Image-guided interstitial high-dose-rate brachytherapy in the treatment of inoperable recurrent head and neck malignancies: An effective option of reirradiation.

BACKGROUND: In recurrent head and neck cancer, therapeutic options are limited and high-quality evidence is rare. The purpose of this report was to present our experience of CT-guided interstitial high-dose rate (HDR) brachytherapy in 4 challenging cases of inoperable recurrent head and neck cancer. METHODS: A 53-year-old man with mucosal melanoma of the paranasal sinuses, a 61-year-old man with myofibroblastic sarcoma of the nasal cavity, a 51-year-old woman with nasopharyngeal cancer, and a 44-year-old woman with orbital leiomyosarcoma were treated with reirradiation by HDR brachytherapy after previous comprehensive therapy, including full course external radiotherapy (RT). RESULTS: All patients showed response to brachytherapy with 1 patient experiencing locoregional failure. The mean lesion-specific disease control was 15 months. Currently, 1 patient is alive and 3 patients died after mean 20 months after treatment. CONCLUSION: In patients with inoperable recurrent head and neck cancer, CT-guided interstitial HDR brachytherapy can play a role in providing palliation and tumor control. © 2017 Wiley Periodicals, Inc. Head Neck 39: E61-E68, 2017.

Computed tomography-guided interstitial high dose rate brachytherapy for centrally located liver tumours: a single institution study.

OBJECTIVES: To evaluate the clinical outcome of computed tomography (CT)-guided interstitial (IRT) high-dose-rate (HDR) brachytherapy (BRT) in the treatment of unresectable primary and secondary liver malignancies. This report updates and expands our previously described experience with this treatment technique. METHODS: Forty-one patients with 50 tumours adjacent to the liver hilum and bile duct bifurcation were treated in 59 interventions of CT-guided IRT HDR BRT. The tumours were larger than 4 cm with a median volume of 84 cm(3) (38-1,348 cm(3)). The IRT HDR BRT delivered a median total physical dose of 20.0 Gy (7.0-32.0 Gy) in twice daily fractions of median 7.0 Gy (4.0-10.0 Gy) in 19 patients and in once daily fractions of median 8.0 Gy (7.0-14.0 Gy) in 22 patients. RESULTS: With a median follow-up of 12.4 months, the local control for metastatic hepatic tumours was 89 %, 73 % and 63 % at 6, 12 and 18 months respectively. The local control for primary hepatic tumours was 90 %, 81 % and 50 % at 6, 12 and 18 months respectively. Severe side effects occurred in 5.0 % of interventions with no treatment-related deaths. CONCLUSIONS: CT-guided IRT HDR BRT is a promising procedure for the radiation treatment of centrally located liver malignancies. KEY POINTS: • Interstitial high-dose-rate brachytherapy (IRT HDR BRT) is a promising treatment for central liver tumours • CT-guided IRT HDR BRT is safe for treating extensive tumours • CT-guided IRT HDR BRT could play a role in managing unresectable hepatic malignancies.

Hypofractionated accelerated computed tomography-guided interstitial high-dose-rate brachytherapy for liver malignancies.

PURPOSE: To report our results of computed tomography (CT)-guided interstitial high-dose-rate (HDR) brachytherapy (BRT) in the local treatment of inoperable primary and secondary liver malignancies. METHODS AND MATERIALS: Between 2000 and 2009, 31 patients underwent a total of 42 BRT procedures for 36 hepatic lesions exceeding 4 cm and located adjacent to the liver hilum and bile duct bifurcation. The median tumor volume was 99 cm(3) (range, 46-1348 cm(3)). The median age was 64 years (range, 27-85 years). The HDR-BRT delivered a median total physical dose of 13.0 Gy (range, 7.0-32.0 Gy) in twice daily fractions of median 7.0 Gy (range, 4.0-10.0 Gy) in 14 patients and in once daily fractions of median 8.0 Gy (range, 7.0-14.0 Gy) in 17 patients. RESULTS: The median followup was 13.3 months with an overall survival rate of 66% at 1 year. The local control rate for patients with metastatic lesions was 79%, 59%, and 59%, and for the subgroup with primary hepatic tumors 88%, 50%, and 50% at 1, 2, and 3 years, respectively. Severe side effects occurred in 4.7% of BRT procedures with no treatment-related deaths. CONCLUSIONS: Our results confirm CT-guided interstitial HDR-BRT to be a safe procedure for the local treatment of inoperable liver malignancies unsuitable for thermal ablation.

