Intraoperative high-dose-rate brachytherapy

Primary peritoneal clear cell carcinoma treated with IMRT and interstitial HDR brachytherapy: a case report

Primary peritoneal clear cell carcinoma (PP‐CCC), which is a rare tumor with poor prognosis, is typically managed with surgery and/or chemotherapy. We present a unique treatment approach for a patient with a pelvic PP‐CCC, consisting of postchemotherapy intensity‐modulated radiation therapy (IMRT) followed by interstitial high‐dose–rate (HDR) brachytherapy. A 54‐year‐old female with an inoperable pelvic‐supravaginal 5.6 cm T3N0M0 PP‐CCC tumor underwent treatment with 6 cycles of carboplatin and taxol chemotherapy. Postchemotherapy PET/CT scan revealed a residual 3.3 cm tumor. The patient underwent CT and MR planning simulation, and was treated with 50 Gy to the primary tumor and 45 Gy to the pelvis including the pelvic lymph nodes, using IMRT to spare bowel. Subsequently, the patient was treated with an interstitial HDR brachytherapy implant, planned using both CT and MR scans. A total dose of 15 Gy in 5 Gy fractions over two days was delivered with Ir‐192 HDR brachytherapy. The total prescribed equivalent 2 Gy dose (EQD2) to the HDR planning target volume (PTV) from both the EBRT and HDR treatments ranged between 63 and 68.8Gy2 due to differential dosing of the primary and pelvic targets. The patient tolerated radiotherapy well, except for mild diarrhea not requiring medication. There was no patient‐reported acute toxicity one month following the radiotherapy course. At four months following adjuvant radiation therapy, the patient had near complete resolution of local tumor on PET/CT without any radiation‐associated toxicity. However, the patient was noted to have metastatic disease outside of the radiation field, specifically lesions in the liver and bone. This case report illustrates the feasibility of the treatment of a pelvic PP‐CCC with IMRT followed by interstitial HDR brachytherapy boost, which resulted in near complete local tumor response without significant morbidity.

PACS number: 87.55.‐x

Surgery combined with brachytherapy in patients with retroperitoneal sarcomas

Purpose

The primary aim of this work was to analyze feasibility of combined treatment of retroperitoneal sarcomas (RS): surgery (S) and intraoperative brachytherapy (IOBRT). The secondary aim was to analyze results and complications after this treatment.

Material and methods

84 patients with retroperitoneal sarcomas were qualified for combined treatment (S and IOBRT) between June 1998 and September 2006. 65 of the patients (77.4%) had local recurrences. Sarcomas with intermediate and high grade of histological malignancy (G2, G3 – 76.2%) were the most frequent within the all surgically treated patients. Resection ability (R0/R1) in analyzed group of patients was estimated as 85% (74 cases). After intraoperative evaluation, 57 (67.8%) patients were qualified for IOBRT. Since 2000, in 34 patients (60%) an adjuvant postoperative external beam radiation therapy (EBRT) in dose of 50 Gy was applied. Median follow-up of the surviving patients was 40 months.

Results

On the basis of the univariate analysis, relevant aspects negatively influencing overall survival rate within the RS group treated with IOBRT were as follows: surgery of sarcoma recurrence (p = 0.002), higher grade of histological malignancy (p = 0.05), histological type different than liposarcoma (p = 0.05) as well as no adjuvant EBRT (p = 0.05). On the basis of multivariate analysis one can ascertain that relevant factors negatively influencing LRFS in RS patients treated with IOBRT were: surgery due to recurrence of sarcoma (p = 0.008) and lack of EBRT (p = 0.01).

Conclusions

Combined treatment (surgery and brachytherapy) was possible to be carried out on 68% of RS patients. The overall number of complications was quite high, however acceptable, taking into consideration the application of extensive, multi-organ treatments in case of sarcoma recurrences in this localization. The results suggest that the method of treatment will improve the final outcome when most of patients will be qualified for treatment of primary sarcomas in experienced centre.

Surgery Combined With Intraoperative Brachytherapy in the Treatment of Retroperitoneal Sarcomas

BACKGROUND

The purpose of this study was to analyze the results of treatment of retroperitoneal soft tissue sarcomas (RSTS) by surgery combined with intraoperative brachytherapy (IOBRT).

METHODS

Seventy adult patients with RSTS were considered for combined treatment (surgery plus IOBRT) between June 1998 and February 2004. There were 64 (91%) recurrent tumors, and 93% of tumors exceeded 5 cm. IOBRT was performed with high-dose-rate Gammamed 12 with iridium 192 (IOBRT time range, 20-87 minutes; median, 56 minutes).

RESULTS

After intraoperative re-evaluation, 24 patients (34%) were found to be ineligible for IOBRT because of multiple intraperitoneal recurrences, macroscopically nonradical resection, poor general condition, and technical aspects. Thirty-seven patients underwent IOBRT immediately after surgery during the same general anesthesia procedure. Nine patients underwent delayed IOBRT within 1 to 3 days after the primary operation. Ten (21.5%) of 46 patients underwent reoperation because of surgical complications. One patient died in the postoperative period. After IOBRT, 24 patients (52%) underwent adjuvant external beam radiotherapy (EBRT) to a total dose of 50 Gy. Over a median follow-up time of 20 months, the estimated 5-year overall survival and local recurrence-free survival rates in IOBRT patients were 55% and 51%, respectively. Application of adjuvant EBRT showed a favorable local control rate.

CONCLUSIONS

The scheduled combined treatment (surgery plus IOBRT) was possible to perform in 66% of RSTS cases that received surgical treatment. The complication rate was high, but we consider it acceptable because of the necessity for extensive aggressive surgical treatment in regionally advanced RSTS. EBRT seems to be an indispensable part of treatment that provides better local control.

High dose rate brachytherapy: its clinical applications and treatment guidelines

Brachytherapy has the advantage of delivering a high dose to the tumor while sparing the surrounding normal tissues. With proper case selection and delivery technique, high-dose-rate (HDR) brachytherapy has great promise, because it eliminates radiation exposure, allows short treatment times, and can be performed on an outpatient basis. Additionally, use of a single-stepping source, allows optimization of dose distribution by varying the dwell time at each dwell position. However, when HDR brachytherapy is used, the treatments must be executed carefully, because the short treatment times do not allow any time for correction of errors, and mistakes can result in harm to patients. Hence, it is very important that all personnel involved in HDR brachytherapy be well trained and be constantly alert. It is expected that the use of HDR brachytherapy will greatly expand over the next decade and that refinements will occur primarily in the integration of imaging (computed tomography, magnetic resonance imaging, intraoperative ultrasonography) and optimization of dose distribution. It is anticipated that better tumor localization and normal tissue definition will help to optimize dose distribution to the tumor and reduce normal tissue exposure. The development of well-controlled randomized trials addressing issues of efficacy, toxicity, quality of life, and costs-versus-benefits will ultimately define the role of HDR brachytherapy in the therapeutic armamentarium.