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Whether brachytherapy based microboosting of the dominant intraprostatic lesion (DIL) improves outcomes over standard approaches is not known. The purpose of this study is to perform a systematic review on brachytherapy microboosting of the DIL to evaluate clinical outcomes and toxicities with this treatment approach. This review was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Databases including Pubmed, Embase, and Google Scholar were queried. About 16 studies met our inclusion criteria. These studies reported PSA control and/or toxicities based on standardized scales. There were 10 studies (two monotherapy, eight combination) that used HDR microboosting on a total of 516 patients. HDR dose (EQD2 assuming alpha/beta of 1.5) to the DIL ranged from 90 to 180 Gy. Most patients were low/intermediate risk. PSA control rates at 5–8 years ranged from 69% to 100%. Acute/late G3-G4 GU/GI toxicities ranged from 0% to 12%. There were six studies (five monotherapy, one combination) that used LDR microboosting on a total of 1041 patients. Studies performed a microboost of 130–150% of the whole gland prescription to the DIL. Most patients were low/intermediate risk. PSA control rates at 5 years ranged from 69% to 98%. Acute/late G3–4 GU/GI toxicities ranged from 0% to 4%. Over 1000 patients have been treated with a brachytherapy based microboost in published series. Severe acute/late toxicities appear limited. PSA control rates with more than 5 years of follow-up are limited. Longer-term follow-up is needed to determine ideal utilization of this approach. [ABSTRACT FROM AUTHOR]

The addition of a boost to the lumpectomy bed after whole-breast (WB) radiotherapy plays a key role in the treatment of patients with breast cancer (BC). The clinical benefits of a boost with high-dose-rate brachytherapy (HDR-BT) after conventional fractionation is supported by a large body of evidence. However, few studies have described its outcomes after a hypofractionated scheme. We included all patients treated with adjuvant WB-IMRT in 15 sessions followed by a single-session HDR-BT boost with local anesthesia on an outpatient basis. Between 2009 and 2017, 638 patients with early-stage BC were treated according to the aforementioned protocol after breast-conserving surgery. Median follow-up was 6 years (4–11). Despite the low incidence of side effects and their slightness, we did identify an impact of breast volume on the risk of acute radiodermatitis, fibrosis, pain and edema. However, we did not identify any relationship between the volume in cubic centimeters of the BT-implant with acute or long-term side effects. 2.2% patients had an actual local relapse, 2.4% a 2nd primary in the same breast and 2.39% were diagnosed with contralateral BC. Event-free survival at 11 years was 85.5% with an overall survival of 95.7%. Adjuvant hypofractionated whole-breast IMRT followed by a single dose HDR-BT boost has a low incidence of acute and chronic toxicity and excellent oncological outcomes. However, it may be worthwhile to intensify self-care protocols and surveillance in women with large breasts who may be at increased risk of side effects. [ABSTRACT FROM AUTHOR]

To analyze clinical outcomes of high-dose-rate (HDR) interstitial brachytherapy boost (ISBT) after external beam radiation therapy (EBRT) or chemoradiotherapy (CRT) for the treatment of anal canal cancers (ACC). A total of 78 patients with ACC were treated at our institution by ISBT. Local Control (LC), disease-free survival (DFS), overall survival (OS), colostomy-free survival (CFS) and toxicity rates were analyzed. With a median followup (FU) of 59.8 months (95% CI [55.8–64.2]), six (7.7%) local recurrences with 2 patients (2.6%) having persistent disease at 3 months were observed. The 5-year rate of LC for the entire population was 92% [83–96%]. The 5-year DFS rate was 86% [76–93%]. The 5-year OS was 96% [88–99%]. In the univariate analysis, chemotherapy was significantly associated with morbidity grade ≥2. Late digestive toxicity grade ≥3 was reported in 8.9% patients, 1 patient underwent colostomy due to toxicity. The 5-year CFS rate was 88% [79–94%]. HDR interstitial brachytherapy boost provide excellent rates of tumor control and colostomy-free survival with a favorable profile of GI toxicity. Continence in anal cancer survivors is a challenge and the boost technique must be discussed in a multidisciplinary approach as part of de-escalation treatments. [ABSTRACT FROM AUTHOR]

