Manual vs. automated implantation of seeds in prostate brachytherapy: Oncologic results from a single-center study

PurposeThe objective of this study was to study survival and tolerance of prostate cancer patients treated with ¹²⁵I permanent interstitial brachytherapy by automated vs. manual implantation of seeds.Methods and MaterialsBetween 2002 and 2010, 349 selected patients were treated with ¹²⁵I brachytherapy by the same team: from 2002 to April 2005, 65 patients with linked seeds and then 284 patients treated using Nucletron First System automated implantation. We analyzed biochemical recurrence-free survival (bRFS) rates and toxicities (univariate and multivariate analyses).ResultsTwo hundred seventy-seven (79.4%) and 69 patients (19.8%) with low- and intermediate-risk disease were treated, respectively (median follow-up: 64 months). The 5-year bRFS rate was 93.1% (95% confidence interval 89.3–95.6) for the entire cohort. The 5-year bRFS rates were 93.4% and 91.7% for patients with low- and intermediate-risk disease, respectively (p = 0.42). In univariate and multivariate analyses, there was no statistically significant difference in the 5-year bRFS rate depending on the implantation technique (93.1% vs. 91.8%, respectively, for automated and linked seeds; p = 0.53). In univariate analysis, only D₉₀ prostate (dose delivered to 90% of the prostate) <140 Gy (p = 0.01), lack of prostate-specific antigen bounce (p = 0.008), and nadir prostate-specific antigen >0.11 (p = 0.01) were predictive factors for bRFS. We observed Grade 3 urethritis in 7 patients (2%), urinary incontinence in 2 patients (0.7%), and Grade 4 proctitis in 2 patients (0.7%).ConclusionsIn this large single-center series, brachytherapy for selected localized prostate cancer achieved excellent rates of biochemical control at 5 years (93.1%) with an acceptable toxicity profile, irrespective of the implantation technique used.     

Do high radiation doses in locally advanced prostate cancer patients treated with 103Pd implant plus external beam irradiation cause increased urinary,rectal, and sexual morbidity?

PurposeTo investigate the morbidity of higher radiation doses in prostate cancer patients.Methods and MaterialsFive hundred eighty-five men treated with seed implantation and external beam irradiation were followed a median of 5 years (range, 2–11). Hormonal therapy (HT) of 9 months duration was used in 504 (86.2%) patients. The biologic effective dose (BED) was calculated using an α/β of 2. Urinary incontinence (UI) and symptoms (IPSS) were prospectively collected. Rectal morbidity was scored according to the Radiation Therapy Oncology Group (RTOG) scale. Two BED dose groups of ≤220 Gy (n = 449) and >220 Gy (n = 136) were used. Comparisons of means were made by Student's t test, and the associations were tested by chi-square analysis (Pearson).ResultsUrinary retention developed in 36 (6.2%) and was not associated with BED or IPSS. Retention occurred more often with prostate volume >50 cc (17%, p = 0.001). The median change in urinary symptoms (IPSS) was 1. Sixty-one percent with high BED were more likely to have increased postimplant symptoms compared with 39% with lower BED (p = 0.025; odds ratio [OR], 1.107; 95% confidence interval [CI], 1.10–1.21). UI occurred in 25 patients (4.3%) and was only associated with a postimplant transurethral resection of the prostate (TURP) (n = 25), 16% vs. 2.3% for no TURP (p = 0.001; OR, 8; 95% CI, 2.4–27). Of the 373 patients initially potent, 204 (54.7%) maintained potency. Impotence was only associated with age at implant (p = 0.001) and HT (p = 0.004). Sixty-two (10.6%) patients had Grade 1–2 and 4 patients had Grade 3–4 (0.7%, 2 ulcers and 2 fistulas) rectal complications. Three of the Grade 3/4 complications occurred with a dose ≤220 Gy.ConclusionA BED >220 Gy does not seem to increase morbidity.     

Long-term biochemical control and cause-specific survival in men with Gleason grade Group 4 and 5 prostate cancer treated with brachytherapy and external beam irradiation

