Brachytherapy For Gynecologic Malignancies Research Articles

Evaluation of Disparity in Physician Assessment of Sexual Dysfunction in Women vs. Men Receiving Brachytherapy for Genitourinary Cancers

<h3>Purpose/Objective(s)</h3> Brachytherapy is an integral component of treatment for genitourinary cancers, but comes with long-term risk of sexual dysfunction, with 90% of women and 50% of men experiencing sexual dysfunction after brachytherapy for gynecologic malignancies and prostate cancer, respectively. We hypothesized that women's sexual health was not being assessed in clinic at the same rate as their male counterparts receiving prostate brachytherapy. We similarly hypothesized that our institutional data would be representative of clinical investigators nationally, with lower rates of sexual function assessment in women compared to men enrolled on clinical trials. <h3>Materials/Methods</h3> Patients with cervical or prostate cancer evaluated for brachytherapy between 2010 and 2021 at a single academic institution were included in this retrospective analysis. Consult notes were reviewed to assess if patients were asked about baseline sexual function with or without patient-reported outcomes (PRO). Chi-square test was used to determine statistically significant differences between the two groups (p<0.05). For a more robust national comparison, we also queried the NIH Clinical Trials Database to determine the proportion of clinical trials assessing sexual function as a primary or secondary endpoint after brachytherapy for prostate or cervical cancer. <h3>Results</h3> We analyzed 126 female and 75 male patients who were evaluated for cervical and prostate cancer brachytherapy, respectively. More men than women were asked about sexual function at time of consult, even though the female cohort was younger (Table 1). Rates of assessment of sexual function were similar in men who were and were not offered ADT [45 (88%) vs. 22 (92%); p=0.65]. Prostate cancer brachytherapy trials were also more likely to assess sexual function compared to those in cervical cancer. <h3>Conclusion</h3> We demonstrate a significant difference between men and women in the ascertainment of sexual function both in our clinic and on brachytherapy clinical trials nationwide. We have previously shown that 79% of women believed that sexual function was an important component of their overall health. Even though brachytherapy has a highly deleterious impact on sexual function, women are not being evaluated for this important functional outcome at the same rate as men. Further studies are warranted to fulfill this unmet need and to understand the barriers to assessing and treating sexual dysfunction in women receiving brachytherapy as part of treatment.

High-Dose-Rate Interstitial Brachytherapy for Deeply Situated Gynecologic Tumors Guided by Combination of Transrectal and Transabdominal Ultrasonography: A Technical Note.

Background and PurposeHigh-dose-rate interstitial brachytherapy (HDR-ISBT) is recommended to obtain a better local tumor control for uterine cancer patients in specific situations such as bulky lesions, an extension to the lateral parametrium, or tumors with irregular shapes. Our group uses real-time transrectal ultrasonography (TRUS) to guide freehand interstitial needle insertion. Occasionally, target tumors locate deeper beyond the rectum and cannot be visualized by TRUS. CT can guide needles to deeply located tumors, but in such cases, repeated image obtainment is required to achieve ideal needle localization. In this report, we present nine cases of patients who underwent HDR-ISBT for deeply situated tumors guided by a combination of transrectal and transabdominal ultrasonography (TR/TA-US).Material and MethodsNine uterine cancer patients whose tumors were located deeper than the reach of TRUS and underwent HDR-ISBT guided by TR/TA-US were presented. All nine cases had no distal organ metastasis and underwent external beam radiation therapy (EBRT) to the pelvic region for 45–50.4 Gy in 25–28 fractions followed by boost HDR-ISBT for deeply situated tumors guided by TR/TA-US.ResultsThere were seven cervical cancer and two endometrial cancer patients: six with extensive uterine corpus invasion, one cervical cancer with massive pelvic lymph node metastasis, one cervical cancer with postoperative pelvic recurrence, and one with left ovarian direct tumor invasion. The median follow-up period was 15 months (range 3–28 months). The average clinical target volume at the time of first HDR-ISBT was 131 ml (range 44–335 ml). The linear distance from the vaginal entrance to the deepest part of the tumor at first time brachytherapy of nine cases was 14.0 (9.0–17.0) cm. HDR-ISBT dose fractionation was 24–30 Gy in four or five fractions. Seven out of nine cases had no local recurrence in the follow-up period. One had local in-field recurrence 25 months after HDR-ISBT. Another case with carcinosarcoma could not obtain local control and underwent salvage hysterectomy for a residual uterine tumor 11 months after HDR-ISBT. Four cases had extra-field recurrence in lymph nodes or distant organs.ConclusionsIn brachytherapy for gynecologic malignancies, deeply situated tumors located out of reach of TRUS may obtain favorable local control by HDR-ISBT guided with TR/TA-US.

