Brachytherapy - Articles in Press

Biopsy and implantation of the seminal vesicles - Corrected Proof

Nelson N. Stone, Vassilios M. Skouteris, Richard G. Stock — 2012-02-06

Abstract: Purpose: To describe the technique and outcomes of seminal vesicle biopsy (SVB) and permanent implantation in patients with T3b prostate cancer.Methods and Materials: Intermediate- and high-risk prostate cancer patients who elected brachytherapy as their treatment of choice were offered SVB for either Gleason score ≥7, prostate-specific antigen levels >10ng/mL, or clinical stage ≥T2b. Three cores were taken from both seminal vesicles at the base of the prostate using transrectal ultrasound. Patients with a positive SVB and either a negative pelvic lymph node dissection or pelvic computerized tomogram were treated with a combination of a partial implant followed by 45Gy of external beam irradiation therapy. During the seed implant, sources were positioned in the anterior wall of the seminal vesicles using intraoperative dosimetry to guide placement. Biochemical freedom from failure was determined using a definition of >0.2ng/mL. Survival was measured using the Kaplan–Meier and Cox proportions projections.Results: Of 526 patients who underwent SVB, 52 (9.9%) were positive for prostate cancer invasion. Clinical stage, prostate-specific antigen levels, and Gleason score were all predictive of a positive SVB (p<0.001). The 10-year biochemical freedom from failure was 64%. Cox regression demonstrated Gleason score (p=0.044) and biologic effective dose (p=0.013) as significant.Conclusions: Patients with pathologically confirmed seminal vesicle involvement of prostate cancer can be successfully identified and managed by a combined approach of permanent seed implantation to the prostate and seminal vesicles followed by external beam irradiation therapy. SVB should be encouraged in men with high-risk prostate cancer and aggressively treated when encountered.

Is there any advantage to three-dimensional planning for vaginal cuff brachytherapy? - Corrected Proof

Hyun Kim, Hayeon Kim, Christopher Houser, Sushil Beriwal — 2012-02-03

Abstract: Purpose: To evaluate whether the three-dimensional (3D) CT-based high-dose rate planning for vaginal cuff brachytherapy offers any advantage over the 2D orthogonal film-based library plans for adjuvant treatment of endometrial cancers.Methods and Materials: Eighty-four consecutive postoperative patients with endometrial cancers treated with vaginal brachytherapy as an adjuvant treatment were analyzed. Patients had CT imaging-based plans. Clinical target volume (CTV) was defined by expanding the upper 2.5cm of the cylinder by 5mm in all directions and editing to exclude any bladder and rectum. The dose prescribed was 7Gy with three fractions at 5mm depth with a goal of D90 ≥100% for CTV. All dosimetric parameters were compared with library-based plans.Results: Both the 2D- and 3D-based plans allowed sufficient dosage to the CTV (D90 for CTV ≥95%). The doses of 0.1, 1, and 2cc to rectum and bladder were significantly higher for 2D-based plans (p≤0.001 in each parameter). D2 cc with 2D plan for rectum and bladder was >100% (range: 103–116%) in 7 (8%) and 6 (7%) patients, respectively. In contrast, no patients had D2 cc >100% with 3D planning for both organs.Conclusion: Three-dimensional CT-based planning for high-dose rate vaginal cuff brachytherapy helps to decrease dose to critical organs without compromising coverage of CTV by customizing the dosimetry according to individual patient anatomy.

Radioactive seed migration after transperineal interstitial prostate brachytherapy and associated development of small-cell lung cancer - Corrected Proof

William C. Chen, Jerald Katcher, Carlos Nunez, Ali M. Tirgan, Rodney J. Ellis — 2012-01-16

Abstract: Purpose: We report a case of lung carcinoma developing in the location of a migrated prostate brachytherapy seed.Methods and Materials: A 57-year-old male nonsmoker was originally diagnosed with prostate adenocarcinoma Group IIB in October 1999. Treatment was completed at an outside local hospital and consisted of hormone suppression, pelvic external beam radiation, and transperineal interstitial permanent prostate brachytherapy with loose iodine-125 seeds.Results: The treatment was unremarkable for any complications, and immediate postimplant evaluation did not reveal any loose seeds. The patient remained clinically without evidence of disease and was asymptomatic until an isolated episode of hematuria in December 2009. Radiographic evaluation noted an incidental right lower lobe lung mass with a 4-mm hyperdensity slightly off-center. Biopsy confirmed Stage IB limited-stage small-cell lung cancer, and he underwent thoracic radiation with concurrent systemic chemotherapy. The mass remained mildly avid on a positron emission tomographic scan after treatment, and he underwent surgical evaluation with final pathology demonstrating no residual tumor but a metal rod-like implant consistent with a migrated radioactive brachytherapy seed.Conclusions: To our knowledge, this is the first case of a long-term adverse sequela seen in the location of a migrated brachytherapy seed. Although reported incidence of pulmonary seed emboli remains low with little measurable consequence on pulmonary function, we must appreciate that a theoretical risk for secondary malignancy remains not only locally within the periprostatic region but also at any site of seed migration.

Dosimetry comparison between TG-43 and Monte Carlo calculations using the Freiburg flap for skin high-dose-rate brachytherapy - Corrected Proof

2012-01-09

Abstract: Purpose: The purpose of this work was to evaluate whether the delivered dose to the skin surface and at the prescription depth when using a Freiburg flap applicator is in agreement with the one predicted by the treatment planning system (TPS) using the TG-43 dose-calculation formalism.Methods and Materials: Monte Carlo (MC) simulations and radiochromic film measurements have been performed to obtain dose distributions with the source located at the center of one of the spheres and between two spheres. Primary and scatter dose contributions were evaluated to understand the role played by the scatter component. A standard treatment plan was generated using MC- and TG-43-based TPS applying the superposition principle.Results: The MC model has been validated by performing additional simulations in the same conditions but transforming air and Freiburg flap materials into water to match TG-43 parameters. Both dose distributions differ less than 1%. Scatter defect compared with TG-43 data is up to 15% when the source is located at the center of the sphere and up to 25% when the source is between two spheres. Maximum deviations between TPS- and MC-based distributions are of 5%.Conclusions: The deviations in the TG-43-based dose distributions for a standard treatment plan with respect to the MC dose distribution calculated taking into account the composition and shape of the applicator and the surrounding air are lower than 5%. Therefore, this study supports the validity of the TPS used in clinical practice.

Practical steps for establishing ocular plaque therapy in developing countries - Corrected Proof

2012-01-09

Abstract: Introduction: Retinoblastoma and uveal melanoma are the most common ocular tumors in children and adults, respectively. Enucleation and external beam radiation therapy are integral in the management of ocular tumors. However, these tumors could also be treated effectively by plaque therapy, which has the potential of preserving the globe and maintaining vision.Methods and materials: We reviewed our experience with the introduction of this technique to our center. Furthermore, we highlighted the critical role of a specialized multidisciplinary team in the successful implementation of this procedure.Discussion: This review represents a detailed report addressing the practical steps for successfully establishing plaque therapy in developing countries.Results: Plaque therapy was successfully implemented at our center in 1.5 years. Integration with an advanced cancer center is crucial for the correct transfer of this complex technology.Conclusion: Complex brachytherapy procedures could be successfully established and implemented in developing countries.

Reirradiation of paraaortic lymph node metastasis by brachytherapy with hyaluronate injection via paravertebral approach: With DVH comparison to IMRT - Corrected Proof

2011-12-30

Abstract: Purpose/Introduction: To safely irradiate retroperitoneal targets as paraaortic lymph node by separating abdominal at-risk organs from the target during irradiation, we created a percutaneous paravertebral approach of high-dose-rate brachytherapy with hyaluronate gel injection (HGI). We report a case treated with this technique.Methods and Materials: We encountered a patient with symptomatic regrowth of paraaortic lymph node metastasis from prostatic cancer. He had previously received 58.4Gy of radiotherapy to the same region 12 months prior. Brachytherapy needles and a HGI needle were deployed via the paravertebral approach under local anesthesia at our outpatient clinic.Results: A single dose of 22.5Gy (equivalent to 60.94Gy in 2Gy per fraction schedule calculated at α/β=10) was delivered to the target, with preservation of the surrounding small intestine by HGI with D2cc (minimum dose to the most irradiated volume of 2mL) of 5.05Gy. Therapeutic ratio was 3.64 times higher for this brachytherapy plan compared with an intensity-modulated radiation therapy plan. At followup at 1 year after brachytherapy, the symptoms had disappeared, tumor size had reduced with no fluorodeoxyglucose accumulation, and prostate-specific antigen level had decreased.Conclusion: We consider that high-dose-rate brachytherapy with the HGI procedure offers effective treatment even in this type of reirradiation situation.

