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To present recommendations for the use of imaging for evaluation and procedural guidance of brachytherapy for cervical cancer patients. An expert panel comprised of members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focused Panel and the American Brachytherapy Society jointly assessed the existing literature and provide data-driven guidance on imaging protocol development, interpretation, and reporting. Image-guidance during applicator implantation reduces rates of uterine perforation by the tandem. Postimplant images may be acquired with radiography, computed tomography (CT), or magnetic resonance imaging (MRI), and CT or MRI are preferred due to a decrease in severe complications. Pre-brachytherapy T2-weighted MRI may be used as a reference for contouring the high-risk clinical target volume (HR-CTV) when CT is used for treatment planning. Reference CT and MRI protocols are provided for reference. Image-guided brachytherapy in locally advanced cervical cancer is essential for optimal patient management. Various imaging modalities, including orthogonal radiographs, ultrasound, computed tomography, and magnetic resonance imaging, remain integral to the successful execution of image-guided brachytherapy. [ABSTRACT FROM AUTHOR]

Aim: To investigate the potential role of a novel spatially fractionated radiation therapy (SFRT) method where heterogeneous dose patterns are created in target areas with virtual rods, straight or curving, of variable position, diameter, separation and alignment personalised to a patient's anatomy. The images chosen for this study were CT scans acquired for the external beam part of radiotherapy.Methods: Ten patients with locally advanced cervical cancer were retrospectively investigated with SFRT. The dose prescription was 30 Gy in 5 fractions to 90% target volume coverage. Peak-and-valley (SFRT_1) and peak-only (SFRT_2) strategies were applied to generate the heterogeneous dose distributions. The planning objectives for the target (CTV) were D90% ≥ 30 Gy, V45Gy ≥ 50-55% and V60Gy ≥ 30%. The planning objectives for the organs at risk (OAR) were: D2cm3 ≤ 23.75 Gy, 17.0 Gy, 19.5 Gy, 17.0 Gy for the bladder, rectum, sigmoid and bowel, respectively. The plan comparison was performed employing the quantitative analysis of the dose-volume histograms.Results: The D2cm3 was 22.4 ± 2.0 (22.6 ± 2.1) and 13.9 ± 2.9 (13.2 ± 3.0) for the bladder and the rectum for SFRT_1 (SFRT_2). The results for the sigmoid and the bowel were 2.6 ± 3.1 (2.8 ± 3.0) and 9.1 ± 5.9 (9.7 ± 7.3), respectively. The hotspots in the target volume were V45Gy = 43.1 ± 7.5% (56.6 ± 5.6%) and V60Gy = 15.4 ± 5.6% (26.8 ± 6.6%) for SFRT_1 (SFRT_2). To account for potential uncertainties in the positioning, the dose prescription could be escalated to D90% = 33-35 Gy to the CTV without compromising any constraints to the OARs CONCLUSION: In this dosimetric study, the proposed novel planning technique for boosting the cervix uteri was associated with high-quality plans, respecting constraints for the organs at risk and approaching the level of dose heterogeneity achieved with routine brachytherapy. Based on a sample of 10 patients, the results are promising and might lead to a phase I clinical trial. [ABSTRACT FROM AUTHOR]

To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic. An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel. Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended. The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19. • An international panel of gynecologic radiation oncologists offer recommendations for RT during the COVID-19 pandemic. • Recommendations for cervical cancer, uterine cancer, vulvar cancer, vaginal cancer and ovarian cancer have been provided. • Recommendations for RT timing, fractionation, and dose have been provided for external beam radiation and brachytherapy. • The panel emphasizes strategies to reduce risk of transmission of the novel SARS-CoV-2 to patients and healthcare workers. • These recommendations may be used any time an event occurs which limits healthcare resources, including natural disasters. [ABSTRACT FROM AUTHOR]

Because of the critical role of brachytherapy in the management of a variety of cancers, it is important for institutions to consider offering brachytherapy if appropriate staff and personal protective equipment are available for the protection of patients and staff. Albuquerque, B.A. Hrycushko, M.M. Harkenrider, Compendium of fractionation choices for gynecologic HDR brachytherapy-an American brachytherapy society Task group report. 11, 2012, 68-75 25 A.S. Taggar, T. Phan, L. Traptow, Cervical cancer brachytherapy in Canada: A focus on interstitial brachytherapy utilization. 105, 2019, 1005-1011 69 E.C. Rijkmans, A. Cats, R.A. Nout, Endorectal brachytherapy boost after external beam radiation therapy in elderly or medically inoperable patients with rectal cancer: Primary outcomes of the phase 1 HERBERT study. [Extracted from the article]

As part of an initiative to improve education and training in prostate brachytherapy, the ABS recently introduced an LDR prostate brachytherapy fellowship program. Participants were required to complete continuing medical education requirements specific to brachytherapy, achieve a minimum level of brachytherapy procedures and enter their clinical cases into a national brachytherapy registry. Gynecologic brachytherapy is an important skill to acquire during radiation oncology residency training; however, most training programs do not have an adequate case volume or complexity to allow for brachytherapy proficiency by the end of residency. [Extracted from the article]

We sought to assess the impact of bladder neck dose (BND) on patient reported urinary toxicity, and feasibility of relative urethral sparing technique in prostate brachytherapy (PB). We retrospectively identified bladder neck as a point dose on post-implant CT scans in patients treated with 131Cs PB. Urinary symptoms were assessed through EPIC questionnaires. Patient cohorts were identified based on mean BND as a percentage of prescription dose with toxicity assessment at each time point. In our cohort of 542 patients, BND was associated with clinically significant acute urinary symptoms and chronic symptoms, as patients receiving >70% of the prescription dose had significantly worse overall EPIC scores than patients receiving ≤70% of prescription dose. There was no difference in bDFS between patients receiving BND ≤70% (96% bDFS) and >70% (94% bDFS) at a median follow up of 57 months. BND has a significant impact on both acute and chronic urinary symptoms, with reduced symptoms reported with BND <70% of prescription dose. With a median follow up of 4.7 years, excellent bDFS has thus far been achieved with relative urethral and bladder neck sparing. Utilizing this constraint should improve urinary symptoms without impacting disease control. [ABSTRACT FROM AUTHOR]

We have been using CT based intracavitary applicator in our clinic for cervical cancer. The advent of new hybrid applicator and short sequence cube MRI sequence opened up opportunity to do advanced MRI based brachytherapy in our clinic. We present the initial clinical experience of Aarhus ring and tandem MR compatible hybrid interstitial applicator with both straight and oblique needles and no ring channel (Varian may need to add TM) which was recently approved for use in a patient with bulky cervical cancer. A 45 years old lady, with initial diagnosis of carcinoma cervix, stage 1B3, completed External beam radiotherapy to a total dose of 45Gy in 25 Fractions, with a good clinical response, was taken up for further treatment with brachytherapy to a total dose of 28 Gy in 4 fractions. Brachytherapy was split into two applications one week apart and two treatment fractions delivered with each application, with 8 hours gap between each fraction.We used 60 degree Aarhus applicator set with Intrauterine tandem of 40 mm length and outer ring diameter of 32 mm. The Ring includes 19 guide holes for plastic interstitial needles arranged in 2 circles, 9 in inner circle for oblique needles and 10 in outer circle for straight needles.After external radiation patient underwent MRI pelvis with only T2 weighted axial and Cube sequences, which showed residual disease limited to cervix on the right side. The depth of needle insertion into the cervix was measured on MRI to be 3cms. Procedure performed under short general anaesthesia and 4 straight plastic needles through the ring were inserted with two on either side along with 4 cm central Tandem. CT and MR performed for both applications and fused. GTV-primary and HR CTV delineated on MRI, while OARs were delineated on CT. A dose of 7 Gy per fraction prescribed to HR CTV. An optimised plan was generated on eclipse treatment planning system with repeat CT planning for remaining fractions. Treatment delivery went uneventful with very minimal blood loss. Average Dose per fraction received by 90 % of volume (D90) of HR CTV was 7.617 Gy and D98 of GTV primary was 10.35 Gy, delivering a total EQD2 of 89 Gy to HR CTV and at the same time delivering 115 Gy to the GTVp. OAR doses were well constrained with Bladder 2cc receiving 79.25 Gy, Rectum 2cc constrained to 53.48 Gy, sigmoid 2cc to 58.99 Gy and small bowel to 51.98 Gy. We successfully implemented MRI based planning with new Aarhus applicator in our clinic. Procedure was uneventful with excellent dosimetry. We will continue to use it in our clinic for patients with locally advanced cancer. [ABSTRACT FROM AUTHOR]

