High-Dose-Rate (HDR) or Pulsed-Dose-Rate (PDR) Perioperative Interstitial Intensity-Modulated Brachytherapy (IMBT) for Local Recurrences of Previously Irradiated Breast or Thoracic Wall Following Breast Cancer

PURPOSE: In patients receiving salvage high-dose-rate (HDR) or pulsed-dose-rate (PDR) brachytherapy for a local recurrence on the chest wall or in the previously treated breast, clinical outcome and benefit were investigated. All patients had previously been treated with full-dose adjuvant external-beam irradiation (EBRT). Disease-free interval after salvage treatment, local tumor control and side effects were analyzed retrospectively. PATIENTS AND METHODS: Between 1996 and 2002, a total of 32 consecutive patients were treated. 13 patients initially treated with mastectomy and postoperative irradiation and 19 patients initially treated with breast-conserving surgery and postoperative irradiation developed a local recurrence. The mean dose of previous radiation therapy was 58 Gy (range, 42-64 Gy), applied by conventional fractionation. After implantation +/- surgery of recurrent disease and CT-based 3-D planning, 15 patients were irradiated with HDR-IMBT (intensity-modulated brachytherapy) with a mean dose of 28 Gy (range, 10-30 Gy, 2 x 2.5 Gy/day at 6-h daily interfraction interval) and 17 patients received PDR-IMBT with a mean dose 30 Gy (range, 10-45 Gy, 5 x 1 Gy/day at 2-h pulse intervals). Four patients underwent additional EBRT using a dose of 24-40 Gy electrons. Treatment was performed only on working days. RESULTS: After a mean post-implant follow-up of 19 months (range, 1-83 months), no signs of local recurrence were observed in 20 of the 32 patients. In twelve patients, local recurrence occurred after a mean follow-up of 13 months (range, 1-78 months). 20 of the 32 patients experienced an additional systemic progress. In one patient, an EORTC/RTOG grade 3 side effect (ulceration of the skin) was described, which was followed by a local recurrence 12 months posttherapeutically. CONCLUSION: Perioperative interstitial HDR/PDR-IMBT of localized breast or thoracic wall recurrences following previous full-dose EBRT appears to be a meaningful salvage treatment with acceptable toxicity.     

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.     

High-dose-rate brachytherapy combined with long-term hormonal therapy for high-risk prostate cancer: results of a retrospective analysis

Purpose High-dose-rate (HDR) brachytherapy combined with hormonal therapy (HTx), without the addition of external beam radiation therapy (EBRT) for high-risk prostate cancer was evaluated retrospectively. Materials and Methods Between May 1995 and April 2002, 35 patients with prostate cancer [Stage≥T2b (UICC 1997) or tumor grading=3 or prostate-specific antigen (PSA) level≥20 ng/mL] were treated with HDR brachytherapy combined with HTx. Most patients (74%) had two or more of these factors. All patients received Iridium-192 HDR brachytherapy with a total dose of 54 Gy/9 fractions/5 days (48 Gy/8 fractions/5 days for the first 6 cases) in one implant session. The median neoadjuvant HTx [luteinizing hormone-releasing hormone (LH-RH) agonist and antiandrogen] period was 7 months. The median adjuvant HTx (ATH) (LH-RH agonist) period was 40 months, and median follow-up was 57 months (range, 23–117 months). Results The 5-year actuarial biochemical control, local control, and disease-free rates were 62%, 96%, and 76% respectively. No patients experienced local and/or regional relapse without distant progression. The 5-year actuarial cause-specific survival and overall survival rates were 89% and 87%, respectively. The acute and late toxicity were moderate and well tolerated. Conclusion HDR brachytherapy plus long-term HTx is at least as effective as conventional EBRT plus long-term HTx.     

