Clinical outcomes using image-guided interstitial brachytherapy for definitive cervical cancer patients with high-risk clinical target volumes greater than 30 cc

PurposeGiven the limited data using an interstitial approach with 3D-based planning for definitive cervical cancer utilizing the GEC-ESTRO defined high-risk clinical target volume (HR-CTV), we reviewed our institutional experience of cervical cancer patients with HR-CTVs ≥ 30 cc to determine whether our clinical and toxicity outcomes are acceptable.MethodsA retrospective review of 37 cervical cancer patients with high-risk clinical target volumes (HR-CTVs) ≥30 cc treated with interstitial image-guided brachytherapy (IS IGBT) was performed. All patients received external beam radiotherapy to a median dose of 45 Gy, followed by IS IGBT delivered in a single implant to a median dose of 6 Gy × 5 fractions. Median HR-CTV was 59 cc. A median HR-CTV D₉₀ of 87.44 Gy was achieved. Kaplan–Meier method was used to evaluate local control (LC), distant control, and overall survival (OS), with stratification by overall treatment time (OTT) ≤ 7 or >7 weeks.ResultsMedian followup was 17 months. The estimated 2-year LC, distant control, and OS were 77.6% (confidence interval [CI]: 63.8–94.5%), 56.8% (CI: 41.3–78.1%), and 54.4% (CI: 39.4–75%), respectively. The 2-year LC for OTT ≤7 weeks and >7 weeks were 100% and 58.3%, respectively (p = 0.026). The 2-year OS for OTT ≤7 weeks and >7 weeks were 77.8% and 38%, respectively (p = 0.021).DiscussionsIS IGBT can achieve a high D₉₀ to the HR-CTV even in the setting of large-volume disease and results in a favorable LC and toxicity profile. OTT > 7 weeks is associated with significant decrease in LC and OS.ConclusionsEfforts should be made to complete whole treatment within 7 weeks as this is associated with improved clinical outcomes.     

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

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

CT-based image-guided brachytherapy in uterine cervical cancer: Effect of tumor dose and volume on local control

Background and PurposeTo determine the optimal primary tumor dose for cervical cancer treatment using computed tomography (CT)-based image-guided brachytherapy (IGBT).Materials and MethodsWe retrospectively reviewed 171 patients with cervical cancer who underwent both external beam radiation therapy (EBRT) and IGBT between May 2015 and December 2019. Majority of EBRT plan included central shielding technique. CT-based IGBT was performed weekly a median of three times. Magnetic resonance imaging preceded the first and third session of IGBT for target delineation.ResultsThe median age of the patients was 64 years (range: 30–91 years). The median follow-up time for living patients was 43 months (range: 6–76 months). The 3-year local control rates according to the International Federation of Gynecology and Obstetrics (FIGO, 2008) stages were 89%, 100%, 92%, 89%, 78%, and 100% for stages IB, IIA, IIB, IIIA, IIIB, and IVA, respectively. The median EBRT dose to the central pelvis and parametrium/pelvic wall was 41.4 Gy and 50.4 Gy, respectively. Patients who received a cumulative 2 Gy equivalent dose (EQD2) (α/β = 10 Gy) of high-risk clinical target volume (HR CTV) D90% ≥ 75 Gy achieved a long-term local control rate of 93%, compared with 80% in those who received <75 Gy (p = 0.02).ConclusionThis is one of the largest CT-based IGBT series examining the treatment of cervical cancer based on the tumor dose-volume relationship. An HR CTV D90% ≥75 Gy was significantly associated with favorable local control in this study.     

Image-guided brachytherapy for cervical cancer: Analysis of D2 cc hot spot in three-dimensional and anatomic factors affecting D2 cc hot spot in organs at risk

