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

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

Prognostic factors for oral tongue carcinoma treated with intra-oral cone electron beam irradiation]

Twenty-five patients with squamous cell carcinoma of the oral tongue were treated with intra-oral cone electron beam irradiation (IOC) during the period from 1985 to 1995. We analyzed the prognostic factors for local control and complications. IOC was applied for T1 (16 cases) and T2 (9 cases) tumors. Hypofractionation was used for IOC (20, 10, or 8 Gy/fr, 1f/wk). The total dose delivered ranged from 40 Gy to 78 Gy. Radiation dose homogenization was done through calculation of the normalized total dose (NTD) for alpha/beta = 10 (tumor) and alpha/beta = 3 (late normal tissue). The two-year local control rates for T1 and T2 were 80.4% and 77.8%, respectively. The two-year local control rates for patients whose overall treatment time (OTT) was < or = 28 days (n = 16) was 100% vs. 41.7% for patients whose OTT was > 28 days (n = 9) (p = 0.002). Multivariate analysis was applied to identify possible prognostic factors for local control. OTT (p = 0.02) was the only variable that significantly influenced local control. The incidence of radiation ulcer was 33.3% (7/21). Significant indicators of ulceration were fraction size (> 10 Gy) and NTD (alpha/beta = 3) (> 130 Gy) (p < 0.05). These results indicate that prolonged OTT was the major reason for the failure of IOC radiotherapy to control local disease and that the relatively high rate of ulceration was due to large fraction size and high NTD (alpha/beta = 3).     

Clinical results of N0 tongue cancer treated with interstitial brachytherapy and management of occult cervical node metastases

One hundred patients with T1-2NO squamous cell carcinoma of the oral tongue were treated with interstitial brachytherapy at the Hyogo Medical Center for Adults between 1962 and 1983. These patients were followed for more than two years. The cumulative five-year survival rate was 89% in T1N0 and 66% in T2N0. The relapse-free survival rate was 88% in T1N0 and 51% in T2N0. The two-year local control rate in the primary site was 100% in T1N0 and 73% in T2N0. Cervical node metastases developed in 41% (T1N0: 33%, T2N0: 43%) of the patients. The five-year survival rate of the patients with subsequent cervical node metastases was 42%, while that of patients without subsequent cervical node metastases was 92% (p less than 0.001). Twenty-seven patients also received prophylactic neck irradiation (average dose: 33.8 Gy). In patients treated with prophylactic neck irradiation, the rate of subsequent cervical node metastases was 37% and the cumulative five-year survival rate was 62%. In the patients without prophylactic neck irradiation, these figures were 41% and 73%, respectively. There was no statistically significant difference between the two groups. Between 1984 and 1986, 28 patients with T1-2 N0 squamous cell carcinoma of the oral tongue were treated with interstitial brachytherapy. These patients were prospectively examined for the ability of chemotherapy to prevent the development of cervical node metastasis. In 13 patients treated with chemotherapy (CDDP 80 mg/m2 + PEP 6 mg/m2 x 5 days), the two-year local control rate was 90%, the incidence of cervical node metastases was 38% and the incidence of distant metastases was 15%.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

5-Year Results of Pulsed Dose Rate Brachytherapy Applied as a Boost after Breast-Conserving Therapy in Patients at High Risk for Local Recurrence from Breast Cancer

