Anna Kulik

Surgery Combined With Intraoperative Brachytherapy in the Treatment of Retroperitoneal Sarcomas

BackgroundThe purpose of this study was to analyze the results of treatment of retroperitoneal soft tissue sarcomas (RSTS) by surgery combined with intraoperative brachytherapy (IOBRT).MethodsSeventy adult patients with RSTS were considered for combined treatment (surgery plus IOBRT) between June 1998 and February 2004. There were 64 (91%) recurrent tumors, and 93% of tumors exceeded 5 cm. IOBRT was performed with high-dose-rate Gammamed 12 with iridium 192 (IOBRT time range, 20–87 minutes; median, 56 minutes).ResultsAfter intraoperative re-evaluation, 24 patients (34%) were found to be ineligible for IOBRT because of multiple intraperitoneal recurrences, macroscopically nonradical resection, poor general condition, and technical aspects. Thirty-seven patients underwent IOBRT immediately after surgery during the same general anesthesia procedure. Nine patients underwent delayed IOBRT within 1 to 3 days after the primary operation. Ten (21.5%) of 46 patients underwent reoperation because of surgical complications. One patient died in the postoperative period. After IOBRT, 24 patients (52%) underwent adjuvant external beam radiotherapy (EBRT) to a total dose of 50 Gy. Over a median follow-up time of 20 months, the estimated 5-year overall survival and local recurrence–free survival rates in IOBRT patients were 55% and 51%, respectively. Application of adjuvant EBRT showed a favorable local control rate.ConclusionsThe scheduled combined treatment (surgery plus IOBRT) was possible to perform in 66% of RSTS cases that received surgical treatment. The complication rate was high, but we consider it acceptable because of the necessity for extensive aggressive surgical treatment in regionally advanced RSTS. EBRT seems to be an indispensable part of treatment that provides better local control.

GEC-ESTRO multicenter phase 3-trial: Accelerated partial breast irradiation with interstitial multicatheter brachytherapy versus external beam whole breast irradiation: Early toxicity and patient compliance

BACKGROUND AND PURPOSE To compare early side effects and patient compliance of accelerated partial breast irradiation (APBI) with multicatheter brachytherapy to external beam whole breast irradiation (WBI) in a low-risk group of patients with breast cancer. MATERIAL AND METHODS Between April 2004 and July 2009, 1328 patients with UICC stage 0-IIA breast cancer were randomized to receive WBI with 50Gy and a boost of 10Gy or APBI with either 32.0Gy/8 fractions, or 30.1Gy/7 fractions (HDR-brachytherapy), or 50Gy/0.60-0.80Gy per pulse (PDR-brachytherapy). This report focuses on early side-effects and patient compliance observed in 1186 analyzable patients. ClinicalTrials.gov identifier: NCT00402519. RESULTS Patient compliance was excellent in both arms. Both WBI and APBI were well tolerated with moderate early side-effects. No grade 4 toxicity had been observed. Grade 3 side effects were exclusively seen for early skin toxicity (radiation dermatitis) with 7% vs. 0.2% (p<0.0001), and breast infection with 0% vs. 0.2% (p=n.s.) for patients treated with WBI and APBI. The incidence of grades 1-2 early side effects for WBI and APBI was 86% vs. 21% (p<0.0001) for skin toxicity, 2% vs. 20% (p<0.0001) for mild hematoma, and 2% vs. 5% (p=0.01) for mild breast infection rates, respectively. No differences had been found regarding grades 1-2 early breast pain (26% vs. 29%, p=0.23). CONCLUSIONS APBI with interstitial multicatheter brachytherapy was tolerated very well and dramatically reduced early skin toxicity in comparison to standard WBI.

