The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for head-and-neck carcinoma.

PURPOSE: To develop recommendations for use of high-dose-rate (HDR) brachytherapy in patients with head-and-neck cancer. METHODS: A panel consisting of members of the American Brachytherapy Society (ABS) performed a literature review, added information based upon their clinical experience, and formulated recommendations for head-and-neck HDR brachytherapy. RESULTS: The ABS recommends the use of brachytherapy as a component of the treatment of head-and-neck tumors. However, the ABS recognizes that some radiation oncologists are reluctant to employ brachytherapy in the head-and-neck region because of the complexity of the postoperative management and concerns about radiation safety. In this regard, HDR eliminates unwanted radiation exposure and thereby permits unrestricted delivery of clinical care to these brachytherapy patients. The ABS made specific recommendations for previously untreated and recurrent head-and-neck cancer patients on patient selection criteria, implant techniques, target volume definition, and HDR treatment parameters (such as time, dose, and fractionation schedules). Suggestions were provided for treatment with HDR alone and in combination with external beam radiation therapy. It should be recognized that only limited experiences exist with HDR brachytherapy in patients with head-and-neck cancers. Therefore, some of these suggested doses have not been extensively tested in clinical practice. Hence, these guidelines will be updated as significant new outcome data are available. Any clinician following these guidelines is expected to use clinical judgment to determine an individual patient's treatment. CONCLUSIONS: Little has been published in the clinical literature on HDR brachytherapy in head-and-neck cancer. Based upon the available information and the clinical experience of the panel members, general and site-specific recommendations were offered. Areas for further investigations were identified.

High dose rate prostate brachytherapy: the California Endocurietherapy (CET) method.

BACKGROUND AND PURPOSE: To describe the rationale, protocol and procedure for the treatment of prostate cancer using high dose rate brachytherapy (HDR-BT) and a non-fixed template technique. MATERIALS AND METHODS: Between July 1991 and December 1998, 491 patients with carcinoma of the prostate were treated using HDR-BT and a non-fixed template technique. AJC stages T(1C)-T(3B), patients with prior transurethral resections of the prostate (TURP) and gland volumes >60 cm(3), were included. Flexible cystoscopy, fluoroscopy and transrectal ultrasound (TRUS) were used and 17 flexiguides were inserted through the perineum. Dosimetry was carried out using localization films. Treatment volume was defined at 4-6 mm outside the peripheral catheters. BT consisted of two implants, separated by 1 week, with two fractions given per implant for a total of four HDR fractions. Dose prescription to the treatment volume was 6 Gy (HDR) per fraction, with an additional dose of 0.5 to 0.75 Gy given where required. RESULTS: Patients with glands >60 cm(3), narrow pubic arches and TURP defects were treated satisfactorily. Symptoms of urinary irritation occurred with variable intensity and abated rapidly 2 weeks after the procedures. There was no high-grade chronic rectal morbidity and most patients reported no rectal symptoms or treatment-related chronic urinary incontinence. CONCLUSIONS: The non-fixed template technique allowed flexibility in flexiguide placement to encompass large glands (>60 cm(3)), extracapsular extension and seminal vesicle involvement without the need for additional flexiguides. Also, small pubic arches and TURP defects posed little problem in positioning the flexiguides. This versatility resulted in complete treatment volume coverage of the prostate.

High dose rate transperineal interstitial brachytherapy for cervical cancer: high pelvic control and low complication rates.

PURPOSE: To report the clinical outcome for cervical carcinoma treated with external beam pelvic radiotherapy and interstitial high dose rate (IS-HDR) brachytherapy. METHODS AND MATERIALS: Between July 1991 and June 1996, 62 patients with locally advanced stage cervical carcinoma or early stage carcinoma that precluded satisfactory tandem and ovoid insertion were treated. Most patients received 36 Gy (range: 25 Gy-45 Gy) external beam radiotherapy (EBRT) to the pelvis prior to brachytherapy implant. EBRT was continued, with central shielding, to a dose of 50 Gy to the pelvic sidewalls. HDR Iridium-192 brachytherapy was given in 6 fractions of 5.5 to 6.0 Gy. The mean follow-up was 40 months. RESULTS: Stage distribution was: Stage IB (12), Stage IIA (1), Stage IIB (26), Stage IIIA (6), Stage IIIB (13), and Stage IVA (4). The overall local tumor control was 94%. Local control rates by FIGO stage were Stage I (12/12) 100%, Stage II (25/27) 93%, Stage III (18/19) 95%, and Stage IV (3/4) 75%. The regional pelvic control rates were overall 81%, Stage I (12/12) 100%, Stage II (22/27) 81%, Stage III (15/19) 79%, and Stage IV (1/4) 25%. Distant metastasis developed in 20 patients (32%). The actuarial 5-year disease-free survival was for all patients 48%, Stage I 81%, Stage II 47%, Stage III 39%, and Stage IV O%. Grade 3-4 delayed morbidity resulting from treatment, occurred in 6.5% (4/62) of patients. A fistula without local recurrence occurred in 1.6% (1/62) patients. CONCLUSIONS: We report excellent local and regional pelvic control results using a 6 fraction IS-HDR brachytherapy protocol for cervical carcinoma. The incidence of severe complications is low and suggests that a consistent brachytherapy technique and multiple HDR fractions are therapeutically advantageous to patients treated for cervical carcinoma.

