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Purpose: Retrospective, single-institution analysis of clinical outcomes and treatment-related toxicity in patients treated with salvage I-125 low-dose rate (LDR) brachytherapy (BT) for locally-recurrent prostate cancer after radiotherapy. Materials and methods: Between 2008 and 2018, 30 patients with biopsy-confirmed prostate cancer recurrence underwent salvage treatment with 1-125 LDR-BT. Of these 30 patients, 14 were previously treated with primary external beam radiotherapy (EBRT; median dose, 73 Gy) and 16 with primary I-125 LDR-BT (145 Gy and 160 Gy in 14 and 2 cases, respectively). At seed implantation, the mean age was 75.8 years, with a median Gleason score of 7 and pre-salvage PSA of

Purpose: To retrospectively evaluate biochemical control and toxicity in patients who underwent 1251 seed brachytherapy (BT) for intermediate-risk prostate cancer (PCa). Materials and Methods: Between January 2004-December 2014, 395 patients with intermediate-risk PCa underwent 1251 BT. Of these, 117 underwent preoperative planning (PP; 145 Gy) and 278 real-time intraoperative preplanning (IoP ; 160 Gy). All patients were followed for >= 6 months (> 5 years in 48% of patients and > 7 years in 13%). Median follow-up was 59 months. Results: Biochemical relapse-free survival (BRFS) rates at 5 and 8 years were, respectively, 91.7% and 82.1%. By treatment group, the corresponding BRFS rates were 93.5% and 90% for IoP and 89% and 76.8% for PP. The maximum dose to the urethra remained unchanged (217 Gy) despite the dose escalation (from 145 to 160 Gy), without any significant increase in treatment-related toxicity (p = 0.13). Overall toxicity outcomes in the series were excellent, with only 3 cases (0.76%) of grade 3 genitourinary toxicity. Conclusion: The real-time intraoperative planning technique at 160 Gy yields better biochemical controls than the preoperative planning technique at 145 Gy. Dose escalation did not increase urinary toxicity. The excellent results obtained with the IoP BT technique support its use as the first treatment option in this patient population. (C) 2020 Greater Poland Cancer Centre. Published by Elsevier B.V. All rights reserved.

Purpose: The use of radiation therapy (RT) for non-melanoma skin cancer (NMSC) has been changing throughout the last century. Over the last decades, the use of radiotherapy has surged with the development of new techniques, applicators, and devices. In recent years, electronic brachytherapy (eBT) devices that use small x-ray sources have been introduced as alternative to radionuclide dependence. Nowadays, several devices have been incorporated, with a few series reported, and with a short follow-up, due to the recent introduction of these systems. The purpose of this work is to describe the clinical results of our series after two years follow-up with a specific eBT system. Material and methods: This is a prospective single-center, non-randomized pilot study, to assess clinical results of electronic brachytherapy in basal cell carcinoma using the Esteya (R) system. In 2014, 40 patients with 60 lesions were treated. Patient follow-up on a regular basis was performed for a period of two years. Results: Twenty-six patients with 44 lesions achieved two years follow-up. A complete response was documented in 95.5% of cases. Toxicity was mild (G1 or G2) in all cases, caused by erythema, erosion, or alopecia. Cosmesis was excellent in 88.6% of cases, and good in the rest. Change in pigmentation was the most frequent cosmetic alteration. Conclusions: This work is special, since the equipment's treatment voltage was 69.5 kV, and this is the first prospective study with long term follow-up with Esteya (R). These preliminary report show excellent results with less toxicity and excellent cosmesis. While surgery has been the treatment of choice, certain patients might benefit from eBT treatment. These are elderly patients with comorbidities or undergoing anticoagulant treatment as well as those who simply refuse surgery or might have other contraindications.

Purpose: Basal cell carcinoma (BCC) is a very common cancer in the Caucasian population. Treatment aims to eradicate the tumor with the lowest possible functional and aesthetic impact. Electronic brachytherapy (EBT) is a treatment technique currently emerging. This study aims to show the outcomes of two consecutive prospective pilot clinical trials using different radiation doses of EBT with Esteya (R) EB system for the treatment of superficial and nodular basal cell carcinoma. Material and methods: Two prospective, single-center, non-randomized, pilot studies were conducted. Twenty patients were treated in each study with different doses. The first group (1) was treated with 36.6 Gy in 6 fractions of 6.1 Gy, and the second group (2) with 42 Gy in 6 fractions of 7 Gy. Cure rate, acute toxicity, and late toxicity related to cosmesis were analyzed in the two treatment groups. Results: In group 1, a complete response in 90% of cases was observed at the first year of follow-up, whereas in group 2, the complete response was 95%. The differences with reference to acute toxicity and the cosmetic results between the two treatment groups were not statistically significant. Conclusions: Our initial experience with Esteya (R) EB system to treat superficial and nodular BCC shows that a dose of 36.6 Gy and 42 Gy delivered in 6 fraction of 7 Gy achieves a 90% and 95% clinical cure rate at 1 year, respectively. Both groups had a tolerable toxicity and a very good cosmesis. The role of EBT in the treatment of BCC is still to be defined. It will probably become an established option for selected patients in the near future.

