Use of a rectal spacer with low-dose-rate brachytherapy for treatment of prostate cancer in previously irradiated patients: Initial experience and short-term results

BackgroundSalvage brachytherapy in patients with prior pelvic radiation carries a risk of rectal injury. Herein, we report our initial experience using a hydrogel spacer between the prostate and the rectum during salvage brachytherapy.Methods and MaterialsA total of 11 patients with prostate cancer and prior radiotherapy (5 prostate brachytherapy, 2 prostate external beam radiation therapy [EBRT], and 4 rectal cancer EBRT) received ¹²⁵I brachytherapy after attempted placement of 10 cc of a diluted hydrogel spacer between the prostate and rectum.ResultsSpacing was achieved in 8 of the 11 (73%) patients but was not possible in 3 (1 prior brachytherapy and 2 prior EBRT) owing to fibrosis and adhesions. For the 8 patients in whom spacing was accomplished, the median space between the prostate and rectum was 10.9 mm (prior EBRT) vs. 7.7 mm (prior brachytherapy), p = 0.048. Median followup was 15.7 months. One patient developed a prostato-rectal fistula requiring a diverting colostomy. The 16-month estimate of late Grade 3 or 4 gastrointestinal or genitourinary toxicity was 26%. One patient developed lymph node–positive recurrence. The 16-month prostate-specific antigen failure-free survival rate was 89%. Compared with baseline, Expanded Prostate Cancer Index Composite for Clinical Practice urinary quality of life (QoL) was significantly worse at 3 and 6 months but not significantly worse by 1 year. There were no significant changes throughout the study period in bowel or sexual QoL.ConclusionHydrogel spacer placements may be feasible in most patients with prior pelvic radiation. Further followup is needed to determine whether spacer placement will produce long-term improvements in toxicity or QoL.     

Re-irradiation with interstitial pulsed-dose-rate brachytherapy for unresectable recurrent head and neck carcinoma

PurposeTo assess the long-term results of protocol-based interstitial pulsed-dose-rate (PDR) brachytherapy combined with simultaneous chemotherapy in selected patients with recurrent head and neck tumors not amenable to salvage surgery.Methods and MaterialsA total of 51 patients with recurrent head and neck cancer were treated with interstitial PDR brachytherapy. Forty patients (78%) had salvage brachytherapy alone using a median total dose of 60 Gy. Salvage brachytherapy in combination with external beam therapy was performed in 11 patients (22%) using a median total dose of D_REF = 27 Gy. Simultaneously with the PDR brachytherapy, a concomitant chemotherapy was administered in 35/51 (69%) of patients. The analysis was performed after a median followup of 58 months.ResultsLocal control rates calculated according to Kaplan–Meier after 2 and 5 years were 71% and 57%, respectively. Comparing results of salvage PDR brachytherapy with or without simultaneous chemotherapy, the 5-year local recurrence-free survival rates were 78.9% vs. 38.5% (p = 0.01), respectively. No other patient or treatment-related parameters had a significant influence on treatment results. A total of 9/51 (17.7%) and 6/51 (11.8%) patients developed soft-tissue necrosis or bone necrosis, respectively, but only 2% of patients required surgical treatment.ConclusionsPDR interstitial brachytherapy with pulse doses between 0.4 and 0.7 Gy/h/24 h with simultaneous chemotherapy is an effective and safe option for curative therapy in selected patients with head and neck cancer in previously irradiated areas, which are not suitable for salvage surgery.     

An MRI-based dose–response analysis of urinary sphincter dose and urinary morbidity after brachytherapy for prostate cancer in a phase II prospective trial

