Quality of life after high-dose-rate brachytherapy monotherapy for prostate cancer

Purpose

There is little information in the literature on health-related quality of life (HRQOL) changes due to high-dose-rate (HDR) brachytherapy monotherapy for prostate cancer.

Materials and Methods

We conducted a prospective study of HRQOL changes due to HDR brachytherapy monotherapy for low risk or favorable intermediate risk prostate cancer. Sixty-four of 84 (76%) patients who were treated between February 2011 and April 2013 completed 50 questions comprising the Expanded Prostate Cancer Index Composite (EPIC) before treatment and 6 and/or 12 months after treatment.

Results

Six months after treatment, there was a significant decrease (p<0.05) in EPIC urinary, bowel, and sexual scores, including urinary overall, urinary function, urinary bother, urinary irritative, bowel overall, bowel bother, sexual overall, and sexual bother scores. By one year after treatment, EPIC urinary, bowel, and sexual scores had increased and only the bowel overall and bowel bother scores remained significantly below baseline values.

Conclusions

HDR brachytherapy monotherapy is well-tolerated in patients with low and favorable intermediate risk prostate cancer. EPIC urinary and sexual domain scores returned to close to baseline 12 months after HDR brachytherapy.     

Dosimetric comparison of vaginal vault brachytherapy vs applicator-guided stereotactic body radiotherapy with volumetric modulated arc therapy and helical tomotherapy for endometrium cancer patients

We performed this dosimetric study to compare a nonstandard volumetric modulated arc therapy (VMAT) and helical tomotherapy (HT) techniques with high-dose rate (HDR) brachytherapy (BRT) plan of vaginal vault in patients with postoperative endometrial cancer (EC). Twelve postoperative patients with early stage EC were included in this study. Three plans were performed for each patient; dosimetric and radiobiological comparisons were made using dose-volume histograms and equivalent dose for determining the planning target volume (PTV) coverages in brachytherapy and external beam radiotherapy, and organs-at-risk (OARs) doses between three different delivery techniques. All the plans achieved adequate dose coverage for PTV; however, the VMAT plan yielded better dose conformity, and the HT plan showed better homogeneity for target volume. With respect to the OARs, the bladder D_2cc was significantly lower in the BRT plan than in the VMAT and HT plans, with the highest bladder D_2cc value being observed in the HT plan. However, no difference was observed in the rectum D_2cc of the three plans. Other major advantages of the BRT plan over the VMAT and HT plans were the relatively lower body integral doses and femoral head doses as well as the fact that the integral doses were significantly lower in the BRT plan than in the VMAT and HT plans. This is the first dosimetric comparison of vaginal vault treatment for EC with BRT, VMAT, and HT plans. Our analyses showed the feasibility of stereotactic body radiotherapy technique as an alternative to HDR-BRT for postoperative management of EC patients.     

Dosimetric and radiobiological investigation of permanent implant prostate brachytherapy based on Monte Carlo calculations

PurposePermanent implant prostate brachytherapy plays an important role in prostate cancer treatment, but dose evaluations typically follow the water-based TG-43 formalism, ignoring patient anatomy and interseed attenuation. The purpose of this study is to investigate advanced TG-186 model-based dose calculations via retrospective dosimetric and radiobiological analysis for a new patient cohort.Methods and MaterialsA cohort of 155 patients treated with permanent implant prostate brachytherapy from The Ottawa Hospital Cancer Centre is considered. Monte Carlo (MC) dose calculations are performed using tissue-based virtual patient models. Dose–volume histogram (DVH) metrics (target, organs at risk) are extracted from 3D dose distributions and compared with those from calculations under TG-43 assumptions (TG43). Equivalent uniform biologically effective dose and tumor control probability are calculated.ResultsFor the target, D₉₀ (V₁₀₀) is 136.7 ± 20.6 Gy (85.8% ± 7.8%) for TG43 and 132.8 ± 20.1 Gy (84.1% ± 8.2%) for MC; D₉₀ is 3.0% ± 1.1% lower for MC than TG43. For organs at risk, MC D_1cc = 104.4 ± 27.4 Gy (TG43: 106.3 ± 28.3 Gy) for rectum and 80.8 ± 29.7 Gy (TG43: 78.4 ± 28.4 Gy) for bladder; D_1cc = 185.9 ± 30.2 Gy (TG43: 191.1 ± 32.0 Gy) for urethra. Equivalent uniform biologically effective dose and tumor control probability are generally lower when evaluated using MC doses. The largest dosimetric and radiobiological discrepancies between TG43 and MC are for patients with intraprostatic calcifications, for whom there are low doses (cold spots) in the vicinity of calcifications within the target, identified with MC but not TG43.ConclusionsDVH metrics and radiobiological indices evaluated with TG43 are systematically inaccurate by upward of several percent compared with MC patient-specific models. Mean cohort DVH metrics and their MC:TG43 variances are sensitive to patient cohort and clinical practice, underlining the importance of further retrospective MC studies toward widespread clinical adoption of advanced model-based dose calculations.     

