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Background: The high‐dose rate (HDR) brachytherapy treatment planning workflow for cervical cancer is a labor‐intensive, time‐consuming, and expertise‐driven process. These issues are amplified in low/middle‐income countries with large deficits in experienced healthcare professionals. Automation has the ability to substantially reduce bottlenecks in the planning process but often require a high level of expertise to develop. Purpose: To implement the out of the box self‐configuring nnU‐Net package for the auto‐segmentation of the organs at risk (OARs) and high‐risk CTV (HR CTV) for Ring‐Tandem (R‐T) HDR cervical brachytherapy treatment planning. Methods: The computed tomography (CT) scans of 100 previously treated patients were used to train and test three different nnU‐Net configurations (2D, 3DFR, and 3DCasc). The performance of the models was evaluated by calculating the Sørensen‐dice similarity coefficient, Hausdorff distance (HD), 95th percentile Hausdorff distance, mean surface distance (MSD), and precision score for 20 test patients. The dosimetric accuracy between the manual and predicted contours was assessed by looking at the various dose volume histogram (DVH) parameters and volume differences. Three different radiation oncologists (ROs) scored the predicted bladder, rectum, and HR CTV contours generated by the best performing model. The manual contouring, prediction, and editing times were recorded. Results: The mean DSC, HD, HD95, MSD and precision scores for our best performing model (3DFR) were 0.92/7.5 mm/3.0 mm/ 0.8 mm/0.91 for the bladder, 0.84/13.8 mm/5.3 mm/1.4 mm/0.84 for the rectum, and 0.81/8.5 mm/6.0 mm/2.2 mm/0.80 for the HR CTV. Mean dose differences (D2cc/90%) and volume differences were 0.08 Gy/1.3 cm3 for the bladder, 0.02 Gy/0.7 cm3 for the rectum, and 0.33 Gy/1.5 cm3 for the HR CTV. On average, 65% of the generated contours were clinically acceptable, 33% requiring minor edits, 2% required major edits, and no contours were rejected. Average manual contouring time was 14.0 min, while the average prediction and editing times were 1.6 and 2.1 min, respectively. Conclusion: Our best performing model (3DFR) provided fast accurate auto generated OARs and HR CTV contours with a large clinical acceptance rate. [ABSTRACT FROM AUTHOR]

Purpose: A meta-analysis is presented comparing clinical outcomes and toxicities between high dose rate (HDR) and pulsed dose rate (PDR) brachytherapy (BT) for anal cancer. Methods and material: Retrospective or prospective clinical trials were identified on electronical databases. Data were collected per Preferred Reporting Items for Systematic Reviews and meta-Analyses guidelines. Pooled effect size for HDR and PDR BT were compared using subgroup analyses. Results: Nine retrospective studies with a total of 481 patients treated were included of which 219 with HDR and 262 with PDR. Significant differences were observed between the two groups for baseline characteristics and treatment. The cumulative proportion of stage T3-T4 was lower in the HDR group, 0.15 [95 % confidence interval (CI) 0.07–0.29] vs 0.27 [95 %CI 0.09–0.57] in the LDR group, p 0.99. The 5 years local control was 0.86 [95 % confidence interval (CI) 0.81–0.91] and 0.83 [95 %CI 0.77–0.89], p = 0.62. Cumulative toxicity-related colostomy proportion was 0.04 [95 %CI 0.02–0.09] and 0.03 [95 %CI 0.02–0.07], p = 0.85. Conclusion: Both modalities provided a good profile of tolerance and are effective organ conservative strategies for patients with anal canal cancer. In parallel with ongoing developments to better determine the optimal fractionation and dose for HDR-BT treatments, especially in large tumors, PDR BT still has a crucial role for dose escalation strategy in advanced cases.

Abstract Background To evaluate whether the use of the internal target volume (ITV) delineation method improves the performance of intensity‐modulated radiotherapy (IMRT) and three‐dimensional conformal radiotherapy (3DCRT) in terms of survival, acute toxicities, and dose–volume parameters. Methods A total number of 477 cervical cancer patients who received concurrent chemoradiotherapy (CCRT) from January 2012 to December 2016 were retrospectively analyzed. They were divided into four groups: the non‐ITV (N‐ITV) + IMRT, ITV + IMRT, N‐ITV + 3DCRT, and ITV + 3DCRT groups, with 76, 41, 327, and 33 patients, respectively. Survival analysis was performed with the Kaplan–Meier and the log‐rank tests, and acute toxicity analysis was performed with the chi‐squared test and the binary logistic regression test. Using the propensity score matching (PSM) method, 92 patients were matched among the four groups, and their dose–volume parameters were assessed with the Kruskal–Wallis method. Results The median follow‐up time was 49 months (1–119) for overall survival (OS). The 5‐year OS rate was 66.4%. The ITV delineation method was an independent prognostic factor for OS (HR [95% CI]: 0.52 [0.27, 0.98], p = 0.044) and progression‐free survival (PFS) (HR [95% CI]: 0.59 [0.36, 0.99], p = 0.045). The ITV + IMRT group had the lowest incidence rate (22%) and the N‐ITV + IMRT group had the highest incidence rate of grade ≥3 hematological toxicity (HT) (46.1%) among the four groups. The pelvic bone marrow relative V10, V20, and V30 in the N‐ITV + IMRT group was higher than those in the ITV + IMRT and N‐ITV + 3DCRT groups (p

Background: To evaluate whether the use of the internal target volume (ITV) delineation method improves the performance of intensity‐modulated radiotherapy (IMRT) and three‐dimensional conformal radiotherapy (3DCRT) in terms of survival, acute toxicities, and dose–volume parameters. Methods: A total number of 477 cervical cancer patients who received concurrent chemoradiotherapy (CCRT) from January 2012 to December 2016 were retrospectively analyzed. They were divided into four groups: the non‐ITV (N‐ITV) + IMRT, ITV + IMRT, N‐ITV + 3DCRT, and ITV + 3DCRT groups, with 76, 41, 327, and 33 patients, respectively. Survival analysis was performed with the Kaplan–Meier and the log‐rank tests, and acute toxicity analysis was performed with the chi‐squared test and the binary logistic regression test. Using the propensity score matching (PSM) method, 92 patients were matched among the four groups, and their dose–volume parameters were assessed with the Kruskal–Wallis method. Results: The median follow‐up time was 49 months (1–119) for overall survival (OS). The 5‐year OS rate was 66.4%. The ITV delineation method was an independent prognostic factor for OS (HR [95% CI]: 0.52 [0.27, 0.98], p = 0.044) and progression‐free survival (PFS) (HR [95% CI]: 0.59 [0.36, 0.99], p = 0.045). The ITV + IMRT group had the lowest incidence rate (22%) and the N‐ITV + IMRT group had the highest incidence rate of grade ≥3 hematological toxicity (HT) (46.1%) among the four groups. The pelvic bone marrow relative V10, V20, and V30 in the N‐ITV + IMRT group was higher than those in the ITV + IMRT and N‐ITV + 3DCRT groups (p < 0.05). Conclusions: The use of ITV for IMRT treatment planning was associated with improved overall survival and progression‐free survival, with lower HT rate. [ABSTRACT FROM AUTHOR]

Delineation of organs at risk (OARs), such as the bladder, rectum and sigmoid, plays an important role in the delivery of optimal absorbed dose to the target owing to the steep gradient in high-dose rate brachytherapy (HDR-BT). In this work, we propose a deep convolutional neural network-based approach for fast and reproducible auto-contouring of OARs in HDR-BT. Images of 113 patients with locally-advanced cervical cancer were utilized in this study. We used ResU-Net deep convolutional neural network architecture, which uses long and short skip connections to improve the feature extraction procedure and the accuracy of segmentation. Seventy-three patients chosen randomly were used for training, 10 patients for validation, and 30 patients for testing. Well established quantitative metrics, such as Dice similarity coefficient (DSC), Hausdorff distance (HD), and average symmetric surface distance (ASSD), were used for evaluation. The DSC values for the test dataset were 95.7 ± 3.7%, 96.6 ± 1.5% and 92.2 ± 3.3% for the bladder, rectum, and sigmoid, respectively. The HD values (mm) were 4.05 ± 5.17, 1.96 ± 2.19 and 3.15 ± 2.03 for the bladder, rectum, and sigmoid, respectively. The ASSDs were 1.04 ± 0.97, 0.45 ± 0.09 and 0.79 ± 0.25 for the bladder, rectum, and sigmoid, respectively. The proposed deep convolutional neural network model achieved a good agreement between the predicted and manually defined contours of OARs, thus improving the reproducibility of contouring in brachytherapy workflow. [ABSTRACT FROM AUTHOR]

Squamous cell carcinoma (SCC) of skin is an uncontrolled growth of cells of epithelium commonly seen in males in fifth to sixth decade of life. Risk factors include fair skin, blonde hair, exposure to sunlight (ultraviolet B), immunosuppression, human papillomavirus, and genetics. Surface mold brachytherapy (SMB) is a well-established treatment for early stage head and neck cancers involving accessible sites. It has evolved from the radium era to low-dose rate and now to high-dose rate intensity-modulated interventional brachytherapy. We present a 50-year-old male patient with squamous carcinoma of the left lower eyelid and was operated for the same. Histopathology was well-differentiated SCC with all positive margins. The patient was then treated by SMB and evaluated for toxicity, local control, and survival.

