0%; p = 0.012). Nuclear ß-catenin intensity tended to inversely correlate with 5-year PFS, although it did not reach statistical significance (62.5% at low vs. 100.0% at high; p = 0.260). SMA intensity was not related to PFS (p = 0.700). CONCLUSION: PORT should be performed immediately after surgery irrespective of margin status or tumor size especially in recurrent case. Nuclear ß-catenin staining intensity of IHC might correlate with local recurrence.

Enhancement of megavoltage electronic portal images for markerless tumor tracking.

PURPOSE: The poor quality of megavoltage (MV) images from electronic portal imaging device (EPID) hinders visual verification of tumor targeting accuracy particularly during markerless tumor tracking. The aim of this study was to investigate the effect of a few representative image processing treatments on visual verification and detection capability of tumors under auto tracking. METHODS: Images of QC-3 quality phantom, a single patient's setup image, and cine images of two-lung cancer patients were acquired. Three image processing methods were individually employed to the same original images. For each deblurring, contrast enhancement, and denoising, a total variation deconvolution, contrast-limited adaptive histogram equalization (CLAHE), and median filter were adopted, respectively. To study the effect of image enhancement on tumor auto-detection, a tumor tracking algorithm was adopted in which the tumor position was determined as the minimum point of the mean of the sum of squared pixel differences (MSSD) between two images. The detectability and accuracy were compared. RESULTS: Deblurring of a quality phantom image yielded sharper edges, while the contrast-enhanced image was more readable with improved structural differentiation. Meanwhile, the denoising operation resulted in noise reduction, however, at the cost of sharpness. Based on comparison of pixel value profiles, contrast enhancement outperformed others in image perception. During the tracking experiment, only contrast enhancement resulted in tumor detection in all images using our tracking algorithm. Deblurring failed to determine the target position in two frames out of a total of 75 images. For original and denoised set, target location was not determined for the same five images. Meanwhile, deblurred image showed increased detection accuracy compared with the original set. The denoised image resulted in decreased accuracy. In the case of contrast-improved set, the tracking accuracy was nearly maintained as that of the original image. CONCLUSIONS: Considering the effect of each processing on tumor tracking and the visual perception in a limited time, contrast enhancement would be the first consideration to visually verify the tracking accuracy of tumors on MV EPID without sacrificing tumor detectability and detection accuracy.

Tumor Boost Using External Beam Radiation in Cervical Cancer Patients Unable to Receive Intracavitary Brachytherapy: Outcome From a Multicenter Retrospective Study (Korean Radiation Oncology Group 1419).

PURPOSE: We conducted this study to evaluate the outcomes of external-beam radiotherapy tumor boost (EBRT-B) in cervical cancer patients who could not receive intracavitary brachytherapy. METHODS: A total of 11 hospitals provided the data of patients who received EBRT-B during the period from January 2005 through October 2012. RESULTS: A total of 75 patients were included. The median radiotherapy dose was 46 Gy (range, 40-54 Gy) for whole pelvis and 24 Gy (range, 9-35 Gy) for EBRT-B. Initial tumor responses assessed at 2 to 6 months after radiotherapy were as follows: 46 with complete response, 22 with partial response, 2 with stable disease, and 3 with progressive disease. After a median follow-up time of 33 months, 30 patients (40.0%) showed disease progression including 21 (28.0%) with local progression. The 5-year local failure-free survival rate was 70.0%. Achieving complete response at the first follow-up visit and an overall treatment time of 53 days or less were significantly related to favorable local failure-free survival. The rate of grade 3 or higher toxicity was 2.6%. CONCLUSIONS: Approximately 70% of patients had local tumor control after curative radiotherapy using EBRT-B. Early tumor response and overall treatment time of 53 days or less were closely associated with favorable local control.

Evaluation of variability in target volume delineation for newly diagnosed glioblastoma: a multi-institutional study from the Korean Radiation Oncology Group.

