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PubMed1997

American Brachytherapy Society (ABS) consensus guidelines for brachytherapy of esophageal cancer. Clinical Research Committee, American Brachytherapy Society, Philadelphia, PA.

INTRODUCTION: There is wide variation in the indications, treatment regimens, and dosimetry for brachytherapy in the treatment of cancer of the esophagus. No guidelines for optimal therapy currently exist. METHODS AND MATERIALS: Utilizing published reports and clinical experience, representatives of the Clinical Research Committee of the American Brachytherapy Society (ABS) formulated guidelines for brachytherapy in esophageal cancer. RESULTS: Recommendations were made for brachytherapy in the definitive and palliative treatment of esophageal cancer. (A) Definitive treatment: Good candidates for brachytherapy include patients with unifocal thoracic adeno- or squamous cancers < or = 10 cm in length, with no evidence of intra-abdominal or metastatic disease. Contraindications include tracheal or bronchial involvement, cervical esophagus location, or stenosis that cannot be bypassed. The esophageal brachytherapy applicator should have an external diameter of 6-10 mm. If 5FU-based chemotherapy and 45-50-Gy external beam are used, recommended brachytherapy is either: (i) HDR 10 Gy in two weekly fractions of 5 Gy each; or (ii) LDR 20 Gy in a single course at 0.4-1 Gy/hr. All doses are specified 1 cm from the midsource or mid-dwell position. Brachytherapy should follow external beam radiation therapy and should not be given concurrently with chemotherapy. (B) Palliative treatment: Patients with adeno- or squamous cancers of the thoracic esophagus with distant metastases or unresectable local disease progression/recurrence after definitive radiation treatment should be considered for brachytherapy with palliative intent. After limited dose (30 Gy) EBRT, the recommended brachytherapy is either: (i) HDR 10-14 Gy in one or two fractions; or (ii) LDR 20-25 Gy in a single course at 0.4-1 Gy/hr. The need for external beam radiation in newly diagnosed patients with a life expectancy of less than 3 months is controversial. In these cases, HDR of 15-20 Gy in two to four fractions or LDR of 25-40 Gy at 0.4-1 Gy/hr may be of benefit. CONCLUSION: ABS guidelines for esophageal brachytherapy now exist and will be updated by the ABS in the future, as clinical data using more uniform treatment techniques becomes available.

Adenocarcinoma↗

PubMedDate not supplied

Phase II study of the American Brachytherapy Society guidelines for the use of high-dose rate brachytherapy in the treatment of cervical carcinoma: is 45-50.4 Gy radiochemotherapy plus 31.8 Gy in six fractions high-dose rate brachytherapy tolerable?

In 2000, the American Brachytherapy Society (ABS) published incompletely evaluated guidelines for curative chemoradiation and high-dose rate (HDR) brachytherapy for cervical cancer: our aim was to assess guideline tolerability in an Asian population. From 2000, all stage I-IVA cervical carcinoma patients were treated following ABS guidelines. Early disease (FIGO stage I/II <4 cm) received 45 Gy whole-pelvis external-beam radiation (EBRT) at 1.8 Gy/fraction, while advanced-stage disease received 50.4 Gy: no central shielding was used. All patients were planned to receive chemotherapy during EBRT, cisplatin 40 mg/m(2) weekly. All patients received 31.8-Gy HDR brachytherapy (six fractions of 5.3 Gy/fraction) to point A via three-channel applicators. Radiotherapy was completed within 8 weeks. Toxicity scoring used Common Toxicity Criteria. Nineteen of 21 (90.4%) patients (8 early, 13 advanced stage) received planned radiation, and 85.7% received planned chemotherapy. Median follow-up was 24 months (range 9-50 months). Three-year overall survival (S) was 79.1% and disease-free survival (DFS) was 64.8%. S/DFS for early and advanced stage was 85.7%/85.7% and 73.3%/47.1%, respectively. Complete response (CR) was achieved by 85.7% of patients, partial response 14.3%. For those in CR, there were no local failures. Acute cystitis occurred in 23.8%, proctitis 4.8%, and gastroenteritis 47.6%. Late cystitis occurred in 9.5%, gastroenteritis 4.8%, and genitourinary fistula (in the presence of progressive disease) 4.8%. No grade 3/4 treatment-related toxicity occurred. The ABS guidelines were well tolerated and efficacious in our study, although longer follow-up is required. Further studies are warranted to validate safety and efficacy of the recommendations.

Adult↗

PubMed2000

American brachytherapy society recommendations for clinical implementation of NIST-1999 standards for (103)palladium brachytherapy. The clinical research committee of the American Brachytherapy Society.