We developed a novel technology capable of detecting early-stage pancreatic cancers using high-resolution three-dimensional endoscopic optical coherence tomography (Endo-OCT), and treating them using high dose rate brachytherapy (HDR) under the Endo-OCT image guidance. This technology integrates our custom-built ultra-high resolution endoscopic three-dimensional OCT diagnostic imaging device with a commercial high dose rate brachytherapy system (HDR), resulting in a compact, portable, easy-to-operate, and low-cost Endo-OCT image-guided high dose rate brachytherapy (OCT-IGHDR) system. The system has the dual functions of diagnosis and treatment that can precisely detect and measure the location and size of the early-stage pancreatic cancer or premalignant lesions and then treat them from the inside of the pancreatic duct with an accurate and focused dose while greatly reducing the radiation toxicity to the neighboring tissues and organs. This minimally-invasive treatment technology could avoid the potential complications from surgery and reduces the high operation cost. This technology could also be applied to treat diseases of the esophagus, rectum, bronchus, and other aerodigestive organs that are suitable for use with an endoscopic device. In this article, we describe the concept of this technology and the preliminary experiments that could demonstrate the concept by using this homemade Endo-OCT machine to image the pancreatic duct for diagnosis of early-stage pancreatic cancer or premalignant lesions and to perform Endo-OCT image-guided brachytherapy.

Objectives: To understand differences in quality of life outcomes between cases with forward planning and cases with inverse planning, we examine patients undergoing high-dose rate brachytherapy combined with external beam radiotherapy for localized prostate cancer. Methods: We prospectively identified 283 patients with localized prostate cancer and divided them into forward planning and inverse planning groups. We extracted data on doses to the prostate, rectum and urethra that could potentially affect quality of life. We also evaluated quality of life using the Japanese version of Medical Outcome Study 8-Items Short Form Health Survey and Expanded Prostate Cancer Index Composite at pre-treatment and at 3, 6, 12 and 24 months after treatment. Wilcoxon signed rank test and Bonferroni correction were used to analyze the irradiation dose and any change in quality of life. Results: Doses to the prostate and rectum were not significantly different between the two groups. Notably, however, doses to the urethra were significantly lower in the inverse planning group than in the forward planning group. Patients in the forward planning group had significantly poorer physical component summary scores at 3 months according to survey results. In Expanded Prostate Cancer Index Composite, patients in the forward planning group had statistically significant poorer urinary, bowel and sexual scores than those in the inverse planning group. Quality of life related to decline in sexual function was significantly reduced in the inverse planning group. Conclusions: Inverse planning in high-dose rate brachytherapy could significantly improve quality of life of patients with prostate cancer. [ABSTRACT FROM AUTHOR]

We developed a novel technology capable of detecting early-stage pancreatic cancers using high-resolution three-dimensional endoscopic optical coherence tomography (Endo-OCT), and treating them using high dose rate brachytherapy (HDR) under the Endo-OCT image guidance. This technology integrates our custom-built ultra-high resolution endoscopic three-dimensional OCT diagnostic imaging device with a commercial high dose rate brachytherapy system (HDR), resulting in a compact, portable, easy-to-operate, and low-cost Endo-OCT image-guided high dose rate brachytherapy (OCT-IGHDR) system. The system has the dual functions of diagnosis and treatment that can precisely detect and measure the location and size of the early-stage pancreatic cancer or premalignant lesions and then treat them from the inside of the pancreatic duct with an accurate and focused dose while greatly reducing the radiation toxicity to the neighboring tissues and organs. This minimally-invasive treatment technology could avoid the potential complications from surgery and reduces the high operation cost. This technology could also be applied to treat diseases of the esophagus, rectum, bronchus, and other aerodigestive organs that are suitable for use with an endoscopic device. In this article, we describe the concept of this technology and the preliminary experiments that could demonstrate the concept by using this homemade Endo-OCT machine to image the pancreatic duct for diagnosis of early-stage pancreatic cancer or premalignant lesions and to perform Endo-OCT image-guided brachytherapy. [ABSTRACT FROM AUTHOR]

• Multi-fraction HDR brachytherapy alone is effective for localised prostate cancer. • Efficacy results to date of single dose 19Gy HDR brachytherapy are conflicting. • For intermediate and high-risk patients, this study suggests single dose 19Gy is suboptimal. • Where biochemical failure occurred, local recurrence in the prostate predominated. HDR brachytherapy alone is effective for the treatment of localised prostate cancer when given in 2–4 or more fractions. Single dose treatment has been explored in small cohort studies to date. This paper reports a large patient population with localised prostate cancer treated with single dose HDR brachytherapy delivering 19 Gy providing early outcome data from this approach. Seven centres across the UK collaborated in this national protocol to deliver 19 Gy to the PTV defined by the prostate capsule and a 3 mm expansion with clearly defined planning constraints for the urethra and rectum. Entry criteria allowed all risk groups provided PSA ≤40 µg/L and staging investigations were negative for metastases. The primary end point was biochemical relapse free survival (bRFS) defined using the Phoenix definition. Toxicity was measured using CTCAE v4.0. A total of 441 patients were entered with median follow up 26 months (range 2–56). Median age was 73 (range 54–84) and 10% were low risk, 65% intermediate risk and 25% high risk. ADT was received by 37.6% overall and 90% of high risk patients for a median period of 6 months. Three year bRFS was overall 88%: this was 100% in low risk, 86% in intermediate risk and 75% in high risk. Only Gleason score was an independent predictor of bRFS. Relapse in 25 patients was assessed radiologically and occurred in the prostate in 15 of these, 11 of whom had localised prostate relapse only. Acute toxicity was low with no grade 3 or 4 events; there were two cases of late urinary stricture and two grade 3 late rectal events. This is the largest cohort of single dose HDR brachytherapy patients treated with a single dose published to date. It shows that with 19 Gy there is 100% bRFS at 3 years in low risk patients but results in intermediate and high risk groups are less encouraging falling to 86% and 75% at 3 years with relapse predominantly in the prostate. Limited by the short follow up period of this study, the long-term outcomes of this single dose HDR approach remains uncertain. It is important to have close ongoing surveillance of this cohort as the data matures. [ABSTRACT FROM AUTHOR]

Context: In the management of cervical cancer, though a number of chemotherapeutic drugs have been used for concomitant chemoradiation, paclitaxel and carboplatin have shown improved overall response rates with acceptable side effects. The use of intracavitary irradiation significantly improves survival and reduces local failures. However, the ideal time-dose-fraction schedule remains controversial with high-dose rate (HDR) brachytherapy. Aims: The aim of this study was to determine the efficacy and safety of paclitaxel and carboplatin for concomitant chemoradiation therapy and to compare the local control, toxicity, and tolerability of the two HDR brachytherapy schedules in patients of carcinoma cervix. Subjects and Methods: The patients were divided randomly into two groups of thirty patients each. Both the groups were treated with a combination of external beam radiotherapy with 50 Gy/5 weeks/25 fractions to whole pelvis along with concomitant chemotherapy. The concomitant chemotherapy schedule was injection paclitaxel (135 mg/m2) and injection carboplatin (area under the curve - 4.5 mg min/ml) at 4-week interval followed by HDR brachytherapy. Following which, patients received HDR-intracranial brachytherapy on the basis of random allocation, Group I: 6 Gy × 3 fractions (weekly) and Group II: 5 Gy × 4 fractions (biweekly). Results and Conclusion: The survival difference between the two groups (weekly and biweekly) was not statistically significant. However, Grade 2–3 rectal reactions in Group I were significantly higher than Group II (P = 0.038). The twice-weekly schedule of brachytherapy was a significant factor influencing the late complication rate but not the local pelvic control rate or overall survival rate.