BACKGROUND: This study aimed for a collaborative evaluation of variability in the target volumes for glioblastoma, determined and contoured by different radiotherapy (RT) facilities in Korea. METHODS: Fifteen panels of radiation oncologists from independent institutions contoured the gross target volumes (GTVs) and clinical target volumes (CTVs) for 3-dimensional conformal RT or intensity-modulated RT on each simulation CT images, after scrutinizing the enhanced T1-weighted and T2-weighted-fluid-attenuated inversion recovery MR images of 9 different cases of glioblastoma. Degrees of contouring agreement were analyzed by the kappa statistics. Using the algorithm of simultaneous truth and performance level estimation (STAPLE), GTVSTAPLE and CTVSTAPLE contours were derived. RESULTS: Contour agreement was moderate (mean kappa 0.58) among the GTVs and was substantial (mean kappa 0.65) among the CTVs. However, each panels' GTVs and modification of CTVs regarding anatomical structures varied. Three-fourth of contoured panels' CTVs encompassed the peritumoral areas of T2-high signal intensity (T2-HSI). Nine of nine GTVSTAPLE encompased the surgical cavity and the T1-enhanced lesions. Eight of nine CTVSTAPLE encompassed the peritumoral T2-HSI area. The median MARGIN90 and the median MARGIN95 were 1.4 cm and 1.5 cm, respectively. CONCLUSIONS: Moderate to substantial agreement existed in target volumes for 3-dimensional or intensity-modulated RT determined by radiation oncologists in Korea. According to the estimated consensus contours, the initial CTV encompassed the GTV with margin less than 2.0 cm and the whole peritumoral areas of T2-HSI. The findings of our study propose the need for further studies and modified guidelines.

Tumor size and lymph node status determined by imaging are reliable factors for predicting advanced cervical cancer prognosis.

The aim of the present study was to investigate the prognostic role of a number of clinical factors in advanced cervical cancer patients. Patients (n=157) with stage IIA-IIB cervical cancer treated at four Hallym Medical Centers in South Korea (Hallym University Sacred Heart Hospital; Kangnam Sacred Heart Hospital; Chuncheon Sacred Heart Hospital; and Kangdong Sacred Heart Hospital) between 2006 and 2010 were retrospectively enrolled. Univariate analysis identified significant predictive values in the following eight factors: i) Cancer stage (P<0.0001); ii) tumor size (≤4 vs. 4-6 cm, P=0.0147; and ≤4 vs. >6 cm, P<0.0001); iii) serum squamous cell carcinoma antigen level (≤2 vs. >15 ng/ml; P=0.0291); iv) lower third vaginal involvement (P<0.0001); v) hydronephrosis (P=0.0003); vi) bladder/rectum involvement (P=0.0015); vii) pelvic (P=0.0017) or para-aortic (P=0.0019) lymph node (LN) metastasis detected by imaging vs. no metastasis; and viii) pelvic LN metastasis identified by pathological analysis (P=0.0289). Furthermore, multivariate analysis determined that tumor size (≤4 vs. 4-6 cm, P=0.0371; and ≤4 vs. >6 cm, P=0.0024) and pelvic LN metastasis determined by imaging vs. no metastasis (P=0.0499) were independent predictive variables. Therefore, tumor size and pelvic LN metastasis measured by imaging were independent predictive factors for the prognosis of advanced cervical cancer. These factors may provide more clinically significant prognostic information compared with the currently used International Federation of Gynecology and Obstetrics staging system.

Electron dose distributions caused by the contact-type metallic eye shield: Studies using Monte Carlo and pencil beam algorithms.

A metallic contact eye shield has sometimes been used for eyelid treatment, but dose distribution has never been reported for a patient case. This study aimed to show the shield-incorporated CT-based dose distribution using the Pinnacle system and Monte Carlo (MC) calculation for 3 patient cases. For the artifact-free CT scan, an acrylic shield machined as the same size as that of the tungsten shield was used. For the MC calculation, BEAMnrc and DOSXYZnrc were used for the 6-MeV electron beam of the Varian 21EX, in which information for the tungsten, stainless steel, and aluminum material for the eye shield was used. The same plan was generated on the Pinnacle system and both were compared. The use of the acrylic shield produced clear CT images, enabling delineation of the regions of interest, and yielded CT-based dose calculation for the metallic shield. Both the MC and the Pinnacle systems showed a similar dose distribution downstream of the eye shield, reflecting the blocking effect of the metallic eye shield. The major difference between the MC and the Pinnacle results was the target eyelid dose upstream of the shield such that the Pinnacle system underestimated the dose by 19 to 28% and 11 to 18% for the maximum and the mean doses, respectively. The pattern of dose difference between the MC and the Pinnacle systems was similar to that in the previous phantom study. In conclusion, the metallic eye shield was successfully incorporated into the CT-based planning, and the accurate dose calculation requires MC simulation.

Analysis of predictive factors for lung injury after forward-planned intensity-modulated radiotherapy in whole breast irradiation.

