Use of stereotactic radiosurgery in the treatment of gynecologic malignancies: A review

Table 1 Summary of case series of stereotactic radiosurgery

Ref.	n	Cancer types	Disease setting	Dose	Response/ control rate	Survival	Grade 3/4 toxicities	Patterns of failure
Molla et al[3]	16	Cervical (7)Uterine (9)	Primary (stage 1-3) and recurrence	EBRT 45 GyTSRS 14-20 Gy/2-5 fractions +/- para-aortic boost (2 pts)	15 pts NED at 12.6 mo (1 recurrence)	Not reported	Rectal bleeding (1)	Not reported
Deodato et al[13]	11	Ovarian (4)Cervical (4)Uterine (3)	Recurrence	SRS 20-30 Gy/4-6 fractions	83.3% overall response rate63% recurrence at 19 mo	Not reported	None	Systemic/distant progression (n = 4)Local progression (n = 1)Local and systemic progression (n = 1)
Guckenburger et al[7]	19	Cervical (12)Uterine (7)	Recurrence	EBRT 50 GySRS 15 Gy/3 fractions+/- vaginal BT (3 pts)	3 yr local control rate 81%	Median OS 25 mo, PFS 16 mo	Intestino-vaginal fistula (2)Small bowel ileus (1)	Systemic progression (n = 7)Local tumor progression (n = 1)Comorbid illness (n = 1)Unknown (n = 1)
Choi et al[10]	30	Cervical (28)Uterine (2)	Recurrence	EBRT 27-45 GySRS 13-45 Gy/1-3 fractions	4 yr local control rate 67.4%	Median PFS 32 mo	Various (5)	Locoregional failure (13.8%)Distant mets (10.3%)Local and distant failure (6.9%)
Dewas et al[9]	16	Cervical (4)Uterine (1)Rectal (4)Anal (6)Bladder (1)	Recurrence	EBRT 36-66 Gy (3 pts)SRS 36 Gy/6 fractions	1 yr local control rate 51.4%	Median OS 11.5 mo (DFS 8.3 mo)	None	Not reported
Haas et al[6]	6	Cervical (6)	Primary (stage 3B-4)	EBRT 45 GySRS 19.5-20 Gy/3-5 fractions+/- 50.4-61.2 Gy IMRT boost (5 pts)	100% local control at 14 mo	100% at 14 mo	None	Not reported
Hsieh et al[2]	9	Cervical (9)	Primary(stage 3B-4A)	EBRT 50.4 GySRS 15-27 Gy/5-9 fractions	3 yr local control rate 77.8%	Median OS 13 mo	Diarrhea (1)Thrombocytopenia (1)Rectal bleeding (3)Rectovaginal fistula (1)	Distant metastases (44%)
Hsieh et al[2]	31	Uterine (31)	Primary(stage 1B-3C)	IMRT or SRS via HT 45-50.4 Gy/25-28 fractionsICBT 4.5-5 Gy x 2-6 fractions	Not reported	Median OS 21 mo	None	Distant metastases
Kubicek et al[19]	11	Cervical 7)Uterine (2)Vaginal (2)	Primary(stage 2-3C) and recurrence	EBRT or IMRT 45-50.4 GySRS 5-27.5 Gy/1-5 fractions	Not reported	73% overall survival at follow-up	Rectal bleeding (1)	Not reported
Kunos et al[20]	3	Vulvar (3)	Recurrence	SRS 24 Gy/3 fractions	Not reported	1-3 mo PFS	None	Out of field recurrence
Kunos et al[15]	5	Endometrial (1) 0varian (3) Cervical (1)	Recurrence	SRS 5-8 Gy x 3-5 fractions	Not reported	Not reported	Fatigue (1)	Distant metastases
Kunos et al[1]Phase II trial	50	Cervix (9) Endometrial (14)Ovarian (25) Vulvar (2)	Recurrence	SRS 24 Gy/3 fractions	6 mo clinical benefit 68%	Median OS 20.2 mo	Hyperbilirubinemia (1)Enterovaginal fistula (1)	Out of fieldrecurrence (62%)

EBRT: External beam radiation therapy; SRS: Stereotactic radiosurgery; NED: No evidence of disease; BT: Brachytherapy; OS: Overall survival: HT: Helical tomotherapy; IMRT: Intensity modulated radiation therapy; PFS: Progression free survival.

Table 2 Indications for SRS in recurrent and metastatic gynecologic malignancy

Recurrent cervical cancer	Recurrence in a previously radiated fields
	Recurrence in patients who are not candidates for pelvic exenteration
Complex oligometastases	Unresectable oligometastases
	Oligometastases in abdominal retroperitoneum
Central nervous system and brain metastases	Intracranial lesions not accessible to Gamma Knife