Feasibility report of conservative surgery, perioperative high-dose-rate brachytherapy (PHDRB), and low-to-moderate dose external beam radiation therapy (EBRT) in pediatric sarcomas

PURPOSE: This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an accelerated boost in patients with pediatric sarcomas. METHODS AND MATERIALS: Five pediatric patients (ages 7-16) with soft tissue sarcomas (STS) or soft tissue recurrences of previously treated osteosarcomas were treated with surgical resection and PHDRB (16-24 Gy) for R0-R1 resections. Patients with STS and osteosarcomas received 27 Gy and 45 Gy of EBRT postoperatively. RESULTS: After a median follow-up of 27 months (range, 12-50) all the patients remain locally controlled. Only 1 patient developed regrowth of pulmonary metastases and died of distant disease at 16 months. CONCLUSIONS: The use of PHDRB is safe in the short-term in this pediatric population. Only 1 patient suffered a partial wound dehiscence that may not be entirely related to PHDRB. Patients with recurrent osteosarcomas can be treated in a fashion similar to their adult soft tissue counterparts and avoid limb amputation. Younger patients with STS may achieve local control and prevent growth retardation with a combination of PHDRB and moderate doses of EBRT.     

Endobronchial brachytherapy and optimization of local disease control in medically inoperable non-small cell lung carcinoma: a matched-pair analysis

PURPOSE: External beam radiation therapy (EBRT) alone for early stage, medically inoperable non-small cell lung cancer (MILC) can produce local disease control and sometimes cure. We have previously reported that higher EBRT doses result in improved disease control and, for patients with tumors > or =3.0 cm, improved survival. This report describes the impact of dose escalation with endobronchial brachytherapy boost during or following EBRT upon local disease control. METHODS AND MATERIALS: Medical records of 404 patients with MILC treated with radiotherapy alone were reviewed. Thirty-nine patients received a planned endobronchial brachytherapy boost during or following a course of EBRT. A matched-pair analysis of disease control and survival was performed by matching each brachytherapy patient to 2 EBRT patients from a reference group of the remaining patients. RESULTS: Endobronchial brachytherapy boost significantly improved local disease control over EBRT alone (58% vs. 32% at 5 years). The local control benefit for brachytherapy was found to be limited to patients with T(1-2) disease or tumors < or =5.0 cm. Among these patients treated with endobronchial boost, EBRT doses of > or =6500 cGy were necessary to optimize local disease control. No overall survival differences were observed at 3 years. Excess toxicity with brachytherapy was not observed. CONCLUSION: Endobronchial brachytherapy boost enhances local disease control rates in MILC treated with EBRT. Local control outcome is optimized when radical EBRT doses are used in conjunction with brachytherapy.     

Intraoperative single fraction high-dose-rate brachytherapy for head and neck cancers

PURPOSE: To report on the use of single fraction high-dose-rate brachytherapy in delivering localized intraoperative radiation therapy to sites in the head and neck region inaccessible to intraoperative electron beam radiotherapy (IOERT). METHODS AND MATERIALS: After maximal surgical resection, 7.5-20 Gy intraoperative high-dose-rate brachytherapy (IOHDR) was delivered to 65 patients using custom-made surface applicators. RESULTS: The 1-, 3-, and 5-year local control rates for the entire group were 77%, 69%, and 59%, respectively. The 1-, 3-, and 5-year overall survival rates were 83%, 63%, and 42%, respectively, with a median overall survival of 50 months. There were no major intraoperative or postoperative complications. CONCLUSIONS: IOHDR can be used to treat selected locally advanced head and neck tumors arising at sites inaccessible to IOERT or at institutions not using IOERT. A prospective multi-institutional study with a larger number of patients treated with IOHDR is needed to firmly establish the efficacy of IOHDR in this population group.     

