title: Evaluation of Survival and Treatment Toxicity With High-Dose-Rate Brachytherapy With Cobalt 60 in Carcinoma of Cervix.
abstract: BACKGROUND
  Cervical cancer remains to be a major health problem and cancer-related cause of death among women in developing countries such as Iran where the most cases are diagnosed in locally advanced stage.
  
  
  OBJECTIVE
  This cross sectional-analytic study aims to report outcome 154 patients with carcinoma of cervix were treated with external beam radiation therapy (EBRT) and high-dose-rate (HDR) brachytherapy with cobalt 60 (Co-6o) remote after loading system.
  
  
  METHODS
  A total of 154 patients with the international federation of gynecologist and oncologist (FIGO) stages I-IVA with histopathologically confirmed carcinoma of cervix, followed by the radiation-oncology ward of Shohada-e-Tajrish Hospital in Tehran, Iran, between February 2008 and March 2015. They were completed their scheduled EBRT and HDR brachytherapy with Co-60 remote after loading system. Out of this, 132 patients completed their standard follow up protocol. They were analyzed for 3-year disease-free survival (DFS), 3-year overall survival (OS) incidence of acute and late complications for HDR brachytherapy.
  
  
  RESULTS
  Fourteen patients (9.1 %) were in stage I (FIGO classification), 8 (5.2%) were in stage IIA, 26 (16.9%) were in stage IIB, 100 (64.9%) were in stage III, and 6 (3.9 %) were in stage IVA. The follow up duration was between 6 - 60 months with a median of 38 months. Overall rectal and bladder treatment toxicity rates were 33.7%. The 3-year DFS rate was 85.7%, 70.7 %, 41% and 16.6% for stages I, II, III, IVA respectively. Favorable prognostic factors in univariate and multivariate analysis were early stage, tumor size < 4 cm (after adjusting for the residual disease after radiation), no pelvic lymph node involvement and 1 week Gap between EBRT and HDR brachytherapy in 3-year DFS (P = 0.001, P = 0.012, P = 0.005, P = 0.005, respectively). The 3-year OS rate was 85.7%, 76.4%, 42%, and 33.3% for stages I, II, III, and IVA, respectively. Favorable prognostic factors in univariate and multivariate analysis were early stage, tumor size < 4 cm, no pelvic lymph node involvement, 1 week gap between EBRT and HDR brachytherapy and no distant metastasis (during the follow up) in 3-year OS (P = 0.001, P = 0.002, P = 0.002, P = 0.002, P = 0.001, respectively).
  
  
  CONCLUSIONS
  HDR brachytherapy with Co-60 remote after loading system was successful and it showed HDR brachytherapy in treating patients with carcinoma of cervix was effective after EBRT with acceptable rectal and bladder complications.
authors.affiliation: Department of Radiation Oncology, Shohada-e-Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran.
authors.forename: Afshin
authors.initials: A
authors.lastname: Rakhsha
authors.affiliation: Department of Radiation Oncology, Shohada-e-Tajrish Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran.
authors.forename: Amir Shahram
authors.initials: AS
authors.lastname: Yousefi Kashi
authors.affiliation: Department of Radiation Oncology, Urmia University of Medical Sciences, Urmia, IR Iran.
authors.forename: Seied Mohsen
authors.initials: SM
authors.lastname: Hoseini
keywords: Brachytherapy; Disease Free Survival; Overall Survival; Treatment