Journal of Medical Imaging and Radiation Oncology

Value of Routine Pelvic Examination in the Follow‐Up of Patients Receiving Adjuvant Radiation Therapy for Endometrial Cancer: An Australian Tertiary‐Centre Experience

ABSTRACTIntroductionPelvic examination is a routine component of post‐treatment surveillance for endometrial cancer, supported by global guidelines. However, there is no evidence of oncological or quality‐of‐life benefit, with data suggesting associated discomfort and potential psychological harm. We evaluate the value of routine pelvic examination in follow‐up protocols after adjuvant radiation therapy.MethodsWe retrospectively reviewed all patients receiving adjuvant radiation therapy for endometrial carcinoma across two combined cancer services between January 2017 and December 2022. All stages and histological subtypes were eligible. At least 12 months of documented follow‐up was required. Patients were stratified by FIGO stage (2009 and 2023) and ESGO/ESTRO risk group.ResultsTwo hundred and sixty‐four of 395 patients met inclusion criteria, with a median follow‐up of 34 months. Whilst demographics were widely distributed, the most common features included endometrioid histology (76.5%), FIGO 2023 stage II (48.5%) and ESGO/ESTRO high‐risk (36.7%).Disease recurrence was identified in 41 patients (15.5%). Only four patients had isolated local recurrence, with most also having distant disease at detection. Only three patients had asymptomatic recurrence found on examination (1.1% of cohort), with only one proceeding to salvage therapy (0.4% of cohort). As expected, higher‐risk groups were associated with worse overall survival (p < 0.001).ConclusionsWe found routine pelvic examination following adjuvant radiation therapy for endometrial cancer results in low recurrence detection rates, with salvageable local recurrences being rare. We advocate for the omission of routine pelvic examination from follow‐up protocols for patients receiving adjuvant radiation therapy, with either clinic‐based or telephone‐based follow‐up being offered on a risk‐stratified basis.

Accuracy of MRI in predicting deep myometrial invasion in endometrial cancer and the influence of leiomyoma, adenomyosis and the microcystic elongated and fragmented tumour pattern

AbstractIntroductionThe most common form of endometrial cancer is Type 1 endometrioid adenocarcinoma. Depth of myometrial invasion is the most important prognostic factor correlating with overall patient survival. The objective was to investigate how accurate magnetic resonance imaging (MRI) is in predicting the depth of myometrial invasion in preoperative assessment, and the influence of leiomyoma and/or adenomyosis, or microcystic, elongated and fragmented (MELF) pattern of invasion on MRI diagnostic performance.MethodRetrospective audit of 235 endometrial cancer patients from the regional Gynaecology Oncology multidisciplinary meeting at Auckland City Hospital, between January 2020 and January 2021. Radiologist assigned stage was compared to histopathology. Presence of leiomyoma, adenomyosis and MELF pattern evaluated followed by analysis under a Biostatistician's supervision.ResultsOverall MRI diagnostic accuracy for depth of myometrial invasion was 86%. For deep myometrial invasion, MRI had a sensitivity of 72% and specificity 91%. Out of the misreported 32/235 cases, 16 demonstrated fibroids and/or adenomyosis leading to a sensitivity of 57% and specificity 93% for deep invasion, compared with 94% and 74% respectively in the population without, demonstrating statistical significance. Thirty seven cases with MELF pattern of invasion showed a sensitivity of 81% and specificity 80% for deep invasion, compared with 63% and 92% respectively in the group without, demonstrating no statistical significance.ConclusionMRI assessment of the depth of myometrial invasion in endometrial cancer has high accuracy. In the presence of background uterine fibroids/adenomyosis, pre‐operative MRI accuracy of evaluating deep invasion shows a statistically significant reduction.

