High Dose Rate Intraluminal Brachytherapy Research Articles

PP04 Presentation Time: 4:57 PM: MRI-Guided Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction: A Preliminary Analysis

PP04 Presentation Time: 4:57 PM: MRI-Guided Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction: A Preliminary Analysis

BRACHY: A Randomized Trial to Evaluate Symptom Improvement in Advanced Non-Small Cell Lung Cancer Treated With External Beam Radiation With or Without High-Dose-Rate Intraluminal Brachytherapy

Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial. Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided α of .05 and 80% power. A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P=.84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P=.49). Between group differences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symptoms, but only hemoptysis was significantly improved (P=.03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups. Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms.

79: A Systematic Review of Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction and Cholangiocarcinoma

79: A Systematic Review of Intraluminal High Dose Rate Brachytherapy in the Management of Malignant Biliary Tract Obstruction and Cholangiocarcinoma

20 TREATMENT OPTIMIZATION AND PROGNOSTIC FACTORS IN ADVANCED ESOPHAGEAL CANCER

Abstract Esophageal cancer is a disease with high mortality due to advanced stage at the time of diagnosis in patients with poor general condition and/or multiple comorbidities which makes them unsuitable for radical treatment. The goal of this clinical trial is finding optimal treatment for this group of patients. Methods Hypothesis of this clinical trial is that sequential use of high dose rate intraluminal brachytherapy, external beam radiotherapy and chemotherapy decreases symptoms of disease, improves quality of life and prolongs overall survival in patients with esophageal cancer that are not candidates for radical treatment. We have included patients with esophageal cancer that are not candidates for radical treatment. Statistical analysis was done only for the patients that have completed planned treatment and not for the intent to treat population. Therefore, statistical analysis was done for 39 patients, 22 in control group and 17 in interventional group. Results In a survival analysis adapted for AJCC stage of the disease, addition of sequential chemotherapy improves overall survival statistically significant (P = 0.004). Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy decreases the degree of: dysphagia (P = 0.001), odynophagia (P = 0.002) and regurgitation (P = 0.008) statistically significant. Decrease of a pain degree is statistically significant only with the use of sequential chemotherapy (P = 0.031). Sequential use of chemotherapy does not improve control over dysphagia (P = 0.872), odynophagia (P = 0.872) and regurgitation (P = 0.872) any further. Patients of female gender have greater improvement of regurgitation score (P = 0.068), pain score (P = 0.09) and quality of life (P = 0.019). Conclusion Sequential use of high dose rate intraluminal brachytherapy and external beam radiotherapy provides a safe use of high radiotherapy doses with minimal exposure of organs at risk, according to dose-volume histogram analysis. Sequential use of chemotherapy, after high dose rate intraluminal brachytherapy and external beam radiotherapy, improves overall survival in patients with esophageal cancer that are not candidates for radical treatment, in comparison to patients who do not receive chemotherapy (P = 0.09).

Comparative Study of two High Dose Rate Intraluminal Brachytherapy Schedules in Locally Advanced (Unresectable) CA Esophagus

Comparative Study of two High Dose Rate Intraluminal Brachytherapy Schedules in Locally Advanced (Unresectable) CA Esophagus

A prospective comparative study between concurrent chemoradiation with brachytherapy boost with concurrent chemoradiation alone in locally advanced cancer esophagus.

Context:Carcinoma esophagus is a highly malignant disease with very low cure rate. Concurrent chemoradiation is the standard of care in patients deemed unfit for surgery. Intraluminal brachytherapy (ILRT) is effective for palliation of dysphagia and is also used as a boost to external beam radiotherapy (EBRT) in curative intent.Aims:The aim of the study was to compare the clinical outcome of definitive concurrent chemoradiation followed by ILRT boost with concurrent chemoradiation alone in locally advanced carcinoma esophagus in terms of tumor response and toxicities.Settings and Design:A single institutional prospective study was carried out between January 2014 and June 2015.Subjects and Methods:Fifty-seven patients of locally advanced carcinoma esophagus were allocated to study and control arms. Both groups were treated with definitive concurrent chemoradiation with 44 Gy of EBRT. The chemotherapy consisted of injection cisplatin 70 mg/m2 intravenous on day 1 with capecitabine 800 mg/m2 b.i.d. daily from day 1 to 4 orally on days 1 and 22 of EBRT. After 2 weeks, the control group was treated with EBRT boost of 10 Gy in 5 fractions, while the study group received intraluminal high-dose rate (HDR) brachytherapy boost of 10 Gy in 2 fractions. No concurrent chemotherapy was administered during ILRT. The treatment outcome was assessed in terms of tumor response and toxicities using the CTCAE version 4.0 criteria.Results:At a median follow-up of 10 months, the overall response rate was 89.2% in the control group (25/28) and 93.10% in the study group (27/29). Acute hematological and gastrointestinal toxicities were noted.Conclusions:HDR ILRT in combination with EBRT is effective for treating dysphagia in cancer esophagus with low incidence of severe complications.