PURPOSE: This study was performed to assess frequency, timings of occurrence, and predictors of radiologic lung damage (RLD) after forward-planned intensity-modulated radiotherapy (FIMRT) for whole breast irradiation. METHODS: We retrospectively reviewed medical records of 157 breast cancer patients and each of their serial chest computed tomography (CT) taken 4, 10, 16, and 22 months after completion of breast radiotherapy (RT). FIMRT was administered to whole breast only (n=152), or whole breast and supraclavicular regions (n=5). Dosimetric parameters, such as mean lung dose and lung volume receiving more than 10 to 50 Gy (V10-V50), and clinical parameters were analyzed in relation to radiologic lung damage. RESULTS: In total, 104 patients (66.2%) developed RLD after whole breast FIMRT. Among the cases of RLD, 84.7% were detected at 4 months, and 15.3% at 10 months after completion of RT. More patients of 47 or younger were found to have RLD at 10 months after RT than patients older than the age (11.7% vs. 2.9%, p=0.01). In univariate and multivariate analyses, age >47 and V40 >7.2% were significant predictors for higher risk of RLD. CONCLUSION: RLD were not infrequently detected in follow-up CT after whole breast FIMRT. More detected cases of RLD among younger patients are believed to have developed at later points after RT than those of older patients. Age and V40 were significant predictors for RLD after whole breast intensity-modulated radiotherapy.

Application of a dummy eye shield for electron treatment planning.

Metallic eye shields have been widely used for near-eye treatments to protect critical regions, but have never been incorporated into treatment plans because of the unwanted appearance of the metal artifacts on CT images. The purpose of this work was to test the use of an acrylic dummy eye shield as a substitute for a metallic eye shield during CT scans. An acrylic dummy shield of the same size as the tungsten eye shield was machined and CT scanned. The BEAMnrc and the DOSXYZnrc were used for the Monte Carlo (MC) simulation, with the appropriate material information and density for the aluminum cover, steel knob and tungsten body of the eye shield. The Pinnacle adopting the Hogstrom electron pencil-beam algorithm was used for the one-port 6-MeV beam plan after delineation and density override of the metallic parts. The results were confirmed with the metal oxide semiconductor field effect transistor (MOSFET) detectors and the Gafchromic EBT2 film measurements. For both the maximum eyelid dose over the shield and the maximum dose under the shield, the MC results agreed with the EBT2 measurements within 1.7%. For the Pinnacle plan, the maximum dose under the shield agreed with the MC within 0.3%; however, the eyelid dose differed by -19.3%. The adoption of the acrylic dummy eye shield was successful for the treatment plan. However, the Pinnacle pencil-beam algorithm was not sufficient to predict the eyelid dose on the tungsten shield, and more accurate algorithms like MC should be considered for a treatment plan.

Variations in dose distribution and optical properties of Gafchromic(TM) EBT2 film according to scanning mode.

PURPOSE: The authors aim was to investigate the effects of using transmission and reflection scanning modes, the film orientation during scanning, and ambient room light on a dosimetry system based on the Gafchromic(TM) EBT2 film model. METHODS: For calibration, the films were cut to 3 × 3 cm(2) and irradiated from 20 to 700 cGy at the depth of maximum dose using 6 and 10 MV photon beams in a 10 × 10 cm(2) field size. Absolute dose calibration of the linear accelerator was done according to the TRS398 protocol. An FG65-G ionization chamber was used to monitor the dose while irradiating the films in solid water. The film pieces were scanned with an EPSON Expression 1680 Pro flatbed scanner in transmission and reflection modes. Authors investigated the effect of orientation on films and examined the optical properties of EBT2 film using an ellipsometer and an ultraviolet (UV)/visible spectrometer to explain the dosimetric dependence of the film on orientation during the scanning process. To investigate the effect of ambient room light, films were preirradiated in 6 and 10 MV photon beams with intensity-modulated radiotherapy (IMRT) quality assurance (QA) plans, and then exposed to room light, either directly for 2 days in a workroom or for 2 months in a film box. Gamma index pass criteria of (3%, 3 mm) were used. RESULTS: The dose response curves based on net optical density (NOD) indicated that the reflection scanning mode can provide a better dose sensitivity than the transmission scanning mode, whereas the standard deviation of the dose is greater in reflection mode than in transmission mode. When the film was rotated 90° from the portrait orientation, the average dose of the EBT2 film decreased by 11.5-19.6% in transmission mode and by 1.5-2.3% in reflection mode. Using an ellipsometer, variation of the refractive index of EBT2 film-the birefringence property-was found to be the largest between 45° (1.72 and 1.71) and 135° (1.8 and 1.77) for 300 and 800 cGy. Absorption spectra of EBT2 films measured with spectrometer were the function of film orientation. The readings in reflection scanning mode were more stable against room light than those in transmission scanning mode, although dose readings increased in both modes after the films were exposed to room light. CONCLUSIONS: The transmission scanning mode exhibited a strong dependence on film orientation during scanning and a change in optical density resulting from room light exposure, so a constant scanning orientation and minimal exposure to light can reduce uncertainty in the measured dose (23 ± 3%). The angular dependence was analyzed using Jones matrices and optical properties of EBT2 film were obtained using an ellipsometer and an UV/visible spectrometer. The reflection scanning mode has relatively good stability with respect to room light and film orientation on a scanner, although the large standard deviation of dose is a disadvantage in measurements of absolute dose. Reflection scanning mode can offer a potential advantage for film dosimetry in radiotherapy, although transmission scanning mode is still recommended for dosimetry as it provides better uncertainty results.