Comparison of prostate volume, shape, and contouring variability determined from preimplant magnetic resonance and transrectal ultrasound images - Corrected Proof

2011-12-26

Abstract: Purpose: To compare preimplant prostate contours and contouring variability between magnetic resonance (MR) and transrectal ultrasound images.Methods and Materials: Twenty-three patients were imaged using ultrasound (US) and MR before permanent brachytherapy treatment. Images were anonymized, randomized, and duplicated, and the prostate was independently delineated by five radiation oncologists. Contours were compared in terms of volume, dimensions, posterior rectal indentation, and observer variability. The Jaccard index quantified spatial overlap between contours from duplicated images.Results: The mean US/MR volume ratio was 0.99±0.08 (p=0.5). The width, height, and length ratios for the prostate were 0.98±0.06 (p=0.09), 0.99±0.08 (p=0.4), and 1.05±0.14 (p=0.1). Rectal indentation was larger on US by 0.18mL (p=0.01) and correlated with prostate volume (p<0.01). MR and US interobserver variability in volume were similar at 3.5±1.7 and 3.3±1.9mL (p=0.6). Intraobserver variability was smaller on US at 1.4±1.1mL compared with MR at 2.4±2.2mL (p=0.01). Local intraobserver variability was lower on US at the midgland slice (p<0.01) but lower on MR at the base (p<0.01) and apex (p<0.01) slices.Conclusions: US is comparable to MR for preimplant prostate delineation, with no significant difference in volume and dimensions. Rectal indentation because of the transrectal ultrasound probe was measurable, although the effects were small. Intraobserver variability was lower on US for the prostate volume but was lower on MR locally at the base and apex. However, the difference was not observed for the interobserver variability, which was similar between MR and US.

Initial clinical experience with multilumen brachytherapy catheters for accelerated partial breast irradiation - Corrected Proof

2011-12-23

Abstract: Purpose: To review the initial experience of three institutions using multilumen catheters to deliver accelerated partial breast irradiation (APBI) and evaluate dosimetric improvements.Methods and materials: Patients were eligible for this analysis if they met criteria for accelerated partial breast irradiation at their respective institution and were not enrolled on the national Phase III trial. Minimum guidelines for treatment planning from the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol were followed. Toxicities were coded using common toxicity criteria version 3.0 criteria.Results: Sixty-two patients were analyzed as part of this study. Median skin spacing was 11mm with a median skin dose of 86.9% (% of prescription dose [PD]). Median rib dose was 76.1% of the PD (range, 4.3–155.7%). The V90, V95, and V100 of the PD for the planning target volume evaluation was 95.4%, 95.2%, and 80.3%, respectively. Seven patients had both skin and rib spacing <7mm, with the median skin dose and rib dose being 113.4% and 130.9% of the PD. For these cases, the median V90, V95, and V100 of the PD was 99.2%, 94.3%, and 81.1%, respectively, whereas the median V150 and V200 were 22.5cc and 7.4cc. Overall, Grade I and II radiation dermatitis were noted in 41.9% and 6.5% of patients.Conclusion: The multilumen device led to improvements in target coverage and normal structure doses compared with traditionally accepted guidelines. Similar toxicities were seen compared with single-lumen devices, even in patients with skin and rib spacing <7mm.

A comparison of the impact of isotope (125I vs. 103Pd) on toxicity and biochemical outcome after interstitial brachytherapy and external beam radiation therapy for clinically localized prostate cancer - Corrected Proof

2011-12-23

Abstract: Purpose: To compare biochemical outcomes and morbidity associated with iodine-125 (125I) and palladium-103 (103Pd) brachytherapy as part of combined modality therapy for clinically localized prostate cancer.Methods and materials: Between October 2002 and December 2008, 259 patients underwent prostate brachytherapy (125I prescription dose, 110Gy: n=199; 103Pd prescription dose, 100Gy: n=60) followed by external beam radiotherapy (median dose, 50.4Gy). Eighty-seven patients also received neoadjuvant androgen deprivation therapy. Toxicities were recorded with CTCAE v 3.0, International Prostate Symptoms Score (IPSS), and International Index of Erectile Function questionnaires.Results: Overall, acute Grade ≥2 genitourinary toxicity occurred in 21% and 30% of patients treated with 125I and 103Pd, respectively (p=0.16). There were no significant differences in IPSS change or urinary quality-of-life scores between the isotopes at 4, 6, or 12 months (p=0.20, 0.21, and 1.0, respectively). IPSS resolution occurred at a median of 11 and 6 months for 125I and 103Pd patients, respectively (p=0.03). On multivariate analysis, only the use of neoadjuvant androgen deprivation therapy was predictive of time to IPSS resolution (p=0.046). Late Grade ≥2 gastrointestinal toxicity occurred in 7% of 125I patients and 6% of patients treated with 103Pd. Of 129 potent patients at baseline, there was better erectile function in patients who received 103Pd (p=0.02); however, the followup was shorter for these patients. The 5-year prostate-specific antigen relapse-free survival for 125I and 103Pd patients was 95.2% and 98.2% (p=0.73), respectively.Conclusion: There were no differences in acute or long-term genitourinary or gastrointestinal toxicity between 125I and 103Pd in combined modality therapy for prostate cancer. There may be less erectile toxicity with the use of 103Pd; however, additional followup of these patients is needed. There was no significant difference in 5-year prostate-specific antigen relapse-free survival between 103Pd and 125I.

Prostate brachytherapy seed migration to a left varicocele - Corrected Proof

2011-12-23

Abstract: Purpose: To report a rare case of seed migration to a left varicocele after transperineal interstitial prostate brachytherapy with loose iodine-125 (125I) seeds.Methods and Materials: A 73-year-old man presented with a serum prostate-specific antigen level of 5.21ng/mL, Gleason score of 7 (3+4), and clinical T1c adenocarcinoma of the prostate. The patient underwent transperineal interstitial prostate brachytherapy with loose 125I seeds followed by external beam radiation therapy. Two weeks after seed implantation, a followup pelvic radiograph was obtained. One month after seed implantation, a pelvic computed tomography scan for postimplant dosimetric analysis was carried out. Subsequent ultrasound examination of the scrotum was undertaken.Results: Two weeks after seed implantation, an anteroposterior pelvic radiograph showed that a migrated seed was overlapped by the scrotum. Postimplant pelvic computed tomography revealed that a seed had migrated to the left side of the scrotum. Subsequent ultrasound examination of the scrotum revealed that the patient had a left varicocele to which the seed had migrated. The patient had no symptoms related to the migrated seed.Conclusions: This is the first report of seed migration to a left varicocele after transperineal interstitial prostate brachytherapy with loose 125I seeds. For the present case, we suggest that the seed moved from the prostate to the left varicocele through the pelvic veins, bypassing the systemic circulation.

Comparison of intracavitary brachytherapy and stereotactic body radiotherapy dose distribution for cervical cancer - Corrected Proof

2011-12-23

Abstract: Purpose: To compare the dose distribution characteristics of stereotactic body radiotherapy (SBRT) with intracavitary high-dose-rate (HDR) brachytherapy in patients with cervical carcinoma.Methods and Materials: HDR intracavitary brachytherapy treatment plans for 11 women with cervical carcinoma were evaluated in this analysis. The total HDR brachytherapy dose was 28Gy given in four fractions. HDR brachytherapy was delivered with the microSelectron HDR therapy unit (Nucletron B. V., Veenendaal, The Netherlands). SBRT plans for each patient were generated with MultiPlan for CyberKnife Robotic Radiosurgery System (Accuray Inc., Sunnyvale, CA). The dose distributions, dose–volume histograms, and maximum dose points of the target and critical organs were recorded for both plans.Results: SBRT yielded significantly better target coverage; the median target coverage for the 100% isodose line was 50.7% for HDR brachytherapy plans, whereas it was 99.1% for SBRT plans. The dose distributions for critical organs were similar in both types of plans. The exceptions were the 25% isodose being significantly better in brachytherapy plans for rectum, and the 100% isodose exposure being higher in brachytherapy plans for rectum, bladder, and sigmoid colon. Some significant differences were also found in maximum doses received by a 2-cc volume of bladder in favor of SBRT plans. In addition, maximum bone marrow doses were significantly higher in SBRT plans.Conclusion: SBRT plans achieved better target coverage and better dose distributions to critical organs except bone marrow compared with HDR brachytherapy plans in patients with locally advanced cervical cancer.

Is prostate-specific antigen percentage decrease predictive of clinical outcome after permanent iodine-125 interstitial brachytherapy for prostate cancer? - Corrected Proof

2011-12-05

Abstract: Objective: To determine the usefulness of prostate-specific antigen (PSA) percentage (vs. pretreatment value assumed as 100%) in prediction of biochemical relapse, after iodine-125 (125I) permanent brachytherapy for prostate cancer, to employ a parameter independent by the initial PSA amount and by the individual prostatic volume.Methods and materials: Our study included 133 patients, 102 still disease free (Group A) and 31 who experienced proven biochemical recurrence (Group B). PSA levels before and after 125I brachytherapy were recorded, and PSA percentage vs. pretreatment values were calculated. Cox regression model, receiver operating characteristic curves, and Kaplan–Meier regression model with log-rank test were calculated.Results: We observed that, in patients submitted to brachytherapy for prostate cancer, a PSA percentage >20% of pretreatment value is highly associated with relapse risk (p<0.0001) and that this association is strongly present since t=6 months of followup (p<0.0001), with a hazard ratio near to five times (4.965), a sensitivity of 72.4%, and specificity of 79.8% related to the chosen cutoff.Discussion: Despite the amount of PSA is the only parameter that the clinicians can deploy to monitor patient’s followup after permanent interstitial brachytherapy for prostate cancer, its evolution in time seems unable to predict early biochemical relapse as it is influenced by prostatic volume and initial PSA amount.Conclusions: Our data suggest that a PSA percentage >20% of pretreatment value at 6 months might represent an early, inexpensive, and useful predictive tool of bad outcome in patients after permanent brachytherapy.

