High Dose Rate Brachytherapy for Inoperable Endometrial Cancer: a Case Series and Systematic Review of the Literature

Endometrial cancer is a common gynaecological cancer, is typically early stage and treated with surgery. For patients where surgery is difficult or dangerous, definitive radiation therapy is the next best option. This study included a single institution case series (step 1) and a systematic review of the literature (step 2). In step 1, all endometrial cancer cases that were treated with definitive image-guided brachytherapy at a single institution from 2008 to 2020 were retrospectively analysed. In step 2, a systematic review of Medline (PubMed) from 1975 to 2020 was carried out using the key words around endometrial cancer and brachytherapy, followed by a narrative synthesis. In total, in step 1, 31 cases were included in this study, stages I-IV, with 96.7% receiving external beam radiation. All patients received three fractions of 7.5 Gy or five fractions of 6 Gy high dose rate brachytherapy, with a median EQD2 of 75.55 (40-84.3). The 2-year Kaplan-Meier (KM) local control was 83.1% and the 2-year KM overall survival was 77.4%. There was no late toxicity ≥grade 3. In step 2, 19 articles were included in the final analysis, with between six and 280 patients. The local control ranged from 70 to 100%, with low toxicity. Definitive radiation therapy with image-guided brachytherapy seems to have good local control with low toxicity for patients who are poor surgical candidates.

Discordance in Perceptions of Barriers to Breast Cancer Treatment Between Hispanic Women and Their Providers

Despite comparable screening and incidence rates that are 26% below that of non-Hispanic Whites, Hispanic women present with breast cancer at more advanced stages of disease, representing a continuing and troubling health disparity for this population. Reducing these disparities warrant more innovative research approaches to better understand perspectives of Hispanic patients regarding barriers to treatment and how these perspectives compare to those of their providers. A pilot qualitative study was conducted at a major urban cancer center in Arizona that measured both patient and provider perspectives regarding barriers to treatment. Through a multimethod qualitative analysis, researchers surveyed patients and providers to identify perceived barriers and discordance in shared understanding. Data collection and analysis consisted of surveying patients and providers, then performing inductive qualitative analysis. Results indicated the highest concordance, or shared understanding, between patients and providers was in recognizing barriers within delivery of care, such as cost of care and insurance coverage. The greatest discordance, or gaps in shared understanding, existed in upstream barriers of the health care system, such as emotional support and trust in systems. These results underscore the gap in shared understanding between patients and providers regarding upstream barriers to care as well as the nonclinical social determinants of health Hispanic patients face in accessing breast cancer treatment. More research is warranted using this approach as a tool to reduce health disparities.

Disintegration of Flower-Like MoS₂ to Limply Allied Layers on Spherical Nanoporous TiO₂: Enhanced Visible-Light Photocatalytic Degradation of Methylene Blue

MoS₂/TiO₂ heterostructure with enhanced photocatalytic activity was successfully synthesized by hydrothermal method. The segmentation of flower-like MoS₂ structure resulted, during the hydrothermal condition in the presence of spherical nanoporous TiO₂ as a growing matrix. A pool of larger spherical TiO₂ particle induces a strain effect, which restricted the size of MoS₂. Meanwhile, the applied hydrothermal pressure leads the segmentation of the bundle-like structure of MoS₂ to individual layer. The obtained heterostructure was characterized by X-ray diffraction, Scanning, and Transmission electron microscopy, X-ray photoelectron spectroscopy, DRS-UV Visible spectra, Photoluminescence, Raman spectroscopy and BET surface area analysis. The photocatalytic activity of these synthesized materials was evaluated for the decomposition of methylene blue (MB) under visible light. The results indicated that MoS₂/TiO₂ heterostructure had higher photocatalytic activity than pristine MoS₂ and TiO₂ materials. After irradiation, the photocatalytic efficiency towards MB degradation was calculated as 67.4, 80.2 and 99.5% for MoS₂, TiO₂, and MoS₂/TiO₂, respectively. The formation of unique, distinct layers of MoS₂ over TiO₂ surface created more active sites for a photocatalytic response. These whole phenomena could enhance the absorption characteristics of dyestuff on the heterostructure and enhance the charge transport after conjugation, which improves MB degradation efficiency.

