2 R. Umezawa et al.

/ Brachytherapy - (2017) -

about 30%, which is unsatisfactory, indicating salvage sur- Table 1

gery as the main remaining curative treatment option (10e Patient characteristic at the time of reirradiation
12). Although a 5-year overall survival (OS) of about 50% Factor
can be yielded through pelvic exenteration, this surgical Age at reirradiation
procedure is associated with significant postoperative com- Median 57 years (range, 34e85 years)
plications and deterioration of quality of life (13e17). !60 years 10
$60 years 8
Nevertheless, a subgroup of patients can benefit from repeat FIGO stage at initial diagnosis
RT when pelvic exenteration is not deemed feasible or is re- IeII 14
jected by the patient. For this purpose, image-guided high- IIIeIV 4
dose-rate (HDR) interstitial brachytherapy (ISBT) as a Pathology
high-precision RT modality seems more preferable SCC 12
Non-SCC 6
compared with external beam radiotherapy (EBRT) Hemoglobin level at reirradiation
because of its dosimetric superiority (18) and its potential Median 12.4 g/dL (range, 7.3e13.6 g/dL)
for biologic dose escalation through hypofractionation. !12.5 g/dL 9
Various studies have demonstrated the effectiveness of $12.5 g/dL 9
ISBT for primary and recurrent cases of gynecological ma- Maximum tumor diameter at reirradiation
Median 36.5 mm (range, 14e68 mm)
lignancies (19e24). In our institution, image-guided HDR- !40 mm 10
ISBT has been performed since 2008. The purpose of the $40 mm 8
present study was to investigate the utility of this approach Prior chemotherapy
for patients with locally recurrent uterine cervical cancer Yes 11
after previous pelvic RT. No 7
Prior radiotherapy
Definitive 4
Methods and materials Postoperative 14
Interval to reirradiation
Patients receiving reirradiation using HDR-ISBT be- Median 14.9 months (range, 3.1e53.6 months)
tween 2008 and 2015 for local gross recurrence of uterine !12 months 7
$12 months 11
cervical cancer after definitive or postoperative RT were CTV D90
analyzed retrospectively. In all evaluated cases, recurrent Median 62.6 Gy (range, 48.6e82.5 Gy)
disease was diagnosed using CT and/or MRI and was !65 Gy 10
confirmed histopathologically. BT was offered if pelvic $65 Gy 8
exenteration was not indicated or if the patients refused ma- CTV 5 clinical target volume; FIGO 5 International Federation of
jor surgery while still seeking active treatment. Cases with Gynecology and Obstetrics; SCC 5 squamous cell carcinoma.
distant metastases, including paraaortic lymphadenopathy,
were excluded from the analysis. All patients were treated Radiotherapy
after providing informed consent, with special focus on the
possibility of severe late toxicities. This study was Our technique of image-guided HDR-ISBT for patients
approved by the Institutional Review Board of the National with uterine cervical cancer has been described in detail
Cancer Center (2015-359). elsewhere (19, 25). In short, catheter implantation was per-
formed transperineally under general or local anesthesia in
the lithotomy position using transrectal ultrasound guid-
Patient characteristics
ance. The Syed-Neblett perineal template (best volume
Eighteen patients were analyzed. The International Feder- out of the clinical target volume [CTV] included in the
ation of Gynecology and Obstetrics stages at initial diagnosis 200% isodose (cc); Best Medical International, Inc, Spring-
were I, II, III, and IV in 9, 5, 2, and 2 patients, respectively. field, VA) was used for advanced tumors in which multiple
There were 12 patients with squamous cell carcinoma, 4 with applicators were needed. Freehand needle insertion was
adenocarcinoma and 2 with adenosquamous carcinoma. The applied for localized small tumors. Titanium seed markers
detailed patient characteristics are shown in Table 1. were inserted into the target as a reference for daily correc-
Regarding the primary treatment, 14 patients received tion of needle declination. After completion of the catheter
surgery and 4 patients received definitive RT. Eight patients and titanium seed implantation, a planning CT data set was
received BRT as part of their previous treatment. The me- acquired using large-bore CT (Aquilion LG; Toshiba, To-
dian interval from initial RT to reirradiation was kyo, Japan) for treatment planning based on 2.0-mm slices
14.9 months (range, 3.1e53.6 months). For reirradiation, using a dedicated planning system (Oncentra; Elekta, Vee-
a combination of EBRT and BRT was performed in 5 pa- nendaal, the Netherlands). The CTV was defined based on
tients. No patient received chemotherapy in conjunction the planning CT data set, the intraoperative transrectal ul-
with reirradiation. Detailed treatment data of each patient trasound findings, and the most recent diagnostic MRI
are shown in Table 2. before ISBT. Reference points were set on the surface of