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Portocarrero-Bonifaz A, Syed S, Kassel M, McKenzie GW, Shah VM, Forry BM, Gaskins JT, Sowards KT, Avula TB, Masters A, Silva SR. Dosimetric and toxicity comparison between Syed-Neblett and Fletcher-Suit-Delclos Tandem and Ovoid applicators in high dose rate cervix cancer brachytherapy. Brachytherapy 2024; 23:397-406. [PMID: 38643046 DOI: 10.1016/j.brachy.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: 12/20/2023] [Revised: 02/21/2024] [Accepted: 03/06/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE To compare patient and tumor characteristics, dosimetry, and toxicities between interstitial Syed-Neblett and intracavitary Fletcher-Suit-Delclos Tandem and Ovoid (T&O) applicators in high dose rate (HDR) cervical cancer brachytherapy. METHODS A retrospective analysis was performed for cervical cancer patients treated with 3D-based HDR brachytherapy from 2011 to 2023 at a single institution. Dosimetric parameters for high-risk clinical target volume and organs at risk were obtained. Toxicities were evaluated using the Common Terminology Criteria for Adverse Events version 5.0. RESULTS A total of 115 and 58 patients underwent Syed and T&O brachytherapy, respectively. Patients treated with Syed brachytherapy were more likely to have larger tumors and FIGO stage III or IV disease. The median D2cc values to the bladder, small bowel, and sigmoid colon were significantly lower for Syed brachytherapy. Patients treated with Syed brachytherapy were significantly more likely to be free of acute gastrointestinal (44% vs. 21%, p = 0.003), genitourinary (58% vs. 36%, p = 0.01), and vaginal toxicities (60% vs. 33%, p = 0.001) within 6 months following treatment compared to patients treated with T&O applicators. In contrast, Syed brachytherapy patients were more likely to experience late gastrointestinal (68% vs. 49%, p = 0.082), genitourinary (51% vs. 35%, p = 0.196), and vaginal toxicities (70% vs. 57%, p = 0.264). CONCLUSIONS Syed-Neblett and T&O applicators are suitable for HDR brachytherapy for cervical cancer in distinct patient populations. Acute toxicities are more prevalent with T&O applicators, while patients treated with Syed-Neblett applicators are more likely to develop late toxicities.
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Affiliation(s)
- Andres Portocarrero-Bonifaz
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY; Physics Department, Pontificia Universidad Catolica del Peru, Lima, Peru.
| | - Salman Syed
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Maxwell Kassel
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Grant W McKenzie
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Vishwa M Shah
- Department of Gynecologic Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Bryce M Forry
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Jeremy T Gaskins
- Department of Bioinformatics & Biostatistics, University of Louisville School of Public Health and Information Sciences, Louisville, KY
| | - Keith T Sowards
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Thulasi Babitha Avula
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Adrianna Masters
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
| | - Scott R Silva
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY
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Nout R, Calaminus G, Planchamp F, Chargari C, Lax SF, Martelli H, McCluggage WG, Morice P, Pakiz M, Schmid MP, Stunt J, Timmermann B, Vokuhl C, Orbach D, Fotopoulou C. ESTRO/ESGO/SIOPe guidelines for the management of patients with vaginal cancer. Radiother Oncol 2023; 186:109662. [PMID: 37244358 DOI: 10.1016/j.radonc.2023.109662] [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: 02/15/2023] [Accepted: 03/29/2023] [Indexed: 05/29/2023]
Abstract
Primary vaginal malignancies are rare, comprising only 2% of all female genital tract malignancies in adults and 4.5% in children. As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) jointly with the European Society for Radiotherapy & Oncology (ESTRO) and the European Society of Pediatric Oncology (SIOPe) developed evidence-based guidelines in order to improve the management of patients with vaginal cancer within a multidisciplinary setting. ESTRO/ESGO/SIOPe nominated practicing clinicians who are involved in the management of vaginal cancer patients and have demonstrated leadership through their expertise in clinical care and research, their national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (13 experts across Europe comprising the international development group). To ensure that the statements were evidence based, the current literature was reviewed and critically appraised. In the case of absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 112 independent international practitionners in cancer care delivery and patient representatives and their comments and input were incorporated and addressed accordingly. These guidelines cover comprehensively the diagnostic pathways as well as the surgical, radiotherapeutical and systemic management and follow-up of adult patients (including those with rare histological subtypes) and pediatric patients (vaginal rhabdomyosarcoma and germ cell tumours) with vaginal tumours.
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Affiliation(s)
- Remi Nout
- Department of radiotherapy, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - Gabriele Calaminus
- Department of paediatric hematology and oncology, University Children's Hospital, Bonn, Germany
| | | | - Cyrus Chargari
- Departement of radiation oncology, Institut Gustave Roussy, Villejuif, France
| | - Sigurd F Lax
- Department of Pathology, Hospital Graz II, Graz and School of Medicine, Johannes Kepler University, Linz, Austria
| | - Hélène Martelli
- Department of Paediatric surgery, Hôpital Universitaire Bicêtre, Paris, France
| | - W Glenn McCluggage
- Department of Pathology, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Philippe Morice
- Department of gynecologic surgery, Institut Gustave Roussy, Villejuif, France
| | - Maja Pakiz
- Department of gynecologic oncology and breast oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Maximilian Paul Schmid
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center Vienna, Vienna, Austria
| | - Jonáh Stunt
- Department of radiotherapy, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Beate Timmermann
- Department of particle therapy, University Hospital Essen, West German Proton Therapy Centre Essen (WPE), West German Cancer Center (WTZ), German Cancer Consortium (DKTK), Essen, Germany
| | - Christian Vokuhl
- Department of pathology, Universitätsklinikum Bonn, Bonn, Germany
| | - Daniel Orbach
- SIREDO Oncology Center (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer), PSL University, Institut Curie, Paris, France
| | - Christina Fotopoulou
- Department of surgery & cancer, Queen Charlotte's & Chelsea Hospital, London, United Kingdom
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3
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Nout RA, Calaminus G, Planchamp F, Chargari C, Lax S, Martelli H, McCluggage WG, Morice P, Pakiz M, Schmid MP, Stunt J, Timmermann B, Vokuhl C, Orbach D, Fotopoulou C. ESTRO/ESGO/SIOPe Guidelines for the management of patients with vaginal cancer. Int J Gynecol Cancer 2023; 33:1185-1202. [PMID: 37336757 DOI: 10.1136/ijgc-2023-004695] [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: 06/21/2023] Open
Abstract
Primary vaginal malignancies are rare, comprising only 2% of all female genital tract malignancies in adults and 4.5% in children. As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) jointly with the European Society for Radiotherapy & Oncology (ESTRO) and the European Society of Pediatric Oncology (SIOPe) developed evidence-based guidelines in order to improve the management of patients with vaginal cancer within a multidisciplinary setting.ESTRO/ESGO/SIOPe nominated practicing clinicians who are involved in the management of vaginal cancer patients and have demonstrated leadership through their expertise in clinical care and research, their national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (13 experts across Europe comprising the international development group). To ensure that the statements were evidence based, the current literature was reviewed and critically appraised.In the case of absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 112 independent international practitionners in cancer care delivery and patient representatives and their comments and input were incorporated and addressed accordingly.These guidelines cover comprehensively the diagnostic pathways as well as the surgical, radiotherapeutical and systemic management and follow-up of adult patients (including those with rare histological subtypes) and pediatric patients (vaginal rhabdomyosarcoma and germ cell tumours) with vaginal tumours.
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Affiliation(s)
- Remi A Nout
- Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Please Select, Netherlands
| | - Gabriele Calaminus
- Department of Paediatric Hematology and Oncology, University Children's Hospital, Bonn, Germany
| | | | - Cyrus Chargari
- Department of Radiation Oncology, Institut Gustave-Roussy, Villejuif, Île-de-France, France
| | - Sigurd Lax
- Pathology, Hospital Graz Sud-West, Graz, Austria
- Johannes Kepler Universitat Linz, Linz, Austria
| | - Hélène Martelli
- Department of Paediatric surgery, Hôpital Universitaire Bicêtre, Paris, France
| | | | - Philippe Morice
- Surgery, Institut Gustave-Roussy, Villejuif, Île-de-France, France
| | - Maja Pakiz
- Department of Gynecologic Oncology and Breast Oncology, University Medical Centre Maribor, Maribor, Slovenia
| | - Maximilian P Schmid
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center Vienna, Wien, Austria
| | - Jonáh Stunt
- Department of Radiotherapy, Erasmus MC Cancer Centre, Rotterdam, Zuid-Holland, Netherlands
| | - Beate Timmermann
- Department of Particle Therapy, University Hospital Essen, Essen, Nordrhein-Westfalen, Germany
- West German Proton Therapy Centre, Essen, Germany
| | - Christian Vokuhl
- Department of Pathology, Universitätsklinikum Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Daniel Orbach
- SIREDO Oncology Center (Care, Innovation and Research for Children, Adolescents and Young Adults with Cancer), Institut Curie, Paris, France
| | - Christina Fotopoulou
- Gynaecologic Oncology, Imperial College London Faculty of Medicine, London, London, UK
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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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5
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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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6
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Zhang G, Wu Z, Yu W, Lyu X, Wu W, Fan Y, Wang Y, Zheng L, Huang M, Zhang Y, Guo C, Zhang J. Clinical application and accuracy assessment of imaging-based surgical navigation guided 125I interstitial brachytherapy in deep head and neck regions. JOURNAL OF RADIATION RESEARCH 2022; 63:741-748. [PMID: 35818292 PMCID: PMC9494534 DOI: 10.1093/jrr/rrac034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/26/2022] [Indexed: 06/15/2023]
Abstract
Brachytherapy has the advantages of being minimally invasive and highly conformal, and it achieves good results in head and neck tumors. To precisely implant the radioactive seeds according to the preplan in deep head and neck regions, the surgical navigation is applied. This study aims to explore the clinical application and accuracy of imaging-based surgical navigation-guided 125I interstitial brachytherapy in terms of seed position. We included 41 patients with tumors in deep head and neck regions. The brachytherapy treatment plan was designed, and the preplanned data were transferred to the navigation system. Needle implantation and seed delivery were performed under surgical navigation system guidance with or without the combination of individual template. The treatment accuracy was evaluated by comparing seed cluster locations between the preoperative treatment plan and the postoperative treatment outcome. A total of 2879 seeds were delivered. The range, mean and median distances between the geometric centers of the preoperative seed point clusters and the postoperative seed point clusters were 0.8-10.5 mm, 4.5 ± 2.3 mm and 4.1 mm, respectively. The differences between preoperative and postoperative volumes of the minimum bounding box of seed point clusters were nonsignificant. In conclusion, the imaging-based surgical navigation system is a promising clinical tool to provide the preplanned data for interstitial brachytherapy intraoperatively, and it is feasible and accurate for the real-time guidance of needle implantation and seed delivery in deep head and neck regions.
