CT-guided interstitial brachytherapy of inoperable non-small cell lung cancer
Zhong-Min Wanga, b, 1, , Jian Lub, 1, , Tao Liuc, , Ke-Min Chend, , Gang Huange, and Fen-Ju Liua, ,
a School of Radiation Medicine and Public Health, Soochow University, 199 Ren Ai Road, Suzhou Industrial Park, Suzhou 215123, Jiangsu, China
b Department of Radiology, Shanghai Ruijin Hospital Luwan Branch, 149 Chongqing South Road, Shanghai 200020, China
c Department of General Surgery, Shanghai Ruijin Hospital Luwan Branch, 149 Chongqing South Road, Shanghai 200020, China
d Department of Radiology, Shanghai Ruijin Hospital, 197 Ruijin Er Road, Shanghai 200025, China
e Nuclear Medicine, School of Medicine, Shanghai Jiao Tong University, 227 Chongqing South Road, Shanghai 200025, China
Received 10 December 2010; revised 17 February 2011; accepted 4 March 2011. Available online 21 April 2011.
Abstract
Purpose
The aim of this study was to assess the technical feasibility, efficacy, and complications of CT-guided interstitial brachytherapy for treating inoperable non-small cell lung cancer (NSCLC).
Materials and methods
Twenty one patients were included in this prospective study. The median age was 72.6 years (57–85). Tumors were treated with brachytherapy that was positioned under CT-fluoroscopy. The treatment planning system (TPS) was used preoperatively to reconstruct three dimensional images of the tumor and to calculate the estimated seed number and distribution. The median matched peripheral dose (MPD) was 130 Gy (range, 100–160 Gy). All procedures were performed under local anesthesia. A follow-up CT was performed 6 weeks later and every 3 months post implantation.
Results
Follow-up period was 2–30 months. The mean diameter of the 21 lung tumors was 4.6 cm (range, 2.8–6.5 cm). The response rate of pain relief was 83.3% (10/12). The pain-free duration was 0–12 months (median: 6 months; 95% CI: 3–9 months). Overall responding rate (CR + PR) for this group of patients was 71.4%. Local tumor control rate was 85.7%. Six (28.6%) patients died as a result of primary tumor progression; thirteen (61.9%) patients died of multi-organ failure or other metastases. Two (9.5%) patients survived to follow-up. At the time of analysis, the median survival time for all patients was 10 months (95% CI: 6.6–13.4 months), with 1 year and 2 year survival rates were 42.4% and 6.5%, respectively. Median survival time for stage II, stage III, and stage IV was 20 months, 9 months, and 8 months, respectively. No major complications were observed. Minor complications (19%) included mild pneumothorax (n = 1), hemosputum (n = 1), pleural effusion (n = 1), and localized skin erythema (n = 1). None of these complications required further treatment, although hospital discharge was delayed. No 125I seeds migrated to other tissues or organs.
Conclusion
Minimally invasive CT-guided interstitial brachytherapy is safe, useful, less complicated and considered as a palliative treatment option for inoperable non-small cell lung cancer.
Keywords: Interstitial brachytherapy; CT-guided intervention; 125I seed; Inoperable non-small cell lung cancer (NSCLC)
Long-Term Results of a Phase II Trial of Ultrasound-Guided Radioactive Implantation of the Prostate for Definitive Management of Localized Adenocarcinoma of the Prostate (RTOG 98-05)
Colleen A Lawton, Daniel Hunt, W Robert Lee, Leonard Gomella, David Grignon, Michael Gillin, Gerard Morton, Thomas M Pisansky, Howard Sandler
Radiation Oncology Medical College of Wisconsin, Milwaukee, WI.
International journal of radiation oncology, biology, physics. 04/2011; DOI: 10.1016/j.ijrobp.2010.05.056
Abstract
PURPOSE: To evaluate the long-term effectiveness of transrectal ultrasound-guided permanent radioactive I(125) implantation of the prostate for organ confined adenocarcinoma of the prostate compared with historical data of prostatectomy and external beam radiotherapy within a cooperative group setting.
METHODS AND MATERIALS: Patients accrued to this study had histologically confirmed, locally confined adenocarcinoma of the prostate clinical stage T1b, T1c, or T2a; no nodal or metastatic disease; prostate-specific antigen level of ≤10 ng/ml; and a Gleason score of ≤6. All patients underwent transrectal ultrasound-guided radioactive I(125) seed implantation into the prostate. The prescribed dose was 145 Gy to the prostate planning target volume.
