Preserving Endocrine Function in Premenopausal Women Undergoing Whole Pelvis Radiation for Cervical Cancer

Melissa A L Vyfhuis; Zachary Fellows; Nathaniel McGovern; Mingyao Zhu; Pranshu Mohindra; Jade Wong; Elizabeth M Nichols

doi:10.14338/IJPT-D-19-00061.1

Preserving Endocrine Function in Premenopausal Women Undergoing Whole Pelvis Radiation for Cervical Cancer

Int J Part Ther. 2019 Summer;6(1):10-17. doi: 10.14338/IJPT-D-19-00061.1. Epub 2019 Aug 23.

Authors

Melissa A L Vyfhuis¹, Zachary Fellows², Nathaniel McGovern¹, Mingyao Zhu¹, Pranshu Mohindra¹, Jade Wong³, Elizabeth M Nichols¹

Affiliations

¹ Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA.
² Department of Radiation Oncology, Johns Hopkins Hospital, Baltimore, MD, USA.
³ Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA.

Abstract

Purpose: Whole pelvis radiation therapy (WPRT) in premenopausal women with cervical cancer can cause permanent ovarian damage, resulting in premature menopause. Oophoropexy, often considered as an initial step, demonstrates safety of sparing 1 ovary at the cost of delay in initiating WPRT. Therefore, we dosimetrically compared volumetric modulated arc radiotherapy (VMAT) and intensity modulated proton therapy (IMPT) techniques to allow for ovarian-sparing WPRT.

Materials and methods: Ten patients previously treated for cervical cancer at our institution were included in this institutional review board-approved analysis. A modified clinical treatment volume (CTV) was designed, sparing 1 ovary (left or right), as determined by the physician (ovarian-sparing CTV) and disease extent, including physical exam, positron emission tomography/computed tomography and magnetic resonance imaging. An ovarian-sparing planning target volume was determined as the ovarian-sparing CTV+5 mm for patients who were supine and 7 mm for those who were prone. All plans were calculated to a dose of 45 Gy with specific optimization goals for target volumes, while attempting to maintain a mean ovary dose (D_mean) < 15 Gy. Dosimetric goals were compared across the 2 modalities using the Mann-Whitney U test.

Results: Both treatment modalities were able to achieve primary clinical goal coverage to the uterus/cervix (P = .529, comparing VMAT versus IMPT), ovarian-sparing CTV (P = .796) and ovarian-sparing planning target volume (P = .004). All 10 IMPT plans were able to accomplish the ovary objective (14.0 ± 1.66 Gy). However, only 4 of the 10 VMAT plans were able to achieve a D_mean < 15 Gy to the prioritized ovary, with an average dose of 15.3 ± 4.10 Gy.

Conclusion: Sparing an ovary in women undergoing WPRT for cervical cancer is dosimetrically feasible with IMPT without sacrificing coverage to important clinical targets. Future work will incorporate the brachytherapy dose to the ovarian-sparing CTV and assess the clinical response of this technique as a means to preserve ovarian endocrine function.

Keywords: endocrine preservation; intensity modulated proton therapy; ovarian cancer; pencil beam scanning.