Adjuvant high-dose-rate and low-dose-rate brachytherapy with external beam radiation in soft tissue sarcoma: a comparison of outcomes

PURPOSE: To compare outcomes of patients treated with low-dose-rate (LDR) adjuvant brachytherapy (BT) + external beam radiation therapy (EBRT) vs. high-dose-rate (HDR) adjuvant BT + EBRT. METHODS AND MATERIALS: Thirty-seven patients with soft tissue sarcoma (STS) were treated with pre- or postoperative external beam irradiation and postoperative LDR or HDR BT. RESULTS: There was no significant difference in the 2-year local control rates (90% with LDR boost vs. 94% for HDR). The rate of National Cancer Institute (NCI) grades 2-4 wound-healing complications was 40% in the LDR group vs. 18% in the HDR group (p = 0.14). On univariate analysis, only suboptimal geometry of the implant predicted for increasing complication rate in the LDR group. In the HDR group, BT dose per fraction, total BT dose, and total biologically equivalent dose (BED3) radiation dose were significant. CONCLUSIONS: HDR and LDR boost BT results in acceptable local control for STS. There is a suggestion that HDR may have lower incidence of severe (grade > or = 3) acute toxicity than LDR.     

Long term outcomes of Carcinoma Buccal Mucosa treated with High Dose Rate Interstitial Brachytherapy

PURPOSE: To analyze the long-term local control, overall survival and toxicity in Carcinoma Buccal Mucosa patients treated with interstitial brachytherapy.METHODS AND MATERIALS: This analysis included patients diagnosed as Carcinoma Buccal Mucosa on biopsy and treated with radical brachytherapy or External Beam Radiotherapy (EBRT) followed by brachytherapy boost. All patients received High dose rate (HDR) interstitial brachytherapy. The total dose was 35 Gy in ten fractions for brachytherapy alone. Patients who received EBRT (50–54 Gy) were boosted by brachytherapy to a dose of 18–24 Gy in 6–8 fractions. All patients were treated using CT based planning.RESULTS: Between 2007 to 2017, a total of 24 patients of Carcinoma Buccal Mucosa received HDR interstitial brachytherapy either alone or as a boost. Majority of the patients were tobacco chewers (80%). 17(71%) patients were clinical stage T2N0M0 and 7(29%) were clinically T1N0M0. At a median follow up of 7 years (3–12 years), the local control rate was 100% in stage I and 88% in stage II. The 5 year overall survival rate was 80%. Two patients developed nodal recurrence and one patient developed distant metastasis within two years of treatment. Tumor size and brachytherapy technique (radical vs. boost) did not impact local control or overall survival (p > 0.05). Majority of the acute toxicities were Grade 1 and 2. One patient developed osteoradionecrosis of the mandible.CONCLUSIONS: Interstitial brachytherapy in early-stage Buccal Mucosa cancer either alone or as a boost provides excellent long term local control and overall survival. The acute and late toxicities are acceptable with majority of the patients presenting with Grade 1 or 2 toxicity.     

Perioperative high-dose-rate brachytherapy in soft tissue sarcomas of the extremity and superficial trunk in adults: initial results of a pilot study

PURPOSE: This study was undertaken to determine the feasibility of perioperative high-dose-rate brachytherapy (PHDRB) as an alternative to standard low-dose-rate brachytherapy in adult patients with soft tissue sarcomas. METHODS AND MATERIALS: Twenty-five adult patients with soft tissue sarcomas of the extremities or the superficial trunk were treated with surgical resection and PHDRB (16, 24, or 32Gy) for negative, close/microscopically positive, or grossly involved surgical resection margins, respectively. External beam radiation therapy (45Gy) was added postoperatively. Adjuvant chemotherapy with ifosfamide and doxorubicin was given to patients with high-grade tumors. RESULTS: Resection margins were negative in 6 patients (24.0%), close/microscopically positive in 18 (72.0%), and grossly involved in 1 (4.0%). One patient (4.0%) with wound dehiscence needed reoperation. Three patients failed in the anatomical region treated, but relapse sites were not adjacent to the area treated with PHDRB. After a median followup of 23.2 months (range 2.8-48.0), the 4-year local and regional control rates were 100% and 80.5%, respectively. Four-year overall survival was 78.2%. CONCLUSIONS: Locoregional control and survival results are encouraging for this high-risk patient population. PHDRB results seem to be similar to those obtained with low-dose-rate brachytherapy.     