High-dose-rate and pulsed-dose-rate brachytherapy in palliative treatment of head and neck cancers - Corrected Proof

2011-11-21

Abstract: Purpose: The main purpose of the study was to assess the results of high-dose-rate brachytherapy (HDRBT) and pulsed-dose-rate brachytherapy (PDRBT) in the palliative treatment of patients with locally or regionally recurrent head and neck cancers. The detailed aims concerned the evaluation of these methods in the context of local control, survival, and complications rates in patients subgrouped by different parameters such as age, gender, primary and recurrent tumor localization, tumor size, treatment method (HDR/PDR), primary treatment method, and radiation dose applied.Methods and Materials: PDRBT and HDRBT were used in 106 and 50 patients, respectively. In 8 patients, BT procedures were performed in combination with simultaneous chemotherapy. Sixteen patients were additionally treated with interstitial hyperthermia. All patients were regularly followed up within 6 months. Local control, complications, and survival were assessed. Materials included 156 patients with head and neck cancers treated palliatively with HDRBT and PDRBT in the Department of Otolaryngology of Poznań University of Medical Sciences and in the Department of Brachytherapy of Greater Poland Cancer Center from January 2002 to November 2008.Results: Complete and partial remissions 6 months after finishing the treatment were achieved in 37.7% of patients, whereas survival rates 12 and 24 months after brachytherapy were estimated for 40% and 17%, respectively. The overall complications rate was 35%.Conclusions: Our results suggest that HDRBT and PDRBT constitute a safe alternative in the palliative treatment of patients with locally or regionally recurrent head and neck cancers with a relapse in a previously irradiated area, which were not qualified or rejected surgery. It gives a good palliative effect with acceptable complication rate.

The comparison of ruthenium brachytherapy and simultaneous transpupillary thermotherapy of choroidal melanoma with brachytherapy alone - Corrected Proof

Andrey A. Yarovoy, Dzhavid A. Magaramov, Evgeniya S. Bulgakova — 2011-11-21

Abstract: Purpose: To compare the outcomes of combined treatment of choroidal melanoma with ruthenium brachytherapy (BT) simultaneously with transpupillary thermotherapy (TTT) and treatment with BT alone.Methods and Materials: Two matched groups of patients, one treated with BT and simultaneous TTT (Group BT+TTT, n=63), the other treated with BT alone (Group BT, n=70) were analyzed retrospectively. The main outcome measures were rate of tumor regression, recurrences, enucleations, metastases, recurrence-free and overall survival rate, and visual acuity, assessed by Kaplan–Meier analysis.Results: Patients were matched according to mean age (p=0.22), mean tumor thickness (6.4 vs. 6.25mm, range 2.5–10.8mm, p=0.59), and mean length of followup (42 vs. 34.4 months, range 3–109, p=0.052). Tumor largest basal diameter (13.0 vs. 12.9mm), tumor location, and mean radiation dose (apical 135 vs. 136Gy and scleral 1294 vs. 1438Gy) were also similar in both groups (p>0.1). Treatment with BT+TTT resulted in higher rate of tumor regression (63% vs. 49%, respectively, p=0.036), lower 5-year tumor recurrence rate (96% vs. 83%, p<0.034), and higher eye-globe preservation (98% vs. 87%, p<0.024) and recurrence-free survival rates (89% vs. 67%, p<0.017) than treatment with BT alone. There was no difference in complications (p>0.5), metastasis-free (93% vs. 81%, p>0.22) and overall survival rates (91% vs. 81%, p>0.39), or in visual outcomes.Conclusion: Combined treatment of choroidal melanoma with ruthenium BT and simultaneous TTT seems to provide higher local control, eye-globe preservation, and recurrence-free survival rates than treatment with BT alone and results in similar rates of metastases and overall survival.

Experimental characterization of the dosimetric properties of a newly designed I-Seed model AgX100 125I interstitial brachytherapy source - Corrected Proof

Zhe Chen, Paul Bongiorni, Ravinder Nath — 2011-11-21

Abstract: Purpose: To measure the dosimetric properties of the Model AgX100 125I source for interstitial brachytherapy.Methods and Materials: The photon energy spectrum emitted by the AgX100 source was measured using a high-resolution germanium spectrometer customized for low-energy brachytherapy source spectrometry. The dose distribution around the source was measured using the 1×1×1mm3 lithium fluoride thermoluminescent dosimeters in water-equivalent solid phantoms. The dosimetric parameters needed for dose calculation using the American Association of Physicists in Medicine Task Group No. 43 (TG-43) formalism were determined and compared with the results of a Monte Carlo simulation by an independent research group and with the TG-43 consensus values of the well-established model 6711 source.Results: It was found that (1) the photon energy spectrum emitted by the AgX100 source was nearly identical to that emitted by the model 6711, (2) the dose-rate constant determined by the photon spectrometry technique (0.957±0.037cGy·h−1·U−1) and by the thermoluminescent dosimeter technique (0.995±0.066cGy·h−1·U−1) was within 1.5% of the corresponding values determined for the model 6711 source, and (3) the radial dose function and the anisotropy function of the AgX100 source were also found to be similar to the consensus data established for the model 6711 source in the TG-43 update report.Conclusions: A comprehensive dosimetric characterization has been carried out for the model AgX100 125I source. The American Association of Physicists in Medicine TG-43 dosimetry parameters for this source has been determined from the experimental data.

Tumor bed-to-skin distance using accelerated partial-breast irradiation with the strut-adjusted volume implant device - Corrected Proof

2011-11-21

Abstract: Purpose: Because of the risk of skin toxicity with single dwell position, single-lumen brachytherapy devices are sometimes contraindicated for tumor cavities 5–7mm from the skin surface. We discuss the use of multicatheter device to treat patients with tumor bed-to-skin distances <7mm.Methods and Materials: We treated 117 patients with accelerated partial-breast irradiation brachytherapy: 77 single-lumen and 40 multicatheter devices. A subset of 12 patients treated with SAVI® had bed-to-skin spacing <7mm. All patients had Tis-2N0 ductal carcinoma with negative margins. A total dose of 34.0Gy in 10 fractions was delivered twice daily. Planning target volume was created using computed tomography–based three-dimensional planning with a 1.0-cm expansion of the lumpectomy cavity. Skin dose was measured dosimetrically, with skin constraints <125% of the prescription. Toxicities were graded, and patients were assessed at various intervals.Results: Of the patients treated with the multicatheter device, 0% (0/12) had their device pulled. At 2 weeks after treatment, fewer than 50% of the patients had skin toxicities of Grades 1–2, all of which resolved by 6 months. The cosmetic outcome was good to excellent at followup.Conclusions: Multicatheter devices permit well-tolerated accelerated partial-breast irradiation in patients with tumor cavities near the skin surface for which the single-lumen device may not be appropriate.

Image-guided vulvovaginal interstitial brachytherapy in the treatment of primary and recurrent gynecological malignancies - Corrected Proof

2011-10-13

Abstract: Purpose: Evaluation of interstitial high-dose-rate brachytherapy (HDRB) to the vulvovaginal region both alone and in combination with external beam radiotherapy (EBRT) for primary or recurrent gynecological malignancy.Methods and Materials: From 1998 to 2009, 37 women with a mean age of 68 years were treated with transperineal interstitial HDRB. Fifteen patients (40.5%) were treated for primary disease, whereas 22 (59.5%) patients were treated for recurrent disease. Median time to local recurrence was 31 months (2–312 months). Primary sites included endometrium (12), vulva (11), vagina (10), vulvovagina (1), cervix (1), and bladder (2). Thirty-one patients (83.7%) in this series were treated with radical intent, whereas 6 (16.3%) were treated with palliative intent. Radically treated patients received between 45 and 60Gy (median, 45Gy) of EBRT. The median number of days from EBRT to HDR boost was 5 days (1–35 days). The HDRB doses ranged from 11Gy in two fractions to 42Gy in six fractions (dose per fraction varied from 4 to 8.5Gy) and fractions were given at least 6–8h apart.Results: Eight of the 31 patients (26%) treated with radical intent relapsed locally. Eleven of 37 patients (30%) treated with either radical or palliative intent recurred locally. The 2- and 5-year local progression-free survival was 74% and 63.4%, respectively. The total progression-free survival, which includes local, locoregional/nodal, and distant recurrence, at 2 and 5 years, was 73.6% and 45.6%, respectively. With a mean follow-up of 27 months (3.8–111.9 months), the median survival for the patient group was 16.6 months with a 2- and 5-year overall survival of 47.7% and 36.4%, respectively. Acute Grade 3 toxicity was seen in 13 (35%) of the 37 patients (skin: 10, urinary: 2, genital: 2, gastrointestinal: 0). No acute Grade 4 toxicities were seen. A total of 10 of the 37 patients (27%) developed late Grade 3 toxicities. Five of the 22 patients (22%) treated for recurrent disease with radical intent developed Grade 3 toxicity (skin: 4, urinary: 2, genital: 1, radiation-induced fracture of acetabulum: 1, and gastrointestinal: 0), whereas 1 of the 6 patients treated with palliative intent had Grade 3 toxicity affecting skin. No late Grade 4 toxicities were seen.Conclusion: This retrospective series suggests that interstitial perineal HDRB is a safe and effective treatment option for primary or locally recurrent gynecological malignancies. It is a valuable option in patients who have received previous EBRT to the pelvis, achieving good local control with acceptable late treatment-related side effects.

