C. Gutierrez

External beam radiotherapy plus high-dose-rate brachytherapy for treatment of locally advanced prostate cancer: The initial experience of the Catalan Institute of Oncology

PURPOSE The objective of this study was to report initial outcomes in patients with locally advanced prostate cancer (CaP) who underwent external beam radiation therapy (EBRT) treatment combined with high-dose-rate brachytherapy (HDR-BT) as a boost. METHODS AND MATERIALS From 2002 to 2007, 114 CaP patients underwent EBRT followed by (192)I HDR-BT. The patients were classified into intermediate- (Group 1) or high- (Group 2) risk groups. The mean total EBRT dose was 60.0Gy (95% confidence interval [CI]: 59.9-60.1) at 2Gy per fraction. After a mean of 20.6 days (95% CI: 18.4-22.8), all the patients received a single-fraction 9-Gy dose of HDR-BT boost. Of the 114 patients in the study, 103 (90.4%) underwent up to 3 years of complete androgen deprivation therapy after diagnosis. RESULTS The mean followup for the entire group was 32.1 months (95% CI: 29.9-34.4). The 4-year biochemical failure-free survival rate was 97.4% and treatment was well-tolerated. CONCLUSIONS Preliminary biochemical control rates after EBRT plus one fraction of 9-Gy HDR-BT are encouraging. This atypical fractionation schedule is cost-effective and reduces patient discomfort and treatment-related risks. More followup is required to confirm these findings.

External beam radiotherapy plus single-fraction high dose rate brachytherapy in the treatment of locally advanced prostate cancer

PURPOSE To evaluate the efficacy and toxicity of external beam radiation therapy (EBRT) plus high-dose-rate brachytherapy (HDRB) as a boost in patients (pts) with intermediate or high-risk prostate cancer. METHODS AND MATERIALS From 2002 to July 2012, 377 pts with a diagnosis of intermediate or high-risk prostate cancer were treated with EBRT plus HDRB. Median patient age was 66 years (range, 41-86). Most patients (347 pts; 92%) were classified as high-risk (stage T2c-T3, or PSA>20 ng/mL, or GS ⩾ 8), with 30 patients (8%) considered intermediate risk. All patients underwent EBRT at a prescribed dose of 60.0 Gy (range, 45-70 Gy) to the prostate and seminal vesicles. A total of 120 pts (31%) received a dose of 46 Gy (45-50 Gy) to the true pelvis. All pts received a single-fraction 9 Gy (9-15 Gy) HDR boost. Most patients (353; 94%) were prescribed complete androgen deprivation therapy (ADT). Overall survival (OS), cause-specific survival (CSS), and biochemical relapse-free survival (BRFS) rates were calculated. In the case of BRFS, patients with <26 months of follow-up (n=106) were excluded to minimize the impact of ADT. RESULTS The median follow-up for the entire sample was 50 months (range, 12-126), with 5-year actuarial OS and CSS, respectively, of 88% (95% confidence interval [CI]: 84-92) and 98% (95% CI: 97-99). The 5-year BRFS was 91% (95% CI: 87-95) in the 271 pts with ⩾ 26 months (median, 60 months) of follow-up. Late toxicity included grade 2 and 3 gastrointestinal toxicity in 17 (4.6%) and 6 pts (1.6%), respectively, as well as grades 2 and 3 genitourinary toxicity in 46 (12.2%) and 3 pts (0.8%), respectively. CONCLUSION These long-term outcomes confirm that EBRT plus a single-fraction HDRB boost provides good results in treatment-related toxicity and biochemical control. In addition to the excellent clinical results, this fractionation schedule reduces physician workload, treatment-related expenses, patient discomfort and risks associated with anaesthesia. We believe these findings support the use of single-fractionation boost techniques.

125I episcleral plaque brachytherapy in the treatment of choroidal melanoma: A single-institution experience in Spain

PURPOSE To analyze the results of episcleral plaque brachytherapy from the Catalan Institute of Oncology in Spain. MATERIALS AND METHODS From September 1996 through December 2004, 120 patients with choroidal melanoma (median age, 59 years) were treated with iodine-125 seeds at our institution. Patients were classified according to the criteria developed by the Collaborative Ocular Melanoma Study (COMS) group, as follows-COMS-I: 3 patients; COMS-II: 87 patients; COMS-III: 24 patients; and indeterminate COMS: 9 patients. Followup ranged from 1 year to 8.4 years. RESULTS Overall survival at 5 and 8 years was 83.9% and 73.3%, respectively. The 5- and 8-year specific survival rate was 85.7%. Local control was 88.2% and 72.7% at 5 and 8 years, respectively. The most common treatment-related toxicity was cataract formation (31.6% of cases), followed by radiation retinopathy (7.5%) and retinal detachment (4.1%). CONCLUSION The results of this institutional retrospective study confirm that the use of iodine-125 episcleral plaques to treat choroidal melanoma offers the potential for conserving a functioning eyeball. The toxicity profile is favorable and disease control is similar to other techniques.