With conventional diagnostic X-ray machines with over couch X-ray tubes, it is not possible to obtain anteroposterior (AP) and lateral (Lat) radiographs without changing the posture of the patients. In an old 300 mA X-ray machine with a fluoroscopy screen (12.4 kg) (1995 model), by substituting the screen with suitable counterweight and making provision to take the hoist pillar up to the edge of the wall, we could get isocentric setup for a hospital stretcher kept near the chest stand. This setup provided acceptable AP–Lat radiographs for brachytherapy localization using “Perspex jig” (Nucletron, Netherlands) and field check radiographs in head and neck, esophagus patients for treatment planning.

Abstract Background In recent years, the delayed side effects associated with radiotherapy for prostate cancer have drawn the interest of urologists. Although urosymphyseal fistula is one of these delayed side effects, this serious complication is rarely described in literature and is poorly recognized. Case presentation We report our experience in treating a 77-year-old male patient with necrotizing fasciitis after high-dose rate brachytherapy plus external beam radiation for prostate cancer. The patient was referred to our hospital with complaints of inguinal swelling and fever. He had a past history of radiotherapy for prostate cancer and subsequent transurethral operation for a stricture of the urethra. Computed tomography showed extensive gas within the femoral and retroperitoneal tissues and pubic bone fracture. Surgical exploration suggested that necrotizing fasciitis was caused by urosymphyseal fistula. Conclusion To the best of our knowledge, this is the first case report of necrotizing fasciitis caused by urosymphyseal fistula after radiotherapy for prostate cancer. There is a strong association between urosymphyseal fistula and prostate radiotherapy with subsequent surgical intervention for bladder neck contracture or urethral stricture. Therefore, surgical treatment for bladder neck contracture or urethral stricture after radiotherapy for prostate cancer should be performed with care. The present case emphasizes the importance of early diagnosis of urosymphyseal fistula. Immediate removal of necrotic tissues and subsequent urinary diversion in the present case may have led to good patient outcome.

Background: Clinical complete response (cCR) in rectal cancer is being evaluated as a tool to identify patients who would not require surgery in the curative management of rectal cancer. Our study reviews mucosal changes after neoadjuvant therapy for rectal cancer in patients treated at our center.Methods: Pathology reports were retrieved for patients treated with neoadjuvant chemoradiation therapy (CRT) or high-dose rate brachytherapy (HDRBT). The macroscopic appearance of the specimen was compared with pathologic staging.Results: This study included 282 patients: 88 patients underwent neoadjuvant CRT and 194 patients underwent HDRBT; all patients underwent total mesorectal excision (TME). There were 160 male and 122 female patients with a median age of 65 years (range 29-87). The median time between neoadjuvant therapy and surgery was 50 and 58 days. Sixty patients (21.2%) were staged as ypT0N0, 21.2% had a pathologic complete response (pCR), and only 3.2% had a cCR. Of the 67 patients with initial involvement of the circumferential radial margin (CRM), 44 converted to pathologic CRM−. Two hundred seventy-three patients (96.8%) had mucosal abnormalities. Of the 222 patients with residual tumor, 70 patients had no macroscopic tumor visualized but an ulcer in its place.Conclusion: Most patients undergoing neoadjuvant therapy for rectal cancer have residual mucosal abnormalities which preclude to a cCR as per published criteria from Brazil. Further studies are required to optimize clinical evaluation and MRI imaging in selected patients. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate age‐related quality of life changes in patients with localized prostate cancer treated by high‐dose rate brachytherapy combined with external beam radiation therapy. Methods: A total of 172 patients with clinically localized prostate cancer were categorized to age groups <75 years and ≥75 years. Changes in their quality of life were evaluated using the Japanese version of Medical Outcome Study 8‐Items Short Form Health Survey, Expanded Prostate Cancer Index Composite and International Index of Erectile Function‐5 at baseline, and followed up to 24 months after treatment. Results: There were no significant differences in Medical Outcome Study 8‐Items Short Form Health Survey scores, and urinary and bowel scores of the Expanded Prostate Cancer Index Composite for older men after treatment. International Index of Erectile Function‐5 summary scores were significantly decreased in both groups. Although sexual function and sexual bother scores were decreased in patients aged <75 years, these scores were maintained in patients aged ≥75 years. Conclusions: Quality of life of prostate cancer patients undergoing high‐dose rate brachytherapy combined with external beam radiation therapy does not seem to be significantly affected by age. [ABSTRACT FROM AUTHOR]

Purpose: In interstitial high-dose rate brachytherapy, liver cancer is treated by internal radiation, requiring percutaneous placement of applicators within or close to the tumor. To maximize utility, the optimal applicator configuration is pre-planned on magnetic resonance images. The pre-planned configuration is then implemented via a magnetic resonance-guided intervention. Mapping the pre-planning information onto interventional data would reduce the radiologist's cognitive load during the intervention and could possibly minimize discrepancies between optimally pre-planned and actually placed applicators. Methods: We propose a fast and robust two-step registration framework suitable for interventional settings: first, we utilize a multi-resolution rigid registration to correct for differences in patient positioning (rotation and translation). Second, we employ a novel iterative approach alternating between bias field correction and Markov random field deformable registration in a multi-resolution framework to compensate for non-rigid movements of the liver, the tumors and the organs at risk. In contrast to existing pre-correction methods, our multi-resolution scheme can recover bias field artifacts of different extents at marginal computational costs. Results: We compared our approach to deformable registration via B-splines, demons and the SyN method on 22 registration tasks from eleven patients. Results showed that our approach is more accurate than the contenders for liver as well as for tumor tissues. We yield average liver volume overlaps of 94.0 ± 2.7% and average surface-to-surface distances of 2.02 ± 0.87 mm and 3.55 ± 2.19 mm for liver and tumor tissue, respectively. The reported distances are close to (or even below) the slice spacing (2.5 - 3.0 mm) of our data. Our approach is also the fastest, taking 35.8 ± 12.8 s per task. Conclusion: The presented approach is sufficiently accurate to map information available from brachytherapy pre-planning onto interventional data. It is also reasonably fast, providing a starting point for computer-aidance during intervention. [ABSTRACT FROM AUTHOR]

Vulvar cancer is a rare gynecological malignancy with incidence rates steadily increasing over the past 10 years. Despite aggressive treatment, recurrent disease is common. Vulvar cancer recurrence poses a significant therapeutic challenge as most patients have been previously treated with surgery and/or radiation limiting the options for additional treatment. There are no consensus guidelines for the treatment of recurrent disease. Current literature supports the use of salvage interstitial brachytherapy. However, the total sample size is small. The goal of this case report is to review the current literature and to provide a guide for the use of salvage interstitial brachytherapy for recurrent disease by describing, in detail, the techniques used to treat two patients with unique cases of vulvar cancer recurrences in women with advanced disease and multiple medical comorbidities.

