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Nagao A, Murakami N, Sakuramachi M, Kashihara T, Takahashi K, Kaneda T, Inaba K, Okuma K, Okamoto H, Nakayama Y, Yonemori K, Igaki H. Role of the gel spacer in safely delivering whole pelvic radiation therapy without central shielding in computed tomography-based image-guided adaptive brachytherapy for uterine cervical cancer patients. Brachytherapy 2024; 23:595-603. [PMID: 38942713 DOI: 10.1016/j.brachy.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 05/11/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND To protect the rectum and bladder from high dose exposure, the Japanese guidelines for managing uterine cervical carcinoma recommend pelvic irradiation with central shielding (CS). Conversely, the European Society for Radiotherapy and Oncology (ESTRO) and the American Brachytherapy Society (ABS) guidelines recommend delivering ≥85 Gy to high-risk clinical target volume D90 (CTVHR D90%). In this study, we investigated whether a gel spacer can enable the safe delivery of the ESTRO/ABS-recommended doses to the target while observing dose constraints for the OARs without using CS in external beam radiation therapy (EBRT). MATERIALS AND METHODS Twenty patients who received definitive radiation therapy without CS and were treated by brachytherapy with a gel spacer between 2017 and 2022 were retrospectively reviewed. The cumulative doses of EBRT and brachytherapy treatment outcomes and incidence of adverse events were also examined. RESULTS The median cumulative CTVHR D90%, rectum D2cm3, and bladder D2cm3 were 86.6 Gy, 62.9 Gy, and 72.0 Gy, respectively. The 2-year local control rate was 95%. There were no CTCAE ≥Grade 3 late gastrointestinal or genitourinary adverse events. CONCLUSIONS The use of gel spacer can enable ESTRO/ABS-recommended dose constraints even without using CS in EBRT, with favorable outcomes and low adverse event rates.
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Affiliation(s)
- Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan; Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Radiation Oncology, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Madoka Sakuramachi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kan Yonemori
- Cancer Medicine, Cooperative Graduate School, The Jikei University Graduate School of Medicine, Tokyo, Japan; Department of Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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Trumpour T, du Toit C, van Gaalen A, Park CKS, Rodgers JR, Mendez LC, Surry K, Fenster A. Three-dimensional trans-rectal and trans-abdominal ultrasound image fusion for the guidance of gynecologic brachytherapy procedures: a proof of concept study. Sci Rep 2024; 14:18459. [PMID: 39117682 PMCID: PMC11310523 DOI: 10.1038/s41598-024-69211-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 08/01/2024] [Indexed: 08/10/2024] Open
Abstract
High dose-rate brachytherapy is a treatment technique for gynecologic cancers where intracavitary applicators are placed within the patient's pelvic cavity. To ensure accurate radiation delivery, localization of the applicator at the time of insertion is vital. This study proposes a novel method for acquiring, registering, and fusing three-dimensional (3D) trans-abdominal and 3D trans-rectal ultrasound (US) images for visualization of the pelvic anatomy and applicators during gynecologic brachytherapy. The workflow was validated using custom multi-modal pelvic phantoms and demonstrated during two patient procedures. Experiments were performed for three types of intracavitary applicators: ring-and-tandem, ring-and-tandem with interstitial needles, and tandem-and-ovoids. Fused 3D US images were registered to magnetic resonance (MR) and computed tomography (CT) images for validation. The target registration error (TRE) and fiducial localization error (FLE) were calculated to quantify the accuracy of our fusion technique. For both phantom and patient images, TRE and FLE across all modality registrations (3D US versus MR or CT) resulted in mean ± standard deviation of 4.01 ± 1.01 mm and 0.43 ± 0.24 mm, respectively. This work indicates proof of concept for conducting further clinical studies leveraging 3D US imaging as an accurate, accessible alternative to advanced modalities for localizing brachytherapy applicators.
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Affiliation(s)
- Tiana Trumpour
- Department of Medical Biophysics, Western University, London, Canada.
- Robarts Research Institute, London, Canada.
| | | | - Alissa van Gaalen
- Department of Physics and Astronomy, University of Waterloo, Waterloo, Canada
| | - Claire K S Park
- Brigham and Women's Hospital and Dana-Farber Cancer Institute, Department of Radiation Oncology, Harvard Medical School, Boston, USA
| | - Jessica R Rodgers
- Department of Physics and Astronomy, University of Manitoba, Winnipeg, Canada
| | | | - Kathleen Surry
- Department of Medical Biophysics, Western University, London, Canada
- Verspeeten Family Cancer Centre, London, Canada
- Department of Oncology, Western University, London, Canada
| | - Aaron Fenster
- Department of Medical Biophysics, Western University, London, Canada
- Robarts Research Institute, London, Canada
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Ito K, Nakajima Y, Ogawa H, Furusawa A, Murofushi KN, Kito S, Kino N, Yasugi T, Uno T, Karasawa K. Phase I/II study of stereotactic body radiotherapy boost in patients with cervical cancer ineligible for intracavitary brachytherapy. Jpn J Radiol 2024; 42:909-917. [PMID: 38625476 PMCID: PMC11286639 DOI: 10.1007/s11604-024-01566-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/25/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE Stereotactic body radiotherapy (SBRT) boost is a promising treatment for cervical cancer patients who are ineligible for intracavitary brachytherapy (ICBT). The aim of this multicenter, single-arm, phase I/II study was to prospectively evaluate the efficacy and toxicity of SBRT boost. MATERIALS AND METHODS ICBT-ineligible patients with untreated cervical cancer were enrolled. Patients underwent whole-pelvic radiotherapy (45 Gy in 25 fractions) with SBRT boost to the primary lesion. In the phase I dose-escalation cohort (3 + 3 design), patients were treated with SBRT boost of 21 or 22.5 Gy in three fractions. Although dose-limiting toxicity was not confirmed, a dose of 21 Gy was selected for the phase II cohort because it was difficult to reproduce the pelvic organs position in two patients during the phase I trial. The primary endpoint was 2-year progression-free survival. RESULTS Twenty-one patients (phase I, n = 3; phase II, n = 18) were enrolled between April 2016 and October 2020; 17 (81%) had clinical stage III-IV (with para-aortic lymph node metastases) disease. The median (range) follow-up was 40 (10-84) months. The initial response was complete response in 20 patients and partial response in one patient. The 2-year locoregional control, progression-free survival, and overall survival rates were 84%, 67%, and 81%, respectively. Grade ≥ 3 toxicity was confirmed in one patient each in the acute (diarrhea) and late (urinary tract obstruction) phases. CONCLUSION These findings suggested that a SBRT boost is more effective than the conventional EBRT boost and can be an important treatment option for ICBT-ineligible patients with cervical cancer. STUDY REGISTRATION This study was registered at the University Hospital Medical Information Network Clinical Trials Registry (UMIN000036845).
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Affiliation(s)
- Kei Ito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan.
| | - Yujiro Nakajima
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
- Department of Radiological Sciences, Komazawa University, 1-23-1 Komazawa, Setagaya-ku, Tokyo, 154-8525, Japan
| | - Hiroaki Ogawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Akiko Furusawa
- Department of Gynecology, Shizuoka Cancer Center Hospital, 1007, Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Keiko Nemoto Murofushi
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Satoshi Kito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Nao Kino
- Department of Gynecology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Toshiharu Yasugi
- Department of Gynecology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chou-ku, Chiba, 260-8677, Japan
| | - Katsuyuki Karasawa
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo, 113-8677, Japan
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Rivera A, Barrios DM, Herbach E, Kahn JM, Williams VM, Mehta KJ, Wolfson A, Portelance L, Kamrava M. Analgesia and Anesthesia Practice Patterns for Gynecologic Brachytherapy Procedures and Potential Impact on Women's Procedural Experience: A National Survey. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)02973-0. [PMID: 39067485 DOI: 10.1016/j.ijrobp.2024.07.2150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/19/2024] [Accepted: 07/06/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE The purpose of this study was to determine the current U.S. practice patterns of analgesia (AG) and anesthesia (AS) for gynecologic brachytherapy (BT) procedures. METHODS AND MATERIALS A 27-item survey created with expertise from 5 brachytherapists was distributed electronically to 90 U.S. radiation oncology academic programs and publicized on social media and at 2 national meetings from June to October 2023. RESULTS Forty-one responses were received (46%). Fifty-four percent identified as female, 66% as Caucasian, and 85% as non-Hispanic/Latino ethnicity. Forty-nine percent use a BT suite ± computed tomography (CT) simulator alone, 39% the operating room ± BT suite or CT simulator or other location, 10% CT simulation room alone, and 2% clinic examination room. Thirty-four percent use general anesthesia alone (GA) for intracavitary BT (n = 41), 20% conscious sedation (CS) alone, 10% oral analgesia (OA) alone, 9% spinal or epidural AS alone, and 27% combination. Among those performing hybrid BT (n = 25), 40% use GA alone, 16% use CS alone, 12% epidural or spinal AS alone, 4% OA alone, and 28% combination. For template interstitial BT (n = 25), 44% use GA alone, 48% epidural alone or in combination with other AS, and 8% CS alone. Twenty-two percent of respondents provide AG or AS during applicator placement only, whereas 32% provide it during placement, planning, treatment, and removal. The most common reasons for not using CS or GA were the lack of AS resources and clinician preference. Seventy-three percent reported the belief that patients suffer from post-traumatic stress disorder symptoms after BT. However, 68% reported not using techniques to alleviate BT-related emotional distress. CONCLUSIONS Many U.S. brachytherapists report using GA, CS, or epidural AS; however, 10% are using only OA, and 22% offer AG/AS only during applicator placement. Furthermore, a majority of respondents believe post-traumatic stress disorder symptoms can occur after BT, but few offer any intervention. AS resources and clinician preferences should be targeted for the expansion of higher-quality care.
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Affiliation(s)
- Amanda Rivera
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida; Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
| | | | - Emma Herbach
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Jenna M Kahn
- Kaiser NW Permanente, Interstate Radiation Oncology Center, Portland, Oregon
| | | | - Keyur J Mehta
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Aaron Wolfson
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
| | - Lorraine Portelance
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida
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Moore LC, Ahern F, Li L, Kallis K, Kisling K, Cortes KG, Nwachukwu C, Rash D, Yashar CM, Mayadev J, Zou J, Vasconcelos N, Meyers SM. Neural network dose prediction for cervical brachytherapy: Overcoming data scarcity for applicator-specific models. Med Phys 2024; 51:4591-4606. [PMID: 38814165 PMCID: PMC11309769 DOI: 10.1002/mp.17230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 05/09/2024] [Accepted: 05/11/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND 3D neural network dose predictions are useful for automating brachytherapy (BT) treatment planning for cervical cancer. Cervical BT can be delivered with numerous applicators, which necessitates developing models that generalize to multiple applicator types. The variability and scarcity of data for any given applicator type poses challenges for deep learning. PURPOSE The goal of this work was to compare three methods of neural network training-a single model trained on all applicator data, fine-tuning the combined model to each applicator, and individual (IDV) applicator models-to determine the optimal method for dose prediction. METHODS Models were produced for four applicator types-tandem-and-ovoid (T&O), T&O with 1-7 needles (T&ON), tandem-and-ring (T&R) and T&R with 1-4 needles (T&RN). First, the combined model was trained on 859 treatment plans from 266 cervical cancer patients treated from 2010 onwards. The train/validation/test split was 70%/16%/14%, with approximately 49%/10%/19%/22% T&O/T&ON/T&R/T&RN in each dataset. Inputs included four channels for anatomical masks (high-risk clinical target volume [HRCTV], bladder, rectum, and sigmoid), a mask indicating dwell position locations, and applicator channels for each applicator component. Applicator channels were created by mapping the 3D dose for a single dwell position to each dwell position and summing over each applicator component with uniform dwell time weighting. A 3D Cascade U-Net, which consists of two U-Nets in sequence, and mean squared error loss function were used. The combined model was then fine-tuned to produce four applicator-specific models by freezing the first U-Net and encoding layers of the second and resuming training on applicator-specific data. Finally, four IDV models were trained using only data from each applicator type. Performance of these three model types was compared using the following metrics for the test set: mean error (ME, representing model bias) and mean absolute error (MAE) over all dose voxels and ME of clinical metrics (HRCTV D90% and D2cc of bladder, rectum, and sigmoid), averaged over all patients. A positive ME indicates the clinical dose was higher than predicted. 3D global gamma analysis with the prescription dose as reference value was performed. Dice similarity coefficients (DSC) were computed for each isodose volume. RESULTS Fine-tuned and combined models showed better performance than IDV applicator training. Fine-tuning resulted in modest improvements in about half the metrics, compared to the combined model, while the remainder were mostly unchanged. Fine-tuned MAE = 3.98%/2.69%/5.36%/3.80% for T&O/T&R/T&ON/T&RN, and ME over all voxels = -0.08%/-0.89%/-0.59%/1.42%. ME D2cc were bladder = -0.77%/1.00%/-0.66%/-1.53%, rectum = 1.11%/-0.22%/-0.29%/-3.37%, sigmoid = -0.47%/-0.06%/-2.37%/-1.40%, and ME D90 = 2.6%/-4.4%/4.8%/0.0%. Gamma pass rates (3%/3 mm) were 86%/91%/83%/89%. Mean DSCs were 0.92%/0.92%/0.88%/0.91% for isodoses ≤ 150% of prescription. CONCLUSIONS 3D BT dose was accurately predicted for all applicator types, as indicated by the low MAE and MEs, high gamma scores and high DSCs. Training on all treatment data overcomes challenges with data scarcity in each applicator type, resulting in superior performance than can be achieved by training on IDV applicators alone. This could presumably be explained by the fact that the larger, more diverse dataset allows the neural network to learn underlying trends and characteristics in dose that are common to all treatment applicators. Accurate, applicator-specific dose predictions could enable automated, knowledge-based planning for any cervical brachytherapy treatment.