Computed tomography-guided interstitial high-dose-rate brachytherapy in the local treatment of primary and secondary intrathoracic malignancies.

INTRODUCTION: Image-guided interstitial (IRT) brachytherapy (BRT) is an effective treatment option as part of a multimodal approach to the treatment of isolated lung tumors. In this study, we report our results of computed tomography-guided IRT high-dose-rate (HDR) BRT in the local treatment of inoperable primary and secondary intrathoracic malignancies. METHODS: Between 1997 and 2007, 55 patients underwent a total of 68 interventional procedures for a total of 60 lung lesions. The median tumor volume was 160 cm³ (range, 24-583 cm³). Thirty-seven patients were men and 18 were women, with a median age of 64 years (range, 31-93 years). The IRT-HDR-BRT delivered a median dose of 25.0 Gy (range, 10.0-32.0 Gy) in twice-daily fractions of 4.0 to 15.0 Gy in 27 patients and 10.0 Gy (range, 7.0-32.0 Gy) in once-daily fractions of 4.0 to 20.0 Gy in 28 patients. RESULTS: The median follow-up was 14 months (range, 1-49 months). The overall survival rate was 63% at 1 year, 26% at 2 years, and 7% at 3 years. The local control rate for metastatic tumors was 93%, 82%, and 82% and for primary intrathoracic cancers 86%, 79%, and 73% at 1, 2, and 3 years, respectively. Pneumothoraces occurred in 11.7% of interventional procedures, necessitating postprocedural drainage in one (1.8%) patient. CONCLUSIONS: In patients with inoperable intrathoracic malignancies, computed tomography-guided IRT-HDR-BRT is a safe and effective alternative to other locally ablative techniques.

Hypofractionated accelerated CT-guided interstitial ¹9²Ir-HDR-Brachytherapy as re-irradiation in inoperable recurrent cervical lymphadenopathy from head and neck cancer.

BACKGROUND: Despite significant improvements in the treatment of head and neck cancer (HNC), lymph node recurrences remain a clinical challenge after primary radiotherapy. The value of interstitial (IRT) brachytherapy (BRT) for control of lymph node recurrence remains unclear. In order to clarify its role a retrospective review was undertaken on the value of computed tomography (CT)-guided IRT high-dose-rate (HDR)-BRT in isolated recurrent disease from HNC. PATIENTS AND METHODS: From 2000 to 2007, 74 patients were treated for inoperable recurrent cervical lymphadenopathy. All patients had previously been treated with radical radiotherapy or chemoradiation with or without surgery. The HDR-BRT delivered a median salvage dose of 30.0 Gy (range, 12.0-36.0 Gy) in twice-daily fractions of 2.0-5.0 Gy in 71 patients and of 30.0 Gy (range, 10.0-36.0 Gy) in once-daily fractions of 6.0-10.0 Gy in three patients. RESULTS: The overall and disease-free survival rates at one, two and three years were 42%, 19%, 6%, and 42%, 37% and 19%, respectively. The local control probability at one, two and three years was 67% at all three time points. Grade III-IV complications occurred in 13% of patients. CONCLUSIONS: In patients with inoperable recurrent neck disease from HNC, hypofractionated accelerated CT-guided IRT-HDR-BRT can play an important role in providing palliation and tumor control.

CT-guided interstitial HDR brachytherapy for recurrent glioblastoma multiforme. Long-term results.

