An age-corrected matched-pair study of erectile function in patients treated with dose-escalated adaptive image-guided intensity-modulated radiation therapy vs. high-dose-rate brachytherapy for prostate cancer

PurposeTo compare erectile dysfunction (ED) after adaptive dose-escalated image-guided intensity-modulated radiotherapy (IG-IMRT) and high-dose-rate interstitial brachytherapy (HDR) monotherapy.Methods and MaterialsLow- and intermediate-risk prostate cancer patients treated with IG-IMRT or HDR were matched on pretreatment ED, age, Gleason score, T-stage, and prostate specific antigen. Patients who received androgen deprivation therapy were excluded. ED was graded by Common Terminology Criteria for Adverse Events v4. Actuarial rates of ED were computed by the Kaplan–Meier method.ResultsThere were 384 patients with median followup of 2.0 years (0.5–6.1) for IG-IMRT and 2.0 years (0.5–8.7) for HDR. The median IG-IMRT dose was 75.6 Gy and HDR dose 38 Gy in four fractions. For patients with no pretreatment ED, actuarial rates of requiring intervention (Grade ≥2 ED) at 3 years were 31% for IG-IMRT and 19% for HDR (p = 0.23), and impotence despite medical intervention (Grade 3) were 0% for IG-IMRT and 6% for HDR (p = 0.06). For patients with Grade 1 pretreatment ED, Grade ≥2 ED at 3 years were 47% for IG-IMRT and 34% for HDR (p = 0.79), and Grade 3 ED were 15% in both groups (p = 0.59). For patients with Grade 2 pretreatment ED, Grade 3 ED at 3 years were 22% for IG-IMRT and 37% for HDR (p = 0.70). No variables were predictive of Grade ≥2 ED following treatment.ConclusionsRates of ED requiring medical intervention for both IG-IMRT and HDR are low and equivalent. Even patients with ED before treatment are likely to maintain potency with medication use at 3 years following treatment.     

Comparison of PSA relapse-free survival in patients treated with ultra-high-dose IMRT versus combination HDR brachytherapy and IMRT

PurposeWe report on a retrospective comparison of biochemical outcomes using an ultra-high dose of conventionally fractionated intensity-modulated radiation therapy (IMRT) vs. a lower dose of IMRT combined with high-dose-rate (HDR) brachytherapy to increase the biologically effective dose of IMRT.MethodsPatients received IMRT of 86.4 Gy (n = 470) or HDR brachytherapy (21 Gy in three fractions) followed by IMRT of 50.4 Gy (n = 160). Prostate-specific antigen (PSA) relapse was defined as PSA nadir + 2. Median followup was 53 months for IMRT alone and 47 months for HDR.ResultsThe 5-year actuarial PSA relapse-free survival (PRFS) for HDR plus IMRT vs. ultra-high-dose IMRT were 100% vs. 98%, 98% vs. 84%, and 93% vs. 71%, for National Comprehensive Cancer Network low- (p = 0.71), intermediate- (p < 0.001), and high-risk (p = 0.23) groups, respectively. Treatment (p = 0.0006), T stage (p < 0.0001), Gleason score (p < 0.0001), pretreatment PSA (p = 0.0037), risk group (p < 0.0001), and lack of androgen-deprivation therapy (p = 0.0005) were significantly associated with improved PRFS on univariate analysis. HDR plus IMRT vs. ultra-high-dose IMRT (p = 0.0012, hazard ratio [HR] = 0.184); age (p = 0.0222, HR = 0.965); and risk group (p < 0.0001, HR = 2.683) were associated with improved PRFS on multivariate analysis.ConclusionDose escalation of IMRT by adding HDR brachytherapy provided improved PRFS in the treatment of prostate cancer compared with ultra-high-dose IMRT, independent of risk group on multivariate analysis, with the most significant benefit for intermediate-risk patients.     

