Subjects -> MEDICAL SCIENCES (Total: 8447 journals)
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MEDICAL SCIENCES (2307 journals)            First | 1 2 3 4 5 6 7 8 | Last

Showing 201 - 400 of 3562 Journals sorted alphabetically
Atención Familiar     Open Access  
Atención Primaria     Open Access   (Followers: 2)
Atención Primaria Práctica     Open Access   (Followers: 1)
Atti della Accademia Peloritana dei Pericolanti - Classe di Scienze Medico-Biologiche     Open Access  
Audiology - Communication Research     Open Access   (Followers: 10)
Auris Nasus Larynx     Full-text available via subscription  
Australasian Journal of Ultrasound in Medicine (AJUM)     Hybrid Journal  
Australian Coeliac     Full-text available via subscription   (Followers: 1)
Australian Family Physician     Full-text available via subscription   (Followers: 3)
Australian Journal of Medical Science     Full-text available via subscription   (Followers: 2)
Autopsy and Case Reports     Open Access  
Avicenna     Open Access   (Followers: 3)
Avicenna Journal of Clinical Medicine     Open Access  
Avicenna Journal of Medicine     Open Access   (Followers: 1)
Bangabandhu Sheikh Mujib Medical University Journal     Open Access   (Followers: 1)
Bangladesh Journal of Anatomy     Open Access   (Followers: 2)
Bangladesh Journal of Bioethics     Open Access  
Bangladesh Journal of Medical Biochemistry     Open Access   (Followers: 4)
Bangladesh Journal of Medical Education     Open Access   (Followers: 2)
Bangladesh Journal of Medical Microbiology     Open Access   (Followers: 4)
Bangladesh Journal of Medical Physics     Open Access   (Followers: 1)
Bangladesh Journal of Medical Science     Open Access  
Bangladesh Journal of Medicine     Open Access   (Followers: 1)
Bangladesh Journal of Physiology and Pharmacology     Open Access  
Bangladesh Journal of Scientific Research     Open Access   (Followers: 1)
Bangladesh Medical Journal     Open Access  
Bangladesh Medical Journal Khulna     Open Access  
Basal Ganglia     Hybrid Journal  
Basic Sciences of Medicine     Open Access   (Followers: 2)
Batı Karadeniz Tıp Dergisi / Medical Journal of Western Black Sea     Open Access  
Baylor University Medical Center Proceedings     Hybrid Journal  
BBA Clinical     Open Access  
BC Medical Journal     Free  
Benha Medical Journal     Open Access  
Beni-Suef University Journal of Basic and Applied Sciences     Open Access   (Followers: 4)
Bijblijven     Hybrid Journal  
Bijzijn     Hybrid Journal   (Followers: 1)
Bijzijn XL     Hybrid Journal  
Bio-Algorithms and Med-Systems     Hybrid Journal   (Followers: 2)
BioDiscovery     Open Access   (Followers: 2)
Bioelectromagnetics     Hybrid Journal   (Followers: 2)
Bioelectronic Medicine     Open Access   (Followers: 1)
Bioengineering & Translational Medicine     Open Access  
Bioethics     Hybrid Journal   (Followers: 18)
Bioethics Research Notes     Full-text available via subscription   (Followers: 14)
Biologics in Therapy     Open Access  
Biology of Sex Differences     Open Access   (Followers: 2)
Biomarker Research     Open Access   (Followers: 3)
Biomarkers in Medicine     Hybrid Journal   (Followers: 2)
BioMed Research International     Open Access   (Followers: 4)
Biomédica     Open Access  
Biomedical & Life Sciences Collection     Full-text available via subscription   (Followers: 3)
Biomedical and Biotechnology Research Journal     Open Access   (Followers: 1)
Biomedical Engineering     Hybrid Journal   (Followers: 17)
Biomedical Engineering and Computational Biology     Open Access   (Followers: 13)
Biomedical Engineering Letters     Hybrid Journal   (Followers: 6)
Biomedical Engineering Research     Open Access   (Followers: 7)
Biomedical Informatics Insights     Open Access   (Followers: 8)
Biomedical Journal     Open Access   (Followers: 4)
Biomedical Materials     Hybrid Journal   (Followers: 7)
Biomedical Microdevices     Hybrid Journal   (Followers: 8)
Biomedical Optics Express     Open Access   (Followers: 6)
Biomedical Photonics     Open Access  
Biomedical Reports     Full-text available via subscription  
Biomedical Research Reports     Full-text available via subscription   (Followers: 2)
Biomedical Safety & Standards     Full-text available via subscription   (Followers: 8)
Biomedical Science and Engineering     Open Access   (Followers: 7)
BioMedicine     Open Access  
Biomedicine Hub     Open Access  
Biomedicines     Open Access   (Followers: 1)
Biomedika     Open Access  
Biomolecular and Health Science Journal     Open Access   (Followers: 1)
Biophysics Reports     Open Access  
BioPsychoSocial Medicine     Open Access   (Followers: 8)
Biosalud     Open Access   (Followers: 1)
Biostatistics & Epidemiology     Hybrid Journal   (Followers: 2)
Birat Journal of Health Sciences     Open Access  
BIRDEM Medical Journal     Open Access   (Followers: 1)
Birth Defects Research     Hybrid Journal  
Birth Defects Research Part A : Clinical and Molecular Teratology     Hybrid Journal   (Followers: 3)
Birth Defects Research Part C : Embryo Today : Reviews     Hybrid Journal  
BJR|Open     Open Access   (Followers: 1)
BJS Open     Open Access   (Followers: 1)
Black Sea Journal of Health Science     Open Access  
BLDE University Journal of Health Sciences     Open Access  
Blickpunkt Medizin     Hybrid Journal  
BMC Biomedical Engineering     Open Access  
BMC Medical Ethics     Open Access   (Followers: 22)
BMC Medical Research Methodology     Open Access   (Followers: 9)
BMC Medicine     Open Access   (Followers: 13)
BMC Obesity     Open Access   (Followers: 8)
BMC Proceedings     Full-text available via subscription   (Followers: 1)
BMC Research Notes     Open Access   (Followers: 4)
BMC Sports Science, Medicine and Rehabilitation     Open Access   (Followers: 34)
BMH Medical Journal     Open Access   (Followers: 2)
BMI Journal : Bariátrica & Metabólica Iberoamericana     Open Access  
BMJ     Hybrid Journal   (Followers: 1784)
BMJ Case Reports     Hybrid Journal   (Followers: 26)
BMJ Evidence-Based Medicine     Hybrid Journal   (Followers: 3)
BMJ Global Health     Open Access   (Followers: 3)
BMJ Innovations     Hybrid Journal   (Followers: 6)
BMJ Leader     Hybrid Journal  
BMJ Open     Open Access   (Followers: 43)
BMJ Open Quality     Open Access   (Followers: 19)
BMJ Open Science     Open Access   (Followers: 1)
BMJ Sexual & Reproductive Health     Hybrid Journal   (Followers: 2)
BMJ Surgery, Interventions, & Health Technologies     Open Access  
Bodine Journal     Open Access  
Boletín del Consejo Académico de Ética en Medicina     Open Access  
Boletín del ECEMC     Open Access  
Boletin Médico de Postgrado     Open Access  
Boletín Médico del Hospital Infantil de México     Open Access  
Bone     Hybrid Journal   (Followers: 18)
Bone and Tissue Regeneration Insights     Open Access   (Followers: 2)
Bone Marrow Research     Open Access   (Followers: 2)
Bone Reports     Open Access  
Bosnian Journal of Basic Medical Sciences     Open Access  
Bozok Tıp Dergisi / Bozok Medical Journal     Open Access  
Brachytherapy     Full-text available via subscription   (Followers: 6)
Brain and Development     Full-text available via subscription   (Followers: 5)
Brain Connectivity     Hybrid Journal   (Followers: 5)
Brain Impairment     Full-text available via subscription   (Followers: 2)
Brazilian Journal of Medical and Biological Research     Open Access  
Brazilian Journal of Medicine and Human Health     Open Access  
Brazilian Journal of Pain (BrJP)     Open Access  
Brazilian Journal of Physical Therapy     Open Access   (Followers: 2)
Breastfeeding Review     Full-text available via subscription   (Followers: 18)
British Journal of Biomedical Science     Full-text available via subscription   (Followers: 7)
British Journal of General Practice     Full-text available via subscription   (Followers: 39)
British Journal of Hospital Medicine     Full-text available via subscription   (Followers: 16)
British Medical Bulletin     Hybrid Journal   (Followers: 6)
Buddhachinaraj Medical Journal     Open Access  
Bulletin Amades     Open Access  
Bulletin de la Société de pathologie exotique     Hybrid Journal   (Followers: 1)
Bulletin of Legal Medicine     Open Access  
Bulletin of Medical Sciences     Open Access  
Bulletin of the History of Medicine     Full-text available via subscription   (Followers: 19)
Bulletin of the Menninger Clinic     Full-text available via subscription  
Bulletin of The Royal College of Surgeons of England     Free  
Bulletin of the Scientific Centre for Expert Evaluation of Medicinal Products     Open Access  
Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz     Hybrid Journal   (Followers: 6)
Burapha Journal of Medicine     Open Access  
Burns     Hybrid Journal   (Followers: 10)
Cadernos de Naturologia e Terapias Complementares     Open Access   (Followers: 1)
Calcified Tissue International     Hybrid Journal   (Followers: 2)
Canadian Bulletin of Medical History     Hybrid Journal  
Canadian Family Physician     Partially Free   (Followers: 13)
Canadian Journal of Pain     Open Access   (Followers: 2)
Canadian Journal of Rural Medicine     Full-text available via subscription   (Followers: 1)
Canadian Medical Association Journal     Open Access   (Followers: 17)
Canadian Medical Education Journal     Open Access   (Followers: 10)
Canadian Prosthetics & Orthotics Journal     Open Access  
Cannabis and Cannabinoid Research     Hybrid Journal   (Followers: 1)
Cardiac Electrophysiology Clinics     Full-text available via subscription   (Followers: 1)
Care Management Journals     Hybrid Journal   (Followers: 5)
Case Reports     Open Access  
Case Reports in Acute Medicine     Open Access   (Followers: 1)
Case Reports in Clinical Medicine     Open Access   (Followers: 2)
Case Reports in Clinical Nutrition     Open Access   (Followers: 1)
Case Reports in Medicine     Open Access   (Followers: 3)
Case Reports in Transplantation     Open Access  
Case Reports in Vascular Medicine     Open Access  
Case Reports in Women's Health     Open Access   (Followers: 4)
Case Study and Case Report     Open Access   (Followers: 5)
CASUS : Revista de Investigación y Casos en Salud     Open Access   (Followers: 1)
CBU International Conference Proceedings     Open Access   (Followers: 3)
Cell & Bioscience     Open Access   (Followers: 6)
Cell Adhesion & Migration     Open Access   (Followers: 9)
Cell and Molecular Response to Stress     Full-text available via subscription   (Followers: 2)
Cell and Tissue Transplantation and Therapy     Open Access   (Followers: 2)
Cell Cycle     Full-text available via subscription   (Followers: 6)
Cell Death and Differentiation     Hybrid Journal   (Followers: 7)
Cell Death Discovery     Open Access   (Followers: 1)
Cell Health and Cytoskeleton     Open Access   (Followers: 1)
Cell Medicine     Open Access   (Followers: 6)
Cell Research     Hybrid Journal   (Followers: 8)
Cell Transplantation     Open Access   (Followers: 4)
CEN Case Reports     Hybrid Journal  
Central African Journal of Medicine     Full-text available via subscription  
Ceylon Journal of Medical Science     Open Access  
Ceylon Medical Journal     Open Access  
Chattagram Maa-O-Shishu Hospital Medical College Journal     Open Access  
Chiang Mai Medical Journal     Open Access  
ChiangRai Medical Journal     Open Access  
Chimerism     Full-text available via subscription  
Chinese Journal of Integrative Medicine     Hybrid Journal   (Followers: 3)
Chinese Journal of Natural Medicines     Full-text available via subscription   (Followers: 1)
Chinese Medical Journal     Open Access   (Followers: 10)
Chinese Medical Record English Edition     Hybrid Journal  
Chinese Medical Sciences Journal     Full-text available via subscription   (Followers: 2)
Chinese Medicine     Open Access   (Followers: 2)
Chinese Medicine     Open Access   (Followers: 4)
Chisholm Health Ethics Bulletin     Full-text available via subscription   (Followers: 1)
CHRISMED Journal of Health and Research     Open Access   (Followers: 2)
Christian Journal for Global Health     Open Access  
Chronic Diseases and Translational Medicine     Open Access  
Chronic Illness     Hybrid Journal   (Followers: 6)
Chronic Wound Care Management and Research     Open Access   (Followers: 4)
Chronobiology International     Hybrid Journal   (Followers: 3)
ChronoPhysiology and Therapy     Open Access  

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Journal Cover
Journal Prestige (SJR): 0.951
Citation Impact (citeScore): 2
Number of Followers: 6  
  Full-text available via subscription Subscription journal
ISSN (Print) 1538-4721
Published by Elsevier Homepage  [3206 journals]
  • Brachytherapy: Expanding the horizons
    • Abstract: Publication date: Available online 16 March 2019Source: BrachytherapyAuthor(s): Chirag Shah, Michael J. Zelefsky
  • Permanent prostate brachytherapy is safe in men with severe baseline lower
           urinary tract symptoms
    • Abstract: Publication date: Available online 16 March 2019Source: BrachytherapyAuthor(s): Jared S. Winoker, Rollin K. Say, Reza Mehrazin, Richard G. Stock, Nelson N. Stone PurposeTo evaluate the long-term urinary outcomes of men with severe pretreatment lower urinary tract symptoms (LUTS) treated with permanent prostate brachytherapy (PPB) ± external beam radiation therapy for localized prostate cancer.Methods and materialsA total of 105 men with International Prostate Symptom Score (IPSS) 20–35 before PPB were categorized by IPSS change at last followup: (1) worse = IPSS rise>3; (2) no change = IPSS change within three points of baseline; (3) improved = IPSS fall by >3 points. We then evaluated patients who worsened vs. those who did not (no change or improved) with respect to incontinence outcomes, LUTS medication usage, and predictors of symptom worsening.ResultsMean followup was 80.3 ± 55.8 months. Mean age was 66.3 ± 7.1 years; mean pretreatment IPSS was 23.6 ± 3.0. Overall mean improvement in IPSS was 7.6 ± 9.3. Specifically, 14.3% (15/105) worsened, 21.9% (23/105) had no significant change, and 63.8% (67/105) improved. There were no patient- or treatment-related factors significantly associated with long-term worsening of urinary symptoms. No men required anticholinergic therapy at last followup, whereas 7% (8/105) were using an alpha blocker. Only 2.9% (3/105) of men were using at least one pad daily at last followup. Alternatively, only 7.7% (8/105) reported subjective incontinence.ConclusionsPPB is an acceptable option in the setting of severe baseline LUTS in appropriately selected and counseled patients when performed by a skilled practitioner.