RESULTS: A total of 101 patients from 27 institutions were accrued to this protocol; by design, no single institution accrued more than 8 patients. There were 94 eligible patients. The median follow up was 8.1 years (range, 0.1-9.2 years). After 8 years, 8 patients had protocol-defined biochemical (prostate-specific antigen) failure (cumulative incidence, 8.0%); 5 patients had local failure (cumulative incidence, 5.5%); and 1 patient had distant failure (cumulative incidence, 1.1%; this patient also had biochemical failure and died of causes not related to prostate cancer). The 8-year overall survival rate was 88%. At last follow-up, no patient had died of prostate cancer or related toxicities. Three patients had maximum late toxicities of Grade 3, all of which were genitourinary. No Grade 4 or 5 toxicities were observed.
CONCLUSIONS: The long-term results of this clinical trial have demonstrated that this kind of trial can be successfully completed through the RTOG and that results in terms of biochemical failure and toxicity compare very favorably with other brachytherapy published series as well as surgical and external beam radiotherapy series. In addition, the prospective, multicenter design highlights the probable generalizability of the outcomes.
Combined radiofrequency ablation and high–dose rate brachytherapy for early-stage non–small-cell lung cancer
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 253-259
Michael D. Chan1, , , Damian E. Dupuy2, William W. Mayo-Smith2, Thomas Ng3 and Thomas A. DiPetrillo1
1 Department of Radiation Oncology, The Warren Alpert Medical School, Brown University, Providence, RI
2 Department of Diagnostic Imaging, The Warren Alpert Medical School, Brown University, Providence, RI
3 Department of Surgery, The Warren Alpert Medical School, Brown University, Providence, RI
Received 30 March 2010; revised 12 July 2010; accepted 19 July 2010. Available online 24 August 2010.
Abstract
Purpose
This retrospective analysis reports the results of patients with early-stage inoperable non–small-cell lung cancer treated with radiofrequency ablation (RFA) followed by adjuvant high–dose rate (HDR) brachytherapy.
Methods and Materials
Seventeen medically inoperable patients with biopsy-proven Stage I non–small-cell lung cancer were treated with RFA followed by single fraction HDR brachytherapy. Brachytherapy catheters were inserted immediately after RFA, and one fraction of HDR brachytherapy was delivered on the same day. Doses of brachytherapy ranged from 14.4 to 20 Gy (median, 18 Gy). Patients were followed clinically and radiographically to determine tumor control and toxicity profile.
Results
Median followup time was 22 months. Of the 17 patients, 3 patients have recurred locally. Each of the patients with local recurrences was originally treated for T2 disease. In total, three of seven cases with T2N0 disease experienced local recurrences, whereas all 9 patients with T1 disease were controlled locally. Five of the 17 patients required a chest tube posttreatment, and 1 patient developed an empyema. There were no deaths within 1 month of treatment.
Conclusions
RFA followed by HDR brachytherapy yields excellent local control with an acceptable toxicity profile for patients with otherwise inoperable early-stage lung cancer.
Keywords: Lung cancer; Radiofrequency ablation; HDR brachytherapy
Article Outline
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 221-227
Treatment of facial cutaneous carcinoma with high–dose rate contact brachytherapy with customized molds
Maria Maroñas1, Jose Luis Guinot1, , , Leoncio Arribas1, Maria Carrascosa1, Maria Isabel Tortajada1, Ruth Carmona2, Marian Estornell1 and Rodrigo Muelas1
1 Department of Radiation Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
2 Department of Radiation Oncology, Hospital Reina Sofia, Córdoba, Spain
Received 31 May 2010; revised 3 August 2010; accepted 9 August 2010. Available online 8 October 2010.
Abstract
Background
The main treatment given for initial stage facial epitheliomas is surgery, although there are alternatives. We present our results with Ir-192 high–dose rate (HDR) contact brachytherapy.
Methods and Materials
Fifty-one epitheliomas, with a mean size of 1.5 cm and a maximum thickness of 3 mm, were treated with HDR contact brachytherapy by means of customized molds, with plastic tubes on bolus for flat surfaces and on wax molds for the nose. A total dose of 48–57 Gy, 3–4 Gy/fraction three times a week, was administered.
Results
After a median followup of 45 months, five tumors relapsed (9.8%), four of them on the tip of the nose. The 5-year actuarial local control rate was 89%, 100% for flat surfaces, and 83% for the nose. All of them were salvaged with surgery. The treatment was well tolerated, 21.6% developed severe acute toxicity, with good or very good late cosmetic results.
Conclusion
HDR contact brachytherapy is a good alternative to treat facial epitheliomas with a maximum thickness of 3 mm. Tip of the nose tumors are not well covered with this technique and a different procedure is required.
