B. Guix

Treatment of skin carcinomas of the face by high-dose-rate brachytherapy and custom-made surface molds ☆

Abstract Purpose: To analyze the results obtained in a prospective group of patients with basal or squamous cell skin carcinomas of the face treated by high-dose-rate (HDR) brachytherapy via custom-made surface molds. Methods and Materials: A total of 136 patients with basal or squamous cell carcinomas of the face were treated between March 1992 and March 1997 by surface molds and HDR brachytherapy with iridium-192. Nineteen patients were treated with standard Brock applicators and 117 patients with custom-made polymethyl methacrylate applicators, built over a plaster mold obtained of the patients face. Minimum dose administered to the tumor was 6000 to 6500 cGy in 33 to 36 fractions at 180 cGy/fraction in lesions of up to 4 cm. Lesions greater than 4 cm were boosted up to 7500–8000 cGy after a 3-week pause. Results: With the custom-made surface molds, the dose distribution was uniform in the surface of the skin and at 5 mm depth in the whole area of the applicator. Differences between the areas of maximum and minimum dose at this depth never reached values higher than 5% of the prescribed dose. At the edges of the custom-made molds dose gradient was sharp, with the detected dose at 5 mm from the applicator being negligible. All the patients were complete responders. There were 3 local recurrences, 1/73 patients treated for primary tumor and 2/63 patients treated for recurrent tumor. Actuarial local control at 5 years for all patients was 98%, for those patients with primary tumors 99%, and for recurrent patients 87%. The treatment tolerance was excellent in all cases. No severe, early, or late, complications were detected. Conclusions: Radiotherapy is a highly effective treatment of skin carcinomas of the face. Custom-made molds, to be used in conjunction with HDR brachytherapy equipment, make possible a uniform dose distribution, with a sharp dose gradient in the limits of applicators. Custom-made surface molds are easy and safe to use, and they fit very accurately for daily treatment. Local control is excellent with minimal sequelae or complications. Probably they will become the standard way of treatment of face skin carcinomas in the near future.

Treatment of keloids by high-dose-rate brachytherapy: A seven-year study.

PURPOSE To analyze the results obtained in a prospective group of patients with keloid scars treated by high-dose-rate (HDR) brachytherapy with or without surgery. METHODS AND MATERIALS One hundred and sixty-nine patients with keloid scars were treated with HDR brachytherapy between December 1991 and December 1998. One hundred and thirty-four patients were females, and 35 were males. The distribution of keloid scars was as follows: face, 77; trunk, 73; and extremities, 19. The mean length was 4.2 cm (range 2-22 cm), and the mean width 1.8 cm (range 1.0-2.8 cm). In 147 patients keloid tissues were removed before HDR brachytherapy treatment, and in 22 HDR brachytherapy was used as definitive treatment. In patients who underwent prior surgery, a flexible plastic tube was put in place during the surgical procedure. Bottoms were used to fix the plastic tubes, and the surgical wound was repaired by absorbable suture. HDR brachytherapy was administered within 30-60 min of surgery. A total dose of 12 Gy (at 1 cm from the center of the catheter) was given in four fractions of 300 cGy in 24 h (at 09.00 am, 15.00 pm, 21.00 pm, and 09.00 am next day). Treatment was optimized using standard geometric optimization. In patients who did not undergo surgery, standard brachytherapy was performed, and plastic tubes were placed through the skin to cover the whole scar. Local anesthesia was used in all procedures. In these patients a total dose of 18 Gy was given in 6 fractions of 300 cGy in one and a half days (at 9.00 am, 3.00 pm, and 9.00 pm; and at 9.00 am, 3.00 pm, and 9.00 pm next day). No further treatment was given to any patient. Patients were seen in follow-up visits every 3 months during the first year, every 6 months in the second year, and yearly thereafter. No patient was lost to follow-up. Particular attention was paid to keloid recurrence, late skin effects, and cosmetic results. RESULTS All patients completed the treatment. After a follow-up of seven years, 8 patients (4.7%) had keloid recurrences. Five of these had undergone prior surgery (local failure rate 3.4%), and 3 had received only HDR brachytherapy (local persistence rate 13.6%). Cosmetic results were considered to be good or excellent in 130/147 patients treated with prior surgery and in 17/22 patients without surgery. Skin pigmentation changes were observed in 10 patients, and telangiectasias in 12 patients. No late effects such as skin atrophy or skin fibrosis were observed during the 7 years of follow-up. CONCLUSIONS HDR brachytherapy is an effective treatment for keloid scars. It is well tolerated and does not present significant side effects. The brachytherapy results were more successful in patients who underwent previous surgical excision of keloid scar than in patients without surgery. We favor HDR brachytherapy rather than superficial X-rays or low energy electron beams in keloid scars, because HDR provides a better selective deposit of radiation in tissues and a lower degree of normal tissue irradiation. Other advantages of high-dose-rate brachytherapy over low-dose-rate brachytherapy are its low cost, the fact that it can be performed on an outpatient basis, its excellent radiation protection, and the better dose distribution obtained. From the clinical perspective, the technique provides a high local control rate without significant sequelae or complications.