Aim This study evaluated the survival outcome, pattern of failure and prognostic factors in cervix uteri cancer patients. Methods We reviewed the data of 60 patients with stages IB-IVA cancer who were treated between January 2004 and December 2010. Results Most patients ( n = 50; 83%) had squamous cell carcinoma. Stage IIB was the most common presentation ( n = 41; 68%). Forty-seven patients (78%) received Cisplatin concurrent with radiotherapy (CRT). The 2- and 4-year overall survival (OS) was 82% and 79%, respectively. Prolongation of the overall treatment time (OAT) for greater than 56 days, advanced stage and pretreatment hemoglobin (Hb) levels (<10 g/dL) negatively predicted OS ( P = 0.039, P = 0.044 and P = 0.008, respectively). The 2- and 4-year disease-free survival (DFS) rates were 80% and 69%, respectively. Vaginal infiltration and brachytherapy (orthogonal versus CT-based planning) were significant factors for the prediction of relapse ( P = 0.048 and P = 0.049, respectively). The 2- and 4-year loco-regional control (LRC) rates were 78% and 70%, respectively, and the distant metastasis-free survival (DMFS) rates were 82% and 79%, respectively. Vaginal infiltration was the only negative predictive factor for LRC ( P = 0.045), and pathological tumor grade was the only factor indicative of distant metastases ( P = 0.037). Grade 3 or 4 late rectal reactions were reported in two patients (3%), and no patients developed grade 3 or 4 urinary reactions. Conclusion The treatment results in our cervix uteri cancer patients and the prognostic factors are comparable to those of previous reports. Orthogonal brachytherapy planning and vaginal infiltration negatively predicted relapse. [ABSTRACT FROM AUTHOR]

Vulvar cancer is a rare gynecological malignancy with incidence rates steadily increasing over the past 10 years. Despite aggressive treatment, recurrent disease is common. Vulvar cancer recurrence poses a significant therapeutic challenge as most patients have been previously treated with surgery and/or radiation limiting the options for additional treatment. There are no consensus guidelines for the treatment of recurrent disease. Current literature supports the use of salvage interstitial brachytherapy. However, the total sample size is small. The goal of this case report is to review the current literature and to provide a guide for the use of salvage interstitial brachytherapy for recurrent disease by describing, in detail, the techniques used to treat two patients with unique cases of vulvar cancer recurrences in women with advanced disease and multiple medical comorbidities. [ABSTRACT FROM AUTHOR]

Aim The aim of this study is to study the treatment efficacy of surgical excision of keloids with postoperative high dose-rate (HDR) brachytherapy. Material and methods Between January 2013 and April 2016, 30 patients with 42 keloids were treated with excision of the keloid scar followed by postoperative HDR brachytherapy. Patients were followed-up after 10 days, 3 months and 6 months. Patient satisfaction and recurrence of keloids were measured. Results No patient had symptoms of any recurrence, but 4 had unacceptable results (score of more than 3). Conclusions Surgical excision with postoperative high-dose rate brachytherapy is effective in preventing recurrence of keloid scars. It also provides cosmetically acceptable results. However, the cost involved in such treatment is a hindrance on the Indian subcontinent. [ABSTRACT FROM AUTHOR]

Radiation therapy is an integral component in the multimodality management of many gastrointestinal (GI) cancers at all stages of clinical presentation. With recent advances in technology and radiation delivery, external beam radiation therapy (EBRT) can be delivered with reduced toxicity. However, despite these advances, EBRT doses are still limited by the presence of radiosensitive serial structures near clinical targets in the GI tract. Relative to EBRT techniques, brachytherapy techniques have a lower integral dose and more rapid fall-off, allowing for high-dose delivery with little normal tissue exposure. Given the unique characteristics of brachytherapy, it is an attractive strategy to treat GI malignancies. This review addresses the application of both high-dose rate brachytherapy (HDRBT) and low-dose rate brachytherapy (LDRBT) to multiple GI malignancies for both definitive and palliative management. [ABSTRACT FROM AUTHOR]

Rats with sarcoma M-1 were exposed to high dose rate irradiation with 169Yb source. In 25 days after introduction of a trocar with sealed capsule with 169Yb source into the tumor, complete tumor regression was observed in 70% animals. The results suggest feasibility of using 169Yb source for high-dose rate brachytherapy and development of the personalized medicine approaches. [ABSTRACT FROM AUTHOR]

Rats with sarcoma M-1 were exposed to high dose rate irradiation with 169Yb source. In 25 days after introduction of a trocar with sealed capsule with 169Yb source into the tumor, complete tumor regression was observed in 70% animals. The results suggest feasibility of using 169Yb source for high-dose rate brachytherapy and development of the personalized medicine approaches. [ABSTRACT FROM AUTHOR]

To investigate the dosimetric and radiobiological differences among volumetric modulated arc therapy (VMAT), high-dose rate (HDR) brachytherapy, and low-dose rate (LDR) permanent seeds implant for localized prostate cancer. A total of 10 patients with localized prostate cancer were selected for this study. VMAT, HDR brachytherapy, and LDR permanent seeds implant plans were created for each patient. For VMAT, planning target volume (PTV) was defined as the clinical target volume plus a margin of 5 mm. Rectum, bladder, urethra, and femoral heads were considered as organs at risk. A 78 Gy in 39 fractions were prescribed for PTV. For HDR and LDR plans, the dose prescription was D 90 of 34 Gy in 8.5 Gy per fraction, and 145 Gy to clinical target volume, respectively. The dose and dose volume parameters were evaluated for target, organs at risk, and normal tissue. Physical dose was converted to dose based on 2-Gy fractions (equivalent dose in 2 Gy per fraction, EQD 2 ) for comparison of 3 techniques. HDR and LDR significantly reduced the dose to rectum and bladder compared with VMAT. The D mean (EQD 2 ) of rectum decreased 22.36 Gy in HDR and 17.01 Gy in LDR from 30.24 Gy in VMAT, respectively. The D mean (EQD 2 ) of bladder decreased 6.91 Gy in HDR and 2.53 Gy in LDR from 13.46 Gy in VMAT. For the femoral heads and normal tissue, the mean doses were also significantly reduced in both HDR and LDR compared with VMAT. For the urethra, the mean dose (EQD 2 ) was 80.26, 70.23, and 104.91 Gy in VMAT, HDR, and LDR brachytherapy, respectively. For localized prostate cancer, both HDR and LDR brachytherapy were clearly superior in the sparing of rectum, bladder, femoral heads, and normal tissue compared with VMAT. HDR provided the advantage in sparing of urethra compared with VMAT and LDR. [ABSTRACT FROM AUTHOR]

Purpose: To analyse and compare the costs of hepatic tumor ablation with computed tomography (CT)-guided high-dose rate brachytherapy (CT-HDRBT) and CT-guided radiofrequency ablation (CT-RFA) as two alternative minimally invasive treatment options of hepatocellular carcinoma (HCC).Materials and Methods: An activity based process model was created determining working steps and required staff of CT-RFA and CT-HDRBT. Prorated costs of equipment use (purchase, depreciation, and maintenance), costs of staff, and expenditure for disposables were identified in a sample of 20 patients (10 treated by CT-RFA and 10 by CT-HDRBT) and compared. A sensitivity and break even analysis was performed to analyse the dependence of costs on the number of patients treated annually with both methods.Results: Costs of CT-RFA were nearly stable with mean overall costs of approximately 1909 €, 1847 €, 1816 € and 1801 € per patient when treating 25, 50, 100 or 200 patients annually, as the main factor influencing the costs of this procedure was the single-use RFA probe. Mean costs of CT-HDRBT decreased significantly per patient ablation with a rising number of patients treated annually, with prorated costs of 3442 €, 1962 €, 1222 € and 852 € when treating 25, 50, 100 or 200 patients, due to low costs of single-use disposables compared to high annual fix-costs which proportionally decreased per patient with a higher number of patients treated annually. A break-even between both methods was reached when treating at least 55 patients annually.Conclusion: Although CT-HDRBT is a more complex procedure with more staff involved, it can be performed at lower costs per patient from the perspective of the medical provider when treating more than 55 patients compared to CT-RFA, mainly due to lower costs for disposables and a decreasing percentage of fixed costs with an increasing number of treatments. [ABSTRACT FROM AUTHOR]

With conventional diagnostic X-ray machines with over couch X-ray tubes, it is not possible to obtain anteroposterior (AP) and lateral (Lat) radiographs without changing the posture of the patients. In an old 300 mA X-ray machine with a fluoroscopy screen (12.4 kg) (1995 model), by substituting the screen with suitable counterweight and making provision to take the hoist pillar up to the edge of the wall, we could get isocentric setup for a hospital stretcher kept near the chest stand. This setup provided acceptable AP-Lat radiographs for brachytherapy localization using "Perspex jig" (Nucletron, Netherlands) and field check radiographs in head and neck, esophagus patients for treatment planning. [ABSTRACT FROM AUTHOR]