Bevacizumab increases late toxicity in re-irradiation with image-guided high-dose-rate brachytherapy for gynecologic malignancies.

IntroductionPatients with recurrent gynecologic malignancies having had pelvic irradiation, generally have limited salvage options. This study investigated patients with gynecologic malignancies, who had a history of pelvic irradiation and received salvage re-irradiation using image-guided high-dose-rate brachytherapy (IG-HDR-BT).Material and methodsPatients with gynecologic malignancies, who had a history of previous irradiation and received re-irradiation using IG-HDR-BT for disease recurrences from June 2014 to March 2020 were included in this study.ResultsA total of 37 patients were included in this retrospective analysis. Primary tumor was uterine cervical cancer in 31 patients, endometrial cancer in 5 patients, and vaginal cancer in 1 patient. Median follow-up period of patients who were alive at the time of analysis was 15.4 months (range, 4.1-61.4 months). Two-year overall survival, progression-free survival, and local control were 68.9%, 49.3%, and 67.5%, respectively. Severe late toxicities ≥ grade 3, which were related to re-irradiation, were observed in 9 patients (24.3%). Usage of bevacizumab in the entire course of treatment was associated with development of late ≥ grade 3 fistula formation, bowel perforation, or vaginal ulcer (50% vs. 6.9%, p = 0.013). Tumor size ≥ 2.5 cm was associated with development of late ≥ grade 3 of rectum, bladder, or vaginal toxicities (0% vs. 28%, p = 0.047).ConclusionsIf the recurrent disease was found in small size and there was no history of bevacizumab usage, re-irradiation with IG-HDR-BT could be considered, even in patients with a previous history of pelvic irradiation.

Current Nursing Care Patterns and the Development of Vaginal Stenosis after Brachytherapy for Gynecological Malignancies

Current Nursing Care Patterns and the Development of Vaginal Stenosis after Brachytherapy for Gynecological Malignancies

Clinical utility and value contribution of an MRI-positive line marker for image-guided brachytherapy in gynecologic malignancies

PurposeThe purpose of this study was to investigate the utility of a novel MRI-positive line marker, composed of C4:S (cobalt chloride–based contrast agent) encapsulated in high-density polyethylene tubing, in permitting dosimetry and treatment planning directly on MRI. Methods and MaterialsWe evaluated the clinical feasibility of the C4:S line markers in nine sequential brachytherapy procedures for gynecologic malignancies, including six tandem-and-ovoid and three interstitial cases. We then quantified the internal resource utilization of an intraoperative MRI-guided procedural episode via time-driven activity-based costing, identifying opportunities for cost-containment with use of the C4:S line markers. ResultsThe C4:S line markers demonstrated the strongest positive signal visibility on 3D constructive interference in steady state (CISS)/FIESTA-C followed by T1-weighted sequences, permitting accurate delineation of the applicator lumen and thus the source path. These images may be fused along with traditional T2-weighted sequences for optimal tumor and anatomy contouring, followed by treatment planning directly on MRI. By eliminating postoperative CT for fusion and applicator registration from the procedural episode, use of the C4:S line markers could decrease workflow time and lower total delivery costs per procedure. ConclusionsThis analysis supports the clinical utility and value contribution of the C4:S line markers, which permit accurate MRI-based dosimetry and treatment planning, thereby eliminating the need for postoperative CT for fusion and applicator registration.

Longitudinal Analysis of Resident Exposure to Brachytherapy in Gynecologic Malignancies from 2007-2018

Longitudinal Analysis of Resident Exposure to Brachytherapy in Gynecologic Malignancies from 2007-2018

Improving brachytherapy efficiency with dedicated dosimetrist planners

PurposeTo investigate the different factors affecting the procedure duration for high-dose-rate brachytherapy for gynecologic malignancies. Methods and MaterialsWe prospectively recorded 86 consecutive vaginal cylinder (VC) treatments and 82 tandem and ovoid treatments. Key time points in the brachytherapy process, identity of the planner and checker, number of treatments per day, and fraction number per patient were recorded. The data were analyzed in a mixed effects linear regression model to account for the within patient correlation. Post hoc pair-wise comparisons were performed using a Dunnett's adjustment for comparisons to a single control group and using a Tukey adjustment for all pair-wise comparisons. ResultsWe focused on several key time intervals in the treatment: total, nursing/anesthesia preprocedure, procedure, contouring, and planning times. In analysis, multiple factors significantly influenced VC timing but not tandem and ovoid timing. The planners were separated and analyzed based on experience and profession. Inexperienced physicists planning times were on average 18 min (p = 0.0010) and 14 min (p = 0.0038) slower than dedicated brachytherapy dosimetrist and experienced physicists, respectively. An increase in the number of procedures for the day of treatment increased the VC total time (p = 0.0218). The VC procedure time changed depending on whether it was the patients' first, second, or third VC treatment (p < 0.0001). ConclusionsThe use of dosimetrists as dedicated planners for brachytherapy is more cost and time efficient. There are multiple variables affecting brachytherapy treatment with actionable opportunities to improve procedure scheduling.

