Preoperative intracavitary irradiation of endometrial carcinoma stage I by a high dose rate afterloading technique

Preoperative intracavitary irradiation was administered to 366 patients with endometrial carcinoma stage I by a high dose rate afterloading method using 60Co sources (bulb-technique). In 275 cases hysterectomy and bilateral salpingo-oophorectomy were performed 6 weeks later and in 91 cases dilation and curettage was used to verify tumor eradication. In 58% of the hysterectomy specimens no residual carcinoma was detected at the histopathologic evaluation. In the group treated with radiotherapy alone 74% showed no carcinoma remnants in the curettings 3 months after therapy. The effect of the fractionation dose was evaluated in relation to the outcome of the histopathologic examination of the hysterectomy and curettage specimens. The proportion of specimens with no residual carcinoma increased from 27% for the 5 Gy per fraction group to 78% for the 10 Gy per fraction group. Recurrences were recorded in 13% in the hysterectomy group and in 29% in the group treated with radiotherapy alone. The nuclear grade of the tumor and the age of the patient were the most important risk factors for tumor recurrence. The 5-year crude survival rate for the combination-treated group was 84% and for the group treated with radiotherapy alone 47%. The corresponding corrected survival rates were 88 and 72% respectively. Serious late radiation reactions were noted in 6.6%. The significant risk factors for radiation reactions were dose per fraction and the age of the patient.     

Intracavitary radiation in the treatment of advanced esophageal carcinoma: A comparison of high dose rate vs. low dose rate brachytherapy

Twenty-two patients were irradiated using two different dose schedules of intracavitary irradiation for palliation of locally advanced or metastatic carcinoma of the esophagus. Irradiation was given solely with either manually afterloaded low/Intermediate dose Cesium-137 (LDR) or high dose rate Iridium-192 (HDR) delivered via remote afterloader. This study was designed to test the effectiveness of HDR intracavitary brachytherapy in the relief of dysphagia and the maintenance of esophageal patency and to compare with our previous experiences with LDR intracavitary brachytherapy. Accelerated treatments were especially suited for patients with poor physical condition or short life expectancy unlikely to complete a full course of external beam irradiation without treatment interruption. Two thousand cGY in three fractions of LDR was compared with 1,250 cGY in one fraction HDR with essentially equal results. © 1993 Wiley-Liss, Inc.     

~(60)Co外照射加高剂量率腔内后装放射治疗鼻咽癌长期观察

目的 :分析6 0 Co外照射加高剂量率后装腔内放射治疗鼻咽癌的长期疗效及晚期放射性并发症。材料与方法 :回顾性分析 1 981年 6月至 1 988年 1 2月采用6 0 Co外照射加高剂量率后装腔内放射治疗鼻咽癌 64例。本组病例都随访 5年以上 ,失访者作死亡统计。结果 :本组病例 5年局部控制率为 82 .8% (5 3 /64)。 5年生存率和无瘤生存率分别为 75 .0 % (4 8/64)和 68.8% (4 4 /64)。鼻咽局部复发 6例 ,远处转移 8例、鼻腔骨肉瘤者 1例。晚期放射并发症 ,鼻腔死骨形成 1例 ,软硬腭骨穿孔 4例。结论 :后装腔内放射治疗适当减少鼻咽癌外照射剂量 ,增加鼻咽腔内加量照射。适应于鼻咽早期原发肿瘤和鼻咽癌外照射后鼻咽腔内残留病灶。为了减少鼻咽腔内晚期放射性并发症值得进一步改进鼻咽施源器     

铱~(192)高剂量率后装加外照射治疗宫颈癌105例分析

目的　研究铱192 高剂量率后装加外照射治疗宫颈癌的疗效 ,并发症等。方法　前瞻性治疗 ,全盆腔外照射DT 2 5～ 3 0Gy/3周后 ,再行腔内铱192 后装治疗和盆腔四野垂直照射 :腔内每周 1次 ,A点剂量每次 5～ 7Gy ,总剂量3 0～ 3 5Gy ,盆腔四野照射 ,宫旁剂量 15～ 2 0Gy/1.5～ 2周。 结果　CR PR 10 0 % ,3年生存率Ⅱ期 89.5 % ,Ⅲ期 80 .4% ,全组 83 .8%。结论　本疗法疗效可靠 ,放射性直肠炎、膀胱炎发生率与传统方法相似 ,放射性阴道损伤略高 ,放疗中、放疗后坚持阴道冲洗非常重要。     

