Search

Introduction: Brachytherapy always remains a keystone in the treatment of gynecological carcinoma for both definitive and adjuvant treatments. Due to the rapid fall-off nature of brachytherapy, the target gets a high dose with a low dose to the normal organs nearby and thereby increasing the tumor control probability. Aims and Objectives: This study aims at the evaluation of local control and toxicities in the carcinoma of the cervix using tandem and cylinder as brachytherapy applicator. Materials and Methods: The study was conducted between January 2014 and December 2018 in a tertiary care hospital. Thirty-one patients who fulfilled our set criterion of Clinical stage IB3–IVA, Performance status Eastern Cooperative Oncology Group 0–2 were selected. All patients were treated initially with external beam radiotherapy and later by high dose rate intracavitary brachytherapy after completion of external beam radiation therapy (EBRT). A dose of 18–21 Gy was delivered to the residual disease in three sessions with a 1-week interval between each session. The dose was optimized in such a way that the organs at risk (OAR), namely bladder and rectum received doses within their tolerance levels. The patients were continuously monitored using Common Terminology Criteria for Adverse Events version 5.0 for both acute and late toxicities and by imaging for local control. Statistical analysis using SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA) was used to evaluate the results. Continuous variables were expressed as mean ± standard deviation, and categorical variables were summarized as frequencies and percentages. Results: Out of the 31 patients, 5 (16.1%) experienced radiation-induced Grade 1 skin changes which were due to EBRT, 1 (3.2%) had Grade 1 G. I. T toxicity, 1 (3.2%) had Grade 1 radiation-induced vaginal mucositis after brachytherapy. At 6–8-week follow-up, all the patients showed no evidence of disease on radiological imaging. At 3 months of follow-up, 1 (3.2%) patient had radiation-induced proctitis of Grades 2 and 3 (9.7%) had radiation-induced cystitis of Grades 1 and 1 (3.2%) had Grade 2 cystitis. At 6 months of follow-up, 1 (3.2%) had Grade 1, 1 (3.2%) had Grade 2, and 1 (3.2%) had Grade 3 radiation-induced proctitis. At 3 months of follow-up, 29 (93.5%) patients had no evidence of disease, while 2 (6.5%) were having residual disease on imaging. At 6 months of follow-up, all the patients were disease-free. At 12 months of follow-up, 26 (83.9%) patients were disease-free, 1 (3.2%) had local recurrence, 2 (6.5%) had distant metastasis, and 2 (6.5%) had expired. At 24 months of follow-up, 26 patients were disease-free. Acute and late toxicities were similar to those used in the treatment of carcinoma cervix by standard brachytherapy applicators. Local control was achieved in 83.87% of cases. Two-year survival was 93.5%. Conclusion: We observed that the tandem and cylinder applicator is an acceptable applicator to be used for intracavitary brachytherapy. It is safe and simple besides this; the toxicities and local control are similar to the other standard applicators used in brachytherapy in carcinoma cervix. However, the required dose prescription to point A was not possible in all the patients due to limitations of OARs. Furthermore, long-term follow-up is needed to see the patterns of failure, recurrence-free survival, overall survival, and long-term toxicities in the treated patients. [ABSTRACT FROM AUTHOR]

Aim: To investigate the ease of tandem application and external os identification by giving sublingual misoprostol before initiation of intracavitary brachytherapy in cancer cervix patients.Materials and Methods: 36 patients with cervical cancer stage IIIB which were supposed to undergo intracavitary brachytherapy(ICBT) were randomly divided into 2 subgroups, group A patients receiving misoprostol and group B not receiving misoprostol.Misoprostol 400 mcg was given sublingually 3 hrs prior to the procedure. The efficacy of the drug was measured as per the ease of identification of os and easier tandem application and amount of bleeding during procedure.Results: Application of tandem and identification of external os was easier and amount of bleeding was also less in patients that were administered sublingual misoprostol.Conclusion: Sublingual Misoprostol given before ICBT helps in cervical ripening and thus leads to easier os recognition and central tandem application and reduce overall anaesthesia time. [ABSTRACT FROM AUTHOR]

