Simultaneous modulated accelerated radiotherapy in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy.

OBJECTIVE: To compare the dosimetry, toxicity, and efficacy of simultaneous modulated accelerated radiotherapy (SMART) with 3-dimensional conformal radiotherapy (3DCRT) in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy. METHODS: Total 32 patients who underwent SMART were retrospectively evaluated. Daily fractions of 2.2 to 2.4 Gy and 1.8 to 2 Gy were prescribed and delivered to gross tumor volume and clinical target volume to a total dose of 63.8 and 52.2 Gy, respectively. A 3DCRT plan was designed for the SMART group and planned to deliver the same prescribed dose. The doses of organs at risk (OARs) were compared. Thirty-six patients who received 3DCRT were used to compare the target dose, toxicities, and efficacy with 32 cases who received SMART. RESULTS: The mean doses delivered to gross tumor volume and clinical target volume were significantly higher in the SMART group than in the 3DCRT group (63.8 vs 55.2 Gy [P < 0.01] and 52.5 vs 48.6 Gy [P < 0.01], respectively). For SMART plan, the doses of OARs were significantly lower than that of 3DCRT plans (small intestine: 25.1 vs 30.9 Gy [P < 0.01], bladder: 35.3 vs 46.3 [P < 0.01], and rectum: 31.7 vs 43.7 [P = 0.002], respectively). The patients experienced less acute and late toxicities in the SMART group (acute toxicities: enteroproctitis, P = 0.019; cystitis, P = 0.013; leukopenia, P = 0.025; late toxicities: enteroproctitis, P = 0.007; and cystitis, P = 0.026, respectively). No significant difference was found for 1-year survival (78.7% vs 67.7%, P = 0.222), but SMART group had a higher 2-year survival rate (2-year: 63.1% vs 39.1%, P = 0.029). CONCLUSIONS: Simultaneous modulated accelerated radiotherapy plans yielded higher dose to the targets and better sparing of OARs than did 3DCRT in cervical cancer with retroperitoneal lymph node metastasis after radical hysterectomy and pelvic lymphadenectomy. Simultaneous modulated accelerated radiotherapy provided better clinical outcomes than did 3DCRT. Long-term follow-up and studies involving more patients are needed to confirm our results.

[Value of positron emission tomography-CT imaging combined with continual detection of CA125 in serum for diagnosis of early asymptomatic recurrence of epithelial ovarian carcinoma].

OBJECTIVE: To evaluate the value of positron emission tomography (PET)-CT imaging combined with continual detection of CA125 in serum for diagnosis of early recurrent ovarian epithelial carcinoma. METHODS: Twenty six patients received PET-CT imaging, who were all diagnosed as primary epithelial ovarian cancer of stage II - IV and had complete remission after cytoreductive surgery and multiple courses of chemotherapy in Shandong Provincial Cancer Hospital. After a steady period, all patients experienced progressive rising of CA125 values 3 times in 2 months. But no positive lesion was found by CT, or although suspicious positive focus was found, the recurrent and (or) metastatic extent was not definite. Out of 26 patients, 16 were delivered rechemotherapy and (or) radiotherapy, and 10 received re-cytoreductive surgery. RESULTS: (1) Of 26 patients, the value of CA125 was more than 35 kU/L in 17, and in 14 of 17, pelvic or abdominal cavity recurrence was diagnosed by CT and PET-CT, and 4 showed simultaneously distant metastasis on PET-CT. In the remaining 3 patients of which CT findings were negative, 2 had pelvic and abdominal cavity recurrence, and one had bone metastasis on PET-CT. Of 9 patients with progressive rising CA125 levels but the value was less than cut-off (< 35 kU/L), only 3 were found recurrence in pelvic and abdominal cavity by CT; however, all showed at least one suspicious recurrent or metastasis lesion on PET-CT. (2) Of 10 patients who received re-cytoreductive surgery, the value of CA125 was higher than cut-off in 6, and less in 4. Four were diagnosed as recurrence by CT and PET-CT, and 6 were only confirmed by PET-CT with 1 - 5 abnormal metabolic lesions found. (3) In 10 patients who received re-cytoreductive surgery, all suspicious positive lesions identified by CT were proved recurrence or metastasis by pathology, and abnormal metabolic lesions showed by PET-CT were all confirmed to be metastasis by postoperative pathology. (4) After 1 month of re-cytoreductive surgery, the value declined by 3.2 fold in 4 whose CA125 value was less than cut-off; in another 6, the value declined to less than cut-off in 4, and in one after 2 cycles of re-chemotherapy, but the remaining one patient had persistent CA125 values more than cut-off. CONCLUSIONS: PET-CT could reveal recurrence and (or) metastasis which may be missed or could not be confirmed by routine diagnostic methods before clinical presentations. Combined with the continual detection of CA125, a high accuracy of diagnosis can be achieved. So it is an effective means for diagnosis of early recurrent ovarian cancer. The re-cytoreductive surgery can be more accurate and radical with the help of PET-CT.

