Post Brachytherapy Research Articles

Patient Experiences of Brachytherapy for Locally Advanced Cervical Cancer: Hearing the Patient Voice Through Qualitative Interviews

BackgroundBrachytherapy for gynaecological cancer is reported to cause pain, anxiety and distress with no clear guidance for optimising patient experiences. The aim of this study was to explore patient experiences of brachytherapy and views on improvements. Materials and MethodsSemi-structured interviews were undertaken with patients who had received brachytherapy for locally advanced cervical cancer. Two cohorts were recruited: cohort one had recently had brachytherapy, cohort two were a year post brachytherapy. Four recruitment sites were selected, where brachytherapy is given in different ways, some with short day case procedures and others having one or two overnight stays with applicators in place. Consecutive patients were invited to interview. Participants were asked to retell their brachytherapy story, with views on their care and ideas for improvement. Interviews were audio-recorded, transcribed and data analysed following Braun and Clarke's method for reflexive thematic analysis.16 ResultsThirty five interviews were conducted (20 in cohort one and 15 in cohort two). Participant's ages ranged from 28 to 87 years. The interview duration ranged from 22 to 78 minutes. Difficult and traumatic experiences were reported, including periods of severe pain and perceptions of poor care. However, some participants described positive experiences and what went well.Three themes were developed: 1) How I got through it 2) Unpleasantness, discomfort and the aftermath 3) Emotional consequences and traumaSome aspects of medium and long duration brachytherapy were found to be more problematic compared with short duration brachytherapy. Exploring experiences at one year post brachytherapy has provided insights into the long-lasting impact of brachytherapy experiences. ConclusionHearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.

Postoperative Echography for Optimization of Radiation Dosimetry in Patients with Uveal Melanoma Treated with Plaque Brachytherapy

1) To describe the technique of post-operative echography to confirm the intended treatment dose to the tumor apex in patients with uveal melanoma treated with plaque brachytherapy, 2) To describe the local tumor control rate and visual outcomes with the brachytherapy strategies used at our institution. Retrospective review SUBJECTS: 372 consecutive patients with uveal melanoma (small, medium, and large) treated with plaque brachytherapy at the University of Iowa from 8/2008-2/2019. Patient demographics and tumor characteristics were recorded for each patient. Patients with posterior tumors treated with plaque brachytherapy (n=355) underwent intra-operative ultrasound to confirm plaque placement, and additional post-operative ultrasound on day 1-3 post plaque insertion. In cases where intra-tumor/episcleral plaque edema or hemorrhage shifted the dose to the prescription point to less than 85 Gray (Gy), the duration of plaque brachytherapy was increased to compensate. Statistical analysis was performed to compare variables associated with need for plaque adjustment. Variables associated with plaque dose needing to be re-calculated, local tumor control, and visual acuity outcomes. In 31 cases (8.3%), post-operative echography showed the tumor apex had shifted outside of the 85 Gy isodose curve, requiring adjustment of the duration of brachytherapy (28 cases) or repositioning of the plaque (3 cases). Collaborative Ocular Melanoma Study (COMS) tumor size was significantly associated with need to adjust the plaque prescription dose (p=0.03), with large tumors having the highest rate of adjustment. Tumor thickness was larger in cases requiring plaque adjustment compared to those that were not adjusted (median 4.9 mm versus 3.0 mm, p<0.01). Local tumor control was 99% (95% CI: 97-100%) at 5 years and 99% (95% CI: 97-100%) at 10 years. The percentage of patients who had experienced a visual acuity decline of ≥3 lines of vision or had less than 20/200 acuity was 14.9% at one year post brachytherapy, 35.3% at three years, and 51.6% at five years. Post-operative ultrasound performed on post-operative day 1-3 after plaque insertion for patients undergoing brachytherapy for uveal melanoma may result in improved local tumor control, particularly in the setting of thicker or larger tumors.

