Perioperative High-dose-rate Brachytherapy Research Articles

Long-term results of intraoperative multicatheter breast implant (IOMBI) for accelerated partial breast irradiation (APBI) on early breast cancer patients

Background and purposeMulticatheter breast brachytherapy is a standard technique for accelerated partial breast irradiation (APBI) in early breast cancer patients. Intraoperative multicatheter breast implant (IOMBI) followed by perioperative high-dose-rate brachytherapy (PHDRBT) offers a novel and advantageous approach. We present long-term oncological, toxicity, and cosmesis outcomes for a well-experienced single institution. Materials and methodsEligible women aged ≥ 40 years with clinically and radiologically confirmed unifocal invasive or in situ ≤ 3 cm breast tumors underwent IOMBI during breast-conserving surgery. Patients meeting APBI criteria by definitive pathologic results received 3.4 Gy × 10fx with PHDRBT. Patients not suitable for APBI received PHDRBT-boost followed by WBRT. ResultsA total of 171 patients underwent IOMBI during BCS, 120 patients (70.1 %) were suitable for APBI and 51 (29.8 %) for anticipated PHDRBT-boost. The median age was 61 years (range: 40–78), the median tumor size was 1.1 cm (range: 0.2–3.5), with a histological diagnosis of invasive ductal carcinoma in 78.9 % and ductal in situ in 21.1 %. A median of 9 catheters (range: 4–14) were used. For APBI, the median CTV and V100 were 40.8 cc (range: 8.6–99) and 35.4 cc (range: 7.2–94). The median of healthy breast tissue irradiated represents 7.2 % (range: 2.3–28 %) and the median local treatment duration was 10 days (range: 7–16). With a median follow-up of 8.8 years (range: 0.3–16.25), the 8-year local, locoregional, and distant control rates were 99 %, 98.1 %, and 100 %. G1-G2 late-toxicity rate was 53.4 %. Long-term cosmetic evaluation was excellent-good in 90.8 %. ConclusionIOMBI&PHDRBT program reports excellent long-term oncological outcomes, with a reduction from unnecessary irradiation exposure which translates into low long-term toxicity and good cosmesis outcomes, especially on well-selected APBI patients.

Pilot Evaluation of Perioperative High Dose Rate Brachytherapy in Head Neck Cancers.

Perioperative high dose rate brachytherapy involves insertion of brachytherapy catheter over the tumor bed during surgical removal of disease followed by radiation in the postoperative period. It has applications in radiotherapy dose escalation or reirradiation and for extending the surgical margins. We report here initial results of treatment in five cases of locally advanced head and neck cancers.

MSOR10 Presentation Time: 5:30 PM: Ultra-Accelerated Perioperative High Dose Rate Brachytherapy for Early Breast Cancer, Preliminary Results from a Phase II Trial

MSOR10 Presentation Time: 5:30 PM: Ultra-Accelerated Perioperative High Dose Rate Brachytherapy for Early Breast Cancer, Preliminary Results from a Phase II Trial

Dose volume histogram constraints in patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative HDR brachytherapy

BackgroundWound healing complications (WHC), osteoradionecrosis (ORN), and nerve damage (ND) are common adverse effects in adult patients with soft tissue sarcomas of the extremities and the superficial trunk treated with surgery and perioperative high dose rate brachytherapy (PHDRB) alone or combined with external beam radiotherapy (EBRT). RationaleAnalysis of the treatment factors contributing to these complications can potentially minimize their occurrence and severity. PatientsA total of 169 patients enrolled in two parallel prospective studies were included in this analysis. Previously Unirradiated cases (Group 1; n = 139) were treated with surgical resection, 16–24 Gy of PHDRB and 45 Gy of EBRT. Adjuvant chemotherapy was given to selected patients with high-grade tumors. Previously irradiated cases (Group 2; n = 30) were treated with surgical resection and 32–40 Gy of PHDRB without further EBRT. MethodsPatient factors, tumor factors, surgical factors, PHDRB factors and EBRT factors were analyzed using Cox univariate and multivariate analysis. ResultsIn Previously Unirradiated cases, WHC, ORN and ND occurred in 38.8%, 5.0% and 19.4%. Multivariate analysis indicated that WHC increased with CTV size (p = 0.02) and CTV2cm3 Physical dose (p = 0.02). ORN increased with Bone2cm3 EQD2 ≥ 67 Gy(p = 0.01) and ND was more frequent in patients with TV100DVH-based dose (tissue volume encompassed by the 100% isodose) ≥ 84 Gy (p < 0.01). In Previously Irradiated cases, WHC, ORN and ND occurred in 63.3%, 3.3% and 23.3%. Multivariate analysis showed that WHC was more frequent in patients with Skin2cm3Lifetime EQD2 ≥ 84 Gy (p = 0.01) and ND was more frequent after CTVD90 Physical Doses ≥ 40 Gy (p < 0.01). ConclusionsWHC in Previously Unirradiated patients can be minimized by using a more conservative CTV definition together with a meticulous implant technique and planning aimed to minimize hyperdose CTV2cm3 areas. In Previously Irradiated patients WHC may be mimimized considering Lifetime EQD2 Skin2cm3 doses. ORN can be reduced by using the Bone2cm3 EQD2 constraint. ND occurs more frequently in patients with large tumors receiving high treated volume doses, but no specific constraints can be recommended due to the lack of peripheral nerve definition during brachytherapy planning.

