Severe complications after hypofractionated high dose rate intracavitary brachytherapy following external beam irradiation for oesophageal carcinoma

The purpose of this study was to evaluate severe complications that developed after high dose rate (HDR) intracavitary brachytherapy for oesophageal carcinoma. Six consecutive patients with oesophageal carcinoma were treated by external beam irradiation (60 Gy in 30 fractions over 6 weeks) followed by hypofractionated intracavitary HDR brachytherapy (10 Gy in 2 fractions). Two of the six patients were alive and well for more than 2-3 years following therapy, but three of the six patients developed treatment-related oesophageal fistulae and died. HDR intracavitary brachytherapy following external beam irradiation is an effective method for radical treatment of oesophageal carcinoma. However, hypofractionated HDR brachytherapy should be used with care.     

Early esophageal carcinoma treated with intracavitary irradiation

Five patients with early esophageal carcinoma were treated by 6-12 Gy of intracavitary irradiation following 50-60 Gy of external irradiation as a boost therapy. Surgery was not performed in these cases. None of the patients had local recurrence after radiation therapy, as demonstrated by esophagography and endoscopy. Three patients have been alive for 1-3 years 10 months. Esophageal ulceration induced by intracavitary irradiation has occurred in three of the five patients; however, intracavitary irradiation is still a beneficial treatment because of its efficacy in controlling local lesions and because radiation ulceration can eventually be cured. Intracavitary irradiation is recommended to follow external irradiation as a boost therapy for the treatment of early esophageal carcinoma.     

Early-stage carcinoma of the external auditory canal treated by intracavitary irradiation with HDR 192Ir-RALS: a case report

We report a case of early-stage carcinoma of the external auditory canal treated by intracavitary irradiation with high-dose-rate (HDR) 192Ir-RALS after 40 Gy by external irradiation. We made an applicator that was inserted into the external auditory canal for the intracavitary irradiation, using a 9 Fr silicone catheter and resin. The total intracavitary radiation dosages were 20 Gy/8 Fr/4 weeks. No severe side effects were noted, and the tumor disappeared. RALS may be indicated for early carcinoma of the external auditory canal for its efficacy and lack of side effects.     

Small, superficial esophageal carcinoma treated with high-dose-rate intracavitary irradiation only

Six patients with small, superficial carcinoma of the esophagus were treated with 18-24 Gy of high-dose-rate intracavitary irradiation only. All patients were examined with an endoscope within 1 month after therapy, and the tumor in all six had disappeared. However, erosion induced by high-dose-rate intracavitary irradiation was seen in five of the patients. Five of the patients have experienced no local recurrence; endoscopic biopsy showed local recurrence in the remaining patient 7 months after radiation therapy. All patients have survived 6-16 months. Esophageal ulceration induced by intracavitary irradiation occurred in three of the six patients; however, the ulcers have been healing with conservative treatment. This new method of using only high-dose-rate intracavitary irradiation appears to be effective in the patient with small, superficial esophageal carcinoma.     

Esophageal fistula associated with intracavitary irradiation for esophageal carcinoma

Fifty-three patients with esophageal carcinoma were treated with high-dose-rate intracavitary irradiation following external irradiation. Ten patients developed esophageal fistula. Perforations were found in the bronchus (four), major vessels (four), pericardium (one), and mediastinum (one). The frequency of fistula occurrence in these patients was not remarkably different from that in 30 other patients treated only with greater than or equal to 50 Gy external irradiation. From the time of the development of esophageal fistula, intracavitary irradiation did not seem to accelerate the development of fistula. The fistulas in our ten patients proved to be associated with tumor, deep ulcer (created before intracavitary irradiation), chemotherapy, infection, and trauma rather than the direct effect of intracavitary irradiation.     

