A national surveillance study of the current status of reirradiation using brachytherapy in Japan

PurposeThis study aimed to explore the current status and pattern of practice for reirradiation using brachytherapy (ReRT-BT) through a survey in Japan.Materials and MethodsWe distributed an e-mail-based questionnaire to 153 institutions equipped with high-dose-rate brachytherapy facilities.ResultsWe received responses from 76 institutions (49.7%). Forty-three of these institutions performed ReRT-BT and 42 institutions (55%) performed ReRT-BT during 2009–2018. However, 29 of the 42 institutions (69%) reported difficulty in obtaining ReRT-BT case information from their respective databases. Almost all the institutions encountered insufficient database system to extract details about the ReRT-BT cases. Responses from 33 institutions included the number of ReRT-BT cases; this increased from 90 in the period 2009–2013 (institution median = 0.5; 0–16) to 172 in the period 2014–2018 (institution median = 2; 0–26). Nine institutions had to perform ReRT-BT for more than one case per year. The major location for cancer treatment was the pelvis (94%), followed by the head and neck (5%) and others (1%). In six site-specific scenarios, barring uterine corpus cancer recurrence, more than 90% of radiation oncologists agreed to perform ReRT-BT, whereas other areas (head and neck, prostate, and rectal cancer) gained 16–37% agreement.ConclusionsThis decade saw an increase in the number of ReRT-BT cases in Japan and radiation oncologists’ interest in ReRT-BT as a viable therapeutic option. However, scarce availability, immature education system, and insufficient database system are barriers to further consensus building.     

High-dose-rate and pulsed-dose-rate brachytherapy in palliative treatment of head and neck cancers

PurposeThe main purpose of the study was to assess the results of high-dose-rate brachytherapy (HDRBT) and pulsed-dose-rate brachytherapy (PDRBT) in the palliative treatment of patients with locally or regionally recurrent head and neck cancers. The detailed aims concerned the evaluation of these methods in the context of local control, survival, and complications rates in patients subgrouped by different parameters such as age, gender, primary and recurrent tumor localization, tumor size, treatment method (HDR/PDR), primary treatment method, and radiation dose applied.Methods and MaterialsPDRBT and HDRBT were used in 106 and 50 patients, respectively. In 8 patients, BT procedures were performed in combination with simultaneous chemotherapy. Sixteen patients were additionally treated with interstitial hyperthermia. All patients were regularly followed up within 6 months. Local control, complications, and survival were assessed. Materials included 156 patients with head and neck cancers treated palliatively with HDRBT and PDRBT in the Department of Otolaryngology of Poznań University of Medical Sciences and in the Department of Brachytherapy of Greater Poland Cancer Center from January 2002 to November 2008.ResultsComplete and partial remissions 6 months after finishing the treatment were achieved in 37.7% of patients, whereas survival rates 12 and 24 months after brachytherapy were estimated for 40% and 17%, respectively. The overall complications rate was 35%.ConclusionsOur results suggest that HDRBT and PDRBT constitute a safe alternative in the palliative treatment of patients with locally or regionally recurrent head and neck cancers with a relapse in a previously irradiated area, which were not qualified or rejected surgery. It gives a good palliative effect with acceptable complication rate.     

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

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

High-dose-rate interstitial brachytherapy for vaginal endometrial cancer recurrence after prior surgery and radiotherapy

PurposeCharacterize the clinical outcomes of endometrial cancer vaginal recurrences after previous surgery and radiation therapy treated with reirradiation including image-guided interstitial high-dose-rate (HDR) brachytherapy.Methods and materialsA single-institution retrospective study identifying women receiving reirradiation for vaginal recurrence of endometrial cancer between 2004 and 2017.ResultsTwenty-three women had vaginal recurrences of endometrial cancer, median 13.7 months (range 3.5–104.9) from initial radiation. All received reirradiation with interstitial HDR brachytherapy, and seven also received external beam radiation. Median reirradiation EQD2_10 was 48 Gy (range 24.0–68.81), and median cumulative EQD2_10 was 106.25 Gy (range 62.26–122.0). Median follow-up after reirradiation was 40.2 months (range 4.5–112.7). At 3 years, overall survival was 56%, cancer-specific survival was 61%, and disease-free survival was 46%. 14 patients experienced disease recurrence; 10 including distant sites, one at a regional node only. Three patients experienced local recurrences, two of whom did not complete the prescribed course of reirradiation. The overall crude local control rate was 87%. Three patients experienced Grade 3 vaginal toxicity. There was no bladder or rectal toxicity with Grade >2.ConclusionsReirradiation including interstitial HDR brachytherapy is a promising option for vaginal recurrences of endometrial cancer after prior radiation, with high rate of local control and acceptable toxicity. However, distant failure is common. Further studies are needed to determine cumulative radiation dose limits and the role of systemic therapy in this scenario.     