Perioperative high-dose-rate brachytherapy (PoHDR) in the multidisciplinary management of adult soft tissue sarcomas: a realistic alternative for a moderate radiotherapy dose escalation

Conservative surgery in combination with local radiation therapy is considered a standard approach for soft tissue sarcomas (STS) leading to high local control rates and widely replacing the need for amputations. A close relationship exists between total radiation dose and local control probability. Combination of external beam radiotherapy and perioperative brachytherapy represents a moderate dose escalation that could contribute to improve local control. From May 2015 to October 2018, 23 patients with histologically proven STS of various locations were prospectively entered into a data registry of perioperative HDR brachytherapy (PoBT) combined with external beam radiotherapy (EBRT). Multidisciplinary treatment comprised wide surgical excision, PoBT (16.5 Gy delivered in 3 fractions of 5.5 Gy twice daily with a gap time of at least 6 h between fractions), and EBRT delivered either pre- or postoperatively (median dose 47 Gy, range 40–57.5 Gy) up to a total accumulated radiotherapy equivalent dose for tumor of 69.5 to 86.5 Gy (median, 76.1 Gy), representing a moderate total dose escalation over the 66 Gy traditionally used. With a median follow-up of 13.4 months (range, 1–35.4 months), 22 patients (96%) remain alive without evidence of local or distant recurrence, 1 patient (4%) is alive with local relapse, and no patient has died because of tumor progression. Treatment-related adverse effects were mild or moderate. No cases of grades 4–5 late toxicity have been observed during the follow-up period. HDR PoBT is safe, feasible, and well tolerated and allows for a moderate radiation dose escalation with acceptable rates of tumor control. Further follow-up is necessary to confirm impact on final outcomes.

Minimally invasive tumor bed implant (MITBI) and peri-operative high-dose-rate brachytherapy (PHDRBT) for accelerated minimal breast irradiation (AMBI) or anticipated boost (A-PHDRBT-boost) in breast-conserving surgery for ductal carcinoma in situ.

PurposeTo evaluate our institutional experience of minimally invasive tumor bed implantation (MITBI) during breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) to deliver peri-operative high-dose-rate brachytherapy (PHDRBT) as accelerated minimal breast irradiation (AMBI) or anticipated boost (A-PHDRBT-boost).Material and methodsPatients older than 40, with clinical and radiological unifocal DCIS < 3 cm were considered potential candidates for accelerated partial breast irradiation (APBI) and were implanted during BCS using MITBI-technique. Patients who in final pathology reports showed free margins and no other microscopic tumor foci, received AMBI with PHDRBT (3.4 Gy BID in 5 days). Patients with adverse features received A-PHDRBT-boost with post-operative external beam radiotherapy (EBRT).ResultsForty-one patients were implanted, and 36 were treated and analyzed. According to final pathology, 24 (67%) patients were suitable for AMBI and 12 (33%) were qualified for A-PHDRBT-boost. Reoperation rate for those with clear margins was 16.6% (6/36); this rate increased to 33% (4/12) for G3 histology, and 66% (4/6) were rescued using AMBI. Early complications were documented in 5 patients (14%). With a median follow-up of 97 (range, 42-138) months, 5-year rates of local, elsewhere, locoregional, and distant control were all 97.2%. 5-year ipsilateral breast tumor recurrence rates (IBTR) were 5.6% (2/36), 8.3% (2/24) for AMBI, and 0% (0/12) for A-PHDRBT-boost patients. Both instances of IBTR were confirmed G3 tumors in pre-operative biopsies; no IBTR was documented in G1-2 tumors. Cosmetic outcomes were excellent/good in 96% of AMBI vs. 67% in A-PHDRBT-boost (p = 0.034).ConclusionsThe MITBI-PHDRBT program allows selection of patients with excellent prognoses (G1-2 DCIS with negative margins and no multifocality), for whom AMBI could be a good alternative with low recurrence rate, decrease of unnecessary radiation, treatment logistics improvement, and over-treatment reduction. Patients whose pre-operative biopsy showed G3 tumor, presents with inferior local control and more risk of reoperation due to positive margins.