  • Intraoperative brachytherapy for resected brain metastases
    • Abstract: Publication date: Available online 6 March 2019Source: BrachytherapyAuthor(s): Sean S. Mahase, Kristina Navrazhina, Theodore H. Schwartz, Bhupesh Parashar, A. Gabriella Wernicke Brain metastases are the most common intracranial malignancies in adults. Surgical resection is the preferred treatment approach when a pathological diagnosis is required, for symptomatic patients who are refractory to steroids, and to decompress lesions causing mass effect. Radiotherapy is administered to improve local control rates after surgical resection. After a brief review of the literature describing the treatment of brain metastases using whole-brain radiotherapy, postoperative stereotactic radiosurgery, preoperative radiosurgery, and brachytherapy, we compare patient-related, technical, practical, and radiobiological considerations of each technique. Finally, we focus our discussion on intraoperative brachytherapy, with an emphasis on the technical aspects, benefits, efficacy, and outcomes of studies utilizing permanent Cs-131 implants.
  • Improved survival for patients with prostate cancer receiving
           high-dose-rate brachytherapy boost to EBRT compared with EBRT alone
    • Abstract: Publication date: Available online 4 March 2019Source: BrachytherapyAuthor(s): Aaron R. Kent, Bronwyn Matheson, Jeremy L. Millar PurposeHigh-dose-rate (HDR) brachytherapy boost is a treatment of intermediate- to high-risk prostate cancer, but long-term clinical outcome data are sparse. We report long-term survival and toxicity data in a cohort of patients treated in a single institution.MethodsBetween 1998 and 2004, 654 patients with localized prostate cancer received either 3-dimensional conformal radiotherapy (median 46 Gy) with an HDR (median 18 Gy in three fractions) boost (“3-D conformal radiotherapy [3DCRT] + HDR”; 215 patients) or 3DCRT alone (“3DCRT”; median 70 Gy; 439 patients) with curative intent. Men with National Comprehensive Cancer Network intermediate risk were offered neoadjuvant androgen deprivation and with high risk were also offered adjuvant androgen deprivation. Data collection included patient-reported outcome measures.ResultsThe 3DCRT + HDR group was older (72.3 vs. 68.9 yrs), had higher presenting PSAs (iPSA) (15.66 and 12.57 ng/mL, respectively), higher proportion of Gleason scores>7 (15.3% vs. 12.4%), and higher proportions of extracapsular disease (29.3% vs. 25.5%). 3DCRT + HDR men had lower proportions of low-risk patients (3.3% vs. 19.4%) and higher proportions of high-risk patients (50.7% vs. 37.4%) than the 3DCRT group. The 5-, 10-, and 15-year overall survival was superior at 92%, 81%, and 67%, respectively, for the 3DCRT + HDR group, compared with 88%, 71%, and 53%, respectively, in the 3DCRT group (p < 0.001). The 5-, 10-, and 15-year cause specific survival also favored the HDR boost group with survival of 96%, 93%, and 87% (3DCRT + HDR) and 95% 88% and 79% (3DCRT), respectively (p < 0.037).ConclusionsHDR brachytherapy boost in conjunction with 3DCRT offered superior overall survival and cause-specific survival in our patient population.
  • Novel intraoperative radiotherapy utilizing prefabricated custom
           three-dimensionally printed high-dose-rate applicators
    • Abstract: Publication date: Available online 22 February 2019Source: BrachytherapyAuthor(s): Brandon S. Imber, Suzanne L. Wolden, Hilda E. Stambuk, Evan Matros, Leonard H. Wexler, Alexander S. Drew, Evan B. Rosen, Ian Ganly, Gil’ad N. Cohen, Antonio L. Damato BackgroundIntraoperative radiotherapy (IORT) is an effective strategy for the delivery of high doses of radiotherapy to a residual tumor or resection cavity with relative sparing of nearby healthy tissues. This strategy is an important component of the multimodality management of pediatric soft tissue sarcomas, particularly in cases where patients have received prior courses of external beam radiotherapy.PurposeTumor beds with significant topographic irregularity remain a therapeutic challenge because existing IORT technologies are typically most reliable with flat surfaces. To address this limitation, we have developed a novel strategy to create custom, prefabricated high-dose-rate (HDR)-IORT applicators designed to match the shape of an anticipated surgical cavity.Methods and MaterialsSilastic applicators are constructed using three-dimensional (3D) printing and are derived from volumetric segmentation of preoperative imaging.ResultsHDR preplanning with the applicators improves dosimetric accuracy and minimizes incremental operative time. In this report, we describe the fabrication process for the 3D-printed applicators and detail our experience utilizing this strategy in two pediatric patients who underwent HDR-IORT as part of complex base of skull sarcoma resections.ConclusionsEarly experience suggests that usage of the custom applicators is feasible, versatile for a variety of clinical situations, and enables the uniform delivery of high superficial doses of radiotherapy to irregularly shaped surgical cavities.
  • The confidence interval reported in this study appears to be an error
    • Abstract: Publication date: Available online 21 February 2019Source: BrachytherapyAuthor(s): W. Robert Lee
  • Radiobiological optimization comparison between pulse-dose-rate and
           high-dose-rate brachytherapy in patients with locally advanced cervical
    • Abstract: Publication date: Available online 21 February 2019Source: BrachytherapyAuthor(s): Pierre Annede, Isabelle Dumas, Antoine Schernberg, Anne Tailleur, Ingrid Fumagalli, Sophie Bockel, Fabien Mignot, Manon Kissel, Eric Deutsch, Christine Haie-meder, Cyrus Chargari PurposeOnly scarce data are available on the possibility to include radiobiological optimization as part of the dosimetric process in cervical cancer treated with brachytherapy (BT). We compared dosimetric outcomes of pulse-dose-rate (PDR) and high-dose-rate (HDR)-BT, according to linear-quadratic model.Methods and MaterialsThree-dimensional dosimetric data of 10 consecutive patients with cervical cancer undergoing intracavitary image-guided adaptive PDR-BT after external beam radiation therapy were examined. A new HDR plan was generated for each patient using the same method as for the PDR plan. The procedure was intended to achieve the same D90 high-risk clinical target volume with HDR as with PDR planning after conversion into dose equivalent per 2 Gy fractions (EQD2) following linear-quadratic model. Plans were compared for dosimetric variables.ResultsAs per study's methodology, the D90 high-risk clinical target volume was strictly identical between PDR and HDR plans: 91.0 Gy (interquartile: 86.0–94.6 Gy). The median D98 intermediate-risk clinical target volume was 62.9 GyEQD2 with HDR vs. 65.0 GyEQD2 with PDR (p < 0.001). The median bladder D2cc was 65.6 GyEQD2 with HDR, vs. 62 GyEQD2 with PDR (p = 0.004). Doses to the rectum, sigmoid, and small bowel were higher with HDR plans with a median D2cc of 55.6 GyEQD2 (vs. 55.1 GyEQD2, p = 0.027), 67.2 GyEQD2 (vs. S 64.7 GyEQD2, p = 0.002), and 69.4 GyEQD2 (vs. 66.8 GyEQD2, p = 0.014), respectively. For organs at risk (OARs), the effect of radiobiological weighting depended on the dose delivered. When OARs BT contribution to D2cc doses was 20 Gy.
  • Dose to the dominant intraprostatic lesion using HDR vs. LDR monotherapy:
           A Phase II randomized trial
    • Abstract: Publication date: Available online 20 February 2019Source: BrachytherapyAuthor(s): Steven Tissaverasinghe, Juanita Crook, Francois Bachand, Deidre Batchelar, Michelle Hilts, Cynthia Araujo, Danielle Anderson, Terry Bainbridge, Brenda Farnquist PurposeTo present the dosimetric results of a Phase II randomized trial comparing dose escalation to the MRI-defined dominant intraprostatic lesion (DIL) using either low-dose-rate (LDR) or high-dose-rate (HDR) prostate brachytherapy.Material and MethodsPatients receiving prostate brachytherapy as monotherapy were randomized to LDR or HDR brachytherapy. Prostate and DILs were contoured on preoperative multiparametric MRI. These images were registered with transrectal ultrasound for treatment planning. LDR brachytherapy was preplanned using I-125 seeds. HDR brachytherapy used intraoperative transrectal ultrasound–based planning to deliver 27 Gy/2 fractions in separate implants. DIL location was classified as peripheral, central, or anterior. A student t-test compared DIL D90 between modalities and DIL locations.ResultsOf 60 patients, 31 underwent LDR and 29 HDR brachytherapy. Up to three DILs were identified per patient (100 total) with 74 peripheral, six central, and 20 anterior DILs. Mean DIL volume was 1.9 cc (SD: 1.7 cc) for LDR and 1.6 cc (SD 1.3 cc) for HDR (p = 0.279). Mean DIL D90 was 151% (SD 30%) for LDR and 132% (SD 13%) for HDR. For LDR, mean peripheral DIL D90 was 159% (SD 27%) and central or anterior 127% (SD 13%). HDR peripheral DILs received 137% (SD 12%) and central or anterior 119% (SD 7%). DIL D90 for peripheral lesions was higher than anterior and central (p < 0.001).ConclusionsDIL location affects dose escalation, particularly because of urethral proximity, such as for anterior and central DILs. HDR brachytherapy may dose escalate better when target DIL is close to critical organs.
  • Monte Carlo study of the relationship between skin dose and optically
           stimulated luminescence dosimeter dose in Pd-103 permanent breast seed
           implant brachytherapy
    • Abstract: Publication date: Available online 18 February 2019Source: BrachytherapyAuthor(s): Steven Nich, Charles Kirkby, J. Eduardo Villarreal-Barajas PurposeTo establish a method for estimating skin dose for patients with permanent breast seed implant based on in vivo optically stimulated luminescence dosimeters (OSLDs) measurements.Methods and MaterialsMonte Carlo simulations were performed in a simple breast phantom using the EGSnrc user code egs_brachy. Realistic models of the IsoAid Advantage Pd-103 brachytherapy source and Landauer nanoDot OSLD were created to model in vivo skin dose measurements where an OSLD would be placed on the skin of a patient with permanent breast seed implant following implantation. Doses to a 0.2 cm3 volume of skin beneath the OSLD and to the sensitive volume within the OSLD were calculated, and the ratio of these values was found for various seed positions inside the breast phantom. The maximum value of this ratio may be used as a conversion factor that would allow skin dose to be estimated from in vivo OSLD measurements.ResultsConversion factors of 0.5 and 1.44 are recommended for OSLDs calibrated to dose to Al2O3 and water, respectively, at the point of measurement in the OSLD. These factors were not significantly affected by the addition of extra seeds in the dose calculations.ConclusionsA method for estimating skin dose from OSLD measurements was proposed. Individual institutions should calibrate OSLDs to Pd-103 seeds to apply the results of this work clinically.
  • Factors associated with deformation accuracy and modes of failure for
           MRI-optimized cervical brachytherapy using deformable image registration
    • Abstract: Publication date: Available online 7 February 2019Source: BrachytherapyAuthor(s): Brandon A. Dyer, Zilong Yuan, Jianfeng Qiu, Stanley H. Benedict, Richard K. Valicenti, Jyoti S. Mayadev, Yi Rong PurposeTo identify factors associated with MRI-to-CT image deformation accuracy and modes of failure for MRI-optimized intracavitary high-dose-rate treatment of locally advanced cervical cancer.Methods and MaterialsTwenty-six patients with locally advanced cervical cancer had preimplantation MRI registered and deformed to postimplantation CT images using anatomically constrained and biomechanical model–based deformable image registration (DIR) algorithms. Cervix (primary) and cervix plus 10-mm margin (secondary) were used as controlling regions of interest for deformation. High-risk clinical target volume defined on pre-MRI was propagated to CT and evaluated for clinical utility in optimizing target volumes using scores 0 (low performing) to 4 (high performing). Quantitative evaluation of deformation performance included Dice index, distance to agreement, center of mass (COM) differences, cervical/uterus volume, and geometric change in organ position for MR-projected structures. Statistical analysis was performed to identify predictors of clinical utility and modes of failure.ResultsAnatomically constrained and biomechanical model–based deformable image registration algorithms achieved clinical utility>3 in 65% and 81% of patients, respectively. This improved to 81% and 85%, respectively, if cervix plus margin was used to drive deformations. Total COM displacement (cervix plus uterus) had the highest sensitivity in predicting low from high clinical utility in optimizing target volumes. Deformation failure (low clinical utility) resulted from high COM displacement, high cervical volume change, and retroverted uterine anatomy.ConclusionsMRI-to-CT deformable image registration using a cervix-controlling region of interest can aid clinical target delineation in cervical brachytherapy and potentially improve brachytherapy implant quality and clinical workflow. Deformation failures warrant further study and prospective deformation validation.