High dose rate afterloading intracavitary therapy in carcinoma of the cervix

From January 1984 through December 1986, 87 patients with previously untreated carcinoma of the cervix received external beam pelvic irradiation and high dose rate intracavitary therapy (HDRT). There were 18 Stage IIA patients, 39 Stage IIB, and 30 Stage IIIB. The median age was 60 years and the median follow-up time was 42 months for patients at risk. Radiotherapy consisted of external megavoltage irradiation to the whole pelvis (median dose 4600 cGy) combined with one (6 patients), two (51 patients), or three (30 patients) HDRT insertions. A high dose rate remote afterloading unit with 60Co sources was used to deliver the HDRT. The prescribed dose to point A was between 800 and 1000 cGy per treatment. The dose rate at point A initially was approximately 150 cGy/min and dropped to approximately 100 cGy/min during the duration of the study. Treatments with multiple fractions were given at weekly intervals. The overall actuarial survival at 5 years was 88% for Stage IIA, 64% for Stage IIB and 32% for Stage IIIB patients. Pelvic recurrence remained the major cause of failure. Grade III and IV late complications included proctitis and bowel obstruction in six patients each. We conclude that HDRT results are similar to those obtained with conventional low dose rate intracavitary systems. HDRT is cost effective and minimizes exposure to personnel. Several questions, such as the total number of insertions required, dose per HDRT insertion, and optimal HDRT insertion schedule remain unanswered and further experience is needed to better clarify these issues.     

Intrauterine high dose rate afterloading brachytherapy: Experience of fractionated therapy using a cervical sleeve technique

Using a standard three-channel Manchester-type tube and ovoid high dose rate applicator system, 46 consecutive patients have been treated for carcinoma of the cervix or endometrium. To facilitate fractionated treatments using high dose rate afterloading, a technique has been developed using an indwelling cervical sleeve inserted under an initial general anaesthetic. All patients received at least two insertions; in five patients we have delivered a total of six consecutive fractions on an outpatient basis without anaesthesia once the sleeve was in situ. Acute morbidity related to the procedure was some degree of uterine pain, which was relieved with nitrous oxide inhalation, and mild, but self-limiting, vaginal discharge. Complete late morbidity data are not yet available, but, in 30% of 25 evaluable patients, minor problems have been observed, particularly vaginal oedema and stenosis. Only one major late event has required surgery.Fractionated afterloading intrauterine brachytherapy can be delivered on an outpatient basis without anaesthesia using this cervical sleeve technique.     

Ⅰ、Ⅱ期鼻咽癌外照射联合高剂量率腔内后装治疗

目的探讨高剂量率腔内后装治疗在鼻咽癌放疗中的作用。材料与方法从１９９２年１月至１９９３年６月，１１０例Ⅰ、Ⅱ期鼻咽癌患者随机分为外照射加高剂量率腔内后装治疗组（综合放疗组）和单纯外照射组（对照组）。综合放疗组外照射鼻咽剂量５６～６０Ｇｙ／２８～３０次／５、６～６周，腔内治疗鼻咽顶壁粘膜下０．３ｃｍ给量８Ｇｙ３次／１．５～２周。对照组外照射鼻咽剂量６６～７２Ｇｙ／３３～３６次／６．６～７．２周。结果治疗后３６个月局部控制率综合放疗组优于对照组（９８，２％对８５．５％，Ｐ＜０．０５）；张口困难发生率，综合放疗组低于对照组（７．３％对４７．３％，Ｐ＜０．００５）。结论外照射加高剂量率腔内后装治疗可提高早期（Ⅰ、Ⅱ期）鼻咽癌的局部控制率。     

Long term results of definitive radiotherapy for cervical carcinoma using four applications of high dose rate afterloading.