Keywords: Cutaneous carcinomas; High–dose rate brachytherapy; Molds; Contact brachytherapy; Facial carcinomas; Skin cancer
Article Outline
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 195-200
Combination of IG-IMRT and permanent source prostate brachytherapy in patients with organ-confined prostate cancer: GU and GI toxicity and effect on erectile function
Vladimir Valakh1, Alexander Kirichenko1, Ralph Miller2, 4, Tara Sunder3, Lindsay Miller1 and Russell Fuhrer1, 4, ,
1 Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA
2 Triangle Urology Group, Pittsburgh, PA
3 Boston College, Chestnut Hill, MA
4 Drexel University College of Medicine, Philadelphia, PA
Received 4 February 2010; revised 23 September 2010; accepted 28 September 2010. Available online 28 October 2010.
Abstract
Purpose
To assess toxicity outcomes of image-guided intensity-modulated radiation therapy (IG-IMRT) combined with permanent prostate seed implant in a cohort of patients with localized prostate cancer.
Methods and Materials
A retrospective analysis was performed on 67 patients with the median pretreatment prostate-specific antigen level of 5.4. The Gleason score was less than 7 in 7 patients, 7 in 52 patients, and greater than 7 in 8 patients. The median followup was 28.2 months (range, 12–89.5 months). Treatment consisted of 45 (n = 65) or 50.4 Gy (n = 2) at 1.8 Gy/fraction of IG-IMRT to the prostate and seminal vesicles. Eight patients had simultaneous irradiation of pelvic lymph nodes to 45 (n = 65) or 50.4 Gy (n = 2). After IG-IMRT, patients received transperineal prostate implant boost with either 103Pd (n = 65, the prescribed D90 of 100 Gy) or 125I (n = 2, D90 of 110 Gy). Eleven patients received androgen deprivation therapy with radiotherapy.
Results
Toxicity higher than Grade 3 was not observed. The combined incidence of acute and late Grade 3 genitourinary toxicity was 6%. The combined incidence of acute and late Grade 3 gastrointestinal toxicity was 3%. At least one episode of gastrointestinal bleeding on followup, which could be attributed to radiation, was recorded in 14.9% of patients. For patients achieving erections before radiation, the 3-year Kaplan–Meier potency preservation rate was 66.5%.
Conclusions
The early toxicity of the combination of IG-IMRT and low–dose rate brachytherapy boost in this study was favorable.
Keywords: IMRT; Radiation therapy; Image guidance; Prostate cancer; Brachytherapy; Combined modality
Article Outline
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 190-194
Intra-articular chromic phosphate (32P) in the treatment of diffuse pigmented villonodular synovitis
Jennifer E. Zook1, , , Daniel L. Wurtz2, Judd E. Cummings2 and Higinia R. Cárdenes1
1 Department of Radiation Oncology, Melvin and Bren Simon Cancer Center, Indiana University, Indianapolis, IN
2 Department of Orthopaedic Surgery, Indiana University, Indianapolis, IN
Received 25 March 2010; revised 11 May 2010; accepted 13 May 2010. Available online 4 August 2010.
Abstract
Purpose
Pigmented villonodular synovitis (PVNS) is an uncommon proliferative lesion of synovial tissue. In diffuse PVNS, recurrence rates are high after resection alone. Adjuvant external beam radiation therapy contributes to improved local control. Limited data exist for intra-articular radioisotope therapy after surgical resection. We report institutional experience with intra-articular chromic phosphate (32P).
Methods and Materials
Records were reviewed from the Department of Radiation Oncology at Indiana University. Nine cases of PVNS treated with 32P were identified (mean age = 40). Seven patients were treated at time of recurrence and 2 patients were treated prophylactically. Intra-articular injections were performed by accessing the joint space, aspirating joint fluid, reinjecting 1–2 mCi of 32P, and barbitaging to ensure good distribution in the joint space. No external beam radiation therapy was delivered. One patient was lost to followup. Mean followup of remaining patients was 20 months (range, 2–48).
Results
Eleven injections were performed in 9 patients. Eight had PVNS in the knee(s) and 1 patient had involvement of the hip. Two patients were treated more than once, one for a recurrence in the same joint at 13 months and another for PVNS of a contralateral joint. Three clinical recurrences (2, 13, and 28 months) were noted. Two of three recurrences were in patients who had bulky diffuse PVNS at the time of injection. Overall local control was 70%. In patients without bulky diffuse PVNS at the time of injection, local control was 88%.
Conclusion
We report success using intra-articular injections of 32P after synovectomy in patients with PVNS.
