1
|
Isohashi F, Yoshida K, Murakami N, Masui K, Ishihara S, Ohkubo Y, Kaneyasu Y, Kinoshita R, Kotsuma T, Takaoka Y, Tanaka E, Nagao A, Ogawa K, Yamazaki H. Reirradiation for recurrent gynecologic cancer using high-dose-rate brachytherapy in Japan: A multicenter survey on practice patterns and outcomes. Radiother Oncol 2024; 195:110269. [PMID: 38583719 DOI: 10.1016/j.radonc.2024.110269] [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: 11/09/2023] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND AND PURPOSE The aim of the study is to examine the present status of reirradiation with high-dose-rate (HDR) brachytherapy for recurrent gynecologic cancer in Japan and to determine the role of this therapy in clinical practice. MATERIALS AND METHODS A retrospective multicenter chart review was performed for reirradiation for gynecologic cancer using HDR brachytherapy. Each center provided information on patient characteristics, treatment outcomes, and complications. RESULTS The study included 165 patients treated at 9 facilities from 2000 to 2018. The analysis of outcomes included 142 patients treated with curative intent. The median follow-up time for survivors was 30 months (range 1-130 months). The 3-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 53 % (95 %CI: 42-63 %), 44 % (35-53 %), and 61 % (50-70 %) for cervical cancer; 100 % (NA), 64 % (30-85 %), and 70 % (32-89 %) for endometrial cancer; and 54 % (13-83 %), 38 % (6-72 %), and 43 % (6-78 %) for vulvar and vaginal cancer, respectively. In multivariate analysis, interval to reirradiation (<1 year) was a significant risk factor for OS, PFS and LC; Gross Tumor Volume (≥25 cm3) was a significant risk factor for OS. Toxicities were analyzed in all enrolled patients (n = 165). Grade ≥ 3 late toxicities occurred in 49 patients (30 %). A higher cumulative EQD2 (α/β = 3) was significantly associated with severe complications. CONCLUSION Reirradiation with HDR brachytherapy for recurrent gynecologic cancer is effective, especially in cases with a long interval before reirradiation.
Collapse
Affiliation(s)
- Fumiaki Isohashi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Radiation Oncology, Nara Medical University, Kashihara, Nara, Japan.
| | - Ken Yoshida
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan; Department of Radiation Oncology, Juntendo University, Hongo, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shunichi Ishihara
- Department of Radiology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan; Department of Radiology, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Yu Ohkubo
- Department of Radiation Oncology, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organization Fukuyama Medical Center, Fukuyama, Hiroshima, Japan; Department of Radiation Oncology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi, Hiroshima, Japan
| | - Rumiko Kinoshita
- Department of Radiation Oncology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiation Oncology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Yuji Takaoka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan; Department of Radiology, Saito Yukoukai Hospital, Ibaraki, Osaka, Japan
| | - Eiichi Tanaka
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji, Tokyo, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hideya Yamazaki
- Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
2
|
Takatsu J, Murakami N, Muramoto Y, Karino T, Oshima M, Kosugi Y, Kawamoto T, Terao Y, Shikama N. Safe dose escalation and reduction of the fraction number of uterine cervical brachytherapy using a gel spacer in the rectovaginal and vesicouterine septum: A planning study. Brachytherapy 2024; 23:115-122. [PMID: 38040605 DOI: 10.1016/j.brachy.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/22/2023] [Accepted: 10/06/2023] [Indexed: 12/03/2023]
Abstract
PURPOSE To evaluate the possibility of dose escalation and reduction of fraction number in cervical brachytherapy using a gel spacer. MATERIAL AND METHODS Twenty patients with uterine cervical cancer treated with image-guided adaptive brachytherapy (IGABT) were selected. Hyaluronic acid gel injection (HGI) was performed in the rectovaginal and vesicouterine septum for 10 patients. The other ten patients were not with HGI. Both groups were treated with IGABT involving tandem/ovoid or cylindrical applicators along with additional interstitial needles. Dose distributions approved by radiation oncologists were retrospectively analyzed, and a dose summation of 45 Gy/25 of external beam radiation therapy and IGABT was performed. Dose constraints for D2cc of bladder, rectum, and sigmoid were 80, 70, and 70 Gy, respectively. Equivalent dose in 2-Gy fractions calculations used α/β = 10 Gy for high-risk clinical target volume (CTVHR) D90 and α/β = 3 Gy for organs at risks (OARs). As a planning study, dose distribution rescaling was conducted to deliver as much dose to CTVHR D90 as possible within the dose constraint limitation for OARs when IGABT was performed for four, three, and two fractions in both groups. RESULTS The median CTVHR D90 was >80 Gy in the non-HGI group and >85 Gy in the HGI group for virtual two and three fractions. Rectum D2cc was significantly lower in the HGI group for three fractions (p < 0.01). CONCLUSIONS In the HGI group, adequate dose delivery to CTVHR could be achieved with a reduced IGABT fraction number while meeting the dose constraints of OARs.
Collapse
Affiliation(s)
- Jun Takatsu
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan.
| | - Yoichi Muramoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Faculty of Medicine, Juntendo University, Tokyo, Japan
| |
Collapse
|
3
|
Nakahara M, Murakami N, Chiba T, Nagao A, Okuma K, Kashihara T, Kaneda T, Takahashi K, Inaba K, Nakayama Y, Kato T, Igaki H. Gynecological technical notes for appropriate spacer injections. Brachytherapy 2024; 23:45-51. [PMID: 38040606 DOI: 10.1016/j.brachy.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/01/2023] [Accepted: 09/27/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Despite its efficacy, if adherence to dose constraints for surrounding normal tissues proves unattainable, the risk of late radiation-related adverse events after primary radiotherapy involving brachytherapy remains a noteworthy concern. Some studies suggest that similar to prostate radiotherapy, spacers may potentially reduce doses to surrounding healthy rectal or bladder tissues. However, guidance on spacer injections for gynecologic brachytherapy is scarce, and the optimal anatomical location for spacer placement remains undefined. We discuss maximizing the effects of spacers from an anatomical perspective. FINDINGS As vesicovaginal and rectovaginal septa form part of the endopelvic fascia and are not uniform tissues, spacer injection resistance varies. In pelvic organ prolapse surgery, saline is injected into the anterior and posterior vaginal walls as a spacer, and the vagina, vesicovaginal septum, and bladder can be fluidly dissected. Relatively firm vesicovaginal septum tissue is used as a reconstructive organ, whereas rectovaginal septum tissue is less dense. Cervical cancer is invasive, involving surrounding fascia and ligaments. Ideally, the vesicovaginal and rectovaginal septa should be resected in radical hysterectomy. Here, spacer adaptation and the technical details of injection are described. When using ultrasound guidance for spacer injection, the target site should be adequately magnified, and the spacer ideally injected into the incision layer during radical hysterectomy. Finally, posthysterectomy, the intestinal tract may adhere to the vaginal cuffs. Therefore, artificial ascites may be useful; however, the spread depends on perioperative manipulation. CONCLUSIONS Anatomical and surgical viewpoints are advantageous for safe, therapeutic, and replicable spacer injection administration.
