Bone Marrow Sparing by Intensity Modulated Proton Beam Therapy in Postoperative Irradiation of Gynecologic Malignancies.

Purpose: The aim of this matched-pair cohort study was to evaluate the potential of intensity-modulated proton therapy (IMPT) for sparring of the pelvic bone marrow and thus reduction of hematotoxicity compared to intensity-modulated photon radiotherapy (IMRT) in the setting of postoperative irradiation of gynaecological malignancies. Secondary endpoint was the assessment of predictive parameters for the occurrence of sacral insufficiency fractures (SIF) when applying IMPT. Materials and Methods: Two cohorts were analyzed consisting of 25 patients each. Patients were treated with IMPT compared with IMRT and had uterine cervical (n = 8) or endometrial cancer (n = 17). Dose prescription, patient age, and diagnosis were matched. Dosimetric parameters delivered to the whole pelvic skeleton and subsites (ilium, lumbosacral, sacral, and lower pelvis) and hematological toxicity were evaluated. MRI follow-up for evaluation of SIF was only available for the IMPT group. Results: In the IMPT group, integral dose to the pelvic skeleton was significantly lower (23.4GyRBE vs 34.3Gy; p < 0.001), the average V5Gy, V10Gy, and V20Gy were reduced by 40%, 41%, and 28%, respectively, compared to the IMRT group (p < 0.001). In particular, for subsites ilium and lower pelvis, the low dose volume was significantly lower. Hematotoxicity was significantly more common in the IMRT group (80% vs 32%; p = 0009), especially hematotoxicity ≥ CTCAE II (36% vs 8%; p = 0.037). No patient in the IMPT group experienced hematotoxicity > CTCAE II. In the IMPT cohort, 32% of patients experienced SIF. Overall SIF occurred more frequently with a total dose of 50.4 GyRBE (37.5%) compared to 45 GyRBE (22%). No significant predictive dose parameters regarding SIF could be detected aside from a trend regarding V50Gy to the lumbosacral subsite. Conclusion: Low-dose exposure to the pelvic skeleton and thus hematotoxicity can be significantly reduced by using IMPT compared to a matched photon cohort. Sacral insufficiency fracture rates appear similar to reported rates for IMRT in the literature.

[Dosimetric analysis of different optimization algorithms for three-dimensional brachytherapy for gynecologic tumors].

OBJECTIVE: To investigate the dosimetric difference between manual and inverse optimization in 3-dimensional (3D) brachytherapy for gynecologic tumors. METHODS: This retrospective study was conducted among a total of 110 patients with gynecologic tumors undergoing intracavitary combined with interstitial brachytherapy or interstitial brachytherapy. Based on the original images, the brachytherapy plans were optimized for each patient using Gro, IPSA1, IPSA2 (with increased volumetric dose limits on the basis of IPSA1) and HIPO algorithms. The dose-volume histogram (DVH) parameters of the clinical target volume (CTV) including V200, V150, V100, D90, D98 and CI, and the dosimetric parameters D2cc, D1cc, and D0.1cc for the bladder, rectum, and sigmoid colon were compared among the 4 plans. RESULTS: Among the 4 plans, Gro optimization took the longest time, followed by HIPO, IPSA2 and IPSA1 optimization. The mean D90, D98, and V100 of HIPO plans were significantly higher than those of Gro and IPSA plans, and D90 and V100 of IPSA1, IPSA2 and HIPO plans were higher than those of Gro plans (P < 0.05), but the CI of the 4 plans were similar (P > 0.05). For the organs at risk (OARs), the HIPO plan had the lowest D2cc of the bladder and rectum; the bladder absorbed dose of Gro plans were significantly greater than those of IPSA1 and HIPO (P < 0.05). The D2cc and D1cc of the rectum in IPSA1, IPSA2 and HIPO plans were better than Gro (P < 0.05). The D2cc and D1cc of the sigmoid colon did not differ significantly among the 4 plans. CONCLUSION: Among the 4 algorithms, the HIPO algorithm can better improve dose coverage of the target and lower the radiation dose of the OARs, and is thus recommended for the initial plan optimization. Clinically, the combination of manual optimization can achieve more individualized dose distribution of the plan.