A comparison of the biological effective dose of 50-kV electronic brachytherapy with 192Ir high-dose-rate brachytherapy for vaginal cuff irradiation - Corrected Proof

2011-10-13

Abstract: Purpose: Advantages for electronic brachytherapy (EBT) of the vaginal cuff include decreased physical dose to the bladder and rectum. Here we compare 192Ir with EBT using biological effective dose (BED) to account for the different radiobiological effectiveness (RBE) predicted for low-energy x-rays.Methods and Materials: Fifteen data sets from five consecutive postoperative endometrial cancer patients treated with EBT were analyzed. Treatment planning was performed using PLATO software. The dose was prescribed as 21Gy in three fractions to a depth of 0.5cm. Physical dose, BED3, and BED10 were evaluated for the mucosa, bladder, and rectum. An RBE value of 1.5 was used for BED calculations.Results: Mucosal physical dose is 28.4% greater with EBT (36.6 vs. 28.5Gy, p<0.05). However, the BED10 is increased by 79.1% (55.6 vs. 99.6Gy, p<0.05) and the BED3 by 71.5% (118.8 vs. 203.7Gy, p<0.05). The physical dose (dose to 50% volume of the organ) to the bladder (9.3 vs. 6.6Gy, p<0.05) and rectum (7.2 vs. 4.2Gy, p<0.05) are reduced with EBT. BED3 to the rectum and bladder are also reduced but to a lesser extent (13 vs. 8.3Gy, p<0.05; 18.9 vs. 14.7Gy, p=0.06, respectively).Conclusions: BED takes into account the higher RBE of low-energy photons generated with EBT and provides a more accurate estimate of the biological effect. When using EBT, physical dose may underestimate the biological effect on the vaginal mucosa and overestimate the benefit for the bladder and rectum. Dose adjustment for EBT based on BED should be considered.

Quantitative evaluation of lower urinary tract symptoms using a visual analog scale in men undergoing permanent brachytherapy - Corrected Proof

2011-10-13

Abstract: Purpose: A previous study showed that a visual analog scale (VAS) that measures quality of life (QOL) in relation to each of the seven items on the International Prostate Symptom Score (IPSS) was found to be significantly more able to identify a patient’s chief complaint. The aim of this study was to assess the two questionnaires with special reference to the symptom that the patient most wants treated via the concomitant use of the IPSS and VAS after permanent brachytherapy (PBT).Methods and Materials: A total of 156 men undergoing PBT were enrolled. The IPSS and VAS were evaluated at the preimplantation stage and at 1–3 months, 6–9 months, and 1 year after PBT. The correlations between the IPSS-QOL score and the total for the 14 symptoms questions included in the IPSS and VAS were statistically calculated. Multivariate analysis was used to investigate which factors could be used to predict the IPSS-QOL after PBT.Results: The correlation coefficients between the IPSS-QOL score and the seven questions on the VAS were higher than those between the IPSS-QOL and the seven questions on the IPSS. Multivariate analysis showed that the strongest factor for determining IPSS-QOL at each time point was nocturia on the VAS.Conclusions: The VAS scale reflected the change in the patients’ QOL more precisely than the IPSS, which examines the frequency of lower urinary tract symptoms. Nocturia plays a key role in determining QOL. VAS could be a promising tool for assessing satisfaction in patients with lower urinary tract symptoms after PBT.

Semiautomatic segmentation for prostate brachytherapy: Dosimetric evaluation - Corrected Proof

2011-09-26

Abstract: Purpose: To demonstrate that manual prostate segmentation in transrectal ultrasound images can be replaced with semiautomatic segmentation.Methods and Materials: Semiautomatic segmentation using a tapered ellipsoid model was applied to transrectal ultrasound images. Region-based volumetric evaluation was performed between original and physician-reviewed semiautomatic contours. For dosimetric assessment, treatment plans generated on semiautomatic contours were overlaid on physician-reviewed semiautomatic contours and dose parameters were computed. To establish a threshold for the acceptable amount of dosimetric degradation below which the adoption of semiautomatic planning is unacceptable, the range of variability in dosimetric quality attributed to manual variability was obtained and compared with that of semiautomatic contours.Results: An average volume error (1—Dice similarity coefficient) of less than 7% between semiautomatic and manual volumes (140 cases) was obtained. The difference between the mean V100 of plans created for semiautomatic contours then overlaid on physician-reviewed semiautomatic contours and the original V100 values, that is, before overlaying on the physician-reviewed contours (41 cases) was lower than 5%. An average total duration of 2–4min, which includes algorithm initialization, 11.67±3.57s algorithm time, and contour modification is required per case. This algorithm is being used at the British Columbia Cancer Agency and to this date has been applied for the treatment of more than 600 patients.Conclusions: In terms of volumetric and dosimetric accuracy, the proposed algorithm is a suitable replacement for manual segmentation in the context of our planning technique. The benefits are shorter segmentation times; greater consistency; less reliance on user experience; and smooth, symmetric contours.

Urethra low-dose tunnels: Validation of and class solution for generating urethra-sparing dose plans using inverse planning simulated annealing for prostate high-dose-rate brachytherapy - Corrected Proof

2011-09-22

Abstract: Purpose: Urethral dose is related to severity of genitourinary toxicity in patients treated with brachytherapy for prostate cancer. This work describes a dose planning method that uses inverse planning to create a low-dose tunnel around the urethra and presents a class solution to achieve this additional dose sparing of the urethra.Methods: Fifteen patients on the Radiation Therapy Oncology Group (RTOG) 0321 protocol were treated for prostate cancer with a high-dose-rate brachytherapy dose boost to an external beam radiation treatment regimen. All were treated with 9.5Gy for each of the two fractions after 45Gy of the external beam radiation. The inverse-planning algorithm, inverse planning simulated annealing (IPSA), was used to create both the standard RTOG protocol (SRP) plan for treatment and the a posteriori urethra dose sparing (UDS) plan consisting of a dose tunnel along the urethra. Both plans maintained the protocol parameters: prostate V100 (volume receiving 100% of prescribed dose)>90% and bladder and rectum V75<1 cm3. In the SRP plans, the urethra surface was optimized to receive <125% of the prescription dose and in the UDS plans <100%. Dose-volume histograms for the clinical treatment volume, bladder, rectum, penile bulb, and urethra for both plans are compared using a paired sample t test with significance claimed for probability values<0.05.Results: UDS planning reduced the urethra V100 from 88% to 58% on average (p<0.01) and the V125 from 3.3% to 0.2% (p < 0.01). Bladder and rectum V75 were maintained at <1 cm3 and not significantly different between plans. Prostate coverage was maintained per protocol at V100>90%, with mean for the SRP V100=93% versus UDS plan V100=90%. Prostate D90 for SRP was 104% versus UDS plan D90=101%. For all patients, the UDS achieved a dose tunnel surrounding the length of the intraprostatic urethra. The class solution for generating UDS is presented.Conclusions: A urethral sparing–focused planning solution using IPSA reduces mean urethral dose by 34%, as compared with IPSA-generated plans based on the RTOG 0321 protocol. This is done while maintaining prostate coverage and critical structure dose. This technique can be applied to all patients in whom urethra toxicity is of particular concern.

Two-step transurethral surgery of the prostate and permanent implant brachytherapy for patients with lower urinary tract symptoms and low- to intermediate-risk prostate cancer - Corrected Proof

2011-09-22

Abstract: Purpose: Prostate brachytherapy is an increasingly used treatment option for low- to intermediate-risk prostate cancer (PCa). However, patients with preexisting lower urinary tract symptoms (LUTS) and PCa, who would otherwise be good brachytherapy candidates, are often contraindicated because of the risk of postoperative urinary morbidity. We report our clinical experience with limited transurethral resection of the prostate (LTURP) and/or transurethral incision of the prostate (TUIP) months before brachytherapy to treat patients with LUTS and low- to intermediate-risk PCa.Methods and Materials: Of 258 men undergoing prostate brachytherapy at our institution between 1998 and 2011, 42 were treated with planned LTURP and/or TUIP well before (mean, 5.7 months) seed implantation. Transurethral surgery was considered before brachytherapy for patients who at presentation required α-blocker therapy for LUTS, had an International Prostate Symptom Score greater than 14 off α-blockers, or had an elevated postvoid residual (>100mL). Patients only proceeded to brachytherapy once LUTS resolved.Results: All 42 patients in our series underwent TUIP (25), LTURP (7), or TUIP/LTURP (10) with mean 5.7 months before prostate brachytherapy for low- or intermediate-risk PCa. Mean International Prostate Symptom Score, peak flow rate, and postvoid residual significantly improved after transurethral surgery, and improvement persisted at the latest followup. No patient developed retention, urethral necrosis, or urinary incontinence after transurethral surgery or brachytherapy (median followup, 39 months and range, 1–121).Conclusions: Planned LTURP and/or TUIP more than 4 months before brachytherapy is a safe and effective treatment strategy for men with LUTS and low- to intermediate-risk PCa.