PURPOSE: The aim of this study was to evaluate effect, toxicity, and cosmesis of a prospectively applied pulsed dose rate (PDR) brachytherapy boost schedule in patients with stage I/II/IIIa invasive breast cancer. PATIENTS AND METHODS: A total of 113 patients were treated after breast-conserving surgery (BCS) and external beam radiotherapy (median 50 Gy, range 46-52). The boost dose was graded in accordance to the pathologic tumor characteristics: 20-25 Gy: incomplete resection (n = 34), vascular invasion (n = 27), close margin resection (n = 41); 15 Gy: T2G3 stage (n = 11). PDR brachytherapy (37 GBq, (192)Ir source) was carried out after geometric volume optimization with 1 Gy/pulse/h. The implantation and dose specification were performed similar to the rules of the Paris system. RESULTS: The overall local failure rate after a median follow-up of 61 months was 4.4% (5/113). The actuarial 5- and 8-year local recurrence-free survival rates were 95% and 93%, respectively. Cosmesis was rated by 90% of the patients as excellent or good. 14/113 patients experienced grade III (all caused by planar telangiectasia) and none of the patients grade IV late toxicity of the skin (RTOG/EORTC). A boost dose of 25 Gy resulted in a significantly higher rate of late toxicity (Fisher's exact test, p < 0.01). CONCLUSIONS: PDR brachytherapy is safe, effective, and provides good cosmesis. A CLDR breast boost can be replaced by PDR brachytherapy without significant loss of therapeutic ratio.     

Role of Interstitial PDR Brachytherapy in the Treatment of Oral and Oropharyngeal Cancer

PURPOSE: To evaluate the role of pulsed-dose-rate interstitial brachytherapy (PDR IBT) in patients with head-and-neck malignancies. PATIENTS AND METHODS: From October 1997 to December 2003, 236 patients underwent PDR IBT for head-and-neck cancer at the authors' department. 192 patients received brachytherapy as part of their curative treatment regimen after minimal non-mutilating surgery, 44 patients were treated with irradiation alone. 144 patients had sole IBT (median D(REF) = 56 Gy), in 92 patients IBT procedures (median D(REF) = 24 Gy) were performed in combination with external irradiation. The pulses (0.4-0.7 Gy/h) were delivered 24 h a day with a time interval of 1 h between two pulses. The analysis of tumor control, survival and treatment-related toxicity was performed after a median follow-up of 26 months (6-75 months). RESULTS: At the time of analysis permanent local tumor control was registered in 208 of 236 patients (88%). At 5 years overall survival and local recurrence-free survival of the entire group were 82-73% and 93-83% for T1/2, and 56% and 83% for T3/4, respectively. Soft-tissue necrosis was seen in 23/236 patients (9.7%) and bone necrosis in 17/236 patients (7.2%). No other serious side effects were observed. CONCLUSION: PDR IBT with 0.4-0.7 Gy/h and 1 h between pulses is safe and effective. These results confirm that PDR IBT of head-and-neck cancer is comparable with low-dose-rate (LDR) brachytherapy - equally effective and less toxic.     

Locally recurrent breast cancer: pulse dose rate brachytherapy for repeat irradiation following lumpectomy-- a second chance to preserve the breast

PURPOSE: To perform and assess the effectiveness of local excision of recurrent tumor followed by postoperative pulse dose rate (PDR) brachytherapy. MATERIALS AND METHODS: From 1994 to 2000, 17 patients who had small recurrent breast carcinomas after initially undergoing breast-conserving therapy (BCT), which included postoperative radiation therapy, were treated with local tumor excision and PDR brachytherapy. Recurrences occurred at a median time of 50 months (range, 11-208 months) after primary treatment. Eight patients underwent a combination of PDR brachytherapy (total dose range, 12.5-28.0 Gy) and external-beam radiation therapy (EBT) (total dose range, 12-30 Gy). Nine patients underwent radiation therapy with 40.2-50.0-Gy PDR brachytherapy only. The prescribed radiation dose was 0.5-1.0 Gy per pulse. Patients were examined for local tumor control and treatment-related side effects. RESULTS: Twelve of 17 patients had no local tumor at a median follow-up time of 59 months (range, 20-84 months); two of these patients showed signs of having distant disease. One patient died after a cerebral stroke without evidence of tumor. Four women treated with combined EBT and brachytherapy had secondary local tumor recurrences 4, 8, 8, and 11 months after therapy and had to undergo mastectomy. Despite having undergone radiation therapy previously, patients had side effects limited to moderate (grade 1-2) fibrosis. CONCLUSION: Local tumor excision combined with PDR brachytherapy for small local-regional tumor recurrences after primary BCT is feasible and well tolerated and might obviate mastectomy. Preliminary experiences are encouraging. Further studies are required for appropriate patient selection.     