The relationship between quality of life and sex role of women with gynecological cancers undergoing brachytherapy.

PURPOSE: This study aims to analyze the relationship between the quality of life and sex roles of women diagnosed with cancer and undergoing brachytherapy. METHODS: The research is a cross-sectional descriptive study. The sample of the study included 116 women over 35 years old who were diagnosed with a gynecologic cancer and underwent intracavitary brachytherapy at the Radiation Oncology Department of a university hospital. Personal information form, SF-36 the Quality of Life Scale, and BEM Sex Role Inventory were used in the study. The researcher collected the data through face-to-face interview. The data were collected in the nurses' room after 3 different brachytherapy treatments that patients received weekly. RESULTS: It was found that the average score of the physical functioning subscale was 32.80 ± 24.33, the average score of role physical was 15.43 ± 28.78, the average score of role emotional was 17.81 ± 28.96, the average score of vitality was 39.13 ± 16.12, the average score of social functioning was 43.53 ± 20.55, the score average of pain was 50.0 ± 20.09, the average score of general health was 42.67 ± 14.61, and the general health of mental health was 55.86 ± 16.12. In the BEM sex roles scale, the average score of BEM femininity was 105.56 ± 13.95, and the average score of BEM masculinity was 80.61 ± 12.77. In our study, a very low, negative, and significant relationship was determined between the role of femininity and emotional role limitation, physical functionality, social functionality, and general health perception in the women undergoing brachytherapy (p < 0.05). CONCLUSIONS: Based on the findings of the present study, we can state that an increase in the "role of femininity" in women undergoing brachytherapy was effective in the decrease in the quality of lives of women. It can be claimed that the results will be a guidance for the nurses who will play an important role in increasing the quality of lives of the women undergoing brachytherapy.

Clinical Outcomes and Dosimetric Evaluationof Interstitial Brachytherapyin Gynecological Malignancies.

BACKGROUND: In management of Carcinoma Cervix, Brachytherapy plays a crucial role. Most commonly used technique is Intracavitary Brachytherapy (ICBT). In cases where ICBT is not technically feasible or it may result in suboptimal dose distribution, Interstitial Brachytherapy (ISBT) is recommended. With this study we wanted to study the clinical outcome and dosimetric details of interstitial brachytherapy in gynecological cancers. MATERIALS & METHODS: We analysed clinicaloutcome and dosimetric details of interstitial brachytherapy (ISBT) done for gynecological malignancies in our institute during the period 1st January 2013 to 31st December 2020. RESULTS: Total of 42 interstitial brachytherapy (ISBT) details were analysed.37 patients had Carcinoma Cervix and 5 patients had Carcinoma Vagina. In the majority of the patients, ISBT dosage schedule was three fractions 7Gy each. D2cc to rectum, bladder, sigmoid and bowel were 4.88 Gy, 5.62 Gy, 3.57 Gy and 2.47 Gy respectively. Mean CTV volume was 129.89 cc. EQD2 dose to CTV combining EBRT and ISBT dose was 85.88 Gy. D90 and D100 to CTV from ISBT were 111.96% and 68.21 % of prescribed dose respectively. Grade III/IV toxicities were seen in 5 (12%) patients. Local control rates at 1year &2 years were 88% & 85.7% respectively. DFS at 1 year, 2 years and 3 years were 80.7%, 72.3% and 65.7% respectively. OS at 1year, 2 years, 4 years and 5 years were 92.5%, 65.5%, 59.5% and 42.3% respectively. CONCLUSION: 3D imagebased dosimetry with CT based planning using MUPIT implant is a feasible option for gynecological malignancies warranting interstitial brachytherapy. In view of good clinical outcomes in terms of toxicity profile, Local control, DFS and OS with acceptable GEC-ESTRO dosimetric data, we recommend routine use interstitial brachytherapy if facilities are available and in clinical situations were ISBT is indicated.