PURPOSE: Recent important developments in palladium-103 ((103)Pd) dosimetry mandate a reevaluation of (103)Pd brachytherapy prescribing practices. METHODS AND MATERIALS: The clinical research committee of the American Brachytherapy Society (ABS) convened a consensus session of brachytherapists and physicists to develop recommendations regarding future dose prescribing guidelines for National Institute of Standards and Technology (NIST-1999) calibrated (103)Pd sources. RESULTS: The ABS recommends that clinicians attempt to reproduce the implant doses delivered and reported in the literature through the past decade. CONCLUSIONS: The following should be immediately implemented for (103)Pd dosimetry: 1) All practicing physicians, physicists, dosimetrists, and suppliers implement NIST-1999 air-kerma strength standard for (103)Pd brachytherapy. 2) All treatment planning systems and dose calculation algorithms must be updated to reflect new dose rate constants. The AAPM-recommended validated value for Theraseed model 200 is 0.665 cGy h(-1) U(-1). The dose rate constant for the Mentor MED3633 seed is currently reported as 0.68 cGy h(-1) U(-1). This latter value and the values for seeds from other manufacturers are awaiting independent confirmation. 3) Physicians who previously prescribed 115 Gy for (103)Pd monotherapy prostate implants should now prescribe 125 Gy. When using (103)Pd as a boost following 45 Gy of external beam irradiation, 100 Gy should be prescribed instead of the previous 90 Gy. It is critical that all three changes be implemented concurrently, because they are interdependent.

Brachytherapy↗

PubMed2002

The American Brachytherapy Society recommendations for low-dose-rate brachytherapy for carcinoma of the cervix.

PURPOSE: This report presents guidelines for using low-dose-rate (LDR) brachytherapy in the management of patients with cervical cancer. METHODS: Members of the American Brachytherapy Society (ABS) with expertise in LDR brachytherapy for cervical cancer performed a literature review, supplemented by their clinical experience, to formulate guidelines for LDR brachytherapy of cervical cancer. RESULTS: The ABS strongly recommends that radiation treatment for cervical carcinoma (with or without chemotherapy) should include brachytherapy as a component. Precise applicator placement is essential for improved local control and reduced morbidity. The outcome of brachytherapy depends, in part, on the skill of the brachytherapist. Doses given by external beam radiotherapy and brachytherapy depend upon the initial volume of disease, the ability to displace the bladder and rectum, the degree of tumor regression during pelvic irradiation, and institutional practice. The ABS recognizes that intracavitary brachytherapy is the standard technique for brachytherapy for cervical carcinoma. Interstitial brachytherapy should be considered for patients with disease that cannot be optimally encompassed by intracavitary brachytherapy. The ABS recommends completion of treatment within 8 weeks, when possible. Prolonging total treatment duration can adversely affect local control and survival. Recommendations are made for definitive and postoperative therapy after hysterectomy. Although recognizing that many efficacious LDR dose schedules exist, the ABS presents suggested dose and fractionation schemes for combining external beam radiotherapy with LDR brachytherapy for each stage of disease. The dose prescription point (point A) is defined for intracavitary insertions. Dose rates of 0.50 to 0.65 Gy/h are suggested for intracavitary brachytherapy. Dose rates of 0.50 to 0.70 Gy/h to the periphery of the implant are suggested for interstitial implant. Use of differential source activity or loading minimizes excessive central dose rates. These recommendations are intended only as guidelines. The responsibility for medical decisions ultimately rests with the treating radiation oncologist. CONCLUSION: Guidelines are suggested for LDR brachytherapy for cervical cancer. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies.

Brachytherapy↗

PubMed2004

Proposed guidelines for image-based intracavitary brachytherapy for cervical carcinoma: report from Image-Guided Brachytherapy Working Group.