Purpose: High-dose rate remote afterloading brachytherapy machine and advanced treatment planning system help in getting optimum dose to tumor and low dose to normal structures. Inverse planning simulated annealing (IPSA) optimization technique has a unique feature of dwell time deviation constraint (DTDC). In this study, six IPSA-based plans having different DTDC values with routinely practiced geometric plus graphical optimization (GO + GrO) have been compared using various dosimetric parameters.Materials and Methods: For this retrospective study, we have generated IPSA-optimized interstitial brachytherapy plans for ten cancer cervix patients. Routinely practiced GO + GrO-based plans were compared with six different IPSA plans having varying DTDC values from 0.0 to 1.0 using different dosimetric indices.Results: Conformity index and homogeneity index (HI) were higher in GO + GrO plans, compared to IPSA-optimized plans. However, HI of IPSA plans was increasing with increasing DTDC values. High-dose volumes were well controllable using DTDC parameter in IPSA-optimized plans. Dose to the rectum and bladder was smaller for IPSA-optimized plans than GO + GrO plans.Conclusions: One of the benefits of applying DTDC in IPSA-optimized plan is that it reduces high-dose volumes. Another advantage is the reduction in rectum and bladder dose. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study is to address the limitation of combined intracavitary‑interstitial (IC/IS) brachytherapy (BT) in locally advanced cervical cancer using standardized applicators and to determine the optimal dose distribution in patients with challenging tumors, innovative methods of customizing and optimizing the IS needle configuration for combined IC/IS BT are proposed and investigated. Materials and Methods: A software module that could customize the IS needle configuration and subsequently generate the digital model of guiding template for three‑dimensional printing was developed and integrated into our in‑house treatment planning system for BT. The inverse optimization method based on the technique of mixed‑integer linear programming was introduced to determine the needle tracks out of a candidate pool and dwell times at corresponding locations to best meet dose objectives. A treatment planning study was conducted to evaluate the feasibility and performance of the proposed methods. Results: The workflow for combined IC/IS BT with customized and inverse optimized IS needle configuration was presented. Dosimetric results of the treatment planning study showed that sufficient target coverage could be obtained with the customized IS needle configuration for challenging cases. The proposed dose‑based optimization method for IS needle configuration was feasible and effective. Improved target coverage and organ‑at‑risk sparing were achieved using the inverse planning method. Conclusions: Using the proposed methods of customizing and optimizing the IS needle configuration, the limitation in the standardized design of combined IC/IS applicators can be addressed, and sufficient target coverage is obtained in cervical cancer patients with unfavorable tumor topography and/or extra lateral expansion. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to retrospectively assess the outcome of interstitial iodine‑125 brachytherapy for unresectable hepatocellular carcinoma (HCC). Materials and Methods: Between February 2013 and March 2019, 57 patients with 108 unresectable HCC lesions treated with computed tomography (CT)‑guided iodine‑125 seed brachytherapy were retrospectively analyzed. The primary endpoint was overall survival (OS). The secondary endpoints included local tumor control and progression‑free survival (PFS). Potential factors associated with OS were assessed. Results: The mean follow‑up duration was 24.3 ± 15.6 months (median, 20.5 months; range, 3.9–66.8 months). The median OS time was 23.6 months (95% confidence interval [CI], 18.4–28.8 months). The 1‑, 2‑, and 3‑year actuarial OS rates were 80.0%, 46.1%, and 24.3%, respectively. The median PFS time was 12 months (95% CI, 9.9–14.5 months). The 1‑ and 2‑year actuarial PFS rates were 50% and 20.1%, respectively. Local progression was noted in 11 (11.3%) of 108 lesions with mean local control time of 20.5 ± 8.8 months. The 1‑ and 2‑year local control rates were 96.5% and 88.8%, respectively. Barcelona clinic liver cancer stage and Child–Pugh score were independent risk factors affecting the prognosis (hazard ratio [HR] = 0.330 [95% CI, 0.128–0.853] and HR = 0.303 [95% CI, 0.151–0.610], respectively). Hepatic artery pseudoaneurysm was found in 1 (1.8%) patient with lesion located in the porta hepatis. No other major complications developed during follow‑up. Conclusion: CT‑guided iodine‑125 brachytherapy may be an effective and safe alternative with promising survival and increased local control rate in unresectable HCC treatment. [ABSTRACT FROM AUTHOR]

