Identification and management of persistently active brachytherapy seed implants.

OBJECTIVE: The purpose of this article is to review the history of permanently implanted brachytherapy sources and to establish methods of identifying radon sources and discussing appropriate management. CONCLUSION: There are likely thousands of people bearing radon seeds that continue to emit radiation decades after implantation. They can be identified by clinical history and emission of characteristic x-rays. Surgical removal of these sources is rarely warranted.

The "Golden Age" of prostate brachytherapy: a cautionary tale.

PURPOSE: To investigate the earliest attempts to use man-made isotopes for prostate brachytherapy. METHODS AND MATERIALS: Two radiogold brachytherapy programs were analyzed, using literature review and interviews of participants. RESULTS: Although (198)Au has been discredited as a source for permanent prostate brachytherapy, the major flaw in the reviewed programs was the misapplication of the isotope. CONCLUSIONS: Safe and effective implant programs are grounded in the sound application of brachytherapy principles. New brachytherapy procedures should arise from the collaboration of radiation oncologists, surgeons, physicists, radiobiologists, and radiation safety specialists.

Inter-institutional variation of implant activity for permanent prostate brachytherapy.

PURPOSE: Despite the existence of guidelines for permanent prostate brachytherapy, it is unclear whether there is interinstitutional consensus concerning the parameters of an ideal implant. METHODS AND MATERIAL: Three institutions with extensive prostate brachytherapy expertise submitted information regarding their implant philosophy and dosimetric constraints, as well as data on up to 50 radioiodine implants. Regression analyses were performed to reflect each institution's utilization of seeds and implanted activity. RESULTS: Despite almost identical implant philosophy, target volume, and dosimetric constraints, there were statistically significant interinstitutional differences in the number of seeds and total implant activity across the range of prostate volumes. For larger volumes, the variation in implanted activity was 25%; for smaller glands, it exceeded 40%. CONCLUSIONS: There remain wide variations in implanted activity between institutions espousing seemingly identical implant strategies, prescription, and dosimetry constraints. Brachytherapists should therefore be wary of using nomograms generated at other institutions.

Ethereal fire: antecedents of radiology and radiotherapy.

OBJECTIVE: The objective is to explore the events that led to the implementation of X-radiation for medical purposes within months of its discovery. CONCLUSION: The century-long experience with electrotherapeutics and the concurrent adoption of ultraviolet light therapy, facilitated the swift inclusion of X-radiation into medical practice.

Classics in brachytherapy: Margaret Cleaves introduces gynecologic brachytherapy.

Intracavitary treatment of gynecologic cancers has been the anchor of brachytherapy, and perhaps the greatest success of radiotherapy, for over a century. The woman who first performed the procedure was neither a surgeon nor radiologist, but an electrotherapeutist who began her career as an alienist. She pursued a prolific academic career despite being disabled by a disease that is no longer recognized. The fascinating life of Margaret Cleaves, the initiator of gynecologic brachytherapy, is recounted.

Adjuvant high-dose-rate and low-dose-rate brachytherapy with external beam radiation in soft tissue sarcoma: a comparison of outcomes.

PURPOSE: To compare outcomes of patients treated with low-dose-rate (LDR) adjuvant brachytherapy (BT) + external beam radiation therapy (EBRT) vs. high-dose-rate (HDR) adjuvant BT + EBRT. METHODS AND MATERIALS: Thirty-seven patients with soft tissue sarcoma (STS) were treated with pre- or postoperative external beam irradiation and postoperative LDR or HDR BT. RESULTS: There was no significant difference in the 2-year local control rates (90% with LDR boost vs. 94% for HDR). The rate of National Cancer Institute (NCI) grades 2-4 wound-healing complications was 40% in the LDR group vs. 18% in the HDR group (p = 0.14). On univariate analysis, only suboptimal geometry of the implant predicted for increasing complication rate in the LDR group. In the HDR group, BT dose per fraction, total BT dose, and total biologically equivalent dose (BED3) radiation dose were significant. CONCLUSIONS: HDR and LDR boost BT results in acceptable local control for STS. There is a suggestion that HDR may have lower incidence of severe (grade > or = 3) acute toxicity than LDR.

Localized non-small cell lung cancer: adjuvant radiotherapy in the era of effective systemic therapy.