PurposeMen with Gleason grade Group (GG) 4 and 5 prostate cancer have high failure rates when treated by conventional therapy. We investigated the effect of higher radiation doses on freedom from biochemical failure (FBF) and prostate cancer mortality (cause-specific survival [CSS]) in men treated with a combination of permanent implant and external beam irradiation (EBRT).Methods and MaterialsThree hundred twenty men with GG4 (n = 186) and 5 (n = 134) prostate cancer were treated with I-125 or Pd-103 implant followed by 45 Gy of EBRT. Radiation doses were converted to the biological equivalent dose (BED). The median age, prostate-specific antigen (PSA), time on hormone therapy, BED, and followup were 69 years, 9.0 ng/mL, 9 months, 210 Gy, and 6.5 years, respectively. FBF and CSS were calculated by Kaplan–Meier method with associations determined by log rank and Cox regression.ResultsTen-year FBF for GG4 vs. 5 was 77.8 vs. 61.3% (p = 0.015), and CSS was 94 vs. 79.3% (p = 0.001). Men with lower PSA had improved FBF and CSS (p < 0.001). Thirty-one of 320 died of prostate cancer of which 10/186 (5.4%) had GG4 and 21/134 (15.7%) GG5 (OR 3.3, p = 0.002). BED <200 Gy was associated with a 2.2× greater BF (p = 0.004) and 2.4× prostate cancer mortality (p = 0.020). Significant covariates on regression analysis for FBF and CSS were PSA (p = 0.014), GG (p = 0.007), BED (p = 0.009), and GG (p = 0.001).ConclusionsSurvival rates for high-grade prostate cancer are favorable when diagnosed in men with lower PSA and treated with doses of BED > 200 Gy. Higher BED is achieved with a combination of I-125 (110 Gy) or Pd-103 (100 Gy) and 45 Gy EBRT.     

I-125 or Pd-103 for brachytherapy boost in men with high-risk prostate cancer: A comparison of survival and morbidity outcomes

PurposeBrachytherapy boost improves biochemical recurrence rates in men with high-risk prostate cancer (HRPC). Few data are available on whether one isotope is superior to another. We compared the oncologic and morbidity outcomes of I-125 and Pd-103 in men with HRPC receiving brachytherapy.Methods and MaterialsOf 797 patients with HRPC, 190 (23.8%) received I-125 or 607 received Pd-103 with a median of 45 Gy of external beam irradiation. Freedom from biochemical failure (FFBF), freedom from metastases (FFMs), cause-specific survival (CSS), and morbidity were compared for the two isotopes by the ANOVA and the χ² test with survival determined by the Kaplan–Meier method and Cox regression.ResultsMen treated with I-125 had a higher stage (p < 0.001), biological equivalent dose (BED) (p < 0.001), and longer hormone therapy (neoadjuvant hormone therapy, p < 0.001), where men treated with Pd-103 had a higher Gleason score (GS, p < 0.001) and longer followup (median 8.3 vs. 5.3 years, p < 0.001). Ten-year FFBF, FFM, and CSS for I-125 vs. Pd-103 were 77.5 vs. 80.2% (p = 0.897), 94.7 vs. 91.9% (p = 0.017), and 95.4 vs. 91.8% (p = 0.346), respectively. Men with T3 had superior CSS (94.1 vs. 79.5%, p = 0.001) with I-125. Significant covariates by Cox regression for FFBF were prostate specific antigen (PSA), the GS, and the BED (p < 0.001), for FFM PSA (p < 0.001) and GS (p = 0.029), and for CSS PSA, the GS (p < 0.001) and the BED (p = 0.022). Prostate cancer mortality was 7/62 (15.6%) for BED ≤ 150 Gy, 18/229 (7.9%) for BED >150–200 Gy, and 20/470 (5.9%) for BED >200 Gy (p = 0.029). Long-term morbidity was not different for the two isotopes.ConclusionsBrachytherapy boost with I-125 and Pd-103 appears equally effective yielding 10-year CSS of over 90%. I-125 may have an advantage in T3 disease. Higher doses yield the most favorable survival.     

Effect of adding androgen deprivation therapy to permanent iodine-125 implantation with or without external beam radiation therapy on the outcomes in patients with intermediate-risk prostate cancer: A propensity score–matched analysis

PurposeThe purpose of the study was to evaluate the effect of adding androgen deprivation therapy (ADT) to brachytherapy with or without external beam radiation therapy on oncological outcomes in prostate cancer.Methods and MaterialsOverall, 1,171 patients with intermediate-risk prostate cancer treated with brachytherapy with or without external beam radiation therapy with or without ADT between 2003 and 2013 were identified. Propensity score matching was used to counter biases between the ADT and non-ADT groups. The biochemical failure-free rate (bFFR), local recurrence-free rate, and overall survival rate were evaluated using Kaplan–Meier curves, and predictors were identified using Cox proportional hazards regression models.ResultsAfter propensity score matching, 405 patients were included in each group. The median followup duration was 9.1 years; the median ADT duration was 6 months. In the ADT versus non-ADT groups, the 9-year bFFR, local recurrence-free rate, and overall survival rate were 93.4% versus 87.8% (p = 0.016), 96.9% versus 98.1% (p = 0.481), and 88.1% versus 90.4% (p = 0.969), respectively. On multivariate analyses, Gleason score (hazard ratio [HR]: 2.52, 95% confidence interval [CI]: 1.58–4.03) and ADT use (HR: 0.55, 95% CI: 0.34–0.89) were associated with biochemical failure. Supplemental external beam radiation therapy use (HR: 0.38, 95% CI: 0.16–0.91) was associated with lower local recurrence rates. Age (HR: 1.12, 95% CI: 1.08–1.16) and comorbidities (HR: 1.56, 95% CI: 1.04–2.34) were associated with all-cause mortality.ConclusionsA risk-benefit assessment between bFFR improvement and the potential side effects of adding ADT to brachytherapy-based radiotherapy is warranted before incorporating ADT as routine practice.     

