Intraluminal High Dose Rate 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

Chemoradiotherapy Combined with Brachytherapy for the Definitive Treatment of Esophageal Carcinoma.

This study aims to investigate the effect of dose escalation with brachytherapy (BT) as an addition to definitive chemoradiotherapy (CRT) on local control and survival in esophageal cancer. From 2001 to 2020, 183 patients with locally limited or locally advanced esophageal cancer received definitive CRT with or without brachytherapy in a two-center study. External-beam radiotherapy was delivered at 50.4 Gy in 1.8 Gy daily fractions, followed by a sequential boost to the primary tumor of 9 Gy in 1.8 Gy daily fractions if indicated. Intraluminal high dose rate (HDR) Ir-192 brachytherapy was performed on 71 patients at 10 Gy in two fractions, with one fraction per week. The combined systemic therapy schedules used included 5-fluorouracil/cisplatin or 5-fluorouracil alone. Cisplatin was not administered in patients receiving brachytherapy. The median local progression-free survival was significantly extended in the BT group (18.7 vs. 6.0 months; p < 0.0001), and the median local control was also significantly prolonged (30.5 vs. 11.3 months, p = 0.008). Overall survival (OS) significantly increased in the BT group (median OS 22.7 vs. 9.1 months, p < 0.0001). No significant difference in the overall rate of acute toxicities was observed; however, the rate of acute esophagitis was significantly higher in the BT group (94.4% vs. 81.2%). Likewise, the overall rate of late toxicities (43.7% vs. 18.8%) was significantly higher in the BT group, including the rate of esophageal stenosis (22.5% vs. 9.8%). There was no difference in the occurrence of life-threatening or lethal late toxicities (grades 4 and 5). Brachytherapy, after chemoradiation with single-agent 5-FU, represents a safe and effective alternative for dose escalation in the definitive treatment of esophageal cancer.

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

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.

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.

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.

YI02.03 Dose Limitations for Radiotherapy of Lung Cancer

YI02.03 Dose Limitations for Radiotherapy of Lung Cancer

Simple Figure of Merit to Assess Intraluminal Brachytherapy Plans

To design a simple figure of merit that can be used to assess the accuracy and optimization of intraluminal High Dose Rate (HDR) brachytherapy plans.

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.

Intraluminal High Dose Rate Brachytherapy for Palliation of Dysphagia in Cancer of the Oesophagus

Intraluminal High Dose Rate Brachytherapy for Palliation of Dysphagia in Cancer of the Oesophagus

Reirradiation of head and neck cancer with high-dose-rate brachytherapy: A customizable intraluminal solution for postoperative treatment of tracheal mucosa recurrence

Purpose Delivering adequate dose to tracheal mucosa recurrence after multiple prior courses of surgery and radiation presented a challenge for radiation delivery. Tumor bed location and size, combined with previous doses to surrounding areas, complicated the use of external beam therapy with either photons or electrons. High-dose-rate (HDR) brachytherapy was explored to provide sufficient dose coverage. Methods and Materials A 45-year-old gentleman presented with recurrent head and neck cancer. After undergoing additional excision of gross tumor in the tracheal region, radiation was recommended to improve local control. The region of residual tumor was confined to a small superficial lesion at the posterior–superior aspect of the trachea, involving mucosa located along the bend of the trachea, immediately deep to the stoma. External beam treatment was discussed but was not recommended based on recurrence location in the prior radiation field and patient’s flexed chin position. HDR technique with a custom applicator was preferred. Results A three-dimensional HDR plan based on computed tomography used a single catheter optimized to cover gross tumor volume as delineated by physician. Prescribed dose was 5 Gy/fraction for six fractions (two fractions/wk). The applicator position was verified daily with computed tomography and physician setup approval before treatment. The patient was positioned on a wing board to allow access to the stoma. HDR brachytherapy was well tolerated. Conclusions Intraluminal HDR brachytherapy is a viable option for providing dose to region inside tracheal stoma. Advantages over photon and electron beam therapy include reduced dose to surrounding tissues previously irradiated, skin dose, and reproducibility of treatment delivery.