PurposeTo compare dose–volume histogram variables for the internal and external urinary sphincters (IUS/EUS) with urinary quality of life after prostate brachytherapy.Methods and MaterialsSubjects were 42 consecutive men from a prospective study of brachytherapy as monotherapy with ¹²⁵I for intermediate-risk localized prostate cancer. No patient received hormonal therapy. Preplanning constraints included prostate V₁₀₀ higher than 95%, V₁₅₀ lower than 60%, and V₂₀₀ lower than 20% and rectal R₁₀₀ less than 1 cm³. Patients completed the Expanded Prostate Cancer Index Composite quality-of-life questionnaire before and at 1, 4, 8, and 12 months after implantation, and urinary domain scores were analyzed. All structures including the IUS and EUS were contoured on T2-weighted MRI at day 30, and doses received were calculated from identification of seeds on CT. Spearman's (nonparametric) rank correlation coefficient (ρ) was used for statistical analyses.ResultsOverall urinary morbidity was worst at 1 month after the implant. Urinary function declined when the IUS V₂₈₅ was 0.4% (ρ = ?0.32, p = 0.04); bother worsened when the IUS V₃₅ was 99% (ρ = ?0.31, p = 0.05) or the EUS V₂₄₀ was 63% (ρ = ?0.31, p = 0.05); irritation increased when the IUS V₃₅ was 95% (ρ = ?0.37, p = 0.02) and the EUS V₂₆₅ was 24% (ρ = ?0.32, p = 0.04); and urgency worsened when the IUS V₃₅ was 99.5% (ρ = ?0.38, p = 0.02). Incontinence did not correlate with EUS or IUS dose.ConclusionsDoses to the IUS and EUS on MRI/CT predicted worse urinary function, with greater bother, irritative symptoms, and urgency. Incorporating MRI-based dose–volume histogram analysis into the treatment planning process may reduce acute urinary morbidity after brachytherapy.     

Clinical and dosimetric factors associated with acute rectal toxicity in patients treated with 131Cs brachytherapy for prostate cancer

Purpose¹³¹Cs has been recently introduced for use in prostate brachytherapy. We wished to identify clinical and dosimetric factors associated with acute bowel/rectal toxicity in patients treated with ¹³¹Cs.Methods and MaterialsPatients treated with ¹³¹Cs prostate brachytherapy at the University of Pittsburgh were asked to complete expanded prostate cancer index composite surveys preoperatively and at 2–4 weeks and 3 months postimplant. We identified patients who experienced acute and persistent acute bowel toxicity to determine if any factors could correlate with either situation.ResultsOne hundred six patients were treated with ¹³¹Cs from September 2006 to May 2008. Thirty-eight percent of patients met our criteria for patient-appreciated acute bowel symptoms. On multivariate analysis, the volume of rectum receiving 50% of the prescribed dose (R-V₅₀; 4.1 vs. 2.6 cc, p = 0.01), R-V₇₅ (1.3 vs. 0.62 cc, p = 0.01), the percentage of the prescribed dose received by 1 cc of the rectum (R-D-1cc; 75% vs. 64%, p = 0.02), and R-D-2cc (63% vs. 54%, p = 0.003) were found to be factors associated with a greater risk of severe acute bowel toxicity. At 3-month followup, 28% of patients had persistent acute bowel toxicity. On multivariate analysis, no factors were identified that correlated with persistent acute bowel toxicity.ConclusionsThis study identifies R-V₅₀, R-V₇₅, R-D-1cc, and R-D-2cc as factors associated with patient-appreciated acute rectal toxicity. We are performing dosimetric analysis to determine the optimal distance for the posterior needles from the prostate–rectal interface to decrease rectal dose while still maintaining adequate coverage of prostate.     

Rectal morbidity after permanent interstitial brachytherapy for prostate cancer—Impact of Day 1 vs. Day 30 computed tomography–based postimplant dosimetry

PurposeThe aim of the study was to evaluate bowel quality-of-life changes after prostate brachytherapy and the impact of Day 1 vs. Day 30 postimplant dosimetry.Methods and MaterialsIn 61 patients, computed tomography (CT) scans were performed at Days 1 and 30 after ¹²⁵I brachytherapy. The patients have been surveyed prospectively before (time A), 1 month (time B), and >1 year after treatment (time C) using a validated questionnaire (Expanded Prostate Cancer Index Composite). Different parameters were tested for their predictive value on bowel quality-of-life changes (bowel bother score decrease >20 points at time B = BB20; bowel bother score decrease >10 points at time C = BC10), including seed displacements.ResultsMean bowel function/bother score decreased 13/13 points at time B (p < 0.01) and 1/4 points at time C (change not significant). BB20 and BC10 were found in 25% and 20% of patients, respectively. Bowel bother score declines at time B correlated well with declines at time C (r = 0.53; p < 0.01). Prostate volume before implantation and the number of seeds per cubic centimeters were found to be predictive for BB20 and BC10. Smaller rectal wall volumes covered by the 60–100% isodoses at Day 1 were (paradoxically) found to be significantly predictive for BC10. Larger posterior seed displacements between Days 1 and 30 were significantly associated with BB20.ConclusionsQuality-of-life scores have not been found to change significantly >1 year after brachytherapy. Larger rectal wall volumes within higher isodoses at Day 1 or 30 were not found to be predisposing for adverse quality-of-life changes.     

