High-dose-rate intraoperative brachytherapy and radical surgical resection in the management of recurrent head-and-neck cancer

PurposeTo report long-term outcomes of high-dose-rate (HDR) intraoperative radiotherapy (IORT) at the time of radical resection for recurrent head-and-neck cancer and determine potential prognostic factors.Methods and MaterialsBetween 7/1998 and 11/2011, 57 patients with recurrent head-and-neck cancer underwent radical resection with curative intent and single-fraction IORT to 59 sites using a Harrison-Anderson-Mick applicator with remotely after-loaded ¹⁹²Ir HDR brachytherapy.ResultsOne- and 3-year in-field progression-free survival (IFPFS) was 67% and 57%, respectively. In a multivariate model, IORT dose >15 Gy (hazard ratio [HR] = 0.11; p = 0.02), and prerecurrence disease-free interval >12 months (HR = 0.29; p = 0.04) independently predicted for superior IFPFS; nodal extracapsular extension (HR = 4.62; p = 0.003) predicted for inferior IFPFS. Three-year overall survival (OS) was 50% vs. 32% in those achieving in-field control vs. those not achieving in-field control (p = 0.04). Grade 3+ toxicity occurred in 37% and was unrelated to IORT dose.ConclusionsHDR-IORT combined with radical surgical resection is associated with durable IFPFS and long-term overall survival in select patients with acceptable treatment-related morbidity. IORT dose >15 Gy should be used to increase the likelihood of disease control. The ability to achieve in-field local control in this poor prognostic cohort was associated with improved survival outcomes.     

External beam radiotherapy plus high-dose-rate brachytherapy for treatment of locally advanced prostate cancer: The initial experience of the Catalan Institute of Oncology

PurposeThe objective of this study was to report initial outcomes in patients with locally advanced prostate cancer (CaP) who underwent external beam radiation therapy (EBRT) treatment combined with high-dose-rate brachytherapy (HDR-BT) as a boost.Methods and MaterialsFrom 2002 to 2007, 114 CaP patients underwent EBRT followed by ¹⁹²I HDR-BT. The patients were classified into intermediate- (Group 1) or high- (Group 2) risk groups. The mean total EBRT dose was 60.0 Gy (95% confidence interval [CI]: 59.9–60.1) at 2 Gy per fraction. After a mean of 20.6 days (95% CI: 18.4–22.8), all the patients received a single-fraction 9-Gy dose of HDR-BT boost. Of the 114 patients in the study, 103 (90.4%) underwent up to 3 years of complete androgen deprivation therapy after diagnosis.ResultsThe mean followup for the entire group was 32.1 months (95% CI: 29.9–34.4). The 4-year biochemical failure-free survival rate was 97.4% and treatment was well-tolerated.ConclusionsPreliminary biochemical control rates after EBRT plus one fraction of 9-Gy HDR-BT are encouraging. This atypical fractionation schedule is cost-effective and reduces patient discomfort and treatment-related risks. More followup is required to confirm these findings.     

Four-year outcomes of hypofractionated high-dose-rate prostate brachytherapy and external beam radiotherapy