High-dose-rate afterloading intraluminal brachytherapy for advanced inoperable rectal carcinoma

Purpose High-dose-rate (HDR) intraluminal brachytherapy for advanced or inoperable tumors of the rectum has been used both palliatively and to dose escalate after chemoradiation for curative treatment. Methods Between 1993 and 2007, 79 patients were treated with HDR afterloading brachytherapy for rectal cancer; 70 patients had adenocarcinoma of the rectum; and 9 patients had squamous cell carcinoma of the anal canal. Fifty-two patients had localized disease but were unfit for major surgery and received radiotherapy with radical intent. Twenty-seven patients with advanced or metastatic disease received palliative treatment. The median age was 82 years (range, 33–97). Radical treatment comprised either chemoradiation followed by intraluminal brachytherapy delivering 12 Gy at 1 cm in two fractions or radical monotherapy delivering up to 36 Gy at 1 cm in six fractions two to three times weekly. Palliative HDR brachytherapy schedules were predominantly 10 Gy at 1 cm single dose. Results Objective local tumor response was seen in 41 of 48 assessable patients (85%); of whom, 28 patients (58%) had a complete response and 13 (27%) had a partial response. The most common symptom was rectal bleeding, which was controlled with a complete response rate of 63%. The median duration of the symptom response was 3 months (range, 1–73), and the median survival of the palliative patients was 6 months (range, 1 week–37 months). The median survival for patients treated with radical intent was 18.5 months (range, 2–119). Six patients reported late toxicity with three cases of rectal ulcer, two strictures, and one fistula. Conclusions Intraluminal HDR brachytherapy is effective as local treatment in both the radical and palliative setting, with high tumor and symptom response rates, and acceptable late toxicity.

Intraluminal brachytherapy in the management of squamous carcinoma of the esophagus

Intraluminal high dose rate brachytherapy (ILHDR BT) is one of several effective modalities for palliation of advanced esophageal cancer. Thirty patients with endoscopic-proven, mostly locally advanced, squamous cell carcinoma of the esophagus, not involving the gastroesophageal junction and without distant metastases, were included in this analysis. Twenty-nine patients received two ILHDR BT sessions of 8 Gy within a week and one patient received only one session. All patients were followed monthly. Outcomes included quality of life (QOL), symptoms control: dysphagia, regurgitation, odynophagia, and chest or back pain, as well as, overall survival. Through 4 months of follow-up, QOL was statistically improved (having lowered scores) in regards to feelings (P= 0.013), sleeping (P= 0.032), eating (P= 0.020), and social life (P= 0.002). The most significantly improved symptom was dysphagia (P < 0.006), with a reduction of 0.52 units or one-half grade. Regurgitation, odynophagia, and pain were lower during follow-up but were not statistically significant. The median overall survival from death of any cause was 165 days (with a 95% confidence interval of 128-195 days). In conclusion, ILHDR BT of advanced squamous esophageal cancer consisting of two out-patient procedures is very successful in achieving the primary objectives of the patients to reduce dysphagia and improve QOL.

Intraluminal high-dose rate brachytherapy (HDR) with or without external radiotherapy in patients with unresectable hilar cholangiocarcinoma

Intraluminal high-dose rate brachytherapy (HDR) with or without external radiotherapy in patients with unresectable hilar cholangiocarcinoma

Endoscopic intraluminal brachytherapy and metal stent in malignant hilar biliary obstruction: a pilot study

Malignant hilar biliary obstruction carries a poor prognosis, as the disease is often unresectable at the time of diagnosis. Various palliative measures as surgical/radiological/ endoscopic drainage with or without radiotherapy/chemotherapy have been tried with dismal outcome. We prospectively studied the effect of unilateral metal stent with intraluminal high dose rate (HDR) brachytherapy in patients with type II malignant hilar biliary obstruction. Eight patients with type II malignant hilar biliary obstruction were treated with contrast-free unilateral metal stenting followed by endoscopic intraluminal brachytherapy (ILBT). A retrospectively analyzed group of 10 patients treated only with contrast-free unilateral metal stenting served as historical controls. A successful drainage was achieved in all, cholangitis occurred in none and no patient died within 30 days in both groups. The mean (+/-SD) patency of metal stent was 305 (+/-183.96) days and 143.9(+/-115.11) days in patients with and without intraluminal brachytherapy, respectively (P=0.03). Mean (+/-SD) survival of these patients was 310 (+/-192.68) days and 154.9 (+/-122.51) days in patients with and without intraluminal brachytherapy, respectively (P=0.05). Kaplan-Meier analysis showed estimated median survival of 225 (95% CI; 169.5, 280.4) days in brachytherapy and 100 (95%CI; 94.1, 105.8) days in control group (P=0.025). No major complications related to metal stent or ILBT were observed. Contrast-free unilateral metal stenting with HDR ILBT in type II malignant hilar biliary obstruction is a safe and effective method of palliation and appears to prolong patient survival as well as patency of stent in these patients, however, a larger, randomized trial is required to validate the same.