A survey on brachytherapy training of gynecological cancer focusing on the competence of residents in China.

BACKGROUND: The brachytherapy is an indispensable treatment for gynecological tumors, but the quality and efficiency of brachytherapy training for residents is still unclear. METHODS: An anonymous questionnaire was designed to collect information on gynecological brachytherapy (GBT) training for radiation oncology residents from 28 training bases in China. The questionnaire content was designed based on the principle of competency based medical education (CBME). The Likert scale was employed to evaluate self-reported competence and comprehension regarding GBT. A total of 132 senior residents were included in the final analysis. RESULTS: 53.79% (71/132) of senior residents had experience in performing image-guided GBT, whereas 76.52% (101/132) had observed the procedure during their standardized residency training. The proportion of senior residents who reported having the self-reported competence to independently complete the GBT was 78.03% for intracavity GBT, 75.00% for vaginal stump GBT, and 50.03% for interstitial GBT, respectively. The number of successful completion of Interstitial, intracavity and vaginal GBT was correlated with the self- confidence of trainees after standardized training. In particular, the independent completion of interstitial GBT for more than 20 cases was an independent factor for the self-reported competence of senior residents. During the training period, 50.76% and 56.82% of the residents had not participated in the specialized examinations and professional GBT courses. CONCLUSIONS: The study revealed that the self-confidence of residents to independently complete brachytherapy was relatively high, and the specialized curriculum setting and training process assessment for brachytherapy training still need to be strengthened in the future.

Educational telerehabilitation program for women with pelvic floor dysfunctions after gynecological pelvic cancer treatment: protocol study for a randomized and controlled clinical trial.

BACKGROUND: Educational and self-care measures are important for women after gynecological pelvic cancer treatment. Pelvic floor muscle training exercises (PFMT) are a conservative treatment for pelvic floor (PF) dysfunction. The purpose is to evaluate the impact of a telerehabilitation and self-care program on PF dysfunctions, reports of urinary incontinence (UI), and physical-emotional factors of participants post-treatment for gynecological pelvic cancer. METHODS: Two-arm randomized clinical trial: an intervention group (IG) will evaluate the effect of a telerehabilitation program on women undergoing clinical practice of radiotherapy for the treatment of gynecological pelvic cancer and a control group (CG) will maintain the routine. Primary outcome is the prevalence of reports of UI, which will be assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). The secondary outcomes will be the severity and impact of UI on quality of life, location and perception of pain intensity, presence and intensity of dyspareunia, vaginal stenosis, fecal incontinence (FI), and levels of physical activity. Statistical analysis will be performed by intention-to-treat, and multivariate mixed effects analysis will be used to compare results. DISCUSSION: Activities in the context of telerehabilitation using PFMT and self-care can represent a viable and effective solution to minimize the side effects of gynecological cancer treatment and improve women's quality of life.

Survival prediction in patients with gynecological cancer irradiated for brain metastases.

BACKGROUND AND PURPOSE: This large population-based, retrospective, single-center study aimed to identify prognostic factors in patients with brain metastases (BM) from gynecological cancers. MATERIAL AND METHODS: One hundred and forty four patients with BM from gynecological cancer treated with radiotherapy (RT) were identified. Primary cancer diagnosis, age, performance status, number of BM, presence of extracranial disease, and type of BM treatment were assessed. Overall survival (OS) was calculated using the Kaplan-Meier method and the Cox proportional hazards regression model was used for multivariable analysis. A prognostic index (PI) was developed based on scores from independent predictors of OS. RESULTS: Median OS for the entire study population was 6.2 months. Forty per cent of patients died within 3 months after start of RT. Primary cancer with the origin in cervix or vulva (p = 0.001),  Eastern Cooperative Oncology Group (ECOG) 3-4 (p < 0.001), and the presence of extracranial disease (p = 0.001) were associated with significantly shorter OS. The developed PI based on these factors, categorized patients into three risk groups with a median OS of 13.5, 4.0, and 2.4 months for the good, intermediate, and poor prognosis group, respectively. INTERPRETATION: Patients with BM from gynecological cancers carry a poor prognosis. We identified prognostic factors and developed a scoring tool to select patients with better or worse prognosis. Patients in the high-risk group have a particular poor prognosis, and omission of RT could be considered.