PurposeHigh-dose-rate (HDR) brachytherapy boost in prostate cancer allows dose escalation and delivery of higher biologically effective dose (BED). We evaluated the outcomes of intensity-modulated radiation therapy (IMRT) and HDR boost in a community setting.Methods and MaterialsBetween July 2003 and April 2008, 148 patients with prostate cancer were treated at Cancer Center of Irvine using two transperineal implants performed 1 week apart (22 Gy delivered in four fractions divided between two insertions and delivered twice daily), followed by IMRT (50.4 Gy). Hormonal therapy was given for 1 year to all patients with Gleason score of 8 or higher.ResultsPatient characteristics are as follows: median age at treatment, 71 years; American Joint Committee on Cancer Group IIB, 53%; Gleason score of 7, 41%; and Gleason score of 8 or higher, 14%. Median followup was 49 months, and median prostate-specific antigen (PSA) nadir was 0.15 ng/mL. The 4-year actuarial biochemical disease-free survival (bDFS) was 96.8/81% by Phoenix/PSA lower than 0.5 ng/mL criteria. According to National Comprehensive Cancer Center Clinical Practice Guidelines–defined recurrence risk groups, 4-year bDFS for low risk was 100/92.9%, intermediate risk was 100/86.7%, and high risk was 94/75.4% by Phoenix/PSA lower than 0.5 ng/mL criteria. No statistically significant difference in bDFS was detected by either failure criteria based on risk group, lymph node risk, or initial PSA. Treatment was well tolerated. Subacute/late genitourinary and gastrointestinal toxicities were limited to 10% and 5%, respectively of all patients.ConclusionsProstate IMRT plus HDR brachytherapy boost was well tolerated with appropriate PSA response and bDFS at 4 years, demonstrated in a community setting. This treatment schema provides a high BED, comparable with hypofractionated prostate regimens previously reported in the literature. Higher BED delivery should be explored in further dose escalation studies.     

Local control in advanced cancer of the nasopharynx: Is a boost dose by endocavitary brachytherapy of prognostic significance?

PurposeTo analyze whether local tumor control in advanced nasopharyngeal cancer (NPC) can be optimized by boosting the primary dose by endocavitary brachytherapy (EBT).Methods and MaterialsTo study the role of EBT, three data sets on NPC, that is, the “Vienna”, “Rotterdam,” and “Amsterdam” series, with a total number of 411 advanced NPC patients, were available. The Rotterdam series consisted of 72 patients (34 T1,2N+ and 38 T3,4N0,+) and were treated with neoadjuvant chemotherapy followed by external beam radiotherapy (dose 70/2 Gy). After 70/2 Gy, a boost was applied by EBT (in case of T1,2N+) or stereotactic radiation (in case of T3,4 tumors). The Amsterdam (Antoni van Leeuwenhoek Hospital/The Netherlands Cancer Institute) series consisted of 76 patients (40 T1,2N+ and 36 T3,4N0,+) and were irradiated to a dose of 70/2 Gy with concomitant chemotherapy. No second boost by EBT was applied.ResultsIn the case of T1,2N+ tumors, the local relapse rate (LRR) was significantly smaller if a boost was applied, that is, 0% (0/34, EBT boost) vs. 14% (14/102, no EBT boost) (p = 0.023). For the T3,4 tumors, an LRR of 10% (4/38, EBT or stereotactic radiation boost) vs. 15% (17/111, no boost) was found (p = 0.463).ConclusionsIn the case of advanced NPC (T1,2N+ vs. T3,4N+,0), for early T-stages (T1,2N+), an EBT boost seems an excellent way to deliver highly conformal high doses of radiation to the nasopharynx, with high local control rates. For advanced T-stages (T3,4N+,0), the reduction in LRR (10% vs. 15%) was not significant (p = 0.463).     

Four-year results using balloon-based brachytherapy to deliver accelerated partial breast irradiation with a 2-day dose fractionation schedule

PurposeWe present 4-year results from a Phase I/II trial using balloon-based brachytherapy to deliver accelerated partial breast irradiation in 2 days.Materials/MethodsForty-five patients received breast-conserving surgery followed by adjuvant radiation therapy using a balloon-based brachytherapy applicator delivering 2800 cGy in four fractions over 2 days. Outcomes analyzed include toxicities scored using the NCI Common Toxicity Criteria v3.0 scale, ipsilateral breast tumor recurrence, regional nodal failure, distant metastasis, disease-free survival, cause-specific survival, and overall survival.ResultsMedian age was 66 years (range, 48–83 years) and median tumor size was 0.6 cm (range, 0.2–2.3 cm). Five percent of patients were node positive (n = 2), whereas 73% was estrogen receptor positive (n = 33). Median followup was 3.7 years (2.4–7.0 years) with greater than 2 years of followup for all patients. Only Grades 1 and 2 chronic toxicities were noted with fat necrosis (18%) and asymptomatic seromas (42%) being the most common toxicities. Seven percent of patients developed ipsilateral rib fractures (n = 3), although this was not statistically associated with maximum rib dose (p = 0.31). Ninety-eight percent of patients had a good or excellent radiation-related cosmetic outcome at the time of last followup. There were no ipsilateral breast tumor recurrences or regional nodal failures; however, 2 patients developed distant metastases. Four-year actuarial disease-free survival, cause-specific survival, and overall survival were 96%, 100%, and 93%, respectively.ConclusionsTreatment of early-stage breast cancer patients with breast-conserving therapy using a 2-day radiation dose schedule resulted in acceptable chronic toxicity and similar clinical outcomes as standard 5-day fractionation.     