Brachytherapy improved dysphagia more than stenting in people with inoperable oesophageal cancer: Abstracted from: Homs MYV, Steyerberg EW, Eijkenboom WMH et al. Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: a multicentre randomised trial. Lancet 2004; 364:1497–504

The prognosis of oesophageal cancer is poor (10–15% 5-year survival rate) and dysphagia is a common complication in advancing disease. Palliative therapy aims to relieve dysphagia and prevent fistulation. Brachytherapy (intraluminal radiotherapy) and stenting are two commonly used palliative techniques for relieving dysphagia. The relative effectiveness of these techniques is not known. The role of teletherapy (TT) supplementary to intraluminal high dose rate (ILHDR) brachytherapy (BT) in the palliation of advanced oesophageal cancer (E33021). Available from: http://www-crp.iaea.org/ (Searched Jan 2005). A randomized phase III study in advanced oesophageal cancer to compare palliation of dysphagia in patients treated with radiotherapy versus chemo-radiotherapy (TROG 03.01/ NCIC CTG ES2). Available from: http://www.ranzcr.edu.au, http://www.ctg.queensu.ca/ (Searched Jan 2005).

211 Intraluminal high dose rate brachytherapy in the treatment of carcinomas of the subhepatic region

The −863 C/A polymorphism in the tumor necrosis factor-α (TNF-α) promoter has been suggested to influence TNF-α expression. Here we elucidated the molecular mechanisms underlying the allele-specific regulation of TNF-α gene expression under basal and LPS-stimulated conditions in THP-1 cells and in human primary macrophages. We show that the binding of two NF-κB complexes, the p50/p50 homodimer and the p50/p65 heterodimer, was upregulated upon LPS stimulation. Both complexes bound to the C-allele whereas the A-allele only bound the p50/p65 complex. Two DNase I hypersensitive sites appeared in the TNF-α promoter after LPS stimulation of THP-1 cells. DNase I hypersensitivity of the TNF-α promoter was also analyzed in human monocytes prepared from individuals of different −863C/A genotype. Hypersensitivity was increased in the promoter harboring the mutant A-allele, particularly after LPS stimulation. In summary, binding of transcription factor NF-κB to the TNF-α promoter is associated with allele-specific remodeling of chromatin structure.

Intraluminal 192Ir brachytherapy following transjugular intrahepatic portosystemic shunt revision : Long-term results and radiotherapy parameters

Purpose: The stenosis or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) occurs in up to 75% of patients within 12 months after treatment. The aim of our investigation was to evaluate the feasibility, safety and efficacy of intraluminal high-dose rate brachytherapy (HDRBT) with Iridium-192 following TIPS revision to prevent restenosis due to pseudointimal hyperplasia. Materials and methods: Between September and November 1996, intraluminal BT was performed in five patients after TIPS revision. The indications for initial TIPS were a Budd–Chiari syndrome in two female patients and recurrent variceal bleeding by alcoholic liver cirrhosis in three male patients. TIPS was created with Wallstents (10 mm diameter in four patients) and Palmaz stent (10 mm diameter in one patient). The re-dilatation was done in all five patients 6 months after first stenting because of restenosis (>50% stent lumen reduction) or occlusion of the stent. A 5-French closed-tip, noncentered BT delivery catheter was used for subsequent radiotherapy. The whole length of the stent and performed dilatation (interventional length — IL) was taken as clinical target length (CTL). A 10-mm safety margin was added proximal and distal to the CTL due to uncertainties of BT source positioning, so forming the planning target length (PTL). To ensure that prescribed dose covers the whole PTL, the active source length (ASL) was 5 mm longer proximal and distal than PTL, so forming the reference isodose length (RIL). A dose of 12 Gy was prescribed in 3 mm distance from the source axis in the mid-plane of the applicator for three patients and in 5 mm distance for two patients. Results: A normal patency (<50% lumen reduction) of the stent was achieved at 44 months follow-up (duplex sonography+portography) in all three patients with liver cirrhosis, whereas further revisions were necessary in two patients with Budd–Chiari syndrome (after 5.5 and 18 months). No acute, subacute or late brachytherapy (BT)-related side effects were seen until now. Conclusion: HDRBT following TIPS revision was safe and feasible in all patients. The exact impact of BT on the TIPS patency should be evaluated in larger clinical trials. Moderate dose escalation and use of today's commercially available centering radiation catheters seem to be necessary.

Standard linear plans in single channel high dose rate brachytherapy: a dosimetric analysis

The use of standard linear plans is proposed for single channel intraluminal High Dose Rate brachytherapy. This technique employs the optimized dwell times derived from a straight line within a curved geometry. Such standardization of the planning procedure ensures expedient delivery of treatment. The 3-D dose distribution resulting from the use of standard linear plans within various curved geometries is investigated. In this study a comparison is made between the dose delivered to the perimeter of the target volume from both standard linear plans and individually optimized plans. Our results demonstrate that the use of a standard linear plan is acceptable in curved geometries, given the current practice of dose and volume specification for high dose rate intraluminal brachytherapy.