1. Prevention by intravesical hyaluronic acid (Cystistat®) of acute radiation-induced cystitis in radiotherapeutic management of cervical cancer
E. González Patiño, N. Salvador Garrido, E. Castro Gómez, R. Miguens Duarte, A. Varela Pazos, E. Canosa Santos, C. Porto Vázquez.
Radiation Oncology Department.
Complexo Hospitalario Universitario. Hospital Clínico. Santiago de Compostela. Spain.
One of the main objectives in the radiotherapeutic management of cervical cancer is to the treat in a period nonsuperior to 8 weeks, since there is evidence that by every day that surpasses this period of time, there is a 1% of loss in the probability of both tumor response and tumoral control. In this therapeutic strategy is fundamental to avoid and control the appearance of secondary toxicity to the treatment that causes these interruptions. The incidence of acute radiation-induced cystitis (RIC) during treatment varies, in the literature, between 3-6.7%. Concomitant use of chemotherapeutic agents may work synergistically to increase the risk of developing bladder injury from radiation. The treatment with intravesical hyaluronic acid (IV-HA) (Cystistat®) has demonstrated its effectiveness in different forms from interstitial cystitis. We present our initial experience in the use if IV-HA instillations in the prevention of RIC in patients diagnosed of cervical neoplasia and treated with a curative chemo-radiotherapy protocol.
CERVICAL CANCER
Patients data
Patients 14
Median age
61,5 y. (39-74)
Pathology
epidermoid carcinoma: 4.
adenocarcinoma: 3.
Stage (FIGO)
IB (> 4 cm): 2 ; II B: 6 ; III A: 1 ; III B: 3
Treatment schedule
week of treatment
IV-HA
- 1
Stage IIB cervical carcinoma
PELVIC
RADIOTHERAPY
CDDP
External beam radiotherapy (EBRT): 45 – 50 Gy/5-5,5 w (1,8 Gy/fx)
IV-HA 1
Concomitant (weekly) chemotherapy: CISPLATINUM (CDDP): 40 mg/m2
CDDP
HDR brachytherapy (HDR-BT): 5 x 5,5 Gy to (point A)
If posible, HDR starts at the four week.
(the day of HDR-brachytherapy: no EBRT or chemotherapy are administred) 2
IV-HA
IV-HA
CDDP
Intravesical hialuronic acid (IV-HA)
(Cystistat®)
One instillation in the week -1.
Weekly instilations during EBRT.
One instillation on each brachytherapy insertion, during the treatment aplication, in order to maintain the same vesical volume (50 ml) used for the planning CT.
A weekly instillation for the following four weeks to the conclusion of treatment. 3
IV-HA
CDDP
IV-HA 4
HDR-BT
IV-HA
CDDP 5
IV-HA
HDR-BT
IV-HA
Evaluation of bladder toxicity (RTOG/EORTC scale) (previously to each IV-HA instilation)
HDR-BT
IV-HA
GRADE 1 2 3 4
PATIENTS (#)
2 (*)
4(*) -- 6
HDR-BT
IV-HA
HDR-BT
IV-HA 7
(*) HDR-BT treatment was started
no patients developed grade III toxicity.
no treatment was disrupted due bladder toxicity
all patients were free of vesical toxicity after the 2nd week of conclusion of treatment
IV-HA 8
(X 4 weeks)
Although these are preliminary results and prospective studies are necesary to confirm this effect, in this short serie of patients the use of IV-HA instillations had a protective effect on the vesical mucosa in the prevention of RIC, allowing finalizing the treatment in the scheduled time. In our opinion, treatment must be started from the begining of chemo-radiotherapy schedule treatment, since the radiation injury takes place already fron initials days of treatment. The study in ongoing in order to have more complete data in the next future.