A feasibility study to investigate the introduction of HDR intraluminal brachytherapy for oesophageal cancer at university hospital galway

Intraluminal high-dose rate (HDR) brachytherapy is considered to be one of the most valuable options for the treatment of oesophageal cancer. This radiotherapy technique involves the insertion of specific types of plastic applicators into the body through the oesophagus. The aim of this project is to assess the feasibility of establishing an HDR intraluminal brachytherapy procedure for oesophageal cancer at University Hospital Galway (UHG). Commissioning was performed for applicators with diameters of 8 mm, 12 mm, and 14 mm. Applicators were provided by Varian Medical Systems. The most distal position of each applicator was determined using a gafchromic film (EBT3). Within this context, there is a dead space for each bougie where the source cannot be loaded. Consequently, the first position available is determined from the end of the dead space. The dead space for the applicators of 8, 12 and 14 mm diameter was found to be at 10 cm, 15 cm and 17 cm from the tip of each applicator, respectively. The most distal source position of the bougies (with diameters of 8 mm, 12 mm or 14 mm) was found to be 50 mm from the end of the dead space. Successful collaboration among specialists working in enormously diverse disciplines (e.g., radiation physicists, oncologists, nurses, and therapists) is the fundamental aspect that will determine the success of establishing HDR intraluminal brachytherapy at UHG. Structures must be developed to assist everyone working in these diverse disciplines to coordinate and safely implement this procedure.

Official Annual Meeting of Indian Brachytherapy Society: 9th ANNUAL CONFERENCE OF INDIAN BRACHYTHERAPY SOCIETY 2019 (IBSCON 2019) PROCEEDINGS.

PurposeTo evaluate and compare response and toxicities in patients treated with chemoradiation alone and chemoradiation with high dose rate intraluminal brachytherapy in carcinoma of the esophagus.Material and methodsA total of 60 patients were included in the study and were divided randomly into 1 arms – CT RT arm and ILBT arm with 30 patients each. CT RT received definitive chemoradiation 54 Gy in 27 fractions with concurrent weekly cisplatin and ILBT received definitive chemoradiation 50 Gy in 25 fractions with concurrent weekly cisplatin followed by two sessions of intraluminal brachytherapy of 4 Gy each. Evaluation of early response was done 1 and 6 months after completion of chemoradiation on a clinical basis and by upper GI endoscopy. Dysphagia scores were recorded before, on completion of treatment and in the 1st and 6th month of follow-up. Acute gastro-intestinal toxicities (fistula, stricture, ulcer, esophagitis) were evaluated.ResultsThe patient characteristics were comparable in both the arms. Dysphagia to solids was more frequent in the chemoradiation alone arm compared to the ILBT arm at the end of 1 month and 6 months. 80% had a complete clinical response in the CT-RT arm compared to 86.7.3% in the ILBT arm. Grade 3 stricture was more frequent in arm 2. Grade 2 ulceration was seen only in arm 2. None of the patients developed fistula or pneumonitis. There was improvement in dysphagia in both the arms with 50% in arm 1 and 67% in arm 2 tolerating a normal solid diet at the end of 6 months.ConclusionsChemoradiation with ILBT for carcinoma of the esophagus provides excellent local control of the disease with acceptable toxicities when compared with chemoradiation alone.