High-dose-rate interstitial brachytherapy vs external beam radiation for the treatment of complex keloids

Postoperative external beam radiation therapy (EBRT) with superficial X-rays or electrons and high-dose-rate brachytherapy (HDR BT) are both viable options for managing keloid scars. However, complex keloid scars are especially challenging to manage. We aim to compare the benefit and challenges between interstitial HDR BT and electron EBRT in treating the complex keloids. Three patients with 7 complex keloids: 3 jaw lines, 1 postauricular, 1 posterior neck, and 2 chest walls are included in this study. All patients are treated to 6 Gy x 3 fractions with HDR BT using the flexible interstitial catheters, and electron EBRT plans were created retrospectively for dosimetric comparison. The average D₉₀ is 21.8 ± 8.3 Gy (1 SD) (121%) and 16.9 ± 1.9 Gy (1SD) (94%) in HDR and EBRT plans, respectively. The average treatment time was 7 minutes per patient (range: 6 – 8.5 minutes) for the HDR BT. Dosimetric comparison reveals that HDR plans provide superior coverage to the keloid scars than the EBRT plans. Clinical workflow is streamlined with HDR procedures. The cosmetic outcome with the interstitial HDR BT is satisfactory.     

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.     

Salvagebehandlung fortgeschrittener Plattenepithelkarzinome der Mundhöhle und des Oropharynx

Purpose

The clinical effect of high-dose-rate (HDR) interstitial brachytherapy combined with tumor resection was investigated in this retrospective study on patients with recurrent oral and oropharyngeal squamous cell carcinoma.

Patients and Methods

Oral and oropharyngeal squamous cell carcinoma in 38 patients were treated over a period of 7 years (1988–1994) by HDR interstitial brachytherapy using Gammamed 12i^® equipment. Pretreatment of patients in terms of irradiation and surgery differed (33 irradiated with a total dose between 60.0 and 75.6 Gy, including 8 patients with additional surgery; 1 patient with surgery alone, and 4 patients without any pretreatment). Indications for interstitial brachytherapy differed according to individual responses to treatment and medical histories.

Results

Interstitial brachytherapy was successful in the majority of patients, i. e. complete remission: 12, partial remission: 19, no change: 2, progression: 5. Local control and overall survival including patients with surgical treatment was 59% and 81% at 6 months and 47% and 49% after 12 months, respectively.

Conclusion

Interstitial HDR brachytherapy with Iridium 192 is recommended in patients with local recurrences or second primary carcinomas after previous external radiotherapy in the head and neck region. Combination of interstitial brachytherapy and surgery is preferable for these patients.     

Radiotherapy of local recurrence of rectal carcinoma

In retrospective, non-randomized study were analyzed 45 patients with local recurrences of rectal carcinoma treated by combined external beam radiotherapy (EBRT) and "High dose rate (HDR) remote afterloading" brachytherapy in the period from January 1st, 1988 to May 1st, 1988. Depending on the localization of the local recurrent disease, 20 patients were with vaginal relapse, 13 with vaginal and presacral, 9 with perineal and 3 with presacral and rectal. Combined radiotherapy was applied as follows: 33 patients (73.3%) had EBRT with endovaginal brachytherapy, 3 (6.7%) EBRT plus intraluminal brachytherapy and 9 (20%) patients EBRT plus interstitial brachytherapy. Techniques with 3 and 4 field for EBRT were used and doses ranged 45-65 Gy with convenient fractionation were applied, combined with the doses ranged 15-35 Gy for brachytherapy. Radiotherapy was planned according to the computer tomography cross image on simulator with computer planning. Complete regression of the tumor was observed in 19 patients (42.2%), and partial in 23 patients (51.1%). Median follow-up period was 34 months (8-72). Acute radiation adverse effects were registered in 32 patients, and late sequels in 6 (13.3%). Overall 3-year survival rate was 54% and disease-free survival rate was 34% in the same period.     

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.     