BACKGROUND: In definitive radiotherapy for cervical carcinoma, combined modality treatment using external beam radiotherapy and brachytherapy is standard. Although the optimal number of afterloading applications is controversial, the majority of authors recommend three applications. METHODS: In this study, the authors investigated the use of 4 applications with iridium-192 afterloading with a dose of 7.5 grays (Gy). Standardized radiotherapy doses were adapted to the individual tumor anatomy using a prospective schedule. RESULTS: In the 73 study patients, actuarial and tumor-related 5-year survival rates by T classification were: T1b: 30% (100% cause specific survival); T2a: 55% (76% cause specific survival); T2b: 50% (60% cause specific survival); T3a: 50% (67% cause specific survival); T3b: 39% (50% cause specific survival); and T4a: 40% (40% cause specific survival). Morbidity, graded according to the National Cancer Institute's Common Toxicity Criteria (CTC) were low: CTC Grade 1: 7 patients (7.6%); CTC Grade 2: 7 patients (7.6%); CTC Grade 3: 1 patient (1.4%); and CTC Grade 4: 1 patient (1.4%). In a multivariate analysis, the T classification was the only significant independent prognostic factor for actuarial survival, tumor related (cause specific) survival, local tumor control and freedom of metastatic disease. The number of afterloading applications was an independent prognostic factor for local tumor control. CONCLUSIONS: Based on the long term results of the current study, external beam radiotherapy combined with 4 afterloading high dose rate applications (total of 30 Gy) appears to be clinically feasible and results in satisfactory survival rates and few side effects.     

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

BACKGROUND AND PURPOSE: High dose rate intraluminal brachytherapy for tumours of the rectal and anal canal which were inoperable either because of the age and frailty of the patient or because of advanced disease has been evaluated. PATIENTS AND METHODS: In a retrospective review of 50 consecutive patients the two main indications for brachytherapy were as part of a radical radiation programme in those unfit for major surgery (26 patients) or as palliation for advanced or metastatic disease (22 patients). Radical treatment was either sole treatment delivering 6 Gy fraction 2 to 3 times weekly up to 36 Gy or as a boost of 12 Gy after 45 Gy in 25 fractions external beam chemoradiation. Palliative treatments were given predominantly as a single dose of 10 Gy. RESULTS: This was predominantly a group of frail elderly patients with a median age of 82 years (range 35-91). Local tumour response was seen in 21/25 assessable patients with 14 complete responses. Median survival for the entire population was 6 months (range 1-54 months); in patients treated with 'radical' intent this was 25 months (range 1.5-54) and in the palliative group 7.2 months (range 1-37). The most common presenting symptom was bleeding per rectum for which a 64% response rate was obtained with 57% complete responses. Mucous discharge responded in 64% with 28% complete responses. The median duration of response was 7 months. CONCLUSION: Intraluminal HDR brachytherapy is an effective local treatment for patients otherwise unfit for radical surgery both as a component of radical treatment, or as a simple single palliative procedure.     

Intermediate dose rate remote afterloading brachytherapy for intraluminal control of bronchogenic carcinoma.

Forty-five patients with symptomatic proximal malignant airway disease received 128 intraluminal intermediate dose rate (IDR) brachytherapy treatments by remote afterloading technique. Multiple small catheters were bronchoscopically placed. Iridium-192 sources delivering an intermediate dose rate (200-1000 rads/hr) were guided under remote computer control. Treatment times were 1-4 hr. Fourteen of these patients also received YAG laser photoresection. External beam radiation was also given (6000 rads) to 16 patients for curative intent and (3000 rads) to 9 patients for palliative intent. Twenty recurrent disease patients were also treated, but they did not receive external irradiation. An obstruction score (OS) was developed in an attempt to quantitate the improvement in intraluminal narrowing. Patients treated with curative intent showed 66% improvement after initial therapy. Initial therapy for palliative patients showed an 84% improvement and for recurrent disease patients, 64% of luminal narrowing was seen. Patients who received laser in addition to brachytherapy showed a 70% reduction. A 67% improvement was seen in those who did not receive laser therapy. The entire group averaged a 69% improvement of narrowing. Four complications, three minor, (1 bronchospasm, and 2 episodes of transient intratreatment increased ventricular irritability) and one major (pneumothorax) were noted. The relatively short treatment times allowed most of the treatments to be performed on an outpatient basis and were well-tolerated by the patients. Forty-four of the 45 patients experienced significant symptomatic improvement. The remote afterloading technique allowed improved radiation protection for personnel.     