  • 125I seeds implantation for treating residual hepatocellular carcinoma
           located beneath the diaphragm after transcatheter arterial
    • Abstract: Publication date: Available online 7 February 2019Source: BrachytherapyAuthor(s): Jie Li, Lijuan Zhang, Qigen Xie, Weiguo Wang, Yanyan Hua, Leyuan Zhou, Zongqiong Sun PurposeThe effect of 125I seed implantation for the treatment of local residual tumor of hepatocellular carcinoma located beneath the diaphragm (HCC-LBD) after transcatheter arterial chemoembolization (TACE) has not yet been reported. This retrospective study was performed to evaluate the safety and efficacy of 125I seeds implantation (ISI) for the treatment of residual HCC-LBD after TACE.Methods and MaterialsA total of 18 patients treated with ISI between August 2012 and March 2018 for residual HCC-LBD after single or multiple TACE were enrolled. Local control, survival, and postoperative complications were analyzed retrospectively. Overall followup time was displayed by survival curves.ResultsThe 18 patients received a total of 20 ISI treatments. The total number of seeds implanted was 650, with a mean of 36 ± 13 seeds per patients (range, 20–70). Mean D90 was 123 Gy. Complete response + partial response (CR + PR) was documented in 14, 16, and 16 of patients at 3, 6, and 12 months after implantation, respectively. In four patients, seeds implantation was performed through the diaphragm; two of these patients developed small pneumothoraces. Pulmonary compression of pneumothorax is less than 30% combined with a little blood in sputum, no chest tightness, shortness of breath, all symptoms subsided without interventions, and the patients were discharged after observation for 2 days. After the procedure, routine blood examination and liver and kidney function were normal.ConclusionThe combination of TACE with ISI appears to be a safe and efficient treatment for residual HCC-BLD.Implications for PracticeThis study evaluated the feasibility, safety, and short-term efficacy of ISI for local residual tumor of hepatocellular carcinoma located beneath the diaphragm (HCC-LBD) after TACE. Results suggest that residual tumor of HCC after TACE located in the posterosuperior part of the liver (segments seven and eight), laparoscopic liver resection, and alblation is difficult to perform and that as a supplement treatment, 125I seeds implantation is safe and easy accessible. TACE combined with 125I seeds has excellent local control effectiveness, and long-term efficacy and survival benefit still need to be more comprehensively evaluated.
  • Understanding the underutilization of cervical brachytherapy for locally
           advanced cervical cancer
    • Abstract: Publication date: Available online 2 February 2019Source: BrachytherapyAuthor(s): Ting Martin Ma, Matthew M. Harkenrider, Catheryn M. Yashar, Akila N. Viswanathan, Jyoti S. Mayadev PurposeTo understand the reasons behind current low utilization of brachytherapy for locally advanced cervical cancer in the United States.Methods and MaterialsA 17-item survey was e-mailed to the American Brachytherapy Society (ABS) listserv of active members in 2018. Responses of attending physicians in the United States were included in the analysis.ResultsAmong a total of 135 respondents, 81 completed the survey. Eighty-four percent agree/strongly agree that cervical brachytherapy is underutilized, and 46.9% disagree/strongly disagree that residents are receiving adequate training for brachytherapy; 75.3% agree/strongly agree that inadequate maintenance of brachytherapy skills is a major obstacle to brachytherapy use; and 71.6% agree/strongly agree that increased time requirement constitutes a major obstacle. Over 97% will recommend brachytherapy for most patients with cervical cancer if given access/time; 72.8% always perform their own brachytherapy, whereas 29.6% reported some type of barrier exists in performing brachytherapy themselves, with time required to perform brachytherapy (9.9%) being a leading factor. A quarter (24.7%) routinely refer to other radiation oncologists for brachytherapy. Even among ABS members, 37.0% reported that they would perform an intensity-modulated radiation therapy or stereotactic body radiation therapy boost in specific scenarios in potentially curable patients. The most common scenario is inability to place a uterine tandem (56.7%).ConclusionsThe underutilization of brachytherapy in cervical cancer is widely recognized by ABS members with inadequate training during residency and inadequate maintenance of skills being possible major contributing factors. Even among ABS members, there are identifiable barriers. Continued advocacy and future initiatives in enhancing access to brachytherapy training and efficiency are needed.
  • Evaluation of bi-objective treatment planning for high-dose-rate prostate
           brachytherapy—A retrospective observer study
    • Abstract: Publication date: Available online 2 February 2019Source: BrachytherapyAuthor(s): Stefanus C. Maree, Ngoc Hoang Luong, Ernst S. Kooreman, Niek van Wieringen, Arjan Bel, Karel A. Hinnen, Henrike Westerveld, Bradley R. Pieters, Peter A.N. Bosman, Tanja Alderliesten PurposeBi-objective treatment planning for high-dose-rate prostate brachytherapy is a novel treatment planning method with two separate objectives that represent target coverage and organ-at-risk sparing. In this study, we investigated the feasibility and plan quality of this method by means of a retrospective observer study.Methods and MaterialsCurrent planning sessions were recorded to configure a bi-objective optimization model and to assess its applicability to our clinical practice. Optimization software, GOMEA, was then used to automatically generate a large set of plans with different trade-offs in the two objectives for each of 18 patients treated with high-dose-rate prostate brachytherapy. From this set, five plans per patient were selected for comparison to the clinical plan in terms of satisfaction of planning criteria and in a retrospective observer study. Three brachytherapists were asked to evaluate the blinded plans and select the preferred one.ResultsRecordings demonstrated applicability of the bi-objective optimization model to our clinical practice. For 14/18 patients, GOMEA plans satisfied all planning criteria, compared with 4/18 clinical plans. In the observer study, in 53/54 cases, a GOMEA plan was preferred over the clinical plan. When asked for consensus among observers, this ratio was 17/18 patients. Observers highly appreciated the insight gained from comparing multiple plans with different trade-offs simultaneously.ConclusionsThe bi-objective optimization model adapted well to our clinical practice. GOMEA plans were considered equal or superior to the clinical plans. In addition, presenting multiple high-quality plans provided novel insight into patient-specific trade-offs.
  • Optimized penile surface mold brachytherapy using latest stereolithography
           techniques: A single-institution experience
    • Abstract: Publication date: Available online 2 February 2019Source: BrachytherapyAuthor(s): Laura D'Alimonte, Ananth Ravi, Joelle Helou, David Morrison, Lucas C. Mendez, Harry Easton, Gerard Morton PurposeTo describe a technique of penile surface mold high-dose-rate (HDR) brachytherapy and early outcomes.Methods and MaterialsFive patients diagnosed with a T1aN0 squamous cell carcinoma of the penis were treated using a penile surface mold HDR brachytherapy technique. A negative impression of the penis was obtained using dental alginate. CT images were acquired of the penile impression; subsequently, a virtual model of the patient's penis was generated. The positive model was imported into a computer-assisted design program where catheter paths were planned such that an optimized offset of 5 mm from the penile surface was achieved. The virtual model was converted into a custom applicator. A total dose of 40 Gy was delivered in 10 fractions. Patients were followed at 1, 3, 6, and 12 months after treatment and then every 6 months thereafter. Toxicities were reported using Common Terminology Criteria for Adverse Events v4.0.ResultsAll patients tolerated treatment well. Acute Grade 2 skin reactions were observed within the first month after treatment. Median followup was 35 months. Late Grade 1 skin toxicities were observed. One patient experienced a urethral stricture requiring dilatation. Two patients developed local recurrence.ConclusionThis technique allows the delivery of penile HDR brachytherapy as an outpatient procedure with minimal discomfort to the patient during each application and is a repeatable and accurate setup. This technique warrants validation in larger series with longer followup.
  • Brachytherapy: A critical component of primary radiation therapy for
           cervical cancer: From the Society of Gynecologic Oncology (SGO) and the
           American Brachytherapy Society (ABS)
    • Abstract: Publication date: Available online 18 January 2019Source: BrachytherapyAuthor(s): Christine H. Holschneider, Daniel G. Petereit, Christina Chu, I-Chow Hsu, Yevgeniya J. Ioffe, Ann H. Klopp, Bhavana Pothuri, Lee-may Chen, Catheryn Yashar Brachytherapy is well-established as an integral component in the standard of care for treatment of patients receiving primary radiotherapy for cervical cancer. A decline in brachytherapy has been associated with negative impacts on survival in the era of modern EBRT techniques. Conformal external beam therapies such intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT) should not be used as alternatives to brachytherapy in patients undergoing primary curative-intent radiation therapy for cervical cancer. Computed tomography or magnetic resonance image-guided adaptive brachytherapy is evolving as the preferred brachytherapy method. With careful care coordination EBRT and brachytherapy can be successfully delivered at different treatment centers without compromising treatment time and outcome in areas where access to brachytherapy maybe limited.
  • Evaluating the influence of prostate-specific antigen kinetics on
           metastasis in men with PSA recurrence after partial gland therapy
    • Abstract: Publication date: Available online 10 January 2019Source: BrachytherapyAuthor(s): Martin T. King, Paul L. Nguyen, Ninjin Boldbaatar, David D. Yang, Vinayak Muralidhar, Clare M. Tempany, Robert A. Cormack, Mark D. Hurwitz, W. Warren Suh, Mark M. Pomerantz, Anthony V. D'Amico, Peter F. Orio PurposeAlthough current Delphi Consensus guidelines do not recommend a specific definition of biochemical recurrence after partial gland therapy, these guidelines acknowledge that serial prostate-specific antigen (PSA) tests remain the best marker for monitoring disease after treatment. The purpose of this study was to determine whether PSA velocity at failure per the Phoenix (nadir + 2 ng/mL) definition is associated with metastasis and prostate cancer-specific mortality (PCSM) in a cohort of patients who experienced PSA failure after partial gland therapy.MethodsBetween 1997 and 2007, 285 patients with favorable risk prostate cancer underwent partial prostate brachytherapy to the peripheral zone. PSA velocity was calculated for 94 patients who experienced PSA failure per the Phoenix (nadir + 2) definition. Fine and Gray competing risks regression was performed to determine whether PSA velocity and other clinical factors were associated with metastasis and PCSM.ResultsThe median time to PSA failure was 4.2 years (interquartile range: 2.2, 7.9), and the median followup time after PSA failure was 6.5 years (3.5–9.7). Seventeen patients developed metastases, and five experienced PCSM. On multivariate analysis, PSA velocity ≥3.0 ng/mL/year (adjusted hazard ratio 5.97; [2.57, 13.90]; p 
  • Evaluation of the accuracy of computer-assisted techniques in the
           interstitial brachytherapy of the deep regions of the head and neck
    • Abstract: Publication date: Available online 9 January 2019Source: BrachytherapyAuthor(s): Guo-Hao Zhang, Xiao-Ming Lv, Wen-Jie Wu, Zhi-Yuan Wu, Lei Zheng, Ming-Wei Huang, Yong Wang, Jian-Guo Zhang PurposeWe sought to investigate the feasibility and accuracy of computer-assisted techniques in the interstitial brachytherapy of the deep regions of the head and neck.Materials and MethodsA computer-assisted brachytherapy workflow was applied to 10 patients with tumors in the deep regions of the head and neck. Based on the brachytherapy treatment preplan, we constructed a digital stereotactic model to accurately transfer the virtual plan into the navigation system, and subsequently printed the individual templates. The navigation system and the individual template were combined together to visualize and guide brachytherapy needle implantation. Preoperative and intraoperative image data were reconstructed and registered to measure and analyze the needle deviation.ResultsA total of 58 needles were successfully inserted in 10 patients with the guidance of computer-assisted techniques and a mean deviation of 5.2 mm. The inserting trajectories and depths of the needles were as follows: from the parotid and masseter regions to the infratemporal fossa or skull base, the range was 15.7–74.6 mm; from the submandibular and retromandibular regions to the infratemporal fossa or skull base, the range was 15.6–70.6 mm; from the infraorbital region to the pterygomandibular region, the range was 63.7–69.7 mm; and from the periorbital region to the intraorbital region, the range was 47.6–61.8 mm. The dose distribution met the treatment requirement well.ConclusionsThe computer-assisted interstitial brachytherapy workflow was proven to be feasible and accurate for the deep regions of the head and neck.
  • Long-term oncological and functional outcomes support use of low-dose-rate
           brachytherapy with or without external beam radiation in young men
           (≤60 years) with localized prostate cancer
    • Abstract: Publication date: Available online 8 January 2019Source: BrachytherapyAuthor(s): Jared S. Winoker, Olamide O. Omidele, Richard G. Stock, Nelson N. Stone PURPOSETo evaluate the oncological and functional outcomes of young men treated with low-dose-rate brachytherapy (BT) for prostate cancer (PCa).MATERIALS AND METHODS423 men aged ≤60 years with clinically localized PCa were treated with BT ± external beam radiation. Biochemical failure was defined by Phoenix criteria. Freedom from biochemical failure (FFbF) and cancer-specific survival (CSS) at 10 and 15 years were estimated by the Kaplan–Meier method with the log-rank test to compare outcomes between National Comprehensive Cancer Network risk groups. The Cox proportional hazards model was used to determine significant predictors for FFbF and CSS.RESULTSMedian followup was 9.9 years (range, 5.1–21.7). Median age was 57 years (range, 39–60), and median prostate-specific antigen was 6.1 ng/mL (range, 0.8–71). Overall, 10- and 15-year FFbF rates were 89% and 88%; 10- and 15-year CSS rates were 99% and 98%. Increasing disease risk was associated with lower FFbF and CSS (p < 0.0001). Biologically effective dose (p < 0.0001) and use of external beam radiation (p = 0.005) were significantly associated with higher FFbF. In men potent before BT, 64% (151/237) had preserved erectile function at a median 10.2 years. There was no significant difference between treatment groups with respect to long-term urinary function (p = 0.56).CONCLUSIONSYounger men treated with BT experience excellent long-term PCa control with low rates of treatment-related toxicity.