Clinical Investigations Surgery combined with brachytherapy in patients with retroperitoneal sarcomas

Purpose The primary aim of this work was to analyze feasibility of combined treatment of retroperitoneal sarcomas (RS): surgery (S) and intraoperative brachytherapy (IOBRT). The secondary aim was to analyze results and complications after this treatment. Material and methods 84 patients with retroperitoneal sarcomas were qualified for combined treatment (S and IOBRT) between June 1998 and September 2006. 65 of the patients (77.4%) had local recurrences. Sarcomas with intermediate and high grade of histological malignancy (G2, G3 – 76.2%) were the most frequent within the all surgically treated patients. Resection ability (R0/R1) in analyzed group of patients was estimated as 85% (74 cases). After intraoperative evaluation, 57 (67.8%) patients were qualified for IOBRT. Since 2000, in 34 patients (60%) an adjuvant postoperative external beam radiation therapy (EBRT) in dose of 50 Gy was applied. Median follow-up of the surviving patients was 40 months. Results On the basis of the univariate analysis, relevant aspects negatively influencing overall survival rate within the RS group treated with IOBRT were as follows: surgery of sarcoma recurrence (p = 0.002), higher grade of histological malignancy (p = 0.05), histological type different than liposarcoma (p = 0.05) as well as no adjuvant EBRT (p = 0.05). On the basis of multivariate analysis one can ascertain that relevant factors negatively influencing LRFS in RS patients treated with IOBRT were: surgery due to recurrence of sarcoma (p = 0.008) and lack of EBRT (p = 0.01). Conclusions Combined treatment (surgery and brachytherapy) was possible to be carried out on 68% of RS patients. The overall number of complications was quite high, however acceptable, taking into consideration the application of extensive, multi-organ treatments in case of sarcoma recurrences in this localization. The results suggest that the method of treatment will improve the final outcome when most of patients will be qualified for treatment of primary sarcomas in experienced centre.

Quality-of-life results for accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation in early breast cancer after breast-conserving surgery (GEC-ESTRO): 5-year results of a randomised, phase 3 trial

BACKGROUND Previous results from the GEC-ESTRO trial showed that accelerated partial breast irradiation (APBI) using multicatheter brachytherapy in the treatment of early breast cancer after breast-conserving surgery was non-inferior to whole-breast irradiation in terms of local control and overall survival. Here, we present 5-year results of patient-reported quality of life. METHODS We did this randomised controlled phase 3 trial at 16 hospitals and medical centres in seven European countries. Patients aged 40 years or older with 0-IIA breast cancer were randomly assigned (1:1) after breast-conserving surgery (resection margins ≥2 mm) to receive either whole-breast irradiation of 50 Gy with a boost of 10 Gy or APBI using multicatheter brachytherapy. Randomisation was stratified by study centre, tumour type, and menopausal status, with a block size of ten and an automated dynamic algorithm. There was no masking of patients or investigators. The primary endpoint of the trial was ipsilateral local recurrence. Here, we present 5-year results of quality of life (a prespecified secondary endpoint). Quality-of-life questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30, breast cancer module QLQ-BR23) were completed before radiotherapy (baseline 1), immediately after radiotherapy (baseline 2), and during follow-up. We analysed the data according to treatment received (as-treated population). Recruitment was completed in 2009, and long-term follow-up is continuing. The trial is registered at ClinicalTrials.gov, number NCT00402519. FINDINGS Between April 20, 2004, and July 30, 2009, 633 patients had accelerated partial breast irradiation and 551 patients had whole-breast irradiation. Quality-of-life questionnaires at baseline 1 were available for 334 (53%) of 663 patients in the APBI group and 314 (57%) of 551 patients in the whole-breast irradiation group; the response rate was similar during follow-up. Global health status (range 0-100) was stable in both groups: at baseline 1, APBI group mean score 65·5 (SD 20·6) versus whole-breast irradiation group 64·6 (19·6), p=0·37; at 5 years, APBI group 66·2 (22·2) versus whole-breast irradiation group 66·0 (21·8), p=0·94. The only moderate, significant difference (difference of 10-20 points) between the groups was found in the breast symptoms scale. Breast symptom scores were significantly higher (ie, worse) after whole-breast irradiation than after APBI at baseline 2 (difference of means 13·6, 95% CI 9·7-17·5; p<0·0001) and at 3-month follow-up (difference of means 12·7, 95% CI 9·8-15·6; p<0·0001). INTERPRETATION APBI with multicatheter brachytherapy was not associated with worse quality of life compared with whole-breast irradiation. This finding supports APBI as an alternative treatment option after breast-conserving surgery for patients with early breast cancer. FUNDING German Cancer Aid.