MSS02 Presentation Time: 3:50 PM: Feasibility of 3D-Printed Endorectal High Dose Rate Brachytherapy Applicator: A Single Patient Case Report

<h3>Purpose</h3> Endorectal brachytherapy is an effective treatment for select patients with rectal cancer, particularly in re-irradiation cases. In the United States, this technique is underutilized. Herein we describe, to our knowledge, the first report of a previously irradiated rectal cancer patient treated with a 3D-printed Endorectal High Dose Rate Brachytherapy Applicator. <h3>Materials and Methods</h3> A 64 year old morbidly obese female who was previously irradiated for endometrial cancer in 2009 presented with newly diagnosed uT3N0, MRI T2N0 rectal adenocarcinoma. Previous radiation records were no longer available other than a treatment summary identifying a total dose of 50.4 Gy in 28 fractions was delivered to the pelvis. Total neoadjuvant therapy was recommended with a watch and wait approach given surgical difficulties in a morbidly obese woman previously irradiated. The mass began 3 cm from the anal verge, extended nearly 5 cm superiorly, and circumferentially involved less than 50% of the rectal lumen. Fiducial markers were placed in the 4 cardinal directions. A 2.5 cm diameter, 18 cm length, 13 multichannel applicator (1 central channel, and 12 outer channels 5mm from cylinder surface) design was designed in <i>Autodesk Fusion 360</i> to ensure adequate coverage (see figure 1). 3D printing was achieved with a FormLabs 3 printer using Surgical Guide V1 resin. [JF1] The applicator was placed on the first day of treatment at CT simulation. The patient was placed in the prone position with the applicator inserted in the rectum. Treatment was delivered in 4 consecutive daily fractions of 6.5 Gy for a total of 26 Gy. <h3>Results</h3> The CTV volume was 19.8 cc and maximum tumor depth was 13 mm. Tumor coverage was excellent with a V200 of 6%, V150 of 23%, V100 of 70%, D90 of 83%. Target coverage was sacrificed to reduce the V200, given unknown previous radiation fields. The bladder D2cc dose was 5.4 Gy[JD2] [MS3] . The patient had complete resolution of rectal bleeding by the 4^th fraction. She reported no acute toxicities. At the time of this report, the patient is 1 month post brachytherapy with no reported toxicities with significantly easier bowel movements and continues to have no bleeding. <h3>Conclusion</h3> To our knowledge, this is the first reported 3D printed Endorectal High Dose Rate Brachytherapy Applicator used in clinical practice. In this case, the patient had early response with no adverse events. We believe 3D printing is a useful tool for Brachytherapists, and a feasible treatment option for rectal cancer patients.

Friday, June 17, 202210:00 AM - 12 PMPO01: Intravascular Brachytherapy of the Coronary Arteries for In Stent In Stent Restenosis: Sicker Patients, but Just as Safe

<h3>Purpose</h3> More than 20 years ago prophylactic intravascular brachytherapy burst into the radiation oncology lexicon, only to be replaced within a few years by the introduction of drug eluting stents. However, restenosis still occurs in 5- 15% of high risk patients with two or more layers of drug eluting stents. We examined our experience in patients with in stent in stent restenosis who have no options for durable revascularization and therefore are forced to lead a shortened and sedentary life, comparing this to our historic control group. <h3>Materials and Methods</h3> A retrospective cohort of 134 patients treated with angioplasty followed by intracoronary brachytherapy was compared to a current high risk group of 122 patients with in stent in stent restenosis. All patients had a minimum 6 month follow up post brachytherapy. None of the original cohort had stenting performed at the time of brachytherapy, while all patients in the restenosis cohort had placement of at least 2 layers of intracoronary stents prior to repeat angioplasty and IVBT. <h3>Results</h3> In the original cohort, there were no intraprocedural deaths, while the high risk cohort had a single intraprocedural death due to intracoronary thrombosis. No high risk patient developed any significant cardiovascular event otherwise at 6 months post-procedure. <h3>Conclusions</h3> Intravascular brachytherapy for in stent in stent restenosis is equally safe compared to the historic post angioplasty IBVT safety profile, despite the fragile nature and relatively high risk disease status of these patients with limited options.

Functional Outcomes after Local Salvage Therapies for Radiation-Recurrent Prostate Cancer Patients: A Systematic Review.