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Affiliation(s)
- Guohao Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Zhiyuan Wu
- Department of Oral and Maxillofacial Surgery, Fujian Provincial Hospital, Fuzhou 350001, PR China
| | - Wenting Yu
- Department of Orthodontics, Beijing Stomatological Hospital, School of Stomatology, Capital Medical University, Beijing 100050, PR China
| | - Xiaoming Lyu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Wenjie Wu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Yi Fan
- Department of Orthodontics, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology, Beijing 100081, PR China
| | - Yong Wang
- Center of Digital Dentistry, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & Research Center of Engineering and Technology for Computerized Dentistry Ministry of Health, Beijing 100081, PR China
| | - Lei Zheng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Mingwei Huang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Yi Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Chuanbin Guo
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, Beijing 100081, PR China
| | - Jianguo Zhang
- Corresponding author. Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices, No. 22 Zhongguancun South Avenue, Haidian District, Beijing 100081, PR China. , Fax Number: 86-10-82195701
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7
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Lucia F, Miranda O, Schick U, Bourbonne V, Duvergé L. Dose escalation by brachytherapy for gynecological cancers. Cancer Radiother 2022; 26:905-910. [DOI: 10.1016/j.canrad.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/01/2022] [Indexed: 11/25/2022]
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Schiff JP, Mahmood M, Huang Y, Powell MA, Mutch D, Dyk PT, Lin AJ, Schwarz JK, Markovina ST, Grigsby PW. The impact of tumor size and histology on local control when utilizing high-dose-rate interstitial brachytherapy for gynecologic malignancies. Gynecol Oncol 2022; 165:486-492. [DOI: 10.1016/j.ygyno.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
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Jhingran A. Updates in the treatment of vaginal cancer. Int J Gynecol Cancer 2022; 32:344-351. [PMID: 35256422 PMCID: PMC8921584 DOI: 10.1136/ijgc-2021-002517] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/13/2022] [Indexed: 12/13/2022] Open
Abstract
Vaginal cancer is a rare cancer. A lot of the data used in the treatment of this cancer are extrapolated from cervical cancer data. Radiation therapy plays a significant role in the treatment of vaginal cancer. The advances in radiation therapy in both external beam and brachytherapy have improved local control, survival, and toxicity. Brachytherapy plays an important role in treating vaginal cancer, but treatment should be individualized to each tumor. Imaging, particularly magnetic resonance imaging, plays an essential role in the management of patients with vaginal cancer, from diagnosis to staging to treatment management to surveillance.
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Affiliation(s)
- Anuja Jhingran
- Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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10
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Kidd EA. Imaging to optimize gynecological radiation oncology. Int J Gynecol Cancer 2022; 32:358-365. [DOI: 10.1136/ijgc-2021-002460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/27/2021] [Indexed: 01/09/2023] Open
Abstract
Gynecological cancers have particularly benefited from the increasing use of imaging to guide radiation treatment planning for both external beam radiation and brachytherapy. While the different gynecological cancers have varying use of imaging, certain trends predominate. CT represents an economical choice for evaluating initial disease extent or potential metastasis at follow-up, particularly for endometrial and ovarian cancers. F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT is particularly useful for assessing the initial disease extent and longer term treatment response of squamous predominant cancers, including cervical, vaginal, and vulvar cancers. With its excellent pelvic soft tissue discrimination, MRI provides the greatest assistance in evaluating the local extent of gynecological tumors, including initial evaluation for non-operative endometrial and vulvar cancer, and assessment before, after and during brachytherapy for cervix, locally recurrent endometrial, and primary vaginal cancers. With more limited availability of MRI, ultrasound can also help guide brachytherapy, particularly during procedures. The benefits of using imaging to better spare bone marrow or earlier assessment of treatment response are topics still being explored, in particular for cervical cancer. As imaging along with radiation oncology technologies continue to evolve and develop, such as with MRI-linacs and ultra high dose rate (FLASH) radiation, we may continue to see increasing use of imaging for advancing gynecological radiation oncology.
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11
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Clinical outcomes and dosimetric predictors of toxicity for re-irradiation of vaginal recurrence of endometrial cancer. Brachytherapy 2022; 21:263-272. [DOI: 10.1016/j.brachy.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 11/20/2022]
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12
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Dosimetric predictors of local control and complications in gynecologic transperineal implant patients: The medical college of wisconsin experience. Brachytherapy 2021; 21:94-109. [PMID: 34937684 DOI: 10.1016/j.brachy.2021.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/19/2021] [Accepted: 08/22/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Investigate the relationship between dosimetric parameters with local control (LC) and complications following transperineal high-dose rate (HDR) interstitial brachytherapy (ISBT) for gynecologic (GYN) malignancies. METHODS AND MATERIALS Between 2001 and 2016, 59 patients were treated for primary or recurrent GYN malignancies. Most patients received external beam irradiation, followed by transperineal ISBT via the Syed-Neblett applicator set with CT-based planning. Treatment plans were retrospectively reviewed to evaluate for an association among LC or toxicity with the equivalent dose at 2 Gy per fraction (EQD2) for the clinical target volume (CTV), 0.1 cc (D0.1cc), and 2 cc (D2cc) volumes of the organs at risk (OAR), low/high dose volumes for the OAR and CTV, and ratio of dose at the core vs. the implant periphery. RESULTS The median follow-up among survivors was 24 months. 34% of patients had a component of local failure and in 12%, this was isolated. Late grade 3 (G3) toxicity occurred in 15% of patients. There were no G4-5 toxicities. Rectal D0.1cc > 75 Gy trended toward significance in predicting the development of non-fistula late G2-3 rectal complications. Bladder D0.1cc > 94 Gy significantly predicted for the development of late G2-3 vesicovaginal fistula formation. The ratio of the total dose at the vaginal surface to the needle periphery above 121% trended in predicting for any complication or fistula formation. CONCLUSIONS HDR ISBT combined with EBRT achieved LC in 66% of patients with advanced or recurrent GYN cancers. Rectal and bladder D0.1cc doses may be predictive of complications as may the ratio of the implant dose at the core vs. periphery.
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13
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Clinical outcomes of distal vaginal and vulvar cancer treated with image-guided brachytherapy. J Contemp Brachytherapy 2021; 13:419-425. [PMID: 34484356 PMCID: PMC8407257 DOI: 10.5114/jcb.2021.108596] [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: 03/02/2021] [Accepted: 06/05/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate treatment outcomes with image-guided brachytherapy (IGBT) for distal vaginal and vulvar cancers. Material and methods Women treated for distal vaginal or vulvar malignancies utilizing IGBT were retrospectively reviewed, and acute and late toxicities were retrospectively graded. Descriptive statistical analysis was performed. Results Eighteen patients were included, out of which, twelve patients (66.7%) were with primary disease of the distal vagina and vulva, most commonly squamous cell carcinoma of the vulva (n = 8, 66.7%), and six with recurrent disease, most commonly recurrent endometrial carcinoma (n = 5, 83.3%). All patients received external beam radiation (EBRT) to a median dose of 45 Gy in 25 fractions, followed by IGBT (range of 15 to 27.5 Gy in 3 to 5 fractions). Mean follow-up was 20.6 months. Mean dose to high-risk clinical target volume (HR-CTV) D90 was 72.4 Gy. Mean D2cc for the rectum, bladder, and urethra were 50 Gy, 50.6 Gy, and 62.9 Gy, respectively. Five patients (27.8%) recurred. Three patients (16.7%) had local recurrence, 1 patient (5.6%) had distant recurrence only, and 1 patient (5.6%) had simultaneous regional and distant recurrence. Grade 3 acute toxicities included 1 (5.6%) vaginal stenosis, 6 (33.3%) dermatitis/mucositis, 2 (11.1%) vaginal pain, and 1 (5.6%) vaginal/vulvar infection. Grade 3 late toxicities comprised 3 (17.7%) cases of vaginal pain and 1 (5.9%) skin/vaginal necrosis. There were no grade 4 or higher toxicities. Conclusions Definitive radiation therapy in the form of EBRT and IGBT provides meaningful loco-regional control in women with distal vaginal and vulvar cancers, with mainly skin and vaginal toxicity.