Are prophylactic antibiotics required for combined intracavitary and interstitial brachytherapy of gynecologic cancers?

The purpose of this study is to evaluate the need for prophylactic antibiotic treatment prior to combined intracavitary and interstitial (hybrid) brachytherapy for gynecologic cancer. A total of 105 gynecologic cancer patients received 405 brachytherapy sessions, including 302 sessions of intracavitary brachytherapy and 103 sessions of hybrid brachytherapy. Prophylactic antibiotics were administered before 35% of the hybrid brachytherapy sessions. The incidence of postbrachytherapy fever and the frequency of subsequent antibiotic use for infection were compared between treatment groups. Among patients treated with hybrid brachytherapy, fever ≥37.5°C occurred in 16.4% of those not receiving prophylactic antibiotics and 16.7% of those receiving prophylactic antibiotics (P > 0.05). Similarly, fever ≥38.0°C occurred in 4.9% of patients not receiving prophylactic antibiotics and 2.4% of those receiving prophylactic antibiotics (P > 0.05). Additional antibiotics were used to treat postbrachytherapy infections in 4.8% of the group receiving prophylactic antibiotics and 0% of those not receiving prophylactic antibiotics, again without statistically significant difference. There were also no significant differences in posttreatment fever incidence and antibiotics use for infection between intracavitary brachytherapy and hybrid brachytherapy sessions. In conclusion, the incidences of infection and fever are low following hybrid brachytherapy, so prophylactic antibiotics are generally unnecessary.

Reirradiation for recurrent gynecologic cancer using high-dose-rate brachytherapy in Japan: A multicenter survey on practice patterns and outcomes.

BACKGROUND AND PURPOSE: The aim of the study is to examine the present status of reirradiation with high-dose-rate (HDR) brachytherapy for recurrent gynecologic cancer in Japan and to determine the role of this therapy in clinical practice. MATERIALS AND METHODS: A retrospective multicenter chart review was performed for reirradiation for gynecologic cancer using HDR brachytherapy. Each center provided information on patient characteristics, treatment outcomes, and complications. RESULTS: The study included 165 patients treated at 9 facilities from 2000 to 2018. The analysis of outcomes included 142 patients treated with curative intent. The median follow-up time for survivors was 30 months (range 1-130 months). The 3-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 53 % (95 %CI: 42-63 %), 44 % (35-53 %), and 61 % (50-70 %) for cervical cancer; 100 % (NA), 64 % (30-85 %), and 70 % (32-89 %) for endometrial cancer; and 54 % (13-83 %), 38 % (6-72 %), and 43 % (6-78 %) for vulvar and vaginal cancer, respectively. In multivariate analysis, interval to reirradiation (<1 year) was a significant risk factor for OS, PFS and LC; Gross Tumor Volume (≥25 cm3) was a significant risk factor for OS. Toxicities were analyzed in all enrolled patients (n = 165). Grade ≥ 3 late toxicities occurred in 49 patients (30 %). A higher cumulative EQD2 (α/ß = 3) was significantly associated with severe complications. CONCLUSION: Reirradiation with HDR brachytherapy for recurrent gynecologic cancer is effective, especially in cases with a long interval before reirradiation.

Probability of normal tissue complications for hematologic and gastrointestinal toxicity in postoperative whole pelvic radiotherapy for gynecologic malignancies using intensity-modulated proton therapy with robust optimization.

