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Sarwar A, Syed L, Patel K, Reid I, Abonyi E, Banas N, Lowe G, Bryant L, Hoskin P. Image-guided Interstitial Brachytherapy in the Treatment of Primary and Recurrent Vulvovaginal Gynaecological Malignancies. Clin Oncol (R Coll Radiol) 2024; 36:6-11. [PMID: 37923687 DOI: 10.1016/j.clon.2023.10.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/24/2023] [Indexed: 11/07/2023]
Abstract
AIMS To evaluate the use, outcomes and toxicities of high dose rate brachytherapy (HDRB) to the vulvovaginal region in previously irradiated and radiotherapy-naïve patients for primary or recurrent gynaecological malignancies. MATERIALS AND METHODS From January 2010 to December 2020, 94 women with a median age of 64 years (range 31-88 years) were treated with interstitial HDRB for vulvovaginal disease. Treatment details, including cumulative radiotherapy doses, were recorded together with reported toxicity, using Common Terminology Criteria for Adverse Events (CTCAE) grading. Dosimetric parameters, including D90, V100 and V150 together with treatment response at 3 months, overall survival, relapse-free survival and long-term toxicity data, were collated from referring centres. RESULTS The median follow-up was 78 months (range 2-301). Primary sites of disease included vagina (37), endometrium (29), vulva (16), ovary (7) and cervix (5). Eighty-six (91.5%) patients were treated with curative intent, eight (8.5%) were palliative treatments. Fifty patients received HDRB for recurrent disease, 39 patients for primary disease and five as part of adjuvant treatment. The anatomical site of disease treated with HDRB ranged from vagina (76), vulva (14) and peri-urethral sites (four). The 2- and 5-year local relapse-free survival rates were 76% and 72%, respectively; 15 patients experienced local failure only, whereas six patients had local and nodal/distant failure. The median time to local recurrence was 8 months (range 2-88 months). The 2- and 5-year overall survival rates for all patients were 67% and 47%, respectively; the median overall survival was 59 months. Seventy-nine (84%) patients had a complete response measured with imaging at 3 months. Grade 3 toxicity was reported in 14 patients (14.8%). CONCLUSION This retrospective series suggests the use of interstitial brachytherapy for vulvovaginal gynaecological malignancy to be an effective and safe treatment option. Good local control was achieved with a tolerable toxicity profile; it is a valuable treatment modality.
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Affiliation(s)
- A Sarwar
- Mount Vernon Cancer Centre, Northwood, UK.
| | - L Syed
- Mount Vernon Cancer Centre, Northwood, UK
| | - K Patel
- Mount Vernon Cancer Centre, Northwood, UK
| | - I Reid
- Mount Vernon Cancer Centre, Northwood, UK
| | - E Abonyi
- Mount Vernon Cancer Centre, Northwood, UK
| | - N Banas
- Mount Vernon Cancer Centre, Northwood, UK
| | - G Lowe
- Mount Vernon Cancer Centre, Northwood, UK
| | - L Bryant
- Mount Vernon Cancer Centre, Northwood, UK
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, UK
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Harkenrider MM, Kamrava M. Embracing a future of progress in gynecologic brachytherapy. Brachytherapy 2023; 22:6-8. [PMID: 36725200 DOI: 10.1016/j.brachy.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 01/31/2023]
Abstract
In the last 20 years, gynecologic brachytherapy has made tremendous advancements, most prominently evidenced by the evolution of cervical cancer brachytherapy. In its 20 year history, Brachytherapy has become known as a journal of science, education, and advocacy for our specialty and for our patients. In this review, we celebrate the 25 most impactful manuscripts in gynecologic brachytherapy in the journal's history.
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Affiliation(s)
- Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL.
| | - Mitchell Kamrava
- Cedars Sinai Medical Center, Department of Radiation Oncology, Los Angeles, CA
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Schiff JP, Mahmood M, Huang Y, Powell MA, Mutch D, Dyk PT, Lin AJ, Schwarz JK, Markovina ST, Grigsby PW. The impact of tumor size and histology on local control when utilizing high-dose-rate interstitial brachytherapy for gynecologic malignancies. Gynecol Oncol 2022; 165:486-492. [DOI: 10.1016/j.ygyno.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
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Dosimetric predictors of local control and complications in gynecologic transperineal implant patients: The medical college of wisconsin experience. Brachytherapy 2021; 21:94-109. [PMID: 34937684 DOI: 10.1016/j.brachy.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Investigate the relationship between dosimetric parameters with local control (LC) and complications following transperineal high-dose rate (HDR) interstitial brachytherapy (ISBT) for gynecologic (GYN) malignancies. METHODS AND MATERIALS Between 2001 and 2016, 59 patients were treated for primary or recurrent GYN malignancies. Most patients received external beam irradiation, followed by transperineal ISBT via the Syed-Neblett applicator set with CT-based planning. Treatment plans were retrospectively reviewed to evaluate for an association among LC or toxicity with the equivalent dose at 2 Gy per fraction (EQD2) for the clinical target volume (CTV), 0.1 cc (D0.1cc), and 2 cc (D2cc) volumes of the organs at risk (OAR), low/high dose volumes for the OAR and CTV, and ratio of dose at the core vs. the implant periphery. RESULTS The median follow-up among survivors was 24 months. 34% of patients had a component of local failure and in 12%, this was isolated. Late grade 3 (G3) toxicity occurred in 15% of patients. There were no G4-5 toxicities. Rectal D0.1cc > 75 Gy trended toward significance in predicting the development of non-fistula late G2-3 rectal complications. Bladder D0.1cc > 94 Gy significantly predicted for the development of late G2-3 vesicovaginal fistula formation. The ratio of the total dose at the vaginal surface to the needle periphery above 121% trended in predicting for any complication or fistula formation. CONCLUSIONS HDR ISBT combined with EBRT achieved LC in 66% of patients with advanced or recurrent GYN cancers. Rectal and bladder D0.1cc doses may be predictive of complications as may the ratio of the implant dose at the core vs. periphery.
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Arya R, Giurcanu M, Jutzy JM, Peters P, Daily EW, Golden DW, McCall AR, Howard AR, Hasan Y, Son CH. Local Control and Use of External Beam Parametrial Boost in the Era of Image-Guided Brachytherapy for Locally Advanced Cervical Cancer. Am J Clin Oncol 2021; 44:565-571. [PMID: 34456239 DOI: 10.1097/coc.0000000000000863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Historically, external beam parametrial boost (EBPB) has been used in locally advanced cervical cancers to supplement radiation dose. However, it has become controversial in the era of image-guided brachytherapy. Modern 3D imaging and brachytherapy techniques have improved delineation and coverage of tumor. Outcomes with and without parametrial boost were analyzed. METHODS Women with cervical cancer involving the parametria (clinically or radiographically) diagnosed between 2001 and 2017 were identified. Clinicopathologic and treatment features, survival and patterns of failure data were collected. Univariate and multivariable data analysis was performed to evaluate association of these variables, including parametrial boost, with local failure-free survival and overall survival. Competing risks analysis was performed for cumulative incidence of local failure, with death and other failures treated as competing events. RESULTS A total of 100 women were identified (median follow-up 26.8 mo). Forty-one (41%) received EBPB; these patients were less likely to have received magnetic resonance imaging, positron emission tomography, interstitial, or high-dose rate brachytherapy. Magnetic resonance imaging, positron emission tomography, dose rate, and treatment era were highly correlated (Cramer's V: 0.43 to 0.68, P<0.01). Two-year overall survival and local failure were 78% and 12% for the entire cohort. While the use of EBPB was not associated with any outcome on multivariable analysis, treatment year after 2009 was highly associated with improved outcomes in all models. CONCLUSIONS In this study, omission of EBPB did not compromise local control or survival in the modern era, supporting a decreased need for standardized use of parametrial boost.
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Affiliation(s)
| | | | - Jessica M Jutzy
- Department of Radiation Medicine, Loma Linda University Health, Loma Linda
| | - Pamela Peters
- Department of Obstetrics and Gynecology, University of California, San Francisco, CA
| | | | | | - Anne R McCall
- Radiation and Cellular Oncology, University of Chicago
| | | | - Yasmin Hasan
- Radiation and Cellular Oncology, University of Chicago
| | - Christina H Son
- Radiation and Cellular Oncology, University of Chicago
- Department of Radiation Oncology, University of Illinois, Chicago, IL
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Stein R, Ganeshan D, Gopireddy DR, Chaudhry A, Kumar S, Bande K, Bhosale P, Lall C. Current update on vaginal malignancies. Abdom Radiol (NY) 2021; 46:5353-5368. [PMID: 34338815 DOI: 10.1007/s00261-021-03228-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/24/2022]
Abstract
Primary vaginal cancers are rare and account for 1-3% of all gynecologic malignancies. There are several histological subtypes that affect a wide range of the population. Imaging plays an important role in the diagnosis, staging, and treatment planning of vaginal cancers. This article reviews the relevant anatomy, clinical findings, imaging characteristics, and recent advances in the management of vaginal malignancies.
