Search

Standard practice entails employing multifractionated high-dose-rate (HDR) BT, administered in 3 to 4 sessions over 3 weeks post Chemoradiation, keeping overall treatment time < 56 days. Mono-application fractionated brachytherapy accelerates the treatment timeline without escalating acute or late toxicities. Recent progress in image-guided brachytherapy in cervical cancer facilitates the attainment of optimal dose volume parameters for both the target and organs at risk. This is the first multinational, multi-institutional study comparing outcomes and toxicity of mono-application fractionated brachytherapy versus multiple-application brachytherapy in carcinoma cervix. Enrolled 401 eligible patients with confirmed cervical cancer, FIGO stages IIA-IVA, intended definitive chemoradiation. Patients post 45-50 Gy external radiation with cisplatin either received mono-application fractionated brachytherapy or multiple-application for interstitial or intracavitary BT. Rectal and bladder doses were strictly maintained within 50% of prescription dose with adequate dosing to high-risk target volume. Demographic data, stage, histology, external radiation dose, brachytherapy dose and fractionation, D2 cc doses to bladder, rectum were recorded. Disease free survival and overall survival at 3 years were obtained along with data on acute and long-term bladder and rectal toxicities. Four hundred one patients, 203 received multiple applications spaced over 3 weeks and 198 received single application multiple deliveries < 48 hours. All patients underwent Intracavitary or Interstitial BT with most common fractionation of 7 Gyx3 or equivalent. Rectal and bladder 2 cc doses were 45% +/- 12% of prescription dose. HRCTV coverage of D90 of 95+/-7 was achieved in all cases. With a median follow up of 36 months (range = 22-37), 3 year disease-free was 0.78 and 0.76, The P value of 0.98 (> 0.05), showed difference in DFS between the two groups was not statistically significant. The 3-year overall survival was 0.72 and 0.71, P value of 0.1 (> 0.05), again statistically insignificant. Cox regression model analysis showed stage wise DFS and OS difference between the groups weren't statistically significant, hence proving the non-inferiority. The 3 year Grade 2 or more bladder and rectal toxicity has been reported in 2.3% and 4.1% in mono application group and 2.9% and 6.3% of multi-application group, statistically insignificant, confirming the credibility of our approach. Our study lays the foundation for a comprehensive investigation into the outcomes and efficacy of mono-application fractionated brachytherapy being non inferior to multiple-application with respect to outcomes and toxicity, providing valuable insights into the management of cervical cancer with reduced overall treatment time and superior resource management. Strict constraints to OARs and accuracy of image guided brachytherapy techniques, long term toxicity could be minimized. [ABSTRACT FROM AUTHOR]

Purpose: In cervical cancer brachytherapy, adding interstitial needles to intracavitary applicators can enhance dosimetry by improving target coverage while limiting normal tissue dose. However, its use is limited to a subset of practitioners with appropriate technical skill. We designed tandem anchored radially guiding interstitial templates (TARGITs) with a 3-dimensional (3D) printing workflow to optimize needle placement and facilitate greater ease-of-use of intracavitary/interstitial (IC/IS) technique. This study compared dosimetry and procedure characteristics between tandem and ovoid (T&O) implants using TARGIT technique versus non-TARGIT technique.Methods and Materials: This single-institution retrospective cohort study included patients undergoing T&O brachytherapy as part of definitive radiation treatment for cervical cancer between February 2017 and January 2021. TARGIT technique was implemented from November 2019 onwards; all prior procedures involved non-TARGIT technique using a no needle or freehand needle approach. Target coverage, dose to organs at risk, and procedure times were evaluated and compared between TARGIT technique and non-TARGIT technique.Results: The cohort included 70 patients with cervical cancer who underwent 302 T&O procedures: 68 (23%) with TARGIT technique and 234 (77%) with non-TARGIT technique, which included 133 no needle and 101 freehand needle implants. TARGIT implants involved longer average procedure times (+6.3 minutes, P < .0001). TARGIT implants achieved a higher mean high-risk clinical target volume V100% than non-TARGIT implants (+4.4%, P = .001), including for large tumors 30 cm3 or greater (+8.1%, P = .002). Average D90 was 4.6 Gy higher and average D98 was 3.2 Gy higher for TARGIT technique compared with non-TARGIT technique (P = .006 and P = .02). Total treatment doses to rectum, bowel, and bladder were not significantly different for TARGIT versus non-TARGIT technique.Conclusions: The 3D-printed TARGIT approach to T&O brachytherapy achieved greater tumor coverage while sparing normal tissues, particularly for large tumor volumes, with only a slight increase in average procedure time. TARGIT represents a creative technological solution for increasing accessibility of advanced IC/IS brachytherapy technique for cervical cancer definitive radiation treatment. [ABSTRACT FROM AUTHOR]