MRI for surgical planning in patients with breast cancer who undergo preoperative chemotherapy

OBJECTIVE: Accurate presurgical evaluation of residual disease appears essential for successful clinical outcome in patients with breast cancer who are undergoing chemotherapy. Our objective was to study the impact on surgical planning of adding serial MRI evaluations of the tumor to standard non-MRI assessments. MATERIALS AND METHODS: MR images of breast tumors obtained before, during, and after preoperative chemotherapy were reviewed in 30 patients. Tumor response was assessed using both size and morphologic MRI criteria. We compared the actual surgical decisions made prospectively on the basis of standard (clinical, mammographic, and sonographic) assessments of response with decisions that would have been made had MRI findings also been considered. MRI investigators were blinded to the ultimate surgical results. Successful breast-conserving surgery was judged on pathologic confirmation of excision margins that were negative for cancer. RESULTS: The standard evaluation led to 16 successful breast-conserving and 14 mastectomy procedures. Using MRI results would have led to major beneficial therapeutic changes in six (20%) of the 30 patients: five patients undergoing primary mastectomy (chemotherapy avoided) and one patient undergoing postchemotherapy mastectomy (unsuccessful breast-conserving surgery avoided). MRI would have added valuable information in 14 (46.7%) of the 30 patients. In seven (23.3%) of the 30 patients, the decision to perform postchemotherapy mastectomy would have been unchanged. In one patient (3.3%), MRI results would not have prevented unsuccessful breast-conserving surgery. In two patients (6.6%), MRI results would have prevented successful breast-conserving surgery from being performed. CONCLUSION: Although the ultimate incidence of breast conservation was potentially similar for the patients (16/30, 53%) in whom the standard evaluation was used and for the patients (14/30, 47%) in whom the MRI-added evaluation was used, MRI was useful in establishing the final treatment earlier in the process, avoiding unnecessary preoperative chemotherapy, or selecting high-risk breast-conserving procedures.     

Intracavitary brachytherapy for carcinoma of the uterine cervix--comparison of HDR (Ir-192) and MDR (Cs-137)

Purpose To compare the results of high dose rate (HDR) (Ir-192) and medium dose rate (MDR) (Cs-137) intracavitary brachytherapy (ICRT) for carcinoma of the uterine cervix. Materials and Methods Between May 1991 and March 2001, a total of 206 patients with Stage I-IVA previously untreated cervical cancer were treated with ICRT combined with external beam radiotherapy (EBRT). HDR was administered to a total of 135 patients: 22 patients in Stage I, 49 in Stage II, 56 in Stage III, and eight in Stage IVA. MDR was administered to a total of 71 patients: six patients in Stage I, 27 in Stage II, 33 in Stage III, and five in Stage IVA. The MDR at point A was 30 Gy/hour for HDR and 1.7 Gy/hour for MDR treatment, and the corresponding median follow-up periods for survivors were 55 and 68 months. Results For the HDR group, 5-year cause-specific survival rates were 90%, 78%, 53% and 33% for Stages I, II, III, and IVA, respectively. For the MDR group, the corresponding rates were 100%, 76%, 51%, and 40%. In the HDR group, 19 patients (14%) developed Grade 2 or higher late complications, and, in the MDR group, four patients (6%) did. Conclusions There was no statistically significant difference in cause-specific survivals between the results of HDR and MDR brachytherapy for cervical cancer. The incidence of late complications tended to be higher for the HDR group than for the MDR group, but did not show a statistically significant difference (p=0.07).     

Accelerated Partial Breast Irradiation with Iridium-192 Multicatheter PDR/HDR Brachytherapy