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Affiliation(s)
- Lance C Moore
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Fritz Ahern
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Lingyi Li
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Karoline Kallis
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Kelly Kisling
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Katherina G Cortes
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Chika Nwachukwu
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Dominique Rash
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Catheryn M Yashar
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Jyoti Mayadev
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Jingjing Zou
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego and Moores Cancer Center, La Jolla, California, USA
| | - Nuno Vasconcelos
- Electrical and Computer Engineering, University of California San Diego, La Jolla, California, USA
| | - Sandra M Meyers
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
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Humphrey P, Dures E, Hoskin P, Cramp F. Patient Experiences of Brachytherapy for Locally Advanced Cervical Cancer: Hearing the Patient Voice Through Qualitative Interviews. Int J Radiat Oncol Biol Phys 2024; 119:902-911. [PMID: 38154511 PMCID: PMC11183299 DOI: 10.1016/j.ijrobp.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/26/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE Brachytherapy for gynecological cancer is reported to cause pain, anxiety, and distress with no clear guidance for optimizing patient experiences. The aim of this study was to explore patient experiences of brachytherapy and views on improvement. METHODS AND MATERIALS Semistructured interviews were undertaken with patients who had received brachytherapy for locally advanced cervical cancer. Two cohorts were recruited: cohort 1 had recently had brachytherapy, and cohort 2 was 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 1 or 2 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 analyzed following Braun and Clarke's method for reflexive thematic analysis. RESULTS Thirty-five interviews were conducted (20 in cohort 1 and 15 in cohort 2). 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 the patient got through it, (2) unpleasantness, discomfort, and the aftermath, and (3) emotional consequences and trauma. Some aspects of medium and long duration brachytherapy were found to be more problematic compared with short duration brachytherapy. Exploring experiences at 1-year post brachytherapy has provided insights into the long-lasting impact of brachytherapy experiences. CONCLUSIONS Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimens and durations, to minimize difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.
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Affiliation(s)
- Pauline Humphrey
- College of Health, Science & Society, University of the West of England, Bristol, United Kingdom; Bristol Cancer Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom.
| | - Emma Dures
- College of Health, Science & Society, University of the West of England, Bristol, United Kingdom
| | - Peter Hoskin
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom; Mount Vernon Cancer Centre, Northwood, United Kingdom
| | - Fiona Cramp
- College of Health, Science & Society, University of the West of England, Bristol, United Kingdom
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Chen ZJ, Li XA, Brenner DJ, Hellebust TP, Hoskin P, Joiner MC, Kirisits C, Nath R, Rivard MJ, Thomadsen BR, Zaider M. AAPM Task Group Report 267: A joint AAPM GEC-ESTRO report on biophysical models and tools for the planning and evaluation of brachytherapy. Med Phys 2024; 51:3850-3923. [PMID: 38721942 DOI: 10.1002/mp.17062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 06/05/2024] Open
Abstract
Brachytherapy utilizes a multitude of radioactive sources and treatment techniques that often exhibit widely different spatial and temporal dose delivery patterns. Biophysical models, capable of modeling the key interacting effects of dose delivery patterns with the underlying cellular processes of the irradiated tissues, can be a potentially useful tool for elucidating the radiobiological effects of complex brachytherapy dose delivery patterns and for comparing their relative clinical effectiveness. While the biophysical models have been used largely in research settings by experts, it has also been used increasingly by clinical medical physicists over the last two decades. A good understanding of the potentials and limitations of the biophysical models and their intended use is critically important in the widespread use of these models. To facilitate meaningful and consistent use of biophysical models in brachytherapy, Task Group 267 (TG-267) was formed jointly with the American Association of Physics in Medicine (AAPM) and The Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) to review the existing biophysical models, model parameters, and their use in selected brachytherapy modalities and to develop practice guidelines for clinical medical physicists regarding the selection, use, and interpretation of biophysical models. The report provides an overview of the clinical background and the rationale for the development of biophysical models in radiation oncology and, particularly, in brachytherapy; a summary of the results of literature review of the existing biophysical models that have been used in brachytherapy; a focused discussion of the applications of relevant biophysical models for five selected brachytherapy modalities; and the task group recommendations on the use, reporting, and implementation of biophysical models for brachytherapy treatment planning and evaluation. The report concludes with discussions on the challenges and opportunities in using biophysical models for brachytherapy and with an outlook for future developments.
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Affiliation(s)
- Zhe Jay Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David J Brenner
- Center for Radiological Research, Columbia University Medical Center, New York, New York, USA
| | - Taran P Hellebust
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Center, Mount Vernon Hospital, Northwood, UK
- University of Manchester, Manchester, UK
| | - Michael C Joiner
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Christian Kirisits
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marco Zaider
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Matsuda Y, Nagamine Y, Irie T, Goto T. Effects of pain management using nonsteroidal anti-inflammatory drug suppositories during brachytherapy for cervical cancer: A single-center prospective observational study. Brachytherapy 2024; 23:257-265. [PMID: 38462384 DOI: 10.1016/j.brachy.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/18/2023] [Accepted: 01/07/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION No standardized pain management protocol exists for intracavitary brachytherapy, and various methods of analgesia have been used in different countries and institutions. This study aimed to investigate the effects of pain management during intracavitary brachytherapy using nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen suppositories. METHODS In this single-center, prospective, observational study, patients undergoing intracavitary brachytherapy for cervical cancer completed a questionnaire survey after each brachytherapy session, which comprised questions regarding pain intensity, satisfaction with analgesia, and desire for effective anesthesia. RESULTS Data analysis was performed using data from 100 brachytherapy sessions of 27 patients. The median numerical rating scale (NRS; 0-10) score for each intracavitary brachytherapy session was 3-4. The median satisfaction scale score for analgesia (5-point scale, 1-5) for each session was approximately 4. Eight patients (29.6%) answered that they desired anesthesia more effective than suppositories at any session of brachytherapy. A comparison of the high (NRS ≥4) and low (NRS ≤3) NRS groups during the first session revealed that the high NRS group tended to have higher NRS scores and lower satisfaction with analgesia during all sessions. A positive correlation was observed between tumor size and the NRS score during the first brachytherapy session. CONCLUSIONS The NRS score was approximately 3-4, and satisfaction with analgesia was approximately 4 out of 5 when NSAIDs or acetaminophen suppositories were used as analgesics during intracavitary brachytherapy for cervical cancer. Although the current pain management protocol is clinically acceptable, inadequate analgesia is indicated in approximately 30% of patients.
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Affiliation(s)
- Yuko Matsuda
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Yusuke Nagamine
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan.
| | - Tomoya Irie
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
| | - Takahisa Goto
- Department of Anesthesiology and Critical Care Medicine, Yokohama City University Hospital, Yokohama, Japan
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Romano KD, Petroni G, Ward K, Zheng W, Mistro M, Libby B, McLaughlin C, Showalter TN, Janowski EM. A randomized trial evaluating a novel hydrogel packing system compared to standard packing during image-guided high-dose rate brachytherapy boost for cervical cancer. Brachytherapy 2024; 23:248-256. [PMID: 38519352 PMCID: PMC11098690 DOI: 10.1016/j.brachy.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/02/2024] [Accepted: 02/16/2024] [Indexed: 03/24/2024]
Abstract
INTRODUCTION The purpose of this prospective randomized trial was to compare the use of a novel vaginal hydrogel packing system (BrachyGel) to standard vaginal packing (VP) during high dose rate (HDR) brachytherapy (BT) for locally advanced cervical cancer (LACC). METHODS This cross-over study included LACC patients receiving HDR BT boost (intracavitary +/- interstitial). All patients received alternating gauze or BrachyGel VP on Arms A and B. Patients, physicians, and physicists evaluated BT characteristics via a 4-point Likert scale. Adverse events (AEs) were prospectively collected and scored per CTCAE. RESULTS The 20 patients enrolled. The mean bladder D2cc difference between gauze and BrachyGel in Arm A was 0.117 Gray (Gy) and in Arm B 0.013 Gy. The mean difference in rectum D2cc in Arm A and Arm B was -0.189 Gy and -0.191 Gy, respectively. The mean dose to 90% of the high-risk clinical target volume (HR-CTV) for gauze compared to BrachyGel was -0.032 Gy (95% CI: 0.472, 0.409). Patient-reported discomfort was similar with BrachyGel and gauze ("mild/moderate" 70.0% vs 74.0%, respectively). The clarity of VP was similar between BrachyGel and gauze (86.8% vs 89.7%, respectively). The completeness of VP was more frequently "excellent/good" with BrachyGel (79.0%) compared to gauze (56.4%). The ease of packing was more frequently "extremely easy" with BrachyGel (21.2% vs 0%). No serious AEs were reported. CONCLUSION This randomized trial found no clinically significant difference in OAR or HR-CTV dosimetry between BrachyGel and standard VP. BrachyGel performed well compared to gauze for the patient and physician use experience.
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Affiliation(s)
- Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA.
| | - Gina Petroni
- School of Public Health Sciences, Division of Biostatistics, University of Virginia, Charlottesville, Virginia, USA
| | - Kristi Ward
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Wendy Zheng
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Matthew Mistro
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Bruce Libby
- H. Lee Moffitt Cancer Center, Department of Radiation Oncology, Tampa, Florida, USA
| | - Christopher McLaughlin
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
| | - Einsley M Janowski
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia, USA
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10
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van Vliet-Pérez SM, van Paassen R, Wauben LSGL, Straathof R, Berg NJVD, Dankelman J, Heijmen BJM, Kolkman-Deurloo IKK, Nout RA. Time-action and patient experience analyses of locally advanced cervical cancer brachytherapy. Brachytherapy 2024; 23:274-281. [PMID: 38418362 DOI: 10.1016/j.brachy.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/31/2023] [Accepted: 01/18/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND AND PURPOSE Although MRI-based image guided adaptive brachytherapy (IGABT) for locally advanced cervical cancer (LACC) has resulted in favorable outcomes, it can be logistically complex and time consuming compared to 2D image-based brachytherapy, and both physically and emotionally intensive for patients. This prospective study aims to perform time-action and patient experience analyses during IGABT to guide further improvements. MATERIALS AND METHODS LACC patients treated with IGABT were included for the time-action (56 patients) and patient experience (29 patients) analyses. Times per treatment step were reported on a standardized form. For the patient experience analysis, a baseline health status was established with the EQ-5D-5L questionnaire and the perceived pain, anxiety and duration for each treatment step were assessed with the NRS-11. RESULTS The median total procedure time from arrival until discharge was 530 (IQR: 480-565) minutes. Treatment planning (delineation, reconstruction, optimization) required the most time and took 175 (IQR: 145-195) minutes. Highest perceived pain was reported during applicator removal and treatment planning, anxiety during applicator removal, and duration during image acquisition and treatment planning. Perceived pain, anxiety and duration were correlated. Higher pre-treatment pain and anxiety scores were associated with higher perceived pain, anxiety and duration. CONCLUSION This study highlights the complexity, duration and impact on patient experience of the current IGABT workflow. Patient reported pre-treatment pain and anxiety can help identify patients that may benefit from additional support. Research and implementation of measures aiming at shortening the overall procedure duration, which may include logistical, staffing and technological aspects, should be prioritized.
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Affiliation(s)
- Sharline M van Vliet-Pérez
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands; Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands.
| | - Rosemarijn van Paassen
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Linda S G L Wauben
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Robin Straathof
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands; Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Nick J van de Berg
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands; Erasmus MC Cancer Institute, Department of Gynaecological Oncology, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jenny Dankelman
- Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | - Ben J M Heijmen
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Inger-Karine K Kolkman-Deurloo
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Remi A Nout
- Erasmus MC Cancer Institute, Department of Radiotherapy, University Medical Center Rotterdam, Rotterdam, The Netherlands
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11
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Sadeghi MH, Sina S, Meigooni AS. Assessing Heterogeneity Effects on Points A, B, and Organs at Risk Doses in High-dose-Rate Brachytherapy for Cervical Cancer - A Comparison of 192Ir and 60Co Sources Using Monte Carlo N-Particle 5. J Med Phys 2024; 49:294-303. [PMID: 39131438 PMCID: PMC11309145 DOI: 10.4103/jmp.jmp_162_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/24/2024] [Accepted: 04/14/2024] [Indexed: 08/13/2024] Open
Abstract
Purpose The present article deals with investigating the effects of tissue heterogeneity consideration on the dose distribution of 192Ir and 60Co sources in high-dose-rate brachytherapy (HDR-BT). Materials and Methods A Monte Carlo N-Particle 5 (MCNP5) code was developed for the simulation of the dose distribution in homogeneous and heterogeneous phantoms for cervical cancer patients. The phantoms represented water-equivalent and human body-equivalent tissues. Treatment data for a patient undergoing HDR-BT with a 192Ir source were used as a reference for validation, and for 60Co, AAPM Task Group 43 methodology was also applied. The dose values were calculated for both source types in the phantoms. Results The results showed a good agreement between the calculated dose in the homogeneous phantom and the real patient's treatment data, with a relative difference of less than 5% for both sources. However, when comparing the absorbed doses at critical points such as Point A right, Point A left, Point B right, Point B left, bladder International Commission on Radiation Units and Measurement (ICRU) point, and recto-vaginal ICRU point, the study revealed significant percentage differences (approximately 5.85% to 12.02%) between the homogeneous and heterogeneous setups for both 192Ir and 60Co sources. The analysis of dose-volume histograms (DVH) indicated that organs at risk, notably the rectum and bladder, still received doses within recommended limits. Conclusions The study concludes that 60Co and 192Ir sources can be effectively used in HDR-BT, provided that careful consideration is given to tissue heterogeneity effects during treatment planning to ensure optimal therapeutic outcomes.
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Affiliation(s)
- Mohammad Hossein Sadeghi
- Department of Nuclear Engineering, School of Mechanical Engineering, Shiraz University, Shiraz, Iran
| | - Sedigheh Sina
- Department of Nuclear Engineering, School of Mechanical Engineering, Shiraz University, Shiraz, Iran
- Radiation Research Center, School of Mechanical Engineering, Shiraz University, Shiraz, Iran
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12
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Ross DH, Gomez K, Harmon G, Mysz ML, Shea SM, Goldberg A, Liotta M, Potkul R, Winder A, Lee B, Jackson J, Roeske JC, Small W, Harkenrider MM. Evaluating outcomes and toxicities for a newly implemented MRI-based brachytherapy program for cervical cancer. Gynecol Oncol 2024; 183:33-38. [PMID: 38492475 DOI: 10.1016/j.ygyno.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVE We report an updated analysis of the outcomes and toxicities of MRI-based brachytherapy for locally advanced cervical cancer from a U.S. academic center. METHODS A retrospective review was performed on patients treated with MRI-based brachytherapy for cervical cancer. EBRT was standardly 45 Gy in 25 fractions with weekly cisplatin. MRI was performed with the brachytherapy applicator in situ. Dose specification was most commonly 7 Gy for 4 fractions with optimization aim of D90 HR-CTV EQD2 of 85-95 Gyα/β=10 Gy in 2 implants each delivering 2 fractions. RESULTS Ninety-eight patients were included with median follow up of 24.5 months (IQR 11.9-39.8). Stage IIIA-IVB accounted for 31.6% of cases. Dosimetry results include median GTV D98 of 101.0 Gy (IQR 93.3-118.8) and HR-CTV D90 of 89 Gy (IQR 86.1-90.6). Median D2cc bladder, rectum, sigmoid, and bowel doses were 82.1 Gy (IQR 75.9-88.0), 65.9 Gy (IQR 59.6-71.2), 65.1 Gy (IQR 57.7-69.6), and 55 Gy (IQR 48.9-60.9). Chronic grade 3+ toxicities were seen in the bladder (8.2%), rectosigmoid (4.1%), and vagina (1.0%). Three-year LC, PFS, and OS were estimated to be 84%, 61.7%, and 76.1%, respectively. CONCLUSION MRI-based brachytherapy demonstrates excellent local control and acceptable rates of high-grade morbidity. These results are possible in our population with relatively large volume primary tumors and extensive local disease.