Palliative treatment with radiotherapy in patients of advanced esophageal carcinoma

Background: Esophageal carcinoma is high prevalence in Asia, including India and most of the patients present in advanced and inoperable stage. Most of the patients have poor nutritional status and low performance status. These patients are unable to tolerate radical treatment. Prognosis of these patients is very poor. There are no enough data of prospective study in palliation of dysphagia of the patients with inoperable esophageal carcinoma with radiotherapy in Eastern India. Objectives: The main objective of our study was palliation of dysphagia of the patients with inoperable esophageal carcinoma with radiotherapy. Materials and Methods: The study was done with 43 patients with histopathologically proven squamous cell carcinoma and/or adenocarcinoma at thoracic esophagus, intraluminal brachytherapy feasible. Patients were received external beam radiotherapy palliative dose 30 Gy in 10 fractions for 2 weeks followed by intraluminal high-dose rate brachytherapy 6 Gy per fraction per week for 2 weeks. Results: In our study, the mean age of the patients was 58 years (age range 48 years–70 years). 1 month after completion of intraluminal brachytherapy, a number of patients with improvement of dysphagia were 34 (79%). The improvement of dysphagia was maintained 25 (73.5%) patients at 3-month completion of treatment and 14 (56%) patients at 6-month completion of treatment. The median duration of dysphagia relief was 5.2 months. Post-radiotherapy complications as chest pain were seen in 10 (23.2%) patients, esophageal strictures were developed in 7 (16.3%) patients, ulcerations were in 4 (9.3%) patients, and esophageal fistula was developed in 1 (2.3%) patient. Conclusion: The patients with advanced inoperable or metastatic esophageal carcinoma and poor performance status, palliative radiotherapy are effective modality of treatment for the improvement of dysphagia.

High-dose rate intraluminal brachytherapy: An effective palliation for cholangiocarcinoma causing bile duct obstruction

High-dose rate intraluminal brachytherapy: An effective palliation for cholangiocarcinoma causing bile duct obstruction

Radiation Dose to Heart and Great Vessels During Esophageal HDR Brachytherapy

Esophageal cancer patients’ initial treatment is high dose rate (HDR) intraluminal brachytherapy. The treatments are often given as 1800cGy over 3 fractions. Currently, post-treatment CT scans are not required for brachytherapy. During a given treatment fraction, the cranial and caudal extent of the disease is identified under fluoroscopic guidance and a predetermined treatment plan is selected based on the clinical observations. A fraction dose of 600cGy is prescribed at 1cm from the centre axis of the treatment catheter. This will inevitably result in the heart being irradiated. The aim of this study is to assess radiation dose received by the heart and great vessels during HDR intraluminal brachytherapy of esophageal cancers. This study evaluated the treatment plans of 11 patients who underwent a CT scan with the catheter in place following intraluminal HDR brachytherapy of the esophagus. A marker wire was placed into the catheter for better visualization. Post-treatment CT data were imported into the Eclipse BrachyVision planning system. Contours of heart and great vessels (aorta, pulmonary artery, superior vena cava) were drawn. The catheter was digitized and all treatment parameters were reproduced in the planning system resulting in the delivered 3-dimensional dose distribution. Homogeneous and heterogeneous dose calculations were performed and the resulting DVHs analyzed for maximum point doses and volume doses. Comparisons were made with Timmerman’s 3-fraction hypofractionated dose constraint recommendations for normal tissues. Volume doses of organs at risk (OARs) were well below the Timmerman dose constraints; however, maximum point doses calculated in the heart greatly exceeded the respective constraint. The dose to the heart was related to the proximity of the heart to the tumour and hence treatment catheter. Differences in calculated OAR doses using homogeneous and heterogeneous dose calculation engines were minimal. The study’s assessment of dose received to the heart and great vessels validated the accuracy of standardized planning of esophageal HDR brachytherapy. Therefore, current protocols without post-treatment CT are satisfactory and heterogeneous dose calculations are not necessary.

A Phase 3, Multicenter, Randomized Trial to Evaluate the Symptomatic and Quality of Life Improvements in Lung Cancer Patients Receiving External Beam Radiation With or Without High Dose Rate Intraluminal Brachytherapy

A Phase 3, Multicenter, Randomized Trial to Evaluate the Symptomatic and Quality of Life Improvements in Lung Cancer Patients Receiving External Beam Radiation With or Without High Dose Rate Intraluminal Brachytherapy

A method for verification of treatment times for high-dose-rate intraluminal brachytherapy treatment