Purpose: A meta-analysis is presented comparing clinical outcomes and toxicities between high dose rate (HDR) and pulsed dose rate (PDR) brachytherapy (BT) for anal cancer., Methods and Material: Retrospective or prospective clinical trials were identified on electronical databases. Data were collected per Preferred Reporting Items for Systematic Reviews and meta-Analyses guidelines. Pooled effect size for HDR and PDR BT were compared using subgroup analyses., Results: Nine retrospective studies with a total of 481 patients treated were included of which 219 with HDR and 262 with PDR. Significant differences were observed between the two groups for baseline characteristics and treatment. The cumulative proportion of stage T3-T4 was lower in the HDR group, 0.15 [95 % confidence interval (CI) 0.07-0.29] vs 0.27 [95 %CI 0.09-0.57] in the LDR group, p < 0.001. Lower BT doses (in equivalent 2-Gy fraction dose) were given for patients in the HDR group, 11.9 Gy [95 %CI 8.2-15.5] vs 19.5 Gy [95 %CI 15.0-24.0] in the PDR group, p < 0.001. No significant differences were found for clinical outcomes or toxicities. The pooled effect size of the overall survival at 5 years for HDR and PDR was respectively 0.82 [95 %CI 0.70-0.94] and 0.82 [95 %CI 0.73-0.91], p > 0.99. The 5 years local control was 0.86 [95 % confidence interval (CI) 0.81-0.91] and 0.83 [95 %CI 0.77-0.89], p = 0.62. Cumulative toxicity-related colostomy proportion was 0.04 [95 %CI 0.02-0.09] and 0.03 [95 %CI 0.02-0.07], p = 0.85., Conclusion: Both modalities provided a good profile of tolerance and are effective organ conservative strategies for patients with anal canal cancer. In parallel with ongoing developments to better determine the optimal fractionation and dose for HDR-BT treatments, especially in large tumors, PDR BT still has a crucial role for dose escalation strategy in advanced cases., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Funding: publication fees were supported by a funding from Elekta (project AMR 2021-0824)., (© 2023 The Authors. Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology.)

The intrinsic physical and radiobiological characteristics of High Dose Rate Brachytherapy (HDR-BT) are well suited to the treatment of prostate cancer. HDR-BT was initially used as a boost to external beam brachytherapy, but has subsequently been employed as the sole treatment, which is termed HDR monotherapy. This review summarizes the clinical outcomes and toxicity results of the principal studies and discusses the radiobiological basis supporting its use. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: To evaluate the dosimetric impact of heterogeneity corrections on both conventional and volume-optimized high-dose-rate (HDR) 192Ir brachytherapy tandem-and-ovoid treatment plans. Methods and Materials: Both conventional and volume-optimized treatment plans were retrospectively created using eight unique CT data sets. In the volume-optimized plans, the clinical target volume (CTV) and organs-at-risk (rectum, bladder, and sigmoid) were contoured on the CT data sets by a single physician. For each plan, dose calculations representing homogeneous water medium were performed using the Task Group (TG-43) formalism and dose calculations with heterogeneity corrections were performed using a commercially available treatment planning system. Results: For the conventional plans, the change in dose between TG-43 and heterogeneity-corrected calculations was assessed for the following points: Point-A (left and right) and International Commission on Radiation Units and Measurements (ICRU) 38 defined rectum and bladder points. It was found that the dose to the ICRU bladder decreased the most (−2.2±0.9%), whereas ICRU rectum (−1.7±0.8%), Point-A right (−1.1±0.4%), and Point-A left (−1.0±0.3%) also showed decreases with heterogeneity-corrected calculations. For the volume-optimized plans, the change in dose between TG-43 and heterogeneity-corrected calculations was assessed for the following dose–volume histogram parameters: D 90 of the CTV and D 2cc of the rectum, bladder, and sigmoid. It was found that D 90 of the CTV decreased by −1.9±0.7% and D 2cc decreased by −2.6±1.4%, −1.0±0.4%, and −2.0±0.6% for the rectum, bladder and sigmoid, respectively, with heterogeneity-corrected calculations. Conclusions: Heterogeneity corrections on high-dose rate plans were found to have only a small dosimetric impact over TG-43-based dose calculations for both conventional Point-A and volume-optimized plans. [Copyright &y& Elsevier]

Abstract: Background: Low-dose rate brachytherapy is a well established treatment modality of oral cancer. Data about high-dose rate (HDR) brachytherapy are still sparse with various fractionation schedules and heterogeneous results. Aim: The aim of our retrospective study was to evaluate the results of HDR brachytherapy with doses of 3Gy twice daily. Patients and methods: Twenty patients with squamous cell tongue cancer were treated in the years 2001–2009 by exclusive HDR BT 18×3Gy twice daily. The plastic tube technique was used. Median follow up was 47 months (7.8–118) since brachytherapy. Results: The local and locoregional control was 85% and 68%, respectively. Bone necrosis developed in one case treated without mandibular shielding and soft tissue necrosis in 2 cases. Conclusion: It can be concluded that HDR brachytherapy with 18×3Gy twice daily is safe with promising local control. The risk of nodal recurrences is substantial. [Copyright &y& Elsevier]

Abstract: Purpose: A patient with a lateral oral tongue cancer was treated with high–dose rate brachytherapy using an oral applicator with embedded lead shielding making conventional simulation, using either kilovoltage computed tomography or radiographs, impossible because of scatter artifact. Methods and materials: Treatment simulation was accomplished using megavoltage computed tomography (MVCT) simulation on a helical tomotherapy unit. Because of difficulty in visualization of the catheters on the patient MVCT images, Velocity AI image registration software (Velocity Medical Solutions, Atlanta, GA) was used to register an MVCT of the applicator itself with the patient MVCT simulation. The treatment plan was manually optimized to prescribe 4Gy/fraction to the gross tumor volume. Results: The patient tolerated the treatment well, with no evidence of disease 6 months after treatment. Thermoluminescent dosimeter measurements showed that the shielding reduced the dose by up to 90%, depending on the location of the thermoluminescent dosimeter. While the patient was treated using dose distributions calculated in a homogeneous medium (Task Group-43), an approximation of the true dose distributions was retrospectively calculated using Acuros (Varian Medical Systems Inc., Palo Alto, CA), which accounts for heterogeneities in the patient. Discussion: Use of the MVCT with image registration allowed treatment planning in the presence of lead shielding. Dose–volume histograms showed that recalculation of the dose using heterogeneity correction did not affect the dose to the gross tumor volume, but that the dose to normal structures (maxilla and mandible) was reduced by the lead shielding. Conclusion: The use of MVCT and image registration allows for optimized planning in the presence of shielding, which would not be possible with conventional kilovoltage computed tomography. [Copyright &y& Elsevier]

Abstract: Purpose: It is a good practice for quality assurance purposes to check the high–dose rate brachytherapy source dwell times obtained from any computerized treatment planning system (TPS) by independent hand calculations. The aim of this work was to prepare a table that would help to calculate the total dwell times for cylindrical applicators used for high–dose rate brachytherapy. Methods and Materials: The results of an earlier investigation of dose rate per unit source strength at different distances from the microSelectron-high–dose rate 192Ir source and the relative weights for dwell times obtained from optimized plans were used to prepare a linear source table. Results: This table gives the product of source strength and total dwell times to deliver 1000cGy at various distances for active lengths ranging from 1 to 8cm and for treatment distances of 1 to 2.25cm. One can use this table to determine the total dwell time necessary to deliver the prescribed dose at a specific distance for the source strength at the time of treatment. This can be compared with the total dwell time calculated by the computerized TPS. Conclusion: The linear source table makes the determination of total dwell time very easy and would help the clinical physicist to check the accuracy of results of the TPS quickly. [Copyright &y& Elsevier]