BACKGROUND AND PURPOSE: Recurrences of glioblastoma multiforme (GBM) within previously irradiated volumes pose a serious therapeutic challenge. This retrospective study evaluates the long-term tumor control of recurrent GBM treated with interstitial high-dose-rate brachytherapy (HDR-BRT). PATIENTS AND METHODS: Between 1995 and 2003, 84 patients were treated for recurrent cerebral GBM located within previously irradiated volumes. All patients had received adjuvant external radiotherapy following primary surgery, with a focal dose up to 60 Gy. The median recurrent tumor volume was 51 cm(3) (3-207 cm(3)), and the HDR-BRT consisted of an afterloading (192)Ir implant which delivered a median dose of 40 Gy (30-50 Gy). Catheter implantation was implemented using interactive computed tomography (CT) guidance under local anesthesia and sedoanalgesia. RESULTS: After a median follow-up of 61 months, 5/84 patients (6%) were alive. The median post-BRT survival was 37 weeks, and the median overall survival 78 weeks. Moderate to severe complications occurred in 5/84 cases (6%). CONCLUSION: For patients with recurrences of GBM within previously irradiated volumes, CT-guided interstitial HDR-BRT is a feasible treatment option that can play an important role in providing palliation.

[Extraordinary manifestation of a gastric carcinoma by leptomeningeal carcinomatosis and spinal metastasis]. / Aussergewöhnliche Manifestation eines Magenkarzinoms mit Meningeosis carcinomatosa und spinaler Metastase.

BACKGROUND: Leptomeningeal carcinomatosis is a rare complication of solid tumors, e. g., breast, lung and gastrointestinal carcinomas. Clinical manifestations are variable with radicular pains with or without neurologic deficiencies as well as headache and hallucinations. CASE REPORT: The rare case of a 57-year-old patient with neurologic symptoms caused by a leptomeningeal carcinomatosis and a spinal metastasis of an asymptomatic signet-ring cell gastric carcinoma is reported. In spite of combined radiochemotherapy the patient died already 4 weeks after discharge from hospital due to an intracerebral hemorrhage. CONCLUSION: Until today, prognosis of leptomeningeal carcinomatosis is poor with a median survival between 3-4 months independently of the primary tumor.

Reirradiation for recurrent neck metastases of head-and-neck tumors using CT-guided interstitial 192Ir HDR brachytherapy.

PURPOSE: To report the therapeutic results obtained with CT-guided interstitial high-dose-rate brachytherapy (HDR-BRT) as exclusive treatment for recurrent neck metastases of head-and-neck tumors. PATIENTS AND METHODS: Between 1995 and 1999, 49 patients with prior radiation therapy (RT) with or without surgery for primary head-and-neck tumors were treated for recurrent neck metastases located within previously irradiated volumes. All patients had fixed lymphadenopathy with a mean tumor volume of 96 cm(3) (range, 15-452 cm(3)). There were 38 males and eleven females with a mean age of 60 years (range, 28-79 years). All patients had previously received RT as primary or adjuvant treatment with a mean dose of 54 Gy (range, 45-80 Gy). 36 patients (73%) underwent surgery, and 26 (53%) received adjuvant or palliative chemotherapy. The accelerated hyperfractionated interstitial HDR-BRT (2 x 3.0 Gy/day) delivered 30 Gy in 37/49 (75%) and 36 Gy in 12/49 implants (25%). RESULTS: At a minimum 6-week follow-up, the response rate was 83% (41/49) with complete remission in 20% (10/49) and partial remission in 63% (31/49) of the implanted tumor sites. 8/49 patients (17%) did not respond to the treatment. After 19 months of median follow-up, the local control rate was 69% and a total of 15/49 patients (30%) experienced local disease progression. Of these, nine (18%) had locoregional progression and six (12%) progression within the treated volume. The median post-BRT survival was 14 months. The overall survival rate was 52% at 1 year, 31% at 2 years, and 6% at 3 years. CONCLUSION: In patients with recurrent cervical lymphadenopathy of head-and-neck tumors, exclusive interstitial HDR-BRT can provide palliation and tumor control.