[Intensity modulated radiation therapy for patients with gynecological malignancies after hysterectomy and chemotherapy/radiotherapy].

OBJECTIVE: To investigate the value of intensity modulated radiation therapy (IMRT) for patient with gynecological malignancies after treatment of hysterectomy and chemotherapy/radiotherapy. METHODS: All 32 patients with cervical or endometrial cancer after hysterectomy received full course IMRT after 1 to 3 cycles of chemotherapy (Karnofsky performance status(KPS) > or =70). Seventeen of these patients underwent postoperative preventive irradiation and the other 15 patients were pelvic wall recurrence and/or retroperitoneal lymph node metastasis, though postoperative radiotherapy and/or chemotherapy had been given after operation. RESULTS: The median dose delivered to the PTV was 56.8 Gy for preventive irradiation, and 60.6 Gy for pelvic wall recurrence or retroperioneal lymph node metastasis irradiation. It was required that 90% of iso-dose curve could covere more than 99% of GTV. However, The mean dose irradiated to small intestine, bladder, rectum, kidney and spinal cord was 21.3 Gy, 37.8 Gy, 35.3 Gy, 8.5 Gy, 22.1 Gy, respectively. Fourteen patients presented grade I (11 patients) or II (3 patients) digestive tract side-effects, Five patients developed grade I or II bone marrow depression. Twelve patients had grade I skin reaction. The overall 1-year survival rate was 100%. The 2- and 3- year survival rate for preventive irradiation were both 100%, but which was 5/7 and 3/6 for the patients with pelvic wall recurrence or retroperioneal lymph node metastasis. CONCLUSION: Intensity modulated radiation therapy can provide a better dose distribution than traditional radiotherapy for both prevention and pelvic wall recurrence or retroperioneal lymph node metastasis. The toxicity is tolerable. The adjacent organs at risk can well be protected.

[Preservation of the saphenous vein during inguinal lymphadenectomy for vulval malignancies].

BACKGROUND & OBJECTIVE: The conventional operation for the patients with vulval malignancies is radical vulvectomy and bilateral inguinal lymphadenectomy with partial saphenous vein trunk ligation and resection, but the quality of life of the patients was declined severely because of multiple postoperative complications. This study was to explore the influences of preserving the saphenous vein during inguinal lymphadenectomy for vulval malignancies on operation, prognosis, and complications. METHODS: A total of 64 patients with vulval malignancies, treated in Shandong Provincial Cancer Hospital from Jan. 1989 to Dec. 2005, were divided into 2 groups: the saphenous vein was preserved in 31 patients and ligated in 33 patients during inguinal lymphadenectomy. The operating time, intraoperative blood loss, 5-year survival rate, recurrence rate, and complications were compared between the 2 groups. RESULTS: The median operating time of bilateral inguinal lymphadenectomy was 155 min (130-170 min) in preservation group, and 140 min (120-170 min) in ligation group (P>0.05). The median intraoperative blood loss was 295 ml (100-450 ml) in preservation group, and 270 ml (150-390 ml) in ligation group (P>0.05). The 5-year overall survival rate was 67.3%û it was 68.0% in preservation group and 66.7% in ligation group (P>0.05). Till Mar. 2006, 5 sides of inguinal lymph nodes relapsed in 3 patients in preservation group, and 7 sides in 5 patients in ligation group; the recurrence rates were 8.9% (5/56), and 12.1% (7/58) (P>0.05). The occurrence rates of acute low extremity lymph edema, low extremity phlebitis, chronic low extremity edema, and chronic leg pain were significantly lower in preservation group than in ligation group (11.3% vs. 25.8%, P<0.05; 43.5% vs. 66.7%, P<0.01; 25.0% vs. 48.3%, P<0.01; 23.2% vs. 46.6%, P<0.01); the occurrence of leg cellulitis and sense abnormity were also less in preservation group than in ligation group (P<0.05). CONCLUSIONS: Preserving the saphenous vein trunk during inguinal lymphadenectomy for vulval malignancies reduces multiple postoperative complications without compromising treatment outcome. This modified operative modality is valuable to be recommended.