PURPOSE: To evaluate perioperative morbidity, toxicity, and cosmetic outcome in patients treated with interstitial brachytherapy to the tumor bed as the sole irradiation modality after breast-conserving surgery. PATIENTS AND METHODS: From November 1, 2000 to January 31, 2004, 176 women with early-stage breast cancer became partakers in a protocol of tumor bed irradiation alone using pulsed-dose-rate (PDR) or high-dose-rate (HDR) interstitial multicatheter implants. Patients became eligible, if their tumor was an infiltrating carcinoma < or = 3 cm in diameter, the surgical margins were clear by at least 2 mm, the axilla was surgically staged node-negative, the tumor was estrogen and/or progesterone receptor-positive, well or moderately differentiated (G1/2), the tumor did not contain an extensive intraductal component (EIC) and the patient's age was > 35 years. Implants were positioned using a template guide, delivering either 49.8 Gy in 83 consecutive hours (PDR) or 32.0 Gy in two daily fractions over 4 days (HDR). Perioperative morbidity, toxicity, and cosmetic outcome were assessed. Interim findings of the first 69 patients, who were treated in this multicenter trial, after a median follow-up of 24 months (range, 15-39 months) are presented. RESULTS: One of the 69 patients (1.4%) developed a bacterial infection of the implant. No other perioperative complications, for example bleeding or hematoma, were observed. Acute toxicity was low: 2.9% of the patients (2/69) experienced mild radiodermatitis. Late toxicity: hypersensation/mild pain 7.2% (5/69), intermittent but tolerable pain 1.4% (1/69), mild dyspigmentation 10.1% (7/69), mild fibrosis 11.6% (8/69), moderate fibrosis 1.4% (1/69), mild telangiectasia (< 1 cm(2)) 11.6% (8/69), and moderate teleangiectasia (1-4 cm(2)) 1.4% (1/69). Good to excellent cosmetic results were observed in 92.4% of the patients evaluated. All patients (n = 176) remained disease-free to the date of evaluation. CONCLUSION: This analysis indicates that accelerated partial breast irradiation with iridium-192 interstitial multicatheter PDR/HDR implants is feasible with low perioperative morbidity, low acute and mild late toxicity, and does not significantly affect cosmetic results at a median follow-up of 24 months.     

Accelerated partial breast irradiation: a dosimetric comparison of three different techniques

PURPOSE: We report the first single-institutional dosimetric comparison of patients treated with three forms of accelerated partial breast irradiation: interstitial HDR brachytherapy, the MammoSite balloon apparatus, and 3D conformal external beam quadrant irradiation (3D-CRT). METHODS: A retrospective dosimetric comparison of interstitial HDR brachytherapy, MammoSite balloon brachytherapy, and 3D-CRT was performed. Thirty patients including 10 from each treatment technique were included for a dosimetric comparison of the dose received by the ipsilateral breast, PTV, heart, and ipsilateral lung. Interstitial patients were treated with 4 Gy in 8 fractions to 32 Gy, and the MammoSite patients were treated with 3.4 Gy in 10 fractions to 34 Gy. 3D-CRT patients were treated with 3.85 Gy in 10 fractions to 38.5 Gy using multiple isocentric beams. The CT images from simulation or implant evaluation were transferred into our 3D treatment planning software. The lumpectomy cavities were outlined for every patient, except the MammoSite patients, where the cavity was defined by the balloon edge. The PTV was constructed as a uniform expansion of 1.5 cm for all interstitial HDR patients, 1.0 cm for the MammoSite patients, and a 1.0 cm expansion in addition to the CTV expansion of 1.0 cm (n=2), and 1.5 cm (n=8) for the 3D-CRT patients. The CTV expansion for 3D-CRT and the PTV expansion for the brachytherapy patients were limited to the chest wall and skin. Normal structures including both ipsilateral lung and breast and heart for left-sided lesions were outlined. The lumpectomy cavity was subtracted from the PTV and normal breast tissue for evaluation. To evaluate dose to the ipsilateral breast and lung, PTV, and heart, a dose-volume histogram (DVH) analysis was performed. All histograms were normalized to the volume of the structure (i.e., expressed as percent volume). RESULTS: The average percentage of the breast receiving 100% and 50% of the prescribed dose (PD) was higher in the 3D-CRT group (24% and 48%, respectively) compared with the MammoSite (5% and 18%, respectively) and interstitial patients (10% and 26%, respectively). Improved coverage of the PTV was noted in the 3D-CRT plans compared with the MammoSite and interstitial HDR plans. With the interstitial HDR technique, 58% of the PTV received 100% of the PD compared with 76% with MammoSite and 100% with 3D-CRT techniques. The percentage of the PTV receiving 90% of the PD was 68%, 91%, and 100% for the interstitial HDR, MammoSite, and 3D-CRT patients, respectively. The ipsilateral lung V20 was slightly higher for 3D-CRT at 5% compared with 0% for both brachytherapy techniques. CONCLUSION: In those treated with 3D-CRT, coverage of the PTV was better with 3D-CRT but varied with the definition used. At the coverage at 90% of the PD, no difference was observed between 3D-CRT and MammoSite (which were both better than interstitial). 3D-CRT resulted in better coverage of the PTV compared with MammoSite or interstitial brachytherapy techniques. Better PTV coverage with 3D-CRT came at the cost of a higher integral dose to the remaining normal breast. Dosimetrically, the best partial breast irradiation technique appears to depend on the clinical situation. Of the brachytherapy techniques, MammoSite appears to be superior in PTV coverage. When comparing MammoSite vs. 3D-CRT PTV coverage at 90% of the PD, the difference was not significantly different.     