Keywords: Pigmented villonodular synovitis; Intra-articular; Chromic phosphate; Benign disease
Article Outline
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 184-189
Optimal application of the Contura multilumen balloon breast brachytherapy catheter vacuum port to deliver accelerated partial breast irradiation
Kenneth M. Tokita1, , , Laurie W. Cuttino2, Frank A. Vicini3, Douglas W. Arthur2, Dorin A. Todor3, Thomas B. Julian4 and Maureen R. Lyden5
1 Cancer Center of Irvine, Irvine, CA
2 Virginia Commonwealth University, Richmond, VA
3 William Beaumont Hospital, Royal Oak, MI
4 Allegheny General Hospital, Pittsburgh, PA
5 BioStat International, Inc., Tampa, FL
Received 13 June 2010; revised 23 July 2010; accepted 26 July 2010. Available online 8 October 2010.
Abstract
Purpose
The impact of using the Contura multilumen balloon (MLB) (SenoRx, Inc., Irvine, CA) breast brachytherapy catheter’s vacuum port in patients treated with accelerated partial breast irradiation (APBI) was analyzed.
Methods and Materials
Data from 32 patients at two sites were reviewed. Variables analyzed included the seroma fluid (SF):air volume around the MLB before and after vacuum port use and on its ability to improve (1) the eligibility of patients for APBI and (2) dose coverage of the planning target volume for evaluation (PTV_EVAL) in eligible patients.
Results
The median SF/air volume before vacuum removal was 6.8 cc vs. 0.8 cc after vacuum removal (median reduction in SF/air volume was 90.5%). Before vacuum port use, the median SF/air volume expressed as percentage of the PTV_EVAL was 7.8% (range, 1.9–26.6) in all patients. After application of the vacuum, this was reduced to 1.2%. Before vacuum port use, 10 (31.3%) patients were not considered acceptable candidates for APBI because the SF/air volume:PTV_EVAL ratio (SF:PTV) was greater than 10% (range, 10.1–26.6%; median, 15.2%). After vacuum port use, the median SF:PTV ratio was 1.6% for a median reduction of 91.5%. In addition, the percentage of the prescribed dose covering greater than or equal to 90% of the PTV_EVAL proportionally increased a median of 8% (range, 3–10%) in eligible patients.
Conclusion
Use of the Contura MLB vacuum port significantly improved the conformity of the target tissue to the balloon surface, leading to reproducible dose delivery and increased target volume coverage. In addition, application of the vacuum allowed the safe treatment of unacceptable patients with APBI.
Keywords: Breast-conserving therapy; Balloon brachytherapy; Contura
Article Outline
Brachytherapy
Volume 10, Issue 3, May-June 2011, Pages 178-183
Case Report
Accelerated partial breast irradiation using the strut-adjusted volume implant single-entry hybrid catheter in brachytherapy for breast cancer in the setting of breast augmentation
Elizabeth S. Bloom1, , , Steve Kirsner2, Bryan E. Mason2, Chris L. Nelson2, Kelly K. Hunt3, Donald P. Baumann4 and Kent A. Gifford2
1 Division of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
2 Division of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, TX
3 Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX
4 Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, TX
Received 7 May 2010; revised 2 June 2010; accepted 8 June 2010. Available online 17 August 2010.
Abstract
Purpose
Accelerated partial breast irradiation (APBI) has gained popularity as an alternative to adjuvant whole breast irradiation; however, owing to limitations of delivery devices for brachytherapy, APBI has not been a suitable option for all the patients. This report evaluates APBI using the strut-adjusted volume implant (SAVI) single-entry catheter to deliver brachytherapy for breast cancer in the setting of an augmented breast.
Methods and Materials
The patient previously had placed bilateral subpectoral saline implants; stereotactic core biopsy revealed estrogen receptor- and progesterone receptor-positive ductal carcinoma in situ of intermediate nuclear grade. The patient underwent needle-localized segmental mastectomy of her left breast; pathologic specimen revealed no residual malignancy. An SAVI 8-1 device was placed within the segmental resection cavity. Treatment consisted of 3.4 Gy delivered twice a day for 5 days for a total dose of 34 Gy. Treatments were delivered with a high-dose-rate 192Ir remote afterloader.
Results
Conformance of the device to the lumpectomy cavity was excellent at 99.2%. Dosimetric values of percentage of the planning target volume for evaluation receiving 90% of the prescribed dose, percentage of the planning target volume for evaluation receiving 95% of the prescribed dose, volume receiving 150% of the prescribed dose, and volume receiving 200% of the prescribed dose were 97.1%, 94.6%, 22.7 cc, and 11.6 cc, respectively. Maximum skin dose was 115% of the prescribed dose. The patient tolerated treatment well with excellent cosmetic results, and limited acute and late toxicity at 8 weeks and 6 months, respectively.