Feasibility and Early Results of Interstitial Intensity-Modulated HDR/PDR Brachytherapy (IMBT) with/without Complementary External-Beam Radiotherapy and Extended Surgery in Recurrent Pelvic Colorectal Cancer

BACKGROUND: A new multimodality treatment concept consisting of extended resection and postoperative fractionated intensity-modulated interstitial brachytherapy (IMBT) was introduced for pelvic recurrence of colorectal carcinoma. PATIENTS AND METHODS: 46 patients received extended resection and single plastic tubes were sutured directly onto the tumor bed. IMBT was started within 2 weeks postoperatively with a median dose of 24.5 Gy (5-35 Gy). Patients were treated either with high-dose-rate brachytherapy (HDR; n = 23) or with pulsed-dose-rate brachytherapy (PDR; n = 23). 25 patients received complementary 45-Gy external-beam irradiation (EBRT) to the pelvic region after explanting the plastic tubes. RESULTS: Median follow-up was 20.6 months (7-107 months) and mean patient survival 25.7 +/- 25.8 months (median 17, range 1-107 months). After 5 years overall survival, disease-free survival and local control rate were 23%, 20% and 33%, significantly influenced by the resectional state. There was a trend in favor of PDR compared to HDR, which reached statistical significance in patients who had not received additional EBRT. CONCLUSION: The combination of extended surgery and postoperative interstitial IMBT is feasible and offers effective interdisciplinary treatment of recurrent colorectal cancer. In this small and inhomogeneous cohort of patients PDR seems to be more effective than HDR, particularly when application of complementary EBRT is not possible. None of the patients who required resection of distant metastasis survived > 2 years in this study.     

Intraoperative Radiotherapy of Soft Tissue Sarcoma of the Extremity

PURPOSE: Evaluation of treatment outcome after intraoperative radiotherapy (IORT) +/- external-beam irradiation (EBRT) in patients with localized soft tissue sarcoma of the extremity at high risk for local recurrence after limb-sparing surgery. PATIENTS AND METHODS: 28 patients treated between 1989 and 1999 were evaluated retrospectively. Patients presented with locally recurrent (n = 17), T2 (n = 20), high-grade (n = 26), or incompletely resected tumors (n = 11). All patients underwent limbsparing surgery and IORT (median dose of 15 Gy) given either with high-dose-rate brachytherapy or a linear accelerator. 25 patients received additional EBRT with a mean of 50.6 Gy (range: 30.6-60 Gy). The mean follow-up time was 4.3 years (95% confidence interval [CI]: 3.0-5.6 years). RESULTS: The 5-year overall and distant disease-free survival rates were 66% and 54%, respectively. The overall actuarial recurrence rate after 5 years is 16% (95% CI: 1%, 31%). The crude rate after 8 years is 18%. Surgical margin status, primary versus recurrent tumor and tumor stage did not show any statistically significant influence (univariate analysis) on local recurrence rates. Patients with T1 tumors exhibited a borderline significant (p = 0.053) better distant disease-free survival (83%) compared to T2 tumors (43%). Five (24%) grade 3-4 late side effects were observed. CONCLUSION: In patients with high-risk soft tissue sarcomas, IORT +/- EBRT after limb-preserving surgery achieves high local control rates. The risk of normal tissue toxicities is comparable to conventional limb-sparing treatment.     