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Alban G, Cheng T, Adleman J, Buzurovic I, Pretz J, Singer L, King M, Lee L. Definitive radiotherapy for vaginal recurrence of early-stage endometrial cancer: survival outcomes and effect of mismatch repair status. Int J Gynecol Cancer 2021; 31:1007-1013. [PMID: 33858956 DOI: 10.1136/ijgc-2021-002536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate clinical outcomes, prognostic factors, and toxicity in patients with vaginal recurrence of early-stage endometrial cancer treated with definitive radiotherapy. METHODS Retrospective review identified 62 patients with stage I-II endometrial cancer and vaginal recurrence treated with external beam radiotherapy and image-guided brachytherapy with definitive intent from November 2004 to July 2017. All patients had prior hysterectomy without adjuvant radiotherapy and >3 months follow-up. Mismatch repair (MMR) status was determined by immunohistochemical staining of the four mismatch repair proteins (MLH1, MSH2, PMS2, and MSH6) when available in the pathology record. Rates of vaginal control, recurrence-free survival, and overall survival were calculated by Kaplan-Meier. Univariate and multivariate analyses were performed by Cox proportional hazards. RESULTS Most patients had endometrioid histology (55, 89%), grade 1 or 2 tumor (53, 85%), and vaginal-only recurrence (55, 89%). With a median follow-up of 39 months (range, 3-167), 3- and 5-year rates of vaginal control, recurrence-free survival, and overall survival were 86% and 82%, 69% and 55%, and 80% and 61%, respectively. On multivariate analysis, non-endometrioid histology (HR 12.5, P<0.01) was associated with relapse when adjusted for chemotherapy use. Patients with non-endometrioid histology also had a 4.5-fold higher risk of death when adjusted for age (P=0.02). Twenty patients had known MMR status, all with grade 1-2 endometrioid tumors and 10 (50%) with MMR deficiency. The 3-year recurrence-free survival was 100% for MMR-proficient tumors and 52% for MMR-deficient (P=0.03). Late grade 2 and 3 gastrointestinal, genitourinary and vaginal toxicity was reported in 27% and 3%, 15% and 2%, and 16% and 2% of patients, respectively. CONCLUSION Definitive radiotherapy with image-guided brachytherapy resulted in 5-year local control rates exceeding 80% and late severe toxicity rates were under 3%. Distant recurrence was common and highest for those with grade 3 or non-endometrioid tumors and MMR deficient grade 1-2 disease.
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Affiliation(s)
- Gabriela Alban
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Teresa Cheng
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jenna Adleman
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ivan Buzurovic
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jennifer Pretz
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Lisa Singer
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Martin King
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Larissa Lee
- Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Westerveld H, Schmid MP, Nout RA, Chargari C, Pieters BR, Creutzberg CL, Sturdza A, Lindegaard JC, van Kesteren Z, Mazeron R, Nesvacil N, Fokdal LU. Image-Guided Adaptive Brachytherapy (IGABT) for Primary Vaginal Cancer: Results of the International Multicenter RetroEMBRAVE Cohort Study. Cancers (Basel) 2021; 13:1459. [PMID: 33806733 PMCID: PMC8004779 DOI: 10.3390/cancers13061459] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/25/2022] Open
Abstract
PURPOSE This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort. METHODS Patients treated with computer tomography (CT)-MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale. RESULTS Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25-57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2-T4 tumors if >80 Gy EQD2α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy. CONCLUSIONS In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.
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Affiliation(s)
- Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Maximilian P. Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Remi A. Nout
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
- Department of Radiotherapy, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3015 Rotterdam, The Netherlands
| | - Cyrus Chargari
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Bradley R. Pieters
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Carien L. Creutzberg
- Department of Radiation Oncology, Leiden University Medical Center, 2333 Leiden, The Netherlands; (R.A.N.); (C.L.C.)
| | - Alina Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Jacob C. Lindegaard
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, 1105 Amsterdam, The Netherlands; (B.R.P.); (Z.v.K.)
| | - Renaud Mazeron
- Brachytherapy Unit, Gustave Roussy Cancer Campus, Université Paris Saclay, 94805 Villesuif, France;
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, 1090 Vienna, Austria; (M.P.S.); (A.S.); (N.N.)
| | - Lars U. Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (J.C.L.); (L.U.F.)
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Dosimetry of a sonolucent material for an ultrasound-compatible gynecologic high-dose-rate brachytherapy cylinder using Monte Carlo simulation and radiochromic film. Brachytherapy 2020; 20:265-271. [PMID: 33039331 DOI: 10.1016/j.brachy.2020.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE he purpose of this study was to study the dosimetric characterization of sonolucent material "TPX" to be used toward gynecologic high-dose-rate brachytherapy treatments using ultrasound-compatible cylinders in non-model-based dose calculation workflows. METHODS Monte Carlo simulations were performed using EGSnrc application egs_brachy in cylinders of polymethylpentene (TPX) plastic, water, and PMMA. Simulations were performed of five 192Ir sources placed longitudinally in ∼3.7 cm diameter, 5.0 cm length cylinders (matching physical cylinders used in film measurements). TPX and PMMA dose distributions and percentage depth dose curves were compared relative to water. Film measurements were performed to validate egs_brachy simulations. TPX and PMMA cylinders were placed in a water tank using 3D-printed supports to position film radially and touching the surface of the cylinders. The same five 192Ir dwell positions were delivered as simulated in egs_brachy. RESULTS The egs_brachy and film percentage depth doses agreed within film uncertainties. The egs_brachy relative dose difference between TPX and water was (0.74 ± 0.09)% and between PMMA and water was (-0.79 ± 0.09)% over the dose scoring phantom. Dose differences for TPX and PMMA relative to water were less than ± 1% within 5 cm of the cylinder surface. CONCLUSIONS In a solid sonolucent sheath of TPX, the dosimetric differences are comparable with PMMA and other applicator materials in clinical use. No additional uncertainty to dose calculation is introduced when treating through TPX cylinders compared with current applicator materials, and therefore, it is acceptable to perform gynecologic brachytherapy treatments with a sonolucent sheath inserted during radiation delivery.
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Kumar M, Thangaraj R, Alva RC, Koushik K, Ponni A, Janaki MG. Interstitial high-dose-rate brachytherapy using cobalt-60 source for cervical cancer: dosimetric and clinical outcomes from a single institute. J Contemp Brachytherapy 2020; 12:351-355. [PMID: 33293974 PMCID: PMC7690231 DOI: 10.5114/jcb.2020.98114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 05/18/2020] [Indexed: 02/01/2023] Open
Abstract
PURPOSE To record and report dosimetric and clinical outcomes of interstitial brachytherapy using cobalt-60 (60Co) source in cervical cancer. MATERIAL AND METHODS Seventy patients who underwent external beam radiotherapy with dose of 45 Gy in 25 fractions, followed by interstitial brachytherapy (ISBT) 6.5 Gy × 4 fractions were included into this study. The ISBT applicators were inserted under combined spinal and epidural anesthesia. Computed tomography (CT) simulation was performed and axial CT images were transferred to treatment planning system. High-risk clinical target volume (CTVHR) and organs at risks (OARs) were contoured. Four fractions of 6.5 Gy were prescribed to CTVHR using inverse planning technique. Patients were followed-up for 3 years. Dosimetric parameters and clinical outcomes were recorded and compared with available literature. RESULTS Seventy patients with FIGO stage IIB-IVA were included in the study. The median EQD2 of 2 cm3 of bladder, rectum, sigmoid and D90 CTVHR were 70 Gy (53-75 Gy), 64 Gy (51-71 Gy), 48 Gy (44-72 Gy), and 77 Gy (70-86 Gy), and dose homogeneity index (DHI), dose non-uniformity ratio (DNR), coverage index (CI), overdose volume index (OI), and conformal index (COIN) were 0.58 (0.39-0.78), 0.42 (0.22-0.61), 0.87 (0.59-0.97), 0.19 (0.09-0.30) and 0.74 (0.52-0.85), respectively. Local control rate at 2 years was 87.14%. Eight patients had local recurrence and one patient had lung metastasis. Also, two patients with local recurrence had recto-vaginal fistula. Two patients had grade 2 proctitis (2.8%) and one patient developed grade 3 proctitis (1.4%). There was no grade 2 or higher bladder toxicity. CONCLUSIONS The dosimetric parameters, local control and toxicities of high-dose-rate interstitial brachytherapy in cervical cancer patients treated by 60Co radioactive source are similar, compared to available literature using iridium-192 (192Ir) source.
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Affiliation(s)
| | | | | | | | - Arul Ponni
- Ramaiah Medical College, Bengaluru, India
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Westerveld H, Nesvacil N, Fokdal L, Chargari C, Schmid MP, Milosevic M, Mahantshetty UM, Nout RA. Definitive radiotherapy with image-guided adaptive brachytherapy for primary vaginal cancer. Lancet Oncol 2020; 21:e157-e167. [PMID: 32135119 DOI: 10.1016/s1470-2045(19)30855-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/17/2019] [Accepted: 12/20/2019] [Indexed: 12/27/2022]
Abstract
Primary vaginal cancer is a rare cancer and clinical evidence to support recommendations on its optimal management is insufficient. Because primary vaginal cancer resembles cervical cancer in many aspects, treatment strategies are mainly adopted from evidence in locally advanced cervical cancer. To date, the organ-sparing treatment of choice is definitive radiotherapy, consisting of external beam radiotherapy and brachytherapy, combined with concurrent chemotherapy. Brachytherapy is an important component of the treatment and its steep dose gradient enables the delivery of high doses of radiation to the primary tumour, while simultaneously sparing the surrounding organs at risk. The introduction of volumetric CT or MRI image-guided adaptive brachytherapy in cervical cancer has led to better pelvic control and survival, with decreased morbidity, than brachytherapy based on x-ray radiographs. MRI-based image-guided adaptive brachytherapy with superior soft-tissue contrast has also been adopted sporadically for primary vaginal cancer. This therapy has had promising results and is considered to be the state-of-the-art treatment for primary vaginal cancer in standard practice.