Exeresis and Brachytherapy as Salvage Treatment for Local Recurrence After Conservative Treatment for Breast Cancer: Results of a Ten-Year Pilot Study

PURPOSE To analyze the long-term results of a pilot study assessing excision and brachytherapy as salvage treatment for local recurrence after conservative treatment of breast cancer. METHODS AND MATERIALS Between December 1990 and March 2001, 36 patients with breast-only recurrence less than 3 cm in diameter after conservative treatment for Stage I or II breast carcinoma were treated with local excision followed by high-dose rate brachytherapy implants (30 Gy in 12 fractions over a period of 5 days). No patient was lost to follow-up. Special attention was paid to local, regional, or distant recurrences; survival; cosmesis; and early and late side effects. RESULTS All patients completed treatment. During follow-up (range, 1-13 years), 8 patients presented metastases (2 regional and 6 distant) as their first site of failure, 1 had a differed local recurrence, and 1 died of the disease. Actuarial results at 10 years were as follows: local control, 89.4%; disease-free survival, 64.4%; and survival, 96.7%. Cosmetic results were satisfactory in 90.4%. No patient had Grade 3 or 4 early or late complications. Of the 11 patients followed up for at least 10 years, all but 1 still had their breast in place at the 10-year stage. CONCLUSIONS High-dose rate brachytherapy is a safe, effective treatment for small-size, low-risk local recurrence after local excision in conservatively treated patients. The dose of 30 Gy of high-dose rate brachytherapy (12 fractions over a period of 5 days twice daily) was well tolerated. The excellent results support the use of breast preservation as salvage treatment in selected patients with local recurrence after conservative treatment for breast cancer.

Monte Carlo calculation of the dose distributions of two 106Ru eye applicators

BACKGROUND AND PURPOSE Beta emitting 106Ru applicators are widely used to treat choroidal melanoma. In view of the importance of clinical applications of this radioisotope and the relative lack of knowledge of the dose distributions, three-dimensional dose maps of two concave applicators were calculated by means of Monte Carlo simulation. MATERIALS AND METHODS Simulations of small CCA and CCB concave applicators manufactured by Bebig were performed using the Monte Carlo code PENELOPE, which allows the description of the structure (geometry and materials) of the applicator in detail. Electrons are emitted from the 106Ru nuclei isotropically, with initial energy randomly sampled from the corresponding Fermi spectra and with initial positions uniformly distributed on the radioactive layer. Primary electrons, as well as the produced delta-rays, are assumed to be absorbed in the medium when they slow down to an energy of 70 keV. Bremsstrahlung photons with energies larger than 7 keV are also simulated. The simulation code has been run on a 166 MHz PENTIUM PC. RESULTS Three-dimensional dose distributions produced by the CCA and CCB applicators in a water sphere, concentric with the applicator, were evaluated. To minimize the magnitude of statistical uncertainties, advantage has been taken of the cylindrical symmetry of the problem. The relative depth-dose (along the symmetry axis of the applicator) was also evaluated from the applicator surface up to distances larger than I cm, with statistical uncertainties of a few percent. Results compare well with data supplied by the manufacturer. CONCLUSIONS We have performed accurate Monte Carlo calculations of three-dimensional dose distributions from CCA and CCB 106Ru applicators. The results, presented in the form of two-dimensional maps, depth-dose distributions along the symmetry axis and lateral dose profiles, provide a detailed description of the dose delivered in treatments of choroidal melanoma.

