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Purpose: Brachytherapy is a mandatory component of primary radiochemotherapy in cervical cancer. The dose can be applied with a traditional intracavitary approach (IC alone) or with multiple catheter brachytherapy to optimize dose distribution in an individual concept. We therefore evaluated whether the utilization of a tandem–ring applicator plus additional intracavitary applicators (add IC) provides an advantage over the traditional IC alone approach, as this method is less time consuming and less invasive compared to a combined intracavitary/interstitial brachytherapy. Methods: Twenty three procedures of intracavitary brachytherapy for cervical cancer with additional intracavitary applicators performed in seven patients treated between 2016 and 2018 in our institution were included in this study. Plans were optimized for D90 HR-CTV with and without the utilization of the additional applicators and compared by statistical analysis. Results: D90 for HR-CTV was 5.71 Gy (±1.17 Gy) for fractions optimized with add IC approach and 5.29 Gy (±1.24 Gy) for fractions without additional applicators (p < 0.01). This translates to a calculated mean EQD2 HR-CTV D90 of 80.72 Gy (±8.34 Gy) compared to 77.84 Gy (±8.49 Gy) after external beam therapy and four fractions of brachytherapy for add IC and IC alone, respectively (p < 0.01). The predictive value of improved coverage of HR-CTV in the first fraction was high. Conclusion: In a subgroup of cases, the addition of intracavitary Heyman capsules can be an alternative to interstitial brachytherapy to improve the plan quality compared to standard IC alone brachytherapy. The benefit from the addition of applicators in the first fraction is predictive for the following fractions. [ABSTRACT FROM AUTHOR]

(1) In breast-conserving therapy (BCT), adjuvant radiation, including tumor bed boost, is mandatory. Safely delivered thermal boost (TB) based on radio-sensitizing interstitial microwave hyperthermia (MWHT) preceding standard high-dose-rate (HDR) brachytherapy (BT) boost has the potential for local control (LC) improvement. The study is to report the long-term results regarding LC, disease-free survival (DFS), overall survival (OS), toxicity, and cosmetic outcome (CO) of HDR-BT boost ± MWHT for early breast cancer (BC) patients treated with BCT. (2) In the years 2006 and 2007, 57 diverse stages and risk (IA-IIIA) BC patients were treated with BCT ± adjuvant chemotherapy followed by 42.5–50.0 Gy whole breast irradiation (WBI) and 10 Gy HDR-BT boost. Overall, 25 patients (group A; 43.9%) had a BT boost, and 32 (group B; 56.1%) had an additional pre-BT single session of interstitial MWHT on a tumor bed. Long-term LC, DFS, OS, CO, and late toxicity were evaluated. (3) Median follow-up was 94.8 months (range 1.1–185.5). LC was 55/57, or 96.5% (1 LR in each group). DFS was 48/57, or 84.2% (4 failures in group A, 5 in B). OS was 46/57, or 80.7% (6 deaths in group A, 5 in B). CO was excellent in 60%, good in 36%, and satisfactory in 4% (A), and in 53.1%, 34.4%, and 9.4% (B), respectively. One poor outcome was noted (B). Late toxicity as tumor bed hardening occurred in 19/57, or 33.3% of patients (9 in A, 10 in B). In one patient, grade 2 telangiectasia occurred (group A). All differences were statistically insignificant. (4) HDR-BT boost ± TB was feasible, well-tolerated, and highly locally effective. LC, DFS, and OS were equally distributed between the groups. Pre-BT MWHT did not increase rare late toxicity. [ABSTRACT FROM AUTHOR]

Purpose: To present a novel, MRI‐compatible dynamicshield intensity modulated brachytherapy (IMBT) applicator and delivery system using 192Ir, 75Se, and 169Yb radioisotopes for the treatment of locally advanced cervical cancer. Needle‐free IMBT is a promising technique for improving target coverage and organs at risk (OAR) sparing. Methods and materials: The IMBT delivery system dynamically controls the rotation of a novel tungsten shield placed inside an MRI‐compatible, 6‐mm wide intrauterine tandem. Using 36 cervical cancer cases, conventional intracavitary brachytherapy (IC‐BT) and intracavitary/interstitial brachytherapy (IC/IS‐BT) (10Ci 192Ir) plans were compared to IMBT (10Ci 192Ir; 11.5Ci 75Se; 44Ci 169Yb). All plans were generated using the Geant4‐based Monte Carlo dose calculation engine, RapidBrachyMC. Treatment plans were optimized then normalized to the same high‐risk clinical target volume (HR‐CTV) D90 and the D2cc for bladder, rectum, and sigmoid in the research brachytherapy planning system, RapidBrachyMCTPS. Plans were renormalized until either of the three OAR reached dose limits to calculate the maximum achievable HR‐CTV D90 and D98. Results: Compared to IC‐BT, IMBT with either of the three radionuclides significantly improves the HR‐CTV D90 and D98 by up to 5.2% ± 0.3% (P < 0.001) and 6.7% ± 0.5% (P < 0.001), respectively, with the largest dosimetric enhancement when using 169Yb followed by 75Se and then 192Ir. Similarly, D2cc for all OAR improved with IMBT by up to 7.7% ± 0.6% (P < 0.001). For IC/IS‐BT cases, needle‐free IMBT achieved clinically acceptable plans with 169Yb‐based IMBT further improving HR‐CTV D98 by 1.5% ± 0.2% (P = 0.034) and decreasing sigmoid D2cc by 1.9% ± 0.4% (P = 0.048). Delivery times for IMBT are increased by a factor of 1.7, 3.3, and 2.3 for 192Ir, 75Se, and 169Yb, respectively, relative to conventional 192Ir BT. Conclusions: Dynamic shield IMBT provides a promising alternative to conventional IC‐ and IC/IS‐BT techniques with significant dosimetric enhancements and even greater improvements with intermediate energy radionuclides. The ability to deliver a highly conformal, OAR‐sparing dose without IS needles provides a simplified method for improving the therapeutic ratio less invasively and in a less resource intensive manner. [ABSTRACT FROM AUTHOR]