Brachytherapy (BT) is an essential component of treatment for locally-advanced cervical cancers in conjunction with external beam radiation therapy (EBRT) and chemotherapy. Brachytherapy is a resource- and labor-intensive treatment not offered in all radiation facilities. Patients may be traveling great distances for treatment due to concentration of these resources. The National Cancer Database (NCDB) was queried for adult women with cervical carcinomas treated with EBRT+BT from 2004-2018. Patients were dichotomized to those who received same-institution treatment (SIT) for EBRT + BT and those who had different-institution treatment (DIT), receiving BT in a reporting facility but not EBRT. Women treated with EBRT in a reporting facility but BT in a non-reporting facility were excluded due to lack of details on the BT-providing facility. One-way independent t-test and ANOVA were used to determine differences groups with respect to distance travelled. Chi-squared analysis was used to determine regional differences and patterns between academic/non-academic facilities. A total of 44,684 women received chemoradiation across 1,236 facilities and 29,076 (65.1%) women received brachytherapy across 1,159 facilities. Of those, 23,513 (80.9%) received brachytherapy in 887 reporting facilities. SIT was delivered to 20,125 (85.6%) and 3,388 (14.4%) received only BT at a reporting facility (DIT). 5,563 received all treatment at non-reporting facilities after diagnosis. The rate of SIT treatment was relatively stable through the reporting period, fluctuating between 82.6% and 86.5% without a trend. The median number of BT cases over the time period per institution was 11 (IQR: 3-32). Academic centers had the highest total caseload per institution (median: 39 cases) with community cancer programs having the lowest (median: 2 cases), p<0.001). Only 14 centers (1.6%) treated ≥ 1 patient/month over the reporting period. Institutions in the top quartile for treatment volume treated 75.0% of all patients while the institutions in the middle quartile treated 22.7% and bottom quartile institutions treated 1.9% of patients (p<0.001). The median crow-fly distance for SIT vs DIT was 10.3 miles vs 33.4 miles (IQR: 4.7-25.4 vs 14.5-63.0 miles, p<0.001). 13.3% of women had to travel > 50 miles for brachytherapy, mostly in the Mountain and West North/South Central regions (p<0.001) and significantly more often for DIT (p<0.001). The median differential distance traveled for patients receiving DIT vs SIT was greatest in the West North Central (IA, KS, MN, MO, ND, NE, SD) at +42.3mi and East South Central (AL, KY, MS, TN) at +43.1mi. Similarly, the differential distance traveled for patients receiving DIT in an academic center was +33.2mi compared to +15.7mi for a comprehensive community program, +13.4mi in an integrated delivery network and +0.1mi for a community program (p<0.001). The distribution of centers offering brachytherapy services for women with cervical cancers differs widely across the country with women in some regions traveling great distances to receive care at high-volume centers. [ABSTRACT FROM AUTHOR]

To summarize recommendations regarding imaging guidance for cervical cancer brachytherapy implant placement from the Society of Abdominal Radiology (SAR) and American Brachytherapy Society (ABS). A comprehensive literature search was conducted on PubMed for image-guided cervical cancer brachytherapy (BT) using radiography, ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Original research studies were included for evaluation if they included sensitivity and specificity of tumor detection, complication rates, or additional quantitative imaging results directly related to brachytherapy, such as geometric distortion measurements. The literature review was evaluated by an expert panel of members from the Society for Abdominal Radiology (SAR) and American Brachytherapy Society (ABS). These data were analyzed to determine an overall level of evidence for each recommendation and the subsequent strength of each claim. Three-dimensional (3D) imaging is recommended for treatment planning whenever feasible due to the rate of toxicities ≥ Grade 3 decreasing from between 0-13.5% with 2D planning to 0-5.8% with 3D planning. US guidance is highly recommended for tandem selection and insertion to reduce uterine perforation rates from 2.3-34%/insertion without US-guidance to 0-1.4%/insertion with US. US-guided interstitial needle placement is feasible when post-implant 3D imaging is available for treatment planning. Post-implant CT is recommended over orthogonal radiography to reduce genitourinary and gastrointestinal complications and evaluate proper applicator positioning. Tumor visualization is optimal on T2-weighted (T2w) MRI, which also provides improved specificity for assessment of parametrial invasion. CT-based treatment planning should refer to prior MRI for high risk-clinical target volume (HR-CTV) contouring, when available. Treatment planning on MRI is highly recommended for HR-CTV delineation, and post-applicator imaging should include at minimum both a 2D sagittal T2w and 3D axial T2w fast spin echo-based sequence. Imaging-guidance for cervical brachytherapy implant placement is now standard-of-care. 3D imaging with MRI is highly recommended for treatment planning purposes, although CT-based planning also results in fewer complications as compared to 2D planning techniques. Ultrasound is useful for applicator placement, but application to treatment planning is limited. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this American Brachytherapy Society task force is to present a literature review and patterns of care by a panel of experts for the management of vaginal recurrence of endometrial cancer. Methods and materials In 2016, the American Brachytherapy Society Board selected a panel of experts in gynecologic brachytherapy to update our current state of knowledge for managing vaginal recurrence of endometrial cancer. Practice patterns were evaluated via an online survey and clinical updates occurred through a combination of literature review and clinical experience and/or expertise. Results There are various retrospective series of patients treated with radiation for vaginal recurrence of endometrial cancer, which include a varied group of patients, multiple treatment techniques, and a range of total doses and demonstrate a wide scope of local control and overall survival outcomes. In the era of image-guided brachytherapy, high local control rates with low significant late-term morbidities can be achieved. Lower rates of local control and higher late-term toxicity are reported in the retreatment setting. In patients with no previous history of radiation treatment, external beam radiation therapy followed by brachytherapy boost should be used. There are varying practices with regard to the definition and appropriate doses of both the high-risk clinical target volume and the intermediate-risk clinical target volume in the setting of vaginal recurrence of endometrial cancer. There are limited data to provide appropriate dose constraints for some organs at risk with the majority of guidance taken from the definitive cervical cancer literature. Conclusions A summary of literature and expert practice patterns for patient selection, dose recommendations, and constraints are provided as guidance for practitioners. [ABSTRACT FROM AUTHOR]

