Definitive high-dose-rate endobronchial brachytherapy of bronchial stump for lung cancer after surgery.

PURPOSE: The aim of this work was to evaluate outcomes after definitive high-dose-rate endobronchial brachytherapy (HDR-BT) for lung cancer. METHODS AND MATERIAL: We treated 34 patients after surgery for lung cancer, without nodal or distant metastases, with HDR-BT. Two groups were analyzed, one with local recurrence in stump after prior surgery (n = 13) and a second with nonradical primary lobar resection found in histopathologically positive margins (n = 21). There were 27 men and 7 women with a median age of 57.4 years. Twenty-five patients received sole brachytherapy with 4 fractions of 7.5 Gy and 9 received combined treatment consisting of 2 fractions of 6 Gy (HDR-BT) and 50 Gy from external beam radiotherapy. Overall survival time (OS) and overall disease-free survival time (OFS) were compared with prognostic factors. RESULTS: The complete local and radiologic response rate evaluated at the first month after HDR-BT was 73.5% (25/34). The partial response rate was 26.5%. OFS time in total group was 17.4 months; OS was 18.8 months. Differences were found in OS between both groups-primary tumor or recurrence (log-rank test, p = 0.048). Differences were not found according to gender (p = 0.36), clinical stage (p = 0.76), histopathology (p = 0.93), treatment dose (p = 0.45), sole or combined treatment (p = 0.16), or grade of remission in week 4 (p = 0.15). CONCLUSIONS: HDR-BT of a stump recurrence or after nonradical resection leads to a long-term OS rate in patients with localized lung cancer and could be considered curative. We found no correlations between OS and chosen clinical data; adjuvant HDR-BT gave better results.

Thermal boost combined with interstitial brachytherapy in breast conserving therapy - Assessment of early toxicity.

BACKGROUND: Hyperthermia (HT) causes a direct damage to cancerous cells and/or sensitize them to radiotherapy with usually minimal injury to normal tissues. Adjuvant HT is probably one of the most effective radiation sensitizers known and works best when delivered simultaneously with radiation. In breast conserving therapy, irradiation has to minimize the risk of local relapse within the treated breast, especially in an area of a tumor bed. Brachytherapy boost reduces 5-year local recurrence rate to mean 5,5%, so there still some place for further improvement. The investigated therapeutic option is an adjuvant single session of local HT (thermal boost) preceding standard CT-based multicatheter interstitial HDR brachytherapy boost in order to increase the probability of local cure. AIM: To report the short-term results in regard to early toxicity of high-dose-rate (HDR) brachytherapy (BT) boost with or without interstitial microwave hyperthermia (MV HT) for early breast cancer patients treated with breast conserving therapy (BCT). MATERIALS AND METHODS: Between February 2006 and December 2007, 57 stage IA-IIIA breast cancer patients received a 10 Gy HDR BT boost after conservative surgery and 42.5-50 Gy whole breast irradiation (WBI) ± adjuvant chemotherapy. 32 patients (56.1%) were treated with additional pre-BT single session of interstitial MW HT to a tumor bed (multi-catheter technique). Reference temperature was 43 °C and therapeutic time (TT) was 1 h. Incidence, severity and duration of radiodermatitis, skin oedema and skin erythema in groups with (I) or without HT (II) were assessed, significant p-value ≤ 0.05. RESULTS: Median follow-up was 40 months. Local control was 100% and distant metastasis free survival was 91.1%. HT sessions (median): reference temperature 42.2 °C, therapeutic time (TT) 61.4 min, total thermal dose 42 min and a gap between HT and BT 30 min. Radiodermatitis grades I and II occurred in 24 and 6 patients, respectively, differences between groups I and II were not significant. Skin oedema and erythema occurred in 48 (85.7%) and 36 (64.3%) cases, respectively, and were equally distributed between the groups. The incidence and duration of skin oedema differed between the subgroups treated with different fractionation protocols of WBI, p = 0.006. Skin oedema was present up to 12 months. No difference in pattern of oedema regression between groups I and II was observed, p = 0.933. CONCLUSION: Additional thermal boost preceding standard HDR BT boost has a potential of further improvement in breast cancer local control in BCT. Pre-BT hyperthermia did not increase early toxicity in patients treated with BCT and was well tolerated. All side effects of combined treatment were transient and were present for up to 12 months. The increase in incidence of skin oedema was related to hypofractionated protocols of WBI. The study has to be randomized and continued on a larger group of breast cancer patients to verify the potential of local control improvement and to assess the profile of late toxicity.

HDR brachytherapy of prostate cancer - two years experience in Greater Poland Cancer Centre.