Objective: Boost radiation using brachytherapy (BT) is a standard treatment for local disease control in concomitant chemoradiation therapy (CCRT) for advanced cervical cancer. However, it is associated with gastrointestinal and genitourinary complications. Hence, this study investigates the feasibility of helical tomotherapy (HT) as an alternative to BT. Methods: Medical records of patients who underwent CCRT between 2000 and 2017 at a single institution were retrospectively reviewed. Patients with stage IIB–IVA cancers were selected based on the 2009 criteria of The International Federation of Gynaecology and Obstetrics. External beam radiation combined with chemotherapy was followed by either BT or HT. The propensity score matching of both groups was calculated using logistic regression analysis. Disease outcomes and treatment-related adverse events were compared between the 2 groups. Results: The matched population included 70 BT patients and 35 HT patients. The 5-year progression-free survival rates for BT and HT were 72.6% and 72.5%, respectively (p=0.721). There was no difference in the overall survival rate between the two groups (p=0.203). The presence of acute and chronic gastrointestinal complications was also similar between the groups (p=0.460 and p=0.563, respectively). The chronic genitourinary toxicities were also comparable (p=0.105). Conclusions: HT boost treatment showed comparable disease outcomes with those observed with conventional BT in patients with advanced cervical cancer. HT could be a complementary boost protocol as a single modality or hybrid with BT in selected patients. Further studies with longer follow-up periods are warranted to confirm long-term outcomes. [ABSTRACT FROM AUTHOR]

To analyze the clinical outcomes and the safety of radiochemotherapy (RCT) and image-guided adaptive brachytherapy (IGABT) and to evaluate the impact of hysterectomy (HT) as completion of treatment for cervical cancer. 145 patients with locally advanced cervical cancer were treated at our institution. Patients underwent RCT and IGABT, then hysterectomy (HT) as completion of treatment was performed, with the exception of patients with surgical contraindications, para aortic metastatic disease or patients who refused surgery. Clinical outcomes and morbidity were retrospectively reviewed in both groups. Local relapse free survival (LRFS), pelvic relapse free survival (PRFS) and overall survival (OS) were analyzed. Completion HT was performed in 90 (62.1%) patients. Complete histological response and microscopic disease were found in 77 patients (85.6%). Local relapse was observed in 14 patients (9.6%) without differences between completion HT group and the definitive RCT and IGABT group (Odds Ratio OR = 1.73 [0.57–5.23], p = 0.33). The estimated 3-year LRFS and PRFS for the entire population were respectively 90% [84%–94%] and 93% [87%–96%], with no significant differences between them (respectively Hazard Ratio HR = 0.57 [0.20–1.64], p = 0.30 and HR = 0.37 [0.10–1.31], p = 0.12). The estimated 3-year OS rate for the whole population was 84% [75%–91%] with no significant differences between groups (HR = 0.81 [0.32–2.06], p = 0.65). Regarding morbidity, grade ≥ 2 vaginal toxicity was more frequent in the definitive RCT and IGABT group (43.6% vs 26.7%, p = 0.04). All grade 4 toxicity events were reported in the completion HT group. Due to high severe toxicity, RCT and IGABT with dose escalation followed by completion hysterectomy don't seem compatible. No benefit and increased severe late morbidity were observed. Combined intracavitary/interstitial technique is mandatory in large target volume at brachytherapy. • Locally advanced cervical cancer in the modern era of Image-guided adaptive brachytherapy. • Impact of hysterectomy as completion of treatment. • Incompatibility of treatments: high grade toxicity without clinical benefits. [ABSTRACT FROM AUTHOR]

Purpose: We report the first cervical cancer cases treated with interstitial electronic brachytherapy (eBT) at our hospital and compare them with plans made with high‐dose‐rate interstitial brachytherapy based on Ir192 (HDR‐BT). Materials and methods: Eight patients with cervical cancer were treated with the Axxent eBT device (Xoft, Inc.). Planning was with magnetic resonance imaging and computed tomography following the recommendations of the EMBRACE protocol. The dosimetry parameters of organs at risk (OAR) were evaluated for the bladder, rectum, and sigmoid colon (D2cc, D1cc, and D0.1cc). In addition, the V150 and V200 of irradiated tissue were compared for both eBT and HDR‐BT. All patients received intensity‐modulated external beam radiation therapy with a regimen of 23 sessions of 2 Gy followed by four sessions of 7 Gy of eBT performed over 2 weeks (two sessions followed by another two sessions a week later) following the EMBRACE recommendations. Each of the eight patients was followed to assess acute toxicity associated with treatment. Results: The doses reaching OAR for eBT plans were lower than for HDR‐BT plans. As for acute toxicity associated with eBT, very few cases of mucositis were detected. No cases of rectal toxicity and one case with grade 1 urinary toxicity were detected. The results at 1 month are equally good, and no relapses have occurred to date. Conclusions: The first results of treatment with the Axxent eBT device are promising, as no recurrences have been observed and toxicity is very low. eBT is a good alternative for treating cervical cancer in centers without access to conventional HDR. [ABSTRACT FROM AUTHOR]