Neoadjuvant interstitial high-dose-rate (HDR) brachytherapy combined with systemic chemotherapy in patients with breast cancer.

BACKGROUND AND PURPOSE: This is the first study investigating neoadjuvant interstitial high-dose-rate (HDR) brachytherapy combined with chemotherapy in patients with breast cancer. The goal was to evaluate the type of surgical treatment, histopathologic response, side effects, local control, and survival. PATIENTS AND METHODS: 53 patients, who could not be treated with breast-conserving surgery due to initial tumor size (36/53) or due to an unfavorable breast-tumor ratio (17/53), were analyzed retrospectively. All but one were in an intermediate/high-risk group (St. Gallen criteria). The patients received a neoadjuvant protocol consisting of systemic chemotherapy combined with fractionated HDR brachytherapy (2 x 5 Gy/day, total dose 30 Gy). In cases, where breast-conserving surgery was performed, patients received additional external-beam radiotherapy (EBRT, 1.8 Gy/day, total dose 50.4 Gy). In patients, who underwent mastectomy but showed an initial tumor size of T3/T4 and/or more than three infiltrated lymph nodes, EBRT was also performed. RESULTS: In 30/53 patients (56.6%) breast-conserving surgery could be performed. The overall histopathologic response rate was 96.2% with a complete remission in 28.3% of patients. 49/53 patients were evaluable for follow-up. After a median of 58 months (45-72 months), one patient showed a mild fibrosis of the breast tissue, three patients had mild to moderate lymphatic edema of the arm. 6/49 (12.2%) patients died of distant metastases, 4/49 (8.2%) were alive with disease, and 39/49 (79.6%) were free from disease. Local recurrence was observed in only one case (2%) 40 months after primary therapy. After mastectomy, this patient is currently free from disease. CONCLUSION: The combination of interstitial HDR brachytherapy and chemotherapy is a well-tolerated and effective neoadjuvant treatment in patients with breast cancer. Compared to EBRT, treatment time is short. Postoperative EBRT of the whole breast -- if necessary -- is still possible after neoadjuvant brachytherapy. Even though the number of patients does not permit definite conclusions, the results are promising regarding survival and the very low rate of local recurrences.

Applicability and dosimetric impact of ultrasound-based preplanning in high-dose-rate brachytherapy of prostate cancer.

BACKGROUND AND PURPOSE: Analyses of permanent brachytherapy seed implants of the prostate have demonstrated that the use of a preplan may lead to a considerable decrease of dosimetric implant quality. The authors aimed to determine whether the same drawbacks of preplanning also apply to high-dose-rate (HDR) brachytherapy. PATIENTS AND METHODS: 15 patients who underwent two separate HDR brachytherapy implants in addition to external-beam radiation therapy for advanced prostate cancer were analyzed. A pretherapeutic transrectal ultrasound was performed in all patients to generate a preplan for the first brachytherapy implant. For the second brachytherapy, a subset of patients were treated by preplans based on the ultrasound from the first brachytherapy implant. Preplans were compared with the respective postplans assessing the following parameters: coverage index, minimum target dose, homogeneity index, and dose exposure of organs at risk. The prostate geometries (volume, width, height, length) were compared as well. RESULTS: At the first brachytherapy, the matching between the preplan and actual implant geometry was sufficient in 47% of the patients, and the preplan could be applied. The dosimetric implant quality decreased considerably: the mean coverage differed by -0.11, the mean minimum target dose by -0.15, the mean homogeneity index by -0.09. The exposure of organs at risk was not substantially altered. At the second brachytherapy, all patients could be treated by the preplan; the differences between the implant quality parameters were less pronounced. The changes of prostate geometry between preplans and postplans were considerable, the differences in volume ranging from -8.0 to 13.8 cm(3) and in dimensions (width, height, length) from -1.1 to 1.0 cm. CONCLUSION: Preplanning in HDR brachytherapy of the prostate is associated with a substantial decrease of dosimetric implant quality, when the preplan is based on a pretherapeutic ultrasound. The implant quality is less impaired in subsequent implants of fractionated brachytherapy.

