title: Definitive salvage for vaginal recurrence of endometrial cancer: the impact of modern intensity-modulated-radiotherapy with image-based HDR brachytherapy and the interplay of the PORTEC 1 risk stratification.
abstract: OBJECTIVE
  Data for salvage radiotherapy for recurrent endometrial cancer are limited especially in the era of modern radiotherapy including IMRT and 3-dimensional image-based HDR brachytherapy. Theoretically, modern radiotherapy reduces the dose to critical organs-at-risk and maximizes dose to the target volume, possibly decreasing morbidity and increasing tumor control.
  
  
  METHODS
  Forty-one patients completing definitive salvage radiotherapy for vaginal recurrence of endometrial cancer from June 2004 to December 2013 were retrospectively reviewed. HDR Brachytherapy was completed using image-based planning with contouring/optimization with each fraction to a median dose of 23.75 Gy in 5 fractions. HDR brachytherapy was preceded by external beam radiotherapy predominately using an IMRT technique (90%) to a median dose of 45 Gy in 25 fractions. Toxicity was reported according to CTCAEv4.
  
  
  RESULTS
  At a median follow-up of 18 months (range: 3-78), the clinical complete response rate was 95%. The 3-year local control, distant control, recurrence free survival, and overall survival were 95%, 61%, 68%, and 67%. Significant predictors of both distant failure and overall survival were primary prognostic factors of depth of myometrial invasion, FIGO stage, and FIGO grade. There was no grade 3+ acute toxicity; the 3-year rate of grade 3+ late toxicity was 8%.
  
  
  CONCLUSIONS
  Salvage IMRT plus 3-dimensional image-based HDR brachytherapy shows excellent tumor control and minimal morbidity for vaginal recurrence of endometrial cancer. Anticipated salvage rates must be taken in the context of primary risk factors including depth of myometrial invasion, FIGO stage, and FIGO grade.
authors.affiliation: University of Pittsburgh Cancer Institute, Department of Radiation Oncology, United States.
authors.forename: John A
authors.initials: JA
authors.lastname: Vargo
authors.affiliation: University of Pittsburgh Cancer Institute, Department of Radiation Oncology, United States.
authors.forename: Hayeon
authors.initials: H
authors.lastname: Kim
authors.affiliation: University of Pittsburgh Cancer Institute, Department of Radiation Oncology, United States.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Houser
authors.affiliation: University of Pittsburgh Cancer Institute, Department of Radiation Oncology, United States.
authors.forename: Hebist
authors.initials: H
authors.lastname: Berhane
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Paniti
authors.initials: P
authors.lastname: Sukumvanich
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Alexander B
authors.initials: AB
authors.lastname: Olawaiye
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Kelley
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Edwards
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: John T
authors.initials: JT
authors.lastname: Comerci
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Marilyn
authors.initials: M
authors.lastname: Huang
authors.affiliation: Department of Gynecologic Oncology, Pittsburgh, United States.
authors.forename: Madeleine
authors.initials: M
authors.lastname: Courtney-Brooks
authors.affiliation: University of Pittsburgh Cancer Institute, Department of Radiation Oncology, United States. Electronic address: beriwals@upmc.edu.
authors.forename: Sushil
authors.initials: S
authors.lastname: Beriwal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000379:methods*; D003131:Combined Modality Therapy; D016889:Endometrial Neoplasms / Q000473:pathology / Q000532:radiotherapy*; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000532:radiotherapy*; D059351:Organ Sparing Treatments / Q000379:methods; D058958:Organs at Risk; D011879:Radiotherapy Dosage; D050397:Radiotherapy, Intensity-Modulated / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D016879:Salvage Therapy / Q000379:methods*; D016896:Treatment Outcome; D014625:Vaginal Neoplasms / Q000473:pathology / Q000532:radiotherapy*
keywords: Endometrial cancer; IMRT; Image-based brachytherapy; PORTEC; Vagina recurrence