CT-guided interstitial HDR-brachytherapy for recurrent glioblastoma multiforme: a 20-year single-institute experience

Purpose

To report our results of computed tomography-guided interstitial high-dose-rate (HDR) brachytherapy (BRT) in the treatment of patients with recurrent inoperable glioblastoma multiforme (GBM).

Patients and methods

Between 1995 and 2014, 135 patients were treated with interstitial HDR BRT for inoperable recurrent GBM located within previously irradiated volumes. Patient’s median age was 57.1 years (14–82 years). All patients were pretreated with surgery, postoperative external beam radiation therapy (EBRT) and systemic chemotherapy (ChT). The median recurrent tumor volume was 42?cm³ (2–207?cm³). The prescribed HDR dose was median 40?Gy (30–50?Gy) delivered in twice-daily fractions of 5.0?Gy over consecutive days. No repeat surgery or ChT was administered in conjunction with BRT. Survival from BRT, progression-free survival (PFS), toxicity as well as the impact of several prognostic factors were evaluated.

Results

At a median follow-up of 9.2 months, the median overall survival following BRT and the median PFS were 9.2 and 4.6 months, respectively. Of the prognostic variables evaluated in univariate analysis, extent of surgery at initial diagnosis, tumor volume at recurrence, as well as time from EBRT to BRT reached statistical significance, retained also in multivariate analysis. Eight patients (5.9%) developed treatment-associated complications including intracerebral bleeding in 4 patients (2.9%), symptomatic focal radionecrosis in 3 patients (2.2%), and severe convulsion in 1 patient (0.7%).

Conclusions

For patients with recurrent GBM, interstitial HDR BRT is an effective re-irradiation method for even larger tumors providing palliation without excessive toxicity.

     

Reirradiation for Recurrent Neck Metastases of Head-and-Neck Tumors Using CT-Guided Interstitial 192Ir HDR Brachytherapy

PURPOSE: To report the therapeutic results obtained with CT-guided interstitial high-dose-rate brachytherapy (HDR-BRT) as exclusive treatment for recurrent neck metastases of head-and-neck tumors. PATIENTS AND METHODS: Between 1995 and 1999, 49 patients with prior radiation therapy (RT) with or without surgery for primary head-and-neck tumors were treated for recurrent neck metastases located within previously irradiated volumes. All patients had fixed lymphadenopathy with a mean tumor volume of 96 cm(3) (range, 15-452 cm(3)). There were 38 males and eleven females with a mean age of 60 years (range, 28-79 years). All patients had previously received RT as primary or adjuvant treatment with a mean dose of 54 Gy (range, 45-80 Gy). 36 patients (73%) underwent surgery, and 26 (53%) received adjuvant or palliative chemotherapy. The accelerated hyperfractionated interstitial HDR-BRT (2 x 3.0 Gy/day) delivered 30 Gy in 37/49 (75%) and 36 Gy in 12/49 implants (25%). RESULTS: At a minimum 6-week follow-up, the response rate was 83% (41/49) with complete remission in 20% (10/49) and partial remission in 63% (31/49) of the implanted tumor sites. 8/49 patients (17%) did not respond to the treatment. After 19 months of median follow-up, the local control rate was 69% and a total of 15/49 patients (30%) experienced local disease progression. Of these, nine (18%) had locoregional progression and six (12%) progression within the treated volume. The median post-BRT survival was 14 months. The overall survival rate was 52% at 1 year, 31% at 2 years, and 6% at 3 years. CONCLUSION: In patients with recurrent cervical lymphadenopathy of head-and-neck tumors, exclusive interstitial HDR-BRT can provide palliation and tumor control.     

