Karel Odrážka

High-Dose-Rate Interstitial Brachytherapy for the Treatment of Penile Carcinoma

Background:Interstitial low-dose-rate (LDR) brachytherapy allows conservative treatment of T1–T2 penile carcinoma. Highdose-rate (HDR) is often considered to be dangerous for interstitial implants because of a higher risk of complications, but numerous reports suggest that results may be comparable to LDR. Nevertheless, there are no data in the literature available regarding HDR interstitial brachytherapy for carcinoma of the penis.Case Report:A 64-year-old man with T1 N0 M0 epidermoid carcinoma of the glans is reported. Interstitial HDR brachytherapy was performed using the stainless hollow needle technique and a breast template for fixation and good geometry. The dose delivered was 18 × 3 Gy twice daily.Results:After 232 days from brachytherapy, the patient was without any evidence of the tumor, experienced no serious radiationinduced complications, and had a fully functional organ.Conclusion:HDR interstitial brachytherapy is feasible in selected case of penis carcinoma, when careful planning and small single fractions are used.Hintergrund:Die interstitielle Low-Dose-Rate-(LDR-)Brachytherapie ermöglicht eine konservative Behandlung von Peniskarzinomen im Stadium T1–T2. Die High-Dose-Rate-(HDR-)Methode gilt in der Praxis oft als gefährlich für die interstitielle Brachytherapie, da ein höheres Komplikationsrisiko befürchtet wird. Mehrere Studien zeigen jedoch, dass die lokale Kontrollrate grundsätzlich zumindest gleich ist wie mit der LDR-Therapie. Zur interstitiellen HDR-Brachytherapie des Peniskarzinoms wurden bisher keine Daten publiziert.Fallbericht:Berichtet wird über einen 64-jährigen Patienten mit einem Plattenepithelkarzinom des Penis T1 N0 M0. Die interstitielle Brachytherapie wurde mit Nadelapplikatoren und Brusttemplate durchgeführt. Die applizierte Dosis betrug 18 × 3 Gy zweimal täglich.Ergebnisse:Der Patient verblieb 232 Tage nach der Brachytherapie ohne Tumor bei völlig funktionsfähigem Organ, ohne dass schwere Strahlenschäden aufgetreten wären.Schlussfolgerung:Die interstitielle Brachytherapie ist im HDR-Verfahren bei ausgewählten Patienten mit Peniskarzinom möglich, wenn eine sorgfältige Planung erfolgt und kleine Einzeldosen verwendet werden.

IMRT using simultaneous integrated boost (66 Gy in 6 weeks) with and without concurrent chemotherapy in head and neck cancer – toxicity evaluation

Summary Aim To evaluate the toxicity of intensity-modulated radiotherapy with simultaneous integrated boost (SIB-IMRT) in head and neck cancer patients treated using a protocol comprising 66 Gy to the PTV1 (planning target volume; region of macroscopic tumour) and 60 Gy and 54 Gy to the regions with high risk (PTV2) and low risk (PTV3) of subclinical disease in 30 fractions in six weeks. Material and Methods Between December 2003 and February 2006, 48 patients (median age 55; range 25–83, performance status 0–1) with evaluable non-metastatic head and neck cancer of various localizations and stages (stages: I–1; II–8; III–12; IV–27 patients, resp.) were irradiated according to the protocol and followed (median follow-up 20 months; range 4–42). Ten patients underwent concurrent chemotherapy (CT) and in 15 patients the regimen was indicated postoperatively because of close or positive margins. In all cases the regimen was used as an alternative to conventional radiotherapy (70 Gy in 7 weeks). The acute and late toxicities were evaluated according to RTOG and RTOG/EORTC toxicity scales, respectively. Results All patients finished the treatment without the need for interruption due to acute toxicity. No patient experienced grade 4 toxicity. More severe acute toxicity was observed in patients with CT, but the most severe toxicity was grade 3. Grade 3 toxicity was observed in the skin, mucous membrane, salivary glands, pharynx/oesophagus and larynx in 8.4%, 35.4%, 39.6% and 2.1%, in the CT subgroup in 10%, 100%, 90%, 10%, respectively. The trend of impairment of acute toxicity by concurrent chemotherapy was statistically confirmed by Fishers exact test (for mucous membranes p=0.000002 and pharyngeal/oesophageal toxicity p=0.0004). The most severe late toxicity was grade 2 subcutaneous tissue (34.2%), mucous membrane (36.8%) and larynx (11.1%), grade 3 in salivary gland (2.6%) and grade 1 in skin (84.2%) and spinal cord (5.4%). The late toxicity was not increased by chemotherapy. Conclusion In light of the toxicity profile we consider the presented regimen to be an alternative to conventional radiotherapy 70 Gy in 7 weeks. The addition of CT requires more intensive supportive care.

