Patient and Tumour Characteristics

• Median age 60 years (26-92)• Karnofsky Status: median 90 (50-100)• Histology: SCC: n=120 (83%)• Tumor size: ≥ 5 cm: n=78 (52%) ≤Ib1,IIA=18(12%)

• Lymph node involvement: n=57 (39%)

- EBT: 45 Gy/1,8 Gy per fraction

- HDR–BT: 4 x 7 Gy (40 Gy (EQD2)) pt A/HR CTV

- Since 2001 (D90): total dose 85+ Gy (EQD2)

- Intracavitary + interstitial, if insufficient response

- Cis-Platinum 5x40mg/m2 (57%), since 4/99

Treatment schedule (Overall treatment time 6-7 weeks)

• HR CTV concept

• GTV, HR CTV+OAR contouring

• Biological modelling (linear-quadratic)

• Dose Volume constraints: OAR (2 cm3): 75/90 Gy (EQD2, α/β3)

• Prescription: HR CTV - (D90): 80-85+ Gy(EQD2, α/β10)

• Prospective 3D image based optimisation

MRI based Treatment Planning

Major Learning Period: 98-2000 (n=73)

Systematic prospective protocol since 2001 (n=72)

no systematic prospective protocol (point A/OAR)

Outcome after complete remission

non central true pelvic and distant recurrence

non central true pelvic

central true pelvic recurrence

pelvic lymph node and distant

pelvic lymph node

distant recurrence

disease free (64%)

•n=138•Treatment time: 98-2003 •Median follow up: 39 months

Stage IIB, Large Tumour, ≥ 5 cm (treated 12/2002)Before EBRT: 5 cm wide, 5 cm thick, 7 cm high: 85 cm3

At 1. Brachytherapy after EBRT:2 cm x 3 cm x 3 cm, 9 cm3,

6 months after treatment:

Radioth&Oncol 2005

Continuous Complete Remission

good remission, sufficient for intracavitary BT

Initial tumor extension

Stage IIIB- (treated 11/1998) Insufficient response-no adaptation of application technique

At Brachytherapyafter EBRT

9 months after treatment

Dose distributionat brachytherapy

At time of diagnosis

Residual tumor Insufficient adaptation Recurrence

Initial tumor extension

Tumor size------- < 5cm------- ≥5cm

CCR at 3 years: Vienna 93-2003 (335 patients)

CCR true pelvis (2001-2003)

and tumour size

Follow up [months]

3624120

CC

R

1,1

1,0

,9

,8

,7

,6

,5

,4

,3

,2

,1

0,0

100%

91%

Total: Events:< 5cm n=34 n=0≥5 cm n=38 n=4 (28) (12) (4) (30) (17) (9)

CCR true pelvis (1998-2000)

and tumour size

Follow up [months]

3624120

CC

R

1,1

1,0

,9

,8

,7

,6

,5

,4

,3

,2

,1

0,0

96%

72%

Total: Events:< 5cm n=33 n=1 (at 36m)≥5 cm n=40 n=10

(30) (26) (22) (23) (15) (10)

CCR true pelvis (98-00) CCR true pelvis (01-03)

Late side effects at 3 years LENT/SOMA: absolute numbers

G 0 G 1 G 2 G 3 G 4

Bladder 124 7 11 1 2

Rectum 135 2 6 2 -

Intestines 136 5

1 - 3

Total 14 18 3 5Period Pts. G3-4

98-00 73 6

01-03 72 2

ConclusionMRI assisted treatment planning

in intracavitary cervical cancer brachytherapy

plus risk adapted interstitial brachytherapy

+ cis-Platinum (145 consecutive patients)

• High local control

tumors < 5 cm: up to 100%

tumors ≥ 5 cm: ~ 90%

• Low rate of side effects G3/4: < 5% (crude)