Brachytherapy for penile cancer: Efficacy and impact on sexual function

PurposePenis brachytherapy (PB) remains an alternative in the cancer treatment. The objective of this study was to assess the oncologic outcomes, sexual function, and the sexual behavior of men treated by PB for a cancer of the penis.Methods and MaterialsBetween 1992 and 2009, 47 patients with a cancer of the penis were treated by PB (¹⁹²Ir), in the Toulouse, Montpellier, and Barcelona cancer centers. The investigation into their sexuality was obtained by means of questionnaire. A total of 21 French patients were approached, of whom 19 (mean age = 73.2 years) agreed to answer the questionnaire (participation rate = 90.5%).ResultsOncologic data: The specific survival and the disease-free survival at 5 years was 87.6% (95% confidence interval, 72.4–94.7%) and 84% (95% confidence interval, 57.6–94.7%), respectively. The rate of preservation of the penis was 66% (n = 31). Sexual data: Among the 17 patients sexually active before brachytherapy, 10 patients remained sexually active after treatment (58.8%). Of the 18 patients who had erections before PB, 17 still had them after treatment (94.4%). Age was the main predictive factor.ConclusionThe PB seems to have a moderated impact on the sexual functions and the sexual behavior of the patients.     

Brachytherapy provides comparable outcomes and improved cost-effectiveness in the treatment of low/intermediate prostate cancer

PurposeTo evaluate the cost-effectiveness and outcomes of low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy compared with intensity-modulated radiation therapy (IMRT) in patients with low/intermediate risk of prostate cancer.Methods and MaterialsOne thousand three hundred twenty-eight patients with low or intermediate risk of prostate cancer were treated with LDR (n = 207), HDR with four fractions (n = 252), or IMRT (n = 869) between January 1992 and December 2008. LDR patients were treated with palladium seeds to a median dose of 120 Gy, whereas HDR patients were treated to a median dose 38.0 Gy (four fractions). IMRT patients received 42–44 fractions with a median dose of 75.6 Gy. Clinical outcomes were compared, including biochemical failure, cause-specific survival, and overall survival.ResultsOverall, no differences in 5-year biochemical control (BC) or cause-specific survival were noted among treatment modalities. The calculated reimbursement for LDR brachytherapy, HDR brachytherapy with four fractions, and IMRT was $9,938; $17,514; and $29,356, respectively. HDR and LDR brachytherapy were statistically less costly to Medicare and the institution than IMRT (p < 0.001), and LDR brachytherapy was less costly than HDR brachytherapy (p = 0.01 and p < 0.001). Incremental cost-effectiveness ratios for cost to Medicare for BC with IMRT were $4045 and $2754 per percent of BC for LDR and HDR brachytherapy, respectively. Incremental cost-effectiveness ratio using institutional cost comparing IMRT with LDR and HDR brachytherapy was $4962 and $4824 per 1% improvement in BC.ConclusionsIn this study of patients with low and intermediate risk of prostate cancer, comparable outcomes at 5 years were noted between modalities with increased costs associated with IMRT.     

Body mass index,dose to organs at risk during vaginal brachytherapy,and the role of three-dimensional CT-based treatment planning

PurposeTo assess the effect of body mass index (BMI) on dose to organs at risk (OARs) during high-dose-rate vaginal brachytherapy and evaluate the role of three-dimensional dose evaluation during treatment planning.Methods and MaterialsThree-dimensional dosimetric data for rectum, bladder, sigmoid colon, and small bowel for 125 high-dose-rate vaginal brachytherapy fractions were analyzed. Dose–volume histograms were generated for D_{0.1 cc} and D_{2 cc} of each OAR. Contributing factors including the use of urinary catheter and cylinder size were also recorded. As different dose fractionations were used, the OAR doses were tabulated as a percent dose prescribed to 0.5 cm. All patients were treated to 4 cm of the vaginal length.ResultsMedian BMI in this cohort was 31.7 kg/m². The BMI values had a weak inverse correlation with D_{0.1 cc} to sigmoid colon (r_s = −0.18, p = 0.047) and D_{0.1 cc} to bladder (r_s = −0.19, p = 0.038). There was a strong inverse correlation of D_{2 cc} and increasing BMI (r_s = −0.64, p = 0.003). The median D_{2 cc} was 25.1% for BMI higher than 31 and 61.9% for BMI of 31 or lower. For D_{0.1 cc}, there was also a strong inverse correlation with increasing BMI (r_s = −0.57, p < 0.001). Median D_{1 cc} was 33.5% for BMI >31 and 84.4% for BMI ≤ 31. On multivariate analysis higher BMI remained a significant predictor of lower small bowel D_{2 cc} (p < 0.001) and D_{0.1 cc} (p < 0.001).ConclusionsWomen with a lower BMI receive higher doses to the bladder and small bowel compared with those with a higher BMI. Three-dimensional dose evaluation should be considered in patients with low BMI, particularly when combined with external beam radiation.     