Abstract: Background: The main treatment given for initial stage facial epitheliomas is surgery, although there are alternatives. We present our results with Ir-192 high–dose rate (HDR) contact brachytherapy. Methods and Materials: Fifty-one epitheliomas, with a mean size of 1.5cm and a maximum thickness of 3mm, were treated with HDR contact brachytherapy by means of customized molds, with plastic tubes on bolus for flat surfaces and on wax molds for the nose. A total dose of 48–57Gy, 3–4Gy/fraction three times a week, was administered. Results: After a median followup of 45 months, five tumors relapsed (9.8%), four of them on the tip of the nose. The 5-year actuarial local control rate was 89%, 100% for flat surfaces, and 83% for the nose. All of them were salvaged with surgery. The treatment was well tolerated, 21.6% developed severe acute toxicity, with good or very good late cosmetic results. Conclusion: HDR contact brachytherapy is a good alternative to treat facial epitheliomas with a maximum thickness of 3mm. Tip of the nose tumors are not well covered with this technique and a different procedure is required. [Copyright &y& Elsevier]

Purpose: To evaluate the 10-year outcomes of intermediate- and high-risk prostate cancer patients treated with a prospective dose escalation hypofractionated trial of pelvic external beam radiation therapy (P-EBRT) with a high-dose-rate (HDR) brachytherapy boost. Methods and Materials: From 1992 to 2007, 472 patients were treated with a HDR boost at William Beaumont Hospital. They had at least one of the following: a prostate-specific antigen (PSA) level of >10 ng/ml, a Gleason score of ≥7, or clinical stage ≥T2b. Patients received 46-Gy P-EBRT and an HDR boost. The HDR dose fractionation was divided into two dose levels. The prostate biologically equivalent dose (BED) low-dose-level group received <268 Gy, and the high-dose group received >268 Gy . Phoenix biochemical failure (BF) definition was used. Results: Median follow-up was 8.2 years (range, 0.4-17 years). The 10-year biochemical failure rate of 43.1% vs. 18.9%, (p < 0.001), the clinical failure rate of 23.4% vs. 7.7%, (p < 0.001), and the distant metastasis of 12.4% vs. 5.7%, (p = 0.028) were all significantly better for the high-dose level group. On Cox multivariate analysis, higher BED levels (p = 0.017; hazard ratio [HR] = 0.586), pretreatment PSA assays (p < 0.001, HR = 1.022), and Gleason scores (p = 0.004) were significant variables for reduced biochemical failure. Higher dose levels (p, 0.002; HR, 0.397) and Gleason scores (p < 0.001) were significant for clinical failure. Grade 3 genitourinary complications were 2% and 3%, respectively, and grade 3 gastrointestinal complication was <0.5%. Conclusions: This prospective trial using P-EBRT with HDR boost and hypofractionated dose escalation demonstrates a strong dose-response relationship for intermediate- and high-risk prostate cancer patients. The improvement at 10 years for locoregional control with higher radiation doses (BED, > 268Gy) has significantly decreased biochemical and clinical failures as well as distant metastasis. [Copyright &y& Elsevier]

Abstract: Purpose: In the management of soft tissue sarcomas, perioperative radiation therapy has been used to reduce the risk of local recurrence after resection. However, a significance of postoperative high–dose rate brachytherapy (HDRBT) remains to be studied. Retrospective analysis was performed to elucidate the role of postoperative HDRBT. Methods and Materials: Twenty-five patients with 26 soft tissue sarcoma lesions underwent postoperative HDRBT using 192Ir remote afterloader without external beam radiation therapy. Ninety-two percent of the lesions were Grade 2 or 3 malignancies, and 50% were resected with positive surgical margins. The remaining 50% had very close margins. Fourteen lesions were treated for local recurrences after previous resections. Applicators of HDRBT were placed during the operation to include only the tumor bed excluding surgical scars. Applied dose was mainly 36Gy/6 fractions/3 d b.i.d. Results: Five-year local recurrence-free survival was 78.2% in all the 26 lesions. Recurrences were not seen within the treated volume of HDRBT. Two groups were defined according to the marginal status and number of previous operations. Group 1 was the lesions with a positive margin and foregoing resections. The remaining lesions were classified as Group 2. Five-year local recurrence-free survival was 43.8% and 93.3% in Group 1 and Group 2, respectively with a statistically significant difference (p =0.004). Conclusions: Postoperative HDRBT was effective in controlling local lesions; but in Group 1 lesions, addition of a wide field external beam radiation therapy seems to be necessary to improve the local control rate. [ABSTRACT FROM AUTHOR]

The article discusses the study which examines the effectiveness of concurrent chemoradiotherapy (CCRT) using high-dose rate intracavitary brachytherapy (HDRICB) to treat patients with patients with advanced cervical cancer. Based on cohort analysis, there were 73 cancer patients have treated with a three-insertion schedule of cisplatin therapy for bladder complications. Meanwhile, physicians have emphasized the interval between drug administration and HDRICB to avoid synergistic effects.

The article offers information on a study which investigated the possible causes and determined risk factors for the increased incidence of nausea and vomiting in patients with prostate cancer being treated with high-dose rate brachytherapy (HDRB). Information on the study subjects is given. Findings from the independent variables studied, such as anesthetics, morphine and method of transport, among others, are discussed.

OBJECTIVE To analyse retrospectively the morbidity and efficacy of high-dose rate (HDR) brachytherapy in patients who had a previous transurethral resection of the prostate (TURP). PATIENTS AND METHODS Morbidities documented in the records of 32 patients with previous TURP and 106 with no previous TURP, treated with HDR brachytherapy for prostate cancer at our institution, were analysed and compared. All patients received HDR brachytherapy as a boost before conformal external beam radiotherapy. We recorded and analysed genitourinary complications, rectal morbidity, and the biochemical control rate as assessed by the prostate-specific antigen (PSA) level. RESULTS All complications of patients who received HDR brachytherapy were recorded during the follow-up. All gastrointestinal and genitourinary complications were not significantly different in patients with or without previous TURP. There was little incontinence or severe morbidity associated with HDR brachytherapy. The PSA-based biochemical control rates were similar in patients with or without previous TURP in each risk group. CONCLUSIONS HDR brachytherapy is a reasonable treatment for localized prostate cancer in patients who have had a previous TURP, with the expectation of low morbidity and satisfactory biochemical control. [ABSTRACT FROM AUTHOR]

Abstract: Objective. : There is no standard high-dose-rate (HDR) brachytherapy dose for locally advanced cervical cancer. The objective of this study was to determine the efficacy, toxicity and clinicopathologic predictive markers affecting survival using cisplatin (CDDP) concomitant with external beam pelvic radiotherapy (EBRT) and two 9-Gy HDR insertions for the treatment of locally advanced cervical cancer. Methods. : 77 consecutive patients with Stage IB2–IV cervical cancer treated with CDDP, EBRT and two 9-Gy HDR insertions were included. Kaplan–Meier methods and Cox proportional hazards models were applied for survival statistics. Results. : Median age was 53. 90% had squamous cell carcinoma. Median follow-up time was 3.5 years (range 0.5–12 years). Overall 5-year progression-free survival (PFS) was 75%. Local control rate and 5-year PFS were 88% and 83%, respectively, for Stages IB2/II, and 68% and 61%, respectively, for Stages III/IV. Grade 3/4 GI symptoms were the most common acute side effects (47%). Grade 3/4 late toxicities occurred in five (6%) patients. Conclusions. : HDR brachytherapy regimens consisting of two 9-Gy HDR insertions have similar efficacy and side effect profiles as other brachytherapy regimens for the treatment of cervical cancer with improved safety and patient convenience. [Copyright &y& Elsevier]

In men with locally advanced/high-risk prostate cancer, there is an ongoing challenge to achieve improved results. Dose escalation studies using three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT) have shown benefit particularly in the intermediate and poor risk groups of patients. Of concern, however, is the increase in documented rectal toxicity. High-dose rate brachytherapy (HDR-BT) as a boost in combination with external beam radiotherapy (EBRT) is an alternative strategy of dose escalation that can potentially achieve an even higher biological equivalent dose (BED) to the tumour. The results so far are very encouraging for men with poor prognosis disease. Moreover the technique is associated with very low rates of acute and late toxicity.Prostate Cancer and Prostatic Diseases (2006) 9, 370–373. doi:10.1038/sj.pcan.4500893; published online 11 July 2006 [ABSTRACT FROM AUTHOR]

