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Venner EK, Ward KA, Wages NA, Walker B, Libby BP, Showalter TN, Romano KD. Evaluating the relationship between vaginal apex "dog ears" and patterns of recurrence in endometrial cancer following adjuvant image guided vaginal cuff brachytherapy. Brachytherapy 2023; 22:139-145. [PMID: 36414525 DOI: 10.1016/j.brachy.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this investigation is to characterize vaginal apex "dog ears" and their association with patterns of treatment failure in patients with endometrial cancer treated with adjuvant high-dose-rate (HDR) single-channel vaginal cuff brachytherapy (VCB). METHODS A retrospective review of patients treated with HDR VCB from 2012 to 2021 for medically operable endometrial cancer at a single institution was conducted. Dog ears, defined as tissue at the apex extending at least 10 mm from the brachytherapy applicator were identified on CT simulation images. Fisher exact test and a multivariate logistic regression model evaluated the association between factors of interest with treatment failure. Vaginal cuff failure free survival (VCFFS) was calculated from first brachytherapy to vaginal cuff recurrence (VCR). RESULTS A total of 219 patients were reviewed. In this sample, 57.5% of patients met criteria for having dog ears. In total, 13 patients (5.9%) developed a VCR. There was no statistically significant difference in the rate of VCR between patients with and without dog ears (7.1% vs. 4.3%, p = 0.56). There was a trend toward increased risk of recurrence with higher grade histology identified in the multivariate logistic regression model (p = 0.085). The estimated 3-year probability of VCFFS was 86%. CONCLUSIONS Vaginal apex dog ears are prevalent but are not found to statistically increase the risk of VCR after VCB in our single institution experience. However, while local failure remains low in this population, we report an absolute value of over twice as many VCRs in patients with dog ears, indicating that with improved dog ear characterization this may remain a relevant parameter for consideration in treatment planning.
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Affiliation(s)
- Emily K Venner
- University of Virginia School of Medicine, Charlottesville, VA
| | - Kristin A Ward
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Nolan A Wages
- University of Virginia, Department of Public Health Sciences, Charlottesville, VA
| | - Bryant Walker
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Bruce P Libby
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL
| | - Timothy N Showalter
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Kara D Romano
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA.
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Manufacturing and evaluation of multi-channel cylinder applicator with 3D printing technology. J Contemp Brachytherapy 2021; 13:80-90. [PMID: 34025740 PMCID: PMC8117717 DOI: 10.5114/jcb.2021.103590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 12/14/2020] [Indexed: 11/17/2022] Open
Abstract
Purpose This study was designed to assess dosimetric characteristics of 3D-printed personalized multi-channel cylinder applicator (MCCA). Material and methods UnionTech RS Pro 600 (UnionTech, Inc., Shanghai, China) 3D printer was used for manufacturing MCCA. The geometry of MCCA was designed with Fusion 360 v.2.0.5827 (Autodesk, Inc.) software. The designed file was exported to Meshmixer v.3.5 (Autodesk, Inc.) to create three-dimensional model in stereolithography (STL) file format, which is the common file format for inputting data to 3D printers. We used high-temp resin, FLHTAM02 model (Formlabs Inc., MA, USA), as material in 3D printing process. This resin model has good resistance to high temperature and compatibility with various solvents. We created a simple cubic shape phantom for dosimetric evaluation of the applicator with Gafchromic EBT3 films. Also, Monte Carlo method was applied to simulate MCCA in the same configuration as in experimental test. Results The mean ± standard deviation (SD) difference between measured and calculated doses in treatment planning system (TPS) for all control points was 0.0860 ±0.0393 Gy, corresponding to 4.01 ±1.21%. The mean ±SD difference between doses calculated by Monte Carlo simulation and TPS for all control points was 0.0996 ±0.0471 Gy, corresponding to 4.58 ±1.05%. The mean ±SD of dose difference between film measurement and Monte Carlo simulation for all control points was 0.0136 ±0.0200 Gy, corresponding to 0.60 ±0.69%. P-value for dose difference between film measurement and TPS, Monte Carlo and TPS, and film measurement and Monte Carlo were 0.7, 0.66, and 0.95, respectively. Conclusions Dosimetric results and mechanical accuracy of MCCA show that high-temp resin with SLA 3D printing technique can be used for producing patient-specific MCCA in brachytherapy.
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Outcomes of intermediate-risk to high-risk stage I endometrial cancer: 10-year clinical experiences of using in-house multi-channel applicators in a single center. Chin Med J (Engl) 2020; 132:1935-1941. [PMID: 31365429 PMCID: PMC6708688 DOI: 10.1097/cm9.0000000000000382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution. METHODS Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate. RESULTS Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4-172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131-1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347-0.958, P = 0.026,). CONCLUSIONS For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.
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Development and preclinical testing of a novel biodegradable hydrogel vaginal packing technology for gynecologic high-dose-rate brachytherapy. J Contemp Brachytherapy 2018; 10:306-314. [PMID: 30237814 PMCID: PMC6142653 DOI: 10.5114/jcb.2018.77952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/06/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose We evaluated the performance of a novel hydrogel-based strategy developed for clinical use as vaginal packing using phantoms and cadavers, and to compare the hydrogel to gauze and balloon packing. Material and methods The biocompatible hydrogel is based on a thiol-Michael addition reaction, with delivery of reagents into the vaginal cavity using a custom-made system. Soft-cured cadavers were used for soft tissue-like mechanical properties. Two cadavers with intact uteri had magnetic resonance imaging (MRI) compatible with tandem and ovoids. For one cadaver, the temperature of the vaginal canal was measured before hydrogel application, during polymerization, and after hydrogel removal. The hydrogel packing and applicator was kept in a second cadaver, which was imaged using computed tomography (CT) and MRI. The hydrogel packing and imaging was repeated for an open multichannel MRI compatible, titanium-based vaginal cylinder placed in a post-hysterectomy cadaver. Results The gel reaction occurred within 90 seconds, indicating polymerization at clinical quantities with a 5°C increase in vaginal temperature. CT and MRI imaging identified the hydrogel readily and showed a conformance to anatomy with few air pockets. The entire hydrogel packing was readily retrieved upon completion of imaging. Conclusions The novel strategy for polyethylene glycol (PEG)-based hydrogel intra-vaginal packing was able to rapidly polymerize in human cadavers with minimal heat production. Delivery was efficient and able to fill the contours of the vaginal cavity and displace tissue away from the applicator axis. The hydrogel has favorable imaging characteristics on CT and MRI, and shows a potential for clinical use, warranting additional studies for the use in humans.