Fat Necrosis after Conserving Surgery and Interstitial Brachytherapy and/or External-Beam Irradiation in Women with Breast Cancer

PURPOSE: To investigate the incidence of fat necrosis, breast tissue fibrosis and breast pain after conserving surgery and accelerated partial-breast irradiation (APBI, group A), whole-breast external-beam irradiation (EBRT, group B), or EBRT combined with an interstitial boost (EBIB, group C) in women with breast cancer. PATIENTS AND METHODS: 85 patients who received breast-conserving therapy from 02/2000 to 03/2002 were analyzed. 30 patients received EBRT, 33 patients APBI, and 22 patients EBIB. Median follow-up was 35.5, 35.0, and 37.5 months, respectively. Fat necrosis was detected and rated by mammograms, fibrosis and pain were clinically rated with the LENT-SOMA scores. RESULTS: The incidence of fat necrosis was 15.3% for all patients; and 15.2%, 20.0%, and 9.0% for groups A, B, and C, respectively. The 3-year fat necrosis-free survival probability was 83%, 76%, and 95% (difference not significant). The mean time to first diagnosis of fat necrosis was 25.6, 26.2, and 26.0 months. No patient needed surgical intervention because of fat necrosis-related pain. Fibrosis was present in 27.3%, 63.3%, and 77.3% (p < 0.001), breast pain in 9.0%, 33.4%, and 18.1% (p < 0.05). CONCLUSION: Asymptomatic fat necrosis is a common finding after both percutaneous and interstitial irradiation after breast-conserving surgery. This analysis did not support the hypothesis that APBI with multicatheter implants leads to higher rates of fat necrosis, fibrosis, or pain.     

The feasibility of a second lumpectomy and breast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer

PURPOSE: With accumulating evidence supporting partial-breast irradiation, we conducted a Phase I/II study to evaluate the role of a second conservative surgery and brachytherapy for patients presenting with a local recurrence/new primary in a breast who has previously undergone a lumpectomy and external radiation therapy for breast cancer. METHODS AND MATERIALS: Fifteen patients with a localized lesion in the breast have undergone a second lumpectomy and received low-dose-rate brachytherapy on protocol. The first 6 patients received a dose of 30Gy. With no unacceptable acute toxicity observed, the brachytherapy dose was increased to 45Gy. Three patients received adjuvant chemotherapy and 8 patients are on antiestrogen therapy. RESULTS: The median time interval between the primary breast cancer diagnosis and the second cancer event in the ipsilateral breast is 94 months (range, 28-211). With a median followup of 36 months after brachytherapy, the 3-year Kaplan-Meier overall survival, local disease-free survival and mastectomy-free survival are 100% and 89%, respectively. There was no Grade 3/4 fibrosis or necrosis observed. All patients had baseline asymmetry due to the breast volume deficit from the second lumpectomy. With breast asymmetry as a given, the cosmetic result observed in all patients has been good to excellent. CONCLUSIONS: Early results suggest low-complication rates, high rate of local control and freedom from mastectomy. Additional studies are needed to establish whether a second lumpectomy and breast brachytherapy are an acceptable alternative to mastectomy for patients presenting with a localized cancer in a previously irradiated breast.     

The equivalent dose contribution from high-dose-rate brachytherapy to positive pelvic lymph nodes in locally advanced cervical cancer

PurposeDefinitive radiation therapy for locally advanced cervical cancer involves external beam radiation therapy (EBRT) and high-dose-rate (HDR) brachytherapy. There remains controversy and practice pattern variation regarding the optimal radiation dose to metastatic pelvic lymph nodes (LNs). This study investigates the contribution of the pelvic LN dose from HDR brachytherapy.Methods and MaterialsFor 17 patients with 36 positive pelvic LNs, each LN was contoured on a computed tomography (CT) plan for EBRT and on brachytherapy planning CTs using positron emission tomographic images obtained before chemoradiation. The mean delivered dose from each plan was recorded, and an equivalent dose in 2-Gy fractions (EQD2) was calculated. A Student's t test was performed to determine if the mean delivered dose is significantly different from the mean prescribed dose and EQD2.ResultsThe average prescribed dose from the total EBRT was 54.09 Gy. The average prescribed HDR dose to International Commission on Radiation Units point A was 26.81 Gy. The average doses delivered to the involved LNs from EBRT and brachytherapy were 54.25 and 4.31 Gy, respectively, with the corresponding EQD2 of 53.45 and 4.00 Gy. There was no statistically significant difference (p < 0.05) between the mean delivered and the prescribed doses for EBRT and between the delivered dose and the EQD2 for EBRT and brachytherapy.ConclusionsOur study shows that the HDR contribution is 7% (4.00 Gy) of the total EQD2 (57.45 Gy). The HDR contribution should be accounted for when prescribing the EBRT boost dose to pelvic LNs for the optimal therapeutic dose.     