Comparison of accuracy and long‐term prognosis between computed tomography‐based and magnetic resonance imaging‐based brachytherapy for cervical cancer: A meta‐analysis

SummaryHigh‐dose‐rate brachytherapy (HDR‐BT) has been shown to play an important role in the treatment of cervical cancer patients. The aim of this systematic review and meta‐analysis was to compare the dose parameters and long‐term effects of MRI‐based, CT‐based and hybrid imaging (MRI/CT)‐based volumetric planning. A systematic search was conducted to identify the clinical studies of BT treatment on cervical cancer patients. After study selection, a total of 13 clinical studies were enrolled for further analysis. No obvious differences were observed among the treatment parameters and the patients included. In detail, no significant difference was observed among these three techniques of volumetric planning in the parameters of high‐risk clinical target volume (HR‐CTV), total dose of D90 or mean fraction dose of D90. Meanwhile, MRI‐based planning was superior to CT‐based treatment in the total dose D2cc to organs at risk (OAR) for the bladder, rectum and sigmoid. Furthermore, no significant difference was observed among MRI‐, CT‐ or hybrid‐based treatments with the mean fraction dose D2cc to OAR for the bladder, rectum or sigmoid. In conclusion, MRI provides good anatomical delineation of the relevant HR‐CTV and OAR, and performed better in the analyses of dose parameters compared with CT. At least one MR image is required to assess the tumour extension, with clinical findings and MRI information facilitating much more accurate CT‐based contouring.

A retrospective audit of treatment pathway for women diagnosed with cervical cancer in the Auckland region 2012–2016

AbstractIntroductionThe purpose of this study was to describe the treatment pathway and timelines of patients diagnosed with FIGO stage IB1‐IVA cervical cancer receiving definitive radiotherapy +/− chemotherapy and the potential improvements made since the previous audit and impact on overall survival (OS), disease‐free survival (DFS) and local control (LC).MethodsThis is a retrospective audit on patients diagnosed with FIGO Stage 1B1‐IVA cervical cancer in the Northland/Auckland region of New Zealand between 2012 and 2016.ResultsThere were 95 patients identified. Median time from referral to start of treatment was 69 days, from referral to first specialist assessment (FSA) 11 days, from FSA to decision to treat (DTT) 41 days and from DTT to start treatment 21 days. There was no statistical difference in time from referral to start of treatment between patients treated with radiotherapy alone or with combined chemoradiotherapy (P < 0.1695). Private FSA (P < 0.0115) and shorter time from MDM to completion of radiological investigations (P < 0.0001) were associated with shorter median times from referral to start of treatment. Median overall treatment time (OTT) was 43 days. The 3‐year OS, LC and DFS were all 100% for Stage IB, 78%, 95% and 78% for Stage II, 79%, 88% and 77% for Stage III and 58%, 57% and 43% for Stage IV.ConclusionThere has been some overall improvement in the treatment pathways, and OTT was less than the recommended 8 weeks. Our 3‐year OS, LC and DFS were comparable with international standards.

Impact of chemotherapy cycles on oncological outcomes in elders with locally advanced cervical cancer treated with concurrent chemoradiotherapy

AbstractIntroductionTo investigate the association between chemotherapy (CMT) cycles and oncological outcomes in elders with locally advanced cervical cancer (LACC) who treated with concurrent chemoradiotherapy (CCRT).MethodsWe retrospective studied 498 elders with LACC who treated with radiotherapy (RT) or CCRT between 2002 and 2018. Patients were divided into three groups: RT, CCRT with 1–4 and CCRT with 5–6 cycles of CMT. We compared progression‐free survival (PFS) and overall survival (OS) among the three groups and explored survival prognostic factors via multivariate analysis and time‐varying analysis effect.ResultsThere were 453 eligible patients; 222, 119 and 112 patients who received RT, CCRT with 1–4 and CCRT with 5–6 cycles of CMT, respectively. Patients in the RT group had older age, poorer performance status, more treatment with conventional RT technique and earlier treatment year comparing with both CCRT groups. Patients who received 5–6 cycles of CMT were less to have underweight, comorbidities and anaemia compared with the RT group. There were patients with lower FIGO stage in 5–6 cycles than in 1–4 cycles of CMT and RT groups. The 5‐year PFS and OS between RT, CCRT with 1–4 and CCRT with 5–6 cycles of the CMT group were significantly different. Performance status, comorbidity, histology, FIGO stage and total received 5–6 CMT cycles were significant prognostic factors of PFS and OS. However, the benefits of receiving 5–6 CMT cycles were evidenced only within the first 2.5 years.ConclusionElders with LACC who received 5–6 cycles of CMT concurrently with RT can improve PFS and OS, but the benefit persisted only within the first 2.5 years.