  • Dosimetric study of CO-60 source step size in uterine cervix intracavitary
           HDR brachytherapy
    • Abstract: Publication date: Available online 5 January 2019Source: BrachytherapyAuthor(s): Arvind Kumar Shukla, Bhupendra Singh Rana, Narinder Paul Singh, Sanjeev Kumar PurposeThe present work reports effects of source step sizes on dose distribution in patients treated with cobalt-60 (Co-60) high-dose-rate afterloading brachytherapy in carcinoma cervix (Ca-cx).Methods and MaterialsThe retrospective study is based on data of 15 patients of Ca-cx treated with Co-60 high-dose-rate intracavitary brachytherapy with dose of 21 Gy in three fractions with source step size of 2.5 mm after external beam radiotherapy of 46 Gy. The effect of source step size on overall treatment procedure was evaluated from prescribed dose volume, dose to organ at risks, and treatment time for source step sizes of 1 mm, 2.5 mm, 5 mm, and 10 mm for each patient.ResultsThe mean dose to bladder point for 1 mm, 2.5 mm, 5 mm, and 10 mm source step sizes was found to be 3.37 Gy (SD: 1.36), 3.44 Gy (SD: 1.38), 3.54 Gy (SD: 1.41), and 3.74 Gy (SD: 1.46), respectively. Similarly, the mean dose received by rectum point for these source step sizes were 2.86 Gy (SD: 0.64), 3.02 Gy (SD: 0.67), 3.25 Gy (SD: 0.71), and 3.63 Gy (SD: 0.73), respectively. The treatment time and prescribed dose coverage volume were both found to be gradually increasing with increase in step size.ConclusionsOur results on Ca-cx brachytherapy using Co-60 source indicate that the prescribed dose volume gradually increases from smaller source step to larger source step size. This results in increase of dose to the bladder and rectum and may lead to increase in toxicity and reduces quality of life. The study recommends that step size more than 5 mm should not be used for uterine cervix intracavitary application using Co-60 source.
  • Comparison of outcomes in early-stage uterine clear cell carcinoma and
           serous carcinoma
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Minsi Zhang, T. Jonathan Yang, Neil B. Desai, Deborah DeLair, Marisa A. Kollmeier, Vicky Makker, Mario M. Leitao, Nadeem R. Abu-Rustum, Kaled M. Alektiar PurposeThe treatment paradigm for uterine clear cell carcinoma is often linked to serous carcinoma. This study compares oncologic outcomes between women with uterine clear cell and serous carcinoma.Methods and MaterialsWe reviewed 114 women with stage I–II uterine clear cell carcinoma (n = 17, 15%) or serous carcinoma (n = 97, 85%) who underwent hysterectomy and salpingo-oophorectomy at our institution from April 1992 to December 2011; 86 (76%) had stage IA, 14 (12%) had stage IB, and 14 (12%) had stage II disease. Median followup was 57 months.ResultsPatients with uterine clear cell and serous carcinoma did not differ significantly by age ≥60 years, stage, or rate of lymphovascular invasion. There was no difference in the number of patients with clear cell or serous histology who received adjuvant radiotherapy (71% vs. 84%, respectively; p = 0.31); however, significantly fewer patients with clear cell histology received adjuvant chemotherapy (35% vs. 67%, respectively; p = 0.02). At 5 years, there were no significant differences in disease-free survival (94% vs. 84%, respectively; p = 0.27), disease-specific survival (100% vs. 92%, respectively; p = 0.20), or overall survival (100% vs. 89%, respectively; p = 0.34). The differences in chemotherapy utilization did not impact pattern of relapse, specifically peritoneal spread (7% vs. 6%, respectively; p = 0.92) or other distant sites (0% vs. 9%, respectively; p = 0.17).ConclusionsOncologic outcomes and recurrence patterns of women with stage I–II uterine clear cell carcinoma compared favorably with those of women with serous carcinoma, despite significantly less adjuvant chemotherapy use. Potential reduction in adjuvant therapy in women with clear cell carcinoma should be studied prospectively.
  • Increasing age predicts poor cervical cancer prognosis with subsequent
           effect on treatment and overall survival
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Bridget A. Quinn, Xiaoyan Deng, Adrianne Colton, Dipankar Bandyopadhyay, Jori S. Carter, Emma C. Fields PurposeStage and histology are well-established prognostic factors for cervical cancer, but the importance of age has been controversial and a clear role for this factor has not yet been defined. Thus, we aim with this study to evaluate the significance of age as an independent prognostic factor in women with cervical cancer and evaluate the therapeutic consequences and survival outcomes as they relate to this factor.Methods and MaterialsThe Surveillance, Epidemiology, and End Results (SEER) database was used to retrospectively analyze patients diagnosed with cervical cancer from 1973 to 2013 in the United States. Data collected included demographics, tumor histology and stage, treatment details, and survival outcomes. Age was grouped into 20–49, 50–69, ≥70 years. Stage was localized (FIGO IA-IB1), regional (IB2-IVA), and distant (IVB). Treatments were classified as “aggressive” (surgery, external beam radiation therapy [XRT] + brachytherapy [BT], surgery + BT, surgery + XRT, or surgery + XRT + BT) or “nonaggressive” (XRT alone, BT alone, or no treatment). Statistical analysis performed on these data included the use of the Log-Rank test, χ2 analysis, and the Cox proportional hazards model.ResultsForty-six thousand three hundred fifty women with cervical cancer were identified using the SEER database. 54% were aged
  • Improving brachytherapy efficiency with dedicated dosimetrist planners
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Dylann K. Fujimoto, Rie von Eyben, Melissa Usoz, Elizabeth A. Kidd PurposeTo investigate the different factors affecting the procedure duration for high-dose-rate brachytherapy for gynecologic malignancies.Methods and MaterialsWe prospectively recorded 86 consecutive vaginal cylinder (VC) treatments and 82 tandem and ovoid treatments. Key time points in the brachytherapy process, identity of the planner and checker, number of treatments per day, and fraction number per patient were recorded. The data were analyzed in a mixed effects linear regression model to account for the within patient correlation. Post hoc pair-wise comparisons were performed using a Dunnett's adjustment for comparisons to a single control group and using a Tukey adjustment for all pair-wise comparisons.ResultsWe focused on several key time intervals in the treatment: total, nursing/anesthesia preprocedure, procedure, contouring, and planning times. In analysis, multiple factors significantly influenced VC timing but not tandem and ovoid timing. The planners were separated and analyzed based on experience and profession. Inexperienced physicists planning times were on average 18 min (p = 0.0010) and 14 min (p = 0.0038) slower than dedicated brachytherapy dosimetrist and experienced physicists, respectively. An increase in the number of procedures for the day of treatment increased the VC total time (p = 0.0218). The VC procedure time changed depending on whether it was the patients' first, second, or third VC treatment (p 
  • Prostate brachytherapy under hypnosedation: A prospective evaluation
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Olivier Chapet, Corina Udrescu, Samy Horn, Alain Ruffion, Fabrice Lorchel, Sonya Gaudioz, Cécile Clamens, Vincent Piriou, Edwige Rigal PurposeHypnosedation (HS) for brachytherapy has been proposed in patients with prostate cancer and has been evaluated.Materials and Methods79 patients were treated with brachytherapy under HS. The Visual Analog Scale questionnaire was used to assess comfort and anxiety and the lowest, mean, and highest level of pain. Data for 79 patients who underwent general anesthesia (GA) and 37 patients who underwent spinal anesthesia (SA) treated at the same period were compared with HS group in terms of medication and treatment duration.Results11 patients (13.9%) requested a GA, because they did not reach the hypnotic level. For the remaining 68 patients, the mean pain and comfort scores evaluated just after the intervention were 3.1 and 7.4, respectively. At 8 weeks, the scores were 2.8 and 7.5, respectively. 66 patients (97%) would choose this approach again and recommend it to other patients. The patients in the HS group received significant less medications than in the GA (remifentanil, propofol, kétamine, phenylephrine, ephedrine…) or SA (sufentanil, midazolam, morphine, bupivacaine…) groups with mean values of 3.1 vs. 7.9 vs. 5.6 (p < 0.0001), respectively. HS increased the mean time of surgery room occupation by 12 min vs. GA and by 20 min vs. SA. However, the recovery room occupation is avoided with HS (GA = 61 min and SA = 67 min) and a shorter duration of a need for a urinary catheter was noted.ConclusionsHS is a feasible and comfortable method of anesthesia and a good alternative to GA and SA for patients undergoing prostate brachytherapy, with reduced treatment duration and number of medications.
  • Patient-reported health-related quality of life outcomes after HDR
           brachytherapy between small (
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Robert H. Press, Tiffany M. Morgan, Patrick K. Cutrell, Chao Zhang, Zhengjia Chen, Sara Rahnema, Martin Sanda, John Pattaras, Pretesh Patel, Ashesh B. Jani, Peter J. Rossi PURPOSEPatients with large prostate glands are underrepresented in clinical trials incorporating brachytherapy due to concerns for excessive toxicity. We sought to compare health-related quality of life (HRQOL) outcomes between small (
  • Radical dose escalation by high-dose-rate brachytherapy for localized
           prostate cancer—Significance of prostate-specific antigen nadir level
           within 18 months as correlation for long-term biochemical control
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Christoph Schroeder, Friedemann Geiger, Frank-André Siebert, René Baumann, Gunnar Bockelmann, Jürgen Schultze, Bernhard Kimmig, Jürgen Dunst, Razvan Galalae PurposeHigh-dose-rate brachytherapy (HDR-BT) for dose escalation in localized prostate cancer has been established as one standard treatment option. However, long-term results at followup (FU) ≥5 years are usually needed to ensure robustness of reported outcomes. Potential benefit of salvage therapy is, nevertheless, higher when relapse is diagnosed early. This study aimed to solve this dilemma by evaluating the prostate-specific antigen (PSA) nadir for early prediction of long-term biochemical control.Methods and MaterialsCombined pelvis-external beam radiation/HDR-BT boost to EQD2>100 Gy (α/β = 3) was performed in 459 consecutively treated patients. These patients with an FU ≥ 24 months were analyzed and stratified in PSA nadir (nPSA)-groups by PSA nadir within 18 months after radiotherapy (nPSA18). Kaplan–Meier/log-rank tests and Cox-regression models were used to compare the study endpoints.ResultsThe mean FU was 77 months. A PSA nadir within 18 months (nPSA18)
  • Permanent prostate brachytherapy monotherapy with I-125 for low- and
           intermediate-risk prostate cancer: Outcomes in 974 patients
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): David M. Routman, Ryan K. Funk, Bradley J. Stish, Lance A. Mynderse, Torrence M. Wilson, Robert McLaren, W. Scott Harmsen, Kristin Mara, Christopher L. Deufel, Keith M. Furutani, Michael G. Haddock, Thomas M. Pisansky, C. Richard Choo, Brian J. Davis PurposeTo report outcomes of patients undergoing low-dose-rate (LDR) brachytherapy and investigate factors associated with biochemical failure and survival.MethodsConsecutive patients undergoing LDR with I-125 at our institution between 1998 through 2013 for primary intact prostate cancer were examined. Those with low- and intermediate-risk disease receiving LDR with a minimum of 2 years followup and at least one post-LDR prostate-specific antigen (PSA) were included.ResultsAbout 974 patients satisfied inclusion criteria. With median followup of 72 months, biochemical failure occurred in 45 patients. Freedom from biochemical failure as defined by the Phoenix criterion was 96% and 88% at 5 and 10 years, worse for intermediate risk as compared with low risk, with 10-year freedom from biochemical failure of 76% versus 92% (hazard ratio [HR] = 3.7, p < 0.001), respectively. On multivariable analysis, increased prebiopsy PSA, Gleason 4 + 3, and no androgen deprivation therapy were associated with biochemical failure. Gleason 4 + 3 was the factor most strongly associated with biochemical failure (HR = 7.01, p < 0.001). No examined factors were associated with local failure. Gleason 4 + 3 disease increased the likelihood of distant metastasis (HR = 12.4, p = 0.003) and prostate cancer–specific death (HR = 13.2, p < 0.001). No difference in outcomes between patients with Gleason 3 + 3 versus 3 + 4 was observed.ConclusionsLDR brachytherapy provided excellent outcomes in this large series of patients treated for localized organ-confined prostate cancer. Local recurrence at 10 years was low at 2.1%. Primary Gleason 4 + 3, higher pretreatment PSA, and no receipt of androgen deprivation therapy were the only factors associated with biochemical failure. Primary Gleason 4 disease was also predictive of distant metastases and decreased prostate cancer–specific survival.
  • Clinical evaluation of an MRI-to-ultrasound deformable image registration
           algorithm for prostate brachytherapy
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Amani Shaaer, Melanie Davidson, Mark Semple, Alexandru Nicolae, Lucas Castro Mendez, Hans Chung, Andrew Loblaw, Chia-Lin Tseng, Gerard Morton, Ananth Ravi PurposeIdentifying dominant intraprostatic lesions (DILs) on transrectal ultrasound (TRUS) images during prostate high-dose-rate brachytherapy (HDR-BT) treatment planning is challenging. Multiparametric MRI (mpMRI) is the tool of choice for DIL identification; however, the geometry of the prostate on mpMRI and on the TRUS may differ significantly, requiring image registration. This study evaluates the efficacy of an in-house software for MRI-to-TRUS DIL registration (MR2US) and compares its results to rigid and B-Spline deformable registration.Methods and MaterialsTen patients with intermediate-risk prostate cancer, each with mpMRI and TRUS data sets, were included in this study. Five radiation oncologists (ROs) with expertise in TRUS-based HDR-BT were asked to cognitively contour the DIL onto the TRUS image using mpMRI as reference. The contours were analyzed for concordance using simultaneous truth and performance level estimation algorithm. Similarity indices, DIL volumes, and distance between centroid positions were measured to compare the consensus contours against the contours from ROs and the automated algorithms; registration time between all contouring methods was recorded.ResultsMR2US registration had the highest dice coefficients among all patients with a mean of 0.80 ± 0.13 in comparison to rigid (0.65 ± 0.20) and B-Spline (0.51 ± 0.30). The distance between centroid positions between simultaneous truth and performance level estimation contour and MR2US, rigid, and B-Spline contours were 5 ± 2, 7 ± 5, and 18 ± 11 mm, respectively. The average registration time was significantly shorter for MR2US (11 ± 2 s) and rigid algorithm (7 ± 1 s) compared to ROs (227 ± 27 s) and B-Spline (199 ± 38 s).ConclusionsThe efficacy of integrating an MRI-delineated DIL into a TRUS-based BT workflow has been validated in this study. The MR2US software is fast and accurate enough to be used for DIL identification in prostate HDR-BT.