鼻咽癌后装腔内放疗个体化施源器剂量学分析

目的:评估热塑面罩固定鼻咽个体化施源器剂量的准确性及其应用价值.方法:选择10例后装放疗患者,分别制作鼻咽个体化施源器并使用面罩固定.每次治疗前均行CT扫描,并在计划系统中重建出施源器位置,获取铱源驻留位点坐标,通过与计划CT比较,计算出施源器位移偏差,进而评估后装治疗剂量的准确性.结果:非面罩固定最远端源驻留位点(P1)平均偏差在X、Y、Z三个方向为(1.62士0.24)、(2.32士0.22)和(2.50士0.28)mm,近端(P5)为(1.13±0.11)、(1.22±0.20)和(1.80±0.15)mm.经面罩固定后个体化施源器最远端源驻留位点(P1)平均位移则分别为(0.82±0.06)、(0.70±0.07)和(0.94±0.08) mm,近端(P5)为(0.70士0.02)、(0.46土0.01)和(0.60土0.03)mm.面罩固定施源器位移偏差导致的感兴趣点(源旁2 cm)剂量误差＜1.2％.结论:使用热塑面罩固定个体化施源器剂量准确,适合鼻咽癌腔内后装治疗.     

Postoperative vaginal irradiation by a high dose-rate afterloading technique in endometrial carcinoma stage I

A high dose-rate (cobalt-60) afterloading technique was used for postoperative vaginal irradiation in a series of 404 women with endometrial carcinoma stage I. The total recurrence rate was 3.7% with 0.7% vaginal lesions. The crude 5-year survival rate for the complete series was 91.8% compared to 13.3% for those with recurrences. Depth of myometrial infiltration (greater than 1/3 of the uterine wall) and nuclear grade were the most important prognostic factors. Clinically significant late radiation reactions (bladder and/or rectum) were recorded in 6.9%. The absorbed dose per fraction and the size of the treatment volume were significantly related to the occurrence of both early and late radiation reactions. Vaginal shortening was closely related to the dose per fraction, length of the reference isodose and the applicator diameter. The shape of the vaginal applicator versus the isodose contours and the importance of the source train geometry and relative activity for absorbed dose inhomogeneities within the treatment volume are discussed. Cumulative radiation effect (CRE) and linear-quadratic (LQ) calculations have been performed and related to tissue reactions within the target volume and in the risk organs. An alpha-beta quotient of 8.8 Gy for vaginal shrinkage effect and 2.0 Gy for late rectal complications are suggested on the basis of calculations using a maximum likelihood method for quantal radiation data.     

Intracavitary irradiation of endometrial carcinoma using a high-intensity 60Co afterloading method

Intracavitary irradiation of endometrial carcinoma with an afterloading technique, employing Cathetron equipment, was used preoperatively and in patients with inoperable disease as a single therapy or together with external pelvic irradiation. In clinical stages I and II, the survival rates of patients treated preoperatively with afterloading techniques and with the manual Heyman method were quite similar, and the radiation induced complications were less frequent with the afterloading technique. In cases with a large uterine cavity, the one-source tandem method was replaced with a specific two-phase intracavitary irradiation technique. In this method the treatment catheter was positioned against one lateral uterine wall in the first phase, and against the opposite lateral uterine wall in the second phase of irradiation. In experimental studies the shape of the dose distribution curves resembled the uterine shape, and the measured doses were quite similar to those calculated from the radiograms. The treatment results of 32 patients irradiated by this method confirmed its clinical usefulness. Our results show that the afterloading technique is a practical alternative to the manual packing method in the preoperative irradiation of endometrial cancer. With specific instrument modifications the new technique is also useful in cases with a large uterine cavity, whereas the details in the treatment strategies using remote intracavitary irradiation alone or in combination with external radiotherapy need further development.     