Abstract Background Paradigm has shifted from 2D to image-guided adaptive brachytherapy (IGABT) for locally advanced cervix cancer (LACC). Increasing reports from pioneering institutions and large retrospective multicenter series have demonstrated improvements in outcome and reduction in toxicity with IGABT. However, there is scarcity of data on magnetic resonance (MR)-IGABT in Chinese patients. Purpose To evaluate the clinical outcome of MR-IGABT for LACC in a single institution in Hong Kong. Material and Methods Patients with FIGO stage IB-IVA LACC treated with definitive external beam radiotherapy +/− concurrent cisplatin followed by MR-IGABT from January 2015 to January 2018 were included. Brachytherapy planning and dose reporting followed the GEC-ESTRO recommendations. Dosimetric and clinical outcomes including local control (LC), pelvic control (PC), cancer-specific survival, overall survival (OS), and toxicity were analyzed. Results Forty-two consecutive patients were included. 71% were FIGO stage IIB or above; 52% had pelvic node involvement. Median high-risk clinical target volume (HRCTV) was 34.7 cm3 (12.3–155.1 cm3). Median dose to HRCTV D 90 was 88.5 Gy (63.4–113.4 Gy) (EQD2 10). Median doses to the D 2cc of bladder, rectum, sigmoid, and small bowel were 83.1 Gy, 67.5 Gy, 69.0 Gy, and 68.9 Gy (EQD2 3), respectively. Median followup was 20.3 months (4.0–35.1 months). 24-month actuarial LC, PC, cancer-specific survival, and OS were 90%, 84%, 90%, and 90%, respectively. Stratification by clinical variables showed that FIGO stage had significant impact on LC and dose to HRCTV on both LC and PC. Treatment was well tolerated without any severe late toxicity. Conclusions Intermediate-term results from systematic MR-IGABT for LACC demonstrate very promising outcomes with minimal toxicity. This fills the gap in evidence for MR-IGABT in Chinese patients. [ABSTRACT FROM AUTHOR]

Purpose: When squamous cell carcinoma of the buccal mucosa (BSCC) extends surrounding anatomical sites such as gingiva, retromolar triangle, or hard palate, it might be challenging to ensure adequate tumor coverage by sole interstitial brachytherapy due to the complexity of catheter implantation. By combining interstitial catheters with an enoral placed, individually assembled "oral spacer plus embedded catheters" device (hybrid of intracavitary-interstitial brachytherapy), it should be easier to deliver the necessary tumoricidal dose to irregular-shaped tumor volumes (clinical target volume - CTV) with improved conformity. The purpose of this analysis was to compare the dose distribution created by the hybrid of intracavitary-interstitial brachytherapy (HBT) with the dose distribution of an interstitial catheter only-approach, based on the interstitial catheters used for HBT (ISBT-only) by evaluating respective treatment plans (HBT plan vs. ISBT-only plan) for the treatment of early stage BSCC. Material and methods: A retrospective analysis was performed for patients with localized BSCC treated between April 2013 and October 2017. All patients received sole HBT without additional external beam radiation therapy or planned neck dissection. Dosimetric parameters taken into account for comparison between actual HBT and virtual ISBT-only were CTV D90, CTV V100, CTV V150, CTV V200, mandible D2cc, and mucosal surface D2cc. Results: Dosimetrically, HBT showed a trend toward better CTV D90 compared to ISBT-only. In addition, HBT demonstrated statistically better CTV V100 coverage compared to ISBT-only. There was no statistically significant difference with respect to CTV V150, CTV V200, and mucosal surface D2cc, while a trend was seen in better mandible D0.1cc between HBT and ISBT-only. Conclusions: The HBT approach appears to enable improved dose coverage of irregular-shaped enoral tumor volumes compared to ISBT-only for patients with early stage BSCC. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of computed tomography (CT)- and magnetic resonance imaging (MRI)-guided interstitial high-dose-rate brachytherapy (HDR IBT = IBT) in patients with metastatic esophageal squamous cell carcinoma. Material and methods: Eleven patients with 21 unresectable metastases of histologically proven esophageal squamous cell carcinoma were included in this retrospective study. Fourteen visceral and 7 lung metastases were treated with image-guided (CT or open MRI guidance) IBT using a 192Iridium source (single fraction irradiation). Clinical and imaging follow-up were performed every 3 months after treatment. Primary endpoint was local tumor control (LTC) and safety. Furthermore, we analyzed safety, progression-free survival (PFS), and overall survival (OS). Results: The median diameter of the target lesions was 2.2 cm (range: 0.7-6.8 cm), treated with a median D100 of 20.1 Gy (range: 10-25 Gy). During a median follow-up of 6.3 months (range: 3-21.8 months), three patients displayed local recurrences, resulting in LTC of 85.7%. Median PFS was 3.4 months and median OS after IBT was 13.7 months. No severe adverse events (grade 3+) requiring hospitalization or invasive intervention were recorded. Conclusions: Image-guided IBT is a safe and effective treatment in patients with metastasized esophageal squamous cell carcinoma. [ABSTRACT FROM AUTHOR]

