A review of safety, quality management, and practice guidelines for high-dose-rate brachytherapy: executive summary.

This white paper was commissioned by the American Society for Radiation Oncology (ASTRO) Board of Directors to evaluate the status of safety and practice guidance for high-dose-rate (HDR) brachytherapy. Given the maturity of HDR brachytherapy technology, this white paper considers, from a safety point of view, the adequacy of general physics and quality assurance guidance, as well as clinical guidance documents available for the most common treatment sites. The rate of medical events in HDR brachytherapy procedures in the United States in 2009 and 2010 was 0.02%, corresponding to 5-sigma performance. The events were not due to lack of guidance documents but failures to follow those recommendations or human failures in the performance of tasks. The white paper summarized by this Executive Summary reviews current guidance documents and offers recommendations regarding their application to delivery of HDR brachytherapy. It also suggests topics where additional research and guidance is needed.

Locoregional recurrence following accelerated partial breast irradiation for early-stage invasive breast cancer: significance of estrogen receptor status and other pathological variables.

BACKGROUND: Understanding risk factors for locoregional recurrence (LRR) after accelerated partial breast irradiation (APBI) can help to guide patient selection for treatment with APBI. Published findings to date have not been consistent. More data are needed as these risk factors continue to be defined. METHODS: A total of 277 women with early-stage invasive breast cancer underwent lumpectomy and were treated adjuvantly at our institution with APBI using high-dose rate brachytherapy. APBI was delivered using multicatheter interstitial brachytherapy (91 %) or single-entry catheter brachytherapy (9 %) to a dose of 32-34 Gy in 8-10 twice daily fractions. Failure patterns and risk factors for recurrence were analyzed. RESULTS: With a median follow-up of 61 months, the 5-year locoregional control rate was 94.4 %. Negative estrogen receptor (ER) status was strongly associated with LRR on multivariate analysis (p < 0.005). Lobular histology, the presence of an extensive intraductal component, and lymphovascular invasion also were significant but to a lesser degree than ER-negative status. Patients with multiple risk factors were at highest risk for LRR. Age was not significantly associated with increased risk for LRR. CONCLUSIONS: The presence of specific pathological features, particularly ER negative status, was associated with increased risk of LRR in this cohort of women treated with APBI. Further investigation is warranted to determine whether patients with adverse pathological risk factors are at higher risk of LRR after APBI than after conventional whole breast irradiation (WBI), as these same features also may place women at risk for LRR after WBI.

The American Brachytherapy Society consensus statement for accelerated partial breast irradiation.

PURPOSE: To develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer. METHODS AND MATERIALS: Members of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience. RESULTS: Increasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment. CONCLUSIONS: These guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.

Postsurgical treatment of early-stage breast cancer with electronic brachytherapy: outcomes and health-related quality of life at 1 year.

OBJECTIVES: This multicenter registry followed up patients with early-stage breast cancer treated with breast-conserving surgery and electronic brachytherapy (EBT). This report provides 1- and 2-year updates to the initial publication. METHODS: Patients were of age 50 years or more with invasive carcinoma or ductal carcinoma in situ, tumor size ≤3 cm, and negative surgical margins. After lumpectomy, patients received EBT in 10 fractions over 5 days (34 Gy total). RESULTS: Of the 69 patients enrolled, 62 were evaluated at 1 year and 20 patients at 2 years after treatment. At 1 year, 28 (45.2%) patients reported adverse events that were possibly, probably, or definitely related to treatment. Most (90%) were grade 1: manageable and typical of radiation therapy. Four events were grade 2: induration/firmness (2), field contracture (1), and seroma (1). One event was grade 3: a draining fistula at the lumpectomy site due to residual effects of a breast infection at 1 month. No recurrences have been reported. Cosmetic ratings were excellent or good in 93.4% of patients at 1 year. Most patients (69%) were energetic most or all of the time. Most patients (69% to 98%) were not affected by individual symptoms of breast disease at 1 year. Generally patients who had an adverse event did not report the corresponding symptom on the quality-of-life questionnaire. CONCLUSIONS: This registry followed up patients with early-stage breast cancer at 1 and 2 years after breast-conserving surgery and EBT. No recurrences have been reported, and adverse effects were acceptable.