Collapse
Affiliation(s)
- Mariko Nakahara
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan.
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan; Department of Radiation Oncology, Juntendo University Graduate School of Medicine, Bunkyo-ku, Japan
| | - Takahito Chiba
- Section of Radiation Safety and Quality Assurance, National Cancer Center Hospital, Tokyo, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
4
|
Sakuramachi M, Murakami N, Nagao A, Kojima K, Miyata Y, Kashihara T, Kaneda T, Takahashi K, Inaba K, Okuma K, Nakayama Y, Okamoto H, Ishikawa M, Igaki H. Hydrogel spacer injection to the meso-sigmoid to protect the sigmoid colon in cervical cancer brachytherapy: A technical report. J Contemp Brachytherapy 2023; 15:465-469. [PMID: 38230404 PMCID: PMC10789158 DOI: 10.5114/jcb.2023.134174] [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: 09/07/2023] [Accepted: 12/17/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose The use of a hydrogel spacer inserted into recto-vaginal fossa is a valuable strategy to mitigate radiation exposure to the rectum during radiation therapy for female pelvic malignancies. However, when the sigmoid colon is in proximity to the cervix, radiation exposure to the sigmoid colon cannot be adequately mitigated with a hydrogel spacer injected into the recto-vaginal fossa. Here, we presented a case, in which a hydrogel spacer was injected into the meso-sigmoid to protect the sigmoid colon. Material and methods A 73-year-old female diagnosed with T3b stage IIIC2r uterine cervical cancer (FIGO 2018) underwent high-dose-rate interstitial brachytherapy consisting of 24 Gy in 4 fractions, following concurrent chemoradiotherapy with external beam radiation therapy of 50 Gy in 25 fractions of whole pelvic radiation therapy. In the initial brachytherapy, the sigmoid colon was in close contact with the uterine cervix. In the second brachytherapy, attempts to create a space between the sigmoid colon and uterine cervix using injected artificial ascites were unsuccessful due to rapid absorption of fluid. In the third and fourth brachytherapy fractions, 5 mL of hydrogel was injected into the meso-sigmoid through a pouch of Douglas under trans-rectal ultrasonography guidance. Dose ratio of sigmoid colon D2cc and high-risk clinical target volume (HR-CTV) D90 of each brachytherapy were evaluated. Results Dose ratio of the sigmoid colon D2cc to HR-CTV D90 was 1.03, 0.43, 0.56, and 0.47 in each respective brachytherapy session, indicating dose escalation to HR-CTV whilst achieving acceptable sigmoid dose with hydrogel spacer injected into the meso-sigmoid. Conclusions The dose ratio of the sigmoid colon to HR-CTV D90 was decreased by introducing a hydrogel spacer into the meso-sigmoid. In cases where the sigmoid colon is in proximity to the cervical tumor, this novel technique can be considered to achieve better clinical outcomes.
Collapse
Affiliation(s)
- Madoka Sakuramachi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ayaka Nagao
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kanako Kojima
- Department of Radiation Oncology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yusaku Miyata
- Department of Radiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoya Kaneda
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Mitsuya Ishikawa
- Department of Gynecology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
5
|
Muramoto Y, Murakami N, Karino T, Sugimoto S, Takatsu J, Oshima M, Kosugi Y, Kawamoto T, Hirayama T, Fujino K, Terao Y, Shikama N. MucoUp® as a spacer in brachytherapy for uterine cervical cancer: A first-in-human experience. Clin Transl Radiat Oncol 2023; 42:100659. [PMID: 37519921 PMCID: PMC10372547 DOI: 10.1016/j.ctro.2023.100659] [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: 04/15/2023] [Revised: 07/03/2023] [Accepted: 07/14/2023] [Indexed: 08/01/2023] Open
Abstract
We first used MucoUp®, a hyaluronic acid used in endoscopic resection, as a spacer in brachytherapy. In five cervical cancer patients, MucoUp® insertion increased a 90% dose of the high-risk CTV to over 80 Gy while decreasing the dose of organs at risk. No related adverse events were observed.
Collapse
Affiliation(s)
- Yoichi Muramoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Tatsuki Karino
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Satoru Sugimoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Jun Takatsu
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Masaki Oshima
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuo Kosugi
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Terufumi Kawamoto
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Takashi Hirayama
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Kazunari Fujino
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Yasuhisa Terao
- Department of Obstetrics and Gynecology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, Juntendo University Hospital, 3-1-3 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan
| |
Collapse
|
6
|
Hilal L, Wu AJ, Reyngold M, Cuaron JJ, Navilio J, Romesser PB, Dreyfuss A, Yin S, Zhang Z, Bai X, Berry SL, Zinovoy M, Nusrat M, Pappou E, Zelefsky MJ, Crane CH, Hajj C. Radiation therapy for de novo anorectal cancer in patients with a history of prostate radiation therapy. Front Oncol 2022; 12:975519. [PMID: 36185296 PMCID: PMC9521738 DOI: 10.3389/fonc.2022.975519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionRadiation therapy (RT) for anorectal cancer after prior prostate cancer RT is usually avoided due to concern for complications. Data on this topic is scarce. Our aim was to evaluate tolerability, toxicity, and clinical outcomes associated with a second course of pelvic radiation in men with de novo anorectal cancers previously treated with RT for prostate cancer.Materials/methodsWe conducted a single-institution retrospective study of men treated with RT for rectal or anal cancer after prior prostate RT. Toxicity data were collected. Treatment plans were extracted to assess doses to organs at risk and target coverage. Cumulative incidence was calculated for local and distant progression. Kaplan-Meier curves were used to estimate overall survival (OS) and progression-free survival (PFS).ResultsWe identified 26 patients who received anorectal RT after prostate cancer RT: 17 for rectal cancer and 9 for anal cancer. None had metastatic disease. Prior prostate RT was delivered using low dose rate brachytherapy (LDR), external beam RT (EBRT), or EBRT + LDR. RT for rectal cancer was delivered most commonly using 50.4Gy/28 fractions (fr) or 1.5 Gy twice-daily to 30-45 Gy. The most used RT dose for anal cancer was 50Gy/25 fr. Median interval between prostate and anorectal RT was 12.3 years (range:0.5 - 25.3). 65% and 89% of rectal and anal cancer patients received concurrent chemotherapy, respectively. There were no reported ≥Grade 4 acute toxicities. Two patients developed fistulae; one was urinary-cutaneous after prostate LDR and 45Gy/25fr for rectal cancer, and the other was recto-vesicular after prostate LDR and 50Gy/25fr for anal cancer. In 11 patients with available dosimetry, coverage for anorectal cancers was adequate. With a median follow up of 84.4 months, 5-yr local progression and OS were 30% and 31% for rectal cancer, and 35% and 49% for anal cancer patients, respectively.ConclusionRT for anorectal cancer after prior prostate cancer RT is feasible but should be delivered with caution since it poses a risk of fistulae and possibly bleeding, especially in patients treated with prior LDR brachytherapy. Further studies, perhaps using proton therapy and/or rectal hydrogel spacers, are needed to further decrease toxicity and improve outcomes.