Purpose: Organ preservation or nonoperative management of rectal cancer is of growing interest. Image guided adaptive endorectal brachytherapy is a radiation dose escalation modality: we explored its role in elderly patients unfit for surgery and patients refusing surgery.Methods and Materials: In this registry study, patients with rectal cancer who were ineligible for surgery received 40 Gy in 16 fractions of pelvic external beam radiation therapy. They subsequently received 3 weekly image guided adaptive brachytherapy boosts of 10 Gy to the residual tumor, for a total of 30 Gy in 3 fractions. Complete clinical response (cCR) and local control were the primary endpoints.Results: 94 patients were included; the median age was 81.1 years. With a median follow-up of 1.9 years, the proportion of cCR was 86.2%, the tumor regrowth proportion was 13.6%, and the cumulative incidence of local relapse was 2.7% at 1 year and 16.8% at 2 years. When considering responders and nonresponders, the 2-year local control was 71.5%. The overall survival at 2 years was 63.6%. Acute rectal grade 1 to 2 toxicity included all patients: 12.8% of patients had late bleeding requiring iron replacement, blood transfusions, or argon plasma therapy.Conclusions: Results of this registry study, evaluating radiation dose escalation for elderly medically unfit patients with unselected tumors, reveal that a high proportion of patients achieved cCR with a manageable toxicity profile. This technology will likely contribute to the challenging nonoperative management paradigm of rectal cancer. [ABSTRACT FROM AUTHOR]

Image-guided adaptive brachytherapy (IGABT) has been proven to improve the local control and survival rate of cervical cancer patients, while reducing the side effects. However, IGABT is time-consuming and difficult to achieve in countries or hospitals with intense medical resources. Compared with radical cervical cancer patients, the anatomical change of postoperative patients during brachytherapy is small. We hypothesis that the dosimetric benefits of adaptive brachytherapy in the treatment of postoperative cervical cancer patients is limited. This study investigates whether there is a balance between the treatment quality and treatment efficiency in postoperative cervical cancer patients without using IGABT. We retrospectively studied 30 postoperative cervical cancer patients who underwent brachytherapy. Each patient had a primary CT (PCT) and an adaptive CT (ACT). The plan developed on the PCT (PCT plan) was introduced into ACT for dose calculation (P-ACT plan) to evaluate the dosimetric effect of anatomy change. The dose difference between P-ACT plan and ACT plan and was compared. The mean value of HRCTV D 100% and V 150% in P-ACT plan are 4.95% and 0.75% lower than those of ACT plan, the difference is not statistically significant (P>0.05). The D 0.1cm³ of bladder, rectum and sigmoid in P-ACT plan are higher 2.13%, 3.17%, and 0.71% than ACT plan, respectively, but the increment is insignificant (P>0.05). The D 2cm³ of bladder and rectum is slightly lower in ACT plan, while the D 2cm³ of sigmoid is slightly lower in P-ACT plan. The dosimetric benefits of IGABT is not remarkable for postoperative cervical cancer patients. The preliminary results of this study show that IGBAT is optional for postoperative patients with cervical cancer in countries or hospitals with tight medical resources. It is necessary to conduct a larger sample and more detailed research further. [ABSTRACT FROM AUTHOR]

Radiation toxicity to the bulboclitoris has not been previously investigated. This retrospective cohort study aims to report sexual side effects of patients who underwent radiotherapy for tumors involving the lower vagina, periurethra, and bulboclitoris (BC). Patients treated between 2017- 2022 for gynecologic cancer involving the low vagina were included. The high-risk clinical target volume (HR-CTV), bladder, rectum, and urethra were contoured on patient imaging during initial treatment planning. The BC was retrospectively contoured using T2 MRI sequences fused to the pre-treatment and brachytherapy CT simulation. Superiorly, the BC was defined as inferior to the pubic symphysis and attached to the suspensory ligament of the clitoris. Laterally, the crura extend on either side of the corpus. Inferiorly, the vestibular bulbs flank the urethra and vagina on either side, extending posteriorly to mid-vagina. Dosimetric data for the BC, vaginal morbidity using the CTCAE 4.0 for vaginal stenosis, and pain scoring of the BC were obtained via chart review. Patients underwent external beam radiotherapy (IMRT) to the pelvis and bilateral inguinal region (45 Gy in 25 fractions) followed by High Dose Rate Ir-192 interstitial brachytherapy in 5 fractions for a total dose of 25 Gy (22.5 - 27.5 Gy). Patients had a median age of 65 years (49-73) with tumors located in the lower vagina, near the BC and urethra. At the time of brachytherapy, in order to cover the HR-CTV, interstitial brachytherapy needles were placed within the BC structure with 58% (33% - 77%) of total interstitial needles placed within the bulbs of the BC. The mean pre-treatment volume of the BC was 16.6 cc (11.9 - 20.9 cc) and at brachytherapy was 12.66 cc (7.3 - 22.1 cc) with Table 1 summarizing radiation doses. At a median follow up of 19.6 months, all patients had a complete local response, with one patient deceased of metastatic disease. In the acute period, all patients reported severe pain in the clitoral glans region and dysuria that completely resolved after 2 years. Grade 1-2 vaginal stenosis occurred in all patients despite vaginal dilator usage. One patient reported decreased clitoral sensitivity and inability to achieve clitoral-mediated orgasm 5 months after radiotherapy. This study demonstrates that the BC receives a significant radiation dose during vaginal brachytherapy treatment which can cause clitoral pain and dysfunction. Further studies are needed to evaluate the dose response of the BC as well as explore methods to spare the organ during radiation therapy in order to minimize toxicity and preserve sexual function. [ABSTRACT FROM AUTHOR]