PurposeTo analyze the D_{2 cc} hot spot in three-dimensional CT and anatomic factors affecting the D_{2 cc} hot spot in organs at risk (OARs).Methods and MaterialsThirty-one patients underwent pelvic CT scan after insertion of the applicator. High-dose-rate treatment planning was performed with standard loading patterns. The D_{2 cc} structures in OARs were generated in three dimensional if the total equivalent dose in 2 Gy exceeded our defined dose limits (hot spot). The location of D_{2 cc} hot spot was defined as the center of the largest D_{2 cc} fragment. The relationship between the hot spot and the applicator position was reported in Digital Imaging and Communication in Medicine coordinates.ResultsThe location of sigmoid, small bowel, and bladder D_{2 cc} hot spots was around the endocervix: The mean location of sigmoid hot spot for lateral view was 1.6 cm posteriorly and 2.3 cm superiorly (Y, 1.6 and Z, 2.3), small bowel was 1.6 cm anteriorly and 2.7 cm superiorly (Y, −1.6 and Z, 2.7). The mean location of bladder hot spot was 1.6 cm anteriorly and 1.6 cm superiorly (Y, −1.6 and Z, 1.6). These hot spots were near the plane of Point A (X, 2.0 or −2.0; Y, 0; and Z, 2.0). The mean location of rectal hot spot was 1.6 cm posteriorly and 1.9 cm inferiorly (Y, 1.6 and Z, −1.9). D_{2 cc} hot spot was affected by uterine wall thickness, uterine tandem position, fibroids, bladder fullness, bowel gas, and vaginal packing.ConclusionsBecause of the location of the D_{2 cc} hot spots, larger tumors present a challenge for adequate tumor coverage with a conventional brachytherapy applicator without an interstitial implant. Additionally, anatomic factors were identified which affect the D_{2 cc} hot spot in OARs.     

Vaginal dose-surface maps in cervical cancer brachytherapy: Methodology and preliminary results on correlation with morbidity

PurposeThe purpose of the study was to develop a methodology for vaginal dose-surface maps (DSMs) in patients with cervix cancer and to investigate dose-surface histogram metrics as predictors for vaginal stenosis (St) and mucositis (Muc).Methods and MaterialsThirty-one patients with locally advanced cervix cancer with no vaginal St/Muc (CTCAE-v3) G ≥ 2 at baseline were analyzed. Patients were divided in four morbidity groups: 15 with St/Muc G0/1, 6 with St G ≥ 2, 4 with St/Muc G ≥ 2, and 6 with Muc G ≥ 2. Patients received external beam radiotherapy and 4-fraction intracavitary/interstitial high-dose-rate brachytherapy using tandem and ovoids. DSMs were generated from inner/outer vaginal surfaces. DSMs of external beam radiotherapy and brachytherapy (Gy EQD2₃) were added based on a system of homologous points, to generate cumulative DSMs. Dose-surface histogram/dose-volume histogram parameters, location of high/intermediate-dose regions, rectovaginal reference point, vaginal lateral 5 mm point doses, and vagina/implant dimensions were investigated for St and Muc prediction. Average/difference DSMs and one-way analysis of variance were used to compare between groups.ResultsBest predictors of stenosis were D_15–25cm2 and upper-vagina S_65–120Gy(%). Cutoffs of ～90 Gy EQD2₃ for D_20cm2 and ～80% for S_65Gy to top 3 cm inner vaginal surface suitably discriminated for stenosis. Spatial dose location on average/difference DSMs showed significantly higher doses (by > 20 Gy, p < 0.001) over longer parts of the dorsolateral vagina and higher rectovaginal reference point doses for any G ≥ 2 morbidity, over the whole circumference of the upper vagina for G ≥ 2 stenosis. Dose-volume histogram parameters were dependent on vaginal wall thickness. An increase of wall thickness from 2 to 4 mm resulted in an increase of D_2cm3 (D_4cm3) of 16% (32%).ConclusionsA novel method was developed to generate vaginal DSMs and spatial-dose metrics. DSMs were found to correlate with vaginal stenosis. The findings of this study are promising and should be further validated on a larger patient cohort, treated with different applicators.     

Quality of life up to 10 years after external beam radiotherapy and/or brachytherapy for prostate cancer

PurposeThe aim of this study was to evaluate quality-of-life changes up to 10 years following three different radiotherapy concepts.Methods and MaterialsIn the years 2000–2003, 295 patients were treated with external beam radiotherapy (EBRT; n = 135; 70.2 Gy in 1.8 Gy fractions), low-dose-rate brachytherapy (LDR-BT with I-125; n = 94; 145 Gy), and high-dose-rate brachytherapy (HDR-BT with Ir-192; n = 66; 18 Gy in two fractions using 4–6 needles) as a boost to EBRT (50.4 Gy in 1.8 Gy fractions). Quality of life was assessed using the Expanded Prostate Cancer Index Composite at median time of 2, 6, and 10 years after treatment.ResultsThe urinary function score 2 years after EBRT (mean 93 points) was significantly higher in comparison to HDR-BT + EBRT (80 points, higher doses to the urethra relevant) and LDR-BT (88 points). After 10 years, only HDR-BT + EBRT (75 points) remained worse (LDR-BT 92 points; EBRT 91 points). Urinary incontinence score decreased from 83 to 76 points in the HDR-BT + EBRT group. No significant differences or changes resulted in the bowel domain. The mean sexual function score (i.e., sexuality score) was significantly higher after LDR-BT versus HDR-BT + EBRT and EBRT (30 vs. 19 and 24 points after 2 years and 25 vs. 13 and 15 points after 10 years, respectively)—a lower patient age and a lower percentage with hormonal treatment need to be considered.ConclusionApart from decreasing sexual function for all patients, decreasing urinary scores were found in the HDR-BT + EBRT group predominantly as a result of increasing incontinence. This study demonstrates the need for optimum BT treatment planning.     