Radiotherapeutic strategies for soft tissue sarcomas in adults]

Soft tissue sarcomas account for under 1% of all cancers in adults. Most soft tissue tumours are benign, only about 1% being characterized clinically and histomorphologically as malignant neoplasms. Since these tumours are often treated by excisional biopsies without any further diagnostic imaging, precise planning of postoperative irradiation therapy is often difficult to achieve. Therefore, all soft tissue tumours with a short history should be regarded as malignant until the contrary has been proven. In general, the mode of tumour resection should be postponed until CT or MR diagnosis is complete and a biopsy of the tumour has been carried out. Whereas benign lesions need only marginal tumour resection, malignant lesions require considerable safety margins. In soft tissue sarcomas of the extremities, which account for 50-60% of all sarcomas, a wide local resection followed by postoperative irradiation with about 66 Gy can guarantee local control rates above 80% and preserve the function of the limb. Radical surgery alone can achieve the same local control, but without the high level of functional integrity. In the case of marginally resectable tumours, preoperative irradiation can induce partial tumour remission and thus allow definitive limb-sparing tumour resection. Recently, multimodal and neoadjuvant therapeutic strategies have been developed. The efficacy of these experimental strategies is not yet proven.     

Interstitial brachytherapy in soft tissue sarcomas

Background

Soft tissue sarcomas are relatively rare tumors with an aggressive natural history associated with a high propensity for local recurrence following conservative surgery. It accounts for 1.8% of all cancers seen at the Tata Memorial Hospital, Mumbai. Organ preserving surgery and tumor bed brachytherapy have revolutionized the management of soft tissue sarcomas.

Patients and Methods

One hundred and seventy-seven patients with histologically proven non-metastatic cases of soft tissue sarcomas in the age group of 16 to 79 years (median 41 years) were treated at the Tata Memorial Hospital between January 1983 and December 1992. One hundred and fifty-one patients who had completed a minimum of 24 months of treatment were studied. There were 100 males (66%) and 51 females (33%). The majority had recurrent lesions (70.3%). Extremities were involved in 75% of patients. Spindle cell sarcoma was the major histologic variant (30%). The patients underwent function preserving surgery and temporary afterloading Ir-192 tumor bed brachytherapy with or without external radiotherapy.

Results

In patients receiving brachytherapy only, 25 out of 33 (75%) were locally controlled after a median follow-up of 30 months. After successful salvage of local failures the overall local control improved to 82%. Similarly in the patients who received both interstitial, brachytherapy and external irradiation, the local control rate after a median follow-up of 40 months was 71% which improved to 86% after successful salvage. The overall treatment related complication rate was less than 1%. The only marginally significant prognostic factor for local control was tumor grade (p=0.06).

Conclusion s

The sequential combination of limited surgery and tumor bed brachytherapy with or without external radiotherapy has been established as an effective alternative to more ablative procedures like amputation. Histologic grade has proven to be a significant factor determining local control.     

Interstitial brachytherapy for soft tissue sarcoma: A single institution experience

PURPOSE: Soft tissue sarcomas (STSs) are an uncommon, histologically diverse group of malignancies, which are primarily treated with surgery. Depending on location and grade, radiation therapy may be used as adjuvant treatment. In this single institution, retrospective series, we examine treatment outcome for STS treated with surgery and adjuvant interstitial brachytherapy (BTX). METHODS AND MATERIALS: Forty-three patients were treated from 1997 to 2005 with adjuvant BTX for primary or recurrent STS. Thirty-four patients were treated for primary and nine for recurrent disease in locations including upper and lower extremity, pelvis, superficial trunk, and retroperitoneum. Twelve patients had low-grade and 31 had high-grade tumors. Most patients had lesions larger than 5 cm. Patients with low-grade tumors received 2500 cGy with BTX, followed by 4500 cGy with external beam radiation therapy (EBRT). High-grade tumors were treated with BTX alone to 4500 cGy if they were considered resectable at the time of diagnosis. For concern about resectability with conservative surgery, patients received 4500 cGy EBRT preoperatively, followed by a 2500 cGy BTX boost. RESULTS: Median followup was 39 months (range, 12-120). Thirty-four patients were known to be alive at last followup. The overall local control rate was 88%; local control was 87% for high-grade tumors and 92% for low-grade tumors. Disease-free survival was 75% overall with 88% free from distant metastases. No patient with low-grade sarcoma developed distant metastasis. Overall survival was 79%. The rate of long-term musculoskeletal or neurologic toxicity >Grade 3 was 7%, with all but a single case occurring in patients treated with EBRT plus BTX. CONCLUSIONS: Adjuvant interstitial BTX seemed to provide acceptable local control with well tolerated treatment in patients with low- and high-grade STS.     

Brachytherapy for pediatric tumors

PURPOSE: Pediatric tumors are generally managed with a multi-modality treatment program that includes surgery, chemotherapy, and teletherapy. The use of teletherapy in young children can result in significant long-term toxicity (especially retardation of growth of bones and organs). The use of brachytherapy is an attractive alternative because brachytherapy irradiates small volumes and can thus potentially minimize complications. METHODS AND MATERIALS: The brachytherapy techniques used are similar to those used in adults. Low-dose-rate brachytherapy with manually-afterloaded removable 192Ir is commonly used though it is associated with some radiation exposure hazards. Low energy radionuclides and remote afterloading technology have been used to reduce the radiation exposure hazards. Teletherapy is often added in the treatment of more extensive tumors, especially in older children. RESULTS: Brachytherapy (as the sole radiation modality) to small volumes in conjunction with chemotherapy and surgery has produced good local control with growth preservation and acceptable late complications in selected patients with localized tumors. CONCLUSION: Brachytherapy increases local control with a decrease in the probability of late complications (especially altered bone and organ growth) in comparison to EBRT. Low energy radionuclides and remote afterloading technology (HDR, IOHDR, and PDR) have been used to extend treatment to infants and younger children while reducing the radiation exposure to patients, family, and medical personnel.     

A phase IB clinical trial of 15 Gy HDR brachytherapy followed by hypofractionated/SBRT in the management of intermediate-risk prostate cancer

PurposeHigh dose-rate (HDR) brachytherapy is commonly administered as a boost to external beam radiation therapy (EBRT). Our purpose was to compare toxicity with increasingly hypofractionated EBRT in combination with a single 15 Gy HDR boost for men with intermediate-risk prostate cancer.Methods and MaterialsForty-two men were enrolled on this phase IB clinical trial to one of three EBRT dose cohorts: 10 fractions, seven fractions, or five fractions. Patients were followed prospectively for safety, efficacy, and health-related quality of life (Expanded Prostate Index Composite). Efficacy was assessed biochemically using the Phoenix definition.ResultsWith a median follow up of 36 months, the biochemical disease-free survival was 95.5%. One man developed metastatic disease at 5 years. There was no significant minimally important difference in EPIC PRO for either urinary, bowel, or sexual domains. There was one acute Grade 3 GI and GU toxicity, but no late Grade 3 GU or GI toxicities.ConclusionFifteen gray HDR brachytherapy followed by a five fraction SBRT approach results in high disease control rates and low toxicity similar to previously reported HDR protocols with significant improvement in patient convenience and resource savings. While mature results with longer follow up are awaited, this treatment approach may be considered a safe and effective option for men with intermediate-risk disease.     

Clinical outcome after treatment with a brachytherapy boost versus external beam boost for anal carcinoma