Long-term results of Perioperative High Dose Rate Brachytherapy (PHDRB) and external beam radiation in adult patients with soft tissue sarcomas of the extremities and the superficial trunk: Final results of a prospective controlled study

BackgroundTo analyze toxicity, patterns of failure, and survival in 106 adult patients with soft tissue sarcomas of the extremity and the superficial trunk treated in a prospective controlled trial of combined Perioperative High Dose Rate Brachytherapy (PHDRB) and external beam radiotherapy (EBRT). MethodsPatients were treated with surgical resection and 16 Gy or 24 Gy of PHDRB for negative or close/positive margins, respectively. EBRT (45 Gy) was added postoperatively. Adjuvant chemotherapy was given to selected patients with high-grade tumors. ResultsThe median follow-up was 7.1 years (range, 0.6–16.0). Grade ≥3 adverse events were observed in 22 patients (20.8%), and grade ≥4 events in 14 patients (13.2%). No grade 5 events were noted. Multivariate analysis (p = 0.003) found that Grade ≥3 toxic events increased with increasing implant volume (TV100). Local control, locoregional control, and distant control rates at 5 and 10 years were 89% and 87%, 82% and 80% and 75% and 69%, respectively. Multivariate analysis (p = 0.024) found that positive margins correlated with decreased local control. Disease-free survival and overall survival rates at 5 and 10 years were 64% and 59% and 73% and 62%, respectively. In multivariate analysis, disease-free survival rates decreased with increasing tumor size (p = 0.0001) and inadequate margins (p = 0.024), and overall survival decreased with increasing tumor size (p = 0.001) and male gender (p = 0.039). ConclusionsThe combination of conservative surgery, high-dose PHDRB, and EBRT produces adequate function and local control in the majority of patients with soft tissue sarcomas of the extremities and the superficial trunk, including a substantial percentage of cases with positive margins. Patients with larger tumors are at a higher risk of complications, treatment failure, and cancer-related death and require an individualized treatment approach.

Perioperative high-dose-rate brachytherapy in locally advanced and recurrent gynecological cancer: Final results of a Phase II trial

PurposeTo determine the long-term results of a Phase II trial of perioperative high-dose-rate brachytherapy (PHDRB) in primary advanced or recurrent gynecological cancer. Methods and MaterialsFifty patients with locally advanced and recurrent gynecological cancer suitable for salvage surgery were included. Unirradiated patients (n = 25) received preoperative chemoradiation followed by surgery and PHDRB (16–24 Gy). Previously irradiated patients (n = 25) received surgery and PHDRB alone (32–40 Gy). ResultsMedian followup was 11.5 years. Eight unirradiated patients (32%) developed Grade ≥3 toxic events including two fatal events. Local and locoregional control rates at 16 years were 87.3% and 78.9%, respectively. Sixteen-year disease-free and overall survival rates were 42.9% and 46.4%, respectively. Ten previously irradiated patients (40.0%) developed Grade ≥3 adverse events, including four fatal events. Local and locoregional control rates at 14 years were 59.6% and 42.6%, respectively. Fourteen-year disease-free and overall survival rates were 16.0% and 19.2%, respectively. ConclusionsPHDRB allows effective salvage of a subset of unfavorable gynecological tumors with high-risk surgical margins. Toxicity was unacceptable at the initial dose levels but deescalation resulted in the absence of severe toxicity without a negative impact on locoregional control. A substantial percentage of patients remain alive and controlled at >10 years including a few previously irradiated cases with positive margins.