Deaths within 12 months after 125I implantation for brachytherapy of prostate cancer: An investigation of radiation safety issues in Japan (2003–2010) - Corrected Proof

2011-09-19

Abstract: Purpose: The International Commission on Radiological Protection recommends removing the prostate before cremation if death occurs within 12 months after 125I brachytherapy. However, the incidence of death within this time frame has not been robustly investigated in any country. The purpose this study was to investigate the incidence and cause of death and actions taken when death has occurred within 12 months after 125I brachytherapy for prostate cancer in Japan.Methods and Materials: Data were extracted from the Japan Radioisotope Association database to investigate the total number of implantation cases, number of early deaths after implantation, cause of death, and postmortem actions between September 2003 and the end of June 2010 in Japan. Early death was defined as occurring within 12 months after 125I brachytherapy for prostate cancer.Results: During the study period, 15,427 patients underwent 125I brachytherapy and 43 (0.28%) died within 12 months after implantation. For 37 of the 43 patients (86%), the brachytherapy source was retrieved together with the prostate gland at autopsy; however, autopsy could not be performed in six (14%) of the deceased patients. The largest proportion of early deaths was because of cerebrovascular or cardiovascular disease (17/43, 40%), followed by malignant tumor (15/43, 35%), and respiratory disease or infection (7/43, 16%).Conclusions: The incidence of early deaths within 12 months after 125I brachytherapy in Japan was 0.28%. In almost all cases, the brachytherapy sources were removed in the intact prostate before the body was cremated and stored appropriately.

Three-year clinical outcome using the Contura multilumen balloon breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI): Improving radiation standards for the optimal application of APBI - Corrected Proof

2011-09-19

Abstract: Purpose: We reviewed our institution’s 3-year clinical experience in treating patients with the Contura multilumen balloon (SenoRx, Inc., Aliso Viejo, CA) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI).Methods and Materials: Forty-six patients treated with breast-conserving therapy received adjuvant radiation using the Contura catheter (34Gy in 3.4Gy fractions). Fourteen patients had Stage 0, 24 had Stage I, and 8 had Stage II breast cancer. Median follow-up was 36 months (range, 1–44 months).Results: Only one local recurrence developed (2%). The rate of persistent seroma formation at latest reported follow-up was 4.3% (2 patients) and the incidence of any clinically detectable telengiectasias was 2.2%. No major toxicities (0% Grade III) have occurred. The median skin dose (% of the prescribed dose) was 99.7. The median dose to 95% of the planning target volume for evaluation was 98.8%. The percentage of patients with excellent/good cosmetic results at 24 (n=23) and 36 (n=22) months was 100% and 97%, respectively.Conclusion: Adjuvant APBI using the Contura multilumen balloon catheter exhibited similar locoregional control, cosmesis, and toxicities to other forms of APBI with similar lengths of follow-up. In addition, improved radiation standards for the delivery of APBI were demonstrated.

Globalization, implantation, cremation…Oh, my! - Corrected Proof

Lawrence T. Dauer — 2011-09-19

When speaking about the flattening of the world, former Secretary-General of the United Nations and Nobel Peace Prize winner, Kofi Annan, once stated, “It has been said that arguing against globalization is like arguing against the laws of gravity.” Medicine is certainly not immune to the globalization pull. Indeed, we have entered a new age of globalized medicine and even “medical tourism” never before even dreamed possible. In addition to opportunities offered by a worldwide information system, there are increasing demands on medicine to continue to fuel growth in both diagnosis and treatment. Indeed, the social media outlets have provided a new avenue for potential patients to learn about and seek forms of treatment, likely increasing overall demand. One obvious example is the crusade to end prostate cancer, the second most frequently diagnosed cancer, and the sixth leading cause of male cancer in the world with nearly a million cases diagnosed each year. In response, the use of permanent radioactive implants (brachytherapy) to treat selected localized prostate cancers continues to increase rapidly worldwide, especially because of the low degree of toxicity, improved quality of life, and a general, long-term, positive prognosis. In the United States, where approximately 220,000 new cases of prostate cancer are diagnosed each year, more than 40,000 implantations for localized prostate neoplasms are performed annually. In Europe, as in other locations, several thousand cases are already treated annually and this number continues to increase.

Predicting biochemical tumor control after brachytherapy for clinically localized prostate cancer: The Memorial Sloan-Kettering Cancer Center experience - Corrected Proof

2011-09-19

Abstract: Purpose: To identify predictors of biochemical tumor control and present an updated prognostic nomogram for patients with clinically localized prostate cancer treated with brachytherapy.Methods and Materials: One thousand four hundred sixty-six patients with clinically localized prostate cancer were treated with brachytherapy alone or along with supplemental conformal radiotherapy. Nine hundred one patients (61%) were treated with Iodine-125 (125I) monotherapy to a prescribed dose of 144Gy, and 41 (4.5%) were treated with Palladium-103 (103Pd) monotherapy to a prescribed dose of 125Gy. In patients with higher risk features (n=715), a combined modality approach was used, which comprised 125I or 103Pd seed implantation or Iridium-192 high–dose rate brachytherapy followed 1–2 months later by supplemental intensity-modulated image-guided radiotherapy to the prostate.Results: The 5-year prostate-specific antigen relapse-free survival (PSA-RFS) outcomes for favorable-, intermediate-, and high-risk patients were 98%, 95%, and 80%, respectively (p<0.001). Multivariate Cox regression analysis identified Gleason score (p<0.001) and pretreatment PSA (p=0.04) as predictors for PSA tumor control. In this cohort of patients, the use of neoadjuvant and concurrent androgen deprivation therapy did not influence biochemical tumor control outcomes. In the subset of patients treated with 125I monotherapy, D90>140Gy compared with lower doses was associated with improved PSA-RFS. A nomogram predicting PSA-RFS was developed based on these predictors and had a concordance index of 0.70.Conclusions: Results with brachytherapy for all treatment groups were excellent. D90 higher than 140Gy was associated with improved biochemical tumor control compared with lower doses. Androgen deprivation therapy use did not impact on tumor control outcomes in these patients.

High-dose-rate interstitial brachytherapy as monotherapy in one fraction and transperineal hyaluronic acid injection into the perirectal fat for the treatment of favorable stage prostate cancer: treatment description and preliminary results - Corrected Proof

2011-09-15

Abstract: Purpose: To evaluate the technical feasibility, acute and late genitourinary (GU) toxicity, and gastrointestinal toxicity after high-dose-rate (HDR) brachytherapy as monotherapy in one fraction with transperineal hyaluronic acid injection into the perirectal fat to displace the rectal wall away from the radiation sources to decrease rectal toxicity.Methods and Materials: Between April 2008 and January 2010, 40 consecutive patients were treated with favorable clinically localized prostate cancer; the median followup was 19 months (range, 8–32). No patients received external beam radiation, and 35% received hormone therapy before brachytherapy. All patients received one implant and one fraction of HDR. Fraction dose was 19Gy. Toxicity was reported according to the Common Toxicity Criteria for Adverse Event, Version 4.0.Results: All patients tolerated the implantation procedure very well with minimal discomfort. No intraoperative or perioperative complications occurred. Acute toxicity Grade 2 or more was not observed in any patients. No chronic toxicity has been observed after treatment. Logistic regression showed that the late Grade 1 GU toxicity was associated with D90 (p=0.050). The 32-month actuarial biochemical control was 100% and 88%, respectively (p=0.06) for low- and intermediate-risk groups.Conclusions: This is the first published report of the use of HDR brachytherapy as monotherapy in one fraction for patients with favorable-risk prostate cancer. This protocol is feasible and very well tolerated with low GU morbidity, no gastrointestinal toxicity, and the same level of low-dose-rate biochemical control at 32 months.

Timing of postseed imaging influences rectal dose–volume parameters for cesium-131 prostate seed implants - Corrected Proof

2011-08-25

Abstract: Purpose: To study the influence of timing of postseed implant imaging on rectal dose–volume parameters for cesium-131 (131Cs) seed prostate implants.Methods and Materials: Fifteen patients were treated in our institution with combination 131Cs brachytherapy followed by pelvic external beam radiation therapy for intermediate to high-risk prostate cancers. For all patients, CT scans were scheduled at 7 days (CT7) and again at 2 months for external beam radiation therapy simulation purpose (CT60) postseed implantation. Comprehensive postseed implant dosimetry was performed for both CT7 and CT60 scans. In each case, dose–volume histogram parameters, rectal separation (the distance between the center of posterior most seed and most anterior rectal wall), and posterior row activity (the total activity implanted within 2–4mm anterior to the posterior wall of the prostate) data were collected. The absolute rectal volumes receiving 100% and 110% prescription dose were also collected.Results: Rectal dose correlated strongly with rectal separation (p<0.001). The mean change in rectal separation between CT7 and CT60 scans was 1.1 (±1.7) mm, and the corresponding change in 0.1-cc rectal dose was 18 (±26.5) Gy. Posterior row activity did not correlate with rectal dose (p=0.51). The mean volume of rectum that receives between 100% and 110% of the prescription dose (RV100 and RV110) increased twofold, between CT7 and CT60 evaluations (0.03 [±0.06] cc vs. 0.07 (±0.05) cc, respectively, p=0.06).Conclusions: Our study has demonstrated that rectal doses after 131Cs seed implants are influenced by the timing of postseed imaging. This may be a consequence of prostatic and periprostatic edema resolution.

Inverse-planned gynecologic high-dose-rate interstitial brachytherapy: Clinical outcomes and dose–volume histogram analysis - Corrected Proof

2011-08-22

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 V100, D90, and D100 for clinical target volume were 97.6%, 90.2, and 68.7Gy10, respectively. Median bladder and rectal D2cc were 76.6 and 79.5Gy3, respectively. Median urethral D10 was 80.6Gy3. 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.