Prostate cancer tumor volume: measurement with endorectal MR and MR spectroscopic imaging

PURPOSE: To determine accuracy of magnetic resonance (MR) and three-dimensional (3D) MR spectroscopic imaging in prostate cancer tumor volume measurement. MATERIALS AND METHODS: Endorectal MR and 3D MR spectroscopic imaging were performed in 37 patients before radical prostatectomy. Two independent readers recorded peripheral zone tumor nodule location and volume. Results were analyzed with step-section histopathologic tumor localization and volume measurement as the standard. Accuracy of tumor volume measurement was assessed with the Pearson correlation coefficient. P values were calculated with a random effects model. Bland-Altman regression analysis was used to evaluate systematic bias between tumor volumes measured with MR imaging and true tumor volumes. Analyses were performed for all nodules and nodules greater than 0.50 cm(3). RESULTS: Mean volume of peripheral zone tumor nodules (n = 51) was 0.79 cm(3) (range, 0.02-3.70 cm(3)). Two readers detected 20 (65%) and 23 (74%) of 31 peripheral zone tumor nodules greater than 0.50 cm(3). For these nodules, measurements of tumor volume with MR imaging, 3D MR spectroscopic imaging, and a combination of both were all positively correlated with histopathologic volume (Pearson correlation coefficients of 0.49, 0.59, and 0.55, respectively); only measurements with 3D MR spectroscopic imaging and a combination of MR and 3D MR spectroscopic imaging demonstrated statistical significance (P <.05). Tumor volume estimation with all three methods was more accurate for higher tumor volumes. CONCLUSION: Addition of 3D MR spectroscopic imaging to MR imaging increases overall accuracy of prostate cancer tumor volume measurement, although measurement variability limits consistent quantitative tumor volume estimation, particularly for small tumors.     

Combined brachytherapy with external beam radiotherapy for localized prostate cancer: reduced morbidity with an intraoperative brachytherapy planning technique and supplemental intensity-modulated radiation therapy

PURPOSE: To report the acute and late treatment-related toxicities of combined permanent interstitial (125)I implantation delivered via real-time intraoperative planning and supplemental intensity-modulated radiotherapy (IMRT) for patients with clinically localized prostate cancer. METHODS AND MATERIALS: One hundred twenty-seven patients were treated with a combined modality (CM) regimen consisting of (125)I implantation (110Gy) using a transrectal ultrasound-guided approach followed 2 months later by 50.4Gy of IMRT directed to the prostate and seminal vesicles. Late toxicity was scored according to the NCI Common Terminology Criteria for Adverse Events toxicity scale. The acute and late toxicities were compared to a contemporaneously treated cohort of 216 patients treated with (125)I alone to a prescribed dose of 144Gy. RESULTS: The incidence of Grade 2 acute rectal and urinary side effects was 1% and 10%, respectively, and 2 patients developed Grade 3 acute urinary toxicities. The 4-year incidence of late Grade 2 gastrointestinal toxicity was 9%, and no Grade 3 or 4 complications have been observed. The 4-year incidence of late Grade 2 gastrourinary toxicities was 15% and 1 patient developed a Grade 3 urethral stricture, which was corrected with urethral dilatation. The percentage of patients who experienced resolution of late rectal and urinary symptoms was 92% and 65%, respectively. Multivariate analysis revealed that in addition to higher baseline International Prostate Symptom Score, those patients treated with implant alone compared to CM were more likely to experience Grade 2 acute urinary symptoms. Increased Grade 2 late rectal toxicities were noted for CM patients (9% vs. 1%; p=0.001) as well as a significant increase for late Grade 2 urinary toxicities (15% vs. 9%; p=0.004). CONCLUSIONS: Adherence to dose constraints with combination real-time brachytherapy using real-time intraoperative planning and IMRT is associated with a low incidence of acute and late toxicities. Acute urinary side effects were significantly less common for CM patients compared to those treated with implantation alone. Late Grade 2 rectal and urinary toxicities were more common for patients treated with CM compared to implant alone.     