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Affiliation(s)
- Rachel Stein
- Department of Radiology, University of Florida School of Medicine - Jacksonville, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL, 32209, USA.
| | | | - Dheeraj Reddy Gopireddy
- Department of Radiology, University of Florida School of Medicine - Jacksonville, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL, 32209, USA
| | - Ammar Chaudhry
- Department of Diagnostic Radiology, City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - Sindhu Kumar
- Department of Radiology, University of Florida School of Medicine - Jacksonville, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL, 32209, USA
| | - Karthik Bande
- Department of Radiology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - Priya Bhosale
- Department of Abdominal Imaging, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chandana Lall
- Department of Radiology, University of Florida School of Medicine - Jacksonville, 655 West 8th Street, C90, 2nd Floor, Clinical Center, Jacksonville, FL, 32209, USA
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Taggar AS, Martell K, Leung E, Banerjee R, Fortin I, Doll CM. Changing Landscape of Radiation Therapy for Advanced Cervical Cancer With a Focus on Interstitial Brachytherapy: A Canadian Practice Patterns Survey. Pract Radiat Oncol 2021; 12:145-154. [PMID: 34678519 DOI: 10.1016/j.prro.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To document the evolution of radical radiation therapy and interstitial brachytherapy (ISBT) utilization practice patterns across Canada, including use of imaging, technical details, and usage of anesthesia/analgesia, and to compare advanced (AC) versus nonadvanced (nAC) brachytherapy (BT) center practices. METHODS AND MATERIALS All Canadian centers with BT services were identified. One gynecology radiation oncologist per center was sent a 64-item questionnaire regarding the center's practice for patients with cervical cancer. Centers were categorized based on availability of advanced BT expertise (AC) versus those referring patients to other centers for advanced BT techniques (nAC). Aggregate responses are reported and compared with practice patterns identified in our previous survey. Descriptive statistics were used to summarize data, and the Fisher exact test, Fisher-Freeman-Halton, or Mann-Whitney-Wilcox test was used for comparisons. RESULTS Thirty-seven of 38 respondents completed the survey (response rate: 97.4%). Compared with 2015, there has been an increase in utilization of magnetic resonance imaging as the sole imaging modality for BT planning: 3 of 26 (11%) versus 12 of 37 (32%; P = .03). The number of centers with the ability to perform ISBT increased in 2020 compared with 2015 (26/37 [70%] vs 13/26 [50%], P = .710); this trend is likely due to an increase in use of hybrid (Vienna, Utrecht, Venezia) applicators (36% [2015] vs 84% [2020]; P = .175). Fifteen (40%) centers had the ability to perform perineal-ISBT (P-ISBT). Sixteen and 21 centers were identified as AC and nAC, respectively. All 16 AC centers had the ability to perform ISBT, compared with only 10 nAC centers (P < .001). A higher proportion of AC centers had fellowship-trained radiation oncologists performing brachytherapy, compared with nAC centers (94% vs 14%, P < .001). In terms of anesthesia, conscious sedation was the only available choice at low-patient-volume centers (8/37, 21%) performing intracavitary BT only. Those performing ISBT had choice of general, spinal, and epidural anesthesia. CONCLUSIONS In Canada, high-quality, modern management radiation therapy practices are consistently offered to patients with cervical cancer. There is a trend toward increased utilization of ISBT. Accumulation of evidence toward the use of ISBT, increased utilization of high-quality imaging modalities such as magnetic resonance imaging, and availability of hybrid applicators are potential contributors for this upward trend.
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Affiliation(s)
- Amandeep S Taggar
- Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Kevin Martell
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, Canada
| | - Eric Leung
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Robyn Banerjee
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, Canada
| | - Israel Fortin
- Department of Radiation Oncology, Hôpital Maisonneuve-Rosemont, Centre affilié à l'Université de Montréal, Montréal, Canada
| | - Corinne M Doll
- Division of Radiation Oncology, Department of Oncology, University of Calgary, Calgary, Canada
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Ostyn M, Burke AM, Fields E, Todor D. Inter-fractional variation of markers and applicators in single-implant high-dose-rate interstitial brachytherapy for gynecologic malignancies. Brachytherapy 2021; 20:771-780. [PMID: 33994342 DOI: 10.1016/j.brachy.2021.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/05/2021] [Accepted: 03/13/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Implanted fiducial markers are a commonly used tool in delineating the CTV in high-dose-rate interstitial brachytherapy (HDR-ISBT) for gynecologic malignancy, but their reliability in gynacological sites is not well understood. These markers and interstitial applicators can experience interfractional motion due to organ swelling or other anatomical changes. The purpose of this study was to evaluate the spatial variation of these features. METHODS AND MATERIALS The spatial positions of 50 implanted markers and 202 needles were tracked in 15 patients treated over 70 fractions of HDR brachytherapy. Marker and/or needle coordinates were extracted from CT images with contours and dose distributions. Automated analysis determined marker self-consistency and displacements between various elements of the implant. RESULTS From start to end fraction, the relative positions of the markers experienced an average magnitude displacement of 4.5 ± 3.0 mm while the average displacement of the applicator tips was 11 ± 8 mm, relative to their respective centers of mass (CM). CONCLUSIONS Markers implanted lateral and superior to the CTV experience greater drift than other implant locations.
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Affiliation(s)
- Mark Ostyn
- Virginia Commonwealth University Health System, Department of Radiation Oncology, 401 College St., Richmond, VA 23298
| | - Aidan M Burke
- Georgetown University, 3700 O St NW, Washington, DC 20057
| | - Emma Fields
- Virginia Commonwealth University Health System, Department of Radiation Oncology, 401 College St., Richmond, VA 23298
| | - Dorin Todor
- Virginia Commonwealth University Health System, Department of Radiation Oncology, 401 College St., Richmond, VA 23298.
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9
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A Dosimetric Comparison of Two Techniques of Brachytherapy in Carcinoma Cervix in Patients with a Difficult Application. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-020-00483-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Keller A, Rodríguez-López JL, Patel AK, Vargo JA, Kim H, Houser CJ, Sukumvanich P, Berger JL, Boisen MM, Edwards RP, Taylor SE, Courtney-Brooks MB, Orr BC, Olawaiye AB, Beriwal S. Early outcomes after definitive chemoradiation therapy with Vienna/Venezia hybrid high-dose rate brachytherapy applicators for cervical cancer: A single-institution experience. Brachytherapy 2020; 20:104-111. [PMID: 32952053 DOI: 10.1016/j.brachy.2020.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/04/2020] [Accepted: 08/07/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The Vienna and Venezia (Elekta) are hybrid intracavitary/interstitial brachytherapy (BT) applicators for cervical cancers unsuitable for intracavitary BT alone to improve target coverage or reduce critical organ dose. There is limited outcome data with the use of these applicators outside published experience of the EMBRACE group. We report feasibility and early outcomes with the use of these hybrid applicators at our institution. METHODS AND MATERIALS Hybrid applicators were used to treat 61 patients with cervical cancer from November 2011 to December 2019. Indications for hybrid applicator use were involvement of the vagina in 10 patients (16%), residual central or parametrial disease in 46 patients (75%), and a narrow introitus in 5 patients (9%). Toxicities were graded using the CTCAE v4.0. Outcomes were assessed with the Kaplan-Meier method. RESULTS Median follow-up was 16 months (IQR 9-32 mos). Median HRCTV volume was 31.6 cm3 (IQR 25-48 cm3). Median HRCTV D90 was 86.1 Gy (IQR 84.3-88.0 Gy). In 54 patients with follow-up PET/CT at 3 months, complete initial imaging response locally was seen in 46 patients.Estimated 12-month Kaplan-Meier overall survival, locoregional control, distant control, and recurrence-free survival estimates were 86.9%, 80.6%, 73.8%, and 65.9%, respectively. The 12-month incidence of Grade 3+ GI/GU chronic toxicities was 5.7%, consisting of vesicovaginal fistula, rectovaginal fistula, and ureterovesical fistula. CONCLUSIONS Our single-institution data support the use of the hybrid applicators, as an alternative to traditional BT applicators when clinically warranted. Use of hybrid applicators is feasible with adequate coverage of disease in the vagina and parametrium.
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Affiliation(s)
- A Keller
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - J L Rodríguez-López
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - A K Patel
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - J A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - H Kim
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - C J Houser
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA
| | - P Sukumvanich
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - J L Berger
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - M M Boisen
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - R P Edwards
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - S E Taylor
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - M B Courtney-Brooks
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - B C Orr
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - A B Olawaiye
- Department of Gynecologic Oncology, UPMC Magee-Womens Hospital, Pittsburgh, PA
| | - S Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, PA.