PURPOSE: To present issues to be considered in, and make proposals for, image-based brachytherapy for cervical cancer. METHODS AND MATERIALS: The Image-Guided Brachytherapy Working Group, consisting of representatives from the Gynecology Oncology Group (GOG), Radiologic Physics Center (RPC), American Brachytherapy Society (ABS), American College of Radiology (ACR), American College of Radiology Imaging Network (ACRIN), American Association of Physicists in Medicine (AAPM), Radiation Therapy Oncology Group (RTOG), and American Society for Therapeutic Radiology and Oncology (ASTRO), proposed guidelines for image-based brachytherapy for cervical cancer. This report was based on their aggregate clinical experience and a review of the literature. It reflects only the personal opinions of the authors and is not meant to be an endorsement from any of the above organizations. RESULTS: The Group recommended T(2)-weighted MRI using a pelvic surface coil with MRI-compatible brachytherapy applicators in place for image-based intracavitary brachytherapy for cervical cancer. Imaging must be performed with the patient in the treatment position, with all other treatment conditions duplicated as closely as possible. Future use of positron emission tomography or positron emission tomography/CT may obviate the need for special applicators. The group proposed the following terminology for image-based brachytherapy. The GTV((I)) is defined as the gross tumor volume as defined through imaging, GTV is defined as the GTV((I)) plus any clinically visualized or palpable tumor extensions, and GTV + cx is defined as the GTV plus the entire cervix. The dose-volume histograms (DVH) of the GTV, GTV((I)), GTV + cx should be performed, and the dose to 100%, 95%, or 90% of the GTV (D(100), D(95), and D(90), respectively) and the percentage of the GTV covered by Point A dose (V(100)) should be reported. Similarly, the DVH of the bladder and rectum wall should be performed, and the maximal dose at any point within the bladder and rectal wall should be reported, along with the maximal dose to a contiguous 1, 2, and 5 cm(3) volume of the bladder and rectum, respectively. In addition, the dose at the International Commission on Radiation Units and Measurements reference point for the bladder and rectum should be reported. The Group thought that the current dose prescription method in use for cervical cancer brachytherapy (i.e., to prescribe to Point A in most institutions) should not be changed as yet, because image-based dosimetry is not ready for routine practice. The Group proposes that for research purposes, individual centers and cooperative groups (e.g., GOG, RTOG, ACRIN) collect image-based dosimetry information and perform DVHs and correlate these data with the clinical outcome to determine which of the above parameters are relevant. The Group encourages external funding for image-based dosimetry and recommends that brachytherapy manufacturers develop image-compatible applicators. CONCLUSION: Although current institutional brachytherapy prescription for cervical cancer should continue, image-based data collection and analysis are needed to optimize cervical cancer brachytherapy. Proposals are made for research in image-based brachytherapy for cervical cancer.

Brachytherapy↗

PubMed2000

The American Brachytherapy Society recommendations for high-dose-rate brachytherapy for carcinoma of the cervix.

PURPOSE: This report presents guidelines for using high-dose-rate (HDR) brachytherapy in the management of patients with cervical cancer, taking into consideration the current availability of resources in most institutions. METHODS: Members of the American Brachytherapy Society (ABS) with expertise in HDR brachytherapy for cervical cancer performed a literature review, supplemented their clinical experience to formulate guidelines for HDR brachytherapy of cervical cancer. RESULTS: The ABS strongly recommends that definitive irradiation for cervical carcinoma must include brachytherapy as a component. Each institution should follow a consistent treatment policy when performing HDR brachytherapy, including complete documentation of treatment parameters and correlation with clinical outcome, such as pelvic control, survival, and complications. The goals are to treat Point A to at least a total low-dose-rate (LDR) equivalent of 80-85 Gy for early stage disease and 85-90 Gy for advanced stage. The pelvic sidewall dose recommendations are 50-55 Gy for early lesions and 55-65 Gy for advanced ones. The relative doses given by external beam radiation therapy (EBRT) vs. brachytherapy depend upon the initial volume of disease, the ability to displace the bladder and rectum, the degree of tumor regression during pelvic irradiation, and institutional preference. As with LDR brachytherapy, every attempt should be made to keep the bladder and rectal doses below 80 Gy and 75 Gy LDR equivalent doses, respectively. Interstitial brachytherapy should be considered for patients with disease that cannot be optimally encompassed by intracavitary brachytherapy. While recognizing that many efficacious HDR fractionation schedules exist, some suggested dose and fractionation schemes for combining the EBRT with HDR brachytherapy for each stage of disease are presented. These recommendations are intended only as guidelines, and the suggested fractionation schemes have not been thoroughly tested. The responsibility for the medical decisions ultimately rests with the treating radiation oncologist. CONCLUSION: Guidelines are established for HDR brachytherapy for cervical cancer. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies. These guidelines will be modified, as image-based treatment becomes more widely available.

Antineoplastic Agents↗

PubMed2005

Acute genitourinary toxicity after high-dose-rate (HDR) brachytherapy combined with hypofractionated external-beam radiation therapy for localized prostate cancer: correlation between the urethral dose in HDR brachytherapy and the severity of acute genitourinary toxicity.