Collapse
Affiliation(s)
- Lara Hilal
- Department of Radiation Oncology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Abraham J. Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - John J. Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - John Navilio
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Paul B. Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alexandra Dreyfuss
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sean Yin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Xing Bai
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sean L. Berry
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Maliha Nusrat
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Emmanouil Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Michael J. Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Christopher H. Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- *Correspondence: Carla Hajj,
| |
Collapse
|
7
|
Murakami N, Okuma K, Kato T, Igaki H. Now is it time to implement spacers in cervical cancer brachytherapy? JOURNAL OF RADIATION RESEARCH 2022; 63:696-698. [PMID: 35726343 PMCID: PMC9303596 DOI: 10.1093/jrr/rrac031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/07/2022] [Indexed: 06/15/2023]
Abstract
Although the international study on MRI-guided brachytherapy in cervical cancer (EMBRACE-I) demonstrated excellent local control regardless of the T stage, up to 14.6% of grade 3-5 late radiation-related toxicities were observed, which is unacceptable. While the efficacy of hydrogel spacers has been established in prostate radiotherapy, its implementation speed in cervical cancer brachytherapy is relatively slow, despite the fact that several articles have reported its efficacy in cervical cancer brachytherapy. The authors believe that using a spacer in cervical cancer brachytherapy and brachytherapy for other gynecologic malignancies will reduce late radiation-related toxicity and improve patients' quality of life; therefore, its rapid implementation is required.
Collapse
Affiliation(s)
- Naoya Murakami
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan, 51-1 Tsukiji, Chuo-ku, Tokyo 104-0045,, Japan, Tel: + [81]-3-3542-2511; Fax: + [81]-3-3545-3567, E-mail:
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, 104-0045, Japan
| |
Collapse
|
8
|
Murakami N, Ando K, Murata M, Murata K, Ohno T, Aoshika T, Kato S, Okonogi N, Saito AI, Kim JY, Yoshioka Y, Sekii S, Tsujino K, Lowanichkiattikul C, Pattaranutaporn P, Kaneyasu Y, Nakagawa T, Watanabe M, Uno T, Umezawa R, Jingu K, Kanemoto A, Wakatsuki M, Shirai K, Igaki H, Itami J. An Asian multi-national multi-institutional retrospective study comparing intracavitary versus the hybrid of intracavitary and interstitial brachytherapy for locally advanced uterine cervical carcinoma. JOURNAL OF RADIATION RESEARCH 2022; 63:412-427. [PMID: 35446962 PMCID: PMC9124620 DOI: 10.1093/jrr/rrac014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 03/05/2022] [Indexed: 06/14/2023]
Abstract
This study is an international multi-institutional retrospective study comparing the clinical outcomes between intracavitary brachytherapy (ICBT) and the hybrid of intracavitary and interstitial brachytherapy (HBT) for locally advanced cervical cancer patients treated with definitive radiation therapy. Locally advanced cervical cancer, the initial size of which is larger than 4 cm and treated by concurrent chemoradiotherapy and image-guided adaptive brachytherapy, were eligible for this retrospective study. Patients who received HBT at least once were included in the HBT group, and patients who received only ICBT were included in the ICBT group. Anonymized data from 469 patients from 13 institutions in Japan, one from Korea and one from Thailand, were analyzed. Two hundred eighty and 189 patients were included in the ICBT group and the HBT group, respectively. Patients in the HBT group had more advanced stage, non-Scc histopathology, a higher rate of uterine body involvement, larger tumor at diagnosis, larger tumor before brachytherapy and a lower tumor reduction ratio. With a median follow-up of 51.3 months (2.1-139.9 months), 4-y local control (LC), progression-free survival (PFS) and overall survival (OS) for the entire patient population were 88.2%, 64.2% and 83%, respectively. The HBT group received a higher HR-CTV D90 than that of the ICBT group (68.8 Gy vs 65.6 Gy, P = 0.001). In multivariate analysis, the non-Scc histological subtype, HR-CTV D95 ≤ 60 Gy, reduction ratio ≤ 29% and total treatment time (TTT) ≥ 9 weeks were identified as the independent adverse prognostic factors for LC. Regarding LC, no difference was found between ICBT and HBT (4-y LC 89.3% vs 86.8%, P = 0.314). After adjustment for confounding factors by propensity score matching, no advantage of applying HBT was demonstrated regarding LC, PFS, or OS. Despite the fact that HBT patients had more adverse clinical factors than ICBT patients, HBT delivered a higher dose to HR-CTV and resulted in comparable LC.
Collapse
Affiliation(s)
- Naoya Murakami
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, Tokyo 104-0045, Japan. ;
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Hiroshi Igaki
- Corresponding author. Department of Radiation Oncology, National Cancer Center Hospital, Tokyo 104-0045, Japan. ;
| | | |
Collapse
|
9
|
Murakami N, Watanabe M, Uno T, Sekii S, Tsujino K, Kasamatsu T, Machitori Y, Aoshika T, Kato S, Hirowatari H, Kaneyasu Y, Nakagawa T, Ikushima H, Ando K, Murata M, Yoshida K, Yoshioka H, Murata K, Ohno T, Okonogi N, Saito A, Ichikawa M, Okuda T, Tsuchida K, Sakurai H, Yoshimura R, Yoshioka Y, Yorozu A, Okamoto H, Inaba K, Kato T, Igaki H, Itami J. Large volume was associated with increased risk of acute non-hematologic adverse events in the hybrid of intracavitary and interstitial brachytherapy for locally advanced uterine cervical cancer: preliminary results of prospective phase I/II clinical trial. Jpn J Clin Oncol 2022; 52:859-868. [PMID: 35470390 DOI: 10.1093/jjco/hyac072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/08/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This is the preliminary results of a multi-center prospective clinical trial evaluating the feasibility of the hybrid of intracavitary and interstitial brachytherapy for locally advanced cervical cancer. METHODS Patients with FIGO stage IB2, IIA2, IIB, IIIA, IIIB and IVA uterine cervical cancer pretreatment width of which was ≥5 cm measured by MRI were eligible. Protocol therapy consisted of 30-30.6 Gy in 15-17 fractions of whole pelvic radiotherapy concurrent with weekly CDDP, followed by 24 Gy in 4 fractions of hybrid of intracavitary and interstitial and pelvic radiotherapy with central shield up to 50-50.4 Gy in 25-28 fractions. The primary endpoint of phase I part was that the rate of grade ≥ 3 acute non-hematologic adverse events related to hybrid of intracavitary and interstitial would be <10%. RESULTS Between October 2015 and October 2019, 74 patients underwent primary registration, with 52 patients eventually proceeding to the secondary registration. The median pretreatment tumor width was 5.7 cm, and FIGO Stages were IB2 10, IIA2 2, IIB 20 and IIIB 20, respectively. The median high-risk clinical target volume D90 was 72.0 Gy (54.8-86.6 Gy, EQD2), rectum D2cc was 53.7 Gy (29.3-80.3 Gy) and bladder D2cc was 69.8 Gy (38.9-84.8 Gy). The rate of grade ≥ 3 non-hematologic adverse events related to hybrid of intracavitary and interstitial was 1.9% (1/52), and 17.3% (9/52) of patients experienced non-hematologic adverse events related to hybrid of intracavitary and interstitial of any grade. In multivariate analysis, high-risk clinical target volume ≥ 35 ml was associated with an increased risk of any grade of acute non-hematologic adverse events related to hybrid of intracavitary and interstitial (P = 0.036). CONCLUSION The feasibility and reproducibility of hybrid of intracavitary and interstitial were demonstrated from a multi-center prospective clinical trial.