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Crowe SB, Pross Z, Nilsson S, Dawes J, Kairn T, Lancaster CM. Characterisation of radiological properties of a brachytherapy moulding material. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2018; 41:731-737. [PMID: 30128906 DOI: 10.1007/s13246-018-0673-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 08/09/2018] [Indexed: 11/24/2022]
Abstract
The use of a non-water-equivalent personalised mould for gynaecological brachytherapy treatments can result in a substantial dose reduction at the treatment site, compared to calculated dose, in lieu of a dose calculation algorithm capable of modelling non-water-equivalent materials. This study describes the characterisation of the radiological properties of a brachytherapy applicator moulding material. Simple line source correction factors for an 192Ir source are obtained through Monte Carlo simulations and verified by film measurements. The dwell position corrections are used to estimate aggregate correction factors for dose deliveries that involve multiple dwell positions, in terms of treatment length, applicator radii and depth of reference dose. For the Fricotan moulding material used locally, the dose reductions varied from 1% for an applicator radius of 0.5 cm to > 4% for radii exceeding 2 cm. The method described in this paper could be used to develop correction factors for other non-water-equivalent moulding materials, in a TG-43UI dose calculation environment.
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Affiliation(s)
- Scott B Crowe
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Australia. .,Queensland University of Technology, Brisbane, Australia.
| | - Zac Pross
- Queensland University of Technology, Brisbane, Australia
| | - Sanna Nilsson
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick, Australia
| | - Jodi Dawes
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Tanya Kairn
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Queensland University of Technology, Brisbane, Australia
| | - Craig M Lancaster
- Cancer Care Services, Royal Brisbane & Women's Hospital, Brisbane, Australia
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Sabater S, Andres I, Lopez-Honrubia V, Berenguer R, Sevillano M, Jimenez-Jimenez E, Rovirosa A, Arenas M. Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment? Cancer Manag Res 2017; 9:351-362. [PMID: 28848362 PMCID: PMC5557121 DOI: 10.2147/cmar.s119125] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.
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Affiliation(s)
- Sebastià Sabater
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Ignacio Andres
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | - Roberto Berenguer
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Marimar Sevillano
- Department of Radiation Oncology, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | | | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan, Reus, Spain
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Binny D, Lancaster CM, Kairn T, Trapp JV, Back P, Cheuk R, Crowe SB. Investigating the use of image thresholding in brachytherapy catheter reconstruction. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2016; 39:913-919. [PMID: 27787758 DOI: 10.1007/s13246-016-0493-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022]
Abstract
This study evaluated the accuracy of image thresholding in the reconstruction of catheters in brachytherapy treatment planning systems. Six test cases including four planar catheter configurations, an interstitial prostate and an intracavitary treatment plan were made use of in this study. The four planar CT scanned catheter arrangements included; catheters placed approximately 1, 0.5 cm apart, catheters closely arranged in a plan (<0.5 cm apart) and a loop arrangement. The intracavitary plan consisted of catheters arranged inside a mould configuration. All reconstruction methods were based on tracking wire markers placed inside the plastic catheters. Each of these catheter arrangements was reconstructed using an existing window adjustment technique (manual reconstruction) in the treatment planning system followed by a CT-based automated thresholding technique available in the same planning system. A corresponding reconstructed catheter was created using a segmented catheter structure using image thresholding from another planning system within the same department. Co-ordinates from all the reconstructed catheters were compared against each other to assess the geometric shift between manual and threshold based reconstruction on each transaxial image using in-house software and the maximum variations were recorded for assessment. It was observed in general that automated thresholding technique could assist in catheter reconstruction for catheters which are greater than 0.5 cm apart. The segmented thresholding method reported smaller variations when compared to the manual reconstruction using window adjustment technique. Automated reconstruction saves time in the brachytherapy planning, however it was noted that it is not feasible for closely spaced catheters. Segmented catheter reconstruction although time consuming, did provide a better alternative in most cases.
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Affiliation(s)
- Diana Binny
- Department of Radiation Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Level 3, Joyce Tweddell Building, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia. .,Queensland University of Technology, Brisbane, Australia.
| | - Craig M Lancaster
- Department of Radiation Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Level 3, Joyce Tweddell Building, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Tanya Kairn
- Queensland University of Technology, Brisbane, Australia.,Genesis Cancer Care Queensland, Brisbane, Australia
| | - Jamie V Trapp
- Queensland University of Technology, Brisbane, Australia
| | - Phil Back
- Department of Radiation Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Level 3, Joyce Tweddell Building, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Robyn Cheuk
- Department of Radiation Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Level 3, Joyce Tweddell Building, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia
| | - Scott B Crowe
- Department of Radiation Oncology, Cancer Care Services, Royal Brisbane and Women's Hospital, Level 3, Joyce Tweddell Building, Butterfield Street, Herston, Brisbane, QLD, 4029, Australia.,Queensland University of Technology, Brisbane, Australia
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