This retrospective treatment-planning study was conducted to determine whether intensity-modulated proton therapy with robust optimization (ro-IMPT) reduces the risk of acute hematologic toxicity (H-T) and acute and late gastrointestinal toxicity (GI-T) in postoperative whole pelvic radiotherapy for gynecologic malignancies when compared with three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated X-ray (IMXT) and single-field optimization proton beam (SFO-PBT) therapies. All plans were created for 13 gynecologic-malignancy patients. The prescribed dose was 45 GyE in 25 fractions for 95% planning target volume in 3D-CRT, IMXT and SFO-PBT plans and for 99% clinical target volume (CTV) in ro-IMPT plans. The normal tissue complication probability (NTCP) of each toxicity was used as an in silico surrogate marker. Median estimated NTCP values for acute H-T and acute and late GI-T were 0.20, 0.94 and 0.58 × 10-1 in 3D-CRT; 0.19, 0.65 and 0.24 × 10-1 in IMXT; 0.04, 0.74 and 0.19 × 10-1 in SFO-PBT; and 0.06, 0.66 and 0.15 × 10-1 in ro-IMPT, respectively. Compared with 3D-CRT and IMXT plans, the ro-IMPT plan demonstrated significant reduction in acute H-T and late GI-T. The risk of acute GI-T in ro-IMPT plan is equivalent with IMXT plan. The ro-IMPT plan demonstrated potential clinical benefits for reducing the risk of acute H-T and late GI-T in the treatment of gynecologic malignances by reducing the dose to the bone marrow and bowel bag while maintaining adequate dose coverage to the CTV. Our results indicated that ro-IMPT may reduce acute H-T and late GI-T risk with potentially improving outcomes for postoperative gynecologic-malignancy patients with concurrent chemotherapy.

Percutaneous interstitial brachytherapy ablation for targeting oligometastatic gynecologic cancers.

INTRODUCTION: Treatment of recurrent oligometastatic gynecologic malignancy may involve targeted surgery, thermal ablation, or CT-guided high-dose-rate interstitial brachytherapy ablation (CT-HDR-IBTA). The purpose of this study was to describe the safety and efficacy of CT-HDR-IBTA for oligometastatic gynecologic malignancies. METHODS: With institutional review board approval (IRB) approval and compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance, we searched our database to assemble a single-arm study cohort of all patients with oligometastatic gynecologic cancers who underwent CT-HDR-IBTA from 2012-2022 with follow-up. The electronic record was reviewed to determine relevant clinicopathological variables including patient demographics, prior treatments, clinical course, local control, and local and distant recurrence with follow-up imaging. RESULTS: The study cohort comprised 37 lesions in 34 patients treated with CT-HDR-IBTA for recurrent oligometastatic uterine (n = 17), cervix (n = 1), or ovarian cancer (n = 16) with an average lesion size of 2.5 cm with an average patient age of 61.4 years. Each lesion was treated with an average radiation dose of 23.8 Gy in 1.8 fractions and a median follow-up time of 24.0 months. The primary efficacy of CT HDR ITBA was 73% with a median progression-free survival of 8.0 months (95% CI 3.6-12.8 months) and with 58% of patients still alive at 43 months with median overall survival not reached. The rate of Grade 1 adverse events was 22% without any Grade 2, 3 or 4 events. CONCLUSIONS: CT HDR IBTA was safe and effective for treating oligometastatic gynecologic cancers in a heavily pretreated cohort.

Can an in-person hands-on applicator-based teaching session improve trainee knowledge and comfort with complex gynecologic brachytherapy?

INTRODUCTION: With the emergence of imaged-based planning and hybrid applicators the complexity of gynecologic brachytherapy has dramatically increased. Despite the known advantages of brachytherapy, notable national declines in utilization of brachytherapy have been documented. Clearly improved education in the sphere of gynecologic brachytherapy is needed. We hypothesize that a hands-on applicator-based training session would improve trainee comfort with gynecologic brachytherapy. METHODS AND MATERIALS: An in-person, applicator-based, hands-on training session was held with trainees from both radiation and gynecologic oncology programs. Trainees practiced assembling and handling applicators while receiving instruction on clinical scenarios in which various applicators are used in gynecologic cancer brachytherapy. Pre- and post-session, participants were administered an objective test of 10 pictorial-based case vignettes to quantify ability to select the correct applicator based on the interpretation of T2-weighted MR images. Participants additionally received a subjective survey to quantify comfort and experience with gynecologic brachytherapy using Likert-type question formatting. RESULTS: A total of 14 trainees participated. Most common case volume experience was 0-10 intracavitary (57%), 0-10 hybrid (71%), and 0-10 interstitial (71%). Pre-session, the most common answer to comfort level was "not comfortable still learning" for all brachytherapy types, and most common answer to largest gap in knowledge was all facets of brachytherapy. Average case-based test score was 3.5/10 pre-session versus 5.3/10 post-session (p = 0.028). Post-session, all respondents reported improved comfort level with brachytherapy. Post-session, most common answer to largest gap in knowledge was applicator/patient selection, and applicator/patient selection was also the largest area of identified improvement. 100% of participants felt repeating the session in the future would be helpful. CONCLUSIONS: Hands-on training with applicators improves both subjective and objective comfort with gynecologic brachytherapy. With 100% of participants requesting to implement this session into resident training, we suggest national opportunities might exist to expand educational processes and improve utilization of complex gynecologic brachytherapy in practice.