High-dose-rate brachytherapy for localized prostate adenocarcinoma post abdominoperineal resection of the rectum and pelvic irradiation: Technique and experience

PurposeTreatment options are limited for patients with localized prostate cancer and a prior history of abdominoperineal resection (APR) and pelvic irradiation. We have previously reported on the successful utility of high-dose-rate (HDR) brachytherapy salvage for prostate cancer failing definitive external beam radiation therapy (EBRT). In this report, we describe our technique and early experience with definitive HDR brachytherapy in patients post APR and pelvic EBRT.Patients and MethodsSix men with newly diagnosed localized prostate cancer had a prior history of APR and pelvic EBRT. Sixteen to 18 HDR catheters were placed transperineally under transperineal ultrasound–guidance. The critical first two catheters were placed freehand posterior to the inferior rami on both sides of the bulbar urethra under cystoscopic visualization. A template was used for subsequent catheter placement. Using CT-based planning, 5 men received 36 Gy in six fractions as monotherapy. One patient initially treated with EBRT to 30 Gy, received 24 Gy in four fractions.ResultsMedian age was 67.5 (56–74) years. At a median followup of 26 (14–60) months, all patients are alive and with no evidence of disease per the Phoenix definition of biochemical failure, with a median prostate-specific antigen nadir of 0.19 ng/mL. Three men have reported grade 2 late genitourinary toxicity. There has been no report of grade 3–5 toxicity.ConclusionTransperineal ultrasound–guided HDR brachytherapy using the above technique should be considered as definitive therapy for patients with localized prostate cancer and a prior history of APR and pelvic EBRT.     

High-dose-rate brachytherapy in combination with conformal external beam radiotherapy in the treatment of prostate cancer

PurposeTo report long-term outcomes for treatment of prostate cancer using dose escalation with high-dose-rate (HDR) brachytherapy and 3-dimensional conformal external beam radiotherapy (3DCRT), and compare them with outcomes for treatment of prostate cancer with 3DCRT alone at the same institution.Methods and MaterialsFrom 1998 to 2003, 587 patients were treated for clinically localized prostate cancer. Patients received either 3DCRT (median, 46 Gy) with a single HDR brachytherapy implant (196 patients) delivering a fractionated dose of 18 Gy (combined group) or 3DCRT (median, 70 Gy; 387 patients; “3DCRT alone”). There were 41.9% patients with intermediate-risk and 42.6% with high-risk disease. In all, 441 patients (75.1%) received neoadjuvant and 116 patients (19.8%) received adjuvant androgen deprivation therapy. The American Society of Therapeutic Radiology and Oncology Phoenix definition for biochemical failure was used.ResultsThe median followup was 5.5 years. The 5- and 7-year biochemical control (BC) rates were 82.5% and 80.3%, respectively, for the combined group and 81.3% and 71%, respectively, for 3DCRT alone; for overall survival, they were 91.9% and 89.5% vs. 88.7% and 86.2%, respectively, whereas for cause-specific survival, they were 96.9% and 96.1% vs. 97.6% and 96.2%, respectively. Cox proportional hazard regression analysis for BC revealed that low Gleason grade, HDR brachytherapy combined with 3DCRT, and adjuvant androgen deprivation therapy were significant in predicting BC. Radiation Therapy Oncology Group Grade 3 late urinary and rectal morbidity rates were 7.1% and 0%, respectively. No Grade ≥4 reactions were detected.ConclusionsHDR brachytherapy combined with 3DCRT was associated with improved BC and minimal toxicity in patients with unfavorable prostate cancer compared with conventional 3DCRT.     

Clinical outcomes of high-dose-rate brachytherapy and external beam radiotherapy in the management of clinically localized prostate cancer