More than 20 years ago prophylactic intravascular brachytherapy burst into the radiation oncology lexicon, only to be replaced within a few years by the introduction of drug eluting stents. However, restenosis still occurs in 5- 15% of high risk patients with two or more layers of drug eluting stents. We examined our experience in patients with in stent in stent restenosis who have no options for durable revascularization and therefore are forced to lead a shortened and sedentary life, comparing this to our historic control group. A retrospective cohort of 134 patients treated with angioplasty followed by intracoronary brachytherapy was compared to a current high risk group of 122 patients with in stent in stent restenosis. All patients had a minimum 6 month follow up post brachytherapy. None of the original cohort had stenting performed at the time of brachytherapy, while all patients in the restenosis cohort had placement of at least 2 layers of intracoronary stents prior to repeat angioplasty and IVBT. In the original cohort, there were no intraprocedural deaths, while the high risk cohort had a single intraprocedural death due to intracoronary thrombosis. No high risk patient developed any significant cardiovascular event otherwise at 6 months post-procedure. Intravascular brachytherapy for in stent in stent restenosis is equally safe compared to the historic post angioplasty IBVT safety profile, despite the fragile nature and relatively high risk disease status of these patients with limited options. [ABSTRACT FROM AUTHOR]

Vaginal cancer is an uncommon malignancy and can be either recurrent or primary. In both cases, brachytherapy places a central role in the overall treatment course. Recent technological advances have led to more advanced brachytherapy techniques, which in turn have translated to improved outcomes for patients with malignancies of the vagina. The aim of this manuscript is to outline the incorporation of modern brachytherapy into the treatment of patients with vaginal cancer including patient selection along with the role of brachytherapy in conjunction with other treatment modalities, various brachytherapy techniques, treatment planning, dose fractionation schedules, and normal tissue tolerance. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this consensus statement from the American Brachytherapy Society (ABS) is to summarize recent advances and to generate general guidelines for the management of medically inoperable endometrial cancer patients with radiation therapy. Methods Recent advances in the literature were summarized and reviewed by a panel of experts. Panel members participated in a series of conference calls and were surveyed to determine their current practices and patterns. This document was reviewed and approved by the full panel, the ABS Board of Directors and the ACR Commission on Radiation Oncology. Results A transition from two-dimensional (2D) to three-dimensional (3D) treatment planning for the definitive treatment of medically inoperable endometrial cancer is described. Magnetic resonance (MR) imaging can be used to define the gross tumor volume (GTV), clinical target volume (CTV), and the organs at risk (OARs). Brachytherapy alone can be used for medically inoperable endometrial cancer patients with clinical Stage I cancer with no lymph node involvement and no evidence of deep invasion of the myometrium on MR imaging. In the absence of MR imaging, a combined approach using external beam and brachytherapy may be considered. Conclusions Recent advances support the use of MR imaging and 3D planning for brachytherapy treatment for medically inoperable endometrial cancer. [ABSTRACT FROM AUTHOR]

Radiation oncology trainees may benefit from more standardized competency-based assessment in practical skills such as contouring which are presently only assessed observationally by attendings. This is especially true in the world of gynecologic brachytherapy, given trends of declining brachytherapy utilization, lower competence reported by graduating residents, and low institutional brachytherapy volumes. We hope to develop a standardized method to objectively grade and assess contours created by radiation oncology residents for competency-based assessment in gynecologic brachytherapy. A magnetic resonance and computed tomography-based cervical cancer brachytherapy contouring simulation will be designed using an interactive online platform, and radiation oncology residents will be asked to contour the gross tumor volume (GTV) and high-risk clinical target volume (HRCTV) as they would for radiation planning. These contours will be evaluated by a gynecologic brachytherapy expert using three-tier system utilized in clinical trials. In addition, three experimental methods will be investigated to determine their suitability as a surrogate for expert evaluation. These include (1) non-expert ("novice") review of contours based on a generated rubric, (2) digital evaluation using dice similarity coefficient, and (3) artificial intelligence software designed to emulate scoring provided by an expert in the field. This study is a work in progress, and we have applied for grant funding through the American Board of Medical Specialties Research and Education Foundation grant. We expect that one or more of the three experimental modalities will result in contour evaluations that do not differ significantly from an evaluation of an expert in the field. This study will also offer insight into the feasibility and practicality of contour evaluation using physician novice, digital metric, and artificial-intelligence-based feedback. If demonstrated to be feasible, practical, and comparable in nature to feedback given by an expert in the field, similar programs may be designed for other sites, both for brachytherapy and external beam radiotherapy. Ultimately, one or more of these experimental evaluation modalities may be considered for use in competency-based evaluation of residents, as they would be much more easily generalizable across residency programs compared to expert contour review. Future directions include implementation of such assessment modalities into formal resident evaluation and utilization of digital and artificial intelligence-based software for assessment of other practical skills including plan evaluation and approval of treatment set-up. [ABSTRACT FROM AUTHOR]

Standard of care for adjuvant treatment of stage III endometrial cancer includes chemotherapy and radiation. In addition to stage, tumor molecular profiles may predict treatment outcomes, and prospective clinical trials are ongoing. However, tumor molecular testing is costly and time-consuming. Our objective was to evaluate the cost-effectiveness of tumor molecular testing in stage III endometrial cancer. A Markov decision model compared two strategies for stage III endometrial cancer: Tumor Molecular Testing (TMT) versus No TMT. TMT included sequential POLE next generation sequencing, mismatch repair immunohistochemistry (IHC), and p53 IHC. POLE -mutated patients were assigned to adjuvant radiation therapy; all others including controls were assigned to adjuvant chemoradiation. First recurrences were treated with 6 cycles of carboplatin and paclitaxel. Second recurrences were treated with pembrolizumab alone for mismatch repair deficient patients and both pembrolizumab and lenvatinib for other patients. Sensitivity analyses were performed to test model robustness. Compared to No TMT, TMT was cost saving with equivalent effectiveness. On one-way sensitivity analysis, TMT remained cost saving over all parameter ranges. TMT was also favored on probabilistic sensitivity analysis in 80% of iterations at a willingness-to-pay threshold of $100,000/quality adjusted life-year (QALY) gained. However, when TMT was compared to mismatch repair IHC alone, TMT cost $182,798/QALY gained. In this model of patients with stage III endometrial cancer, TMT was cost saving compared to No TMT. However, when compared to mismatch repair IHC alone, TMT was economically unfavorable. • Tumor molecular testing is an area of ongoing investigation in endometrial carcinoma. • A Markov decision model was created to compare two strategies: tumor molecular testing versus no tumor molecular testing. • For stage III endometrial cancer, TMT was cost saving with equivalent effectiveness compared to no TMT. [ABSTRACT FROM AUTHOR]

Purpose: The goal of this study was to determine the dose contributions from image guided adaptive brachytherapy (IGABT) to individual suspicious pelvic lymph nodes (pLNN) in cervical cancer patients. Data were collected in two cancer centers, University of Pittsburgh Cancer Institute (UPCI) and University Medical Center Utrecht (UMCU). Material and methods: 27 and 15 patients with node positive cervical cancer treated with HDR (high dose rate) or PDR (pulsed dose rate)-IGABT were analyzed. HDR-IGABT (UPCI) was delivered with CT/MRI compatible tandem-ring applicators with 5.0-6.0 Gy x five fractions. PDR-IGABT (UMCU) dose was delivered with Utrecht tandem-ovoid applicators with 32 x 0.6 Gy x two fractions. Pelvic lymph nodes with short axis diameter of ≥ 5 mm on pre-treatment MRI or PET-CT were contoured for all BT-plans. Dose contributions to individual pLNN expressed as D90 (dose to 90% of the volume) were calculated from dose-volume histograms as absolute and relative physical dose (% of the reference dose) for each fraction. For each node, the total dose from all fractions was calculated, expressed in EQD2 (equivalent total dose in 2 Gy fractions). Results: Fifty-seven (UPCI) and 40 (UMCU) individual pLNN were contoured. The mean D90 pLNN was 10.8% (range 5.7-25.1%) and 20.5% (range 6.8-93.3%), respectively, and therefore different in the two centers. These values translate into 2.7 Gy (1.3-6.6 Gy) EQD2 and 7.1 Gy (2.2-36.7 Gy) EQD2, respectively. Differences are caused by the location of the individual nodes in relation to the spatial dose distribution of IGABT, differences in total dose administered and radiobiology (HDR versus PDR). Conclusions: The IGABT dose contribution to individual pelvic nodes depends on patient and treatment related factors, and varies considerably. [ABSTRACT FROM AUTHOR]