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

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

Experience of high-dose-rate brachytherapy for head and neck cancer treated by a customized intraoral mold technique

Radiotherapy of head and neck cancer has become more successful with the advances in treatment modalities and use of a multidisciplinary approach. Higher quality treatment and a team approach to radiotherapy have thus been required for head and neck cancer. This study presents the clinical experience of high-dose-rate (HDR) brachytherapy for head and neck cancer treated by a customized intraoral mold technique. Two patients are reported for whom we created dental prostheses as the radiation carriers for HDR brachytherapy of their head and neck cancers. HDR brachytherapy with the dental prostheses reported here was feasible and effective for eradicating the head and neck cancer. It has been demonstrated that HDR brachytherapy using a customized intraoral technique can be a treatment option for patients who are not candidates for surgery or external irradiation. It is strongly suggested that specialized dentists are needed who are familiar with not only the anatomy and function of the head and neck region but also radiotherapy. Dental radiologists should take responsibility for constructing irradiation prostheses. If they do, they have the potential to improve the quality of life of patients who undergo radiotherapy for head and neck cancer.     

Values of biologically equivalent doses in healthy tissues: Comparison of PDR and HDR brachytherapy techniques

PurposeThe aim of this work was to compare the values of doses measured in healthy tissues in chosen pulsed-dose-rate (PDR) brachytherapy (PDRBT) and high-dose-rate (HDR) brachytherapy (HDRBT) fractionation schemas.Methods and MaterialsFifty-one patients treated with PDRBT were qualified for calculations. This group included patients with head and neck cancer, brain tumor, breast cancer, sarcoma, penile cancer, and rectal cancer. The doses were calculated in chosen points in surrounded organs at risk (OaR). The biologically equivalent dose (BED) formula was used to compare doses in PDRBT and HDRBT.ResultsOne ascertained that in biologically equivalent (to PDR) HDRBT, the increase of fractional dose from 4 to 10 Gy caused the necessity to decrease the total dose in treatment target (p < 0.001). The use of HDR instead of PDR essentially caused lower physical and biologic doses in examined OaR. In many examined critical points in OaR where BED in the treatment area was the same, one ascertained the decrease of total physical HDR dose according to the growth of the fractional dose. Similar dependences were observed for BED.ConclusionsThe use of biologically equivalent HDRBT instead of PDRBT caused the decrease of physical doses in the treatment target and the decrease of physical doses and BEDs in OaR. Prolongation of intervals between pulses in PDRBT was connected with lower values of BED doses in healthy tissues.     

Technique for the administration of high-dose-rate brachytherapy to the bile duct using a nasobiliary catheter

PurposeCholangiocarcinoma patients who are potential candidates for liver transplantation may be treated with high-dose-rate (HDR) brachytherapy using a minimally invasive nasobiliary catheter in an effort to escalate the radiotherapy dose to the tumor and maximize local control rates. This work describes the equipment, procedures, and quality assurance (QA) that enables successful administration.Methods and MaterialsThis work describes the nasobiliary catheter placement, simulation, treatment planning, treatment delivery, and QA. In addition, a chart review was performed of all patients who received endoscopic retrograde cholangiopancreatography for HDR bile duct brachytherapy at our institution from 2007 to 2017. The review evaluated how many patients were treated and the number of patients who could not be treated because of anatomic and/or equipment limitations.ResultsFrom 2007 to 2017, 122 cholangiocarcinoma patients have been treated with HDR brachytherapy using a nasobiliary catheter. Three patients underwent catheter placement but did not receive brachytherapy treatment due to catheter migration between placement and treatment or because the HDR afterloader was unable to extend the source wire into the treatment site. Periodic QA is recommended for ensuring whether the HDR afterloader is capable of extending the source wire through an extensive and curved path.ConclusionsIntraluminal HDR brachytherapy with a nasobiliary catheter can be successfully administered. Procedures and QA are described for ensuring safety and overcoming technical challenges.     