High dose rate brachytherapy in the treatment of prostate cancer.

Because the HDR brachytherapy treatments are delivered within minutes and on an outpatient basis, HDR brachytherapy is very well tolerated by patients and offers complete radiation safety. Published studies2, 11, 12, 13, 16, 17, 18, 22, 24, 25 have shown high local clinical and biochemical control rates. Chronic complications have been acceptably low. Very low rates of urinary incontinence and high sexual potency rates have been reported. Gastrointestinal morbidity has been minimal. The development of Ir-192 HDR afterloading brachytherapy and refinements in the dosimetry have ushered in a new era in prostate brachytherapy. The control of the radiation dose and the ability to shape the radiation treatment envelope using a stepping source have allowed a giant step forward in radiation oncology technology. It is now possible to deliver tumoricidal doses of radiation conformally to the prostate while minimizing the dose to the bladder, urethra, and rectum. At present, HDR afterloaded brachytherapy is the optimal whole-organ and tumor-specific conformal radiation therapy for prostate cancer.

The use and advantages of a multichannel vaginal cylinder in high-dose-rate brachytherapy.

PURPOSE: This paper describes California Endocurietherapy's (CET) high-dose-rate (HDR) multichannel cylinder, the rationale for its design, procedure for its insertion, and the dosimetry involved in its use. A study was done that compared the doses achieved using the CET multichannel cylinder to the same cylinder if it only had a central channel. METHODS AND MATERIALS: The CET multichannel vaginal cylinder was inexpensively constructed, using parts from various suppliers. After insertion in the patient, the cylinder is affixed to a base plate to prevent displacement. Two sets of orthogonal films (without and with rectal barium) are taken in preparation for digitization of the catheters, bladder, rectal, and pelvic sidewall points. Using HDR brachytherapy planning software, the dose distribution is adjusted to achieve the prescribed dose (5 Gy HDR) 5 mm lateral to the cylinder surface, 5 mm lateral at the proximal parametrial tissue, and 4 mm superior to the vaginal apex. Doses to the bladder and rectum are limited to approximately 85% and 75%, respectively, of the prescribed dose. The plan is optimized on geometric parameters. For dose comparison to treatment using a central channel cylinder, the lateral channels are de-activated, leaving only the central channel activated. Dose points are placed 5 mm laterally and superiorly from the cylinder surface, and the plan is optimized to deliver a uniform dose to the defined dose points. The doses and treatment volumes are statistically compared. RESULTS: The CET multichannel cylinder allows much better dose control than the central channel cylinder. The multichannel cylinder achieves lower bladder and rectal doses by 14% and 15%, respectively, when compared to the central channel cylinder. By increasing the dwell times of certain dwell positions, the prescription dose is achieved in the vaginal apex and proximal parametrial tissues and along the length of the cylinder. CONCLUSION: The multichannel cylinder enables more flexibility in isodose shaping and dose control to various points and structures when compared to the conventional central channel cylinder.

Hormone receptors in hepatoblastoma: a demonstration of both estrogen and progesterone receptors.

A case of mixed hepatoblastoma occurring in a four-year-old girl is described. Light and electron micrographs illustrate a predominant mesenchymal component and a less conspicuous epithelial element. The tumor contained specific cytosolic protein receptors for estrogen and progesterone. The estrogen receptor titer was 10.5 fmol/mg cytosol protein and the progesterone receptor titer was 62.2 fmol/mg cytosol protein.

Hepatomas: hormone receptors and therapy.

Prompted by studies that suggested a causal relationship between sex steroids and human liver cancer, we assayed specimens of hepatoma from five patients and adjacent liver tissue from three of the same patients for estrogen receptors. After finding that the assay material contained specific cytosolic receptor proteins for estradiol, we treated a second group of five patients who had hepatomas with progestin. This therapy resulted in tumor regression in two of these patients.

Bone involvement in hairy-cell leukemia.

Destructive bone involvement is a rarely recognized complication of hairy-cell leukemia (leukemic reticuloendotheliosis). We report a case in which localized hip pain and lytic bone lesions were the presenting manifestations. A second case of bone involvement in a patient with previously diagnosed hairy-cell leukemia is also described. These cases are compared with the nine cases of hairy-cell leukemia with bone involvement previously published in the medical literature.

Behçet's disease: a case with hemoptysis, pseudotumor cerbri, and arteritis.

A case of Behçet's diease with massive hemoptyis is described. The hemoptysis occurred during disease exacerbation with extensive oropharyngeal and laryngeal ulcerations, and responded to high-dose corticosteroid therapy. Other unusual manifestations included a light sensitive dermatitis, pseudotumor cerebri, and right bundle branch block. Also, arteritis and subsequent occlusion of the femoral and popliteal arteries occurred. Although uncommon, pumonary involvement may be life-threatening and should be treated with corticosteroids. Both pulmonary and neurologic involvement tend to occur with active aphthosis and respond to corticosteroids. This case underscores the protean nature of the organ system involvement in Behçet's disease and supports the concept that vasculitis is a primary pathophysiologic event.