Should helical tomotherapy replace brachytherapy for cervical cancer? Case report
© Hsieh et al; licensee BioMed Central Ltd. 2010
Received: 31 May 2010
Accepted: 23 November 2010
Published: 23 November 2010
Stereotactic body radiation therapy (SBRT) administered via a helical tomotherapy (HT) system is an effective modality for treating lung cancer and metastatic liver tumors. Whether SBRT delivered via HT is a feasible alternative to brachytherapy in treatment of locally advanced cervical cancer in patients with unusual anatomic configurations of the uterus has never been studied.
A 46-year-old woman presented with an 8-month history of abnormal vaginal bleeding. Biopsy revealed squamous cell carcinoma of the cervix. Magnetic resonance imaging (MRI) showed a cervical tumor with direct invasion of the right parametrium, bilateral hydronephrosis, and multiple uterine myomas. International Federation of Gynecology and Obstetrics (FIGO) stage IIIB cervical cancer was diagnosed. Concurrent chemoradiation therapy (CCRT) followed by SBRT delivered via HT was administered instead of brachytherapy because of the presence of multiple uterine myomas with bleeding tendency. Total abdominal hysterectomy was performed after 6 weeks of treatment because of the presence of multiple uterine myomas. Neither pelvic MRI nor results of histopathologic examination at X-month follow-up showed evidence of tumor recurrence. Only grade 1 nausea and vomiting during treatment were noted. Lower gastrointestinal bleeding was noted at 14-month follow-up. No fistula formation and no evidence of haematological, gastrointestinal or genitourinary toxicities were noted on the most recent follow-up.
CCRT followed by SBRT appears to be an effective and safe modality for treatment of cervical cancer. Larger-scale studies are warranted.
It has been demonstrated that concurrent chemoradiation therapy (CCRT) followed by intracavity radiation is effective in the treatment of advanced cervical cancer . Although external beam radiotherapy combined with brachytherapy is associated with high survival rates and low complication rates [2, 3], patients with contraindications to brachytherapy, namely patients with unusual anatomic configurations of the pelvis or tumors, may benefit from higher doses of external beam irradiation . However, studies have shown that external beam irradiation used throughout the treatment course for cervical cancer is associated with poor survival, poor local control, and a high incidence of side effects [3, 4]. Molla et al. found that the use of intensity-modulated radiation therapy (IMRT) to deliver a final boost to areas at high risk for relapse in patients with endometrial or cervical cancer was feasible, well tolerated, and may be considered an acceptable alternative to brachytherapy . Helical tomotherapy (HT), an image-guided IMRT, can deliver highly conformal dose distributions and provides an impressive critical organ sparing ability for cervical cancer . Studies have shown that stereotactic body radiation therapy (SBRT), when using image-guided IMRT capable of delivering high doses of radiation in hypo-fractions, such as the HT system, is an effective and well-tolerated treatment for local control of tumors metastatic to the liver and lung [7, 8]. Herein, we report on a patient with locally advanced cervical cancer that was treated with HT-guided SBRT rather than brachytherapy because the presence of an unusual anatomic configuration of the uterus was a contraindication to the use of brachytherapy.
External-beam irradiation could be an alternative to brachytherapy in cervical cancer patients with contraindications to external irradiation and brachytherapy . IMRT and 3-dimensional conformal radiotherapy (3DCRT) are now widely used radiotherapy techniques for various cancers and have been shown to be acceptable alternatives to brachytherapy for the treatment of gynecologic malignancies [5, 9].
Uterine myomas are the most common neoplasms of the female pelvis, occurring in 20 - 25% of women of reproductive age  and the common symptoms were menorrhagia or metrorrhagia, or both [14–16]. It is the existence and level of bother of uterine fibroid symptoms that lead women to seek treatment, with the current standard of care being abdominal hysterectomy [17, 18].
Symptoms of chronic radiation proctitis can manifest as mucous rectal discharge, diarrhea, urgency, pain, bleeding, and anemia. Radiation proctitis can be treated using steroid therapy [19, 20], aminosalicylates , sucralfate enemas in combination with  or without  sulfasalazine, formalin [23, 24], endoscopic Nd:YAG laser treatment [25, 26], electrocoagulation, argon plasma coagulation [27, 28], or hyperbaric oxygen [29, 30]. However, the effectiveness of many of those therapeutic modalities has not been proven in controlled trials.
HT-guided SBRT appears to be an effective and safe alternative to brachytherapy for treatment of cervical cancer in patients with contraindications to that conventional treatment modality. Long-term follow-up is needed to confirm these preliminary findings. Radiation oncologists need to monitor the maximum doses to organs at risk around the tumor in order to avoid SBRT-induced complications.
Written informed consent was obtained from the patient for publication of this case report and all accompanying images. A copy of the written consent is available for review.
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