Electronic brachytherapy for postsurgical adjuvant vaginal cuff irradiation therapy in endometrial and cervical cancer: A retrospective study

PurposeA new platform for brachytherapy called electronic brachytherapy (EBT) has been developed, which uses a miniature X-ray source to generate low-energy radiation. A retrospective study of adverse events and clinical outcomes in patients treated with EBT to the vaginal cuff, either as monotherapy or in combination with external beam radiation therapy (EBRT), was conducted.Methods and MaterialsMedical records were reviewed from 16 patients treated with postoperative EBT for endometrial (n = 13) or cervical cancer (n = 3) between February 2009 and November 2010. Patients received either intracavitary vaginal EBT alone or EBT in combination with EBRT. The radiobiologic effectiveness of EBT was assumed to be one.ResultsMedian follow-up was 20.5 months (range, 7–36 months). When EBT was used alone (n = 5), the median dose per fraction, number of fractions, and total dose delivered were: 6 Gy (range, 5.5–6.2 Gy), 5 fractions (range, 5–6), and 30 Gy (range, 30–34 Gy), respectively. When EBT was combined with EBRT, the EBT component median dose per fraction, number of fractions, and total dose delivered were: 5 Gy (range, 4.5–7 Gy), 2 fractions (range, 2–4), and 14 Gy (range, 9–20 Gy), respectively. The median EBRT dose was 45 Gy (range, 45–49.2 Gy). Our local control rate, locoregional (pelvic) control rate, and overall survival rate were 94%, 94%, and 88%, respectively. Of the 16 patients, 4 patients reported Grade 2 or greater toxicity (25%); however, there were no Grade 4–5 adverse events. Gynecologic, genitourinary, and gastrointestinal adverse events accounted for 57% (n = 4), 43% (n = 3), and 0% (n = 0) of all Grade 2 or greater side effects. No Grade 2 or higher toxicities were noted in patients treated with EBT alone.ConclusionEBT is an acceptable means of delivering postoperative vaginal brachytherapy and appears comparable with other methods; as the sole method of treatment, the toxicity rates of EBT are low.     

PSA bounce after prostate brachytherapy with or without neoadjuvant androgen deprivation

PurposeTo assess the impact of PSA bounce (PB) on biochemical failure (BF) and clinical failure (CF) in brachytherapy patients treated with or without neoadjuvant androgen deprivation (AD).Methods and MaterialsFrom 1987 to 2003, 691 patients with clinical stage T1–T3N0M0 prostate cancer were treated with external beam radiotherapy (EBRT) and high-dose-rate (HDR) brachytherapy boost (n = 407), HDR brachytherapy alone (n = 93), or permanent seed implant (n = 191). Three hundred seventeen patients (46%) received neoadjuvant/adjuvant AD with RT. BF was scored using 3 definitions (ASTRO—3 rises, nadir + 2 ng/ml, and threshold 3 ng/ml) based on current and absolute nadir (AN) methodologies. PB was defined as any increase in PSA followed by a decrease to the prior baseline or lower. The median followup was 4.0 years.ResultsForty-six patients (7%) experienced CF at 5 years. PB of ≥0.1, ≥1.0, and ≥2.0 ng/ml at any time after RT occurred in 330 (48%), 60 (9%), and 22 patients (3%) respectively. The use of an AN definition reduced the likelihood of scoring PB as BF across all levels. The patients receiving AD experienced significantly longer bounce duration. Bounce <1.0 ng/ml showed no association with CF. For bounce ≥1.0 ng/ml, 10% demonstrated CF vs. 6% without bounce of this amplitude (p = 0.27). Bounces ≥1.0 ng/ml were more likely to be scored as BFs for definitions based on current nadir (3 rises: 20% vs. 13%, nadir + 2: 43% vs. 11%, 3 at/after nadir: 57% vs. 12%) than those based on AN (3 rises: 8% vs. 10%, nadir + 2: 18% vs. 11%, 3 at/after nadir: 13% vs. 11%).ConclusionsBounces ≥1.0 ng/ml are rare after brachytherapy with or without neoadjuvant AD, occurring in less than 10% of patients. Low PBs have little impact on BF, but as PB amplitude increases, the BF rate increases. BF definitions based on AN are less sensitive to PB after brachytherapy.     

