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Only a few studies have explored whether high-dose-rate interstitial brachytherapy (HDR-ISBT) can be indicated as a palliative/symptomatic treatment. We present the good results of palliative treatment using HDR-ISBT combined with external beam radiotherapy (ERT) in a patient of base of tongue cancer (cT4aN1M0). The patient was an 81-year-old male who complained of local pain. He had a previous irradiation history for head and neck cancer receiving ERT with systemic chemotherapy and radical surgery 15 years ago. Since it might be difficult for him to receive radical radiation doses using ERT alone, palliative ERT of relatively lower doses of 37.5 Gy in 15 fractions was selected. One month after ERT, HDR-ISBT was implemented as a booster. Considering the burden on physical condition, single-fraction HDR-ISBT was selected. We employed a new technique in which we did not penetrate the ventral surface of the tongue to reduce the risk of infection and bleeding. The planning-aim dose was 9.5 Gy. The dose that covered 90% of the clinical target volume was 9.6 Gy. The treatment ended without any problems. Acute complications were not observed. The tumor size decreased, and local pain disappeared at post-treatment day 84. No late complications were observed. Two years and 8 months after the treatment, the patient is alive without any obvious recurrence. Additional single-fraction HDR-ISBT boost may be a useful modality as a palliative/symptomatic intent. The implantation technique and dose–fraction schedule may be important for the safe treatment of older patients or those with poor performance status. [ABSTRACT FROM AUTHOR]

The recurrence rate of cervical cancer after primary treatment can reach 60%, and a poor prognosis is reported in most cases. Treatment options for the recurrence of cervical cancer mainly depend on the prior treatment regimen and the location of recurrent lesions. Re-irradiation is still considered as a clinical challenge, owing to a high incidence of toxicity, especially in in-field recurrence within a short period of time. Recent advances in radiotherapy have preliminarily revealed encouraging outcomes of re-irradiation. Several centers have concentrasted on stereotactic body radiation therapy (SBRT) for the treatment of well-selected cases. Meanwhile, as the image-guiding techniques become more precise, a better dose profile can also be achieved in brachytherapy, including high-dose-rate interstitial brachytherapy (HDR-ISBT) and permanent radioactive seed implantation (PRSI). These treatment modalities have shown promising efficacy with a tolerable toxicity, providing further treatment options for recurrent cervical cancer. However, it is highly unlikely to draw a definite conclusion from all of those studies due to the large heterogeneity among them and the lack of large-scale prospective studies. This study mainly reviews and summarizes the progress of re-irradiation for recurrent cervical cancer in recent years, in order to provide potential treatment regimens for the management of re-irradiation.

Prostate squamous cell carcinoma (pSCC) rarely develops as a secondary cancer after treatment with low-dose-rate brachytherapy (LDR-BT). There is no established effective treatment for the disease condition. Herein, we present a 78-year-old man who developed pSCC 8 years after LDR-BT. He was subsequently selected to receive a combined multimodal treatment with high-dose-rate interstitial brachytherapy (HDR-ISBT), external beam radiation therapy, and chemotherapy for his pSCC. Eleven months later, he displayed no biochemical failure nor clinical radiographic recurrence. However, MRI detected a newly developed prostatic-rectal fistula (grade 4), and a colostomy was performed to relieve pain and inflammation. To our knowledge, this is the first report to perform a combined multimodal treatment with HDR-ISBT for pSCC suspected as a secondary cancer due to LDR-BT.