Management of Bartholin’s gland carcinoma using high-dose-rate interstitial brachytherapy boost

PurposeTo describe the patterns of use, clinical outcomes, and dose–volume histogram parameters of high-dose-rate interstitial brachytherapy (HDR-ISBT) in the management of Bartholin’s gland cancer.Methods and MaterialsFive patients with Stage II–III Bartholin‘s gland carcinoma treated with CT-based HDR-ISBT boost were reviewed. Plans were generated using an inverse planning simulated annealing algorithm. Dose–volume histogram parameters were assessed. The total doses of HDR-ISBT and EBRT were converted to total equivalent dose in 2 Gy (EQD₂).ResultsAll 5 patients received HDR-ISBT as a boost (median dose, 30 Gy) after EBRT (median dose, 45 Gy). Three patients received postoperative irradiation for gross residual tumor or positive surgical margins and 2 patients were treated by primary chemoradiotherapy. The median V₁₀₀, D₉₀, and D₁₀₀ for the CTV were 98.3%, 89 Gy₁₀, and 64 Gy₁₀ (EQD₂), respectively. A complete response was observed in all patients. No local recurrence occurred. All patients remain alive and free of disease (median followup, 78 months; range, 8–93). Severe vaginal toxicities were observed, including vaginal necrosis that resolved with hyperbaric oxygen therapy.ConclusionsHDR-ISBT boost after EBRT offers excellent long-term local control in patients with Bartholin’s gland carcinoma. HDR-ISBT should be considered for positive surgical margins or residual tumor after surgery and for locally advanced malignancies treated by primary chemoradiotherapy.     

Comparison of efficacy and safety of low-dose-rate vs. high-dose-rate intraluminal brachytherapy boost in patients with superficial esophageal cancer

PurposeTo compare the efficacy and the incidence of complications of high-dose-rate (HDR) and low-dose-rate (LDR) intraluminal brachytherapy (IBT) boost after external beam radiation therapy in patients with superficial esophageal cancer.Methods and MaterialsFifty-four consecutive patients with Stage I thoracic esophageal squamous cell carcinoma who were treated with definitive radiotherapy using IBT between 1991 and 2007 were studied retrospectively. LDR-IBT and HDR-IBT were performed for 19 and 35 patients, respectively. After external beam radiation therapy of 56–60 Gy with a conventional fractionation, LDR-IBT (5 Gy × 2) or HDR-IBT (3 Gy × 3) was given within 2 weeks. The median follow-up was 47 months (7–151 months).ResultsOverall, the 5-year overall survival, cause-specific survival (CSS), and locoregional control (LRC) rates were 61%, 86%, and 79%, respectively. The 5-year overall survival, CCS, and LRC rates did not differ significantly between the LDR-IBT and HDR-IBT groups (68% vs. 58% (p = 0.50), 83% vs. 85% (p = 0.63), and 84% vs. 75% (p = 0.42), respectively). Salvage treatment was given in 8 locally recurrent patients, and 6 patients were rescued. The Grade ≥2 late morbidities of esophagus and heart/lung were observed in 5 patients (4 in the LDR-IBT group and 1 in the HDR-IBT group) and 2 patients (one from each group), respectively.ConclusionsIn view of the safety profile and effectiveness, our results encourage the continued adoption of HDR-IBT as radiation boost in medically inoperable or elderly superficial esophageal cancer patients undergoing definitive radiotherapy.     