Purpose: To test, though a control-cohort study, the hypothesis that concurrent chemoradiotherapy (CCRT) using weekly cisplatin, plus high-dose rate intracavitary brachytherapy (HDRICB) is superior to radiation (RT) alone in patients with advanced cervical cancer. Methods and Materials: A total of 171 patients with Stage IIB–III cervical cancer were enrolled in this study. Seventy patients were treated with CCRT and the results were compared with those of 101 patients who had been treated with RT using the same protocol at an early period. RT consisted of 45 Gy in 25 fractions to the whole pelvis, followed by a 12.6-Gy boost to the parametrium. Four courses of HDRICB using 6.0 Gy to Point A were performed. Chemotherapy consisted of weekly cisplatin at a dose of 40 mg/m2 for 5–6 cycles. Results: The 4-year actuarial survival was 74% for the CCRT group and 68% for the RT group (p = 0.60). The 4-year pelvic relapse-free survival was 87% for the CCRT group and 85% for the RT group (p = 0.37). The 4-year distant metastases-free survival was 75% for the CCRT group and 76% for the RT group (p = 0.44). The cumulative incidence of gastrointestinal and genitourinary injuries of grade 3 or above was 14.3% for the CCRT group and 7.9% for the RT group (p = 0.19). Conclusion: This study did not show a survival benefit of CCRT with weekly cisplatin and HDRICB for Stage II–III cervical cancer, nor did it demonstrate a significant increase of late complications when comparing with RT alone. [Copyright &y& Elsevier]

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Purpose: Several investigations have revealed that the α/β ratio for prostate cancer is atypically low, and that hypofractionation or high-dose-rate (HDR) brachytherapy regimens using appropriate radiation doses may be expected to yield tumor control and late sequelae rates that are better or at least as favorable as those achieved with conventional radiation therapy. In this setting, we attempted treating localized prostate cancer patients with HDR brachytherapy combined with hypofractionated external beam radiation therapy (EBRT). The purpose of this study was to evaluate the feasibility of using this approach, with special emphasis on the relationship between the severity of acute genitourinary (GU) toxicity and the urethral dose calculated from the dose–volume histogram (DVH) of HDR brachytherapy. Methods and Materials: Between September 2000 and December 2003, 70 patients with localized prostate cancer were treated by iridium-192 HDR brachytherapy combined with hypofractionated EBRT at the Gunma University Hospital. Hypofractionated EBRT was administered in fraction doses of 3 Gy, three times per week; a total dose of 51 Gy was delivered to the prostate gland and the seminal vesicles using the four-field technique. No elective pelvic irradiation was performed. After the completion of EBRT, all the patients additionally received transrectal ultrasonography (TRUS)-guided HDR brachytherapy. The fraction size and the number of fractions in HDR brachytherapy were prospectively changed, whereas the total radiation dose for EBRT was fixed at 51 Gy. The fractionation in HDR brachytherapy was as follows: 5 Gy × 5, 7 Gy × 3, 9 Gy × 2, administered twice per day, although the biologic effective dose (BED) for HDR brachytherapy combined with EBRT, assuming that the α/β ratio is 3, was almost equal to 138 in each fractionation group. The planning target volume was defined as the prostate gland with 5-mm margin all around, and the planning was conducted based on computed tomography images. The number of patients in each fractionation group was as follows: 13 in the 5-Gy group; 19 in the 7-Gy group, and 38 in the 9-Gy group. The tumor stage was T1 in 10 patients, T2 in 36 patients, and T3 in 24 patients. The Gleason score was 2–6 in 11 patients, 7 in 34 patients, and 8–10 in 25 patients. Androgen ablation was performed in all the patients. The median follow-up duration was 14 months (range 3–42 months). The toxicities were graded based on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity criteria. Results: The main symptoms of acute GU toxicity were dysuria and increase in urinary frequency or nocturia. The grade distribution of acute GU toxicity in the patients was as follows: Grade 0–1, 39 patients (56%), and Grade 2–4, 31 patients (44%). One patient who developed acute urinary obstruction was classified as having Grade 4 toxicity. Comparison of the distribution of the grade of acute GU toxicity among the different fractionation groups revealed no statistically significant differences among the groups. The urethral dose in HDR brachytherapy was evaluated using the following DVH parameters: V30 (percentage of the urethral volume receiving 30% of the prescribed radiation dose), V80, V90, V100, V110, V120, V130, and V150. The V30–110 values in the patients with Grade 2–4 acute GU toxicity were significantly higher than those in patients with Grade 0–1 toxicity. On the other hand, there were no significant differences in the V120–150 values between patients with Grade 0–1 and Grade 2–4 toxicity. Regarding the influence of the number of needles implanted for the radiation therapy, patients with 11 needles or less showed a significantly higher incidence of Grade 2–4 acute GU toxicity compared with those with 12 needles or more (p &#60; 0.05). Conclusions: It was concluded that HDR brachytherapy combined with hypofractionated EBRT is feasible for localized prostate cancer when considered from the viewpoint of acute toxicity. Increase in the fraction dose or reduction in the number of fractions in HDR brachytherapy did not affect the severity of acute GU toxicity, and the volume of urethra receiving an equal or lower radiation dose than the prescribed dose was more closely associated with the grade severity of acute GU toxicity than that receiving a higher than the prescribed dose. [Copyright &y& Elsevier]

Objective. To determine the efficacy of high-dose rate brachytherapy as adjuvant treatment for Stage I/II papillary serous or clear cell endometrial cancer.Methods. A retrospective study of all patients with Stage I/II papillary serous or clear cell endometrial cancer treated with high-dose rate brachytherapy between 1995 and 2001 was performed. Following surgical staging, which included hysterectomy with pelvic and aortic lymphadenectomy, all patients without extrauterine disease were treated with high-dose rate brachytherapy and followed for recurrence. The locations of recurrences were noted and were classified as local or distant.Results. Three (13%) recurrences occurred among 24 patients with Stage I/II papillary serous or clear cell carcinoma. The risk of recurrence was similar for papillary serous and clear cell cancer (12% vs. 12%). Local control was achieved in 96%. The risk of recurrence for those with no myometrial invasion, less than 1/2, or more than 1/2 myometrial invasion was 0%, 10%, and 50%, respectively (P < 0.04). Two of the three recurrences were distant and all patients with recurrence died despite additional treatment.Conclusions. High-dose rate brachytherapy (HDR) as the sole adjuvant treatment of Stage I/II papillary serous or clear cell carcinoma is associated with a 13% risk of recurrence. Although local control with HDR is excellent, the risk of distant recurrence is increased with deep myometrial invasion. High-dose rate brachytherapy is adequate for Stage IA cases, but more aggressive treatment combining chemotherapy with HDR should be evaluated for more advanced Stage I/II cases. [Copyright &y& Elsevier]

The effect of therapeutic modalities on sexual potency is an important consideration for patients choosing a treatment for prostate cancer. We assessed erectile function after iridium-192 (1r-192) high-dose rate (HDR) brachytherapy with external beam radiation therapy (EBRT), and examined the efficacy of sildenafil after this treatment. Forty-two prostate cancer patients (T1c to T3bN0M0) were treated with 22Gy HDR brachytherapy with 36.8Gy EBRT without neoadjuvant hormone therapy. Erectile function was assessed using a 5-item version of the International Index of Erectile Function questionnaire (IIEF-5), pre, 3 and 12 months after treatment, Potency was defined as an IIEF-5 score ≥11. Ten patients with potency before HDR brachytherapy with EBRT with or without neoadjuvant hormone therapy requested Sildenafil 3 months after treatment. The mean IIEF-5 score of all patients was 10.5 ± 8.5, 4.5 ± 5.3 (p < 0.001), and 3.8 ± 4.7 (p < 0.001), pre, 3 and 12 months after treatment, respectively. Seventeen (40.4%) patients were potent before treatment. The mean IIEF-5 score of those patients was 15.8 ± 3.2, 9.6 ± 5.1 (p = 0.04), and 11.3 ± 6.1 (p = 0.06), pre, 3 and 12 months after treatment, respectively. Ten of 17 (58.8%) patients maintained their potency 12 months after treatment. In 10 patients with potency before treatment who were treated with sildenafil, the mean IIEF-5 score increased from 6.2 ± 3.5 at 3 months to 13.6 ± 5.1 (p < 0.001) at 12 months after treatment. Eight of 10 (80%) patients treated with sildenafil had recovered 12 months after treatment. HDR brachytherapy with EBRT can be performed with favorable results for maintaining potency. [ABSTRACT FROM AUTHOR]