Purpose: Surface electronic brachytherapy (EBT) is an alternative radiotherapy solution to external beam electron radiotherapy and high-dose-rate radionuclide-based brachytherapy. In fact, it is also an alternative solution to surgery for a subgroup of patients. The objective of this work is to confirm the clinical efficacy, toxicity and cosmesis of a new EBT system, namely Esteya ® in the treatment of nodular and superficial basal cell carcinoma (BCC). Material and methods: This is a prospective single-center, non-randomized pilot study to assess the efficacy and safety of EBT in nodular and superficial BCC using the Esteya ® system. The study was conducted from June 2014 to February 2015. The follow up time was 6 months for all cases. Results: Twenty patients with 23 lesions were included. A complete response was documented in all lesions (100%). A low level of toxicity was observed after the 4 th fraction in all cases. Erythema was the most frequent adverse event. Cosmesis was excellent, with more than 60% of cases without skin alteration and with subtle changes in the rest. Conclusions: Electronic brachytherapy with Esteya ® appears to be an effective, simple, safe, and comfortable treatment for nodular and superficial BCC associated with excellent cosmesis. It could be a good choice for elderly patients, patients with contraindications for surgery (due to comorbidities or anticoagulant drugs) or patients where surgery would result in a more disfiguring outcome. A longer follow-up and more studies are needed to confirm these preliminary results. J Contemp Brachytherapy 2015; 7, 3: 231-238 DOI: 10.5114/jcb.2015.52140

AIM: The present retrospective study was to compare toxicity and survival outcomes in a group of low-risk PCa patients treated with either the preoperative planning technique (145 Gy) or the real-time IoP technique (160 Gy). BACKGROUND: The two most common permanent seed implantation techniques are preoperative planning (PP) with 145 Gy and real-time intraoperative planning (IoP) with 160 Gy. Although IoP has largely replaced PP at many centres in recent years, few studies have directly compared these two techniques. MATERIALS AND METHODS: Retrospective study of 408 patients with low-risk PCa treated with permanent seed implant brachytherapy at our institution between October 2003 and December 2014. Of these, 187 patients were treated with PP at a dose of 145 Gy while 221 received real-time IoP with 160 Gy. RESULTS: At a median follow up of 90 months, 5- and 8-year rates of biochemical relapse-free survival (BRFS) were 94.8% and 86% with the IoP technique versus 90.8% and 83.9%, respectively, with PP. The maximum dose to the urethra was

Purpose: The purpose of this study is to compare high frequency ultrasonography (HFUS) and histpathologic assessment done by punch biopsy in order to determine depth of basal cell carcinoma (BCC), in both superficial and nodular BCCs prior to brachytherapy treatment. Material and methods: This study includes 20 patients with 10 superficial and 10 nodular BCCs. First, punch biopsy was done to confirm the diagnosis and to measure tumour depth (Breslow rate). Subsequently, HFUS was done to measure tumour depth to search for correlation of these two techniques. Results: Neither clear tendency nor significance of the punch biopsy vs. HFUS depth determination is observed. Depth value differences with both modalities resulted patient dependent and then consequence of its uncertainty. Conceptually, HFUS should determine the macroscopic lesion (gross tumour volume – GTV), while punch biopsy is able to detect the microscopic extension (clinical target volume – CTV). Uncertainties of HFUS are difficult to address, while punch biopsy is done just on a small lesion section, not necessarily the deepest one. Conclusions: According to the results, HFUS is less accurate at very shallow depths. Nodular cases present higher depth determination differences than superficial ones. In our clinical practice, we decided to prescribe at 3 mm depth when HFUS measurements give depth lesion values smaller than this value. J Contemp Brachytherapy 2014; 6, 4: 356–361 DOI: 10.5114/jcb.2014.47860