Experiences with a New High-Dose-Rate Brachytherapy (HDR-BT) Boost Technique for T3b Prostate Cancer

PURPOSE: Experiences with a new high-dose-rate brachytherapy (HDR-BT) boost technique in 41 patients with stage T3b prostate cancer are presented. PATIENTS AND METHODS: The patients received 18 Gy of HDR-BT (9 Gy on days 1 + 8) plus 50.4 Gy of EBRT. 20 patients (group A) had BT applicators placed into the prostate alone resulting in 18 Gy to prostate and 0 Gy (tip) to 12 Gy (base) to seminal vesicles (SV). The cumulative EQD2 (equivalent dose in 2-Gy fractions, alpha/beta 1.5 Gy) to the SV was 47.5-73.3 Gy. 21 patients (group B) had BT applicators placed into both prostate and SV resulting in 18 Gy to prostate and to > 80% (but not 100%) of the SV (cumulative EQD2 81.5-101.5 Gy). Both groups were compared for acute and late toxicity and for biochemical relapse-free survival (bRFS). RESULTS: The 3-year bRFS was 57% for group A and 79% for group B patients (p = 0.29). A grade 3 acute toxicity (CTC 2.0) was not observed. Grade 2 acute toxicity (proctitis, cystitis, skin toxicity) was comparable in both groups. A grade 3 late toxicity did not occur. Impotence rates were 35% in group A and 24% in group B, respectively (p = 0.73). CONCLUSION: The new HDR-BT technique (group B) was associated only with minor acute and late toxicity and appears to result in better bRFS than the conventional HDR-BT technique (group A). The results must be confirmed in a prospective trial.     

Radiography-based treatment planning compared with computed tomography (CT)-based treatment planning for intracavitary brachytherapy in cancer of the cervix: analysis of dose-volume histograms

PURPOSE: To analyze the dose-volume histograms (DVHs) of the tumor volume and organs at risk by CT-based treatment planning compared with conventional radiography-based treatment planning for intracavitary brachytherapy in cancer of the cervix. METHODS AND MATERIALS: Fifteen consecutive patients with cancer of the cervix (1 IB1, 3 IB2, 7 IIB, 4 IIIB) were treated with plastic CT-compatible HDR intracavitary applicators and underwent postimplant pelvic CT scans with applicators in place. CT-images were transferred to the PLATO treatment planning system. The gross tumor volume (GTV) and organs at risk were digitized. Dwell positions in the uterine tandem and colpostats were identified and registered for each patient. All patients were treated with 6 Gy per fraction to Point A using radiography-based planning. For the CT-based planning, DVHs were performed for the GTV, bladder, rectum, sigmoid colon, and small bowel in the pelvis. The dose delivered to 3% volume of the organs at risk (D3%) was compared with the respective ICRU reference doses. RESULTS: For stage IB(I), IB2, IIB, and IIIB disease the mean GTV was 20.5 cc, 56.6 cc (54.2-57.2), 63.7 cc (55.4-118.9), and 77.6 cc (49.4-102.9), respectively. The 6 Gy pear-shaped volume (PSV) encompassed an average GTV of 98.5%, 89.5%, 79.5%, and 59.5% for stages IBI, IB2, IIB, and IIIB, respectively. The mean dose for the ICRU bladder point and D3% was 3.72 Gy (1.51-5.53) and 4.74 Gy (1.70-10.10), respectively. The mean dose for the ICRU rectal point and D3% was 3.97 Gy (2.09-5.37) and 3.52 Gy (2.05-4.08), respectively. The D3% for the sigmoid colon was highest (3.88 Gy), followed by the rectum (3.52 Gy), and the small bowel (3.36 Gy). CONCLUSION: Radiography-based conventional treatment planning overestimates tumor dose, especially those with more advanced tumors. To correlate DVHs for tumor control, improved tumor imaging is necessary.     