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Affiliation(s)
- Henrike Westerveld
- Department of Radiation Oncology, Amsterdam University Medical Centers, AMC, Amsterdam, Netherlands.
| | - Nicole Nesvacil
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Cancer Campus, Université Paris Saclay, France; Institut de Recherche Biomédicale des Armées, Brétigny-sur-Orge, France
| | - Maximilian P Schmid
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Michael Milosevic
- Radiation Medicine Program, Department of Radiation Oncology, Princess Margaret Cancer Centre and Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Umesh M Mahantshetty
- Department of Radiation Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Remi A Nout
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, Netherlands
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Zaffino P, Moccia S, De Momi E, Spadea MF. A Review on Advances in Intra-operative Imaging for Surgery and Therapy: Imagining the Operating Room of the Future. Ann Biomed Eng 2020; 48:2171-2191. [PMID: 32601951 DOI: 10.1007/s10439-020-02553-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
With the advent of Minimally Invasive Surgery (MIS), intra-operative imaging has become crucial for surgery and therapy guidance, allowing to partially compensate for the lack of information typical of MIS. This paper reviews the advancements in both classical (i.e. ultrasounds, X-ray, optical coherence tomography and magnetic resonance imaging) and more recent (i.e. multispectral, photoacoustic and Raman imaging) intra-operative imaging modalities. Each imaging modality was analyzed, focusing on benefits and disadvantages in terms of compatibility with the operating room, costs, acquisition time and image characteristics. Tables are included to summarize this information. New generation of hybrid surgical room and algorithms for real time/in room image processing were also investigated. Each imaging modality has its own (site- and procedure-specific) peculiarities in terms of spatial and temporal resolution, field of view and contrasted tissues. Besides the benefits that each technique offers for guidance, considerations about operators and patient risk, costs, and extra time required for surgical procedures have to be considered. The current trend is to equip surgical rooms with multimodal imaging systems, so as to integrate multiple information for real-time data extraction and computer-assisted processing. The future of surgery is to enhance surgeons eye to minimize intra- and after-surgery adverse events and provide surgeons with all possible support to objectify and optimize the care-delivery process.
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Affiliation(s)
- Paolo Zaffino
- Department of Experimental and Clinical Medicine, Universitá della Magna Graecia, Catanzaro, Italy
| | - Sara Moccia
- Department of Information Engineering (DII), Universitá Politecnica delle Marche, via Brecce Bianche, 12, 60131, Ancona, AN, Italy.
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Piazza Leonardo da Vinci, 32, 20133, Milano, MI, Italy
| | - Maria Francesca Spadea
- Department of Experimental and Clinical Medicine, Universitá della Magna Graecia, Catanzaro, Italy
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Evaluation of a new bi-valve vaginal speculum applicator design for gynecologic interstitial brachytherapy. J Contemp Brachytherapy 2020; 12:27-34. [PMID: 32190067 PMCID: PMC7073339 DOI: 10.5114/jcb.2020.92406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 12/30/2019] [Indexed: 12/11/2022] Open
Abstract
Purpose We designed a bi-valve vaginal speculum high-dose-rate (HDR) interstitial gynecologic brachytherapy applicator. This allows for both a direct view of the cervix and image-guided brachytherapy applicator placement. The purpose of this study was to assess the validity of the new applicator. Material and methods The applicator was designed to have a 25-mm arc, which can be spread transversely to 35-mm wide, with 10 insertion holes; it was produced using a stereolithographic printer with biocompatible Dental SG resin. For resin radiodensity was measured in Hounsfield units (HU) using computed tomography (CT). Comparing the new applicator with a conventional intracavitary applicator, we evaluated the treated volume (including dimensions of 100% isodose volume at the central axis), V100/D90/D98 for a hypothetical cervix (a 2-cm-long and 4-cm-diameter cylinder), and dose points of organs at risk (OARs) (at 25 and 30 mm from the tandem). Based on dose-volume histogram (DVH) analysis of the cervix and dose points of OARs, the range of tolerance for the percent dose difference in the prescription dose was set at 5%. Results The mean radiodensity of the Dental SG resin, which was magnetic resonance imaging compatible, was 118 HU. Dimensions of the 100% isodose volume measured at the central axis were 4.4 × 6.6 × 7.4 cm for the new applicator and 4.3 × 6.0 × 7.7 cm for the intracavitary applicator. The 100% prescription dose volumes were 110 cc and 113 cc for the new and conventional applicator, respectively. The percent difference in the hypothetical cervix V100, D90, and D98 between the new and intracavitary applicator were within 5%. The percent differences in dose points of OARs at 25 and 30 mm between the new and conventional applicators were within 5%. Conclusions Our speculum applicator can reproduce a conventional pear-shaped dose distribution. Our current clinical practice will use this applicator, which can improve the patient’s treatment results.
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Clinical and Dosimetric Comparison of Interstitial Applications Using Martinez Universal Perineal Interstitial Template (MUPIT) and Syed–Neblett Template for Carcinoma Cervix. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2019. [DOI: 10.1007/s40944-019-0295-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rodgers JR, Bax J, Surry K, Velker V, Leung E, D'Souza D, Fenster A. Intraoperative 360-deg three-dimensional transvaginal ultrasound during needle insertions for high-dose-rate transperineal interstitial gynecologic brachytherapy of vaginal tumors. J Med Imaging (Bellingham) 2019; 6:025001. [PMID: 30989088 DOI: 10.1117/1.jmi.6.2.025001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/13/2019] [Indexed: 11/14/2022] Open
Abstract
Brachytherapy, a type of radiotherapy, may be used to place radioactive sources into or in close proximity to tumors, providing a method for conformally escalating dose in the tumor and the local area surrounding the malignancy. High-dose-rate interstitial brachytherapy of vaginal tumors requires precise placement of multiple needles through holes in a plastic perineal template to deliver treatment while optimizing dose and avoiding overexposure of nearby organs at risk (OARs). Despite the importance of needle placement, image guidance for adaptive, intraoperative needle visualization, allowing misdirected needles to be identified and corrected during insertion, is not standard practice. We have developed a 360-deg three-dimensional (3-D) transvaginal ultrasound (TVUS) system using a conventional probe with a template-compatible custom sonolucent vaginal cylinder and propose its use for intraoperative needle guidance during interstitial gynecologic brachytherapy. We describe the 3-D TVUS mechanism and geometric validation, present mock phantom procedure results, and report on needle localization accuracy in patients. For the six patients imaged, landmark anatomical features and all needles were clearly visible. The implementation of 360-deg 3-D TVUS through a sonolucent vaginal cylinder provides a technique for visualizing needles and OARs intraoperatively during interstitial gynecologic brachytherapy, enabling implants to be assessed and providing the potential for image guidance.
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Affiliation(s)
- Jessica Robin Rodgers
- University of Western Ontario, School of Biomedical Engineering, London, Ontario, Canada.,University of Western Ontario, Robarts Research Institute, London, Ontario, Canada
| | - Jeffrey Bax
- University of Western Ontario, Robarts Research Institute, London, Ontario, Canada
| | - Kathleen Surry
- London Health Sciences Centre, Department of Medical Physics, London Regional Cancer Program, London, Ontario, Canada
| | - Vikram Velker
- London Health Sciences Centre, Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Eric Leung
- Sunnybrook Health Sciences Centre, Department of Radiation Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
| | - David D'Souza
- London Health Sciences Centre, Department of Radiation Oncology, London Regional Cancer Program, London, Ontario, Canada
| | - Aaron Fenster
- University of Western Ontario, School of Biomedical Engineering, London, Ontario, Canada.,University of Western Ontario, Robarts Research Institute, London, Ontario, Canada
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Evaluation of the accuracy of computer-assisted techniques in the interstitial brachytherapy of the deep regions of the head and neck. Brachytherapy 2019; 18:217-223. [DOI: 10.1016/j.brachy.2018.12.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/14/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022]
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Hanania AN, Myers P, Yoder AK, Bulut A, Henry Yu Z, Eraj S, Bowers J, Bonnen MD, Echeverria A, Hall TR, Anderson ML, Ludwig M. Inversely and adaptively planned interstitial brachytherapy: A single implant approach. Gynecol Oncol 2019; 152:353-360. [DOI: 10.1016/j.ygyno.2018.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 01/27/2023]
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Characterizing the impact of adaptive planning on image-guided perineal interstitial brachytherapy for gynecologic malignancies. Brachytherapy 2018; 17:352-359. [DOI: 10.1016/j.brachy.2017.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/18/2017] [Accepted: 11/07/2017] [Indexed: 11/18/2022]
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Abstract
OBJECTIVES In women with endometrial carcinoma (EC), tumor recurrences tend to occur in the 2- to 3-year period following surgical staging. Management of disease recurrence in EC poses significant challenges. These patients represent a heterogenous group where histologic subtypes, previous adjuvant management, interval since completion of adjuvant therapy, and size and site(s) of disease recurrence all have important implications on salvage therapies and prognosis. No randomized controlled trials have been published to determine optimal management in this group of patients. An expert panel was convened to reach consensus on the most appropriate management options in this group of patients. METHODS The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. RESULTS Five clinical variants were developed to address common scenarios in the management of women with recurrent EC. Group members reached consensus on the appropriateness of specific evaluation and treatment approaches with numerical ratings. CONCLUSIONS In combining available medical literature and expert opinions, this manuscript may serve as an aid for other practitioners in the appropriate management of women with recurrent EC.
