HPV, cancer, locally advanced stage, radiotherapy... At the age of 58, it feels like I have lived my life again

Cervical cancer - the number one malignant tumor of the female reproductive tract

Cervical cancer is one of the most common malignant tumors in women. In my country, the number of cervical cancer cases is more than 100,000 per year, ranking first among malignant tumors of the female reproductive tract. High-risk HPV infection is one of the important causes of cervical cancer. Common symptoms of cervical cancer include postmenopausal vaginal bleeding and abnormal secretions. As the disease progresses to the late stage, patients may experience ureteral obstruction, hydronephrosis and other discomfort symptoms.

Liping discovered contact vaginal bleeding 9 years after menopause. She was tested in the hospital for human papillomavirus 16 and was found to be positive. The colposcopy biopsy result showed squamous cell carcinoma. Combined with the results of other auxiliary examinations, she was diagnosed with cervical cancer (stage IIIC1).

What is the concept of cervical cancer stage IIIC1?

It means that the cancer cells have spread beyond the uterus and have metastasized to the pelvic lymph nodes, but have not yet involved the aortic lymph nodes, and are in the locally advanced stage.

Locally advanced cancer is not incurable and life is short.

HPV, cancer, locally advanced stage...Liping was brought into an abyss of extreme anxiety and panic by these successive blows.

She originally thought that the worst-case scenario would be surgery to remove the cancerous parts of the uterus and cervix and that would be the end of it. However, the disease is now in a locally advanced stage and she is worried that she will not be able to keep up with the growth of the tumor and will soon say goodbye to her family.

"Doctor, this disease... is there any cure? ... How much time do I have left?"

She murmured the question over and over again.

"certainly!"

The doctor's firm tone instantly pulled her back to the door to light after she had fallen into the abyss.

"It is crucial to carry out radical radiotherapy + synchronous sensitization chemotherapy during this period. Active cooperation with the treatment can achieve complete cure." The doctor added.

"Radiotherapy? Chemotherapy? Will that be painful?"

Li Ping couldn't help but think of the haggard appearance of terminally ill cancer patients in movies and TV dramas who lost their hair, shaved their heads, and had pale lips.

The doctor was well aware of Liping's concerns. He knew very well that in the fight against cancer, radiotherapy and chemotherapy were double-edged swords. While killing tumors, they would also have multiple effects on normal tissues.

Therefore, how to use advanced technical means to accurately defeat tumors, reduce damage to normal tissues, and ensure quality of life is a goal that doctors have been pursuing for a long time.

"You don't have to be too stressed. There are many technical methods to choose from for radiotherapy. We can choose the best plan for you."

The doctor then introduced the treatment plan in detail to Liping and her family, and asked them to participate in the decision-making process.

The doctor said that at present, for locally advanced cervical cancer of stage IIB and above like Liping, the standard treatment is radical radiotherapy combined with platinum-based synchronous chemotherapy, and radical radiotherapy for cervical cancer is mainly external radiotherapy, followed by close-range boost mode of irradiation of the cervix and its adjacent tumors. In external radiotherapy, the internal iliac, external iliac, obturator, presacral, common iliac pelvic lymphatic drainage areas and central areas such as the cervix, uterine body, and vagina need to be irradiated. Due to the large irradiation range of the target area, the irradiation dose of adjacent normal tissues such as the bladder, rectum, and small intestine also increases accordingly. Therefore, it is crucial to protect the tissues near the irradiated area. Simply put, we must work hard to cure the disease while ensuring that we suffer less.

Although Liping did not fully understand the explanations of these further professional treatments, she knew that doctors needed to choose the best way to curb the spread of her tumor while minimizing adverse damage as much as possible.

New precision radiotherapy method rekindles new hope for life

After full communication and discussion between the doctor and the patient, it was finally determined that Liping's radiotherapy plan would use "online adaptive radiotherapy based on iterative cone beam CT (iCBCT), using 9-field equally divided fixed-field intensity modulated radiotherapy (IMRT) technology."

So, what is online adaptive radiotherapy?

It uses high-definition image-guided radiotherapy (IGRT) before each treatment to evaluate the patient's organ anatomy and physiological changes, or feedback information during the treatment process such as the anatomical position and size of the tumor, analyze the differences between fractionated radiotherapy and the initial radiotherapy plan design, and make real-time adjustments to the treatment plan based on current changes.