Custom mold applicator high-dose-rate brachytherapy for nonmelanoma skin cancer-An analysis of 273 lesions

PURPOSE

Nonmelanoma skin cancer is the most commonly diagnosed malignancy in the United States. A modern version of surface brachytherapy, "topographic applicator brachytherapy" (TAB), can be used to treat early-stage nonmelanoma skin cancer (ES-NMSC). The purpose of this study was to evaluate the acute toxicity, chronic toxicity, and recurrence rates of patients with ES-NMSC treated with TAB.

METHODS AND MATERIALS

From 2010 to 2013, 172 patients with 273 ES-NMSC tumors were consecutively treated with TAB. A custom applicator was created using a thermoplastic mold with Harrison Anderson Mick applicators. Dose fractionation schemes included 40 Gy in eight fractions delivered twice per week or 48 Gy in 16 fractions delivered four times per week.

RESULTS

Of the 273 tumors treated, 23.8% were located on the nose, 54.2% were basal cell carcinoma, 76.2% were Stage I, 89.3% were treated definitively, 98.9% completed treatment, and 75.5% received 40 Gy in eight fractions. Median followup was 25.0 months (0.5-71.0 months). Maximum acute toxicity was G0, 0.4%; G1, 33.3%; G2, 48.7%; G3, 12.1%; and G4, 5.1%. Local recurrence was 4.8% at 25 months, with median time to recurrence being 9 months. There was no regional or distant metastasis documented during the followup. Chronic toxicities included erythema (4.4%), chronic ulceration (4.0%), telangiectasia (2.6%), and pigmentation changes (2.2%).

CONCLUSIONS

TAB was able to provide excellent local control (95.2%) with low rates of Grades 3 and 4 toxicities for treatment of ES-NMSC. TAB is a reasonable alternative to surgical resection when there is concern of poor cosmesis/wound healing.

Skin surface brachytherapy: A survey of contemporary practice patterns

PURPOSE

The aim of this study was to define current patterns of care among radiation oncologists who use skin surface brachytherapy for the treatment of cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC) in academic and community settings.

METHODS AND MATERIALS

A 30-question electronic survey was administered to clinician members of the American Brachytherapy Society. The respondents were asked to provide details regarding their clinical practice and their approach to skin surface brachytherapy.

RESULTS

A total of 16 surveys were returned. Among the respondents, aggregate experience varied from 8 to 1800 cases. Most preferred brachytherapy over external beam radiation because of shorter treatment course, conformality of treatment for irregular or curved targets, and shallow dose deposition. Of the total, 60% of respondents routinely estimated lesion depth via ultrasound before initiating treatment. Treatment margin on gross disease varied widely (range, 3-15 mm; median, 5 mm). Hypofractionation was the preferred dose schedule. Prescribed doses ranged from 30 Gy in five fractions to 64 Gy in 32 fractions (EQD2, 40 Gy-65 Gy). There was a tendency to increase the number of fractions for larger targets, although some used the same fractionation regardless of anatomic location or lesion size. There was no consensus on dosimetric constraints, and some respondents reported cases of severe toxicity, particularly when treating the pretibial skin.

CONCLUSIONS

This pattern of care study suggests that skin brachytherapy can be a convenient and safe tool for treatment of BCC and cSCC. Prospective trials and the development of expert consensus guidelines would be beneficial for optimizing skin surface brachytherapy and reducing practice variation.

Multiple dural-based hemangiopericytomas

Here we report the case of a 57-year-old man who underwent resection of a dural-based hemangiopericytoma (HPC) in the left frontoparietal region. The patient was treated with radiation therapy and remained symptom-free for 10 years. At 67 years of age, he presented with a mass in the left frontal region near the same area as the first tumor, in addition to a separate smaller mass in the right middle cranial fossa. Resection of the larger left frontal mass revealed an HPC. Follow-up imaging 9 months later showed a significant increase in size of the right middle cranial fossa mass. This third mass was resected, and histological examination also demonstrated an HPC.