Financial toxicity (FT) affects about 50% of patients with gynecologic cancer. Brachytherapy (BT) is an important component of treatment for many of these patients. We aimed to assess factors that contribute to FT in patients with gynecologic cancer who undergo BT. Gynecologic oncology patients undergoing BT from October 2017-February 2021 completed a survey that included demographics, EQ-5D-3L to measure quality of life, and Comprehensive Score for Financial Toxicity (COST) tool to measure FT. High FT was defined as a COST score ≤23. We stratified patients into 3 groups: vaginal BT (VBT) only, VBT with external beam radiation therapy (EBRT + VBT), or "other" types of BT with external beam radiation therapy (EBRT + other BT). "Other" types of BT included tandem with ovoids/ring and interstitials. Data are presented as percent or median (interquartile range) and compared with Chi-square/Fisher's exact test and Wilcoxon rank-sum test, respectively. We used modified Poisson regression to calculate risk ratios (RR) and 95% confidence intervals (CI). Among 101 respondents, median COST score was 30 (21-35); 28% had high FT (median COST: 14 (9-19)) and 72% had low FT (median COST: 32 (28-37)). Respondents were white (81%), 9% Black, and 7% Asian. Median age was 63 (57-71), with a younger age in the high FT group [59 (49-62)] compared to the low FT group [67 (61-72), p<0.01]. In the high FT group, 68% of patients had private insurance, whereas 38% had private insurance in the low FT group (p<0.01). Most patients (71%) had uterine cancer, followed by cervical (23%) and vaginal/vulvar (6%) cancer. The majority (69%) had stage I disease; 51% received VBT alone, 29% received EBRT + VBT, and 21% received EBRT + other BT. Treatment group was significantly associated with FT. VBT alone was more common in the low FT group (58%) than the high FT group (32%), and EBRT + VBT was less common in the low FT group (21%) than the high FT group (50%, p=0.01). Patients who had EBRT + VBT were 2.8 times (95% CI 1.2-6.5) more likely to have high FT compared to VBT patients; this association was attenuated when adjusting for age and insurance (RR 2.0; 95% CI 0.84-4.7). Of the assessed cost-coping strategies, borrowing money was reported by 31% of the EBRT + VBT, 24% of the EBRT + other BT, and 2% of the VBT groups (p<0.01), and reduced leisure spending was reported by 31% of the EBRT + VBT, 5% of the EBRT + other BT, and 16% of the VBT groups (p<0.01). A substantial proportion of patients going through BT have high FT. Younger age and private insurance were associated with higher FT. There is a higher risk of FT associated with undergoing EBRT. Patients who go through only VBT were least likely to have high FT. Patients going through EBRT were more likely to borrow money and reduce leisure spending as cost-coping strategies. Further research is needed to understand specific drivers of high FT for patients receiving EBRT and to evaluate FT over time. [ABSTRACT FROM AUTHOR]

ERPs have been adopted by many surgical specialties and have demonstrated improved outcomes, including shorter hospital stay, decreased healthcare costs, improved time to functional recovery and patient satisfaction.1 There is no current data evaluating ERP for patients undergoing brachytherapy. We plan to implement an ERP for patients with gynecologic malignancies, who will receive brachytherapy, with the goal to standardize and optimize the peri-operative phase and evaluate the impact on patient experience. A single institution, prospective study evaluating the outcomes of patients undergoing GYN-BT before (33 patients) and after (33 patients) the implementation of an ERP. The ERP will include multidisciplinary interventions that span the pre-, intra-, and post-operative phases; including pre-habilitation, early referral to social work and psychiatric services, patient/caregiver education, pre-operative carbohydrate-loading, goal directed fluids, and opioid-sparing analgesia. Questionnaires to assess patient reported outcomes (PROs) at baseline, post-brachytherapy, and 60-day follow-up are collected. The EORTC QLQ-C30 consists of 30 items scored on a 4-point Likert scale and linearly transformed to a score, ranging from 0-100. Higher scores for functional scales and global health represent a favorable outcome, whereas a higher score for a symptom is unfavorable. A difference >10 was considered significant. Sixteen patients have been enrolled on study and completed baseline PRO questionnaires. Mean EORTC-QLQ-C30 global health score was 41.7, comparing unfavorably to the reference population of females with any cancer diagnosis2(59.3). Social functioning was worse (58.3) compared to the reference population (72.1), but there was no significant difference in physical, role, emotional or cognitive functioning. Additionally, this patient population had a significantly higher symptom burden, specifically fatigue (48.6 vs 37.7), nausea/vomiting (21.9vs 10.8), appetite loss (35.4 vs 23.8), and diarrhea (20.8 vs 9.3). Notably, mean score for financial difficulties was 45.8, more than double the reference value of 17.5. A significant proportion of patients described depression (56.3%), worry (68.8%) and interference with family life (62.5%). Baseline data show that female patients with gynecologic malignancies represent a population with high-symptom burden and social stress. This data highlights the significant need for improved social support and multi-disciplinary care. We propose an ERP, with pre-habilitation and medical optimization, in combination with early referral to social work and psychiatric resources to standardize and improve care for this high-risk patient population. [ABSTRACT FROM AUTHOR]

