Acute problems during low-dose-rate intracavitary brachytherapy for cervical carcinoma

The MRI-guided two adaptive brachytherapy fractions versus one adaptive brachytherapy fraction in one application for the cervical cancer: a retrospective study

PURPOSE

This study retrospectively compared the clinical and toxicity outcomes for the cervical cancer of the MRI-guided two adaptive brachytherapy (IGABT) fractions versus one IGABT fraction in one application.

METHODS

One hundred and twenty patients with cervical cancer received external beam radiotherapy combined with or without concurrent chemotherapy, which was followed by the IGABT. The IGABT in 63 patients had one IGABT in each application (Arm 1), while in the other 57 patients, at least one treatment was two continuous IGABT every other day in one application (Arm 2). Clinical outcomes including overall survival (OS), cancer specific survival (CSS), progression free survival (PFS), local control (LC) were analyzed. Brachytherapy-related toxicities were evaluated, which included pain, dizziness, nausea/vomiting, fever/infection, blood loss during the removal of applicator and needles, the deep venous thrombosis, and other acute toxicities. The Common Terminology Criteria for Adverse Events (CTC-AE 5.0) was used to evaluate the incidence and severity of toxicities of the urinary system, lower digestive system, and reproduction system. Kaplan-Meier and the Log-rank test were used to analyze the clinical outcomes.

RESULTS

The median follow-up time of the patients in Arm 1 and Arm 2 was 23.5 and 12.0 months, respectively. The overall treatment time was significantly shorter in Arm 2 than Arm 1 (60 vs. 64 d; P = 0.017). The OS, CSS, PFS, and LC in Arm1 and Arm 2 was 77.8% vs. 86.0% (P = 0.632), 77.8% vs. 87.7% (P = 0.821), 68.3% vs. 70.2% (P = 0.207), and 92.1% vs. 94.7% (P = 0.583), respectively. The highest NRS of the pain during brachytherapy waiting period (2.22 ± 1.84 vs. 3.02 ± 1.65; P < 0.001) and at the time of the removal of the applicator (4.69 ± 1.49 vs. 5.30 ± 1.18; P < 0.001) in the patients who received one hybrid intracavitary and interstitial brachytherapy (IC/ISBT) in one application and two continuous IC/ISBT every other day in one application were significantly different. So far four patients with grade 3 late toxicities have been reported.

CONCLUSIONS

The findings of this study demonstrated that the two continuous IGABT every other day in one application is a logistically applicable, safe, and effective treatment strategy that could shorten the overall treatment time and reduce the medical cost, comparing with the one IGABT in one application.

Perioperative anesthesia management for brachytherapy in cancer patients: A retrospective observational study

BACKGROUND AND AIMS

Anesthetic management for brachytherapy require repeated exposure to anesthesia in elderly patients with comorbidities. The varying locations provide an anesthesiologist with further challenges.

MATERIAL AND METHODS

We studied retrospectively anesthesia type, details of anesthetic techniques and complications that occurred in patients having received anesthesia for brachytherapy in our institute in the last 6 years. Categorical variables were described as frequency and percentage, and continuous variables described as median and interquartile range. For continuous variables, mean values compared using two sample t tests for independent samples.

RESULTS

The majority of patients were females who received brachytherapy for carcinoma cervix. A higher percentage of carcinoma breast and male genitourinary malignancies had comorbidities. Predominant side effects included 22 (1.85%) had hypotension, 19 (1.59%) had difficulty in putting spinal, 13 (1.09%) patients had tachycardia and 11 (0.92%) had headache in the postoperative period.

CONCLUSION

Neuraxial block as anesthetic technique in pelvic brachytherapy using fentanyl as additive helped reduce the dose of local anesthetic and avoided the complications of high spinal. The choice of anesthesia can vary depending on the duration and site of brachytherapy keeping in consideration the patient's factors.

Anaesthesia for brachytherapy—5½ yr of experience in 1622 procedures

BACKGROUND

Brachytherapy presents the anaesthetist with unique problems. Information on anaesthesia for brachytherapy, however, is limited. The aim of this paper is to report on our experience involving a large number of brachytherapy procedures.

METHODS

A retrospective analysis of records of 1622 anaesthetic procedures in 952 patients is presented. Records were analysed in respect of patient data, tumour localization, brachytherapy treatment and the type and duration of anaesthetic procedures.

RESULTS

More than one-third of patients were at high risk (ASA III or IV) and 40% were more than 60 yr. Repetitive treatments were performed on half of the patients. Breast cancer was the most common indication. The average duration of anaesthesia for pelvic brachytherapy was more than 3 h, with a high degree of variability. Regional anaesthesia was used in 30% of all cases and was the predominant technique for pelvic brachytherapy. Spinal catheter techniques represented a high proportion of those receiving regional anaesthesia. Complications resulting from regional and general anaesthesia were minor and no serious incidents occurred.

CONCLUSIONS

Based on a large number of procedures, this study gives an example of anaesthetic management in brachytherapy. A substantial minority of patients would be considered high risk for surgical intervention. Regional anaesthesia was the principal technique used when dealing with tumours of the lower body.