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Small bowel perforation caused by applicator implantation in high-dose-rate interstitial brachytherapy for recurrent pelvic tumor: a case report. J Contemp Brachytherapy 2020; 12:188-192. [PMID: 32395144 PMCID: PMC7207236 DOI: 10.5114/jcb.2020.93875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/05/2020] [Indexed: 11/23/2022] Open
Abstract
High-dose-rate interstitial brachytherapy (HDR-ISBT) is widely used for the treatment of pelvic tumors. However, there are a few reports on complications of applicator implantation in HDR-ISBT. We describe a case of small bowel perforation caused by applicator implantation in an 82-year-old male patient with recurrence tumor in the pelvis treated with HDR-ISBT. Eventually, the patient underwent laparotomy and partial intestinal resection. We recognized the site where the applicator was inserted into a part of the tumor on the mucosal surface. Pathological examination confirmed that the tumor had infiltrated the small intestine directly and that the infiltrated part had reached the submucosa. This is the first published report about small bowel perforation caused by applicator implantation. In cases where intestinal infiltration of the tumor is suspected, HDR-ISBT should be performed with maximum caution.
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3D printer-based novel intensity-modulated vaginal brachytherapy applicator: feasibility study. J Contemp Brachytherapy 2020; 12:17-26. [PMID: 32190066 PMCID: PMC7073342 DOI: 10.5114/jcb.2020.92407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/18/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose To design a novel high-dose-rate intracavitary applicator which may lead to enhanced dose modulation in the brachytherapy of gynecological cancers. Material and methods A novel brachytherapy applicator, auxiliary equipment and quality control phantom were modeled in SketchUp Pro 2017 modeling software and printed out from a MakerBot Replicator Z18 three-dimensional printer. As a printing material polylactic acid (PLA) filament was used and compensator materials including aluminum, stainless-steel and Cerrobend alloy were selected according to their radiation attenuation properties. To evaluate the feasibility of the novel applicator, two sets of measurements were performed in a Varian GammaMed iX Plus high-dose rate iridium-192 (192Ir) brachytherapy unit and all of the treatment plans were calculated in Varian BrachyVision treatment planning system v.8.9 with TG43-based formalism. In the first step, catheter and source-dwell positioning accuracy, reproducibility of catheter and source positions, linearity of relative dose with changing dwell times and compensator materials were tested to evaluate the mechanical stability of the designed applicator. In the second step, to validate the dosimetric accuracy of the novel applicator measured point dose and two-dimensional dose distributions in homogeneous medium were compared with calculated data in the treatment planning system using PTW VeriSoft v.5.1 software. Results In mechanical quality control tests source-dwell positioning accuracy and linearity of the designed applicator were measured as ≤ 0.5 mm and ≤ 1.5%, respectively. Reproducibility of the treatment planning was ≥ 97.7% for gamma evaluation criteria of 1 mm distance to agreement and 1% dose difference of local dose. In dosimetric quality control tests, maximum difference between measured and calculated point dose was found as 3.8% in homogeneous medium. In two-dimensional analysis, the number of passing points was greater than 90% for all measurements using gamma evaluation criteria of 3 mm distance to agreement and 3% dose difference of local dose. Conclusions The novel brachytherapy applicator met the necessary requirements in quality control tests.
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13
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Jung H, Shen C, Gonzalez Y, Albuquerque K, Jia X. Deep-learning assisted automatic digitization of interstitial needles in 3D CT image based high dose-rate brachytherapy of gynecological cancer. Phys Med Biol 2019; 64:215003. [PMID: 31470425 DOI: 10.1088/1361-6560/ab3fcb] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Digitization of interstitial needles is a complicated and tedious process for the treatment planning of 3D CT image based interstitial high dose-rate brachytherapy (HDRBT) of gynecological cancer. We developed a deep-learning assisted auto-digitization method for interstitial needles. The digitization method consisted of two steps. The first step used a deep neural network with a U-net structure to segment all needles from CT images. The second step simultaneously clustered the segmented voxels into different needle groups and generated the needle central trajectories by solving an optimization problem. We evaluated the effectiveness of the developed method in ten interstitial HDRBT patient cases that were not used in the training of the U-net. Average number of needles per case was 20.7. For the segmentation step, average Dice similarity coefficient between automatic and manual segmentation was 0.93. For the digitization step, Hausdorff distance between needle trajectories determined by our method and manually by qualified medical physicists was ~0.71 mm on average and mean difference of tip positions was ~0.63 mm, which were considered acceptable for HDRBT treatment planning. It took ~5 min to complete the digitization process of an interstitial HDRBT case. The achieved accuracy and efficiency made our method clinically attractive.
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Affiliation(s)
- Hyunuk Jung
- Medical Artificial Intelligence and Automation (MAIA) Lab, University of Texas Southwestern Medical Center, Dallas, TX 75235, United States of America. Innovative Technology Of Radiotherapy Computation and Hardware (iTORCH) Lab, University of Texas Southwestern Medical Center, Dallas, TX 75235, United States of America. Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX 75235, United States of America
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Raziee H, D'Souza D, Velker V, Barnes E, Taggar A, Mendez L, Leung E. Salvage Re-irradiation With Single-modality Interstitial Brachytherapy for the Treatment of Recurrent Gynaecological Tumours in the Pelvis: A Multi-institutional Study. Clin Oncol (R Coll Radiol) 2019; 32:43-51. [PMID: 31402286 DOI: 10.1016/j.clon.2019.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
Abstract
AIMS Recurrent gynaecological tumours can cause significant morbidity with limited salvage options. This study investigates the strategy of salvage single-modality interstitial brachytherapy (SM-ISBT) for recurrent gynaecological pelvic cancer at two specialised ISBT centres. MATERIALS AND METHODS Patients who had received salvage SM-ISBT for pelvic recurrence of gynaecological cancers from September 2008 to January 2017 were included. None had distant metastasis at the time of recurrence. Local control, progression-free and overall survival and long-term toxicities were evaluated. RESULTS Twenty-six patients with a median follow-up of 24 months (range 2.5-106.3 months) after SM-ISBT were included. Primary cancer sites were endometrium (20), cervix (4), vulva (1) and vagina (1). All patients had prior whole-pelvic external beam irradiation and 16 had prior brachytherapy. The median disease-free survival prior to SM-ISBT was 20.3 months (interquartile range 9.9-30.5). SM-ISBT was delivered with high dose rate technique over three to six fractions. The median high-risk clinical target volume was 34.6 cm3, with a median D90 of 29.1 Gy (range 16.1-64.6). The median bladder, rectum and sigmoid D2cm3 were 15.5, 18.7 and 3.7 Gy, respectively. After SM-ISBT, complete and partial responses were achieved in 17 (64%) and 5 (19%) patients, respectively. Two (7.4%) patients had grade 3 toxicities (both vaginal stenosis), with no grade 4 complications. Eighteen patients (69%) recurred, including local, regional and metastatic in 14 (54%), 8 (30%) and 5 (19%) patients, respectively. Two-year local control, progression-free survival and overall survival were 50, 38 and 78%, respectively. In follow-up, 12 patients (46%) remained in local control. CONCLUSIONS Salvage SM-ISBT re-irradiation for pelvic recurrence of gynaecological malignancies was feasible and safe. With limited salvage options, the local control obtained in more than a quarter of patients seems reasonable. Further efforts are needed to establish a consensus about the optimal patient selection, dose fractionation, implant technique and combination with systemic therapies.
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Affiliation(s)
- H Raziee
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; BC Cancer, Surrey, British Columbia, Canada
| | - D D'Souza
- Department of Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - V Velker
- Department of Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - E Barnes
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - A Taggar
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - L Mendez
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; Department of Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - E Leung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Odette Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Tian Z, Yen A, Zhou Z, Shen C, Albuquerque K, Hrycushko B. A machine-learning-based prediction model of fistula formation after interstitial brachytherapy for locally advanced gynecological malignancies. Brachytherapy 2019; 18:530-538. [PMID: 31103434 DOI: 10.1016/j.brachy.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE External beam radiotherapy combined with interstitial brachytherapy is commonly used to treat patients with bulky, advanced gynecologic cancer. However, the high radiation dose needed to control the tumor may result in fistula development. There is a clinical need to identify patients at high risk for fistula formation such that treatment may be managed to prevent this toxic side effect. This work aims to develop a fistula prediction model framework using machine learning based on patient, tumor, and treatment features. METHODS AND MATERIALS This retrospective study included 35 patients treated at our institution using interstitial brachytherapy for various gynecological malignancies. Five patients developed rectovaginal fistula and two developed both rectovaginal and vesicovaginal fistula. For each patient, 31 clinical features of multiple data types were collected to develop a fistula prediction framework. A nonlinear support vector machine was used to build the prediction model. Sequential backward feature selection and sequential floating backward feature selection methods were used to determine optimal feature sets. To overcome data imbalance issues, the synthetic minority oversampling technique was used to generate synthetic fistula cases for model training. RESULTS Seven mixed data features were selected by both sequential backward selection and sequential floating backward selection methods. Our prediction model using these features achieved a high prediction accuracy, that is, 0.904 area under the curve, 97.1% sensitivity, and 88.5% specificity. CONCLUSIONS A machine-learning-based prediction model of fistula formation has been developed for patients with advanced gynecological malignancies treated using interstitial brachytherapy. This model may be clinically impactful pending refinement and validation in a larger series.