Intraoperative Radiotherapy of Soft Tissue Sarcoma of the Extremity

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

Managing nasopharyngeal carcinoma with intracavitary brachytherapy: one institution's 45-year experience

PURPOSE: At our institution, we have been using intracavitary brachytherapy as a boost in selected cases of both primary and recurrent nasopharyngeal carcinoma. The local control, distant metastasis-free rate, overall survival, and morbidity are presented. METHODS AND MATERIALS: Between January 1, 1955, and August 2000, 576 patients with a diagnosis of nasopharyngeal carcinoma were seen at the department of radiation oncology, University of California-San Francisco, and 55 patients received intracavitary brachytherapy as one part of their treatment. All patients were treated with megavoltage external beam radiation, including 43 patients treated for initial disease and 12 for recurrence. Brachytherapy was routinely used for early cases of T1 and T2 lesions and selected cases of more advanced lesions, as well as recurrent lesions. The median age was 48 years (range 22-85 years); there were 17 women and 38 men, and 39 patients were ethnic Chinese, 13 were white, and 3 were other races. Stage at treatment (primary and recurrent) was I (n=13), II (n=18), III (n=19), and IV (n=5); 18 patients had concurrent chemotherapy. The brachytherapy applicators used were Rotterdam (n=24), balloon (n=16), ovoid (n=14), and ribbon (n=1). The dose rate was high (n=24), low (n=29), or pulsed (n=2). External beam doses ranged from 54 to 72 Gy for primary disease and 30 to 42 Gy for recurrent disease. Brachytherapy doses ranged from 5 to 7 Gy for high dose rate and 10 to 54 Gy for low dose rate. RESULTS: With a median follow-up of 36 months in those who were treated for primary carcinoma, the 5-year estimate of local control was 89%, the distant metastasis-free rate was 75%, and the overall survival estimate was 86%. Recurrent patients had a median follow-up of 50 months; the 5-year estimate of local control was 64%, the distant metastasis-free rate was 100%, and the overall survival estimate was 91%. Patients with Stage I or II disease had a longer overall survival compared with those with Stage III or IV (p=0.05). There was a significant difference in the rate of distant metastases due to nodal status (N0 vs. N1-N3, p=0.02) or to overall stage (I/II vs. III/IV, p=0.005). CONCLUSIONS: Intracavitary boost brachytherapy was found to be effective and well tolerated in selected cases of both primary and recurrent nasopharyngeal carcinoma.     

CT-image-based conformal brachytherapy of breast cancer. The significance of semi-3-D and 3-D treatment planning.

PURPOSE: To compare the conventional 2-D, the simulator-guided semi-3-D and the recently developed CT-guided 3-D brachytherapy treatment planning in the interstitial radiotherapy of breast cancer. PATIENTS AND METHODS: In 103 patients with T1-2, N0-1 breast cancer the tumor bed was clipped during breast conserving surgery. Fifty-two of them received boost brachytherapy after 46 to 50 Gy teletherapy and 51 patients were treated with brachytherapy alone via flexible implant tubes. Single, double and triple plane implant was used in 6, 89 and 8 cases, respectively. The dose of boost brachytherapy and sole brachytherapy prescribed to dose reference points was 3 times 4.75 Gy and 7 times 5.2 Gy, respectively. The positions of dose reference points varied according to the level (2-D, semi-3-D and 3-D) of treatment planning performed. The treatment planning was based on the 3-D reconstruction of the surgical clips, implant tubes and skin points. In all cases the implantations were planned with a semi-3-D technique aided by simulator. In 10 cases a recently developed CT-guided 3-D planning system was used. The semi-3-D and 3-D treatment plans were compared to hypothetical 2-D plans using dose-volume histograms and dose non-uniformity ratios. The values of mean central dose, mean skin dose, minimal clip dose, proportion of underdosaged clips and mean target surface dose were evaluated. The accuracy of tumor bed localization and the conformity of planning target volume and treated volume were also analyzed in each technique. RESULTS: With the help of conformal semi-3-D and 3-D brachytherapy planning we could define reference dose points, active source positions and dwell times individually. This technique decreased the mean skin dose with 22.2% and reduced the possibility of geographical miss. We could achieve the best conformity between the planning target volume and the treated volume with the CT-image based 3-D treatment planning, at the cost of worse dose homogeneity. The mean treated volume was reduced by 25.1% with semi-3-D planning, however, it was increased by 16.2% with 3-D planning, compared to the 2-D planning. CONCLUSION: The application of clips into the tumor bed and the conformal (semi-3-D and 3-D) planning help to avoid geographical miss. CT is suitable for 3-D brachytherapy planning. Better local control with less side effects might be achieved with these new techniques. Conformal 3-D brachytherapy calls for new treatment planning concepts, taking the irregular 3-D shape of the target volume into account. The routine clinical application of image-based 3-D brachytherapy is a real aim in the very close future.     