  • Comparison of two iodine-125 brachytherapy implant techniques for the
           treatment of lung tumor: Preplanning and intraoperative planning
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Ranran Li, Zhang Ying, Yuan Yuan, Qi Lin, Jianjian Dai, Ruicai Xu, Baocheng Geng, Mingyong Han PurposeTo compare preplanning and intraoperative planning methods of lung tumor brachytherapy based on postimplant CT images and dosimetric outcomes.Methods and MaterialsDetailed postimplant evaluations of iodine-125 seed implants were performed in 15 patients using a preplanning technique and in 15 patients treated with an intraoperative planning technique. The implant details, dosimetric parameters, and implant quality indices were compared. Furthermore, the dose to the lung and the incidence of complications were compared.ResultsThe planning target volume was similar in both groups (p = 0.496). The median V100%, V150%, and V200% values (the percent of the planning target volume receiving 100%, 150%, and 200% of the prescription dose) for the intraoperative planning technique were 95.65%, 76.47%, and 59.80%, respectively. The median V100%, V150%, and V200% values for the preplanning methodology were 88.86%, 69.23%, and 28.30%, respectively (p < 0.01). The median values of the coverage index, c1, conformity index, and plan quality index were higher in the intraoperative planning group than in the preplanning group (p < 0.05). The overdose volume index and dose nonhomogeneity ratio were higher in the intraoperative group (p < 0.05), and the dose homogeneity index was lower in the intraoperative group (p < 0.05) than in the preplanning group. No significant differences were observed in the reference dose (VREF), external index, or lung doses between the two groups. The incidences of pneumothorax and hemoptysis were minimal in both groups.ConclusionThese data showed that the intraoperative planning method was superior to the preplanning method for the treatment of lung tumors.
  • A systematic review comparing radiation toxicity after various endorectal
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): An-Sofie Verrijssen, Thirza Opbroek, Murillo Bellezzo, Gabriel P. Fonseca, Frank Verhaegen, Jean-Pierre Gerard, Arthur Sun Myint, Evert J. Van Limbergen, Maaike Berbee PurposeA clinical complete response is seen after neoadjuvant chemoradiation for rectal tumors in 15%–20% of patients. These patients can potentially be spared mutilating total mesorectal excision surgery through a watch-and-wait policy. Recent studies show that dose escalation by a radiation boost increases the clinical complete response rate. The boost dose to the tumor can be administered through external beam radiotherapy or through internal radiotherapy using techniques like contact therapy, low-dose-rate or high-dose-rate brachytherapy (BT). However, limited information is available concerning treatment-related toxicity of these techniques. With this systematic review, we aim to summarize and compare published data concerning acute and late toxicity after contact X-ray therapy (CXT) and BT for rectal cancer.Methods and Materials/ResultsThirty-eight studies reporting toxicity after endorectal radiation techniques for rectal cancer were included, resulting in 3682 patients for analysis. Direct comparison of toxicity by the different radiation modes was hampered by various combinations of endorectal techniques, a lack of clear reporting of toxicity scores, dose prescription, technique used, and treated volumes. ≥ Grade 3 rectal toxicity was reported in 2.9% of patients having received only CXT; 6.3% of patients who received only BT had Grade 3 rectal toxicity, and BT also caused Grade 3 urinary toxicity in 1 patient.ConclusionAll techniques reported some ≥ Grade 3 toxicity. Toxicity after CXT was confined to the rectum, whereas after BT, urogenital toxicity and skin toxicity were seen as well. Unfortunately, few specific conclusions could be drawn regarding the dose-related risk of toxicity for the various techniques due to nonuniform reporting strategies and missing information. To enable future comparisons and improvements, the endorectal radiation field urgently needs consensus guidelines on dose reporting, dose prescription, treatment volume specification, and toxicity reporting.
  • Treatment of metastatic, imatinib refractory, gastrointestinal stroma
           tumor with image-guided high-dose-rate interstitial brachytherapy
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Jazan Omari, Ralph Drewes, Manig Matthias, Konrad Mohnike, Max Seidensticker, Ricarda Seidensticker, Tina Streitparth, Jens Ricke, Maciej Powerski, Maciej Pech PurposeEvaluation of efficacy and safety of CT- or MRI-guided high-dose-rate interstitial brachytherapy (iBT) in the treatment of advanced, imatinib refractory, metastatic gastrointestinal stroma tumors (GISTs) was the objective of this retrospective study.Methods and MaterialsA cumulative number of 40 unresectable metastases (30 hepatic, 10 peritoneal) were treated with iBT in 10 selected patients with histologically proven GISTs. Six patients had peritoneal disease, and 5 patients were even progressing under sunitinib (second line)—thus iBT was applied as a salvage maneuver. IBT uses an interstitially introduced 192iridium source in a high-dose-rate irradiation regime to destroy vital cells in a single fraction. Response to treatment was assessed clinically and with acquisition of MRI/CT every 3 months.ResultsLocal tumor control was reached in 97.5% of all treated metastases during a median time of 25 months—only one local relapse was observed during followup. The median diameter of the irradiated lesions was 2.4 cm (range 0.6–11.2 cm); a median dose of 15 Gy (range 6.7–21.96 Gy) was applied. The median progression-free survival after iBT was 6.8 (range 3.0–20.2) months; the median overall survival was 37.3 months (range 11.4–89.7). Two major complications (Common Terminology for Adverse Events grade 3) occurred following the intervention: local hemorrhage and pneumothorax, successfully dealt with by angiographic embolization and pleural drainage, respectively.ConclusionsIn selected patients with metastatic, imatinib refractory GISTs, iBT safely enables high rates of local tumor control and presents an alternative, anti-neoplastic treatment option even in a salvage situation.
  • Individualized 3D-printed templates for high-dose-rate interstitial
           multicathether brachytherapy in patients with breast cancer
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Cynthia Aristei, Valentina Lancellotta, Marco Piergentini, Giacomo Costantini, Simonetta Saldi, Sara Chierchini, Antonella Cavalli, Luca Di Renzo, Oscar Fiorucci, Massimo Guasticchi, Vittorio Bini, Alessandro Ricci PurposeHigh-dose-rate, multicatheter interstitial brachytherapy is technically complex and operator-dependent, requiring lengthy training and specialized skills. Furthermore, until the advent of contouring on computerized tomography (CT) images, difficulties existed in locating the target volume precisely. The present article reports the results of a study that aimed at producing and validating a 3D-printed template to aid in target volume localization for multicatheter interstitial brachytherapy in patients with breast cancer.Methods and MaterialsThirteen patients, candidates for accelerated partial breast irradiation or boost, were enrolled in the study. The target volume was defined on CT slices, and a template with empty spaces corresponding to the target volume projection on the patient's skin was produced by a 3D printer. The procedure was compared with the standard method followed in our center (1) visually, by assessing overlap between the target volume projections on the patient's skin, (2) by X-ray findings, and (3) by intraclass correlation coefficient.ResultsVisual assessment and X-ray findings showed the 3D-printed target volume always fell within the standard volume in all 13 patients. The intraclass correlation coefficient indicated moderate agreement for both the medial and the lateral skin projections.ConclusionsThe 3-D printed templates constitute a quick, easy, and reliable method to localize the target volume for high-dose-rate interstitial multicathether brachytherapy in patients with breast cancer and can safely be used in clinical practice.
  • Low cardiac and left anterior descending coronary artery dose achieved
           with left-sided multicatheter interstitial-accelerated partial breast
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Jacob S. Witt, Robert W. Gao, Lisa J. Sudmeier, Stephen A. Rosenberg, David M. Francis, Charles R. Wallace, Rupak K. Das, Bethany M. Anderson PurposeStudies have shown that an additional mean dose of 1 Gy to the heart can increase the relative risk of cardiac events. The purpose of this study was to quantify the dose delivered to the heart and left anterior descending artery (LAD) in a series of patients with left-sided breast cancer (BC) or ductal carcinoma in situ treated with multicatheter-accelerated partial breast irradiation (MC-APBI) at a single institution.Methods and MaterialsPatients with left-sided BC or ductal carcinoma in situ treated consecutively from 2005 to 2011 with MC-APBI were retrospectively identified. Cardiac and LAD contours were generated for each patient. Cardiac dosimetry and distance to the planning target volume were recorded. Patient health records were reviewed and cardiac events were recorded based on Common Terminology Criteria for Adverse Events version 4.0.ResultsTwenty consecutive patients with left-sided BC treated with MC-APBI were retrospectively identified. Median followup was 41.4 months. Mean equivalent dose in 2 Gy fractions delivered to the heart and LAD were 1.3 (standard deviation: 0.7, range: 0.2–2.9) and 3.8 (standard deviation: 3.0, range: 0.4–11.3) Gy, respectively. There was an inverse linear relationship (R2 = 0.52) between heart-to-lumpectomy cavity distance and mean heart equivalent dose in 2 Gy fractions. One patient (5%) experienced symptomatic cardiac toxicity.ConclusionsMC-APBI consistently delivers average doses to the heart and LAD that are similar to those achieved in most series with deep inspiration breath-hold and lower than free-breathing radiotherapy techniques. Distance from the heart to the lumpectomy cavity and the availability of other heart-sparing technologies should be considered to minimize the risk of cardiac toxicity.
  • Standardization and automation of quality assurance for high-dose-rate
           brachytherapy planning with application programming interface
    • Abstract: Publication date: January–February 2019Source: Brachytherapy, Volume 18, Issue 1Author(s): Bin Cai, Michael B. Altman, Francisco Reynoso, Jose Garcia-Ramirez, Angell He, Sharbacha S. Edward, Imran Zoberi, Maria A. Thomas, Hiram Gay, Sasa Mutic, Jacqueline E. Zoberi PurposeTo standardize and automate the high-dose-rate (HDR) brachytherapy planning quality assurance (QA) process utilizing scripting with application programming interface (API) in a commercially available treatment planning system (TPS).Methods and MaterialsSite- and applicator-dependent plan quality (PQ) evaluation criteria and plan integrity (PI) checklists were established based on published guidelines, clinical protocols, and institutional experience. User designed C# programs (“scripts”) were created and executed through the API to access planning information in TPS. A set of standardized quality control reports, focusing on PQ evaluations and PI checks, were automatically generated. Information derived from the TPS was compared against predetermined QA metrics with color-coded pass/fail indicators to aid and enhance the efficiency of plan evaluation. Five independent, blinded observers reviewed mock plans with simulated errors to validate the scripts and to quantify the improvement of plan review efficiency.ResultsScripts were developed for HDR prostate and breast. Forty-one parameters were reported/checked in the PI report; the PQ report returned dose-volume indices and an independent check of dwell time. All simulated errors were detected by the PI scripts with appropriate warning messages displayed, and any values failing to meet the planning constraints were red-flagged successfully in the PQ report. An average time reduction of 16 min for plan review was observed when using the scripts.ConclusionsAPI scripting-based automated planning QA for HDR brachytherapy including PI checks and PQ evaluations was designed and implemented. The simulated error study showed promising results in terms of error catching and efficiency improvement.
  • Development and dosimetric assessment of a patient-specific elastic skin
           applicator for high-dose-rate brachytherapy
    • Abstract: Publication date: Available online 7 December 2018Source: BrachytherapyAuthor(s): So-Yeon Park, Seonghee Kang, Jong Min Park, Hyun Joon An, Do Hoon Oh, Jung-in Kim PurposeThe purpose of this study was to develop a patient-specific elastic skin applicator and to evaluate its dosimetric characteristics for high-dose-rate (HDR) brachytherapy.Methods and MaterialsWe simulated the treatment of a nonmelanoma skin cancer on the nose. An elastic skin applicator was manufactured by pouring the Dragon Skin (Smooth-On Inc., Easton, PA) with a shore hardness of 10A into an applicator mold. The rigid skin applicator was printed using high-impact polystyrene with a shore hardness of 73D. HDR plans were generated using a Freiburg Flap (FF) applicator and patient-specific rigid and elastic applicators. For dosimetric assessment, dose-volumetric parameters for target volume and normal organs were evaluated. Global gamma evaluations were performed, comparing film measurements and treatment planning system calculations with various gamma criteria. The 10% low-dose threshold was applied.ResultsThe V120% values of the target volume were 56.9%, 70.3%, and 70.2% for HDR plans using FF, rigid, and elastic applicators, respectively. The maximum doses of the right eyeball were 21.7 Gy, 20.5 Gy, and 20.5 Gy for the HDR plans using FF, rigid, and elastic applicators, respectively. The average gamma passing rates were 82.5% ± 1.5%, 91.6% ± 0.8%, and 94.8% ± 0.2% for FF, rigid, and elastic applicators, respectively, with 3%/3 mm criterion.ConclusionsPatient-specific elastic skin applicator showed better adhesion to irregular or curved body surfaces, resulting in better agreement between planned and delivered dose distributions. The applicator suggested in this study can be effectively implemented clinically.