PURPOSE: The aim of this work was to analyze the results and complications of three treatment schemes of patients with initially localized prostate cancer after two years of observation time. MATERIAL AND METHODS: Sixty-three patients were enrolled into the study and divided into groups according to radiation schemes (I group - EBRT 50 Gy/BRT 15 Gy, II - EBRT 46 Gy/BRT 2 × 10 Gy, III group - BRT 3 × 15 Gy). Group I, II and III consisted of 46 (73%), 14 (22.2%), 3 (4.8%) patients, respectively. The low-, intermediate- and high risk groups consisted of 23 (36.5%), 18 (28.5%) and 22 (35%) men, respectively. Results and tolerance of the treatment and acute complications in analyzed groups were discussed. RESULTS: Median observation time was 24 months. Complete remission was observed in 43 patients (68.3%) out of the whole group. Locoregional and distal metastases progression were noted in 4 patients (6.4%). Partial remission was observed in low-, intermediate- and high risk group: 7.9%, 9.5% and 9.5% of all men. Nadir of PSA results were estimated as mean value of 0.094 ng/ml, average 0.0-0.63. The mean value for the complete group decreased from 0.98 ng/ml (range 0.0-9.7) in the third months to 0.32 ng/ml after one year (0.0-3.34) of the end of treatment time. Urologic and gastrointenstinal side effects were noted in different rates according to 1 month observation (dysuria - 22.2%, urinary incontinence - 7.9%, frequency - 58.7%, weak stream - 68.3%, rectal bleeding - 15.9%). CONCLUSIONS: 1. HDR brachytherapy of prostate cancer can be used as a boost after or before the external beam radiation therapy in different treatment schemes. 2. In selected groups under investigation trials, sole HDR-BRT is a suitable method of treatment. 3. To confirm superiority of analyzed modality treatment a prospective investigation with larger groups of patients would be required.

Vital role of volume and number of needles in HDR brachytherapy (HDR-BT) of prostate cancer.

PURPOSE: The quality of HDR-BT of prostate cancer depends on operator skills, anatomy, prostate volume and relation to surrounding tissues as well as previous diseases and treatments of a patient. There is a rare data available concerning the minimum number of needles and its influence on dose distribution, side effects and long-term outcome. The study is to determine the minimal prostate volume and minimum number of needles suitable for HDR-BT in order to obtain an implant of good quality. MATERIAL AND METHODS: 181 patients with localized prostate cancer were treated with interstitial HDR-BT boost. 15 Gy from HDR-BT was administered after 50 Gy from EBRT. Clinical, volumetric and dosimetric data were collected. Treatment plans were divided into Group A, consisted of optimal treatment plans (P-D90 > 90%, P-V200 < 15%, U-D10 < 125%, U-Dmax < 160%, R-D10 < 85%) and Group B, with suboptimal plans. RESULTS: The difference between two groups was statistically significant (p = 0.013) with regard to number of needles. There was no statistically significant difference concerning prostatic volume. Median number of inserted needles in the first and the second group resulted in 15 (range 9-18) and 13 (range 8-18), respectively. Differences were the most eminent in patients with prostate glands of small volume (< 20 cc). In the study, either the minimum number of needles nor minimal prostate gland volume were not clearly defined in terms of high probability of achieving a good quality implant. CONCLUSIONS: Larger volume and higher number of needles are related to an advanced probability of treatment plan with all DVC fulfilled. The minimum number of needles suggested is > 9, optimally ≥ 13. Furthermore, the minimal prostate volume recommended is > 12 cc, optimally ≥ 18 cc. The volume of insufficient size and/or small number of needles results in suboptimal treatment plans.

HDR endobronchial brachytherapy (HDRBT) in the management of advanced lung cancer--comparison of two different dose schedules.

PURPOSE: The aim of this work is to compare the results of various treatment protocols used in palliative HDRBT with the view of analyzing differences in survival and diminishing breathing difficulties. MATERIAL AND METHODS: A total of 648 patients with advanced lung cancer were divided into two groups according to their clinical stage and the Zubrod-ECOG-WHO score. 303 (46.8%) patients received a total dose of 22.5 Gy in 3 fractions once a week, and 345 (53.2%) patients received a single fraction of 10 Gy. They were under clinical and endobronchial observation taking into consideration survival rates, local remission and duration of symptom relief such as dyspnoea, breathing, cough and haemoptysis. RESULTS: There was no difference in the length of survival time between the two groups of patients (log-rank test, p=0.055). Patients showing improvement (objective response) survived longer than those who showed no change or progression (F Cox, p=0.000001). In multivariate analysis the other statistically important prognostic factors were: clinical stage of primary tumor (F Cox, p=0.000002), Zubrod-ECOG-WHO score (F Cox, p=0.002) and age of patients (F Cox, p=0.004). CONCLUSIONS: The two treatment protocols showed similar efficiency in overcoming difficulties in breathing. Prognostic factors that significantly correlated with survival length were: grade of remission after treatment, clinical stage and performance status.