Purpose: To examine clinical outcomes and relapse patterns in locally advanced vulvar carcinoma treated using preoperative chemotherapy and intensity modulated radiation therapy (IMRT). Methods and Materials: Forty-two patients with stage I-IVA (stage I, n=3; stage II, n=13; stage III, n=23; stage IVA, n=3) vulvar cancer were treated with chemotherapy and IMRT via a modified Gynecological Oncology Group schema using 5-fluorouracil and cisplatin with twice-daily IMRT during the first and last weeks of treatment or weekly cisplatin with daily radiation therapy. Median dose of radiation was 46.4 Gy. Results: Thirty-three patients (78.6%) had surgery for resection of vulva; 13 of these patients also had inguinal lymph node dissection. Complete pathologic response was seen in 48.5% (n=16) of these patients. Of these, 15 had no recurrence at a median time of 26.5 months. Of the 17 patients with partial pathological response, 8 (47.1%) developed recurrence in the vulvar surgical site within a median of 8 (range, 5-34) months. No patient had grade ≥3 chronic gastrointestinal/genitourinary toxicity. Of those having surgery, 8 (24.2%) developed wound infections requiring debridement. Conclusions: Preoperative chemotherapy/IMRT was well tolerated, with good pathologic response and clinical outcome. The most common pattern of recurrence was local in patients with partial response, and strategies to increase pathologic response rate with increasing dose or adding different chemotherapy need to be explored to help further improve outcomes. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of this study was to determine the patterns of failure in patients diagnosed with cervical cancer treated with definitive radiotherapy and who subsequently had complete metabolic response (CMR) seen on early post-therapy (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging. Additionally, we sought to determine what factors predict disease recurrence in this patient population. Methods and materials: We reviewed the records of 155 patients diagnosed with cervical cancer from stages IB1 to IVA who were treated with definitive chemoradiation therapy between 2003 and 2011 and had a FDG-PET at 10–16weeks following completion of therapy. One hundred and twelve (72.0%) had CMR on follow-up FDG-PET and comprised the patients in this study. Results: The median age of patients with CMR was 51years and the median tumor size 4.9cm. Median follow up was 15months. Of the 112 patients, 11 (9.8%) had a recurrence and six (5.4%) had isolated local recurrences, and five (4.5%) had distant recurrence. Median time to recurrence was 9months. Three-year actuarial disease-free survival and overall survival rates were 78.9% and 88.0% respectively. On Cox regression multivariate analysis, tumor size was predictive of increased risk of local recurrence in these patients with CMR with p <0.025. Age, stage, histology and nodal positivity were not significant for predicting local, distant or any recurrence. Conclusion: Patients treated with concurrent chemoradiation had a CMR which demonstrated good clinical outcomes in terms of local control. There were equal numbers of patients suffering local and distant recurrences. In patients with a CMR, only tumor size was an independent predictor for local recurrence. [Copyright &y& Elsevier]

Abstract: Purpose: There is limited published data on high-dose-rate interstitial brachytherapy (HDRBT) for cervical cancer resulting in no consensus on a fractionation schedule. This study reports our experience of CT-based HDRBT for treating locally advanced cervical cancer. Methods and Materials: Forty-seven patients diagnosed with Stage IIB–IVA cervical cancer not suitable for intracavitary brachytherapy were treated with HDRBT from March 2005 to November 2010. All patients received external beam radiation therapy with a median dose of 45Gy and all had one interstitial implantation followed by 3.75–5Gy×5 fractions in a twice daily (BID) schedule. Total doses for clinical target volume and organs at risk, including rectum, bladder, and sigmoid, were summated and normalized to a biologically equivalent dose of 2Gy per fraction. At 3 months posttherapy, early response was assessed with clinical examination and positron emission tomography (PET/CT) imaging. Results: Median clinical target volume D 90 (dose delivered to 90% of the clinical target volume) was 76.3 (59.0–86.9) Gy and the 2cc dose to the bladder, rectum, and sigmoid colon organs were 70.2 (55.9–77.7), 65.8 (54.9–80.6), and 56.5 (45.0–71.2) Gy, respectively. Posttreatment, 12 patients had evidence of persistent disease on PET/CT. Eleven of the 35 patients who had complete response developed recurrences. Two patients developed late Radiation Therapy Oncology Group ≥3 rectal toxicities. Two-year actuarial local control, disease-free survival, overall survival, and Grade ≥3 toxicities were 61%, 43%, 59%, and 10%, respectively. Conclusion: Our approach of a single implantation procedure followed by five fractions of HDRBT was well tolerated with early results demonstrating a moderate response and local control rate with acceptable toxicities. [Copyright &y& Elsevier]

Purpose: Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute–Designated Comprehensive Cancer Center Network. Methods: In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10–14 fractions for certain clinical situations. The data were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010. Results: In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1–5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1–5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1–1.4) for community and 1.3 (confidence interval, 1.1–1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001). Conclusion: This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice. [Copyright &y& Elsevier]

Abstract: Purpose: To 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 Materials: Thirty 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 3.75–5.0Gy 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 2Gy per fraction. Results: Seventeen 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 2Gy per fraction for 2cc of bladder, rectum, and sigmoid was 55.0, 56.3, 50.0Gy, respectively. The median D 90 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. Conclusions: Initial results of 3D HDRB using our fractionation schedule in the treatment of vaginal cancers showed good local response with acceptable morbidities. [Copyright &y& Elsevier]

Abstract: Purpose: To present recommendations for the use of interstitial brachytherapy in patients with vaginal cancer or recurrent endometrial cancer in the vagina. Methods: A panel of members of the American Brachytherapy Society reviewed the literature, supplemented that with their clinical experience, and formulated recommendations for interstitial brachytherapy for primary or recurrent cancers in the vagina. Results: Patients with bulky disease (approximately >0.5cm thick) should be considered for treatment with interstitial brachytherapy. The American Brachytherapy Society reports specific recommendations for techniques, target volume definition, and dose–fractionation schemes. Three-dimensional treatment planning is recommended with CT scan and/or MRI. The treatment plan should be optimized to conform to the clinical target volume and should reduce the dose to critical organs, including the rectum, bladder, urethra, and sigmoid colon. Suggested doses in combination with external beam radiation therapy and summated equivalent doses in 2Gy fractions are tabulated. Conclusion: Recommendations are made for interstitial brachytherapy for vaginal cancer and recurrent disease in the vagina. Practitioners and cooperative groups are encouraged to use these recommendations to formulate treatment and dose-reporting policies. Such a process will result in meaningful outcome comparisons, promote technical advances, and lead to appropriate utilization of these techniques. [Copyright &y& Elsevier]