PurposeTo report prostate-specific antigen (PSA) relapse-free survival and treatment-related toxicity outcomes after combining high-dose-rate (HDR) brachytherapy with external beam radiotherapy (EBRT) for patients with clinically localized prostate cancer.Methods and MaterialsBetween 1998 and 2009, 229 patients were treated with HDR brachytherapy followed 3 weeks later by supplemental EBRT. The HDR brachytherapy boost consisted of three fractions of ¹⁹²Ir (5.5–7.5 Gy per fraction), and EBRT consisted of intensity-modulated radiotherapy delivering an additional 45.0–50.4 Gy directed to the prostate gland and seminal vesicles. Median follow-up was 61 months.ResultsSeven-year PSA relapse-free survival for low-, intermediate-, and high-risk patients were 95%, 90%, and 57%, respectively (p < 0.001). Among high-risk patients treated with biological equivalent doses in excess of 190 Gy, 7-year PSA relapse-free survival was 81%. In multivariate analysis, Gleason scores of ≥8 predicted for increased risk of biochemical failure, whereas the use of short-term neoadjuvant androgen deprivation therapy did not influence tumor-control outcomes even among intermediate- or high-risk patients. Seven-year incidence of distant metastases for low-, intermediate-, and high-risk patients were 5%, 3%, and 17%, respectively. Seven-year incidence of late Grade 2 and 3 genitourinary toxicities were 22.1% and 4.9%, respectively and the 7-year incidence of Grade 2 and 3 gastrointestinal toxicities were 1% and 0.4%, respectively.ConclusionHDR prostate brachytherapy in conjunction with supplemental EBRT results in excellent biochemical relapse-free survival rates with a low incidence of severe late genitourinary or gastrointestinal toxicities. The use of short-term neoadjuvant androgen deprivation did not influence long-term biochemical tumor control in this cohort.     

Four-year outcomes of hypofractionated high-dose-rate prostate brachytherapy and external beam radiotherapy

PurposeHigh-dose-rate (HDR) brachytherapy boost in prostate cancer allows dose escalation and delivery of higher biologically effective dose (BED). We evaluated the outcomes of intensity-modulated radiation therapy (IMRT) and HDR boost in a community setting.Methods and MaterialsBetween July 2003 and April 2008, 148 patients with prostate cancer were treated at Cancer Center of Irvine using two transperineal implants performed 1 week apart (22 Gy delivered in four fractions divided between two insertions and delivered twice daily), followed by IMRT (50.4 Gy). Hormonal therapy was given for 1 year to all patients with Gleason score of 8 or higher.ResultsPatient characteristics are as follows: median age at treatment, 71 years; American Joint Committee on Cancer Group IIB, 53%; Gleason score of 7, 41%; and Gleason score of 8 or higher, 14%. Median followup was 49 months, and median prostate-specific antigen (PSA) nadir was 0.15 ng/mL. The 4-year actuarial biochemical disease-free survival (bDFS) was 96.8/81% by Phoenix/PSA lower than 0.5 ng/mL criteria. According to National Comprehensive Cancer Center Clinical Practice Guidelines–defined recurrence risk groups, 4-year bDFS for low risk was 100/92.9%, intermediate risk was 100/86.7%, and high risk was 94/75.4% by Phoenix/PSA lower than 0.5 ng/mL criteria. No statistically significant difference in bDFS was detected by either failure criteria based on risk group, lymph node risk, or initial PSA. Treatment was well tolerated. Subacute/late genitourinary and gastrointestinal toxicities were limited to 10% and 5%, respectively of all patients.ConclusionsProstate IMRT plus HDR brachytherapy boost was well tolerated with appropriate PSA response and bDFS at 4 years, demonstrated in a community setting. This treatment schema provides a high BED, comparable with hypofractionated prostate regimens previously reported in the literature. Higher BED delivery should be explored in further dose escalation studies.     

Interstitial brachytherapy vs. intensity-modulated radiation therapy for patients with cervical carcinoma not suitable for intracavitary radiation therapy