American Brachytherapy Society consensus guidelines for thoracic brachytherapy for lung cancer

PURPOSE

To update brachytherapy recommendations for pretreatment evaluation, treatment, and dosimetric issues for thoracic brachytherapy for lung cancer.

METHODS AND MATERIALS

Members of the American Brachytherapy Society with expertise in thoracic brachytherapy updated recommendations for thoracic brachytherapy based on literature review and clinical experience.

RESULTS

The American Brachytherapy Society consensus guidelines recommend the use of endobronchial brachytherapy for disease palliation in patients with central obstructing lesions, particularly in patients who have previously received external beam radiotherapy. The use of interstitial implants after incomplete resection may improve outcomes and provide enhanced palliation. Early reports support the use of CT-guided intratumoral volume implants within clinical studies. The use of brachytherapy routinely after sublobar resection is not generally recommended, unless within the confines of a clinical trial or a registry.

CONCLUSIONS

American Brachytherapy Society recommendations for thoracic brachytherapy are provided. Practitioners are encouraged to follow these guidelines and to develop further clinical trials to examine this treatment modality to increase the evidence base for its use.

Effect of intensity-modulated radiation therapy with SIB technique on local control and toxicity for neoadjuvant pelvic radiation with concurrent 5-fluorouracil based chemotherapy for rectal cancer compared with three-dimensional conformal radiation therapies

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Background: To compare the areas of residual disease after neoadjuvant pelvic radiation with 5-FU based chemotherapy for rectal cancer using Intensity Modulated Radiation Therapy (IMRT) with simultaneous integrated boost (SIB) technique compared to 3D Conformal Radiation Therapy (3DCRT) Methods: Fourty nine (49) consecutive rectal cancer patients treated with pelvic radiation and concurrent 5-FU based chemotherapy were analyzed. We compared twenty-eight (28) patients treated on an institutional IMRT protocol versus twenty-one (21) patients treated with 3DCRT. All patients received 45-50.4 Gy to the pelvis in 3DCRT group. All patients with IMRT received 45 Gy in 25 fractions to the pelvic no des. The primary rectal tumor recieved a simultaneous integrated boost to a dose of 50 Gy in 25 fractions. IMRT planning was done with dose constraints for bladder, rectum, and small bowel and bone marrow. All patients in both groups received 5-FU based chemotherapy during radiation. Evaluation of toxicity was based on RTOG criteria. 2 patients in the 3DCRT group and 2 in IMRT group received either growth factors or blood-products transfusion and needed hospitalization during treatment secondary to acute toxicities. Results: All patients completed their prescribed course of radiation. CR rates were 5/21(23%) in 3DCRT and 4/28(25%) in the IMRT-SIB (p-value 0.74). 9/21(42%) in 3D and 19/29(65%) in the IMRT group underwent Low anterior resection according to the location of the tumor. There was no grade 4 toxicity in the IMRT-SIB group. Overall grade 2 toxicity in 3D Vs IMRT-SIB group was - GI -52% Vs 19%, GU- 8% Vs 8%, skin 42 Vs 4%, hematologic 33 Vs 47%. Overall Grade 1 toxicity in 3DCRT Vs IMRT group was- GI- 33% Vs 52%, GU 23% vs 28%, Skin 52% Vs 38%, hematologic 4% Vs 33%. Conclusions: Neoadjuvant pelvic radiation with 5 FU for rectal cancer has similar local control rates. There is less GI, skin and hematologic toxicity when delivered via IMRT-SIB versus 3DCRT. IMRT is safe and may allow dose escalation with potential probability of increased tumor response.

Phase II trial of adjuvant pelvic radiation "sandwiched" between ifosfamide or ifosfamide plus cisplatin in women with uterine carcinosarcoma

OBJECTIVE

Uterine carcinosarcoma (CS) is a rare uterine tumor with an extremely poor prognosis. In the adjuvant setting, efficacy has been shown with radiotherapy (RT), systemic chemotherapy, or both. This is the first report describing the efficacy and toxicity of adjuvant ifosfamide or ifosfamide plus cisplatin "sandwiched" with RT in patients with surgically staged and completely resected uterine carcinosarcoma.

