title: MRI-guided adaptive radiotherapy in locally advanced cervical cancer from a Nordic perspective.
abstract: BACKGROUND
  The first Nordic protocol for three-dimensional (3D) planned radiotherapy in locally advanced cervical cancer was the prospective NOCECA study (1994-2000). NOCECA consisted of computed tomography (CT)-based 3D conformal external beam radiotherapy (EBRT) with a simultaneous integrated boost (SIB) to the primary tumour combined with brachytherapy (BT) based on x-ray imaging. In NOCECA the planning aim was to achieve 80 Gy at point A from EBRT and BT combined. However, the balance of dose between EBRT and BT was determined by tumour size at diagnosis with more EBRT dose given to point A and less by BT in more advanced stages. In 2005 image-guided adaptive brachytherapy (IGABT) based on magnetic resonance imaging (MRI) and optimisation of the BT dose distribution to the remaining tumour and cervix at time of BT (HR CTV) was introduced in Aarhus. EBRT remained like in NOCECA until 2008 when the SIB to the primary tumour was abandoned and IMRT was introduced as routine technique. In this study, we report outcome of our first five-year experience with IGABT using our NOCECA cohort as reference.
  
  
  METHODS
  The NOCECA cohort comprising 99 patients was compared with 140 consecutive patients treated by IGABT. Patients with para-aortic nodes were excluded in NOCECA but were present in 9% of the patients treated with IGABT. No patient in NOCECA received chemotherapy whereas concomitant cisplatin was given to 79% of the IGABT patients.
  
  
  RESULTS
  With IGABT actuarial local control was 91% at three years. When comparing NOCECA with IGABT overall survival was significantly improved from 63% to 79% (p = 0.005). In parallel, both moderate and severe late morbidity were reduced by about 50% (p = 0.02).
  
  
  CONCLUSIONS
  Introduction of IGABT reduced morbidity and generated a very high rate of local control, which likely has improved survival by at least as much as concomitant chemotherapy.
authors: Department of Oncology, Aarhus University Hospital , Aarhus , Denmark.
authors: Jacob Christian
authors: JC
authors: Lindegaard
authors: Lars Ulrik
authors: LU
authors: Fokdal
authors: Søren Kynde
authors: SK
authors: Nielsen
authors: Jens
authors: J
authors: Juul-Christensen
authors: Kari
authors: K
authors: Tanderup
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000401:mortality / Q000532:radiotherapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000401:mortality / Q000532:radiotherapy; D003718:Denmark; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008875:Middle Aged; D009367:Neoplasm Staging; D011379:Prognosis; D011446:Prospective Studies; D011880:Radiotherapy Planning, Computer-Assisted; D061089:Radiotherapy, Image-Guided; D050397:Radiotherapy, Intensity-Modulated; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000532:radiotherapy*