Investigators in Europe, Canada, and the United States recently established a definitive role for adjuvant systemic chemotherapy following resection of early-stage non-small cell lung cancer (NSCLC). This was no small accomplishment, as upward of 20 randomized trials had previously been conducted. The role of postoperative radiotherapy (PORT) has been studied with far less vigor in the modern era. A 1998 meta-analysis of randomized trials suggesting that PORT was detrimental to survival included studies of doubtful quality. The value of PORT should be considered in the same context as recent chemotherapy trials. Advances in imaging have improved the accuracy of staging, patient selection, and target definition. Modern dosimetry and accelerator technologies have advanced the capacity to deliver radiation to the target with less tissue toxicity. Evolving philosophies in dosing and fractionation should improve the therapeutic ratio. Finally, it is reasonable to assume that the importance of local control will be enhanced in the setting of better systemic therapies. We will review the data on PORT and address critical issues in the design of trials to assess the role of modern radiotherapy in the integrated approach to management of early-stage NSCLC.

Dose-intensive thoracic radiation therapy for patients at high risk with early-stage non-small-cell lung cancer.

Recent studies suggest that radiation therapy (RT) dose escalation in early-stage non-small-cell lung cancer (NSCLC) is feasible when 3-dimensional therapy is used. However, the accompanying prolongation of the treatment course when standard fractionation is used could be suboptimal from a practical and biologic standpoint. We report results of a compressed course of RT for patients with pathologically documented clinical stage 1 NSCLC who were unsuitable for curative surgery because of pulmonary dysfunction or other medical comorbidities. Thirty-one lesions were treated with dose-intensive RT (eg, fraction>or=2.25 Gy and nominal total dose>or=60 Gy) and have been followed up for >or=6 months from the completion of treatment. All patients completed therapy without interruption. Three patients developed grade 3 pulmonary toxicity 1-3 months after therapy. The overall tumor response rate was 88% (35% complete response and 53% partial response), whereas in-field tumor progression was documented for 5 of 31 lesions. Actuarial median survival was 38 months and 3-year overall survival was 60%, and most deaths were secondary to intercurrent disease. Moderately accelerated single daily fractionated RT is feasible for high-risk patients with early-stage NSCLC and merits further investigation.

Afterloading: The Technique That Rescued Brachytherapy.

Although brachytherapy had been established as a highly effective modality for the treatment of cancer, its application was threatened by mid-20th century due to appreciation of the radiation hazard to health care workers. This review examines how the introduction of afterloading eliminated exposure and ushered in a brachytherapy renaissance.

Dawn of prostate brachytherapy: 1915-1930.

PURPOSE: To investigate the origins of prostate brachytherapy. METHODS AND MATERIALS: A review of contemporary journals and texts was conducted. RESULTS: Prostate brachytherapy was performed frequently by leading urologists before 1930. Both temporary and permanent implant techniques were developed using radium and radon through intracavitary and interstitial approaches. Transperineal implantation of permanent sources was first performed 80 years ago. CONCLUSION: Prostate brachytherapy has its origins in the early part of the last century.

Buried emanation; the development of seeds for permanent implantation.

PURPOSE: To chronicle the development of radioactive sources for permanent implantation. METHODS AND MATERIALS: Review of contemporary literature. RESULTS: The value of ionizing radiation in the treatment of malignancy was appreciated soon after Roentgen's and Becquerel's discoveries. Brachytherapy was developed to treat tumors that were poorly controlled by early X-ray equipment. Sources and techniques for permanent implantation were devised in the first quarter of the 20th century. CONCLUSIONS: Long before the creation of artificial isotopes, pioneering physicists and clinicians fashioned seeds from naturally occurring radionuclides and ingenuity.

Introduction of transperineal image-guided prostate brachytherapy.

The modern prostate brachytherapy procedure is characterized by ultrasound guidance, template assistance, and a return to a "closed" transperineal approach. This review traces the introduction and evolution of these elements and charts the development of the procedure from the ashes of previous, failed efforts.

The evolution of computerized treatment planning for brachytherapy: American contributions.

PURPOSE: To outline the evolution of computerized brachytherapy treatment planning in the United States through a review of technological developments and clinical practice refinements. MATERIAL AND METHODS: A literature review was performed and interviews were conducted with six participants in the development of computerized treatment planning for brachytherapy. RESULTS: Computerized brachytherapy treatment planning software was initially developed in the Physics Departments of New York's Memorial Hospital (by Nelson, Meurk and Balter), and Houston's M. D. Anderson Hospital (by Stovall and Shalek). These public-domain programs could be used by institutions with adequate computational resources; other clinics had access to them via Memorial's and Anderson's teletype-based computational services. Commercial brachytherapy treatment planning programs designed to run on smaller computers (Prowess, ROCS, MMS), were developed in the late 1980s and early 1990s. These systems brought interactive dosimetry into the clinic and surgical theatre. CONCLUSIONS: Brachytherapy treatment planning has evolved from systems of rigid implant rules to individualized pre- and intra-operative treatment plans, and post-operative dosimetric assessments. Brachytherapy dose distributions were initially calculated on public domain programs on large regionally located computers. With the progression of computer miniaturization and increase in processor speeds, proprietary software was commercially developed for microcomputers that offered increased functionality and integration with clinical practice.