PURPOSE: To evaluate the outcome after definitive whole pelvis external beam radiotherapy (EBRT) followed by brachytherapy (BT) boost after treatment break vs. external beam boost without break in the treatment of anal carcinoma. METHODS AND MATERIALS: Eighty-one consecutive patients with invasive anal carcinoma were analyzed retrospectively. Patients treated with an interstitial (192)Ir high-dose-rate (HDR) implant boost of 14Gy/7 fractions/3d given 3 weeks after completion of whole pelvis 45Gy EBRT were compared with those treated with external beam boost of 14.4Gy, started immediately after completion of whole pelvis 45Gy EBRT. Concomitant chemotherapy (CT) with mitomycin C was applied during whole pelvis EBRT depending on tumor stage. Pattern of care, local disease control (LC), cancer-specific survival (CSS), overall survival (OS), toxicity, and quality of life (QOL) were assessed. RESULTS: Radiotherapy with or without concomitant CT achieved clinical complete response in 93.4% of patients. In early stage tumors, (192)Ir-HDR BT boost with CT resulted in a 5-year LC and CSS of 100%. In all patients, BT boost did not result in improved LC, OS, and CSS compared with EBRT boost, despite stage and treatment bias favoring small tumors to be treated with BT. The 5-year and 10-year OS were 66% and 44% (BT boost) and 66% and 52% (EBRT boost), respectively. Subgroup analysis of Stages I and II disease revealed no significant improvement after BT boost compared with EBRT boost. Acute skin toxicity was less common in the BT boost group (whole cohort: p=0.14; Stages I-IIIa: p=0.05), but long-term morbidity and QOL were similar. No local necrosis was seen after BT boost and the 10-year sphincter preservation rate was 87% in these patients. CONCLUSIONS: Interstitial (192)Ir-HDR implant boost with break and EBRT boost without break yield similar results. Acute skin toxicity is reduced with BT boost but long-term morbidity and QOL are identical. BT boost is most beneficial in early stage tumors but the advantage of BT seems to be limited due to its invasiveness, doctor dependence, and logistic circumstances.     

Interstitial High-Dose-Rate Brachytherapy in the Treatment of Base of Tongue Carcinoma

BACKGROUND AND PURPOSE:. To date none of the studies examined the feasibility and efficacy of interstitial high-dose-rate (HDR) brachytherapy in the treatment of carcinoma of the tongue base. Therefore the aim of this study was to contribute to this issue. PATIENTS AND METHODS:. Between 1992 and 2000 37 patients (mean age 55 years) with T1-4 and N0-3 carcinoma of the base of tongue were presented. Neck dissection was carried out in twelve cases (32%). 30 patients with advanced stage received brachytherapy boost after 50-66.5 Gy (mean, 60 Gy) locoregional external beam irradiation (EBI) and 7 patients with early stage (T1-2, N0) were managed locally with wide tumor excision and sole brachytherapy. 4 of them underwent neck dissection and the others were subjected to 50 Gy regional EBI. The mean dose of boost and sole brachytherapy was 18 Gy and 28 Gy, respectively. RESULTS:. The median follow-up time for surviving patients was 51 months. The 7 sole brachytherapy patients are living with no evidence of disease. For patients treated with EBI and brachytherapy boost, the 5-year actuarial rate of local, locoregional recurrence-free and overall survival was 60%, 52% and 46%, respectively. For all patients in univariate analysis larger tumor size (T4 vs. T1-3) was significant negative predictor of local (RR: 7.23) and locoregional control (RR: 3.87), but nodal involvement was not. Delayed soft tissue ulceration and osteoradionecrosis occurred in 4 (13%) EBI and brachytherapy treated patients. None of the sole brachytherapy patients experienced severe late radiation toxicity. CONCLUSION:. EBI combined with interstitial HDR brachytherapy boost result in acceptable local tumor control with low incidence of late side effects in patients with advanced disease. Fractionated sole HDR brachytherapy following tumor excision is a feasible treatment option for patients with early stage cancer and gives excellent local results.     

