•Redesigned Venezia™ treats advanced cervical and vaginal vault recurrent cancer.•Dosimetric analysis compared new design and original Venezia™ on tumour and organs.•Proven to increase dose to tumour ...while maintain similar dose to organs at risk.•3D printed redesigned Venezia™ is biocompatible, inexpensive, and patient specific.
Venezia™ is an interstitial brachytherapy applicator for treating advanced cervical and vaginal vault recurrent cancer. However, there are limitations that lead to suboptimal target coverage. 3D printing introduction allows the redesign of Venezia™ for bulky and irregular-shaped tumors.
This study first describes three new designs included: 1) add-on needles template allowed for an extra layer of straight and oblique needles, 2) redesigned vaginal cap so straight and oblique needles can be used together and 3) redesigned central tube allowed vaginal vault interstitial needle insertion. Drawbacks to original Venezia™ and rationale for using these new designs were discussed. Dosimetric analysis by comparing the original Venezia™ with new design for 10 cases in Oncentra treatment planning system v4.5 (Elekta, Stockholm, Sweden) to observe the dose differences in gross tumor volume (GTV), high risk clinical target volume (HRCTV), intermediate clinical target volume (IRCTV) and organs at risk.
For the dosimetric comparison, there were statistically significantly increased median minimal dose to 98% (D98%) of GTV, 90% (D90%) of HRCTV, and IRCTV for the new design with p-value of 0.008, 0.005 and 0.0018, respectively. Comparing the physical dose of D98% of GTV, D90% of HRCTV, and IRCTV when using the new design, it averagely increased by 11.7%, 8.0%, 19.4%, respectively per fraction.
Dosimetric comparison revealed the new designs increased the dose to GTV, HRCTV and IRCTV and fulfilled the dose constraints of bladder, rectum and sigmoid. The 3D printed new design is biocompatible, inexpensive and can be patient specific.
Definitive radiotherapy for cervical cancer consists of external-beam radiotherapy (EBRT) and brachytherapy. In EBRT, a central shield (CS) reduces the dose to the rectum and bladder. The combination ...of whole-pelvic (WP)- and CS-EBRT and brachytherapy is the standard radiotherapy protocol in Japan. Despite clinical studies, including multi-institutional clinical trials, showing that the Japanese treatment protocol yields favorable treatment outcomes with low rates of late radiation toxicities, dose-volume parameters for the Japanese treatment protocol remain to be established. We conducted a retrospective dose-volume analysis of 103 patients with uterine cervical cancer treated with the Japanese protocol using computed tomography-based adaptive brachytherapy. The 2-year overall survival and 2-year local control rates according to FIGO stage were 100% and 100% for Stage I, 92% and 94% for Stage II, and 85% and 87% for Stage III-IV, respectively. Late adverse effects in the rectum and bladder were acceptable. Receiver operating characteristic analysis discriminated recurrence within the high-risk clinical target volume (HR-CTV) (n = 5) from no local recurrence (n = 96), with the optimal response obtained at a dose of 36.0 GyEQD2 for HR-CTV D90 and 28.0 GyEQD2 for HR-CTV D98. These values were used as cut-offs in Fisher exact tests to show that high HR-CTV D90 and HR-CTV D98 doses for brachytherapy sessions were significantly associated with tumor control within the HR-CTV. These data suggest a contribution of brachytherapy to local tumor control in WP- and CS-EBRT and brachytherapy combination treatment, warranting validation in multi-institutional prospective studies.
About 3–9% of patients with endometrial cancer are unable to undergo surgery due to medical comorbidities, including morbid obesity, or age-related frailty syndrome. An alternative curative option is ...irradiation. The aim of this prospective study was to evaluate clinical outcomes of high-dose-rate intracavitary brachytherapy (HDR-ICBT) treatment in such patients.
Seventy-eight patients with FIGO stage I-II endometrial cancer disqualified from surgery were treated with HDR-ICBT with 45–52,5 Gy prescribed to high-risk clinical target volume (HR-CTV) in 5–9 fractions given once a week. All fractions were planned using computed tomography (CT) scans.
The median follow-up time was 67 months. Median age was 79 years (range: 42–93 years). Median body mass index (BMI) was 39,1 kg/m2 (range: 24,2–68 kg/m2). We observed no statistically significant impact of BMI ≥ 40 on overall survival (OS) or prgression free survival (PFS). The 3- and 5-year OS for the whole population were 69% and 55%, respectively. The impact of high risk features (FIGO II, grade 3 or type 2 cancer) on OS was significant (p = 0,049). The 5-year cumulative incidence of local failure, distant metastases and non-cancer death were 12,9% 95% CI: 5,4%–20,5%, 6,4% 95% CI: 0,9%–11,9%, 33,1% 95% CI: 22,3%–43,9%, respectively. The 5-year risk of cancer and non-cancer death were 9% (95% CI: 3%–16%) and 36% (95% CI: 25%–47%), respectively. We observed G1 vaginal apex stenosis only.