Purpose: Soft tissue sarcoma (STS) is rare but aggressive neoplasm. Interstitial brachytherapy (ISBT) alone or combined with external beam radiotherapy (EBRT) as post-operative treatment improves loco-regional (LRC) and distant control. Material and methods: Out of twenty-nine non-metastatic STS (lower limb 64%) patients (median age 37 yrs), treated with surgery and post-operative ISBT during February 2011 - December 2016, 27 patients with > 6 months follow-up were analyzed. Spindle cell sarcoma was the commonest (24%) histology. Eleven patients (44%) received EBRT (45-50 Gy), where ISBT was used as boost (16-20 Gy). Fourteen patients (56%) received ISBT alone (4 Gy per fractio). Treatment was done with a 60 Cobalt (60Co) source high-dose-rate system. Results: With a median follow-up of 20 months (17-51 months), LRC rate was 85.7% (with EBRT 90.5% and ISBT 83.2% alone). Median disease-free survival (DFS) was 39.7 ±3.9 months (32-47.2 months). Median loco-regional failure-free survival (LRRFS) was 43.8 ±3.6 months (36.8-50.9 months). Distant failure-free survival (DFFS) was 18 months (15.5-26.6 months). Overall survival was 42.4 ±3.4 months (35.7-48.1 months). Tumor grade was a significant factor for DFFS. Total radiation dose (including EBRT) has significant influence on DFS and LRRFS. 14.8% patients developed = grade 2 late toxicity (skin atrophy, hypo-pigmentation, and telangiectasia). Conclusions: Combination of surgery and ISBT with/out EBRT improves local and distant control with acceptable late toxicities. 60Co-based ISBT is safe and gives a good outcome. [ABSTRACT FROM AUTHOR]

Background: Previous results from the GEC-ESTRO trial showed that accelerated partial breast irradiation (APBI) using multicatheter brachytherapy in the treatment of early breast cancer after breast-conserving surgery was non-inferior to whole-breast irradiation in terms of local control and overall survival. Here, we present 5-year results of patient-reported quality of life.Methods: We did this randomised controlled phase 3 trial at 16 hospitals and medical centres in seven European countries. Patients aged 40 years or older with 0-IIA breast cancer were randomly assigned (1:1) after breast-conserving surgery (resection margins ≥2 mm) to receive either whole-breast irradiation of 50 Gy with a boost of 10 Gy or APBI using multicatheter brachytherapy. Randomisation was stratified by study centre, tumour type, and menopausal status, with a block size of ten and an automated dynamic algorithm. There was no masking of patients or investigators. The primary endpoint of the trial was ipsilateral local recurrence. Here, we present 5-year results of quality of life (a prespecified secondary endpoint). Quality-of-life questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30, breast cancer module QLQ-BR23) were completed before radiotherapy (baseline 1), immediately after radiotherapy (baseline 2), and during follow-up. We analysed the data according to treatment received (as-treated population). Recruitment was completed in 2009, and long-term follow-up is continuing. The trial is registered at ClinicalTrials.gov, number NCT00402519.Findings: Between April 20, 2004, and July 30, 2009, 633 patients had accelerated partial breast irradiation and 551 patients had whole-breast irradiation. Quality-of-life questionnaires at baseline 1 were available for 334 (53%) of 663 patients in the APBI group and 314 (57%) of 551 patients in the whole-breast irradiation group; the response rate was similar during follow-up. Global health status (range 0-100) was stable in both groups: at baseline 1, APBI group mean score 65·5 (SD 20·6) versus whole-breast irradiation group 64·6 (19·6), p=0·37; at 5 years, APBI group 66·2 (22·2) versus whole-breast irradiation group 66·0 (21·8), p=0·94. The only moderate, significant difference (difference of 10-20 points) between the groups was found in the breast symptoms scale. Breast symptom scores were significantly higher (ie, worse) after whole-breast irradiation than after APBI at baseline 2 (difference of means 13·6, 95% CI 9·7-17·5; p<0·0001) and at 3-month follow-up (difference of means 12·7, 95% CI 9·8-15·6; p<0·0001).Interpretation: APBI with multicatheter brachytherapy was not associated with worse quality of life compared with whole-breast irradiation. This finding supports APBI as an alternative treatment option after breast-conserving surgery for patients with early breast cancer.Funding: German Cancer Aid. [ABSTRACT FROM AUTHOR]

Purpose With an aim to evaluate and report high dose date interstitial brachytherapy (HDR-ISBT) in vulvar cancers, we undertook this retrospective analysis. Methods and Materials Histologically proven vulvar cancers treated with HDR-ISBT between 2001 and 2016 were analyzed. Radiotherapy details, clinical outcome in terms of local control rates, survivals, and toxicities were evaluated. Results A total of 38 patients received HDR-ISBT, with definitive radiation in 29 (76.3%), adjuvant postoperative in six (15.8%) and salvage radiation in three (7.9%) patients. Of them, 29 patients received brachytherapy boost and nine patients ISBT alone. BT procedure included freehand plastic tube technique in 23 (single [ n = 5] or multiple plane [ n = 18]), 13 patients with template based and two patients combined approach. Patients with brachytherapy alone received median EQD2 of 38.4 Gy 10 (35.5–46.7 Gy 10 ), as boost received median 23.3 Gy 10 (13–37.3 Gy 10 ). At 3-month post-treatment response evaluation, 30 patients achieved clinically complete response, two patients partial response and six maintained postoperative status. With a median follow-up of 30 months, 29 (76.3%) were disease free, and 9 (23.7%) patients had relapsed disease with four patients expired due to disease and two died of other causes. The 5-year overall survival, disease free survival, and local control rates were 82%, 51%, and 77%, respectively. Conclusions HDR-ISBT in vulvar cancer is a feasible and a viable option with acceptable and comparable outcomes. [ABSTRACT FROM AUTHOR]

Purpose/objectives: The aim of this study is to analyze the results of exclusive interstitial brachytherapy (IBT) as a conservative approach in the treatment of penile cancer confined to the glans or the shaft with long-term follow-up in a single institution.Materials/methods: Between July 1992 and November 2013, 73 consecutive patients with non-metastatic invasive penile cancer were treated by Low dose rate (LDR) IBT in our institution. The localization of the primary lesion was glands in 67 patients (91.8 %) and shaft in 6 patients (8.2 %). All 73 patients presented with squamous cell carcinoma with grades of differentiation as follows: 34 patients with grade 1 (44.7 %), 9 patients with grade 2 (11.8 %), 9 patients with grade 3 (11.8 %) and 21 patients unknown (28.8 %). Six patients (7.8 %) presented with in situ carcinoma, 55 patients (75,3 %) presented with T1, 11 patients (15 %) presented with T2, and one patient (1.3 %) presented with Tx. Inguinal nodal dissection was performed in 29 patients (38.2 %); 13 patients (17.8 %) presented with histologically confirmed positive ganglion. After circumcision, IBT was performed using a hypodermic needle. The median dose delivered was 60 Gy (range, 40 to 70 Gy). The median activity of the iridium-192 wire was 1.12 mCi/cm, and the median reference isodose rate was 0.4 Gy/h (range, 0.2-1.2). Patients with histological inguinal metastases received external beam radiotherapy to the selected inguinal affected area with a median dose of 45 Gy (30-55 Gy).Results: The median follow-up time was 51.8 months (range 34.4 to 68.7). The 5-year overall survival was 82.0 %, with eight deaths from cancer and five non-cancer-related deaths. Disease-specific survival was 91.4 %, relapse-free survival was 64.4 %, and local relapse-free survival as 74 %. Total or partial penile preservation was 87.9 % at 5-years. Complications rates at 5 years were 6.6 % urethral stenosis (five patients), two patients (2.6 %) with pain related to sexual intercourse and four patients (5.3 %) with dysuria grade 2. Five patients (6.8 %) required penile amputation for necrosis.Conclusions: IBT provides good local control with organ preservation, excellent tolerance and low complication rates in early-stage penile cancers. [ABSTRACT FROM AUTHOR]

Purpose Previous studies on reproducibility in gynecologic high-dose-rate interstitial brachytherapy (HDRIB) have reported caudal needle displacements as high as 14–27.9 mm. The needle-template units in these studies were, however, sutured to the perineum, which gradually moved away from the target due to edema. To overcome the caudal force from the edema, we have been using fully stretched elastic tapes that exert cranial force on the template. To evaluate the effectiveness of our technique, caudal needle displacements relative to the target were investigated using CT coordinates. Methods and Materials Twenty-nine gynecologic cancer patients were treated using HDRIB. The template was pressed into the perineum using two elastic tapes. All patients underwent pretreatment and posttreatment CTs to obtain craniocaudal coordinates for the needles and the clinical target volume. Results The median displacements for the 533 needles relative to the clinical target volume were −0.8 mm (range, −5.7 to +4.7 mm). Absolute craniocaudal displacement >3 mm was observed in only 14.4% of the needles, with a maximum displacement of only 5.7 mm. Conclusions The use of elastic tapes achieved smaller displacements compared to those in previous reports. This was a simple but effective technique to minimize needle displacement for gynecologic HDRIB. [ABSTRACT FROM AUTHOR]

Purpose: The study assessed the outcomes of patients at a single institution with locally advanced primary and recurrent pelvic malignancies treated with interstitial high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy (BT), using a modified Syed-Neblett template. Material and methods: Between 1996 and 2010, 60 patients with primary or recurrent pelvic malignancies were treated with interstitial BT. Thirty three patients had primary malignancies with 6.1% being stage I, 33.3% stage II, 45.5% stage III, and 15.2% stage IV; the remaining 27 patients were recurrent malignancies. Fifty four patients received external beam radiotherapy (EBRT) as part of their treatment course. The median EBRT, BT, and EBRT + BT doses were 45 Gy, 20 Gy, and 65 Gy, respectively. Thirty eight patients received concurrent chemotherapy with EBRT. Complete response (CR) was defined by absence of clinical and radiographic disease on first follow-up. Toxicity was graded as per Common Terminology Criteria for Adverse Events, version 4.0. Results: The median follow-up was 37 months (4-234 months) and initial CR was achieved in 91%. For primary cancers at diagnosis, 5-year local control (LC), 5-year progression-free survival (PFS), 5-year overall survival (OS) were 65%, 64%, and 42% respectively. For recurrent cancers at diagnosis, 5-year LC, 5-year PFS, and 5-year OS were 80%, 51%, and 37%, respectively. There was a significant difference in both OS and PFS among different tumor sites (p < 0.05), with vaginal cancers having the best 5-year OS (55%) and PFS (84%). There was a total of 1 acute toxicity ≥ grade 3, 6 late grade 3 toxicities, and late grade 4 toxicity. Conclusions: Our series suggests that interstitial BT using a modified Syed-Neblett template is a safe and effective treatment for primary or recurrent pelvic malignancies. This technique allowed effective LC and 97% of patients had preservation of both bladder and rectal function. [ABSTRACT FROM AUTHOR]

Purpose To identify dosimetric predictors of outcome and toxicity in patients receiving CT-planned interstitial brachytherapy (ISBT) for gynecologic cancers. Methods and Materials Patients who received ISBT between 2009 and 2014 were reviewed. Demographic, disease specific, treatment, and toxicity data were collected. Logistic regression was used to model toxicity. A least absolute shrinkage and selection operator penalty was used to identify relevant predictors. Receiver operating characteristic curves were used to analyze the relation between dosimetric factors and urinary toxicity. Results Seventy-three patients received ISBT (21 at time of cancer recurrence and 52 at the first presentation). Thirty-six patients had cervical cancer, 16 had vaginal cancer, 13 had uterine cancer, and 8 had vulvar cancer. ISBT was performed using both high-dose-rate and low-dose-rate 192 Ir sources (27 low dose rate and 46 high dose rate). With a median followup of 12 months, Grade 3 vaginal, urinary, and rectal toxicity occurred in 17.8%, 15.1%, and 6.8% of patients, respectively. No patients experienced Grade 4 or 5 toxicity. Dose to 0.1cc of urethra predicted for development of Grade 3 urinary toxicity (area under the curve of 0.81; 95% confidence interval: 0.66, 0.96). A 10% probability of a Grade 3 urinary toxicity associated with a dose of 23.1 equivalent dose in 2 Gy fractions (95% confidence interval: 9.51, 36.27 equivalent dose in 2 Gy fractions). Conclusions ISBT is a safe treatment for gynecologic malignancies. The dose to 0.1cc significantly predicts for severe urinary toxicity. Our data suggests that dose to a small urethral volume may be the most significant predictor of urinary toxicity in patients receiving ISBT for gynecologic cancer. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate biochemical failure (BF) and prostate cancer specific mortality (PCSM) in intermediate-risk (IR) brachytherapy patients stratified into favorable and unfavorable cohorts, and to compare those outcomes to patients with low (LR) and high-risk (HR) disease. Material and methods: From March 1995 till February 2012, 2,502 consecutive patients underwent permanent interstitial brachytherapy for clinically localized prostate cancer. Patients were stratified into risk groups as per the NCCN guidelines with further stratification of the intermediate risk cohort into unfavorable (primary Gleason pattern 4, ≥ 50% positive biopsies or ≥ 2 IR features) and favorable cohorts. Median follow-up was 8.5 years. The brachytherapy prescription dose was prescribed to the prostate gland with generous periprostatic margins. Biochemical failure was defined as a PSA > 0.40 ng/ml after nadir. Patients with metastatic prostate cancer or non-metastatic castrate resistant disease who died of any cause were classified as dead of prostate cancer. Multiple parameters were evaluated for effect on outcomes. Results: Fifteen year BF for LR, favorable IR, unfavorable IR, and HR were 1.4%, 2.2%, 7.1%, and 11.1% (p < 0.001), respectively. At 15 years, PCSM for LR, favorable IR, unfavorable IR, and HR was 0.3%, 0.6%, 2.2% and 4.6% (p < 0.001), respectively. In multivariate analysis, BF was best predicted by risk group, pre-implant PSA, percent positive biopsies, prostate volume, and ADT duration, while PCSM was most closely related to risk group, percent positive biopsies and prostate volume. Conclusions: Patients with favorable IR disease have biochemical and PCSM outcomes comparable to those of patients with LR disease. Although unfavorable IR has greater than a 3-fold increased risk of BF and PCSM when compared to favorable IR, the outcomes remain superior to those men with HR disease. [ABSTRACT FROM AUTHOR]

Purpose Multichannel vaginal cylinder brachytherapy (MCVCB) has the potential to sculpt dose distribution, although this is typically reserved for lesions <5-mm thick. The aim of this study was to investigate the dosimetric consequences of treating lesions with MCVCB of varying locations, ≥5 mm in thickness. Methods and Materials Patients previously treated with MCVCB were randomly selected to each fill one of six categories based on location (lateral, anterior, or vaginal cuff and/or apex) and size of cylinder (2.5 or 3.0 cm). Based on magnetic resonance image, each patient's target lesion was extended circumferentially into theoretical high-risk clinical target volumes measuring 5, 7, and 10 mm in thickness. Image-based brachytherapy treatment plans for each of the six patients' three target volumes were generated. Total 2 Gy per fraction equivalent dosages (EQD2) were calculated using an external beam radiation therapy dose of 45 Gy in 25 fractions in conjunction with a high-dose-rate brachytherapy dose of 25 Gy in five fractions. Results Maximum EQD2 vaginal surface doses in gray for 5-, 7-, and 10-mm targets were as follows (location-cylinder size): lateral-3.0 cm: 122/153/210, lateral-2.5 cm: 145/195/301, anterior-3.0 cm: 115/135/197, anterior-2.5 cm: 132/173/283, apex-3.0 cm: 173/241/367, and apex-2.5 cm: 349/461/706. Total rectal EQD2 D 2 cc ranged from 53.9 to 67.2 Gy. Total bladder EQD2 D 2 cc ranged from 51.5 to 71.2 Gy. Conclusions The vaginal surface dose seems to be the dose-limiting structure for anterior, lateral, and apical vaginal lesions. Caution should be taken when treating lesions >5 mm in depth, with particular attention to vaginal surface dose, especially for apical lesions and with smaller cylinders. In such cases, interstitial brachytherapy should be given strong consideration. [ABSTRACT FROM AUTHOR]

Purpose: Dose coverage is crucial for successful treatment in mono-brachytherapy. Since few and very high dose fractions are used, there is an important balance between dwell positioning outside the clinical target volume (CTV) and possible damage on adjacent normal tissue. The purpose of this study was to evaluate the possibility of having dwell positions close to the CTV surface, while maintaining an acceptable dose distribution, and to investigate the robustness in terms of known geometrical uncertainties of the implant. Material and methods: This study included 37 patients who had received brachytherapy for prostate cancer as a monotherapy with the following schedules: 2 x 14 Gy or 3 x 11 Gy, each fraction separated by two weeks. The source dwell positions were activated 5 mm outside CTV. New optimizations were simulated for dwell positions at 3, 2, 1, and 0 mm. Inverse and graphical optimization were applied according to the relative dose constraints: V100 CTV ≥ 97%, Dmax, urethra ≤ 110%, and D10 rectal mucosa ≤ 65%. The V100, normal tissue outside CTV was used to evaluate dose variations caused by different dwell positions. Prostate geometries and dose distributions for the different dwell positions outside the CTV were used to investigate the impact on the CTV dose distribution due to geometrical uncertainties. Results: Both V100, CTV, and V100, normal tissue decreased, 98.6% to 92.2%, and 17 cm³ to 9.0 cm³, for dwell activation from 5 mm to 0 mm. The evaluation of both simulated longitudinal geometrical uncertainties and different source dwell activations implied that V100, CTV ranged from 98.6% to 86.3%. Conclusions: It is possible to reduce the V100, normal tissue by decreasing the source dwell positions outside the CTV from 5 to 3 mm, while maintaining dose constraints. In combination with the estimated geometrical uncertainties, however, the source dwell positions need to be 5 mm from the surface in order to maintain a robust implant. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Soft tissue sarcomas are uncommon, but relatively aggressive tumours. Although surgical resection remains the primary therapeutic modality for all localised tumours, brachytherapy combined with function-preserving excision is a popular treatment for extremity soft tissue sarcomas. The objective of this study was to evaluate the effect of interstitial permanent brachytherapy using I125 seeds in patients undergoing the combined modality in the management of soft tissue sarcomas at our institution. Materials and methods: Between January 2007 and January 2012, 110 adult patients aged 18–86 years (median = 44 years) with extremity soft tissue sarcomas and who underwent interstitial permanent brachytherapy as part of the local treatment were included in this study. Treatment included wide local excision of the tumour and brachytherapy using a permanent I125 implantation. Complications were assessed in terms of wound complication and peripheral nerve damage. Results: After a median follow-up of 43.7 months, the local control, disease-free survival and overall survival for the entire cohort studied were 74, 54 and 77%, respectively. The actual rates of wound complications requiring reoperation and nerve damage were 4.5 and 1.8%, respectively. Conclusions: We conclude that interstitial permanent brachytherapy with I125 after function-preserving surgery results in a satisfactory outcome in patients with extremity soft tissue sarcomas and the complication rate is low. [Copyright &y& Elsevier]

Abstract: Purpose: To develop a consensus statement between the American Brachytherapy Society (ABS) and Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology (GEC-ESTRO) for the use of brachytherapy in the primary management of carcinoma of the penis. Methods and Materials: The American Brachytherapy Society and Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology convened a group of expert practitioners and physicists to develop a statement for the use of 192Ir in low-dose-rate (LDR), pulse-dose-rate, and high-dose-rate (HDR) brachytherapy for penile cancer. Results: Decades of brachytherapy experience with LDR 192Ir wire and pulse-dose-rate 192Ir sources for this rare malignancy indicate a penile preservation rate of 70% at 10 years postimplant. Chief morbidities remain stenosis of the urethral meatus and soft tissue ulceration at the primary site. Nonhealing ulceration can be successfully managed with various measures including hyperbaric oxygen treatment. HDR brachytherapy implant procedures are technically similar to LDR. The optimal HDR dose and fractionation schemes are being developed. Conclusions: The good tumor control rates, acceptable morbidity, and functional organ preservation warrant recommendation of brachytherapy as the initial treatment for invasive T1, T2, and selected T3 penile cancers. [Copyright &y& Elsevier]

Abstract: Purpose: Interstitial low–dose rate brachytherapy (BRT) allows a conservative treatment of T1–T2 penile carcinoma. High–dose rate (HDR) BRT is often considered as a dangerous method for interstitial implants because of higher risk of complications. However, numerous reports suggest that results of HDR-BRT may be comparable to low–dose rate BRT. There are no data available in the literature regarding HDR interstitial BRT for carcinoma of the penis. Methods and Materials: Ten patients with early penile carcinoma were treated by interstitial hyperfractionated HDR-BRT at the dose of 18 times 3Gy twice daily between years 2002 and 2009. Breast interstitial BRT template was used for fixation and precise geometry reconstruction of stainless hollow needles. Results: Median followup was 20 months. Our BRT technique and fractionation schedule was well tolerated by all patients. Acute reaction consisted predominantly of penis edema and Grade 2 radiation mucositis that dissolved during 8 weeks after the treatment. We neither observed any postradiation necrosis nor urethral stenosis. The worst late side effects recorded were mild telanagiectasias in the treatment region. At the last followup, all patients were alive without evidence of the tumor and with fully functional organ. Conclusions: Hyperfractionated interstitial HDR-BRT with 18 times 3Gy per fraction twice daily is a promising method in selected patients of penile carcinoma and deserves further evaluation in a larger prospective study. [Copyright &y& Elsevier]