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Affiliation(s)
- Dylan H Ross
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA
| | - Kayeromi Gomez
- Loyola University Medical Center, Maywood, IL 60153, USA; Biostatistics Collaborative Core, Clinical Research Office, Health Sciences Campus. Loyola University Chicago, Maywood, IL 60153, USA
| | - Grant Harmon
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA
| | - Michael L Mysz
- Loyola University Medical Center, Maywood, IL 60153, USA
| | - Steven M Shea
- Loyola University Medical Center, Maywood, IL 60153, USA; Department of Radiology and Medical Imaging, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Ari Goldberg
- Loyola University Medical Center, Maywood, IL 60153, USA; Department of Radiology and Medical Imaging, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Margaret Liotta
- Loyola University Medical Center, Maywood, IL 60153, USA; Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Ronald Potkul
- Loyola University Medical Center, Maywood, IL 60153, USA; Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Abigail Winder
- Loyola University Medical Center, Maywood, IL 60153, USA; Department of Obstetrics and Gynecology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Brian Lee
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA
| | - Jacob Jackson
- Loyola University Medical Center, Maywood, IL 60153, USA
| | - John C Roeske
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL 60153, USA; Loyola University Medical Center, Maywood, IL 60153, USA.
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13
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Parisi S, Sciacca M, Ferrantelli G, Chillari F, Critelli P, Venuti V, Lillo S, Arcieri M, Martinelli C, Pontoriero A, Minutoli F, Ercoli A, Pergolizzi S. Locally advanced squamous cervical carcinoma (M0): management and emerging therapeutic options in the precision radiotherapy era. Jpn J Radiol 2024; 42:354-366. [PMID: 37987880 DOI: 10.1007/s11604-023-01510-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
Squamous cervical carcinoma (SCC) requires particular attention in diagnostic and clinical management. New diagnostic tools, such as (positron emission tomography-magnetic resonance imaging) PET-MRI, consent to ameliorate clinical staging accuracy. The availability of new technologies in radiation therapy permits to deliver higher dose lowering toxicities. In this clinical scenario, new surgical concepts could aid in general management. Lastly, new targeted therapies and immunotherapy will have more room in this setting. The aim of this narrative review is to focus both on clinical management and new therapies in the precision radiotherapy era.
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Affiliation(s)
- S Parisi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - M Sciacca
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - G Ferrantelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy.
| | - F Chillari
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - P Critelli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - V Venuti
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - S Lillo
- Radiation Oncology Unit, Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - M Arcieri
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - C Martinelli
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - A Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - F Minutoli
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
| | - A Ercoli
- Obstetrics and Gynecology Unit, Department of Human Pathology of Adult and Childhood ``G. Baresi'', University Hospital ``G. Martino'', Messina, Italy
| | - S Pergolizzi
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Via Consolare Valeria, 1, 98124, Messina, ME, Italy
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14
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Takatsu J, Murakami N, Muramoto Y, Karino T, Oshima M, Kosugi Y, Kawamoto T, Terao Y, Shikama N. Safe dose escalation and reduction of the fraction number of uterine cervical brachytherapy using a gel spacer in the rectovaginal and vesicouterine septum: A planning study. Brachytherapy 2024; 23:115-122. [PMID: 38040605 DOI: 10.1016/j.brachy.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 10/06/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE To evaluate the possibility of dose escalation and reduction of fraction number in cervical brachytherapy using a gel spacer. MATERIAL AND METHODS Twenty patients with uterine cervical cancer treated with image-guided adaptive brachytherapy (IGABT) were selected. Hyaluronic acid gel injection (HGI) was performed in the rectovaginal and vesicouterine septum for 10 patients. The other ten patients were not with HGI. Both groups were treated with IGABT involving tandem/ovoid or cylindrical applicators along with additional interstitial needles. Dose distributions approved by radiation oncologists were retrospectively analyzed, and a dose summation of 45 Gy/25 of external beam radiation therapy and IGABT was performed. Dose constraints for D2cc of bladder, rectum, and sigmoid were 80, 70, and 70 Gy, respectively. Equivalent dose in 2-Gy fractions calculations used α/β = 10 Gy for high-risk clinical target volume (CTVHR) D90 and α/β = 3 Gy for organs at risks (OARs). As a planning study, dose distribution rescaling was conducted to deliver as much dose to CTVHR D90 as possible within the dose constraint limitation for OARs when IGABT was performed for four, three, and two fractions in both groups. RESULTS The median CTVHR D90 was >80 Gy in the non-HGI group and >85 Gy in the HGI group for virtual two and three fractions. Rectum D2cc was significantly lower in the HGI group for three fractions (p < 0.01). CONCLUSIONS In the HGI group, adequate dose delivery to CTVHR could be achieved with a reduced IGABT fraction number while meeting the dose constraints of OARs.
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Affiliation(s)
- Jun Takatsu
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
| | - Yoichi Muramoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
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Chen D, Parsa R, Chauhan K, Lukovic J, Han K, Taggar A, Raman S. Review of brachytherapy clinical trials: a cross-sectional analysis of ClinicalTrials.gov. Radiat Oncol 2024; 19:22. [PMID: 38351013 PMCID: PMC10863227 DOI: 10.1186/s13014-024-02415-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION Characterizing the landscape of clinical trials including brachytherapy can provide an overview of the current status and research trends which may guide further areas of investigation. METHOD We queried 449,849 clinical trials from the ClinicalTrials.gov registry using brachytherapy-related keywords from 1980 to 2023, yielding 245 multi-arm and 201 single-arm, brachytherapy trials. Multi-arm and single-arm brachytherapy trials were compared using 12 trial protocol elements. RESULTS The number of trials including brachytherapy has increased over time, with over 60% of trials registered in 2010 onwards. The majority of clinical trials were Phase 2 or 3, evaluated both safety and efficacy, and were funded by academic sponsors. The most common tumor sites evaluated in brachytherapy clinical trials include prostate, cervix, liver, endometrium, and breast. CONCLUSION There remains continued interest in clinical trials including brachytherapy focused on evaluation of novel delivery systems, treatment planning, and new indications. More brachytherapy clinical trials are needed to define the optimal clinical utilization and advance prospective research in this field.
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Affiliation(s)
- David Chen
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rod Parsa
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kabir Chauhan
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
| | - Jelena Lukovic
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kathy Han
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Amandeep Taggar
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Srinivas Raman
- Princess Margaret Cancer Centre, Radiation Medicine Program, Toronto, ON, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
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Ndarukwa S, Flores JA, Rosenblatt E, Berger D, Akbarov K, Hedden N, Chopra S, Hande V, Rubio AP. Brachytherapy Workflow Practices: Analysis of Different Workflow Scenarios in Patients With Cervical Cancer and Impact on IGBT Implementation-An IAEA Study. JCO Glob Oncol 2024; 10:e2300336. [PMID: 38386958 PMCID: PMC10898675 DOI: 10.1200/go.23.00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 10/19/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024] Open
Abstract
PURPOSE The workflow of brachytherapy (BT) is an essential aspect of treatment to consider in image-guided brachytherapy (IGBT). It has an overarching effect influencing patient throughput and the number of cancer treatments that can be performed as it occupies equipment, space, and personnel. There is limited research addressing this issue. Under the International Atomic Energy Agency's Coordinated Research Activity titled IGBT for cervix cancer: An implementation study, our study analyzes various scenarios in the clinical workflow of BT delivery for cervical cancer. It aims to determine the extent to which these scenarios allow the routine implementation of IGBT. With this information, current barriers and individualized adaptations to efficient workflows can be identified to enhance the global application of IGBT, leading to better cervical cancer treatment. MATERIALS AND METHODS A web-based poll of questions regarding practices in BT workflow was presented to 62 participants from low-, lower middle-, upper middle-, and high-income countries (19 countries). RESULTS This study highlighted diversity in BT practices across countries, income levels, and regions. It identified variations in workflow, patient throughput, and resource availability, which can have implications for the efficiency and quality of BT treatments. Scenario A, utilizing multiple locations for the steps of the BT procedure, was the most commonly used. The availability of resources, such as imaging devices and trained personnel, varied among the participating centers and remained challenging for IGBT implementation and sustainability. CONCLUSION The design of the BT facility plays a vital role in improving efficiency, with a dedicated BT suite contributing to an efficient workflow but limiting patient throughput, especially for high-volume centers. Although IGBT is effective, its implementation requires consideration of various logistical challenges and should be individualized.
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Affiliation(s)
- Sandra Ndarukwa
- Applied Radiobiology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Jerickson Abbie Flores
- Applied Radiobiology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Eduardo Rosenblatt
- Applied Radiobiology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Daniel Berger
- Section of Dosimetry and Medical Radiation Physics, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Kamal Akbarov
- Applied Radiobiology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Natasha Hedden
- Applied Radiobiology and Radiotherapy Section, Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Supriya Chopra
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Varsha Hande
- Advanced Centre for Treatment Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Alfredo Polo Rubio
- City Cancer Challenge, Technical Cooperation and Capacity Development, Geneva, Switzerland
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17
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Gagrani V, Kabara J, Shukla A, Rathore NK, Rajpurohit VS, Jangid PK, Manna S. A comparative study between two different dose fractionation schedules of cobalt-60-based HDR intracavitary brachytherapy in carcinoma cervix stages IIB-IIIC1. J Cancer Res Ther 2024:01363817-990000000-00058. [PMID: 38261446 DOI: 10.4103/jcrt.jcrt_286_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/04/2023] [Indexed: 01/25/2024]
Abstract
INTRODUCTION High dose rate (HDR) intracavitary brachytherapy (ICBT) is an integral element in the treatment of carcinoma uterine cervix. The main objective of brachytherapy in carcinoma cervix is to deliver a lethal dose to tumor cells without inducing unacceptable damage to the surrounding normal tissue. Because the absorbed dose falls off rapidly, higher doses can be safely delivered to the targeted tissue over a short time. The quest for optimum dose and fractionation schedule in HDR ICBT is still ongoing, and there is no uniform consensus. This study aimed to assess the acute dose-related toxicities of HDR brachytherapy schedule of 7 Gy x 3 fractions over 6 Gy x 4 fractions in the treatment of cervical cancer. OBJECTIVE The aim of this study was to study the acute treatment-related gastrointestinal (GI) and genitourinary (GU) toxicities between two HDR brachytherapy regimens. MATERIAL AND METHODS This is a prospective institutional study carried out from May 2018 to September 2018. In this time period, 66 patients of cervical cancers fulfilling our inclusion criteria were treated with concurrent chemoradiation (CCRT) following brachytherapy. During treatment, patients were randomized to arm A-7 Gy per fraction for three fractions and arm B-6 Gy per fraction for four fractions. Acute GI and GU toxicities were assessed using Common Terminology Criteria for Adverse Events (CTCAE) Version 4.03. All patients were kept for follow-up for 3 months in this study. RESULTS There is no statistically significant difference between the two arms for acute GI and GU toxicities, and the results were comparable. CONCLUSIONS Considering the increased hospital burden of locally advanced cervical cancer patients in the Indian context, the HDR brachytherapy schedule of 7 Gy per fraction is preferable to 6 Gy per fraction for a lesser fractionation schedule.
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Affiliation(s)
- Vaibhav Gagrani
- Department of Radiation Oncology, Asian Cancer Hospital, Jaipur, Rajasthan, India
| | - Jyoti Kabara
- Department of Anesthesia, GBH Medical College and General Hospital, Udaipur, Rajasthan, India
| | - Arvind Shukla
- Department of Radiation Oncology, RNT Medical College, Udaipur, Rajasthan, India
| | - N K Rathore
- Department of Radiation Oncology, RNT Medical College, Udaipur, Rajasthan, India
| | - Vikram S Rajpurohit
- Department of Radiation Oncology, RNT Medical College, Udaipur, Rajasthan, India
| | - Pawan K Jangid
- Department of Radiation Oncology and Medical Physics, SMS Medical College, Jaipur, Rajasthan, India
| | - Sumanta Manna
- Specialty of Medical Physics, Kalyan Singh Super Specialty Cancer Institute, Lucknow, Uttar Pradesh, India
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Massock W, Kim Y, Dresner MA, Sun W, Caster J, Adams Q, Jespersen J, St-Aubin J. MRI-Guided High-Dose-Rate Gynecologic Brachytherapy Using an MR-Linac as an MR Simulator: A Single Institutional Experience. Pract Radiat Oncol 2024; 14:70-79. [PMID: 37652344 DOI: 10.1016/j.prro.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/07/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE The goal of this study was to commission the use of a magnetic resonance linear accelerator (MR-linac; Unity) for imaging of gynecologic high-dose-rate (HDR) brachytherapy. This included optimizing imaging protocols and workflow development. METHODS AND MATERIALS T1-weighted and T2-weighted HDR imaging protocols were optimized on the Unity for HDR gynecologic imaging and treatment planning. Phantom measurements using these protocols were performed to determine geometric distortion and to assess reconstruction accuracy of the applicator compared with the ground truth computed tomography image. A treatment plan was created within the treatment planning system that was then delivered to a phantom. New workflows were developed which were tested with a full dry run with a healthy volunteer including patient transfer, anesthesia considerations, and data transfer. Validation of the workflow was completed on 1 patient who received imaging on both the Unity magnetic resonance imaging (MRI) and on a dedicated 3 Tesla MRI simulator. RESULTS Imaging analysis results were favorable with MR-linac images with a maximum distortion of 0.96 mm and a 1.36-mm over a 350-mm diameter spherical volume on the T1- and T2-weighted images, respectively, and the maximum effect of the applicator was 0.36 ppm of the main magnetic field. Reconstruction uncertainties of the Venezia applicator's tandem and 2 lunar-ovoids on the MR-linac images were within the 2-mm tolerance of the International Commission on Radiation Units and Measurements Report 89. Treatment planning and delivery was performed on the MR-HDR quality assurance phantom without issue. Dry run and healthy volunteer imaging showed adequate performance of both vital monitoring and HDR equipment. For the patient for which both the Unity MRI and 3 Tesla images were acquired, 95.78% and 95.80% of the high risk clinical target volume received 100% of the dose, respectively. Both plans were considered clinically acceptable. CONCLUSIONS Unity MR-linac images were successfully used in gynecologic HDR brachytherapy treatment planning, and a usable workflow was established.