High-Dose-Rate Brachytherapy for Small-Sized Peripherally Located Lung Cancer

BACKGROUND: The demand for minimally invasive therapies is increasing in the treatment of small peripheral non-small cell lung cancer (NSCLC). PATIENTS AND METHODS: Twelve patients with T1-2 N0 M0 peripheral NSCLC were treated by high-dose-rate brachytherapy with (192)Ir radioactive source. RESULTS: A (192)Ir source was introduced into the tumors percutaneously in five patients (percutaneous brachytherapy) or transbronchially in seven patients (transbronchial brachytherapy). Whereas irradiation was performed with a single fraction of 20 Gy in percutaneous brachytherapy, it was hypofractionated from 5 x 5 Gy to 2 x 12.5 Gy in transbronchial brachytherapy. Complications were generally mild in all patients, although focal radiation pneumonitis was observed in most patients. Primary recurrence occurred in three patients, including one with a T2 tumor and one treated by brachytherapy as a salvage treatment for recurrence after conformal radiotherapy. When brachytherapy is evaluated as a primary treatment for T1 N0 M0 NSCLC, local control rate is 88.9% and estimated 5-year survival rate is between 60% and 70%. CONCLUSION: Brachytherapy has a potential to be a method to treat peripheral T1 N0 M0 NSCLC.     

Radical radiotherapy compared with surgery for advanced squamous cell carcinoma of the base of tongue

PURPOSE: This study reports on T3/T4 base of tongue (BOT) tumors treated at the Erasmus MC (Rotterdam) with external beam radiotherapy (EBRT) and brachytherapy (BT). Local control, survival, and functional outcome are compared to results obtained in similar patients treated at the Vrije University Medical Center (VUMC, Amsterdam) by surgery and postoperative RT (PORT). METHODS AND MATERIALS: At Rotterdam 46/2 Gy was given to the primary and bilateral neck, followed by an implant using low-dose-rate (LDR 24-35 Gy; median 27 Gy), or fractionated high-dose-rate (fr. HDR 20-28 Gy; median 24 Gy). A neck dissection (ND) was performed in case of N+ disease. 67% of BOT tumors had a T4 cancer. At Amsterdam surgery (S) followed by PORT 40-70 Gy (median 60 Gy) was performed; 26% BOT tumors were T4. Sex, age and nodal distribution were similar. Actuarial local control and survival were computed. Performance Status Scale (PSS) scores were established. Xerostomis was determined on visual analog scales (VAS). RESULTS: Local failure at 5-years was 37% (Rotterdam) vs. 9% (Amsterdam) (p < 0.01). The overall survival was not significantly different (median 2.5 years vs. 2.9 years, respectively [p = 0.47]). The PSS favored brachytherapy. Both groups were equally affected by xerostomia. CONCLUSIONS: The 5-year local control was 65% with EBRT and BT. This result is strongly affected by 4 patients with residual disease after implantation. The Rotterdam patients had more advanced BOT tumors (67% vs. 26% T4), explaining the higher local failure rate. Given the organ preservation properties of radiotherapy-only and the better PSS scores, the jury is still out on the optimal treatment for BOT tumors.     