High-dose-rate brachytherapy boost for carcinoma of external auditory canal

PurposeTo report dosimetry and outcome in a case of early stage carcinoma of external ear (T1N0M0) treated with radical radiotherapy alone using a combination of external beam radiotherapy (EBRT) and intracavitary irradiation with a high-dose-rate (HDR) ¹⁹²Ir remote afterloading system.Methods and MethodsA 64-year-old gentleman who was diagnosed as T1N0M0 carcinoma of external ear was treated with combination of external beam radiation therapy followed by brachytherapy (BRT). A total dose of 40 Gy was delivered by EBRT, following which a 6-Fr catheter for the HDR ¹⁹²Ir remote afterloader, fixed by a customized acrylic mold, was inserted into the external auditory canal (EAC) and a total intracavitary radiation dose of 22.5 Gy (4.5 Gy/F) was given.ResultsEvaluation at the completion of treatment and at the end of 4-year followup revealed no evidence of the disease.ConclusionsIn the radical treatment of early stage EAC carcinoma, combination of external beam radiation therapy and BRT may be a modality of choice for its efficacy, less severe side effects, and better cosmetic results.     

Radiation treatment of varicoid carcinoma: a case report

The authors describe a 70-year-old male who was found to have varicoid carcinoma of the esophagus. He was treated with combined external irradiation and intracavitary irradiation; however, the cancer was not locally controlled.     

Radiotherapy of carcinoma of the uterine cervix--high dose rate intracavitary irradiation using a linear source arrangement

We analyzed the records of 339 patients with squamous cell carcinoma of the uterine cervix. The patients were treated by irradiation alone in the period of 1973-1985 with external and high-dose rate intracavitary irradiation using linear source arrangement. The reason for using the linear source arrangement was to ensure the position of source as well as to simplify the technique of intracavitary irradiation. First, external irradiation was performed mainly with a dosage of 50Gy/25f four times a week or 50.4Gy/28f five times a week. Intracavitary irradiation was then carried out mainly with a dose of 30Gy/6f two times a week or 35Gy/7f two times a week and dose was indicated at point A. The 5-year survival rate of all 330 patients were 51.4%, and 55.1% for stage I (N = 19), 66.7% for stage II (N = 88), 47.1% for stage III (N = 212), 33.7% for stage IV (N = 20). Of the patients followed up for 24 months and found to have recurrence, 21.8% (39/179) had a recurrence in the pelvis and 22.1% (39/175) were found to have a distant metastasis. Of the patients followed up for over 24 months, 21.5% 932/149) developed intestinal complications and 12.2% (18/149) developed bladder complications. However complications Grade 2-4 were 5.4% for intestinal complications and 2.0% for bladder complications. From these results high-dose-rate intracavitary irradiation using a linear source arrangement was considered to be an effective treatment of carcinoma of the uterine cervix and to produce a standard results of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Histopathological study of the esophageal injury induced by high-dose-rate intracavitary irradiation. Experimental study on the rabbits]

Despite the effectiveness of the intracavitary irradiation as the boost therapy for the esophageal cancer, the side effect of the normal part of the esophagus has not been studied enough. The purpose of this study is to investigate the histopathological responses of the rabbit esophagus to the high-dose-rate intracavitary irradiation. Esophageal ulcer was observed in the specimen received a dose of 15 Gy during 7 to 28 days after irradiation. Before the mucosal changes were observed, edema and cell infiltration were found in lamina propria. Chronic injury such as necrosis and degeneration of epithelium, and degeneration of the wall of blood vessels was seen at 6 months. No marked changes were found in the specimen received doses of 5 and 10 Gy. The influences of administration of mucosal protection agent and cancer chemotherapeutic drug were also studied. Administration of mucosal protection agent protected the occurrence of severe ulcer and accelerated the recovery from mucosal damage. Administration of cancer chemotherapeutic agent enhanced the radiation injury by the intracavitary irradiation of the esophagus. In conclusion, it was strongly suggested that a single dose of the high-dose-rate intracavitary irradiation should be reduced less than 10 Gy to prevent the esophagus from severe injury.     