Endovascular brachytherapy of transjugular intrahepatic portosystemic shunt

Purpose: To evaluate the technical feasibility and efficacy of endovascular brachytherapy with Iridium-192 in the prevention of restenosis caused by neointimal hyperplasia of transjugular intrahepatic portosystemic shunt (TIPS).Materials and Methods: The endovascular brachytherapy with high dose rate automatic afterloading system was performed in six patients with recurrent of stenosis of TIPS. We used a single dose fraction of 12 Gy delivered at 3 millimeter (mm) from the source axis to the stenotic vessel segment in five patients with spiral Z-stent, and 15 Gy at 5 mm in one patient with Wallstent.Results: Follow-up time ranged from 148 to 639 days. In one patient, restenosis occurred in the treated vessel segment, diagnosed 71 days after endovascular brachytherapy by doppler ultrasound. All other patients were, during the follow-up time, without restenosis in the irradiated vessel segment. Radiation-associated side effects were not observed.Conclusions: Endovascular brachytherapy of TIPS is technically feasible and may be done as a part of the percutaneous revision of the shunt. This pilot study may be the largest experience of treating TIPS restenosis in humans to date. For definitive conclusions, a lot of studies are needed.

[Five-year results of IMRT for prostate cancer - tumor control].

BACKGROUND Intensity-modulated radiation therapy (IMRT) is the method of choice in external-beam radiotherapy tolocalized prostate cancer. This work analyses five year results of IMRT with a dose of 78/82 Gy. PATIENTS AND METHODS From June 2003 to December 2007, the IMRT technique was employed to treat 233 patients with T1-3 N0 M0 prostate cancer. It was supplemented by hormone therapy especially in high-risk patients. Two IMRT techniques were applied - IMRT with a dose of 78 Gy in 39 fractions to prostate and seminal vesicles (SV) (IMRT 78) and IMRT with simultaneous integrated 82 Gy boost to prostate concurrently with 73,8 Gy in 41 fractions to SV (IMRT SIB 82). The IMRT 78 technique was used in 160 patients (69%). Seventy-three (31%) patients with intermediate (IR) or high-risk (HR) prostate cancer without SV involvement were treated with IMRT SIB 82 technique. The PSA relapse was defined as an increase in PSA of at least 2.0 ng/mL above the nadir or in comparison to the value at the initiation of hormone therapy. Clinical relapse was defined as an occurence of distant metastases and/or local recurrence. RESULTS The median follow-up of our patients´ population was 4.3 years (range 0.6-8.9 years). The estimated 5-year PSA relapse-free survival in low-risk (LR), IR and HR patients was 86%, 89% and 83%, respectively (p = NS). In a multivariate analysis, Gleason score (GS) 8-10 was associated with significantly higher risk of PSA relapse (RR 2.76), while higher age at the time of diagnosis significantly decreased the PSA relapse risk (RR 0.94). The estimated 5-year clinical relapse-free survival in LR, IR and HR patients was 100%, 99% and 95%, respectively (p = NS). In a univariate analysis, both GS and PSA had a significant impact on the 5-year clinical relapse-free survival - GS 2-7 97 % vs GS 8-10 88 % (p = 0.03), PSA 20 98 % vs PSA > 20 85 % (p < 0.01). CONCLUSION Treatment of localized prostate cancer using IMRT with a dose 78/82 Gy yielded an excellent 5-year tumour control with a risk of clinical relapse being less than 5%.

Testicular Choriocarcinoma with Jejunal Metastasis Complicated by Intestinal Perforation and Acute Peritonitis

Intestinal metastases are rare, and only few cases of intestinal perforations secondary to metastatic cancer have been reported. Case Report: We report here a case of a 25-year-old male with testicular pure choriocarcinoma and synchronous bilateral multiple lung metastases. After failure of four lines of chemotherapy, in the context of rapidly progressive advanced metastatic disease, the metastases appeared not only in the usual metastatic sites but also in less common sites, including small bowel and skin. The course was complicated by perforation of bowel secondary to metastasis and purulent peritonitis that necessitated surgical intervention. Conclusion: The possibility of small bowel perforation should be considered in differential diagnosis of patients with advanced testicular tumors presenting with abdominal pain.

Endovascular brachytherapy in the prevention of vascular restenosis

PURPOSE To evaluate the technical feasibility and efficacy of endovascular brachytherapy for prophylaxis of restenosis after femoropopliteal percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS Ten patients with recurrence of stenosis in the femoropopliteal region underwent PTA followed by endovascular irradiation with Iridium-192 a high-dose rate after-loading technique. We used a single fraction of dose 12 Gy given in 3 mm from the source axis in the stenotic vessel segment. RESULTS During follow-up of 59-580 days restenosis occurred in four patients 111, 460, 472 and 580 days after irradiation. All other patients are without restenosis. No radiation-associated side effects were observed. CONCLUSIONS Endovascular brachytherapy of restenosis in the femoropopliteal region is technically feasible, and may be done as a part of the PTA. These encouraging results open the possibility of reduction of restenosis by the present method.