Imaging Clues to Differentiate Uterine From Adnexal Masses—Value of Vascular Anatomy and Enhancement Patterns—A Pictorial Essay

ABSTRACTIn gynaecologic imaging, recognising the organ of origin of a pelvic mass, uterine versus adnexal, is crucial because it significantly impacts the surgical approach and treatment outcome. Ultrasound is the first line of imaging for female pelvic masses. However, due to its inherent drawbacks, ultrasonography cannot delineate the origin of large masses that distort the normal relations between the pelvic organs. Contrast‐enhanced MR imaging (CE‐MRI) is a problem‐solving tool due to its multidimensional imaging capabilities and soft tissue contrast. Imaging features such as the anatomical location, signal intensity of mass on T2W images, displacement/mass effect on adjacent pelvic/vascular structures and enhancement patterns are studied for making this distinction. A key aspect of this differentiation is the analysis of vascular anatomy, displacement of vessels and the patterns of enhancement. This pictorial essay discusses how the vascular supply, displacement of vessels and enhancement pattern of masses on MRI provide imaging clues which help in distinguishing uterine from adnexal masses.

The impact of skeletal muscle abnormalities on tolerance to adjuvant chemotherapy and radiation and outcome in patients with endometrial cancer

AbstractIntroductionSkeletal muscle abnormalities, such as low skeletal muscle mass, measured by skeletal muscle index (SMI), and low skeletal muscle quality, measured by skeletal muscle density (SMD), are associated with poor prognosis in cancer. There has been little investigation of their impact on tolerance to radiation therapy and overall outcome in gynaecologic cancers. We examined the effect of low SMI and SMD on treatment tolerance and survival outcomes in patients with endometrial cancer receiving pelvic radiation.MethodsStage IB‐IVA patients with endometrial cancer treated at one institution between 2007 and 2017 were reviewed. All patients received hysterectomy and pelvic radiation. SMI was based on the cross‐sectional area of skeletal muscle at the L3 vertebral body. SMD was expressed as the mean radiation attenuation in Hounsfield units (HUs) at the same vertebral level.ResultsSixty‐four patients met criteria for analysis. Forty‐four per cent had low SMI (<41 cm2/m2), 80% had low SMD (mean < 33 HU if BMI> 25 and mean < 41 HU if BMI < 25), and 33% had both. Patients with both features were less likely to complete planned chemotherapy (p = 0.01); this was consistent on multivariate analysis. Radiation treatments were well‐tolerated regardless of SMI or SMD. On survival analysis, having both low SMI and low SMD was associated with poorer outcomes compared with having either individual factor (p = 0.04).ConclusionLarge percentages of patients with endometrial cancer have low skeletal muscle mass and density. Low skeletal muscle measures predict for poor tolerance to chemotherapy in this patient population. Compliance with adjuvant radiation is high, regardless of SMI and SMD.

Evaluation of plan quality, safety, and toxicity of brachytherapy for locally advanced cervical cancer in an Australian setting following changes in prescription and applicator design

AbstractIntroductionChemoradiotherapy with MRI‐guided brachytherapy boosts is the standard of care for locally advanced cervical cancer. Data from the RetroEMBRACE and EMBRACE I trials provide dose‐response curves for target volumes and OAR. This study evaluated plan quality, safety and toxicity following escalation of the CTV_HR D90 prescription from 80–90 Gy to 85–95 Gy for two different applicator designs.MethodsA retrospective dosimetric plan quality review was undertaken for consecutively treated locally advanced cervical cancer brachytherapy boosts between 2017 and 2022, and the relationships between implant total reference air kerma (TRAK), CTV_HR volume and vaginal dose were investigated. Safety and ≤grade 3 toxicity results were evaluated.ResultsSeventy patients were identified. All patients received a CTV_HR D90 dose >85 Gy and rectum D2cm3 of <75 Gy, while 88.6% of patients received a bladder D2cm3 <90 Gy. Needles were used in 48.6% of patients, and the mean percentage needle TRAK was 38.2%. Increasing the percentage of needle TRAK decreased vaginal TRAK. Sixty‐three patients had more than 12 months of follow‐up (median 27 months). From this cohort, grade 3 or higher toxicity for vaginal, genitourinary, gastrointestinal and fistula events were seen in 3.2%, 1.6%, 0% and 3.2% of patients, respectively.ConclusionIncreased dose prescriptions and a change of applicator design were successfully adopted into an Australian practice. Applicator design and interstitial needle use affect the plan quality and ability to meet OAR dose constraints following target dose escalation. No safety concerns with needle use or dose escalation were identified.