Endorectal magnetic resonance imaging for predicting pathologic T3 disease in Gleason score 7 prostate cancer: Implications for prostate brachytherapy

PurposeTo determine the ability of endorectal magnetic resonance imaging (erMRI) and other pretreatment factors to predict the presence and extent of extraprostatic extension (EPE) in men with Gleason score (GS) 7 prostate cancer.Methods and MaterialsWe included patients with clinical stage T1c–T2c, GS = 7 (3 + 4 or 4 + 3), and prostate-specific antigen (PSA) <10 ng/mL who underwent pre-prostatectomy erMRI. We compared pathologic EPE findings with pretreatment factors.ResultsOne hundred seventy-one men were eligible for inclusion. Pretreatment characteristics were: median age = 60 years (42–76); median PSA 4.9 ng/mL (0.4–9.9); GS 3 + 4 = 61%; T1c = 51%; T2a = 25%; T2b = 21%; T2c = 3%; ≥50% positive cores = 46%; EPE-positive (EPE+) erMRI = 28%. Thirty-three percent had pathologic EPE. Increasing T-stage (p < 0.0001) and EPE+ erMRI (p < 0.0001) were significant predictors of pathologic EPE, whereas GS (4 + 3 vs. 3 + 4) (p = 0.14), percentage of positive core biopsies (p = 0.15), and pretreatment PSA (p = 0.41) were not. Median EPE distance was 1.75 mm (range, <1–15 mm). The rates of EPE >5 mm and EPE >3 mm were 11% and 15%, respectively. The odds ratios for erMRI detection of any EPE and of EPE >5 mm were 3.06 and 3.75, respectively.ConclusionsT-stage and EPE+ erMRI predict pathologic EPE in men with GS 7 prostate cancer. The ability of erMRI to detect EPE increases with increasing EPE distance. These findings may be useful in patient selection for prostate brachytherapy monotherapy.     

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

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

Androgen deprivation-mediated cytoreduction before interstitial brachytherapy for prostate cancer does not abrogate the elevated risk of urinary morbidity associated with larger initial prostate volume

PURPOSE: We examined whether prostate volume reduction after a short course of androgen deprivation (AD) lowered the risks of acute and chronic urinary morbidity related to radioactive seed implantation for low-risk prostate cancer. METHODS AND MATERIALS: Eighty-one patients received AD for cytoreduction before interstitial brachytherapy alone. Urinary morbidity was carefully assessed for all patients during a median followup of 53 (range, 23-78) months after treatment. Outcomes were then compared with those of a control group of 81 patients who were matched 1:1 based on identical prostate volume measured at the time of radioactive seed implant, but who had not received AD. RESULTS: Despite effective cytoreduction (median, 30% prostate volume reduction) with AD, prolonged catheterization was required significantly more often for patients who had received AD when compared with the control group of patients who were implanted at identical prostate volumes but who had not received AD (27% vs. 9%, p = 0.02). This finding remained statistically significant on multivariate analysis (p = 0.04). Surgical intervention (9% vs. 4%, p = 0.09) and subsequent urinary incontinence (4% vs. 1%, p = 0.16) were also more frequent among patients who had received AD when compared with implant volume-matched controls. CONCLUSIONS: Patients who achieved smaller prostate volumes through the use of AD maintained a significantly elevated risk (threefold) for urinary complications, commensurate with their initially large prostate volume, when compared with a control group of patients who were implanted at identical prostate volumes but who had not received AD. Therefore, patients presenting with larger prostate glands that would warrant a short course of AD before implant should be counseled accordingly when discussing options for local therapy.     