Conclusions
Breast augmentation should not be an exclusion criterion for the option of APBI. The SAVI single-entry catheter is another option to successfully complete APBI using brachytherapy for breast cancer in the setting of an augmented breast.
Keywords: Accelerated partial breast irradiation; Breast augmentation; Brachytherapy; SAVI
Article Outline
Volume 10, Issue 2, Pages A1-A12, 87-170 (March-April 2011)
Prostatic length predicts functional outcomes after iodine-125 prostate brachytherapy
Raj P. Pal, Jaimin R. Bhatt, Masood A. Khan, Stuart Duggleby, Philip Camilleri, C. Richard Bell, Christine Elwell, Roger B. Kunkler
Abstract
Purpose To determine the value of prostatic length as a predictor of urinary morbidity after brachytherapy for prostate cancer.
Methods and Materials Between May 2002 and September 2008, 214 consecutive patients received brachytherapy for localized prostate cancer at our institution. A prospective analysis of factors predicting urinary toxicity was carried out for these patients. To evaluate urinary morbidity, the posttreatment International Prostate Symptom Score (IPSS) at 3, 9, and 18 months together with rates of urinary retention was recorded.
Results The mean patient age was 62 years, and the mean followup period was 24.4 months. The median IPSS before treatment was 5 (range, 0–20). This increased to 15 (0–33) at 3 months, before subsequently falling to 8 (0–31) and 6 (0–35) at 9 and 18 months, respectively. Twenty-six of 214 (12%) patients experienced urinary retention. Both prostatic length (p-value = 0.001, <0.001) and volume (p-value = 0.002, <0.001) correlated with a higher posttreatment IPSS at 3 and 9 months. In addition, prostate length and volume predicted those patients developing urinary retention requiring catheterization (p-value <0.001, <0.001). Pretreatment IPSS predicted IPSS at 3, 9, and 18 months (p-value <0.001, <0.001, and 0.011) but did not significantly correlate with retention rates. Other factors predicting IPSS at 3 months included radiation dose (D90) (p-value = 0.01) and number of needles used (p-value = 0.01).
Conclusion Prostatic length is a useful tool for determining urinary toxicity after brachytherapy for prostate cancer and should be included in the pretreatment assessment.
High–dose rate brachytherapy in the treatment of penile carcinoma—First experience
Jiøí Petera, Igor Sirák, Linda Kašaová, Zuzana Maèingová, Petr Paluska, Milan Zouhar, Petr Kutílek, Miloš Brod'ák, Milan Vošmik
Abstract
Purpose Interstitial low–dose rate brachytherapy (BRT) allows a conservative treatment of T1–T2 penile carcinoma. High–dose rate
(HDR) BRT is often considered as a dangerous method for interstitial implants because of higher risk of complications. However, numerous
reports suggest that results of HDR-BRT may be comparable to low–dose rate BRT. There are no data available in the literature regarding HDR
interstitial BRT for carcinoma of the penis. Methods and Materials Ten patients with early penile carcinoma were treated by interstitial
hyperfractionated HDR-BRT at the dose of 18 times 3 Gy twice daily between years 2002 and 2009. Breast interstitial BRT template was
used for fixation and precise geometry reconstruction of stainless hollow needles. Results Median followup was 20 months. Our BRT
technique and fractionation schedule was well tolerated by all patients. Acute reaction consisted predominantly of penis edema and
Grade 2 radiation mucositis that dissolved during 8 weeks after the treatment. We neither observed any postradiation necrosis nor
urethral stenosis. The worst late side effects recorded were mild telanagiectasias in the treatment region. At the last followup, all patients
were alive without evidence of the tumor and with fully functional organ. Conclusions Hyperfractionated interstitial HDR-BRT with 18 times 3
Gy per fraction twice daily is a promising method in selected patients of penile carcinoma and deserves further evaluation in a larger prospective study.