Validation of the NCCN prostate cancer favorable- and unfavorable-intermediate risk groups among men treated with I-125 low dose rate brachytherapy monotherapy

PurposeTo validate the 2019 NCCN subgroups of favorable- and unfavorable-intermediate risk (IR) prostate cancer among patients treated with brachytherapy, who are underrepresented in the studies used to develop the 2019 NCCN classification.MethodsWe included all 2,705 men treated with I-125 LDR brachytherapy monotherapy at a single institution, and who could be classified into the 2019 NCCN risk groups. Biochemical failure and distant metastasis rates were calculated using cumulative incidence analysis.ResultsOf 1,510 IR patients, 756 (50%) were favorable-IR, and 754 (50%) were unfavorable-IR. Median follow up was 48 months (range, 3–214). As compared to favorable-IR, the unfavorable-IR group was associated with significantly higher rates of biochemical failure (HR, 2.87; 95% CI, 2.00–4.10; p < 0.001) and distant metastasis (HR, 3.14; 95% CI, 1.78–5.50, p < 0.001). For favorable-IR vs. unfavorable-IR groups, 5-year estimates of biochemical failure were 4.3% (95% CI, 2.6–6.1%) vs. 17.0% (95% CI, 13.6–20.5%; p < 0.001), and for distant metastasis were 1.6% (95% CI, 0.5–2.6%) vs. 5.4% (95% CI, 3.3–7.4%; p < 0.001), respectively. Patients with one unfavorable-intermediate risk factor (unfavorable-IRF; HR, 2.27; 95% CI, 1.54–3.36; p < 0.001) and 2–3 unfavorable-IRFs (HR, 4.42; 95% CI, 2.89–6.76; p < 0.001) had higher biochemical failure rates; similar findings were observed for distant metastasis (1 unfavorable-IRF: HR, 2.46; 95% CI, 1.34–4.53, p = 0.004; 2–3 unfavorable-IRFs: HR, 4.76; 95% CI, 2.49–9.10, p < 0.001).ConclusionsThese findings validate the prognostic utility of the 2019 NCCN favorable-IR and unfavorable-IR prostate cancer subgroups among men treated with brachytherapy. Androgen deprivation was not beneficial in any subgroup. Alternative treatment intensification strategies for unfavorable-IR patients are warranted.     

Prognostic implications of visceral obesity on gastric adenocarcinoma: does it really matter?

PurposeTo evaluate the association of visceral adiposity measured on computed tomography (CT) in preoperative period with lymph node (LN) metastasis and overall survival in gastric adenocarcinoma patients.MethodsPreoperative CT scans of 246 gastric adenocarcinoma patients who did not receive neoadjuvant chemoradiotherapy were evaluated. Visceral fat area (VFA), subcutaneous fat area (SFA) and Total fat area (TFA), VFA/TFA ratio were quantified by CT. VFA/TFA > 29% was defined as visceral obesity. The differentiation, t-stage, n-stage and the number of harvested-metastatic LNs were noted. The maximum thickness of tumor and localization were recorded from CT. Chi-square, Student's t-test, multiple Cox regression, Spearman's correlation coefficient, and Kaplan-Meier algorithm were performed.ResultsThe overall survival (OS) rates and N-stage were not different significantly between viscerally obese and non-obese group (p = 0.994, p = 0.325). The number of metastatic LNs were weakly inversely correlated with VFA (r = −0.144, p = 0.024). Univariate analysis revealed no significant association between visceral obesity and OS or LN metastasis (p = 0.377, p = 0.736). In multivariate analyses, OS was significantly associated with poorly differentiation (HR = 1.72, 95% CI =1.04–2.84, p = 0.035), higher pathologic T and N stage (T4 vs T1 + T2 HR = 2.67, 95% CI =1.18–6.04, p = 0.019; T3 vs T1 + T2 HR = 1.98, 95% CI = 0.90–4.33, p = 0.089; N3b vs N0 HR = 2.97, 95% CI1.45–6.0, p = 0.003; N3 (3a+ 3b) vs N0 HR = 2.24 95% CI =1.15–4.36, p = 0.018).ConclusionVisceral obesity may not be a prognostic factor in resectable gastric adenocarcinoma patients.     