A retrospective study of bladder morbidity in patients receiving intracavitary brachytherapy as all or part of their treatment for cervix cancer

A retrospective study has been undertaken in an attempt to identify physical parameters that could confidently be used to predict an enhanced risk of bladder morbidity following intracavitary brachytherapy. 366 women received brachytherapy as all, or part, of their treatment for cervical cancer at the Christie Hospital in 1990 and 1991, and of these, 60 patients developed identifiable bladder morbidity (graded on a scale of 1-4 using the Franco-Italian glossary). These were age and stage matched with 60 asymptomatic women who were also treated for cervical cancer by brachytherapy during the same time period. The sizes of applicators used in the two groups were noted and compared. The two groups were also compared with respect to the heights of the applicator set above the symphysis pubis, the degree of anteversion or retroversion of the applicator sets and where possible, the doses at the International Commission on Radiation Units and Measurements (ICRU) bladder reference point. Where CT scans of the applications were available, these were reviewed to see if any differences in the size, shape or location of the bladder were apparent. No significant difference was found between the two groups of patients for any of the parameters investigated. The physical factors investigated in this study cannot be used to reliably predict bladder complications. There was a significant correlation between bladder morbidity and morbidity in other pelvic sites.     

Adrenal gland volume measurement in septic shock and control patients: a pilot study

Objectives:

To compare adrenal gland volume in septic shock patients and control patients by using semi-automated volumetry.

Methods:

Adrenal gland volume and its inter-observer variability were measured with tomodensitometry using semi-automated software in 104 septic shock patients and in 40 control patients. The volumes of control and septic shock patients were compared and the relationship between volume and outcome in intensive care was studied.

Results:

The mean total volume of both adrenal glands was 7.2?±?2.0 cm³ in control subjects and 13.3?±?4.7 cm³ for total adrenal gland volume in septic shock patients (p?<?0.0001). Measurement reproducibility was excellent with a concordance correlation coefficient value of 0.87. The increasing adrenal gland volume was associated with a higher rate of survival in intensive care.

Conclusion:

The present study reports that with semi-automated software, adrenal gland volume can be measured easily and reproducibly. Adrenal gland volume was found to be nearly double in sepsis compared with control patients. The absence of increased volume during sepsis would appear to be associated with a higher rate of mortality and may represent a prognosis factor which may help the clinician to guide their strategy.     

Equivalent uniform dose, D(90), and V(100) correlation with biochemical control after low-dose-rate prostate brachytherapy for clinically low-risk prostate cancer

PURPOSE: To assess the correlation of postimplant dosimetric quantifiers with biochemical control of prostate cancer after low-dose-rate brachytherapy. MATERIALS AND METHODS: Generalized equivalent uniform dose (EUD), dose in Gy to 90% of the prostate gland (D(90)), and percentage of the prostate receiving 100% of the prescribed dose (V(100)) were calculated from the postimplant dose-volume histogram (DVH) for 140 patients undergoing low-dose-rate prostate brachytherapy (LDRPB) monotherapy from 1997 to 2003 at Duke University and the Durham VA Medical Center. Biochemical recurrence was defined according to the American Society for Therapeutic Radiology and Oncology consensus definition. RESULTS: Median followup after LDRPB was 50 months. There was a 7% biochemical recurrence rate (10/140) at last clinical followup. The median EUD was 167 Gy (range, 41-245). The median D(90) was 139 Gy (range, 45-203). The median V(100) was 88% (range, 44-100). The overall 5-year biochemical recurrence-free survival (bRFS) was 94.2%. The 5-year bRFS was 100% for EUD> or =167 Gy and 89.4% for EUD <167 Gy (p=0.008); 100% for D(90) > or =140 Gy and 90.4% for D(90) <140 Gy (p=0.020); 100% for V(100) > or =88%; and 90.3% for V(100) <88% (p=0.017). There was no statistically significant correlation between any of these factors and overall survival. CONCLUSIONS: In our series of 140 patients with low-risk prostate cancer treated with LDRPB alone, we observed a statistically significant correlation between EUD, D(90), and V(100) and bRFS. The generalized EUD, a calculated value that incorporates the entire prostate DVH, appears to be at least as well correlated with bRFS as D(90) or V(100), and may more completely represent the totality of the dose distribution.     

Technique adaptation,strategic replanning,and team learning during implementation of MR-guided brachytherapy for cervical cancer