Cervical cancer (ca-cx) is a leading cause of cancer death in women worldwide. Low and Middle-Income countries (LMICs) account for 90% of case mortalities annually. Treatment include surgery, RT +/- chemotherapy. RT consist of EBRT +/- brachytherapy (BT) or exclusive BT for stage IA. LMIC access to RT is crucial for the global control of ca-cx. However, most studies on RT capacity in LMICs have focused on EBRT. This study assesses progress in the BT capacity in LMICs. It analyzes the current demand and deficits based on the updated survey of global RT facilities and epidemiological trends of ca-cx. We projected the 2022 incidence of ca-cx for each LMIC from GLOBOCAN, a database of global cancer registries maintained by the IACR. Using an optimal BT utilization (BTU) of 71.4%, we estimate the demand for BT in each LMIC. The BTU is the proportion of cases with BT indication. Evidence-based estimates informed BTU of 71.4% for ca-cx in LMICs. We obtained the number of BT units in each LMIC from the IAEA DIRAC. Per IAEA, an HDR unit can deliver 1,920 RT frx a year. Prior studies show an average of 3 frx per RT course for ca-cx in LMICs. The required BT for each LMIC was computed as (I * BTU * 3) / (1,920). Deficit was analyzed from available BT as of Feb 2022 and compared to 2014. 2022 anticipates 591,610 new ca-cx cases in 133 LMICs, for which 422,410 would require BT. 80 LMICs had BT, and 53 had none. There are 1,199 BT in all LMICs, a 198% increase from 402 in 2014 and exceeds the demand of 661 needed to control ca-cx. However, there was an inequitable geographic distribution & regional deficit. Sub-Sahara Africa (SSA) and East Asia /Pacific (EA/P) had deficit of 114 and 110 BT respectively. These regions meet only 36% and 47% of the needed BT. They have also had the slowest progress from 2014. An analysis at the economic level showed that low-income economies (LIEs) were more likely to have BT deficit. Only 3 of 27 LIEs meet full coverage. BT coverage in LIEs is 6.5% which pales in comparison to 279% and 168% for upper and lower-middle-income economies, respectively. There is progress in BT access for ca-cx in LMICs from last decade. However, a regional deficit persists. The shortage is most dire in the LIEs located in the EA/P and SSA subcontinents. The findings of this study should be taken with some caution. The IAEA-DIRAC captures RT facilities worldwide but is self-reported data. Also, this study, like prior IAEA studies, analyzed with HDR-BT capacity. HDRs are more efficient than LDR which the available resource in some LMICs. There is a limited report of the BT specifications on DIRAC. Finally, ca-cx is not sole indication for BT, even though it is the main indication in LMICs. While previous analyses on BT capacity in LMICs have only utilized epidemiological data of ca-cx, a growing BT utilization for prostate and other gynecologic cancers should be noted. We, therefore, anticipate a slight decrease in our estimated capacities when all other indications are factored, although likely inconsequential. [ABSTRACT FROM AUTHOR]

Purpose: Predictive factors for biochemical recurrence (BCR) in localized prostate cancer (PCa) after brachytherapy are insufficient to date. Cellular radiosensitivity depends on DNA double-strand breaks, mainly repaired by the nonhomologous end-joining (NHEJ) system. We analyzed whether the expression of NHEJ proteins can predict BCR in patients treated by brachytherapy for localized PCa.Methods and Materials: From 983 PCa cases treated by brachytherapy between March 2000 and March 2012, 167 patients with available biopsy material suitable for in situ analysis were included in the study. The median follow-up time was 47 months. Twenty-nine patients experienced BCR. All slides were reviewed to reassess the Gleason score. Expression of the key NHEJ proteins DNA-PKcs, Ku70, and Ku80, and the proliferation marker Ki67, was studied by immunohistochemistry performed on tissue microarrays.Results: The Gleason scores after review (P=.06) tended to be associated with BCR when compared with the score initially reported (P=.74). Both the clinical stage (P=.02) and the pretreatment prostate-specific antigen level (P=.01) were associated with biochemical failure. Whereas the expression of Ku80 and Ki67 were not predictive of relapse, positive DNA-PKcs nuclear staining (P=.003) and higher Ku70 expression (P=.05) were associated with BCR. On multivariate analysis, among pretreatment variables, only DNA-PKcs (P=.03) and clinical stage (P=.02) remained predictive of recurrence. None of the patients without palpable PCa and negative DNA-PKcs expression experienced biochemical failure, compared with 32% of men with palpable and positive DNA-PKcs staining that recurred.Conclusions: Our results suggest that DNA-PKcs could be a predictive marker of BCR after brachytherapy, and this might be a useful tool for optimizing the choice of treatment in low-risk PCa patients. [ABSTRACT FROM AUTHOR]