Clinical assessment of tumor clearance during radiotherapy as a prognostic factor of early glottic carcinoma.

From 1967 through 1985, 358 cases of early glottic carcinoma were treated with telecobalt therapy at the Department of Radiology, Osaka University Medical School. Among 278 cases treated with 2 Gy a day, the tumor response of 262 cases at 40, 50 and 60 Gy were evaluated by direct or indirect laryngoscope. The five-year local control rates of these evaluable cases of T1 and T2 glottic carcinoma were 79% and 70%, respectively. The local control rates of T1 glottic carcinoma with tumor clearance and persistence at 40 Gy were 83% (119/143) and 64% (43/67), and those of T2 cases were 86% (18/21) and 58% (18/31), respectively. The local control rates of the cases with tumor clearance and persistence at 40 Gy were same between T1 and T2 cases. The tumor clearance rates of T1 cases were significantly higher than those of T2 cases (p < 0.005). T2 glottic carcinoma had larger tumor volumes and slower tumor regression and resulted in lower control rates compared with T1 glottic carcinoma. The difference in the radiation dose of T1 and T2 glottic carcinoma with the same clearance rate was estimated as 15 Gy using logit analysis.     

Indikationen und ergebnisse der HDR-afterloading-therapie bei erkrankungen der haut und schleimhaut mit standardisierten oberflächenapplikatoren (Leipzig-Applikator)

BACKGROUND: In our department we have developed a standardized applicator for HDR brachytherapy of surface lesions, the so called Leipzig-applicator. We have used this method since September 1987, initially with a Decatron remote afterloading machine, but more recently from November 1990 with a microSelectron-HDR. We report about our experience of 10 years. PATIENTS AND METHOD: Since 1987 we treated 520 patients in 3,026 fractions with this method. In most of the cases we irradiated tumors of the skin of the face, but we also treated tumors of the mouth, of the tongue, of the perianal region and the external genitalia. The histological types were in most of the cases squamous cell carcinomas and basal cell carcinomas, but we also treated tumors like Kaposi-sarcomas, melanomas and skin manifestations of lymphomas and solid organ tumors. We also irradiated benign lesions like keloids after excision. We use single doses between 5 and 10 Gy once to twice a week. The isodose distribution was depending of the tissue infiltration of the tumor. The total dose was 30 to 40 Gy. RESULTS: In 91% of the cases we obtained a complete remission of the tumor, in 6% a partial remission. Recurrences appeared in 8% of the patients. In most cases the reason of the recurrence was a lower brachytherapy dose because of a prior radiotherapy. We didn't observe any severe late radiation reaction. CONCLUSION: We consider that our series of patients treated with HDR brachytherapy and a range of standardized applicators demonstrates that this is a successful method of treating surface lesions.     

Efficacy and safety of a 3D-printed applicator for vaginal brachytherapy in patients with central pelvic-recurrent cervical cancer after primary hysterectomy

PURPOSEIntracavitary and/or interstitial brachytherapy is an integral component of the management of patients with central pelvic-recurrent cervical cancer after primary hysterectomy, and is typically delivered using conventional applicators. We investigated the efficacy and safety of three-dimensional (3D)-printed, customizable applicators for those patients.METHODS AND MATERIALSTwenty-six patients were treated with combination external beam radiotherapy and brachytherapy. Patients with lesions ≤1 and >1 cm before brachytherapy were treated with intracavitary and interstitial brachytherapy, respectively. Dosimetric plans were compared between the vaginal cylinder and 3D-printed applicator for the first 9 patients. Outcomes and treatment-related complications were also investigated.RESULTSThe median tumor size before brachytherapy was 0.81 cm. Intracavitary, interstitial, and combined interstitial-intracavitary brachytherapy were performed in 22 (85%), 3 (11%), and 1 (4%) of the patients, respectively. The clinical target volume (CTV) coverage goal was achieved with all 3D-printed plans but failed with three single-channel cylinder plans (33.3%). Owing to 3D-printed transvaginal applicator guidance, there was no need to adjust the needle position after implantation. The mean CTV dose for all patients was 71 ± 8.2 Gy; all met the dose constraints to the organs at risk, but 1 (4%) had a rectal D_2cc overdose. The 2-year local control, progression-free survival, and overall survival rates were 87.8%, 71.0%, and 91.6%, respectively. Four patients (21%) developed early grade 3–4 hematological toxicities and 1 (4%) developed a late grade 3 adverse event.CONCLUSIONSHigh-quality intracavitary and/or interstitial brachytherapy can be achieved using a 3D-printed applicator and yields favorable outcomes with acceptable toxicity.     

