title: Severe gastrointestinal complications in the era of image-guided high-dose-rate intracavitary brachytherapy for cervical cancer.
abstract: OBJECTIVE
  The purposes of this analysis are to report a modern series of severe gastrointestinal toxic effects after definitive chemoradiotherapy in the treatment of locally advanced cervical cancer at our institution and to review the existing literature on factors that contribute to toxic effects and preventive strategies and management.
  
  
  METHODS
  Our institution's cervical cancer cohort was evaluated for patients with late grade 3 to 4 gastrointestinal toxic effects who were retrospectively reviewed for clinical or dosimetric parameters that could have contributed to late toxic effects. A review of the published literature was performed to identify factors associated with late toxic effects, prophylactic agents, and corrective therapy.
  
  
  RESULTS
  Five of 85 patients were identified as having late grade 3 to 4 gastrointestinal toxic effects with a median follow-up of 13.3 months. Two of 5 patients developed late grade 3 toxic effects, and 3 of 5 developed late grade 4 toxic effects. Three of the 5 patients reviewed ultimately required permanent colostomies. Cumulative median dose (in equivalent dose in 2-Gy fractions) of clinical target volume to the hottest 90% was 107.2 Gy, rectal dose to the hottest 2 cc (D2cc) was 81.7 Gy, sigmoid D2cc was 61.7 Gy, and bladder D2cc was 79.5 Gy. No patient had evidence of disease recurrence in the pelvis. One patient developed oligometastatic disease in the suprarenal gland and was successfully salvaged with adrenalectomy.
  
  
  CONCLUSIONS
  Despite its risk of toxic effects, intracavitary brachytherapy remains a critical component of the treatment of locally advanced cervical cancer. Even with modern radiotherapy planning and delivery techniques, extra attention is warranted to continue to strive for optimal outcomes.
authors.affiliation: Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, Virginia.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Trifiletti
authors.affiliation: Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, Virginia.
authors.forename: W
authors.initials: W
authors.lastname: Tyler Watkins
authors.affiliation: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia School of Medicine, Charlottesville, Virginia.
authors.forename: Linda
authors.initials: L
authors.lastname: Duska
authors.affiliation: Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, Virginia.
authors.forename: Bruce B
authors.initials: BB
authors.lastname: Libby
authors.affiliation: Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, Virginia. Electronic address: tns3b@virginia.edu.
authors.forename: Timothy N
authors.initials: TN
authors.lastname: Showalter
mesh_terms: D000328:Adult; D001918:Brachytherapy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005767:Gastrointestinal Diseases / Q000209:etiology*; D006801:Humans; D008875:Middle Aged; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D002583:Uterine Cervical Neoplasms / Q000532:radiotherapy*
keywords: brachytherapy; cervical cancer; gastrointestinal; high dose rate; rectum; toxicity