Abstract: Purpose: Squamous carcinoma (SCC) of the penis affects about 1 in 100,000 men in western societies. Interstitial brachytherapy can be an effective penis-conserving modality for T1, T2, and selected T3 tumors. Unfortunately, few radiation oncology trainees have the opportunity to treat a case of penile cancer during their residency, and few centers have brachytherapy expertise for this tumor site. We report our technique that has been developed and refined over the past 20 years. Materials and Methods: From 1989 to 2009, we have been using brachytherapy to treat penile SCC and have experience with 75 cases. From 1989 to 1998, manual afterloading was used with 192Ir wire or seeds, and from 1999 to the present, pulse dose rate automated afterloading. Sixty Gray is delivered over a period of 4–5 days. Results: Patient selection for penile brachytherapy and the technical and dosimetric aspects of the procedure will be discussed along with posttreatment care and followup. Conclusions: Brachytherapy is an effective treatment for T1, T2, and selected T3 SCC of the penis. Efficacy depends on careful planning and appreciation of dosimetry. [Copyright &y& Elsevier]

Abstract: Purpose: Locally advanced squamous cell cancers of the head and neck (SCCHN) with bone and cartilage invasion (BCI) or those with soft-tissue invasion (STI) have been treated with resection followedup with chemoradiotherapy (CRT) or definitive CRT. However, locoregional recurrence remained a large component of treatment failure. High-dose-rate interstitial brachytherapy (BT) has been used for dose escalation to further prevent local relapse. This is a review of our experience. Methods and Materials: T4N0-3M0 locally advanced oral cavity and oropharyngeal squamous cell carcinoma (SCCA) patients underwent definitive CRT or radiotherapy (RT) followedup with brachytherapy (BT). RT doses ranged from 45 to 50.4Gy. The patients were reassessed at this dose and if response was inadequate, patients underwent BT. BT doses ranged from 24 to 30Gy at 3–4Gy per fraction BID with 6h in between fractions. Concurrent chemotherapy was platinum based. Results: Twenty patients were treated with CRT or RT alone followed by BT. Thirteen patients had STI and 7 had BCI; 14 patients were treated with CRT followed by BT; and 6 patients were treated with RT alone followed by BT. Five-year locoregional control was 61%. Five-year overall survival was 29%. When we excluded the patients treated with RT alone, 5-year overall survival was 36%. Nodal status was the only prognostic factor. Conclusions: This study suggests CRT followedup with BT for patients with T4 locally advanced SCCHN of the oral cavity, and oropharynx is a feasible treatment option. In patients with poor response to CRT, BT may be used for dose escalation to increase locoregional control. [Copyright &y& Elsevier]

Abstract: Purpose: The purpose of this study was to evaluate local control, survival and complication rate after treatment of soft tissue sarcoma (STS) with limb-sparing surgery combined with pulsed-dose rate (PDR) interstitial brachytherapy (BRT) and external beam radiotherapy (EBRT). Patients and methods: A retrospective review of 39 adult patients (female/male=25/14, mean age 51(range 21–78) years) with STS who underwent primary limb-sparing surgery combined with PDR BRT (20Gy) and additional post-operative EBRT (50Gy) during the years 1995–2004. Results: Five patients developed local recurrence after a mean follow-up of 3.4 (1.5–5.9) years. The probability of local recurrence free 5 years survival was 83%. At the time of follow-up 10 patients had died (mean follow-up 2.3 (0.8–7.1) years) and 29 patients were still alive (mean follow-up 5.9 (2.1–11.2) years). The overall 5-year survival rate was 76%. Nineteen (49%) patients suffered from some degree of decreased force or function of the affected extremity, 16 (41%) suffered from oedema, 12 (31%) had persistent pain, 8 (21%) suffered from wound complications, and in 4 (10%) of these patients plastic surgery were required. Conclusion: Limb sparing surgery, combined with PDR BRT and EBRT can result in good local control in patients with soft tissue sarcomas. BRT is an effective modality with good cosmetic results and acceptable toxicity. [Copyright &y& Elsevier]

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]

Abstract: The Kiel University technique of intensity modulated brachytherapy boost implantations complementary to external beam radiation used in the treatment of prostate cancer patients was improved by involving real-time three-dimensional transrectal ultrasound analysis of the prostate gland both before implantation and after the implantation but before capture of the transrectal ultrasound images for real-time dynamic treatment planning. Implantation technique, treatment planning procedure, and dose delivery are described as practiced at the University Hospital Schleswig-Holstein Campus Lübeck, Germany. [Copyright &y& Elsevier]

Abstract: Objectives: As the number of patients with prostate cancer treated with permanent radioactive implants is increasing world wide, long-term data on tumor control and treatment morbidity become available. Materials: Biochemical and clinical tumor control appears to be as effective as after radical prostatectomy or external beam radiation therapy in early prostate cancer. Results: The risk of posttreatment urinary incontinence and bowel dysfunction is low and erectile function can be preserved in the majority of patients. However, prostate brachytherapy requires a careful selection of patients as pretreatment factors predict for long-term outcome. The need for combined modality approaches in intermediate and high risk patients remains controversely discussed. The continuous refinement of intraoperative planning techniques and the elucidation of the etiology of urinary, sexual and bowel dysfunction should result in further improvements in biochemical outcomes and decreased morbidity. Conclusions: Improved and standardized postimplantation evaluation will make outcome data more reliable and comparable. [Copyright &y& Elsevier]

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

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