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Affiliation(s)
- Zhen Tian
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX; Department of Radiation Oncology, Emory University, Atlanta, GA
| | - Allen Yen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Zhiguo Zhou
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Chenyang Shen
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brian Hrycushko
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX.
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Hawkins PG, Tang M, Vineberg KA, Young L, Kovach K, Lee C, Maturen KE, Uppal S, Owen D, Schipper MJ, Prisciandaro JI, Jolly S. Dosimetric impact of interfractional organs at risk variation during high-dose rate interstitial brachytherapy for gynecologic malignancies. Med Dosim 2018; 44:239-244. [PMID: 30336971 DOI: 10.1016/j.meddos.2018.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/28/2022]
Abstract
We sought to develop a framework for the identification and management of patients at risk for organs at risk (OARs) overdosing due to interfractional anatomic variation during high-dose rate interstitial brachytherapy for gynecologic malignancies. We analyzed 40 high-dose rate interstitial brachytherapy fractions from 10 patients. Planned OAR doses were compared to delivered doses, which were calculated from computed tomography scans obtained prior to each treatment fraction. Doses were converted to equivalent doses in 2 Gy fractions (EQD2) and doses to the most exposed 2 cm3 (D2cc) were reviewed. Patients were risk-stratified by identifying dose thresholds corresponding to a 10% or lower risk of receiving an OAR dose exceeding the corresponding planning constraint. For each OAR, 30% to 62.5% of patients received total doses greater than planned, although the magnitude of these differences was <4 Gy in over 75% of cases. Using EMBRACE II guidelines, one patient who had met the planning constraint for bladder and one for small bowel were found to have received doses exceeding the recommended limits. We next calculated thresholds for estimating the risk of OAR overdosing in individual patients and developed a framework based on these thresholds to direct time- and resource-intensive imaging and replanning efforts toward patients who are most likely to derive benefit. In summary, differential OAR dosing due to interfractional anatomic variation is common but likely rarely clinically meaningful. The proposed framework could decrease toxicity and maximize clinical efficiency.
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Affiliation(s)
- Peter G Hawkins
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Ming Tang
- Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Karen A Vineberg
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Young
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Kelly Kovach
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Choonik Lee
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shitanshu Uppal
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA; Department of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
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Abstract
Radiotherapy plays a critical role in the management of cervix carcinoma, in the adjuvant setting for patients with high-risk pathologic features and in the definitive setting for locoregionally advanced disease. External beam radiotherapy fields encompass potential areas of microscopic disease spread in addition to known areas of gross disease. In the presence of gross disease, however, escalation of dose is required that is best accomplished using a brachytherapy boost to spare surrounding normal organs from toxicity. This article addresses indications for radiotherapy in the management of nonmetastatic cervix cancer and reviews various radiotherapy techniques, with a heavy focus on brachytherapy.
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Affiliation(s)
- Lana de Souza Lawrence
- Department of Radiation Oncology, Christiana Care Health Services, 4701 Ogletown Stanton Road, Suite 1109, Newark, DE 19713, USA.
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18
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Feddock J, Cheek D, Steber C, Edwards J, Slone S, Luo W, Randall M. Reirradiation Using Permanent Interstitial Brachytherapy: A Potentially Durable Technique for Salvaging Recurrent Pelvic Malignancies. Int J Radiat Oncol Biol Phys 2017; 99:1225-1233. [PMID: 29029888 DOI: 10.1016/j.ijrobp.2017.08.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/31/2017] [Accepted: 08/21/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To present a time-to-failure (TTF) analysis for all patients treated with permanent interstitial brachytherapy (PIB) at our institution, with additional analyses to correlate successful reirradiation and to identify the frequency of severe grade 3 to 4 toxicity. METHODS AND MATERIALS Forty-two previously irradiated patients received curative or palliative intent PIB for a recurrent pelvic malignancy between January 2009 and August 2016. Minimum follow-up was 6 months after the PIB procedure. All patients had a biopsy-proven recurrence and were treated using PIB alone (n=32) or in combination with a short course of additional radiation therapy (n=10). Competing risk analyses were performed to assess the risk of failures in the presence of death without failure. Exploratory analyses were performed for factors related to failure using competing risk analyses and the Gray statistic. RESULTS A total of 61 PIB implants were performed among 42 patients with a median follow-up of 16.3 months. Fifty-two implants were performed as the first salvage reirradiation to a solitary recurrence (8 patients had more than 1 lesion); the success rate for initial reirradiation using PIB was 73% (38 cases out of 52), and the median TTF was not reached. Nine patients underwent a second repeat PIB to the same recurrence as a form of salvage; 3 (33%) remain without evidence of recurrence. The median TTF after second salvage was 7.7 months. Even with the limited sample size, prolonged TTF was marginally associated with definitive intent (P=.07) and the extent of disease at the time of PIB (P=.08). Grade 3+ toxicities were seen in 8 patients (16.7%). CONCLUSIONS Permanent interstitial brachytherapy is a feasible and potentially durable treatment modality that can be used to curatively salvage selected recurrent pelvic malignancies in a previously irradiated field.
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Affiliation(s)
- Jonathan Feddock
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky.
| | - Dennis Cheek
- Division of Medical Physics, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Cole Steber
- College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Jason Edwards
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Stacey Slone
- Department of Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Wei Luo
- Division of Medical Physics, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Marcus Randall
- Department of Radiation Medicine, Markey Cancer Center, University of Kentucky, Lexington, Kentucky
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Taggar AS, Phan T, Traptow L, Banerjee R, Doll CM. Cervical cancer brachytherapy in Canada: A focus on interstitial brachytherapy utilization. Brachytherapy 2016; 16:161-166. [PMID: 27914911 DOI: 10.1016/j.brachy.2016.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 10/17/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Brachytherapy (BT) techniques for cervical cancer in Canada have changed over the last decade, with evolution to high-dose-rate and image-guided BT. However, there are currently no national data on the use of interstitial BT (IBT). The purpose of this study was to document IBT utilization in Canadian centers, as well as update details of cervical cancer BT practices. METHODS AND MATERIALS All Canadian centers with gynecologic BT services (n = 33) were identified, and one gynecology radiation oncologist per center was sent a 33-item e-mail questionnaire regarding their center's practice for cervical cancer BT in 2015. Responses were reported and compared with practice patterns identified in a 2012 Canadian survey. RESULTS The response rate was 85% (28/33 centers). The majority (93%) of respondents used high-dose-rate BT, similar to the 2012 survey; 96% of centers had transitioned to three-dimensional (MRI/CT)-based planning in 2015 vs. 75% in 2012 (p = 0.03); 57% centers incorporated MRI for treatment planning in 2015 compared to 38% in 2012 (p = 0.15); the majority (13/16) using a combination of MRI and CT; 50% (14/28 centers) had the capacity to perform IBT, whereas 71% of those that did not referred patients to other centers. Of centers performing IBT, the majority (11/14) used template-based techniques with a median of 6 (range 2-20) needles/catheters and an average of 4 (range 1-5) fractions. Catheters were placed using: strategy based on pre-op imaging (21%), intra-op ultrasound (50%), intra-op MRI (7%), and intra-op CT (21%). The most common dose/fractionation schedules were 6 Gy × 5 fractions (40%), 8 Gy × 3 fractions (19%), and 7 Gy × 4 fractions (15%). CONCLUSIONS In Canada, treatment of cervical cancer continues to evolve. IBT has been adopted by half of the responding centers. As more centers move to MRI-based image-guided treatment planning, IBT will become an even more integral part of cervical cancer treatment.
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Affiliation(s)
- Amandeep S Taggar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Tien Phan
- Department of Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | - Laurel Traptow
- Department of Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | - Robyn Banerjee
- Department of Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada
| | - Corinne M Doll
- Department of Oncology, Tom Baker Cancer Center, University of Calgary, Calgary, AB, Canada.
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Feasibility study of toxicity outcomes using GEC-ESTRO contouring guidelines on CT based instead of MRI-based planning in locally advanced cervical cancer patients. Brachytherapy 2016; 16:126-132. [PMID: 27816539 DOI: 10.1016/j.brachy.2016.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/29/2016] [Accepted: 09/21/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To report late rectal and bladder toxicity outcomes of a CT-based image-guided brachytherapy (IGBT) technique for treatment of cervical cancer. METHODS AND MATERIALS Between 2008 and 2014, 95 women with International Federation of Gynecology and Obstetrics stage IB to IVA cervical carcinoma treated with definitive concurrent cisplatin-based chemotherapy and external beam radiation therapy 50.4 Gy in 28 fractions followed by planned prescription dose of 7 Gy × 4 fractions of high-dose-rate IGBT was retrospectively reviewed. At each implantation, all patients had a urinary catheter in situ and received bowel enema before undergoing planning CT simulation. A high-risk clinical target volume (HRCTV) as per GEC-ESTRO guidelines and the entire cervix, rectum, and bladder was contoured on the simulation CT according to Radiation Therapy Oncology Group Gynaecology Contouring Atlas. Reported doses to HRCTV and organs at risk were recorded. Toxicities were recorded using National Cancer Institute Common Terminology Criteria for Adverse Events version 3. RESULTS The median followup time was 29 months. The mean HRCTV equivalent dose in 2 Gy fractions (EQD2) of external beam radiation therapy combined with brachytherapy was 80 Gy (standard deviation [SD], 11), and the rectal doses to 2 cm3 (D2cc) EQD2 and bladder D2cc EQD2 were 74 Gy (SD, 6) and 79 Gy (SD, 15), respectively. Twenty-two patients (23%) had grade 2 proctitis and 10 patients (11%) had grade 3 proctitis. Four patients (4%) had grade 2 cystitis and two patients (2%) had grade 3 cystitis. No patients had ≥ grade 4 toxicity. CONCLUSIONS Despite CT-based brachytherapy planning, reported organ at risk toxicity was still significant compared with reported MRI-based planning series. Coimplementation of interstitial IGBT using the European Study on MRI-guided Brachytherapy in Locally Advanced Cervical Cancer (EMBRACE) protocol or using intensity-modulated radiation therapy during the external beam phase treatment might help to limit these late toxicities.