Interobserver variations of target volume delineation in multicatheter partial breast brachytherapy after open cavity surgery

PURPOSE To investigate interobserver variations of target volume delineations in accelerated partial breast irradiation with multicatheter brachytherapy (BT) and to assess the impact of guidelines on consistency of contouring. METHODS AND MATERIALS A contouring study with two phases in interstitial accelerated partial breast irradiation after open cavity surgery was conducted by the Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology Breast Cancer Working Group. Contours of cavity and planning target volume (PTV) on preimplant and postimplant CT images were delineated. In Phase 1, nine radiation oncologists defined the target volumes of 5 patients, whereas in Phase 2, four observers draw the contours of 4 patients applying guidelines. In Phase 1, experience in breast BT after open cavity surgery was assessed. The delineations were compared between Phase 1 and Phase 2, the impact of guidelines was assessed, and cavity visualization score was related to consistency of delineations. RESULTS Significant interobserver variability in delineations of lumpectomy cavity and PTV was observed among the participants. Observers with BT experience after open cavity surgery outlined the cavity and PTV more consistently (conformity indexgen: 0.52 vs. 0.48 and 0.59 vs. 0.55 for preimplant and postimplant cavities). For all volumes, the mean Vmax/Vmin was 2.2 vs. 2.8. Having used guidelines all conformity indices increased significantly. For cavity, the increase was 14% and 11%, whereas for the PTV, 28% and 17% on the preimplant and postimplant CT images, respectively. A strong correlation was found between consistency of contours and cavity visualization score. CONCLUSIONS Simple guidelines on defining the lumpectomy cavity significantly increased the consistency of contouring. Reliable consistency of target volume definition can be expected only for good cavity visibility.

Keloids and Hypertrophie Scars

Abnormal skin scarring was first described in the Smith papyrus between 2500 and 3000 BC [7]. In 1817, Alibert proposed the word “cheloide” (keloid) to differentiate these lesions from malignant neoplasms [2]. Today, keloids and hypertrophie scars are recognized as uncontrolled proliferations of fibrous tissue after injury or trauma to the skin [15]. However, meanwhile hypertrophie scars are confined to the extent of the original wound; in contrast, keloids invade the surrounding skin [15].

ESTRO-ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated Partial Breast Irradiation alone or as boost – GEC-ESTRO Breast Cancer Working Group practical recommendations

PURPOSE This consensus statement from the Breast Cancer Working Group of Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO) aims at generating practical guidelines for multi-catheter image-guided brachytherapy in the conservative management of breast cancer patients used for either Accelerated Partial Breast Irradiation (APBI) or for a breast boost. METHODS Recent advances in techniques of multi-catheter brachytherapy were summarized and all the relevant literature was reviewed by a panel of experts. Panel members of the GEC-ESTRO experts participated in a series of conferences, supplemented their clinical experience, were surveyed to determine their current practices and patterns, performed a literature review, and formulated recommendations for implementing APBI with multi-catheter brachytherapy, focusing on treatment planning issues, catheter insertion, dosimetry and quality assurance. This document was reviewed and approved by the full panel, the GEC-ESTRO executive board and by the ACROP (Advisory Committee on Radiation Oncology Practice). RESULTS Three-dimensional (3D) treatment planning, catheter insertion techniques, dosimetry and methods of quality assurance for APBI and boost with multi-catheter image-guided brachytherapy after breast conserving surgery are described. Detailed recommendations for daily practice including dose constraints are given. CONCLUSIONS Recent standards and guidelines for the use of APBI with different multi-catheter image-guided brachytherapy techniques have been defined. Different techniques are used to insert the catheters. Guidelines are mandatory to assure precise catheter insertion for coverage of the target volume and to guarantee high-quality dosimetry. The same rules apply for brachytherapy based boost irradiation for breast cancer after whole breast irradiation as well as for partial breast re-irradiation.