Dosimetric comparison of multichannel with one single-channel vaginal cylinder for vaginal cancer treatments with high-dose-rate brachytherapy

PurposeTo compare the three-dimensional (3D) image (CT/MR)-based planning with a multichannel vaginal cylinder (MVC) to a single-channel vaginal cylinder (SVC) for the treatment of vaginal cancer.Methods and MaterialsA total of 20 consecutive patients were treated with 3D CT/MR image-based high-dose-rate (HDR) brachytherapy using an MVC. All patients received external beam radiation therapy before HDR brachytherapy. A brachytherapy dose of 20–25 Gy of more than five fractions was delivered to clinical target volume (CTV). Retrospectively, treatment plans for all patients were generated using the central channel only to mimic an SVC applicator. The SVC plans were optimized to match CTV coverage with MVC plans. Dose homogeneity index as well as bladder, rectum, sigmoid, and urethral doses were compared.ResultsThe mean D₉₀ for CTV was 74.2 Gy (range: 48.8–84.1 Gy). The mean (±standard deviation) of dose homogeneity index for MVC vs. SVC was 0.49 (±0.19) and 0.52 (±0.23), respectively (p = 0.09). Mean bladder 0.1, 1, and 2 cc doses for MVC vs. SVC were 69 vs. 71.2 Gy (p = 0.35), 61.4 vs. 63.8 Gy (p = 0.1), and 59.5 vs. 60.9 Gy (p = 0.31), respectively. Similarly, mean rectum 0.1, 1, and 2 cc doses for MVC vs. SVC were 67.2 vs. 75.4 Gy (p = 0.005), 60.0 vs. 65.6 Gy (p = 0.008), and 57.3 vs. 62.0 Gy (p = 0.015), respectively, and mean sigmoid doses were 56.3 vs. 60.5 Gy (p = 0.10), 50.9 vs. 53.1 Gy (p = 0.09), and 49.1 vs. 50.7 Gy (p = 0.10), respectively.ConclusionThe 3D CT-/MR-based plan with MVC may provide better dose distribution in the management of certain clinical situations of vaginal cancer requiring intracavitary brachytherapy, especially in minimizing potential late rectal complications.     

Optimization for high-dose-rate brachytherapy of cervical cancer with adaptive simulated annealing and gradient descent

PurposeTo validate an in-house optimization program that uses adaptive simulated annealing (ASA) and gradient descent (GD) algorithms and investigate features of physical dose and generalized equivalent uniform dose (gEUD)–based objective functions in high-dose-rate (HDR) brachytherapy for cervical cancer.MethodsEight Syed/Neblett template-based cervical cancer HDR interstitial brachytherapy cases were used for this study. Brachytherapy treatment plans were first generated using inverse planning simulated annealing (IPSA). Using the same dwell positions designated in IPSA, plans were then optimized with both physical dose and gEUD-based objective functions, using both ASA and GD algorithms. Comparisons were made between plans both qualitatively and based on dose–volume parameters, evaluating each optimization method and objective function. A hybrid objective function was also designed and implemented in the in-house program.ResultsThe ASA plans are higher on bladder V_75% and D_2cc (p = 0.034) and lower on rectum V_75% and D_2cc (p = 0.034) than the IPSA plans. The ASA and GD plans are not significantly different. The gEUD-based plans have higher homogeneity index (p = 0.034), lower overdose index (p = 0.005), and lower rectum gEUD and normal tissue complication probability (p = 0.005) than the physical dose-based plans. The hybrid function can produce a plan with dosimetric parameters between the physical dose-based and gEUD-based plans. The optimized plans with the same objective value and dose–volume histogram could have different dose distributions.ConclusionsOur optimization program based on ASA and GD algorithms is flexible on objective functions, optimization parameters, and can generate optimized plans comparable with IPSA.     