Repeat re-irradiation with interstitial HDR-brachytherapy for an in-field isolated nodal recurrence in a patient with HPV-positive squamous cell carcinoma of the head and neck

PURPOSELocoregionally recurrent head and neck cancer is a complex clinical scenario that often requires multimodality treatment. These patients have often previously received definitive treatment with a combination of surgery, radiation therapy, and systemic therapy, which can make further management difficult. A second isolated locoregional failure is rare and clinicians are faced with a challenge to optimize disease control while minimizing treatment-related toxicity.METHODS AND MATERIALSIn this report, we present the diagnosis, management, and outcomes of a patient with an isolated locoregional recurrence who was previously treated with two courses of radiation. The patient was treated with a second course of reirradiation using interstitial brachytherapy as well as a discussion regarding patient selection and optimal management for recurrent head and neck cancer.RESULTSRepeat reirradiation using interstitial HDR-brachytherapy with the use of an alloderm spacer was successfully delivered to the patient for an in-field right neck nodal recurrence. He received a total EQD2/BED dose of 127.70/153.24 Gy. At 1-year followup, the patient was without evidence of recurrent disease or new significant side effects.CONCLUSIONRecurrent head and neck cancer should be managed with a multidisciplinary approach given the complex clinical scenario. Reirradiation is a commonly used salvage measure for recurrent head and neck cancer that requires careful planning and patient selection due to prior treatment-related effects and dose constraints. We reported a case of a second course of reirradiation using interstitial HDR-brachytherapy for locoregionally recurrent head and neck cancer and showed no recurrence of disease or worsening long term side effects at 1 year.     

Three-dimensional image-based planning for cervix brachytherapy with bilateral hip prostheses: A solution using MVCT with helical tomotherapy

PurposeWe present a method of three-dimensional image-based planning for cervix high-dose-rate (HDR) brachytherapy for patients with bilateral metal hip prostheses using megavoltage computed tomography (MVCT) imaging.Methods and MaterialsTwo patients with bilateral metal hip prostheses were treated with our standard HDR brachytherapy fractionation and critical structure tolerance limits for cervical cancer. MVCT imaging was used for treatment planning because of artifacts present in kilovoltage computed tomography (kVCT), which did not allow visualization of the organs of interest.ResultsThe MVCT images provided adequate contrast to allow the contouring of organs at risk and the digitization of HDR applicators. HDR brachytherapy treatment planning was successfully accomplished based on MVCT images for 2 patients with bilateral metal hip prostheses.ConclusionsUsing MVCT imaging eliminated streak artifacts, which improved the image quality for treatment planning. MVCT offers an option for three-dimensional planning for cervix brachytherapy in patients with bilateral hip prostheses.     

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.     

High-dose-rate brachytherapy for previously irradiated patients with recurrent esophageal cancer

Purpose Our objective was to assess the feasibility, efficacy, and complications of high-dose-rate (HDR) brachytherapy for patients with recurrent esophageal cancer after external radiotherapy. Materials and methods Six patients with recurrent esophageal cancer after external radiotherapy were treated with HDR brachytherapy (Ir-192 source) from January 2003 to February 2004. The median age of the patients was 69 years. All patients had received external radiotherapy (median dose 60 Gy) before HDR brachytherapy. All patients underwent HDR brachytherapy once a week with a dose of 4 or 5 Gy per fraction in the esophageal mucosa (median total dose 20 Gy). The Kaplan-Meier method was used to calculate local control rates. Results The median overall survival period was 30.0 months. Local control was observed in five patients and residual tumor in one patient. Persistent local control was observed in two patients. No patient died of esophageal cancer, and all patients survived. We observed no severe late complications related to HDR brachytherapy. Conclusion These data suggest that HDR brachytherapy is an effective and safe treatment for patients with recurrent esophageal cancer after external radiotherapy.     

The American Brachytherapy Society prostate brachytherapy LDR/HDR simulation workshops: Hands-on,step-by-step training in the process of quality assurance

PurposeEducation and training on prostate brachytherapy for radiation oncology and medical physics residents in the United States is inadequate, resulting in fewer competent radiation oncology personnel to perform implants, and is a factor in the subsequent decline of an important, potentially curative cancer treatment modality for patients with cancer. The American Brachytherapy Society (ABS) leadership has recognized the need to establish a sustainable medical simulation low-dose-rate (LDR) and high-dose-rate (HDR) brachytherapy workshop program that includes physician–physicist teams to rapidly translate knowledge to establish high-quality brachytherapy programs.MethodsThe ABS, in partnership with industry and academia, has held three radiation oncology team–based LDR/HDR workshops composed of physician–physicist teams in Chicago in 2017, in Houston in 2018, and in Denver in 2019. The predefined key metric of success is the number of attendees who returned to their respective institutions and were actively performing brachytherapy within 6 months of the prostate brachytherapy workshop.ResultsOf the 111 physician/physicist teams participating in the Chicago, Houston, and Denver prostate brachytherapy workshops, 87 (78%) were actively performing prostate brachytherapy (51 [59%] HDR and 65 [75%] LDR).ConclusionsThe ABS prostate brachytherapy LDR/HDR simulation workshop has provided a successful education and training structure for medical simulation of the critical procedural steps in quality assurance to shorten the learning curve for delivering consistently high-quality brachytherapy implants for patients with prostate cancer. An ABS initiative, intended to bend the negative slope of the brachytherapy curve, is currently underway to train 300 new competent brachytherapy teams over the next 10 years.     

