Radiotherapy in Gynecological Cancer: State of the Art

A special issue of Cancers (ISSN 2072-6694). This special issue belongs to the section "Cancer Therapy".

Deadline for manuscript submissions: 20 April 2025 | Viewed by 5906

Special Issue Editors


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Guest Editor
Fonaments Clinics Department, Faculty of Medicine, Universitat de Barcelon, Barcelona, Spain
Interests: interventional radiotherapy; brachytherapy techniques; gynecological oncology; educational gynecology
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Guest Editor
Radiation Oncology Unit, Gemelli Molise Hospital, Campobasso, Italy
Interests: radiation oncology; gynecological, breast and gastrointestinal tract neoplasms

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Guest Editor
Gemelli ART (Advanced Radiation Therapy)-Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
Interests: interventional radiotherapy (brachytherapy); metabolic radiotherapy; medical software development; eye cancer; vulvar cancer; skin cancer; head and neck cancer; prostate cancer
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

This Special Issue of Cancers considers the quick evolution of radiation oncology in the gynaecological tumour sites of endometrial, cervical, vaginal and vulvar cancers. Considering the variety of advances achieved in the last decade, radiotherapy in gynaecological cancer has become increasingly well established and there has been an increase in cancer treatment results. At present, new indications and new techniques to be employed in this scenario include intensity-modulated radiotherapy, image-guided external beam irradiation, image-guided brachytherapy, stereotactic body radiation and intraoperative radiotherapy between others. Recently, tumour markers have been related to radiotherapy indications, leading omics-based and other adjuvant treatments to now be in the pipeline. Artificial intelligence is currently being developed for future use in this field.

This is a promising Special Issue that aims to establish the state of the art in the radiotherapy of gynaecological cancers via reviews or research articles developed by radiation oncologists, medical oncologists and medical physicists, with a view into the future.

The Guest Editors of this Special Issue look forward to receiving your contributions.

Dr. Àngeles Rovirosa
Dr. Gabriella Macchia
Dr. Luca Tagliaferri
Guest Editors

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Keywords

  • interventional radiotherapy
  • brachytherapy techniques
  • gynecological oncology
  • educational gynecology
  • gynecological cancer

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Published Papers (5 papers)