Pancreatic cancer, also known as exocrine pancreatic carcinoma or pancreatic ductal adenocarcinoma, is one of the most challenging tumor entities worldwide, which is characterized as a highly aggressive disease with dismal overall prognosis. Treatment options for patients with locally advanced pancreatic cancer include surgery, chemotherapy, and radiotherapy. In many cases, surgical resection is not possible due to the advanced stage at diagnosis and poor responses to current treatments, therefore, treatment alternatives have to be performed. However, brachytherapy through radioactive 125I seeds (RIS) implantation into pancreatic cancer has been first applied in unresectable carcinoma and made accuracy curative effects. Therapeutic procedures of RIS implantation for pancreatic carcinoma were not identical in domestic medical centers, making it hard to achieve homogeneity and affecting the efficacy seriously at last. To maximize the benefits of RIS for patients with pancreatic cancer, Chinese Medical Doctor Association of Radioactive Seed Implantation Technology Expert Committee and Committee of Minimally Invasive Therapy in Oncology, Chinese Anti-Cancer Association, Radioactive Seed Therapy Branch organized and helped establish China expert consensus on RIS implantation for the treatment of pancreatic cancer, to provide a reference for clinical practices. [ABSTRACT FROM AUTHOR]

The aim of this study is to develop expert consensus statement for recommendations of patient selection criteria, prescription dose, and procedure of computed tomography (CT)-guided 125I radioactive seeds permanent interstitial brachytherapy. Members of Chinese medical association radiation oncology branch, Chinese medical association radiation therapy professional committee, Chinese cancer society minimally invasive surgery branch seed therapy group, Chinese geriatric cancer society minimally invasive surgery branch, Beijing medical association radiation oncology professional committee, China northern radioactive seeds brachytherapy group formed a committee, which consists of physician members who come from the department of radiation oncology, surgery, intervention, internal medicine, ultrasound, and nuclear medicine. The leader of the group organized experts to write the first draft based on clinical experience and literature review and then sent the draft to the commissioner for consultation, finally reached a consensus. Guidelines for patient selection criteria, prescription dose of 125I seed for different kinds of carcinomas, activity of per seed, and workflow of CT-guided permanent interstitial radioactive seed implantation (RSI) are presented in this study. The procedure of CT-guided RSI comprised eight steps: indication selection, preoperative preparation, preoperative CT simulation and position setup, preplan, intraoperative needle insertion, RSI, postoperative dosimetric evaluation, and follow-up. Patient selection criteria are developed. Guidelines for prescription dose of 125I seed for different kinds of carcinomas, activity of per seed, and workflow of CT-guided permanent interstitial RSI are provided. [ABSTRACT FROM AUTHOR]