PurposeInterstitial brachytherapy (IBT) is the standard alternative treatment for patients with cervical carcinoma not suitable for intracavitary radiotherapy. There is an emerging belief that intensity-modulated radiotherapy (IMRT) has the potential to replace IBT. We aimed to compare the dosimetry achieved by IBT and IMRT in such patients.Methods and MaterialsThe CT imaging data, previously used for IBT planning of 12 patients with cervical carcinoma, were transferred to IMRT planning system to generate parallel IMRT plans. Prescribed dose to the planning target volume (PTV) was 20 Gy delivered in 2-weekly high-dose-rate fractions of 10 Gy each with IBT (biologically equivalent dose [BED₁₀] 40 Gy) and 33 Gy/13 fractions/2.5 wk with IMRT (BED₁₀ 41 Gy). For comparison, dose–volume parameters for target and organs at risk were recorded and expressed in terms of BED₁₀ and BED₃, respectively.ResultsFor PTV, the mean D₉₅ (dose received by 95% of PTV) was better with IBT (57.16 Gy vs. 41.47 Gy, p = 0.003). The mean conformity index was 0.94 and 0.90 with IBT and IMRT, respectively (p = 0.034). IBT delivered significantly reduced doses to 1.0 cc (D_max), 5.0 cc (D_{5 cc}), 50% (D₅₀), and 75% (D₇₅) of bladder volume as compared with IMRT. The mean rectal D_max was significantly better with IBT as compared with IMRT (54.64 Gy vs. 62.63 Gy, p = 0.02).ConclusionsIBT provides superior PTV coverage and organs at risk sparing to IMRT. Thus, IBT remains the standard treatment for patients with cervical carcinoma unsuitable for intracavitary radiotherapy.     

Phase I/II trial of single-fraction high-dose-rate brachytherapy-boosted hypofractionated intensity-modulated radiation therapy for localized adenocarcinoma of the prostate

PurposeA Phase I/II protocol was conducted to examine the toxicity and efficacy of the combination of intensity-modulated radiation therapy (IMRT) with a single-fraction high-dose-rate (HDR) brachytherapy implant.Methods and MaterialsFrom 2001 through 2006, 26 consecutive patients were treated on the trial. The primary objective was to demonstrate a high rate of completion without experiencing a treatment-limiting toxicity. Eligibility was limited to patients with T stage ≤2b, prostate-specific antigen (PSA) ≤20, and Gleason score ≤7. Treatment began with a single HDR fraction of 6 Gy to the entire prostate and 9 Gy to the peripheral zone, followed by IMRT optimized to deliver in 28 fractions with a normalized total dose of 70 Gy. Patients received 50.4 Gy to the pelvic lymph node. The prostate dose (IMRT and HDR) resulted in an average biologic equivalent dose >128 Gy (α/β = 3). Patients whose pretreatment PSA was ≥10 ng/mL, Gleason score 7, or stage ≥T2b received short-term androgen ablation.ResultsMedian followup was 53 months (9–68 months). There were no biochemical failures by either the American Society of Therapeutic Radiology and Oncology or the Phoenix definitions. The median nadir PSA was 0.32 ng/mL. All the 26 patients completed the treatment as prescribed. The rate of Grade 3 late genitourinary toxicity was 3.8% consisting of a urethral stricture. There was no other Grade 3 or 4 genitourinary or gastrointestinal toxicities.ConclusionsSingle-fraction HDR-boosted IMRT is a safe effective method of dose escalation for localized prostate cancer.     

High-dose-rate surface brachytherapy to boost elongated,curvilinear incisional scars after extrapleural pneumonectomy for malignant pleural mesothelioma treated with adjuvant intensity-modulated radiation therapy

PurposeProviding adequate dosimetric coverage of elongated, curvilinear incisions during adjuvant intensity-modulated radiation therapy (IMRT) after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) creates technical challenges. We explored high-dose-rate (HDR) surface brachytherapy to supplement dose to multiple curvilinear incisions. This modality circumvents the technical limitations of relying on multiple en face electron fields while minimizing dose to adjacent normal tissues.Methods and MaterialsA 59-year-old man presented with a left-sided, Stage III, T3N2M0, epithelioid MPM. After undergoing a left EPP, adjuvant IMRT was recommended to improve local control. An eight-field IMRT plan was designed to encompass the postoperative hemithorax. Incisional scars were lengthy and extended beyond the hemithoracic target volume. Both en face electron and surface HDR plans were prepared and evaluated based on dosimetric coverage of the incisional scars, dose to normal tissues, reliability of setup, and treatment delivery.ResultsHDR was preferred. The patient was planned and treated in the right lateral decubitus position. HDR source catheters were placed along the incisions atop 5-mm bolus. A composite plan including IMRT and brachytherapy dose contributions was produced. Boosts of incisional scars were performed in six fractions (three fractions per week) of 3 Gy prescribed to 12 mm from the catheter. HDR brachytherapy was well tolerated.ConclusionsSurface HDR brachytherapy is a viable option for supplemental dose to incisional scars at risk of local recurrence after EPP for MPM. Advantages over electron beam therapy include avoidance of field abutments and feathering, less tissue–bone interface dose uncertainty and reproducibility of treatment delivery.     