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Affiliation(s)
- Whitney Massock
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Yusung Kim
- Department of Radiation Physics, MD Anderson Cancer Center, Houston, Texas
| | | | - Wenqing Sun
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Joseph Caster
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Quentin Adams
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Jill Jespersen
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa
| | - Joel St-Aubin
- Department of Radiation Oncology, University of Iowa, Iowa City, Iowa.
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Huang YJ, DeCesaris CM, Sarkar V, Zhao H, Kunz J, Nelson G, Li X, Suneja G, Burt LM, Gaffney DK. Image-guided preplanning workflow for high-dose-rate interstitial brachytherapy for gynecological malignancies. Brachytherapy 2024; 23:25-34. [PMID: 37777394 DOI: 10.1016/j.brachy.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE To demonstrate image-guided preplan workflows for high-dose-rate (HDR) brachytherapy for advanced gynecological malignancies. METHODS AND MATERIALS Two different preplanning scenarios are presented: (1) CT- or MRI-based preplan with partial applicator in place; (2) Preplans generated from prior fractions. The first scenario can be applied to Syed-Neblett template-based implants or hybrid brachytherapy applicators, while the second scenario applies to hybrid applicators. Both scenarios use MRI or CT images acquired with the applicator in place to demonstrate tumor and applicator relative locations and therefore, provide the ability to show optimized suggested needle positions including the implant depths before the actual insertion. RESULTS The preplanning techniques have demonstrated feasibility and shown five areas of potential improvement: (1) shorter procedure time, (2) decreased number of total needles inserted, (3) shorter physician tumor contour time, (4) shorter planning time, and (5) evaluation of appropriateness for brachytherapy. CONCLUSIONS The use of image-guided brachytherapy preplanning improves clinical efficiency and is recommended for consideration for adaptation into clinical workflows for HDR interstitial and hybrid brachytherapy.
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Affiliation(s)
- Y Jessica Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT.
| | | | - Vikren Sarkar
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Hui Zhao
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Jeremy Kunz
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Geoff Nelson
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Xing Li
- Department of Radiation Oncology, Inova Schar Cancer Institute, Fairfax, VA
| | - Gita Suneja
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - Lindsay M Burt
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, University of Utah, Salt Lake City, UT
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Dhabal S, Basu A, Sau S, Sau S, Maiti PK, Chakravarty A. Clinical outcome after high dose rate intracavitary brachytherapy with traditional point 'A' dose prescription in locally advanced carcinoma of uterine cervix: dosimetric analysis from the perspective of computed tomography imaging-based 3-dimensional treatment planning. Obstet Gynecol Sci 2024; 67:67-75. [PMID: 37817413 DOI: 10.5468/ogs.23048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/09/2023] [Indexed: 10/12/2023] Open
Abstract
OBJECTIVE To analyze tumour response and toxicity with respect to cumulative radiotherapy dose to target and organs at risk (OARs) with computed tomography (CT)-based image guided adaptive brachytherapy planning for locally advanced carcinoma cervix. METHODS Patients were treated with two-dimensional concurrent chemoradiotherapy to whole pelvis followed by intracavitary brachytherapy (ICBT) with dose prescription to point 'A'. CT image-based delineation of high-risk clinical target volume (HR-CTV), urinary bladder, rectum and sigmoid colon was done with generation of dose-volume histogram (DVH) data and optimization of doses to target and OARs. Follow up assessments were done for response of disease and toxicity with generation of data for statistical analysis. RESULTS One hundred thirty-six patients were enrolled in the study. Delineated volume of HR-CTV ranged from 20.9 to 37.1 mL, with median value of 30.2 mL. The equivalent dose in 2 Gy per fraction (EQD2) for point 'A' ranged from 71.31 to 79.75 Gy with median value of 75.1 Gy and EQD2 HR-CTV D90 ranged from 71.9 to 89.7 Gy with median value of 85.1 Gy. 69.2% of patients showed complete response and after median follow-up of 25 months, 50 patients remained disease free, of whom, 74.0% had received ≥85 Gy to HR-CTV D90 versus 26.0% receiving <85 Gy to HR-CTV D90. CONCLUSION s Amidst the unavailability of magnetic resonance imaging facilities in low middle income countries, incorporation of CT-image based treatment planning into routine practice for ICBT provides the scope to delineate volumes of target and OARs and to generate DVH data, which can prove to be a better surrogate for disease response and toxicity.
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Affiliation(s)
- Suman Dhabal
- Department of Radiation Oncology, Burdwan Medical College, Purba Bardhaman, West Bengal, India
| | - Abhishek Basu
- Department of Radiation Oncology, Burdwan Medical College, Purba Bardhaman, West Bengal, India
| | - Saikat Sau
- Department of Cardiology, Burdwan Medical College, Purba Bardhaman, West Bengal, India
| | - Sourav Sau
- Department of Radiation Oncology, Burdwan Medical College, Purba Bardhaman, West Bengal, India
| | - Pradip Kumar Maiti
- Department of Radiation Oncology, Agartala Government Medical College, Agartala, India
| | - Abhay Chakravarty
- Department of Radiation Oncology, Burdwan Medical College, Purba Bardhaman, West Bengal, India
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Wang Y, Jian W, Zhu L, Cai C, Zhang B, Wang X. Attention-Gated Deep-Learning-Based Automatic Digitization of Interstitial Needles in High-Dose-Rate Brachytherapy for Cervical Cancer. Adv Radiat Oncol 2024; 9:101340. [PMID: 38260236 PMCID: PMC10801665 DOI: 10.1016/j.adro.2023.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 07/31/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Deep learning can be used to automatically digitize interstitial needles in high-dose-rate (HDR) brachytherapy for patients with cervical cancer. The aim of this study was to design a novel attention-gated deep-learning model, which may further improve the accuracy of and better differentiate needles. Methods and Materials Seventeen patients with cervical cancer with 56 computed tomography-based interstitial HDR brachytherapy plans from the local hospital were retrospectively chosen with the local institutional review board's approval. Among them, 50 plans were randomly selected as the training set and the rest as the validation set. Spatial and channel attention gates (AGs) were added to 3-dimensional convolutional neural networks (CNNs) to highlight needle features and suppress irrelevant regions; this was supposed to facilitate convergence and improve accuracy of automatic needle digitization. Subsequently, the automatically digitized needles were exported to the Oncentra treatment planning system (Elekta Solutions AB, Stockholm, Sweden) for dose evaluation. The geometric and dosimetric accuracy of automatic needle digitization was compared among 3 methods: (1) clinically approved plans with manual needle digitization (ground truth); (2) the conventional deep-learning (CNN) method; and (3) the attention-added deep-learning (CNN + AG) method, in terms of the Dice similarity coefficient (DSC), tip and shaft positioning errors, dose distribution in the high-risk clinical target volume (HR-CTV), organs at risk, and so on. Results The attention-gated CNN model was superior to CNN without AGs, with a greater DSC (approximately 94% for CNN + AG vs 89% for CNN). The needle tip and shaft errors of the CNN + AG method (1.1 mm and 1.8 mm, respectively) were also much smaller than those of the CNN method (2.0 mm and 3.3 mm, respectively). Finally, the dose difference for the HR-CTV D90 using the CNN + AG method was much more accurate than that using CNN (0.4% and 1.7%, respectively). Conclusions The attention-added deep-learning model was successfully implemented for automatic needle digitization in HDR brachytherapy, with clinically acceptable geometric and dosimetric accuracy. Compared with conventional deep-learning neural networks, attention-gated deep learning may have superior performance and great clinical potential.
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Affiliation(s)
- Yuenan Wang
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Wanwei Jian
- Department of Radiation Therapy, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lin Zhu
- Department of Radiation Therapy, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Chunya Cai
- Department of Radiation Therapy, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Bailin Zhang
- Department of Radiation Therapy, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xuetao Wang
- Department of Radiation Therapy, The Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
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22
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Sarwar KA, Hussain S, Syed AS, Khan K, Maqsood T, Azeem T. Outcomes and comparison of dosimetric parameters between intracavitary (Fletcher) and combined intracavitary/interstitial (Utrecht) brachytherapy in locally advanced cervical cancer. Brachytherapy 2024; 23:10-17. [PMID: 37813708 DOI: 10.1016/j.brachy.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE To report outcomes of combined intracavitary/interstitial (IC/IS) image-guided brachytherapy (IGBT) in locally advanced cervical cancer, and to compare its dosimetric parameters with intracavitary-only (IC) brachytherapy in a first-in-country experience. METHODS AND MATERIALS Between January 2021 and September 2022, a total of 160 insertions were done in 40 patients with FIGO IB3-IVA cervical cancer undergoing IGBT using a hybrid (Utrecht) applicator. Corresponding treatment plans for IC brachytherapy were generated during treatment, and optimized. A preplanned comparison of dosimetric parameters, defined in GEC-ESTRO was conducted. RESULTS The clinical use of a hybrid IC/IS applicator was feasible in all insertions. An average of 14 needles were inserted in each patient over four fractions. Mean HR-CTV D90 and D98 was 86 (SD 1.9) Gy and 75.7 (SD 2.3) Gy using hybrid applicator, and 80 (SD 5.4) Gy and 69.8 (SD 5.2) Gy using IC applicator, with a mean dose gain of 6.0 (SD 5.0) Gy and 5.9 (SD 4.7) Gy (p <0.001), respectively. Likewise, mean D2cc for bladder and sigmoid were significantly lower in the hybrid technique. Mean contribution of brachytherapy to total HR-CTV D90 (in absolute EQD2 Gy) was 41.7 Gy using IC/IS applicator while 35.7 Gy for IC-only applicator (p = 0.027). Clinical response at 12 weeks showed an overall response rate (ORR) and complete response (CR) rates of 92.5% and 77.5%, respectively. CONCLUSIONS IGBT using a hybrid IC/IS applicator showed excellent tolerability and yielded favorable results, resulting in significant dosimetric improvement in terms of primary target dose, and sparing OARs.
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Affiliation(s)
- Kashif Ali Sarwar
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan.
| | - Sameed Hussain
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
| | - Abdus Samad Syed
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
| | - Khurram Khan
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
| | - Talha Maqsood
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
| | - Tariq Azeem
- Combined Military Hospital, National University of Medical Sciences (NUMS), Rawalpindi, Pakistan
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Hsieh K, Bloom JR, Dickstein DR, Hsieh C, Marshall D, Ghiassi-Nejad Z, Raince J, Lymberis S, Chadha M, Gupta V. Dose and fractionation regimen for brachytherapy boost in cervical cancer in the US. Gynecol Oncol 2024; 180:55-62. [PMID: 38052109 DOI: 10.1016/j.ygyno.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/06/2023] [Accepted: 11/12/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. METHODS We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. RESULTS Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). CONCLUSIONS In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.
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Affiliation(s)
- Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Julie R Bloom
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Celina Hsieh
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Deborah Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Zahra Ghiassi-Nejad
- Department of Radiation Oncology, Columbia University Medical Center, New York, NY, United States of America
| | - Jagdeep Raince
- Department of Radiation Oncology, New York University Langone Health, New York, NY, United States of America
| | - Stella Lymberis
- Department of Radiation Oncology, New York University Langone Health, New York, NY, United States of America
| | - Manjeet Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Grover S, Lichter KE, Likhacheva A, Jang JW, Ning MS, Robin TP, Small W, Kudchadker RJ, Swamidas J, Chopra S, Rai B, Sharma SD, Sharma DN, Kuppusamy T, Yang R, Berger D, Mendez LC, Glaser S, Erickson DL, Chino J, Mourtada F, Abdel-Wahab M, Jhingran A, Simonds H, Mahantshetty U. The American Brachytherapy Society and Indian Brachytherapy Society consensus statement for the establishment of high-dose-rate brachytherapy programs for gynecological malignancies in low- and middle-income countries. Brachytherapy 2023; 22:716-727. [PMID: 37704540 DOI: 10.1016/j.brachy.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/17/2023] [Accepted: 07/03/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE The global cervical cancer burden is disproportionately high in low- and middle-income countries (LMICs), and outcomes can be governed by the accessibility of appropriate screening and treatment. High-dose-rate (HDR) brachytherapy plays a central role in cervical cancer treatment, improving local control and overall survival. The American Brachytherapy Society (ABS) and Indian Brachytherapy Society (IBS) collaborated to provide this succinct consensus statement guiding the establishment of brachytherapy programs for gynecological malignancies in resource-limited settings. METHODS AND MATERIALS ABS and IBS members with expertise in brachytherapy formulated this consensus statement based on their collective clinical experience in LMICs with varying levels of resources. RESULTS The ABS and IBS strongly encourage the establishment of HDR brachytherapy programs for the treatment of gynecological malignancies. With the consideration of resource variability in LMICs, we present 15 minimum component requirements for the establishment of such programs. Guidance on these components, including discussion of what is considered to be essential and what is considered to be optimal, is provided. CONCLUSIONS This ABS/IBS consensus statement can guide the successful and safe establishment of HDR brachytherapy programs for gynecological malignancies in LMICs with varying levels of resources.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA.
| | - Katie E Lichter
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA
| | - Anna Likhacheva
- Department of Radiation Oncology, Sutter Health Sacramento, Sacramento, CA
| | - Joanne W Jang
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
| | - Matthew S Ning
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tyler P Robin
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernadin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Rajat J Kudchadker
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jamema Swamidas
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Bhavana Rai
- Department of Radiation Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dutt Sharma
- Department of Radiation Oncology, Bhabha Atomic Research Centre, Mumbai, Maharashtra, India
| | - Daya N Sharma
- Department of Radiation Oncology, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India
| | - Thayalan Kuppusamy
- Department of Radiation Oncology, Dr Kamakshi Memorial Hospital, Chennai, Tamil Nadu, India
| | - Ruijie Yang
- Department of Radiation Oncology, Cancer Center, Peking University Third Hospital, Beijing, China
| | - Daniel Berger
- Department of Nuclear Sciences and Division of Human Health, Section of Dosimetry and Medical Radiation Physics, International Atomic Energy Agency, Vienna, Austria
| | - Lisbeth Cordero Mendez
- Division of Human Health, Applied Radiation Biology and Radiotherapy Section, International Atomic Energy Agency, Vienna, Austria
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Delnora L Erickson
- Department of Radiation Oncology, Walter Reed National Military Center, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Junzo Chino
- Deptartment of Radiation Oncology, Duke Cancer Center, Durham, NC
| | - Firas Mourtada
- Department of Radiation Oncology, Helen F. Graham Cancer Center and Research Institute, Christiana Care Health System, Sidney Kimmel Cancer Center, Newark, DE
| | - May Abdel-Wahab
- Department of Nuclear Sciences and Division of Human Health, Section of Applied Radiation Biology and Radiotherapy, International Atomic Energy Agency, Vienna, Austria
| | - Anuja Jhingran
- Division of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hannah Simonds
- Department of Radiation Oncology, Stellenbosch University, Stellenbosch, South Africa
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Hu Y, Jin Y, Wang D, Luo Y. Observation of hemostatic effectiveness and safety of ultrasound-CT guided 3D intracavitary and interstitial brachytherapy in the treatment of larger cervical cancer with bleeding: A retrospective study. Medicine (Baltimore) 2023; 102:e34904. [PMID: 37713892 PMCID: PMC10508520 DOI: 10.1097/md.0000000000034904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/03/2023] [Indexed: 09/17/2023] Open
Abstract
Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death in women. This study explored the effectiveness and safety of ultrasound-CT guided 3D intracavitary and interstitial brachytherapy (US-CT-3D-IGBT) in the treatment of larger cervical cancer with bleeding. A retrospective study was conducted on 31 patients with larger cervical squamous cell carcinoma (tumor short diameter >4 cm) with vaginal bleeding. US-CT-3D-IGBT was used to deliver a single high-dose prescription of high-risk clinical target volume (HR-CTV) 1000 to 1200 centigray (cGy) to the cervical tumor, followed by conventional intensity-modulated radiation therapy (IMRT) synchronous chemoradiotherapy (45-50 gray (Gy)/25-28 fraction(f)) with weekly cisplatin 25 mg/m2. After external radiotherapy, simple intracavitary brachytherapy (BT) combined with manual interstitial BT was administered at 30 Gy/5F or 28 Gy/4F. Within 24 hours after high-dose 3D-IGBT, bleeding stopped in 2 patients (6.4%), and bleeding was reduced in a total of 11 patients (35.4%) within 48 hours. A total of 29 patients achieved hemostasis within 72 hours, with an effective rate of 93.5%. The remaining 2 patients reached the clinical hemostasis requirement on the 4th and 5th day. All patients experienced a significant reduction in vaginal bleeding after the initial BT, with an average reduction of 66 mL (160-20 mL). US-CT-3D-IGBT is effective in rapidly controlling bleeding in patients with larger cervical cancer (tumor short diameter >4 cm), and the treatment is relatively safe and feasible.