The Role of Interstitial Brachytherapy in Gynecologic Malignancies. The Importance of MRI Compatible Applicators in Volume Definition and Treatment Planning

The Role of Interstitial Brachytherapy in Gynecologic Malignancies. The Importance of MRI Compatible Applicators in Volume Definition and Treatment Planning

Impact of Adaptive Planning on Image-Guided Perineal Brachytherapy for Gynecologic Malignancies

Impact of Adaptive Planning on Image-Guided Perineal Brachytherapy for Gynecologic Malignancies

Detecting Applicator Displacement During HDR Interstitial Brachytherapy for Gynecologic Malignancies

Detecting Applicator Displacement During HDR Interstitial Brachytherapy for Gynecologic Malignancies

204: Do Rectal Tubes improve Dosimetry in Interstitial Brachytherapy for Gynecological Malignancies?

204: Do Rectal Tubes improve Dosimetry in Interstitial Brachytherapy for Gynecological Malignancies?

Evaluation of different magnetic resonance imaging contrast materials to be used as dummy markers in image-guided brachytherapy for gynecologic malignancies.

ObjectiveTo identify a contrast material that could be used as a dummy marker for magnetic resonance imaging.Materials and MethodsMagnetic resonance images were acquired with six different catheter-filling materials-water, glucose 50%, saline, olive oil, glycerin, and copper sulfate (CuSO4) water solution (2.08 g/L)-inserted into compatible computed tomography/magnetic resonance imaging ring applicators placed in a phantom made of gelatin and CuSO4. The best contrast media were tested in four patients with the applicators in place.ResultsIn T2-weighted sequences, the best contrast was achieved with the CuSO4-filled catheters, followed by saline- and glycerin-filled catheters, which presented poor visualization. In addition (also in T2-weighted sequences), CuSO4 presented better contrast when tested in the phantom than when tested in the patients, in which it provided some contrast but with poor identification of the first dwell position, mainly in the ring.ConclusionWe found CuSO4 to be the best solution for visualization of the applicator channels, mainly in T2-weighted images in vitro, although the materials tested presented low signal intensity in the images obtained in vivo, as well as poor precision in determining the first dwell position.

Interstitial Brachytherapy for Gynecological Malignancies: A Systematic Review of Treatment, Technique and Toxicities in the Era of Three-Dimensional Planning

Interstitial Brachytherapy for Gynecological Malignancies: A Systematic Review of Treatment, Technique and Toxicities in the Era of Three-Dimensional Planning

A radiopaque polymer hydrogel used as a fiducial marker in gynecologic-cancer patients receiving brachytherapy.

We assessed a novel Food and Drug Administration-approved hydrogel, synthesized as absorbable iodinated particles, in gynecologic-cancer patients undergoing computed tomography (CT) or magnetic resonance (MR) based brachytherapy after external beam radiation. Nineteen patients underwent CT-guided (n = 13) or MR-guided (n = 6) brachytherapy for gynecologic cancers. Seventy-seven hydrogel injections were placed. The hydrogel material was injected into gross residual disease and/or key anatomic landmarks in amounts ranging from 0.1 to 0.4 mL. The visibility of the tracer was scored on CT and on MR images using a 5-point scoring scale. A Cohen's kappa statistic was calculated to assess interobserver agreement. To assess the unadjusted effects of baseline parameters on hydrogel visibility, we modeled visibility using a linear mixed-effect model. Injections were without complication. The kappa statistic was 0.77 (95% confidence interval [CI], 0.68-0.87). The volume of hydrogel injected was significantly associated with visibility on both CT (p = 0.032) and magnetic resonance imaging (p = 0.016). We analyzed visibility by location, controlling for amount. A 0.1-cc increase in volume injected was associated with increases of 0.54 (95% CI = 0.05-1.03) in the CT visibility score and 0.83 (95% CI = 0.17-1.49) in the MR visibility score. Injection of 0.4 cc or more was required for unequivocal visibility on CT or MR. No statistically significant correlation was found between tumor type, tumor location, or anatomical location of injection and visibility on either CT or magnetic resonance imaging. In this first report of an injectable radiopaque hydrogel, targets were visualized to assist with three-dimensional-based brachytherapy in gynecologic malignancies. This marker has potential for several applications, is easy to inject and visualize, and caused no acute complications.