Perianal mucinous carcinoma successfully treated with a combination of external beam radiotherapy and high dose rate interstitial brachytherapy

The case of an 84-year-old man with perianal mucinous carcinoma is presented. The tumour was 6 cm in diameter and extended into the surrounding tissues. Taking the patient's advanced age and disease into account, rectosigmoidectomy and colostomy were carried out without resection of most of the tumour. Radiotherapy consisted of pre-operative external beam radiotherapy (EBRT) of 40 Gy in 20 fractions, post-operative EBRT of 24 Gy in 12 fractions, and high dose rate interstitial brachytherapy of 12 Gy in a single fraction. The patient tolerated the entire course of radiotherapy well. The patient is doing well without regrowth or complications 7 years after radiotherapy. To our knowledge, there have been no reports on the successful outcome of radiotherapy for perianal mucinous carcinoma. This case suggests that a combination of EBRT plus interstitial brachytherapy boost may play a role in the definitive treatment of perianal mucinous carcinoma.     

Twice-daily high-dose-rate brachytherapy for medically inoperable uterine cancer

PURPOSE: Medically inoperable patients with uterine cancer pose a therapeutic challenge. We developed a twice-daily schedule of high-dose-rate brachytherapy (HDRB) after a single insertion procedure that required a hospitalization of 3 days. METHODS AND MATERIALS: Favorable patients were offered brachytherapy alone, and all other patients received HDRB after pelvic external beam radiation therapy (EBRT). The prescribed dose was 7Gyx5 fractions and 4-5Gyx4-5 fractions for those treated after EBRT. HDRB was delivered with a b.i.d. schedule (4-6-h interval). RESULTS: Twenty-two patients (21 Stage I, 1 Stage IIB) were deemed medically inoperable. Sixteen patients received EBRT followed by HDRB, and six received HDRB alone. There were no procedural complications or significant acute toxicity. No thromboembolic events occurred within 30 days of the implant. CONCLUSIONS: This technique allows patients to be treated using a single procedure for insertion, with brief hospitalization for twice-daily HDRB.     

Post-treatment complications of soft tissue tumours

Purpose

To identify local and distant complications of patients with soft tissue tumours and evaluate their relationships to types of therapy.

Methods and materials

Fifty-one patients (29 males and 22 females, ages 14–80 years) with 34 malignant and 17 benign soft tissue tumours were evaluated for local and distant complications after resection or amputation only (26 patients) or after the addition of radiotherapy (25 patients: 17 patients had external beam therapy, 7 patients had external beam therapy and brachytherapy, and one patient had extracorporeal irradiation and reimplantation). Duration of follow-up averaged 3.75 years for malignant tumours and 2.79 years for benign tumours. Follow-up studies included radiography, T1- and T2-weighted magnetic resonance (MR) imaging, dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), computed tomography for thoracic and abdominal metastases, and 3-phase technetium-99m-labeled-methylene-diphosphonate scintigraphy for bone metastases.

Results

Recurrent tumours were 2.2 times more frequent in patients who had undergone their initial resection at an outside hospital as compared with those first treated at the university hospital. Nine of 11 recurrences occurred after marginal surgery. Metastases from soft tissue sarcomas, most commonly to lung (nine patients) and to bone and muscle (five patients), showed no specific relationship to type of therapy. DCE-MRI differentiated rapidly enhancing soft tissue recurrences (11 patients) and residual tumours (6 patients) from slowly enhancing muscle inflammation, and non-enhancing fibrosis and seromas that usually did not enhance. Seromas developed in 76% of patients who had postoperative radiation therapy and in 7.7% of patients who had only surgery. Subcutaneous and cutaneous oedema and muscle inflammation was at least four times more frequent after adjunct radiotherapy than after resection alone. Irrespective of the type of treatment, inflammatory changes in muscle and subcutaneous and cutaneous tissue and the majority of seromas were evident at the first follow-up study. Although seromas after resection and external beam therapy resolved with time, seromas after additional brachytherapy persisted. Inflammatory changes in muscle and cutaneous and subcutaneous tissue after resection alone disappeared by the second follow-up study, whereas these changes after radiotherapy resolved months to years after treatment. Fourteen of 51 patients showed MR findings of chronic muscular atrophy, predominantly located in the lower extremity. Heterotopic ossification was seen in three patients after resection and amputation without radiotherapy. Except for one patient with aggressive fibromatosis, bone and nerve complications occurred in patients with soft tissue malignancy. Twelve patients had osteoporosis. Six patients sustained fractures in irradiated osteoporotic bone of the lower extremity, and one patient had a vertebral fracture in radiographically normal but irradiated bone. In addition, one patient was found to have a medullary infarct in an irradiated femur. In nerve entrapment, DCE-MRI demonstrated the rapidly enhancing recurrent tumour or non-enhancing fibrosis surrounding the slowly enhancing nerve. T1- and T2-weighted MR images displayed the acute and chronic sequelae of nerve entrapment and nerve transection with denervation as T2-hyperintense acute muscle atrophy or T1-hypertense chronic fatty muscular atrophy with decrease in muscle volume.