Demonstrating the Hallmarks of Gynecologic Malignancies by Translating Radiation Therapy Theory to Clinical Practice: A Student and Mentor Perspective.

A radiation therapist (RTT) is a key member of the radiation oncology team responsible for delivering radiation and providing direct patient care to individuals undergoing cancer treatment. Stony Brook University's School of Health Professions, in collaboration with Mount Sinai Health System's Department of Radiation Oncology, offers a unique RTT Program structure: a 4-year baccalaureate degree followed by a 12-month clinical non-credit, non-degree certificate. The RTT Program embeds concepts such as the theory of gynecologic malignancies, introduced in the didactic setting and mastered in the clinical environment. The program assigns credentialed RTTs, referred to as "RTT mentors" to students upon acceptance to the program. These mentors offer additional support to students by translating theoretical and practical aspects of the curriculum and guiding students through their academic and clinical education. This article aims to demonstrate how the hallmarks of gynecologic malignancies are integrated into radiation therapy education, from both the student's and mentor's perspectives, and across the didactic and clinical setting.

Enhancing quality assurance in radiotherapy for gynaecological cancers: implementation of an on-demand peer review process.

OBJECTIVES: Ensuring high-quality radiotherapy requires peer-reviewing target volumes. The Royal College of Radiologists recommends peer review specifically for individual target volumes in cases of gynaecological cancers. This study presents the outcomes of implementing an on-demand peer review system for gynaecological cancers within our institute. METHODS: The peer review process was planned for gynaecological cancer cases intended for curative radiotherapy. After junior clinical oncologists (COs) completed the segmentation, two senior COs specializing in gynaecological cancers conducted the peer review. All peer review outcomes were recorded prospectively. The audit process compliance, the proportion of patients requiring major and minor modifications in target volumes, the direction of changes, and the factors influencing these changes were reported. RESULTS: A total of 230 patients were eligible, and out of these, 204 (88.3%) patients underwent at least one peer review. Among the patients, 108 required major modifications in their target volumes. P-charts revealed a stabilization in the need for major modifications at the end of three months, indicating that 38.2% and 28% of patients still required major modifications for the nodal and primary CTV, respectively. Multivariable analysis demonstrated that major modifications were associated with the use of extended field radiotherapy and radical radiation in non-cervical primary cases. CONCLUSIONS: An on-demand peer review system was feasible and resulted in clinically meaningful, major modifications in the target volumes for 53% of patients. ADVANCES IN KNOWLEDGE: Gynaecological cancers require ongoing peer review to ensure quality of care in radiotherapy. A flexible on-demand system not only ensures that patient treatment start is not delayed but also has an important educational role for junior trainees.

Effects of Integrated Music-Video Therapy on Pain and Anxiety During High-Dose-Rate Brachytherapy.