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Affiliation(s)
- Yuefeng Hu
- Department of Radiotherapy Oncology, Hainan Cancer Hospital, Haikou, China
| | - Ying Jin
- Department of Ultrasonography, Hainan Cancer Hospital, Haikou, China
| | - Dongdong Wang
- Department of Radiophysics, Hainan Cancer Hospital, Haikou, China
| | - Yunxiu Luo
- Department of Radiotherapy Oncology, Hainan Cancer Hospital, Haikou, China
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McAlarnen LA, Small C, Tostrud L, Pan AY, Erickson B, Bedi M, Bradley WH. Considerations for pharmacologic thromboprophylaxis following inpatient brachytherapy for gynecologic malignancies. Brachytherapy 2023; 22:630-639. [PMID: 37394350 PMCID: PMC10757857 DOI: 10.1016/j.brachy.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/13/2023] [Accepted: 06/06/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE Brachytherapy irradiation carries risks of both bleeding and venous thromboembolism (VTE). No screening or management recommendations for VTE in this setting have been developed. Our study aims to understand the incidence of VTE, compile published anticoagulation guidelines, and call for future guidelines to address thromboprophylaxis in this population. METHODS AND MATERIALS A retrospective, single institution study of patients undergoing brachytherapy irradiation between 2012 and 2022 was undertaken. We analyzed 2 cohorts: 87 patients undergoing brachytherapy with an inpatient admission, and 66 patients assessed for risk of VTE or bleeding after discharge from an inpatient admission for brachytherapy. Caprini risk scores were calculated for each patient, and statistical analyses were performed. RESULTS Eighty-seven patients were included, and 25% had a VTE diagnosis. Forty-seven (54%) of patients included underwent brachytherapy as definitive treatment of cervical cancer, and 16 (18%) received brachytherapy irradiation to treat recurrent endometrial cancer. In the cohort of 66 patients assessed for risk of VTE or bleeding after brachytherapy discharge, 23 (34.8%) were discharged with thromboprophylaxis, and 43 (65.2%) were discharged without thromboprophylaxis. None of the patients discharged on thromboprophylaxis were diagnosed with a VTE within 90 days of discharge after brachytherapy, whereas 3 of 43 (7%) discharged without thromboprophylaxis were diagnosed with a VTE, OR and 95% CI: 0.25 (0.01-5.29), p = 0.37. Of the 23 patients discharged on thromboprophylaxis, 1 was readmitted for bleeding OR and 95% CI: 5.8 (0.22-155.18), p = 0.29. The median Caprini score was 11. CONCLUSIONS VTE is a common occurrence in patients undergoing brachytherapy. Patients undergoing brachytherapy irradiation who require inpatient admission represent a unique population, and specialty organizations should develop consensus recommendations to address these clinical challenges.
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Affiliation(s)
- Lindsey A McAlarnen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI.
| | - Christina Small
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Lauren Tostrud
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI
| | - Amy Y Pan
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Meena Bedi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - William H Bradley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI
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Chee N, McGrath A, Thompson SR, Knox MC, Marengo L, Jackson M, Favero JP, Watterson L. Comparison of three analgesic regimens in women undergoing cervical brachytherapy. Brachytherapy 2023; 22:607-615. [PMID: 37423807 DOI: 10.1016/j.brachy.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 07/11/2023]
Abstract
PURPOSE Effective periprocedural analgesia is an important aspect of cervical brachytherapy delivery, with implications for patient comfort and attendance for subsequent fractions. We compared the efficacy and safety of three analgesic modalities: intravenous patient-controlled analgesia (IV-PCA), continuous epidural infusion (CEI) and programmed-intermittent epidural bolus with patient-controlled epidural analgesia (PIEB-PCEA). METHODS AND MATERIALS Ninety-seven brachytherapy episodes involving 36 patients between July 2016 and June 2019 in a single tertiary center were retrospectively reviewed. Episodes were divided into two key phases: Phase 1 (while applicator remained in situ) and Phase 2 (following applicator removal until discharge or 4 h). For the primary endpoint, pain scores were retrieved and analyzed by analgesic modality with respect to median score and an internally defined "unacceptable" pain experience (>20% of scores being ≥4/10; i.e., moderate or greater). Total nonepidural oral morphine equivalent dose (OMED) and toxicity/complication events were reported as secondary endpoints. RESULTS In Phase 1, there was a significantly higher median pain score (p < 0.001) and more episodes with unacceptable pain scores (46%) in the IV-PCA group compared with either epidural modality (6-14%; p < 0.001). In Phase 2, we observed a greater median pain score (p = 0.007) and higher proportion of patient episodes with unacceptable pain scores (38%) in the CEI group compared with both the IV-PCA (13%) and PIEB-PCEA (14%) groups (p = 0.001). There was a significant difference in median OMED used throughout all phases across the PIEB-PCEA (0 mg), IV-PCA (70 mg), and CEI (15 mg) groups (p < 0.001). CONCLUSIONS PIEB-PCEA is safe and offers superior analgesia compared to IV-PCA or CEI for pain control after applicator placement in cervical brachytherapy.
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Affiliation(s)
- Nicholas Chee
- Department of Anaesthesia, Royal Hospital for Women, Randwick, NSW, Australia; Nepean Hospital, Kingswood, NSW, Australia
| | - Alyson McGrath
- Department of Anaesthesia, Royal Hospital for Women, Randwick, NSW, Australia
| | - Stephen R Thompson
- Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, Australia; Prince of Wales Clinical School, Faculty of Medicine & Health, UNSW, Sydney, NSW, Australia
| | - Matthew C Knox
- Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, Australia; St George and Sutherland Clinical School, Faculty of Medicine & Health, UNSW, Sydney, NSW, Australia
| | - Luca Marengo
- Department of Anaesthesia, Royal Hospital for Women, Randwick, NSW, Australia
| | - Michael Jackson
- Department of Radiation Oncology, Prince of Wales Hospital, Randwick, NSW, Australia; Prince of Wales Clinical School, Faculty of Medicine & Health, UNSW, Sydney, NSW, Australia
| | - John-Paul Favero
- Department of Anaesthesia, Royal Hospital for Women, Randwick, NSW, Australia
| | - Leonie Watterson
- Department of Anaesthesia, Royal Hospital for Women, Randwick, NSW, Australia.
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Dhaka S, Rajani A, Kumar HS, Sharma N, Jakhar SL, Harsh K. Interfraction variations in doses at OARs during three-dimensional high dose rate brachytherapy planning of cervix cancer. J Cancer Res Ther 2023; 19:1136-1141. [PMID: 37787275 DOI: 10.4103/jcrt.jcrt_797_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Objective The American Brachytherapy (BT) Society recommends that BT must be included as a component of the definitive radiation therapy for cervical carcinoma because recurrences and complications are decreased when BT is used in addition to external beam radiotherapy. The aim of this study is to quantify the interfraction dose variations (VARacts) during high dose rate (HDR) BT, the effect of variation in dose in terms of excess "unrecognized" dose to OAR and to conclude the reason of the variation in reference of applicator position/geometry versus deformation of the organ at risk (OAR) concerned. Materials and Methods Total 30 patients of carcinoma cervix, biopsy proven, between June 2018 and May 2019, were taken for the study. All patients were treated with external beam radiation therapy to a dose of 50 Gy in 25 fractions over 5 weeks, followed by three fractions of HDR intracavitary brachytherapy (ICBT) (7.5 Gy to point A in each fraction) by two-dimensional (2D) X-ray-based planning. Before treatment in the first and last fraction of BT, computed tomography (CT) scan was done for every patient. Then, a 3D-based planning was performed with CT images on our HDR Plus software with image sequence option. VARact was calculated. Rigid image registration of consecutive fraction images was used for quantification of the hypothetical variation in dose (VARhypo) arising exclusively due to changes in applicator placement and geometry. Results The mean contoured rectal volumes for the first and third fractions were 41.49 cc and 44.72 cc, respectively, while the respective volumes for bladder were 9.33 cc and 9.35 cc cm. These differences were statistically insignificant (P value: 0.263 and 0.919 for rectum and bladder, respectively). The mean equivalent dose in 2 Gy fraction (EQD2) bladder D2cc was 5.68 Gy and 5.79 Gy in the first and third fraction ICBT, respectively. The mean EQD2 for the rectal D2cc was 11.63 Gy and 12.85 Gy in the first and third fraction ICBT, respectively. None of the patients had an actual cumulative EQD2 more than 90 Gy for bladder, but 36.66% of the patients had a rectal dose exceeding the tolerance (75 Gy). Regression plots showed that VARhypo alone could predict about 42.2% of the VARact in the rectum and 19.2% of the VARact in the bladder. Thus, the remaining variation was due to the organ deformation-related dose variations between the two fractions. Conclusions There were no statistically significant variations in the volumes or doses of OAR between the two fractions. However, a significant proportion of patients may have a higher dose to the OAR in the third fraction in the absence of individualized planning. This increase is likely to be more detrimental where higher doses per fraction are used. Variations in OAR doses may be caused by organ deformation and/or changes in applicator placement/geometry.
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Affiliation(s)
- Saroj Dhaka
- Department of Radiation Oncology, S. P. Medical College, Bikaner, Rajasthan, India
| | - Anil Rajani
- Department of Radiation Oncology, SN Medical College, Jodhpur, Rajasthan, India
| | - H S Kumar
- Department of Radiotherapy, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India
| | - Neeti Sharma
- Department of Radiation Oncology, S. P. Medical College, Bikaner, Rajasthan, India
| | - Shankar Lal Jakhar
- Department of Radiotherapy, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India
| | - Kamlesh Harsh
- Department of Radiotherapy, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, Rajasthan, India
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Gutiérrez Miguélez C, Rodríguez Villalba S, Villafranca Iturre E, Fuentemilla Urio N, Richart Sancho J, Córdoba Lago S, Pino Sorroche F, Gracia Lucio R, Herreros Martínez A, Najjari-Jamal D. Recommendations of the Spanish brachytherapy group of the Spanish Society of Radiation Oncology and the Spanish Society of Medical Physics for interstitial high-dose-rate brachytherapy for gynaecologic malignancies. Clin Transl Oncol 2023; 25:912-932. [PMID: 36445642 PMCID: PMC10025210 DOI: 10.1007/s12094-022-03016-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/12/2022] [Indexed: 12/02/2022]
Abstract
The present document includes consensus-based recommendations from the Brachytherapy Group (GEB) of the Spanish Society of Radiation Oncology (SEOR) and the Spanish Society of Medical Physics (SEFM) for interstitial high-dose-rate (HDR) brachytherapy (BT) for gynaecologic malignancies. A nine-item survey-which included questions on experience with interstitial BT; indications and technique; applicator type; magnetic resonance imaging (MRI)-based planning; dose; fractionation schedule; and treatment planning-was sent to all radiation oncology departments (n = 174) in Spain in 2021. Responses were received from 36 centres (50% of all centres [n = 72] with a BT unit). The consensus-based recommendations presented here are based on a review of the available literature, professional experience among the group of experts, and in-person discussions held during the annual meeting of these two societies. We describe the results of the survey and the following: indications; contraindications; patient selection; description of applicators; role of imaging in planning; contouring; dose prescription; dosimetric reconstruction; optimisation; and dose indications for cancers of the cervix, vagina, and vulva. The various clinical scenarios in which interstitial BT is used in the treatment of gynaecological tumours are described in detail, including cervix intracavitary/interstitial hybrid HDR-BT; cervix perineal templates/freehand implants; primary vaginal malignancies/vaginal recurrences; and vulvar interstitial implants.