PURPOSE: Several investigations have revealed that the alpha/beta ratio for prostate cancer is atypically low, and that hypofractionation or high-dose-rate (HDR) brachytherapy regimens using appropriate radiation doses may be expected to yield tumor control and late sequelae rates that are better or at least as favorable as those achieved with conventional radiation therapy. In this setting, we attempted treating localized prostate cancer patients with HDR brachytherapy combined with hypofractionated external beam radiation therapy (EBRT). The purpose of this study was to evaluate the feasibility of using this approach, with special emphasis on the relationship between the severity of acute genitourinary (GU) toxicity and the urethral dose calculated from the dose-volume histogram (DVH) of HDR brachytherapy. METHODS AND MATERIALS: Between September 2000 and December 2003, 70 patients with localized prostate cancer were treated by iridium-192 HDR brachytherapy combined with hypofractionated EBRT at the Gunma University Hospital. Hypofractionated EBRT was administered in fraction doses of 3 Gy, three times per week; a total dose of 51 Gy was delivered to the prostate gland and the seminal vesicles using the four-field technique. No elective pelvic irradiation was performed. After the completion of EBRT, all the patients additionally received transrectal ultrasonography (TRUS)-guided HDR brachytherapy. The fraction size and the number of fractions in HDR brachytherapy were prospectively changed, whereas the total radiation dose for EBRT was fixed at 51 Gy. The fractionation in HDR brachytherapy was as follows: 5 Gy x 5, 7 Gy x 3, 9 Gy x 2, administered twice per day, although the biologic effective dose (BED) for HDR brachytherapy combined with EBRT, assuming that the alpha/beta ratio is 3, was almost equal to 138 in each fractionation group. The planning target volume was defined as the prostate gland with 5-mm margin all around, and the planning was conducted based on computed tomography images. The number of patients in each fractionation group was as follows: 13 in the 5-Gy group; 19 in the 7-Gy group, and 38 in the 9-Gy group. The tumor stage was T1 in 10 patients, T2 in 36 patients, and T3 in 24 patients. The Gleason score was 2-6 in 11 patients, 7 in 34 patients, and 8-10 in 25 patients. Androgen ablation was performed in all the patients. The median follow-up duration was 14 months (range 3-42 months). The toxicities were graded based on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity criteria. RESULTS: The main symptoms of acute GU toxicity were dysuria and increase in urinary frequency or nocturia. The grade distribution of acute GU toxicity in the patients was as follows: Grade 0-1, 39 patients (56%), and Grade 2-4, 31 patients (44%). One patient who developed acute urinary obstruction was classified as having Grade 4 toxicity. Comparison of the distribution of the grade of acute GU toxicity among the different fractionation groups revealed no statistically significant differences among the groups. The urethral dose in HDR brachytherapy was evaluated using the following DVH parameters: V30 (percentage of the urethral volume receiving 30% of the prescribed radiation dose), V80, V90, V100, V110, V120, V130, and V150. The V30-110 values in the patients with Grade 2-4 acute GU toxicity were significantly higher than those in patients with Grade 0-1 toxicity. On the other hand, there were no significant differences in the V120-150 values between patients with Grade 0-1 and Grade 2-4 toxicity. Regarding the influence of the number of needles implanted for the radiation therapy, patients with 11 needles or less showed a significantly higher incidence of Grade 2-4 acute GU toxicity compared with those with 12 needles or more (p < 0.05). CONCLUSIONS: It was concluded that HDR brachytherapy combined with hypofractionated EBRT is feasible for localized prostate cancer when considered from the viewpoint of acute toxicity. Increase in the fraction dose or reduction in the number of fractions in HDR brachytherapy did not affect the severity of acute GU toxicity, and the volume of urethra receiving an equal or lower radiation dose than the prescribed dose was more closely associated with the grade severity of acute GU toxicity than that receiving a higher than the prescribed dose.

Aged↗

PubMed2005

Acute genitourinary toxicity after high dose rate (HDR) brachytherapy combined with hypofractionated external-beam radiation therapy for localized prostate cancer: Second analysis to determine the correlation between the urethral dose in HDR brachytherapy and the severity of acute genitourinary toxicity.

