A randomized study for dosimetric assessment and clinical impact of bone marrow sparing intensity-modulated radiation therapy versus 3-dimensional conformal radiation therapy on hematological and gastrointestinal toxicities in cervical cancer.

Background: Cervical cancer requires multimodality therapy, resulting in acute toxicities. Intensity-modulated radiation therapy (IMRT) is postulated to spare bone marrow (BM) and bowel to reduce acute hematological and gastrointestinal (GI) toxicities of chemoradiotherapy. Patients and Methods: This is a prospective randomized phase III study enrolling patients with Stage IB to IVA cervical carcinoma in two arms receiving either three-dimensional conformal radiotherapy (3DCRT) or IMRT from December 2017 to December 2019. The primary objective was to compare the hematologic toxicities (Grade 2 or more neutropenia as the primary factor) and the secondary objectives were to compare GI toxicities, and dosimetric analysis for volumes of BM, and bowel irradiated. SPSS version 20 was used for all statistical calculations. Results: Eighty patients with histopathologically confirmed cervical cancer were randomized to receive IMRT or 3DCRT (40 in each arm). The median age of the patients was 56.5 (36-67) and 59.5 (37-68) years, respectively, in IMRT and 3DCRT arms. The median dose of external radiation was 50 Gy in 25 fractions, and of brachytherapy was 24 Gy in 3 fractions in both the arms. The incidence of grade ≥2 neutropenia was 42.5% and 15% in the 3DCRT and IMRT arms, respectively (P < 0.001). All patients received concurrent chemotherapy with cisplatin, with the median number of cycles being 5 (range 3-5) in both the arms. All five cycles of concurrent chemotherapy could be completed in 25 (62.5%) patients in the IMRT arm and 24 (60%) patients in the 3DCRT arm. Conclusions: IMRT significantly reduces acute hematologic and GI toxicities compared with 3DCRT with a better dosimetry profile.

Pediatric extremity rhabdomyosarcoma treated with re-brachytherapy in recurrent setting.

Rhabdomyosarcomas (RMS) are pediatric soft-tissue sarcomas arising from immature mesenchymal cells that are intended to form striated skeletal muscles. Brachytherapy delivers high-dose of precised radiation to the target tissue with high conformity, sparing the nearby normal tissues, hence allowing dose escalation and reducing the likelihood of normal tissue toxicity. There is a scarcity of reports on the use of brachytherapy for extremity RMS. We report the case of pediatric extremity RMS treated with re-brachytherapy in recurrent setting. A 4-year-old boy diagnosed with RMS of right upper arm underwent local excision of the lesion. Postoperative magnetic resonance imaging showed suspicious residual lesion. Revision surgery followed by brachytherapy with 30 Gy in 10 fractions twice a day over 5 days was delivered. The child developed local recurrence after 12 months. Reexcision and re-irradiation with brachytherapy were done delivering 27 Gy in 9 fractions twice a day over 5 days. The child is disease-free 18 months posttreatment with no significant disparity in limb length suggestive of successful preservation of growth epiphysis. Re-irradiation with interstitial brachytherapy can be considered as an option for the treatment of recurrent pediatric extremity rhabdomyosarcoma, in conjunction with surgery and chemotherapy, despite treated previously with brachytherapy.

Brachytherapy in head and neck malignancies: Indian Brachytherapy Society (IBS) recommendations and guidelines.

PURPOSE: Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC. MATERIAL AND METHODS: A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings. RESULTS: The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe. CONCLUSIONS: IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Indian Brachytherapy Society Guidelines for radiotherapeutic management of cervical cancer with special emphasis on high-dose-rate brachytherapy.

Brachytherapy (BT) for locally advanced cervical cancer is vital for optimal outcomes. There is heterogeneity in brachytherapy treatment practice for cervical cancer across India. In an attempt to standardize various processes involved in cervical cancer brachytherapy, the expert members of the Indian Brachytherapy Society (IBS) developed a document related to radiation therapy treatment of cervical cancer with special emphasis on brachytherapy. The guidelines are based on high quality clinical evidence, expert opinion and consensus wherever evidence was lacking. The document provides a guide for external beam radiation and details of all the processes involved in high-dose-rate (HDR) brachytherapy including patient selection, preparation, principles and technique of BT applications, target and normal tissue definition, dose prescriptions, BT planning, reporting parameters, common complications of BT and their management, scope for research, etc. In summary, we present here practical tips and tricks, recording and reporting of cervical cancer brachytherapy, which can be implemented in various clinical environments and forms the basis of this report.

High-dose-rate interstitial brachytherapy in recurrent head and neck cancer: an effective salvage option.