Purpose: This study was aimed to increase the quality of high dose rate (HDR) intraluminal brachytherapy treatment. For this purpose, an easy, fast and accurate patient-specific quality assurance (QA) tool has been developed. This tool has been implemented at Bahawalpur Institute of Nuclear Medicine and Oncology (BINO), Bahawalpur, Pakistan. Methods: ABACUS 3.1 Treatment planning system (TPS) has been used for treatment planning and calculation of total dwell time and then results were compared with the time calculated using the proposed method. This method has been used to verify the total dwell time for different rectum applicators for relevant treatment lengths (2-7 cm) and depths (1.5-2.5 cm), different oesophagus applicators of relevant treatment lengths (6-10 cm) and depths (0.9 & 1.0 cm), and a bronchus applicator for relevant treatment lengths (4-7.5 cm) and depth (0.5 cm). Results: The average percentage differences between treatment time T M with manual calculation and as calculated by the TPS is 0.32% (standard deviation 1.32%) for rectum, 0.24% (standard deviation 2.36%) for oesophagus and 1.96% (standard deviation 0.55%) for bronchus, respectively. These results advocate that the proposed method is valuable for independent verification of patient-specific treatment planning QA. Conclusion: The technique illustrated in the current study is an easy, simple, quick and useful for independent verification of the total dwell time for HDR intraluminal brachytherapy. Our method is able to identify human error-related planning mistakes and to evaluate the quality of treatment planning. It enhances the quality of brachytherapy treatment and reliability of the system.

Assessing patient characteristics and radiation-induced non-targeted effects in vivo for high dose-rate (HDR) brachytherapy

Purpose: To test whether blood, urine, and tissue based colony-forming assays are a useful clinical detection tool for assessing fractionated treatment responses and non-targeted radiation effects in bystander cells.Materials and methods: To assess patients’ responses to radiation treatments, blood serum, urine, and an esophagus explant-based in vivo colony-forming assay were used from oesophageal carcinoma patients. These patients underwent three fractions of high dose rate (HDR) intraluminal brachytherapy (ILBT).Results: Human keratinocyte reporters exposed to blood sera taken after the third fraction of brachytherapy had a significant increase in cloning efficiency compared to baseline samples (p < 0.001). Such results may suggest an induced radioresistance response in bystander cells. The data also revealed a clear inverse dose-rate effect during late treatment fractions for the blood sera data only. Patient characteristics such as gender had no statistically significant effect (p > 0.05). Large variability was observed among the patients’ tissue samples, these colony-forming assays showed no significant changes throughout fractionated brachytherapy (p > 0.05).Conclusion: Large inter-patient variability was found in the urine and tissue based assays, so these techniques were discontinued. However, the simple blood-based assay had much less variability. This technique may have future applications as a biological dosimeter to predict treatment outcome and assess non-targeted radiation effects.

EP-1614: High dose-rate intraluminal brachytherapy as palliative treatment of malignant obstructive jaundice

EP-1614: High dose-rate intraluminal brachytherapy as palliative treatment of malignant obstructive jaundice

High dose rate intraluminal brachytherapy in esophageal cancer: Our experience

High dose rate intraluminal brachytherapy in esophageal cancer: Our experience

Near-catheter dosimetry of a HDR brachytherapy source using Gafchromic film

High dose rate intraluminal brachytherapy treatments can be delivered using as few as one or two afterloading catheters, delivering doses of up to 10Gy at 10mm, leading to high dose gradients and extreme hot spots close to the catheter. These conditions have the potential to damage the patient's health tissues, possibly leading to necrosis, or even death from uncontrolled bleeding. Ionisation chambers and solid state detectors are limited in their usefulness for near-catheter dosimetry because of their physical size and in some cases energy and dose rate dependence. In contrast, radiochromic film has a large dose-response range, excellent spatial resolution, near-energy independence for megavoltage photons and the ability to measure dose in two dimensions, making it ideal for this application. The aim of this study was to measure the location and relative magnitude of any dosimetric hot spots produced by a typical endobronchial treatment plan. The study also investigated the effect of the step size of the (192)Ir source on both the dose hot spots and dose distribution. Our measurements show that for a typical single catheter treatment with 2.5mm step size the maximum dose hot spots at the catheter surface are up to 37 times the prescription dose, up to 40 times for a 5mm step size, and up to 46 times for a 10mm step size. It is important that brachytherapy clinicians and physicists understand that hot spot magnitude increases with source step sizes and are aware of the risks associated with this form of brachytherapy treatment.