Collapse
Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Miho Watanabe
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Uno
- Diagnostic Radiology and Radiation Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shuhei Sekii
- Department of Radiation Therapy, Kitaharima Medical Center, Ono, Japan.,Department of Radiation Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Kayoko Tsujino
- Department of Radiation Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Takahiro Kasamatsu
- Department of Obstetrics and Gynecology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yumiko Machitori
- Department of Radiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Tomomi Aoshika
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Shingo Kato
- Department of Radiation Oncology, Saitama Medical University International Medical Center, Hidaka, Japan
| | | | - Yuko Kaneyasu
- Department of Radiation Oncology, National Hospital Organisation Fukuyama Medical Center, Fukuyama, Japan
| | - Tomio Nakagawa
- Department of Radiation Oncology, National Hospital Organisation Fukuyama Medical Center, Fukuyama, Japan
| | - Hitoshi Ikushima
- Department of Therapeutic Radiology, Tokushima University Graduate School of Medicine, Tokushima, Japan
| | - Ken Ando
- Department of Radiation Oncology, Gunma Prefectural Cancer Center, Ota, Japan.,Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masumi Murata
- Department of Radiation Oncology, Gunma Prefectural Cancer Center, Ota, Japan
| | - Ken Yoshida
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Osaka, Japan.,Department of Radiology, Kansai Medical University Medical Center, Osaka, Japan
| | - Hiroto Yoshioka
- Department of Radiation Oncology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kazutoshi Murata
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan.,Department of Radiation Oncology, QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Tatsuya Ohno
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Noriyuki Okonogi
- Department of Radiation Oncology, QST Hospital, National Institutes for Quantum Science and Technology, Chiba, Japan
| | - Anneyuko Saito
- Department of Radiation Oncology, Juntendo University School of Medicine Graduate School of Medicine, Tokyo, Japan
| | - Mayumi Ichikawa
- Department of Radiation Oncology, Yamagata University Faculty of Medicine Graduate School of Medical Science, Yamagata, Japan
| | - Takahito Okuda
- Department of Radiation Oncology, Toyota Memorial Hospital, Toyota, Japan
| | - Keisuke Tsuchida
- Department of Radiation Oncology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba Faculty of Medicine, Tsukuba, Japan
| | - Ryouichi Yoshimura
- Department of Radiation Therapeutics and Oncology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuo Yoshioka
- Department of Radiation Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Atsunori Yorozu
- Department of Radiation Oncology, National Hospital Organisation Tokyo Medical Center, Tokyo, Japan
| | - Horoyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
10
|
Effect of Hyaluronate Acid Injection on Dose-Volume Parameters in Brachytherapy for Cervical Cancer. Adv Radiat Oncol 2022; 7:100918. [PMID: 35647394 PMCID: PMC9133393 DOI: 10.1016/j.adro.2022.100918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 11/21/2022] Open
|
11
|
Feng Z, Hooshangnejad H, Shin EJ, Narang A, Lediju Bell MA, Ding K. The Feasibility of Haar Feature-Based Endoscopic Ultrasound Probe Tracking for Implanting Hydrogel Spacer in Radiation Therapy for Pancreatic Cancer. Front Oncol 2021; 11:759811. [PMID: 34804959 PMCID: PMC8599366 DOI: 10.3389/fonc.2021.759811] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/11/2021] [Indexed: 01/24/2023] Open
Abstract
Purpose We proposed a Haar feature-based method for tracking endoscopic ultrasound (EUS) probe in diagnostic computed tomography (CT) and Magnetic Resonance Imaging (MRI) scans for guiding hydrogel injection without external tracking hardware. This study aimed to assess the feasibility of implementing our method with phantom and patient images. Materials and Methods Our methods included the pre-simulation section and Haar features extraction steps. Firstly, the simulated EUS set was generated based on anatomic information of interpolated CT/MRI images. Secondly, the efficient Haar features were extracted from simulated EUS images to create a Haar feature dictionary. The relative EUS probe position was estimated by searching the best matched Haar feature vector of the dictionary with Haar feature vector of target EUS images. The utilization of this method was validated using EUS phantom and patient CT/MRI images. Results In the phantom experiment, we showed that our Haar feature-based EUS probe tracking method can find the best matched simulated EUS image from a simulated EUS dictionary which includes 123 simulated images. The errors of all four target points between the real EUS image and the best matched EUS images were within 1 mm. In the patient CT/MRI scans, the best matched simulated EUS image was selected by our method accurately, thereby confirming the probe location. However, when applying our method in MRI images, our method is not always robust due to the low image resolution. Conclusions Our Haar feature-based method is capable to find the best matched simulated EUS image from the dictionary. We demonstrated the feasibility of our method for tracking EUS probe without external tracking hardware, thereby guiding the hydrogel injection between the head of the pancreas and duodenum.
Collapse
Affiliation(s)
- Ziwei Feng
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States.,Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hamed Hooshangnejad
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eun Ji Shin
- Department of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Muyinatu A Lediju Bell
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
12
|
Hydrogel spacers and prostate brachytherapy. Brachytherapy 2021; 21:75-78. [PMID: 34711449 DOI: 10.1016/j.brachy.2021.08.005] [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: 08/02/2021] [Accepted: 08/13/2021] [Indexed: 11/21/2022]
|
13
|
Interstitial brachytherapy for gynecologic malignancies: Complications, toxicities, and management. Brachytherapy 2021; 20:995-1004. [PMID: 33789823 DOI: 10.1016/j.brachy.2020.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 11/21/2022]
Abstract
From both a disease and management perspective, locally advanced gynecologic cancers present a significant challenge. Dose escalation with brachytherapy serves as a key treatment, providing conformal radiation while sparing at-risk organs. Intracavitary brachytherapy techniques have been shown to be effective, with improving tumor control and toxicity profiles with the advent of three-dimensional image planning. Despite this, the variations in tumor size, location, and pelvic anatomy may lead to suboptimal dosimetry with standard intracavitary applicators in some clinical scenarios. The addition of interstitial needles (interstitial brachytherapy (ISBT)) can improve the conformality of brachytherapy treatments by adding needles to peripheral (and central) regions of the target volume, improving the ability to escalate doses in these undercovered regions while sparing organs at risk. Interstitial brachytherapy can be delivered by intracavitary and interstitial hybrid applicators (ICBT/ISBT), perineal template (P-ISBT), or by free-hand technique. ISBT has however yet to be widely available because of concerns of complications and toxicities from this specialized treatment. However, with the increasing use of three-dimensional image-guided brachytherapy, there is an opportunity to increase the level of expertise in the gynecologic radiation oncology community with an improved understanding of the potential complications and morbidity. In this article, we review the acute and long-term toxicity in both ICBT/ISBT and P-ISBT using image-guided brachytherapy.