18F‐fluorodeoxyglucose PET‐CT‐guided pelvic chemoradiation therapy using helical tomotherapy for locally advanced carcinoma cervix without para‐aortic nodal disease: Clinical and patient‐reported outcomes from a prospective phase 2 study

AbstractIntroductionLocally advanced carcinoma cervix (LACC) is a heterogeneous disease with variable combinations of primary tumour extensions with or without nodal involvement. Metabolic information from 18 fluro‐deoxyglucose positron emission tomography combined with contrast‐enhanced computerized tomography (FDG PET‐CT) may potentially augment treatment decision‐making for LACC. This study ascertained FDG‐PET CT influence on chemoradiation therapy (CTRT) decisions in LACC. We report oncologic and patient‐reported outcome measures (PROMs).MethodsFDG PET‐CT scans were reviewed independently by two nuclear medicine specialists and two radiation oncologists. Pelvic CTRT plan digressions were documented and therapy was adapted accordingly. Pelvis radiation (50 Gy/25#/5 weeks) using tomotherapy with weekly cisplatin was used in node‐negative disease. Dose‐escalated simultaneous integrated boost (SIB) 60 Gy/25#/5 weeks was delivered to involved pelvic nodes. All received brachytherapy. Post‐treatment PET‐CT scans were at 6 months. Functional assessment of cancer therapy scores were calculated at baseline, treatment completion, 3 months, 1 year and 3 years.ResultsBetween November 2015 and January 2018, 85 patients were screened, and 77 consented. Extrapelvic disease was seen in 12 (16%) patients (9 para‐aortic nodes, 2 distant metastases and 1 synchronous carcinoma breast); 60 patients were included in the final analysis. Decision changes were seen in 10/77 (13%) screened, 8/60 (13%) included and 32 (53.3%) received SIB. Post‐treatment, 27 (45%) had grade 2 GI/GU/GYN toxicity, one (2%) had grade 3 GI and five (8.3%) had grade 3 neutropenia. At median follow‐up of 54.2 months (95% CI 52.8–58.3), 5‐year local failure, pelvic nodal and para‐aortic nodal‐free survival were 86.8% (95% CI 78.0–96.6), 85.2% (95% CI 76.1–95.3) and 85.2% (95% CI 76.2–95.4). Functional assessment of cancer therapy trial outcome index (FACT TOI) improved by 10.43 at 3 months with no further decline. Grade 3 toxicity was noted for abdominal pain in one (1.7%), cystitis in four (6.7%) and lymphoedema in one (1.7%) at 5 years.ConclusionPET‐CT resulted in major decision changes in 13%. PET‐adapted CTRT was associated with acceptable toxicity, encouraging long‐term survival and improvement in PROMS.

Dosimetric comparison of high‐dose rate cervix brachytherapy with and without interstitial needles and the impact on target volume coverage, and organ at risk constraints

AbstractIntroductionThe aim of this audit was to compare the data from the Wellington Blood and Cancer Centre (WBCC) with international reported experience by quantifying the dosimetric impact of interstitial needles on target coverage and organ at risk (OAR) doses.MethodsAll patients identified as having had interstitial needles as part of their treatment out of a cohort of 120 radically treated cervical cancer patients between 2013 and 2019 were included. Each patient acted as their own control with two treatment plans optimised for each fraction; the clinically treated plan and a re‐optimisation without the use of interstitial needles. Plan optimisation was completed according to the departmental protocol and cumulative equivalent doses for 2 Gy fractions (EQD2) were calculated.ResultsEighteen patients were suitable for evaluation. A total of 52 insertions with interstitial needles were performed, of the 148 needles inserted, 119 (80.4%) were loaded. HRCTV D90% coverage mean was EQD2 5.4 Gy (0.5–10.6 Gy) higher for the course containing loaded interstitial needles, while no significant change was observed with regards to OAR doses. This improved coverage is in line with international standards which report 4.4–9.0 Gy.ConclusionWBCC’s early experience of interstitial cervix brachytherapy has shown our target coverage improvements meet previously published international standards and confirms the value of this technique. This audit supports ongoing use of interstitial needles at the WBCC.