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Affiliation(s)
- Cristina Gutiérrez Miguélez
- Radiation Oncology Department, Institut Català d'Oncologia, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB) Catalonia, Hospitalet de Llobregat, Spain.
| | | | | | | | - Jose Richart Sancho
- Radiation Oncology Department, Hospital Clínica Benidorm, Benidorm, Spain
- Radiation Oncology Department, Hospital Universitario San Juan, Alicante, Spain
| | - Sofía Córdoba Lago
- Radiation Oncology Department, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Francisco Pino Sorroche
- Radiophysics Department, Institut Català d'Oncologia, Hospitalet de Llobregat, Catalonia, Spain
| | - Ruth Gracia Lucio
- Radiophysics Department, Institut Català d'Oncologia, Hospitalet de Llobregat, Catalonia, Spain
| | | | - Dina Najjari-Jamal
- Radiation Oncology Department, Institut Català d'Oncologia, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB) Catalonia, Hospitalet de Llobregat, Spain
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Vijayakumar S, Nittala MR, Duggar WN, King M, T. Lirette S, Yang CC, Mundra E, Woods WC, Otts J, Doherty M, Panter P, Howard C, Ridgway M, Allbright R. The Influence of Patient and System Factors on the Radiotherapy Treatment Time in the Treatment of Non-metastatic Cervical Cancer Patients in a Rural and Resource-Lean State’s Safety-Net Hospital: Benefits of Strategic Planning. Cureus 2023; 15:e35954. [PMID: 37038585 PMCID: PMC10082667 DOI: 10.7759/cureus.35954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2023] [Indexed: 03/12/2023] Open
Abstract
Objective To decrease radiotherapy treatment time (RTT), measured from the day of initiation of radiotherapy to the day of its completion, specific strategies were initiated in early 2020 in the only academic safety-net medical center in a rural, resource-lean state. The factors that can succeed and those that need further improvements were analyzed in this initial assessment phase of our efforts to shorten the RTT. Methods This is an analysis of 28 cervix cancer patients treated with magnetic resonance imaging (MRI)-guided brachytherapy (February 2020-November 2021). The relationship between independent and dependent variable were analyzed by simple linear regression, and p-values ≤ 0.05 were considered statistically significant. SPSS software version 28.0 (IBM, Armonk, NY, USA) was used for statistical analysis. Results Two RTT groups (≤ 60 (32.1%) vs. > 60 days {67.9%}) with median RTT of 68 days (range, 51 to 106 days) were analyzed. Caucasians represented 66.7% of the RTT ≤ 60 days group. Four 'issues' were identified that increased the RTT: non-compliance, learning curve (early days of implementation of MRI-guided brachytherapy in the department), stage IV comorbidities, and with more than one issue mentioned; 77.8% with no issues had ≤ 60 days RTT vs. 26.3% for the > 60 days group. The breakdown of the no-issues factor by calendar year showed the RTT of ≤ 60 days was achieved higher in 2021 (85.7% vs. 20.0%; p=0.023) compared to 2020. For this entire cohort, the RTT of ≤ 60 days was achieved higher in 2021 (50.0% vs. 8.3%; p=0.019) compared to 2020. Data also showed improvement in RTT of ≤ 60 days for every sequential six months. 'Non-compliance' and 'learning curve' were the most important factors among patients having the longest RTTs. Conclusion The RTT can be further decreased. As a result of this preliminary analysis of the our strategic planning approach of 'circular' "See it," "Own it," "Solve it," and "Do it" and go back to the first step again, we plan to implement the following strategies in the immediate future to shorten the RTTs further and, in turn, improve our overall outcomes (local/regional control, disease-free survival, and overall survival): (a) Interdigitate MRI-guided brachytherapy during external beam radiotherapy (EBRT); patients who can not get the interdigitated brachytherapy procedures performed during the course of EBRT for any reason will receive two brachytherapy procedures per week; (c) attempt to add a cervix cancer care navigator to our staff to help patients having social issues, thus leading to compliance problems; (d) finally, in a year or two after these new strategic implementations, the RTT data will be reanalyzed.
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Murakami N, Okuma K, Takahashi A, Kato T, Igaki H. Is it time to modify the Japanese Uterine Cervical Cancer Guidelines to recommend a higher dose for radio-resistant tumors? Jpn J Clin Oncol 2023; 53:179-181. [PMID: 36373890 DOI: 10.1093/jjco/hyac171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022] Open
Abstract
Compared with the European or the United States' uterine cervical cancer management guidelines, which aim to deliver >85 Gy EQD2 (the equivalent effective dose in 2 Gy per fraction) to the high-risk clinical target volume (CTVHR) D90 (minimal dose of 90% of the CTVHR), the dose goal of the corresponding Japanese guidelines does not recommend delivering such a high dose to the CTVHR D90. Subsequently, while the rate of late radiation-induced toxicities is reported to be much lower in the Japanese schedule, the local control rate is relatively inferior to that of clinical results reported by the IntErnational study on MRI-guided BRAchytherapy in CErvical cancer study (EMBRACE-I) in which the dose goal for CTVHR D90 was >85 Gy and showed >90% local control regardless of tumor stage. In daily clinical practice, patients with residual disease supposedly due to insufficient total dose delivery are occasionally referred to our hospital for the possibility of re-irradiation, which is not usually recommended because the risk of late severe radiation-induced toxicity is high. In this report, the authors hope to raise a discussion in our community about modifying our treatment guidelines to recommend a higher dose at least for patients with poor response.
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Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Ayaka Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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Harkenrider MM, Kamrava M. Embracing a future of progress in gynecologic brachytherapy. Brachytherapy 2023; 22:6-8. [PMID: 36725200 DOI: 10.1016/j.brachy.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/03/2022] [Indexed: 01/31/2023]
Abstract
In the last 20 years, gynecologic brachytherapy has made tremendous advancements, most prominently evidenced by the evolution of cervical cancer brachytherapy. In its 20 year history, Brachytherapy has become known as a journal of science, education, and advocacy for our specialty and for our patients. In this review, we celebrate the 25 most impactful manuscripts in gynecologic brachytherapy in the journal's history.
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Affiliation(s)
- Matthew M Harkenrider
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL.
| | - Mitchell Kamrava
- Cedars Sinai Medical Center, Department of Radiation Oncology, Los Angeles, CA
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Underutilization of brachytherapy for cervical cancer in the United States. Brachytherapy 2023; 22:15-20. [PMID: 36504160 DOI: 10.1016/j.brachy.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 12/13/2022]
Abstract
Brachytherapy is a critical component of the definitive management of cervical cancer and allows for the safe delivery of about half of the total effective radiation dose needed for optimal outcomes. Moreover, the dose distribution of brachytherapy is highly conformal, allowing for a therapeutic index currently unmatched by alternative techniques. However, a modern brachytherapy program requires special equipment, infrastructure, and procedural expertise. Unfortunately, multiple lines of evidence suggest that brachytherapy is currently underutilized in the United States. In this review, we examine the importance of brachytherapy, contemporary recommendations, and avenues for growth.
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Shiao JC, Holt DE, Stuhr K, Schubert L, Robin T, Fisher CM. The Kelowna template for combined intracavitary and interstitial brachytherapy for gynecologic malignancies: Design, application, treatment planning, dosimetric and treatment outcomes. Brachytherapy 2022; 21:823-832. [PMID: 36192312 DOI: 10.1016/j.brachy.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE We report the feasibility, experience, and early outcomes of the combined intracavitary and interstitial dedicated applicator using the Kelowna GYN template (Varian, Palo Alto, CA). METHODS AND MATERIALS The Kelowna GYN template is CT compatible and used for the treatment of gynecologic cancers. In cases with patients that have an intact uterus, a modified applicator system using the Kelowna GYN template and a 3D printed adapter piece allows for compatibility with an intrautaerine tandem. RESULTS We reviewed the treatment course of 23 patients comprising of 86 fractions of HDR treatment. Median D90 for cervical tumors (n = 7) was 82.4 Gy (range 77.7-92.6); for postoperative cervical tumors (n = 2) was 73.9 Gy (range 72.0-5.8); for vaginal tumors (n = 4) was 85.8 Gy (range 79.8-88.1); for recurrent endometrial (n = 10) was 86.9 Gy (range 74.8-103.2). Median EQD2 D2cc for bladder was 72.4 Gy (range 47.7-99.4), for rectum was 61.2 Gy (range 52.4-80.6), and for sigmoid colon of 50.5 Gy (44.3-66.9). At a median follow-up of 12 months, 2 patients had a local recurrence. Two patients had distant recurrence: one with carcinomatosis at 6 months, and one with pulmonary metastases at 3 months. No patients had late grade three toxicities. CONCLUSIONS Our single institutional experience supports the use of the Kelowna template as a robust system as a combined IC-IS applicator resulting in versatile and reproducible implants for a variety of gynecologic malignancies.
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Affiliation(s)
- Jay C Shiao
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO
| | | | - Kelly Stuhr
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO
| | - Leah Schubert
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO
| | - Tyler Robin
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO
| | - Christine M Fisher
- Department of Radiation Oncology, University of Colorado Cancer Center, Aurora, CO.
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Kut C, Kao T, Morcos M, Kim Y, Boctor E, Viswanathan AN. 3D-printed Magnetic Resonance (MR)-based gynecological phantom for image-guided brachytherapy training. Brachytherapy 2022; 21:799-805. [PMID: 36050143 PMCID: PMC10810234 DOI: 10.1016/j.brachy.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 07/14/2022] [Accepted: 07/21/2022] [Indexed: 01/16/2023]
Abstract
PURPOSE/OBJECTIVES There is a clinical need to develop anatomic phantoms for simulation-based learning in gynecological brachytherapy. Here, we provide a step-by-step approach to build a life-sized gynecological training phantom based on magnetic resonance imaging (MRI) of an individual patient. Our hypothesis is that this phantom can generate convincing ultrasound (US) images that are similar to patient scans. METHODS Organs-at-risk were manually segmented using patient scans (MRI). The gynecological phantom was constructed using positive molds from 3D printing and polyvinyl chloride (PVC) plastisol. Tissue texture/acoustic properties were simulated using different plastic softener/hardener ratios and microbead densities. Nine readers (residents) were asked to evaluate 10 cases (1 ultrasound image per case) and categorize each as a "patient" or "phantom" image. To evaluate whether the phantom and patient images were equivalent, we used a multireader, multicase equivalence study design with two composite null hypotheses with proportion (pr) at H01: pr ≤ 0.35 and H02: pr ≥ 0.65. Readers were also asked to review US videos and identify the insertion of an interstitial needle into the pelvic phantom. Computed Tomography (CT) and magnetic resonance (MR) images of the phantom were acquired for a feasibility study. RESULTS Readers correctly classified "patient" and "phantom" scans at pr = 53.3% ± 6.2% (p values 0.013 for H01 and 0.054 for H02, df = 5.96). Readers reviewed US videos and identified the interstitial needle 100% of the time in transabdominal view, and 78% in transrectal view. The phantom was CT and MR safe. CONCLUSIONS We have outlined a manufacturing process to create a life-sized, gynecological phantom that is compatible with multi-modality imaging and can be used to simulate clinical scenarios in image-guided brachytherapy procedures.
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Affiliation(s)
- Carmen Kut
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Tracy Kao
- Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, IL
| | - Marc Morcos
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD
| | - Younsu Kim
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | - Emad Boctor
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, MD.
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Washington B, Randall M, Fabian D, Cheek D, Wang C, Luo W. Statistical Analysis of Interfraction Dose Variations of High-Risk Clinical Target Volume and Organs at Risk for Cervical Cancer High-Dose-Rate Brachytherapy. Adv Radiat Oncol 2022; 7:101019. [PMID: 36110265 PMCID: PMC9468354 DOI: 10.1016/j.adro.2022.101019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/29/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose High-dose-rate (HDR) brachytherapy for cervical cancer treatment includes significant uncertainties. The aim of this study was to quantify the interfraction dosimetric variation (IDV) of the high-risk clinical target volume (HRCTV) from the prescribed dose and the corresponding effect on organ-at-risk (OAR) dose based on a comprehensive statistical analysis. Methods and Materials Fifty patients with cervical cancer treated with high-dose-rate intracavity brachytherapy from October 2019 to December 2020 were retrospectively analyzed. The OARs of interest were the rectum, bladder, sigmoid, and bowel. The dosimetric parameters evaluated for all patients was the dose absorbed by 90% of the HRCTV ( D 90 ) and the dose absorbed by 0.1 ( D 0.1 c c ) and 2 cm3 ( D 2 c c ) of each respective OAR. The HRCTV variations were from the prescribed dose and the OAR variations were from the corresponding tolerance dose. Distribution fitting of the HRCTV variations was determined to quantify the IDV. Comparative statistics of the HRCTV variations with the OAR variations were conducted to determine correlations. Results The mean HRCTV variation from the prescribed dose was -2.53% ± 8.74%. The HRCTV variations and OAR variations showed moderate to weak linear correlations despite the variations being relative to each other, with the bladder D 2 c c having the strongest correlation. There was a 30.0% (±2.62%, 95% confidence interval) probability of underdosing the HRCTV (-5% variation from prescription) and a 23.3% (±2.62%, 95% confidence interval) probability of overdosing the HRCTV (+5% variation from prescription). This tendency to underdose the HRCTV was a consequence of HRCTV IDV not being normally distributed. Conclusions HRCTV dosimetric variations and OAR variations were complexly correlated with the bladder D 2 c c having the strongest correlation. HRCTV IDV was best described as a left-skewed distribution that indicates a tendency of underdosing the HRCTV. The clinical significance of such dose variations is expected and will be further investigated.
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Affiliation(s)
- Brien Washington
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Marcus Randall
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Denise Fabian
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Dennis Cheek
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
| | - Chi Wang
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Wei Luo
- Department of Radiation Medicine, University of Kentucky, Lexington, Kentucky
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Nandi M, Pokala N, Perumareddy V, Sarkar S, Chanda S. Reporting of Inter Fraction Dose Variations of Organs at Risk in Computed Tomography-Guided High Dose Rate Intracavitary Brachytherapy in Carcinoma Cervix. J Med Phys 2022; 47:394-397. [PMID: 36908489 PMCID: PMC9997529 DOI: 10.4103/jmp.jmp_91_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 11/03/2022] [Accepted: 11/04/2022] [Indexed: 01/11/2023] Open
Abstract
Assess the interfraction dose variations of the organs at risk (OARs) in carcinoma cervix high dose rate (HDR) computed tomography (CT)-guided intra cavitary brachytherapy (ICBT). 120 CT scans of 40 patients who had undergone three fractions of ICBT (7 Gy/fr) were analyzed. Dose to Point A and the minimum doses to the volumes of 2, 1, and 0.1cc of bladder, rectum and sigmoid colon were recorded. Revised plans were generated in 20 patients. Paired t-test was used to compare the difference in the means. Point "A" mean dose difference was statistically significant between the treated and revised plans. For bladder, the difference in means of dosage to all volumes, whilst for the rectum and sigmoid colon, the low volume dosage (0.1cc) was statistically significant. Absence of individualized planning would have resulted in underdosage of tumor and increased dosage of up to 30% to OARs. CT-guided ICBT should be implemented for each HDR fraction treatment.