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21
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Rodríguez Villalba S, Richart Sancho J, Otal Palacín A, Perez-Calatayud J, Santos Ortega M. Development and clinical implementation of a new template for MRI-based intracavitary/interstitial gynecologic brachytherapy for locally advanced cervical cancer: from CT-based MUPIT to the MRI compatible Template Benidorm. Ten years of experience. J Contemp Brachytherapy 2016; 8:404-414. [PMID: 27895682 PMCID: PMC5116450 DOI: 10.5114/jcb.2016.63187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/22/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To study outcome and toxicity in 59 patients with locally advanced cervix carcinoma treated with computed tomography (CT)-based Martinez universal perineal interstitial template (MUPIT) and the new magnetic resonance imaging (MRI)-compatible template Benidorm (TB). MATERIAL AND METHODS From December 2005 to October 2015, we retrospectively analyzed 34 patients treated with MUPIT and 25 treated with the TB. Six 4 Gy fractions were prescribed to the clinical target volume (CTV) combined with external beam radiotherapy (EBRT). The organs at risk (OARs) and the CTV were delineated by CT scan in the MUPIT implants and by MRI in the TB implants. Dosimetry was CT-based for MUPIT and exclusively MRI-based for TB. Dose values were biologically normalized to equivalent doses in 2 Gy fractions (EQD2). RESULTS Median CTV volumes were 163.5 cm3 for CT-based MUPIT (range 81.8-329.4 cm3) and 91.9 cm3 for MRI-based TB (range 26.2-161 cm3). Median D90 CTV (EBRT + BT) was 75.8 Gy for CT-based MUPIT (range 69-82 Gy) and 78.6 Gy for MRI-based TB (range 62.5-84.2 Gy). Median D2cm3 for the rectum was 75.3 Gy for CT-based MUPIT (range 69.8-132.1 Gy) and 69.9 Gy for MRI-based TB (range 58.3-83.7 Gy). Median D2cm3 for the bladder was 79.8 Gy for CT-based MUPIT (range 71.2-121.1 Gy) and 77.1 Gy for MRI-based TB (range 60.5-90.8 Gy). Local control (LC) was 88%. Overall survival (OS), disease free survival (DFS), and LC were not statistically significant in either group. Patients treated with CT-based MUPIT had a significantly higher percentage of rectal bleeding G3 (p = 0.040) than those treated with MRI-based TB, 13% vs. 2%. CONCLUSIONS Template Benidorm treatment using MRI-based dosimetry provides advantages of MRI volume definition, and allows definition of smaller volumes that result in statistically significant decreased rectal toxicity compared to that seen with CT-based MUPIT treatment.
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Affiliation(s)
| | | | | | - Jose Perez-Calatayud
- Radiotherapy Department, Hospital Clínica Benidorm, Benidorm, Alicante; Radiotherapy Department, La Fe University and Polytechnic Hospital, Valencia, Spain
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22
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Institutional experience using interstitial brachytherapy for the treatment of primary and recurrent pelvic malignancies. J Contemp Brachytherapy 2016; 8:173-80. [PMID: 27504125 PMCID: PMC4965502 DOI: 10.5114/jcb.2016.61062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 06/17/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Al Feghali KA, Elshaikh MA. Why brachytherapy boost is the treatment of choice for most women with locally advanced cervical carcinoma? Brachytherapy 2016; 15:191-9. [DOI: 10.1016/j.brachy.2015.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/23/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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Grover S, Harkenrider MM, Cho LP, Erickson B, Small C, Small W, Viswanathan AN. Image Guided Cervical Brachytherapy: 2014 Survey of the American Brachytherapy Society. Int J Radiat Oncol Biol Phys 2015; 94:598-604. [PMID: 26867888 DOI: 10.1016/j.ijrobp.2015.11.024] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Indexed: 01/27/2023]
Abstract
PURPOSE To provide an update of the 2007 American brachytherapy survey on image-based brachytherapy, which showed that in the setting of treatment planning for gynecologic brachytherapy, although computed tomography (CT) was often used for treatment planning, most brachytherapists used point A for dose specification. METHODS AND MATERIALS A 45-question electronic survey on cervical cancer brachytherapy practice patterns was sent to all American Brachytherapy Society members and additional radiation oncologists and physicists based in the United States between January and September 2014. Responses from the 2007 survey and the present survey were compared using the χ(2) test. RESULTS There were 370 respondents. Of those, only respondents, not in training, who treat more than 1 cervical cancer patient per year and practice in the United States, were included in the analysis (219). For dose specification to the target (cervix and tumor), 95% always use CT, and 34% always use MRI. However, 46% use point A only for dose specification to the target. There was a lot of variation in parameters used for dose evaluation of target volume and normal tissues. Compared with the 2007 survey, use of MRI has increased from 2% to 34% (P<.0001) for dose specification to the target. Use of volume-based dose delineation to the target has increased from 14% to 52% (P<.0001). CONCLUSION Although use of image-based brachytherapy has increased in the United States since the 2007 survey, there is room for further growth, particularly with the use of MRI. This increase may be in part due to educational initiatives. However, there is still significant heterogeneity in brachytherapy practice in the United States, and future efforts should be geared toward standardizing treatment.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Linda P Cho
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Beth Erickson
- Department Radiation Oncology, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christina Small
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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25
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Yoshida K, Yamazaki H, Kotsuma T, Takenaka T, Ueda MM, Miyake S, Tsujimoto Y, Masui K, Yoshioka Y, Sumida I, Uesugi Y, Shimbo T, Yoshikawa N, Yoshioka H, Tanaka E, Narumi Y. Simulation analysis of optimized brachytherapy for uterine cervical cancer: Can we select the best brachytherapy modality depending on tumor size? Brachytherapy 2015; 15:57-64. [PMID: 26612700 DOI: 10.1016/j.brachy.2015.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 09/30/2015] [Accepted: 10/12/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE To choose the optimal brachytherapeutic modality for uterine cervical cancer, we performed simulation analysis. METHODS AND MATERIALS For each high-risk clinical target volume (HR CTV), we compared four modalities [classical conventional intracavitary brachytherapy (ConvICBT), Image-guided ICBT (IGICBT), intracavitary/interstitial brachytherapy (ICISBT), and interstitial brachytherapy (ISBT) with perineal approach] using dose-volume histograms using eight sizes of HR CTV (2 × 2 × 2 cm to 7 × 4 × 4 cm) and organs at risk model. RESULTS In ConvICBT, the doses covered 90% of the HR CTV [D90(HR CTV)] decreased from 197% prescribed dose (PD) for the HR CTV size (2 × 2 × 2 cm) to 73% PD for 5 × 4 × 4 cm, whereas the other three modalities could achieve 100% PD for all HR CTV sizes. The minimum doses received by the maximally irradiated 2-cm(3) volumes for organs at risks of IGICBT demonstrated lower values than those of ConvICBT for the HR CTV size of 4 × 3 × 3 cm or smaller. ICISBT demonstrated lower values than those of IGICBT for 4 × 3 × 3 cm or larger. ISBT demonstrated lowest values for 5 × 4 × 4 cm or larger. CONCLUSIONS HR CTV size of 4 × 3 × 3 cm seems to be a threshold volume in this simulation analysis, and IGICBT is a better choice for smaller HR CTV than the threshold volume. On larger HR CTV, ICISBT or ISBT is the better choice.