Perioperative high-dose-rate brachytherapy (PHDRB) in previously irradiated head and neck cancer: Initial results of a Phase I/II reirradiation study

BACKGROUND: This study was undertaken to determine the feasibility of salvage surgery and perioperative high-dose-rate brachytherapy (PHDRB) at the dose/fractionation schedule proposed in patients with previously irradiated, recurrent head and neck cancer or second primary tumors arising in a previously irradiated field. METHODS AND MATERIALS: Twenty-five patients were treated with surgical resection and PHDRB. The PHDRB dose was 4 Gy b.i.d. x 8 (32 Gy) for R0 resections and 4 Gy b.i.d. x 10 (40 Gy) for R1 resections. Further external beam radiotherapy or chemotherapy was not given. RESULTS: Resections were categorized as R0 (negative margins of at least 10 mm) in 3 patients (12.0%) and R1 (negative margins of less than 10 mm or microscopically positive margins) in 22 (88.0%). Twelve patients with R1 resections had microscopically positive margins (48%), and 10 patients had close margins (40%), with a median of 2.0 mm. Ten patients (40.0%) developed Radiation Therapy Oncology Group Grade 3 or greater toxicity. Seven patients (28%) presented complications requiring a major surgical procedure. Four of these complications appeared in the immediate postoperative period and were surgical in nature (flap failure, n = 2; fistula, n = 2), and the other three were mainly related to the brachytherapy procedure (n = 2) or the radiation dose delivered (n = 1). One patient died on postoperative day 11 due to bleeding. After a median followup of 14 months, the 4-year local control rate and overall survival were 85.6% and 46.4%, respectively. CONCLUSIONS: Surgical salvage and PHDRB at the dose/fractionation proposed are feasible in this high-risk population. Toxicity is high, but not substantially different from other reirradiation series. Four-year local control results are encouraging taking into account that 22 of 25 patients (88%) had either close or microscopically positive margins.     

5-Year Results of Pulsed Dose Rate Brachytherapy Applied as a Boost after Breast-Conserving Therapy in Patients at High Risk for Local Recurrence from Breast Cancer