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Affiliation(s)
- Moujhuri Nandi
- Department of Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, Jharkhand, India
| | - Neelima Pokala
- Department of Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, Jharkhand, India
| | - Vaishnavi Perumareddy
- Department of Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, Jharkhand, India
| | - Sujata Sarkar
- Department of Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, Jharkhand, India
| | - Sudeep Chanda
- Department of Radiation Oncology, Meherbai Tata Memorial Hospital, Jamshedpur, Jharkhand, India
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Gultekin M, Yilmaz MT, Yuce Sari S, Yildiz D, Ozyigit G, Yildiz F. Stereotactic body radiotherapy boost in patients with cervical cancer. J OBSTET GYNAECOL 2022; 42:3033-3040. [PMID: 35653802 DOI: 10.1080/01443615.2022.2081790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Our aim was to evaluate the oncological outcomes of stereotactic body radiotherapy (SBRT) boost in patients with cervical cancer. The data of 21 patients who received SBRT boost after definitive radiotherapy (RT) or chemoradiotherapy (CRT) between March 2012 and April 2019 were retrospectively evaluated. External beam radiotherapy (EBRT) was applied to patients with a total dose of 50.4 Gy in 28 fractions. Kaplan-Meier method was used for survival analysis (IBM SPSS 23 software) and p < .05 value was considered significant. After definitive RT or CRT, there was a complete response in 9 (43%) patients, partial response in 11 (52%) patients and stable disease in 1 (5%) patient. The median follow-up period was 28 months (range, 7.5-88 months). Two-years cancer-specific survival rate was 80%. While 2-year LC rate was 75% in patients with residual tumour size <4 cm, it was 50% when there was ≥4 cm residual tumour after definitive CRT (p = .1). The treatment was well-tolerated and no acute or late toxicity was observed. Although brachytherapy (BRT) is an essential part of the treatment in locally advanced cervical cancer, SBRT may be used in patients with small residual disease who are not candidate for BRT. IMPACT STATEMENTCervical cancer is one of the most common cancers in the world, and external beam radiotherapy (EBRT) and brachytherapy (BRT) are the main treatment options. However, in rare cases where BRT is not feasible, it has been questioned whether stereotactic body radiotherapy (SBRT) as an alternative to BRT.What is already known on this subject? Nowadays, BRT still appears to be the gold standard treatment. However, studies with a small number of patients and short follow-up periods in the literature show that SBRT can be a good alternative in cases where BRT cannot be performed.What do the results of this study add? Our study is one of the series with the largest number of patients in the literature and with the longest follow-up period. In this area where there is no prospective study, we think that retrospective data with high patient numbers are enlightening.What are the implications of these findings for clinical practice and/or further research? Our study shows that SBRT is an alternative option in cases with small residual disease where BRT cannot be applied, and it provides a basis for a prospective randomised study.
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Affiliation(s)
- Melis Gultekin
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Melek Tugce Yilmaz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Sezin Yuce Sari
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Demet Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gokhan Ozyigit
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ferah Yildiz
- Department of Radiation Oncology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Comparative Analysis of 60Co and 192Ir Sources in High Dose Rate Brachytherapy for Cervical Cancer. Cancers (Basel) 2022; 14:cancers14194749. [PMID: 36230672 PMCID: PMC9563337 DOI: 10.3390/cancers14194749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
High-dose-rate (HDR) brachytherapy (BT) is an essential treatment for cervical cancer, one of the most prevalent gynecological malignant tumors. In HDR BT, high radiation doses can be delivered to the tumor target with the minimum radiation doses to organs at risk. Despite the wide use of the small HDR 192Ir source, as the technique has improved, the HDR 60Co source, which has the same miniaturized geometry, has also been produced and put into clinical practice. Compared with 192Ir (74 days), 60Co has a longer half-life (5.3 years), which gives it a great economic advantage for developing nations. The aim of the study was to compare 60Co and 192Ir sources for HDR BT in terms of both dosimetry and clinical treatment. The results of reports published on the use of HDR BT for cervical cancer over the past few years as well as our own research show that this treatment is safe and it is feasible to use 60Co as an alternative source.
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Change in image-guided planning strategies over time impacts oncologic and survival outcomes for intracavitary cervical cancer brachytherapy. Brachytherapy 2022; 21:668-677. [PMID: 35871130 DOI: 10.1016/j.brachy.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/28/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022]
Abstract
PURPOSE Intracavitary cervical brachytherapy (BT) has transitioned from a two-dimensional nonvolumetric (NV) dosimetry system to three-dimensional computed tomography (CT) and/or magnetic resonance imaging (MRI)-based planning techniques. The purpose of this study is to retrospectively evaluate the relative improvements in image-guided planning strategies over time with regards to dosimetry, survival, and toxicity. METHODS AND MATERIALS A single site retrospective review of 95 locally advanced cervical cancer patients treated with concurrent chemoradiation and high dose rate BT from 2009 to 2016 were divided into three BT planning groups: point-A based NV dosimetry using CT imaging (n = 37), CT-based volumetric dosimetry (n = 33), and MRI-based volumetric dosimetry (n = 25). Overall survival (OS), progression free survival (PFS), and pelvic control (PC) at 5 years were plotted using Kaplan-Meier curves. Univariate and multivariate (MVA) cox proportional-hazards models calculated hazard-ratios (HZ). Finally, acute and late grade 3-4 toxicities were compared between the cohorts. RESULTS Both MRI and CT had significantly less D2cc to bowel (p < 0.001) and sigmoid (p < 0.001) compared to NV-based planning. On MVA, age (<60 vs. ≥60 years) was significant for worse 5-year OS (HZ: 2.48) and PC (HZ: 5.25). MRI, with NV as the reference, had significantly improved 5-year OS (HZ: 0.26), PFS (HZ: 0.34) and PC (HZ: 0.16). There was no significant difference in grade ≥3 toxicities between the cohorts. CONCLUSIONS CT and MRI-based 3D planning had significantly less D2cc to bowel and sigmoid. MRI-based planning had significant improvement in 5-year OS, PFS, and LC compared to NV on MVA.
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Murakami N, Okuma K, Kato T, Igaki H. Now is it time to implement spacers in cervical cancer brachytherapy? JOURNAL OF RADIATION RESEARCH 2022; 63:696-698. [PMID: 35726343 PMCID: PMC9303596 DOI: 10.1093/jrr/rrac031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/07/2022] [Indexed: 06/15/2023]
Abstract
Although the international study on MRI-guided brachytherapy in cervical cancer (EMBRACE-I) demonstrated excellent local control regardless of the T stage, up to 14.6% of grade 3-5 late radiation-related toxicities were observed, which is unacceptable. While the efficacy of hydrogel spacers has been established in prostate radiotherapy, its implementation speed in cervical cancer brachytherapy is relatively slow, despite the fact that several articles have reported its efficacy in cervical cancer brachytherapy. The authors believe that using a spacer in cervical cancer brachytherapy and brachytherapy for other gynecologic malignancies will reduce late radiation-related toxicity and improve patients' quality of life; therefore, its rapid implementation is required.
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Affiliation(s)
- Naoya Murakami
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan, 51-1 Tsukiji, Chuo-ku, Tokyo 104-0045,, Japan, Tel: + [81]-3-3542-2511; Fax: + [81]-3-3545-3567, E-mail:
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
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Dankulchai P, Harn-Utairasmee P, Prasartseree T, Nakkasae P, Trikhirhisthit K, Sithiwong W, Thephamongkhol K, Petsuksiri J, Apiwarodom N, Iampongpaiboon P, Chansilpa Y. Vaginal 11-point and volumetric dose related to late vaginal complications in patients with cervical cancer treated with external beam radiotherapy and image-guided adaptive brachytherapy. Radiother Oncol 2022; 174:77-86. [PMID: 35839936 DOI: 10.1016/j.radonc.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To investigate the vaginal 11-point and volumetric dose-toxicity relationships in definitive cervical cancer radiotherapy. METHODS A retrospective cohort study of patients with cervical cancer with a complete response of at least 12 months was performed. Additional per vaginal examinations and patient-scoring questionnaires on the date of patient enrolment were assessed for vaginal strictures. Retrospective dosimetric analysis of vaginal 11-point and volumetric doses was performed with descriptive and probit analyses to investigate dose-toxicity relationships. RESULTS Ninety-seven patients were included in the study, with a 20-month median follow-up. The incidence rate of grade 3 vaginal strictures was 22.7%. A comparison between patients with grade 1-3 vaginal strictures revealed significant differences in age, stage, initial tumour size, and vaginal involvement. PIBS + 2, PIBS, PIBS-2, D + 5, and D2cc were all significantly different among grade 1-3 vaginal strictures and showed significant probit coefficients. The lateral dose points were significantly higher in grade 2 strictures, but negative probit coefficients failed to establish causal inferences. Post-estimation analyses yielded effective doses (ED) for 15% and 20% probability of grade 3 vaginal strictures (ED15 and ED20) for PIBS + 2 at 57.4 and 111 Gy3, respectively. PIBS-2 yielded an ED20 of 7 Gy3. D + 5 yielded positive ED10, ED15, and ED20 values of 52.2, 66.6, and 78 Gy3, respectively. CONCLUSIONS This study showed a significant relationship between age, tumour size, and lower-third vaginal involvement with the incidence of vaginal toxicity. The goal of a cumulative radiotherapy dose of ≤ 55 Gy3 to PIBS + 2, ≤5 Gy3 to PIBS-2, and ≤ 65 Gy3 to D + 5 points may reduce the risk of grade 3 vaginal stenosis to less than 15-20%.
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Affiliation(s)
- Pittaya Dankulchai
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand.
| | | | - Tissana Prasartseree
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Pitchayut Nakkasae
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Kyrhatii Trikhirhisthit
- Division of Radiation Oncology, Department of Radiology, Sawanpracharak Hospital, Nakhon Sawan, Thailand
| | - Wiwatchai Sithiwong
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Kullathorn Thephamongkhol
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Janjira Petsuksiri
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Nantakan Apiwarodom
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Porntip Iampongpaiboon
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
| | - Yaowalak Chansilpa
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Thailand
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System-level capacity of high dose rate (HDR) brachytherapy for management of cervical cancer in an upper middle-income country: a case study from Brazil. Int J Radiat Oncol Biol Phys 2022; 114:545-553. [PMID: 35779808 DOI: 10.1016/j.ijrobp.2022.06.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 04/20/2022] [Accepted: 06/10/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ensuring optimal access to radiotherapy (RT) facilities is challenging for many countries. External beam RT and brachytherapy (BCT) are required to treat advanced cervical cancer. In this analysis, we evaluate the system-level capacity of brachytherapy in Brazil and its relationship with access to complete cervix cancer radiation treatment with both external beam radiotherapy and BCT. METHODOLOGY We used official government reports to compile data on BCT and Linear accelerator (LINAC) numbers, geographic distribution and coverage, cervical cancer annual incidence, and prevalence in Brazil. We also evaluated changes in national BCT capacity between 2001 and 2021. The 2020 relationship between cervical cancer cases for RT per BCT unit, LINAC per BCT unit, and the LINAC supply for each Brazilian state and region were evaluated. For comparison, the LINAC per BCT unit ratio in Brazil was compared with Europe using International Atomic Energy Agency data. RESULTS 85% (23/27) of Brazilian states have at least one brachytherapy unit; nationally, there are 117 cervical cancer cases for RT per BCT unit. Compared with the benchmark of 200 cervical cancer cases per BCT device per year, there are enough BCT units to fill capacity in Brazil nationally and regionally. The ratio of total cervix cancer cases per BCT unit decreased substantially over time from 142 in 2013 to 117 in 2021 (p<0.0001). Nationally, there are 252 LINAC units in the public system with a ratio of 1,985 new cancer cases/LINAC. Brazilian regions have a LINAC shortage ranging from 15 to 141 units. There were 2.55 LINACs per BCT unit in Brazil, compared with 3.25 in Europe (p=0.012). CONCLUSION Over 20 years, BCT capacity in Brazil has increased to meet the cervical cancer demand. However, the LINAC shortage has persisted over the decades, impacting the access to complete treatment and possibly the oncological outcomes. These data can help organize the patient treatment flow, avoid treatment delays, and improve survival.
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Jacobsen MC, Beriwal S, Dyer BA, Klopp AH, Lee SI, McGinnis GJ, Robbins JB, Rauch GM, Sadowski EA, Simiele SJ, Stafford RJ, Taunk NK, Yashar CM, Venkatesan AM. Contemporary image-guided cervical cancer brachytherapy: Consensus imaging recommendations from the Society of Abdominal Radiology and the American Brachytherapy Society. Brachytherapy 2022; 21:369-388. [PMID: 35725550 DOI: 10.1016/j.brachy.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/15/2022] [Accepted: 04/24/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To present recommendations for the use of imaging for evaluation and procedural guidance of brachytherapy for cervical cancer patients. METHODS An expert panel comprised of members of the Society of Abdominal Radiology Uterine and Ovarian Cancer Disease Focused Panel and the American Brachytherapy Society jointly assessed the existing literature and provide data-driven guidance on imaging protocol development, interpretation, and reporting. RESULTS Image-guidance during applicator implantation reduces rates of uterine perforation by the tandem. Postimplant images may be acquired with radiography, computed tomography (CT), or magnetic resonance imaging (MRI), and CT or MRI are preferred due to a decrease in severe complications. Pre-brachytherapy T2-weighted MRI may be used as a reference for contouring the high-risk clinical target volume (HR-CTV) when CT is used for treatment planning. Reference CT and MRI protocols are provided for reference. CONCLUSIONS Image-guided brachytherapy in locally advanced cervical cancer is essential for optimal patient management. Various imaging modalities, including orthogonal radiographs, ultrasound, computed tomography, and magnetic resonance imaging, remain integral to the successful execution of image-guided brachytherapy.
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Affiliation(s)
- Megan C Jacobsen
- The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX
| | - Sushil Beriwal
- Allegheny Health Network, Department of Radiation Oncology, Pittsburgh, PA; Varian Medical Systems, Palo Alto, CA
| | - Brandon A Dyer
- Legacy Health, Department of Radiation Oncology, Portland, OR
| | - Ann H Klopp
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | - Susanna I Lee
- Massachusetts General Hospital, Department of Radiology, Boston, MA
| | - Gwendolyn J McGinnis
- The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX
| | | | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Department of Abdominal Imaging, Houston, TX
| | | | - Samantha J Simiele
- The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX
| | - R Jason Stafford
- The University of Texas MD Anderson Cancer Center, Department of Imaging Physics, Houston, TX
| | - Neil K Taunk
- University of Pennsylvania, Department of Radiation Oncology, Philadelphia, PA
| | - Catheryn M Yashar
- University of California San Diego, Department of Radiation Oncology, San Diego, CA
| | - Aradhana M Venkatesan
- The University of Texas MD Anderson Cancer Center, Department of Abdominal Imaging, Houston, TX.