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Affiliation(s)
- Ken Yoshida
- Department of Radiation Oncology, Osaka Medical College, Takatsuki, Osaka, Japan.
| | - Hideya Yamazaki
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Tadashi Takenaka
- Department of Radiology, National Hospital Organization Himeji Medical Center, Himeji, Hyogo, Japan
| | - Mari Mikami Ueda
- Department of Radiology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Shunsuke Miyake
- Department of Radiology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Yutaka Tsujimoto
- Department of Radiology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Koji Masui
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasuo Uesugi
- Department of Radiation Oncology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Taiju Shimbo
- Department of Radiation Oncology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Nobuhiko Yoshikawa
- Department of Radiation Oncology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Hiroto Yoshioka
- Department of Radiation Oncology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Yoshifumi Narumi
- Department of Radiology, Osaka Medical College, Takatsuki, Osaka, Japan
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Glaser SM, Kim H, Beriwal S. Multichannel vaginal cylinder brachytherapy—Impact of tumor thickness and location on dose to organs at risk. Brachytherapy 2015; 14:913-8. [DOI: 10.1016/j.brachy.2015.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/13/2015] [Accepted: 08/24/2015] [Indexed: 11/16/2022]
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Shin SM, Duckworth TL, Cooper BT, Curtin JP, Schiff PB, DeWyngaert JK, Lymberis SC. Use of a Flexible Inflatable Multi-Channel Applicator for Vaginal Brachytherapy in the Management of Gynecologic Cancer. Front Oncol 2015; 5:201. [PMID: 26442213 PMCID: PMC4568766 DOI: 10.3389/fonc.2015.00201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 08/31/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Evaluate use of novel multi-channel applicator (MC) Capri™ to improve vaginal disease coverage achievable by single-channel applicator (SC) and comparable to Syed plan simulation. MATERIALS AND METHODS Twenty-eight plans were evaluated from four patients with primary or recurrent gynecologic cancer in the vagina. Each received whole pelvis radiation, followed by three weekly treatments using HDR brachytherapy with a 13-channel MC. Upper vagina was treated to 5 mm depth to 1500 cGy/3 fractions with a simultaneous integrated boost totaling 2100 cGy/3 fractions to tumor. Modeling of SC and Syed plans was performed using MC scans for each patient. Dosimetry for MC and SC plans was evaluated for PTV700 cGy coverage, maximum dose to 2 cm(3) to bladder, rectum, as well as mucosal surface points. Dosimetry for Syed plans was calculated for PTV700 cGy coverage. Patients were followed for treatment response and toxicity. RESULTS Dosimetric analysis between MC and SC plans demonstrated increased tumor coverage (PTV700 cGy), with decreased rectal, bladder, and contralateral vaginal mucosa dose in favor of MC. These differences were significant (p < 0.05). Comparison of MC and Syed plans demonstrated increased tumor coverage in favor of Syed plans which were not significant (p = 0.71). Patients treated with MC had no cancer recurrence or ≥grade 3 toxicity. CONCLUSION Use of MC was efficacious and safe, providing superior coverage of tumor volumes ≤1 cm depth compared to SC and comparable to Syed implant. MC avoids excess dose to surrounding organs compared to SC, and potentially less morbidity than Syed implants. For tumors extending ≤1 cm depth, use of MC represents an alternative to an interstitial implant.
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Affiliation(s)
- Samuel M Shin
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Tamara L Duckworth
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Benjamin T Cooper
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - John P Curtin
- Department of Obstetrics and Gynecology, NYU Langone Medical Center , New York, NY , USA
| | - Peter B Schiff
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - J Keith DeWyngaert
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
| | - Stella C Lymberis
- Department of Radiation Oncology, NYU Langone Medical Center, NYU Perlmutter Cancer Center , New York, NY , USA
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Brachytherapy for malignancies of the vagina in the 3D era. J Contemp Brachytherapy 2015; 7:312-8. [PMID: 26622234 PMCID: PMC4643736 DOI: 10.5114/jcb.2015.54053] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 08/19/2015] [Accepted: 08/23/2015] [Indexed: 01/21/2023] Open
Abstract
Vaginal cancer is an uncommon malignancy and can be either recurrent or primary. In both cases, brachytherapy places a central role in the overall treatment course. Recent technological advances have led to more advanced brachytherapy techniques, which in turn have translated to improved outcomes for patients with malignancies of the vagina. The aim of this manuscript is to outline the incorporation of modern brachytherapy into the treatment of patients with vaginal cancer including patient selection along with the role of brachytherapy in conjunction with other treatment modalities, various brachytherapy techniques, treatment planning, dose fractionation schedules, and normal tissue tolerance.
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Mesko S, Swamy U, Park SJ, Borja L, Wang J, Demanes DJ, Kamrava M. Early clinical outcomes of ultrasound-guided CT-planned high-dose-rate interstitial brachytherapy for primary locally advanced cervical cancer. Brachytherapy 2015; 14:626-32. [DOI: 10.1016/j.brachy.2015.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/01/2015] [Accepted: 04/16/2015] [Indexed: 11/16/2022]
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Dise J, Liang X, Scheuermann J, Anamalayil S, Mesina C, Lin LL, Teo BKK. Development and evaluation of an automatic interstitial catheter digitization tool for adaptive high-dose-rate brachytherapy. Brachytherapy 2015; 14:619-25. [DOI: 10.1016/j.brachy.2015.05.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/01/2015] [Accepted: 05/11/2015] [Indexed: 11/16/2022]
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Amsbaugh MJ, Bhatt N, Hunter T, Gaskins J, Parker L, Metzinger D, Amsbaugh A, Sowards K, El-Ghamry M. Computed tomography planned interstitial brachytherapy for recurrent gynecologic cancer. Brachytherapy 2015; 14:600-5. [PMID: 26087868 DOI: 10.1016/j.brachy.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To report outcomes and identify predictors of toxicity in patients undergoing reirradiation with interstitial brachytherapy (ISBT) for recurrent cancers of the female reproductive tract. METHODS AND MATERIALS Twenty-one patients received ISBT performed using (192)Ir sources (10 low dose rate and 11 high dose rate) at our institution between 2009 and 2013. Demographic, disease specific, treatment, toxicity, and outcome data were collected. Kaplan-Meier and proportional hazard models were used to estimate survival and logistic regression to model toxicity. A least absolute shrinkage and selection operator penalty was used to identify relevant predictors of outcome and toxicity. RESULTS Eleven patients had uterine cancer, 7 patients had cervical cancer, and 3 patients had vulvar cancer. One-year actuarial freedom from local-regional failure, progression-free survival (PFS), and overall survival were 71.5%, 66.0%, and 82.2%, respectively. Tumor size was a significant predictor of worse PFS and overall survival (1 cm increase in tumor size = hazard ratio [HR], 1.61; 95% confidence interval [CI]: 1.16, 2.62 for PFS; HR, 2.02; 95% CI: 1.21, 3.38). Grade 3 or higher vaginal, urinary, and rectal toxicity occurred in 28.5%, 9.5%, and 19% of patients, respectively. Urethra D0.1cc predicted for grade 2 or higher urinary toxicity (one equivalent dose in 2 Gy fraction increase = HR, 1.156; 95% CI: 1.001, 1.335). CONCLUSIONS Reirradiation with ISBT is both safe and effective. In patients with recurrent cancer, urethra D0.1cc predicts for increased urinary toxicity. Increased tumor size is a negative prognostic factor in patients receiving ISBT for cancer recurrence.
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Affiliation(s)
- Mark J Amsbaugh
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Neal Bhatt
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Thomas Hunter
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Lynn Parker
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Daniel Metzinger
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Ashley Amsbaugh
- Department of Anesthesia and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Keith Sowards
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Moataz El-Ghamry
- Department of Radiation Oncology, University of Louisville, Louisville, KY.
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Is there a subset of patients with recurrent cancer in the vagina who are not candidates for interstitial brachytherapy that can be treated with multichannel vaginal brachytherapy using graphic optimization? J Contemp Brachytherapy 2015; 7:135-41. [PMID: 26034494 PMCID: PMC4444458 DOI: 10.5114/jcb.2015.51231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/12/2015] [Accepted: 03/14/2015] [Indexed: 11/30/2022] Open
Abstract
Purpose To evaluate recurrent vaginal cancer treated with vaginal brachytherapy (VBT) using graphic optimization in patients not amenable to surgery and interstitial brachytherapy (ISBT). Material and methods We retrospectively reviewed the records of 5 patients with recurrent cancer in the vagina that were deemed not to be good candidates for ISBT implant because of medical reasons. All patients received computed tomography/magnetic resonance imaging (CT/MRI) based evaluation in addition to a detailed clinical examination, and were noted to have recurrent nodules in the vagina with size ranging from 10-25 mm. Four of the 5 patients had recurrent disease in the vaginal apex, whereas one patient had recurrence in the lateral vaginal wall. Subsequently, all patients were treated with external beam radiation therapy (EBRT) followed by multichannel vaginal cylinder (MVC)-based VBT using graphic optimization for shaping the isodose to improve the clinical target volume (CTV) coverage, as well as to spare the organs at risk (OAR). The dose to the bladder and rectum with regard to 0.1 cc, 1 cc, and 2 cc were recorded. Results Median age of the patients was 78 years (range 58-86 years). Thickness of the lesions before VBT ranged from 6-15 mm. All patients were followed up with MRI at 3 months. All patients but one demonstrated complete clinical/ radiological response of the tumor. No patient had any grade III/IV toxicity at 24 months. Conclusions MVC-based VBT using graphic optimization is safe and yields favorable results if used judiciously.