Simple SummaryLocal salvage therapies are offered to prostate cancer (PCa) patients with recurrent disease following primary radiation therapy with initial curative intent. Favorable oncologic outcome is the primary aim of salvage therapy, but many patients may be left with treatment-related adverse consequences, potentially affecting their quality of living. The aim of this review was to evaluate the rates and severity of various functional outcomes after salvage therapy in patients with radiation recurrent PCa. Local salvage therapies are associated with impaired urinary and sexual functions depending on the specific salvage strategy. However, accurate estimation of the likelihood of these sequalae may be predictable based on the high pre-salvage general and disease specific health status. Despite these adverse consequences and impaired quality of life, oncologic advantage of local salvage treatment post radiation recurrence prostate cancer seems justified in general, but shared decision working with an informed patient is essential. This paper serves as a discussion platform for this process.Purpose: To assess the rate and severity of functional outcomes after salvage therapy for radiation recurrent prostate cancer. Methods: This systematic review of the MEDLINE/PubMed database yielded 35 studies, evaluating salvage radical prostatectomy (RP), brachytherapy (BT), high-intensity focal ultrasound (HIFU) and cryotherapy (CT) after failure of primary radiation therapy. Data on pre- and post-salvage rates and severity of functional outcomes (urinary incontinence, erectile dysfunction, and lower urinary tract symptoms) were collected from each study. Results: The rates of severe urinary incontinence ranged from 28–88%, 4.5–42%, 0–6.5%, 2.4–8% post salvage RP, HIFU, CT and BT, respectively. The rates of erectile dysfunction were relatively high reaching as much as 90%, 94.6%, 100%, 62% following RP, HIFU, CT and BT, respectively. Nonetheless, the high pre-salvage rates of ED preclude accurate estimation of the effect of salvage therapy. There was an increase in the median IPSS following salvage HIFU, BT and CT ranging from 2.5–3.4, 3.5–12, and 2, respectively. Extended follow-up showed a return-to-baseline IPSS in a salvage BT study. The reported data suffer from selection, reporting, publication and period of study biases, making inter-study comparisons inappropriate. Conclusions: local salvage therapies for radiation recurrent PCa affect continence, lower urinary tract symptoms and sexual functions. The use of local salvage therapies may be warranted in the setting of local disease control, but each individual decision must be made with the informed patient in a shared decision working process.

A Case of Thrombotic Vasculopathy in the Setting of High-Dose Hydroxyurea Use

This case study describes the presentation of a 76-year-old male with a past medical history that included atrial fibrillation, essential hypertension, coronary artery disease status post cardiac stent placement, heart failure, hyperlipidemia, thyroid cancer (with thyroid resection resulting in hypothyroidism), prostate cancer status post brachytherapy (in remission), and a history of JAK2-positive myeloproliferative disease. He presented with painful areas of hyperpigmentation appearing as purple discoloration to his neck, lower abdominal skinfold, and bilateral groin areas that progressed to painful ulcerations a few weeks after a myocardial infarction. Due to the patient’s multiple medical conditions and uncommon presentation of wounds, a multidisciplinary team was involved in his care. Differential diagnosis included antiphospholipid syndrome, symmetrical drug-related intertriginous and flexural exanthema, warfarin-induced necrosis, cutaneous thrombotic vasculopathy, myeloproliferative disorder, and high-dose hydroxyurea therapy. It was determined by the authors that the high-dose hydroxyurea therapy was the cause of the wounds. Because of the patient’s initial health status, treatment of the wounds included use of collagenase and sodium hypochlorite solution to reduce the risk of infection and attempt to promote autolytic debridement until surgical wound debridement could be done. The patient required multiple hospital stays, but ultimately his health status improved and the wounds resolved with the assistance of the combined efforts of the multidisciplinary team to diagnose and treat this complex patient and his uncommon wound presentation.

