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Radiation for Ovarian Cancer

Radiation - is used only occasionally in ovarian cancer, it used to be common to treat patients with whole abdominal radiation for advanced ovary cancer (see here) the current standard is with surgery followed by chemotherapy (see NCCN flow chart, though it may be considered for relapses see here.) There is some contradictory evidence that whole abdominal radiation may be effective for very small sized residual cancer after surgery or chemotherapy. There is good evidence that radiation can relieve symptoms for tumor masses that are no loner responding to chemotherapy (palliative treatment.)

Chemotherapy (after surgery) is the primary treatment for ovarian cancer, but if the cancer relapses, then palliative radiation may be as effective (or more so) than further chemo (see tables and  studies below.)  In some women the cancer keeps recurring only low in the pelvis causing a bowel obstruction (see picture here) and radiation may be effective at treating or preventing this problem

Also there may still be role for whole abdominal radiation (WAR) combined with pelvic radiation to improve the overall cure rate (see summary table for whole abdominal radiation)

Palliative Therapy for Relapsed Ovarian Cancer
  Complete Response Partial Total Response
Chemotherapy 7 - 10% 0 - 35% 15 - 40%
Radiation 28 - 71% 19 - 45% 70 - 94%
ovary_palliation.gif (12942 bytes)

see other studies below
Int J Radiat Oncol Biol Phys 1987 Jan;13(1):17-21

Palliative radiotherapy for ovarian cancer.

Adelson. Large single-fraction irradiation is effective palliation for advanced ovarian cancer. It has an acceptable complication rate and requires only a limited number of visits (i.e., one treatment per 4-week course) to administer. Forty-two patients received single or multiple fractions of (three maximum) 10 Gray (Gy) to the pelvis. Tumor size before and after radiotherapy was evaluable in 34 patients and decreased in 25. Bleeding decreased or stopped in 15 of 21 patients, and pain lessened or ceased in 11 of 20 patients.  The safest and most efficient dose may be one or two fractions, since three 10 Gy fractions may not increase palliation.

Cancer 1994 Dec 1;74(11):2979-83

Recurrent ovarian cancer. Effective radiotherapeutic palliation after chemotherapy failure.

Corn. Median RT dose was 35 Gy (range: 7.5-45 Gy). The median fraction size was 2.5 Gy (range, 1-5 Gy). For the entire group, complete palliative response was 51% and overall palliative response was 79%. The median duration of palliation was 4 months, which reflected palliation until death in 90% of cases. The overall response rates by symptoms were: pulmonary symptom relief in 75%, vaginal bleeding control in 90%, rectal bleeding control in 85%, pain relief in 83%, and neurologic symptoms controlled in 50%. Biologically effective doses of at least 44 Gy10 (e.g., 3500 cGy/14 fractions = BED10 of 44) should be sought to maximize the probability of complete response. These results are comparable to the published experience of second-line chemotherapy in the treatment of focally symptomatic ovarian cancer recurrences.

Gynecol Oncol 1993 Dec;51(3):349-54

Limited-field radiotherapy as salvage treatment of localized persistent or recurrent epithelial ovarian cancer.

Davidson. Thirty-five patients with persistent or recurrent epithelial ovarian cancer were treated with salvage pelvic or para-aortic radiotherapy for disease limited to the pelvis (29), para-aortic retroperitoneum (5), or vaginal cuff (1). Including pelvic boosts, the median dose delivered to the treatment field was 4600 cGy (range 4000-7000); 2 patients received additional treatment with a permanent 125I implant. Median actuarial and progression-free survivals for all patients from start of radiotherapy were 40 and 14 months, respectively. These findings indicate that limited-field salvage radiotherapy has an acceptable complication rate and may prolong the symptom-free survival interval in selected patients.

Gynecol Oncol 1997 Jun;65(3):453-60

Long-term survival with whole abdominopelvic irradiation in platinum-refractory persistent or recurrent ovarian cancer.

Cmelak.  Median doses of 28 Gy to the abdomen and 48 Gy to the pelvis were delivered using open-field techniques and liver and kidney shielding. the 5-year actuarial disease-specific survival was 47% in all 41 patients, and 50% in the 22 platinum-refractory patients. Five-year disease-specific survival of all patients with residual tumors less than 1.5 cm was 53%; 0% for patients with tumors greater than 1.5 cm. Five-year disease-specific survivals by initial stage were: stage I and II, 75%; stage III, 40%; and stage IV, 15%. Stage I, II, or III patients with residual disease up to 1.5 cm before WAI had a 10-year actuarial disease-specific survival of 40%. With acceptable toxicity, WAI results appear to be as good as or better than second-line chemotherapy, particularly in platinum-refractory patients.

Int J Radiat Oncol Biol Phys 1998 Jun 1;41(3):543-9

A randomized study of two doses of abdominopelvic radiation therapy for patients with optimally debulked Stage I, II, and III ovarian cancer.

Fyles. Patients were stratified and randomized to either the control arm, treated with an abdominal dose of 22.5 Gy in 22 fractions, or the experimental arm of 27.5 Gy in 27 fractions. A pelvic boost dose of 22.5 Gy was used in both arms.  Overall survival (OS) at 5 years was 83% in the low-dose arm and 72% in the high-dose arm (p = 0.3). Disease-free survival (DFS) at 5 years was 74% and 67% in the low-dose and high-dose arms, respectively (p = 0.5).