Perioperative HDR brachytherapy for reirradiation in head and neck recurrences: single-institution experience and systematic review.

The aim of our study was to evaluate the outcomes of patients reirradiated with high-dose-rate (HDR) intensity-modulated brachytherapy (IMBT) for recurrent head and neck cancer and to perform a systematic review of the literature. Patients treated with prior radiation doses >65 Gy were considered. After resection of macroscopic disease, catheters were fixed to the tumor bed. The total dose was 30 Gy in 12 fractions of 2.5 Gy twice daily for 5 days a week. A systematic literature search was conducted through several electronic databases including Medline/PubMed, Scopus, Embase and the Cochrane library. Seventeen patients were included; median overall survival was 19 months with a median local control interval of 15 months. Median follow-up was 36 months. Seven papers were considered for the review. IMBT could play an important role in the retreatment of recurrent head and neck cancer.

EP-1092: Perioperative high dose rate brachytherapy in previously irradiated head and neck cancer: Results

EP-1092: Perioperative high dose rate brachytherapy in previously irradiated head and neck cancer: Results

Perioperative high dose rate brachytherapy (PHDRB) in previously irradiated head and neck cancer: Results of a phase I/II reirradiation study

Background and purposeThis study was undertaken to determine the feasibility of salvage surgery and PHDRB in patients with previously irradiated, recurrent head and neck cancer or second primary tumors arising in a previously irradiated field. Methods and MaterialsSixty-three patients were treated with surgical resection and PHDRB. The PHDRB dose was 4Gy b.i.d.×8 (32Gy) for R0 resections and 4Gy b.i.d.×10 (40Gy) for R1 resections, respectively. Further external beam radiotherapy or chemotherapy was not given. ResultsResections were categorized as R0 in 7 patients (11.1%) and R1 in 56 (88.9%). Thirty-four patients with R1 resections (54.0%) had microscopically positive margins, and 22 patients (34.9%) had close margins. Thirty-two patients (50.8%) developed RTOG grade 3 or greater adverse events including 3 fatal events. After a median follow-up of 6.8years, the 5-year locoregional control rate and 5-year overall survival rates were 55.0% and 35.6%, respectively. ConclusionsSurgical resection and PHDRB is a successful treatment strategy in selected patients with previously irradiated head and neck cancer. Long-term locoregional control can be achieved in a substantial number of cases despite a high rate of inadequate surgical resections although at the expense of substantial toxicity.

Freiburg Flap from 2D to 3D: A Novel Peri-Operative High Dose Rate Brachytherapy Approach

A 16 year old patient with a second recurrence of Wilms tumour within a previously irradiated field presented a technically challenging case to treat. Due to the close proximity of previously irradiated organs at risk including the single remaining ureter, a high dose rate brachytherapy technique allowing for steep dose drop off surrounding the target volume and minimal low dose wash was considered the most suitable option. We report the novel use of the Freiburg flap applicator to form a modified 3-dimensional catheter arrangement in order to treat the tumour bed immediately following surgical excision. Following excision of the tumour and temporary transposition of the right ureter away from the treatment volume, the brachytherapy team assessed the dimensions of the tumour bed to be treated. Under sterile conditions, the Freiburg flap was carefully cut down and reshaped, undergoing several iterations before an optimal shape was achieved. By curving the modified flap and suturing the edges together, a bespoke 3-dimensional applicator designed to custom fit the surgical cavity was formed. Gauze packing filled the central space in the applicator and 13 catheters with fixation buttons were threaded through the channels. The modified flap was inserted and sutured into the surgical cavity and the small bowel packed away from the treatment volume. A vacuum dressing was used to temporarily seal the surgical site with care taken to minimise curvature of the catheters. The patient remained intubated and sedated throughout treatment. The post-implant CT demonstrated good conformity of the modified Freiburg flap to the surgical cavity. Each channel could be easily visualised and accurately identified. A highly conformal plan was produced delivering a D90 dose of 32.9Gy in 5 bi-daily fractions to the tumour bed CTV and achieving organ at risk doses below set thresholds. Acceptable stability and consistency of the implant and organs at risk were verified daily via CT scan. All HDR brachytherapy treatments were delivered as planned, free from catheter obstructions, radiation or medical emergencies. The Freiburg flap has been successfully converted from a flat 2-dimensional sheet to a customised 3-dimensional applicator. This modified flap maintained good conformity to the surgical cavity and stability over the course of treatment. A highly conformal dose to the tumour bed CTV was planned and delivered without incident.