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Outpatient-based high-dose-rate interstitial brachytherapy for gynecologic malignancies. Brachytherapy 2015; 14:231-7. [DOI: 10.1016/j.brachy.2014.11.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 11/05/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
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Yoshida K, Yamazaki H, Takenaka T, Kotsuma T, Miyake S, Mikami Ueda M, Yoshida M, Masui K, Yoshioka Y, Uesugi Y, Shimbo T, Yoshikawa N, Yoshioka H, Aramoto K, Narumi Y, Yamada S, Tatsumi K, Tanaka E. Preliminary results of MRI-assisted high-dose-rate interstitial brachytherapy for uterine cervical cancer. Brachytherapy 2015; 14:1-8. [DOI: 10.1016/j.brachy.2014.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/28/2014] [Accepted: 07/30/2014] [Indexed: 10/24/2022]
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Yao R, Templeton AK, Liao Y, Turian JV, Kiel KD, Chu JC. Optimization for high-dose-rate brachytherapy of cervical cancer with adaptive simulated annealing and gradient descent. Brachytherapy 2014; 13:352-60. [DOI: 10.1016/j.brachy.2013.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 10/09/2013] [Accepted: 10/29/2013] [Indexed: 01/30/2023]
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Rettenmaier CR, Rettenmaier NB, Abaid LN, Brown JV, Micha JP, Mendivil AA, Wojciechowski T, Goldstein BH, Markman M. The Incidence of Genitourinary and Gastrointestinal Complications in Open and Endoscopic Gynecologic Cancer Surgery. Oncology 2014; 86:303-7. [DOI: 10.1159/000360294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 02/02/2014] [Indexed: 11/19/2022]
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Wooten CE, Randall M, Edwards J, Aryal P, Luo W, Feddock J. Implementation and early clinical results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies. Gynecol Oncol 2014; 133:268-73. [DOI: 10.1016/j.ygyno.2014.02.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/05/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
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D'Souza D, Wiebe E, Patil N, Sugimoto A, Prefontaine M, Aulakh S, Whiston F, Stitt L, Surry K. CT-based interstitial brachytherapy in advanced gynecologic malignancies: outcomes from a single institution experience. Brachytherapy 2014; 13:225-32. [PMID: 24613570 DOI: 10.1016/j.brachy.2014.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 01/29/2014] [Accepted: 02/05/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of women receiving a "short" course of high-dose-rate gynecologic interstitial brachytherapy (HDR-ISBT) boost with CT-based 3D planning. METHODS AND MATERIALS Forty-seven women with no prior radiation received HDR-ISBT from August 2004 to February 2012. The mean external beam radiotherapy dose was 45 Gy. A mean HDR-ISBT boost dose of 18.4 Gy was delivered over 2-4 fractions. Dose volume histograms (DVHs) were computed for organs at risk and clinical target volume. RESULTS With a median followup of 34.8 months, the 3-year local control rate was 68%. Sixteen patients were identified to have tumor recurrence (including eight local). The median time to any recurrence was 26.8 months. Relapse-free survival and overall survival at 3 years was 65% and 73%, respectively. Ten patients experienced Grade 3 late toxicity, mainly vaginal (5) and proctitis (3). The mean prescription volume (V100) was 85 cc and the mean D90 to CTV was 98%. The mean cumulative dose to tumor was 69.9 Gy (equivalent dose in 2 Gy). The mean cumulative equivalent dose in 2 Gy to D2cc of bladder and rectum was 60.9 Gy and 63.0 Gy, respectively. CONCLUSION A "short" course HDR-ISBT is effective, safe, and convenient with acceptable local control and toxicity. Higher dose per fraction is similar to an external beam radiotherapy stereotactic boost with the inherent advantages of brachytherapy. A shorter overall time for HDR-ISBT means less time that patients are immobilized and in hospital, making it less resource intensive than a longer course.
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Affiliation(s)
- David D'Souza
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada; Department of Oncology, Western University, London, Ontario, Canada.
| | - Ericka Wiebe
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Nikhilesh Patil
- Department of Radiation Oncology, Nova Scotia Cancer Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Akira Sugimoto
- Department of Oncology, Western University, London, Ontario, Canada; Department of Obstetrics and Gynecology, London Health Sciences Centre, London, Ontario, Canada
| | - Michel Prefontaine
- Department of Oncology, Western University, London, Ontario, Canada; Department of Obstetrics and Gynecology, London Health Sciences Centre, London, Ontario, Canada
| | - Simran Aulakh
- Department of Medical Biophysics, Western University, London, Ontario, Canada
| | - Frances Whiston
- Clinical Research Unit, London Regional Cancer Program, London, Ontario, Canada
| | - Larry Stitt
- Clinical Research Unit, London Regional Cancer Program, London, Ontario, Canada
| | - Kathleen Surry
- Department of Oncology, Western University, London, Ontario, Canada; Department of Medical Biophysics, Western University, London, Ontario, Canada; Department of Medical Physics, London Regional Cancer Program, London, Ontario, Canada
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Kim H, Rajagopalan MS, Houser C, Beriwal S. Dosimetric comparison of multichannel with one single-channel vaginal cylinder for vaginal cancer treatments with high-dose-rate brachytherapy. Brachytherapy 2013; 13:263-7. [PMID: 24080298 DOI: 10.1016/j.brachy.2013.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/15/2013] [Accepted: 08/22/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the three-dimensional (3D) image (CT/MR)-based planning with a multichannel vaginal cylinder (MVC) to a single-channel vaginal cylinder (SVC) for the treatment of vaginal cancer. METHODS AND MATERIALS A total of 20 consecutive patients were treated with 3D CT/MR image-based high-dose-rate (HDR) brachytherapy using an MVC. All patients received external beam radiation therapy before HDR brachytherapy. A brachytherapy dose of 20-25Gy of more than five fractions was delivered to clinical target volume (CTV). Retrospectively, treatment plans for all patients were generated using the central channel only to mimic an SVC applicator. The SVC plans were optimized to match CTV coverage with MVC plans. Dose homogeneity index as well as bladder, rectum, sigmoid, and urethral doses were compared. RESULTS The mean D90 for CTV was 74.2Gy (range: 48.8-84.1Gy). The mean (±standard deviation) of dose homogeneity index for MVC vs. SVC was 0.49 (±0.19) and 0.52 (±0.23), respectively (p=0.09). Mean bladder 0.1, 1, and 2cc doses for MVC vs. SVC were 69 vs. 71.2Gy (p=0.35), 61.4 vs. 63.8Gy (p=0.1), and 59.5 vs. 60.9Gy (p=0.31), respectively. Similarly, mean rectum 0.1, 1, and 2cc doses for MVC vs. SVC were 67.2 vs. 75.4Gy (p=0.005), 60.0 vs. 65.6Gy (p=0.008), and 57.3 vs. 62.0Gy (p=0.015), respectively, and mean sigmoid doses were 56.3 vs. 60.5Gy (p=0.10), 50.9 vs. 53.1Gy (p=0.09), and 49.1 vs. 50.7Gy (p=0.10), respectively. CONCLUSION The 3D CT-/MR-based plan with MVC may provide better dose distribution in the management of certain clinical situations of vaginal cancer requiring intracavitary brachytherapy, especially in minimizing potential late rectal complications.
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Affiliation(s)
- Hayeon Kim
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA
| | - Malolan S Rajagopalan
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA
| | - Chris Houser
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Magee-Womens Hospital, Pittsburgh, PA.
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Stereotactic body radiotherapy as an alternative to brachytherapy in gynecologic cancer. BIOMED RESEARCH INTERNATIONAL 2013; 2013:898953. [PMID: 24000329 PMCID: PMC3755408 DOI: 10.1155/2013/898953] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 07/12/2013] [Indexed: 12/11/2022]
Abstract
Introduction. Brachytherapy plays a key role in the treatment of many gynecologic cancers. However, some patients are unable to tolerate brachytherapy for medical or other reasons. For these patients, stereotactic body radiotherapy (SBRT) offers an alternative form of treatment. Methods. Retrospective review of patients prospectively collected on SBRT database is conducted. A total of 11 gynecologic patients who could not have brachytherapy received SBRT for treatment of their malignancies. Five patients have been candidates for interstitial brachytherapy, and six have required tandem and ovoid brachytherapy. Median SBRT dose was 25 Gy in five fractions. Results. At last followup, eight patients were alive, and three patients had died of progressive disease. One patient had a local recurrence. Median followup for surviving patients was 420 days (median followup for all patients was 120 days). Two patients had acute toxicity (G2 dysuria and G2 GI), and one patient had late toxicity (G3 GI, rectal bleeding requiring cauterization). Conclusions. Our data show acceptable toxicity and outcome for gynecologic patients treated with SBRT who were unable to receive a brachytherapy boost. This treatment modality should be further evaluated in a phase II study.