Impact of radiotherapy modalities on outcomes in the adjuvant management of uterine carcinosarcoma: A National Cancer Database analysis

PurposeIn the postoperative management of uterine carcinosarcoma (UCS), the roles of individual radiotherapy (RT) modalities, chiefly external-beam radiotherapy (EBRT) and brachytherapy (BT), remain undefined. We analyzed the survival impact of EBRT and BT using the National Cancer Database.Methods and materialsWe abstracted women diagnosed with UCS from 2004 to 2012 who received hysterectomy and had complete RT information. Cox multivariate analysis and propensity-score matched analyses were used to compare survival among radiotherapeutic approaches.ResultsWe identified 1229 women receiving no radiotherapy, 472 receiving EBRT alone, 331 receiving BT alone, and 271 receiving EBRT+BT. On multivariate analysis of the entire analytic cohort, survival was significantly improved among patients receiving EBRT+BT combination (hazard ratio [HR] 0.72, 95% confidence interval [CI] = 0.58–0.89, p < 0.01), but not among those receiving EBRT alone (HR 0.93, 95% CI = 0.79–1.10, p = 0.41) or BT alone (HR 0.84, 95% CI = 0.68–1.03, p = 0.09). These results were confirmed on propensity-score matches for EBRT vs. no RT (HR 0.89, 95% CI = 0.73–1.07, p = 0.34), BT vs. no RT (HR 0.80, 95% CI = 0.63–1.03, p = 0.09), and EBRT+BT vs. no RT (HR 0.74, 95% CI = 0.58–0.96, p = 0.02).ConclusionsEBRT+BT combination is associated with an overall survival advantage in UCS and warrants consideration in the adjuvant management of this disease.     

Relationship between Day 0 dosimetric parameters and biochemical relapse-free survival in patients treated with transperineal permanent prostate interstitial brachytherapy with 125I seeds

ObjectivesTo determine the relationship between dosimetric parameters obtained on postimplantation Day 0 and biochemical relapse-free survival (bRFS) in patients treated with ¹²⁵I transperineal interstitial permanent prostate brachytherapy (TIPPB).MethodsTwo-hundred twenty men with low-risk (n = 155, 70.4%), low-volume intermediate-risk (n = 63, 28.7%), or high-risk (n = 2, 0.9%) prostate cancer were treated with TIPPB between December 2000 and June 2006. Seventy-four (33.6%) patients received short-term (3–6 months) androgen suppression therapy before TIPPB. The median followup for patients free of biochemical failure was of 37.9 months (range, 24.0–84.5 months).ResultsThe receiver operating characteristic (ROC) analysis established a best-fit cutoff value for the quantifiers D₉₀ and V₁₀₀ of 147 Gy and 92%, respectively. The Kaplan–Meier analysis of bRFS at the cutoff value of D₉₀ = 147 Gy using the ASTRO, nadir + 2, and combined (ASTRO and nadir + 2) definitions showed a trend toward statistical significance for the ASTRO (p = 0.076) and nadir + 2 (p = 0.064) definitions and a statistically significant correlation for the combined definition (p = 0.033). The corresponding 7-year bRFS for the D₉₀ >147 Gy and D₉₀ ≤147 Gy subsets using the ASTRO, nadir + 2, and combined definitions were 96.5% vs. 89.7% (ASTRO, p = 0.076); 93.7% vs. 70.5% (nadir + 2, p = 0.064); and 94.4 vs. 75.5% (combined, p = 0.033). The V₁₀₀ (%) cutoff value of 92% predicted by the ROC analysis was not significant. Among other cutoff values, only D₉₀ = 140 Gy (p = 0.050) and D₉₀ = 160 Gy (p = 0.098) showed a trend toward statistical significance when the nadir + 2 and the ASTRO definitions were used. The rest of dosimetric, tumor, and patient parameters did not show statistical correlation with bRFS in the Kaplan–Meier analysis.ConclusionsThe cutoff value of D₉₀ = 147 Gy obtained on postimplantation Day 0 showed a trend toward significant correlation with bRFS when the standard ASTRO and nadir + 2 definitions were used and a weak but statistically significant correlation with bRFS as per the nonstandard combined definition in a series of patients with predominantly low-risk disease (70.4%) treated at high radiation doses (median D₉₀ = 152.9 Gy, median V₁₀₀ = 92.5%).     