Abstract: Purpose: To develop recommendations for the use of adjuvant vaginal cuff brachytherapy after hysterectomy and update previous American Brachytherapy Society (ABS) guidelines. Methods and Materials: A panel of members of the ABS performed a literature review, supplemented their clinical experience, and formulated recommendations for adjuvant vaginal cuff brachytherapy. Results: The ABS endorses the National Comprehensive Cancer Network guidelines for indications for radiation therapy for patients with endometrial cancer and cervical cancer and the guidelines on quality assurance of the American Association on Physicists in Medicine. The ABS made specific recommendations for applicator selection, insertion techniques, target volume definition, dose fractionation, and specifications for postoperative adjuvant vaginal cuff therapy. The ABS recommends that applicator selection should be based on patient anatomy, target volume geometry, and physician judgment. The dose prescription point should be clearly specified. Suggested doses were tabulated for treatment with brachytherapy alone, and in combination with external beam radiation therapy, when applicable. A properly fitted brachytherapy applicator should be selected that conforms to the vaginal apex and achieves mucosal contact with optimal tumor and normal tissue dosimetry. Dose prescription points may be individually selected but doses should be reported at the vaginal surface and at 0.5-cm depth. Conclusions: Recommendations are made for adjuvant vaginal cuff brachytherapy. Practitioners and cooperative groups are encouraged to use these recommendations to formulate their treatment and dose reporting policies. These recommendations will permit meaningful comparisons of reports from different institutions and lead to better and more appropriate use of vaginal brachytherapy. [Copyright &y& Elsevier]

Abstract: Purpose: This report presents an update to the American Brachytherapy Society (ABS) high-dose-rate (HDR) brachytherapy guidelines for locally advanced cervical cancer. Methods: Members of the ABS with expertise in cervical cancer formulated updated guidelines for HDR brachytherapy using tandem and ring, ovoids, cylinder, or interstitial applicators for locally advanced cervical cancer. These guidelines were written based on medical evidence in the literature and input of clinical experts in gynecologic brachytherapy. Results: The ABS affirms the essential curative role of tandem-based brachytherapy in the management of locally advanced cervical cancer. Proper applicator selection, insertion, and imaging are fundamental aspects of the procedure. Three-dimensional imaging with magnetic resonance or computed tomography or radiographic imaging may be used for treatment planning. Dosimetry must be performed after each insertion before treatment delivery. Applicator placement, dose specification, and dose fractionation must be documented, quality assurance measures must be performed, and followup information must be obtained. A variety of dose/fractionation schedules and methods for integrating brachytherapy with external-beam radiation exist. The recommended tumor dose in 2-Gray (Gy) per fraction radiobiologic equivalence (normalized therapy dose) is 80–90Gy, depending on tumor size at the time of brachytherapy. Dose limits for normal tissues are discussed. Conclusion: These guidelines update those of 2000 and provide a comprehensive description of HDR cervical cancer brachytherapy in 2011. [Copyright &y& Elsevier]

Background: The molecular subtype by hormone receptor status predicts recurrence in the adjuvant setting. Here, we report recurrence patterns by molecular subtype following neoadjuvant chemotherapy (NACT) to identify subgroups prone to recurrence. Materials and Methods: We retrospectively analyzed 331 patients receiving NACT plus lumpectomy and whole breast radiation therapy (RT) (n = 155), or mastectomy with (n = 122) or without (n = 50) adjuvant RT. Tumors were classified by immunohistochemical (IHC) surrogate markers into luminal A (strong ER+/PR+; HER2-), luminal B (weak-to-moderate ER+/PR+; HER2-), HER2 (HER2+), and triple-negative/basal subtypes. Results: The median follow-up was 43 months (range 10-104). The 5-year disease-free survival (DFS) was 71.4, 70.1, 70.4, and 62.1% for luminal A, luminal B, HER2, and basal subtypes, respectively. The 5-year distant recurrence rates were 25.8, 28.7, 28.7, and 35.2%. The 5-year locoregional recurrence rates were 3.8, 1.6, 1.3, and 4.2%. Molecular class (p = 0.003) and pathologic complete response (pCR; p = 0.004) predicted distant recurrence, DFS, and overall survival (OS). Only the omission of adjuvant RT following mastectomy (p = 0.006) predicted locoregional recurrence. Conclusions: IHC subclassification and pCR predict distant failure, DFS, and OS in the neoadjuvant setting. While not predictive of locoregional recurrence, the total number of events were small. More work is needed to define if molecular class can predict patients at risk for locoregional recurrence. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to analyze the dosimetric outcome of 3D image-guided high-dose-rate (HDR) brachytherapy planning for cervical cancer treatment and compare dose coverage of high-risk clinical target volume (HRCTV) to traditional Point A dose. Thirty-two patients with stage IA2–IIIB cervical cancer were treated using computed tomography/magnetic resonance imaging–based image-guided HDR brachytherapy (IGBT). Brachytherapy dose prescription was 5.0–6.0 Gy per fraction for a total 5 fractions. The HRCTV and organs at risk (OARs) were delineated following the GYN GEC/ESTRO guidelines. Total doses for HRCTV, OARs, Point A, and Point T from external beam radiotherapy and brachytherapy were summated and normalized to a biologically equivalent dose of 2 Gy per fraction (EQD2). The total planned D90 for HRCTV was 80–85 Gy, whereas the dose to 2 mL of bladder, rectum, and sigmoid was limited to 85 Gy, 75 Gy, and 75 Gy, respectively. The mean D90 and its standard deviation for HRCTV was 83.2 ± 4.3 Gy. This is significantly higher (p < 0.0001) than the mean value of the dose to Point A (78.6 ± 4.4 Gy). The dose levels of the OARs were within acceptable limits for most patients. The mean dose to 2 mL of bladder was 78.0 ± 6.2 Gy, whereas the mean dose to rectum and sigmoid were 57.2 ± 4.4 Gy and 66.9 ± 6.1 Gy, respectively. Image-based 3D brachytherapy provides adequate dose coverage to HRCTV, with acceptable dose to OARs in most patients. Dose to Point A was found to be significantly lower than the D90 for HRCTV calculated using the image-based technique. Paradigm shift from 2D point dose dosimetry to IGBT in HDR cervical cancer treatment needs advanced concept of evaluation in dosimetry with clinical outcome data about whether this approach improves local control and/or decreases toxicities. [Copyright &y& Elsevier]