PURPOSE: We have been treating localized prostate cancer with high-dose-rate (HDR) brachytherapy combined with hypofractionated external beam radiation therapy (EBRT) at our institution. We recently reported the existence of a correlation between the severity of acute genitourinary (GU) toxicity and the urethral radiation dose in HDR brachytherapy by using different fractionation schema. The purpose of this study was to evaluate the role of the urethral dose in the development of acute GU toxicity more closely than in previous studies. For this purpose, we conducted an analysis of patients who had undergone HDR brachytherapy with a fixed fractionation schema combined with hypofractionated EBRT. METHODS AND MATERIALS: Among the patients with localized prostate cancer who were treated by 192-iridium HDR brachytherapy combined with hypofractionated EBRT at Gunma University Hospital between August 2000 and November 2004, we analyzed 67 patients who were treated by HDR brachytherapy with the fractionation schema of 9 Gy x two times combined with hypofractionated EBRT. Hypofractionated EBRT was administered at a fraction dose of 3 Gy three times weekly, and a total dose of 51 Gy was delivered to the prostate gland and seminal vesicles using the four-field technique. No elective pelvic irradiation was performed. After the completion of EBRT, all the patients additionally received transrectal ultrasonography-guided HDR brachytherapy. The planning target volume was defined as the prostate gland with a 5-mm margin all around, and the planning was conducted based on computed tomography images. The tumor stage was T1c in 13 patients, T2 in 31 patients, and T3 in 23 patients. The Gleason score was 2-6 in 12 patients, 7 in 34 patients, and 8-10 in 21 patients. Androgen ablation was performed in all the patients. The median follow-up duration was 11 months (range 3-24 months). The toxicities were graded based on the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer toxicity criteria. RESULTS: The main symptoms of acute GU toxicity were dysuria and increase in the urinary frequency or nocturia. The grade distribution of acute GU toxicity in the patients was as follows: Grade 0-1, 42 patients (63%); Grade 2-3, 25 patients (37%). The urethral dose in HDR brachytherapy was determined using the following dose-volume histogram (DVH) parameters: V30 (percentage of the urethral volume receiving 30% of the prescribed radiation dose), V80, V90, V100, V110, V120, V130, and V150. In addition, the D5 (dose covering 5% of the urethral volume), D10, D20, and D50 of the urethra were also estimated. The V30-V150 values in the patients with Grade 2-3 acute GU toxicity were significantly higher than those in patients with Grade 0-1 toxicity. The D10 and D20, but not D5 and D50, values were also significantly higher in the patients with Grade 2-3 acute GU toxicity than in those with Grade 0-1 toxicity. Regarding the influence of the number of needles implanted, there was no correlation between the number of needles implanted and the severity of acute GU toxicity or the V30-V150 values and D5-D50 values. CONCLUSIONS: It was concluded that HDR brachytherapy combined with hypofractionated EBRT is feasible for localized prostate cancer, when considered from the viewpoint of acute toxicity. However, because the urethral dose was closely associated with the grade of severity of the acute GU toxicity, the urethral dose in HDR brachytherapy must be kept low to reduce the severity of acute GU toxicity.

Aged↗

PubMed2006

Controversies and new developments in gynecologic brachytherapy: image-based intracavitary brachytherapy for cervical carcinoma.

The current clinical practice for cervical cancer intracavitary brachytherapy in most centers is to prescribe the dose to point A. However, this is an empirical point and does not necessarily reflect dose to the tumor. Although 3-dimensional image-based treatment planning is extensively used in prostate brachytherapy, only a few institutions have used it to shape the dose distribution in cervical brachytherapy. To facilitate and standardize image-based dosimetry for cervical cancer brachytherapy, the American Image-guided Brachytherapy Working Group and the European Gynecological GEC-ESTRO Working Group have recently proposed nomenclature for volume definition and recommendations for image-based intracavitary brachytherapy for cervical cancer. The recommendations of the 2 groups are very similar and are discussed together in this article. Proposals are made for research in image-based brachytherapy for cervical cancer. At a recent transatlantic image-based cervical cancer brachytherapy workshop (Chicago, IL, July 28, 2005), it was suggested that because the recommendations are so similar and to prevent confusion, the nomenclature suggested by the European Group be adopted and future joint contouring workshops be organized to facilitate image-based cervical cancer brachytherapy.

Brachytherapy↗

PubMed2000

A comparison of complications between ultrasound-guided prostate brachytherapy and open prostate brachytherapy.

PURPOSE: Prostate brachytherapy has reemerged during the 1990s as a treatment for clinically localized prostate cancer. The renewed popularity of prostate brachytherapy is largely due to the use of transrectal ultrasound of the prostate, which allows for more accurate isotope placement within the prostate when compared to the open approach. The present study investigates whether this improved cancer control is at the expense of increased morbidity by comparing the morbidity after transrectal ultrasound-guided prostate brachytherapy to the morbidity after prostate brachytherapy performed via an open approach. METHODS AND MATERIALS: All men in the Medicare population who underwent prostate brachytherapy in the year 1991 were identified. These men were further stratified into those men who underwent prostate brachytherapy via an open approach and the men who underwent prostate brachytherapy with ultrasound guidance. All subsequent inpatient, outpatient, and physician (Part B) Medicare claims for these men from the years 1991-1993 were then analyzed to determine outcomes. RESULTS: In the year 1991, 2124 men in the Medicare population underwent prostate brachytherapy. An open approach was used in 715 men (33.7%), and ultrasound guidance was used in 1409 men (66.3%). Mean age for both cohorts was 73.7 years with a range of 50.7-92.8 years for the ultrasound group and 60.6-92. 1 years for the open group. A surgical procedure for the relief of bladder outlet obstruction was performed in 122 men (8.6%) in the ultrasound group and in 54 men (7.6%) in the open group. An artificial urinary sphincter was placed in 2 men (0.14%) in the ultrasound group and in 2 men (0.28%) in the open group. A penile prosthesis was implanted in 10 men (0.71%) in the ultrasound group and in 4 men (0.56%) in the open group. A diagnosis code for urinary incontinence was carried by 95 men (6.7%) in the ultrasound group and by 45 men (6.3%) in the open group. A diagnosis code for erectile dysfunction was carried by 90 men (6.3%) in the ultrasound group and by 64 men (9.0%) in the open group. CONCLUSION: Prostate brachytherapy performed with ultrasound guidance does not appear to increase significantly complications resulting from the procedure. Both techniques appear to offer similar rates of procedures performed to correct urinary incontinence, bladder outlet obstruction and erectile dysfunction. The limitations of claim information in determining patient outcomes, however, must be considered when evaluating this data.