  • Subcutaneous spacer injection to reduce skin toxicity in breast
           brachytherapy: A pilot study on mastectomy specimens
    • Abstract: Publication date: Available online 5 December 2018Source: BrachytherapyAuthor(s): Gerson M. Struik, Jean-Philippe Pignol, Inger-Karine Kolkman-Deurloo, Jeremy Godart, Gerda M. Verduijn, Linetta B. Koppert, Erwin Birnie, Ali Ghandi, Taco M. Klem PurposeAccelerated partial breast irradiation is a treatment option for selected patients with early-stage breast cancer. Some accelerated partial breast irradiation techniques lead to skin toxicity with the skin dose as a main risk factor. Biodegradable spacers are effective and safe in prostate brachytherapy to protect the rectum. We hypothesize that a subcutaneous spacer injection reduces the skin dose in breast brachytherapy.Methods and MaterialsUltrasound-guided spacer injections, either hyaluronic acid (HA) or iodined polyethylene glycol (PEG), were performed on fresh mastectomy specimens. Success was defined as a spacer thickness of ≥5 mm in the high-dose skin area. Usability was scored using the system usability scale. Pre and postinjection CT scans were used to generate low-dose-rate seed brachytherapy treatment plans after defining a clinical target volume. Maximum dose to small skin volumes (D0.2cc) and existence of hotspots (isodose ≥90% on 1 cm2 of skin) were calculated as skin toxicity indicators.ResultsWe collected 22 mastectomy specimens; half had HA and half had PEG injection. Intervention success was 100% for HA and 90.9% for PEG (p = NS). Hydrodissection was feasible in 81.8% with HA and 63.6% with PEG. Median system usability scale score was 97.5 for HA and 82.5 for PEG (p < 0.001). Mean D0.2cc was 80.8 Gy without spacer and 53.7 Gy with spacer (p < 0.001). Skin hotspots were present in 40.9% without spacer but none with spacer (p < 0.001).ConclusionsA spacer injection in mastectomy specimens is feasible. An extra 5 mm space is always achieved, thereby potentially reducing the skin dose dramatically in low-dose-rate seed breast brachytherapy.
  • Patient-reported sexual adjustment after definitive chemoradiation and
           MR-guided brachytherapy for cervical cancer
    • Abstract: Publication date: Available online 30 November 2018Source: BrachytherapyAuthor(s): Jessica L. Conway, Rachel Gerber, Kathy Han, Haiyan Jiang, Jason Xie, Akbar Beiki-Ardakani, Anthony Fyles, Michael Milosevic, Deborah Williamson, Jennifer Croke PurposeThe treatment of locally advanced cervical cancer with definitive chemoradiation (CRT) is associated with vaginal toxicity and altered sexual satisfaction. This prospective study assessed patient-reported sexual adjustment, vaginal dosimetry, and physician-reported vaginal toxicity in patients with cervical cancer treated with CRT and MR-guided brachytherapy (BT).Materials and MethodsBetween 2008 and 2010, International Federation of Gynecologists and Obstetricians stage IB-IVA patients with cervical cancer receiving definitive CRT were enrolled in a feasibility study assessing MR-guided BT. Patients completed the validated sexual adjustment questionnaire (SAQ) before BT (baseline) and during followup. Physician-reported vaginal toxicity was recorded. The International Commission on Radiation Units and Measurements rectovaginal point, mean vaginal dose, and D2cm3 were calculated. Mean SAQ scores at baseline and followup assessments were calculated. Mean time effects were estimated using a linear mixed-effects model. A multivariable linear mixed-effects model was used to examine the association between total and individual scores (repeated measures) and covariates.ResultsSixty patients were approached to participate: 29 consented and 27 completed the SAQ at baseline and followup. The diagnosis of cervical cancer and treatment negatively impacted sexual relationships in 61% and 39%, respectively. There were no significant changes in sexual adjustment over time (p = 0.599). There were no associations between sexual adjustment and the International Commission on Radiation Units and Measurements rectovaginal point dose or clinical vaginal involvement. Patients with higher International Federation of Gynecologists and Obstetricians stages (≥IIB) had significantly worse sexual adjustment (p = 0.005).ConclusionCRT and MR-guided BT negatively impacted sexual relationships in patients with cervix cancer; however, there were no significant longitudinal changes in patient-reported sexual adjustment. Worse sexual adjustment may be associated with more advanced disease presentations.
  • Risk analysis of electronic intraoperative radiation therapy for breast
    • Abstract: Publication date: Available online 30 November 2018Source: BrachytherapyAuthor(s): Dominique Rash, David Hoffman, Ryan Manger, Irena Dragojević PurposeTo evaluate the process and improve safety of intraoperative radiation therapy (IORT) for early-stage breast cancers treated with electronic brachytherapy.Methods and MaterialsA multidisciplinary team conducted a failure mode and effects analysis (FMEA) for IORT breast cancer treatments by first developing a process map. This map was then used to identify failure modes for all steps in the treatment workflow. Risk priority numbers (RPNs) were assigned to each failure mode and were calculated as the product of the failure mode's probability of occurrence (O), severity (S), and lack of detectability (D). Corrective steps were implemented to address failure modes with the highest risk, and a revised process was generated.ResultsThe steps with the highest risk failure modes were related to source calibration, use of correct plan and dwell times, and the correct site and intent. The introduction of a physician calibration check and an extended time-out checklist reduced the risk of these failure modes. The highest risk steps in the Xoft breast IORT treatment process are associated with source calibration and manual entry of dwell positions for each balloon size and volume combination. High-risk failure modes that could be mitigated with improved hardware and software interlocks were identified.ConclusionHigh-risk failure modes are identified with FMEA and addressed with corrective steps. This application of FMEA can be used in principle for clinical processes throughout breast cancer care. This analysis demonstrates the importance of well-designed QC policies, procedures, and oversight in a Xoft electronic brachytherapy program for breast cancer IORT.
  • Impact on treatment time of MRI-based brachytherapy in two implants (4
           doses) compared with CT-based brachytherapy in five implants for cervical
    • Abstract: Publication date: Available online 26 November 2018Source: BrachytherapyAuthor(s): Christina Small, Grant Harmon, John Weaver, Vince Vivirito, Ramon Durazo-Arvizu, William Small, Matthew M. Harkenrider PurposeConcurrent chemoradiotherapy and brachytherapy is the standard of care for locally advanced cervical cancer. Brachytherapy is an integral part of treatment and has improved overall survival. Research is needed to ascertain the planning modalities and schedules to best use resources and optimize treatment time course. We hypothesized that MRI-based brachytherapy when delivered with the described regimen would not prolong, and potentially shorten, overall treatment time as compared with CT-based brachytherapy.Methods and MaterialsThis study was a single-institution retrospective review within the years 2008 through 2018. Patients with cervical cancer of any stage who underwent definitive chemoradiotherapy and either CT- or MRI-based brachytherapy were included. The primary outcome variable for this study was time (in days). Overall treatment time was defined as the number of days from the first until the last day of radiotherapy. Univariate analysis was performed using Stata statistical software.ResultsExternal beam radiotherapy doses were generally 45–50.4 Gy. CT-based and MRI-based brachytherapy were performed in 55 and 49 patients, respectively. The median treatment time for brachytherapy with CT-based planning was 19.0 days and with MRI-based planning was 9.0 days (p 
  • The American Brachytherapy Society consensus statement for electronic
    • Abstract: Publication date: Available online 26 November 2018Source: BrachytherapyAuthor(s): Martin C. Tom, Jaroslaw T. Hepel, Rakesh Patel, Mitchell Kamrava, Shahed N. Badiyan, Gil'ad N. Cohen, Chirag Shah PurposeBrachytherapy is utilized in the treatment of many different malignancies; although traditionally performed with low-dose-rate or high-dose-rate techniques, more recently, electronic brachytherapy (EB) has emerged as a potential alternative. At this time, there are no evidence-based guidelines to assist clinicians in patient selection for EB and concerns exits regarding differences in dosimetry as compared to traditional brachytherapy techniques. As such, the American Brachytherapy Society appointed a group of physicians and physicists to create a consensus statement regarding the use of EB.Methods and MaterialsPhysicians and physicists with expertise in brachytherapy created a site-directed consensus statement for appropriate patient selection and utilization of EB based on a literature search and clinical experience.ResultsEB has been utilized to deliver accelerated partial breast irradiation with, thus far acceptable local control and toxicity rates including a randomized trial that used EB to deliver intraoperative radiotherapy; however, prospective data with large patient numbers and long-term follow up are needed. Increasing numbers of patients have been treated with EB for nonmelanomatous skin cancers; although, preliminary data are promising, there is a lack of data comparing EB to traditional radiotherapy techniques as well as a lack of long-term follow up. For treatment of the vaginal cuff with EB, small retrospective studies have been reported without long-term follow up.ConclusionsIn light of a randomized trial in breast showing higher rates of recurrence and the lack of prospective data with mature follow up with other sites, as well as concerns regarding dosimetry, it is not recommended that EB be utilized for accelerated partial breast irradiation, nonmelanomatous skin cancers, or vaginal cuff brachytherapy outside prospective clinical trials at this time.
  • Predictive factors of benefit from iodine-125 brachytherapy for
           hepatocellular carcinoma with portal vein tumor thrombosis
    • Abstract: Publication date: Available online 19 November 2018Source: BrachytherapyAuthor(s): Junqing Lin, Han Jiang, Weizhu Yang, Na Jiang, Qubin Zheng, Ning Huang, Xiaolong Wang, Ang Li, Jingyao Huang PurposeThe aims of this study were to evaluate treatment responses and predictive factors for overall survival (OS) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) treated with iodine-125 (125I) brachytherapy.Methods and MaterialsSeventy-seven HCC patients with PVTT underwent 125I brachytherapy after transcatheter arterial chemoembolization. Clinical, laboratory, and radiological evaluation were performed before and after treatment, as well as at 4–6 weeks intervals for 7 years to assess the efficacy and toxicity of therapy. Treatment response was assessed using modified response evaluation criteria in solid tumors. OS and predictive factors for each subgroup were evaluated after treatment.ResultsIn total, 11 patients (14.29%) achieved complete response, and 41 patients (53.25%) achieved partial response. The response rate (complete response + partial response) was 67.53% (52/77). The median OS was 9 months. The multivariable Cox regression model indicated that post-treatment tumor size with PVTT (p = 0.016, hazard ratio [HR] = 1.889, 95% confidence interval [CI]: 1.127 to 3.166) and baseline hemoglobin (p = 0.013, HR=0.518, 95% CI: 0.308 to 0.872) and alkaline phosphatase (p = 0.002, HR=2.275, 95% CI: 1.338 to 3.868) levels were significant independent predictors of OS.Conclusions125I brachytherapy results in favorable treatment responses in HCC patients with PVTT. Notably, post-treatment tumor size and baseline hemoglobin and alkaline phosphatase levels are significant independent predictive factors for OS and provide the most predictive information regarding OS.
  • Using a surgical prostate-specific antigen threshold of>0.2 ng/mL to
           define biochemical failure for intermediate- and high-risk prostate cancer
           patients treated with definitive radiation therapy in the ASCENDE-RT
           randomized control trial
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): W. James Morris, Tom Pickles, Mira Keyes PurposeTo compare biochemical failure using a prostate-specific antigen (PSA) threshold of>0.2 ng/mL to that using Phoenix threshold (nadir+2 ng/mL).Methods and MaterialsAndrogen suppression combined with elective nodal and dose-escalated radiation therapy (the ASCENDE-RT trial) is a randomized control trial in which 276 high-risk and 122 intermediate-risk patients were randomized to (1) a standard arm with 12 months of androgen deprivation therapy, pelvic external beam radiation therapy (EBRT) to 46 Gy, and an EBRT boost (dose-escalated EBRT [DE-EBRT]) to 78 Gy, or (2) an experimental arm which substituted a low-dose-rate prostate brachytherapy boost (LDR-PB). The primary endpoint was biochemical progression-free survival (b-PFS) using the Phoenix threshold. In this reanalysis of ASCENDE-RT, the b-PFS using phoenix is compared to the surgical PSA threshold of>0.2 ng/mL.ResultsCompared to nadir+2 ng/mL, the>0.2 ng/mL PSA threshold doubled the number of relapse events from 69 to 139. However, the increase was confined to the DE-EBRT subjects. The 7-year Kaplan-Meier b-PFS after DE-EBRT declined from 76% using nadir+2 ng/mL to 38% using the>0.2 ng/mL threshold (p 0.2 ng/mL) versus 88% (nadir+2 ng/mL) (p = 0.319).ConclusionsReplacing Phoenix with a surgical threshold greatly increased biochemical failure after DE-EBRT boost but had no effect after LDR-PB. As a result of this finding, PSA outcomes after surgery or brachytherapy can be directly compared by using the surgical definition of PSA failure. In this context, a brachytherapy boost appears to produce superior b-PFS compared to contemporary surgical series.