Purpose: To identify predictors of grade 3-4 complications and grade 2-4 rectal toxicity after three-dimensional image-guided high-dose-rate (HDR) interstitial brachytherapy for gynecologic cancer. Methods and Materials: Records were reviewed for 51 women (22 with primary disease and 29 with recurrence) treated with HDR interstitial brachytherapy. A single interstitial insertion was performed with image guidance by computed tomography (n = 43) or magnetic resonance imaging (n = 8). The median delivered dose in equivalent 2-Gy fractions was 72.0 Gy (45 Gy for external-beam radiation therapy and 24 Gy for brachytherapy). Toxicity was reported according to the Common Toxicity Criteria for Adverse Events. Actuarial toxicity estimates were calculated by the Kaplan-Meier method. Results: At diagnosis, the median patient age was 62 years and the median tumor size was 3.8 cm. The median D90 and V100 were 71.4 Gy and 89.5%; the median D2cc for the bladder, rectum, and sigmoid were 64.6 Gy, 61.0 Gy, and 52.7 Gy, respectively. The actuarial rates of all grade 3-4 complications at 2 years were 20% gastrointestinal, 9% vaginal, 6% skin, 3% musculoskeletal, and 2% lymphatic. There were no grade 3-4 genitourinary complications and no grade 5 toxicities. Grade 2-4 rectal toxicity was observed in 10 patients, and grade 3-4 complications in 4; all cases were proctitis with the exception of 1 rectal fistula. D2cc for rectum was higher for patients with grade 2-4 (68 Gy vs 57 Gy for grade 0-1, P=.03) and grade 3-4 (73 Gy vs 58 Gy for grade 0-2, P=.02) rectal toxicity. The estimated dose that resulted in a 10% risk of grade 2-4 rectal toxicity was 61.8 Gy (95% confidence interval, 51.5-72.2 Gy). Discussion: Image-guided HDR interstitial brachytherapy results in acceptable toxicity for women with primary or recurrent gynecologic cancer. D2cc for the rectum is a reliable predictor of late rectal complications. Three-dimensional-based treatment planning should be performed to ensure adequate tumor coverage while minimizing the D2cc to the rectum. [Copyright &y& Elsevier]

Purpose: To analyze patient, disease, and treatment-related factors regarding their impact on local control after interstitial multicatheter accelerated partial breast irradiation (APBI). Methods and Materials: Between November 2000 and April 2005, 274 patients with early breast cancer were recruited for the German–Austrian APBI Phase II trial (ClinicalTrials.gov identifier: NCT00392184). In all, 64% (175/274) of the patients received pulsed-dose-rate (PDR) brachytherapy and 36% (99/274) received high-dose-rate (HDR) brachytherapy. Prescribed reference dose for HDR brachytherapy was 32 Gy in eight fractions of 4 Gy, twice daily. Prescribed reference dose in PDR brachytherapy was 49.8 Gy in 83 consecutive fractions of 0.6 Gy each hour. Total treatment time was 3 to 4 days. Results: The median follow-up time was 64 months (range, 9–110). The actuarial 5-year local recurrence free survival rate (5-year LRFS) was 97.7%. Comparing patients with an age <50 years (49/274) vs. ≥50 years (225/274), the 5-year LRFS resulted in 92.5% and 98.9% (exact p = 0.030; 99% confidence interval, 0.029–0.032), respectively. Antihormonal treatment (AHT) was not applied in 9% (24/274) of the study population. The 5-year LRFS was 99% and 84.9% (exact p = 0.0087; 99% confidence interval, 0.0079–0.0094) in favor of the patients who received AHT. Lobular histology (45/274) was not associated with worse local control compared with all other histologies (229/274). The 5-year LRFS rates were 97.6% and 97.8%, respectively. Conclusions: Local control at 5 years is excellent and comparable to therapeutic successes reported from corresponding whole-breast irradiation trials. Our data indicate that patients <50 years of age ought to be excluded from APBI protocols, and that patients with hormone-sensitive breast cancer should definitely receive adjuvant AHT when interstitial multicatheter APBI is performed. Lobular histology need not be an exclusion criterion for future APBI trials. [Copyright &y& Elsevier]

Purpose: To determine the additional value of fluorodeoxyglucose-positron emission tomography (PET) for clinical target volume definition in the planning of computed tomography (CT)-guided interstitial brachytherapy for liver metastases. Patients and Methods: A total of 19 patients with liver metastases from colorectal cancer treated in 25 sessions were included in the present study. All patients had undergone fluorodeoxyglucose-PET for patient evaluation before interstitial CT-guided brachytherapy. A contrast-enhanced CT scan of the upper abdomen was obtained for radiation planning. The clinical target volume (CTV) was defined by a radiation oncologist and radiologist. After registration of the CT scan with the PET data set, the target volume was defined again using the fusion images. Results: PET revealed one additional liver lesion that was not visible on CT. The median CT-CTV (defined using CT and magnetic resonance imaging) was 68 cm3 (range 4–260). The PET/CT-CTV (median, 78 cm3; range, 4–273) was significantly larger, with a median gain of 24.5% (interquartile range, 2.1–71.5%; p = .022). An increased CTV was observed in 15 cases and a decrease in 6; in 4 cases, the CT-CTV and PET/CT-CTV were equal. Incomplete dose coverage of PET/CT-CTVs was indicative of early local progression (p = .004); however, CT-based radiation plans did not show significant differences in the local control rates when stratified by dose coverage. Conclusion: Retrospective implementation of fluorodeoxyglucose-PET for CTV specification for CT-guided brachytherapy for colorectal liver metastases revealed a significant change in the CTVs. Additional PET-positive tumor regions with incomplete dose coverage could explain unexpected early local progression. [Copyright &y& Elsevier]