Aged↗

PubMed2001

The American Brachytherapy Society recommendations for brachytherapy of soft tissue sarcomas.

PURPOSE: This report presents the American Brachytherapy Society (ABS) guidelines for the use of brachytherapy for patients with soft tissue sarcoma. METHODS AND MATERIALS: Members of the ABS with expertise in soft tissue sarcoma formulated brachytherapy guidelines based upon their clinical experience and a review of the literature. The Board of Directors of the ABS approved the final report. RESULTS: Brachytherapy used alone or in combination with external beam irradiation is an established means of safely providing adjuvant local treatment after resection for soft tissue sarcomas in adults and in children. Brachytherapy options include low dose rate techniques with iridium 192 or iodine 125, fractionated high dose rate brachytherapy, or intraoperative high dose rate therapy. Recommendations are made for patient selection, techniques, dose rates, and dosages. Complications and possible interventions to minimize their occurrence and severity are reviewed. CONCLUSION: Brachytherapy represents an effective means of enhancing the therapeutic ratio, offering both biologic and dosimetric advantage in the treatment of patients with soft tissue sarcoma. The treatment approach used depends upon the institution, physician expertise, and the clinical situation. Guidelines are established for the use of brachytherapy in the treatment of soft tissue sarcomas in adults and in children. Practitioners and cooperative groups are encouraged to use these guidelines to formulate their treatment and dose-reporting policies. These guidelines will be modified, as further clinical results become available.

Adult↗

PubMed2001

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

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

Brachytherapy↗

PubMed2002

The COMS randomized trial of iodine 125 brachytherapy for choroidal melanoma: IV. Local treatment failure and enucleation in the first 5 years after brachytherapy. COMS report no. 19.

OBJECTIVE: To describe the frequency and predictors of local treatment failure and enucleation after iodine 125 (I(125)) brachytherapy in patients with choroidal melanoma treated and followed up in a large randomized clinical trial. DESIGN: Prospective, noncomparative, interventional case series within a randomized, multicenter clinical trial. PARTICIPANTS: Patients enrolled in the Collaborative Ocular Melanoma Study (COMS) trial of enucleation versus brachytherapy between February 1987 and July 1998; tumors measured 2.5 to 10.0 mm in apical height and no more than 16.0 mm in longest basal dimension. METHODS: I(125) brachytherapy was administered via episcleral plaque according to a standard protocol. Follow-up ophthalmic evaluations, including ophthalmic ultrasound and fundus photography, were performed according to a standard protocol at baseline, every 6 months thereafter for 5 years, and subsequently at annual intervals. Survival analysis methods were used to estimate the cumulative risk of postirradiation treatment failure and enucleation. Factors associated with treatment failure and enucleation of plaqued eyes were evaluated using Cox proportional hazards analysis. MAIN OUTCOME MEASURES: Reports of enucleation and of local treatment failure, defined as tumor growth, recurrence, or extrascleral extension, derived from clinical reports based on echographic and photographic documentation. RESULTS: As of September 30, 2000, 638 of the 650 patients randomized to brachytherapy and so treated had been followed up for 1 year or longer, and 411 had been followed up for at least 5 years. Sixty-nine eyes were enucleated during the first 5 years after brachytherapy, and treatment failure was reported for 57 eyes. The Kaplan-Meier estimate of proportion of patients undergoing enucleation by 5 years was 12.5% (95% confidence interval [CI], 10.0%-15.6%); the risk of treatment failure was 10.3% (95% CI, 8.0%-13.2%). Treatment failure was the most common reason for enucleation within 3 years of treatment; beyond 3 years, ocular pain was most common. Risk factors for enucleation were greater tumor thickness, closer proximity of the posterior tumor border to the foveal avascular zone, and poorer baseline visual acuity in the affected eye. Risk factors for treatment failure were older age, greater tumor thickness, and proximity of the tumor to the foveal avascular zone. Local treatment failure was associated weakly with reduced survival after controlling for baseline tumor and personal characteristics (adjusted risk ratio, 1.5; P = 0.08). CONCLUSIONS: Local treatment failure and enucleation were relatively infrequent events after I(125) brachytherapy within the COMS. Treatment failure typically occurred early and was associated weakly with poorer survival. The COMS randomized trial documented the absence of a clinically or statistically significant difference in survival for patients randomly assigned to enucleation versus brachytherapy. This analysis documents the efficacy of brachytherapy to achieve sustained local tumor control and to conserve the globe.