An iodine-125 seed strand combined with a metal stent versus a metal stent alone for obstructive jaundice caused by pancreatic ductal adenocarcinoma

PurposeThe purpose of this study was to assess the efficacy of an iodine-125 (¹²⁵I) seed strand combined with a metal stent compared with a metal stent for treatment of obstructive jaundice caused by pancreatic ductal adenocarcinoma (PDAC).Methods and MaterialsA retrospective analysis was carried out of patients who were referred to Shanghai Zhongshan Hospital of Fudan University with a diagnosis of PDAC between January 1, 2010 and January 31, 2019. A total of 110 consecutive patients with obstructive jaundice caused by PDAC were divided into the iodine-125 seed strand combined with a metal stent group (Group A = 48) and the metal stent group (Group B = 62). The primary outcome was stent obstruction–free survival time, and secondary outcomes were overall survival and complications.ResultsThe median stent obstruction–free survival time was 133.0 (95% confidence interval (CI): 166.093–149.907) days, and the median overall survival was 212.0 (95% CI: 187.183–236.817) days in all patients. Median stent obstruction–free survival time was 175 days (95% CI 103.165–246.835 days) in Group A versus 120 days (95% CI 87.475–152.525 days) in Group B (p = 0.035). A lower Eastern Cooperative Oncology Group (ECOG) score (p = 0. 000) and iodine-125 seed strand combined with metal stent implantation (p = 0.008) were associated with a longer stent obstruction–free survival time. Obstruction length (p = 0.083), ECOG score (p = 0.000), and iodine-125 seeds (p = 0.037) might have potential impact on stent obstruction–free survival time and were included for multivariable analysis using the Cox proportional hazards model. Stent restenosis was observed in 18.8% (9/48) of patients in Group A and 54.8% (34/62) in Group B, respectively. There was no significant difference in median survival between Group A and Group B (p = 0.409). The median survival in Group A was 209 days (95% CI 150.750–267.250) and 202 days (95% CI 190.624–233.376) in Group B. The median survival of patients with a lower ECOG score was better than that of patients with a higher ECOG score (267 days vs 132 days, p = 0.000). The Grade 3 or 4 complications occurred in 4 (8.3%) of the 48 patients in Group A (one case of hemobilia, one case of liver abscess, two cases of choleperitonitis) and in 5 (8.1%) of the 62 patients in Group B (one case of hemobilia, two cases of liver abscess, two cases of choleperitonitis) (p = 0.972).ConclusionsImplantation of an iodine-125 seed strand combined with a metal stent provides longer obstruction-free survival time compared with a metal stent in patients with obstructive jaundice caused by PDAC. It seems reasonable to choose an iodine-125 seed strand combined with a metal stent as a treatment for these patients.     

Comparison of dose-escalated,image-guided radiotherapy vs. dose-escalated,high-dose-rate brachytherapy boost in a modern cohort of intermediate-risk prostate cancer patients

PurposeWe compared outcomes in intermediate-risk prostate cancer patients treated with dose-escalated adaptive image-guided radiation therapy (IGRT) or dose-escalated high-dose-rate brachytherapy boost (HDR-B).Methods and MaterialsPatients with intermediate-risk prostate cancer by National Comprehensive Cancer Network criteria were treated with either CT-based off-line adaptive IGRT (n = 734) or HDR-B (n = 282). IGRT was delivered with 3D-conformal or intensity-modulated radiation therapy with a median dose of 77.4 Gy. For HDR-B, the whole pelvis received a median 46 Gy, and the prostate 2 implants of 9.5 Gy (n = 71), 10.5 Gy (n = 155), or 11.5 Gy (n = 56).ResultsMedian followup was 3.7 years for IGRT and 8.0 years for HDR-B (p < 0.001). Eight-year biochemical control was 86% for IGRT and 91% for HDR-B (p = 0.22), disease-free survival 67% for IGRT and 79% for HDR-B (p = 0.006), and overall survival 75% for IGRT and 86% for HDR-B (p = 0.009). Cause-specific survival (8-year, 100% vs. 99%), freedom from distant metastases (98% vs. 97%), and freedom from local recurrence (98% vs. 98%) did not differ (p > 0.50 each). A worse prognosis group was defined by percent positive prostate biopsy cores >50%, perineural invasion, or stage T2b–c, encompassing 260 (35%) IGRT and 171 (61%) HDR-B patients. These patients evidenced a 5-year biochemical control of 96% for HDR-B and 87% for IGRT (p = 0.002).ConclusionsDose-escalated IGRT and HDR-B both yield excellent clinical outcomes for patients with intermediate-risk prostate cancer. Improved biochemical control with HDR-B for patients with worse pretreatment characteristics suggests that a subgroup of intermediate-risk prostate cancer patients may benefit from dual-modality treatment.     