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.     

Analysis of high–dose rate brachytherapy dose distribution resemblance in CyberKnife hypofractionated treatment plans of localized prostate cancer

The present study is to analyze the CyberKnife hypofractionated dose distribution of localized prostate cancer in terms of high–dose rate (HDR) brachytherapy equivalent doses to assess the degree of HDR brachytherapy resemblance of CyberKnife dose distribution. Thirteen randomly selected localized prostate cancer cases treated using CyberKnife with a dose regimen of 36.25 Gy in 5 fractions were considered. HDR equivalent doses were calculated for 30 Gy in 3 fractions of HDR brachytherapy regimen. The D_5% of the target in the CyberKnife hypofractionation was 41.57 ± 2.41 Gy. The corresponding HDR fractionation (3 fractions) equivalent dose was 32.81 ± 1.86 Gy. The mean HDR fractionation equivalent dose, D_98%, was 27.93 ± 0.84 Gy. The V_100% of the prostate target was 95.57% ± 3.47%. The V_100% of the bladder and the rectum were 717.16 and 79.6 mm³, respectively. Analysis of the HDR equivalent dose of CyberKnife dose distribution indicates a comparable resemblance to HDR dose distribution in the peripheral target doses (D_98% to D_80%) reported in the literature. However, there is a substantial difference observed in the core high-dose regions especially in D_10% and D_5%. The dose fall-off within the OAR is also superior in reported HDR dose distribution than the HDR equivalent doses of CyberKnife.     

Clinical outcomes of high-dose-rate interstitial gynecologic brachytherapy using real-time CT guidance

PurposeTo evaluate clinical outcomes of CT-guided high-dose-rate (HDR) interstitial brachytherapy for primary and recurrent gynecologic cancer.Methods and MaterialsRecords were reviewed for 68 women (34 with primary disease and 34 with recurrence) treated with CT-guided HDR interstitial brachytherapy between May 2005 and September 2011. Interstitial application was performed under general anesthesia using an iterative approach of catheter insertion and adjustment with serial image acquisition by CT in a dedicated brachytherapy suite. The median fractional brachytherapy dose was 3.9 Gy delivered twice daily in seven fractions. The median cumulative dose in equivalent 2-Gy fractions was 74.8 Gy. Actuarial survival estimates were calculated using the Kaplan–Meier method, and toxicity was reported by Common Toxicity Criteria.ResultsPrimary disease sites were endometrial (34), cervical (17), vaginal (11), ovarian (3), and vulvar (3). Median age was 61.5 years, and tumor size at diagnosis was 3.4 cm. Median D₉₀ and V₁₀₀ were 73.6 Gy and 87.5%, respectively; median D_2cc for bladder, rectum, and sigmoid were 67.1, 64.6, and 53.7 Gy, respectively. With a median followup of 17 months, actuarial rates of local control, progression-free survival, and overall survival at 2 years for all patients were 86%, 60%, and 64%, respectively. There were 9 grade 3 late toxicities (six gastrointestinal and three vulvovaginal).ConclusionsHDR interstitial brachytherapy with CT-guided catheter placement results in acceptable local control, toxicity, and survival rates for women with primary or recurrent gynecologic cancer. Durable pelvic control may be achieved in most patients with this specialized brachytherapy technique.     

Gleason score 7 prostate cancer treated with interstitial brachytherapy with or without supplemental external beam radiation and androgen deprivation therapy: Is the primary pattern on needle biopsy prognostic?