Three-dimensional image-based high-dose-rate interstitial brachytherapy for vaginal cancer

PurposeTo evaluate dosimetric and clinical outcomes of three-dimensional (3D) image–based high-dose-rate (HDR) interstitial brachytherapy (HDRB) in patients with vaginal cancers.Methods and MaterialsThirty patients with vaginal cancers were treated with HDRB using Syed-Neblett template. CT scan was done after placement of needles for confirmation of placement and treatment planning. The target volume and organs at risk, including clinical target volume (CTV), rectum, bladder, and sigmoid colon, were contoured on CT scans. Twenty-eight (93.3%) patients received external beam radiation therapy at a median 45 (24.0–50.4) Gy in 12–28 fractions, followed by HDRB at 3.75–5.0 Gy per fraction in five fractions. Total doses for CTV and organs at risk from external beam radiation therapy and HDRB were summated and normalized to a biologically equivalent dose of 2 Gy per fraction.ResultsSeventeen patients (56.7%) with primary vaginal cancer and 13 patients (43.3%) with recurrent vaginal cancers were treated with 3D HDRB. The mean CTV was 39.3 ± 25.7 cm³, and the median tumor diameter was 3.3 (1.3–8.0) cm. The median biologically equivalent dose of 2 Gy per fraction for 2 cc of bladder, rectum, and sigmoid was 55.0, 56.3, 50.0 Gy, respectively. The median D₉₀ for high-risk CTV was 74.3 (36.3–81.1) Gy. The mean volume receiving 100%, 150%, and 200% of prescribed dose was 90.7 ± 10.0%, 41.3 ± 14.6%, and 17.7 ± 8.3%, respectively. With a median followup of 16.7 months, the respective 1-/2-year locoregional and overall survival rates were 84.4%/78.8% and 82.1%/70.2%, respectively. There were no Grade ≥3 gastrointestinal complications. Late complications of Grade 3 vaginal ulceration and Grade 4 vaginal necrosis were seen in two cases.ConclusionsInitial results of 3D HDRB using our fractionation schedule in the treatment of vaginal cancers showed good local response with acceptable morbidities.     

A planning study of simultaneous integrated boost with forward IMRT for multiple brain metastases

The objective of this study was to evaluate the dose conformity and feasibility of whole-brain radiotherapy with a simultaneous integrated boost by forward intensity-modulated radiation therapy in patients with 1 to 3 brain metastases. Forward intensity-modulated radiation therapy plans were generated for 10 patients with 1 to 3 brain metastases on Pinnacle 6.2 Treatment Planning System. The prescribed dose was 30 Gy to the whole brain (planning target volume [PTV]_wbrt) and 40 Gy to individual brain metastases (PTV_boost) simultaneously, and both doses were given in 10 fractions. The maximum diameters of individual brain metastases ranged from 1.6 to 6 cm, and the summated PTVs per patient ranged from 1.62 to 69.81 cm³. Conformity and feasibility were evaluated regarding conformation number and treatment delivery time. One hundred percent volume of the PTV_boost received at least 95% of the prescribed dose in all cases. The maximum doses were less than 110% of the prescribed dose to the PTV_boost, and all of the hot spots were within the PTV_boost. The volume of the PTV_wbrt that received at least 95% of the prescribed dose ranged from 99.2% to 100%. The mean values of conformation number were 0.682. The mean treatment delivery time was 2.79 minutes. Ten beams were used on an average in these plans. Whole-brain radiotherapy with a simultaneous integrated boost by forward intensity-modulated radiation therapy in 1 to 3 brain metastases is feasible, and treatment delivery time is short.     