Injuries of the sigmoid colon following radiation therapy of carcinoma of the uterine cervix--a method of estimating the radiation dose to the sigmoid colon

Grade 2 or 3 injuries of the sigmoid colon were observed in 4 out of 42 patients with carcinoma of the uterine cervix who were treated by radiation therapy. The irradiation was planned as the combination of the external irradiation (whole pelvic 30 Gy and 20 Gy with central shielding by 25 fractions, 5 weeks) and the intracavitary irradiation (RALS, 19 Gy at point A by 3 fractions). To analyze the causes of the radiation sigmoiditis, we have investigated the following factors: age, dose at point A, dose at point C, grade of tandem dislocation, uterine angle, obesity score, evidence of previous surgery to the pelvic cavity and hypertension. The dose at point C and the grade of tandem dislocation were determined from the confirming X-Ps at RALS therapy and external irradiation. The superimposition of these films was performed with corrections for the angle between the projection direction of the X-Ps and the vertical magnification factor of the central shielding area. Point C was defined as a point 2 cm anterior to the intersection of the tandem axis and a curvilinear line 1 cm outside from the margin of central shield on the X-Ps. Grades of tandem disclocation were decided as the number of tandem tips which were outside of the central shielding area on X-Ps. As the results, the doses at point C showed very high statistical significance (p less than 0.001) with the evidence of radiation sigmoiditis. All the cases with radiation sigmoiditis were received over 1290cGy at point C. Age had also some significance (p less than 0.05) with radiation sigmoiditis.(ABSTRACT TRUNCATED AT 250 WORDS)     

外照射加腔内照射治疗食管癌的前瞻性研究

目的观察一定剂量的外照射后不同时期加腔内放射治疗的疗效及副作用，以探讨较适当的腔内照射时机。方法100例食管癌患者随机分2组，A组：35Gy外照射后，即开始内外照射同期进行。B组：50Gy外照射后开始腔内照射。两组外照射总吸收剂量均为50Gy，采用常规分割照射，1.8—2Gy，次，5次，周。腔内照射5Gy，次，每周1次，共2次。结果A组的1、3和5年局控率分别为60．2％、39．8％和36．2％，B组的1、3和5年局控率分别为54．1％、32．8％和29．2％；P=0．5118。两组的1、3和5年生存率分别为52．0％、26．0％、21．8％和54．0％、23．4％、16．7％，P=0．8159。A组和B组急性放射性食管炎的发生率分别为70％（35/50）和48％（24/50），P=0．038，但严重的食管炎（Ⅲ级及以上）的发生率相当，均为4％。A组和B组食管瘘的发生率分别为8％（4／50）和10％（5／50）。结论于35Gy外照射后同期加腔内照射及外照射50Gy结束后即局部补加腔内照射均是可行的。两种治疗方案相比，前者急性放射性食管炎的发生率高于后者，但晚期并发症无增加。     

Squamous cell carcinoma of the external auditory canal: two cases treated with high dose rate 192Ir remote afterloading system (RALS)

We report two cases of early-stage external auditory canal cancer treated by intracavitary irradiation with a high dose rate (HDR) 192Ir remote afterloading system (RALS) for preoperative treatment. A 6-Fr catheter for the HDR 192Ir remote afterloader, fixed by a plastic earplug, was inserted into the external auditory canal in two cases (case 1, T2N0M0; case 2, T1N0M0). The total intracavitary radiation dosages were 50 Gy (10 Gy/2 Fr/wk for 5 wks) for case 1, and 42 Gy (15 Gy/5 Fr/wk for 3 wks) for case 2. No external irradiation was given in either case. Surgical resection was performed in both cases, three to four weeks after irradiation. Histopathological examination confirmed the post-irradiation changes of necrosis, hyalinosis, and calcification, although vivid cancer cells remained. In preoperative irradiation of external auditory cancer, this method, although limited to treating early-stage cancers, may be a modality of choice for its efficacy and less severe side effects.     