Evaluation of the accuracy of computer-assisted techniques in the interstitial brachytherapy of the deep regions of the head and neck

PurposeWe sought to investigate the feasibility and accuracy of computer-assisted techniques in the interstitial brachytherapy of the deep regions of the head and neck.Materials and MethodsA computer-assisted brachytherapy workflow was applied to 10 patients with tumors in the deep regions of the head and neck. Based on the brachytherapy treatment preplan, we constructed a digital stereotactic model to accurately transfer the virtual plan into the navigation system, and subsequently printed the individual templates. The navigation system and the individual template were combined together to visualize and guide brachytherapy needle implantation. Preoperative and intraoperative image data were reconstructed and registered to measure and analyze the needle deviation.ResultsA total of 58 needles were successfully inserted in 10 patients with the guidance of computer-assisted techniques and a mean deviation of 5.2 mm. The inserting trajectories and depths of the needles were as follows: from the parotid and masseter regions to the infratemporal fossa or skull base, the range was 15.7–74.6 mm; from the submandibular and retromandibular regions to the infratemporal fossa or skull base, the range was 15.6–70.6 mm; from the infraorbital region to the pterygomandibular region, the range was 63.7–69.7 mm; and from the periorbital region to the intraorbital region, the range was 47.6–61.8 mm. The dose distribution met the treatment requirement well.ConclusionsThe computer-assisted interstitial brachytherapy workflow was proven to be feasible and accurate for the deep regions of the head and neck.     

125I seeds implantation for treating residual hepatocellular carcinoma located beneath the diaphragm after transcatheter arterial chemoembolization

PurposeThe effect of ¹²⁵I seed implantation for the treatment of local residual tumor of hepatocellular carcinoma located beneath the diaphragm (HCC-LBD) after transcatheter arterial chemoembolization (TACE) has not yet been reported. This retrospective study was performed to evaluate the safety and efficacy of ¹²⁵I seeds implantation (ISI) for the treatment of residual HCC-LBD after TACE.Methods and MaterialsA total of 18 patients treated with ISI between August 2012 and March 2018 for residual HCC-LBD after single or multiple TACE were enrolled. Local control, survival, and postoperative complications were analyzed retrospectively. Overall followup time was displayed by survival curves.ResultsThe 18 patients received a total of 20 ISI treatments. The total number of seeds implanted was 650, with a mean of 36 ± 13 seeds per patients (range, 20–70). Mean D90 was 123 Gy. Complete response + partial response (CR + PR) was documented in 14, 16, and 16 of patients at 3, 6, and 12 months after implantation, respectively. In four patients, seeds implantation was performed through the diaphragm; two of these patients developed small pneumothoraces. Pulmonary compression of pneumothorax is less than 30% combined with a little blood in sputum, no chest tightness, shortness of breath, all symptoms subsided without interventions, and the patients were discharged after observation for 2 days. After the procedure, routine blood examination and liver and kidney function were normal.ConclusionThe combination of TACE with ISI appears to be a safe and efficient treatment for residual HCC-BLD.Implications for PracticeThis study evaluated the feasibility, safety, and short-term efficacy of ISI for local residual tumor of hepatocellular carcinoma located beneath the diaphragm (HCC-LBD) after TACE. Results suggest that residual tumor of HCC after TACE located in the posterosuperior part of the liver (segments seven and eight), laparoscopic liver resection, and alblation is difficult to perform and that as a supplement treatment, ¹²⁵I seeds implantation is safe and easy accessible. TACE combined with ¹²⁵I seeds has excellent local control effectiveness, and long-term efficacy and survival benefit still need to be more comprehensively evaluated.     

Reducing seed migration to near zero with stranded-seed implants: Comparison of seed migration rates to the chest in 1000 permanent prostate brachytherapy patients undergoing implants with loose or stranded seeds

PurposePulmonary seed emboli to the chest may occur after permanent prostate brachytherapy (PPB). The purpose of this study is to analyze factors associated with seed migration to the chest in a large series of PPB patients from a single institution undergoing implant with either loose seeds (LS), mixed loose and stranded seeds (MS), or exclusively stranded seeds in an absorbable vicryl suture (VS).Methods and MaterialsBetween May 1998 and July 2015, a total of 1000 consecutive PPB patients with postoperative diagnostic chest x-rays at 4 months after implant were analyzed for seed migration. Patients were grouped based on seed implant technique: LS = 391 (39.1%), MS = 43 (4.3%), or VS = 566 (56.6%). Univariate and multivariate analysis were performed using Cox proportional hazards regression models to determine predictors of seed migration.ResultsOverall, 18.8% of patients experienced seed migration to the chest. The incidence of seed migration per patient was 45.5%, 11.6%, and 0.9% (p < 0.0001), for patients receiving LS, MS, or VS PPB, respectively. The right and left lower lobes were the most frequent sites of pulmonary seed migration. On multivariable analysis, planimetry volume (p = 0.0002; HR = 0.7 per 10 cc [0.6–0.8]), number of seeds implanted (p < 0.0001, HR = 2.4 per 25 seeds [1.7–3.4]), LS implant (p < 0.0001, HR = 15.9 [5.9–42.1]), and MS implant (p = 0.001, HR = 7.9 [2.3–28.1]) were associated with seed migration to the chest.ConclusionsIn this large series, significantly higher rates of seed migration to the chest are observed in implants using any LS with observed hazard ratios of 15.9 and 7.9 for LS and MS respectively, as compared with implants using solely stranded seeds.     