Online adaptive radiotherapy has many obvious advantages in this regard. Online adaptive radiotherapy can solve the problem of tumor position and shape changes during treatment, and is particularly suitable for cases where the tumor itself or the surrounding normal organs change greatly between each fraction; and compared with offline adaptation, the patient does not need to leave the treatment bed during the radiotherapy fraction, and the pre-treatment scan image can be quickly re-formulated and implemented. This allows accurate radiotherapy of each tumor, which not only improves the accuracy of target area irradiation, but also better protects the normal tissue around the tumor.

Online adaptive radiotherapy overall treatment process

Regaining a healthy body from cancer in two months

Liping can't remember the name and principle of this technology, but she knows the benefits it can bring to her. Each time she only needs to lie on the treatment bed for more than 20 minutes, and the machine will quickly re-formulate a treatment plan based on the pre-treatment scan image and perform precise radiotherapy, while protecting other normal tissues to a great extent.

I thought I would have to go through a painful tug-of-war with radiotherapy, but the 28 online adaptive radiotherapy sessions in one month passed quickly. Liping never dreamed that her cervical space-occupying lesions would be significantly smaller than before. Then came five sessions of three-dimensional brachytherapy in the past half month, and six courses of cisplatin-sensitized chemotherapy during the external irradiation period. As the treatment progressed, her physical condition got better and better.

One month and four months after the treatment, Liping did not experience any recurrence or metastasis. What is even more worthy of celebration is that during the entire radiotherapy process, she only had mild diarrhea and did not experience any hematological, urogenital, or other radiotherapy-related adverse reactions.

Pelvic MRI image of the patient before radiotherapy showed a slightly longer cervical circumference and a high T2 signal (arrow)

Pelvic MRI images of the patient after radiotherapy A. After 26 rounds of radiotherapy, the cervix is ​​slightly longer in circumference and has a high T2 signal (arrow); B. One month after radiotherapy, the cervical T2 signal is lower than before (arrow); C. No abnormal signal is seen in the cervix 4 months after radiotherapy

▶ Last words

After going through cancer, radiotherapy and chemotherapy, Li Ping can finally say with a smile:

"Cancer is scary, but not as scary as it is in movies and TV shows. I can really trust my illness to doctors and advanced technology."

The doctors were also very happy about Liping's recovery, because this was the first radical radiotherapy for cervical cancer in China based on iterative cone beam CT (iCBCT) artificial intelligence online adaptive radiotherapy technology . This technology effectively solved the problem of loss of radiotherapy target area in cervical cancer patients due to factors such as large pelvic organ activity and tumor regression, and initially demonstrated clinical advantages in the degree of precision treatment.

Cervical cancer is one of the most common malignant tumors in women, which has a significant impact on women's physiology, psychology and even life. Although tens of millions of women suffer from cervical cancer, Liping is undoubtedly very lucky to have caught the "first train" of clinical application of online adaptive radiotherapy equipment based on iterative cone beam CT (iCBCT).

Mature technology and equipment, experienced doctors, trust and support from patients... have brought more opportunities for advancement in Liping's "life train". I believe that with the continuous upgrading of medical technology in the future, it will accompany more patients and go further in the fight against cancer.

▌This article is rewritten based on the article "Online Adaptive Radiotherapy for Locally Advanced Cervical Cancer: A Case Report" published in the 5th issue of Peking Union Medical College Journal in 2023

Original author: Wang Guangyu, Yan Junfang, Wang Zhiqun, Zhang Yu, Sun Xiansong, Li Jing, Li Wenbo, Yang Bo, Zhang Fuquan

Text rewrite: Wang Yan Liu Yang

Recommended reading:

New at Union Medical College | Online adaptive radiotherapy makes tumor treatment more accurate and safer

References:
[1] Wang Guangyu, Yan Junfang, Wang Zhiqun, et al. A case of locally advanced cervical cancer treated with online adaptive radiotherapy technology [J]. Peking Union Medical College Journal, 2023, 14(5): 1101-1105.

[2]Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries［J］. CA Cancer J Clin, 2021, 71: 209-249.

[3] Naga Ch P, Gurram L, Chopra S, et al. The management of locally advanced cervical cancer[J]. Curr Opin Oncol, 2018, 30: 323-329.

[4] Klopp AH, Yeung AR, Deshmukh S, et al. Patient-Reported Toxicity During Pelvic Intensity-Modulated Radiation Therapy: NRG Oncology-RTOG 1203[J]. J Clin Oncol, 2018, 36: 2538-2544.

Editor: Liu Yang and Zhao Na

Proofreading: Li Na, Li Yule, Dong Zhe, Li Huiwen

Producer: Wu Wenming

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