Comparison of brachytherapy with advanced EBRT techniques (intensity-modulated radiotherapy–stereotactic body radiotherapy)

Brachytherapy has intrinsic advantages compared to modern EBRT techniques, mainly intensity-modulated radiotherapy (IMRT) and stereotactic body radiotherapy (SBRT), due to the close contact between radioactive sources and volume to treat. IMRT has generally been used to irradiate the pelvis but with less toxicity.104 The main drawback to the use of EBRT techniques is that the vagina moves, so there is a risk of geographical “miss of target”, which leads to increased margins and higher integral doses to small bowel.105 Average VC movement for 11 patients was 16.2 ± 8.3 mm during an EBRT course, with a maximum movement of 34.5 mm.106 Large variations in bladder and rectum volumes correlate with significant displacement of the VC.107 Aydogan et al108 concluded that IMRT could be an alternative to HDR brachytherapy and provided a suitable immobilization system. Both techniques, brachytherapy and IMRT, covered the target volume well, but brachytherapy produced higher doses. In order to control vaginal movements an applicator-guided IMRT technique has been proposed.109 It was used to compare 3D conformal radiotherapy (3D-CRT), IMRT and volumetric-modulated arc therapy (VMAT) in irradiating the VC.110 Dose coverage was similar across the three techniques. VMAT showed the highest level of conformity and produced a significant reduction in rectal and bladder volumes compared with 3D-CRT. VMAT needed 28% less monitor units compared with IMRT, and treatment duration reduced from 11 to <3 minutes for a dose of 6 Gy. Pedicini et al111,112 compared VMAT, IMRT and 3D-CRT using a vaginal cylinder for vaginal immobilization to 3D brachytherapy. The cylinder was able to reduce the movement in the VMAT course and reduced planning target volume margin to 2 mm. EBRT techniques always delivered higher integral doses but reduced rectal doses compared with brachytherapy. VMAT produced a uniform dose distribution, while VCB doses were much higher than the prescription. No direct cost comparisons between these modalities have been published, but three fractions of VCB course with one image study has been calculated to cost between US$1235 and $1293,95 while four to five fractions of SBRT for lung cancer cost $10616.113


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In summary, we believe that despite the widespread use of the VCB and the simplicity of its performance, several technical subjects have to be considered by the radiation oncologists aside from the usual groups of risk involved in patient selection. The technical subjects reported so far have been reviewed here, although additional research is merited, such as the impact of VCB on survival, dose–fractionation direct comparisons or the use of short schedules.

Acknowledgment

The authors would like to thank Phil Hoddy for language editing.

Disclosure

The authors report no conflicts of interest in this work.


Sebastià Sabater,1 Ignacio Andres,1 Veronica Lopez-Honrubia,1 Roberto Berenguer,1 Marimar Sevillano,1 Esther Jimenez-Jimenez,2 Angeles Rovirosa,3 Meritxell Arenas,4

1Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete, 2Department of Radiation Oncology, Hospital Son Espases, Palma de Mallorca, 3Department of Radiation Oncology, Hospital Clinic, Barcelona, 4Department of Radiation Oncology, Hospital Universitari Sant Joan, Reus, Spain 


References

1. Bray F, Loos AH, Oostindier M, Weiderpass E. Geographic and temporal variations in cancer of the corpus uteri: incidence and mortality in pre- and postmenopausal women in Europe. Int J Cancer. 2005;117(1):123–131.

2. Ferlay J, Soerjomataram I, Dikshit R, et al. Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359–E386.

3. Creutzberg CL, Nout RA. The role of radiotherapy in endometrial cancer: current evidence and trends. Curr Oncol Rep. 2011;13(6):472–478.

4. Ishiyama H, Satoh T, Sekiguchi A, et al. Comparison of three different techniques of low-dose-rate seed implantation for prostate cancer. J Contemp Brachytherapy. 2015;7(1):3–9.

5. Hasan S, Francis A, Hagenauer A, et al. The role of brachytherapy in organ preservation for penile cancer: a meta-analysis and review of the literature. Brachytherapy. 2015;14(4):517–524.

6. Arenas M, Arguis M, Diez-Presa L, et al. Hypofractionated high-dose-rate plesiotherapy in nonmelanoma skin cancer treatment. Brachytherapy. 2015;14(6):859–865.

7. Takacsi-Nagy Z, Martinez-Mongue R, Mazeron JJ, Anker CJ, Harrison LB. American Brachytherapy Society Task Group Report: combined external beam irradiation and interstitial brachytherapy for base of tongue tumors and other head and neck sites in the era of new technologies. Brachytherapy. 2017;16(1):44–58.

8. Arenas M, Gascon M, Rovirosa A, et al. The effect of lymphadenectomy and radiotherapy on recurrence and survival in endometrial carcinoma. Experience in a population reference centre. Rep Pract Oncol Radiother. 2015;20(1):50–56.

