Evaluation of morbidity after external radiotherapy and intracavitary brachytherapy in 771 patients with carcinoma of the uterine cervix or endometrium

Purpose: The aim of the present study was to evaluate early and late radiation morbidity and to assess the factors influencing morbidity in patients with cervical or endometrial cancer treated by a combination of external radiotherapy (ERT) and intracavitary brachytherapy (IBRT).

Materials and methods: Early and late radiation morbidity were evaluated retrospectively using RTOG/EORTC criteria and Franco-Italian glossary in 771 patients treated between November 1992 and December 1999.

Results: Four hundred and seven patients (52.8%) had endometrial carcinoma and 364 (47.2%) had carcinoma of the cervix. One hundred and fifty-four patients with cervical carcinoma were inoperable. In patients with endometrial carcinoma total doses at the vagina, bladder and rectum were 60.36 Gy, 56.2 Gy and 55.6 Gy respectively. Biologically equivalent doses (BED) for the same points were 79.35, 68.63 and 67.37, respectively for early effects and 123.67, 97.65 and 94.85, respectively for late effects. One hundred and sixty-nine patients (41.5%) developed acute morbidity, grade I and II bladder morbidity being the most common type and 85 patients (20.9%) developed late morbidity, grade I and II vaginal morbidity being the most common type. No grade IV morbidity was recorded. Total doses at the vagina, bladder and rectum in operated cervix cancer patients were 60.51 Gy, 56.53 Gy and 55.67 Gy, respectively. BED for the same points were 79.77, 69.36 and 67.52, respectively for early effects and 124.74, 99.3 and 95.17, respectively for late effects. Eighty patients (38.1%) developed early morbidity. Grade I and II bladder morbidity was the most common type. Sixty-five patients (30.9%) developed late morbidity, vaginal morbidity being the most common type. Total doses at the vagina, bladder and rectum in inoperable patients were 70.92 Gy, 66.71 Gy and 62.38 Gy, respectively. BED for the same points were 97.43, 89.64 and 81.63, respectively for early effects and 159.3, 143.16 and 126.56, respectively for late effects. Sixty patients (39%) developed acute morbidity which was grade I or II bladder morbidity in 95%. Ninety-five patients (61.7%) developed late morbidity which was grade I-III vaginal morbidity in 94%.

Conclusion: Patients with cervical or endometrial cancer can be treated safely by a combination of ERT and IBRT. However the patients should be assessed before, during and after treatment and at every period of follow-up using a standard and well-defined system in order to define and predict the morbidity rate.

Morbidity; External radiotherapy; Intracavitary brachytherapy; Carcinoma of the uterine cervix; Endometrial carcinoma

[1] Chassagne D., Sismondi P., Horio! J.C. et al.: "A glossary for reporting complications of treatment in gynecological cancers". Radiother. Oncol., 1993, 26, 195.

[2] LENT/SOMA Tables. Radiother. Oncol., 1995, 35, 27.

[3] Pedersen D., Bentzen S. M., Overgaard J.: "Early and late radiotherapeutic morbidity in 442 consecutive patients with locally advanced carcinoma of the uterine cervix". Int. J. Radiat. Oncol. Biol. Phys., 1994, 29, 941.

[4] Sinistrero G., Sismondi P., Rumore A., Zola P.: "Analysis of complications of cervix carcinoma treated by radiotherapy using the Franco-Italian glossary". Radiother. Oncol., 1993, 26, 203.

[5] Perez C. A., Brady L. W.: "Overview". In: Principles and Practice of Radiation Oncology, 2"'Ed. (eds.) Perez C. A., Brady L. W. Philadelphia, J.B. Lippincott, 1992, 51.

[6] Lanciano R. M., Martz K., Montana G. M., Hanks G. H.: "Influence of age, prior abdominal surgery, fraction size and dose on complications after radiation therapy for squamous cell cancer of the uterine cervix". Cancer, 1992, 69, 2124.

[7] Noyes W. R., Peters N. E., Thomadsen B. R. et al.: "Impact of optimized treatment planning for tandem and ring, and tandem and ovoids, using high dose rate brachytherapy for cervical cancer" Int. J. Radiat. Oncol. Biol. Phys., 1995, 31, 79.

[8] Ogino I., Kitamura T., Okamoto N. et al.: "Late rectal complication following high dose rate intracavitary brachytherapy in cancer of the cervix". Int..!. Radial. Oneal. Biol. Phys., 1995, 31, 725.

[9] Perez C. A., Breaux S., Bedwinek J.M. et al.: "Radiation therapy alone in the treatment of carcinoma of the uterine cervix. II. Analysis of complications". Cancer, 1984, 54, 235.

[10] Crook J.M., Esche B. A., Chaplain G., Isturiz J., Sentenac I., Horiot J.C.: "Dose-volume analysis and the prevention of radiation sequelae in cervical cancer". Radiother. Oneal., 1987, 8, 321.

[11] Pourquier H., Delard R., Archille E., Daly N. J., Horiot J. C., Keiling R. et al.: "A quantified approach to the analysis and prevention of urinary complications in radiotherapeutic treatment of cancer of the cervix". Int. J. Radiat. Oncol. Biol. Phys., 1987,13, 1025.

[12] Kapp K., Stuecklschweiger G., Kapp D., Hackl A.: "Dosimetry of intracavitary placements for uterine and cervical carcinoma: results of orthogonal film, TLD and CT-assisted techniques" Radiother. Oncol., 1992, 24, 137.

[13] Kapp K.S .,S tuecklschweiger G. F., Kapp D.S., Poschauko J., Hackl A.: "Carcinoma of the cervix: analysis of complications after primary external beam radiation and Ir-192 HDR brachytherapy". Radifiother. Oncol., 1997, 42, 143.

[14] Montana G. S., Fowler W. C.: "Carcinoma of the cervix: Analysts of bladder and rectal radiation dose and complications". Int. J Radial. Oncol. Biol. Phys., 1989, 16, 95.

[15] Sorbc B. G., Smeds A. C.: "Postoperative vaginal irradiation with high-dose-rate afterloading technique in endometrial carcinoma Stage I". Int. J. Radiat. Oneal. Biol. Phys., 1990, 18, 305.

[16] Perez C. A., Fox S., Lockett M. A., Grigsby P. W., Camel H. M., Galakatos A. et al.: "Impact of dose in outcome of irradiation alone in carcinoma of the uterine cervix: Analysis of two different methods". Int. J. Radial. Oncol. Biol. Phys., 1991, 21, 885.

[17] Pourquier H., Bubois J. B., Delard R.: "Cancer of the uterine cervix: Dosimetric guidelines for prevention of late rectal and rectosigmoid complications as a result of radiotherapeutic treatment". Int. J. Radial. Oneal. Biol. Phys., 1982, 8, 1887.