Endoluminal high-dose-rate brachytherapy for early stage and recurrent esophageal cancer in medically inoperable patients

The management of superficial primary and recurrent esophageal cancer (EC) in medically inoperable patients is complex. Endoluminal high-dose-rate (HDR) brachytherapy has shown mixed results in terms of toxicity and local control. In this study, we examined the outcomes and toxicities in a set of patients with superficial primary and recurrent EC treated with a consistent HDR technique. Between 8/2008 and 7/2011, 14 patients were treated with HDR intraluminal brachytherapy, 10 (71.4%) with recurrent disease, and 4 (28.6%) with previously unirradiated lesions. Patients received three weekly fractions to a median dose of 12 Gy (range, 10-15 Gy); dose was prescribed to 7-mm median depth with mucosal dose limited to 8-10 Gy using a 12-14-mm applicator. Median followup was 15.4 months. Overall freedom from failure (OFFF) and overall survival (OS) at 18 months were 30.8% (95% confidence interval [CI]: 5.2, 56.4) and 72.7% (95% CI: 45.3, 100), respectively. For patients with recurrent disease, OFFF and OS at 18 months were 11.1% (95% CI: 0, 32.1) and 55.6% (95% CI: 15.4, 95.8), respectively. For patients with previously unirradiated disease, OFFF and OS at 18 months were 75.0% (95% CI: 31.6, 100) and 100.0%, respectively. Eight (57.1%) patients had Grade 1 acute adverse effects; 6 (42.9%) patients had chronic Grade 1 adverse effects; 1 (7.1%) patient developed Grade 2 stricture. Grade 3 tracheoesophageal fistula occurred in 1 (7.1%) patient. One patient died before completion of treatment of unrelated causes. HDR endoluminal brachytherapy is a well-tolerated treatment for superficial primary and recurrent EC in medically inoperable patients.

The involvement of serum serotonin levels producing radiation-induced bystander effects for an in vivo assay with fractionated high dose-rate (HDR) brachytherapy

Purpose: The primary goal of this investigation was to observe whether measurable levels of bystander factor(s) can be detected in esophageal carcinoma patients’ urine samples taken after undergoing high dose rate (HDR) intraluminal brachytherapy (ILBT). However, a small pilot study was developed to evaluate whether serotonin [5-Hydroxytryptamine (5-HT)] serum levels play an active role in the mechanisms of radiation-induced bystander effects (RIBE) at high doses.Materials and methods: In the present study, a colony-forming in vivo assay was developed and used for the detection of non-targeted effects. Samples of urine were collected from five esophageal carcinoma patients undergoing fractionated HDR-ILBT. To observe whether 5-HT modulates the bystander effect at higher doses, different batches of foetal bovine serum (FBS) and 5-HT were tested on the same urine samples before and after brachytherapy.Results: Some of our data suggests statistically significant evidence for serotonin playing an active role as a signalling molecule at higher doses when patients underwent HDR-ILBT.Conclusion: However, a more thorough investigation, with a larger sample size, is warranted before serotonin can be known to play a role in bystander effects at this particular dose range and treatment regime.

Long-term results of curative intraluminal high dose rate brachytherapy for endobronchial carcinoma

BackgroundThe treatment strategy of central lung tumors is not established. Intraluminal brachytherapy (ILBT) is widely used for palliative treatment of endobronchial tumors, however, it is also a promising option for curative treatment with limited data. This study evaluates the results after ILBT for endobronchial carcinoma.MethodSixteen-endobronchial carcinoma of 13 patients treated with ILBT in curative intent for 2000 to 2008 were retrospectively reviewed. ILBT using high dose rate 192 iridium thin wire system was performed with 5 Gy/fraction at mucosal surface. The patient age ranged from 57 to 82 years old with median 75 years old. The 16 lesions consisted of 13 central endobronchial cancers including 7 roentgenographically occult lung cancers and 3 of tracheal cancers. Of them, 10 lesions were treated with ILBT of median 20 Gy combined with external beam radiation therapy of median 45 Gy and 6 lesions were treated with ILBT alone of median 25 Gy.ResultsMedian follow-up time was 32.5 months. Two-year survival rate and local control rate were 92.3% and 86.2%, respectively. Local recurrences were observed in 2 lesions. Three patients died due to lung cancer (1 patient) and intercurrent disease (2 patients). Complications greater than grade 2 were not observed except for one grade 3 dyspnea.ConclusionsILBT combined with or without EBRT might be a curative treatment option in inoperable endobronchial carcinoma patients with tolerable complication.