Aim: The aim of this retrospective study was to assess treatment outcomes for patients with locally advanced gynecological malignancies being treated with interstitial brachytherapy using Martinez universal perineal interstitial template (MUPIT) and to study the acute and late sequelae and survival after treatment by this technique.Materials and Methods: Ninety seven patients untreated with histopathological confirmation of carcinoma of cervix (37) vault (40) and vagina (20) were treated by combination of external beam RT (EBRT) using megavoltage irradiation to pelvis to dose of 4000-5000 cGy followed by interstitial brachytherapy using MUPIT between September 2001 to March 2005. Median age was 46 years. Only those patients who were found unsuitable for conventional brachytherapy or in whom intracavitatory radiotherapy was found to be unlikely to encompass a proper dose distribution were treated by interstitial template brachytherapy using MUPIT application and were enrolled in this study. The dose of MUPIT was 1600-2400 cGy in 4-6# with 400 cGy/# and two fractions a day with minimum gap of six hours in between two fractions on micro-HDR. Criteria for inclusion of patients were as follows: Hb minimum 10 gm/dl, performance status--70% or more (Karnofsy scale), histopathological confirmation FIGO stage IIB-IIIB (excluding frozen pelvis).Results: Among the 97 patients studied, 12 patients lost to follow-up and hence they were excluded from the study. Follow-up of rest of the patients was then done up to September 2006. The duration of follow-up was in the range of 20-60 months. Parameters studied were local control rate, complication rate, mortality rate and number of patients developing systemic metastasis. Local control was achieved in 56/85 (64.7%) and complication rate was 15/85 (17.6%). Local control was better for nonbulky tumors compared bulky tumors irrespective of stage of disease. Local control was better in patients with good regression of disease after external beam radiotherapy. Time of gap between EBRT and implant also had an impact on the outcome.Conclusion: Interstitial template brachytherapy by MUPIT is a good alternative to deliver high dose radiation in locally advanced gynecological malignancies where conventional brachytherapy application is either not feasible or likely to give optimal dose distribution. Loco regional control obtained is definitely better than EBRT alone and within the accepted range of complications. [ABSTRACT FROM AUTHOR]

INTRODUCTION- Brachytherapy is an integral component in the treatment of carcinoma cervix. Identification and dilatation of cervical canal is a key step in intracavitary brachytherapy for carcinoma cervix. There is a reported incidence of 1.75-13% uterine perforations during intracavitary brachytherapy and the reasons can be either due to anatomical distortions of the cervix, cervical stenosis due to advanced disease, post irradiation fibrosis, previous cone biopsy, retroverted/retroflexed and extremely anteverted/anteflexed uterus and intense fibrosis seen following neoadjuvant therapy. A variety of techniques have been described to assist in accurate placement of the uterine tandem prior to afterloading of which the use of Misoprostol was studied at our institute. MATERIALS AND METHODS- A prospective study was started from December 2015 - July 2017.This study included patients of carcinoma cervix stage II A to IIIB. All patients received standard concurrent chemo-radiation followed by 3 sessions of brachytherapy. Tablet Misoprostol 200 micrograms was administered orally at bed time prior to procedure and early morning on the day of the Brachytherapy for cervical dilatation. RESULTS-.A total of Sixty nine patients were treated during the study duration .Patient age ranged from 38-68 years and median age was 48 years. Most of the patients underwent brachytherapy under sedation. Misoprostol was administered to all the patients. The cervical os was easily identified in 66 patients. Uterocervical length was estimated by uterine sound. The cervical os was easily negotiated in 66 patients but 52 required serial cervical dilation. In 3 patients the os could not be identified under sedation and the procedure was terminated and rescheduled for insertion under general anesthesia. CONCLUSION- A good brachytherapy application is a cornerstone to the success of treatment outcome in cervical cancers. In locally advanced cervical cancer the anatomical distortions and fibrosis is a frequent observation during brachytherapy. With a background of the efficacy of misoprostol in various non-oncological settings such as cervical preparation for abortions and dilatation and curettage, its use was found safe and effective in cervical dilatation for brachytherapy in carcinoma cervix. It is cost effective especially in centres where facility of ultrasonography during brachytherapy applicator insertion is not available. [ABSTRACT FROM AUTHOR]