Multicatheter breast implant during breast conservative surgery: Novel approach to deliver accelerated partial breast irradiation

PurposeTo assess the safety, feasibility, and efficacy of free-hand intraoperative multicatheter breast implant (FHIOMBI) and perioperative high-dose-rate brachytherapy (PHDRBT) in early breast cancer. Methods and MaterialsPatients with early breast cancer candidates for breast conservative surgery (BCS) were prospectively enrolled. Patients suitable for accelerated partial breast irradiation (APBI) (low or intermediate risk according GEC-ESTRO criteria) received PHDRBT (3.4 Gy BID × 10 in 5 days). Patients not suitable for APBI (high risk patients according GEC-ESTRO criteria) received PHDRBT boost (3.4 Gy BID × 4 in 2 days) followed by whole breast irradiation. ResultsFrom June 2007 to November 2014, 119 patients were treated and 122 FHIOMBI procedures were performed. Median duration of FHIOMBI was 25 minutes. A median of eight catheters (range, 4–14) were used. No severe intraoperative complications were observed. Severe early postoperative complications (bleeding) were documented in 2 patients (1.6%), wound healing complications in 3 (2.4%), and infection (mastitis or abscess) in 2 (1.6%). PHDRBT was delivered as APBI in 88 cases (72.1%) and as a boost in 34 (27.8%). The median clinical target volume T was 40.8 cc (range, 12.3–160.5); median D90 was 3.32 Gy (range, 3.11–3.85); median dose homogeneity index was 0.72 (range, 0.48–0.82). With a median followup of 38.4 months (range, 8.7–98.7) no local, elsewhere, or regional relapses were observed; there was only one distant failure in PHDRBT boost. No major (acute or late) RTOG grade 3 or higher were documented in any of the 119 patients treated with PHDRBT. Cosmetic outcome in APBI patients was excellent or good in (87.0%) and fair or poor in (11.9%) while in boost patients was excellent or good in (76.4%) and fair in (23.5%). ConclusionThe FHIOMBI-PHDRBT program does not add complications to conservative surgery. It allows precise selection of APBI patients and offers excellent results in disease control and cosmetics. It also offers logistic advantages because it dramatically shortens the time of local treatment and avoids further invasive procedures.

Time to loading and locoregional control in perioperative high-dose-rate brachytherapy: The tumor bed effect revisited.

To determine whether the time to loading (TTL) affects locoregional control. Locoregional control status was determined in 301 patients enrolled in several perioperative high-dose-rate brachytherapy (PHDRB) prospective studies conducted at the University of Navarre. The impact of the time elapsed from catheter implantation to the first PHDRB treatment (TTL) was analyzed. Patients treated with PHDRB alone (n = 113), mainly because of prior irradiation, received 32 Gy in eight twice-a-day treatments or 40 Gy in 10 twice-a-day treatments for negative or close/positive margins, respectively. Patients treated with PHDRB + external beam radiation therapy (EBRT) (n = 188) received 16 Gy in four twice-a-day treatments or 24 Gy in six twice-a-day treatments for negative or close/positive margins followed by 45 Gy of EBRT in 25 treatments. After a median followup of 6.5 years (range, 2-13.6+), 113 patients have failed (37.5%), 65 in the PHDRB-alone group (57.5%) and 48 in the combined PHDRB + EBRT group (25.5%). Patients who started PHDRB before Postoperative Day 5 had a 10-year locoregional control rate of 66.7% and patients who started PHDRB on Postoperative Day 5 or longer had a 10-year locoregional control rate of 51.8% (p = 0.009). Subgroup analysis detected that this difference was only observed in the recurrent cases treated with PHDRB alone (Subset 2; n = 99; p = 0.004). No correlation could be detected between locoregional control rate and TTL in the other patient subsets although a trend toward a decreased locoregional control rate after a longer TTL was observed when they were grouped together (p = 0.089). Patients should start PHDRB as soon as possible to maximize locoregional control especially in those recurrent cases treated with PHDRB alone. The time effect in other disease scenarios is less clear.

Volume of high-dose regions and likelihood of locoregional control after perioperative high-dose-rate brachytherapy: do hotter implants work better?