Phase I trial of pelvic nodal dose escalation with hypofractionated IMRT for high-risk prostate cancer.

PURPOSE: Toxicity concerns have limited pelvic nodal prescriptions to doses that may be suboptimal for controlling microscopic disease. In a prospective trial, we tested whether image-guided intensity-modulated radiation therapy (IMRT) can safely deliver escalated nodal doses while treating the prostate with hypofractionated radiotherapy in 5½ weeks. METHODS AND MATERIALS: Pelvic nodal and prostatic image-guided IMRT was delivered to 53 National Comprehensive Cancer Network (NCCN) high-risk patients to a nodal dose of 56 Gy in 2-Gy fractions with concomitant treatment of the prostate to 70 Gy in 28 fractions of 2.5 Gy, and 50 of 53 patients received androgen deprivation for a median duration of 12 months. RESULTS: The median follow-up time was 25.4 months (range, 4.2-57.2). No early Grade 3 Radiation Therapy Oncology Group or Common Terminology Criteria for Adverse Events v.3.0 genitourinary (GU) or gastrointestinal (GI) toxicities were seen. The cumulative actuarial incidence of Grade 2 early GU toxicity (primarily alpha blocker initiation) was 38%. The rate was 32% for Grade 2 early GI toxicity. None of the dose-volume descriptors correlated with GU toxicity, and only the volume of bowel receiving ≥30 Gy correlated with early GI toxicity (p = 0.029). Maximum late Grades 1, 2, and 3 GU toxicities were seen in 30%, 25%, and 2% of patients, respectively. Maximum late Grades 1 and 2 GI toxicities were seen in 30% and 8% (rectal bleeding requiring cautery) of patients, respectively. The estimated 3-year biochemical control (nadir + 2) was 81.2 ± 6.6%. No patient manifested pelvic nodal failure, whereas 2 experienced paraaortic nodal failure outside the field. The six other clinical failures were distant only. CONCLUSIONS: Pelvic IMRT nodal dose escalation to 56 Gy was delivered concurrently with 70 Gy of hypofractionated prostate radiotherapy in a convenient, resource-efficient, and well-tolerated 28-fraction schedule. Pelvic nodal dose escalation may be an option in any future exploration of potential benefits of pelvic radiation therapy in high-risk prostate cancer patients.

Dosimetric comparison of left-sided whole breast irradiation with 3DCRT, forward-planned IMRT, inverse-planned IMRT, helical tomotherapy, and topotherapy.

BACKGROUND AND PURPOSE: To compare left-sided whole breast conventional and intensity-modulated radiotherapy (IMRT) treatment planning techniques. MATERIALS AND METHODS: Treatment plans were created for 10 consecutive patients. Three-dimensional conformal radiotherapy (3DCRT), forward-planned IMRT (for-IMRT), and inverse-planned IMRT (inv-IMRT) used two tangent beams. For-IMRT utilized up to four segments per beam. For helical tomotherapy (HT) plans, beamlet entrance and/or exit to critical structures was blocked. Topotherapy plans, which used static gantry angles with simultaneous couch translation and inverse-planned intensity modulation, used two tangent beams. Plans were normalized to 50Gy to 95% of the retracted PTV. RESULTS: Target max doses were reduced with for-IMRT compared to 3DCRT, which were further reduced with HT, topotherapy, and inv-IMRT. HT resulted in lowest heart and ipsilateral lung max doses, but had higher mean doses. Inv-IMRT and topotherapy reduced ipsilateral lung mean and max doses compared to 3DCRT and for-IMRT. CONCLUSIONS: All modalities evaluated provide adequate coverage of the intact breast. HT, topotherapy, and inv-IMRT can reduce high doses to the target and normal tissues, although HT results in increased low doses to large volume of normal tissue. For-IMRT improves target homogeneity compared with 3DCRT, but to a lesser degree than the inverse-planned modalities.

Outcomes after accelerated partial breast irradiation in patients with ASTRO consensus statement cautionary features.