Introduction: Treating localized high-risk prostate cancer with a combination of external beam radiation therapy (EBRT) and high-dose-rate brachytherapy (HDR-BT) is a common approach. Moderately hypofractionated EBRT and a single HDR-BT boost simplifies the treatment. We aim to present our five-year results., Methods: In this study, 355 patients treated with moderately hypofractionated EBRT (42 Gy in 14 fractions) and a single HDR-BT boost (14.5 Gy) at Örebro University Hospital between 2008 and 2018 were included. They were followed with regular PSA tests., Results: The median age of the cohort was 70 years (range: 51-81) and the median follow-up duration was 56 months (range: 6-150). Among them, 45% were classified as very high-risk, 38% as high-risk and 17% as intermediate-risk. Adjuvant androgen deprivation therapy (ADT) with a median duration of 24 months was given to 75% of the patient cohort. The estimated 5-year failure free survival rates were 79% (whole cohort), 66% (very high-risk), 90% (high-risk) and 85% (intermediate-risk), respectively. Initial PSA > 10 ng/mL, Gleason score 9-10 and tumor stage T3 were significantly associated with biochemical failure (BF). A PSA bounce occurred in 53 (15%) cases and was inversely associated with BF (p = 0.001) for patients receiving ADT., Conclusions: Moderately hypofractionated EBRT and a single HDR-BT boost seems to be an effective treatment against intermediate- and high-risk localized prostate cancer. Treatment escalation strategies should be investigated for very high-risk patients where the risk of recurrence remains high., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

To evaluate the role and technique of a vaginal cuff brachytherapy (VB) boost to adjuvant external beam (EB) radiation for endometrial cancer through a systematic review. Relevant trials were identified through a systematic search of the literature. A total of 21 prospective and retrospective studies which had a patient cohort undergoing EB + VB was identified to evaluate for rates of vaginal and pelvic recurrences, overall survival, and toxicity. Additional database studies were utilized to demonstrate differences in local control and overall survival between EB and EB + VB. While there is limited prospective evidence to guide the use of a VB boost after EB, the evidence suggests that patients with a higher risk of a vaginal recurrence such as those with cervical stromal involvement in select Stage III patients may derive local control and survival benefits from a VB boost. Additional individual risk factors such as grade, histology, extent of invasion, margin status, age, and the use of lower doses of EB should be considered when deciding when to add a VB boost. [ABSTRACT FROM AUTHOR]

Margin negative resection in pancreatic cancer remains the only curative option but is challenging, especially with the retroperitoneal margin. Intraoperative radiation therapy (IORT) can improve rates of local control but requires specially designed facilities and equipment. This retrospective review describes initial results of a novel implantable mesh of uni-directional low dose rate (LDR) Pd-103 sources (sheet) used to deliver a focal margin-directed high-dose boost in patients with concern for close or positive margins. Eleven consecutive patients from a single institution with resectable or borderline resectable pancreatic cancer with concern for positive margins were selected for sheet placement and retrospectively reviewed. Procedural outcomes, including the time to implant the device and complications, and clinical outcomes, including survival and patterns of failure, are reported. A dosimetric comparison of the LDR sheet with hypothetical stereotactic body radiotherapy (SBRT) boost is reported. One patient had a resectable disease, and 10 patients had a borderline resectable disease and underwent neoadjuvant treatment. Sheet placement added 15 min to procedural time with no procedural or sheet-related complications. At a median follow up of 13 months, 64% (n = 7) of patients are alive and 55% (n = 6) are disease-free. Compared to a hypothetical SBRT boost, the LDR sheet delivered a negligible dose to kidneys, liver, and spinal cord with a 50% reduction in max dose to the small bowel. This is the first report of the use of an implantable uni-directional LDR brachytherapy sheet in patients with resected pancreatic cancer with concern for margin clearance, with no associated toxicity and favorable clinical outcomes. [ABSTRACT FROM AUTHOR]