PURPOSE: High-dose-rate (HDR) interstitial brachytherapy has an established role in head and neck malignancies and offers good survival rates; however, there is scant data on improved local control (LC) and treatment-related complications in recurrent cases. We present our results in patients with recurrent head and neck cancers treated with HDR interstitial brachytherapy. MATERIAL AND METHODS: Twenty-five patients with recurrent head and neck cancers were treated with HDR interstitial brachytherapy using Iridium 192 between 2009 and 2016. Of these, 75% received radical brachytherapy, and 25% received external beam radiation therapy (EBRT) followed by brachytherapy boost. Treatment sites included oral cavity (15/25) and oropharynx (10/25). Median dose of 4.5 Gy was administered twice per day, with median total brachytherapy dose of 40.5 Gy in radical and 27 Gy for EBRT cases. RESULTS: With median follow-up of 25 months, 4 local recurrences were observed within first year of follow-up. Two-year local control and overall survival outcomes for the entire group were 75% and 68%, respectively. Local control rate with radical BRT vs. BRT as a boost following EBRT was found to be significant (2-year LCR 62% vs. 85%; p < 0.02). Dosimetric assessment revealed D90 - 4.08 Gy, V100 - 94.1%, V150 - 24.7%, and V200 - 10.1%. Xerostomia, altered taste, and dysphagia were the major complications commonly grade 1 and 2. Grade 3 toxicity was only 2%. Pre-treatment volume > 85 cc had a negative impact on overall survival (26 months vs. 12 months; p = 0.02), and interval time between primary and recurrence more than 15 months had an impact on the local control rate (p < 0.01). CONCLUSIONS: Results of HDR interstitial brachytherapy have shown acceptable local control and overall survival rates along with tolerable toxicities and morbidity in recurrent head and neck cancers.

High-dose-rate interstitial brachytherapy in head and neck cancer: do we need a look back into a forgotten art - a single institute experience.

PURPOSE: To evaluate the treatment outcomes with high-dose-rate (HDR) interstitial brachytherapy (HDR-BRT) in head and neck cancers (HNC). MATERIAL AND METHODS: Fifty-eight patients with HNC as per American Joint Committee on Cancer (AJCC) TNM staging criteria were analyzed retrospectively between 2008 and 2015. Forty-two patients received external beam radiotherapy (EBRT) with HDR-BRT and 16 patients received BRT alone. The survival was calculated with respect to median biological equivalent doses (BED) and median 2 Gy equivalent dose (EQD2), keeping α/ß = 10 for tumor. Loco-regional control and disease free survival was assessed. RESULTS: The median follow-up period was 25 months (2-84 months). The disease-free survival (DFS) probability at year 1 was 82.7%, and 68% at year 7. The overall survival probability was 91.3% at year 1 and 85.8% at year 7. The local control rate was 70%. The rate of recurrence was 30%. Distant metastasis rate was 17.2%. The median BED and EQD2, respectively, were 86.78 Gy and 71.6 Gy. The DFS was 74.1% and 75.9% in patients receiving a dose more than median BED and EQD2, respectively, and was 64.8% and 61.5% for less than the median dose. CONCLUSIONS: The overall outcome was good with implementation of HDR-BRT used alone or as boost, and shows DFS as better when the dose received is more than the median BED and median EQD2. The role of HDR-BRT in HNC is a proven, effective, and safe treatment method with excellent long term outcome as seen in this study, which reflects the need for reviving the forgotten art and science of interstitial brachytherapy in HNC.

Quantitative estimation of doses to salivary glands from using brachytherapy in head and neck cancers.

PURPOSE: To quantify the percentage doses received by salivary glands (SGDs) in head and neck interstitial brachytherapy (BT). METHODS AND MATERIALS: The study included 43 patients who underwent high-dose rate iridium-192 implant for oral cavity and oropharyngeal lesions treated with BT as a boost. BT dose varied with disease stage and external radiation dose, with the total mean dose of 66±4Gy. Patients were divided into two groups, midline and lateralized, based on anatomic implant location. Different dose parameters such as D(max), D(mean), DV(30%) of individual glands were derived from dose volume histogram representing the percentage maximum dose, mean dose, and dose received by 30% volume of individual SGDs, respectively. For better perception of the impact of BT on individual SGDs, the doses received are extrapolated to radical BT dose of 60Gy. RESULTS: For lateralized implants, the highest dose received by ipsilateral parotid (PTD) was 12.3% seen in tonsillar implants. The contralateral PTD receives minimal doses. As expected, the ipsilateral submandibular gland (SMG) received high doses in the range of 80% of the total prescribed dose, whereas contralateral SMG received 10% of ipsilateral dose. For the midline implants, the mean dose range for PTD was 7-11% of the total prescribed dose and for SMG between 17% and 56%, depending on the location. CONCLUSIONS: The study quantifies the percentage doses received by the individual SGDs in interstitial head and neck BT for use in future planning of the BT procedures and for salivary functional studies, prediction of damage, and quality-of-life parameters.

Treatment outcome with low-dose-rate interstitial brachytherapy in early-stage oral tongue cancers.