PURPOSE: To evaluate outcomes among women with American Society for Radiation Oncology (ASTRO) consensus statement cautionary features treated with brachytherapy-based accelerated partial breast irradiation (APBI). METHODS AND MATERIALS: Between March 2001 and June 2006, 322 consecutive patients were treated with high-dose-rate (HDR) APBI at the University of Wisconsin. A total of 136 patients were identified who met the ASTRO cautionary criteria. Thirty-eight (27.9%) patients possessed multiple cautionary factors. All patients received 32 to 34 Gy in 8 to 10 twice-daily fractions using multicatheter (93.4%) or Mammosite balloon (6.6%) brachytherapy. RESULTS: With a median follow-up of 60 months, there were 5 ipsilateral breast tumor recurrences (IBTR), three local, and two loco-regional. The 5-year actuarial rate of IBTR was 4.8%±4.1%. The 5-year disease-free survival was 89.6%, with a cause-specific survival and overall survival of 97.6% and 95.3%, respectively. There were no IBTRs among 32 patients with ductal carcinoma in situ (DCIS) vs. 6.1% for patients with invasive carcinoma (p=0.24). Among 104 patients with Stage I or II invasive carcinoma, the IBTR rate for patients considered cautionary because of age alone was 0% vs. 12.7% in those deemed cautionary due to histopathologic factors (p=0.018). CONCLUSIONS: Overall, we observed few local recurrences among patients with cautionary features. Women with DCIS and patients 50 to 59 years of age with Stage I/II disease who otherwise meet the criteria for suitability appear to be at a low risk of IBTR. Patients with tumor-related cautionary features will benefit from careful patient selection.

Post-surgical treatment of early-stage breast cancer with electronic brachytherapy: an intersociety, multicenter brachytherapy trial.

INTRODUCTION: Electronic brachytherapy (EBT) was developed to allow accelerated partial breast irradiation to be performed in a patient procedure room with minimal shielding. This observational, nonrandomized, multicenter study evaluated EBT as a post-surgical adjuvant radiation therapy for early stage breast cancer. METHODS: This study included women aged 50 years or more with invasive carcinoma or ductal carcinoma in situ, tumor size ≤3 cm, negative lymph node status, and negative surgical margins. The endpoints were skin and subcutaneous toxicities, efficacy outcomes, cosmetic outcomes, and device performance. In this interim report, 1-month, 6-month, and 1-year follow-up data are available on 68, 59, and 37 patients, respectively. RESULTS: The EBT device performed consistently, delivering the prescribed 34 Gy to all 69 patients (10 fractions/patient). Most adverse events were Grade 1 and included firmness, erythema, breast tenderness, hyperpigmentation, pruritis, field contracture, seroma, rash/desquamation, palpable mass, breast edema, hypopigmentation, telangiectasia, and blistering, which were anticipated. Breast infection occurred in two (2.9%) patients. No tumor recurrences were reported. Cosmetic outcomes were excellent or good in 83.9%-100% of evaluable patients at 1 month, 6 months, and 1 year. CONCLUSION: This observational, nonrandomized, multicenter study demonstrates that this EBT device was reliable and well tolerated as an adjuvant radiation therapy for early stage breast cancer.

Breast conserving surgery and accelerated partial breast irradiation after prior breast radiation therapy.

OBJECTIVE: Although mastectomy has been traditional treatment for breast cancer after prior radiotherapy, patients are increasingly requesting additional breast conservation. This report details our experience of accelerated partial breast irradiation (APBI) as a component of salvage breast conserving treatment. METHODS: Eleven patients with prior external beam radiotherapy to the breast were treated with lumpectomy and APBI using high dose rate iridium-192 to a dose of 34 gray with 10 twice-daily fractions over 5 days. Six patients were previously treated for Hodgkin disease, 4 for invasive or in situ breast cancer, and 1 for soft tissue sarcoma. All had tumor ≤2 cm, negative nodes, and negative margins. RESULTS: At median follow-up of 53.7 months, 10 patients were alive without evidence of disease recurrence following treatment which occurred at median interval of 19.1 years after prior radiotherapy. One was lost to follow-up. One developed mastitis under treatment requiring oral and IV antibiotics. Another received oral antibiotics for 6 weeks following formation of a draining sinus tract with contracture and painless fibrosis. Three others reported slight to moderate firmness. Four noted mild hyperpigmentation, but none developed telangiectasia. One patient with prior whole breast radiation had necrosis requiring mastectomy 9.4 months following retreatment, with pathology revealing a chronic breast abscess. Of the 9 women with successful breast conservation, all but one reported satisfaction pursuing breast conservation rather than mastectomy. CONCLUSIONS: Repeat lumpectomy and APBI for in-breast tumor recurrence after prior external beam radiotherapy has been delivered with acceptable outcomes, justifying a phase II multicenter trial for validation.