Rectovaginal radiation fistula repair using an obturator fasciocutaneous thigh flap

BACKGROUND

Rectovaginal fistulae are a known complication of pelvic radiotherapy utilizing locally applied isotope implants. Most often, either permanent colostomy or reconstruction with a well-vascularized flap is necessary. Traditional techniques for fistula repair utilize bulky muscle flaps, disfiguring pudendal artery flaps or may require laparotomy.

CASE

We describe the management of a 26-year-old woman with a large radiation-induced rectovaginal fistula. A fasciocutaneous medial thigh flap based on terminal branches of the obturator artery and vein was used without colostomy and resulted in pain-free sexual function and minimal vulva disfigurement.

CONCLUSION

A medial thigh fasciocutaneous flap without muscle can be transferred into the vagina on the obturator vessels and may become the preferred method for managing large rectovaginal fistulas.

Factors determining acute normal tissue reactions during postoperative radiotherapy in endometrial cancer: analysis of 317 consecutive cases

BACKGROUND AND PURPOSE

Acute radiotherapy reactions are commonly underestimated and under-reported in the literature. Our aim was to evaluate the incidence and risk factors for acute reactions during postoperative radiotherapy in endometrial cancer patients.

MATERIAL AND METHODS

Performed was detailed retrospective analysis of 317 endometrial cancer patients given postoperative radiotherapy. Two hundred forty seven patients (78%) received both intracavitary (BRT) and external beam irradiation (EBRT), 49 patients (15%) received only BRT and 21 patients (7%) - only EBRT. BRT included radium (Ra) or cesium (Cs). The mean total dose at 0.5 cm for Ra and Cs was 50.5+/-10.3 Gy and 48.4+/-15.0 Gy, respectively, and the mean dose rate - 0.47+/-0.06 Gy/h and 1.42+/-0.41 Gy/h, respectively. Mean EBRT dose in the ICRU reference point was 49.0+/-3.7 Gy given in fractions of 1.54-2.49 Gy (mean 2.0+/-0.17 Gy). Radiotherapy and Oncology Group classification system was employed to score acute reactions. The impact of patient- and treatment-related factors on the risk of acute bowel and urinary bladder reactions was assessed with uni- and multivariate tests.

RESULTS

Acute radiotherapy reactions of any grade occurred in 265 patients (84%) including bowel complications in 66% and urinary bladder complications in 36%. There were 21 severe (grade 3 or 4) reactions, all but one seen in the patients treated with combined EBRT and BRT. Higher total dose (P=0.024), higher EBRT dose (P=0.022) and higher age (P=0.026) were correlated with increased acute bowel toxicity in univariate analysis. Multivariate analysis showed that higher EBRT dose (P=0.015) and older age (P=0.016) were independently correlated with the risk of acute bowel events. Higher total dose (P=0.009), BRT dose (P=0.029), BRT dose rate (P=0.004), EBRT fraction size (P=0.007), the use of Cs BRT (P=0.001) and lower parity (P=0.041) were correlated with increased risk of acute bladder toxicity in univariate test. Multivariate analysis demonstrated that the independent risk factors for acute bladder events were BRT dose rate (P=0.002) and low parity (P=0.042) and there was a trend for EBRT dose (P=0.076). In multivariate analysis there was no impact of other clinical factors (FIGO stage, diabetes mellitus, hypertension, prior abdominal surgery) on the risk of acute bowel and/or bladder reactions nor was the impact of surgery-to-radiotherapy interval, overall radiotherapy time and overall treatment time.

CONCLUSIONS

The risk of acute reactions depends both on treatment-related (BRT dose rate, EBRT dose) and patient-related factors (age, parity). Precise treatment prescription, planning and verification are of paramount concern. Further studies are warranted to evaluate the impact of extrinsic and intrinsic factors associated with acute normal tissue injury.

One versus two intracavitary brachytherapy applications in early-stage cervical cancer patients undergoing definitive radiation therapy

PURPOSE

The purpose of this study was to compare the outcomes of early stage cervical cancer patients undergoing definitive radiation therapy (RT) with one versus two low-dose-rate intracavitary brachytherapy (ICB) applications.

METHODS AND MATERIALS

Between 1983 and 1993, 140 stage IB-IIA patients underwent whole-pelvis RT (WPRT) and ICB. Prior to 1988, 56 patients (40%) received two ICB applications. After 1988, our policy was modified and subsequently 84 (60%) patients underwent one application. Patient, tumor, and treatment characteristics, outcome, and complications of the two groups were compared.

RESULTS

The groups were balanced in terms of race, hemoglobin level, histology, grade, treatment duration, chemotherapy, and follow-up. The single-application group, however, had more stage IB disease, had small (< or =4 cm) tumors, and received higher WPRT and lower point A doses. Overall, the two groups had similar 5-year local control (P = 0.83) and disease-free (P = 0.23) and cause-specific (P = 0.29) survival rates. Moreover, no differences were seen when analyzed by tumor size or stage. On multivariate analysis, the number of applications was not correlated with recurrence (P = 0.59, hazard rate = 1.1, 95% confidence interval = 0.6-2.2). Chronic complications were similar in the two groups.

CONCLUSION

Our nonselected comparison of one versus two ICB applications in early-stage cervical cancer patients reveals comparable outcomes and complication rates for the two approaches. These results support the use of a single application in early-stage patients undergoing definitive RT.