PURPOSE: Although radical radiotherapy is known to be equally effective for early-stage oral tongue cancers (T1-2 N0) with the added advantage of organ and function preservation, surgery remains the preferred treatment. We present outcome of patients treated with brachytherapy (BT) either radical or boost. MATERIALS AND METHODS: Fifty-seven patients (T1/T2 31/26) were studied. Seventeen patients (30%) were treated with radical BT (50-67 Gy) while 40 (70%) with external beam radiation therapy (EBRT) + BT (36-56 Gy + 15-38 Gy]. Low-dose-rate (LDR) BT was delivered with 192 Ir wires, using plastic bead technique with varied dose rates (<60 cGy/h in 29 patients, 60-90 cGy/h in 17, and >90 cGy/h in 11). RESULTS: The overall local control (LCR) was achieved in 59.7% (34/57) patients. LCR for T1 and T2 was 67.8% and 50%, respectively. A total of 23 patients had failures [local: 20 (T1: 8; T2: 12 patients), node: 5 (T1:2; T2: 3), and local + nodal: 3]. Overall 5-year disease-free survival and overall survival (OAS) were 51% and 67%, respectively and those for T1 and T2 was 64.5/77.4% and 38.5/54% respectively (P = 0.002). All 16 patients were salvaged. Median survival after salvage treatment was 13.5 months (6-100 months). Soft tissue necrosis was observed in 12.3% (7/57) and osteoradionecrosis in two patients. CONCLUSION: BT, as an integral part of radical radiation therapy in early-stage tongue cancers, appears to be an effective alternative treatment modality with preservation of the organ and function without jeopardizing the outcome.

High-dose-rate brachytherapy boost for carcinoma of external auditory canal.

PURPOSE: To report dosimetry and outcome in a case of early stage carcinoma of external ear (T1N0M0) treated with radical radiotherapy alone using a combination of external beam radiotherapy (EBRT) and intracavitary irradiation with a high-dose-rate (HDR) (192)Ir remote afterloading system. METHODS AND METHODS: A 64-year-old gentleman who was diagnosed as T1N0M0 carcinoma of external ear was treated with combination of external beam radiation therapy followed by brachytherapy (BRT). A total dose of 40Gy was delivered by EBRT, following which a 6-Fr catheter for the HDR (192)Ir remote afterloader, fixed by a customized acrylic mold, was inserted into the external auditory canal (EAC) and a total intracavitary radiation dose of 22.5Gy (4.5Gy/F) was given. RESULTS: Evaluation at the completion of treatment and at the end of 4-year followup revealed no evidence of the disease. CONCLUSIONS: In the radical treatment of early stage EAC carcinoma, combination of external beam radiation therapy and BRT may be a modality of choice for its efficacy, less severe side effects, and better cosmetic results.

Brachytherapy boost: a novel approach for epiglottic carcinoma.

PURPOSE: Epiglottic (epilaryngeal) carcinoma has been treated conventionally by radical external beam radiotherapy or partial laryngectomy. The aim of this study is to evaluate the role of brachytherapy boost as a novel approach for lingual epiglottic lesions. METHODS AND MATERIALS: Twenty-three patients with T(2-3)N(0-1) lingual epiglottic carcinoma (SCC) were treated with curative intent between January 1990 and December 2001 using low dose rate interstitial (192)Ir implant boost, moderate dose of 25Gy at 0.5cm (mean dose rate, 50.5 cGy/h) 3 weeks after moderate dose of external beam radiotherapy (mEBRT) of 46Gy/23#/28-31d. RESULTS: Complete response after mEBRT was observed in 18 of the 23 patients (78%) and partial response was seen in 5 of the 23 patients (22%). After implant, all patients had complete response. Locoregional control was seen in 19 of the 23 patients (82.6%). Two patients developed distant metastases. Disease-free survival and overall survival at 5 years were 68.3% and 66.7%, respectively. Disease-free survival at 5 years showed a trend toward better outcome for biologically equivalent doses >85Gy compared with biologically equivalent doses <85Gy (80% vs. 68%) (p=0.18). All patients had minimal to acceptable xerostomia. CONCLUSIONS: Interstitial boost with mEBRT is feasible, effective, and a novel approach for lingual epiglottic lesions.

Malignant pilar tumor of the scalp: a case report and review of literature.

Pilar tumor is a rare neoplasm arising from the external root sheath of the hair follicle and is most commonly observed on the scalp. These tumors are largely benign, often cystic, and are characterized by trichilemmal keratinization. Wide local excision has been the standard treatment. Recent reports have described a rare malignant variant with an aggressive clinical course and a propensity for nodal and distant metastases which, therefore, merits aggressive treatment. In this report, we present a case of malignant pilar tumor of the scalp with multiple nodal metastases at presentation. Diagnostic and therapeutic considerations, in the form of adjuvant radiotherapy, are subsequently discussed.