Identification of comorbidities that place men at highest risk of death from androgen deprivation therapy before brachytherapy for prostate cancer

PurposeTo determine which specific comorbidities predispose men to excess mortality by androgen deprivation therapy (ADT) given before and during brachytherapy for prostate cancer.Methods and MaterialsWe analyzed 5972 men with T1c–T3b prostate cancer treated with brachytherapy-based radiation with or without neoadjuvant ADT. Cox multivariable analysis with propensity scoring was used to determine if ADT was associated with increased all-cause mortality (ACM) in men divided into groups stratified by cardiac comorbidities. Tests for interaction between risk group and outcome were performed.ResultsADT was associated with increased ACM in men with a history of myocardial infarction or congestive heart failure, regardless of whether they underwent revascularization (adjusted hazard ratio [AHR], 2.1 [95% confidence interval {CI}, 1.02–4.17; p = 0.04]) or not (AHR, 1.8 [95% CI, 1.05–3.20; p = 0.03]), but this effect was not seen in men with less severe comorbidity. However, among men with diabetes, there was a significant interaction with risk group (p = 0.01) such that ADT was associated with excess mortality in men with low-risk disease (AHR = 2.21 [1.04–4.68]; p = 0.04) but not in men with intermediate or high-risk disease (AHR, 0.64 [0.33–1.22]; p = 0.17).ConclusionsADT was associated with excess ACM in all patients with a history of congestive heart failure or myocardial infarction, regardless of whether they were revascularized, and in diabetics with low-risk disease. ADT for gland downsizing before brachytherapy should be avoided in these men.     

Predictors of urinary toxicity with MRI-assisted radiosurgery for low-dose-rate prostate brachytherapy

PurposeMRI-assisted radiosurgery (MARS) is a modern technique for prostate brachytherapy that provides superior soft tissue contrast. The purpose of this analysis was to evaluate treatment planning factors associated with urinary toxicity, particularly damage to the membranous urethra (MUL) and external urethral sphincter (EUS), after MARS.Material and MethodsWe retrospectively reviewed 227 patients treated with MARS. Comparisons were made between several factors including preimplantation length of the MUL and EUS dosimetric characteristics after implantation with longitudinal changes in American Urological Association (AUA) urinary symptom score.ResultsRates of grade 3 urinary incontinence and obstructive urinary symptoms were 4% and 2%. A piecewise mixed univariate model revealed that MUL and V₂₀₀, V₁₅₀, V₁₂₅, and D₅ to the EUS were all associated with increased rates of urinary toxicity over time. On univariate logistic regression, MUL >14.2 mm (odds ratio [OR] 2.03 per cm³, 95% confidence interval [CI] 1.10–3.77, p = 0.025), V₁₂₅ to the EUS (OR 3.21 cm³, 95% CI 1.18–8.71, p = 0.022), and use of the I-125 isotope (OR 3.45, 95% CI 1.55–7.70, p = 0.001) were associated with subacute urinary toxicity (i.e., that occurring at 4–8 months). Optimal dose-constraint limits to the EUS were determined to be V₂₀₀ < 0.04 cm³ (p = 0.002), V₁₅₀ < 0.12 cm³ (p = 0.041), V₁₂₅ < 0.45 cm³ (p = 0.033), D₃₀ < 160 Gy (p = 0.004), and D₅ < 218 Gy (p = 0.016).ConclusionsMARS brachytherapy provides detailed anatomic information for treatment planning, implantation, and quality assurance. Overall rates of urinary toxicity are low; however, several dosimetric variables associated with the EUS were found to correlate with urinary toxicity.     

Impact of marital status on receipt of brachytherapy and survival outcomes in locally advanced cervical cancer

PurposeMarriage has been associated with enhanced survival among cancer patients, but conflicting correlations have been suggested in cervical cancer. We assessed the impact of marital status on receipt of brachytherapy and survival in women with locally advanced cervical cancer.Methods and MaterialsThree thousand, eight hundred and twelve patients with Stage IB2–IVA cervical cancer diagnosed from 2006 to 2015 treated with external beam radiotherapy were identified from the California Cancer Registry. Chi-square tests were used to compare patient characteristics by marital status and boost type. The association of marital status with brachytherapy (BT) receipt was assessed using multiple logistic regression. Fine and Gray competing risks and Cox proportional hazards regressions were used to estimate cervical cancer–specific survival (CCSS) and overall survival (OS), respectively.ResultsMost women were unmarried (58.8%). Half (50.4%) received BT, while 33.1% received no boost; most (86.3%) received chemotherapy. Unmarried women had similar odds of receiving BT as married women (OR = 1.07, 95% CI: 0.90-1.28, p = 0.4370) but were less likely to receive chemotherapy (84.3% vs. 89.1%, p < 0.0001). Singlehood was significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.03-1.42, p < 0.0174) and OS (hazard ratio = 1.18, 95% CI: 1.03-1.36, p < 0.0153). Not receiving a radiation boost was also significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.02-1.43, p = 0.0317) and OS (hazard ratio = 1.21, 95% CI: 1.05-1.40, p = 0.0100).ConclusionsThere were no differences in BT receipt in married vs. unmarried patients. However, unmarried patients had worse CCSS and OS and were less likely to receive chemotherapy. Interventions targeting social factors are needed to improve outcomes in this vulnerable population.     