Permanent seed brachytherapy for locally recurrent prostate cancer after radical prostatectomy: A case report and review of the literature

PurposeTo describe the management of a patient with locally recurrent prostate cancer in the prostate bed, 10 years after a radical prostatectomy.Methods and MaterialsA 71-year-old man had a radical prostatectomy for a Gleason 7 clinical T2a carcinoma of the prostate in 2000. Final pathologic stage was pT3a pN0. Postoperatively his prostate-specific antigen was undetectable, but by 2008 it was 1.0 ng/mL and in 2011 it reached to 1.43 ng/mL. He was referred for consideration of salvage radiotherapy. Staging workup was negative but transrectal ultrasound revealed a 15 cc recurrence in the prostate bed. A combination of external beam radiation therapy (4600/23/4.5 weeks to the pelvis) and a brachytherapy boost (115 Gy) was selected for definitive management. Androgen ablation was not used.ResultsThe treatment was well tolerated. The brachytherapy boost was planned in a similar fashion to a de novo implant for an intact prostate. The postimplant dosimetry was evaluated using magnetic resonance imaging-computed tomography (MR–CT) fusion and appeared satisfactory. Acute toxicity was minimal. Six months after brachytherapy, the prostate-specific antigen had fallen from 1.43 to 0.05 ng/mL.ConclusionsDose escalation with combined external beam and brachytherapy may be feasible if recurrent disease can be visualized using transrectal ultrasound and encompassed in an implanted volume. Although longer followup and a larger series of patients are required to demonstrate safety and efficacy, consideration should be given this approach.     

The role of dose escalation with intracavitary brachytherapy in the treatment of localized CNS malignancies: Outcomes and toxicities of a prospective study

PurposeThis single-institution prospective study was designed to investigate the feasibility and safety of dose escalation with GliaSite (Proxima Therapeutics Inc., Alpharetta, GA) brachytherapy for the treatment of patients with newly diagnosed and recurrent central nervous system (CNS) tumors after neurosurgical resection. We now report mature results of this trial, its outcomes, and a toxicity profile.Methods and MaterialsTen adult consecutive patients with recurrent and newly diagnosed CNS malignancies underwent GliaSite brachytherapy after maximally safe neurosurgical resection between 2004 and 2007. GliaSite balloon was placed intraoperatively, and the size was selected so as to conform to the surgical cavity. Low-dose-rate radiation was delivered with an aqueous solution of organically bound ¹²⁵I (Iotrex: sodium 3-(¹²⁵I)-iodo-4-hydroxybenzenesulfonate; Proxima Therapeutics Inc.), introduced into the balloon portion of the device via a subcutaneous port. Two to 3 weeks later, the device was filled with Iotrex for a median dwell time of 94.3 hours (range, 68.0–120.5 hours), after which the balloon was explanted. A commercial 3-D planning system was used for a detailed analysis of dosimetry. Median dose of 52.0 Gy (range, 45.0–60.0 Gy) was prescribed 0.5–1.0 cm from the balloon surface. Radiation Therapy Oncology Group (RTOG) criteria were used to assess acute and long-term toxicities associated with this technique. Followup was assessed with MRI scans and was available on all enrolled patients.ResultsMedian followup for surviving patients was 38 months (range, 18–57 months). Mean size of GliaSite balloon was 3.4 cm (range, 2.0–4.0 cm). Mean volume of filling was 19.0 cc (range, 4.0–35.0 cc). Median activity of Iotrex was 301.6 mCi (range, 95.0–515.4 mCi). Median survival was 14.0 months for the entire cohort after the treatment with the GliaSite device. Of our cohort, 6/10 (60%) patients sustained recurrence (20% local and 40% distant). Median time to recurrence after treatment with GliaSite was 8.0 months, and median time to death after recurrence was 7.5 months. There were no RTOG Grade 3 or 4 acute or late toxicities. Followup MRI imaging did not identify any evidence of radiation necrosis.ConclusionsOur data indicate that treatment with GliaSite balloon brachytherapy is feasible and safe, while rendering acceptable local control and minimal acute and long-term toxicities for newly diagnosed and recurrent CNS malignancies. These encouraging results compel us to embark on testing larger numbers of patients with this treatment modality.     

