Alina Sturdza

Objectives: To assess the impact of magnetic resonance imaging (MRI) versus computed tomography (CT) on target delineation and dosimetry in adjuvant vaginal cuff brachytherapy (VBT) for endometrial cancer. Methods: Twenty-five consecutive patients receiving adjuvant high-dose-rate VBT after hysterectomy were prospectively included. All underwent standardized treatment of 4 × 5 Gy in 5 mm tissue depth using a vaginal cylinder with a fixed loading pattern; individualized optimization was permitted for suboptimal coverage or proximity of organs at risk (OARs). For each patient, clinical target volume (CTV) and OARs (bladder, rectum, sigmoid, bowel) were contoured on both CT and MRI of the first fraction. Dosimetric parameters (CTV D90, D98, D50; OAR D2cc) were compared. Treatment characteristics and outcomes were analyzed retrospectively. Results: Median CTV was smaller on MRI (9.8 cm³) than on CT (13.6 cm³). CTV coverage was comparable between modalities, with mean EQD2 D90 of 5.32 Gy per fraction on MRI versus 5.10 Gy per fraction on CT (p = 0.433) and mean EQD2 D98 of 3.95 Gy per fraction on MRI versus 3.80 Gy per fraction on CT (p = 0.491). In contrast, EQD2 D50 was significantly higher on MRI-based plans than on CT-based plans (9.12 vs. 8.62 Gy per fraction, p = 0.012). OAR D2cc values showed no significant differences between modalities. Most patients (80%) were treated with the institutional standard plan, and 20% required individualized optimization. After a median follow-up of 25 months (range 0–72), five patients (20%) recurred (one local, one regional, three distant), and one (4%) died. No grade ≥ 3 gastrointestinal or genitourinary toxicities occurred among patients with available data. Conclusions: In this small exploratory cohort, MRI-based planning delineated smaller CTVs, whereas the evaluated target-coverage and OAR-dose parameters were broadly similar between modalities. These findings suggest that CT-based planning may be adequate for many routine cases, with MRI potentially useful for selected, anatomically complex patients. Confirmation in larger multicenter studies is required.

The standard treatment for locally advanced cervical cancer typically includes concomitant chemoradiation, a regimen known to induce severe hematologic toxicity (HT). Particularly, pelvic bone marrow dose exposure has been identified as a contributing factor to this hematologic toxicity. Chemotherapy further increases bone marrow suppression, often necessitating treatment interruptions or dose reductions. A systematic search for original articles published between 1 January 2006 and 7 January 2024 that reported on chemoradiotherapy for locally advanced cervical cancer and hematologic toxicities was conducted. Twenty-four articles comprising 1539 patients were included in the final analysis. HT of grade 2 and higher was observed across all studies and frequently exceeded 50%. When correlating active pelvic bone marrow and HT, significant correlations were found for volumes between 10 and 45 Gy and HT of grade 3 and higher. Several dose recommendations for pelvic bone and pelvic bone marrow sparing to reduce HT were established, including V10 < 90–95%, V20 < 65–86.6% and V40 < 22.8–40%. Applying dose constraints to the pelvic bone/bone marrow is a promising approach for reducing HT, and thus reliable implementation of therapy. However, prospective randomized controlled trials are needed to define precise dose constraints and optimize clinical strategies.

Purpose: This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort. Methods: Patients treated with computer tomography (CT)–MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale. Results: Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25–57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2–T4 tumors if >80 Gy EQD2_α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy. Conclusions: In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.

Recently, guidelines for endometrial cancer (EC) were released that guide treatment decisions according to the tumors’ molecular profiles. To date, no real-world data regarding the clinical feasibility of molecular profiling have been released. This retrospective, monocentric study investigated the clinical feasibility of molecular profiling and its potential impact on treatment decisions. Tumor specimens underwent molecular profiling (testing for genetic alterations, (immune-)histological examination of lymphovascular space invasion (LVSI), and L1CAM) as part of the clinical routine and were classified according to the European Society for Medical Oncology (ESMO) classification system and to an integrated molecular risk stratification. Shifts between risk groups and potential treatment alterations are described. A total of 60 cases were included, of which twelve were excluded (20%), and eight of the remaining 48 were not characterized (drop-out rate of 16.7%). Molecular profiling revealed 4, 6, 25, and 5 patients with DNA polymerase-epsilon mutation, microsatellite instability, no specific molecular profile, and TP53 mutation, respectively. Three patients had substantial LVSI, and four patients showed high L1CAM expression. Molecular profiling took a median of 18.5 days. Substantial shifts occurred between the classification systems: four patients were upstaged, and 19 patients were downstaged. Molecular profiling of EC specimens is feasible in a daily routine, and new risk classification systems will change treatment decisions substantially.