Prostate cancer radiation and urethral strictures: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis to determine the prevalence and predictors of urethral stricture development post radiation therapy (RT) for prostate cancer (PCa). Published articles in PubMed/Medline, Cochrane, and Embase databases from January 2000 to April 2016 were queried. Inclusion criteria were any study that reported the prevalence of urethral strictures following external beam radiation therapy (EBRT), brachytherapy (BT), or both as a primary treatment for PCa. Forty-six articles met our inclusion criteria. A summary estimate of the proportion of patients who developed a urethral stricture was derived via a random effects meta-analysis. In total, 16,129 PCa patients underwent either EBRT (5681, 35.2%), BT (5849, 36.3%), or both (4599, 28.5%). Overall, 630 strictures were diagnosed at follow-up with a pooled estimate period prevalence of 2.2% (95% confidence interval, CI 1.9-2.6%) in a median follow-up time of 4 years (interquartile range, IQR 2.7-5). Of which, the pooled estimate prevalence was 1.5% (95% CI 0.9-2%) post EBRT, 1.9% (95% CI 1.3-2.4%) post BT, and 4.9% (95% CI 3.8-6%) post both EBRT and BT. Of 20 studies reporting a median time to stricture formation, the overall median time was 2.2 years (IQR 1.8-2.5, range 1.4-9). In a meta-regression analysis, receiving both EBRT and BT increased the estimated difference in proportion of stricture diagnoses by 3% (95% CI 1-6%), p = 0.018 compared to EBRT alone. An increase in median follow-up time was found to significantly increase the risk of developing urethral strictures (p = 0.04). With a short-term follow-up, urethral strictures occur in 2.2% of men with PCa receiving radiotherapy. Receiving both EBRT and BT increased the risk of stricture formation. Longer follow-up is needed to determine the long-term natural history of stricture formation after RT.

Holmium Laser Ablation of the Prostate Gland Followed by Brachytherapy for Treatment of Patients with Clinically Localized Prostate Carcinoma and Obstructive Urinary Symptoms

According to the 2012 American Brachytherapy Society consensus guidelines for permanent prostate brachytherapy obstructive urinary symptoms, enlarged median lobe and large prostate volume are relative contraindications for this treatment because 40 to 50 percent of these patients may go into urinary retention or require a catheter for intermittent self catheterization due to worsening of their obstructive urinary symptoms. The purpose of this study was to assess the role of holmium laser ablation of the prostate (HoLAP) prior to brachytherapy (BT) in preventing post BT urinary complications.

Salvage brachytherapy for prostate bed recurrence following radical prostatectomy.

218 Background: Approximately 10% of patients who undergo a radical prostatectomy (RP) for localized prostate cancer subsequently experience a local recurrence. A small percentage of these patients present with prostate bed nodules (PBN). We present here, a case series of 12 patients treated with low dose rate brachytherapy (BT) for a PBN post RP. Methods: All 12 patients had biopsy confirmed cases of recurrent adenocarcinoma in the prostatic bed. At the time of PBN diagnosis, 2 patients had received EBRT, 2 patients had received ADT, and 1 patient had undergone HIFU. Patients were confirmed to have a negative CT and bone scan prior to salvage BT. All patients received salvage BT with I-125 prescribed to 144 Gray. Results: The median interval between RP and BT was 8 years (range 0.5- 17.9), median PSA prior to BT was 4.53 ng/ml (range 0.55-15.2), and the median age was 69 (range 59-86). Forty-two percent of patients had a PBN Gleason score of 8, 33% had a score of 7, and a score was not reported for 25% of patients due to prior EBRT or ADT use. The median follow up for this series is 26.5 months (range 1-69). At the time of this analysis, 10 patients were evaluable for biochemical failure (bF) (nadir+2) and distant metastases (DM). The one and two year rates of bF were 0% and 52%. There was no association between pre-BT PSA and bF, nor between pre-BT Gleason score and bF. Two patients subsequently developed DM at 17 months and 55 months after BT. The pelvic lymph nodes were the site of DM for both patients. The median PSA velocity post BT was -0.120 ng/ml/yr (range -1.404- 9.096). Five patients had a negative PSA velocity at last follow-up, while 4 had an increasing PSA velocity. Velocity could not be defined for 3 patients (insufficient PSA n=2, ADT n=1). To date, no gastrointestinal or urinary toxicities have been noted. Conclusions: Brachytherapy as a salvage treatment for a PBN appears to be well tolerated. The rates of bF and DM following salvage BT are comparable to those of salvage EBRT for this patient population. Intermediate-term biochemical control was attained in a sub-set of patients with declining PSA at last follow-up.

66 oral 3-dimensional MR spectroscopic imaging of prostate pre and post brachytherapy

66 oral 3-dimensional MR spectroscopic imaging of prostate pre and post brachytherapy

150 MRI-CT fusion to assess post Brachytherapy (BT) prostate volume and the effects of prolonged edema on dosimetry

150 MRI-CT fusion to assess post Brachytherapy (BT) prostate volume and the effects of prolonged edema on dosimetry