Accelerated Partial-Breast Irradiation with Interstitial Implants

PURPOSE: To describe relative skin dose estimations and their impact on cosmetic outcome in interstitial multicatheter accelerated partial-breast irradiation (APBI). PATIENTS AND METHODS: Between April 2001 and January 2005, 105 consecutive patients with early breast cancer were recruited in Erlangen, Germany, for this substudy of the German-Austrian APBI phase II trial. 51% (54/105) received pulsed-dose-rate (PDR), and 49% (51/105) high-dose-rate (HDR) brachytherapy. Prescribed reference dose for HDR brachytherapy was 32 Gy in eight fractions of 4 Gy, twice daily. Prescribed reference dose in PDR brachytherapy was 49.8 Gy in 83 consecutive fractions of 0.6 Gy every hour. Total treatment time was 3-4 days. With a wire cross on the skin surface during the brachytherapy-planning procedure the minimal, mean and maximal relative skin doses (SD(min%), SD(max%), SD(mean%)) were recorded. Endpoint of this evaluation was the cosmetic outcome in relation to the relative skin doses. RESULTS: Median follow-up time was 38 months (range, 19-65 months). Cosmetic results for all patients were excellent in 57% (60/105), good in 36% (38/105), and fair in 7% (7/105). The SD(min%) (27.0% vs. 31.7%; p = 0.032), SD(mean%) (34.2% vs. 38.1%; p = 0.008), and SD(max%) (38.2% vs. 46.4%; p = 0.003) were significantly lower for patients with excellent cosmetic outcome compared to patients with a suboptimal outcome. SD(mean%) (37.6% vs. 34.2%; p = 0.026) and SD(max%) (45.4% vs. 38.2%; p = 0.008) were significantly higher for patients with good cosmetic outcome compared with the patients with excellent results. CONCLUSION: The appraisal of skin doses has been shown to be relevant to the achievement of excellent cosmetic outcome. Further investigations are necessary, especially on the basis of CT-based brachytherapy planning, to further improve the treatment results of multicatheter APBI.     

乳腺癌保乳术后放射治疗的疗效观察

目的观察乳腺癌保乳术后放射治疗的疗效和美观效果。方法109例保乳术后在我科接受全乳外照射和瘤床加量(boost)放疗,79例应用高剂量率插植技术,T1肿瘤用单排插植,针距为1.5cm,T2以上肿瘤用双排或三排插植。针距间单次剂量(DB)10～12Gy,靶区周边剂量为85%DB。30例采用电子线常规外照射15Gy。全乳照射应用6MV直线加速器,采用双切线半野照射技术,靶区剂量为45～52Gy(平均48.6Gy)。采用医生评分与患者问卷方法评价美观效果。结果全组109例应用KaplanMeier方法统计5年实际生存率为93.8%。局部复发率为6.5%。全组无放射性溃疡发生,5例出现位于插植针孔周围急性皮肤炎症。在经临床随访体检的75例中,医生打分和患者自评满意度为优的比例分别为87%和81%,无统计学意义(P>0.05)。48例经组织间插植加量放疗;27例经电子线外照加量放疗。两组满意度医生总评为优的患者比例分别为81.2%和85.2%,差异无统计学意义(P>0.05)。结论乳腺癌保乳术后放疗可降低局部复发率,并发症少。不同的瘤床加量放疗方法不影响美观效果。