Short-course palliative radiation therapy leads to excellent bleeding control: A single centre retrospective study.

PURPOSE: To compare and evaluate the utility of varying hemostatic radiotherapy prescriptions for emergent palliation of bleeding tumors. MATERIALS AND METHODS: This retrospective study analyzed 112 consecutive patients treated with radiotherapy for emergent palliation of bleeding tumors at an academic institution. Study endpoints included: primary bleeding control; re-bleeding rate after initial control; treatment interruption rate; overall survival; and death within 30 days of treatment. RESULTS: The most commonly prescribed fractionations were: 20 Gy in 5 fractions, 30 Gy in 10 fractions, and 8 Gy in a single fraction. The overall primary bleeding control rate was 89%. By location, primary bleeding control rates were 89% (31/35), 80% (16/20), 88% (14/16), 93% (13/14), 100% (9/9), and 100% (6/6) for gastrointestinal, genitourinary, head and neck, thoracic, extremity, and gynecologic sites, respectively. The overall re-bleeding rate following initial bleeding control was 25%. Female patients had a significantly reduced risk of bleeding recurrence (HR 0.18 [0.04-0.79], p = 0.02). Longer fractionation regimens (>5 fractions) were not associated with a reduced incidence of re-bleeding (p = 0.65), but were associated with more treatment interruptions (p = 0.02). The 1-year overall survival rate in this population was 24%, with mortality greater in patients with poor performance status (HR 2.99 [1.36-6.58], p = 0.007). CONCLUSIONS: Regardless of prescription, palliative radiotherapy is highly effective for primary bleeding control, with both long and short regimens demonstrating equal hemostatic effect and durability in the emergent setting. Longer radiotherapy regimens (>5 fractions), however, are accompanied by increased treatment interruptions and hospital days. Therefore, shorter hemostatic regimens (<5 fractions) are preferable in this palliative setting, with respect to minimizing treatment burden for patients while achieving symptomatic relief.

Use of Aggressive Surveillance for Locoregional Endometrial Cancer After Local Therapy.

PURPOSE/OBJECTIVES: Current guidelines do not recommend routine surveillance imaging as part of follow-up care for patients treated for locoregional endometrial carcinoma. This study seeks to determine the potential benefit of routine surveillance imaging by evaluating outcomes of patients whose recurrences were detected on routine surveillance compared to those whose recurrences were identified after presenting with symptoms. MATERIALS/METHODS: We conducted a retrospective review of patients who developed recurrence after surgical treatment, with or without adjuvant therapy, for locoregional endometrial carcinoma. A total of 149 patients were identified with adequate clinical information regarding the recurrence. Cox proportional hazards regression analysis was used to estimate overall survival and progression-free survival. RESULTS: The median age of patients at diagnosis was 69.2 years (range, 38.0-99.5 years). Initial stages included stage I, 49.7%; stage II, 10.1%; stage III, 38.3%; and stage IV, 1.3%. Histologic diagnoses included endometrioid adenocarcinoma, 48.3%; and other diagnoses (including papillary serous carcinoma, clear cell carcinoma, and carcinosarcoma), 51.7%. Patients were initially treated with a variety of therapies: surgery alone in 20.8%, surgery and radiation in 25.5%, surgery and chemotherapy in 12.1%, and trimodality therapy in 41.6%. Sites of recurrence included 20.8% vaginal, 14.8% pelvic and 64.4% distant sites. Recurrences were detected asymptomatically in 86 patients (57.7%) and symptomatically in 63 patients (42.3%). Of those detected asymptomatically, 80.2% were detected by imaging. Overall, when comparing symptomatic versus asymptomatic recurrences, there was no difference in overall survival (hazard ratio, 1.24; 95% confidence interval, 0.84-1.83; P = 0.29) or progression-free survival (hazard ratio, 1.14; 95% confidence interval, 0.77-1.70; P = 0.52). CONCLUSIONS: Patients who develop asymptomatic recurrences of their endometrial carcinoma do not seem to have a better prognosis than those who present with symptomatic recurrences. Thus, these results do not support routine imaging surveillance for patients treated for locoregional endometrial carcinoma. Further prospective evaluation is needed.

The Impact of Adjuvant Therapy on Survival and Recurrence Patterns in Women With Early-Stage Uterine Carcinosarcoma: A Multi-institutional Study.