Volume 10, Issue 2, Pages A1-A12, 87-170 (March-April 2011)
Optimization of high–dose-rate intracavitary brachytherapy schedule in the treatment of carcinoma of the cervix
Firuza Darius Patel, Pankaj Kumar, Gunaseelan Karunanidhi, Suresh Chander Sharma, Rakesh Kapoor
Abstract
Purpose At our institute, we use high–dose-rate (HDR) intracavitary brachytherapy (ICBT) schedule of 9 Gy per fraction for two fractions after external beam radiotherapy (EBRT) in patients with advanced carcinoma of the cervix. But American Brachytherapy Society recommends that individual fraction size should be less than 7 Gy per fraction in such patients. We present the results of comparison of our institution standard schedule with biologically equivalent dose of 6.8 Gy per fraction for three fractions in terms of local control, disease-free survival, and late toxicity. Methods and Materials Between October 2003 and August 2007, 104 patients with carcinoma of the uterine cervix (Stages IIB and IIIB) were treated with EBRT and HDR ICBT. After EBRT, patients were randomized to one of the treatment arms. ICBT dose in Control Arm A (n = 52) was 9 Gy per fraction in two fractions, 1 week apart, and in Study Arm B (n = 52), it was 6.8 Gy per fraction in 3 fractions, 1 week apart. Results The median followup was 31.48 months. The 3-year actuarial local control was 81.35% in Arm A and 65.18% in Arm B (p = 0.0423), and the 3-year actuarial disease-free survival was 64.97% in Arm A and 49.47% in Arm B (p = 0.0393). The 3-year actuarial risk of developing any Grade 3 or worse late toxicity was 7.47% in Arm A and 3.57% in Arm B (p = 0.2907). Conclusion In our setup, HDR brachytherapy at 9 Gy per fraction in two fractions is safe and effective with good local control, survival, and manageable normal tissue toxicity.
Volume 10, Issue 2, Pages A1-A12, 87-170 (March-April 2011)
Reirradiation of head and neck cancer with high-dose-rate brachytherapy: A customizable intraluminal solution for postoperative treatment of tracheal mucosa recurrence
Laura A. Doyle, Amy S. Harrison, David Cognetti, Ying Xiao, Yan Yu, Haisong Liu, Peter H. Ahn, P. Rani Anné, Timothy N. Showalter
Abstract
Purpose Delivering adequate dose to tracheal mucosa recurrence after multiple prior courses of surgery and radiation presented a challenge for radiation delivery. Tumor bed location and size, combined with previous doses to surrounding areas, complicated the use of external beam therapy with either photons or electrons. High-dose-rate (HDR) brachytherapy was explored to provide sufficient dose coverage. Methods and Materials A 45-year-old gentleman presented with recurrent head and neck cancer. After undergoing additional excision of gross tumor in the tracheal region, radiation was recommended to improve local control. The region of residual tumor was confined to a small superficial lesion at the posterior–superior aspect of the trachea, involving mucosa located along the bend of the trachea, immediately deep to the stoma. External beam treatment was discussed but was not recommended based on recurrence location in the prior radiation field and patient’s flexed chin position. HDR technique with a custom applicator was preferred. Results A three-dimensional HDR plan based on computed tomography used a single catheter optimized to cover gross tumor volume as delineated by physician. Prescribed dose was 5 Gy/fraction for six fractions (two fractions/wk). The applicator position was verified daily with computed tomography and physician setup approval before treatment. The patient was positioned on a wing board to allow access to the stoma. HDR brachytherapy was well tolerated. Conclusions Intraluminal HDR brachytherapy is a viable option for providing dose to region inside tracheal stoma. Advantages over photon and electron beam therapy include reduced dose to surrounding tissues previously irradiated, skin dose, and reproducibility of treatment delivery.
A novel ytterbium-169 brachytherapy source and delivery system for use in conjunction with minimally invasive wedge resection of early-stage lung cancer
Kara Lynne Leonard, Thomas A. DiPetrillo, John J. Munro, David E. Wazer
Abstract
Purpose To describe a novel source–delivery system for intraoperative brachytherapy in patients with early-stage lung cancer that is readily adaptable to a video-assisted thoracoscopic surgery approach and can be precisely delivered to achieve optimal dose distribution. Methods and Materials Radioactive ytterbium-169 (169Yb) was sealed within a titanium tube 0.28 mm in diameter and then capped and resealed by titanium wires laser welded to the tube to serve as the legs of a tissue-fastening system. Dose simulations were performed using Monte Carlo computer code (Los Alamos National Laboratory, Los Alamos, NM) to mimic the geometric and elemental compositions of the source, fastening apparatus, and surroundings. Results Five test source capsules were subjected to a tensile load to failure. Failure in each capsule occurred in the wire of the fastener leg; there were no weld failures. Monte Carlo simulations and subsequent dose measurement showed the perturbation by the source legs in the deployed (bent over) position to be small (4–5%) for 169Yb and much less than that for iodine-125 (32%). Conclusion We have developed a 169Yb brachytherapy source–delivery system that can be used in conjunction with commercially available surgical stapling instruments, facilitates the precise placement of brachytherapy sources relative to the surgical margin, assures the seeds remain fixed in their precise position for the duration of the treatment, overcomes the technical difficulties of manipulating the seeds through the narrow surgical incision associated with video-assisted thoracoscopic surgery, and reduces the radiation dose to the clinicians.
Brachytherapy. 2011 Apr 15. [Epub ahead of print]
American College of Radiology Appropriateness Criteria Permanent Source
Brachytherapy for Prostate Cancer.
