Vaginal tolerance of CT based image-guided high-dose rate interstitial brachytherapy for gynecological malignancies.
BACKGROUND
Purpose of this study was to identify predictors of vaginal ulcer after CT based three-dimensional image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for gynecologic malignancies.


METHODS
Records were reviewed for 44 female (14 with primary disease and 30 with recurrence) with gynecological malignancies treated with HDR-ISBT with or without external beam radiation therapy. The HDR-ISBT applicator insertion was performed with image guidance by trans-rectal ultrasound and CT.


RESULTS
The median clinical target volume was 35.5 ml (2.4-142.1 ml) and the median delivered dose in equivalent dose in 2 Gy fractions (EQD2) for target volume D90 was 67.7 Gy (48.8-94.2 Gy, doses of external-beam radiation therapy and brachytherapy were combined). For re-irradiation patients, median EQD2 of D(2cc) for rectum and bladder, D0.5cc, D(1cc), D(2cc), D(4cc), D(6cc) and D(8cc) for vaginal wall was 91.1 Gy, 100.9 Gy, 260.3 Gy, 212.3 Gy, 170.1 Gy, 117.1 Gy, 105.2 Gy, and 94.7 Gy, respectively. For those without prior radiation therapy, median EQD2 of D(2cc) for rectum and bladder, D(0.5cc), D(1cc), D(2cc), D(4cc), D(6cc) and D(8cc) for vaginal wall was 56.3 Gy, 54.3 Gy, 147.4 Gy, 126.2 Gy, 108.0 Gy, 103.5 Gy, 94.7 Gy, and 80.7 Gy, respectively. Among five patients with vaginal ulcer, three had prior pelvic radiation therapy in their initial treatment and three consequently suffered from fistula formation. On univariate analysis, re-irradiation and vaginal wall D(2cc) in EQD2 was the clinical predictors of vaginal ulcer (p = 0.035 and p = 0.025, respectively). The ROC analysis revealed that vaginal wall D(2cc) is the best predictor of vaginal ulcer. The 2-year incidence rates of vaginal ulcer in the patients with vaginal wall D(2cc) in EQD2 equal to or less than 145 Gy and over 145 Gy were 3.7% and 23.5%, respectively, with a statistically significant difference (p = 0.026).


CONCLUSIONS
Re-irradiation and vaginal D(2cc) is a significant predictor of vaginal ulcer after HDR-ISBT for gynecologic malignancies. Three-dimensional image-guided treatment planning should be performed to ensure adequate target coverage while minimizing vaginal D(2cc) in order to avoid vagina ulcer.
Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji Chuo-ku, Tokyo 104-0045, Japan. namuraka@ncc.go.jp.
Naoya
N
Murakami
Takahiro
T
Kasamatsu
Minako
M
Sumi
Ryoichi
R
Yoshimura
Ken
K
Harada
Mayuka
M
Kitaguchi
Shuhei
S
Sekii
Kana
K
Takahashi
Kotaro
K
Yoshio
Koji
K
Inaba
Madoka
M
Morota
Yoshinori
Y
Ito
Jun
J
Itami
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005833:Genital Neoplasms, Female / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000532:radiotherapy*; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D011832:Radiation Injuries / Q000453:epidemiology; D011836:Radiation Tolerance; D011879:Radiotherapy Dosage; D061089:Radiotherapy, Image-Guided / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed / Q000009:adverse effects; D014456:Ulcer / Q000453:epidemiology / Q000209:etiology; D014621:Vagina / Q000528:radiation effects*; D014623:Vaginal Diseases / Q000453:epidemiology / Q000209:etiology