PurposeMR-guided brachytherapy (MRgBT) with interstitial needles is associated with improved outcomes in cervical cancer patients. However, there are implementation barriers, including magnetic resonance (MR) access, practitioner familiarity/comfort, and efficiency. This study explores a graded MRgBT implementation strategy that included the adaptive use of needles, strategic use of MR imaging/planning, and team learning.Methods and MaterialsTwenty patients with cervical cancer were treated with high-dose-rate MRgBT (28 Gy in four fractions, two insertions, daily MR imaging/planning). A tandem/ring applicator alone was used for the first insertion in most patients. Needles were added for the second insertion based on evaluation of the initial dosimetry. An interdisciplinary expert team reviewed and discussed the MR images and treatment plans.ResultsDosimetry-trigger technique adaptation with the addition of needles for the second insertion improved target coverage in all patients with suboptimal dosimetry initially without compromising organ-at-risk (OAR) sparing. Target and OAR planning objectives were achieved in most patients. There were small or no systematic differences in tumor or OAR dosimetry between imaging/planning once per insertion vs. daily and only small random variations. Peer review and discussion of images, contours, and plans promoted learning and process development.ConclusionsTechnique adaptation based on the initial dosimetry is an efficient approach to implementing MRgBT while gaining comfort with the use of needles. MR imaging and planning once per insertion is safe in most patients as long as applicator shifts, and large anatomical changes are excluded. Team learning is essential to building individual and programmatic competencies.     

Long-term oncological and functional outcomes support use of low-dose-rate brachytherapy with or without external beam radiation in young men (≤60 years) with localized prostate cancer

PURPOSE

To evaluate the oncological and functional outcomes of young men treated with low-dose-rate brachytherapy (BT) for prostate cancer (PCa).

The incidence of radioepidermitis and the dose-response relationship in parotid gland cancer patients treated with 125I seed brachytherapy

Background

We studied the incidence and dose–response relationship of radioepidermitis in parotid gland carcinoma patients treated with [¹²⁵I] seed brachytherapy in the hopes of designing an optimized pre-implant treatment plan that would reduce the incidence and severity of radioepidermitis in patients receiving this therapy.

Patients and methods

Between January 2007 and May 2010, 100 parotid gland cancer patients were treated postoperatively with [¹²⁵I] seed brachytherapy. The matched peripheral dose (MPD) was 80–140 Gy, and [¹²⁵I] seed activity was 0.7–0.8 mCi. The mean dose delivered to the skin was calculated in the post-implant CT on day 0 following implantation. Grades of acute and late dermatitis were evaluated at 2, 6, 12, and 18 months post-implantation.

Results

Most patients experienced grade 0–2 acute and late skin side effects (86 and 97?%, respectively), though a small subset developed severe complications. Most grade 1–3 effects resolved within 6 months of implantation, though some grade 1–3 effects and all grade 4 effects remained unchanged throughout the 18-month follow-up period. Grade 3 and 4 effects were most prominent (75 and 25?%, respectively) with doses of 110–140 Gy; doses higher than 140 Gy produced only grade 4 effects.

Conclusion

[¹²⁵I] seed brachytherapy produced acceptable levels of acute and late radioepidermitis with a good clinical outcome. A mean dose under 100 Gy delivered to the skin was safe, though doses of 110–140 Gy should be given with caution and extra monitoring; doses greater than 140 Gy are dangerous and likely to produce grade 4–5 effects.

     

High-dose-rate interstitial brachytherapy as monotherapy in one fraction of 20.5 Gy for the treatment of localized prostate cancer: Toxicity and 6-year biochemical results

PurposeTo evaluate acute and late genitourinary toxicity, the gastrointestinal toxicity, and the long-term biochemical control after high-dose-rate (HDR) monotherapy in one fraction (20.5 Gy).Materials and MethodsBetween May 2011 and October 2014, 60 consecutive patients with low- and intermediate-risk prostate cancer were treated; the median followup was 51 months (range 30–79). All patients received one implant and one fraction of 20.5 Gy HDR real-time U/S planned with transperineal hyaluronic acid injection into the perirectal. Toxicity was reported according to the Common Toxicity Criteria for Adverse Event, Version 4.0 (CTAE v4.03) by the National Cancer Institute. Biochemical failure was defined according to the “Phoenix definition”.ResultsOur experience in a single fraction of 20.5 Gy HDR brachytherapy is well-tolerated. No intraoperative or perioperative complications occurred. Grade 1 acute genitourinary toxicity occurred in 36% of patients, Grade 2 or more was not observed, only 1 patient requiring the use of a catheter for 7 days in the immediate postoperative period. No gastrointestinal toxicity was observed. No chronic toxicity has been observed after treatment. Morbidity is practically the same as that obtained with 19 Gy in our previously published article but the actuarial biochemical control was better, 82% (±3%) at 6 years.ConclusionsA single dose of 20.5 Gy resulted in a low genitourinary morbidity and no gastrointestinal toxicity and achieves good levels of biochemical disease control.