Impact of marital status on receipt of brachytherapy and survival outcomes in locally advanced cervical cancer

PurposeMarriage has been associated with enhanced survival among cancer patients, but conflicting correlations have been suggested in cervical cancer. We assessed the impact of marital status on receipt of brachytherapy and survival in women with locally advanced cervical cancer.Methods and MaterialsThree thousand, eight hundred and twelve patients with Stage IB2–IVA cervical cancer diagnosed from 2006 to 2015 treated with external beam radiotherapy were identified from the California Cancer Registry. Chi-square tests were used to compare patient characteristics by marital status and boost type. The association of marital status with brachytherapy (BT) receipt was assessed using multiple logistic regression. Fine and Gray competing risks and Cox proportional hazards regressions were used to estimate cervical cancer–specific survival (CCSS) and overall survival (OS), respectively.ResultsMost women were unmarried (58.8%). Half (50.4%) received BT, while 33.1% received no boost; most (86.3%) received chemotherapy. Unmarried women had similar odds of receiving BT as married women (OR = 1.07, 95% CI: 0.90-1.28, p = 0.4370) but were less likely to receive chemotherapy (84.3% vs. 89.1%, p < 0.0001). Singlehood was significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.03-1.42, p < 0.0174) and OS (hazard ratio = 1.18, 95% CI: 1.03-1.36, p < 0.0153). Not receiving a radiation boost was also significantly associated with worse CCSS (subdistribution hazard ratio = 1.21, 95% CI: 1.02-1.43, p = 0.0317) and OS (hazard ratio = 1.21, 95% CI: 1.05-1.40, p = 0.0100).ConclusionsThere were no differences in BT receipt in married vs. unmarried patients. However, unmarried patients had worse CCSS and OS and were less likely to receive chemotherapy. Interventions targeting social factors are needed to improve outcomes in this vulnerable population.     

How might financial pressures have impacted brachytherapy? A proposed narrative to explain the declines in cervical and prostate brachytherapy utilization

Rates of brachytherapy administration in the United States have declined for both cervical and prostate cancers, and we argue that the available facts suggest financial considerations are a major contributor to this issue. In this narrative, we discuss financial pressures that have existed for cervical and prostate brachytherapy and how they may have influenced their declining usage, consider other proposed influences, and provide suggestions for future research to understand the scope of the issue.     

Understanding the underutilization of cervical brachytherapy for locally advanced cervical cancer

PurposeTo understand the reasons behind current low utilization of brachytherapy for locally advanced cervical cancer in the United States.Methods and MaterialsA 17-item survey was e-mailed to the American Brachytherapy Society (ABS) listserv of active members in 2018. Responses of attending physicians in the United States were included in the analysis.ResultsAmong a total of 135 respondents, 81 completed the survey. Eighty-four percent agree/strongly agree that cervical brachytherapy is underutilized, and 46.9% disagree/strongly disagree that residents are receiving adequate training for brachytherapy; 75.3% agree/strongly agree that inadequate maintenance of brachytherapy skills is a major obstacle to brachytherapy use; and 71.6% agree/strongly agree that increased time requirement constitutes a major obstacle. Over 97% will recommend brachytherapy for most patients with cervical cancer if given access/time; 72.8% always perform their own brachytherapy, whereas 29.6% reported some type of barrier exists in performing brachytherapy themselves, with time required to perform brachytherapy (9.9%) being a leading factor. A quarter (24.7%) routinely refer to other radiation oncologists for brachytherapy. Even among ABS members, 37.0% reported that they would perform an intensity-modulated radiation therapy or stereotactic body radiation therapy boost in specific scenarios in potentially curable patients. The most common scenario is inability to place a uterine tandem (56.7%).ConclusionsThe underutilization of brachytherapy in cervical cancer is widely recognized by ABS members with inadequate training during residency and inadequate maintenance of skills being possible major contributing factors. Even among ABS members, there are identifiable barriers. Continued advocacy and future initiatives in enhancing access to brachytherapy training and efficiency are needed.