Conclusion

This study suggests a possible relationship between types of treatment of soft tissue tumours and subsequent complications. Postoperative radiotherapy was associated with a significant number of patients with seromas, muscle, cutaneous and subcutaneous inflammation, and fractures. Incomplete or difficult surgery resulted in residual or recurrent tumours and heterotopic ossification. Muscle atrophy and nerve entrapment were related to both treatments (resection alone or radiotherapy after resection). Diligent follow-up of patients with soft tissue tumours with recognition of these complications and their differentiation from recurrent or residual tumour can help guide clinical care and may negate the need for surgery when benign disease is defined.     

Identifying disparities in brachytherapy delivery for locally advanced cervical cancer

IntroductionThe standard of care for locally advanced cervical cancer is concurrent chemotherapy and external beam radiation therapy (EBRT) followed by a brachytherapy boost. Some studies show a decreased usage of brachytherapy in cervical cancer patients despite the standard of care and known survival advantage. This study aims to characterize the utilization of brachytherapy in Oregon and identify where disparities in treatment may exist.MethodsThe Oregon State Cancer Registry database was used to identify patients diagnosed with FIGO Stage IB2-IVB cervical cancer between 2007 and 2016. Patients who received initial EBRT were categorized by whether they received brachytherapy boost or not. Age at diagnosis, county of patient residence, rural-urban status of the county, race/ethnicity, and insurance payer were studied using multivariable logistic regression to identify possible underserved populations. Survival data was compared using a Cox proportional hazard survival model.Results401 patients who received primary EBRT for FIGO stage IB2-IVB cervical cancer were identified in the 10-year span. Breakdown by stage is: 16% stage IB2, 23.9% stage II, 37.4% stage III, and 22.7% stage IV. Of those, 154 (38.4%) received brachytherapy boost treatment, 75 (18.7%) received a different boost modality, and 42.9% received no boost. Stage IV (p = 0.001) and uninsured patients (p = 0.04) were significantly less likely to receive brachytherapy. Older age was also associated with decreased brachytherapy usage, as each additional year of life decreased brachytherapy receipt by 1.8% (p = 0.04). Native American and Pacific Islander patients were the only group significantly more likely to receive brachytherapy (p=0.003). There was no significant difference in the rate of brachytherapy boost identified based on urban/rural status of the county (p = 0.63 to 0.69), other racial/ethnic categories (p = 0.66 to 0.80), or among the other stages (p=0.45 to 0.63). In Cox proportional hazard survival analysis, patients that received brachytherapy showed a 42% reduction in risk of cancer specific mortality, though this did not reach the predetermined level of statistical significance (p = 0.057).ConclusionsThe brachytherapy boost rate among locally advanced cervical cancer patients was 38.4%. The data also indicated a likely reduction in cancer specific mortality in patients receiving brachytherapy. Older patients, stage IV patients, and uninsured patients were less likely to receive brachytherapy. Given the low overall brachytherapy usage, these data indicate access and delivery of brachytherapy care needs to be improved across the state. The increased brachytherapy use in the American Indian and Pacific Islander patient population should be further studied to identify facilitators to treatment completion and potentially extrapolate to other groups.