Abstract: Purpose: 131Cs has been recently introduced for use in prostate brachytherapy. We wished to identify clinical and dosimetric factors associated with acute bowel/rectal toxicity in patients treated with 131Cs. Methods and Materials: Patients treated with 131Cs prostate brachytherapy at the University of Pittsburgh were asked to complete expanded prostate cancer index composite surveys preoperatively and at 2–4 weeks and 3 months postimplant. We identified patients who experienced acute and persistent acute bowel toxicity to determine if any factors could correlate with either situation. Results: One hundred six patients were treated with 131Cs from September 2006 to May 2008. Thirty-eight percent of patients met our criteria for patient-appreciated acute bowel symptoms. On multivariate analysis, the volume of rectum receiving 50% of the prescribed dose (R-V 50; 4.1 vs. 2.6cc, p =0.01), R-V 75 (1.3 vs. 0.62cc, p =0.01), the percentage of the prescribed dose received by 1cc of the rectum (R-D-1cc; 75% vs. 64%, p =0.02), and R-D-2cc (63% vs. 54%, p =0.003) were found to be factors associated with a greater risk of severe acute bowel toxicity. At 3-month followup, 28% of patients had persistent acute bowel toxicity. On multivariate analysis, no factors were identified that correlated with persistent acute bowel toxicity. Conclusions: This study identifies R-V 50, R-V 75, R-D-1cc, and R-D-2cc as factors associated with patient-appreciated acute rectal toxicity. We are performing dosimetric analysis to determine the optimal distance for the posterior needles from the prostate–rectal interface to decrease rectal dose while still maintaining adequate coverage of prostate. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: With the increasing elderly population, more women with newly diagnosed endometrial cancer may not be surgical candidates due to medical comorbidities. Definitive radiation therapy with external beam radiation (EBRT) and/or brachytherapy is a reasonable primary treatment for endometrial cancer in patients who cannot undergo surgery. Methods: A retrospective review identified 26 women 75 years and older with endometrial cancer who were not operative candidates due to comorbidities and received definitive radiation. Results: The median age of the treated patients was 83, all of whom had significant medical comorbidities precluding surgical treatment. Seventy-three percent of the patients had stage T1 disease, 19% were stage T2, and 8% were stage T3. Seventy-three percent of patients received EBRT before brachytherapy (median dose: 45 Gy). The median brachytherapy dose was 20 Gy in 5 fractions. The types of brachytherapy used were Rotte Y applicator (42%), tandem and cylinder (42%), and ring and tandem (16%). Median followup was 12 months (1–60 months). No treatment breaks were required for the entire group and only 2 patients (8%) developed late toxicity. The overall survival for all patients was 89% and 28% at 1 and 2 years, respectively. Disease-specific survival for all patients was 93% at 1 year and 73% at 3 years. Conclusions: The results in this study indicate that definitive radiation with EBRT and/or brachytherapy for endometrial cancer is feasible and well tolerated in an elderly population. [Copyright &y& Elsevier]

The article reviews the study on the complete pathologic response of breast cancer patients to neoadjuvant chemotherapy. It hypothesizes a similar response for using the semiquantitative immunohistochemistry for estrogen, progesterone, and human epidermal growth factor receptors. It confirms the hormone receptor negative paradox that implied the worst overall survival due to the higher relapse in residual disease.

To analyze the initial clinical outcomes for breast cancer patients treated with intensity-modulated radiation therapy (IMRT) in a large integrated cancer center network. A total of 495 patients with breast cancer received IMRT following breast conserving surgery among nine cancer centers. Seven community cancer centers span a 100-mile radial distance from the two central academic sites. All nine cancer centers followed the same clinical pathway guidelines for the radiotherapeutic management of breast cancer. IMRT planning for all centers was performed at one central location, D3 Advanced Radiation Planning Service. The median IMRT prescription dose was 50 Gy followed by a boost with median dose of 10 Gy. The median breast volume was 918 cm3. The median Dose Homogeneity Index (DHI) was 93%. The median % of ipsilateral lung volume receiving >20 Gy was 4.6%. For left breast IMRT, the median % heart volume receiving more than 5% of prescription dose was 13.1. There was no statistical difference in the mean DHI, heart and lung dose between the academic and community sites. For all patients, NCI CTC Grades 0,1,2,3 for acute skin erythema was 16%, 55%, 28%, and 1%, respectively. The rates of Grade 0,1,2,3 acute skin desquamation were 75%, 20%, 4%, and 1%, respectively. There was no statistically significant difference in acute skin toxicities (>grade 2) among the academic and community cancer centers. With centralized processes, IMRT can be safely and effectively delivered in a large health system with an admixture of academic and community centers but long-term follow-up is necessary. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To provide longitudinal follow-up and assess the intermediate outcomes in breast cancer patients treated with the MammoSite® radiation therapy system. Methods and Material: Ninety-two patients with histologically proven stage 0-II breast cancer were treated with MammoSite® accelerated partial breast irradiation after breast-conserving surgery. The catheter was placed at the time of surgery or postoperatively. Treatment prescription was 3.4Gy b.i.d. for a period of five days using high-dose-rate afterloading. Clinical and dosimetric parameters including dose to 90% of PTV, volume of PTV receiving 100% of dose, volume of PTV receiving 150% of dose, edited PTV, and dose homogeneity index were analyzed as variables correlating with late effects. Results: All patients received the prescribed treatment. Seventy-seven percent of patients had intraoperative catheter placement, which was associated with a higher rate of persistent seroma (79%). The presence of seroma did not affect cosmesis. Ten patients developed telangiectasia at a median of 20.5 months. Skin dose and balloon-to-skin distance had a significant correlation with the development of telangiectasia that significantly affected cosmetic grading. The telangiectasia incidence for maximum skin dose of >100% and >125% of the prescription dose were 28% and 63%, compared with 0% (p =0.0001) and 4.2% (p =0.0001) for doses of ≤100% and ≤125%, respectively. Overall, most patients had excellent cosmetic results, and local control of disease was excellent. Conclusions: MammoSite® radiation therapy system demonstrates excellent local control and cosmetic outcome with extended followup. The maximum skin dose should be kept below 100% to reduce late effects on skin and improve cosmetic outcome. The persistence of seroma is higher with intraoperative placement of the catheter, and therefore postoperative placement is preferred. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of this study was to determine whether the ClearPath (CP) multicatheter hybrid device was able to achieve acceptable dosimetry in patients in whom the proximity of the breast surgical cavity to the skin precluded treatment with intracavitary MammoSite (MS) brachytherapy. Methods and materials: The study consisted of 11 patients who had the MS catheter placed and who were subsequently not treated due to inadequate skin distance. A phantom scan of the CP multicatheter hybrid device was superimposed on the MS CT scan and a dosimetric comparison was performed. Results: The median MS balloon size, diameter, and minimum skin distance were 40cc, 4.1cm, and 5mm, respectively. The D 90, V 100, V 150, and V 200 with MS vs. CP were 95.29% vs. 97.06%, 88.8% vs. 91.3%, 35.7% vs. 38.0%, and 9.4% vs. 9.6%, respectively. The median maximum skin dose was 5.5Gy vs. 3.9Gy (p <.0001). The median dose homogeneity index (DHI) was 0.60 vs. 0.59 (p =.09). The median maximum rib, heart, and lung dose were 2.17Gy vs. 2.18Gy, 2.17Gy vs. 2.18Gy, and 0.50Gy vs. 0.56Gy, respectively. Conclusion: The hybrid CP catheter reduced the skin dose significantly without compromising the planning target volume coverage, DHI, or dose to other critical organs. The use of this device has the potential to increase the applicability of accelerated partial breast brachytherapy (APBI) in patients with a surgical cavity close to skin compared with balloon brachytherapy. [Copyright &y& Elsevier]