Endoresection Versus Iodine-125 Plaque Brachytherapy for the Treatment of Choroidal Melanoma

PURPOSE To compare the effectiveness of pars plana vitrectomy endoresection with iodine-125 brachytherapy in the treatment of choroidal melanoma. DESIGN A nested case-control study (1:2) from a surgical cohort. METHODS The study comprised 81 choroidal melanoma patients treated with either endoresection or iodine-125 brachytherapy. Twenty-seven patients who had undergone endoresection were matched according to tumor height and postequatorial tumor location with 54 cases treated with iodine-125 brachytherapy. Metastatic disease, overall survival, local tumor recurrence, visual acuity, and secondary enucleation rates were analyzed and compared between groups. RESULTS Metastatic spread was observed in 11 patients in the iodine-125 brachytherapy group vs only 1 patient in the endoresection group (20.4% and 3.7%, respectively, P = .053). Fourteen patients died during follow-up: 11 in the brachytherapy arm vs 3 in the endoresection arm (20.4% and 11.1%, respectively, P = .238). For the iodine-125 brachytherapy and endoresection groups, respectively, the 5-year Kaplan-Meier estimates were as follows: overall survival, 81.5% vs 89.2% (log-rank test, P = .429;); relapse-free survival, 96.6% vs 92.4% (P = .2); visual acuity retention equal or superior to 20/200, 66.4% vs 59.9% (P = .083), and eye retention, 85.7% vs 87.8% (P = .942). CONCLUSIONS Endoresection for choroidal melanoma is an effective treatment modality in selected cases of posterior choroidal melanomas, with outcomes similar to those obtained with iodine-125 brachytherapy.

Twenty-year experience in the management of squamous cell anal canal carcinoma with interstitial brachytherapy

ObjectivesThe aim of this study was to retrospectively evaluate clinical characteristics, local control, acute and late toxicity, and prognostic factors of patients with anal canal carcinoma treated with brachytherapy.MethodsFrom 1989 to 2009, 38 patients were treated with iridium 192 low-dose-rate (N=26) or pulsed-dose-rate (N=12) interstitial brachytherapy at a single institution. The median age was 62 years (range, 38–86 years). The TNM classification was as follows: 10 T1, 22 T2, 5 T3 and 1 T4; 32 N0, 3 N1 and 3 N2. Most patients (32/38) received either a first course of radiochemotherapy (N=22) or radiotherapy alone (N=10) consisting of a total delivered dose of 45 Gy to the pelvis (range, 32–50) followed by a boost a median of 18 days later of 15–35 Gy (median 20 Gy) to the anal canal. The remaining 6 cases were treated with brachytherapy alone (dose range, 60–65 Gy).ResultsWith a median follow-up of 30 months (range, 4–200), 2- and 5-year local control rates were 91% and 87%, respectively. Preservation of the anal sphincter was achieved in 32 patients (84%). Three patients experienced incontinence after brachytherapy. Only 2 patients showed chronic mucositis grade 3/4. Age proved to be a statistically significant prognostic factor for overall survival in the univariate (p=0.033) and multivariate analyses (p=0.018). Concurrent chemotherapy with external beam radiotherapy was a statistically significant prognostic factor for disease-free survival in the univariate and multivariate analyses (p=0.007 and p=0.044, respectively).ConclusionsInterstitial brachytherapy appears to be an effective and well tolerated treatment for anal carcinoma offering both high local tumour control and anal sphincter preservation.

INTRAVITREAL DEXAMETHASONE IMPLANT FOR RADIATION MACULOPATHY SECONDARY TO PLAQUE BRACHYTHERAPY IN CHOROIDAL MELANOMA.

Purpose: To evaluate the efficacy of intravitreal dexamethasone implant 0.7 mg (Ozurdex) in radiation maculopathy secondary to plaque brachytherapy in choroidal melanoma. Methods: Twelve eyes diagnosed of radiation maculopathy secondary to plaque brachytherapy and treated with intravitreal dexamethasone implant were included. Visual acuity, foveal thickness using spectral domain optical coherence tomography, and grade of macular edema, using Horgan classification, were evaluated. Results: Mean age was 65.5 ± 28 years (range, 40–82 years). Mean follow-up was 8.2 ± 7.8 months (range, 2–28 months). Mean visual acuity before treatment was, in logarithm of the minimum angle of resolution scale, 1 ± 0.58 (range, 0.4–2) and mean final visual acuity 0.8 ± 0.58 (range, 0.2–2), showing a nonsignificant trend to improvement (P = 0.091; Wilcoxons test). Foveal thickness before treatment was 416 ± 263 &mgr;m (range, 222–725 &mgr;m) and final foveal thickness 254 ± 170 &mgr;m (range, 145–750), showing a significant decrease (P = 0.016; Wilcoxons test). Referring to Horgan classification, a significant reduction in grades before and after treatment was demonstrated (P = 0.007; Wilcoxons test). Conclusion: Ozurdex is a useful treatment for radiation maculopathy associated to plaque brachytherapy for uveal melanoma, with a significant decrease in foveal thickness and a significant improvement in Horgan classification. This anatomical improvement was correlated with a moderate improvement in visual acuity.