Higher percentage of positive biopsy cores and Gleason score are associated with a greater degree of prostate gland shrinkage after neoadjuvant cytoreductive therapy - Corrected Proof

2011-08-08

Abstract: Purpose: To determine whether adverse pathologic features, including tumor grade and percent positive biopsy (PPB) cores, predict for prostate size reduction after neoadjuvant cytoreductive therapy.Methods and Materials: Eighty-two consecutive patients who were diagnosed with prostate cancer by transperineal template–guided mapping biopsy (TTMB) received neoadjuvant cytoreductive therapy. The median number of biopsy cores was 59. Thirty patients received a leutinizing hormone–releasing hormone agonist and bicalutamide, whereas 52 patients received bicalutamide (50mg daily) and dutasteride (0.5mg daily). A transrectal ultrasound volumetric study of the prostate gland and ellipsoid volume determinations of the prostate gland and transition zone (TZ) were obtained immediately before TTMB and at 90 days (±7 days) after the initiation of neoadjuvant medical therapy. Univariate and multivariate regression analyses were performed to identify predictors of prostate gland and TZ volume reduction.Results: At TTMB, the mean prostate volumetric and ellipsoid volumes were 55.4 cm3 and 49.0 cm3, respectively. After neoadjuvant medical therapy, the mean volumetric and ellipsoid prostate volumes were 30.8 cm3 and 28.5 cm3, respectively. On average, the prostate volume decreased by 43.9% and 41.0% on volumetric and ellipsoid measurements, respectively. The TZ volume decreased from 19.8 cm3 to 10.1 cm3 (mean volume reduction of 47.7%). In multivariate analysis, prostate volume cytoreduction was most closely associated with PPB (p=0.014), TTMB prostate volume (p=0.01), and drug regimen (p=0.001).Conclusions: The degree of prostate volume cytoreduction was positively associated with higher Gleason score and PPBs. Greater reductions in prostate volume may be an indicator of more aggressive cancer.

Reirradiation of prostate cancer with rectum preservation: Eradicative high-dose-rate brachytherapy with natural type hyaluronate injection - Corrected Proof

Kazushi Kishi, Morio Sato, Shintaro Shirai, Tetsuo Sonomura, Ryuichi Yamama — 2011-08-08

Abstract: Introduction: Reirradiation of locally recurrent prostate cancer after radiotherapy is limited because of its toxicity to the rectum that is closely adjacent to the prostate. To solve geometric anatomic constraints, including rectal size and distance from the prostate, we developed a technique that modifies the geometry by noninvasive direct intervention.Methods and Materials: In a patient with local recurrence of prostate cancer at 18 months after initial radiotherapy of 61.8GyELQ2,3 (gray equivalent in 2Gy/fraction at α/β=3 calculated with linear quadratic [LQ] model) to the prostate, we prescribed 16Gy (60.8GyELQ2,3 or 78.2GyELQ2,1.6) of reirradiation by high-dose-rate brachytherapy, using a bolus injection of native-type hyaluronate to create and maintain a distance between the prostate and the rectum and decrease rectal size during treatment.Results: The procedure was achieved in 10min, without complications. Rectal D2cc of the reirradiation was 5.58Gy (9.58GyELQ2,3). Compared with the initial radiation, the gel injection resulted in an improved therapeutic ratio. The patient was regularly followed up at our clinic; at over 3.5 years after reirradiation, there was no evidence of recurrence or radiation-related toxicities greater than Grade 2, maintaining a nadir prostate-specific antigen level of 0.03ng/mL without hormonal therapy.Conclusion: We consider that this technique is useful for achieving safe and curative reirradiation of prostate cancer.

Interfraction accumulation of seroma during accelerated partial breast irradiation: Preliminary results of a prospective study - Corrected Proof

2011-08-08

Abstract: Purpose: To quantify and characterize the process of seroma accumulation during accelerated partial breast irradiation using multicatheter balloon brachytherapy.Materials and Methods: Twenty-two patients were treated using the Contura Multilumen brachytherapy catheter to a dose of 34Gy in 10 fractions over 5 treatment days. Serial aspirations of the vacuum port of the catheter were performed at the time of CT simulation and before each treatment. Volume and characteristics of fluid drawn were recorded. Univariate analysis was performed to evaluate various factors predictive of seroma formation.Results: Median patient age was 59.5 years, body mass index was 31, and volume of surgical specimen was 62.4cm3. Median time from breast conservation surgery to placement of Contura catheter was 18.5 days. Pericatheter seroma, typically scant with a median volume of 0.75mL, was noted in 91% of patients at CT simulation. A total of 203 aspirations were performed with a median-aspirated seroma volume of 4.05mL. There was no significant correlation between the volume of seroma and histology (invasive vs. in situ), quadrant of location, body mass index, reexcision or reoperation, days from breast conservation surgery to balloon placement, or the volume of specimen removed. Radiation treatment factors, including balloon volume, balloon to skin distance, and planning target volume evaluation, also did not correlate with aspirated seroma.Conclusions: Interfraction seroma accumulation has a variable pattern of development with no discernible predictors of occurrence. Routine pretreatment aspirations via vacuum port may potentially improve dosimetric reproducibility for a minority of patients.

A comparison of brachytherapy techniques for partial breast irradiation - Corrected Proof

Jaroslaw T. Hepel, David E. Wazer — 2011-08-05

Abstract: Accelerated partial breast irradiation has emerged as an important treatment option for select patients with early-stage breast cancer. Numerous techniques for the delivery of accelerated partial breast irradiation have been developed involving both external beam and brachytherapy techniques. Brachytherapy techniques in general have the advantage of directly targeting the tumor bed and are not hampered by the requirement for large planning target volume margins needed with external beam techniques to account for uncertainties in targeting a very mobile organ, easily affected by patient and respiratory motion. We review established brachytherapy techniques and new emerging approaches. Technical considerations, available clinical data, advantages and shortcomings of each technique are reviewed.

Monte Carlo calculations of AAPM Task Group Report No. 43 dosimetry parameters for the 125I I-Seed AgX100 source model - Corrected Proof

Firas Mourtada, Justin Mikell, Geoffrey Ibbott — 2011-08-04

Abstract: Purpose: The purpose of this study was to determine the dosimetric parameters of the AgX100, a new 125I brachytherapy seed model, using Monte Carlo (MC) simulations according to the protocol specified by the updated American Association of Physicists in Medicine Task Group No. 43 Report (TG-43U1) and compare these parameters with those of the established brachytherapy 125I seed models 6711 and I25.S06.Methods and Materials: Independent verification of the new seed geometry was performed using high-resolution digital radiography and scanning electron microscopy. MCNPX v.2.5 MC simulations of the AgX100 seed were performed to derive its TG-43U1 parameters, the dose rate constant, the radial dose function, and the two- and one-dimensional anisotropy functions in liquid water. A dosimetric error propagation analysis was also performed to include uncertainty because of seed manufacturing tolerances and physics parameters.Results: The MC-calculated dose rate constant for the AgX100 seed was 0.943cGy·h−1·U−1±2.6% (k=1) based on the air kerma strength for a simulated point detector. Tabulated results of the radial dose function for line and point source approximations and the two-dimensional anisotropy function are also reported.Conclusions: The MC-predicted dose distribution of the AgX100 seed was found to be comparable with that of the model 6711 seed but much different from the dose distribution of the model I25.S06 seeds. However, at shallow distances, there were some dosimetric differences between the AgX100 and 6711 seed, which warrant separate TG-43U1 parameters for use in clinical treatment planning systems.

Objective automated assessment of time trends in prostate edema after 125I implantation - Corrected Proof

2011-08-04

Abstract: Purpose: To present an objective automated method to determine time trends in prostatic edema resulting from iodine-125 brachytherapy.Methods and Materials: We followed 20 patients, implanted with stranded seeds, with seven consecutive CT scans to establish a time trend in prostate edema. Seed positions were obtained automatically from the CT series. The change in seed positions was used as surrogate for edema. Two approaches were applied to model changes in volume. (1) A cylindrical model: seeds from the compared distribution were linked to the reference distribution of Day 28. After alignment, the compared distribution was scaled in cylindrical coordinates, leading to the changes in radial and craniocaudal directions. The volume changes were calculated using these scaling factors. (2) A spherical model: distances of seeds to the center of gravity of all seeds were used as a measure to model volume changes.Results: With Day 28 as reference, the observed volume changes were smaller than 18% ± 6% (1 standard deviation) for the cylindrical model and 12% ± 7% for the spherical model. One day after implantation, the implanted prostate was less than 10% larger than in the reference scan for both models. Apart from Day 0, both models showed similar volume changes.Conclusions: We present an objective automated method to determine changes in the implanted prostate volume, eliminating the influence of an observer in the assessment of the prostate size. The implanted volume change was less than 18% ± 7% for the studied group of 20 patients. Edema was 9% ± 5% from 1 day after implantation onward.

