title: Image-guided adaptive brachytherapy in cervical cancer: Patterns of relapse by brachytherapy planning parameters.
abstract: Cervical cancer patients with a bulky high-risk clinical target volume (HR-CTV) get the largest benefit of dose escalation in terms of local control. However, the expected survival benefit could be lessened by a higher metastatic risk. We examined the patterns of relapse according to major prognostic factors: the HR-CTV volume and to the D90 HR-CTV.
  
  
  
  The clinical records of patients treated with pulsed-dose-rate image-guided adaptive brachytherapy after concurrent pelvic chemoradiation were reviewed. All patients had an optimal workup before treatment comprising a 18-fluorodeoxyglucose positron emission tomography/computed tomography and a para-aortic lymph node dissection. Patients with initial extrapelvic disease were excluded.
  
  
  
  A total of 109 patients fulfilled inclusion criteria. Median followup was 39 months. An HR-CTV volume ≥40 cm(3) was associated with a poorer local failure-free survival. There was a strong inverse correlation between the HR-CTV volume and the D90 of the HR-CTV (correlation coefficient r = -0.696; p < 0.001) with increasing HR-CTV volume being associated with a decreasing D90 HR-CTV. A D90 HR-CTV <85 Gy and an HR-CTV volume ≥40 cm(3) were significant univariate factors for experiencing nonlocal failure (p = 0.002 and 0.035, respectively), even after exclusion of local relapses.
  
  
  
  A lower ability to reach the target D90 HR-CTV planning and an HR-CTV volume ≥ 40 cm(3) correlated with a high propensity of relapsing at distance, these factors being interrelated. Next step of treatment personalization should design strategies integrating this risk, which is now the main cause of failure.
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France; Effets biologiques des rayonnements, Institut de Recherche Biomédicale des Armées, Bretigny-sur-Orge, France; Department of Surgery, Gustave Roussy, Villejuif, France. Electronic address: cyrus.chargari@gustaveroussy.fr.
authors.forename: Cyrus
authors.initials: C
authors.lastname: Chargari
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Renaud
authors.initials: R
authors.lastname: Mazeron
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Escande
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Maroun
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Dumas
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Florent
authors.initials: F
authors.lastname: Martinetti
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Tafo-Guemnie
authors.affiliation: INSERM1030, Gustave Roussy Cancer Campus, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France; Department of Surgery, Gustave Roussy, Villejuif, France.
authors.forename: Eric
authors.initials: E
authors.lastname: Deutsch
authors.affiliation: Department of Surgery, Gustave Roussy, Villejuif, France; University Paris-Sud, SIRIC SOCRATES, Faculte de Médecine, Le Kremlin-Bicêtre, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Morice
authors.affiliation: Brachytherapy Unit, Department of Radiotherapy, Gustave Roussy, Villejuif, France; Radiotherapy Department, Gustave Roussy, Villejuif, France.
authors.forename: Christine
authors.initials: C
authors.lastname: Haie-Meder
mesh_terms: D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000628:therapy*; D000328:Adult; D000368:Aged; D001918:Brachytherapy / Q000379:methods*; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000628:therapy*; D059248:Chemoradiotherapy / Q000379:methods; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008279:Magnetic Resonance Imaging / Q000379:methods; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D000072078:Positron Emission Tomography Computed Tomography; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods; D016896:Treatment Outcome; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging / Q000628:therapy*
keywords: Cervical cancer; Dose escalation; High-risk clinical target volume; Image-guided adaptive brachytherapy; Planning aim