Pathological complete response with immunotherapy and brachytherapy to 15 metastatic liver lesions in a single patient.

Materials & methods: High dose rate interstitial brachytherapy (HDR-IBT) treatment plan for 15 metastatic liver lesions in a patient with pancreatic cancer was retrieved and analyzed for liver dose parameters and diaphragm dose. Serial 18F-FDG PET-CT scans were reviewed for disease response assessment and left liver lobe volume. Serial laboratory records were analyzed for liver parameters. Results: Left liver lobe volume increased from 241 cm3 pre-HDR-IBT to estimated 600 cm3 after seven sessions of HDR-IBT. Metabolic complete response (CR) and subsequently pathological CR was confirmed in the right hepatotectomy specimen for all the 15 PET-CT avid lesions treated with HDR-IBT. Maximum diaphragm dose in a single fraction was 82 Gy. The liver parameters were stable and patient did not develop radiation induced liver disease. Discussion: This is the largest reported series of HDR-IBT to liver lesions in a single patient. This first ever reported combined treatment of immunotherapy (IT) and HDR-IBT had likely rendered this patient disease free both at local the liver and systemically. Metabolic CR by PET-CT can be seen as early as 46 days after HDR-IBT. Diaphragm can tolerate very high doses of radiation and repeated treatment. Conclusion: In this patient HDR-IBT for multiple liver lesions with IT is well tolerated. PET-CT can be used for response assessment of HDR-IBT liver. Synergistic effect of IT with HDR-IBT and it's role as bridging for liver resection has clinical potential and should be further studied in prospective trials.

Palliative brachytherapy to axilla and hypopharynx in elderly patient with hypopharyngeal squamous cell carcinoma - case report.

Brachytherapy (BT) is an important local treatment of tumor and it can be applied to different anatomical sites either in a curative or palliative setting. BT can deliver large dose of radiation to the tumor while sparing the surrounding normal tissue which translates into a better therapeutic ratio compared to external beam radiotherapy. However, the evidence for the use of brachytherapy in the palliative setting is lacking in the literature. In this case report, we describe the brachytherapy technique and outcome of a patient with squamous cell carcinoma of the hypopharynx who underwent palliative brachytherapy to the hypopharynx and metastatic tumor at the right axilla.

Case Report-Staged brachytherapy achieving complete metabolic response in unresectable oligometastatic colorectal cancer to the liver.

Liver is the most common site for metastasis from colorectal cancer (CRC). Non-surgical treatment options for oligometastatic CRC confined to the liver which represents an intermediate state in the metastatic cascade are fast expanding. Currently, several liver-directed local therapeutic options are available, such as hepatic arterial infusion (HAI) therapy, radio-frequency ablation (RFA), transarterial chemoembolization (TACE), stereotactic body radiotherapy and high dose rate brachytherapy (HDRBT). Many factors such as patient's fitness, liver function (LF), tumour size, location of the tumour in the liver and scheduling of systemic therapy need to be considered when selecting patients for surgery or local liver-directed therapy. This case report illustrates a successful local treatment with staged HDRBT for a large and unresectable, liver only oligometastatic disease from CRC. This patient underwent 4 cycles of chemotherapy (FOLFOX 4) followed by primary tumour resection and first stage of HDRBT to liver for a residual 14 cm tumour after the chemotherapy. After completing a further 4 cycles of chemotherapy with the same regimen, the tumour remained stable at 8 cm. She underwent a second stage of HDRBT to the same lesion and a repeat PET-CT scan done 8 weeks after the second HDRBT showed complete metabolic response. To our knowledge, this is the largest CRC metastatic liver lesion that has been successfully treated with HDRB.

Lateral wedge with medial only cardiac shielding (LEMONADE) technique in left chest wall adjuvant radiotherapy.

BACKGROUND: This dosimetric study compared lateral wedge with medial only cardiac shielding (LEMONADE) technique, for left chest wall (LCW) irradiation against three other commonly used techniques. MATERIALS AND METHODS: Dosimetric parameters of 22 consecutive LBC patients treated using the P1 (LEMONADE technique) were compared with 3 other virtually reconstructed plans : no cardiac shielding with paired wedges; P2 (paired wedges and medial only Y-direction shielding) and P3 (paired wedges and bilateral Y-direction shielding). RESULTS: P1 showed better target volume (TV) coverage with the mean 90% isodose coverage of 85.59% ± 5.44 compared to 78.90% ± 8.59 and 74.22% ± 9.50 for P2 and P3, respectively. Compared to no cardiac shielding, for a 4.65% drop in TV coverage the V26Gy of heart dropped from 6.68% to a negligible 0.85% for P1. TV receiving < 30Gy is also significantly lesser for P1 compared to P2 and P3 (5.42% vs 10.64% and 15.8%), whilst there is a small difference of 2.75% between no cardiac shielding and P1. CONCLUSION: With the improvement in BC survival rate, cardiac toxicity associated with adjuvant irradiation for LBC is a major concern. P1 (LEMONADE) technique has a good compromise between cardiac sparing and target coverage and should suffice for most LCW irradiations. Furthermore, the LEMONADE technique is a simple, reproducible and involves fast planning for cardiac sparing, which is ideal for under-resourced departments with heavy workload.