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Intensity modulated radiation therapy boost in locally-advanced cervical cancer in the absence of brachytherapy
  1. Roberta Lazzari1,
  2. Giulia Riva2,
  3. Matteo Augugliaro1,
  4. Andrea Vavassori1,
  5. Samantha Dicuonzo1,
  6. Federica Cattani3,
  7. Stefania Comi3,
  8. Nicoletta Colombo4 and
  9. Barbara Alicja Jereczek-Fossa1,5
  1. 1Department of Radiotherapy, IEO, European Institute of Oncology IRCCS, Milan, Italy
  2. 2Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
  3. 3Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
  4. 4Medical Gynecologic Oncology Unit, IEO European Institute of Oncology, IRCCS and University of Milan-Bicocca, Milan, Italy
  5. 5Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
  1. Correspondence to Dr Matteo Augugliaro, Department of Radiotherapy, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, Milan, Italy; matteo.augugliaro{at}


Objective Standard treatment in locally-advanced cervical cancer is external beam radiotherapy concomitant with platinum-based chemotherapy, followed by brachytherapy. The goal of our study was to determine whether an intensity modulated radiation therapy (IMRT) boost is feasible in patients unfit for brachytherapy.

Methods We retrospectively analyzed data of 25 patients unfit for brachytherapy with median age 55 years (range, 30–82) with locally-advanced/metastatic cervical cancer who underwent external beam radiotherapy to pelvis ±para-aortic lymph nodes and sequential IMRT boost between July 2014 and December 2017. Total dose of 45–50.4 Gy in 25–28 fractions (1.8 Gy/fraction) was administered to the cervix, uterus, parametria, ovaries, vaginal tissues (based on vaginal extension), involved lymph nodes, or relevant draining lymph-nodal groups. Para-aortic nodes were included if involved at radiological staging or if common iliac nodes were positive. The IMRT boost included all residual tumor after external beam radiotherapy identified on MRI. The Kaplan–Meier method was used to calculate 2 years' overall survival, 2 years' progression-free survival, and 2 years' local control. Overall survival- and progression-free survival were calculated considering the starting of radiotherapy or neo-adjuvant chemotherapy if prescribed, while local control was calculated from the end of radiotherapy.

Results Median radiation dose to pelvis ±para-aortic lymph nodes was 50.4 Gy (45–50.4), boost treatment was homogeneously performed to a total dose of 25 Gy in five fractions every other day.

After a median follow-up of 26 months (range, 4–77), tumor persistence at cervix at 6 months from the end of radiotherapy or local recurrence occurred in five women (20%), eight (32%) experienced a further distant progression (two of them had also tumor persistence). Two-year local control and overall survival rates for all stages were 78% and 67%, respectively. According to Common Terminology Criteria for Adverse Events v.4 scoring criteria, 10 patients experienced gastrointestinal and/or genitourinary grade G1-2 acute toxicity. G2 rectal late toxicity requiring laser-coagulation was registered in two patients, there were no gastrointestinal and/or genitourinary acute or late toxicities≥G3.

Conclusion The combination of external beam radiotherapy and brachytherapy remains the standard of care, however our preliminary data show the feasibility of IMRT boost in terms of toxicity with promising results in terms of local control and overall survival.

  • cervical cancer
  • cervix
  • IMRT boost
  • radiotherapy

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  • Contributors RL, BAJ-F conceived the presented idea. RL, GR, AV, SD, MA developed the theory and performed the computations. FC, SC verified the analytical methods. RL, GR, MA wrote the manuscript with support from AV, SD. NC. BAJ-F supervized the findings of this work. All authors discussed the results and contributed to the final manuscript.

  • Funding This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5x1000 funds.

  • Competing interests None declared.

  • Patient consent for publication All patients gave written informed consent for the use of the anonymized data for research andeducational purpose.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. The data that support the findings of this study are available from the corresponding author, upon reasonable request.