Correlation between treatment plan parameters and particular prognostic factors in prostate cancer treated with high-dose-rate brachytherapy (HDR-BT) as a boost.

PURPOSE: Certain constraints for target coverage and dose limits in Organs at Risk (OARs) shows some evidence that doses values and homogeneity index in treated volume depends on prognostic factors such as prostate volume, location of urethra and the number of inserted applicators. Our study is to determine the relation between values of the doses in prostate, OARs and particular prognostic factors related to HDR-BT of prostate cancer. MATERIAL AND METHODS: The amount of 190 patients with localized prostate cancer were treated with interstitial HDR-BT between July 2006 and July 2007. The HDR-BT was administered as a boost for previously delivered 50 Gy dose from external beam radiotherapy. Dose volume parameters were determined such as: Dmin, Dmax, Dmean, D90, V100, V150 and V200 for prostate and Dmin, Dmax, Dmean, D10 and V100 for urethra and rectum (OARs), respectively. These parameters were correlated with prognostic factors such as: age, staging (TNM), Gleason score, initial PSA level (i-PSA), number of needles and volume of the prostate. RESULTS: The mean value of D90 was 91.3%, range 65.9-102.8%. Mean urethral D10 was 121, 8%, range 78.8-152.9%. Mean rectal D10 was 81.3%, range 37.4-101.0%. Statistically significant relationship was found between staging (TNM), prostate volume, and the number of needles used for implant and increased prostate D90 and decreased V200. The prognostic factor was only the age which was related to increased urethral D10 and Dmax. No correlation was found between any prognostic factor and rectal wall DVH parameters. CONCLUSIONS: Increased prostate volume with improved D90 and greater number of implanted needles results in better target coverage (higher V100), better dose distribution (lower V200) and decreased dose delivered to the urethra (lower urethral D10, Dmax), with no evident influence on rectal wall. Further investigation with closed follow-up should give an answer whether the above corresponds with morbidity and outcome.

HDR brachytherapy (HDR-BT) combined with stent placement in palliative treatment of esophageal cancer.

PURPOSE: In the study we present the initial results of palliative treatment using combined methods of HDR-BT and stent insertion in patients with advanced esophagus cancer. MATERIAL AND METHODS: Fifty patients were treated in the Great Poland Cancer Center using HDR-BT between June 2001 and December 2005 and they were enrolled into the study. All patients underwent endoscopic insertion of self-expanding, metal, endoesophageal stents owing to blockages in the lumen of the esophagus which excluded brachytherapy. The group included 41 men and 9 women, aged between 44 and 79 years (average 59.3 years). 36 of patients received 3 fractions of HDR once a week of 7.5 Gy, up to total dose of 22.5 Gy, 14 patients received 2 fractions of 7.5 Gy (15 Gy). RESULTS: The average patient observation period was 5.4 months. Complete remission (CR) was observed after 4 weeks in 2 cases (4%), partial remission (PR) in 31 (62%), no remission (NR) was seen in 6 patients (12%) and progression was noted in 11 cases (22%). Complications of brachytherapy for esophageal cancer were observed in 11 patients (22%), ulceration in 1 patient (2%), haemorrhage in 1 patient (2%) and bronchotracheal fistulas in 9 (18%) patients. The average observation period for patients with bronchotracheal fistulas was notably shorter than in remaining patients and amounted 3.5 months. CONCLUSIONS: 1. Endoscopic implantation of stents to the lumen of the esophagus provides access to esophagus and, in many cases, allows application of HDR-BT. 2. HDR-BT for advanced esophageal cancer brought relief from dysphagia in most of patients. 3. The combination of the two methods of treatment represents an effective choice for palliative care of this group of patients, with a complication rate similar to observed one in the instance of brachytherapy alone.

[Oral appliances in the treatment of snoring]. / Ustne aparaty protetyczne w leczeniu chrapania.

There are many methods of snoring treatment from conservative and prosthetic to surgical. The snoring sound is produced by vibration of the soft tissues of the pharynx, soft palate and also uvula. Snoring occurs in 50% of the adult male population and it can be isolated or sign of the obstructive sleep apnoea syndrome. Oral appliances modify the position of the mandibule, the tongue and other structures in oral cavity. Oral appliances are recommended for the treatment of snoring and mild obstructive sleep apnoea syndrome. That is why we constructed the study to assess wheather oral appliances correct snoring. 12 mails (aged 43-57) with intensive snoring for at least 50% of the sleep time were qualified to the treatment with oral appliances. The decision about the type of the device were made by ENT surgeon and maxillo-facial surgeon. The various oral appliances were used; some of which were modyfied by us. During the treatment snoring was tested with Poly-Mesam device. The best results were obtained with the use of devices that correct the position of soft palate and uvula. All the devices decreased snoring significantly. They were tolerated by the majority of patients.