Purpose: To assess the intermediate clinical outcomes of medically inoperable patients with endometrial cancer treated with definitive Rotte “Y” applicator high-dose-rate brachytherapy (HDRB) over a 10-year period. Methods and Materials: Forty-nine inoperable patients were treated with HDRB from 1997 to 2007. Forty three (84%) were markedly obese (body mass index >35 kg/m2). Thirty-one patients (63.3%) underwent two-dimensional treatment planning, whereas 18 patients (36.7%) underwent three-dimensional treatment planning. Thirty five of the patients (71.4%) were first treated with external beam radiotherapy (EBRT). For patients receiving EBRT in addition to HDRB, the median Y-applicator dose was 20 Gy in 5 fractions; for patients receiving HDRB alone it was 35 Gy in 5 fractions. All patients received two Y-applicator treatments per day. Results: Median follow-up time for all patients was 33 months. Acute HDRB toxicities were limited to Grade 1 and 2 occurring in 5 patients. One patient had a myocardial infarction. Four patients had late Grade 2 or 3 toxicity. Three patients had local recurrence (median time to recurrence, 16 months). The 3- and 5-year actuarial cause-specific survival rates were 93% and 87%, respectively; the overall survival rate was 83% and 42%, respectively, at 3 and 5 years. Conclusions: Twice-daily HDRB using a Y-applicator is a well-tolerated and efficacious regimen for the definitive treatment of medically inoperable patients with early-stage endometrial cancer. The recent incorporation of three-dimensional treatment planning has the potential to further decrease treatment morbidities. [Copyright &y& Elsevier]

Abstract: Purpose: This study reports on prostate edema after prostate brachytherapy using Cesium-131 (131Cs) and describes our method to compensate. Methods and materials: Thirty-one patients underwent brachytherapy using an afterloading technique. Volume measurements of the prostate were taken at various time intervals relative to the date of implant. Real-time operating room dosimetry was used for seed placement on the postneedle prostate volume. The prostate volumes at the various time points were used to determine the effect of prostate edema on dosimetry. Results: Increase in prostate volume occurred immediately after needle placement, as measured by both ultrasound (mean increase of 17.7% (0–75.0%) from 36.8 to 46.9cc) and Day 0 CT (mean increase of 15.3% (0–54.8%) to 45.9cc). Day 0 assessment of dosimetry revealed a median D 90 of 102.7% (86.7–133.4%), median V 100 of 91.8% (75.9–98.4%), median V 150 of 44.4% (23.8–81.3%), and median V 200 of 16.3% (7.8–36.9%). This edema dissipated over the next 4 weeks, with resultant changes in dosimetric parameters. By 4 weeks, prostate volume had returned to the preimplant volume (37.7cc) with increased D 90 (118.2%), V 100 (95.6%), V 150 (63.9%), and V 200 (28.4%). Conclusions: There is significant immediate edema with prostate brachytherapy. This affects the dosimetry of the implant substantially. Because of this edema, our planning for brachytherapy is done on the postneedle implant volume. Quality assurance studies should be done on the same day as the implant to avoid substantial overestimation of dosimetric parameters. [Copyright &y& Elsevier]

Abstract: Objective.: Intensity-modulated radiation therapy (IMRT) is a rapidly maturing technology that allows delivery of radiation dose in a more conformal manner by varying the radiation beams spatially or temporally. The purpose of the study was to assess the clinical outcome in patients with locally-advanced vulvar cancers treated using preoperative chemotherapy with IMRT. Methods.: Eighteen patients with stage II–IVA cancer were treated with a modified GOG schema using 5-fluorouracil (5-FU) and cisplatin with twice-daily (BID) IMRT during the first and last weeks of treatment. Surgery was planned for 6–8 weeks post-treatment. Results.: The median follow-up time was 22 months (2–60 months). Fourteen patients had surgery performed with pathological complete response (pCR) in 9 (64%) patients and partial response (pPR) in 5 patients. There were no recurrences in the 9 patients who achieved pCR whereas 3/5 with pPR had local recurrence (p =0.027). Four patients did not have surgery: one patient died a week after treatment while 2 of the remaining 3 patients had local recurrences. Acute desquamative skin reactions in the vulva and perineum were seen in all patients. Three of the 14 patients who had surgery had prolonged wound complications requiring debridement. No patients had radiation-related acute or late toxicity of grade =3. The 2-year cause specific and overall survivals were 75% and 70% respectively. Conclusion.: Preoperative chemotherapy and IMRT were well tolerated with good clinical response and early clinical outcome. Pathological complete response predicts better outcomes. Prospective clinical trials with sufficient patient numbers and follow-up are needed to determine the true impact of IMRT in these patients. [Copyright &y& Elsevier]

Purpose: The purpose of this study was to evaluate the efficacy of HDR brachytherapy for primary or recurrent vaginal cancer. Methods: Between the years 2000 to 2006, 18 patients with primary or recurrent vaginal cancer were treated with brachytherapy (HDRB). Six patients had primary vaginal cancer (stage II to IVA) while 12 were treated for isolated vaginal recurrence (primary cervix = 4, vulva = 1 and endometrium = 7). Five patients had previous pelvic radiation therapy. All except one patient received external beam radiation therapy to a median dose of 45 Gy (range 31.2 -55.8 Gy). The HDRB was intracavitary using a vaginal cylinder in 5 patients and interstitial using a modified Syed-Nesblett template in 13 patients. The dose of interstitial brachytherapy was 18.75 Gy in 5 fractions delivered twice daily. The median follow-up was 18 months (range 6-66 months). Results: Complete response (CR) was achieved in all but one patient (94%). Of these 17 patients achieving a CR, 1 had local recurrence and 3 had systemic recurrence at a median time of 6 months (range 6-22 months). The 2-year actuarial local control and cause-specific survival for the entire group were 88% and 82.5%, respectively. In subset analysis, the crude local control was 100% for primary vaginal cancer, 100% for the group with recurrence without any prior radiation and 67% for group with recurrence and prior radiation therapy. Two patients had late grade 3 or higher morbidity (rectovaginal fistula in one patient and chronic vaginal ulcer resulting in bleeding in one patient). Both these patients had prior radiation therapy. Conclusion: Our small series suggests that HDRB is efficacious for primary or recurrent vaginal cancer. Patients treated with primary disease and those with recurrent disease without prior irradiation have the greatest benefit from HDRB in this setting. The salvage rate for patients with prior radiation therapy is lower with a higher risk of significant complications. Additional patients and follow-up are ongoing to determine the long-term efficacy of this approach. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to evaluate the clinical implementation of tangential field IMRT using sliding window technique and to compare dosimetric parameters with 3-dimensional conformal radiation therapy (3DCRT). Twenty breast cancer patients were randomly selected for comparison of intensity modulated radiation therapy (IMRT)-based treatment plan with 3DCRT. Inverse treatment was performed using the sliding window technique, employing the Eclipse® Planning System (version 7.1.59, Varian, Palo Alto, CA). The dosimetric parameters compared were V95 (the percentage of target volume getting ≥95% of prescribed dose), V105, V110, and dose homogeneity index, DHI (percentage of target volume getting between 95% and 110% of prescribed dose). The mean V95, DHI, V105, and V110 for target volume for IMRT vs. 3D were 90.6% (standard deviation [SD]: 3.2) vs. 91% (SD: 3.0), 87.7 (SD: 6.0) vs. 82.6 (SD: 7.8), 27.3% (SD: 20.3) vs. 49.4% (SD: 14.3), and 2.8 (SD: 5.6) vs. 8.4% (SD: 7.4), respectively. DHI was increased by 6.3% with IMRT compared to 3DCRT (p < 0.05). The reductions of V105 and V110 for the IMRT compared to 3DCRT were 44.7% and 66.3%, respectively (p < 0.01). The mean dose and V30 for heart with IMRT were 2.3 (SD: 1.1) and 1.05 (SD: 1.5) respectively, which was a reduction by 6.8% and 7.9%, respectively, in comparison with 3D. Similarly, the mean dose and V20 for the ipsilateral lung and the percentage of volume of contralateral volume lung receiving > 5% of prescribed dose with IMRT were reduced by 9.9%, 2.2%, and 35%, respectively. The mean of total monitor units used for IMRT and 3DCRT was about the same (397 vs. 387). The tangential field IMRT for intact breast using sliding window technique was successfully implemented in the clinic. We have now treated more than 1000 breast cancer patients with this technique. The dosimetric data suggest improved dose homogeneity in the breast and reduction in the dose to lung and heart for IMRT treatments, which may be of clinical value in potentially contributing to improved cosmetic results and reduced late treatment-related toxicity. [Copyright &y& Elsevier]

