title: Adaptive 3D image-guided brachytherapy: a strong argument in the debate on systematic radical hysterectomy for locally advanced cervical cancer.
abstract: OBJECTIVE
  To evaluate the outcomes of patients with locally advanced cervical cancer treated with three-dimensional image-guided brachytherapy (IGABT) after concomitant chemoradiation (CCRT).
  
  
  METHODS
  Data from patients treated with CCRT followed by magnetic resonance imaging-guided or computed tomography-guided pulsed-dose-rate brachytherapy, performed according to the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology guidelines, were reviewed. At first, stage I or II patients systematically underwent radical hysterectomy or were offered a randomized study evaluating hysterectomy. Then, hysterectomy was limited to salvage treatment.
  
  
  RESULTS
  Of 163 patients identified, 27% had stage IB, 57% had stage II, 12% had stage III, and 3% had stage IVA disease. The mean dose delivered (in 2-Gy dose equivalents) to 90% of the high-risk clinical target volume was 78.1 ± 9.6 Gy, whereas the doses delivered to organs at risk were maintained under the usual thresholds. Sixty-one patients underwent a hysterectomy. Macroscopic residual disease was found in 13 cases. With a median follow-up of 36 months (range, 5-79 months), 45 patients had relapsed. The 3-year overall survival rate was 76%. Local and pelvic control rates were 92% and 86%, respectively. According to the Common Toxicity Criteria 3.0, 7.4% of patients experienced late grade 3 or 4 toxicity. Most of those had undergone postradiation radical surgery (2.9% vs. 14.8; p = .005).
  
  
  CONCLUSIONS
  IGABT combined with CCRT provides excellent locoregional control rates with low treatment-related morbidity, justifying the elimination of hysterectomy in the absence of obvious residual disease. Distant metastasis remains an important first relapse and may warrant more aggressive systemic treatment.
authors.affiliation: Department of Radiation Oncology, Institut de Cancérologie Gustave Roussy, Villejuif, France. renaud.mazeron@igr.fr
authors.forename: Renaud
authors.initials: R
authors.lastname: Mazeron
authors.forename: Jennifer
authors.initials: J
authors.lastname: Gilmore
authors.forename: Isabelle
authors.initials: I
authors.lastname: Dumas
authors.forename: Jérôme
authors.initials: J
authors.lastname: Champoudry
authors.forename: Jennifer
authors.initials: J
authors.lastname: Goulart
authors.forename: Ben
authors.initials: B
authors.lastname: Vanneste
authors.forename: Anne
authors.initials: A
authors.lastname: Tailleur
authors.forename: Philippe
authors.initials: P
authors.lastname: Morice
authors.forename: Christine
authors.initials: C
authors.lastname: Haie-Meder
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy; D059248:Chemoradiotherapy; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal; D021621:Imaging, Three-Dimensional; D053208:Kaplan-Meier Estimate; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009367:Neoplasm Staging; D002583:Uterine Cervical Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery