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A novel concept for an organ-preserving treatment of pediatric urogenital and perianal rhabdomyosarcoma includes high dose rate brachytherapy following surgical tumor resection. For the duration of the brachytherapy of 6 days plus 2-day recovery break the patients are not allowed to move and are kept under deep sedation, which can lead to difficult weaning from mechanical ventilation, withdrawal, delirium, and prolonged hospital stay. The aim of this study was to evaluate a protocol which includes a switch from fentanyl to ketamine 3 days prior to extubation to help ensure a rapid extubation and transfer from PICU.Patients who underwent surgical tumor resection of rhabdomyosarcoma and subsequent brachytherapy were treated according to a standardized protocol. We evaluated doses of fentanyl, midazolam and clonidine, time of extubation, length of PICU stay and occurrence of withdrawal symptoms and delirium. We compared fentanyl dose at time of extubation, duration of weaning from mechanical ventilation and time to discharge from PICU with patients after isolated severe traumatic brain injury.Twentytwo patients (age 39.9 ± 29.8 months) were treated in our PICU to undergo brachytherapy. Extubation was performed 21.6 ± 13.5 h after the last brachytherapy session with an average fentanyl dose of 1.5 ± 0.5 µg/kg/h and patients were discharged from PICU 58.4 ± 30.3 h after extubation, which all is significantly lower compared to the control group (extubation after 88.0 ± 42.2 h, p 0.001; fentanyl dose at the time of extubation 2.5 ± 0.6 µg/kg/h, p 0.001; PICU discharge after 130.1 ± 148.4 h, p 0.009). Withdrawal symptoms were observed in 9 patients and delirium in 13 patients.A standardized analgesia and sedation protocol including an opioid break, scoring systems to detect withdrawal symptoms and delirium, and tapering plans contributes to successful early extubation and discharge from PICU after long-term deep sedation.

Purpose To focus on technical aspects of the implementation of interstitial high dose rate brachytherapy, with a step-by-step approach. Materials and methods Patients were selected during multidisciplinary tumor boards, according to inclusion criteria adapted from GEC-ESTRO guidelines. A CT scan was performed a few days before implantation. On pre-implant CT, using surgical scar and clips, surgical and pathological reports, and preoperative images, we delineated the tumor bed to be included in the Clinical Target Volume (CTV), according to GEC ESTRO Recommendations. A 3D virtual implant simulation of the best catheter positions was performed in order to cover the target volume. Implantation was then carried out under local anaesthetic using 3D projections of the catheter inlets and outlets. Dosimetry was performed on post-implantation CT scan. A dose of 34 Gy was delivered in 10 fractions. Acute and late side effects, and local control were evaluated 2 and 8 months after treatment. Results Between July 2017 and January 2020, 20 patients were treated with accelerated partial breast irradiation. Dose constraints regarding target volume coverage, overdose, dose homogeneity, conformation index and organs at risk were met in 94.7%, 100%, 63.2%, 0% and 89.5% of the treatment plans, respectively. Grade 1-2 acute adverse events were observed in 21% of patients, with no grade 3-4 events. Conclusion The first dosimetric results and early clinical tolerance and efficacy achieved by the implementation of breast interstitial multicatheter brachytherapy in routine clinical practice are very encouraging, and confirm the interest of extending this practice.

High dose rate (HDR) brachytherapy treatment planning usually involves optimization methods to deliver uniform dose to the target volume and minimize dose to the healthy tissues. Four optimizations were used to evaluate the high-risk clinical target volume (HRCTV) coverage and organ at risk (OAR). Dose-volume histogram (DVH) and dosimetric parameters were analyzed and evaluated. Better coverage was achieved with PGO (mean CI = 0.95), but there were no significant mean CI differences than GrO (p = 0.03322). Mean EQD2 doses to HRCTV (D90) were also superior for PGO with no significant mean EQD2 doses than GrO (p = 0.9410). The mean EQD2 doses to bladder, rectum, and sigmoid were significantly higher for NO plan than PO, GrO, and PGO. PO significantly reduced the mean EQD2 doses to bladder, rectum, and sigmoid but compromising the conformity index to HRCTV. PGO was superior in conformity index (CI) and mean EQD2 doses to HRCTV compared with the GrO plan but not statistically significant. The mean EQD2 doses to the rectum by PGO plan slightly exceeded the limit from ABS recommendation (mean EQD2 dose = 78.08 Gy EQD2). However, PGO can shorten the treatment planning process without compromising the CI and keeping the OARs dose below the tolerance limit.

Summary Objective Radiotherapy remains an essential part of the management of locally advanced cervical cancer. Post-treatment surveillance allows for tumor response assessment and early detection of progressive prosecutions or local recurrences that may benefit from salvage treatment. The objective of this work is to assess the effectiveness of this therapeutic modality. Materials methods This is a retrospective study of 69 patients treated with concomitant radiation chemotherapy followed by high dose rate intracavitary brachytherapy. The tumor response was assessed by gynecologic physical examination at three months after the end of treatment. Results Median age of patients is 54.9 years (33–78 years). The most common histological type is squamous cell carcinoma (89.9%). The average dose received during external radiotherapy is 52.2 Gy (46–60 Gy). The average dose received during brachytherapy is 27.5 Gy (18–28 Gy). Three months after completion of treatment, 95.6% of patients had complete tumor remission, and only 4.4% had a tumor residue of 1 cm. Conclusion Radiation chemotherapy with brachytherapy allows for improved short-term local control in cervical cancer.

Purpose A prospective phase 2 study was conducted to evaluate the feasibility and safety of single-application multifractionated (SA-MF), high-dose-rate (HDR), image guided adaptive brachytherapy (IGABT) for cervical cancer. Methods and Materials Patients (N = 41) with International Federation of Gynaecology and Obstetrics 2009 stage IIB-IVA disease recruited between 2017 and 2019 underwent SA-MF. After completion of external beam radiation therapy of 50 Gy in 25 fractions, patients received magnetic resonance IGABT. The IGABT protocol consisted of a single brachytherapy (BT) application and treatment with 3 fractions of HDR (9 Gy on day 1; 2 fractions of 7 Gy with a minimum 6-hour gap on day 2) after achieving planning aims of the high-risk clinical target volume (HRCTV) receiving >84 Gy EQD2 and 2 cm3 of the bladder and rectum/sigmoid receiving ≤85 Gy and Results Thirty-eight patients were treated as per the protocol. All patients underwent Intracavitary + Interstitial BT with needles (median, 4; range, 3-11). The mean ± standard deviation HRCTV volume was 41 ± 21 cm3 and HRCTV D90 dose was 87.2 ± 3.6Gy. The 0.1 cm3 and 2 cm3 to bladder, rectum, and sigmoid were –103.2 ± 10.6 Gy and –84.6 ± 6.8 Gy, 82.2 ± 9.5 Gy and –68.3 ± 5.7 Gy, and 83.5 ± 9.8 Gy and –69.5 ± 5.9 Gy, respectively. Six patients required reoptimization before the second fraction to meet planning aims. Mean overall treatment time was 47 ± 6 days. With a median follow up of 22 months (range, 2-37), 2-year local control and disease-free and overall survival were 90.1%, 85%, and 94.5%, respectively. So far 1 patient with grade II and 2 patients with grade III rectal toxicities have been reported. Conclusion Magnetic resonance IGABT with SA-MF BT was feasible in 95% of patients. The dosimetric parameters and clinical results achieved so far look promising.

BACKGROUND AND PURPOSE Despite the excellent clinical outcomes from brachytherapy treatments compared with other modalities and the low associated costs, there have been reports of a decline in utilization of brachytherapy. The aim of this study was to investigate in detail the trend in utilization of brachytherapy in the province of Quebec, Canada, from 2011 to 2019. MATERIALS AND METHODS All radiotherapy clinics in the province of Quebec, and among these the clinics that provide brachytherapy treatments, were identified. This observational retrospective cohort study involved analysis of data compiled by the Ministere de la Sante et des Services Sociaux du Quebec for the period of 2011 to end of 2019 on all brachytherapy procedures performed in the province of Quebec. Time series graphs were used to describe the number of high dose rate (HDR) and low dose rate (LDR) brachytherapy treatments during the studied time period. Statistical analysis was conducted using R statistical software. RESULTS Between 2011 and 2019, 12 hospitals in the province of Quebec provided radiotherapy treatments, and all of them offered brachytherapy services. The median annual number of brachytherapy sessions was 4413 (range 3930-4829). HDR brachytherapy represented over 90% of all brachytherapy treatments throughout the study period. Significant changes over time were observed in the number of treatments: at least 5% change was seen only for the two most common subtypes of brachytherapy, HDR interstitial and HDR intracavitary, with an increase of 9.6% and a decrease of 9.2%, respectively. The use of other subtypes of brachytherapy (HDR-plesiotherapy, LDR-interstitial, LDR-intracavitary, LDR-eye plaque) was stable between 2011 and 2019, with ≤ 2.5% variation. CONCLUSION This study demonstrates an overall steady use of brachytherapy between 2011 and 2019 in Quebec. Brachytherapy offers numerous advantages for the treatment of diverse cancer sites. Although more sophisticated external beam radiotherapy treatments have emerged in the last decades, the precision and cost-effectiveness of brachytherapy remain unbeaten. To ensure the continued use and availability of brachytherapy, governments must put in place policies and regulations to that effect. Training and exposure of future health care professionals to brachytherapy within Quebec and Canada is essential to provide all patients the same access to this life saving modality.

purpose This practice parameter aims to detail the processes, qualifications of personnel, patient selection, equipment, patient and personnel safety, documentation, and quality control and improvement necessary for an HDR brachytherapy program. Methods and Materials This practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO). Results Brachytherapy is a radiotherapeutic modality in which radionuclide or electronic sources are used to deliver a radiation dose at a distance of up to a few centimeters by surface, intracavitary, intraluminal, or interstitial application. Brachytherapy alone or combined with external beam radiotherapy plays an important role in the management and treatment of patients with cancer. High-dose-rate (HDR) brachytherapy uses radionuclides, such as iridium-192, at dose rates of ≥12 Gy/hr to a designated target point or volume, and it is an important treatment for a variety of malignant and benign conditions. Its use allows for application of high doses of radiation to defined target volumes with relative sparing of adjacent critical structures. Conclusions HDR brachytherapy requires detailed attention to personnel, equipment, patient and personnel safety, and continuing staff education. Coordination between the radiation oncologist and treatment planning staff and effective quality assurance procedures are important components of successful HDR brachytherapy programs.

This study aims to evaluate the efficacy, feasibility, tolerability, and toxicity of concurrent chemotherapy and brachytherapy for locally advanced cervical carcinoma.Forty patients of cervical carcinoma were included in this study. The study period ranges from October 2016 to September 2019. Patients were evaluated and treated as per the protocol: external beam radiotherapy (50 Gy in 25 fractions) and concurrent weekly chemotherapy with injection (Inj.) cisplatin (30 mg/mOut of 40 patients enrolled in the study, 36 patients completed the treatment (17 Stage II and 19 Stage III). The incidence of Grade I and II skin toxicities were 78% and 10%, respectively. The incidence of genitourinary toxicities with respect to Grade I and II were 72% and 12%, respectively. There were Grade III hematological toxicities in two patients and the brachytherapy treatment was delayed for 4-6 days. The overall complete response was found in 28 (78%) patients, partial response in six (16.7%) patients, and progressive disease in two (5.6%) patients at 3 months of follow-up. On the last follow-up, 21 (58%) patients were disease-free and there was disease failure in seven patients (5 local recurrence and 2 with distant metastasis).Brachytherapy with the addition of concurrent chemotherapy is effective and feasible with acceptable toxicity for advanced stages of carcinoma cervix. This study upholds an interesting approach that can be regarded as feasible and tolerable for cervical cancer patients.

BACKGROUND AND PURPOSE To analyse the cumulative incidence of any failure (AF), prostate cancer-specific failure (PCSF), any death (AD), prostate cancer-specific death (PCSD), and local control in 2387 men with prostate cancer (PC), consecutively treated with combined high-dose-rate brachytherapy (HDRBT) and external beam radiotherapy (EBRT) from 1998 to 2010. MATERIAL AND METHODS A retrospective, single-institution study of men with localised PC. The mean age was 66 years and 54.7% had high-risk PC according to the Cambridge prognostic group (CPG) classification. The treatment was delivered as EBRT (2 Gy × 25) and HDRBT (10 Gy × 2) with combined androgen blockade (CAB). The median follow-up was 10.2 years. RESULTS The cumulative incidence of PCSD at 10 years was 5% [CI 95% 0.04-0.06]. The 10 years PCSD per risk group were: low (L) 0.4%, intermediate favourable (IF) 1%, intermediate unfavourable (IU) 4.3%, high-risk favourable (HF) 5.8%, and high-risk unfavourable (HU) 13.9%. The PCSF rate at 10 years was 16.5% [CI 95% 0.15-0.18]. The PCSF per risk group at 10 years were: L 2.5%, IF 5.5%, IU 15.9%, HF 15.6%, and HU 38.99%. PCSF occurred in 399 men, of whom 15% were found to have local failure. The estimated frequency of local failure in the entire cohort was 1.2%. CONCLUSIONS HDRBT combined with EBRT is an effective treatment with long-term overall survival and excellent local control for patients with PC. The low rate of local recurrence among men with relapse suggests that these patients were micro metastasised at time of treatment, which calls for improved methods to detect disseminated disease.

Purpose Partial aponeurectomy (PA) is a standard procedure for Dupuytren's contracture (DC). Here we report a novel approach using surgery combined with perioperative high dose rate (192Ir-HDR) brachytherapy. Methods and patients From March 2018 until February 2020, thirteen rays of 6 patients with Dupyutren's contractures underwent PA followed by HDR brachytherapy. After removal of fibrous tissue and mobilization of the tendons, one to three catheters per patient were placed intraoperatively. Immediately after surgery, a planning computer tomography with 3D-planning was performed. Then 10-12 Gy were given to 0-2 mm from the catheters' surface and the catheters were removed 6-12 h after brachytherapy. Results No complications were observed. The mean contractures were reduced from 55.4° (standard error SE 19.6) to 15.4° (SE 6.7; p Conclusions HDR brachytherapy in combination with surgery is feasible and harbors the potential for combined modality therapy to reduce relapse rates of advanced or relapsing DC. Controlled studies are warranted to investigate the role of bimodal therapy compared with PA alone.

Highlights • Biochemical failure rates after focal salvage high-dose-rate brachytherapy are high. • Evidence on predictors for failure is limited to whole-gland salvage radiotherapy. • Two prediction models for biochemical failure were developed and internally validated. • Based on pre- and post-salvage characteristics we can identify high-risk patients. • These models can be used for patient counselling at baseline and during follow-up., Background and purpose Magnetic resonance-guided focal salvage high-dose-rate brachytherapy (FS-HDR-BT) for radiorecurrent prostate cancer (PCa) shows low toxicity rates. However, biochemical failure (BF) after treatment occurs frequently. We developed two prediction models for BF (Phoenix definition) with the aim of enhancing patient counselling before FS-HDR-BT and during follow-up. Materials and methods A prospective cohort of 150 radiorecurrent PCa patients treated with FS-HDR-BT between 2013 and 2020 was used for model development and internal validation. Multivariable Cox Proportional Hazards regression was applied. For model 1, only pre-salvage variables were included as candidate predictors. For model 2, additional (post-)salvage characteristics were tested. After calibration, nomograms and webtools were constructed. Finally, three risk groups were identified. Results Sixty-one patients (41%) experienced BF. At baseline (model 1), age, gross tumour volume, pre-salvage PSA, and pre-salvage PSA doubling time (PSADT) were predictive of BF. During follow-up (model 2), age, pre-salvage PSA and PSADT, seminal vesicle involvement, post-salvage time to PSA nadir, and percentage PSA reduction were predictive of BF. The adjusted C-statistics were 0.73 (95% CI: 0.66–0.81) and 0.84 (95% CI: 0.78–0.90), respectively, with acceptable calibration. Estimated 2-year biochemical disease-free survival for the low-, intermediate-, and high-risk groups were 84%, 70%, and 31% (model 1), and 100%, 71%, and 5% (model 2). Conclusion Two models are provided for prediction of BF in patients with radiorecurrent PCa treated with FS-HDR-BT. Based on pre- and post-salvage characteristics, we are able to identify patients with a high risk of BF. These findings can aid patient counselling for FS-HDR-BT.

Author(s): Kunogi, Hiroaki; Hsu, I-Chow; Sasai, Keisuke | Abstract: PurposeBulky chest wall recurrence after mastectomy presents a therapeutic challenge because of high-dose of radiation required to control the disease, and its proximity to low-tolerance organs at risk. We report a case of successful computed tomography (CT)-guided high-dose-rate (HDR) salvage interstitial brachytherapy (ISBT) boost.Material and methodsA 70-year-old female initially presented with a tumor in right breast, and was treated with mastectomy and adjuvant chemotherapy, followed by hormonal therapy for 5 years without adjuvant radiotherapy. In 2018, 20 years after the initial treatment, she developed unresectable chest wall recurrence that measured 10.5 cm × 7.3 cm × 4.5 cm, with bone and parietal pleura invasion. Biopsy revealed invasive pleomorphic lobular carcinoma [estrogen receptor (ER)-positive, progesterone receptor (PR)-negative, HER2-negative]. There was no evidence of metastatic disease.ResultsThe patient underwent external beam radiotherapy (EBRT) plus ISBT. After EBRT of 50 Gy in 25 fractions was completed, CT-guided ISBT was performed as an outpatient treatment. HDR dose was 16 Gy delivered in 2 fractions with 2 implants. Dose was prescribed to gross tumor volume. ISBT plans were created using inverse planning simulated annealing (IPSA) algorithm. Gross tumor volume D90% plus EBRT dose was 82 Gy equivalent dose of 2 Gy (EQD2), assuming α/β of 4 for breast carcinoma. The patient continued on hormonal therapy. At the 30-month follow-up, the patient remains in remission. The tumor could not be detected by magnetic resonance imaging (MRI) or positron emission tomography (PET). There were no severe treatment-related complications.ConclusionsCT-guided HDR ISBT boost can be a useful modality in individualizing treatment strategies for breast cancer patients with unresectable bulky chest wall recurrence.

To investigate the effect of proximal intramedullary nail (pFNA) internal fixation and hip replacement. Methods: 100 patients with rough fractures were selected from December 2012 to December 2015, fixed group with 50 patients in fixed group, hip replacement, incision length, intra operative bleeding, surgery, postoperative implantation, hospitalization, weight exercise time, complications and preoperative hip Harris scores. Results: incision length, intra operative bleeding, surgical time, complications were significantlylower than the replacement group, P 0.05). Conclusion: Hip replacement and pFNA internal fixation have good treatment effect, the former is conducive to the early activity of elderly patients, the latter has small trauma and less complication, which should be selected according to clinical needs. To sum up, hip replacement and pFNA internal fixation have good efficacy in the treatment of crude Cologne fractures in the elderly, the former is conducive to the early activity of the elderly patients, but the latter has small trauma and few complications, which should be selected according to clinical needs.

Highlights • This paper evaluated lesion-directed prostatic high dose rate brachytherapy. • Lesions defined by prostate specific membrane antigen positron emission tomography. • Dose escalation was confirmed using whole-mount digital histology. • Targeting lesions led to significantly higher dose to high-grade histologic cancer., Background and purpose Prostate specific membrane antigen positron emission tomography imaging (PSMA-PET) has demonstrated potential for intra-prostatic lesion localization. We leveraged our existing database of co-registered PSMA-PET imaging with cross sectional digitized pathology to model dose coverage of histologically-defined prostate cancer when tailoring brachytherapy dose escalation based on PSMA-PET imaging. Materials and methods Using a previously-developed automated approach, we created segmentation volumes delineating underlying dominant intraprostatic lesions for ten men with co-registered pathology-imaging datasets. To simulate realistic high-dose-rate brachytherapy (HDR-BT) treatments, we registered the PSMA-PET-defined segmentation volumes and underlying cancer to 3D trans-rectal ultrasound images of HDR-BT cases where 15 Gray (Gy) was delivered. We applied dose/volume optimization to focally target the dominant intraprostatic lesion identified on PSMA-PET. We then compared histopathology dose for all high-grade cancer within whole-gland treatment plans versus PSMA-PET-targeted plans. Histopathology dose was analyzed for all clinically significant cancer with a Gleason score of 7or greater. Results The standard whole-gland plans achieved a median [interquartile range] D98 of 15.2 [13.8–16.4] Gy to the histologically-defined cancer, while the targeted plans achieved a significantly higher D98 of 16.5 [15.0–19.0] Gy (p = 0.007). Conclusion This study is the first to use digital histology to confirm the effectiveness of PSMA-PET HDR-BT dose escalation using automatically generated contours. Based on the findings of this study, PSMA-PET lesion dose escalation can lead to increased dose to the ground truth histologically defined cancer.

Purpose Radiotherapy with high-dose-rate (HDR) brachytherapy is used to treat nonmelanoma skin cancers. We retrospectively analyzed a hypofractionated regimen to assess its safety and efficacy in elderly patients ≥70 years. Methods and Materials Forty-eight patients with 67 lesions treated since 2016 with catheter-based iridium-192 HDR brachytherapy using a custom mold or three-dimensional–printed applicator met inclusion criteria. Treatment was 36 Gy in six weekly fractions. Local and locoregional control were assessed with Kaplan–Meier curves. Acute and late toxicity were graded as per Common Terminology Criteria for Adverse Events, version 5. Cosmesis was defined as “excellent” (indistinguishable from untreated skin), “good” (minimal changes), or “poor” (extensive changes). Univariate analyses were performed. Results Median age was 85.7 years, and 21 were female. Durable local control occurred in 63 lesions (94.0%), giving estimated local control of 100% at 6 months, 95.1% at 1 year, and 88.8% at 2 years. No factors were predictive of local control on univariate analysis. All experienced acute toxicity that ultimately resolved: 28.4% Grade 2 and 4.5% Grade 3. Larger treatment volume receiving ≥36 Gy was associated with increased Grade ≥2 acute toxicity. Patients experienced late Grade 2 and late Grade 4 toxicity after 6.5% treatments each. Younger age was associated with increased Grade ≥2 late toxicity. “Good” or better cosmesis occurred in 93.2%, and “poor” cosmesis was associated with lower extremities and larger lesions. Conclusions Hypofractionated HDR brachytherapy using 36 Gy in six weekly fractions is associated with satisfactory locoregional control and cosmesis with minimal risk of severe acute or late toxicities.

Purpose To perform a propensity-score matched analysis comparing stereotactic body radiation therapy (SBRT) boost and high-dose-rate (HDR) boost for localized prostate cancer. Methods and Materials A single-institution retrospective chart review was conducted of men treated with pelvic external beam radiation therapy (EBRT) and SBRT boost (21 Gy and 19 Gy in 2 fractions) to the prostate for prostate cancer. A cohort treated at the same institution with HDR brachytherapy boost (19 Gy in 2 fractions) was compared. Propensity-score (PS) matching and multivariable Cox regression were used for analysis. Outcomes were biochemical recurrence freedom (BCRF) and metastasis freedom (MF). Results One hundred thirty-one men were treated with SBRT boost and 101 with HDR boost with median follow-up of 73.4 and 186.0 months, respectively. In addition, 68.8% of men had high-risk and 26.0% had unfavorable-intermediate disease, and 94.3% received androgen deprivation therapy. Five- and 10-year unadjusted BCRF was 88.8% and 85.3% for SBRT and 91.8% and 74.6% for HDR boost (log-rank P = .3), and 5- and 10-year unadjusted MF was 91.7% and 84.3% for SBRT and 95.8% and 82.0% for HDR (log-rank P = .8). After adjusting for covariates, there was no statistically significant difference in BCRF (hazard ratio [HR] 0.81; 95% confidence interval [CI], 0.37-1.79; P = .6) or MF (HR 1.07; 95% CI, 0.44-2.57; P = .9) between SBRT and HDR boost. Similarly, after PS matching, there was no statistically significant difference between SBRT and HDR (BCRF: HR 0.66, 0.27-1.62, P = .4; MF: HR 0.84, 0.31-2.26, P = .7). Grade 3+ genitourinary and gastrointestinal toxicity in the SBRT cohort were 4.6% and 1.5%, and 3.0% and 0.0% in the HDR cohorts (P = .4, Fisher exact test). Conclusions SBRT boost plus pelvic EBRT for prostate cancer resulted in similar BCRF and MF to HDR boost in this single institution, PS matched retrospective analysis. Toxicity was modest. Prospective evaluation of SBRT boost for the treatment of unfavorable-intermediate and high-risk prostate cancer is warranted.

Aim The dominant intraprostatic lesion (DIL) is the commonest site of relapse after single dose high-dose-rate brachytherapy (HDR-BT) for localised prostate cancer. This study investigated toxicity and clinical outcomes of focal dose escalation to the DIL with dose de-escalation to the remaining prostate. Materials/Methods Between November 2012 and July 2016, 50 patients with localised prostate adenocarcinoma received single fraction HDR-BT. 21 Gy was prescribed to the DIL, with two de-escalation prescription schedules for the remaining prostate. Primary outcomes included biochemical no evidence of disease (bNED), local recurrence free survival (LRFS), and metastasis free survival (MFS). Secondary outcomes included late genitourinary, gastrointestinal and sexual toxicity. Kaplan—Meier analyses with log rank tests were used to estimate bNED, LRFS and MFS. Results With a median follow up of 70.6 months, 15 patients developed biochemical failure, including 8 in the group that received minor dose de-escalation to the non-DIL prostate (group 1) and 7 in the group that received moderate de-escalation (group 2). Five-year bNED was 88% in group 1 and 76% in group 2 (p = 0.05). Overall 4-year and 5-year FFLF in group 1 was 100% and 96% and in group 2 92% and 84%. These differences were statistically significant (p = 0.03). No acute ≥G3 genitourinary or ≥G2 gastrointestinal toxicity was reported. The median IIEF decreased in the first 6 months improving to a peak median score of 20 at 54 months. Conclusion Focal boost to the DIL did not improve biochemical or local control after single-fraction HDR monotherapy compared to what would be expected from 19 Gy single fraction treatment to the whole gland.

Background and purpose: 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.Materials and methods: 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. Seventythree 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.Results: 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.Conclusion: 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. (c) 2021 Elsevier B.V. All rights reserved. Radiotherapy and Oncology 159 (2021) 231-240

During radiotherapy for pelvic tumors, there might be insufficient radiation doses delivered that result from concerns of immediately adjacent critical organs, most notebly the rectum. Several measures have been proposed to reduce the rectal doses, such as use of a radioprotective spacer to shift the rectum away from the lesion or an endorectal balloon to reduce the internal target volume (ITV). The removal of rectal gas is supposed to achieve the similar effect by reducing the rectal volume and ITV. This is because the distance of the rectum to lesions can be increased with decreasing rectal volumes, which also makes it easy for physicists to avoid the rectum during field design. Besides, a reduced ITV can be obtained due to stability in rectal volume, as with use of an endorectal balloon. The procedure is most suitable for patients receiving stereotactic body radiotherapy (SBRT) and high dose rate brachytherapy (HDR-BR) because of limited treatment sessions. In this study, we showed that the rectal dose decreased significantly with rectal gas extraction, as manifested by dose parameters of D2 cm3 and D0.1 cm3 (the doses delivered to the most exposed 2 cm, 3 and 0.1 cm3 of the rectum, respectively). This technique is especially benefitable for candidates with excessive rectal gas fillings.

Introduction Despite the rising popularity of high-dose-rate (HDR) brachytherapy and use of Co-60 in the country, local data on brachytherapy outcomes are lacking. The study reviewed the incidence of toxicities and recurrences in patients with cervical cancer treated with Co-60 intracavitary HDR brachytherapy in a tertiary government hospital in the Philippines. Methods Records of patients with cervical cancer who completed external beam radiotherapy (EBRT) and brachytherapy from 2016 to 2018 were reviewed. Patient-related (age, smoking history, body mass index, histology, stage, mass size) and treatment-related (overall treatment time [OTT], EBRT machine used, brachytherapy fractionation, dose prior to midline shielding/central tumor dose [CTD]) parameters were analyzed for possible associations with the incidence of toxicities and recurrences. Results One hundred and sixty-three patients were identified and reviewed for baseline characteristics. Patients who had inadequate follow-up ( Conclusion We present outcomes of GI and GU toxicities, and locoregional and distant recurrences after chemoradiation and Co-60 HDR brachytherapy in a tertiary government hospital in the Philippines. Our study suggests that CTD was significantly associated with incidence of toxicities, while OTT was weakly associated with recurrence. Interventions should be made to control these factors, especially in high-volume, low-resource cancer centers.

PURPOSE To develop a simulation model for GammaMed Plus high dose rate 192 Ir brachytherapy source in TOPAS Monte Carlo software and validate it by calculating the TG-43 dosimetry parameters and comparing them with published data. METHODS We built a model for GammaMed Plus high dose rate brachytherapy source in TOPAS. The TG-43 dosimetry parameters including air-kerma strength SK , dose-rate constant Λ, radial dose function gL (r), and 2D anisotropy function F(r,θ) were calculated using Monte Carlo simulation with Geant4 physics models and NNDC 192 Ir spectrum. Calculations using an old 192 Ir spectrum were also carried out to evaluate the impact of incident spectrum and cross sections. The results were compared with published data. RESULTS For calculations using the NNDC spectrum, the air-kerma strength per unit source activity SK /A and Λ were 1.0139 × 10-7 U/Bq and 1.1101 cGy.h-1 .U-1 , which were 3.56% higher and 0.62% lower than the reference values, respectively. The gL (r) agreed with reference values within 1% for radial distances from 2 mm to 20 cm. For radial distances of 1, 3, 5, and 10 cm, the agreements between F(r,θ) from this work and the reference data were within 1.5% for 15°

Highlights • The optimal sequence of HDR-BT boost and EBRT for prostate cancer is unclear. • We compared early toxicity based on the timing of HDR-BT boost. • The timing of HDR-BT was not based on any specific patient or clinical factors. • We found no difference in early GI/GU toxicity between the two groups. • Longer follow-up is needed to evaluate late toxicity and long-term disease control., Background We present the first report comparing early toxicity outcomes with high-dose rate brachytherapy (HDR-BT) boost upfront versus intensity modulated RT (IMRT) upfront combined with androgen deprivation therapy (ADT) as definitive management for intermediate risk or higher prostate cancer. Methods and Materials We reviewed all non-metastatic prostate cancer patients who received HDR-BT boost from 2014 to 2019. HDR-BT boost was offered to patients with intermediate-risk disease or higher. ADT use and IMRT target volume was based on NCCN risk group. IMRT dose was typically 45 Gy in 25 fractions to the prostate and seminal vesicles ± pelvic lymph nodes. HDR-BT dose was 15 Gy in 1 fraction, delivered approximately 3 weeks before or after IMRT. The sequence was based on physician preference. Biochemical recurrence was defined per ASTRO definition. Gastrointestinal (GI) and Genitourinary (GU) toxicity was graded per CTCAE v5.0. Pearson Chi-squared test and Wilcoxon tests were used to compare toxicity rates. P-value

Purpose Using multiparametric MRI data and the pathologic data from radical prostatectomy specimens, we simulated the treatment planning of dose-escalated high-dose-rate brachytherapy (HDR-BT) to the Multiparametric MRI dominant intraprostatic lesion (mpMRI-DIL) to compare the dose potentially delivered to the pathologically confirmed locations of the high-grade component of the cancer. Methods and Materials Pathologist-annotated prostatectomy midgland histology sections from 12 patients were registered to preprostatectomy mpMRI scans that were interpreted by four radiologists. To simulate realistic HDR-BT, we registered each observer's mpMRI-DILs and corresponding histology to two transrectal ultrasound images of other HDR-BT patients with a 15-Gy whole-gland prescription. We used clinical inverse planning to escalate the mpMRI-DILs to 20.25 Gy. We compared the dose that the histopathology would have received if treated with standard treatment plans to the dose mpMRI-targeting would have achieved. The histopathology was grouped as high-grade cancer (any Gleason Grade 4 or 5) and low-grade cancer (only Gleason Grade 3). Results 212 mpMRI-targeted HDR-BT plans were analyzed. For high-grade histology, the mpMRI-targeted plans achieved significantly higher median [IQR] D98 and D90 values of 18.2 [16.7–19.5] Gy and 19.4 [17.8–20.9] Gy, respectively, in comparison with the standard plans (p = 0.01 and p = 0.003). For low-grade histology, the targeted treatment plans would have resulted in a significantly higher median D90 of 17.0 [16.1–18.4] Gy in comparison with standard plans (p = 0.015); the median D98 was not significantly higher (p = 0.2). Conclusions In this retrospective pilot study of 12 patients, mpMRI-based dose escalation led to increased dose to high-grade, but not low-grade, cancer. In our data set, different observers and mpMRI sequences had no substantial effect on dose to histologic cancer.

Concurrent chemoradiotherapy is considered the standard treatment for the locally advanced cancer cervix (LACC). Radiotherapy is commonly administered by a three-dimensional conformal radiotherapy (3DCRT) approach followed by brachytherapy (BT). High dose rate (HDR) BT is commonly administered; however, several drawbacks exist including invasive technique, pain, requirement of anesthesia, and operative risks. We assessed the dosimetric difference between the HDR BT and the volumetric modulated arc therapy (VMAT) boost in those patients. Ten patients were selected retrospectively with LACC and all received whole pelvis radiotherapy followed by BT boost of 7 Gy in three fractions. The computed tomography (CT) image was transferred to the Varian system for the VMAT plan while the one with the applicator was transferred to the Sagi planning system and the high-risk clinical target volume (HR-CTV), bladder, rectum, sigmoid, and small bowel were delineate with a margin of 5 mm were added to the CTV to create the planning target volume (PTV). The D90 for the PTV in VMAT boost was lower than received by the HR-CTV in the BT boost. Mean volume of the PTV was higher than that of the HR-CTV. The D2cc was higher in VMAT for bladder, sigmoid, and rectum while the D2cc for the small bowel in BT was higher compared with the VMAT. The VMAT is an option that exists for patients who refuse BT or cannot tolerate it, or in case of nonavailability of BT or a nonworking machine.

Treatment planning in high dose‐rate brachytherapy has traditionally been conducted with manual forward planning, but inverse planning is today increasingly used in clinical practice. There is a large variety of proposed optimization models and algorithms to model and solve the treatment planning problem. Two major parts of inverse treatment planning for which mathematical optimization can be used are the decisions about catheter placement and dwell time distributions. Both these problems as well as integrated approaches are included in this review. The proposed models include linear penalty models, dose–volume models, mean‐tail dose models, quadratic penalty models, radiobiological models, and multiobjective models. The aim of this survey is twofold: (i) to give a broad overview over mathematical optimization models used for treatment planning of brachytherapy and (ii) to provide mathematical analyses and comparisons between models. New technologies for brachytherapy treatments and methods for treatment planning are also discussed. Of particular interest for future research is a thorough comparison between optimization models and algorithms on the same dataset, and clinical validation of proposed optimization approaches with respect to patient outcome. Funding: Swedish Research CouncilSwedish Research CouncilEuropean Commission [VR-NT 2015-04543]; Swedish Cancer SocietySwedish Cancer Society [CAN 2017/1029, CAN 2018/622]

Purpose 3D printing has become a popular and widely available technique of rapid prototyping. The impact of used materials on the dose distribution has been studied for high energy sources. However, brachytherapy sources emit lower energy photons, and materials used in 3D printing may differ. This study was conducted to analyze the influence of common materials (polylactic acid – PLA and acrylonitrile butadiene styrene – ABS) used in stereolithography. Material and methods A 3D-printed phantom was designed, printed, and used to calibrate Gafchromic films. In the next step, a range of 1 mm thick plates of PLA and ABS (from zero to thirty) were inserted between source and detector to measure the impact of studied materials on delivered dose. Measurements were performed using a calibrated radiochromic film and Farmer ionization chamber in water. Results No statistically significant correlation (p = 0.4854) between the thickness of inserted PLA and the dose delivered to the film was obtained. With ionization chamber, Spearman’s rank order test showed a significant correlation (p = 0.00004); however, the correlation was found weak. In case of ABS measurement, a statistically significant (p = 0.0159), yet weak negative correlation was found between the thickness of used material and the dose delivered to the film. On the other hand, a weak statistically significant (p = 0.0212) but positive correlation was found when the dose was measured with Farmer ionization chamber. We find these correlations false, as all measured doses were within the measurement uncertainty range (film ±8.0%, Farmer ±8.8%) from 100% of the prescribed dose. Conclusions According to obtained results, with the accuracy of measurement under clinical conditions, the impact of highly filled PLA and ABS printed objects on the dose distribution from an 192Ir source in water can be omitted.

Purpose/objective Long-term follow up of single dose high-dose rate brachytherapy (HDR BT) for localised prostate cancer has revealed higher than expected rates of biochemical and local failure. This study aimed (i) to investigate the pattern of relapse within the prostate with reference to the initial site of disease in those patients; and (ii) to examine if there were any relationships between the HDR BT dosimetric parameters to these areas of recurrence. Materials/methods A retrospective review of treatment records of patients who received 19 Gy single fraction of HDR BT was carried out. A matched pair analysis used one control for each biochemical recurrence case matched with pre-treatment Clinical target volume (CTV) size, Gleason score, T stage, risk category and presence of an identifiable dominant intraprostatic nodule (DIL) for each biochemical recurrence case identified. For all datasets, the pre HDR BT DILs were delineated on the diagnostic pre-treatment T2-weighted MRI and planning CT images. For patients with local recurrence post HDR BT, the recurrent nodules were contoured on the diagnostic T2-weighted MRI and choline PET which were registered to the original HDR BT planning CT. Dosimetric parameters of CTV, planning target volume (PTV), DIL and organs at risk (OARs) were evaluated. Wilcoxon signed-rank test was performed to investigate if there were any significant differences in dosimetric parameters between cases and controls. Cox regression analysis was performed to explore if there were any clinical and dosimetric parameters predicting for biochemical progression free survival (bPFS), local recurrence free survival (LR-PFS) and DIL recurrence free survival (DIL-PFS). Results Between 2013 and 2018, 180 patients received 19 Gy HDR-BT monotherapy. With a median follow up of 36 months, 19 (10.6%) patients developed biochemical recurrence. Of the 19 patients with biochemical failure, 13 had a local recurrence, including 7 who occurred at the site of DIL. Thirty-eight intermediate/high risk patients were included in the matched pair analysis. No statistically significant differences were found in all CTV, PTV, DIL and OAR dosimetric parameters between cases and controls (p > 0.05). For the Cox regression analysis, none of the covariates investigated were found to be statistically significant factors to predict for bPFS, LC-PFS and DIL-PFS. Conclusion No associations between biochemical recurrences and HDR BT dosimetry were identified in our cohort of patients receiving 19 Gy single fraction HDR BT. A large proportion of recurrences occurred at the site of original disease. HDR BT for intermediate/high risk prostate cancer should be undertaken using a minimum of two fractions.

Purpose To compare brachytherapy (BT) boost of low-dose-rate (LDR) and high-dose-rate (HDR) techniques in patients diagnosed with intermediate-risk prostate cancer. Material and methods Between January 2005 and February 2018, 142 patients (50 LDR and 92 HDR) with intermediate-risk prostate cancer were treated with a BT boost, and retrospectively analyzed. Prescribed dose was 45 Gy with external beam radiotherapy (EBRT) plus 100-108 Gy with LDR-BT, and 60 Gy with EBRT plus one fraction of 10 Gy with HDR-BT. 99% of patients received androgen deprivation therapy (ADT) for 6 months. Primary endpoint was to compare LDR and HDR boosts in terms of biochemical progression-free survival (bPFS). Secondary endpoint, after re-classifying patients into "favorable" and "unfavorable" sub-groups, was to analyze differences with a similar treatment intensity. Results Median overall follow-up for the total cohort was 66.5 months (range, 16-185 months). There were no significant differences in bPFS, overall survival, cause specific survival, local failure, lymph node failure, or distant failure when LDR or HDR was employed. bPFS at 90 months was 100% for favorable, and 89% and 85% for unfavorable patients at 60 months and 90 months, respectively (log-rank test, p = 0.017). The crude incidence of genitourinary acute and chronic toxicity grade 3 was 0.7% and 4%, respectively. Twelve patients (8%) had chronic rectal hemorrhage grade 2, in whom argon was applied (4 LDR and 8 HDR). Conclusions Combined treatment is an excellent therapeutic option in patients with intermediate-risk prostate carcinoma, with similar results in both LDR and HDR approaches and very low toxicities. Importantly, the current literature has indicated that unfavorable-risk patients belong to a different category, and should be treated as patients with high-risk factors. Therefore, the stratification and identification of both risk groups is extremely relevant.

This study compares the plan quality of high-dose-rate brachytherapy (HDR-BT) and volumetric modulated arc therapy (VMAT) for superficial irradiation of large areas of skin with significant curvature in one or more planes. A total of 14 patients from two centres previously treated with either HDR-BT or VMAT were retrospectively replanned using the alternative technique. Sites included scalp and lower limbs. Identical computed tomography (CT) scans, clinical target volume (CTV) and organs at risk (OARs) and prescription were used for both techniques. Conformity, skin surface dose and OAR doses were compared. Conformity index was consistently better with VMAT than HDR-BT (p

Purpose Multiple dwell positions (“multidwell”) within a Leipzig-style applicator can be used to increase dose uniformity and treatment area. Model-based dose calculation algorithms (MBDCAs) are necessary for accurate calculations involving these applicators because of their nonwater equivalency and complex geometry. The purpose of this work was to create template plans from MBDCA calculations and present their dwell times and positions for users of these applicators without access to MBDCAs. Methods and Materials The Leipzig-style solid applicator model within our treatment planning system was used to design template plans. Five template plans, normalized to 0.3 cm depth within a water phantom, were optimized using the treatment planning system MBDCA. Each template plan contained unique dwell positions, times, and active lengths (0.5–1.5 cm). A single-dwell distribution was optimized for comparison. The stem of this applicator stops within the shell; therefore, one template plan contained an intrafraction rotation to determine the largest dose distribution achievable. Effects of imperfect applicator rotation were quantified by inserting rotational offsets and comparing the V100%, D95%, and minimum dose coverage for planning target volumes created from 80%/90% isodose lines. Results The 90% (80%) isodose line dimensions at 0.3 cm depth for single-dwell increased from 0.94 × 0.97 (1.53 × 1.57) cm2 to 2.09 × 1.24 (2.75 × 1.88) cm2 in the largest template plan. Manually inserted angular offsets up to ±10° for the template plan requiring rotation preserved V100%, D95%, and minimum dose within 2.0%, 1.9%, and 8.0%, respectively. Conclusion A set of template plans was created to provide accessibility to the multidwell methodology, even for users without access to MBDCAs. Each template plan should be reviewed before clinical implementation.

Highlights • Severe toxicity is as low as 3% (GU), 0% (GI) and 15% (ED). • Lower impact is predicted for patients with favorable function at baseline. • Lower dose to the urethra (D10%, Background and purpose Local re-treatment of radiorecurrent prostate cancer is potentially curative. However, the increased risk of severe toxicity may outweigh the opportunity of cancer control. This study aims to evaluate treatment-related toxicity from ultrafocal salvage high-dose-rate brachytherapy (HDR-BT) and to investigate potential risk factors. Materials and methods Toxicity data from 150 treated patients (July 2013–November 2019) was collected from a prospective registry. The treatment aim was to deliver a single dose of 19 Gy to the recurrent lesion as identified on multiparametric MRI and PET-CT. Treating physicians graded genitourinary (GU) and gastro-intestinal (GI) toxicity and erectile dysfunction (ED) using the Common Terminology Criteria for Adverse Events (CTCAE) 4.0, at baseline and during follow-up. Domains with substantial (≥10%) new-onset grade ≥ 2 toxicity were further evaluated using mixed effects logistic regression to find potential risk factors. Results Median follow-up time was 20 months (IQR 12–31). Over time, new-onset grade 2 and 3 toxicity was recorded in 41% and 3% (GU), 5% and 0% (GI) and 22% and 15% (ED). While GI toxicity remained stably low, grade ≥ 2 GU toxicity and ED were seen twice as frequent in the late phase (>3 months after treatment). Significant risk factors for grade ≥ 2 toxicity were baseline GU toxicity (grade ≥ 2), baseline ED (grade ≥ 2), IPSS (cut-off ≥ 14) and urethral dose (D10%, cut-off ≥ 17 Gy). Conclusion Ultrafocal salvage HDR-BT is a safe re-treatment option, especially in patients with a favorable symptom profile at baseline. Adherence to urethral dose constraints is important to avoid GU toxicity.

Purpose To develop a method combining CT scout images with axial images to improve the localization accuracy of catheter tips in high‐dose‐rate (HDR) brachytherapy treatments. Materials and Methods CT scout images were utilized along with conventionally reconstructed axial images to aid the localization of catheter tips used during HDR treatment planning. A method was developed to take advantage of the finer image resolution of the scout images to more precisely identify the tip coordinates. The accuracies of this method were compared with the conventional method based on the axial CT images alone, for various slice thicknesses, in a computed tomography dose index (CTDI) head phantom. A clinical case which involved multiple interstitial catheters was also selected for the evaluation of this method. Locations of the catheter tips were reconstructed with the conventional CT‐based method and this newly developed method, respectively. Location coordinates obtained via both methods were quantitatively compared. Results Combination of the scout and axial CT images improved the accuracy of identification and reconstruction of catheter tips along the longitudinal direction (i.e., head‐to‐foot direction, more or less parallel to the catheter tracks), compared to relying on the axial CT images alone. The degree of improvement was dependent on CT slice thickness. For the clinical patient case, the coordinate differences of the reconstructed catheter tips were 2.6 mm ± 0.9 mm in the head‐to‐foot direction, 0.4 mm ± 0.2 mm in the left‐to‐right direction, and 0.6 mm ± 0.2 mm in the anterior‐to‐posterior direction, respectively. Conclusion Combining CT scout and axial images demonstrates the ability to provide a more accurate identification and reconstruction of the interstitial catheter tips for HDR brachytherapy treatment, especially in the longitudinal direction. The method developed in this work has the potential to be implemented clinically together with automatic segmentation in modern brachytherapy treatment planning systems, in order to improve the reconstruction accuracy of HDR catheters.

Background . Prostate cancer (PCa) is one of the most common malignant diseases in men worldwide, with over 1.1 million cases of PCa reported annually. In the Russian Federation, the proportion of patients with stage I—II PCa from 2008 to 2018 increased from 37.6 % to 56 %, which in turn allows more and more patients to perform radical treatment methods. However, it should be noted that the number of patients with both recurrent PCa after radiation therapy (external beam radiation therapy (EBRT) or brachytherapy) and with local recurrence after radical prostatectomy (RPE) is steadily increasing. Objective . Improve treatment outcomes for patients with recurrent PCa. Materials and methods. A. F. Tsyb Medical Radiological Research Center — branch of the National Medical Research Radiological Center, since 2016, has been treating patients with recurrent PCa using salvage high-dose brachytherapy (SHDR) (192Ir) after radical radiation treatment (EBRT, brachytherapy) or with local recurrence after RPE. Patients with recurrent PCa were divided into three groups, depending on the type of initial radical treatment: patients with recurrent disease after RPE, after EBRT and after brachytherapy. Results . The most favorable results of SHDR were registered in the group of patients with local recurrence after RPE: in 7 patients out of 8 (87 %), one year after the PSA, the prostate-specific antigen (PSA) level was less than 0.1 ng/mL. In 1 patient, the PSA level dropped to 0.71 ng/mL (baseline 2.47 ng/mL) two years after salvage treatment. Currently, there is a further decrease in PSA levels. Results after SHDR ( 192 Ir) in patients with relapse after EBRT: of 8 patients, 2 (25 %) had PSA levels less than 0.2 ng/mL after a year. In 4 patients, the PSA level two years after treatment was more than 2.0 ng/mL. In these patients, a relapse was registered. Another 2 patients also had a repeated relapse after SHDR. The following results were obtained after carrying out SHDR in patients with relapse after braahythempy (both low- and high-dose). Of the 12patients, 7patients (58 %) had PSA levels less than 0.5 ng/mL two years after SHDR. SHDR was performed in the mode of two fractions of 12.5 Gyerahwith an interval of two weeks between them. In 3 patients, the PSA level exceeded 0.5 ng/ mL two years after the salvage treatment, and therefore, a second relapse is determined in them. Another 2 patients also had a repeated relapse. Conclusion . This article provides preliminary results of our research. We would like to reiterate that as possible options for the treatment of local recurrence of PCa, it is possible to choose salvage prostatectomy, salvage radiation therapy, hormonal therapy or SHDR brachytherapy. In some cases EBRT is used in this category of patients, however, this can lead to the development of severe radiation damage. The choice of a treatment method in case of recurrent PCa is a complex problem, the decision of which is based on many factors. The clinical course of PCa, the prevalence of the disease, the level of markers, and molecular genetic data are taken into account.