Preliminary results of radiation dose escalation for locally advanced nasopharyngeal carcinoma

PURPOSE: To study the safety and efficacy of dose escalation in tumor for locally advanced nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: From September 2000 to June 2004, 50 patients with T3-T4 NPC were treated with intensity-modulated radiotherapy (IMRT). Fourteen patients had Stage III and 36 patients had Stage IVA-IVB disease. The prescribed dose was 76 Gy to gross tumor volume (GTV), 70 Gy to planning target volume (PTV), and 72 Gy to enlarged neck nodes (GTVn). All doses were given in 35 fractions over 7 weeks. Thirty-four patients also had concurrent cisplatin and induction or adjuvant PF (cisplatin and 5-fluorouracil). RESULTS: The average mean dose achieved in GTV, GTVn, and PTV were 79.5 Gy, 75.3 Gy, and 74.6 Gy, respectively. The median follow-up was 25 months, with 4 recurrences: 2 locoregional and 2 distant failures. All patients with recurrence had IMRT alone without chemotherapy. The 2-year locoregional control rate, distant metastases-free and disease-free survivals were 95.7%, 94.2%, and 93.1%, respectively. One treatment-related death caused by adjuvant chemotherapy occurred. The 2-year overall survival was 92.1%. CONCLUSIONS: Dose escalation to 76 Gy in tumor is feasible with T3-T4 NPC and can be combined with chemotherapy. Initial results showed good local control and survival.     

Results of high dose rate afterloading brachytherapy boost to conventional external beam radiation therapy for initial and locally advanced prostate cancer.

PURPOSE: To evaluate the impact on biochemical control (bNED), acute and late gastro-intestinal (GI) and urological (GU) morbidity of initial and locally advanced prostate cancer treated with fractionated transrectal ultrasound-guided (TRUS) high dose rate after loading brachytherapy (HDR-B) as a boost to conventional external beam radiation therapy (EBRT). PATIENTS AND METHODS: From March 1997 to February 2000 a total of 119 patients with any of the following characteristics were eligible for study entry: biopsy proven adenocarcinoma Gleason scored (GS), initial prostatic specific antigen (PSA) level dosage 1992 AJCC clinical stage T3a or less, and prostatic volume <60 cc. All patients had prior to HDR-B a course of EBRT 6 MV photons to a median dose of 45 Gy, in 1.8 Gy fractions, to the prostate and seminal vesicles only. HDR-B treatment planning and dosimetric calculations were generated with the Nucletron Planning System. Patients were grouped into two groups, according to their risk for biochemical failure: low-risk group without (LR) or with neoadjuvant total androgen deprivation (AD) prior to EBRT (LR+AD) and high-risk group without (HR) or with neoadjuvant AD (HR+AD), for bNED and dose-escalation protocol. LR encompassed patients who presented GS<6, T1 or T2a and or initial PSA<10 ng/ml, who were treated with 16 Gy (4 Gy fractions, b.i.d.) HDR-B. The remaining patients were grouped into HR or HR+AD and received 20 Gy (5 Gy fractions, b.i.d.) HDR-B. The planning was optimized using the standard geometric optimization. Biological effective doses (BED) for tumor control and late responding tissue were calculated using a alpha/beta ratio of 1.5 and 3 Gy, respectively. They were matched with bNED, acute and late gastrointestinal (GI) and urological (GU) morbidity, according to the RTOG/EORTC scoring criteria. RESULTS: Median age of patients was 68 years (range 47-83), with a median follow-up of 41 months (range 18-48). The crude and actuarial biochemical controls (bNED) in 48 months for all patients were 69.5 and 75.3%, respectively. When grouped into LR, LR+AD, HR and HR+AD the actuarial bNED were 78.2, 76, 76 and 72.3% (P=0.89), respectively. Acute GU and GI morbidity G1-2 were seen in 18.5% (20/108) and 10.2% (11/108) of patients with spontaneous regression. Late GI and GU morbidity G1-2 were seen in 12% (13/108) and 4.6 (5/108) of patients, with no need of intervention. No acute or late G3-4 GU or GI morbidity was seen. CONCLUSIONS: There are many advantages in HDR-B, but the most important ones are the capability of on-line dosimetry, quality control and the procedure being very conformal. There is a low incidence of GU and GI acute and late morbidity with acceptable bNED when treating initial and locally advanced prostate cancer with HDR-B as a boost to EBRT, but we still need to wait for results of phase III open trials that analyze HDR-B and conformal therapy.     

Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation

Analysis of the data obtained from a survey of 56 institutions treating a total of over 17,000 cervix cancer patients with high dose rate (HDR) remote afterloading, shows that the average fractionation regimen is about 5 fractions of 7.5 Gy each to Point A, regardless of stage of disease. Comparison with historical controls treated by the same clinicians at low dose rate (LDR), showed that 5-year survival was statistically significantly better for HDR versus LDR for Stage III patients (47.2% compared to 42.6%, P = 0.005) and for all patients pooled together (60.8% vs. 59.0% P = 0.045). Morbidity rates were considerably lower for HDR versus LDR for both severe (2.23% vs. 5.34%, P less than 0.001) and moderate plus severe complications (9.05% vs. 20.66%, P less than 0.001). There is an apparent geometrical advantage of HDR intracavitary therapy in that there is a reduction in the "hot-spot" rectal and bladder doses relative to Point A of, on average, (13 +/- 4)% for the HDR compared to the LDR treatments. Fractionation of the HDR treatments significantly influenced toxicity: morbidity rates were highly significantly lower for Point A doses/fraction less than or equal to 7 Gy compared with greater than 7 Gy for both severe injuries (1.28% vs. 3.44%, P less than 0.001) and moderate plus severe (7.58% vs. 10.51%, P less than 0.001). The effect of dose/fraction on cure rates was equivocal. Finally, the data showed that for conversion from LDR to HDR the total dose to Point A was reduced on average by a factor 0.54 +/- 0.06.     

High dose rate lntraluminal radiation in a combined modality treatment plan for carcinoma of the esophagus

We have previously reported results for treatment of adenocarcinomas and squamous cell carcinomas of the mid and distal esophagus as well as the use of intraluminal high-dose rate radiation (HDR-RT) for palliation of carcinoma of the esophagus. In this report we describe the results of a chemotherapy/HDR-RT/esophagectomy management program. Examination of the surgical specimens revealed a complete response in only 13% of patients and locoregional recurrence was disappointing. There were no operative deaths nor were there major complications attributable to the preoperative treatment. Two-year survival was 33%, only slightly better than that previously achieved by us with either primary surgery or primary external beam radiation among “curative” candidates with locoregional disease. HDR in combination with our selected chemotherapy regimen is insufficient for locoregional control and must be supplemented either by esophagectomy or external beam radiation for even modest long-term survival. © 1993 Wiley-Liss, Inc.     

复发期鼻咽癌的再程治疗:调强放射治疗技术的实施及展望

外放射治疗是局部复发性鼻咽癌再程治疗的主要手段.不同的放疗技术,如常规放疗、立体定向放疗、近距离治疗、三维适形放疗、调强适形放疗各有其特点.调强适形放疗作为革命性的新技术,在复发鼻咽癌的治疗中发挥其独特的优势,既能提高肿瘤靶区的剂量同时又能减少鼻咽周围正常组织的照射剂量,从而提高治疗增益比,值得大力推广和应用.     

Remote afterloading techniques for the treatment of nasopharyngeal and endometrial cancer

Simple methods of delivering intracavitary radiation to the nasopharynx and endometrium using remote afterloading apparatus are described. Considerable flexibility of isodose distribution is possible at both sites even without refinement of the systems described.