Cesium-131 Low-Dose Rate Interstitial Brachytherapy as a Salvage Re-Irradiation Technique in Treating Cervical and Uterine Cancer Pelvic Recurrence with Prior History of Pelvic Radiation

PURPOSE/OBJECTIVE(S)

Pelvic recurrence among cervical and uterine cancer patients with prior history of pelvic radiation is a poor prognostic factor and remains challenging. The standard of care is pelvic exenteration, which is a highly morbid surgical procedure. The purpose of this study is to report local control rate and toxicity profile of Cesium-131 low-dose rate interstitial brachytherapy (LDR) as a salvage re-irradiation technique in managing pelvic relapse.

MATERIALS/METHODS

We reviewed procedures and outcomes from patients with previously irradiated uterine corpus or cervix neoplasms, who subsequently relapsed and then underwent cesium-131 LDR implants between January 2016 and December 2022. Patient demographics, treatment planning variables, and disease response were reviewed. Acute toxicities, late toxicities, and local control rate were compiled for this study.

RESULTS

A total of 12 eligible patients (6 cervical and 6 uterine cancer) with 16 cesium-131 LDR implants were included in this study. The majority (75%) of pelvic relapses occurred at the exocervix (cervix-intact) or vaginal cuff (post-hysterectomy). Median time from disease relapse to cesium implant was 32 days. The average area of implementation was 9 cm2 and average number of seeds implanted was 16. The mean prescription dose was 50 Gy. Six patients also received high-dose rate vaginal intracavitary brachytherapy in addition to cesium-131 LDR. Median follow up was 12 months. 81% of cesium implants achieved complete response at first post-treatment follow-up, while the remaining 19% demonstrated partial response. The 6-months local control rate was 79%. After cesium implant, 25% patients had local recurrence and 33% with distal metastasis. The most reported acute toxicities included vaginal mucositis (63%), dysuria (50%) and pain (19%). All patients had various degrees of vaginal stenosis and strictures long-term. Only 1 (8%) out of 12 patients, with 4 repeated cesium-131 LDR implants, developed a rectovaginal fistula and chronic pain.

CONCLUSION

Cesium-131 LDR interstitial brachytherapy is a safe and feasible salvage re-irradiation technique in treating pelvic relapse among uterine corpus or cervix cancer patients with prior history of pelvic radiation. Local control rate at 6-months was acceptable with minimum toxicity. Long-term follow up is warranted to validate the efficacy of cesium-131 LDR. We conclude that cesium-131 LDR interstitial brachytherapy is a promising alternative to pelvic exenteration in selective patient population. Future prospective study is warranted.

Survey of current practices from an international task force for gynecological stereotactic ablative radiotherapy

Background

Stereotactic Ablative Radiotherapy (SABR) is an effective treatment that improves local control for many tumours. However, the role of SABR in gynecological cancers (GYN) has not been well-established. We hypothesize that there exists considerable variation in GYN-SABR practice and technique. The goal of this study is to describe clinical and technical factors in utilization of GYN-SABR among 11 experienced radiation oncologists.

Materials and methods

A 63 question survey on GYN-SABR was sent to 11 radiation oncologists (5 countries) who have published original research, conducted trials or have an established program at their institutions. Responses were combined and analyzed at a central institution.

Results

Most respondents indicated that salvage therapy (non-irradiated or re-irradiated field) for nodal (81%) and primary recurrent disease (91%) could be considered standard options for SABR in the setting of inability to administer brachytherapy. All other indications should be considered on clinical trials. Most would not offer SABR as a boost in primary treatment off-trial without absolute contraindications to brachytherapy. Multi-modality imaging is often (91%) used for planning including PET, CT contrast and MRI. There is a wide variation for OAR tolerances however small bowel is considered the dose-limiting structure for most experts (91%). Fractionation schedules range from 3 to 6 fractions for nodal/primary definitive and boost SABR.

Conclusions

Although SABR has become increasingly standard in other oncology disease sites, there remains a wide variation in both clinical and technical factors when treating GYN cancers. Nodal and recurrent disease is considered a potential indication for SABR whereas other indications should be offered on clinical trials. This study summarizes SABR practices among GYN radiation oncologists while further studies are needed to establish consensus guidelines for GYN-SABR treatment.

Helical tomotherapy versus conventional radiation to deliver abdominopelvic radiation

While whole abdominopelvic radiation (APRT) provided satisfactory radiation dosimetry for the treatment of cancers with peritoneal dissemination, APRT was abandoned due to unsatisfactory tumor control from necessary radiation shielding of vital organs. Our goal was to develop a helical tomotherapy (TOMO) abdominopelvic radiation technique improving target tissue coverage while dose-limiting vital organs, especially hematopoietic bone marrow. This study reports our clinical development of a TOMO abdominopelvic radiation technique for treatment of patients with advanced stage ovarian cancer. Novel chemoradiosensitizing agent clinical trials incorporating our TOMO abdominopelvic radiation technique for treatment of patients with recurrent ovarian cancer are under development.

Bony changes at the lateral epicondyle of possible significance in tennis elbow syndrome

Examination of a large number (1232) of elbows from skeletal specimens revealed that 16% displayed a characteristic pattern of bone formation exactly underlying the area of exquisite point tenderness at the lateral humeral epicondyle found in clinical cases of tennis elbow. These changes are usually not seen on standard roentgenograms and can be missed, even at the time of surgery, because this area is not commonly exposed in standard tennis elbow approaches. In a group of clinical cases of tennis elbow (20 patients), similar bony changes could be demonstrated in the majority (60%) of patients with chronic tennis elbow symptoms by the use of specialized x-ray techniques-most notably, coronal reconstructions with computed axial tomography. Ten cadaver specimens were also dissected to delineate the muscular and capsulotendinous insertions in this area. We call attention to these bony changes in the supposition that they may be involved in the development and persistence of symptoms in tennis elbow.

First rib metamorphosis: its possible utility for human age-at-death estimation

Human first ribs demonstrate predictable, sequential changes in shape, size, and texture with increasing age, and thus, can be used as an indicator of age at death. Metamorphosis of the first rib's head, tubercle, and costal face was documented in a cross-sectional sample of preadult and adult first ribs of known age at death from the Hamann-Todd skeletal collection (Cleveland Museum of Natural History, Cleveland, Ohio). Blind tests of the usefulness of the first rib as an age indicator were conducted, including tabulation of intraobserver and interobserver inaccuracies and biases. First rib age estimates show inaccuracies and biases by decade comparable to those generated by other aging techniques. Indeed, the first rib method is useful as an isolated age indicator. When used in conjunction with other age indicators, the first rib improves the quality of summary age assessments.

A radiographic study of the development of the human mandibular dentition

This paper presents new data on the absolute timing of the growth of the mandibular permanent teeth, with an emphasis on the timing of the completion of the enamel crown. Two collections of cranio-dental radiographs were analyzed: (1) 267 juveniles from a contemporary pediatric dental clinic (Case Western Reserve University School of Dentistry, Cleveland, Ohio), and (2) 36 individuals sampled longitudinally from the Bolton-Brush Growth Study Center. The ages of the individuals span from three months to 18 years of age and the study includes both cross-sectional and longitudinal data. Comparisons of the ages of attainment of the Cleveland samples with other schedules of dental development are made. The relative contribution of the multiple underlying sources of variation producing the differences between the radiographically based developmental schedules remain elusive.