Purpose: To investigate the feasibility of our novel image-based high-dose-rate interstitial brachytherapy (HDR-ISBT) for uterine cervical cancer, we evaluated the dose–volume histogram (DVH) according to the recommendations of the Gynecological GEC-ESTRO Working Group for image-based intracavitary brachytherapy (ICBT). Methods and Materials: Between June 2005 and June 2007, 18 previously untreated cervical cancer patients were enrolled. We implanted magnetic resonance imaging (MRI)-available plastic applicators by our unique ambulatory technique. Total treatment doses were 30–36 Gy (6 Gy per fraction) combined with external beam radiotherapy (EBRT). Treatment plans were created based on planning computed tomography with MRI as a reference. DVHs of the high-risk clinical target volume (HR CTV), intermediate-risk CTV (IR CTV), and the bladder and rectum were calculated. Dose values were biologically normalized to equivalent doses in 2-Gy fractions (EQD2). Results: The median D90 (HR CTV) and D90 (IR CTV) per fraction were 6.8 Gy (range, 5.5–7.5) and 5.4 Gy (range, 4.2–6.3), respectively. The median V100 (HR CTV) and V100 (IR CTV) were 98.4% (range, 83–100) and 81.8% (range, 64–93.8), respectively. When the dose of EBRT was added, the median D90 and D100 of HR CTV were 80.6 Gy (range, 65.5–96.6) and 62.4 Gy (range, 49–83.2). The D2cc of the bladder was 62 Gy (range, 51.4–89) and of the rectum was 65.9 Gy (range, 48.9–76). Conclusions: Although the targets were advanced and difficult to treat effectively by ICBT, MRI-aided image-based ISBT showed favorable results for CTV and organs at risk compared with previously reported image-based ICBT results. [Copyright &y& Elsevier]

Purpose: To assess the quality of life (QOL) of oral cancer patients treated with low-dose-rate interstitial brachytherapy (LDR-BT) alone. Methods and Materials: Between June 2005 and July 2006, a total of 56 patients with oral cancer were enrolled in this prospective study. QOL was assessed by means of the core questionnaire and head and neck questionnaire module of the European Organization for Research and Treatment of Cancer (EORTC Quality of Life Questionnaire-Core 30 [QLQ-C30] and QLQ Head and Neck 35 [H&N35]). The questionnaires were distributed to the patients before the start of treatment and 3 months, 6 months, and 12 months after the start of LDR-BT. Results: It was possible to analyze the results for 20 of the initial 56 patients because they did not experience metastasis or recurrence during this study. No functions or symptoms asked about in the QLQ-C30 deteriorated during the first year. The emotional function score steadily and significantly increased. No symptoms in the QLQ-H&N35 significantly deteriorated. The scores for pain, trouble with social eating, and weight loss on the QLQ-H&N35 steadily and significantly decreased. Age, gender, and LDR-BT source had no effect on the change in QOL during the first year, but T-stage significantly affected the change in global health status, tumor site affected the changes in swallowing, sensory problems, sticky saliva, and complications affected the changes in pain, swallowing, and mouth opening. Conclusions: QOL of oral cancer patients treated with LDR-BT is high. However, tumor stage, tumor site, and complications affected the changes in a few functions and symptoms during the first year. [Copyright &y& Elsevier]