Transperineal Low-Dose Rate Iridium-192 Interstitial Brachytherapy in Cervical Carcinoma Stage IIB

PURPOSE: To assess local control, survival and complications in patients with cervical carcinoma Stage IIB treated radically with transperineal Iridium-192 low-dose rate interstitial brachytherapy following external beam radiotherapy. PATIENTS AND METHODS: 65 women (age 25-70 years, mean 47 years) with cervical carcinoma Stage IIB were initially treated with external beam radiotherapy on a telecobalt or 6 MV linear accelerator to a dose of 50 Gy delivered in 5-6 weeks. After 2-3 weeks of completing external radiation, patients received interstitial brachytherapy with Iridium-192 (activity 0.5-1 mCi/cm) using a Syed-Neblett perineal template. The median dose delivered to the implant volume was 24 Gy (range 20-32 Gy) delivered at an average dose rate of 0.70 Gy/h (range 0.40-1.20 Gy/h). A point defined at 1.5 cm lateral to the central uterine tandem at the level of os was taken as a representative for assessing the dose to the cervix. Mean doses delivered by interstitial brachytherapy to point A, cervix, point B and rectum were 38 Gy, 34 Gy, 16 Gy and 16 Gy, respectively. RESULTS: At a median follow-up of 53 months, the actuarial disease free survival and overall survival for 65 patients at both 5 and 10 years was 64% and 44%, respectively. Response to radiotherapy was a strong predictor of local control with 82% of patients continuing to have pelvic control after initial complete response. Overall, nine (14%) patients had persistent disease, ten (15%) developed a central recurrence after initial control and three patients developed distant metastasis on follow-up. No patient had any immediate treatment-related complication. Late toxicity included grade I-II rectal reactions in five patients and grade IV bladder complication (vesico-vaginal fistula) in two patients. 5 years after treatment, one patient developed intestinal obstruction, which was relieved after conservative management. Two patients developed vaginal stenosis. The 5- and 10-year disease free survival was 48% in patients aged less than 45 years as compared to 80% in patients of more than 45 years (p = 0.009). Dose to the cervical point was a prognostic indicator with 5- and 10-year disease free survival of 47% in patients who received < 35 Gy in comparison to 80% in patients who had > 35 Gy (p = 0.03). There was no difference in local control and survival in patients with minimal and moderate parametrial involvement. Bulky disease (> 4 cm) at presentation and a longer gap between external radiation and brachytherapy showed a trend towards inferior local control. CONCLUSIONS: Interstitial brachytherapy after external beam irradiation in patients with cervical carcinoma Stage IIB results in acceptable local control, survival and complication rates. Increased dose to the cervical disease results in improved local control and survival and should therefore be considered while optimizing brachytherapy treatment plans. Comparison of the results with those of standard intracavitary therapy remains to be proven in a randomized trial.     

Radiotherapy of bile duct carcinoma using intracatheter 198Au grains.

Eight patients with bile duct carcinoma were treated with radiotherapy using intracatheter 198Au grains. The intracatheter 198Au grains in an inner tube were inserted into a percutaneous transhepatic catheter. A plastic tip was placed between these grains to improve spatial and temporal dose allocation. This method and 192Ir wire irradiation resemble each other closely in dose distribution, but the former has the following advantages over the latter. 1) The number of 198Au grains used can be changed quite easily in accordance with the length of the stenosis. 2) The half-life of 198Au is about 2.7 days, and a dose of 25-40 Gy at 1.0 cm from the source is delivered over this period. The medical staff can protect themselves from radioactivity when the sources are withdrawn after brachytherapy. 3) 192Ir wire is not used very frequently in spite of its long half-life (74 days) because bile duct carcinoma is uncommon. 4) In Japan, 198Au grains can be purchased on a weekly basis, so treatment plans can be easily made. The eight patients also received external irradiation and the median survival after onset of radiotherapy was 7.9 months. There have been few systemic or local complications.     

Histopathological study of the esophageal injury induced by high-dose-rate intracavitary irradiation

The histopathological responses of the rabbit esophagus to high-dose-rate intracavitary irradiation were investigated. After 5, 10 or 15 Gy irradiation using a remote afterloading system, the rabbits were sacrificed on different occasions. The esophagus was excised from each animal and examined histopathologically. Esophageal ulcer was observed 7 to 28 days after the irradiation of the highest dose. Edema and cell infiltration in the lamina propria proceeded mucosal changes like ulcer. Chronic injuries such as mucosal necrosis were seen at 6 months.     