The recurrence rate of cervical cancer after primary treatment can reach 60%, and a poor prognosis is reported in most cases. Treatment options for the recurrence of cervical cancer mainly depend on the prior treatment regimen and the location of recurrent lesions. Re-irradiation is still considered as a clinical challenge, owing to a high incidence of toxicity, especially in in-field recurrence within a short period of time. Recent advances in radiotherapy have preliminarily revealed encouraging outcomes of re-irradiation. Several centers have concentrasted on stereotactic body radiation therapy (SBRT) for the treatment of well-selected cases. Meanwhile, as the image-guiding techniques become more precise, a better dose profile can also be achieved in brachytherapy, including high-dose-rate interstitial brachytherapy (HDR-ISBT) and permanent radioactive seed implantation (PRSI). These treatment modalities have shown promising efficacy with a tolerable toxicity, providing further treatment options for recurrent cervical cancer. However, it is highly unlikely to draw a definite conclusion from all of those studies due to the large heterogeneity among them and the lack of large-scale prospective studies. This study mainly reviews and summarizes the progress of re-irradiation for recurrent cervical cancer in recent years, in order to provide potential treatment regimens for the management of re-irradiation. [ABSTRACT FROM AUTHOR]

High-dose-rate interstitial brachytherapy (HDR-ISBT) is widely used for the treatment of pelvic tumors. However, there are a few reports on complications of applicator implantation in HDR-ISBT. We describe a case of small bowel perforation caused by applicator implantation in an 82-year-old male patient with recurrence tumor in the pelvis treated with HDR-ISBT. Eventually, the patient underwent laparotomy and partial intestinal resection. We recognized the site where the applicator was inserted into a part of the tumor on the mucosal surface. Pathological examination confirmed that the tumor had infiltrated the small intestine directly and that the infiltrated part had reached the submucosa. This is the first published report about small bowel perforation caused by applicator implantation. In cases where intestinal infiltration of the tumor is suspected, HDR-ISBT should be performed with maximum caution.

Background: The present study investigated the acute mucosal reaction (AMR) after high-dose-rate interstitial brachytherapy at 54 Gy/9 fractions (HDR54) as monotherapy administered twice a day for tongue cancer in 13 patients, and attempted to validate HDR54 by comparing the AMR with that of our previously reported HDR at 60 Gy/10 fractions (HDR60), and low-dose-rate interstitial brachytherapy at approximately 70 Gy (LDR70)., Methods: The European Organization for Research on Treatment of Cancer/ Radiation Therapy Oncology Group scoring system with modifications (score: 1-4.5) was used to evaluate AMR. The time courses of the AMR scores of HDR54 were recorded. The time courses of the AMR of HDR54, HDR 60, and LDR70 were each divided into 6 phases and compared., Results: The number of cases in the HDR54 group with a lower score (1-2) at the time of the initial response was significantly higher (12 cases) than those in the HDR60 group (1 case) (p=0.0077) and LDR70 group (1 case) (p=0.0077). In the HDR54 group, the time between the end of treatment and appearance of the first response was significantly longer (median: 3 days) than those in the HDR60 group (median: 1 day) (p<0.001) and LDR70 group (median: 1 day) (p<0.001). No significant differences were observed in the maximum score, its duration, or other parameters., Conclusions: The results indicated that the AMR of HDR54 started later and was gentler and more easily tolerated than the other two methods, suggesting the validity of HDR54 in terms of AMR.

Abstract High‐dose‐rate interstitial brachytherapy (HDR‐ISBT) achieved excellent local control of the bulky sebaceous carcinoma of the eyelid. However, we must pay attention to dose of eyelid and cornea about late toxicity of HDR‐ISBT.

Prostate squamous cell carcinoma (pSCC) rarely develops as a secondary cancer after treatment with low-dose-rate brachytherapy (LDR-BT). There is no established effective treatment for the disease condition. Herein, we present a 78-year-old man who developed pSCC 8 years after LDR-BT. He was subsequently selected to receive a combined multimodal treatment with high-dose-rate interstitial brachytherapy (HDR-ISBT), external beam radiation therapy, and chemotherapy for his pSCC. Eleven months later, he displayed no biochemical failure nor clinical radiographic recurrence. However, MRI detected a newly developed prostatic-rectal fistula (grade 4), and a colostomy was performed to relieve pain and inflammation. To our knowledge, this is the first report to perform a combined multimodal treatment with HDR-ISBT for pSCC suspected as a secondary cancer due to LDR-BT. [ABSTRACT FROM AUTHOR]