Relative survival of patients with uveal melanoma managed in a single center.

To assess the 5-year relative survival of patients diagnosed with uveal melanoma (UM) in a single center. UM patients were recruited from 1995 to 2004 (N=155) and were followed until December 2008. Relative survival (RS) methods were used to assess excess mortality. An RS regression model was fitted by sex, age, tumor origin, treatment, and tumor size to estimate the excess hazard rate (EHR) of death from UM. The overall 5-year RS was 90%, lower in women (84.6%) than in men (100%), lower in patients older than 60 years (88.8%) compared with those younger than or of 60 years of age (94.8%). Large tumors (80.8%) showed lower RS than medium (95.1%) and small ones (98.3%). Enucleated patients (80.5%) had lower RS compared with those who received brachytherapy (93.6%) and other treatments (94.7%). A significant EHR was found for women (EHR: 3.65), patients older than 60 years (EHR: 2.25), large-sized melanoma (EHR: 2.45), and during the third (EHR: 5.37) and fourth year (EHR: 3.01) of follow-up. This is the first Spanish study in a single center reporting RS among UM patients, taking into account clinical characteristics. Prognostic factors that explained RS among UM patients were sex, age, tumor size, and the year of follow-up. We also found a peak of excess mortality from the third until the fourth year after diagnosis, which warrants strict follow-up of these patients during this time interval.

The use of an interstitial boost in the conservative treatment of breast cancer: how to perform it routinely in a radiotherapy department

Purpose To demonstrate the utility of a boost with interstitial brachytherapy (BT) in breast-conserving therapy (BCT) by doing a thorough review of the literature and describing in detail our technique for delivering this boost. Material and methods Our department has been delivering the boost with interstitial BT since 1989, in most cases with rigid needles and a theoretical dosimetry. In the early years, we used low-dose-rate (LDR) with iridium-192 wires. The dose administered was 15 Gy if there were no risk factors for local relapse or 20-25 Gy in the presence of risk factors. The risk factors considered were the presence of a close margin (less than 10 mm) and an extensive intraductal component (more than 25%). After 2002, we switched to high-dose-rate (HDR); using the linear quadratic model we changed the low dose to 3 fractions of 4.5 Gy in the case of no risk factors for local relapse or to 3 fractions of 5 Gy in the presence of risk factors. Results In 79 consecutive boost patients treated in our department between 2010 and 2011, with a median follow-up of 46 months, the local control rate was 97.47%. With respect to cosmesis, fibrosis occurred in 17 cases (21.5%) and hyperpigmentation in 26 cases (32.9%). Our hospitals results are comparable in terms of local control and cosmesis to those of other authors. Conclusions This educational article describes our departments boost technique with rigid needles and comments briefly on our results using this technique in a group of consecutively treated patients in our department. A review of the literature and the published results on local control and cosmesis is also described.

EP-1266: Interstitial brachytherapy using MUPIT in locally advanced or recurrent gynecological malignancies

Purpose/Objective: Uterine cervical carcinoma is still remaining one of the main mortality reasons for female population in the developing world. Inspite of widely accessible screening and diagnostic procedures in the vast majority of cases in our country cervical cancer is revealed in locally advanced stages with metastasis in pelvic and paraaortal lymph nodes in up to 34% of patients. Concurrent chemoradiotherapy is the treatment of choice for cervical cancer today but the presence of positive lymph nodes require escalation of EBRT dose to these targets. The aim of this research was analysis of treatment results of 62 node positive cervical cancer patients. Materials and Methods: We used the method of integrated boost by volumetric arc therapy (VMAT) to increase the EBRT dose in target while keeping relatively low doses at the organs at risk (bowel, rectum, bladder, femoral heads, pelvic bones). Planning was done in automatic regimen and the dose distribution was better (more conformal) if two dynamic arcs with 15 MV photon beams were used. Number of fractions were 25. Fraction dose prescribed to the pelvis (primary tumor and regional zone) was 2.0 Gy while to the metastatic lymph nodes – 2.3 Gy at the same fraction what makes totally 50 and 59 Gy respectively (EQD2 by α/β = 10). From the first day of treatment patients received concurrently weekly cisplatin in dose 40 mg/m (max. 70 mg), 5 infusions. After 46 Gy of EBRT we started HDR brachytherapy which was consisted of two weekly 9.0 Gy fractions to HRCTV. Results: We analysed close results of the treatment which were assessed one month after the course completed. Complete regression, partial regression and stabilisation of the tumor developed in 83,9% (n=52), 11,3% (n=7), and 4,8% (n=3) cases respectively. Early hematological toxicity, enteritis, rectitis and cystitis of II – III stages observed in 42,3%, 15,4%, 11,2% and in 4,3% cases accordingly. Conclusions: VMAT EBRT with integrated boost, HDR brachytherapy and concurrent cisplatin appears to be safe and effective treatment modality for pelvic lymph node metastatic uterine cervical carcinoma providing high rate local tumor control and acceptable early toxicity. But to do final conclusions we need longer follow up period.