Mediastinal lymphadenopathy may predict 30-day mortality in patients with COVID-19

PurposeThere is scarce data on the impact of the presence of mediastinal lymphadenopathy on the prognosis of coronavirus-disease 2019 (COVID-19). We aimed to investigate whether its presence is associated with increased risk for 30-day mortality in a large group of patients with COVID-19.MethodIn this retrospective cross-sectional study, 650 adult laboratory-confirmed hospitalized COVID-19 patients were included. Patients with comorbidities that may cause enlarged mediastinal lymphadenopathy were excluded. Demographics, clinical characteristics, vital and laboratory findings, and outcome were obtained from electronic medical records. Computed tomography scans were evaluated by two blinded radiologists. Univariate and multivariate logistic regression analyses were performed to determine independent predictive factors of 30-day mortality.ResultsPatients with enlarged mediastinal lymphadenopathy (n = 60, 9.2%) were older and more likely to have at least one comorbidity than patients without enlarged mediastinal lymphadenopathy (p = 0.03, p = 0.003). There were more deaths in patients with enlarged mediastinal lymphadenopathy than in those without (11/60 vs 45/590, p = 0.01). Older age (OR:3.74, 95% CI: 2.06–6.79; p < 0.001), presence of consolidation pattern (OR:1.93, 95% CI: 1.09–3.40; p = 0.02) and enlarged mediastinal lymphadenopathy (OR:2.38, 95% CI:1.13–4.98; p = 0.02) were independently associated with 30-day mortality.ConclusionIn this large group of hospitalized patients with COVID-19, we found that in addition to older age and consolidation pattern on CT scan, enlarged mediastinal lymphadenopathy were independently associated with increased mortality. Mediastinal evaluation should be performed in all patients with COVID-19.     

Partial-breast irradiation versus whole-breast radiotherapy for early breast cancer: A systematic review and update meta-analysis

PurposeThe purpose of this study was to compare the treatment outcomes of partial-breast irradiation (PBI) versus whole-breast radiotherapy (WBRT) in early breast cancer.Methods and MaterialsEligible randomized clinical trials were identified on Medline, Embase, the Cochrane Library, and the proceedings of annual meetings through December 2019. A meta-analysis for local recurrence (LR), overall mortality (OM), and non-breast cancer mortality (NBCM) was conducted. When possible, the outcomes were calculated for 5, 7, and 10 years of followup. A subgroup analysis by PBI technique (brachytherapy [BT], external beam radiotherapy [EBRT], intraoperative radiotherapy [IORT], and mixed) was performed. A p value < 0.05 was considered significant.ResultsEleven randomized clinical trials with a total of 14,436 patients (7186 PBI vs. 7250 WBRT) were included in the meta-analysis. The odds ratio (OR) for LR in 5 y was 1.46 (95% CI 1.15–2, p = 0.024) for PBI. In the subgroup analysis, no significant difference for LR was observed between PBI and WBRT using BT (p = 0.51), EBRT (p = 0.25), or mixed techniques (p = 0.89). The only subgroup with statistical difference was IORT 3.1 (95% CI 1.2–7.6, p = 0.014). No significant difference in LR was observed with 7 and 10 years among the groups. The OM had no difference at 5, 7, and 10 years of followup for any subgroup. A nonsignificant difference was observed comparing PBI with WBRT for NBCM OR = 1.24 (95% CI 0.98–1.57, p = 0.07). The rates of cardiac death, contralateral breast cancer, and development of second tumor were not significant.ConclusionsThe LR with PBI is low and similar to WBRT in selected early breast cancer with a longer followup. The subgroup analysis detected a significant difference for LR associated with IORT and no significant difference for BT and EBRT. Our results confirm a nonsignificant difference for OM and NBCM between PBI and WBRT.     

Efficacy and safety of prophylactic abdominal aortic balloon occlusion versus internal iliac arterial balloon occlusion for placenta accreta spectrum disorder: A systematic review and meta-analysis