To determine whether perioperative high-dose-rate brachytherapy (PHDRB) implants with larger high-dose regions produce increased locoregional control. Patients (n=166) enrolled in several PHDRB prospective studies conducted at the University of Navarre were analyzed. The PHDRB was given to total doses of 16Gy/4 b.i.d. or 24Gy/6 b.i.d. treatments for negative or close/positive margins along with 45Gy/25 Rx of external beam radiation therapy. The histogram-based generalized equivalent uniform dose (EUD) formulism was used to quantify and standardize the dose-volume histogram into 2-Gy equivalents. The region of interest analyzed included: tissue volume encompassed by the prescription isodose of 4Gy (TV100). Routine dose reporting parameters such as physical dose and single-point 2-Gy equivalent dose were used for reference. After a median followup of 7.4 years (range, 3-12+), 50 patients have failed, and 116 remain controlled at last followup. Overall, EUD was not different in the patients who failed compared with controls (89.1Gy vs. 86.5Gy; p=not significant). When patients were stratified by risk using the University of Navarre Predictive Model, very high-risk patients (i.e., tumors ≥3cm resected with close <1mm/positive margins) had an improved locoregional control with higher EUD values (p=0.028). This effect was not observed in low-, intermediate-, and high-risk University of Navarre Predictive Model categories. In very high-risk patients, enlarged high-dose regions can produce a dose-response effect. Routine dose reporting methods such as physical dose and single-point 2-Gy equivalent dose may not show this effect, but it can be revealed by histogram-based EUD assessment.

Minimally Invasive Intraoperative Multicatheter Breast Implant for Perioperative High-Dose-Rate Brachytherapy in Early Breast Cancer Treated With Conservative Surgery

To assess the safety and feasibility of MIOMBI in breast conservative surgery of breast cancer. Multicatheter Interstitial Breast Brachytherapy (MIBB) is an effective and safe technique for Accelerated Partial Breast Irradiation (APBI) in properly selected breast cancer patients treated with conservative surgery. MIBB technique allows reach the highest dose conformity and sparing healthy tissue ability respect of different APBI methods (Balloon, 3DCRT and Intraoperative Radiotherapy). MIBB is usually performed as closed-cavity procedure. This condition allows proper selection patients for APBI according to definitive pathological features but has some disadvantages since implies a second operation room visit for patient, determine a indirect visualisation of tumor bed with the consequently risk to make a geographical error dimmed frequently by performing extensive implants. Minimally Invasive Intraoperative Multicatheter Breast Implant (MIOMBI) represents an alternative to classic MIBB procedure with potential logistics, clinical and cosmetics advantages. Patients with early breast cancer candidates for conservative surgery were eligible for MIOMBI technique with 6F flexible catheters. Perioperative high-dose-rate brachytherapy (PHDRBT) was delivered as APBI (3.4 Gy for 10 in five days) in patients who met low- and intermediate-risk criteria according to GEC ESTRO recommendations, (women older than 40 years, infiltrating ductal carcinoma less than 2 cm with extensive intraductal carcinoma less than 25%, pN0, free margins more than 2mm and intraductal carcinoma less than 3 cm.) Those patients who did not meet previous criteria receive PHDRBT as anticipatory boost (4 fractions of 3.4 Gy in two days BAT) followed by hypofractionated whole breast irradiation 39.9 Gy in 15 fractions. From April 2010 to July 2013 101 consecutive breast cancer patients have been treated with conservative surgery and MIOMBI. The median time for MIOMBI procedure was 25 minutes. The median of number of catheter employed was 9 (4-14). No intraoperative complications were observed. Major complications RTOG grade 3-4 (acute and late) was observed only in one patient (1%) who suffered bleeding complication after implant remove. Infection (mastitis or abscess) was observed in 3 patients (2%). Fat necrosis with no symptoms was observed in 2 patients. PHDRBT was delivered as APBI in 64 patients (60%) and as a boost in 34 (40%). The median of CTV-T (clips zone plus 2 cm) was 41 cc with a median D90 of 3.27 Gy (96%) and DHI in CTV-T of 0.71. The median V100 and V150 was 60cc and 13cc, respectively, with a median DHI of 0.76. Median D10 in high-risk skin zone was 1.91 Gy (56%). With a median followup of 22 months (2-34) no (local, elsewhere, regional or distant) failure was observed. Cosmetic outcomes were evaluated in 46 of 64 APBI treatments (71%) with excellent and good results in 61% and 37%, respectively, and fair in 2%. Minimally invasive intraoperative multicatheter breast implant (MIOMBI) for perioperative high-dose-rate brachytherapy (PHDRBT) avoids a second surgical procedure, allows direct visualisation of tumor bed reducing the implant extension and keeps all advantages (dosimetric and proper selection patients for APBI) of the classic MIBB technique.