Brachytherapy (BT) after surgical resection of keloids reduces the risk of local recurrence, but standardization of dose/technique is lacking. Typical keloid BT treatment utilizes a single-channel source prescribed to 5-mm depth. We investigated the dosimetry of a volume-based target definition for interstitial high-dose-rate BT treatment of keloids. We retrospectively identified consecutive 14 patients who had a total of 20 keloids treated with interstitial high-dose-rate BT for keloids at our institution between 2004 and 2014. Keloids were treated with a single 8 Gy fraction prescribed to 5 mm beneath the scar within 36 h of surgery. Retrospectively, a 3-mm skin high-risk clinical target volume (HR-CTV) was contoured under the scar for volume-based dose calculations. Mean (SD) HR-CTV was 3.91 cm3 (3.1) and mean (SD) HR-CTV dose was 11.3 Gy (3.6). Mean D 90 (SD) was 62.9% (25.8) and mean V 100 (SD) was 56.5% (26.4). The mean V 150 (SD), V 200 (SD), and V 300 (SD) were as follows: 37.6% (19.9), 25.1% (14.4), and 11.3% (6.5), respectively. No local failures were reported at 9 months median followup. There were no Grade 2 or higher late toxicities. Using a volume-based target definition, a wide range of target coverage was observed. This is likely a consequence of the curvature of the skin and the challenges of keeping the catheter equidistant from the skin across the target. Additional data are needed to define the potential clinical impact on outcomes/toxicities of dosimetric correlates with single-catheter BT keloid treatment. [ABSTRACT FROM AUTHOR]

High‐dose‐rate interstitial brachytherapy (HDR‐ISBT) achieved excellent local control of the bulky sebaceous carcinoma of the eyelid. However, we must pay attention to dose of eyelid and cornea about late toxicity of HDR‐ISBT. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the report was the evaluation of application with image-guided high-dose-rate (HDR) interstitial brachytherapy in patients undergoing conventional chemo-radiotherapy for perineal locally recurrent rectal cancer (LRRC). Material and methods: 75-year-old female patient presented with LRRC three years after total mesorectal excision (TME) surgery for rectal cancer with tubular adenocarcinoma (stage IIIB). Despite conventional chemotherapy and external beam radiotherapy, the re-recurrent lesion expanded as 4.5 × 5.5 cm2 located in perineum with skin invasion. The loco-regional recurrent tumor was treated with HDR interstitial brachytherapy under ultrasound guidance and magnetic resonance imaging-based treatment planning. The brachytherapy dose was 50 Gy in 10 fractions of 5 Gy each for 5 weeks. Results: Removal of the perineal LRRC was securely achieved by image-guided HDR interstitial brachytherapy technique. The refractory tumor healed uneventfully after interstitial brachytherapy without recurrence during 26 months of follow-up. The patient had good quality of life without serious complications of treatment. Conclusions: Image-guided HDR interstitial brachytherapy in selected patient with LRRC in perineum is a proven, effective, and safe treatment method with relatively long-term outcome. [ABSTRACT FROM AUTHOR]