  • Cost-effectiveness of prostate boost with high-dose-rate brachytherapy
           versus intensity-modulated radiation therapy in the treatment of
           intermediate-high risk prostate cancer
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Charles C. Vu, Kevin G. Blas, Thomas B. Lanni, Gary S. Gustafson, Daniel J. Krauss PurposeThe recently published ASCENDE-RT randomized clinical trial demonstrated improved biochemical control, albeit with increased toxicity, for a prostate boost with brachytherapy versus external beam radiation therapy alone in patients with intermediate-high risk prostate cancer. In this study, we investigated the cost-effectiveness of these two modalities in the treatment of intermediate-high risk prostate cancer.Methods and materialsA multistate Markov model was created to model a patient with intermediate-high risk prostate cancer. The two treatment options modeled were (1) 23 fractions of intensity-modulated radiation therapy (IMRT) and two fractions of high-dose-rate prostate brachytherapy (brachytherapy boost) and (2) 44 fractions of IMRT (IMRT alone). Each patient received 1 year of hormone therapy, per the ASCENDE-RT protocol. Model assumptions, including clinical outcomes, toxicity, and utilities were derived from the medical literature. Costs of radiation therapy were estimated using Medicare reimbursement data.ResultsThe estimated expected lifetime cost of brachytherapy boost was $68,696, compared to $114,944 for IMRT alone. Brachytherapy boost significantly lowered expected lifetime treatment costs because it decreased the incidence of metastatic castration-resistant prostate cancer, cutting the use of expensive targeted therapy for metastatic castration-resistant prostate cancer. Brachytherapy boost had an expected quality-adjusted life years of 10.8 years, compared to 9.3 years for IMRT alone. One-way sensitivity analyses of our results found brachytherapy boost to be cost-effective over a wide range of cost, utility, and cancer progression rate assumptions.ConclusionsIMRT with high-dose-rate brachytherapy boost is a cost-effective treatment for intermediate-high risk prostate cancer compared to IMRT alone.
  • Inferring postimplant dose distribution of salvage permanent prostate
           implant (PPI) after primary PPI on CT images
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Kibrom Berihu Girum, Alain Lalande, Magali Quivrin, Igor Bessières, Noelle Pierrat, Etienne Martin, Luc Cormier, Aurélie Petitfils, Jean Marc Cosset, Gilles Créhange PurposeTo evaluate the dose distribution of additional radioactive seeds implanted during salvage permanent prostate implant (sPPI) after a primary permanent prostate implant (pPPI).Methods and MaterialsPatients with localized prostate cancer were primarily implanted with iodine-125 seeds and had a dosimetric assessment based on day 30 postimplant CT (CT1). After an average of 6 years, these patients underwent sPPI followed by the same CT-based evaluation of dosimetry (CT2). Radioactive seeds on each CT were detected. The detected primary seeds on CT1 and CT2 were registered and then removed from CT2 referred as a modified CT2 (mCT2). Dosimetry evaluations (D90 and V100) of sPPI were performed with dedicated planning software on CT2 and mCT2. Indeed, prostate volume, D90, and V100 differences between CT2 and either CT1 or mCT2 were calculated, and values were expressed as mean (standard deviation).ResultsThe mean prostate volume difference between sPPI and pPPI over the 6 patients was 9.85 (7.32) cm3. The average D90 and V100 assessed on CT2 were 486.5 Gy (58.9) and 100.0% (0.0), respectively, whereas it was 161.3 Gy (47.5) and 77.3% (25.2) on mCT2 (p = 0.031 each time). The average D90 the day of sPPI [145.4 Gy (11.2)] was not significantly different from that observed on mCT2 (p = 0.56).ConclusionPostimplant D90 and V100 of sPPI after pPPI can be estimated on CT images after removing the primary seeds.
  • Long-term outcomes analysis of low-dose-rate brachytherapy in clinically
           T3 high-risk prostate cancer
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Manuj Agarwal, Arpit M. Chhabra, Neha Amin, Michelle H. Braccioforte, Jason K. Molitoris, Brian J. Moran PurposeThe available data demonstrating that superiority of LDR brachytherapy (LDR-BT) boost in high-risk prostate cancer patients under represents patients with extracapsular extension (T3a) and/or seminal vesicle invasion (T3b) have been limited. We report long-term clinical outcomes data for patients with cT3a/b disease receiving LDR-BT.Methods and MaterialsNinety-nine men (median age: 69.4 years) with cT3a/bN0M0 high-risk prostate adenocarcinoma received definitive LDR-BT or LDR-BT boost after external beam radiation therapy (EBRT) at a single institution between 1998 and 2007. About 86% of patients received androgen deprivation therapy. Freedom from biochemical failure (FFBF), prostate cancer–specific survival (PCSS), and overall survival (OS) was calculated using the Kaplan–Meier method with the Phoenix definition used as definition of failure. Cox regression analysis was used to compare outcomes between clinical stage, initial PSA, Gleason Score, and percent core positive rate.ResultsWith a median followup of 7 years, 7-year rate of FFBF, PCSS, and OS for the entire cohort was 65.2% (±5.6%), 90.1% (±3.6%), and 77.9% (±4.7%), respectively. LDR-BT boost patients achieved a 7-year FFBF rate of 73.5 (±6.5%). No significant difference in outcomes was present between T3a or T3b disease, Gleason score, iPSA stratification and percent core positive rates.ConclusionsLDR-BT, primarily as a boost in conjunction with ADT and EBRT, is not only feasible, but also highly effective in men with cT3a and cT3b high-risk prostate cancer resulting in excellent biochemical control and survival outcomes. LDR-BT boost implantation of patients should be strongly considered for cT3 patients given the merits of trimodality care.
  • Selection of patients who would not require long-term prostate-specific
           antigen monitoring after low-dose-rate brachytherapy
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Naoya Niwa, Kazuhiro Matsumoto, Toru Nishiyama, Yasuto Yagi, Choichiro Ozu, Ken Nakamura, Shiro Saito, Mototsugu Oya PurposeTo identify patients at extremely low risk of biochemical recurrence (BCR) of prostate cancer after low-dose-rate brachytherapy (LDR-BT) to determine when prostate-specific antigen (PSA) monitoring can be stopped.Methods and MaterialsWe retrospectively reviewed clinicopathologic data of patients with prostate cancer who underwent LDR-BT between 2003 and 2011. Of 1569 patients reviewed, 689 (43.9%) received combination external beam radiotherapy, and 970 (61.8%) had neoadjuvant hormonal therapy. We stratified patients according to risk factors identified by multivariate analysis and assessed the factors for an association with BCR (defined as ≥2 ng/mL higher than the nadir).ResultsThe median followup was 96 months. Of 1531 patients who were BCR-free at 3 years after treatment, 76 subsequently developed BCR; of 1500 who were BCR-free at 5 years, 45 eventually had BCR. On multivariate analysis, independent risk factors for BCR were the National Comprehensive Cancer Network risk group at diagnosis and PSA levels at 3 or 5 years after radiotherapy. In the low-risk group, no patient with a PSA level ≤0.2 ng/mL at 3 years after radiotherapy subsequently developed BCR. In the intermediate-risk group, no patients with a PSA level ≤0.2 ng/mL at 5 years subsequently developed BCR.ConclusionsThe National Comprehensive Cancer Network risk group at diagnosis and PSA values at 3 and 5 years after LDR-BT are independently associated with a risk of later BCR. Using these two factors may help to select patients for whom PSA monitoring could be stopped because they have an extremely low risk of later BCR.
  • Does postoperative irradiation improve survival in early-stage endometrial
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Sebastia Sabater, Ignacio Andres, Veronica Lopez-Honrubia, Maria Magdalena Marti-Laosa, Susana Castro-Larefors, Roberto Berenguer, Esther Jimenez-Jimenez, Marimar Sevillano, Angeles Rovirosa, Meritxell Arenas Endometrial cancer is the most common gynecological cancer in developed countries. Postoperative irradiation has been shown to lower locoregional relapses among high-intermediate risk endometrial cancer patients. In addition, vaginal cuff brachytherapy has demonstrated similar control to external beam radiotherapy but with lower toxicity. Although randomized trials have failed to translate that into better overall survival, reports from large databases, such as the National Cancer Database and the Surveillance, Epidemiology, and End Results database, have shown evidence of a statistical relationship between postoperative irradiation and survival in the intermediate- and high-risk groups.This review will address the risk groups that have led the therapeutic decisions and then we will review the clinical results accordingly. Special attention will be paid to the survival results based on the data presented through an analysis of the large databases that suggest a possible survival benefit.
  • Multivariate normal tissue complication probability modeling of vaginal
           late toxicity after brachytherapy for cervical cancer
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Pierre Annede, Hugues Mailleux, Patrick Sfumato, Marjorie Ferré, Aurélie Autret, Leonel Varela Cagetti, Alban Macagno, Pierre Fau, Cyrus Chargari, Agnès Tallet, Michel Resbeut, Christophe Zemmour, Laurence Gonzague, Jean-Marie Boher PurposeTo explore the best variables combination for a predictive model of vaginal toxicity in cervical cancer patients undergoing brachytherapy (BT).Methods and MaterialsClinical and 3-dimensional dosimetric parameters were retrospectively extracted from an institutional database of consecutive patients undergoing intracavitary BT after external beam radiation therapy from 2006 to 2013 for a cervical cancer. A least absolute shrinkage and selection operator selection procedure in Cox's proportional hazards regression model was performed to select a set of relevant predictors for a multivariate normal tissue complication probability model of Grade ≥2 vaginal late toxicity. Outcomes reliability was internally assessed by bootstrap resampling method.ResultsOne hundred sixty-nine women were included in the present study with a median followup time of 3.8 years (interquartile range [IQR], 1.9–5.6 years). The 2 years and 5 years cumulative incidence rates of Grade ≥2 late vaginal toxicity were 19.9% and 27.5%, respectively. Among 31 metrics and six clinical factors extracted, the optimal model included two dosimetric variables: V70Gy and D5% (the percentage volume that received a dose greater or equal to 70 Gy and the minimum dose given to the hottest 5% volume, respectively). Area under the ROC curve at 2 and 5 years of followup were 0.85 and 0.91, respectively. Regarding internal validation, median area under the ROC curve of bootstrap predictions was 0.83 (IQR, 0.78–0.88) and 0.89 (IQR, 0.85–0.93) at 2 and 5 years of followup, respectively.ConclusionsA multivariate normal tissue complication probability model for severe vaginal toxicity based on two dosimetric variables (V70Gy and D5%) provides reliable discrimination capability in a cohort of cervical cancer treated with external beam radiation therapy and BT.
  • Does adjuvant concurrent or sequential chemotherapy increase the
           radiation-related toxicity of vaginal brachytherapy for endometrial cancer
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Karina Nieto, Brendan Martin, Nghia Pham, Laura Palmere, Scott R. Silva, Abigail Winder, Margaret Liotta, Ronald K. Potkul, William Small, Matthew M. Harkenrider PurposeTo compare radiation toxicity in endometrial cancer patients treated with adjuvant vaginal brachytherapy (VBT) vs. VBT with concurrent chemotherapy (CCT) or sequential chemotherapy (SCT)MethodsWe retrospectively analyzed 131 patients with endometrial cancer treated with VBT without external beam radiation therapy. Toxicities were graded according to the Common Terminology Criteria for Adverse Events v4.03. CCT was defined as VBT delivered between the first and last cycle of chemotherapy (CT); SCT was defined as VBT delivered before or after CT.ResultsMedian followup was 36 months, with a 3-year survival rate of 88%. Of the 131 patients, 92 were treated with VBT alone, 34 with VBT and CCT, and 5 with VBT and SCT. The most common toxicity was vaginal stricture, with 30 (22.9%) patients affected. The distribution of toxicities was vaginal 28%, urinary 12%, rectal 11%, and fatigue 5%; none greater than Grade 2. Compared with patients treated with VBT alone, the addition of CT did not increase the chance of vaginal stricture formation (p = 0.84). The difference in system-specific toxicities between treatment modalities was not statistically significant.ConclusionThe most common pelvic toxicity from VBT is vaginal stenosis with other toxicities being infrequent and generally Grade 1. The addition of CT in a sequential or concurrent fashion did not increase the rate of pelvic toxicity from VBT alone.
  • Multi-institutional evaluation of the reproducibility and the accuracy of
           the objective breast cosmesis scale
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Valentina Lancellotta, Ludwig Seipelt, Jean-Michelle Hannoun-Levi, Luca Tagliaferri, Marie-Eve Chand, Elisabetta Perrucci, Vincenzo Valentini, Cynthia Aristei, Gyoergy Kovács, Tamer Soror PurposeThe aim of the present work is to assess the Objective Breast Cosmesis Scale (OBCS) in a patient cohort that was treated in two hospitals. Their treatment-related cosmetic changes were recorded on nonstandardized photographs.Methods and MaterialsNineteen female patients were enrolled in two radiation oncology centers (Nice, France, and Perugia, Italy). All patients had undergone breast-conserving surgery (BCS) and received adjuvant accelerated partial breast irradiation using interstitial fractionated multicatheter high-dose-rate brachytherapy. One photograph before and another after accelerated partial breast irradiation was taken for each patient to record changes in breast cosmesis. Using the OBCS, before and after photographs were analyzed by measuring distances between anatomic features. OBCS scores from four doctors (two males [one radiation oncologist and one post-grad trainee] and two females [one radiation oncologist and one post-grad trainee]) were compared.ResultsAgreement was high between trainees and specialist, and males and females before and after treatment. The intraclass correlation coefficient ranged from 0.867 to 0.950 before treatment and from 0.876 to 0.952 afterward. The coefficient of variation ranged from 12% to 26.5% before treatment, and from 13% to 21.4% afterward.ConclusionsThe OBCS is easy, time-efficient, reproducible, cost-effective, and reliable. Its potential practical applications merit further investigation in future studies.
  • Skin dose estimation using virtual structures for Contura Multi-Lumen
           Balloon breast brachytherapy
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): YuHuei Jessica Huang, Fan-Chi Frances Su, David K. Gaffney, Kristine E. Kokeny, Hui Zhao, Prema Rassiah-Szegedi, Bill J. Salter, Matthew M. Poppe PurposeTo propose a workflow that uses ultrasound (US)-measured skin–balloon distances and virtual structure creations in the treatment planning system to evaluate the maximum skin dose for patients treated with Contura Multi-Lumen Balloon applicators.Methods and MaterialsTwenty-three patients were analyzed in this study. CT and US were used to investigate the interfractional skin–balloon distance variations. Virtual structures were created on the planning CT to predict the maximum skin doses. Fitted curves and its equation can be obtained from the skin–balloon distance vs. maximum skin dose plot using virtual structure information. The fidelity of US-measured skin distance and the skin dose prediction using virtual structures were assessed.ResultsThe differences between CT- and US-measured skin–balloon distances values had an average of −0.5 ± 1.1 mm (95% confidence interval [CI] = −1.0 to 0.1 mm). Using virtual structure created on CT, the average difference between the predicted and the actual dose overlay maximum skin dose was −1.7% (95% CI = −3.0 to −0.4%). Furthermore, when applying the US-measured skin distance values in the virtual structure trendline equation, the differences between predicted and actual maximum skin dose had an average of 0.7 ± 6.4% (95% CI = −2.3% to 3.7%).ConclusionsIt is possible to use US to observe interfraction skin–balloon distance variation to replace CT acquisition. With the proposed workflow, based on the creation of virtual structures defined on the planning CT- and US-measured skin–balloon distances, the maximum skin doses can be reasonably estimated.