Collapse
|
14
|
Image-Guided Brachytherapy for Salvage Reirradiation: A Systematic Review. Cancers (Basel) 2021; 13:cancers13061226. [PMID: 33799617 PMCID: PMC7999189 DOI: 10.3390/cancers13061226] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Local recurrence in gynecological malignancies occurring in a previously irradiated field is a difficult clinical issue. Curative-intent treatment is salvage surgery and is associated with non-negligible peri-operative morbidity and has a substantial impact on long-term quality of life. Reirradiation, using three-dimensional image-guided brachytherapy (3D-IGBT), might be a suitable alternative, especially in non-operable patients. The aim of this review is to report outcomes and toxicities of reirradiation 3D-IGBT in this context. 3D-IGBT appears to be a feasible alternative to salvage surgery in inoperable patients, with an acceptable outcome for patients who have no other curative therapeutic options, however long-term toxicities were high in some studies. Each case should be referred to highly experienced expert centers. Abstract Background: Local recurrence in gynecological malignancies occurring in a previously irradiated field is a challenging clinical issue. The most frequent curative-intent treatment is salvage surgery. Reirradiation, using three-dimensional image-guided brachytherapy (3D-IGBT), might be a suitable alternative. We reviewed recent literature concerning 3D-IGBT for reirradiation in the context of local recurrences from gynecological malignancies. Methods: We conducted a large-scale literature research, and 15 original studies, responding to our research criteria, were finally selected. Results: Local control rates ranged from 44% to 71.4% at 2–5 years, and overall survival rates ranged from 39.5% to 78% at 2–5 years. Grade ≥3 toxicities ranged from 1.7% to 50%, with only one study reporting a grade 5 event. Results in terms of outcome and toxicities were highly variable depending on studies. Several studies suggested that local control could be improved with 2 Gy equivalent doses >40 Gy. Conclusion: IGBT appears to be a feasible alternative to salvage surgery in inoperable patients or patients refusing surgery, with an acceptable outcome for patients who have no other curative therapeutic options, however at a high cost of long-term grade ≥3 toxicities in some studies. We recommend that patients with local recurrence from gynecologic neoplasm occurring in previously irradiated fields should be referred to highly experienced expert centers. Centralization of data and large-scale multicentric international prospective trials are warranted. Efforts should be made to improve local control while limiting the risk of toxicities.
Collapse
|
15
|
Sturdza A, Viswanathan AN, Erickson B, Yashar C, Bruggeman A, Feddock J, Klopp A, Beriwal S, Gaffney D, Han K, Kamrava M. American Brachytherapy Society working group report on the patterns of care and a literature review of reirradiation for gynecologic cancers. Brachytherapy 2020; 19:127-138. [PMID: 31917178 DOI: 10.1016/j.brachy.2019.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 11/22/2019] [Accepted: 11/27/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Recurrences of previously irradiated gynecological malignancies are uncommon. Standardized management of these cases is not well established. We aim to provide an in-depth literature review and present current practice patterns among an international group of experienced practitioners in the reirradiation setting of gynecologic cancers. METHODS AND MATERIALS An extensive literature search was performed and 35 articles were selected based on preset criteria. A 20-question online survey of 10 experts regarding their retreatment practices was also conducted. RESULTS The reviewed publications include a diverse group of patients, multiple treatment techniques, a range of total doses, local control, overall survival, and toxicity outcomes. Overall, local control ranged from 44% to 88% over 1-5 years with OS in the range of 39.5-82% at 2-5 years. Late G3-4 toxicity varied very broadly from 0% to 42.9%, with most papers reporting serious toxicities greater than 15%. The most common reirradiation technique utilized was brachytherapy. Some low-dose-rate data suggest improved outcomes with doses >50 Gy. The high-dose-rate data are more varied with some studies suggesting improved local control with doses >40 Gy. In general, a longer time interval between the first and second course of radiation as well as recurrences <2-4 cm tend to have improved outcomes. CONCLUSIONS Reirradiation with brachytherapy results in relatively reasonable local control and toxicities for women with recurrent gynecologic cancers. The appropriate dose for each case needs to be individualized given the heterogeneity of cases. Multidisciplinary management is critical to develop individualized plans and to clearly communicate potential side effects and expected treatment outcomes. TAKE HOME MESSAGE Reirradiation with brachytherapy is an acceptable effective organ preserving approach for recurrent gynecologic cancers with a reasonable local control and toxicity profile. Each case requires multidisciplinary management to develop an individualized approach. Monitoring for potential long-term toxicities is essential.
Collapse
Affiliation(s)
- Alina Sturdza
- Department of Radiation Oncology and Radiation Biology, Medical University of Vienna, Comprehensive Cancer Center Vienna, Austria.
| | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Medicine, Baltimore, MD
| | - Beth Erickson
- Department of Radiation Oncology, Medical College of Wisconsin
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego
| | - Andrew Bruggeman
- Department of Radiation Medicine and Applied Sciences, University of California San Diego
| | | | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman cancer center
| | - David Gaffney
- Department of Radiation Oncology, University of Utah
| | - Kathy Han
- Department of Radiation Oncology, University of Toronto
| | | |
Collapse
|
16
|
Murakami N, Nakamura S, Kashihara T, Kato T, Shibata Y, Takahashi K, Inaba K, Okuma K, Igaki H, Nakayama Y, Galalae R, Itami J. Hyaluronic acid gel injection in rectovaginal septum reduced incidence of rectal bleeding in brachytherapy for gynecological malignancies. Brachytherapy 2019; 19:154-161. [PMID: 31879238 DOI: 10.1016/j.brachy.2019.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/04/2019] [Accepted: 11/17/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study was to report our initial clinical results of hyaluronic acid gel injection (HGI) in the rectovaginal septum (RVS) to reduce the incidence of rectal bleeding in vaginal brachytherapy for gynecologic malignancies. METHODS AND MATERIALS Since 2008, CT based image-guided adaptive brachytherapy (IGABT) was initiated, and since 2015, HGI in the RVS was introduced in our institution. Vaginal cylinder with or without tandem or additional interstitial needles were applied for patients with gynecologic malignancies. Rectum dosimetric parameters and incidence of late rectum bleeding were compared between patients with and without HGI in the RVS. RESULTS Between May 2008 and October 2017, 83 patients with gynecologic malignancies were treated with IGABT involving vaginal cylinder. Eleven patients who were treated for palliative intention were excluded, and 72 patients were subjected to the analysis. Of the total 72 patients 46 were with uterine cervical cancer, 19 uterine corpus cancer, five vaginal cancer, one vulvar cancer, and one ovarian cancer. Fifteen and 57 patients were irradiated with and without HGI in the RVS, respectively. With a median follow-up period of 57.7 (4.7-123.1) months, 30 (41.7%) patients suffered from radiation-related rectal bleeding. Patients with HGI in the RVS had a statistically significant lower incidence of rectal bleeding compared with those without it (13.3% vs. 49.1%, p = 0.01). CONCLUSIONS HGI in the RVS reduced the incidence of late rectal bleeding for patients with gynecologic malignancies treated by vaginal cylinder and was not associated with HGI-procedure-related adverse events.