High-dose-rate brachytherapy with or without intensity modulated radiation therapy as salvage treatment for an isolated,gross local recurrence of prostate cancer post-prostatectomy

PurposeTo evaluate the use of high-dose-rate (HDR) brachytherapy ± intensity modulated radiation therapy (IMRT) as salvage therapy for patients with an isolated, gross local recurrence of prostate cancer after radical prostatectomy.Methods and MaterialsBetween October 2009 and May 2013, the authors treated six patients with salvage iridium-192 HDR brachytherapy ± IMRT for biopsy-proven, recurrent prostate cancer post-prostatectomy. In each patient, a pelvic MRI scan or CT scan demonstrated a nodule (range 1.6, 4.7 cm) in the prostate bed. Although prostate-specific antigen values were 0.2–9.5 ng/mL at the time of salvage brachytherapy, there was no pelvic adenopathy on CT or MRI scan, and a bone scan was negative in all cases. Five patients were treated with IMRT to 4500–5040 cGy in 25–28 fractions to the prostate bed followed by two 950 cGy HDR brachytherapy fractions separated by 1–2 weeks. A sixth patient underwent HDR brachytherapy monotherapy consisting of 3800 cGy in four fractions over 3 days. Toxicities were graded according to the Common Terminology Criteria for Adverse Events, version 4.0.ResultsMedian followup was 9 months (range 3, 40 months). All six patients have been free of androgen deprivation therapy and have an undetectable prostate-specific antigen. One patient developed late Grade 2 urinary incontinence. There was no late grade ≥2 gastrointestinal toxicity.ConclusionsHDR brachytherapy ± IMRT is a safe and effective salvage therapy option for an isolated, gross local recurrence of prostate cancer after radical prostatectomy and merits further study.     

Concurrent chemoradiation for cervical cancer: Comparison of LDR and HDR brachytherapy

PurposeTo compare clinical outcomes between low-dose-rate (LDR) brachytherapy and high-dose-rate (HDR) brachytherapy for cervical cancer patients.Methods and MaterialsAll consecutive newly diagnosed cervical cancer patients undergoing pretreatment 18-fluorodeoxyglucose positron emission tomography imaging and treated with curative-intent definitive chemoradiation from 1997 to 2016 at a U.S. academic center were included. Brachytherapy boost was LDR or HDR 2D treatment planning from 1997 to 2005 and HDR with MR-based 3D planning from 2005 to 2016. Local control (LC), cancer-specific survival (CSS), and late bowel/bladder complications were evaluated.ResultsTumor stages were International Federation of Gynecology and Obstetrics IB1-IIB (n = 457; 75%) and III-IVA (n = 152; 25%). Brachytherapy was LDR for 104 patients and HDR for 505 patients. Concurrent weekly cisplatin was administered to 536 patients (88%). With median followup of 9.4 years, there was no difference in LC (p = 0.24) or CSS (p = 0.50) between LDR and HDR brachytherapy. Cox multivariable regression showed that only International Federation of Gynecology and Obstetrics stage III-IVA (HR=2.4, p = 0.004) was associated with worse LC. A propensity-matched cohort (90 LDR vs. 90 HDR) was created, and the 5-year LC rates were 88% LDR and 82% HDR, p = 0.26; 5-year CSS rates were 66% LDR and 58% HDR, p = 0.19; 5-year grade ≥3 bowel/bladder toxicities were 23% LDR and 16% HDR, p = 0.44. For all patients, the 5-year late toxicity in stage III-IVA patients was higher with LDR 47% vs. HDR 15%, p = 0.03, with no difference in LC, 86% and 75%, respectively (p = 0.09).ConclusionsThere was no difference in LC with either LDR or HDR brachytherapy. The late complication rate was reduced with HDR and 3D-planned brachytherapy compared to LDR and 2D-planned brachytherapy.     