The purpose of this study was to analyze and compare clinical outcomes of low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy boost (ISBT) after EBRT or radio chemotherapy for the treatment of anal canal cancers. One hundred patients with anal canal cancers were treated at our institution by ISBT [LDR (n = 50); HDR (n = 50)]. Chronic toxicity rates, local control, disease-free survival, overall survival, and colostomy-free survival of the two different dose-rate brachytherapy modalities were analyzed and compared. With a median followup of 42.2 months (95% CI, [34.5–48.8]), 9 (9% [4.8–16.2%]) local recurrences were observed, 4 (8% [3.2–18.8%]) in LDR vs. 5 (10% [4.4–21.4%]) in HDR group (odds ratio [OR] = 1.28 [0.32–5.07], p = 0.73). The 5-year rate of local control for the entire population was 90% [81–95%], 93% [79–98%] vs. 86% [69–94%] for LDR and HDR, respectively (p = 0.38). The 5-year disease-free survival rate for all patients was 82% [71–90%], 88% [73–95%] vs. 72% [44–88%] for LDR and HDR, respectively (p = 0.21). The 5-year overall survival rate for global population was 94% [84–98%], with no significant differences between LDR (97% [79–100%]) and HDR (93% [80–98%]) (p = 0.27). The 5-year colostomy-free survival rate was 92% [83–96%], respectively, 95% [83–99%] vs. 86% [69–94%] for LDR and HDR (p = 0.21). Significant differences were found in terms of chronic toxicity rates, with 28 (56% [42.3–68.8%]) patients concerned in low-dose-rate brachytherapy vs. 17 (34% [22.4–47.9%]) in high-dose-rate brachytherapy (OR = 0.40 [0.18–0.91], p = 0.03). Local recurrence rates were comparable between both groups; HDR brachytherapy seem to have a better toxicity profile. Our data confirmed the finding that HDR can be used to safely administer ISBT without increasing chronic toxicity. [ABSTRACT FROM AUTHOR]

We describe methods to improve dose delivery for patients with rectal cancer receiving boost brachytherapy after external beam radiotherapy. Patients with rectal cancer who were ineligible or refusing surgery are treated with external beam radiotherapy and subsequently with three weekly image-guided volume-adapted high-dose-rate brachytherapy boosts of 10 Gy to the residual clinical target volume, for a total of 30 Gy in three fractions. Tungsten shielding placed at the center of intracavitary mold applicator and double-balloon technique was used to improve dose conformity to the target. Our results show that the use of tungsten shield and double balloon reduces the dose gradient within the target volume to receive the prescription boost dose of 10 Gy from maximum dose of 60 Gy down to 20 Gy. We outlined two methods for achieving higher high-dose-rate brachytherapy dose conformity using the tungsten shielding rods (to spare contralateral healthy tissues) and double-balloon technique (to decrease dose gradient within the target to minimize dose to the proximal mucosa). [ABSTRACT FROM AUTHOR]

Purpose Dose escalation for prostate cancer can be achieved with a combination of external beam radiotherapy (EBRT) and brachytherapy (BT) boost to increase local control. For high-dose-rate (HDR)-BT, optimal fractionation remains under debate. The objective was to assess the clinical outcome of three schemes of HDR-BT boost. Methods and Materials Retrospective single institution data collection was performed. Patients received 46 Gy EBRT then an HDR-BT boost: 3 × 6 Gy, 2 × 9 Gy, or 1 × 14 Gy. HDR needles were placed under general anesthesia with endorectal ultrasonography guidance. CT-scan and treatment were performed postoperatively. Results Between 2009 and 2012, 159 patients were included. Nine patients (5.7%) were low, 32 (20.1%) intermediate, and 118 (74.2%) high risk (D'Amico classification) without significant difference between the three BT schemes. With a median followup of 61 months, 5-year biochemical relapse–free survival, 5-year local relapse–free survival, 5-year metastases-free survival, and 5-year overall survival rates were 86.6% (SE 2.7%), 98.3% (SE 1%), 95.3% (SE 1%), and 96.5% (SE 1.5%), respectively, with no significant difference between the BT schemes. The rates of acute ≥ G2 genitourinary and ≥G2 gastrointestinal toxicities were 11.3% and 6.3%, respectively ( p = NS). The rates of late genitourinary ≥ G2 and gastrointestinal ≥ G2 toxicities (at last followup) were 9.4% and 0.6% with, respectively, 0.6% and 0% of G4 ( p = NS). Conclusions Hypofractionation up to a single-fraction HDR-BT boost for prostate cancer yields similar results in terms of biochemical control and late toxicity compared with two or three-fraction schemes. Single fraction HDR-BT appears acceptable for boosting prostate cancer after definitive EBRT. [ABSTRACT FROM AUTHOR]