Collapse
Affiliation(s)
- Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Nakamura
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.
| | - Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshihiro Shibata
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kae Okuma
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Yuko Nakayama
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Razvan Galalae
- Department of Radiation Therapy, Evangelische Kliniken, Gelsenkirchen, Germany
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
17
|
Kashihara T, Murakami N, Tselis N, Kobayashi K, Tsuchida K, Shima S, Masui K, Yoshida K, Takahashi K, Inaba K, Umezawa R, Igaki H, Ito Y, Kato T, Uno T, Itami J. Hyaluronate gel injection for rectum dose reduction in gynecologic high-dose-rate brachytherapy: initial Japanese experience. JOURNAL OF RADIATION RESEARCH 2019; 60:501-508. [PMID: 31034570 PMCID: PMC6640896 DOI: 10.1093/jrr/rrz016] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/29/2019] [Indexed: 06/09/2023]
Abstract
Perirectal hyaluronate gel injection (HGI) appears to be a promising technique for healthy tissue dose sparing in pelvic radiotherapy. In this analysis, we report our initial experience of HGI in gynecologic brachytherapy, focusing on its safety and effectiveness for dose reduction to the rectum. Between July 2013 and May 2014, 36 patients received HGI for primary/salvage gynecologic brachytherapy. Dosimetric effect analysis was based on pre- and post-HGI computed tomography dataset registration with corresponding dose-volume histogram evaluation. The maximum dose to the most exposed 0.1 cm3 (D0.1cm3) and 2.0 cm3 (D2.0cm3) were used as index values for rectum and bladder dose evaluation. The dose indexes for target volume (TV) coverage were TV D90/V100. In all cases, HGI was well tolerated, with no acute or late adverse events documented at a median follow-up of 220 days (range, 18-1046 days). Rectum D2.0cm3 and D0.1cm3 were significantly decreased by HGI (P < 0.001 and P = 0.003, respectively), with no significant impact on dosimetric parameters of bladder and TV coverage. Factors correlating negatively with the dosimetric effect of HGI were an increasing number of interstitial catheters (P = 0.003) as well as Lcranial100% (P = 0.014) and Lcranial80% (P = 0.001) [i.e. the length from the anal verge to the most cranial point at which the 100% and 80% isodose lines, respectively, crossed the rectum]. The concept of HGI for gynecologic brachytherapy is plausible, and our initial experience indicates it to be an effective technique for rectal dose reduction in radiotherapy of intrapelvic tumours.
Collapse
Affiliation(s)
- Tairo Kashihara
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Naoya Murakami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Nikolaos Tselis
- Department of Radiotherapy and Oncology, University of Frankfurt, Theodor-W.-Adorno-Platz 1 , Frankfurt am Main, Germany
| | - Kazuma Kobayashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Keisuke Tsuchida
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Satoshi Shima
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Koji Masui
- Department of Radiology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto, Japan
| | - Ken Yoshida
- Department of Radiation Oncology, Osaka Medical College, Daigakucho 2-7, Takatsuki, Osaka, Japan
| | - Kana Takahashi
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Koji Inaba
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Rei Umezawa
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Yoshinori Ito
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Tomoyasu Kato
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| | - Takashi Uno
- Department of Radiology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, Japan
| | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tsukiji 5-1-1, Chuo-ku, Tokyo, Japan
| |
Collapse
|
18
|
Hyaluronic gel injection into the vesicovaginal septum for high-dose-rate brachytherapy of uterine cervical cancer: an effective approach for bladder dose reduction. J Contemp Brachytherapy 2019; 11:1-7. [PMID: 30911303 PMCID: PMC6431109 DOI: 10.5114/jcb.2019.82612] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to report our initial experience of hyaluronic acid gel injection (HGI) in the vesicovaginal septum (VVS) for bladder dose reduction in brachytherapy (BT) for uterine cervical carcinoma. Material and methods Between September 2016 and May 2018, 15 uterine cervical cancer patients received HGI in the VVS as a part of their definitive radiotherapy (RT) treatment consisting of external beam radiation therapy (EBRT) with additional BT. Of those, 9 patients received BT both with and without HGI, and remaining 6 patients were excluded because these 6 patients received HGI in the VVS for all BT fractions. All 9 patients received HGI in the rectovaginal septum. For these patients, the dosimetric parameters bladder D2cc, HR-CTV D90, and rectum D2cc were selected, and two groups were generated (BT with vs. without HGI in the VVS) for dosimetric comparison. Results The median cumulative EQD2 for HR-CTV, rectum D2cc, and bladder D2cc for the 9 patients were 73.3, 52.8, and 67.1, respectively. While no statistical difference could be detected for rectal dose reduction, bladder dose was significantly less in the group with HGI in the VVS compared to that without (449 cGy [range, 416-566, 1SD = 66.1] vs. 569 cGy [range, 449-647, 1SD = 59.5], p = 0.033), with no compromising of target coverage. Although it did not reach statistically significance, there was a trend toward better HR-CTV D90 in the group with HGI compared to that without HGI in the VVS (713 cGy vs. 706 cGy, p = 0.085). No severe bleeding, hematuria, bladder wall injury, or urethral injury requiring hospitalization was experienced in association with HGI in the VVS. Conclusions HGI in the VVS can be performed safely and can effectively reduce the bladder dose in BT for uterine cervical cancer patients.
Collapse
|
19
|
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.
Collapse
|
20
|
Tang Q, Zhao F, Yu X, Wu L, Lu Z, Yan S. The role of radioprotective spacers in clinical practice: a review. Quant Imaging Med Surg 2018; 8:514-524. [PMID: 30050786 DOI: 10.21037/qims.2018.06.06] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The delivery of high dose radiotherapy to tumors is often limited by the proximity of the surrounding radiosensitive normal tissues, even using modern techniques such as intensity modulated radiation therapy (IMRT). Previous studies have reported that placement of a spacer can effectively displace normal tissues. So that they are some distance away from the lesion, thus allowing for the safe delivery of high-dose radiation. The application of radioprotective spacers was first reported 30 years ago regarding radiotherapy of tongue and abdominal cancers; more recently, they are increasingly being used in prostate cancer. This review focuses on the published data concerning the features of different types of spacers and their application in various tumor sites. Placement-related complications and the cost-effectiveness of the spacers are also discussed. With the increasing use of high-precision radiotherapy in clinical practice, especially the paradigm-changing stereotactic body radiotherapy (SBRT), more robust studies are warranted to further establish the role of radioprotective spacers through materials development and novel placement techniques.