The prospective assessment of the prostatic cancer mortality with PSA progression in the groups treated or not treated by salvage local brachytherapy.

85Background: The effectiveness of diagnostics of local recurrence of prostatic adenocarcinoma after radical radiotherapy and local retreatment high definition brachytherapy and its influence on the prostatic cancer survival. Methods: 55 patients with locally advanced prostatic adenocarcinoma with rising PSA level after radical radiotherapy and exclusion of distant metastases underwent prostatic biopsy. ECOG performance status 0-1 were eligible. The histopathological confirmation was obtained in 22 cases, and 33 patients had negative biopsy. In the case of positive biopsy radical salvage brachytherapy was performed in all patients. In the case of negative biopsy definitive anti-androgen therapy was administered in patients with PSA progression. Anti – androgen therapy was performed as adjuvant and neoadjuvant treatment after brachytherapy. In the course of the long (median 108months) observation we assessed prostatic specific mortality in both groups. In addition we assessed time to PSA progression during...

Brachytherapy for vaginal intraepithelial neoplasia

OBJECTIVE To retrospectively evaluate the efficacy of high-dose-rate brachytherapy of vaginal intraepithelial neoplasia with a special focus on analysis of toxicity. STUDY DESIGN Twenty consecutive patients were irradiated with brachytherapy of vaginal intraepithelial neoplasia with component ca in situ (N=3). Late complications of the vagina graded using the CTCAE v.3.0. General assessment three-step scale was introduced for simplicity of analysis. RESULTS The median age was 57 years (range: 28-80 years). The median follow-up time was 39 months (range: 14-115 months). Vaginal intraepithelial neoplasia recurrence was observed in 1 patient. The 3-year disease free survival rate was 90% (95% confidence interval [CI]: 71-100%). Observed late side effects: libido grades 1-2 in 15 (75%), vaginal discharge grade 2 (pad use indicated) in 2 (10%), dryness grade 2 (dyspareunia) in 7 (35%), mucositis grades 2-3 in 6 (30%), stenosis grades 2-3 in 7 (35%) and vaginitis grades 2-3 in 4 (20%) cases. General assessment was good in 9 (45%), average in 2 (10%), and bad in 9 (45%) patients. Treatment dose affected the toxicity (p=0.05). In groups of patients irradiated with biologically equivalent dose (assuming α/β=3Gy) of 47.3-63Gy and ≥70Gy, the risk of poor or moderate toxicity amounted to 16.7% (95% CI: 0-47%) and 71.4% (95% CI: 48-95%), respectively. CONCLUSION Brachytherapy revealed to be effective method of vaginal intraepithelial neoplasia treatment, but applying EQD2≥70Gy into vagina generates unacceptable toxicity.

OC-0089: Reirradiation in recurrent cervical and vaginal cancer: analysis of effectiveness and toxicity

OC-0089 Reirradiation in recurrent cervical and vaginal cancer: analysis of effectiveness and toxicity. A. Zolciak-Siwinska, M. Dabkowski, M. Bijok, M. Kawczynska, W. Michalski, A. Kulik The Maria Sklodowska-Curie Memorial Cancer Center, Department of Brachytherapy, Warsaw, Poland The Maria Sklodowska-Curie Memorial Cancer Center, Medical Physics Department, Warsaw, Poland The Maria Sklodowska-Curie Memorial Cancer Center, Biostatistics Department, Warsaw, Poland

Brachyterapia śródoperacyjna mięsaków przestrzeni zaotrzewnowej – technika napromieniania i ocena wczesnej tolerancji☆

Streszczenie Miesaki zlokalizowane w przestrzeni zaotrzewnowej są zmianami wystepujqcymi stosunkowo rzadko a metodą zasadniczą leczenia radykalnego jest zabieg operacyjny. Radioterapia stosowana jest jako leczenie uzupelniające w wiekszości przypadkow. W niniejszym doniesieniu autorzy przedstawiają metode napromieniania lozy po usunietym guzie nowotworowym wykorzystującą źrodlo o wysokiej mocy dawki (brachyterapia metodą HDR). Napromienianie przeprowadzane jest w trakcie trwania zabiegu operacyjnego a wstepne obserwacje wskazują na dobrą tolerancje przez chorych przedstawianej metody.