OBJECTIVE: The aim of the study was to characterize the impact of adjuvant therapy on survival in women with stage I/II uterine carcinosarcoma after primary surgery. METHODS: We reviewed records of 118 consecutively treated women with 2009 International Federation of Gynecology and Obstetrics stage I/II uterine carcinosarcoma who underwent hysterectomy between 1990 and 2014 at 4 academic institutions. Patients were categorized by adjuvant treatment group into observation, chemotherapy only, radiation only, and combined chemotherapy and radiation. Survival analyses were conducted using Kaplan-Meier and Cox proportional hazards models. RESULTS: Median follow-up was 28 months (range, 1-244 months). Lymphadenectomy was performed in 94 patients (80%). Postoperative management included observation (n = 37 [31%]), chemotherapy alone (n = 19 [16%]), radiation therapy (RT) alone (n = 24 [20%]), and combined RT and chemotherapy (n = 38 [32%]). Radiation therapy modality included vaginal brachytherapy in 22 patients, pelvic external beam RT in 21 patients, and combination in 19 patients. In 58% of women, chemotherapy consisted of carboplatin/paclitaxel. Median overall survival for all women was 97 months. On univariate analysis, adjuvant treatment group was associated with improved overall survival (hazard ratio [HR], 0.74; confidence interval [CI], 0.58-0.96; p = 0.02), freedom from vaginal recurrence (HR, 0.55; CI, 0.37-0.82]; p = 0.004), and freedom from any recurrence (HR, 0.70; CI, 0.54-0.92; p = 0.01). Pairwise comparisons demonstrated a significant benefit to chemoradiation over other adjuvant treatments. Adjuvant treatment group remained a significant covariate for all 3 end points on multivariate analysis as well. In addition, lymphadenectomy improved overall survival on multivariate analysis (HR, 0.24; CI, 0.09-0.61; p = 0.003). Of patients under observation only who had a recurrence, 8 (44%) of 18 had a recurrence in the vagina as the sole site of recurrence. By contrast, of women who received vaginal brachytherapy, significantly fewer had a recurrence in the vagina (1/42 [2.3%]; p < 0.003, log-rank test). CONCLUSIONS: In women with early-stage uterine carcinosarcoma, our data suggest superior survival end points with combined RT and chemotherapy. The frequency of vaginal recurrence suggests a role for incorporating vaginal brachytherapy in the adjuvant management of this disease.

Development and evaluation of an automatic interstitial catheter digitization tool for adaptive high-dose-rate brachytherapy.

PURPOSE: To develop and evaluate an automatic interstitial catheter digitization algorithm for use in adaptive high-dose-rate brachytherapy for gynecologic cancers using the Syed-Neblett template. METHODS AND MATERIALS: We developed an automatic catheter digitization tool, which uses a region growing algorithm in conjunction with a spline model of the catheters. Seed locations were selected in each catheter for the region growing algorithm. The region growing was constrained by a spline model of the catheters, which prevents intercatheter crossover or incorrect digitization due to air pockets. Plan reoptimization was performed on successive day computed tomography scans using dwell positions for the Day 1 computed tomography. This method was applied to 10 patients who had received high-dose-rate interstitial brachytherapy using the Syed-Neblett template. The prescribed dose was 18.75 or 20 Gy delivered in five fractions, twice daily, and more than 3 consecutive days. Dosimetric comparisons were made between automatically and manually digitized plans. RESULTS: The region growing algorithm was able to successfully digitize all catheters. The mean difference between automatic and manually digitized positions was 0.4 ± 0.2 mm. No significant difference was found in dosimetric parameters between the automatic and manually digitized plans. The mean D90% of the clinical target volume over all 3 days of treatment of the manual vs. reoptimized automatic plans was 94.3 ± 6.58% and 92.32 ± 8.34%, respectively (p = 0.50). CONCLUSIONS: The algorithm discussed in this article is the first developed for adaptive interstitial brachytherapy for a large number of catheters (14 on average). The algorithm has future potential in digitization quality assurance. A region growing algorithm was developed to automatically digitize interstitial catheters in high-dose-rate brachytherapy. This automatic digitization tool was shown to be accurate compared with manual digitization.