Collapse
Affiliation(s)
- Qiuying Tang
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Feng Zhao
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Xiaokai Yu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Lingyun Wu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Zhongjie Lu
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Senxiang Yan
- Department of Radiation Oncology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| |
Collapse
|
21
|
|
22
|
Damato AL, Kassick M, Viswanathan AN. Rectum and bladder spacing in cervical cancer brachytherapy using a novel injectable hydrogel compound. Brachytherapy 2017; 16:949-955. [PMID: 28619385 DOI: 10.1016/j.brachy.2017.04.236] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 03/19/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study was to evaluate injection of a novel hydrogel (TraceIT; Augmenix, Waltham, MA) between the cervix, rectum, and bladder in female cadavers compared with, and in addition to, the current standard of gauze packing, for organ-at-risk sparing in cervical cancer brachytherapy planning. METHODS AND MATERIALS This brachytherapy cadaver study used T2-weighted MRI and CT imaging to compare three scenarios: (1) gauze packing alone, (2) hydrogel injection placed in the cervical fornices and rectovaginal septum, and (3) gauze packing in conjunction with hydrogel injection. Hydrogel distribution was evaluated. Doses to 2 cm3 volumes (D2cc) for the rectum, bladder, and sigmoid were collected. Statistical significance (p < 0.05) was evaluated using a two-tailed paired t test. RESULTS Hydrogel was successfully injected to space the bladder and rectum from the cervix in all five cadavers. The spacer was easily identifiable on both CT and MRI. The use of hydrogel in addition to packing resulted in a 22% decrease in rectum D2cc dose (p = 0.02), a 10% decrease in bladder D2cc (p = 0.27), and no change in sigmoid D2cc dose. No difference was observed between hydrogel only vs. gauze packing only. CONCLUSIONS Our results revealed a significant clinically meaningful decrease in rectal D2cc associated with the use of hydrogel in addition to gauze packing-TraceIT hydrogel holds promise as a spacer in cervical cancer therapy.
Collapse
Affiliation(s)
- Antonio L Damato
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Akila N Viswanathan
- Department of Radiation Oncology and Molecular Radiation Science, Johns Hopkins Medicine, Baltimore, MD.
| |
Collapse
|
23
|
Rao AD, Feng Z, Shin EJ, He J, Waters KM, Coquia S, DeJong R, Rosati LM, Su L, Li D, Jackson J, Clark S, Schultz J, Hutchings D, Kim SH, Hruban RH, DeWeese TL, Wong J, Narang A, Herman JM, Ding K. A Novel Absorbable Radiopaque Hydrogel Spacer to Separate the Head of the Pancreas and Duodenum in Radiation Therapy for Pancreatic Cancer. Int J Radiat Oncol Biol Phys 2017; 99:1111-1120. [PMID: 28943075 DOI: 10.1016/j.ijrobp.2017.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 01/25/2023]
Abstract
PURPOSE We assessed the feasibility and theoretical dosimetric advantages of an injectable hydrogel to increase the space between the head of the pancreas (HOP) and duodenum in a human cadaveric model. METHODS AND MATERIALS Using 3 human cadaveric specimens, an absorbable radiopaque hydrogel was injected between the HOP and duodenum by way of open laparotomy in 1 case and endoscopic ultrasound (EUS) guidance in 2 cases. The cadavers were subsequently imaged using computed tomography and dissected for histologic confirmation of hydrogel placement. The duodenal dose reduction and planning target volume (PTV) coverage were characterized using pre- and postspacer injection stereotactic body radiation therapy (SBRT) plans for the 2 cadavers with EUS-guided placement, the delivery method that appeared the most clinically desirable. Modeling studies were performed using 60 SBRT plans consisting of 10 previously treated patients with unresectable pancreatic cancer, each with 6 different HOP-duodenum separation distances. The duodenal volume receiving 15 Gy (V15), 20 Gy (V20), and 33 Gy (V33) was assessed for each iteration. RESULTS In the 3 cadaveric studies, an average of 0.9 cm, 1.1 cm, and 0.9 cm HOP-duodenum separation was achieved. In the 2 EUS cases, the V20 decreased from 3.86 cm3 to 0.36 cm3 and 3.75 cm3 to 1.08 cm3 (treatment constraint <3 cm3), and the V15 decreased from 7.07 cm3 to 2.02 cm3 and 9.12 cm3 to 3.91 cm3 (treatment constraint <9 cm3). The PTV coverage improved or was comparable between the pre- and postinjection studies. Modeling studies demonstrated that a separation of 8 mm was sufficient to consistently reduce the V15, V20, and V33 to acceptable clinical constraints. CONCLUSIONS Currently, dose escalation has been limited owing to radiosensitive structures adjacent to the pancreas. We demonstrated the feasibility of hydrogel separation of the HOP and duodenum. Future studies will evaluate the safety and efficacy of this technique with the potential for more effective dose escalation using SBRT or intensity-modulated radiation therapy to improve the outcomes in patients with unresectable pancreatic cancer.
Collapse
Affiliation(s)
- Avani D Rao
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ziwei Feng
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eun Ji Shin
- Department of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jin He
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kevin M Waters
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Stephanie Coquia
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Robert DeJong
- Department of Radiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lauren M Rosati
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lin Su
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dengwang Li
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Juan Jackson
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Stephen Clark
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey Schultz
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Danielle Hutchings
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Seong-Hun Kim
- Department of Gastroenterology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ralph H Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Theodore L DeWeese
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - John Wong
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amol Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Kai Ding
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland.
| |
Collapse
|
24
|
Lorenzo C, Andrea P, Barbara V, Denis P, Rosaria FM, Piero F, Viviana V, Alberto I, Mario C, Brugnatelli S, Tommaso D, Bugada D, Marcello M, Mario A, Francesca V, Roberto O, Paolo D. Surgical spacer placement prior carbon ion radiotherapy (CIRT): an effective feasible strategy to improve the treatment for sacral chordoma. World J Surg Oncol 2016; 14:211. [PMID: 27507254 PMCID: PMC4977725 DOI: 10.1186/s12957-016-0966-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
Background Sacral chordoma (SC) is a neoplasm arising from residual notochordal cells degeneration. SC is difficult to manage mainly because of anatomic location and tendency to extensive spread. Carbon ion radiotherapy (CIRT) is highly precise to selectively deliver high biological effective dose to the tumor target sparing the anatomical structure on its path even if when SC is contiguous to the intestine, and a surgical spacer might be an advantageous tool to create a distance around the target volume allowing radical curative dose delivery with a safe dose gradient to the surrounding organs. This paper describes a double approach—open and hand-assisted laparoscopic—for a silicon spacer placement in patients affected by sacral chordoma undergoing carbon ion radiotherapy. Methods Six consecutive patients have been enrolled for surgical spacer placement—open (three) or hand-assisted (three)—prior carbon ion radiotherapy treatment in order to increase efficacy of carbon ion radiotherapy minimizing its side effects. Results Results showed that silicon spacer placement for SC treatment is feasible both via laparoscopic and laparotomic approach. Conclusions Its use might improve CIRT safety and thus efficacy for SC treatment.