PurposeTo assess the efficacy and safety of abdominal aortic (AA) balloon occlusion versus internal iliac arteries (IIA) balloon occlusion in patients with placenta accreta spectrum (PAS) disorders.MethodsDatabases of Embase, PubMed, Web of Science and Cochrane Library were systematically searched from inception to May 2020. The relevant literature was screened and the quality was assessed. RevMan software 5.3 was used to analyze the data.ResultsSix studies involving 239 patients in AA occlusion and 281 patients in IIA occlusion were included. The results demonstrated that the intraoperative hemorrhage volume (MD − 410.61 ml, 95% CI -779.74 to −41.47 ml, p < 0.001), balloon dilatation duration (MD -5.34 min, 95% CI -9.91 to −0.77 min, p = 0.02) and fetus radiation dose (MD-20.81 mGy, 95% CI -31.84 to −9.78 mGy, p < 0.001) were significantly less in AA occlusion compared to IIA occlusion. There was no significant difference in the rate of lower extremity thrombosis between AA occlusion and IIA occlusion (OR 0.21, 95% CI 0.02 to 2.21, p = 0.19); similarly, no significant differences were found in blood transfusion volume (MD −344.50 ml, 95% CI -735.74 to 46.74 ml, p = 0.08), the rate of hysterectomy (OR 0.99, 95% CI 0.22 to 4.44, p = 0.99) and other outcome variables.ConclusionThe available data demonstrated AA occlusion was more effective in reducing intraoperative hemorrhage volume and fetus radiation dose compared with IIA occlusion in patients with PAS disorders. Larger studies or randomized controlled trials are needed to further assert this evidence.     

A meta-analysis of short-term and long-term effects of indocyanine green fluorescence imaging in hepatectomy for liver cancer

ObjectivesThis meta-analysis aimed to compare the short-term and long-term effects of indocyanine green fluorescence imaging in hepatectomy for liver cancer.MethodsThe databases PubMed, Embase, Scopus, Cochrane Library, Web of Science, ScienceDirect, and major scientific websites were screened up to January 2023. Randomized controlled trials and observational studies comparing fluorescence navigation-assisted and fluorescence-free navigation-assisted hepatectomy for liver cancer were included. Our meta-analysis comprises overall results and 2 subgroup analyses based on surgery type (laparoscopy and laparotomy). These estimates are presented as mean differences (MD) or odds ratio (OR) estimates with 95% CIs.ResultsWe analyzed 16 studies that included 1260 patients with liver cancer. Our results showed that fluorescent navigation-assisted hepatectomy were significantly more shorter than fluorescence-free navigation-assisted hepatectomy in the following parameters: operative time [MD = -16.19; 95% CI: -32.27 to -0.11; p = 0.050], blood loss [MD = -107.90; 95% CI: -160.46 to -55.35; p < 0.001], blood transfusion [OR = 0.5; 95% CI: 0.35 to 0.72; p = 0.0002], hospital stay [MD = -1.60; 95% CI: -2.33 to -0.87; p < 0.001], and postoperative complications [OR = 0.59; 95% CI: 0.42 to 0.82; p = 0.002], The one-year disease-free survival rate [OR = 2.87; 95% CI: 1.64 to 5.02; p = 0.0002] was higher in the fluorescent navigation-assisted hepatectomy group.ConclusionsIndocyanine green fluorescence imaging has good clinical value and can improve the short-term and long-term results of hepatectomy for liver cancer.     

Transperineal mapping biopsy improves selection of brachytherapy boost for men with localized prostate cancer

PURPOSETo determine if transperineal mapping biopsy (TPMB) can improve the selection of brachytherapy alone (BT) or brachytherapy boost (BTB) in men with localized prostate cancer.Methods and MaterialsTwo hundred and eighteen men underwent TPMB with a mean of 48.6 cores retrieved. Comparisons were made between prebiopsy risk features and biopsy results to treatment choice with associations tested with ANOVA (bootstrap), χ² test (Pearson), and linear regression. Survival estimates were tested by the Kaplan–Meier method with comparisons by log rank.ResultsMean age, prostate specific antigen (PSA), prostate specific antigen density (PSAD), and prostate volume were 67.2 years, 8.1 ng/mL, 0.19, and 50.3 cc, respectively. 105 (48.2%) biopsies were positive for Gleason Group (GG) 1: 34 (32.4%), 2: 21 (20%), 3: 31 (29.5%), 4: 7 (6.7%), and 5: 12 (11.4%). The mean number of positive cores (PCs) was 7.3 (median 6, range 1–37). Men with six or more PCs had higher PSA (11.3 vs. 6.0 ng/mL, p = 0.025) and PSAD (0.34 vs. 0.13, p = 0.013). Overall brachytherapy was used in 74 (70.5%) as either monotherapy or boost therapy. Men with BTB had higher PSA (9.7 vs. 6.7 ng/mL, p = 0.029), PSAD (0.27 vs. 0.16, p = 0.007), GG (3.3 vs. 1.8, p < 0.001), more bilateral disease (75.9% vs. 55.6%, odds ratio 3.9, p = 0.008), and PCs (10.9 vs. 4.4, p < 0.001). On linear regression, only GG (p = 0.008) and PCs (p = 0.044) were associated with BTB. Biochemical-free failure at 5 years was 92.7%.ConclusionsTPMB improves the selection of patients for BTB. Men with more PCs are more likely to have BTB. Restricting the need for BTB to those with greater volume prostate cancer may reduce radiation side effects.