Purpose The aim of the study was to give recommendations on patient selection criteria for the administration of boost doses after whole-breast irradiation (WBI) in invasive breast cancer based on available clinical evidence complemented by expert opinion. Methods and Materials A systematic search of the PubMed database was conducted to identify factors associated with increased risk for local failure that can define risk groups, and to provide evidence for an adequate guidance to the use of the boost as a function of the risk of local recurrence in breast-conserving therapy. The authors reviewed the published clinical evidence for the use of boost after WBI, complemented by other relevant studies and, through a series of formal meetings communications, formulated the recommendations presented in this article. Results The GEC-ESTRO Breast Cancer Working Group recommends three categories guiding patient selection for the use of a boost after WBI: (1) a low-risk group for whom boost adds little benefit, including patients aging at least 50 years with unicentric, unifocal, and clear surgical margins of at least 2 mm and no axillary lymph nodes invasion. In this group, a boost of 10–16 Gy EQD2 after WBI (25fr × 2 Gy or 15 fr × 2.67 Gy) is optional and not mandatory, (2) a high-risk group, for whom boost is considered mandatory and where dose escalation above 16 Gy EQD2 should be considered; including patients aging ≤40 years with close margins, extensive intraductal component or triple-negative phenotype, or patients with positive resection margins regardless of patient age, and (3) an intermediate-risk group, for whom the boost (10–16 Gy EQD2) is considered mandatory, includes patients below 40 years without major risk criteria, patients >40 years and <50 years regardless of any risk factors, or patients >50 years with any risk factor (close margins, tumor size >3 cm, extensive intraductal component, lymphovascular invasion, lymph node invasion, multicentric or multifocal tumors, triple-negative phenotype, or after neoadjuvant chemotherapy in case of residual tumor). Conclusions These recommendations may provide a clinical guidance regarding the use of boost after WBI in invasive breast cancer and holds for standard and hypofractionated WBI. Furthermore they should promote further clinical research focusing on controversial issues in the treatment of early-stage breast carcinoma. [ABSTRACT FROM AUTHOR]

Purpose To analyze the efficacy of a protocol-based brachytherapy (BT) boost after external beam radiation therapy (EBRT) with simultaneous chemotherapy in patients with anal carcinoma. Methods and Materials About 190 patients have been analyzed. Around 143 patients were identified with a good clinical response at the end of EBRT. Another 47 patients received an additional BT boost to the residual tumor at 6 weeks after end of chemoradiation. Results The 5-year incidence of local recurrence was 24% in patients with BT boost and 19% in patients without BT boost ( p = 0.238). The 5-year disease-free survival rate, overall survival rate, and colostomy-free survival rate were 64% and 75% and 76.1% in the BT group and 69% ( p = 0.212), 72% ( p = 0.924), and 82.7% ( p = 0.488) in the non-BT group. We found no differences in late toxicity between the groups. Conclusions For patients with anal cancer with not a good response to 50–59 Gy EBRT with simultaneous chemotherapy, the further dose escalation using the BT boost up to a mean of 67.5 Gy seems to improve the clinical outcome to the same level as observed in patients with a good response to ERBT, without an increase in late side effects. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To analyze the clinical outcome and toxicity data of the first 100 consecutive patients treated with a single-fraction high-dose-rate brachytherapy (HDR-BT) and external beam radiotherapy (EBRT). Methods and Materials: Two-hundred eighty patients have been treated with HDR-BT boost for localized intermediate- to high-risk prostate cancer. Among these, the outcome and toxicity of the first 100 patients treated with a single HDR-BT fraction were assessed. A median dose of 60Gy EBRT was given to the prostate and vesicles. Interstitial HDR-BT of 10Gy was performed during the course of EBRT. Results: Median followup time was 61.5 months. The 5-year actuarial rates of overall survival, cause-specific survival, disease-free survival, and biochemical no evidence of disease (bNED) for the entire cohort were 93.3%, 99.0%, 89.3%, and 85.5%, respectively. The 7-year actuarial rate of bNED was 84.2% for the intermediate-risk group and 81.6% for the high-risk group (p =0.8464). The 7-year actuarial rates of bNED for Grade 1, 2, and 3 tumors were 97.5%, 80.0%, and 67.1%, respectively. The 5-year probability for developing late Grade 3 gastrointestinal and genitourinary (GU) toxicity was 2.1% and 14.4%, respectively. Grade 3 GU complications occurred significantly more frequently in patients with a history of preirradiation transurethral resection (29.1% vs. 8.8%; p =0.0047). Conclusions: Five-year outcome after 60Gy EBRT plus a single fraction of 10Gy HDR-BT boost is encouraging. Preradiation transurethral resection significantly increases the risk of late severe GU complications. [Copyright &y& Elsevier]

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