PURPOSE: This study aimed to examine the effect of integrated music-video therapy on pain and anxiety of gynecologic cancer patients at different stages of brachytherapy. DESIGN: This study used a single-group crossover design. METHODS: Data on 27 patients diagnosed with gynecologic cancer and receiving brachytherapy were collected from February 2018 to January 2019. Participants' pain and anxiety levels were measured four times using a numerical rating scale (before, during, after applicator insertion, and during the radiation). In addition, vital signs were measured three times (before, after applicator insertion, and during radiation). Data were analyzed for frequency and percentage. The normality and homogeneity of the dependent variables were tested using the Kolmogorov-Smirnov and Mann-Whitney U tests, respectively. RESULTS: Significant differences were found between the experimental and control phases in pain degree during radiation exposure (Z = -1.68, p = .046) and anxiety degree during applicator insertion (Z=-4.42, p = .000), after applicator insertion (Z = -4.85, p = .000), and during radiation exposure (Z = -5.38, p = .000). However, no significant difference was found between the changes in blood pressure, pulse, and respiration at any time point. CONCLUSIONS: The findings suggest the need to actively employ integrated music-video therapy to reduce acute pain and anxiety in gynecologic cancer patients undergoing brachytherapy. CLINICAL IMPLICATIONS: This study provides insights into the methodological approaches for implementing integrated music-video therapy in clinical practice, targeting the reduction of acute pain and anxiety triggered by gynecological surgeries and procedures.

Stereotactic radiosurgery for brain metastases arising from gynecological malignancies: A retrospective treatment outcome analysis.

BACKGROUND: This retrospective study aims to assess the efficacy of stereotactic radiosurgery (SRS) in the treatment of brain metastases (BM) originating from gynecological cancers. It focuses on local control (LC), distant tumor control (DTC), and overall survival (OS). METHODS: The analysis comprised 18 individuals with gynecological-origin BM treated with SRS at the Hadassah Medical Center from 2004 to 2021. Statistical analyses evaluate factors impacting LC, DTC, and OS. RESULTS: A total of 36 BM of gynecological origin underwent SRS. The median age at the first SRS treatment was 60 years, with a median time of 24.5 months from the primary malignancy diagnosis to BM detection. The 12-month LC rate per patient was 84.6 %, and 5.6 % per BM. Only two instances of local recurrence were observed. The DTC at 12 months was 75 %, with a 29 % overall. Non-significant trends indicating a correlation with distant brain failure with increased cumulative volume and the occurrence of craniotomy before SRS. The median OS of the cohort was 16.5 months from SRS treatment. The 6, 12, 18, and 24-month survival rates were 77.8 %, 66.7 %, 50 %, and 22.2 % respectively. Higher number of BM was associated with lower OS (p = 0.046). On multivariate analysis, age was a significant factor for OS (p = 0.03), demonstrating that older age was associated with a more favorable prognosis. CONCLUSION: This study supports SRS effectiveness for treating BM from gynecological cancers and suggests similar outcomes to more common malignancies.

Procedural interventions for oligoprogression during treatment with immune checkpoint blockade in gynecologic malignancies: a case series.

OBJECTIVE: To evaluate the feasibility and outcomes of performing procedural interventions, defined as surgical resection, tumor ablation, or targeted radiation therapy, for oligoprogressive disease among patients with gynecologic malignancies who are treated with immune checkpoint blockade. METHODS: Patients with gynecologic cancers treated with immune checkpoint blockade between January 2013 and October 2021 who underwent procedural interventions including surgical resection, interventional radiology ablation, or radiation therapy for oligoprogressive disease were identified. Procedures performed before immune checkpoint therapy initiation or ≥6 months after therapy completion were excluded. Long immunotherapy duration prior to intervention was defined as ≥6 months. Progression-free survival and overall survival were calculated from procedure date until disease progression or death, respectively. RESULTS: During the study period, 886 patients met inclusion criteria and received immune checkpoint blockade therapy. Of these, 34 patients underwent procedural interventions for oligoprogressive disease; 7 underwent surgical resection, 3 underwent interventional radiology ablation, and 24 underwent radiation therapy interventions. Primary disease sites included uterus (71%), ovary (24%), and cervix (6%). Sites of oligoprogression included abdomen/pelvis (26%), bone (21%), lung (18%), distant lymph node (18%), brain (9%), liver (6%), and vagina (3%). Most tumors (76%) did not exhibit microsatellite instability or mismatch repair deficiency. Approximately half (53%) of the patients had long immune checkpoint therapy duration prior to intervention. Median progression-free survival following the procedure was 5.3 months (95% CI, 3.1-9.9), and median overall survival was 21.7 months (95% CI, 14.9-not estimable). Long versus short immune checkpoint therapy duration prior to procedure and length of immune checkpoint therapy had no effect on progression-free or overall survival. CONCLUSIONS: Procedural interventions for patients with oligoprogression on immune checkpoint blockade therapy are feasible and demonstrate favorable outcomes. With expanding use of immune checkpoint therapy, it is important to investigate combined modalities to maximize therapeutic benefit for patients with gynecologic cancers.