CT-aided volumetry and prognosis in cervical carcinoma

Since January 1981, 128 CT evaluations were systematically applied to 85 patients of histologically proven squamous cell carcinoma of the cervix uteri before and after external irradiation (i.e., at the beginning of intracavitary therapy). CT-measured cervical mass volume and mass-pelvic wall distance were analyzed in relation to prognosis, namely, local control at one year after irradiation and three-year survival. Regardless of clinical stage, CT-measured volume and mass-pelvic wall distance were revealed to be closely related to prognosis. In 46 patients whose cervical mass volume regressed to less than 48 cm3 after external irradiation, 44 (95.6%) were locally controlled for more than a year, and the three-year actuarial survival of this group was 71.6 + 6.2%. On the contrary, in those whose volume was over 48 cm3 at the end of external irradiation, only 3 out of 18 were locally controlled, and the three-year survival was 7.4 + 6.0. Mass-pelvic wall distance was also related to tumor control. CT was found to provide fairly objective, reproducible information for detecting the high-risk subgroup in cervical carcinoma under uniform treatment conditions.     

Classical tandem-source dwelling covering the entire uterus: essential in modern intracavitary radiotherapy for cervical cancer?

PURPOSE: We investigated whether conventional tandem-source dwelling to cover the entire uterus, classically regarded as the target volume, is necessary in modern intracavitary radiotherapy (ICRT) for cervical cancer. MATERIALS AND METHODS: The study included 95 cervical squamous cell carcinoma patients treated by high-dose-rate ICRT (point A dose was 6.0 Gy, with three to five insertions per patient) after external beam radiotherapy (EBRT), with central pelvic doses of 12-50 Gy. The tandem-source dwell length was adjusted to the target volume specified by magnetic resonance (MR) imaging. A tandem applicator was inserted as far as the uterine fundus in accordance with the post-EBRT MR-assessed cavity length. The pre-EBRT MR-specified target volume was used for the dwell-length adjustment. The safety of the dwell-length adjustment was assessed in terms of treatment failure. RESULTS: The dwell-length adjustment was made in 248 of 366 total insertions with a dwell-length reduction of 5-55 mm (median 15 mm) at the corpus. Pelvic failure was identified in 22 patients with a 2-year pelvic disease-free survival rate of 75.6% but without evidence of failure at dwelling-skipped corpuses. CONCLUSION: Given after pelvic EBRT and ICRT of full-length dwelling in part, which may have eradicated possible subclinical extension, adjustment of the tandem-source dwell length to the MR-specified target volume appeared to be safe.     

Esophageal stricture following high-dose-rate intracavitary irradiation for esophageal cancer

Severe esophageal stricture developed in four of 12 patients who survived for more than 2 years after treatment for esophageal cancer consisting of external irradiation followed by high-dose-rate intracavitary irradiation. The strictures were seen between 13 and 21 months after initiation of radiation therapy. The length of the strictures appeared to relate to the length of the tumor before treatment and to the magnitude of the intracavitary dose. One of the four patients was helped by balloon dilatation.     

The effect on dosimetry of changing from the lithotomy to the supine position in treating uterine cancer with the Cathetron and external radiotherapy.

Uterine carcinoma can be treated by combined external and intracavitary irradiation. With an afterloading technique intracavitary irradiation is given with the patients in the lithotomy position. External irradiation is given with the patient in the supine position. A lead shield is used with the external fields to cover the tissues which are close to the intracavitary sources and receive high doses. The positions of the intracavitary sources seen on radiographs taken when the patient is in the lithotomy position are transferred to films taken with the patient in the supine position. From the latter the position and profile of the shield are calculated. It is shown that a reliable transfer of the positions of the sources and determination of the necessary shielding cannot be achieved in this way. It is therefore concluded that both intracavitary and external irradiation should be carried out with the patient in the supine position.