Inverse-planned gynecologic high-dose-rate interstitial brachytherapy: clinical outcomes and dose--volume histogram analysis

PurposeTo present clinical outcomes and dose–volume histogram parameters of three-dimensional image–based high-dose-rate interstitial brachytherapy (HDR-ISBT) in patients with primary or recurrent gynecologic cancer unsuitable for intracavitary brachytherapy (ICB).Methods and MaterialsRecords of 43 women treated between 2001 and 2009 with iridium-192 gynecologic HDR-ISBT boost, using a Syed–Neblett template and inverse planning simulated annealing dose optimization, were reviewed. Median HDR-ISBT dose was 30 Gy, delivered in 4–6 Gy/fraction. Dose–volume histogram parameters recommended by the Groupe Européen de Curiethérapie–European Society for Therapeutic Radiology and Oncology for image-based ICB were analyzed. Total doses were normalized to 2 Gy fractions (biologically equivalent dose in 2 Gy fractions). Local control (LC) and survival were calculated using Kaplan–Meier method. Toxicities were defined according to Common Terminology Criteria for Adverse Events v3.0.ResultsThere were 34 primary malignancies (cervix = 12, vagina = 15, Bartholin’s gland = 5, and vulva = 2) and 9 recurrences. International Federation of Gynecology and Obstetrics stage distribution for primary cancers was I = 2, II = 13, III = 15, and IV = 4. Median followup was 19.3 months (range, 0–92.2). Two-year LC was 87% for primary cancers, and 45% for recurrent cancers, respectively (p = 0.0175). Median V₁₀₀, D₉₀, and D₁₀₀ for clinical target volume were 97.6%, 90.2, and 68.7 Gy₁₀, respectively. Median bladder and rectal D_2 cc were 76.6 and 79.5 Gy₃, respectively. Median urethral D₁₀ was 80.6 Gy₃. Twelve patients experienced Grades 3 and 4 late morbidity, but toxicities were transient. Only 2 patients had persistent severe toxicities. A trend toward increased risk for vaginal necrosis was observed with a clinical target volume >84 cc.ConclusionsHDR-ISBT may achieve good LC in gynecologic cancer unsuitable for ICB, especially in primary malignancies with a 2-year LC rate higher than 85%. Delivery of such high doses has potential advantages but may predispose to adverse effects, reversible in most cases.     

Three-year clinical outcome using the Contura multilumen balloon breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI): improving radiation standards for the optimal application of APBI

PurposeWe reviewed our institution’s 3-year clinical experience in treating patients with the Contura multilumen balloon (SenoRx, Inc., Aliso Viejo, CA) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI).Methods and MaterialsForty-six patients treated with breast-conserving therapy received adjuvant radiation using the Contura catheter (34 Gy in 3.4 Gy fractions). Fourteen patients had Stage 0, 24 had Stage I, and 8 had Stage II breast cancer. Median follow-up was 36 months (range, 1–44 months).ResultsOnly one local recurrence developed (2%). The rate of persistent seroma formation at latest reported follow-up was 4.3% (2 patients) and the incidence of any clinically detectable telengiectasias was 2.2%. No major toxicities (0% Grade III) have occurred. The median skin dose (% of the prescribed dose) was 99.7. The median dose to 95% of the planning target volume for evaluation was 98.8%. The percentage of patients with excellent/good cosmetic results at 24 (n = 23) and 36 (n = 22) months was 100% and 97%, respectively.ConclusionAdjuvant APBI using the Contura multilumen balloon catheter exhibited similar locoregional control, cosmesis, and toxicities to other forms of APBI with similar lengths of follow-up. In addition, improved radiation standards for the delivery of APBI were demonstrated.     