A proposal for the stratification of the risk of locoregional failure after surgical resection, perioperative high dose rate brachytherapy, and external beam irradiation: The University of Navarre predictive model

To develop a simple clinical model predictive of locoregional failure after complete surgical resection followed by perioperative high-dose-rate brachytherapy (PHDRB) and external beam irradiation (EBRT). Patients (n=166) enrolled in several PHDRB prospective studies conducted at the University of Navarre were analyzed. PHDRB was given to total doses of 16 Gy/4 b.i.d. or 24 Gy/6 b.i.d. treatments for negative or close/positive margins along with 45Gy of EBRT. After a median followup of 7.4 years (range, 3-12+), 50 patients have failed and 116 remain controlled at last followup. Tumor size, with a cutoff point set at 3cm (p=0.041) and margin status (positive and <1mm vs. negative ≥1mm, p=0.0001) were independent predictors of locoregional control. These two parameters were used to develop a four-tiered, hierarchical scoring system that stratified patients into low-risk (negative ≥1mm margins and size ≤3cm), intermediate-risk (negative ≥1mm margins, and size >3cm), high-risk (positive and <1mm margins and size ≤3cm), and very high-risk categories (positive and <1mm margins and size >3cm). This classification yields 5-year locoregional control rates of 92.3%, 78.0%, 65.5%, and 48.0% for low-, intermediate-, high-, and very high-risk categories, respectively. The predictive ability of the model is highly significant (p=0.0001) with an area under the curve of 0.72 (0.64-0.81). The risk of locoregional failure after combined surgical resection, PHDRB, and EBRT is mainly determined by the number of residual clonogens, which is inversely proportional to the status of the surgical margins and directly related to the size of the resected tumor. These two parameters generate a four-tiered predictive model that seems to be valid for a number of different common tumors and clinical settings.

Recurrent earlobe keloids treated with perioperative high dose rate brachytherapy

Recurrent earlobe keloids treated with perioperative high dose rate brachytherapy

Conservative Surgery and Intraoperative Radiation Therapy for Locally Recurrent Soft-tissue Sarcomas of the Extremities and the Superficial Trunk

To evaluate the patterns of failure and toxicity of a salvage program which includes Wide Local re-Excision (WLE) and Intraoperative Electron Beam Radiation Therapy (IOERT) or Perioperative High Dose-Rate Brachytherapy (PHDRB) in patients with Isolated local Recurrences of Soft Tissue Sarcomas (ILR) of the extremities and the superficial trunk.

Second breast-conserving surgery and reirradiation with interstitial high-dose-rate brachytherapy for the management of intra-breast recurrences -- 5-year results

The purpose of our work was to evaluate the efficacy of second breast-conserving surgery (BCS) and reirradiation with interstitial high-dose-rate (HDR) brachytherapy (BT) for the management of local recurrences. Between 1999 and 2010, fifteen patients initially treated for breast carcinoma by BCS and radiation therapy who had isolated intra-breast recurrence underwent second BCS and perioperative HDR multicatheter BT. Breast cancer related events, late side effects, and cosmetic results were assessed. At a median follow-up of 62 months (range: 11-127) second local recurrence has not occurred, yielding a 100% mastectomy-free survival. Four patients (27%) developed subsequent distant metastasis and died of breast cancer. The 5-year actuarial rate of disease-free and overall survival was 69% and 85%, respectively. Cosmetic results were rated excellent, good, fair, poor, and unknown in 1 (7%), 10 (66%), 2 (13%), 1 (7%), and 1 (7%) patients, respectively. Grade 2 fibrosis and skin toxicity occurred in 1 (7%) and 1 (7%) patients. Asymptomatic fat necrosis was detected in 9 (60%) women. No patient developed grade 3-4 late side effects. Second BCS followed by partial breast reirradiation is a safe and effective option for the management of selected patients developing intra-breast recurrence after previous breast-conserving therapy. Perioperative HDR BT may decrease the risk of second local relapse with acceptable cosmetic results and low rate of late side effects.