Expert Panel on Radiation Oncology–Prostate, Frank SJ, Arterbery VE, Hsu IC, Abdel-Wahab M, Ciezki JP,
Hahn NM, Mohler JL, Moran BJ, Rosenthal SA, Rossi CJ Jr, Yamada Y, Merrick G.
Source
Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, TX.
Abstract
PURPOSE:
Permanent prostate brachytherapy has emerged as a standard of care treatment for approximately 50,000 men annually who present with
clinically localized prostate cancer. The purpose of this review was to provide clarification on the appropriateness criteria and management
considerations for the treatment of prostate cancer with permanent prostate brachytherapy.
METHODS:
Panel members with expertise on prostate cancer were assembled and provided several clinical scenarios for consensus treatment and
management guidelines. Prostate cancer patient vignettes were presented along with specific management recommendations based on
an extensive review of the modern brachytherapy literature. The brachytherapy topic development and review consists of two parts which
require extensive participation by the expert panel. The American College of Radiology (ACR) Appropriateness Criteria (AC) are derived
from a multidisciplinary panel of experts from both the academic and private practice settings. The first activity is a review of the current
literature with development of an evidence table, referenced narrative, and ratings table of treatments. The second activity is the consensus-
building process using a modified Delphi technique via an anonymous voting process.
RESULTS:
Most brachytherapy series have demonstrated favorable morbidity profiles and durable biochemical control rates for patients with low-,
intermediate-, and high-risk features. However, as brachytherapy followups have matured, it has become increasingly apparent that
efficacy and morbidity are highly dependent on implant quality.
CONCLUSION:
Continued attempts to refine patient selection, brachytherapy treatment planning philosophy, technique, and postimplant management
should result in further improvements in biochemical outcome and decreased brachytherapy-related morbidity.
Published by Elsevier Inc.
3D-CT implanted interstitial brachytherapy for T2b nasopharyngeal carcinoma
Yu-Feng Ren , Yuan-Hong Gao , Xin-Ping Cao , Wei-Jun Ye and Bin S Teh
Radiation Oncology 2010, 5:113doi:10.1186/1748-717X-5-113
Abstract (provisional)
Background
To compare the results of external beam radiotherapy in combination with 3D- computed tomography (CT)-implanted interstitial high
dose rate brachytherapy (ERT/3D-HDR-BT) versus conventional external beam radiotherapy (ERT) for the treatment of stage T2b
nasopharyngeal carcinoma (NPC).
Methods
Forty NPC patients diagnosed with stage T2b NPC were treated with ERT/3D-HDR-BT under local anesthesia. These patients received
a mean dose of 60 Gy, followed by 12-20 Gy administered by 3D-HDR-BT. Another 101 patients diagnosed with non-metastatic T2b NPC
received a mean dose of 68 Gy by ERT alone during the same period.
Results
Patients treated with ERT/3D-HDR-BT versus ERT alone exhibited an improvement in their 5-y local failure-free survival rate
(97.5% vs. 80.2%, P = 0.012) and disease-free survival rate (92.5% vs. 73.3%, P = 0.014). Using multivariate analysis, administration
of 3D-HDR-BT was found to be favorable for local control (P = 0.046) and was statistically significant for disease-free survival (P = 0.021).
The incidence rate of acute and chronic complications between the two groups was also compared.
Conclusions
It is possible that the treatment modality enhances local control due to improved conformal dose distributions and the escalated
radiation dose applied
A comprehensive dosimetric comparison between 131Cs and 125I brachytherapy sources for COMS eye plaque implant
Hualin Zhang1, Douglas Martin1, Sou-Tung Chiu-Tsao2, Ali Meigooni3, Bruce R. Thomadsen
Abstract
Purpose
To verify the dosimetric characteristics of 131Cs source in the Collaborative Ocular Melanoma Study (COMS) eye plaque brachytherapy, to compare 131Cs with 125I in a sample implant, and to examine the accuracy of treatment planning system in dose calculation.
Methods and Materials
Monte Carlo (MC) technique was used to generate three-dimensional dose distributions of a 16-mm COMS eye plaque loaded with 131Cs and 125I brachytherapy sources separately. A spherical eyeball, 24.6mm in diameter, and an ellipsoidal tumor, 6mm in height and 12mm in diameter, were used to evaluate the doses delivered. The simulations were carried out both with and without the gold and gold alloy plaque. A water-equivalent seed carrier was used instead of the silastic insert designed for thetraditional COMS eye plaque. The 13 sources involved were also individually simulated to evaluate the intersource effect. In addition, a treatment planning system was used to calculate the doses at the central axis for comparison with MC data.