3D conformal HDR brachytherapy and external beam irradiation combined with temporary androgen deprivation in the treatment of localized prostate cancer.

PURPOSE: To evaluate treatment outcome of 3D conformal high dose rate (HDR) brachytherapy and external beam irradiation (EBRT) combined with temporary androgen deprivation for patients with localized prostate cancer. PATIENTS AND METHODS: Between January 1997 and September 1999 we treated 102 patients with stage T1-3 N0 M0 prostate cancer. Stage T1-2 was found in 71, T3 in 31 patients. Median pretreatment PSA level was 15.3 ng/ml. After ultrasound-guided transrectal implantation of four afterloading needles, CT based 3D brachytherapy planning was performed. All patients received four HDR implants using a reference dose per implant of 5 or 7Gy. Time between each implant was 14 days. After brachytherapy EBRT followed up to 39.6 or 45.0 Gy. All patients received temporary androgen deprivation, starting 2-19 months before brachytherapy, ending 3 months after EBRT. RESULTS: Median follow-up was 2.6 years (range 2.0-4.1 years). Actuarial biochemical control rate was 87% at 2 years and 82% at 3 years. In 14 patients we noted biochemical failure, in five patients clinical failure. Overall survival was 90%, disease specific survival 98.0% at 3 years. Acute grade 3 toxicity occurred in 4%, late grade 3 toxicity in 5%. One patient developed a prostatourethral-rectal fistula as late grade 4 toxicity. The conformal quality of 300 HDR implants was analyzed using dose volume histograms. CONCLUSIONS: 3D conformal HDR brachytherapy and EBRT combined with temporary androgen deprivation is an effective treatment modality for prostate cancer with minimal associated toxicity and encouraging biochemical control rates after a median follow-up of 2.6 years.

Palliative interstitial HDR brachytherapy for recurrent rectal cancer. Implantation techniques and results.

PURPOSE: To report the methods and clinical results of CT-based interstitial high-dose-rate (HDR) brachytherapy procedures for the palliative treatment of recurrent rectal cancer. PATIENTS AND METHODS: A total of 44 brachytherapy implants were performed in 38 patients. CT-guided catheter implants were performed in 34 patients under local anesthesia and sedation, and four patients were implanted intraoperatively. Of 40 CT-guided implants, 20 were done using metallic needles introduced via the sacrum and 20 were transperineal implants of plastic tubes in the presacral region. Postimplant CT scans were used for three-dimensional (3-D) conformal brachytherapy planning. Patients implanted with metallic needles were given a single fraction of 10-15 Gy using HDR (192)Ir, and those who received transperineal implants of plastic catheters were given fractionated brachytherapy, 5 Gy twice daily to a total dose of 30-40 Gy. The median tumor volume was 225 cm(3) with a range of 41-2,103 cm(3). RESULTS: After a median follow-up of 23.4 months, a total of 13/38 patients were alive. The median postbrachytherapy survival was 15 months with 18 of the 25 deaths due to distant metastases. Tumor response was as follows: 6/38 partial remission, 28/38 stable disease, and 4/38 local progression. A planning target volume (PTV) coverage > 85% was achieved in 42/44 implants. The treatment was well tolerated, and no acute complications were observed. One patient developed a fistula after 8 months. Pain relief was recorded in 34 patients (89.5%), and the median duration of this palliative effect was 5 months with a range of 1-13 months. CONCLUSIONS: Interstitial HDR brachytherapy is a valuable tool for the delivery of high doses and achieves effective palliation in recurrent rectal carcinoma.