Rectal toxicity and rectal dosimetry in low-dose-rate iodine-125 permanent prostate implants: A long-term study in 1006 patients - Corrected Proof

2011-07-15

Abstract: Objective: To describe the acute and late rectal toxicity in 1006 prostate brachytherapy patients implanted 1998–2003. To determine whether rectal dose–volume histogram as well as patient and treatment factors were associated with rectal toxicity.Materials and Methods: Median followup was 60.7 months. Rectal dosimetry was calculated as dose–volume histogram of the rectum using Day 28 CT-based dosimetry and expressed as volume of the rectum in cc receiving 50%, 100%, and 150% of the prescription dose (VR50cc, VR100cc, and VR150cc, respectively). Univariate and multivariate analyses were performed to examine the influence of patient, implant, dosimetry, and learning curve factors on the development of acute and late toxicities using a modified Radiation Therapy Oncology Group (RTOG) scale. Acute toxicity was analyzed using logistic regression and late toxicity using Cox proportional hazards regression. Analysis of variance was used to examine the association between rectal toxicity and rectal dose.Results: Rectal dosimetry in 93.5% and rectal toxicity in 96.2% have been recorded. Median VR100=1.05cc. Late RTOG Grades 0, 1, 2, 3, and 4 were recorded in 68%, 23%, 7.3%, 0.9%, and 0.2% patients, respectively. On multivariate analysis, acute RTOG ≥2 rectal toxicity was associated with urinary retention (p=0.036) and learning curve (p=0.015); late RTOG ≥2 was associated with the presence of acute toxicity (p=0.0074), higher VR100 (p=0.030) and learning curve (p=0.027).Conclusions: Late rectal RTOG ≥2 rectal toxicity in this cohort was 8%. Increased VR100, presence of acute rectal toxicity, and learning curve were associated with higher rate of late RTOG ≥2 toxicity. Severe late rectal toxicity after prostate brachytherapy was rare.

Experimental measurements and Monte Carlo simulations of dose perturbation around a nonradioactive brachytherapy seed due to 6- and 18-MV photons - Corrected Proof

James Paul Steinman, Mohammad Bakhtiari, Harish Kumar Malhotra — 2011-07-08

Abstract: Purpose: Radioactive seeds used in permanent prostate brachytherapy are composed of high-Z metals and may exceed 100 in a patient. If supplemental external beam treatment is administered afterward, the seeds may cause substantial dose perturbation, which is being investigated in this article.Methods and Materials: Film measurements using 6-MV beam were primarily carried out using Kodak XV2 film layered above and below a nonradioactive iodine-125 (125I) seed. Monte Carlo simulations were carried out using DOSXYZnrc. Other experimental comparisons looked at changing beam energy, depth, and field size, including two opposing fields’ pair. Effect of multiple seeds spatially spaced 0.5cm vertically was also studied.Results: For a single 125I seed, on XV film, there is a localized dose enhancement of 6.3% upstream and −10.9% downstream. With two opposing fields, a cold spot around the seed of ∼3% was noticed. Increasing beam energy and field size decreased the magnitude of this effect, whereas the effect was found to increase with the increasing Z of material. DOSXYZnrc and EBT-2 film verified maximum dose enhancement of +15% upstream and −20% downstream of the 125I seed surface.Conclusions: In general, the dose perturbation because of the seeds was spatially limited to ∼2mm upstream and ∼5mm downstream to the incident beam. Similar to other heterogeneities, the seeds perturbation depends on incident beam energy, field size, and its Z. With multiple seeds spatially apart and multiple radiation fields routinely used in external beam radiotherapy, the cumulative effect may not result in clinically significant dose perturbation.

Biochemical and clinical experience with real-time intraoperatively planned permanent prostate brachytherapy - Corrected Proof

2011-07-04

Abstract: Purpose: To evaluate patient characteristics and dosimetric parameters that predict biochemical failure (BCF) after real-time planned low-dose-rate prostate brachytherapy.Methods and Materials: From 1998 to 2008, a low-risk cohort by National Comprehensive Cancer Network criteria of 341 men with a median followup of 41.6 months was analyzed. This cohort had a median age of 65.1 years, prostate volume of 35.8cc, and pretreatment prostate-specific antigen of 5.6ng/mL. Patients had predominately Gleason 6 (95.9%) and T1c (81.3%) disease. About 3.6% of the patients received androgen deprivation therapy. Kaplan–Meier and Cox proportional hazards survival analysis methods were used to analyze predictors of BCF (Phoenix definition).Results: At 72 months, freedom from BCF was 91.1% (95% confidence interval=85.0–94.8). The median D90 was 145.9Gy, and the median V100 was 90.3%. Because of infrequent BCF, the following prostate volume groups were examined: 15–<25, 25–<35, 35–<45, and 45+cc. Of all possible predictors, only small prostate volume (15–<25cc group) was significantly associated with BCF (hazard ratio=8.44, 95% confidence interval=1.82–39.14, p=0.007). Using Kaplan–Meier analysis, time to BCF was also significantly increased in the lowest prostate volume 15–<25cc group with 24.1% failing at 48 months compared with 1.6–5.1% among the other groups.Conclusions: Real-time planned low-dose-rate prostate brachytherapy provides excellent biochemical control as a single-agent treatment for low-risk prostate cancer with 91.1% freedom from BCF at 72 months. Only prostate volume less than 25cc was an independent predictor of BCF.

Four-year results using balloon-based brachytherapy to deliver accelerated partial breast irradiation with a 2-day dose fractionation schedule - Corrected Proof

2011-07-04

Abstract: Purpose: We present 4-year results from a Phase I/II trial using balloon-based brachytherapy to deliver accelerated partial breast irradiation in 2 days.Materials/Methods: Forty-five patients received breast-conserving surgery followed by adjuvant radiation therapy using a balloon-based brachytherapy applicator delivering 2800cGy in four fractions over 2 days. Outcomes analyzed include toxicities scored using the NCI Common Toxicity Criteria v3.0 scale, ipsilateral breast tumor recurrence, regional nodal failure, distant metastasis, disease-free survival, cause-specific survival, and overall survival.Results: Median age was 66 years (range, 48–83 years) and median tumor size was 0.6cm (range, 0.2–2.3cm). Five percent of patients were node positive (n=2), whereas 73% was estrogen receptor positive (n=33). Median followup was 3.7 years (2.4–7.0 years) with greater than 2 years of followup for all patients. Only Grades 1 and 2 chronic toxicities were noted with fat necrosis (18%) and asymptomatic seromas (42%) being the most common toxicities. Seven percent of patients developed ipsilateral rib fractures (n=3), although this was not statistically associated with maximum rib dose (p=0.31). Ninety-eight percent of patients had a good or excellent radiation-related cosmetic outcome at the time of last followup. There were no ipsilateral breast tumor recurrences or regional nodal failures; however, 2 patients developed distant metastases. Four-year actuarial disease-free survival, cause-specific survival, and overall survival were 96%, 100%, and 93%, respectively.Conclusions: Treatment of early-stage breast cancer patients with breast-conserving therapy using a 2-day radiation dose schedule resulted in acceptable chronic toxicity and similar clinical outcomes as standard 5-day fractionation.

Comparison of efficacy and safety of low-dose-rate vs. high-dose-rate intraluminal brachytherapy boost in patients with superficial esophageal cancer - Corrected Proof

2011-06-23

Abstract: Purpose: To compare the efficacy and the incidence of complications of high-dose-rate (HDR) and low-dose-rate (LDR) intraluminal brachytherapy (IBT) boost after external beam radiation therapy in patients with superficial esophageal cancer.Methods and Materials: Fifty-four consecutive patients with Stage I thoracic esophageal squamous cell carcinoma who were treated with definitive radiotherapy using IBT between 1991 and 2007 were studied retrospectively. LDR-IBT and HDR-IBT were performed for 19 and 35 patients, respectively. After external beam radiation therapy of 56–60Gy with a conventional fractionation, LDR-IBT (5Gy×2) or HDR-IBT (3Gy×3) was given within 2 weeks. The median follow-up was 47 months (7–151 months).Results: Overall, the 5-year overall survival, cause-specific survival (CSS), and locoregional control (LRC) rates were 61%, 86%, and 79%, respectively. The 5-year overall survival, CCS, and LRC rates did not differ significantly between the LDR-IBT and HDR-IBT groups (68% vs. 58% (p=0.50), 83% vs. 85% (p=0.63), and 84% vs. 75% (p=0.42), respectively). Salvage treatment was given in 8 locally recurrent patients, and 6 patients were rescued. The Grade ≥2 late morbidities of esophagus and heart/lung were observed in 5 patients (4 in the LDR-IBT group and 1 in the HDR-IBT group) and 2 patients (one from each group), respectively.Conclusions: In view of the safety profile and effectiveness, our results encourage the continued adoption of HDR-IBT as radiation boost in medically inoperable or elderly superficial esophageal cancer patients undergoing definitive radiotherapy.