Purpose: The aim of this study was to evaluate effect, toxicity, and cosmesis of a prospectively applied pulsed dose rate (PDR) brachytherapy boost schedule in patients with stage I/II/IIIa invasive breast cancer. Patients and Methods: A total of 113 patients were treated after breast-conserving surgery (BCS) and external beam radiotherapy (median 50 Gy, range 46-52). The boost dose was graded in accordance to the pathologic tumor characteristics: 20-25 Gy: incomplete resection (n = 34), vascular invasion (n = 27), close margin resection (n = 41); 15 Gy: T2G3 stage (n = 11). PDR brachytherapy (37 GBq, ¹⁹²Ir source) was carried out after geometric volume optimization with 1 Gy/pulse/h. The implantation and dose specification were performed similar to the rules of the Paris system. Results: The overall local failure rate after a median follow-up of 61 months was 4.4% (5/113). The actuarial 5- and 8-year local recurrence-free survival rates were 95% and 93%, respectively. Cosmesis was rated by 90% of the patients as excellent or good. 14/113 patients experienced grade III (all caused by planar telangiectasia) and none of the patients grade IV late toxicity of the skin (RTOG/EORTC). A boost dose of 25 Gy resulted in a significantly higher rate of late toxicity (Fisher's exact test, p < 0.01). Conclusions: PDR brachytherapy is safe, effective, and provides good cosmesis. A CLDR breast boost can be replaced by PDR brachytherapy without significant loss of therapeutic ratio. Ziel: Diese Studie diente der Evaluierung von Effektivität, Toxizität und kosmetischen Ergebnissen eines prospektiv applizierten PDR- (pulsed dose-rate-)Brachytherapieboostkonzeptes bei Patienten mit invasivem Mammakarzinom im Stadium I/II/IIIa. Patienten und Methoden: Insgesamt wurden 113 Patienten nach brusterhaltender Therapie (BET) und externer Bestrahlung (Median 50 Gy, Range 46-52) behandelt. Die Boostdosis wurde anhand histopathologischer Tumorcharakteristika graduiert (Tabelle 1): 20-25 Gy: inkomplette Resektion (n = 34), Lymphgefäß- oder Gefäßinvasion (n = 27), "close-margin"-Resektion (n = 41); 15 Gy: T2G3 Stadium (n = 11). Die gepulste Brachytherapie (37 GBq, ¹⁹²Ir-Quelle) wurde nach geometrischer Volumenoptimierung mit 1 Gy/Puls/h durchgeführt. Applikation und Dosisspezifikation erfolgten in Anlehnung an das Pariser System. Ergebnisse: Die Lokalrezidivrate betrug nach einer medianen Nachbeobachtungszeit von 61 Monaten 4,4% (5/113). Das aktuarische lokalrezidivfreie 5- und 8-Jahres-Überleben betrug 95% bzw. 93% (Abbildungen 1 und 2). 90% der Patienten beurteilten ihre kosmetischen Ergebnisse als gut oder exzellent (Tablle 3). Bedingt durch flächige Teleangiektasien im Boostareal entwickelten 14/113 Patienten eine Grad-III-Spättoxizität (0/113 Grad IV) der haut (RTOG/EORTC, Tabelle 2). Eine Boostdosis von 25 Gy resultierte in einer signifikant erhöhten Spättoxizitätsrate (Fishers Exakt-Test, p < 0,01, Abbildung 3). Schlussfolgerung: Die gepulste Brachytherapie ist sicher und effektiv. Die kosmetischen Ergebnisse sind gut. Der interstitielle CLDR-Mammaboost kann durch die PDR-Brachytherapie ohne signifikanten Verlust an therapeutischer Breite ersetzt werden.     

Image-guided brachytherapy following external-beam radiation therapy for patients with inoperable endometrial cancer

ObjectiveTo investigate the outcomes of definitive external-beam radiation therapy (EBRT) plus image-guided brachytherapy (IGBT) in patients with endometrial cancer (EC) unsuitable for surgery.MethodsA total of 50 patients with inoperable EC were included. The patients received EBRT in a median dose of 45 Gy to the pelvis over 5 weeks. Thereafter, the patients received brachytherapy using tandem and ovoid applicators. High-risk clinical target volume (HR-CTV) and gross tumor volume in brachytherapy (GTVp) were defined by the assistance of patients’ pre-IGBT magnetic resonance imaging.ResultsThe medical records of the 50 patients were analyzed. The main causes of inoperability were anesthesia contraindications, namely medical comorbidities and obesity. The median cumulative D90s (the minimum dose delivered to 90% of the volume) in EQD2 (equivalent dose in 2-Gy fractions) to the HR-CTV and GTVp were 72.9 Gy10 (range, 64.9 to 80.3) and 166.2 Gy10 (range, 123.0 to 189.8), respectively. Over a median follow-up period of 27 months, 8 of the patients died of cancer. The 2-year overall and cancer-specific survival rates were 75% and 83%, respectively. The cumulative incidences of pelvic and distant failure were 4% (n = 2) and 16% (n = 8), respectively. Gastrointestinal complications of grade 2 or above were noted in 2 patients (4%), and a grade 2 genitourinary complication was noted in one.ConclusionsFor patients with inoperable EC, EBRT followed by IGBT is an effective approach for achieving high local control without a high risk of complications.