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Rao YJ, Hui C, Chundury A, Schwarz JK, DeWees T, Powell MA, Mutch DG, Grigsby PW. Which patients with inoperable vulvar cancer may benefit from brachytherapy in addition to external beam radiation? A Surveillance, Epidemiology, and End Results analysis. Brachytherapy 2017; 16:831-840. [PMID: 28533162 DOI: 10.1016/j.brachy.2017.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/26/2017] [Accepted: 03/29/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE It is unknown whether brachytherapy after external beam radiation (EBRT + BT) results in improved outcomes compared with EBRT alone for patients with inoperable vulvar cancer. The purpose of this study was to compare survival outcomes for patients who received these treatment modalities. METHODS AND MATERIALS Data between 1973 and 2011 from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were analyzed. Patients with Federation of International Gynecologists and Obstetricians stage I-IVA vulvar cancer treated with definitive EBRT + BT or EBRT alone were included. Patients with prior surgical resection were excluded. Disease-specific survival (DSS) and overall survival were compared using the Kaplan-Meier method and Cox proportional hazard models. RESULTS A total of 649 patients were analyzed, of which 617 received EBRT alone and 32 received EBRT + BT. Median follow-up was 33 months in surviving patients. The use of brachytherapy declined from 16% of cases treated in 1973-1980 to 4% in 2001-2011 (p = 0.04). EBRT + BT vs. EBRT alone was not significantly associated with improved DSS (45% vs. 33% at 5 years) or overall survival (34% vs. 24% at 5 years) on univariate or multivariate analyses. On post hoc subgroup analyses, brachytherapy consolidation was associated with higher 5-year DSS in a composite subgroup that included patients with stage IVA disease, tumor >4 cm, or node-positive disease (52% vs. 27%, p = 0.02). CONCLUSIONS Utilization of BT consolidation with EBRT for vulvar cancer is declining in the United States. EBRT + BT is not associated with improved survival compared with EBRT alone in the overall group of patients. Certain subgroups of patients might benefit from brachytherapy, but this hypothesis requires validation in future studies.
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Affiliation(s)
- Yuan James Rao
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Caressa Hui
- Saint Louis University School of Medicine, Saint Louis, MO
| | - Anupama Chundury
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Julie K Schwarz
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Todd DeWees
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Matthew A Powell
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - David G Mutch
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Perry W Grigsby
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO.
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Mendez LC, Weiss Y, D'Souza D, Ravi A, Barbera L, Leung E. Three-dimensional-guided perineal-based interstitial brachytherapy in cervical cancer: A systematic review of technique, local control and toxicities. Radiother Oncol 2017; 123:312-318. [DOI: 10.1016/j.radonc.2017.03.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/16/2017] [Accepted: 03/07/2017] [Indexed: 10/19/2022]
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Rodgers JR, Surry K, Leung E, D'Souza D, Fenster A. Toward a 3D transrectal ultrasound system for verification of needle placement during high-dose-rate interstitial gynecologic brachytherapy. Med Phys 2017; 44:1899-1911. [PMID: 28295403 DOI: 10.1002/mp.12221] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/13/2017] [Accepted: 03/09/2017] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Treatment for gynecologic cancers, such as cervical, recurrent endometrial, and vaginal malignancies, commonly includes external-beam radiation and brachytherapy. In high-dose-rate (HDR) interstitial gynecologic brachytherapy, radiation treatment is delivered via hollow needles that are typically inserted through a template on the perineum with a cylinder placed in the vagina for stability. Despite the need for precise needle placement to minimize complications and provide optimal treatment, there is no standard intra-operative image-guidance for this procedure. While some image-guidance techniques have been proposed, including magnetic resonance (MR) imaging, X-ray computed tomography (CT), and two-dimensional (2D) transrectal ultrasound (TRUS), these techniques have not been widely adopted. In order to provide intra-operative needle visualization and localization during interstitial brachytherapy, we have developed a three-dimensional (3D) TRUS system. This study describes the 3D TRUS system and reports on the system validation and results from a proof-of-concept patient study. METHODS To obtain a 3D TRUS image, the system rotates a conventional 2D endocavity transducer through 170 degrees in 12 s, reconstructing the 2D frames into a 3D image in real-time. The geometry of the reconstruction was validated using two geometric phantoms to ensure the accuracy of the linear measurements in each of the image coordinate directions and the volumetric accuracy of the system. An agar phantom including vaginal and rectal canals, as well as a model uterus and tumor, was designed and used to test the visualization and localization of the interstitial needles under idealized conditions by comparing the needles' positions between the 3D TRUS scan and a registered MR image. Five patients undergoing HDR interstitial gynecologic brachytherapy were imaged using the 3D TRUS system following the insertion of all needles. This image was manually, rigidly registered to the clinical postinsertion CT scan based on the vaginal cylinder of the needle template. The positions of the tips and the trajectory of the needle paths were compared between the modalities. RESULTS The observed geometric errors of the system were ≤ 0.3 mm in each of the three coordinate planes of the 3D US image and the mean measured volumetric error was 0.10 cm3 . In the phantom study, the mean needle tip difference was 1.54 ± 0.71 mm and the mean trajectory difference was 0.94 ± 0.89 degrees (n = 14). In the in vivo study, a total of 73 needles were placed, of which 88% of needles were visible and 79% of tips were identifiable in the 3D TRUS images. Six of the nine needles that were not visible were due to shadowing artifacts created by the presence of the vaginal cylinder of the needle template. The mean distance between corresponding needle tips in the two modalities was 3.82 ± 1.86 mm and the mean trajectory difference was 3.04 ± 1.63 degrees for the five patients. CONCLUSIONS In this proof-of-concept study, the 3D TRUS system allowed for localization of needles not obscured by shadowing artifacts, providing a method for visualizing needles intra-operatively during HDR interstitial brachytherapy of gynecologic cancers and providing the potential for 3D image-guidance.
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Affiliation(s)
- Jessica Robin Rodgers
- Biomedical Engineering Graduate Program, The University of Western Ontario, London, ON, N6A 3K7, Canada.,Robarts Research Institute, The University of Western Ontario, London, ON, N6A 5B7, Canada
| | - Kathleen Surry
- Department of Medical Physics, London Regional Cancer Program, London, ON, N6A 5W9, Canada
| | - Eric Leung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5, Canada
| | - David D'Souza
- Department of Radiation Oncology, London Regional Cancer Program, London, ON, N6A 5W9, Canada
| | - Aaron Fenster
- Biomedical Engineering Graduate Program, The University of Western Ontario, London, ON, N6A 3K7, Canada.,Robarts Research Institute, The University of Western Ontario, London, ON, N6A 5B7, Canada
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Comparison of outcomes for MR-guided versus CT-guided high-dose-rate interstitial brachytherapy in women with locally advanced carcinoma of the cervix. Gynecol Oncol 2017; 145:284-290. [PMID: 28318644 DOI: 10.1016/j.ygyno.2017.03.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 02/27/2017] [Accepted: 03/07/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose was to compare local control (LC), overall survival (OS) and dose to the organs at risk (OAR) in women with locally advanced cervical cancer treated with MR-guided versus CT-guided interstitial brachytherapy (BT). METHODS 56 patients (29 MR, 27 CT) were treated with high-dose-rate (HDR) interstitial BT between 2005-2015. The MR patients had been prospectively enrolled on a Phase II clinical trial. Data were analyzed using Kaplan-Meier (K-M) and Cox proportional hazards statistical modeling in JMP® & R®. RESULTS Median follow-up time was 19.7months (MR group) and 18.4months (CT group). There were no statistically significant differences in patient age at diagnosis, histology, percent with tumor size >4cm, grade, FIGO stage or lymph node involvement between the groups. Patients in the MR group had more lymphovascular involvement compared to patients in the CT group (p<0.01). When evaluating plans generated, there were no statistically significant differences in median cumulative dose to the high-risk clinical target volume or the OAR. 2-year K-M LC rates for MR-based and CT-based treatments were 96% and 87%, respectively (log-rank p=0.65). At 2years, OS was significantly better in the MR-guided cohort (84% vs. 56%, p=0.036). On multivariate analysis, squamous histology was associated with longer OS (HR 0.23, 95% CI 0.07-0.72) in a model with MR BT (HR 0.35, 95% CI 0.08-1.18). There was no difference in toxicities between CT and MR BT. CONCLUSION In this population of locally advanced cervical-cancer patients, MR-guided HDR BT resulted in estimated 96% 2-year local control and excellent survival and toxicity rates.
