Intensity modulated radiation therapy for definitive treatment of paraortic relapse in patients with endometrial cancer Shervin M. Shirvani, MD, Ann.

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Intensity modulated radiation therapy for definitive treatment of paraortic relapse in patients with endometrial cancer Shervin M. Shirvani, MD, Ann H. Klopp, MD, PhD, Anna Likhacheva, MD, Anuja Jhingran, MD, Pamela T. Soliman, MD, MPH, Karen H. Lu, MD, Patricia J. Eifel, MD Practical Radiation Oncology Volume 3, Issue 1, Pages e21-e28 (January 2013) DOI: 10.1016/j.prro.2012.03.013 Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Figure 1 Radiographic response of involved paraortic nodes following definitive therapy according to gross tumor volume (GTV) at time of radiation therapy and maximum prescribed dose. (Red, complete response; Green, partial response or stable disease; Blue, paraortic progression or relapse; White, unknown; Flags are tagged to the responses for the 8 patients who underwent partial surgical debulking.) Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Figure 2 A 69-year-old woman with stage IB, grade 1 endometrial adenocarcinoma with pathologically confirmed paraortic recurrence 3 years after initial therapy. The recurrence was refractory to systemic chemotherapy and was subsequently treated with definitive intensity modulated radiation therapy (IMRT) alone. (A) Preradiation therapy axial computed tomographic (CT) image demonstrating the enlarged paraortic node (white arrow). (B) IMRT plan to deliver 63 Gy to the gross node in 28 daily fractions. The paraortic nodal basin was treated to 50.4 Gy. (C) Surveillance positron emission tomography-CT scan obtained approximately 4 years following IMRT demonstrates complete resolution of the involved node. The patient was also without evidence of disease elsewhere. Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Figure 3 Overall survival (A) and progression-free survival (B) from the date of paraortic nodal recurrence. Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Figure 4 “Bowel-push” technique: The paraortic basin and grossly involved node that constitute the progression-free survival (lavender) are near the junction of the prior pelvic fields. Therefore, the new intensity modulated radiation therapy plan results in a large hot spot (white arrows) in the composite plan (column A). After designating the “bowel-push” structure (aqua) as an avoidance structure (column B), better conformality around the gross node is achieved (orange arrows) with concomitant reduction of normal tissue exposure in the bowel-push region. Exposure of bowel to low-dose radiation in the anterior abdomen is also reduced. Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Figure 5 Dose-volume histogram of plan in Fig 4, with (solid) and without (dashed) the bowel-push structure designated as an avoidance structure. There is diminishment of dose to the bowel inside the bowel-push region with minimal impact on dosimetry of the target and other organs-at-risk. Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions

Supplementary Material (JPEG) Figure e1 Practical Radiation Oncology 2013 3, e21-e28DOI: (10.1016/j.prro.2012.03.013) Copyright © 2013 American Society for Radiation Oncology Terms and Conditions