Purpose We analyzed clinical data to evaluate the effectiveness of image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) for pelvic recurrence of uterine cancer. Methods and Materials Between 2003 and 2011, 56 patients were treated with HDR-ISBT with or without external beam radiotherapy (EBRT). The median followup time was 33 months (range, 1–109 months). Pre-ISBT treatments included radical hysterectomy for 35 patients (Group A), radical hysterectomy with postoperative radiotherapy for 8 patients (Group B), and radical radiotherapy for 13 patients (Group C). We initiated MRI-assisted CT-based planning for the last 49 patients. The median ISBT single fraction dose was 6 Gy. The median total doses were 30 and 54 Gy with and without EBRT (range, 30–50 Gy) for Group A, respectively and 48 Gy without EBRT for Groups B and C. Results The 3-year local control (LC) rates were 85%, 75%, and 46% for Groups A, B, and C, respectively ( p = 0.017). The 3-year LC rates were 84%, 73%, and 33% for clinical target volume at the time of HDR-ISBT of <10, 10–29, and ≥30 cc, respectively ( p = 0.005). The 3-year LC results tended to be higher for patients whose D 100 (clinical target volume) was equal or higher than 67.1 Gy ( p = 0.098). A total of 13 late complications of Grades 3–5 occurred in 11 patients (20%). Conclusions Our image-guided HDR-ISBT for pelvic recurrence of uterine cancer provided good treatment outcomes. The treatment results for patients who underwent radical surgery with or without postoperative radiotherapy are better than those for patients who underwent radical radiotherapy. [ABSTRACT FROM AUTHOR]

Background: We retrospectively examined outcomes of salvage high-dose-rate interstitial brachytherapy (HDR-ISBT) for locally recurrent rectal cancer (LRRC). Methods: Nine patients with LRRC were treated with salvage HDR-ISBT. Their median age was 63 years. The median maximum diameter of LRRC was 40 mm (range 20-80 mm). Adenocarcinomas were histologically confirmed in all cases. The prescribed dose was 30 Gy/5 fractions/3 days to 50 Gy/10 fractions/6 days in the combined external-beam radiotherapy group (four patients) and 54 Gy/9 fractions/5 days to 60 Gy/10 fractions/6 days in the monotherapeutic group (five patients). Median follow-up time was 90 months (range 6-221 months). Results: Local control at final follow-up was achieved in five of nine patients. Of these five patients, one experienced a locally re-recurrent tumor in the vaginal wall 33 months after treatment and received re-HDR-ISBT as re-salvage treatment. The 8-year overall survival, local control, and progression-free survival rates were 56, 44, and 33 %, respectively. Based on the Common Terminology Criteria for Adverse Events ver. 4.03, the following Grade 3 adverse events were observed in three patients (≥3 months): Grade 3 skin ulceration in one patient who showed tumor invasion of the skin and whose V100 was 400 cc; Grade 3 vaginal perforation in one patient whose tumor had invaded the vaginal wall; and Grade 3 vagina-to-bladder fistula in one patient whose tumor received re-irradiation. Late adverse events above Grade 3 were not observed. Conclusions: Long-term follow-up results revealed that salvage HDR-ISBT is a promising treatment for LRRC with tolerable toxicity. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: We investigated daily needle applicator displacement during high-dose-rate interstitial brachytherapy. Methods and Materials: Ten patients with previously untreated uterine cervical cancer received 30Gy in five fractions during 3 days of high-dose-rate interstitial brachytherapy combined with external beam radiotherapy using our unique ambulatory technique. To analyze displacement, we obtained daily computed tomography (CT) images for 147 flexible needle applicators at 21 and 45h after implantation. The distance was defined as the length between the center of gravity of titanium markers and the needle applicator tips along the daily CT axis. We adapted dwell positions of the treatment source to cover clinical target volume with a 15-mm cranial margin. Results: The median displacement was 1mm (range, −6 to 12mm) at 21h and 2mm (range, −9 to 14mm) at 45h, respectively. Statistically significant caudal displacement was observed only between the displacement at 0 and 21h (p <0.0001), and not between the displacement at 21 and 45h (p =0.1). In cases with displacement of 3mm or more, we changed dwell positions to correct the treatment plan. We corrected 45 applicators (31%) at 21h and 67 (46%) at 45h. Conclusions: We investigated needle applicator displacement in our ambulatory technique using daily CT examination and considered that a 15-mm cranial margin was sufficient to cover clinical target volume. [Copyright &y& Elsevier]