PURPOSE: To compare radiotherapy using accelerated fractionation (6 fractions per week) and concurrent chemotherapy with conventional radiotherapy (5 fractions per week) and concurrent chemotherapy to assess acute toxicities, response at 6 weeks and locoregional control at 3 months in locally advanced carcinoma cervix patients. MATERIALS & METHODS : 40 patients with histologically proven carcinoma cervix (International Federation of Gynecology and Obstetrics, FIGO stage IIB-IIIB) were prospectively non-randomized to arm A (study arm): 20 patients and arm B (control arm): 20 patients. Arm A received External Beam Radiotherapy with accelerated fractionation (6 fractions per week) and arm B received EBRT with conventional fractionation (5 fractions per week). Patients in both the arms received radiation to a dose of 45- 50.4 Gy in 25-28 fractions using the conformal radiation technique (3DCRT). All patients received concurrent chemotherapy with Inj. Cisplatin 40mg/m2 weekly as a radio sensitizer. After completion of brachytherapy, patients inboth the arms received High dose rate (HDR) brachytherapy either intracavitary or interstitial brachytherapy to a dose of 21-24 Gy in 3 or 4 fractions after completion of EBRT. The patients were assessed weekly for toxicities during EBRT. Toxicities were recorded as per RTOG criteria. Response at 6 weeks and locoregional control at 3 months after treatment was assessed by clinical examination. RESULTS : Data was analyzed from 17 patients in study arm and 20 patients in control arm. The median Overall treatment time (OTT) was statistically significantly shortened in accelerated arm when compared to conventional fractionated arm (44 vs. 51 days, p value = 0.0008). Lower GI toxicity was statistically significantly higher in accelerated arm (p value = 0.0436). Upper GI, skin and haematological toxicities were comparable between two arms. Overall response at 6 weeks and locoregional control at 3 months after treatment were comparable CONCLUSION : The results of our study indicate that accelerated fractionation with concurrent cisplatin is a viable option to conventional fractionation with concurrent cisplatin in patients with advanced cervical cancer. However, further randomized trials with larger sample sizes and longer duration of follow-up are required [ABSTRACT FROM AUTHOR]

INTRODUCTION : To discuss the technical aspect of interstitial brachytherapy in soft tissue sarcomas including method of implant, total radiation dose, and wound morbidity and short follow up of these patients. We reviewed our patients who were treated by conservative surgery (wide excision), interstitial implant and external beam radiation therapy. MATERIALS AND METHODS: Nine patients with primary, recurrent or post excision residual soft tissue sarcomas of trunk and extremities underwent surgical resection (wide excision) and received adjuvant radiotherapy including interstitial brachytherapy as a sole treatment (35 Gy at 10 fractions ) or as a boost (6 or 7 fractions) before EBRT. Catheters were placed with regular intervals of 1 cm immediately after wide excision ( with adequate margins ) or post operatively as a separate procedure. Brachytherapy consisted of high dose rate, Iridium-192 implant which delivered at 3.5 Gy/fraction, twice a day, starting from 5th post operative day. Average size of the tumors were 6.5cms and consisted of 7 different histological types. RESULTS: All patients completed planned interstitial brachytherapy without acute side effects directly related with catheter implantation such as infection or bleeding. Wound morbidity was seen in 2 patients (wound dehiscence, marginal skin discoloration, serous discharge). With median follow up duration of 10 months (range 3-24 months), no recurrences were observed. CONCLUSION: The high dose rate interstitial brachytherapy is easy and safe way to minimize the radiation dose delivered to the adjacent normal tissue and to decrease radiation induced chronic morbidity such as fibrosis by reducing the total dose of external radiotherapy in the management of soft tissue sarcoma with conservative surgery. [ABSTRACT FROM AUTHOR]