PurposeTo evaluate the effect of primary Gleason pattern on biochemical progression-free survival (bPFS), cause-specific survival (CSS), and overall survival (OS) in Gleason 7 prostate cancer patients treated with low-dose-rate (LDR) interstitial brachytherapy with or without supplemental external beam radiation therapy and androgen deprivation therapy.Methods and MaterialsWe retrospectively reviewed the medical records of 932 consecutive patients with biopsy-confirmed Gleason 7 prostate cancer who received LDR interstitial brachytherapy as a component of their definitive treatment regimen. Treatment outcomes were compared between patients with primary Gleason pattern 3 and 4.ResultsWith a median followup of 7.4 years, the 10- and 14-year bPFS, CSS, and OS for the entire Gleason 7 study group were 95.7/95.7%, 98.6/98.6% and 77.2/64.3%, respectively. When biochemical control was evaluated as a function of primary Gleason pattern, the primary pattern 3 had a statistically higher 10- and 14-year bPFS (97.8/97.8% vs. 93.1/93.1%, p = 0.006). The Gleason pattern 3 patients also trended toward a higher 10- and 14-year CSS (99.3/99.3% vs. 96.9/96.9%, p = 0.058). OS was not statistically different between the two Gleason 7 cohorts.ConclusionsGleason 7 prostate cancer patients treated with LDR interstitial brachytherapy have an excellent long-term outcome. There was a small but statistically significant advantage in bPFS and a trend toward improved CSS in patients with a primary Gleason pattern of 3.     

High-dose-rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma

PurposeHigh-dose-rate (HDR) intraluminal brachytherapy for advanced or inoperable tumors of the rectum has been used both palliatively and to dose escalate after chemoradiation for curative treatment.MethodsBetween 1993 and 2007, 79 patients were treated with HDR afterloading brachytherapy for rectal cancer; 70 patients had adenocarcinoma of the rectum; and 9 patients had squamous cell carcinoma of the anal canal. Fifty-two patients had localized disease but were unfit for major surgery and received radiotherapy with radical intent. Twenty-seven patients with advanced or metastatic disease received palliative treatment. The median age was 82 years (range, 33–97). Radical treatment comprised either chemoradiation followed by intraluminal brachytherapy delivering 12 Gy at 1 cm in two fractions or radical monotherapy delivering up to 36 Gy at 1 cm in six fractions two to three times weekly. Palliative HDR brachytherapy schedules were predominantly 10 Gy at 1 cm single dose.ResultsObjective local tumor response was seen in 41 of 48 assessable patients (85%); of whom, 28 patients (58%) had a complete response and 13 (27%) had a partial response. The most common symptom was rectal bleeding, which was controlled with a complete response rate of 63%. The median duration of the symptom response was 3 months (range, 1–73), and the median survival of the palliative patients was 6 months (range, 1 week–37 months). The median survival for patients treated with radical intent was 18.5 months (range, 2–119). Six patients reported late toxicity with three cases of rectal ulcer, two strictures, and one fistula.ConclusionsIntraluminal HDR brachytherapy is effective as local treatment in both the radical and palliative setting, with high tumor and symptom response rates, and acceptable late toxicity.     

Efficacy of high-dose-rate interstitial brachytherapy in patients with oral tongue carcinoma

PurposeTo evaluate the results of high-dose-rate (HDR)-interstitial brachytherapy (ISBT) in oral tongue carcinomas.Methods and MaterialsBetween September 1999 and August 2007, 50 patients were treated for oral tongue carcinoma with HDR-ISBT. The patient's mean age was 58 years. Forty-two patients were in T1–2 stage and 8 patients were in T3 stage; 16 patients were in N+ stage and 34 patients in N0 stage. Exclusive ISBT was given to 17 patients (34%) in T1–2 N0 stage and complementary to external beam radiotherapy (EBRT) to 33 patients (66%). A perioperative technique was performed on 14 patients. The median total dose was 44 Gy when HDR was used alone (4 Gy per fraction) and 18 Gy when complementary to 50 Gy EBRT (3 Gy per fraction).ResultsThe median followup was 44 months. Actuarial disease-free survival rates at 3 and 5 years were 81% and 74%, respectively. Local failure developed in 7 patients. Actuarial local control (LC) rates were 87% and 79% at 3 and 5 years in T1–2 stage 94.5% and 91% and T3 stage 43% and 43% (with salvage surgery). Exclusive HDR cases showed LC in 100% of the cases, and the combined group (EBRT + HDR) showed LC in 80% and 69% of the cases at 3 and 5 years (p = 0.044). Soft-tissue necrosis developed in 16% and bone necrosis in 4% of the cases.ConclusionsHDR brachytherapy is an effective method for the treatment of oral tongue carcinoma in low-risk cases. Doses per fraction between 3 and 4 Gy yield LC and complication rates similar to low-dose rate. The perioperative technique promises encouraging results.     