Gynecol Oncol 1998 Apr;69(1):36-41

Palliative benefit of external-beam radiation in the management of platinum refractory epithelial ovarian carcinoma.

Gelblum. Forty-seven patients with platinum-refractory epithelial ovarian carcinoma were referred for palliative radiation and 33 (70%) were evaluable for response. Of the 33 evaluable patients, 23 (69.7%) had a complete resolution of symptoms after radiation, 8 (24%) had a partial resolution, and 2 were unassessable because of unrelated medical complications. The median duration of response was 11 months (range 1-86) and closely approximated their survival. External-beam radiation therapy can provide effective and durable palliation of symptoms in platinum-refractory epithelial ovarian carcinoma patients.

Obstet Gynecol 1985 Jan;65(1):60-6

Whole abdominal radiation as salvage therapy for epithelial ovarian cancer.

Hacker Thirty patients found to have residual epithelial ovarian cancer at second-look laparotomy were treated with whole abdominal radiation as salvage therapy. Dosage fractions were 120 rad per day until 3000 rad were delivered, then the pelvis was boosted to 5000 rad at 180 rad per day. Four of 16 patients (25%) with microscopic residual disease before radiation remain alive and free of disease at 22 to 41 months. Two of six (33%) patients with minimal (less than or equal to 5 mm) residual disease remain alive and free of disease 19 to 40 months after radiation treatment. Patients with residual nodules greater than 5 mm uniformly did poorly. Patients who progressed on primary chemotherapy had a median survival of seven months, compared with more than 38 months for chemotherapy responders. Chronic bowel morbidity was a significant problem, with 30% of patients surviving at least four months from completion of radiation requiring laparotomy for small bowel obstruction.

Gynecol Oncol 1990 Mar;36(3):338-42

Whole-abdominal radiotherapy for patients with minimal residual epithelial ovarian cancer.

Kucera. Sixteen patients with advanced epithelial ovarian cancer who were treated with cytoreductive surgery followed by multiagent chemotherapy were found to have residual tumor masses less than 2 cm in greatest diameter at reexploration and were treated with whole-abdominal radiation (19-31 Gy). Thirteen patients also received pelvic boosts to a total pelvic dose of 41-53.7 Gy.  Delayed complications were severe and included 9 patients with radiation enterocolitis, 8 of whom required intestinal resection or diversion. These data suggest that few patients with persistent ovarian cancer following surgery and chemotherapy will be salvaged with radiotherapy.

Gynecol Oncol 1988 Sep;31(1):122-36

Hyperfractionation of whole-abdomen radiation therapy: salvage treatment of persistent ovarian carcinoma following chemotherapy.

Morgan. Fifteen patients have been treated with a twice-a-day whole-abdomen, open-field radiation technique delivering 80 cGy per fraction, to a total dose of 3040 cGy in 19 treatment days. The mean survival to date is 20 months with four patients alive more than 2 years, and two patients alive for greater than 3 years from their radiation therapy. This technique offers a chance for a long, disease-free interval and possible cure in well-defined cases of chemotherapy-treated patients with persistent ovarian carcinoma.

Gynecol Oncol 1989 Dec;35(3):307-13

Whole-abdomen radiation therapy in ovarian carcinoma: its role as a salvage therapeutic modality.

Reddy. Radiation was delivered with an open-field technique that extended from the domes of the diaphragm to the obturator foramina. Doses of 2500 cGy were planned to the whole abdomen, with a boost of another 2500 cGy to the pelvic and or paraaortic nodes when indicated. Two-year actuarial survival and recurrence-free survival rates are 47 and 32%, respectively. The survival and recurrence-free survival rates for the group with microscopic residual disease--61 and 33%, respectively--are better than those for the patients with macroscopic residual disease--36 and 18%.

Int J Radiat Oncol Biol Phys 1993 Nov 15;27(4):879-84

Salvage whole abdomen radiation therapy: its role in ovarian cancer.

Reddy. 44 patients who failed one or more chemotherapeutic regimens were treated with whole abdomen radiation therapy. Forty patients had epithelial carcinoma of the ovary and the remaining had primary adenocarcinoma of the peritoneal cavity. Radiation was delivered with an open-field technique and 2500 cGy were planned to the whole abdomen, with a boost when indicated. Prior to radiation, the amount of residual disease after debulking was noted to be microscopic in one-half of the patients and macroscopic in the other half. The 4-year actuarial survival and recurrence-free survival rates for the entire group were 23% and 22%, respectively. The survival and recurrence-free survival rates for the group with microscopic residual disease at 37% and 42% were significantly better than those for the patients with macroscopic residual disease at 9% and 5% (p < 0.005; p < 0.001) at 4 years, respectively. Patients with disease limited to pelvis only had a recurrence-free survival of 56% compared to 0% when the upper abdomen was involved (p < 0.005).

Cancer J Sci Am 1997 Nov-Dec;3(6):358-63

Whole-abdomen radiation therapy as salvage treatment for epithelial ovarian carcinoma.

Sedlacek. Dosage fractions were planned at 100 to 150 cGy daily to 3000 to 3500 cGy, followed by a pelvic boost at 150 to 180 cGy daily.  Survival rates at years 1 through 5 were 66%, 48%, 26%, 15%, and 15%, respectively. Residual disease at initiation of radiation correlated strongly with length of survival. The patients with microscopic disease survived an average of 63 months (range, 30-111 months). Patients with disease larger than 2 cm survived an average of 9 months (range, 5-17 months).


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