Purpose: To assess the early clinical outcomes with concurrent cisplatin and extended-field intensity-modulated radiotherapy (EF-IMRT) for carcinoma of the cervix. Methods and Materials: Thirty-six patients with Stage IB2–IVA cervical cancer treated with EF-IMRT were evaluated. The pelvic lymph nodes were involved in 19 patients, and of these 19 patients, 10 also had para-aortic nodal disease. The treatment volume included the cervix, uterus, parametria, presacral space, upper vagina, and pelvic, common iliac, and para-aortic nodes to the superior border of L1. Patients were assessed for acute toxicities according to the National Cancer Institute Common Toxicity Criteria for Adverse Events, version 3.0. All late toxicities were scored with the Radiation Therapy Oncology Group late toxicity score. Results: All patients completed the prescribed course of EF-IMRT. All but 2 patients received brachytherapy. Median length of treatment was 53 days. The median follow-up was 18 months. Acute Grade ≥3 gastrointestinal, genitourinary, and myelotoxicity were seen in 1, 1, and 10 patients, respectively. Thirty-four patients had complete response to treatment. Of these 34 patients, 11 developed recurrences. The first site of recurrence was in-field in 2 patients (pelvis in 1, pelvis and para-aortic in 1) and distant in 9 patients. The 2-year actuarial locoregional control, disease-free survival, overall survival, and Grade ≥3 toxicity rates for the entire cohort were 80%, 51%, 65%, and 10%, respectively. Conclusion: Extended-field IMRT with concurrent chemotherapy was tolerated well, with acceptable acute and early late toxicities. The locoregional control rate was good, with distant metastases being the predominant mode of failure. We are continuing to accrue a larger number of patients and longer follow-up data to further extend our initial observations with this approach. [Copyright &y& Elsevier]

Purpose: To determine the dosimetric and toxicity differences between prone and supine position intensity-modulate radiotherapy in endometrial cancer patients treated with adjuvant radiotherapy. Methods: Forty-seven consecutive endometrial cancer patients treated with adjuvant RT were analyzed. Of these, 21 were treated in prone position and 26 in the supine position. Dose–volume histograms for normal tissue structures and targets were compared between the two groups. Acute and chronic toxicity were also compared between the cohorts. Results: The percentage of volume receiving 10, 20, 30, 40, 45, and 50 Gy for small bowel was 89.5%, 69%, 33%, 12.2%, 5%, and 0% in the prone group and 87.5%, 62.7%, 26.4%, 8%, 4.3%, and 0% in the supine group, respectively. The difference was not statistically significant. The dose–volume histograms for bladder and rectum were also comparable, except for a slightly greater percentage of volume receiving 10 Gy (1.5%) and 20 Gy (5%) for the rectum in the prone group. Acute small bowel toxicities were Grade 1 in 7 patients and Grade 2 in 14 patients in the prone group vs. Grade 1 in 6 patients and Grade 2 in 19 patients in the supine group. Chronic toxicity was Grade 1 in 7 patients and Grade 3 in 1 patient in the prone group and Grade 1 in 5 patients in the supine group. Conclusion: These preliminary results suggest that no difference exists in the dose to the normal tissue and toxicity between prone and supine intensity-modulated radiotherapy for endometrial cancer. Longer follow-up and more outcome studies are needed to determine whether any differences exist between the two approaches. [Copyright &y& Elsevier]

Abstract: Purpose: The study aimed to assess the outcome of locally advanced cervical and vaginal cancer treated with high-dose-rate interstitial brachytherapy (HDRB). Methods and materials: Between 1998 and 2004, 16 previously unirradiated patients with locally advanced cervical and vaginal cancer not suitable for intracavitary brachytherapy because of distorted anatomy or extensive vaginal disease were treated with HDRB in combination with external beam radiotherapy. All patients received whole pelvis external beam radiation therapy (EBRT) followed by interstitial implantation. The median whole pelvis external beam dose was 45Gy (range, 39.6–50.4Gy) with 11 patients receiving parametrial boost to a median dose of 9Gy. Twelve (75%) of these patients received chemotherapy concurrent with external beam. All patients received a single HDRB procedure using a modified Syed–Neblett template. A CT scan was performed postimplant for needle placement verification and treatment planning purpose. Dose was prescribed to the tumor volume based on the radiographic and clinical examination. All patients received 18.75Gy in five fractions delivered twice daily. The median followup was 25 months (6–69 months). Results: Median cumulative biologic effective dose (EBRT+HDRB) to tumor volume was 78.9Gy10 with the range of 72.5–85.2Gy10. Median cumulative biologic effective dose for the rectum and bladder were 99.4Gy3 (range, 79.6–107.8Gy3) and 96.4Gy3 (range, 78.3–105.3Gy3), respectively. Complete response was achieved in 13 (81%) patients with 3 patients having persistent disease. Five of these 13 patients developed recurrence at a median time of 14 months (distant in 4 and local and distant in 1). The 5-year actuarial local control and cause-specific survival were 75% and 64%, respectively. In subset analysis, 5-year actuarial local control was 63% for cervical cancer patients and 100% for vaginal cancer patients. No patient had acute Grade 3 or 4 morbidity. Grade 3 or 4 delayed morbidity resulting from treatment occurred in 1 patient with 5-year actuarial rate of 7%. Three patients had late Grade 2 rectal morbidity and 1 patient had Grade 2 small bowel morbidity. Conclusions: Our series suggests that single interstitial implantation procedure with five fractions of 3.75Gy each to target volume is an effective and safe fractionation schedule. The integration of imaging modality helps in decreasing dose to the critical organs. Additional patients and followup are ongoing to determine the long-term efficacy of this approach. [Copyright &y& Elsevier]

Abstract: Objective. : To assess local control and chronic toxicity with IMRT for adjuvant treatment of endometrial carcinoma. Methods. : Forty-seven patients with endometrial cancer were treated with adjuvant IMRT and HDR brachytherapy (HDRB). The external beam dose was between 45 and 50.4 Gy, and all patients received 10 Gy in 2 fractions of HDRB to the vaginal cuff. Eight of these patients were treated with extended field to include the paraaortic region. Results. : IMRT dosimetry showed excellent coverage of the planning target volume (PTV) with mean PTV 95, PTV 110 and PTV 120 of 97.8%, 8.2% and 0.9% respectively. At a median follow-up of 20 months, four patients have recurred at extra pelvic sites. No patient had pelvic recurrence. The treatment was well tolerated with late toxicities as follows: small bowel grade 1: 25%, rectal grade 1: 2% and bladder grade 1: 13%. One patient had grade 3 small bowel toxicity. The 3-year actuarial rate of grade 2 or greater toxicity, disease-free survival and overall survival rate were 3.3%, 84% and 90%, respectively. Conclusions. : The preliminary analysis of IMRT for adjuvant treatment of endometrial carcinoma shows excellent local control and low toxicity. However, longer follow-up and more patients are needed to ascertain whether the benefits of IMRT treatment seen here translate into long-term reductions in toxicities and local recurrence. [Copyright &y& Elsevier]