Results
The gold plaque had significantly reduced the dose in the tumor volume; at the prescription point of this study, that is, 6mm from the edge of inner sclera, the gold plaque reduced the dose by about 7% for both types of 131Cs and 125I sources, but the gold alloy plaque reduced the dose only by 4% for both types of sources. The intersource effect reduced the dose by 2% for both types of sources. At the same prescription dose, the treatment with the gold plaque applicator tended to create more hot regions for either type of sources than were seen with the homogeneous water phantom. The doses of TPS agree with the MC.
Conclusion
The 131Cs source is comparable to the 125I source in the eye plaque brachytherapy. The TPS can provide accurate dose calculations for eye plaque implants with either type of sources
Brachytherapy
Volume 9, Issue 4, Pages 289-384 (October-December 2010)
High–dose rate brachytherapy alone in postoperative soft tissue sarcomas with close or positive margins
Jun Itami1, Minako Sumi1, Yasuo Beppu2, Hirokazu Chuman2, Akira Kawai2, Naoya Murakami1, Madoka Morota1, Hiroshi Mayahara1, Ryoichi Yoshimura1, Yoshinori Ito1, Yoshikazu Kagami1
Abstract
Purpose
In the management of soft tissue sarcomas, perioperative radiation therapy has been used to reduce the risk of local recurrence after resection. However, a significance of postoperative high–dose rate brachytherapy (HDRBT) remains to be studied. Retrospective analysis was performed to elucidate the role of postoperative HDRBT.
Methods and Materials
Twenty-five patients with 26 soft tissue sarcoma lesions underwent postoperative HDRBT using 192Ir remote afterloader without external beam radiation therapy. Ninety-two percent of the lesions were Grade 2 or 3 malignancies, and 50% were resected with positive surgical margins. The remaining 50% had very close margins. Fourteen lesions were treated for local recurrences after previous resections. Applicators of HDRBT were placed during the operation to include only the tumor bed excluding surgical scars. Applied dose was mainly 36Gy/6 fractions/3 d b.i.d.
Results
Five-year local recurrence-free survival was 78.2% in all the 26 lesions. Recurrences were not seen within the treated volume of HDRBT. Two groups were defined according to the marginal status and number of previous operations. Group 1 was the lesions with a positive margin and foregoing resections. The remaining lesions were classified as Group 2. Five-year local recurrence-free survival was 43.8% and 93.3% in Group 1 and Group 2, respectively with a statistically significant difference (p=0.004).
Conclusions
Postoperative HDRBT was effective in controlling local lesions; but in Group 1 lesions, addition of a wide field external beam radiation therapy seems to be necessary to improve the local control rate.
Efficacy of high-dose-rate interstitial brachytherapy in patients with oral tongue carcinoma
Jose Luis Guinot, Miguel Santos, Maria Isabel Tortajada, Maria Carrascosa, Enrique Estellés, Juan Bosco Vendrell, Rodrigo Muelas, Maria Luisa Chust, Jose Luis Mengual, Leoncio Arribas
Abstract
Purpose
To evaluate the results of high-dose-rate (HDR)-interstitial brachytherapy (ISBT) in oral tongue carcinomas.
Methods and Materials
Between September 1999 and August 2007, 50 patients were treated for oral tongue carcinoma with HDR-ISBT. The patient's mean age was 58 years. Forty-two patients were in T1–2 stage and 8 patients were in T3 stage; 16 patients were in N+ stage and 34 patients in N0 stage. Exclusive ISBT was given to 17 patients (34%) in T1–2 N0 stage and complementary to external beam radiotherapy (EBRT) to 33 patients (66%). A perioperative technique was performed on 14 patients. The median total dose was 44 Gy when HDR was used alone (4 Gy per fraction) and 18 Gy when complementary to 50 Gy EBRT (3 Gy per fraction).
Results
The median followup was 44 months. Actuarial disease-free survival rates at 3 and 5 years were 81% and 74%, respectively. Local failure developed in 7 patients. Actuarial local control (LC) rates were 87% and 79% at 3 and 5 years in T1–2 stage 94.5% and 91% and T3 stage 43% and 43% (with salvage surgery). Exclusive HDR cases showed LC in 100% of the cases, and the combined group (EBRT + HDR) showed LC in 80% and 69% of the cases at 3 and 5 years (p = 0.044). Soft-tissue necrosis developed in 16% and bone necrosis in 4% of the cases.
Conclusions
HDR brachytherapy is an effective method for the treatment of oral tongue carcinoma in low-risk cases. Doses per fraction between 3 and 4 Gy yield LC and complication rates similar to low-dose rate. The perioperative technique promises encouraging results.