Risk Factors and Survival Impact Associated With Documentation of Radiation Therapy Refusal in Patients With Gynecologic Cancer.

PURPOSE: Radiation therapy (RT) refusal is known to have deleterious effects on survival for multiple cancer types. Factors associated with RT refusal by patients with gynecologic malignancies have not been well described. This study aimed to examine factors associated with and the survival impact of documented RT refusal among patients with gynecologic cancers. METHODS AND MATERIALS: This study analyzed data from the National Cancer Database (NCDB) of patients with gynecologic cancers diagnosed between 2004 and 2020. Patients were included if they had complete survival data and a documented RT recommendation by their treating physician in the NCDB. Patients coded as received RT were compared with those coded as refused RT in the NCDB using a multivariate log binomial regression with robust variance to yield incidence rate ratios (IRR). Overall survival was analyzed using a multivariate (MV) Cox proportional hazards model to yield hazard ratios. RESULTS: This study identified 209,976 patients. A total of 5.75% (n = 12,081) patients were coded as refusing RT. Multivariable IRR showed that documentation of RT refusal was positively associated with older age (MV IRR, 1.04; 95% CI, 1.041-1.045), Native Hawaiian Pacific Islander race (1.72 [1.27-2.32]), and increased morbidity (score = 1: 1.06 [1.02-1.11]; score = 2: 1.20 [1.12-1.29]; score ≥3: 1.26 [1.14-1.38]). Negative associations were seen with Hispanic ethnicity (0.74 [0.67-0.80]), having insurance (0.58 [0.53-0.63]), and annual income >$74,063 (0.85 [0.81-0.90]). During the 16-year period, a statistically significant test for trend (P = .001) for increasing RT refusal was noted. RT refusal was associated with a significantly higher risk of death (MV hazard ratio, 1.59 [1.55-1.63]). CONCLUSIONS: For patients with gynecologic malignancies diagnosed from 2004 to 2020, an increase in documented RT refusal is associated with decreased overall survival in all disease types. Targeted interventions aimed at mitigating potential sociodemographic barriers to receipt of RT are warranted.

Image-guided preplanning workflow for high-dose-rate interstitial brachytherapy for gynecological malignancies.

PURPOSE: To demonstrate image-guided preplan workflows for high-dose-rate (HDR) brachytherapy for advanced gynecological malignancies. METHODS AND MATERIALS: Two different preplanning scenarios are presented: (1) CT- or MRI-based preplan with partial applicator in place; (2) Preplans generated from prior fractions. The first scenario can be applied to Syed-Neblett template-based implants or hybrid brachytherapy applicators, while the second scenario applies to hybrid applicators. Both scenarios use MRI or CT images acquired with the applicator in place to demonstrate tumor and applicator relative locations and therefore, provide the ability to show optimized suggested needle positions including the implant depths before the actual insertion. RESULTS: The preplanning techniques have demonstrated feasibility and shown five areas of potential improvement: (1) shorter procedure time, (2) decreased number of total needles inserted, (3) shorter physician tumor contour time, (4) shorter planning time, and (5) evaluation of appropriateness for brachytherapy. CONCLUSIONS: The use of image-guided brachytherapy preplanning improves clinical efficiency and is recommended for consideration for adaptation into clinical workflows for HDR interstitial and hybrid brachytherapy.