Purpose/objective(s): Brachytherapy is a critical component of definitive chemo-radiation for locally advanced cervical cancer. However, studies have shown that a large portion of patients do not received brachytherapy as part of their treatment. We hypothesized that access to care due to lack of insurance might prevent patients from receiving brachytherapy as part of their treatment, and patients in states that expanded Medicaid under the affordable care act would therefore be more likely to receive brachytherapy after expansion.Materials/methods: The National Cancer Database was queried for cases from 2004 to 2016 of women with stage IIb-IVa cervical cancer treated with definitive radiation and chemotherapy. Patients were excluded if they received primary directed surgery, did not receive chemotherapy, had missing or incomplete radiation information, or had their Medicaid expansion status censored due to age < 40. A difference in difference (DID) analysis was performed to compare the uninsured rate and the rate of brachytherapy before and after expansion of Medicaid in states that did vs states that did not expand Medicaid. Multivariable analysis (MVA) for lack of insurance and completion of brachytherapy was adjusted for stage, race, facility type, median income, Charlson comorbidity and insurance (brachy analysis only).Results: A total of 12,409 patients were included with a median age of 55. Most patients were treated at an academic center (50%) and 74% were white. Overall, 56% of patients lived in states that expanded Medicaid early (2010-2013, 21%) or late (2014, 35%). The proportion of patients without insurance significantly decreased in early and late expansion states (-3.2%, -6.6% respectively, P < 0.001) with no significant change in non-expansion states. The decrease in uninsured patients remained significant on multivariable analysis (DID MVA -5.2% early expansion, -6.8% late expansion, P < 0.05). The overall rate of brachytherapy usage increased in expansion states (+8.4% early, +5.0% late expansion, P < 0.001) and in states that did not expand coverage (+4.4%, P < 0.001). However, there was no increase in usage of brachytherapy in expansion states compared to non-expansion states on univariate or multivariate analysis (DID MVA 0.6% [-3.9-5.3] early expansion, -0.2% [-4.6-4.0] late expansion).Conclusion: Medicaid expansion and a subsequent decrease in the uninsured population did not increase the proportion of patients receiving brachytherapy as part of their definitive chemo-radiation for cervical cancer. Our study suggests that lack of insurance, while important, is not the only factor limiting access to standard of care treatment for cervical cancer. Further research into access and availability of brachytherapy is needed.Author Disclosure: S. Freije: None. E.M. Steele: None. S.E. Robertson: None. O. Ishaq: None. J.A. Holmes: None. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the therapeutic results obtained with 192Ir low-dose-rate interstitial brachytherapy in T2N0 mobile tongue carcinoma. Patients and Methods: Between December 1979 and January 1998, 279 patients with T2N0 mobile tongue carcinoma were treated by exclusive low-dose-rate brachytherapy, with or without neck dissection. 192Ir brachytherapy was performed according to the “Paris system” with a median total dose of 60 Gy (median dose rate, 0.5 Gy/h). Results: Overall survival was 74.3% and 46.6% at 2 and 5 years. Local control was 79.1% at 2 years and regional control, respectively, 75.9% and 69.5% at 2 and 5 years (Kaplan–Meier method). Systematic dissection revealed 44.6% occult node metastases, and histologic lymph node involvement was identified as the main significant factor for survival. Complication rate was 16.5% (Grade 3, 2.9%). Half of the patients presented previous and/or successive malignant tumor (ear-nose-throat, esophagus, or bronchus). Conclusion: Exclusive low-dose-rate brachytherapy is an effective treatment for T2 tongue carcinoma. Regional control and survival are excellent in patients undergoing systematic neck dissection, which is mandatory in our experience because of a high rate of occult lymph node metastases. [Copyright &y& Elsevier]

Background: A significant portion of head-and-neck cancer patients will develop persistent or recurrent disease after definitive treatment. Radiation therapy is often used as definitive therapy or as an adjunct to surgery. Recurrent cancer of the head and neck in the previously irradiated field is, thus, a common occurrence and poses a therapeutic challenge. Some studies have evaluated low-dose-rate (LDR) brachytherapy as a therapeutic option, including a large case series with long-term follow-up by our own institution. High-dose-rate (HDR) brachytherapy offers therapeutic advantages over LDR brachytherapy. This study evaluates the local control and outcomes of patients with previously irradiated recurrent head-and-neck cancer treated with HDR interstitial brachytherapy. Methods and Materials: Between 1997 and 2002, 30 patients who received prior radiation therapy for primary tumors of the head and neck were treated for biopsy-proven recurrent disease. All patients received previous radiation as definitive therapy alone or as adjunct to surgery. All patients were inoperable, refused surgery, or had gross residual disease after salvage surgery for their recurrent disease. Thirty-six sites on the 30 patients were implanted by application of high-dose-rate interstitial brachytherapy techniques with mean tumor dose of 34 Gy (18–48 Gy) in twice daily fractions of 300 to 400cGy per fraction. Results: At a minimum follow-up of 12 months, local tumor control was achieved in 69% of implanted sites. Disease-specific survival at 1 and 2 years was 54% and 45%, respectively. Overall survival at 1 and 2 years was 56% and 37%, respectively. Grade 3/4 late complications occurred in 16% of the patients. No fatal complications occurred. Conclusion: HDR brachytherapy can play an important role in the salvage treatment of previously irradiated recurrent head-and-neck cancer. This study shows that comparable results are obtained by HDR brachytherapy with fewer late complications than were indicated by previously reported data for LDR brachytherapy. [Copyright &y& Elsevier]

Purpose: The aim of this work was to adapt a computer-assisted real-time three-dimensional (3D) navigation system for interstitial brachytherapy procedures. Methods and materials: The 3-D navigation system Surgical Planning and Orientation Computer System (SPOCS; Aesculap, Tuttlingen, Germany) was adapted for use in interstitial brachytherapy. A special needle holder with mounted infrared-emitting diodes (IRED) for 3D navigation–based needle implantation was developed. Measurements were made on a series of different phantoms to study the feasibility and the overall accuracy and precision of the navigation system with regard to single-needle application and volume implants (multiple-needle implantations). In all, 250 single implants and 20 volume implants were performed. Accuracy was measured as the target registration error (TRE) between the preoperatively defined and the achieved target position. Results: Analyses of the 250 different targets showed a mean TRE for single-needle applications of 1.1 mm (SD ± 0.4 mm), 0.9 mm (SD ± 0.3 mm), and 0.7 mm (SD ± 0.3 mm) in the x, y, and z direction, respectively. The maximal deviation was 2.3 mm. The corresponding TRE in the x, y, and z direction for volume implants was 1.6 mm (SD ± 0.4 mm), 1.9 mm (SD ± 0.6 mm), and 1.0 mm (SD ± 0.4 mm), respectively. The maximum deviation was 2.9 mm. Conclusions: The adaptation of a commercially available surgical planning and navigation system to interstitial brachytherapy is feasible. It enables virtual planning and improved accuracy in 3D interstitial needle implantation. [Copyright &y& Elsevier]

