doi:10.1016/j.ijrobp.2006.02.041 CLINICAL INVESTIGATION Female Genital Tract PRELIMINARY OUTCOME AND TOXICITY REPORT OF EXTENDED-FIELD, INTENSITY-MODULATED RADIATION THERAPY FOR GYNECOLOGIC MALIGNANCIES JOSEPH K. SALAMA, M.D.,* ARNO J. MUNDT, M.D.,* † JOHN ROESKE,PH.D.,* † AND NEIL MEHTA, M.D.* *Department of Radiation and Cellular Oncology, University of Chicago, Chicago, IL; and † Department of Radiation Oncology, University of Illinois, Chicago, IL Purpose: The aim of this article is to report a preliminary analysis of our initial clinical experience with extended-field intensity-modulated radiotherapy for gynecologic malignancies. Methods and Materials: Between November 2002 and May 2005, 13 women with gynecologic malignancies were treated with extended-field radiation therapy. Of the women, 7 had endometrial cancer, 4 cervical cancer, 1 recurrent endometrial cancer, and 1 suspected cervical cancer. All women underwent computed tomography planning, with the upper vagina, parametria, and uterus (if present) contoured within the CTV. In addition, the clinical target volume contained the pelvic and presacral lymph nodes as well as the para-aortic lymph nodes. All acute toxicity was scored according to the Common Terminology Criteria for Adverse Events (CTCAE v 3.0). All late toxicity was scored using the Radiation Therapy Oncology Group late toxicity score. Results: The median follow-up was 11 months. Extended-field intensity-modulated radiation therapy (IMRT) for gynecologic malignancies was well tolerated. Two patients experienced Grade 3 or higher toxicity. Both patients were treated with concurrent cisplatin based chemotherapy. Neither patient was planned with bone marrow sparing. Eleven patients had no evidence of late toxicity. One patient with multiple previous surgeries experienced a bowel obstruction. One patient with bilateral grossly involved and unresectable common iliac nodes experienced bilateral lymphedema. Extended-field-IMRT achieved good local control with only 1 patient, who was metastatic at presentation, and 1 patient not able to complete treatment, experiencing in-field failure. Conclusions: Extended-field IMRT is safe and effective with a low incidence of acute toxicity. Longer follow-up is needed to assess chronic toxicity, although early results are promising. © 2006 Elsevier Inc. Intensity-modulated radiation therapy, Gynecology, Extended field, para-aortics. INTRODUCTION Extended-field radiotherapy, treatment of the pelvic and para-aortic nodal chains in contiguity, has long been a component of the armamentarium against gynecologic malignancies. In cervical cancer patients, the presence of metastatic spread to the para-aortic nodes portends a poor prognosis (1). In patients with locally advanced cervical cancer and positive para-aortic nodes, treatment of both the primary and gross nodal disease is necessary for radical treatment (2). A randomized trial conducted by the Radiation Therapy Oncology Group (RTOG) demon- strated an overall survival benefit to extended-field ra- diotherapy over pelvic radiotherapy for patients with cervical cancer (3). Furthermore, extended-field radiation therapy has been shown to improve local control in stage IIIC endometrial cancer patients (4). However, treatment of the pelvis and para-aortic nodal regions is not without its own inherent toxicity. In the recent update of the RTOG 90-01 trial, 12% of patients treated with extended-field radiotherapy had late Grade 3 to 4 toxicity (5). RTOG 79-02 reported an 8% risk of Grade 4 to 5 toxicity with extended-field treatment com- pared with 4% in the pelvic-only arm, which approached statistical significance (p = 0.06) (3). The addition of concurrent chemotherapy to extended-field radiotherapy magnifies the acute toxicity. Single-institution studies have reported 24% acute Grade 3 to 4 gastrointestinal toxicity and 24% incidence of treatment interruptions with concomitant cisplatin and extended-field radiation therapy (6, 7). Prospective phase II cooperative group trials have reported 49% Grade 3 to 4 acute bowel tox- icity (8) and 49% acute Grade 3 to 4 toxicities (2) with Reprint requests to: Joseph K. Salama, M.D., Department of Radiation and Cellular Oncology, University of Chicago, 5758 S. Maryland Avenue, MC 9006, Chicago, IL 60637-1407. Tel: (773) 702-6870; Fax: (773) 834-7340; E-mail: jsalama@ radonc.uchicago.edu Received Nov 7, 2005, and in revised form Jan 24, 2006. Accepted for publication Feb 9, 2006. Int. J. Radiation Oncology Biol. Phys., Vol. 65, No. 4, pp. 1170 –1176, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/06/$–see front matter 1170