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Research

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22 pages, 1312 KiB  
Article
Retrospective Evaluation of GEC-ESTRO Constraints for Definitive Radiochemotherapy with Brachytherapy and Correlation with Oncologic Outcome in Cervical Cancer: A Monocenter Study
by Tom Schönicke, Raphael Koch, Isabel Vogt, Isabel Falke, Hans Theodor Eich and Gabriele Reinartz
Cancers 2024, 16(20), 3495; https://doi.org/10.3390/cancers16203495 - 15 Oct 2024
Viewed by 541
Abstract
Background: This study aims to evaluate patients with locally advanced cervical cancer who underwent definitive radiochemotherapy, including brachytherapy, at the University Hospital of Muenster (UKM), focusing on target volume coverage, oncologic outcome parameters, and organs at risk (OAR) toxicities. Results are compared with [...] Read more.
Background: This study aims to evaluate patients with locally advanced cervical cancer who underwent definitive radiochemotherapy, including brachytherapy, at the University Hospital of Muenster (UKM), focusing on target volume coverage, oncologic outcome parameters, and organs at risk (OAR) toxicities. Results are compared with the Gyn GEC-ESTRO (GGE) recommendations. Methods: Of a cohort of 48 patients, treated between 2013 and 2023, the physical radiation treatment planning with application of CT and MRI and oncologic follow-up data was analyzed. Target volume structures, comprising the high-risk clinical target volume (HR-CTV), intermediate-risk clinical target volume (IR-CTV), Point A, and corresponding EQD2(α/β=10) doses were determined. Endpoints included local tumor control, overall survival (OS), recurrence-free survival (RFS), and progression-free survival (PFS). Total OAR (D2cc) EQD2(α/β=3) doses were correlated with adverse events defined by CTCAE v5.0 and LENT-SOMA criteria. Results: Median follow-up was 58.0 months (95% CI [27.6, 88.4]). FIGO stage I was present in 7 (15%) patients, II in 13 (27%), and III in 28 (58%) patients. A total of 38 (79%) patients showed a complete remission 3 months after treatment. The 5-year event-free rate was 67.4% (95% CI [49.3, 80.3]) for OS, 77.0% (95% CI [56.7, 88.6]) for RFS and 68.1% (95% CI [49.7, 80.9]) for PFS. Incomplete radiation treatment and advanced tumor stages led to worse outcomes. Meeting Point A GGE recommendations increased chances for complete remission and could decrease chances of an event occurring for OS, PFS, and RFS. Compliance with GGE recommendations lowered the chances of OAR toxicity occurring. Conclusions: MRI-based target volume definition for brachytherapy in cervical cancer may improve patients’ OS, PFS, and RFS. Time-to-event endpoints are consistent with comparable studies, and adherence to current ESGO/ESTRO/ESP guidelines is endorsed. Full article
(This article belongs to the Special Issue Radiotherapy in Gynecological Cancer: State of the Art)
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10 pages, 1093 KiB  
Article
Assessing the Adequacy of Traditional Vertebral Landmarks as Upper Border of Whole Pelvic Radiotherapy Field for Stage IB2-IIB Cervical Cancer
by Ji Hwan Jo, Jeong Won Lee and Ki Ho Seol
Cancers 2024, 16(15), 2743; https://doi.org/10.3390/cancers16152743 - 1 Aug 2024
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Abstract
This study investigates the impact of insufficient common iliac lymph node (CIN) irradiation on treatment outcomes in patients with stage IB2-IIB cervical cancer receiving concurrent chemoradiotherapy (CCRT). We retrospectively analyzed 68 patients with Federation of Gynecology and Obstetrics stage IB2-IIB, treated with weekly [...] Read more.
This study investigates the impact of insufficient common iliac lymph node (CIN) irradiation on treatment outcomes in patients with stage IB2-IIB cervical cancer receiving concurrent chemoradiotherapy (CCRT). We retrospectively analyzed 68 patients with Federation of Gynecology and Obstetrics stage IB2-IIB, treated with weekly cisplatin-based CCRT from 2008 to 2018. Patients received external-beam whole pelvic radiotherapy (WPRT) and concurrent cisplatin chemotherapy, followed by high-dose-rate brachytherapy. The WPRT upper border was at L4-5 in 61 patients and L3-4 in 7 patients. Thirty-seven patients had the CIN area fully included (full-CIN group), while 31 had partial inclusion (partial-CIN group). Recurrence rates and survival outcomes were analyzed over a median follow-up of 111 months. Patient characteristics and the irradiated dose were comparable. Treatment failure occurred in three patients (8.1%) in the full-CIN group and in six patients (19.4%) in the partial-CIN group, with CIN and para-aortic lymph node recurrence in two and one patients, respectively. The 5-year cumulative recurrence rate was 0% for the full-CIN group and 11.4% for the partial-CIN group (p = 0.04). Cause-specific survival was 100% vs. 87.1% (p = 0.025), and the overall survival was 94.3% vs. 87.1% (p = 0.44). Fully including the CIN area in WPRT is crucial for stage IB2-IIB cervical cancer. Vascular anatomical margins should be considered over vertebral landmarks. Full article
(This article belongs to the Special Issue Radiotherapy in Gynecological Cancer: State of the Art)
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14 pages, 2676 KiB  
Article
Stages I–III Inoperable Endometrial Carcinoma: A Retrospective Analysis by the Gynaecological Cancer GEC-ESTRO Working Group of Patients Treated with External Beam Irradiation and 3D-Image Guided Brachytherapy
by Ángeles Rovirosa, Yaowen Zhang, Kari Tanderup, Carlos Ascaso, Cyrus Chargari, Elzbieta Van der Steen-Banasik, Piotr Wojcieszek, Magdalena Stankiewicz, Dina Najjari-Jamal, Peter Hoskin, Kathy Han, Barbara Segedin, Richard Potter and Erik Van Limbergen
Cancers 2023, 15(19), 4750; https://doi.org/10.3390/cancers15194750 - 27 Sep 2023
Cited by 3 | Viewed by 1823
Abstract
Background/Purpose: Analyse the outcomes of stages I–III inoperable endometrial cancer (IEC) patients treated with external-beam-irradiation (EBRT) and 3D-image-guided-brachytherapy (IGBT). Material and Methods: Medical records of IEC patients receiving EBRT + IGBT in eight European and one Canadian centres (2004–2019) were examined, including: pelvic [...] Read more.
Background/Purpose: Analyse the outcomes of stages I–III inoperable endometrial cancer (IEC) patients treated with external-beam-irradiation (EBRT) and 3D-image-guided-brachytherapy (IGBT). Material and Methods: Medical records of IEC patients receiving EBRT + IGBT in eight European and one Canadian centres (2004–2019) were examined, including: pelvic ± para-aortic EBRT and lymph node boost; anaesthetic procedure, applicators, BT-planning imaging, clinical target volume (CTV), brachytherapy schedule, and EQD2 to the CTV(α/β=4.5Gy) and D2 cm3(α/β=3Gy) for organs at risk. Complications are evaluated using CTCAEv4 scores. The 2- and 5-year survival probability according to stages was estimated (cancer-specific survival (CSS), disease-free survival (DFS), local relapse-free survival (LRFS), loco-regional relapse-free survival (LRRFS), and distant metastasis-free survival (DMFS)). Statistics: descriptive analysis and the Kaplan–Meier method. Results: 103 patients (stages: I-44, II-14, III-44) were included. Median follow-up: 28 months (7–170). All patients received pelvic ± para-aortic EBRT. Median D90-EQD2(α/β=4.5) to the CTV:73.3 Gy (44.6–132.7), 69.9 Gy (44.7–87.9 and 75.2 Gy (55.1–97) in stages I, II, and III, respectively. Thirty patients presented relapse (stages: 10-I, 3-II, 17-III): 24 uterine (stages: 7-I, 3-II, 14-III), 15 nodal (stages: 4-I, 1-II, 10-III), and 23 distant (stages: 6-I, 2-II, 15-III). Five year CSS was 71.2% (stages: 82%-I-II and 56%-III) and DFS, LRFS, LRRFS, and DMFS were 55.5%, 59%, 72%, and 67.2%, respectively. Late G3-G4 complications (crude): 1.3% small bowel, 2.5% rectum, and 5% bladder. Conclusion: In stages I–III of the IEC, EBRT + IGBT offer good 2- and 5-year CSS of 88.7% and 71.2%, respectively, with the best outcomes in stages I–II. Prospective studies are needed to determine how better outcomes can be achieved. Full article
(This article belongs to the Special Issue Radiotherapy in Gynecological Cancer: State of the Art)
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Review