Interfractional Needle Displacement During Multifraction HDR Interstitial Brachytherapy for Gynecological Malignancies

Interfractional Needle Displacement During Multifraction HDR Interstitial Brachytherapy for Gynecological Malignancies

Can Combined Intracavitary/Interstitial Approach Be an Alternative to Interstitial Brachytherapy in Computed Tomography-Guided Adaptive Brachytherapy for Gynecological Malignancies?: A Dosimetric Study

Can Combined Intracavitary/Interstitial Approach Be an Alternative to Interstitial Brachytherapy in Computed Tomography-Guided Adaptive Brachytherapy for Gynecological Malignancies?: A Dosimetric Study

Rectal and Bladder Toxicity in Patients Receiving CT-guided HDR Interstitial Brachytherapy for Gynecologic Malignancies

Rectal and Bladder Toxicity in Patients Receiving CT-guided HDR Interstitial Brachytherapy for Gynecologic Malignancies

Study of dosimetric variation due to interfraction organ movement in High Dose Rate Interstital (MUPIT) brachytherapy for gynecologic malignancies

Study of dosimetric variation due to interfraction organ movement in High Dose Rate Interstital (MUPIT) brachytherapy for gynecologic malignancies Ten patients with cancer of uterine cervix who underwent interstitial brachytherapy using MUPIT templates were CT scanned (CT1) using which bladder, rectum and CTV were delineated. The treatment plan PCT1 was generated and optimized geometrically on the volume. CT scan (CT2) was repeated before the second fraction of the treatment CTV and critical organs were delineated. The plan (PCT2) was created by reproducing the Plan PCT1 in the CT2 images and compared with PCT1. Bladder, Rectum and CTV percentage volume variation ranges from +28.6% to -34.3%, 38.4% to -14.9% and 8.5% to -15.2% respectively. Maximum dose variation in bladder was +17.1%, in rectum was up to +410% and in CTV was -13.0%. The dose to these structures varies independently with no strong correlation with the volume variation. Hence it is suggested that repeat CT and re-planning is mandatory before second fraction execution.

Evaluation of a Simple Method for CT Guided Interstitial Brachytherapy in Gynecologic Malignancies

Evaluation of a Simple Method for CT Guided Interstitial Brachytherapy in Gynecologic Malignancies

Brachytherapy management of the retroverted uterus using ultrasound-guided implant applicator placement

Purpose Patients with a retroverted uterus present a dilemma for brachytherapy in gynecologic malignancies because of the challenges of the procedure and the risk of uterine perforation. The purpose of this study was to evaluate the efficacy and outcome of ultrasound-guided brachytherapy applicator placement and intraoperative uterine anteversion in patients with gynecologic malignancies, who have a retroverted uterus. Methods and materials Thirty-three brachytherapy insertions were performed in 18 patients with retroverted uterus (cervical cancer, 17; vaginal cancer, 1). The endocervical canal was dilated, the intrauterine Fletcher tandem was inserted in retroverted fashion and then anteverted along with the uterus under continuous ultrasound guidance. The anteverted tandem position was secured with vaginal packing and use of a second and/or third flange on the tandem stem. Treatment was delivered with low-dose-rate brachytherapy using afterloading with 137Cs. Brachytherapy was combined with external beam radiation in all patients. Median post-therapy follow-up was 2.17 years (range, 0.75–9.25 years). Results Procedure. Ultrasound-guided dilation of the cervix was achieved in all procedures. Sounding of the retroverted uterus up to the fundus was accomplished successfully in all but one procedure (because severe retroflexion of the uterus and fixation of the fundus to the sacrum). Ultrasound-guided anteversion of the inserted tandem and uterus was achieved in all procedures. No ultrasonographic evidence of perforation was seen in any of the procedures. Intraoperative radiographs showed satisfactory position of the applicators in 31 of the 33 procedures; 2 cases were re-packed resulting in acceptable final applicator position. No backward rotation of the tandem was observed over the duration of the low-dose-rate brachytherapy application. The mean ratio between the dose to the rectum and Point A was 73%; the ratio between the dose to the bladder and Point A was 76%. Outcome. In the 17 patients with cervical cancer, 2-year pelvic tumor control rate was 100%, and 2-year actuarial disease-free survival was 73%. The patient with vaginal cancer has no evidence of disease 5 months post-therapy. There was one complication (1/18 patients, 5.5%): a rectal stricture in a patient with stage IVA cervical cancer requiring colostomy. Conclusions The use of ultrasound-guided uterine anteversion for brachytherapy applicator placement is feasible and results in acceptable outcome and complication rates in a population otherwise difficult to manage and at high risk for uterine perforation. Based on these results, this method is likely preferable to brachytherapy with a retroverted tandem, or to the omission of brachytherapy.