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Fallon J, Park SJ, Yang L, Veruttipong D, Zhang M, Van T, Wang PC, Fekete AM, Cambeiro M, Kamrava M, Steinberg ML, Demanes DJ. Long term results from a prospective database on high dose rate (HDR) interstitial brachytherapy for primary cervical carcinoma. Gynecol Oncol 2016; 144:S0090-8258(16)31496-2. [PMID: 28029448 DOI: 10.1016/j.ygyno.2016.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/13/2016] [Accepted: 10/14/2016] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Present long-term outcomes in primary cervical cancer treated with external beam and high dose rate interstitial brachytherapy. METHODS High dose rate (HDR) interstitial (IS) brachytherapy (BT) and external beam (EBRT) were administered from 1992 to 2009 to 315 patients who were unsuitable for intracavitary (IC) BT alone. Histology was 89% squamous cell, 8% adenocarcinoma, and 3% adenosquamous. FIGO stage was I-14%, II-47%, III-34%, and IVA-5%. Median tumor size was 6cm. Lymph node metastases were 26% pelvic and 9.5% para-aortic. Treatment planning was 49% 2D and 51% 3D-CT. The mean doses were central EBRT EQD210 37.3±4.3Gy (sidewall 49.2±3.6Gy) and HDR EQD210 42.3±5.3Gy (nominal 5.4Gy×6 fractions using a mean of 24 catheters and 1 tandem). Total EQD210 mean target dose was 79.5±5.4Gy. Standardized planned dose constraints were ICRU points or D0.1cc bladder 80%, rectum 75% and urethra 90% of the HDR dose per fraction. Morbidity assessment was CTCAEv3. Median and mean follow-up were 50 and 61months (3-234). RESULTS The 10-year actuarial local control was 87%, regional control 84%, and loco-regional control 77%. Distant metastasis free survival was 66%, cause specific survival 56%, disease free survival 54%, and overall survival 40%. The rates of late grade GU and GI toxicities were 4.8% G3 and 5.4% G4. CONCLUSIONS Template-guided interstitial can be safely performed to successfully deliver high radiation dose to locally advanced cervix cancer and avoid excessive dose and injury to adjacent vital pelvic organs. We achieved high tumor control with low morbidity in patients who were poor candidates for intracavitary brachytherapy.
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Affiliation(s)
- Julia Fallon
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Sang-Jung Park
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Lisa Yang
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Darlene Veruttipong
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Mingle Zhang
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Thanh Van
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Pin-Chieh Wang
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Alexandra M Fekete
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Mauricio Cambeiro
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Mitchell Kamrava
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - Michael L Steinberg
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States
| | - D Jeffrey Demanes
- California Endocurietherapy at UCLA, Department of Radiation Oncology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
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Rodríguez Villalba S, Richart Sancho J, Otal Palacín A, Perez-Calatayud J, Santos Ortega M. Development and clinical implementation of a new template for MRI-based intracavitary/interstitial gynecologic brachytherapy for locally advanced cervical cancer: from CT-based MUPIT to the MRI compatible Template Benidorm. Ten years of experience. J Contemp Brachytherapy 2016; 8:404-414. [PMID: 27895682 PMCID: PMC5116450 DOI: 10.5114/jcb.2016.63187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/22/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To study outcome and toxicity in 59 patients with locally advanced cervix carcinoma treated with computed tomography (CT)-based Martinez universal perineal interstitial template (MUPIT) and the new magnetic resonance imaging (MRI)-compatible template Benidorm (TB). MATERIAL AND METHODS From December 2005 to October 2015, we retrospectively analyzed 34 patients treated with MUPIT and 25 treated with the TB. Six 4 Gy fractions were prescribed to the clinical target volume (CTV) combined with external beam radiotherapy (EBRT). The organs at risk (OARs) and the CTV were delineated by CT scan in the MUPIT implants and by MRI in the TB implants. Dosimetry was CT-based for MUPIT and exclusively MRI-based for TB. Dose values were biologically normalized to equivalent doses in 2 Gy fractions (EQD2). RESULTS Median CTV volumes were 163.5 cm3 for CT-based MUPIT (range 81.8-329.4 cm3) and 91.9 cm3 for MRI-based TB (range 26.2-161 cm3). Median D90 CTV (EBRT + BT) was 75.8 Gy for CT-based MUPIT (range 69-82 Gy) and 78.6 Gy for MRI-based TB (range 62.5-84.2 Gy). Median D2cm3 for the rectum was 75.3 Gy for CT-based MUPIT (range 69.8-132.1 Gy) and 69.9 Gy for MRI-based TB (range 58.3-83.7 Gy). Median D2cm3 for the bladder was 79.8 Gy for CT-based MUPIT (range 71.2-121.1 Gy) and 77.1 Gy for MRI-based TB (range 60.5-90.8 Gy). Local control (LC) was 88%. Overall survival (OS), disease free survival (DFS), and LC were not statistically significant in either group. Patients treated with CT-based MUPIT had a significantly higher percentage of rectal bleeding G3 (p = 0.040) than those treated with MRI-based TB, 13% vs. 2%. CONCLUSIONS Template Benidorm treatment using MRI-based dosimetry provides advantages of MRI volume definition, and allows definition of smaller volumes that result in statistically significant decreased rectal toxicity compared to that seen with CT-based MUPIT treatment.
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Affiliation(s)
| | | | | | - Jose Perez-Calatayud
- Radiotherapy Department, Hospital Clínica Benidorm, Benidorm, Alicante; Radiotherapy Department, La Fe University and Polytechnic Hospital, Valencia, Spain
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Manuel MM, Cho LP, Catalano PJ, Damato AL, Miyamoto DT, Tempany CM, Schmidt EJ, Viswanathan AN. Outcomes with image-based interstitial brachytherapy for vaginal cancer. Radiother Oncol 2016; 120:486-492. [PMID: 27321150 DOI: 10.1016/j.radonc.2016.05.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To compare clinical outcomes of image-based versus non-image-based interstitial brachytherapy (IBBT) for vaginal cancer. METHODS AND MATERIALS Of 72 patients with vaginal cancer treated with brachytherapy (BT), 47 had image guidance (CT=31, MRI=16) and 25 did not. Kaplan-Meier (KM) estimates were generated for any recurrence, local control (LC), disease-free interval (DFI), and overall survival (OS) and Cox models were used to assess prognostic factors. RESULTS Median age was 66 and median follow-up time was 24months. Median cumulative EQD2 dose was 80.8Gy in the non-IBBT group and 77Gy in the IBBT group. For non-IBBT versus IBBT, the 2-year KM LC was 71% vs. 93% (p=0.03); DFI was 54% vs. 86% (p=0.04); and OS 52% vs. 82% (p=0.35). On multivariate analysis, IBBT was associated with better DFI (HR 0.24, 95% CI 0.07-0.73). Having any 2 or more of chemotherapy, high-dose-rate (HDR) BT or IBBT (temporally correlated variables) significantly reduced risk of relapse (HR=0.33, 95% CI=0.13-0.83), compared to having none of these factors. CONCLUSION Over time, the use of chemotherapy, HDR, and IBBT has increased in vaginal cancer. The combination of these factors resulted in the highest rates of disease control. Image-guided brachytherapy for vaginal cancer patients maximizes disease control.
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Affiliation(s)
- Matthias M Manuel
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - Linda P Cho
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - Paul J Catalano
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Department of Biostatistics, Harvard School of Public Health, Boston, USA
| | - Antonio L Damato
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - David T Miyamoto
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Clare M Tempany
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Ehud J Schmidt
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA.
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Al Feghali KA, Elshaikh MA. Why brachytherapy boost is the treatment of choice for most women with locally advanced cervical carcinoma? Brachytherapy 2016; 15:191-9. [DOI: 10.1016/j.brachy.2015.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 11/23/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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Amsbaugh MJ, Bhatt N, Hunter T, Gaskins J, Parker L, Metzinger D, Amsbaugh A, Sowards K, El-Ghamry MN. Computed tomography–planned interstitial brachytherapy for locally advanced gynecologic cancer: Outcomes and dosimetric predictors of urinary toxicity. Brachytherapy 2016; 15:49-56. [DOI: 10.1016/j.brachy.2015.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/03/2015] [Accepted: 10/01/2015] [Indexed: 11/29/2022]
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Vargo JA, Viswanathan AN, Erickson BA, Beriwal S. Gynecologic Brachytherapy: Cervical Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grover S, Harkenrider MM, Cho LP, Erickson B, Small C, Small W, Viswanathan AN. Image Guided Cervical Brachytherapy: 2014 Survey of the American Brachytherapy Society. Int J Radiat Oncol Biol Phys 2015; 94:598-604. [PMID: 26867888 DOI: 10.1016/j.ijrobp.2015.11.024] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Indexed: 01/27/2023]
Abstract
PURPOSE To provide an update of the 2007 American brachytherapy survey on image-based brachytherapy, which showed that in the setting of treatment planning for gynecologic brachytherapy, although computed tomography (CT) was often used for treatment planning, most brachytherapists used point A for dose specification. METHODS AND MATERIALS A 45-question electronic survey on cervical cancer brachytherapy practice patterns was sent to all American Brachytherapy Society members and additional radiation oncologists and physicists based in the United States between January and September 2014. Responses from the 2007 survey and the present survey were compared using the χ(2) test. RESULTS There were 370 respondents. Of those, only respondents, not in training, who treat more than 1 cervical cancer patient per year and practice in the United States, were included in the analysis (219). For dose specification to the target (cervix and tumor), 95% always use CT, and 34% always use MRI. However, 46% use point A only for dose specification to the target. There was a lot of variation in parameters used for dose evaluation of target volume and normal tissues. Compared with the 2007 survey, use of MRI has increased from 2% to 34% (P<.0001) for dose specification to the target. Use of volume-based dose delineation to the target has increased from 14% to 52% (P<.0001). CONCLUSION Although use of image-based brachytherapy has increased in the United States since the 2007 survey, there is room for further growth, particularly with the use of MRI. This increase may be in part due to educational initiatives. However, there is still significant heterogeneity in brachytherapy practice in the United States, and future efforts should be geared toward standardizing treatment.