Purpose: Although accelerated partial breast irradiation (APBI) as the sole radiation modality after lumpectomy has shown promising results for select breast cancer patients, published experiences thus far have provided limited information on treatment planning methodology and quality assurance measures. A novel three-dimensional computed tomography (CT)-based treatment planning method for accurate delineation and geometric coverage of the target volume is presented. A correlation between treatment volume and irradiation time has also been studied for quality assurance purposes. Methods and Materials: Between May 2002 and January 2003, 50 consecutive patients underwent an image-guided interstitial implant followed by CT-based treatment planning and were subsequently treated with APBI with a high-dose-rate (HDR) brachytherapy remote afterloader. Target volume was defined as the lumpectomy cavity +2 cm margin modified to >/=5 mm to the skin surface. Catheter reconstruction, geometric optimization, and manual adjustment of irradiation time were done to optimally cover the target volume while minimizing hot spots. Dose homogeneity index (DHI) and percent of target volume receiving 100% of the prescription dose (32 Gy in 8 fractions or 34 Gy in 10 fractions) was determined. Additionally, the correlation between the treatment volume and irradiation time, source strength, and dose was then analyzed for manual verification of the HDR computer calculation. Results: In all cases, the lumpectomy cavity was covered 100%. Target volume coverage was excellent with a median of 96%, and DHI had a median value of 0.7. For each plan, source strength times the treatment time for every unit of prescribed dose had an excellent agreement of +/-7% to the Manchester volume implant table corrected for modern units. Conclusions: CT-based treatment planning allowed excellent visualization of the lumpectomy cavity and normal structures, thereby improving target volume delineation and optimal coverage, relative to conventional orthogonal film dosimetry. Using the Manchester volume implant table calculated irradiation time can be used as quality assurance for the HDR computed time. Thus dosimetric quality assurance and adequate target volume coverage can be concurrently confirmed, allowing prospective evaluation and optimization of implants. [ABSTRACT FROM AUTHOR]

Purpose: Low-dose-rate interstitial brachytherapy (LDRIB) represents an effective modality for treatment of oropharyngeal carcinoma. The drawback is radioexposure of medical personnel. To eliminate this concern, we initiated high-dose-rate interstitial brachytherapy (HDRIB) in 1993. The present study evaluated the efficacy and complications associated with this approach.Methods and materials: Between 1993 and 2003, HDRIB ± external radiotherapy was used to treat 83 oropharyngeal squamous cell carcinomas. Median duration of follow-up was 26 months (range, 1–108 months). Of the 82 patients, 76 were previously untreated and 6 displayed previous history of head and neck cancer. T distribution comprised T1 (n = 7), T2 (n = 47), T3 (n = 24), and T4a (n = 5). External radiotherapy of 46 Gy was combined with 21 Gy/3.5 fractions/2 days HDRIB for 68 lesions, and 48 Gy/8 fractions/5 days HDRIB alone was used for 15 lesions. Involved nodes were either boosted by external radiotherapy or resected.Results: Five-year local control, regional control, cause-specific and overall survival rates were 82%, 84%, 88%, and 64%, respectively. Local control rates for early (T1/T2) and advanced (T3/T4) tumors were 89% and 66%, respectively (p = 0.02). Transient soft tissue necrosis was experienced in 29% of patients. No bone sequelae were observed in previously untreated patients.Conclusions: High-dose-rate interstitial brachytherapy could achieve excellent local control and acceptable rates of complication, equivalent to reported results for LDRIB series. Given the advantage of radioprotection, HDRIB may replace LDRIB in the treatment of oropharyngeal carcinoma. [Copyright &y& Elsevier]

Purpose: To reveal a predictive factor for biochemical recurrence (BCR) after permanent prostate brachytherapy (PPB) using iodine-125 seed implantation in patients with localized prostate cancer classified as low or intermediate risk based on National Comprehensive Cancer Network (NCCN) guidelines. Methods and Materials: From January 2004 to December 2009, 414 consecutive Japanese patients with clinically localized prostate cancer classified as low or intermediate risk based on the NCCN guidelines were treated with PPB. The clinical factors including pathological data reviewed by a central pathologist and follow-up data were prospectively collected. Kaplan-Meier and Cox regression analyses were used to assess the factors associated with BCR. Results: Median follow-up was 36.5 months. The 2-, 3-, 4-, and 5-year BCR-free rates using the Phoenix definition were 98.3%, 96.0%, 91.6%, and 87.0%, respectively. On univariate analysis, the Gleason score, especially primary Gleason grade 4 in biopsy specimens, was a strong predicting factor (p < 0.0001), while age, initial prostate-specific antigen (PSA) level, T stage, and minimal dose delivered to 90% of the prostate volume (D90) were insignificant. Multivariate analysis indicated that a primary Gleason grade 4 was the most powerful prognostic factor associated with BCR (hazard ratio = 6.576, 95% confidence interval, 2.597–16.468, p < 0.0001). Conclusions: A primary Gleason grade 4 carried a worse BCR prognosis than the primary grade 3 in patients treated with PPB. Therefore, the indication for PPB in patients with a Gleason sum of 4 + 3 deserves careful and thoughtful consideration. [ABSTRACT FROM AUTHOR]