One thousand cases of cobalt-based high dose rate brachytherapy treated at a tertiary care center: A retrospective study

PurposeThis is a study of our experience with Co-60 high dose rate brachytherapy (HDR BT) from a tertiary care center.Materials and MethodsOne thousand patients were treated with Cobalt-based HDR BT for more than 6 years. The practice of BT was analyzed for clinical outcome, physical, radiobiological, and technical aspects.ResultsAmong those 1000 patients, 906 (90.6%) patients had gynecologic cancer, 29 (2.9%) patients had intraluminal BT, 63 (6.3%) hadhead &neck (2.1%), keloid (2.1%) and mold BT (2.1%), and 2 (0.2%) had sarcoma. Dose rate decreased by 48.9%, and treatment time increased from 9.33 to 18.27 min over 5 years. No patients treatment was abandoned because of machine-related problems.ConclusionCobalt-based HDR BT is preferable in terms of lesser source exchanges, relatively uniform treatment time, quality assurance requirement, and cost.     

Endoluminal high-dose-rate brachytherapy for early stage and recurrent esophageal cancer in medically inoperable patients

PurposeThe management of superficial primary and recurrent esophageal cancer (EC) in medically inoperable patients is complex. Endoluminal high-dose-rate (HDR) brachytherapy has shown mixed results in terms of toxicity and local control. In this study, we examined the outcomes and toxicities in a set of patients with superficial primary and recurrent EC treated with a consistent HDR technique.Methods and MaterialsBetween 8/2008 and 7/2011, 14 patients were treated with HDR intraluminal brachytherapy, 10 (71.4%) with recurrent disease, and 4 (28.6%) with previously unirradiated lesions. Patients received three weekly fractions to a median dose of 12 Gy (range, 10–15 Gy); dose was prescribed to 7-mm median depth with mucosal dose limited to 8–10 Gy using a 12–14-mm applicator.ResultsMedian followup was 15.4 months. Overall freedom from failure (OFFF) and overall survival (OS) at 18 months were 30.8% (95% confidence interval [CI]: 5.2, 56.4) and 72.7% (95% CI: 45.3, 100), respectively. For patients with recurrent disease, OFFF and OS at 18 months were 11.1% (95% CI: 0, 32.1) and 55.6% (95% CI: 15.4, 95.8), respectively. For patients with previously unirradiated disease, OFFF and OS at 18 months were 75.0% (95% CI: 31.6, 100) and 100.0%, respectively. Eight (57.1%) patients had Grade 1 acute adverse effects; 6 (42.9%) patients had chronic Grade 1 adverse effects; 1 (7.1%) patient developed Grade 2 stricture. Grade 3 tracheoesophageal fistula occurred in 1 (7.1%) patient. One patient died before completion of treatment of unrelated causes.ConclusionsHDR endoluminal brachytherapy is a well-tolerated treatment for superficial primary and recurrent EC in medically inoperable patients.     

Single-fraction brachytherapy as monotherapy for early-stage prostate cancer: The UCSF experience

PurposeHigh-dose-rate (HDR) brachytherapy as monotherapy is an effective treatment option for localized prostate cancer, but experience with single-fraction brachytherapy is limited by studies with small sample size. We report a large single-institution experience with single-fraction HDR brachytherapy as monotherapy for early-stage prostate cancer.Methods and MaterialsRetrospective chart review was performed for men treated with HDR brachytherapy as monotherapy for low- to intermediate-risk prostate cancer. Competing risk analyses were performed to estimate subdistribution hazard ratio and cumulative incidence of biochemical recurrence (BCR) and prostate cancer–specific mortality.ResultsWe identified 124 men with a median followup of 2.2 years (interquartile range 25th to 75th percentile: 1.8–3). Overall, 21.0% of patients (n = 26) were low risk, 44.4% (n = 55) were favorable intermediate risk, and 34.7% (n = 43) were unfavorable intermediate risk. At 2 years, the cumulative incidence of BCR was 3.5%: 0% for low risk, 4.0% for favorable intermediate risk patients, and 4.5% for unfavorable intermediate risk patients. In total, 12 BCRs were observed (9.7%) and approximately half occurred after median followup of 2.2 years. Compared with low-risk and favorable intermediate-risk disease, unfavorable intermediate-risk disease was significantly associated with BCR (subdistribution hazard ratio: 3.6, 95% CI: 1.1 to 11.1, p = 0.03). Prostate cancer–specific mortality was 0%. No patient experienced Grade 3 or higher acute or late genitourinary toxicity.ConclusionsSingle-fraction brachytherapy for early-stage prostate cancer was safe with promising short-term disease control rates, especially for low-risk patients. Longer term followup is needed as we observed an overall BCR rate of 9.7%.     

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

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