METHODS

Women with surgically staged CS with no gross residual disease were initially administered ifosfamide (1.2 g/m(2)/day×5 days) with cisplatin (20 mg/m(2)/day×5 days) every 3 weeks for 3 cycles followed by pelvic external beam RT and brachytherapy followed by 3 additional cycles of ifosfamide (1.0 g/m2/day) with cisplatin (20 mg/m(2)/day×5 days) every 3 weeks. Similar to the GOG trial in recurrent CS (Sutton et al., 2000), the addition of cisplatin added toxicity without additional efficacy, so mid-study, the cisplatin was eliminated from the regimen. Toxicities were recorded and disease-free survival (DFS) was calculated with Kaplan-Meier statistical methods.

RESULTS

In total, 12 patients received ifosfamide and cisplatin and 15 patients received ifosfamide alone, both 'sandwiched' with RT. The median follow up was 35.9 months (range 6-88). The 2 year DFS was similar in both the ifosfamide/cisplatin and ifosfamide groups (log-rank p=0.16), so they were combined for analysis. 19 patients (70%) completed the protocol. As expected, stage 1 patients had a better 2-year DFS (18.75 ± 1.12 months; log-rank p=0.008 when compared to stages 2, 3, 4). Also, in stages 2, 3 and 4 patients, the DFS was 15.81 ± 1.73 months. Grade 3/4 neutropenia, anemia and thrombocytopenia occurred in 18%, 4% and 4% of cycles, respectively.

CONCLUSIONS

Ifosfamide "sandwiched" with RT appears to be an efficacious regimen for surgically staged CS patients with no residual disease, even in patients with advanced stage. The addition of cisplatin to the regimen added toxicity without improving efficacy. Even with ifosfamide alone, the efficacy of this 'sandwich' regimen comes with a moderate but tolerable toxicity profile.

Phase II trial of adjuvant pelvic radiation "sandwiched" between combination paclitaxel and carboplatin in women with uterine papillary serous carcinoma

OBJECTIVE

To evaluate the safety and survival in women treated with adjuvant pelvic radiation "sandwiched" between six cycles of paclitaxel and carboplatin chemotherapy with completely resected UPSC.

METHODS

Surgically staged women with UPSC (FIGO stage 1-4) and no visible residual disease were enrolled. Treatment involved paclitaxel (175 mg/m(2)) and carboplatin (AUC=6.0-7.5) every 21 days for 3 doses, followed by radiation therapy (RT), followed by an additional 3 cycles of paclitaxel and carboplatin (AUC=5-6). Survival analysis, using Kaplan-Meier methods, was performed on patients who completed at least 3 cycles of chemotherapy and RT.

RESULTS

A total of 81 patients were enrolled, of which 72 patients completed the first 3 cycles of chemotherapy followed by prescribed RT. Median age was 67 years (range: 43-82 years). 59/72 (82%) had disease confined to the uterus and 13/72 (18%) had completely resected extra-uterine disease (stage 3 and 4). 65 (83%) completed the protocol. Overall PFS and OS for combined stage 1 and 2 patients was 65.5 ± 3.6 months and 76.5 ± 4.3 months, respectively. PFS and OS for combined stage 3 and 4 patients was 25.8 ± 3.0 and 35.9 ± 5.3 months, respectively. Three-year % survival probability for stage 1 and 2 patients was 84% and for stage 3 and 4 patients was 50%. Of the 435 chemotherapy cycles administered, there were 11(2.5%) G3/G4 non-hematologic toxicities. 26(6.0%) cycles had dose reductions and 37(8.5%) had dose delays.

CONCLUSIONS

Compared to prior studies of single modality adjuvant therapy, RT "sandwiched" between paclitaxel and carboplatin chemotherapy is well-tolerated and highly efficacious in women with completely resected UPSC.