Background: Carcinoma cervix commonly presents at locally advanced stages such as FIGO stage IIB- IVA. External beam radiation therapy ± concurrent chemotherapy followed by brachytherapy (BT) forms the mainstay of treatment in such cases. Interstitial Brachytherapy is used in cases with distorted anatomy, extensive (lower) vaginal wall involvement, bulky residual disease post external beam radiation therapy (EBRT) and parametrium involvement upto lateral pelvic wall so as to cover target volumes adequately. Aim: To determine clinical and dosimetric outcomes in locally advanced carcinoma cervix cases treated with External beam radiation therapy +/- concurrent chemotherapy followed by interstitial brachytherapy using template MUPIT (Martinez Universal Perineal Interstitial Template). Material and Methods: Retrospective analysis of 40 patients of locally advanced carcinoma cervix treated from Dec.2009 to June 2016. Initial treatment: EBRT (dose: 45-50.4Gy in 25-28 fractions) ± concurrent chemotherapy followed by interstitial brachytherapy using MUPIT. Procedure done under spinal anesthesia using clinico-radiological findings to cover target adequately. Median No. needles inserted-25 (Range 17-29). Planning CT scan done and target volumes (GTVB, HR-CTV and IR-CTV) contoured. BT Prescription dose (normalized to 5mm box surface): 20- 25Gy in 5 fractions given twice daily with minimum 6 Hrs. gap in-between using HDR Ir192 source. Patients were followed up over median duration of 29.5 months. Kaplan Meier Survival Curves were plotted for survival rate calculation. Statistical analysis was performed using SPSS program for Windows, version 21.0. Results: The mean target volume doses achieved - HRCTV D90 - 83.86Gy (Range: 76.3-98.6 Gy), IRCTV D90 -72.89Gy (Range: 61.94-79.7Gy), mean V100: 164.23cc (Range:115.58-196.17 cc), mean V200: 17.20cc (Range: 8.74-32 cc). The mean V200/V100 was 10.26%. At 2 years, locoregional control (LRC) was 74.2%, disease free survival (DFS) was 64.9% and overall survival (OS) was 67.1%. At 3 years the LRC - 66.6%, DFS - 58.2% and OS - 67.1%. Chronic rectal toxicity was seen in 9 patients {Grade 3(n=3), Grade 4(n=2)}, while late Grade 3 bladder toxicity was seen in 1 patient. Conclusion: Uniform dose coverage of larger target volumes can be achieved with interstitial brachytherapy as compared to historical controls of intracavitary brachytherapy. This dosimetric advantage results in achievement of excellent locoregional control and survival rates with equivalent complication rate as compared to conventional intracavitary brachytherapy. Interstitial Brachytherapy remains brachytherapy of choice in locally advanced carcinoma cervix. [ABSTRACT FROM AUTHOR]

INTRODUCTION In the era of image based brachytherapy for cervical cancer, use of traditional point A based prescriptions are becoming less popular. With the advent of CT scan, Image based brachytherapy replaced the X-ray based point A prescription. AIM To calculate point A dose in CT based planning of intracavitary brachytherapy. OBJECTIVES PRIMARY: To calculate the dose to point A in CT based target volume contouring in Carcinoma cervix patients undergoing ICBT following External Beam Radiotherapy. SECONDARY: To calculate the EQD2 dose to bladder, rectum and CTV. MATERIALS AND METHODS Dosimetric data of 25 patients of Carcinoma Cervix FIGO stages IIA-IIIB who underwent Intracavitary Brachytherapy following External Beam Radiotherapy. Patients underwent Intracavitary brachytherapy with Modified Fletcher Suit applicators (Central tandem+2 ovoids). 1 hour after the procedure, patients were taken for CT simulation with Foley's catheter clamped 20 minutes prior to simulation. Scan was done from L5 level to mid-thigh with 2.5mm slice thickness. After simulation images were transferred to Oncentra treatment planning system for contouring and planning. CTV include entire cervix and uterus 1cm short of fundus. Bladder and rectum were marked as Organs at risk. External beam radiotherapy doses 50Gy/25 fractions (n=12), 45Gy/25 fractions(n=10), 50.4Gy/28 fractions(n=3). RESULTS: Mean Point A dose on the right side was 4.23Gy(65.83% of prescription dose) and on the left side it was 4.17Gy(64.91% of prescription dose). Mean Target dose D90 was 75.77% of prescription dose. Mean EQD2 EBRT(Gy) Mean EQD2 HDR BT(Gy) Total EQD2 (Gy) Target 47.9 28.4 76.3Gy Bladder(D2cc) 47.08 23.78 70.86Gy Rectum(D2cc) 47.08 19.71 66.8Gy CONCLUSION: In volume based brachytherapy, the Point A and CTV D90 are underdosed because of over-contour of HR-CTV. Therefore, MRI is the gold standard for image based brachytherapy for precise delineation of HR-CTV. [ABSTRACT FROM AUTHOR]