title: Inverse Planned High-Dose-Rate Brachytherapy for Locoregionally Advanced Cervical Cancer: 4-Year Outcomes.
abstract: OBJECTIVE
  Evaluate the efficacy and toxicity of image guided brachytherapy using inverse planning simulated annealing (IPSA) high-dose-rate brachytherapy (HDRB) boost for locoregionally advanced cervical cancer.
  
  
  METHODS
  From December 2003 through September 2009, 111 patients with primary cervical cancer were treated definitively with IPSA-planned HDRB boost (28 Gy in 4 fractions) after external radiation at our institution. We performed a retrospective review of our experience using image guided brachytherapy. Of the patients, 70% had a tumor size >4 cm, 38% had regional nodal disease, and 15% had clinically evident distant metastasis, including nonregional nodal disease, at the time of diagnosis. Surgical staging involving pelvic lymph node dissection was performed in 15% of patients, and 93% received concurrent cisplatin-based chemotherapy. Toxicities are reported according to the Common Terminology Criteria for Adverse Events version 4.0 guidelines.
  
  
  RESULTS
  With a median follow-up time of 42 months (range, 3-84 months), no acute or late toxicities of grade 4 or higher were observed, and grade 3 toxicities (both acute and late) developed in 8 patients (1 constitutional, 1 hematologic, 2 genitourinary, 4 gastrointestinal). The 4-year Kaplan-Meier estimate of late grade 3 toxicity was 8%. Local recurrence developed in 5 patients (4 to 9 months after HDRB), regional recurrence in 3 (6, 16, and 72 months after HDRB), and locoregional recurrence in 1 (4 months after HDR boost). The 4-year estimates of local, locoregional, and distant control of disease were 94.0%, 91.9%, and 69.1%, respectively. The overall and disease-free survival rates at 4 years were 64.3% (95% confidence interval [CI] of 54%-73%) and 61.0% (95% CI, 51%-70%), respectively.
  
  
  CONCLUSIONS
  Definitive radiation by use of inverse planned HDRB boost for locoregionally advanced cervical cancer is well tolerated and achieves excellent local control of disease. However, overall survival continues to be limited by the high rates of distant metastasis.
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, California.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Tinkle
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, California.
authors.forename: Vivian
authors.initials: V
authors.lastname: Weinberg
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, California.
authors.forename: Lee-May
authors.initials: LM
authors.lastname: Chen
authors.affiliation: Gynecologic Oncology, The Permanente Medical Group, San Francisco, California.
authors.forename: Ramey
authors.initials: R
authors.lastname: Littell
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, California.
authors.forename: J Adam M
authors.initials: JAM
authors.lastname: Cunha
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, California.
authors.forename: Rajni A
authors.initials: RA
authors.lastname: Sethi
authors.affiliation: Gynecologic Oncology, California Pacific Medical Center, San Francisco, California.
authors.forename: John K
authors.initials: JK
authors.lastname: Chan
authors.affiliation: Department of Radiation Oncology, University of California, San Francisco, California. Electronic address: ichow.hsu@ucsf.edu.
authors.forename: I-Chow
authors.initials: IC
authors.lastname: Hsu
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000009:adverse effects / Q000379:methods*; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality / Q000473:pathology / Q000532:radiotherapy; D015331:Cohort Studies; D016001:Confidence Intervals; D018572:Disease-Free Survival; D005260:Female; D006417:Hematuria / Q000209:etiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology; D058958:Organs at Risk / Q000000981:diagnostic imaging / Q000528:radiation effects; D011832:Radiation Injuries / Q000473:pathology; D011859:Radiography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D061089:Radiotherapy, Image-Guided / Q000379:methods*; D012189:Retrospective Studies; D013997:Time Factors; D047368:Tumor Burden; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000401:mortality / Q000473:pathology* / Q000532:radiotherapy*