A simple technique for the generation of institution-specific nomograms for permanent prostate cancer brachytherapy.

PURPOSE: Nomograms once had a vital role in prostate brachytherapy practice. Although some of their functions have been assumed by computerized dosimetry, many programs still find them useful to determine the number and strength of seeds to be ordered in advance of the implant. As it has been demonstrated that brachytherapists differ in their implant practices and preferences (in regard to seed distribution and total implanted activity), we propose a simple technique for generating institution-specific nomograms. MATERIAL AND METHODS: Using the data generated by previous implants, we demonstrate a simple technique, utilizing ubiquitous software, for generating nomograms to predict seed number, strength, and total implant activity. RESULTS: Despite wide variations in the degree of post-implant swelling (+12% to +56%), nine of the first ten implants using the generated nomogram have met all target dose parameters. CONCLUSIONS: It is appropriate for each institution to develop nomograms specific to their prostate brachytherapy technique and constraints. Nomograms can estimate the number and strength of seeds to be ordered, and may partially compensate for the effects of implant-induced swelling.

The phylogeny of permanent prostate brachytherapy.

Permanent prostate brachytherapy has been practiced for more than a century. This review examines the influence of earlier procedures on the modern transperineal ultrasound-directed technique. A literature review was conducted to examine the origin of current clinical practice. The dimensions of the modern brachytherapy seed, the prescription dose, and implant/teletherapy sequencing are vestigial features, which may be suboptimal in the current era of low-energy photon-emitting radionuclides and computerized dose calculations. Although the modern transperineal permanent prostate implant procedure has proven to be safe and effective, it should undergo continuous re-evaluation and evolution to ensure that its potential is maximized.

Whitmore, Henschke, and Hilaris: The reorientation of prostate brachytherapy (1970-1987).

PURPOSE: Urologists had performed prostate brachytherapy for decades before New York's Memorial Hospital retropubic program. This paper explores the contribution of Willet Whitmore, Ulrich Henschke, Basil Hilaris, and Memorial's physicists to the evolution of the procedure. METHODS AND MATERIALS: Literature review and interviews with program participants. RESULTS: More than 1000 retropubic implants were performed at Memorial between 1970 and 1987. Unlike previous efforts, Memorial's program benefited from the participation of three disciplines in its conception and execution. CONCLUSIONS: Memorial's retropubic program was a collaboration of urologists, radiation therapists, and physicists. Their approach focused greater attention on dosimetry and radiation safety, and served as a template for subsequent prostate brachytherapy programs.

Robert Abbe: early American brachytherapist.

PURPOSE: To assess Robert Abbe's career and contributions to brachytherapy, in the context of the work of contemporary European and American investigators. METHODS AND MATERIALS: Examination of his lectures and journal articles, as well as contemporaneous newspaper accounts, textbooks, and archival material. RESULTS: Although not the first American to apply radium therapeutically, Robert Abbe was among the earliest to acquire and systematically use a clinically significant quantity. He replicated early European experimental and clinical work, and published a large series of cases treated with generally favorable results. Abbe was the first American to emphasize the role of radiobiology in optimizing therapeutic ratio. His eloquence and stature helped legitimize the new therapeutic modality. CONCLUSIONS: Robert Abbe was probably the nation's most influential early brachytherapist.

From the lost radium files: misadventures in the absence of training, regulation, and accountability.

PURPOSE: Radium was the foundation of brachytherapy in the early decades of the 20th century. Despite being a most precious and perilous substance, it was mislaid with surprising frequency. This essay explores how it was lost, the efforts taken to recover it, and measures instituted to prevent mishandling. METHODS AND MATERIALS: Review of contemporary literature, government publications, archives, and lay press. RESULTS: Radium is a particularly dangerous substance because of its long half-life, its gaseous daughter (radon), and the high-energy emissions of its decay products. Despite the hazard, it was unregulated for most of the century. Any physician could obtain and administer it, and protocols for safe handling were generally lacking. Change came with appreciation of the danger, regulation, mandated training, and the institution of a culture of accountability. Unfortunately, careless management of medical radionuclides remains a global hazard. CONCLUSION: Responsible stewardship of radioactive material was not a high priority, for practitioners or the federal government, for much of the 20th century. As a result, large quantities of radium had gone astray, possibly subjecting the general public to continued radiation exposure. Lessons from the radium era remain relevant, as medical radionuclides are still mishandled.