Low initial human papilloma viral load implicates worse prognosis in patients with uterine cervical cancer treated with radiotherapy.

PURPOSE: To evaluate whether human papillomavirus (HPV) viral load measured in cervical smear and HPV type 18 are associated with radiotherapy outcomes in uterine cervical cancer. PATIENTS AND METHODS HPV DNA: was semiquantitatively measured in the cervical smears of 169 radiotherapy patients. HPV viral load was classified as low or high according to median HPV DNA titer and examined for its prognostic value. The multivariable Cox proportional hazards model was used to adjust for covariates. A relapse-predicting model was constructed to classify three risk groups for disease-free survival (DFS), which were used for internal validation. RESULTS: Patients with lower HPV viral load showed worse DFS in univariate analysis. HPV type 18, younger patient age, stage group, nodal status, histologic grade, and histologic type were other prognostic factors for poor DFS. Among these factors, all except stage group were associated with HPV viral load. Multivariate analysis showed the strong influence of HPV viral load for poor DFS. The prognostic model developed using our outcome data performed well in predicting the risk of relapse. CONCLUSION: Our data suggest that HPV viral load is a strong independent prognostic factor for DFS. HPV type 18 showed a significant relationship with poor radiotherapy outcome in univariate analysis, but not in multivariate analysis.

Concurrent radiotherapy with paclitaxel/carboplatin chemotherapy as a definitive treatment for squamous cell carcinoma of the uterine cervix.

OBJECTIVES: To evaluate the toxicity and the efficacy of paclitaxel/carboplatin chemoradiotherapy as a definitive treatment for squamous cell cancer of the uterine cervix. METHODS: From March 2000 to January 2004, 33 patients with squamous cell cancer of the uterine cervix were treated with concurrent chemoradiotherapy including 2 cycles of paclitaxel (135 mg/m(2)) and carboplatin (area under the time-concentration curve 4.5 mg min/ml) at 4-week interval. Seven patients received adjuvant chemotherapy with the same chemotherapeutic regimen. All patients received external beam radiotherapy with 41.4-51.4 Gy (median 50.4 Gy) to the whole pelvis. Twenty-eight patients received boost irradiation to the cervix by brachytherapy with 25.6-43.3 Gy (median 34.6 Gy) and 5 patients by external beam radiotherapy with 10.8-14.4 Gy (median 14.4 Gy). RESULTS: A median follow-up period was 27 months (range: 6-53 months). Acute hematological toxicity of grade 3 or 4 developed in 20 patients (61%), and acute gastrointestinal toxicity of grade 3 developed in 1 patient (3%). Vesicovaginal fistula occurred in 2 patients (6%). All patients achieved objective response (CR 70%, PR 30%) in 2 months after termination of treatment. One patient had a local progression in cervix, and 4 patients developed distant metastases. The 3-year estimated disease-free survival rates for stages I-IIA, IIB, III and IV were 67%, 91%, 88% and 50%, respectively. The 3-year estimated survival rates for stages I-IIA, IIB, III and IV were 89%, 91%, 88% and 50%, respectively. CONCLUSION: Concurrent chemoradiotherapy with paclitaxel and carboplatin is effective to achieve an excellent pelvic control.