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Interstitial brachytherapy vs. intensity-modulated radiation therapy for patients with cervical carcinoma not suitable for intracavitary radiation therapy. Brachytherapy 2013; 12:311-6. [DOI: 10.1016/j.brachy.2012.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 09/27/2012] [Accepted: 10/19/2012] [Indexed: 11/30/2022]
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Lee LJ, Damato AL, Viswanathan AN. Clinical outcomes of high-dose-rate interstitial gynecologic brachytherapy using real-time CT guidance. Brachytherapy 2013; 12:303-10. [DOI: 10.1016/j.brachy.2012.11.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 11/14/2012] [Accepted: 11/28/2012] [Indexed: 12/12/2022]
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Abstract
Brachytherapy is an essential part of radiotherapy treatment for cervical cancer. Over the decades, it has evolved from manual loading of radium and caesium to remote after-loaders and from low-dose and medium-dose rates to high-dose rates. Over the past 10 years, 3D image-based Brachytherapy has evolved and established itself as the gold standard, improving local control and overall survival, and significantly reducing toxicity. In this article, we review some of the available literature on gynaecologic brachytherapy, more specifically on topics such as dose rates, high-dose-rate/pulsed-dose-rate (HDR/PDR) brachytherapy and image-based brachytherapy (IBBT), and present some of the evidence that establishes IBBT.
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Dosimetric impact of interfraction catheter movement and organ motion on MRI/CT guided HDR interstitial brachytherapy for gynecologic cancer. Radiother Oncol 2013; 107:112-6. [DOI: 10.1016/j.radonc.2012.12.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 11/13/2012] [Accepted: 12/19/2012] [Indexed: 11/17/2022]
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Iftimia I, Cirino ET, Mower HW, McKee AB. Treatment planning methodology for the Miami Multichannel Applicator following the American Brachytherapy Society recently published guidelines: the Lahey Clinic experience. J Appl Clin Med Phys 2013; 14:4098. [PMID: 23318396 PMCID: PMC5714050 DOI: 10.1120/jacmp.v14i1.4098] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/04/2012] [Accepted: 09/03/2012] [Indexed: 11/23/2022] Open
Abstract
The objective of this study was to develop a standardized procedure from simulation to treatment delivery for the multichannel Miami applicator, in order to increase planning consistency and reduce errors. A plan is generated prior to the 1st treatment using the CT images acquired with the applicator in place, and used for all 3 fractions. To confirm the application placement before each treatment fraction, an AP image is acquired and compared with the AP baseline image taken at simulation. A preplanning table is generated using the EBRT doses and is used to compute the maximum allowable D2cc for bladder, rectum, and sigmoid, and the mean allowable dose for the upper vaginal wall per HDR brachytherapy fraction. These data are used to establish the criteria for treatment planning dose optimization. A step‐by‐step treatment planning approach was developed to ensure appropriate coverage for the tumor (D90>100% prescribed dose of 700 cGy/fraction) and the uninvolved vaginal surface (dose for the entire treatment length > 600 cGy/fraction), while keeping the organs at risk below the tolerance doses. The equivalent dose 2 Gy (EQD2) tolerances for the critical structures are based on the American Brachytherapy Society (ABS) recently published guidelines. An independent second check is performed before the 1st treatment using an in‐house Excel spreadsheet. This methodology was successfully applied for our first few cases. For these patients: the cumulative tumor dose was 74–79 EQD2 Gy10 (ABS recommended range 70–85); tumor D90 was >100% of prescribed dose (range 101%–105%); cumulative D2cc for bladder, rectum, and sigmoid were lower than the tolerances of 90, 75, and 75 EQD2 Gy3, respectively; cumulative upper vaginal wall mean dose was below the tolerance of 120 EQD2 Gy3; the second check agreement was within 5%. By using a standardized procedure the planning consistency was increased and all dosimetric criteria were met. PACS numbers: 87.55‐x, 87.56 bg
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Affiliation(s)
- Ileana Iftimia
- Radiation Oncology Department, Lahey Clinic, Burlington, MA 01805, USA.
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Lee LJ, Viswanathan AN. Predictors of Toxicity After Image-guided High-dose-rate Interstitial Brachytherapy for Gynecologic Cancer. Int J Radiat Oncol Biol Phys 2012; 84:1192-7. [DOI: 10.1016/j.ijrobp.2012.01.085] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 01/11/2012] [Accepted: 01/29/2012] [Indexed: 10/27/2022]
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Kannan N, Beriwal S, Kim H, Houser C, Mogus R, Sukumvanich P, Olawaiye AB, Richard S, Kelley JL, Edwards RP, Krivak TC. High-dose-rate interstitial computed tomography–based brachytherapy for the treatment of cervical cancer: Early results. Brachytherapy 2012; 11:408-12. [DOI: 10.1016/j.brachy.2012.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 01/21/2012] [Accepted: 02/16/2012] [Indexed: 11/24/2022]
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Viswanathan AN, Beriwal S, De Los Santos JF, Demanes DJ, Gaffney D, Hansen J, Jones E, Kirisits C, Thomadsen B, Erickson B. American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: high-dose-rate brachytherapy. Brachytherapy 2012; 11:68-75. [PMID: 22265437 DOI: 10.1016/j.brachy.2011.06.008] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/29/2011] [Accepted: 06/30/2011] [Indexed: 12/26/2022]
Abstract
PURPOSE This report presents an update to the American Brachytherapy Society (ABS) high-dose-rate (HDR) brachytherapy guidelines for locally advanced cervical cancer. METHODS Members of the ABS with expertise in cervical cancer formulated updated guidelines for HDR brachytherapy using tandem and ring, ovoids, cylinder, or interstitial applicators for locally advanced cervical cancer. These guidelines were written based on medical evidence in the literature and input of clinical experts in gynecologic brachytherapy. RESULTS The ABS affirms the essential curative role of tandem-based brachytherapy in the management of locally advanced cervical cancer. Proper applicator selection, insertion, and imaging are fundamental aspects of the procedure. Three-dimensional imaging with magnetic resonance or computed tomography or radiographic imaging may be used for treatment planning. Dosimetry must be performed after each insertion before treatment delivery. Applicator placement, dose specification, and dose fractionation must be documented, quality assurance measures must be performed, and followup information must be obtained. A variety of dose/fractionation schedules and methods for integrating brachytherapy with external-beam radiation exist. The recommended tumor dose in 2-Gray (Gy) per fraction radiobiologic equivalence (normalized therapy dose) is 80-90Gy, depending on tumor size at the time of brachytherapy. Dose limits for normal tissues are discussed. CONCLUSION These guidelines update those of 2000 and provide a comprehensive description of HDR cervical cancer brachytherapy in 2011.
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Affiliation(s)
- Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA.
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Beriwal S, Rwigema JCM, Higgins E, Kim H, Houser C, Sukumvanich P, Olawaiye A, Richard S, Kelley JL, Edwards RP, Krivak TC. Three-dimensional image-based high-dose-rate interstitial brachytherapy for vaginal cancer. Brachytherapy 2012; 11:176-80. [DOI: 10.1016/j.brachy.2011.05.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/16/2011] [Accepted: 05/18/2011] [Indexed: 11/30/2022]
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Inverse-planned gynecologic high-dose-rate interstitial brachytherapy: clinical outcomes and dose--volume histogram analysis. Brachytherapy 2011; 11:181-91. [PMID: 21862418 DOI: 10.1016/j.brachy.2011.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 06/01/2011] [Accepted: 06/16/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE To present clinical outcomes and dose-volume histogram parameters of three-dimensional image-based high-dose-rate interstitial brachytherapy (HDR-ISBT) in patients with primary or recurrent gynecologic cancer unsuitable for intracavitary brachytherapy (ICB). METHODS AND MATERIALS Records of 43 women treated between 2001 and 2009 with iridium-192 gynecologic HDR-ISBT boost, using a Syed-Neblett template and inverse planning simulated annealing dose optimization, were reviewed. Median HDR-ISBT dose was 30Gy, delivered in 4-6Gy/fraction. Dose-volume histogram parameters recommended by the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology for image-based ICB were analyzed. Total doses were normalized to 2Gy fractions (biologically equivalent dose in 2Gy fractions). Local control (LC) and survival were calculated using Kaplan-Meier method. Toxicities were defined according to Common Terminology Criteria for Adverse Events v3.0. RESULTS There were 34 primary malignancies (cervix=12, vagina=15, Bartholin's gland=5, and vulva=2) and 9 recurrences. International Federation of Gynecology and Obstetrics stage distribution for primary cancers was I=2, II=13, III=15, and IV=4. Median followup was 19.3 months (range, 0-92.2). Two-year LC was 87% for primary cancers, and 45% for recurrent cancers, respectively (p=0.0175). Median V(100), D(90), and D(100) for clinical target volume were 97.6%, 90.2, and 68.7Gy(10), respectively. Median bladder and rectal D(2)(cc) were 76.6 and 79.5Gy(3), respectively. Median urethral D(10) was 80.6Gy(3). Twelve patients experienced Grades 3 and 4 late morbidity, but toxicities were transient. Only 2 patients had persistent severe toxicities. A trend toward increased risk for vaginal necrosis was observed with a clinical target volume >84cc. CONCLUSIONS HDR-ISBT may achieve good LC in gynecologic cancer unsuitable for ICB, especially in primary malignancies with a 2-year LC rate higher than 85%. Delivery of such high doses has potential advantages but may predispose to adverse effects, reversible in most cases.
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