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.     

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.     

Long-term outcomes with high-dose-rate brachytherapy for the management of base of tongue cancer

PurposeTo report the long-term results of a prospective, nonrandomized clinical trial using high-dose-rate (HDR) brachytherapy (BT) for the management of base of the tongue (BOT) tumors.Methods and MaterialsBetween January 1992 and June 2011, 60 patients (mean age, 57 years; range, 36–78 years) with T1–T4 and N0-3 carcinoma of BOT were treated. Fifty-six patients (93%) had advanced (Stage III-IV) disease. HDR BT boost (mean dose, 17 Gy; range, 12–30 Gy) was delivered after 50–70 Gy (mean 62 Gy) locoregional external beam irradiation. Seventeen patients (28%) received radiochemotherapy (RCT) with cisplatin.ResultsThe 5-year actuarial rate of local tumor control, locoregional tumor control, overall survival (OS), and cancer-specific survival (CSS) was 57%, 50%, 47%, and 61%, respectively. OS was significantly better in patients (n = 17) receiving RCT (69% vs. 39%; p = 0.005). Delayed soft-tissue ulceration occurred in seven patients (12%). Only one patient (<2%) developed osteoradionecrosis. In univariate analysis, the tumor size (T1–T2–T3 vs. T4) was found to have a significant effect on CSS (p = 0.043), whereas the nodal status (N0 vs. N+) affected locoregional tumor control (p = 0.042), OS (p = 0.002), and CSS (p = 0.015). Low histologic grade (1–2) was associated with better CSS (p = 0.020), whereas RCT significantly improved OS (p = 0.012).ConclusionsExternal beam irradiation combined with interstitial HDR BT boost results in good local tumor control with an acceptable rate of late side effects in patients with BOT carcinoma. RCT improves OS. Our results are similar to those reported with traditional low-dose-rate BT implants.     

Postoperative management of keloids: Low-dose-rate and high-dose-rate brachytherapy

PurposeWe report the experience of the Radiation Oncology Department of the European Institute of Oncology in Milan, Italy, on the adjuvant low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy. Brachytherapy might be useful to improve keloids recurrence rate or reduce keloids treatment side effects instead of external beam radiotherapy.Methods and MaterialsData on 70 consecutive patients treated after complete keloid surgical excision were retrospectively analyzed. First 38 patients and 46 keloids were treated with adjuvant LDR brachytherapy and the following 39 patients and 50 keloids underwent HDR treatment. Median delivered dose of LDR therapy was 16 Gy; HDR median dose was 12 Gy. Sixty-four keloids (66.7%) were symptomatic at diagnosis with pain, itching, or stress.ResultsFourteen relapses over 46 treated keloids (30.4%) were observed in the LDR group and 19 of 50 keloids (38%) in the HDR group (p = 0.521). Recurrence rate was significantly higher in males (p = 0.009), in patients younger than 44 years (p < 0.0001), for arms, neck, and chest wall anatomic sites (p = 0.0001) and for symptomatic keloids (p = 0.017). Aesthetic outcome was better in case of larger keloids (>8 cm) (p = 0.064). Symptomatic relief was achieved in 92% of HDR patients and only 68% of LDR patients (p = 0.032).ConclusionsPostoperative brachytherapy is an effective treatment for keloids. In our study, LDR and HDR treatments resulted in similar recurrence rate. Better symptomatic relief was reported in case of HDR treatment compared with the LDR regimen.