Prognostic importance of tobacco use in men receiving definitive prostate brachytherapy

PurposeSeveral prominent publications have identified an overall association between tobacco use and an increased risk of disease recurrence and disease-specific mortality in prostate cancer patients. The authors explored whether tobacco use adversely impacts treatment outcomes in men treated with permanent interstitial brachytherapy.Methods and MaterialsFrom April 1995 to August 2008, 2057 patients underwent brachytherapy by a single brachytherapist. Median follow-up was 7.5 years. The role of tobacco use as a prognostic factor for biochemical progression-free survival, cause-specific survival, and overall survival was investigated. Differences in survival between smokers and nonsmokers were compared using Kaplan–Meier curves and log-rank tests.ResultsCurrent smokers presented with a lower body mass index (p < 0.001), smaller prostate size (p = 0.003), younger age (p < 0.001), higher prostate-specific antigen level (p = 0.002), a trend toward higher percentage biopsy core involvement (p = 0.08), higher incidence of perineural invasion (p = 0.015), and higher risk disease (p < 0.001) than former or nonsmokers. There was no difference in biochemical progression-free survival (p = 0.30) or cause-specific survival (p = 0.72) at 10 years for smokers compared with nonsmokers. On univariate and multivariate analysis, tobacco use was an adverse risk factor for overall survival (p < 0.001). There was no association between smoking and any prostate cancer-specific outcome.ConclusionsSmokers treated with brachytherapy have excellent outcomes and are at no higher risk of treatment failure than men who are nonsmokers.     

Prostate brachytherapy in men with gland volume of 100 cc or greater: Technique,cancer control,and morbidity

PurposeTo determine the outcomes of prostate seed implantation in men with prostate volume (PV) of 100 cc or greater (PV100).MethodsA total of 2051 men with localized prostate cancer were treated with permanent prostate brachytherapy of whom 34 (1.7%) had PV100 (mean, 126.2; range, 100–205 cc). The PV100 patients were older (mean, 69 vs. 66 years; p = 0.031), had higher initial prostate-specific antigen level (20.4 vs. 9.6 ng/mL, p < 0.001), and received a lower dose (182 vs. 194 Gy₂ biologic equivalent dose, p = 0.032). There were no differences in clinical stage, Gleason score, and baseline International Prostate Symptom Score. The mean followup time was 6.7 years (range, 2–18). Biochemical freedom from failure (bFFF) was defined using the Phoenix definition.ResultsThe BFFF at 10 years was no different between PV100 and smaller glands (82.4% vs. 84.5%, p = 0.71). At last followup, mean International Prostate Symptom Score for PV100 increased from 8.5 to 9.1 against 7.4 to 9.2 for smaller glands (p = 0.935). Urinary retention rates were higher for PV100 (6/34, 17.6% vs. 148/2017, 7.3%; odds ratio, 2.71; 95% confidence interval, 1.1–6.6; p = 0.038). Postimplant transurethral resection of the prostate was performed in none of the 34 patients with PV100 against 66 of the 2017 patients (3.3%, p < 0.001). Long-term radiation proctitis for PV100 were 1 of 34 (2.9%) against 82 of 2017 (4.1%, p = 0.741). Rectourethral fistula occurred in 4 patients (0.19%), that is, 1 of 34 (2.9%) in PV100 group and 3 of 2017 (0.1%, p < 0.001).ConclusionThis study demonstrates the feasibility of implanting patients with PV100. Very large PV does not influence bFFF. Although urinary retention rates were higher, the long-term urinary symptoms were no different between the two groups. Requirement for transurethral resection of the prostate was no higher in patients with PV100. Radiation proctitis rates were similar for both.     