To the Editor: We have read with an interest the letter to the Editor titled “New technologies for non-melanoma skin cancer”. In this letter, the authors comment on our article [1] about the clinical implementation of a new system for skin brachytherapy (Esteya® electronic brachytherapy by Elekta, Stockholm, Sweden) and they asked for a reply to their letter. We would like to thank the authors for their interest in our publication and would like to respond to their letter. First of all we need to clarify that in our study we chose to exclude irregularly shaped lesions, lesions with a diameter > 2 cm, and lesions with a depth larger than 4 mm because of the design of the radiation therapy system that was used. Lesions included in our work using the specific features of the Esteya® device, in fact represent the vast majority of non-melanoma skin cancer primary presentations. The Esteya® electronic brachytherapy system (E-eBT) is delivered with a set of applicators up to 3 cm in diameter. When treating non-melanoma skin cancer, typically a margin of 0.5 cm is added to the GTV. Consequently, the maximum diameter of lesions to be treated is 2 cm. The system has a dose-gradient of about 8% per mm, therefore with lesions deeper than 0.4 cm, the overdose at the first skin layers will exceed 130% and this might impact cosmetic outcome. This is the reason we limited inclusion to lesions with a depth of 4 mm or less. Finally, E-eBT applicators are designed with a flat surface to allow full contact with the skin. Avoiding air gaps between applicator and skin is a prerequisite because of the significant impact of air gaps on the dose to the lesion. Nowadays, we have the possibility to use a new set of more precise applicators for treatment of lesions in difficult areas. When we say that irregular areas are not suitable for EBT, we only mean those locations that, despite applying some pressure, are not entirely in contact with the applicator. These cases should be treated with other types of brachytherapy/radiotherapy. In our experience there are only a few locations where one cannot get a flat surface by applying mild pressure. Only larger lesions in areas with angled surfaces result in bone or cartilage, for example impeding/preventing a flat surface being obtained; this can be on the inner canthus of the eye, or for example on the pinna, and on the peri-alar nose groove. We have, however, successfully treated several “difficult cases” of BCC located on for example the nasal tip, retroauricular region, and scalp with E-eBT. It is our experience that the vast majority of NMSC lesions can be treated with the Esteya® electronic brachytherapy system. We disagree with the authors of the letter stating that “NMSC often have irregular shapes and a diameter longer than 2 cm”, and “most cases of NMSC are recurrent and located in the periorbital area (i.e. inner canthus)”. In fact, most NMSC are small, usually less than 20 mm, and the majority of lesions are located on the face, especially on the nose. Both surgery and radiation therapy are very effective and recurrence is usually found in less than 10% of cases. There is, however, a bias of patients submitted to radiotherapy since only difficult cases and lesions that have failed other treatments are referred. Better communication and cooperation between dermatology and RT services will improve referral and benefit both patients and care givers. For the less frequent appearing lesions with dimensions and shapes that are outside of the range included in our study, other radiotherapy treatment solutions besides Esteya® electronic brachytherapy are available such as brachytherapy moulds, isotope based brachytherapy with interstitial-or flap applicators, and treatment with electrons. We have read with great interest the article of Pontoriero et al. [2] that the authors of the letter to the Editor referred to. In this article, Pontoriero et al. reported their experience treating a deeply invasive lesion on the inner canthus of the eye with the Cyberknife system. Although in their case report the patient seems to have a good clinical outcome, we do have some concerns with promoting this technology in general for skin cancer treatment around the eye based on this single case. We consider the risk of intrafraction-movement as high because of very long treatment time associated with the large number of beams. In addition, there are challenges associated with the dose build up in the first layers of the skin beam, the inverse planning calculation algorithm on the first fractions of millimeter of the skin, and the use of a bolus. Also, protecting the eye from radiation damage is not easy. In our opinion, more robust research is needed to prove this technique as safe and beneficial when other therapies, such as interstitial brachytherapy with more substantial evidences are available. That new sophisticated techniques such as “Cyber Knife®” – as Dr. Pontoriero described in his letter – or particulate radiation, as a proton beam therapy, etc., could be used in selected cases, complying properly the goals for treatment of theses tumors. But on the other hand, even when it is desirable, a good knowledge on the part of radiation oncologist specialist of the full potential of these new techniques is required. The cost and complexity of these techniques, together with the necessary investment in human resources to fit the goal of these treatments, as well as short follow up of every single case referred, become, at least in our opinion, the accurate approach as a non-elective treatment for non-melanoma skin cancer. In our practice, this type of lesions on the inner canthus use to be treated with an HDR interstitial implant, with catheters just subcutaneous, and the eyes protected with a lead sheet. Although it is small invasive procedure, in our hospitals we prefer it to IMRT because of the robustness, simplicity, eye protection, dose gradient through normal tissue, and guarantee of full coverage of the lesion. In our group, we have accumulated over years a great experience treating successfully this kind of difficult tumors with this approach. We want to express our gratitude to both the letter authors and the Journal Editor, to have the opportunity to include this discussion.

Although surgery is usually the first-line treatment for nonmelanoma skin cancers, radiotherapy (RT) may be indicated in selected cases. Radiation therapy as primary therapy can result in excellent control rates, cosmetics, and quality of life. Brachytherapy is a radiation treatment modality that offers the most conformal option to patients. A new modality for skin brachytherapy is electronic brachytherapy. This involves the placement of a high dose rate X-ray source directly in a skin applicator close to the skin surface, and therefore combines the benefits of brachytherapy with those of low energy X-ray radiotherapy. The Esteya electronic brachytherapy system is specifically designed for skin surface brachytherapy procedures. The purpose of this manuscript is to describe the clinical implementation of the new Esteya electronic brachytherapy system, which may provide guidance for users of this system. The information covered includes patient selection, treatment planning (depth evaluation and margin determination), patient marking, and setup. The justification for the hypofractionated regimen is described and compared with others protocols in the literature. Quality assurance (QA) aspects including daily testing are also included. We emphasize that these are guidelines, and clinical judgment and experience must always prevail in the care of patients, as with any medical treatment. We conclude that clinical implementation of the Esteya brachytherapy system is simple for patients and providers, and should allow for precise and safe treatment of nonmelanoma skin cancers.