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Prisciandaro J, Zoberi JE, Cohen G, Kim Y, Johnson P, Paulson E, Song W, Hwang KP, Erickson B, Beriwal S, Kirisits C, Mourtada F. AAPM Task Group Report 303 endorsed by the ABS: MRI Implementation in HDR Brachytherapy-Considerations from Simulation to Treatment. Med Phys 2022; 49:e983-e1023. [PMID: 35662032 DOI: 10.1002/mp.15713] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 04/11/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
Abstract
The Task Group (TG) on Magnetic Resonance Imaging (MRI) Implementation in High Dose Rate (HDR) Brachytherapy - Considerations from Simulation to Treatment, TG 303, was constituted by the American Association of Physicists in Medicine's (AAPM's) Science Council under the direction of the Therapy Physics Committee, the Brachytherapy Subcommittee, and the Working Group on Brachytherapy Clinical Applications. The TG was charged with developing recommendations for commissioning, clinical implementation, and on-going quality assurance (QA). Additionally, the TG was charged with describing HDR brachytherapy (BT) workflows and evaluating practical consideration that arise when implementing MR imaging. For brevity, the report is focused on the treatment of gynecologic and prostate cancer. The TG report provides an introduction and rationale for MRI implementation in BT, a review of previous publications on topics including available applicators, clinical trials, previously published BT related TG reports, and new image guided recommendations beyond CT based practices. The report describes MRI protocols and methodologies, including recommendations for the clinical implementation and logical considerations for MR imaging for HDR BT. Given the evolution from prescriptive to risk-based QA,1 an example of a risk-based analysis using MRI-based, prostate HDR BT is presented. In summary, the TG report is intended to provide clear and comprehensive guidelines and recommendations for commissioning, clinical implementation, and QA for MRI-based HDR BT that may be utilized by the medical physics community to streamline this process. This report is endorsed by the American Brachytherapy Society (ABS). This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | - Gil'ad Cohen
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Perry Johnson
- University of Florida Health Proton Therapy Institute, Jacksonville, FL
| | | | | | - Ken-Pin Hwang
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Sushil Beriwal
- Allegheny Health Network Cancer Institute, Pittsburgh, PA
| | | | - Firas Mourtada
- Sidney Kimmel Cancer Center at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Woodhouse KD, Devlin PM, Kollmeier M, Lin LL, Orio P, Ouhib Z, Song D, Viswanathan AN, Watanabe Y, Yu Y, Small W, Schechter NR. ACR-ABS-ASTRO Practice Parameter for the Performance of Low-Dose-Rate Brachytherapy. Am J Clin Oncol 2022; 45:243-248. [PMID: 35485607 DOI: 10.1097/coc.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM/OBJECTIVES/BACKGROUND The American College of Radiology (ACR), the American Brachytherapy Society (ABS), and the American Society for Radiation Oncology (ASTRO) have jointly developed the following practice parameter for the performance of low-dose-rate (LDR) brachytherapy. LDR brachytherapy is the application of radioactive sources in or on tumors in a clinical setting with therapeutic intent. The advantages of LDR brachytherapy include improving therapeutic ratios with lower doses to nontarget organs-at-risk and higher doses to a specific target. METHODS This practice parameter was developed according to the process described under the heading. The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Radiation Oncology of the Commission on Radiation Oncology, in collaboration with ABS and ASTRO. RESULTS This practice parameter was developed to serve as a tool in the appropriate application of this evolving technology in the care of cancer patients or other patients with conditions where radiation therapy is indicated. It addresses clinical implementation of LDR brachytherapy including personnel qualifications, quality assurance standards, indications, and suggested documentation. This includes a contemporary literature search. CONCLUSIONS This practice parameter is a tool to guide the use of LDR brachytherapy and does not assess relative clinical indication for LDR brachytherapy when compared with other forms of brachytherapy or external beam therapy, but to focus on the best practices required to deliver LDR brachytherapy safely and effectively, when clinically indicated. Comparative costs of versus other modalities therapy may also need to be considered.
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Affiliation(s)
| | | | | | | | - Peter Orio
- Boca Raton Regional Hospital, Lynn Cancer Institute, Boca Raton, FL
| | - Zoubir Ouhib
- Boca Raton Regional Hospital, Lynn Cancer Institute, Boca Raton, FL
| | | | | | | | - Yan Yu
- Thomas Jefferson University, Woodbury, NJ
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Loyola University Chicago, Maywood, IL
| | - Naomi R Schechter
- Keck Medical Center of USC, Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
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Tomizawa K, Oike T, Ando K, Irie D, Sakai M, Shimada H, Ohno T. Patient-Derived Training Simulator for Image-Guided Adaptive Brachytherapy of Locally Advanced Cervical Cancers: Development and Initial Use. J Clin Med 2022; 11:jcm11113103. [PMID: 35683490 PMCID: PMC9181139 DOI: 10.3390/jcm11113103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 02/05/2023] Open
Abstract
Image-guided adaptive brachytherapy (IGABT) using intracavitary and interstitial (IC/IS) techniques plays a pivotal role in definitive radiotherapy for locally advanced cervical cancers. However, the training opportunities for interstitial needle application are limited, preventing this technique from becoming widespread. This study aimed to develop a training simulator for IC/IS brachytherapy. The simulator consists of a soft silicone tumor phantom and acrylic tube mimicking the vagina; it has high visibility because of translucent materials and is compatible with computed tomography (CT) and magnetic resonance imaging (MRI). A patient harboring a typical bulky and irregular-shaped cervical tumor was selected from 495 in-house IGABT-treated candidates, and a tumor phantom (68 × 49 × 45 mm) modeled on this patient was produced from three-dimensional real-scale measurements of the MRI-based high-risk clinical target volume at first brachytherapy. In trial use by two physicians with different levels of IGABT skills, a Fletcher-Suit Asian Pacific applicator, and a Venezia applicator with interstitial needles were nicely applied to the simulator, facilitating successful creation of CT-based treatment plans consistent with clinical practice. Thus, the training simulator can be useful for the training of IC/IS brachytherapy, and warrants further research employing a greater number of phantoms and practitioners to verify its educational value.
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Affiliation(s)
- Kento Tomizawa
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (K.T.); (K.A.); (D.I.); (T.O.)
| | - Takahiro Oike
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (K.T.); (K.A.); (D.I.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (M.S.); (H.S.)
- Correspondence: ; Tel.: +81-27-220-8383
| | - Ken Ando
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (K.T.); (K.A.); (D.I.); (T.O.)
| | - Daisuke Irie
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (K.T.); (K.A.); (D.I.); (T.O.)
| | - Makoto Sakai
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (M.S.); (H.S.)
| | - Hirofumi Shimada
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (M.S.); (H.S.)
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (K.T.); (K.A.); (D.I.); (T.O.)
- Gunma University Heavy Ion Medical Center, 3-39-22 Showa-machi, Maebashi 371-8511, Gunma, Japan; (M.S.); (H.S.)
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Knowledge-based three-dimensional dose prediction for tandem-and-ovoid brachytherapy. Brachytherapy 2022; 21:532-542. [PMID: 35562285 DOI: 10.1016/j.brachy.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/28/2022] [Accepted: 03/12/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of this work was to develop a knowledge-based dose prediction system using a convolution neural network (CNN) for cervical brachytherapy treatments with a tandem-and-ovoid applicator. METHODS A 3D U-NET CNN was utilized to make voxel-wise dose predictions based on organ-at-risk (OAR), high-risk clinical target volume (HRCTV), and possible source location geometry. The model comprised 395 previously treated cases: training (273), validation (61), test (61). To assess voxel prediction accuracy, we evaluated dose differences in all cohorts across the dose range of 20-130% of prescription, mean(SD) and standard deviation (σ), as well as isodose dice similarity coefficients for clinical and/or predicted dose distributions. We examined discrete Dose-Volume Histogram(DVH) metrics utilized for brachytherapy plan quality assessment (HRCTV D90%, and bladder and/or rectum and/or sigmoid D2cc) with ΔDx=Dx,actual-Dx,predicted Pearson correlation coefficient, standard deviation, and mean further quantifying model performance. RESULTS Ranges of voxel-wise dose difference accuracy (δD¯±σ) for 20-130% dose interval in training (test) sets ranged from [-0.5% ± 2.0% to +2.0% ± 14.0%] ([-0.1% ± 4.0% to +4.0% ± 26.0%]) in all voxels, [-1.7% ± 5.1% to -3.5% ± 12.8%] ([-2.9% ± 4.8% to -2.6% ± 18.9%]) in HRCTV, [-0.02% ± 2.40% to +3.2% ± 12.0%] ([-2.5% ± 3.6% to +0.8% ± 12.7%]) in bladder, [-0.7% ± 2.4% to +15.5% ± 11.0%] ([-0.9% ± 3.2% to +27.8% ± 11.6%]) in rectum, and [-0.7% ± 2.3% to +10.7% ± 15.0%] ([-0.4% ± 3.0% to +18.4% ± 11.4%]) in sigmoid. Isodose dice similarity coefficients ranged from [0.96,0.91] for training and [0.94,0.87] for test cohorts. Relative DVH metric prediction in the training (test) set were HRCTV ΔD¯90±σΔD=-0.19 ± 0.55Gy(-0.09 ± 0.67 Gy), bladder ΔD¯2cc±σΔD= -0.06 ± 0.54Gy(-0.17 ± 0.67 Gy), rectum ΔD¯2cc±σΔD= -0.03 ± 0.36Gy(-0.04 ± 0.46 Gy), and sigmoid ΔD¯2cc±σΔD= -0.01 ± 0.34Gy(0.00 ± 0.44 Gy). CONCLUSIONS A 3D knowledge-based dose predictions provide voxel-level and DVH metric estimates that could be used for treatment plan quality control and data-driven plan guidance.
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Murakami N, Watanabe M, Uno T, Sekii S, Tsujino K, Kasamatsu T, Machitori Y, Aoshika T, Kato S, Hirowatari H, Kaneyasu Y, Nakagawa T, Ikushima H, Ando K, Murata M, Yoshida K, Yoshioka H, Murata K, Ohno T, Okonogi N, Saito A, Ichikawa M, Okuda T, Tsuchida K, Sakurai H, Yoshimura R, Yoshioka Y, Yorozu A, Okamoto H, Inaba K, Kato T, Igaki H, Itami J. Large volume was associated with increased risk of acute non-hematologic adverse events in the hybrid of intracavitary and interstitial brachytherapy for locally advanced uterine cervical cancer: preliminary results of prospective phase I/II clinical trial. Jpn J Clin Oncol 2022; 52:859-868. [PMID: 35470390 DOI: 10.1093/jjco/hyac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/08/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This is the preliminary results of a multi-center prospective clinical trial evaluating the feasibility of the hybrid of intracavitary and interstitial brachytherapy for locally advanced cervical cancer. METHODS Patients with FIGO stage IB2, IIA2, IIB, IIIA, IIIB and IVA uterine cervical cancer pretreatment width of which was ≥5 cm measured by MRI were eligible. Protocol therapy consisted of 30-30.6 Gy in 15-17 fractions of whole pelvic radiotherapy concurrent with weekly CDDP, followed by 24 Gy in 4 fractions of hybrid of intracavitary and interstitial and pelvic radiotherapy with central shield up to 50-50.4 Gy in 25-28 fractions. The primary endpoint of phase I part was that the rate of grade ≥ 3 acute non-hematologic adverse events related to hybrid of intracavitary and interstitial would be <10%. RESULTS Between October 2015 and October 2019, 74 patients underwent primary registration, with 52 patients eventually proceeding to the secondary registration. The median pretreatment tumor width was 5.7 cm, and FIGO Stages were IB2 10, IIA2 2, IIB 20 and IIIB 20, respectively. The median high-risk clinical target volume D90 was 72.0 Gy (54.8-86.6 Gy, EQD2), rectum D2cc was 53.7 Gy (29.3-80.3 Gy) and bladder D2cc was 69.8 Gy (38.9-84.8 Gy). The rate of grade ≥ 3 non-hematologic adverse events related to hybrid of intracavitary and interstitial was 1.9% (1/52), and 17.3% (9/52) of patients experienced non-hematologic adverse events related to hybrid of intracavitary and interstitial of any grade. In multivariate analysis, high-risk clinical target volume ≥ 35 ml was associated with an increased risk of any grade of acute non-hematologic adverse events related to hybrid of intracavitary and interstitial (P = 0.036). CONCLUSION The feasibility and reproducibility of hybrid of intracavitary and interstitial were demonstrated from a multi-center prospective clinical trial.
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Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Miho Watanabe
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shuhei Sekii
- Department of Radiation Therapy, Kitaharima Medical Center, Ono, Japan.,Department of Radiation Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Kayoko Tsujino
- Department of Radiation Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Takahiro Kasamatsu
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yumiko Machitori
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomomi Aoshika
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan
| | | | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organisation Fukuyama Medical Center, Fukuyama, Japan
| | - Tomio Nakagawa
- Department of Radiation Oncology, National Hospital Organisation Fukuyama Medical Center, Fukuyama, Japan
| | - Hitoshi Ikushima
- Department of Therapeutic Radiology, Tokushima University Graduate School of Medicine, Tokushima, Japan
| | - Ken Ando
- Department of Radiation Oncology, Gunma Prefectural Cancer Center, Ota, Japan.,Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masumi Murata
- Department of Radiation Oncology, Gunma Prefectural Cancer Center, Ota, Japan
| | - Ken Yoshida
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Osaka, Japan.,Department of Radiology, Kansai Medical University Medical Center, Osaka, Japan
| | - Hiroto Yoshioka
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kazutoshi Murata
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Radiation Oncology, QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Noriyuki Okonogi
- Department of Radiation Oncology, QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Anneyuko Saito
- Department of Radiation Oncology, Juntendo University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Mayumi Ichikawa
- Department of Radiation Oncology, Yamagata University Faculty of Medicine Graduate School of Medical Science, Yamagata, Japan
| | - Takahito Okuda
- Department of Radiation Oncology, Toyota Memorial Hospital, Toyota, Japan
| | - Keisuke Tsuchida
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba Faculty of Medicine, Tsukuba, Japan
| | - Ryouichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsunori Yorozu
- Department of Radiation Oncology, National Hospital Organisation Tokyo Medical Center, Tokyo, Japan
| | - Horoyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
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Tseng M, Ngoi NYL, Tan DSP, Tong PSY. Combined modality management of advanced cervical cancer including novel sensitizers. Int J Gynecol Cancer 2022; 32:246-259. [DOI: 10.1136/ijgc-2021-003137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/07/2022] [Indexed: 11/04/2022] Open
Abstract
The management of advanced cervical cancer has evolved with time. Combined modality treatments for cervical cancer have been shown to improve clinical outcomes for these patients. The role of surgery is reviewed in this article for specific situations such as the treatment of bulky lymph nodes and even in the metastatic setting. External beam radiotherapy and brachytherapy techniques have improved which has decreased patient toxicity. Systemic therapy such as chemotherapy, immunotherapy, and novel sensitizing agents have been extensively studied and have shown promising results. The combination of these three different modalities of treatment can be tailored to each specific patient to achieve the best outcomes. We review the recent advances and various international guidelines for the management of cervical cancer in this article.
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