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14 pages, 1208 KiB  
Review
The Effects of Gynecological Tumor Irradiation on the Immune System
by Jesus Romero Fernandez, Sofia Cordoba Largo, Raquel Benlloch Rodriguez and Beatriz Gil Haro
Cancers 2024, 16(16), 2804; https://doi.org/10.3390/cancers16162804 - 9 Aug 2024
Viewed by 833
Abstract
Radiobiology has evolved from a mechanistic model based on DNA damage and response factors into a more complex model that includes effects on the immune system and the tumor microenvironment (TME). Irradiation has an immunomodulatory effect that can manifest as increased anti-tumor immunity [...] Read more.
Radiobiology has evolved from a mechanistic model based on DNA damage and response factors into a more complex model that includes effects on the immune system and the tumor microenvironment (TME). Irradiation has an immunomodulatory effect that can manifest as increased anti-tumor immunity or immunosuppression. Irradiation promotes an inflammatory microenvironment through the release of pro-inflammatory cytokines and endothelial damage, which recruit immune system cells to the irradiated area. Radiation-induced immunogenic cell death (ICD), characterized by the release of damage-associated molecular patterns (DAMPs) and tumor antigens, triggers an anti-tumor immune response of both innate and adaptive immunity. Anti-tumor immunity can manifest at a distance from the irradiated area, a phenomenon known as the abscopal effect (AE), which involves dendritic cells and CD8+ T cells. Irradiation also produces an immunosuppressive effect mediated by tumor-associated macrophages (TAMs) and regulatory T lymphocytes (Tregs), which counterbalances the immunostimulatory effect. In this work, we review the mechanisms involved in the radiation-induced immune response, which support the combined treatment of RT and immunotherapy, focusing, where possible, on gynecologic cancer. Full article
(This article belongs to the Special Issue Radiotherapy in Gynecological Cancer: State of the Art)
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Other

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21 pages, 651 KiB  
Systematic Review
Hematologic Toxicity and Bone Marrow-Sparing Strategies in Chemoradiation for Locally Advanced Cervical Cancer: A Systematic Review
by Dinah Konnerth, Aurelie Gaasch, Annemarie Zinn, Paul Rogowski, Maya Rottler, Franziska Walter, Johannes Knoth, Alina Sturdza, Jan Oelmann, Freba Grawe, Raphael Bodensohn, Claus Belka and Stefanie Corradini
Cancers 2024, 16(10), 1842; https://doi.org/10.3390/cancers16101842 - 11 May 2024
Viewed by 1254
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Radiotherapy in Gynecological Cancer: State of the Art)
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