Purpose: To introduce a new optimization algorithm that improves DVH results and is designed for the type of heterogeneous dose distributions that occur in brachytherapy. Methods: The new optimization algorithm is based on a prior mathematical approach that uses mean doses of the DVH metric tails. The prior mean dose approach is referred to as conditional value-at-risk (CVaR), and unfortunately produces noticeably worse DVH metric results than gradient-based approaches. We have improved upon the CVaR approach, using the so-called Truncated CVaR (TCVaR), by excluding the hottest or coldest voxels in the structure from the calculations of the mean dose of the tail. Our approach applies an iterative sequence of convex approximations to improve the selection of the excluded voxels. Data Envelopment Analysis was used to quantify the sensitivity of TCVaR results to parameter choice and to compare the quality of a library of 256 TCVaR plans created for each of prostate, breast, and cervix treatment sites with commercially-generated plans. Results: In terms of traditional DVH metrics, TCVaR outperformed CVaR and the improvements increased monotonically as more iterations were used to identify and exclude the hottest/coldest voxels from the optimization problem. TCVaR also outperformed the Eclipse-Brachyvision TPS, with an improvement in PTVD95% (for equivalent organ-at-risk doses) of up to 5% (prostate), 3% (breast), and 1% (cervix). Conclusions: A novel optimization algorithm for HDR treatment planning produced plans with superior DVH metrics compared with a prior convex optimization algorithm as well as Eclipse-Brachyvision. The algorithm is computationally efficient and has potential applications as a primary optimization algorithm or quality assurance for existing optimization approaches., (© 2020 IOP Publishing Ltd.)

3D image-guided brachytherapy (3D-IGBT) has become a standard therapy for cervical cancer. However, the use of 3D-IGBT is limited in East and Southeast Asia. This study aimed to clarify the current usage patterns of 3D-IGBT for cervical cancer in East and Southeast Asia. A questionnaire-based survey was performed in 11 countries within the framework of the Forum for Nuclear Cooperation in Asia. The questionnaire collected the treatment information of patients with cervical cancer who underwent 3D-IGBT. The cumulative external beam radiotherapy and 3D-IGBT doses were summarized and normalized to a biological equivalent dose of 2 Gy per fraction (EQD2) using a linear-quadratic model. Of the 11 institutions representing the participating countries, six (55%) responded to the questionnaire. Overall, data of 36 patients were collected from the six institutions. Twenty-one patients underwent whole-pelvic irradiation and 15 underwent whole-pelvic irradiation with central shielding. Patients received a median of four treatment sessions of 3D-IGBT (range, 2-6). All 3D-IGBT sessions were computed tomography (CT)-based and not magnetic resonance image-based. The median doses to the high-risk clinical target volume D90, bladder D2cc, rectum D2cc and sigmoid colon D2cc were 80.9 Gy EQD2 (range, 58.9-105.9), 77.7 Gy EQD2 (range, 56.9-99.1), 68.0 Gy EQD2 (range, 48.6-90.7) and 62.0 Gy EQD2 (range, 39.6-83.7), respectively. This study elucidated the current patterns of 3D-IGBT for the treatment of cervical cancer in East and Southeast Asia. The results indicate the feasibility of observational studies of CT-based 3D-IGBT for cervical cancer in these countries., (© The Author(s) 2020. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.)

Background: In recent years, the delayed side effects associated with radiotherapy for prostate cancer have drawn the interest of urologists. Although urosymphyseal fistula is one of these delayed side effects, this serious complication is rarely described in literature and is poorly recognized., Case Presentation: We report our experience in treating a 77-year-old male patient with necrotizing fasciitis after high-dose rate brachytherapy plus external beam radiation for prostate cancer. The patient was referred to our hospital with complaints of inguinal swelling and fever. He had a past history of radiotherapy for prostate cancer and subsequent transurethral operation for a stricture of the urethra. Computed tomography showed extensive gas within the femoral and retroperitoneal tissues and pubic bone fracture. Surgical exploration suggested that necrotizing fasciitis was caused by urosymphyseal fistula., Conclusion: To the best of our knowledge, this is the first case report of necrotizing fasciitis caused by urosymphyseal fistula after radiotherapy for prostate cancer. There is a strong association between urosymphyseal fistula and prostate radiotherapy with subsequent surgical intervention for bladder neck contracture or urethral stricture. Therefore, surgical treatment for bladder neck contracture or urethral stricture after radiotherapy for prostate cancer should be performed with care. The present case emphasizes the importance of early diagnosis of urosymphyseal fistula. Immediate removal of necrotic tissues and subsequent urinary diversion in the present case may have led to good patient outcome.

Herein, we investigate the long-term clinical outcomes for cervical cancer patients treated with in-room computed tomography-based brachytherapy. Eighty patients with Stage IB1-IVA cervical cancer, who had undergone treatment with combined 3D high-dose rate brachytherapy and conformal radiotherapy between October 2008 and May 2011, were retrospectively analyzed. External beam radiotherapy (50 Gy) with central shielding after 20-40 Gy was performed for each patient. Cisplatin-based chemotherapy was administered concurrently to advanced-stage patients aged ≤75 years. Brachytherapy was delivered in four fractions of 6 Gy per week. In-room computed tomography imaging with applicator insertion was performed for treatment planning. Information from physical examinations at diagnosis, and brachytherapy and magnetic resonance imaging at diagnosis and just before the first brachytherapy session, were referred to for contouring of the high-risk clinical target volume. The median follow-up duration was 60 months. The 5-year local control, pelvic progression-free survival and overall survival rates were 94%, 90% and 86%, respectively. No significant differences in 5-year local control rates were observed between Stage I, Stage II and Stage III-IVA patients. Conversely, a significant difference in the 5-year overall survival rate was observed between Stage II and III-IVA patients (97% vs 72%; P = 0.006). One patient developed Grade 3 late bladder toxicity. No other Grade 3 or higher late toxicities were reported in the rectum or bladder. In conclusion, excellent local control rates were achieved with minimal late toxicities in the rectum or bladder, irrespective of clinical stage., (© The Author 2016. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.)

Purpose: The efficacy of image-guided high-dose rate brachytherapy for cervical cancer is limited by the ineffective rectal sparing devices available commercially and the potential applicator movement. We developed a novel device using a balloon catheter and a belt immobilization system, serving for rectal dose reduction and applicator immobilization purposes, respectively., Methods: The balloon catheter is constructed by gluing a short inflatable tube to a long regular open-end catheter. Contrast agent (10) cm 3 is injected into the inflatable end, which is affixed to the tandem and ring applicator, to displace the posterior vaginal wall. The belt immobilization system consists of a specially designed bracket that can hold and fix itself to the applicator, a diaper-like Velcro fastener package used for connecting the patient's pelvis to the bracket, and a buckle that holds the fasteners to stabilize the whole system. The treatment data for 21 patients with cervical cancer using both balloon catheter and belt immobilization system were retrospectively analyzed. Computed tomography and magnetic resonance images, acquired about 30 minutes apart, were registered to evaluate the effectiveness of the immobilization system., Results: In comparison with a virtual rectal blade, the balloon decreased the rectal point dose by 34% ± 4.2% (from 276 ± 57 to 182 ± 38 cGy), corresponding to an extra sparing distance of 7.9 ± 1.1 mm. The maximum sparing distance variation per patient is 1.4 ± 0.6 mm, indicating the high interfractional reproducibility for rectum sparing. With the immobilization system, the mean translational and rotational displacements of the applicator set are <3 mm and <1.5°, respectively, in all directions., Conclusions: The rectal balloon provides significant dose reduction to the rectum and it may potentially minimize patient discomfort. The immobilization system permits almost no movement of the applicator during treatment. This work has the potential to be promoted as a standardized solution for high-dose rate treatment of cervical cancer.