Relationship between prostate-specific antigen bounce body fat distribution and body mass index in permanent seed brachytherapy for prostate cancer - Corrected Proof

2011-06-23

Abstract: Purpose: To analyze the influence of body mass index (BMI) and adipose tissue distribution on prostate-specific antigen (PSA) bounce after iodine-125 prostate brachytherapy.Methods and Materials: We studied 20 patients who had PSA bounce (≥0.50ng/mL) after exclusive prostate brachytherapy. These patients were compared with 48 patients without a bounce (<0.50ng/mL). All patients in the comparison group had a followup of ≥24 months and a last PSA ≤0.5ng/mL. Within these 48 patients, there was a group matched for age (n=20). Univariate and multivariate logistic models were estimated to assess the association between age, baseline PSA, prostate volume, D90, visceral fat (VF) volume, and BMI on PSA-bouncing status.Results: When comparing the patients with a bounce to those without, only BMI showed a significantly different distribution (mean, 25.18 vs. 27.47kg/m2; p=0.0342). On a multivariate analysis, BMI had an odds ratio of 0.85 (95% confidence interval, 0.71–0.99, p=0.049), indicating that an increase of 1kg/m2 in BMI is associated with a 15% reduction in the odds of having a bounce. In the univariate analysis with the matching patients, BMI was a significant predictor of a bounce (p=0.0147). In the multivariate conditional logistic model, BMI showed a trend toward an influence on a bounce (p=0.0615). All other factors, including VF, did not have any influence on a PSA bounce.Conclusions: Patients with a lower BMI are more likely to experience a PSA bounce ≥0.50ng/mL. VF did not have an influence on a PSA bounce.

Long-term results of 1-week intravaginal high-dose-rate brachytherapy alone for endometrial cancer - Corrected Proof

2011-06-20

Abstract: Objective: To compare the biologic equivalence in terms of local control and toxicity of a short course of high-dose-rate intravaginal brachytherapy alone (IVBa) delivered over five consecutive days (25Gy/5Rx/5 days) to other more protracted classical schemes 21Gy/3Rx/14–28 days (Postoperative Radiation Therapy in Endometrial Carcinoma [PORTEC]-2/Memorial Sloan-Kettering Cancer Center).Methods and Materials: From February 2001 to May 2008, 122 patients with International Federation of Gynecology and Obstetrics Stage IaG3–IIIaG2 endometrial adenocarcinoma were treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by postoperative IVBa. Seventy-seven patients (63.1%) underwent surgical staging. Total IVBa dose was 25Gy in five consecutive daily fractions prescribed at 0.5-cm depth.Results: After a median followup of 4.1 years, the rates of Radiation Therapy Oncology Group Grades 1, 2, and ≥3 complications were 12.9%, 3.4%, and 0.8%, respectively. Five patients (4.1%) presented locoregional failures: two isolated nodal pelvic failures, one vaginal pelvic relapse (intra-abdominal lymph node metastases), one vaginal distant failure, and one combined locoregional and distant failure. The 8.5-year actuarial vaginal control rate was 97.5%, and the pelvic control rate was 94.3%. Six other patients developed distant metastases alone. The 8.5-year actuarial overall and disease-free survival rates were 90.3% and 87.2%, respectively. Univariate analysis revealed that histologic grade, deep myometrial invasion, advanced age, and categorization as high intermediate–risk patient according to the PORTEC-2 and the Gynecologic Oncology Group (GOG)-99 stratifications were statistically significant prognostic factors. After multivariate analysis, histologic grade (p=0.001) and high intermediate risk according to GOG-99 (p=0.004) and PORTEC-2 (p=0.001) remained significant.Conclusions: The proposed scheme reproduces the excellent results obtained with more protracted schemes and has the added advantage of shortened overall treatment time.

Dosimetric effect of interfractional needle displacement in prostate high-dose-rate brachytherapy - Corrected Proof

Nataliya Kovalchuk, Keith M. Furutani, O. Kenneth Macdonald, Thomas M. Pisansky — 2011-06-20

Abstract: Purpose: To quantify the dosimetric deviations that would arise from delivering subsequent prostate high-dose-rate fractions with only needle readjustment and no replanning after the first fraction.Methods and Materials: Patients were treated with either two implant sessions (two 9.5-Gy fractions per session) separated by 2–4 weeks or with one implant session and external beam radiotherapy. After needle placement, needle positions were adjusted under CT guidance, after which dosimetric planning was performed before each fraction. To evaluate the consequence of not replanning before the second fraction, we analyzed the dosimetric parameters of 45 consecutive implants (26 patients). Needles with optimized dwell positions from the first fraction were transferred to the needle positions in the second fraction. Needle displacement between fractions was assessed as well as changes in plan metrics.Results: After adjustment, the mean interfractional needle displacement was 3.5mm. If replanned, the probability of planning target volume D90% ≥95% is 100%, prostate V100% ≥95% is 87%, and urethra V115% ≤10% is 78%. If treated without replanning, the probability of planning target volume D90% ≥95% is 82%, prostate V100% ≥95% is 53%, and urethra V115% ≤10% is 69%. Even for implants with minimal needle displacement (<3mm) and minimal prostate volume change (<3cc), the dosimetric consequence of not replanning the second fraction would result in 46% of cases with a prostate V100% <95%.Conclusion: The dosimetric consequences of not replanning the second fraction for prostate high-dose-rate implants results in significantly inferior plan metrics.

Comparison of cellular damage response to low-dose-rate 125I seed irradiation and high-dose-rate gamma irradiation in human lung cancer cells - Corrected Proof

Honghong Chen, Yizhong Bao, Lei Yu, Rongfei Jia, Wenying Cheng, Chunlin Shao — 2011-06-13

Abstract: Purpose: To investigate the difference of cellular response between low-dose-rate (LDR) 125I seed irradiation and high-dose-rate (HDR) γ-irradiation in human lung cancer cells.Methods and Materials: A549 and NCI-H446 cells with or without wortmannin (WM) treatment were exposed to 125I seeds and γ-rays, respectively. Cell survival, micronuclei (MN) formation, and the expressions of Ku70/Ku80 proteins were measured.Results: There was a strong negative correlation between survival and MN formation for both irradiations, and the MN inductions of NCI-H446 were about twofolds of those of A549, and the survival of NCI-H446 was lower than that of A549, indicating the radiosensitivity of NCI-H446 cells was greater than that of A549 cells. Interestingly, at 4-Gy radiation, NCI-H446 cells were more sensitive to LDR irradiation than HDR irradiation. WM treatment enhanced the radiosensitivity of A549 cells evenly to 125I seed and γ-irradiation, but this treatment led NCI-H446 cells to be more sensitive to LDR 125I. Further results revealed that the expression of phosphorylated Ku80 protein was enhanced in irradiated A549, but in contrast, it was markedly decreased in NCI-H446 cells after 4-Gy LDR 125I irradiation as that compared with γ-irradiated and nonirradiated cells.Conclusion: NCI-H446 cells were more sensitive to LDR 125I irradiation than HDR irradiation, and this sensitivity could be further enhanced by WM treatment. But no obvious differences of cellular response to both irradiations were observed in A549. Ku as molecular markers together with cell proliferation rate can be used to predict the radiosensitivity of tumor cells to LDR 125I seed irradiation.

3D image-based HDR interstitial brachytherapy for vaginal cancer - Corrected Proof

2011-06-13

Abstract: Purpose: To evaluate dosimetric and clinical outcomes of three-dimensional (3D) image–based high-dose-rate (HDR) interstitial brachytherapy (HDRB) in patients with vaginal cancers.Methods and Materials: Thirty patients with vaginal cancers were treated with HDRB using Syed-Neblett template. CT scan was done after placement of needles for confirmation of placement and treatment planning. The target volume and organs at risk, including clinical target volume (CTV), rectum, bladder, and sigmoid colon, were contoured on CT scans. Twenty-eight (93.3%) patients received external beam radiation therapy at a median 45 (24.0–50.4)Gy in 12–28 fractions, followed by HDRB at 3.75–5.0Gy per fraction in five fractions. Total doses for CTV and organs at risk from external beam radiation therapy and HDRB were summated and normalized to a biologically equivalent dose of 2Gy per fraction.Results: Seventeen patients (56.7%) with primary vaginal cancer and 13 patients (43.3%) with recurrent vaginal cancers were treated with 3D HDRB. The mean CTV was 39.3±25.7 cm3, and the median tumor diameter was 3.3 (1.3–8.0)cm. The median biologically equivalent dose of 2Gy per fraction for 2cc of bladder, rectum, and sigmoid was 55.0, 56.3, 50.0Gy, respectively. The median D90 for high-risk CTV was 74.3 (36.3–81.1)Gy. The mean volume receiving 100%, 150%, and 200% of prescribed dose was 90.7±10.0%, 41.3±14.6%, and 17.7±8.3%, respectively. With a median followup of 16.7 months, the respective 1-/2-year locoregional and overall survival rates were 84.4%/78.8% and 82.1%/70.2%, respectively. There were no Grade ≥3 gastrointestinal complications. Late complications of Grade 3 vaginal ulceration and Grade 4 vaginal necrosis were seen in two cases.Conclusions: Initial results of 3D HDRB using our fractionation schedule in the treatment of vaginal cancers showed good local response with acceptable morbidities.

Whitmore, Henschke, and Hilaris: The reorientation of prostate brachytherapy (1970–1987) - Corrected Proof

Jesse N. Aronowitz — 2011-06-03

Abstract: Purpose: Urologists had performed prostate brachytherapy for decades before New York’s Memorial Hospital retropubic program. This paper explores the contribution of Willet Whitmore, Ulrich Henschke, Basil Hilaris, and Memorial’s physicists to the evolution of the procedure.Methods and Materials: Literature review and interviews with program participants.Results: More than 1000 retropubic implants were performed at Memorial between 1970 and 1987. Unlike previous efforts, Memorial’s program benefited from the participation of three disciplines in its conception and execution.Conclusions: Memorial’s retropubic program was a collaboration of urologists, radiation therapists, and physicists. Their approach focused greater attention on dosimetry and radiation safety, and served as a template for subsequent prostate brachytherapy programs.