Collapse
Affiliation(s)
- Cobianchi Lorenzo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy. .,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy. .,Department of General Surgery, IRCCS San Matteo Foundation, University of Pavia, Piazzale Golgi, Pavia, 27100, Italy.
| | - Peloso Andrea
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy
| | - Vischioni Barbara
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Panizza Denis
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Fiore Maria Rosaria
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Fossati Piero
- Department of Radiation Oncology, European Institute of Oncology (IEO), Milan, Italy
| | - Vitolo Viviana
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Iannalfi Alberto
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Ciocca Mario
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Silvia Brugnatelli
- IRCCS Policlinico San Matteo Foundation, Department of Onco-Hematology, Oncology Section, Pavia, Italy
| | - Dominioni Tommaso
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy
| | - Dario Bugada
- Department of Surgical Science, University of Parma, Parma, Italy
| | - Maestri Marcello
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy
| | - Alessiani Mario
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy
| | - Valvo Francesca
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy
| | - Orecchia Roberto
- Department of Radiation Oncology and Medical Physics, Centro Nazionale Adroterapia Oncologica (CNAO), Pavia, Italy.,Department of Radiation Oncology, European Institute of Oncology (IEO), Milan, Italy
| | - Dionigi Paolo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.,IRCCS Policlinico San Matteo Foundation, General Surgery 1, Pavia, Italy
| |
Collapse
|
25
|
Müller AC, Mischinger J, Klotz T, Gagel B, Habl G, Hatiboglu G, Pinkawa M. Interdisciplinary consensus statement on indication and application of a hydrogel spacer for prostate radiotherapy based on experience in more than 250 patients. Radiol Oncol 2016; 50:329-36. [PMID: 27679550 PMCID: PMC5024663 DOI: 10.1515/raon-2016-0036] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 04/17/2016] [Indexed: 12/19/2022] Open
Abstract
Background The aim of the study was to reach a consensus on indication and application of a hydrogel spacer based on multicentre experience and give new users important information to shorten the learning curve for this innovative technique. Methods The interdisciplinary meeting was attended by radiation oncologists and urologists, each with experience of 23 – 138 hydrogel injections (SpaceOAR®) in prostate cancer patients before dose-escalated radiotherapy. User experience was discussed and questions were defined to comprise practical information relevant for successful hydrogel injection and treatment. Answers to the defined key questions were generated. Hydrogel-associated side effects were collected to estimate the percentage, treatment and prognosis of potential risks. Results The main indication for hydrogel application was dose-escalated radiotherapy for histologically confirmed low or intermediate risk prostate cancer. It was not recommended in locally advanced prostate cancer. The injection or implantation was performed under transrectal ultrasound guidance via the transperineal approach after prior hydrodissection. The rate of injection-related G2-toxicity was 2% (n = 5) in a total of 258 hydrogel applications. The most frequent complication (n = 4) was rectal wall penetration, diagnosed at different intervals after hydrogel injection and treated conservatively. Conclusions A consensus was reached on the application of a hydrogel spacer. Current experience demonstrated feasibility, which could promote initiation of this method in more centres to reduce radiation-related gastrointestinal toxicity of dose-escalated IGRT. However, a very low rate of a potential serious adverse event could not be excluded. Therefore, the application should carefully be discussed with the patient and be balanced against potential benefits.
Collapse
Affiliation(s)
| | | | - Theodor Klotz
- Department of Urology, Hospital Weiden, Weiden, Germany
| | - Bernd Gagel
- Department of Radiation Oncology, Hospital Weiden, Weiden, Germany
| | - Gregor Habl
- Department of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Gencay Hatiboglu
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Michael Pinkawa
- Department of Radiation Oncology, RWTH Aachen University, Aachen, Germany
| |
Collapse
|
26
|
Trifiletti DM, Garda AE, Showalter TN. Implanted spacer approaches for pelvic radiation therapy. Expert Rev Med Devices 2016; 13:633-40. [DOI: 10.1080/17434440.2016.1195682] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Daniel M. Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Allison E. Garda
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N. Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| |
Collapse
|
27
|
Vargo JA, Viswanathan AN, Erickson BA, Beriwal S. Gynecologic Brachytherapy: Vaginal Cancer. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
28
|
Bair RJ, Bair E, Viswanathan AN. A radiopaque polymer hydrogel used as a fiducial marker in gynecologic-cancer patients receiving brachytherapy. Brachytherapy 2015; 14:876-80. [PMID: 26481393 DOI: 10.1016/j.brachy.2015.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/12/2015] [Accepted: 08/27/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE We assessed a novel Food and Drug Administration-approved hydrogel, synthesized as absorbable iodinated particles, in gynecologic-cancer patients undergoing computed tomography (CT) or magnetic resonance (MR) based brachytherapy after external beam radiation. METHODS AND MATERIALS Nineteen patients underwent CT-guided (n = 13) or MR-guided (n = 6) brachytherapy for gynecologic cancers. Seventy-seven hydrogel injections were placed. The hydrogel material was injected into gross residual disease and/or key anatomic landmarks in amounts ranging from 0.1 to 0.4 mL. The visibility of the tracer was scored on CT and on MR images using a 5-point scoring scale. A Cohen's kappa statistic was calculated to assess interobserver agreement. To assess the unadjusted effects of baseline parameters on hydrogel visibility, we modeled visibility using a linear mixed-effect model. RESULTS Injections were without complication. The kappa statistic was 0.77 (95% confidence interval [CI], 0.68-0.87). The volume of hydrogel injected was significantly associated with visibility on both CT (p = 0.032) and magnetic resonance imaging (p = 0.016). We analyzed visibility by location, controlling for amount. A 0.1-cc increase in volume injected was associated with increases of 0.54 (95% CI = 0.05-1.03) in the CT visibility score and 0.83 (95% CI = 0.17-1.49) in the MR visibility score. Injection of 0.4 cc or more was required for unequivocal visibility on CT or MR. No statistically significant correlation was found between tumor type, tumor location, or anatomical location of injection and visibility on either CT or magnetic resonance imaging. CONCLUSIONS In this first report of an injectable radiopaque hydrogel, targets were visualized to assist with three-dimensional-based brachytherapy in gynecologic malignancies. This marker has potential for several applications, is easy to inject and visualize, and caused no acute complications.
Collapse
Affiliation(s)
- Ryan J Bair
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA
| | - Eric Bair
- Department of Endodontics, University of North Carolina, Chapel Hill, NC; Department of Biostatistics, University of North Carolina, Chapel Hill, NC
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA.
| |
Collapse
|
29
|
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]
|
30
|
|
31
|
Kamrava M. Potential role of ultrasound imaging in interstitial image based cervical cancer brachytherapy. J Contemp Brachytherapy 2014; 6:223-30. [PMID: 25097565 PMCID: PMC4105650 DOI: 10.5114/jcb.2014.43778] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 06/05/2014] [Accepted: 06/26/2014] [Indexed: 11/17/2022] Open
Abstract
In 2012, more than 500,000 cases of cervical cancer were diagnosed worldwide. Over three quarters of these cases occur in less developed countries [1]. Advancements in image-guided brachytherapy are resulting in improved outcomes and reduced morbidity for women with this disease, but its worldwide adoption is hampered by lack of accessibility to advanced imaging techniques. Ultrasound is emerging as a potential option for tumor visualization, brachytherapy catheter placement, and treatment planning. While additional work is needed, ultrasound can potentially serve as the sole imaging modality for catheter insertion and planning. This paper will review our current knowledge on the use of ultrasound in interstitial brachytherapy treatment for cervical cancer.
Collapse
Affiliation(s)
- Mitchell Kamrava
- Department of Radiation Oncology, University of California, Los Angeles, USA
| |
Collapse
|