Evaluating adjacent organ radiation doses from postoperative intracavitary vaginal vault brachytherapy for endometrial cancer

PurposeTo document doses received by critical organs during adjuvant high-dose-rate (HDR) vaginal vault brachytherapy.Methods and MaterialsPatients treated with HDR vaginal vault radiation between January 1, 2009, and January 31, 2012, who had a CT simulation with the treatment cylinder in situ were included. The CT scans were retrospectively reviewed and the rectum, sigmoid, small bowel, and bladder were contoured. Standardized plans treating the upper 4 cm of the vaginal vault were used to deliver a total of 21 Gy (Gy) at 0.5 cm from the apex of the vaginal vault in three fractions.ResultsThere were 41 patients. Median age was 62 years. The median vaginal cylinder diameter was 3 cm. The mean 2cc dose to the rectum, sigmoid, small bowel, and bladder were 5.7, 4.7, 4.0, and 5.6 Gy, respectively. Bladder volume ranged from 67–797 cc. Assuming minimal interfraction organ variation, the equivalent dose in 2 Gy/fraction was extrapolated from data and may be near or beyond organ tolerance for rectum, sigmoid, and small bowel in some cases. Spearman correlation found that increased bladder volume was not associated with adjacent organs at risk dose but may be associated with a trend (p = 0.06) toward increased bladder dose (R = 0.30).ConclusionsThis study describes the dose received by adjacent critical structures during vaginal vault HDR brachytherapy. This is important information for documentation in the rare setting of treatment-related toxicity or recurrence. Bladder volume was not associated with dose to adjacent organs.     

Reirradiation of paraaortic lymph node metastasis by brachytherapy with hyaluronate injection via paravertebral approach: With DVH comparison to IMRT

Purpose/IntroductionTo safely irradiate retroperitoneal targets as paraaortic lymph node by separating abdominal at-risk organs from the target during irradiation, we created a percutaneous paravertebral approach of high-dose-rate brachytherapy with hyaluronate gel injection (HGI). We report a case treated with this technique.Methods and MaterialsWe encountered a patient with symptomatic regrowth of paraaortic lymph node metastasis from prostatic cancer. He had previously received 58.4 Gy of radiotherapy to the same region 12 months prior. Brachytherapy needles and a HGI needle were deployed via the paravertebral approach under local anesthesia at our outpatient clinic.ResultsA single dose of 22.5 Gy (equivalent to 60.94 Gy in 2 Gy per fraction schedule calculated at α/β = 10) was delivered to the target, with preservation of the surrounding small intestine by HGI with D_2cc (minimum dose to the most irradiated volume of 2 mL) of 5.05 Gy. Therapeutic ratio was 3.64 times higher for this brachytherapy plan compared with an intensity-modulated radiation therapy plan. At followup at 1 year after brachytherapy, the symptoms had disappeared, tumor size had reduced with no fluorodeoxyglucose accumulation, and prostate-specific antigen level had decreased.ConclusionWe consider that high-dose-rate brachytherapy with the HGI procedure offers effective treatment even in this type of reirradiation situation.     

High-intensity focused ultrasound combined with transarterial chemoembolization for unresectable hepatocellular carcinoma: Long-term follow-up and clinical analysis

ObjectiveHigh-intensity focused ultrasound (HIFU) combined with transarterial chemoembolization (TACE) has been used to treat unresectable HCC, but its long-term effects and major prognostic factors remain to be determined. The purpose of this study was to assess its long-term effects and find major prognostic factors to help us select eligible patients in the future.Methods73 patients with unresectable HCC received follow-up after HIFU + TACE. The variables of sex, age, AFP level, liver function, tumor location, tumor number, tumor size, TNM staging (5th edition), TNM staging (6th edition), portal vein invasion, ultrasonic pathway of HIFU, TACE session and ablation response were evaluated by univariate analysis. Those variables with significant difference were assessed by multivariate analysis.ResultsThe mean follow-up time was 11.7 ± 11.1 months (range, 1–60 months). The median survival time and overall survival rates of 1, 2, 3-year were 12 months, 49.1%, 18.8%, 8.4%, respectively. 45.2% patients achieved complete ablation. At the end of follow-up, 51 patients (69.9%) died from tumor progression (27 patients), liver function failure (18 patients), hemorrhage of upper digestive tract (3 patients) and infection (3 patients). 1 with liver abscess, 2 with serious skin burns and 2 with rib fracture were observed after HIFU. On univariate analysis, age (P = 0.017), tumor size (P = 0.000), tumor number (P = 0.039), the 5th edition of TNM staging (P = 0.023), portal vein invasion (P = 0.02) and ablation response (P = 0.000) had significant difference. On multivariate analysis, ablation response (P = 0.001) and tumor size (P = 0.013) were major prognostic factors.ConclusionHIFU combined with TACE is a safe method with a low rate of severe complications. As major prognostic factors, ablation response and tumor size may help us predict the survival and select eligible patients clinically.