CT-guided HDR-ICBT is a feasible and safe management of FIGO stage I endometrial cancer in obese and elderly patients. The survival outcome of the treated group is influenced more by associated comorbidities than by the progression of endometrial cancer.
•Obese and elderly patients may be unable to undergo surgery due to comorbidities.•Intracavitary brachytherapy alone is a safe and efficient method of treatment in early-stage endometrial cancer.•Overall survival significantly depended on FIGO stage and histology.•Body mass index did not influence survival outcomes.
Introduction
The aim of this audit was to compare the data from the Wellington Blood and Cancer Centre (WBCC) with international reported experience by quantifying the dosimetric impact of ...interstitial needles on target coverage and organ at risk (OAR) doses.
Methods
All patients identified as having had interstitial needles as part of their treatment out of a cohort of 120 radically treated cervical cancer patients between 2013 and 2019 were included. Each patient acted as their own control with two treatment plans optimised for each fraction; the clinically treated plan and a re‐optimisation without the use of interstitial needles. Plan optimisation was completed according to the departmental protocol and cumulative equivalent doses for 2 Gy fractions (EQD2) were calculated.
Results
Eighteen patients were suitable for evaluation. A total of 52 insertions with interstitial needles were performed, of the 148 needles inserted, 119 (80.4%) were loaded. HRCTV D90% coverage mean was EQD2 5.4 Gy (0.5–10.6 Gy) higher for the course containing loaded interstitial needles, while no significant change was observed with regards to OAR doses. This improved coverage is in line with international standards which report 4.4–9.0 Gy.
Conclusion
WBCC’s early experience of interstitial cervix brachytherapy has shown our target coverage improvements meet previously published international standards and confirms the value of this technique. This audit supports ongoing use of interstitial needles at the WBCC.
Endometrial cancer is a common gynaecological cancer, is typically early stage and treated with surgery. For patients where surgery is difficult or dangerous, definitive radiation therapy is the next ...best option. This study included a single institution case series (step 1) and a systematic review of the literature (step 2). In step 1, all endometrial cancer cases that were treated with definitive image-guided brachytherapy at a single institution from 2008 to 2020 were retrospectively analysed. In step 2, a systematic review of Medline (PubMed) from 1975 to 2020 was carried out using the key words around endometrial cancer and brachytherapy, followed by a narrative synthesis. In total, in step 1, 31 cases were included in this study, stages I–IV, with 96.7% receiving external beam radiation. All patients received three fractions of 7.5 Gy or five fractions of 6 Gy high dose rate brachytherapy, with a median EQD2 of 75.55 (40–84.3). The 2-year Kaplan-Meier (KM) local control was 83.1% and the 2-year KM overall survival was 77.4%. There was no late toxicity ≥grade 3. In step 2, 19 articles were included in the final analysis, with between six and 280 patients. The local control ranged from 70 to 100%, with low toxicity. Definitive radiation therapy with image-guided brachytherapy seems to have good local control with low toxicity for patients who are poor surgical candidates.
Abstract Intracavitary–interstitial applicators for MRI guided brachytherapy are becoming increasingly important in locally advanced cervical cancer. The 3D printing technology enables a versatile ...method for obtaining a high degree of individualisation of the implant. Our clinical workflow is presented and exemplified by a stage IVA cervical cancer with superior dose distribution.
Abstract Objective Since the Group Européen de Curiethérapie and the European Society for Radiotherapy and Oncology (GEC–ESTRO) published recommendations for 3D MRI-based image-guided adaptive ...brachytherapy (IGBT) in the treatment of cervical cancer, many institutions have implemented this technique and favourable results were documented. We investigated if introduction of IGBT in our centre indeed improved treatment outcomes and reduced toxicity compared to conventional brachytherapy (CBT). Methods A retrospective analysis was done of outcomes of patients with stage IB-IVA cervical cancer treated with primary radiation therapy with curative intent between 2000 and 2012. Outcome measures were overall and disease-free survival, pelvic control, distant metastasis and treatment related adverse events (AE). Results 126 patients were analysed; 43 had been treated with CBT between 2000–2007, and 83 with IGBT between 2007–2012. External beam radiation (mean; 46.6 Gy) was combined with concurrent weekly cisplatin (51.6%), or hyperthermia (24.6%); radiation alone was used in 23.8%. Median follow-up was 121.8 months for CBT patients, vs. 42.3 months for IGBT. Complete remission was achieved in 83.7% of patients in the CBT group and in 98.8% of IGBT patients (p < 0.01). Overall survival at 3 years was 51% and 86%, respectively (p = 0.001). Pelvic recurrence was found in 32% vs. 7% (p < 0.001). Most patients had low grade adverse events. High grade (3–4) AE occurred in 15.4% vs. 8.4% at 3 years (p = 0.06). Conclusion Introduction of IGBT for cervical cancer has led to significantly increased 3-year locoregional control and survival rates, whilst reducing late morbidity.