35 Dozymetria w uzupełniającej brachyterapii HDR w oszczędzającym leczeniu raka sutka

Cel pracy: Celem pracy byto por6wnanie dawki obliczonej przy uzyciu tr6jwymiarowego systemu planowania leczenia z pomiarami in vivo w wybranych punktach. Material i metody: Od 1998 roku w Zakfadzie Brachyterapii Centrum Onkologii w Warszawie stosowana jest brachyterapia HDR jako boost po skoriczonej radioterapii wiqzkami zewn~trznymi w oszcz~dzajqcym leczeniu raka piersi. Leczenie rozpoczyna si~ ad tumorektomii, po czym napromienia siEi! cafy sutek dwoma polami przeciwlegtymi. Tydzieri po zakonczeniu radioterapii wiqzkami zewn~trznymi pacjentki otrzymujq 10-12 Gy z brachyterapii HDR na loz~ po guzie, zlokalizowanq na podstawie pooperacyjnej mammografii. Planowanie leczenia odbywa si~ na podstawie protokofu pooperacyjnego i mammografii. Liczba igief, w kt6rych porusza si~ zr6dfo Ir-192, ich rozkfad i dtugose aktywna zalezq ad wielkosci lazy po tumorektomi i odlegtosci od powierzchni sk6ry. Dawka na sk6r~ ad brachyterapii jest obliczana przy pomocy tr6jwymiarowego systemu planowania leczenia ABACUS firmy Sauerwein Gmbh, a nast~pnie jest mierzona dawkomierzami TLD. Wyniki i wnioski: Wielkose dawki na sk6rEi! ma duiy wptyw na efekt kosmetyczny catego leczenia. Por6wnanie pomiar6w i obJiczen pozwolito na modyfikacje i optymalizacjEi! dtugosci aktywnej prowadnic.

29 Paliatywna jednofrakcyjna brachyterapia HDR u chorych na zaawansowanego miejscowo niedrobnokomórkowego raka płuca

Cel pracy Ocena skuteczności i tolerancji jednorazowego napromienianiania dooskrzelowego izotopem Ir 192 HDR chorych na zaawansowanego miejscowo raka pluca. W okresie od grudnia 1995 do stycznia 2000 w Zakladzie Brachyterapii Centrum Onkologii w Warszawie leczono napromienianiem dooskrzelowym grupe 176 chorych, w tym 134 mezczyzn i 42 kobiety w wieku od 39 do 82 lat (średnio 61 lat) z potwierdzonym w badaniu histopatologicznym niedrobnokomorkowym rakiem pluca. Do powyzszego leczenia kwalifikowano chorych ze wznową po uprzedniej radykalnej lub paliatywnej teleradioterapii oraz chorych z pierwotnie zaawansowanym procesem nowotworowym (IIIA–B, IV), w niskim stopniu sprawności (Ksc Wszyscy chorzy napromieniani byli zrodlem Ir 192 o wysokiej aktywności, wprowadzanym techniką afterloading za pomocą aparatu Gammamed 12i, po uprzednim umieszczeniu w obszarze nacieku jednego lub kilku aplikatorow. Zakres stosowanych dawek wahal sie w granicach od 10 do 15 Gy, w zalezności od przebytego leczenia. Okres obserwacji w badanej grupie chorych wynosil od 1 do 18 miesiecy (średnio 4.6 miesiecy). W trakcie badan kontrolnych oceniano odpowiedz na przeprowadzone leczenie oraz jego tolerancje.