Abstract: Purpose: To introduce an effective ambulatory technique in high-dose-rate interstitial brachytherapy (HDR-ISBT) for prostate cancer, we investigated the displacement distance using our novel calculation method. Methods and Materials: Sixty-four patients treated with HDR-ISBT as monotherapy were examined. Of these, 4, 17, and 43 patients were administered treatment doses of 38Gy (3 days), 49Gy (4 days), and 54Gy (5 days), respectively. For dose administration, we used 776 flexible applicators with a removable template (ambulatory technique). Using CT images, we calculated the relative coordinates of the metal markers and applicators. From these coordinates, to analyze displacement during treatment, we measured the distance between the tip of the needle applicator and the center of gravity of the markers along the average applicator vector. Results: The median displacement distance for all applicators was 7mm (range, −14 to 24), and that of each treatment schedule was 4, 6, and 9mm for 38, 49, and 54Gy, respectively. Of the 776 applicators, displacement of >10mm was seen in 198 (26%) applicators and >15mm in 57 (7%) applicators. Body height (p <0.0001) and anticoagulant usage (p <0.0001) were significant factors influencing displacement. Conclusions: We investigated needle applicator displacement using our unique method. Additional cranial margins are necessary if there is no repositioning of the dwell position. CT scanning should be performed daily during treatment for checking the position of the applicator to detect and rectify the issue of displacement. [Copyright &y& Elsevier]

Abstract: Purpose: For safer treatment of seminal vesicles (SVs), we initiated a new technique using an anchor applicator for high-dose-rate interstitial brachytherapy (HDR-ISBT) of prostate cancer. Methods and materials: Between January 2004 and March 2005, 23 intermediate- to high-risk patients were treated with HDR-ISBT as monotherapy. Transrectal ultrasonography guided implantation of the treatment applicator in and around the prostate gland and proximal SV. We used an “anchor” applicator to prevent posterior displacement of the SV. After insertion of the anchor applicator, the actual treatment applicator was implanted at the best position for optimal SV coverage. SV coverage was analyzed using a dose-volume histogram. Results: Implantation of the applicator on the posterior side of the SV was successful for 43 of 46 SVs (93%). The median percentage of the SVs receiving the prescribed dose was 41% (range 11–86%). Only one case of acute Grade 2 toxicity (3%) was seen. Conclusions: Our anchor applicator technique for HDR-ISBT can separate the SV from the rectum. This is the first report of dose-volume histogram analysis of the SV for HDR-ISBT. [Copyright &y& Elsevier]

The aim of this study was to improve the performance status of prostate cancer patients during high-dose-rate interstitial brachytherapy (HDR-ISBT). To this end, we have developed a new ambulatory implant technique. Ten prostate cancer patients were treated with HDR-ISBT as monotherapy from October 2003 until March 2004. We utilized a new removable template, a flexible applicator with a nonmetallic bead and button stopper, and an inner catheter connecting the applicator and the transfer tube of the brachytherapy unit. We shortened the connector end of the flexible applicator to enable the patient to sit down and walk freely during the treatment time. All 10 patients could walk without any support. No problem in the application was observed. Our new ambulatory implant technique for HDR-ISBT was able to improve the performance status of prostate cancer patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to report the clinical results of salvage high-dose-rate interstitial brachytherapy (HDR-ISBT) for patients with cervical cancer with pelvic recurrence after hysterectomy., Patients and Methods: When there was no indication for total pelvic extenteration (TPE) and the tumor depth was more than 5 mm of invasion in the paracolpium, salvage HDR-ISBT was applied., Results: A total of 26 patients were included in this study. The median number of fractions and dose per fraction of HDR-ISBT were 5 (range=3-20 fractions) and 6 Gy (range=2.5-6 Gy), respectively. Three-year local control, progression-free survival, and overall survival were 51.1%, 34.4% and 57.1%, respectively. Combination of external-beam radiation therapy, clinical target volume D90 greater than 65 Gy, and dose per fraction greater than 5 Gy were associated with favorable local control., Conclusion: For patients with recurrent cervical cancer post hysterectomy who are not candidates for TPE, salvage HDR-ISBT is a possible curative treatment modality., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)