PurposeCervical stump cancer is a carcinoma that grows on the cervical stump after a sub-total hysterectomy. There have been no studies on the application of 3D brachytherapy in cervical stump ...cancer. In the present study, we aimed to compare the curative effects, toxicity, and dosimetry of 3D and 2D brachytherapy in cervical stump cancer.Material and methodsThirty-one patients admitted between 2012 and 2021, who were concurrently treated with intensity-modulated radiation therapy and brachytherapy for cervical stump cancer were divided into three groups according to the brachytherapy techniques: 2D brachytherapy, 3D image-guided brachytherapy (3D-IGBT), and 2D + 3D. For patients undergoing 2D brachytherapy and 3D-IGBT, data on survival, complications, and dose to target area or organs at risk (OARs) were collected and compared. Furthermore, dosimetry difference was investigated by reconstructing the 2D plan into a 3D plan.ResultsThe median follow-up duration of all patients was 58 months. The overall 5-year progression-free survival, overall survival, and local control rates were 69.6%, 90.2%, and 78.2%, respectively. Late complications in the rectum, sigmoid colon, and bladder were milder in 3D brachytherapy than in 2D brachytherapy. Concerning the D90 value of clinical target volume (CTV) and D2cm3 value of OARs in EQD2, the 3D brachytherapy provided a lower dose to CTV (76.5 Gy vs. 95.9 Gy, on average) and OARs compared with 2D brachytherapy.ConclusionsDespite lacking statistical significance, 3D brachytherapy showed better outcomes regarding late toxicity than 2D brachytherapy, owing to the lower dose coverage in the bladder, rectum, sigmoid colon, and small intestine.
PurposeTo report outcomes of using image-guided hybrid intra-cavitary/interstitial applicators under moderate sedation for locally advanced cervical cancer patients in our institution. Material and ...methodsA total of 69 fractions of brachytherapy with hybrid applicators were performed in 33 patients from January 2017 to April 2021. All patients underwent MRI pelvis 1 week pre-brachytherapy to determine suitability for interstitial brachytherapy and pre-plan needle placement. All insertion of applicators were performed under moderate sedation with midazolam and/or fentanyl. Fifty-eight (84.1%) fractions were planned with CT alone. Clinical outcomes, dose volume parameters, and toxicities were analyzed. ResultsThe median follow-up was 28 months. A total of 320 needles (median, 5 needles per fraction) were implanted, with a median insertion depth of 3 cm (range, 1.5-4 cm). The median high-risk clinical target volume (HR-CTV) during initial brachytherapy was 34.5 cc (range, 17.8-74.7 cc). The median total EQD2 D2cc of the rectum, bladder, sigmoid, and small intestine colon was 71.8 Gy, 81.5 Gy, 69 Gy, and 58.3 Gy, respectively. The 2-year local control and overall survival were 80.7% and 77.7%, respectively. Larger volume HR-CTV was significantly associated with worse local control (HR = 1.08, p = 0.005) and overall survival (HR = 1.04, p = 0.015). None of the patients required in-patient admission or blood transfusion post-procedure. Late grade 3 gastrointestinal and genitourinary toxicities were observed in 4 patients (12.2%). ConclusionsHybrid applicators inserted under moderate sedation are feasible and safe. Image-guided interstitial brachytherapy with CT planning aided by MRI performed 1 week pre-brachytherapy is associated with favorable outcomes and modest toxicities.
•MR-IGABT in cervix cancer improved target coverage and reduced irradiated volumes.•ISVs correlated with CTVHR volumes showing dose adaptation with tumour size.•From the perspective of normal tissue ...complications PDR was more sparing than HDR.•Larger EBRT doses of 50 Gy increased the irradiated volumes at doses of 60 Gy.
To investigate the isodose surface volumes (ISVs) for 85, 75 and 60 Gy EQD2 for locally advanced cervix cancer patients.
1201 patients accrued in the EMBRACE I study were analysed. External beam radiotherapy (EBRT) with concomitant chemotherapy was followed by MR based image-guided adaptive brachytherapy (MR-IGABT). ISVs were calculated using a predictive model based on Total Reference Air Kerma and compared to Point A-standard loading systems. Influence of fractionation schemes and dose rates was evaluated through comparison of ISVs for α/β 10 Gy and 3 Gy.
Median V85 Gy, V75 Gy and V60 Gy EQD210 were 72 cm3, 100 cm3 and 233 cm3, respectively. Median V85 Gy EQD210 was 23% smaller than in standard 85 Gy prescription to Point A. For small (<25 cm3), intermediate (25–35 cm3) and large (>35 cm3) CTVHR volumes, the V85 Gy was 57 cm3, 70 cm3 and 89 cm3, respectively. In 38% of EMBRACE patients the V85 Gy was similar to standard plans with 75–85 Gy to Point A. 41% of patients had V85 Gy smaller than standard plans receiving 75 Gy at Point A, while 21% of patients had V85 Gy larger than standard plans receiving 85 Gy at Point A.
MR-IGABT and individualized dose prescription during EMBRACE I resulted in improved target dose coverage and decreased ISVs compared to standard plans used with classical Point A based brachytherapy. The ISVs depended strongly on CTVHR volume which demonstrates that dose adaptation was performed per individual tumour size and response during EBRT.
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