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

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

The use of the MammoSite balloon applicator in re-irradiation of the breast

PurposeTo examine the feasibility of using the MammoSite brachytherapy applicator in the retreatment of the previously irradiated breast.Methods and materialsBetween March 2004 and March 2007, three patients previously treated with external beam radiotherapy were retreated using the MammoSite brachytherapy device. Two patients were treated for an ipsilateral breast tumor recurrence after breast conservation surgery and postoperative irradiation, whereas the third patient developed an in-field breast cancer likely associated with Hodgkin's disease mantle irradiation 27 years before. The recurrent histology of two was ductal carcinoma in situ ([DCIS] one originally presenting as infiltrating ductal carcinoma [IDC] and the other as DCIS), whereas the Hodgkin's disease patient presented with IDC. All patients received a twice-daily tumor dose of 3400 cGy at 340 cGy/fraction. The mean maximum skin dose was 53.4% (range, 49.5–60.3%) of the prescribed dose.ResultsWith a mean followup of 32 months, no patient developed a local recurrence. Cosmesis in all three cases as graded by the National Surgical Adjuvant Breast and Bowel Project, cosmesis criteria was excellent (Grade I) in all cases. Dosimetric calculations demonstrated that the device allows for appropriate local irradiation while sparing the previously irradiated skin of the involved breast as defined by the protocol standard.ConclusionsUse of the MammoSite device in the treatment of the previously irradiated breast is feasible and may provide adequate local control as well as acceptable cosmesis in carefully selected patients.     

Effect of low tube kV on radiation dose and image quality in retrospective ECG-gated coronary CT angiography

IntroductionCoronary computed tomography angiography (CCTA) has emerged as a useful diagnostic imaging modality in the assessment of coronary artery disease. However, the potential risks due to exposure to ionizing radiation associated with CCTA have raised concerns.ObjectivesCCTA can be done with low dose technique to reduce radiation exposure, without compromise of image quality or diagnostic capabilities.Material and methodsForty patients referred for CCTA were examined with low kV (100 kV for patients ?85–61 kg and 80 kV for patients ?60 kg). The dose length product (DLP) were compared with other group (40 patients) with comparable body weight, scan length and acquisition parameters. The second group was selected from PACS database, for which CCTA was done with standard 120 kV.ResultsThere was considerable reduction of radiation dose about 40% with 100 kV and 60% with 80 kV compared to standard 120 kV CCTA protocols with preserved image quality.ConclusionThe use of lower tube voltage leads to significant reduction in radiation exposure in CCTA. Image quality in non-obese patients is not negatively influenced.     

Phase I/II trial of single-fraction high-dose-rate brachytherapy-boosted hypofractionated intensity-modulated radiation therapy for localized adenocarcinoma of the prostate

PurposeA Phase I/II protocol was conducted to examine the toxicity and efficacy of the combination of intensity-modulated radiation therapy (IMRT) with a single-fraction high-dose-rate (HDR) brachytherapy implant.Methods and MaterialsFrom 2001 through 2006, 26 consecutive patients were treated on the trial. The primary objective was to demonstrate a high rate of completion without experiencing a treatment-limiting toxicity. Eligibility was limited to patients with T stage ≤2b, prostate-specific antigen (PSA) ≤20, and Gleason score ≤7. Treatment began with a single HDR fraction of 6 Gy to the entire prostate and 9 Gy to the peripheral zone, followed by IMRT optimized to deliver in 28 fractions with a normalized total dose of 70 Gy. Patients received 50.4 Gy to the pelvic lymph node. The prostate dose (IMRT and HDR) resulted in an average biologic equivalent dose >128 Gy (α/β = 3). Patients whose pretreatment PSA was ≥10 ng/mL, Gleason score 7, or stage ≥T2b received short-term androgen ablation.ResultsMedian followup was 53 months (9–68 months). There were no biochemical failures by either the American Society of Therapeutic Radiology and Oncology or the Phoenix definitions. The median nadir PSA was 0.32 ng/mL. All the 26 patients completed the treatment as prescribed. The rate of Grade 3 late genitourinary toxicity was 3.8% consisting of a urethral stricture. There was no other Grade 3 or 4 genitourinary or gastrointestinal toxicities.ConclusionsSingle-fraction HDR-boosted IMRT is a safe effective method of dose escalation for localized prostate cancer.