  • Endobronchial brachytherapy—A novel approach for the management of
           airway amyloidosis
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Assaf Moore, Mordechai R. Kramer, David Silvern, Osnat Shtraichman, Aaron M. Allen PurposeAirway amyloidosis is an uncommon condition and may have variable clinical course. There is no proven systemic therapy, and the management mainly relies on local invasive treatments. Several reports have found external beam radiotherapy to produce durable responses. The optimal dose and fractionation has not been determined. Endobronchial brachytherapy (EBB) has never been reported to affect this disease.MethodsThe study includes a retrospective chart review of all patients with airway amyloidosis treated with EBB at the Davidoff Cancer Center. Data include symptoms, radiotherapy method and dose, treatment outcomes, and toxicities.ResultsThree patients were included. Patients were either symptomatic with extensive airway involvement or have undergone multiple local procedures with rapid recurrence of the amyloid deposits. Two patients had upper and 1 patient had lower airway involvement. Two were treated with external beam radiotherapy and EBB and 1 was treated with EBB only. All patients achieved rapid improvement of symptoms with visible improvement in followup bronchoscopies. EBB doses ranged from 7.5 to 10 Gy. Of the seven lesions treated with EBB, only one lesion recurred 6 months from treatment. No major toxicities were reported.ConclusionsEBB is effective and safe for the management of airway amyloidosis and can offer long-term control. This is the first report of EBB for this indication. EBB should be further explored as means of minimizing the irradiated lung volume.
  • Evaluation of effective treatment depth in skin cancer treatments with
           electronic brachytherapy
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Samantha A.M. Lloyd, Douglas A. Rahn, Jeremy D.P. Hoisak, Irena Dragojević PurposeTo evaluate changes in the percent depth dose (PDD) and effective depth of treatment due to force applied by the applicator during treatments of nonmelanoma skin cancer with the Xoft electronic brachytherapy system.MethodsTo simulate compressible tissue, a 5-mm tissue-equivalent bolus was used. A soft x-ray ion chamber was used for output measurements, which were performed for all Xoft surface applicators with plastic endcaps in place. Output was first measured at 5 mm depth with minimal pressure from the applicator on the bolus and then repeated after applying uniform pressure on the applicator to calculate the change in PDD and effective treatment depth.ResultsFor the 10-mm cone, a moderate force of 5 N changed the PDD by more than 20%. The effect was also pronounced for the 20-mm cone, while minimal for the 35- and 50-mm cones. Even when only a moderate force was applied, the effective prescription depth changed by several millimeters, on the order of a typical prescription depth.ConclusionBased on the results of this simulation, excessive pressure applied on the skin by the applicator can drastically alter the PDD and effective treatment depth. The effect is most pronounced for the 10- and 20-mm cones, which tend to be used most frequently. Inappropriate applicator placement may therefore result in significant consequences such as excessive dose to the target, severe skin reaction, permanent discoloration, skin indentation, and poor overall cosmesis upon completion of treatment.
  • Combining brachytherapy and immunotherapy to achieve in situ tumor
           vaccination: A review of cooperative mechanisms and clinical opportunities
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Ravi B. Patel, Claire C. Baniel, Raghava N. Sriramaneni, Kristin Bradley, Stephanie Markovina, Zachary S. Morris As immunotherapies continue to emerge as a standard component of treatment for a variety of cancers, the imperative for testing these in combination with other standard cancer therapies grows. Radiation therapy may be a particularly well-suited partner for many immunotherapies. By modulating immune tolerance and functional immunogenicity at a targeted tumor site, radiation therapy may serve as a method of in situ tumor vaccination. In situ tumor vaccination is a therapeutic strategy that seeks to convert a patient's own tumor into a nidus for enhanced presentation of tumor-specific antigens in a way that will stimulate and diversify an antitumor T cell response. The mechanisms whereby radiation may impact immunotherapy are diverse and include its capacity to simultaneously elicit local inflammation, temporary local depletion of suppressive lymphocyte lineages, enhanced tumor cell susceptibility to immune response, and immunogenic tumor cell death. Emerging data suggest that each of these mechanisms may display a distinct dose–response profile, making it challenging to maximize each of these effects using external beam radiation. Conversely, the highly heterogenous and conformal dose distribution achieved with brachytherapy may be optimal for enhancing the immunogenic capacity of radiation at a tumor site while minimizing off-target antagonistic effects on peripheral immune cells. Here, we review the immunogenic effects of radiation, summarize the clinical rationale and data supporting the use of radiation together with immunotherapies, and discuss the rationale and urgent need for further preclinical and clinical investigation specifically of brachytherapy in combination with immunotherapies. Harnessing these immunomodulatory effects of brachytherapy may offer solutions to overcome obstacles to the efficacy of immunotherapies in immunologically “cold” tumors while potentiating greater response in the context of immunologically “hot” tumors.
  • A revised dosimetric characterization of 60Co BEBIG source: From
           single-source data to clinical dose distribution
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Sara Abdollahi, Mahdieh Dayyani, Elie Hoseinian-Azghadi, Hashem Miri-Hakimabad, Laleh Rafat-Motavalli PurposeAlthough the dosimetric characterization of 60Co BEBIG source can be found in several literature studies, the data sets show major discrepancies and the lack of uncertainty analyses. This study tried to determine an accurate dosimetric data set for this source using Monte Carlo (MC) simulations along with detailed uncertainty analysis. To explore how different dosimetric data sets can make changes in practical situations, clinical dose distributions based on our results were compared with the dose distributions derived from Granero et al. and consensus data sets.Methods and MaterialsThe MC simulations were performed with Monte Carlo N-Particle eXtended code (MCNPX) version 2.6.0 and the TG-43 parameters were estimated adhering to the American Association of Physicists in Medicine (AAPM) and European SocieTy for Radiotherapy and Oncology (ESTRO) 229 report. The dose rate distributions for single-source and two typical clinical cases, including one intracavitary and one interstitial, were calculated using an in-house code on the basis of the TG-43 formalism.ResultsThe total uncertainties for water dose rate on source transverse axis at 1 cm and 5 cm, air kerma strength, and dose rate constant were evaluated to be 0.10%, 0.09%, 0.04%, and 0.11%, respectively. Meaningful differences were found for the interstitial case in which 22% of clinical target volume (CTV) showed differences from ±1% to ±10% or even larger.ConclusionsThe MC uncertainty was derived about 16 times smaller than the typical MC component stated in TG-138, partly because of large number of histories and partly because the spectra of 60Co and also its photons' attenuation coefficients are adequately accurate. The results showed that in the clinical situations, the applicator geometry and the superposition of single-source dose distributions can reduce the differences observed between several data sets.
  • Real-time dose-rate monitoring with gynecologic brachytherapy: Results of
           an initial clinical trial
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Matthew D. Belley, Oana Craciunescu, Zheng Chang, Brian W. Langloss, Ian N. Stanton, Terry T. Yoshizumi, Michael J. Therien, Junzo P. Chino PurposeA nanoscintillator-based fiber-optic dosimeter (nanoFOD) was developed to measure real-time dose rate during high-dose-rate (HDR) brachytherapy. A trial was designed to prospectively test clinical feasibility in gynecologic implants.Methods and MaterialsA clinical trial enrolled women undergoing vaginal cylinder HDR brachytherapy. The nanoFOD was fixed to the cylinder alongside two thermoluminescent dosimeters (TLDs). Treatment was delivered and real-time dose rates captured by the nanoFOD. The nanoFOD and TLD positions were identified in CT images and used to extract the treatment planning system (TPS) calculated dose. The nanoFOD and TLD cumulative doses were compared with the TPS.ResultsNine women were enrolled for 30 fractions, and real-time data were available in 27 treatments. The median ratio of nanoFOD/TPS dose was 1.00 (IQR 0.94–1.02), with a TLD/TPS ratio of 1.01 (IQR 0.98–1.04). Of the nanoFOD dose measurements, 63% were within 5% of the TPS, 26% between 5 and 10% of the TPS, and the remaining 11% between 10 and 20% of the TPS dose. Of the TLD measurements, 70% were within 5% of the TPS, 22% between 5 and 10% of the TPS, and 7% between 10 and 20% of the TPS dose.ConclusionsReal-time dose-rate measurements during HDR brachytherapy were feasible using the nanoFOD and cumulative dose per fraction showed reasonable agreement to TLD and TPS doses. Additional studies to determine dose thresholds that would yield a low false alarm rate and ongoing device development efforts to improve localization of the scintillator in CT images are needed before this detector should be used to inform clinical decisions.
  • Modeling of the direction modulated brachytherapy tandem applicator using
           the Oncentra Brachy advanced collapsed cone engine
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Habib Safigholi, Bob van Veelen, Yury Niatsetski, William Y. Song PurposeThe direction modulated brachytherapy (DMBT) magnetic resonance–compatible tandem applicator, made from a tungsten alloy rod, has six symmetric peripheral grooves, designed specifically to enhance intensity modulation capacity through achieving directional radiation dose profiles. In this work, the directional dose distributions of the DMBT tandem were modeled and calculated with the Oncentra Brachy advanced collapsed cone engine (ACE), which was validated against Monte Carlo (MC) calculations.Methods and MaterialThe prototype 3D tandem applicator model was created for use in the Oncentra Brachy treatment planning system. The 192Ir source was placed inside a DMBT tandem in one and six channels as a single dwell position (DP) per channel with the same index length, as well as 1 DP in a standard tandem. Dose distributions were calculated in a water medium by both ACE and MC and compared.ResultsFor 1DP/6DP inside the DMBT and 1DP inside the standard tandem, respectively, the mean dose differences were 3.5/3.3% and
  • A novel rectal applicator for contact radiotherapy with HDR
           192Ir sources
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Murillo Bellezzo, Gabriel P. Fonseca, An-Sofie Verrijssen, Robert Voncken, Michiel R. Van den Bosch, Hélio Yoriyaz, Brigitte Reniers, Maaike Berbée, Evert J. Van Limbergen, Frank Verhaegen PurposeDose escalation to rectal tumors leads to higher complete response rates and may thereby enable omission of surgery. Important advantages of endoluminal boosting techniques include the possibility to apply a more selective/localized boost than using external beam radiotherapy. A novel brachytherapy (BT) rectal applicator with lateral shielding was designed to be used with a rectoscope for eye-guided positioning to deliver a dose distribution similar to the one of contact x-ray radiotherapy devices, using commonly available high-dose-rate 192Ir BT sources.Methods and MaterialsA cylindrical multichannel BT applicator with lateral shielding was designed by Monte Carlo modeling, validated experimentally with film dosimetry and compared with results found in the literature for the Papillon 50 (P50) contact x-ray radiotherapy device regarding rectoscope dimensions, radiation beam shape, dose fall-off, and treatment time.ResultsThe multichannel applicator designed is able to deliver 30 Gy under 13 min with a 20350 U (5 Ci) source. The use of multiple channels and lateral shielding provide a uniform circular treatment surface with 22 mm in diameter. The resulting dose fall-off is slightly steeper (maximum difference of 5%) than the one generated by the P50 device with the 22 mm applicator.ConclusionsA novel multichannel rectal applicator for contact radiotherapy with high-dose-rate 192Ir sources that can be integrated with commercially available treatment planning systems was designed to produce a dose distribution similar to the one obtained by the P50 device.
  • Perioperative high-dose-rate brachytherapy in locally advanced and
           recurrent gynecological cancer: Final results of a Phase II trial
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Rafael Martínez-Monge, Germán Valtueña Peydró, Mauricio Cambeiro, José Manuel Aramendía, Marta Gimeno, Marta Santisteban, Fernando Lecanda, Jose Angel Minguez, Juan L. Alcázar, Matías Jurado
  • Reviewers Listing 2018
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s):
  • Phase II study of intraoperative dosimetry for prostate brachytherapy
           using registered ultrasound and fluoroscopy
    • Abstract: Publication date: November–December 2018Source: Brachytherapy, Volume 17, Issue 6Author(s): Junghoon Lee, Robert F. Hobbs, Marianna Zahurak, Sook Kien Ng, Zhe Zhang, E. Clif Burdette, Theodore L. DeWeese, Daniel Y. Song PurposeTo assess the performance of a system of intraoperative dosimetry and obtain estimates of dosimetry outcomes achieved when utilizing the system in a Phase II clinical trial.Methods and MaterialsForty-five patients undergoing permanent Pd-103 seed implantation for prostate cancer were prospectively enrolled. Seed implantation was performed and dose was tracked intraoperatively using intraoperative registered ultrasound and fluoroscopy (iRUF). Three-dimensional seed locations were computed from X-rays and registered to ultrasound for intraoperative dosimetry, followed by adaptive plan modification to achieve prostate V100 ≥95% and ≥95% D90. Time required for iRUF was recorded. Postoperative CT/MRI scans were performed 1 day after the implantation and used as reference for dosimetric analysis. Dosimetric parameters for the prostate and urethra were compared between standard ultrasound-based dosimetry (USD), iRUF, and postoperative CT/MRI.ResultsMean total time for iRUF was
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