Prospective comparison of rectal dose reduction during intracavitary brachytherapy for cervical cancer using three rectal retraction techniques

Effect of the ACY-1 gene on HER2 and TRAIL expression in rectal carcinoma

The incidence of rectal carcinoma (RC) is increasing and the age at onset of the disease is reducing. Therefore, elucidating the pathogenesis of RC is beneficial for early diagnosis and improving the prognosis. Aminoacylase-1 (ACY-1) is abnormally expressed in various malignant tumor tissues. Furthermore, the human epidermal growth factor receptor-2 (HER2) gene is involved in tumor metastasis and invasion, while tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces tumor cell apoptosis. The aim of the present study was to investigate the effect of the ACY-1 gene on the expression of HER2 and TRAIL in RC. Cancerous and adjacent tissues from RC patients were collected. ACY-1 expression was analyzed by immunohistochemistry. The rectal cancer cell lines HT29 and SW620, and normal colorectal mucosal epithelial fetal human cells were cultured in vitro. ACY-1 gene and protein expression levels were tested by reverse transcription-quantitative PCR and western blotting. ACY-1 small interfering RNA (siRNA) was transfected into HT29 and SW620 cells. Cell proliferation was detected by thiazolyl blue MTT assay. Caspase-3 activity was assessed using a commercial kit. HER2 and TRAIL expression levels were determined by western blotting. ACY-1 expression was significantly increased in cancer tissue compared with adjacent tissue (P<0.05). ACY-1 expression was elevated in HT29 and SW620 cells compared with normal colorectal mucosal epithelial cells (P<0.05). ACY-1 siRNA transfected into HT29 cells downregulated its expression, inhibited cell proliferation, enhanced caspase-3 activity, reduced HER2 expression and upregulated TRAIL expression (P<0.05). ACY-1 expression was found to be increased in rectal cancer tissue. Therefore, targeting the ACY-1 gene may regulate HER2 and TRAIL expression levels, and may reduce the occurrence and inhibit the development of rectal cancer.

Dosimetric comparison of two different applicators and rectal retraction methods used in inverse optimization-based intracavitary brachytherapy for cervical cancer

Purpose

The purpose of this study was to evaluate the dosimetric differences between two different applicators and rectal-retraction methods used in image-guided brachytherapy (IGBT) for locally advanced cervical cancer (LACC).

Material and methods

Ten patients with LACC treated with definitive chemoradiotherapy and inverse optimization-based IGBT were included in this study. In each patient, at least one fraction of IGBT was performed using tandem-ovoids (TO) with vaginal gauze packing (VGP) or tandem-ring (TR) with rectal-retractor (RR). High-risk clinical target volume (CTV_HR) and intermediate-risk CTV (CTV_IR) were defined as CTVs, and bladder, rectum, sigmoid, small bowel, urethra, and vaginal mucosa were defined as organs at risk (OARs). All patients received 50.4 Gy external beam radiotherapy (EBRT) in 28 fractions. After EBRT, 28 Gy high-dose-rate (HDR) IGBT in 4 fractions was delivered to central disease. A plan comparison was performed using dose-volume histogram (DVH) and treatment planning parameters for CTVs and OARs.

Results

There were no significant differences in D₉₀ values of CTV_HR. In terms of rectum dose, TR with RR was found to be significantly better than TO with VGP (p < 0.0001 for D_2cm3 and p < 0.013 for V_5Gy). Although, there were no statistically significant differences in D_2cm3 value of bladder, sigmoid, small bowel, upper vaginal mucosa, and urethra, mean value of D_2cm3 for all defined OARs were found lower in TR than in TO. Bladder V_7Gy, upper vaginal mucosa V_7Gy, middle and lower vaginal mucosa D_2cm3 values were all found to be significantly lower for TR than for TO (p < 0.035). CTV_HR and CTV_IR volumes contoured in TR were approximately 11% and 9% smaller than TO, respectively.

Conclusions

The results showed that there were no statistically differences in D₉₀ value of CTV_HR and CTV_IR. However, all DVH parameters for OARs in TR with RR were found to be better than in TO with VGP.

Clinical analysis of speculum-based vaginal packing for high-dose-rate intracavitary tandem and ovoid brachytherapy in cervical cancer

Purpose

Intra-vaginal packing is used to fix the applicator and displace organs at risk (OAR) during high-dose-rate intracavitary tandem and ovoid brachytherapy (HDR-ICB). We retain the speculum from applicator placement as a dual-function bladder and rectum retractor during treatment. Our objective is to review salient techniques for OAR displacement, share our packing technique, and determine the reduction in dose to OAR and inter-fraction variability of dose to OAR, associated with speculum-based vaginal packing (SBVP) in comparison to conventional gauze packing during HDR-ICB.

Material and methods

We reviewed HDR-ICB treatment plans for 45 patients, including 10 who underwent both conventional gauze packing and SBVP. Due to institutional inter-provider practice differences, patients non-selectively received either packing procedure. Packing was performed under conscious sedation, followed by cone beam computed tomography used for dosimetric planning. Maximum absolute and percent-of-prescription dose to the International Commission of Radiation Units bladder and rectal points in addition to D_0.1cc, D_1.0cc, and D_2.0cc volumes of the bladder and rectum were analyzed and compared for each packing method using an independent sample t-test.

Results

Of the 179 fractions included, 73% and 27% used SBVP and gauze packing, respectively. For patients prescribed 6 Gy to point A, SBVP was associated with reduced mean D_0.1cc bladder dose, inter-fraction variability in D_0.1cc bladder dose by 9.3% (p = 0.026) and 9.0%, respectively, and statistically equivalent rectal D_0.1cc, D_1.0cc, and D_2.0cc. Patients prescribed 5.5 Gy or 5 Gy to point A after dose optimization, were less likely to benefit from SBVP. In the intra-patient comparison, 80% of patients had reduction in at least one rectum or bladder parameter.

Conclusions

In patients with conducive anatomy, SBVP is a cost-efficient packing method that is associated with improved bladder sparing and comparable rectal sparing relative to gauze packing during HDR-ICB without general anesthesia.