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Affiliation(s)
- Surbhi Grover
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Linda P Cho
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Beth Erickson
- Department Radiation Oncology, Froedtert Hospital and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christina Small
- Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts
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Chopra S, Dora T, Engineer R, Mechanery S, Agarwal P, Kannan S, Ghadi Y, Swamidas J, Mahantshetty U, Shrivastava SK. Late rectal toxicity after image-based high-dose-rate interstitial brachytherapy for postoperative recurrent and/or residual cervical cancers: EQD2 predictors for Grade ≥II toxicity. Brachytherapy 2015; 14:881-8. [DOI: 10.1016/j.brachy.2015.08.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 08/02/2015] [Accepted: 08/20/2015] [Indexed: 10/23/2022]
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Mesko S, Swamy U, Park SJ, Borja L, Wang J, Demanes DJ, Kamrava M. Early clinical outcomes of ultrasound-guided CT-planned high-dose-rate interstitial brachytherapy for primary locally advanced cervical cancer. Brachytherapy 2015; 14:626-32. [DOI: 10.1016/j.brachy.2015.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/01/2015] [Accepted: 04/16/2015] [Indexed: 11/16/2022]
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Villalba SR, Sancho JR, Palacin AO, Calatayud JP, Ortega MS. A new template for MRI-based intracavitary/interstitial gynecologic brachytherapy: design and clinical implementation. J Contemp Brachytherapy 2015; 7:265-72. [PMID: 26622229 PMCID: PMC4643734 DOI: 10.5114/jcb.2015.54051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/05/2015] [Accepted: 08/10/2015] [Indexed: 12/04/2022] Open
Abstract
PURPOSE To describe the potential clinical use of a new brachytherapy applicator for gynecological tumors, with special attention to locally advanced cervical carcinoma. This device allows the combination of intracavitary radiotherapy and MRI-compatible transperineal interstitial needles. The design of this template addresses the disadvantages of currently commercially available templates: the inability of the intracavitary component to reach deep into the cervix (MUPIT), and the MRI-incompatibility of these templates (MUPIT and Syed), which necessitates use of CT imaging for the dosimetry. MATERIAL AND METHODS The newly developed Benidorm Template applicator allows titanium needles in a template with straight and angled holes to provide different angles of divergence to be used with currently existing MRI-compatible intrauterine tubes. It can provide total coverage of the craniocaudal and lateral extension of the tumor (intrautherus, parametrial, and paravaginal). This method is mainly indicated in advanced cervical carcinoma with bulky parametrial invasion (medial or distal), with bulky primary disease that responds poorly to external beam radiotherapy extensive paravaginal involvement (tumor thickness greater than 0.5 cm) extending to the middle or lower third of the vagina, or for disease that has invaded the bladder or rectum (stage IVA). RESULTS Between April 2013 until December 2014, we treated 15 patients with locally advanced cervical carcinoma employing the Benidorm Template. The median dose at D90 for the CTV was 79.8 Gy (71.5-89.9 Gy), at D2cc for the bladder it was 77.6 Gy (69.8-90.8 Gy), and at D2cc for the rectum it was 71.9 Gy (58.3-83.7 Gy). Values expressed in EQD2, assuming α/β of 10 for CTV and 3 for OAR. CONCLUSIONS This new applicator allows the use of MRI-based dosimetry, thus providing the advantages of MRI volume definition. As such, it facilitates determination of complete intracavitary and interstitial CTV coverage and the sparing of normal tissues.
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Affiliation(s)
| | | | | | - Jose Perez Calatayud
- Radiotherapy Department, Hospital Clínica Benidorm, Benidorm, Alicante
- Radiotherapy Department, La Fe University and Polytechnic Hospital, Valencia, Spain
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Viswanathan AN, Erickson BA. Seeing is saving: The benefit of 3D imaging in gynecologic brachytherapy. Gynecol Oncol 2015; 138:207-15. [DOI: 10.1016/j.ygyno.2015.02.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/26/2015] [Indexed: 12/18/2022]
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Outpatient combined intracavitary and interstitial cervical brachytherapy: barriers and solutions to implementation of a successful programme - a single institutional experience. J Contemp Brachytherapy 2015. [PMID: 26207117 PMCID: PMC4499522 DOI: 10.5114/jcb.2015.52625] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Involvement of parametrial disease in locally advanced cervical patients poses a challenge for women undergoing brachytherapy. Current use of the Fletcher suit applicator may not adequately cover the high risk clinical target volume (HR CTV), especially in the parametrial region due to the physical qualities of brachytherapy from the inverse square law and the need to respect organs at risk (OAR) constraints, and leads to lower local control rates. Combined intracavitary and interstitial brachytherapy with the use of 1 or 2 interstitial needles allows adequate coverage of the HR CTV and the clinical evidence have demonstrated a correlation with better clinical results. This procedure is often resource intensive, requiring inpatient stay and magnetic resonance imaging (MRI) planning. In departments where such resources are limited, there is a poor uptake of interstitial brachytherapy. This article discusses the technique of combined intracavitary and interstitial brachytherapy in an outpatient setting, and explores the issues and barriers for implementation and suggestions to overcome such barriers.
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Amsbaugh MJ, Bhatt N, Hunter T, Gaskins J, Parker L, Metzinger D, Amsbaugh A, Sowards K, El-Ghamry M. Computed tomography planned interstitial brachytherapy for recurrent gynecologic cancer. Brachytherapy 2015; 14:600-5. [PMID: 26087868 DOI: 10.1016/j.brachy.2015.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/14/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To report outcomes and identify predictors of toxicity in patients undergoing reirradiation with interstitial brachytherapy (ISBT) for recurrent cancers of the female reproductive tract. METHODS AND MATERIALS Twenty-one patients received ISBT performed using (192)Ir sources (10 low dose rate and 11 high dose rate) at our institution between 2009 and 2013. Demographic, disease specific, treatment, toxicity, and outcome data were collected. Kaplan-Meier and proportional hazard models were used to estimate survival and logistic regression to model toxicity. A least absolute shrinkage and selection operator penalty was used to identify relevant predictors of outcome and toxicity. RESULTS Eleven patients had uterine cancer, 7 patients had cervical cancer, and 3 patients had vulvar cancer. One-year actuarial freedom from local-regional failure, progression-free survival (PFS), and overall survival were 71.5%, 66.0%, and 82.2%, respectively. Tumor size was a significant predictor of worse PFS and overall survival (1 cm increase in tumor size = hazard ratio [HR], 1.61; 95% confidence interval [CI]: 1.16, 2.62 for PFS; HR, 2.02; 95% CI: 1.21, 3.38). Grade 3 or higher vaginal, urinary, and rectal toxicity occurred in 28.5%, 9.5%, and 19% of patients, respectively. Urethra D0.1cc predicted for grade 2 or higher urinary toxicity (one equivalent dose in 2 Gy fraction increase = HR, 1.156; 95% CI: 1.001, 1.335). CONCLUSIONS Reirradiation with ISBT is both safe and effective. In patients with recurrent cancer, urethra D0.1cc predicts for increased urinary toxicity. Increased tumor size is a negative prognostic factor in patients receiving ISBT for cancer recurrence.
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Affiliation(s)
- Mark J Amsbaugh
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Neal Bhatt
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Thomas Hunter
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Jeremy Gaskins
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, KY
| | - Lynn Parker
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Daniel Metzinger
- Department of Obstetrics Gynecology and Women's Health, University of Louisville, Louisville, KY
| | - Ashley Amsbaugh
- Department of Anesthesia and Perioperative Medicine, University of Louisville, Louisville, KY
| | - Keith Sowards
- Department of Radiation Oncology, University of Louisville, Louisville, KY
| | - Moataz El-Ghamry
- Department of Radiation Oncology, University of Louisville, Louisville, KY.
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Poulin E, Racine E, Binnekamp D, Beaulieu L. Fast, automatic, and accurate catheter reconstruction in HDR brachytherapy using an electromagnetic 3D tracking system. Med Phys 2015; 42:1227-32. [DOI: 10.1118/1.4908011] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Redesign of process map to increase efficiency: Reducing procedure time in cervical cancer brachytherapy. Brachytherapy 2015; 14:471-80. [PMID: 25572438 DOI: 10.1016/j.brachy.2014.11.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/13/2014] [Accepted: 11/18/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To increase intraprocedural efficiency in the use of clinical resources and to decrease planning time for cervical cancer brachytherapy treatments through redesign of the procedure's process map. METHODS AND MATERIALS A multidisciplinary team identified all tasks and associated resources involved in cervical cancer brachytherapy in our institution and arranged them in a process map. A redesign of the treatment planning component of the process map was conducted with the goal of minimizing planning time. Planning time was measured on 20 consecutive insertions, of which 10 were performed with standard procedures and 10 with the redesigned process map, and results were compared. Statistical significance (p < 0.05) was measured with a two-tailed t test. RESULTS Twelve tasks involved in cervical cancer brachytherapy treatments were identified. The process map showed that in standard procedures, the treatment planning tasks were performed sequentially. The process map was redesigned to specify that contouring and some planning tasks are performed concomitantly. Some quality assurance tasks were reorganized to minimize adverse effects of a possible error on procedure time. Test dry runs followed by live implementation confirmed the applicability of the new process map to clinical conditions. A 29% reduction in planning time (p < 0.01) was observed with the introduction of the redesigned process map. CONCLUSIONS A process map for cervical cancer brachytherapy was generated. The treatment planning component of the process map was redesigned, resulting in a 29% decrease in planning time and a streamlining of the quality assurance process.