Aged↗

PubMed1999

The American brachytherapy society survey of brachytherapy practice for carcinoma of the cervix in the United States.

PURPOSE: The purpose of this study was to survey the brachytherapy practice for cervical cancer in the United States. METHODS: The Clinical Research Committee of the American Brachytherapy Society (ABS) performed a retrospective survey of individual physicians of the ABS and American Society of Therapeutic Radiologists and Oncologists regarding the details of the brachytherapy techniques they personally used in the treatment of cervical cancer patients for the year 1995. The replies (some of which may have been an estimate only) were tabulated. The scope of this survey did not allow us to verify the data by chart audits. RESULTS: A total of about 3500 questionnaires were mailed out; 521 responses were received. Of these responders, 206 (40%) did not perform any brachytherapy for carcinoma of the cervix in 1995. Of the other 315 responders reporting a total of 4892 patients treated in 1995, 88% used low dose rate (LDR) while 24% used high dose rate (HDR). There was a wide variation in the doses used. For LDR treatments, the median total external beam radiation therapy (EBRT) dose was 45 and 50 Gy and the LDR dose was 42 and 45 Gy for early and advanced cancers, respectively. For HDR treatments, the median EBRT dose was 48 and 50 Gy and the median HDR dose was 29 and 30 Gy for early and advanced cancers, respectively. The median dose per fraction was 6 Gy for a median of five fractions. Interstitial brachytherapy was used as a component of the treatment in 6% of the patients by 21% of responders. Very few responders treated with pulsed or medium dose rates. CONCLUSION: This retrospective survey showed the current brachytherapy practice pattern in the treatment of cervical cancer in the United States and can serve as a basis for future prospective national brachytherapy data registry. There was wide variation in the practice pattern, emphasizing the urgent need for consensus on these issues.

Brachytherapy↗

PubMed1999

Curative radiotherapy with high-dose-rate brachytherapy boost for localized esophageal carcinoma: dose-effect relationship of brachytherapy with the balloon type applicator system.

BACKGROUND AND PURPOSE: This study analyzed the feasibility, local control and toxicity in potentially curable patients with esophageal carcinoma treated with a combination of external irradiation and high-dose-rate (HDR) brachytherapy using a balloon type applicator system to minimize hot spots on the mucosa. MATERIALS AND METHODS: During the 9 years, 124 patients with esophageal carcinoma and no apparent extraesophageal spread were treated with 40-60 Gy of external irradiation followed by 8-24 Gy of HDR brachytherapy. The fraction size of brachytherapy was 4-6 Gy. We developed a new applicator with 15 mm external diameter inflatable balloons. The reference point was a point 12.5 mm depth from the mid source. The study end points were local control, late toxicity and palliative effect. RESULTS: All 124 patients completed the planned radiotherapy. Local control rate was 69/124 (56%). There was a trend toward better local control rate for T1 lesions with increasing dose via brachytherapy. Of 69 patients with local control, treatment-related ulcers occurred in 28 patients, leading to death in four. The incidence of ulcers increased with increasing brachytherapy dose; 1/6 with 12 Gy, 16/43 with 16 Gy, 6/ 12 with 20 Gy, 4/5 with 24 Gy. Esophageal benign strictures occurred in ten patients and in all cases developed from ulcers. The incidence of freedom from dysphagia was not dose-dependent. CONCLUSION: A combination of external irradiation and HDR brachytherapy with the balloon type applicator was feasible and well tolerated. Although better local control was achieved by a higher dose of brachytherapy, the higher dose caused more severe esophageal injury.

Adult↗

PubMedDate not supplied

The American Brachytherapy Society perspective on intravascular brachytherapy.

BACKGROUND: Recent clinical studies indicate that intravascular brachytherapy (IVB) can reduce the rate of restenosis substantially after angioplasty procedures. However, no clinical guidelines exist for optimal therapy. METHODS: The members of the IVB Subcommittee of the American Brachytherapy Society (ABS) identified the areas of consensus and controversies in IVB to issue the ABS perspective on IVB, based on analysis of published reports and the clinical experience of the members in brachytherapy. RESULTS: IVB is still experimental. The long-term efficacy, toxicity, the target tissue, and dose required for IVB are not established. The ABS recommends that IVB procedures must be performed, with careful attention to radiation-related issues, in the context of controlled multidisciplinary clinical trials with the approval of the institutional review board, the Nuclear Regulatory Commission, the Food and Drug Administration, and under an Investigational Device Exemption. The therapeutic radiologist, with a qualified radiation physicist, is responsible for dose prescription and delivery and needs to be present during the IVB procedure as part of this multidisciplinary team. The long-term outcome from these studies should be reviewed critically and published in peer-reviewed journals. The ABS endorsed the dosimetric guidelines of the American Association of Physicists in Medicine Task Group 60 (AAPM TG-60) report. The ABS recommends that dose specification be defined clearly; to allow comparisons between studies, the dose should be prescribed at 2 mm from the source for intracoronary brachytherapy and at an average luminal radius of +2 mm for peripheral vascular brachytherapy. The prescription doses at the above point is generally in the 12-18 Gy range. Comprehensive procedures for quality assurance, radiation protection, and emergencies should be in place before initiating an IVB program. Higher energy beta sources, lower energy gamma sources, dose-volume histograms, and correlation of three-dimensional reconstructions of delivered dose with patterns of failure are areas for further research. CONCLUSION: The ABS perspective on IVB is presented to assist the interventional team in developing protocols for the use of IVB in the prevention of restenosis. Long-term outcome data with a standardized reporting system are needed to establish the role of brachytherapy in preventing vascular restenosis. Endovascular brachytherapy is a new and evolving modality, and these recommendations are subject to modifications as new data become available.