Adaptation and validation of the Spanish version of the Patient-Oriented Prostate Utility Scale (PORPUS)

AbstractObjective The Patient-Oriented Prostate Utility Scale (PORPUS) is a combined profile and utility-based quality of life measure for prostate cancer patients. Our objectives were to adapt the PORPUS into Spanish and to assess its acceptability, reliability, and validity.MethodsThe PORPUS was adapted into Spanish using forward and back translations and cognitive debriefing. PORPUS was administered jointly with the SF-36 and the Expanded Prostate Index Composite (EPIC) to 480 Spanish prostate cancer patients treated with radical prostatectomy or radiotherapy. The Spanish PORPUS scores’ distribution and reliability were examined and compared with the original instrument. To evaluate construct validity, relationships were assessed between PORPUS and other instruments (testing hypotheses of the original PORPUS study), and among known groups defined by side effect severity.ResultsReliability coefficient was 0.76 (similar to the original PORPUS’ 0.81). Spanish PORPUS items presented correlations ranging 0.57–0.88 with the corresponding EPIC domains, as in the original PORPUS study (0.60–0.83). Both PORPUS-P and PORPUS-U showed significant differences and large effect sizes (0.94–1.90) when comparing severe versus no problem groups on urinary, bowel, sexual and hormonal side effects defined by EPIC.ConclusionsA conceptually equivalent Spanish version was obtained, with high reliability and good construct validity, similar to the original Canadian PORPUS version. It can therefore be used to measure health-related quality of life and utilities in Spanish prostate cancer patients.

GEC-ESTRO ACROP recommendations in skin brachytherapy

PURPOSE The aim of this publication is to compile available literature data and expert experience regarding skin brachytherapy (BT) in order to produce general recommendations on behalf of the GEC-ESTRO Group. METHODS We have done an exhaustive review of published articles to look for general recommendations. RESULTS Randomized controlled trials, systemic reviews and meta-analysis are lacking in literature and there is wide variety of prescription techniques successfully used across the radiotherapy centers. BT can be delivered as superficial application (also called contact BT or plesiotherapy) or as interstitial for tumours thicker than 5 mm within any surface, including very irregular. In selected cases, particularly in tumours located within curved surfaces, BT can be advantageous modality from dosimetric and planning point of view when compared to external beam radiotherapy. The general rule in skin BT is that the smaller the target volume, the highest dose per fraction and the shortest overall length of treatment can be used. CONCLUSION Skin cancer incidence is rising worldwide. BT offers an effective non-invasive or minimally invasive and relative short treatment that particularly appeals to elder and frail population.

Whole-breast hypofractionated IMRT and brachytherapy boost after conservative surgery for breast cancer: Early results of a prospective non-randomised trial.

46 Background: To report early results obtained in a prospective group of patients (pts) treated with whole breast IMRT radiotherapy plus a brachytherapy boost to the tumor bed after conservative surgery, given either with hypofractionated or normofractionated radiotherapy. METHODS Between 12/2008 and 06/2014, 829 pts with <4cm, N0-2 breast cancers treated with conservative surgery were assigned to enter the study. Pts were offered to be treated either with IMRT hypofrationated whole breast and lymphnode areas (if needed) radiotherapy 42.6 Gy (266cGyx16 fractions) plus a 7 Gy boost to the tumor bed, (hypofractionated group) or IMRT normofractionated 50 Gy (200cGyx25) to the whole breast and lymphatic areas (when needed) plus 16 Gy brachytherapy boost (200cGyx8 fractions) (normofractionated group). Treatment assignation was done according to the patients preference or, if none, were randomly assigned to have both groups uniformly balanced. During treatment and follow-up special attention was taken to early and late side-effects, breast fibrosis, arm lymphedema, skin reaction, patient satisfaction and local, regional and distant disease control. RESULTS A total of 309 pts were included in the hypofractionated group and 520 in the normofractionated group. All patients completed treatment. Pts were evaluated weekly during treatment and every 3 months for the first 2 years of follow-up and in a yearly basis after. Photographs were taken at each visit. SOMA-LENT scales were used in every visit. For quality of life EORTC QLQ-C30 plus the BR-15 module were used. No pts had adverse side-effect that required treatment ending in any group. In the hypofractionated group, there were 1 LR, 1 M1 and 1 death due to the disease. In the normofractionated group there were 12 LR, 7 M1 and 4 patients died due to the disease. CONCLUSIONS Hypofractionated IMRT to the whole breast followed by a 1 fraction HDR breast implant was a safe and effective method of treatment for early breast cancer treated with conservative surgery, even in those patients N+ in which the supraclavicular fossa was included in the treatment fields. Pts satisfaction was greater in the hypofractionated group.