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Srivastava A, Datta NR. Brachytherapy in cancer cervix: Time to move ahead from point A? World J Clin Oncol 2014; 5:764-74. [PMID: 25302176 PMCID: PMC4129539 DOI: 10.5306/wjco.v5.i4.764] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 02/28/2014] [Accepted: 04/03/2014] [Indexed: 02/06/2023] Open
Abstract
Brachytherapy forms an integral part of the radiation therapy in cancer cervix. The dose prescription for intracavitary brachytherapy (ICBT) in cancer cervix is based on Tod and Meredith's point A and has been in practice since 1938. This was proposed at a time when accessibility to imaging technology and dose computation facilities was limited. The concept has been in practice worldwide for more than half a century and has been the fulcrum of all ICBT treatments, strategies and outcome measures. The method is simple and can be adapted by all centres practicing ICBT in cancer cervix. However, with the widespread availability of imaging techniques, clinical use of different dose-rates, availability of a host of applicators fabricated with image compatible materials, radiobiological implications of dose equivalence and its impact on tumour and organs at risk; more and more weight is being laid down on individualised image based brachytherapy. Thus, computed tomography, magnetic-resonance imaging and even positron emission computerized tomography along with brachytherapy treatment planning system are being increasingly adopted with promising outcomes. The present article reviews the evolution of dose prescription concepts in ICBT in cancer cervix and brings forward the need for image based brachytherapy to evaluate clinical outcomes. As is evident, a gradual transition from "point" based brachytherapy to "profile" based image guided brachytherapy is gaining widespread acceptance for dose prescription, reporting and outcome evaluation in the clinical practice of ICBT in cancer cervix.
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Viswanathan AN, Lee LJ, Eswara JR, Horowitz NS, Konstantinopoulos PA, Mirabeau-Beale KL, Rose BS, von Keudell AG, Wo JY. Complications of pelvic radiation in patients treated for gynecologic malignancies. Cancer 2014; 120:3870-83. [DOI: 10.1002/cncr.28849] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 04/30/2014] [Accepted: 05/01/2014] [Indexed: 01/05/2023]
Affiliation(s)
- Akila N. Viswanathan
- Department of Radiation Oncology; Brigham and Women's Hospital and Dana-Farber Cancer Institute; Boston Massachusetts
| | - Larissa J. Lee
- Department of Radiation Oncology; Brigham and Women's Hospital and Dana-Farber Cancer Institute; Boston Massachusetts
| | - Jairam R. Eswara
- Division of Urology; Washington University School of Medicine; St. Louis Missouri
| | - Neil S. Horowitz
- Division of Gynecologic Oncology; Brigham and Women's Hospital; Boston Massachusetts
| | | | | | - Brent S. Rose
- Harvard Radiation Oncology Residency Program; Boston Massachusetts
| | | | - Jennifer Y. Wo
- Department of Radiation Oncology; Massachusetts General Hospital; Boston Massachusetts
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Damato AL, Townamchai K, Albert M, Bair RJ, Cormack RA, Jang J, Kovacs A, Lee LJ, Mak KS, Mirabeau-Beale KL, Mouw KW, Phillips JG, Pretz JL, Russo AL, Lewis JH, Viswanathan AN. Dosimetric consequences of interobserver variability in delineating the organs at risk in gynecologic interstitial brachytherapy. Int J Radiat Oncol Biol Phys 2014; 89:674-81. [PMID: 24803035 DOI: 10.1016/j.ijrobp.2014.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 02/26/2014] [Accepted: 03/05/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE To investigate the dosimetric variability associated with interobserver organ-at-risk delineation differences on computed tomography in patients undergoing gynecologic interstitial brachytherapy. METHODS AND MATERIALS The rectum, bladder, and sigmoid of 14 patients treated with gynecologic interstitial brachytherapy were retrospectively contoured by 13 physicians. Geometric variability was calculated using κ statistics, conformity index (CIgen), and coefficient of variation (CV) of volumes contoured across physicians. Dosimetric variability of the single-fraction D0.1cc and D2cc was assessed through CV across physicians, and the standard deviation of the total EQD2 (equivalent dose in 2 Gy per fraction) brachytherapy dose (SD(TOT)) was calculated. RESULTS The population mean ± 1 standard deviation of κ, CIgen, and volume CV were, respectively: 0.77 ± 0.06, 0.70 ± 0.08, and 20% ± 6% for bladder; 0.74 ± 06, 0.67 ± 0.08, and 20% ± 5% for rectum; and 0.33 ± 0.20, 0.26 ± 0.17, and 82% ± 42% for sigmoid. Dosimetric variability was as follows: for bladder, CV = 31% ± 19% (SD(TOT) = 72 ± 64 Gy) for D0.1cc and CV = 16% ± 10% (SD(TOT) = 9 ± 6 Gy) for D2cc; for rectum, CV = 11% ± 5% (SD(TOT) = 16 ± 17 Gy) for D0.1cc and CV = 7% ± 2% (SD(TOT) = 4 ± 3 Gy) for D2cc; for sigmoid, CV = 39% ± 28% (SD(TOT) = 12 ± 18 Gy) for D0.1cc and CV = 34% ± 19% (SD(TOT) = 4 ± 4 Gy) for D2cc. CONCLUSIONS Delineation of bladder and rectum by 13 physicians demonstrated substantial geometric agreement and resulted in good dosimetric agreement for all dose-volume histogram parameters except bladder D0.1cc. Small delineation differences in high-dose regions by the posterior bladder wall may explain these results. The delineation of sigmoid showed fair geometric agreement. The higher dosimetric variability for sigmoid compared with rectum and bladder did not correlate with higher variability in the total brachytherapy dose but rather may be due to the sigmoid being positioned in low-dose regions in the cases analyzed in this study.
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Affiliation(s)
- Antonio L Damato
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts.
| | - Kanopkis Townamchai
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Michele Albert
- Department of Radiation Oncology, Saint Anne's Hospital Regional Cancer Center, Fall River, Massachusetts
| | - Ryan J Bair
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Robert A Cormack
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Joanne Jang
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Arpad Kovacs
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Larissa J Lee
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Kimberley S Mak
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | | | - Kent W Mouw
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - John G Phillips
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - Jennifer L Pretz
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - Andrea L Russo
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts
| | - John H Lewis
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts
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Damato AL, Viswanathan AN, Cormack RA. Validation of mathematical models for the prediction of organs-at-risk dosimetric metrics in high-dose-rate gynecologic interstitial brachytherapy. Med Phys 2014; 40:101711. [PMID: 24089901 DOI: 10.1118/1.4819946] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Given the complicated nature of an interstitial gynecologic brachytherapy treatment plan, the use of a quantitative tool to evaluate the quality of the achieved metrics compared to clinical practice would be advantageous. For this purpose, predictive mathematical models to predict the D2cc of rectum and bladder in interstitial gynecologic brachytherapy are discussed and validated. METHODS Previous plans were used to establish the relationship between D2cc and the overlapping volume of the organ at risk with the targeted area (C0) or a 1-cm expansion of the target area (C1). Three mathematical models were evaluated: D2cc = α*C1 + β (LIN); D2cc = α - exp(-β*C0) (EXP); and a mixed approach (MIX), where both C0 and C1 were inputs of the model. The parameters of the models were optimized on a training set of patient data, and the predictive error of each model (predicted D2cc - real D2cc) was calculated on a validation set of patient data. The data of 20 patients were used to perform a K-fold cross validation analysis, with K = 2, 4, 6, 8, 10, and 20. RESULTS MIX was associated with the smallest mean prediction error <6.4% for an 18-patient training set; LIN had an error <8.5%; EXP had an error <8.3%. Best case scenario analysis shows that an error ≤ 5% can be achieved for a ten-patient training set with MIX, an error ≤ 7.4% for LIN, and an error ≤ 6.9% for EXP. The error decreases with the increase in training set size, with the most marked decrease observed for MIX. CONCLUSIONS The MIX model can predict the D2cc of the organs at risk with an error lower than 5% with a training set of ten patients or greater. The model can be used in the development of quality assurance tools to identify treatment plans with suboptimal sparing of the organs at risk. It can also be used to improve preplanning and in the development of real-time intraoperative planning tools.
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Affiliation(s)
- Antonio L Damato
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts 02115
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Chen X, Egger J. Development of an open source software module for enhanced visualization during MR-guided interstitial gynecologic brachytherapy. SPRINGERPLUS 2014; 3:167. [PMID: 24790816 PMCID: PMC4004789 DOI: 10.1186/2193-1801-3-167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 01/02/2014] [Indexed: 11/17/2022]
Abstract
In 2010, gynecologic malignancies were the 4th leading cause of death in U.S. women and for patients with extensive primary or recurrent disease, treatment with interstitial brachytherapy may be an option. However, brachytherapy requires precise insertion of hollow catheters with introducers into the tumor in order to eradicate the cancer. In this study, a software solution to assist interstitial gynecologic brachytherapy has been investigated and the software has been realized as an own module under (3D) Slicer, which is a free open source software platform for (translational) biomedical research. The developed research module allows on-time processing of intra-operative magnetic resonance imaging (iMRI) data over a direct DICOM connection to a MR scanner. Afterwards follows a multi-stage registration of CAD models of the medical brachytherapy devices (template, obturator) to the patient’s MR images, enabling the virtual placement of interstitial needles to assist the physician during the intervention.
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Affiliation(s)
- Xiaojun Chen
- Institute of Biomedical Manufacturing and Life Quality Engineering, School of Mechanical engineering, Shanghai Jiao Tong University, Dong Chuan Road 800, Shanghai, Post Code: 200240 China
| | - Jan Egger
- Department of Medicine, University Hospital of Giessen and Marburg (UKGM), Baldingerstraße, Marburg, 35043 Germany
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