Brachytherapy↗

PubMed2006

Calculated and measured brachytherapy dosimetry parameters in water for the Xoft Axxent X-Ray Source: an electronic brachytherapy source.

A new x-ray source, the model S700 Axxent X-Ray Source (Source), has been developed by Xoft Inc. for electronic brachytherapy. Unlike brachytherapy sources containing radionuclides, this Source may be turned on and off at will and may be operated at variable currents and voltages to change the dose rate and penetration properties. The in-water dosimetry parameters for this electronic brachytherapy source have been determined from measurements and calculations at 40, 45, and 50 kV settings. Monte Carlo simulations of radiation transport utilized the MCNP5 code and the EPDL97-based mcplib04 cross-section library. Inter-tube consistency was assessed for 20 different Sources, measured with a PTW 34013 ionization chamber. As the Source is intended to be used for a maximum of ten treatment fractions, tube stability was also assessed. Photon spectra were measured using a high-purity germanium (HPGe) detector, and calculated using MCNP. Parameters used in the two-dimensional (2D) brachytherapy dosimetry formalism were determined. While the Source was characterized as a point due to the small anode size, < 1 mm, use of the one-dimensional (1D) brachytherapy dosimetry formalism is not recommended due to polar anisotropy. Consequently, 1D brachytherapy dosimetry parameters were not sought. Calculated point-source model radial dose functions at gP(5) were 0.20, 0.24, and 0.29 for the 40, 45, and 50 kV voltage settings, respectively. For 1<r<7 cm, measured point-source model radial dose functions were typically within 4% of calculated results. Calculated values for F(r, theta) for all operating voltages were within 15% of unity along the distal end (theta=0 degree), and ranged from F(1 cm, 160 degrees) = 0.2 to F(15 cm, 175 degrees) = 0.4 towards the catheter proximal end. For all three operating voltages using the PTW chamber, measured dependence of output as a function of azimuthal angle, psi, was typically on average +/-3% for 0 degree < or = psi < or = 360 degrees. Excluding an energy response function, measurements of normalized photon energy spectra were made for three operating voltages, and were typically within 2% agreement with the normalized Monte Carlo calculated spectra. In general, the model S700 Source exhibited depth dose behavior similar to low-energy photon-emitting low dose rate sources 125I and l03Pd, yet with capability for variable and much higher dose rates and subsequently adjustable penetration capabilities. This paper presents the calculated and measured in-water brachytherapy dosimetry parameters for the model S700 Source at the aforementioned three operating voltages.

Brachytherapy↗

PubMed2001

[Reirradiation with brachytherapy for recurrent tongue cancer after initial brachytherapy].

The purpose of this study was to assess the efficacy of reirradiation with brachytherapy in the treatment of patients with tongue cancer that had recurred after initial brachytherapy. A retrospective analysis was performed in 12 patients with tongue cancer treated by reirradiation with brachytherapy using rigid linear sources such as the 226Ra-needle or 192Ir-hairpin at Kyushu University Hospital from 1978 to 1998. The patients included 8 men and 4 women, who ranged in age from 30 to 69 years (mean, 52 years). At the time of reirradiation, 7 patients had stage I cancer, and 5 had stage II cancer, according to the UICC (1997) classification. The median follow-up time of the surviving patients was 92 months. The 5-year relapse-free and cause-specific survival rates were 31% and 64%, respectively. The 5-year cause-specific survival rate varied according to the interval between the first and second course of brachytherapy and was 25% for intervals of less than 12 months and 83% for intervals of more than 12 months. Only 4 patients with local recurrence were recognized after their second course of brachytherapy. Among the 6 patients who survived more than 2 years after reirradiation without local recurrence, symptomatic complications such as soft tissue necrosis and minimal bone necrosis were found in 3 patients, but these side effects were not serious enough to require surgery. Reirradiation with a second course of brachytherapy may be useful in the treatment of patients with tongue cancer that recurs more than 12 months after initial brachytherapy.

Adult↗