9. Kilgore LC, Partridge EE, Alvarez RD, et al. Adenocarcinoma of the endometrium: survival comparisons of patients with and without pelvic node sampling. Gynecol Oncol. 1995;56(1):29–33.

10. ASTEC Study Group, Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. Lancet. 2009;373(9658):125–136.

11. Benedetti Panici P, Basile S, Maneschi F, et al. Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial. J Natl Cancer Inst. 2008;100(23):1707–1716.

12. Mariani A, Dowdy SC, Cliby WA, et al. Prospective assessment of lymphatic dissemination in endometrial cancer: a paradigm shift in surgical staging. Gynecol Oncol. 2008;109(1):11–18.

13. Papadia A, Remorgida V, Salom EM, Ragni N. Laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic oncology. J Am Assoc Gynecol Laparosc. 2004;11(3):297–306.

14. Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009;27(32):5331–5336.

15. Papadia A, Imboden S, Siegenthaler F, et al. Laparoscopic indocyanine green sentinel lymph node mapping in endometrial cancer. Ann Surg Oncol. 2016;23(7):2206–2211.

16. Huang HJ, Tang YH, Chou HH, et al. Treatment failure in endometrial carcinoma. Int J Gynecol Cancer. 2014;24(5):885–893.

17. Mariani A, Webb MJ, Keeney GL, Lesnick TG, Podratz KC. Surgical stage I endometrial cancer: predictors of distant failure and death. Gynecol Oncol. 2002;87(3):274–280.

18. Blecharz P, Urbanski K, Mucha-Malecka A, et al. Hematogenous metastases in patients with stage I or II endometrial carcinoma. Strahlenther Onkol. 2011;187(12):806–811.

19. Murphy KT, Rotmensch J, Yamada SD, Mundt AJ. Outcome and patterns of failure in pathologic stages I-IV clear-cell carcinoma of the endometrium: implications for adjuvant radiation therapy. Int J Radiat Oncol Biol Phys. 2003;55(5):1272–1276.

20. Barlin JN, Wysham WZ, Ferda AM, et al. Location of disease in patients who die from endometrial cancer: a study of 414 patients from a single institution. Int J Gynecol Cancer. 2012;22(9):1527–1531.

21. Harkenrider MM, Adams W, Block AM, Kliethermes S, Small W Jr, Grover S. Improved overall survival with adjuvant radiotherapy for high-intermediate and high risk stage I endometrial cancer. Radiother Oncol. 2017;122(3):452–457.

22. Chino JP, Jones E, Berchuck A, Secord AA, Havrilesky LJ. The influence of radiation modality and lymph node dissection on survival in early-stage endometrial cancer. Int J Radiat Oncol Biol Phys. 2012;82(5):1872–1879.

23. Lee CM, Szabo A, Shrieve DC, Macdonald OK, Gaffney DK. Frequency and effect of adjuvant radiation therapy among women with stage I endometrial adenocarcinoma. JAMA. 2006;295(4):389–397.

24. Mell LK, Carmona R, Gulaya S, et al. Cause-specific effects of radiotherapy and lymphadenectomy in stage I-II endometrial cancer: a population-based study. J Natl Cancer Inst. 2013;105(21):1656–1666.

25. Bertelsen K, Ortoft G, Hansen ES. Survival of Danish patients with endometrial cancer in the intermediate-risk group not given postoperative radiotherapy: the Danish Endometrial Cancer Study (DEMCA). Int J Gynecol Cancer. 2011;21(7):1191–1199.

26. Fanning J, Hoffman ML, Andrews SJ, Harrah AW, Feldmeier JJ. Cost-effectiveness analysis of the treatment for intermediate risk endometrial cancer: postoperative brachytherapy vs. observation. Gynecol Oncol. 2004;93(3):632–636.

27. Patel MK, Cote ML, Ali-Fehmi R, Buekers T, Munkarah AR, Elshaikh MA. Trends in the utilization of adjuvant vaginal cuff brachytherapy and/or external beam radiation treatment in stage I and II endometrial cancer: a surveillance, epidemiology, and end-results study. Int J Radiat Oncol Biol Phys. 2012;83(1):178–184.

28. Arenas M, Sabater S, Gascon M, et al. Quality assurance in radiotherapy: analysis of the causes of not starting or early radiotherapy withdrawal. Radiat Oncol. 2014;9:260.

29. Sabater S, Arenas M, Berenguer R, et al. Body mass index and doses at organs at risk in a Mediterranean population treated with postoperative vaginal cuff brachytherapy. Cancer Res Treat. 2015;47(3):473–479.

30. Iati G, Pontoriero A, Mondello S, et al. Three-dimensional treatment planning for vaginal cuff brachytherapy: dosimetric effects on organs at risk according to patients position. Brachytherapy. 2014;13(6):568–571.