Breast brachytherapy devices.

Multiple institutions have explored accelerated partial breast irradiation (APBI). The method of APBI with the longest reported follow-up is multicatheter interstitial brachytherapy. Balloon brachytherapy was introduced to simplify the APBI procedure. The MammoSite device was the first breast brachytherapy device designed for the treatment of APBI to hit the market. The MammoSite catheter was adopted rapidly in both academic and community settings and has led to a great increase in the number of patients undergoing the APBI procedure. We introduce and describe five additional breast brachytherapy devices.

The surgeon's role in breast brachytherapy.

Although two-thirds of invasive breast cancers and half of non-invasive breast cancers are amenable to lumpectomy, only about 70% of such patients choose breast conservation. Of that group, up to one-third do not follow-up with radiation therapy despite it being clinically indicated. The reasons include the patient's and surgeon's attitude toward breast conservation as well as the inconvenience and distance of a suitable radiation facility. The advent of shorter courses of radiation therapy may encourage more patients to seek adjuvant therapy. An increasingly popular and more convenient alternative to traditional whole-breast radiation therapy in patients with early-stage breast cancer is accelerated partial breast irradiation (APBI), for which the American Society of Breast Surgeons and the American Brachytherapy Society have promulgated guidelines for candidate selection. Although several methods are emerging, the most widely used brachytherapy technique utilizes the MammoSite single-catheter balloon brachytherapy device. In a best practices symposium convened in 2006, breast surgeons from academic and community practices with extensive experience in balloon brachytherapy developed general guidelines for integrating APBI into a breast surgical practice. Important considerations include patient age, histology, tumor location and size, and breast size. Thoughtful lumpectomy planning is essential to optimize balloon placement. Real-time sonographic guidance is essential as the surgeon should attend closely to volume excised and cavity shape. A cavity evaluation device can act as a place holder while patient suitability for APBI is considered. Many breast surgeons expert in this procedure insert the balloon catheter in the office either through a de novo skin entrance site removed from the lumpectomy incision or through the original incision. Optimally, insertion occurs within 2-3 weeks after lumpectomy. Close and continual communication with the radiation oncologist is essential to assure optimal outcomes. In this review, several key aspects of a successful APBI program from a surgeon's perspective as well as a consensus panel from a best practices symposium on the topic herein are highlighted.

A dosimetric comparison of MammoSite and ClearPath high-dose-rate breast brachytherapy devices.

PURPOSE: A new form of partial breast irradiation (PBI), ClearPath (CP) breast brachytherapy, has been introduced. We present our results of a dosimetric comparison of MammoSite (MS) and CP PBI. METHODS AND MATERIALS: The dimensions of the CP device were reconstructed onto the MS planning CT scans for 15 previously treated patients. The mean %V(100), %V(150), %V(200) (percent of the PTV that received 100%, 150%, and 200% of the prescription dose, respectively), ipsilateral breast %V(50) (percent of the ipsilateral normal breast that received 50% of the prescription dose), ipsilateral lung %V(30) (percent of the ipsilateral lung that received 30% of the prescription dose), the heart %V(5) (percent of the heart that received 5% of the prescription dose), and the maximum skin point dose per fraction were then determined for each patient using the two methods of balloon-based PBI. RESULTS: The mean %V(100) was 96.5% vs. 96.5%, the mean %V(150) was 42.1% vs. 42.9% (p=ns), and the mean V(200) was 11.4% vs. 15.2% (p<.05) for the MS and CP methods, respectively. The mean ipsilateral breast %V(50) was 19.8% vs.18.0% (p<.05), the mean ipsilateral lung %V(30) was 3.7% vs. 2.8% (p<.05), the mean heart %V(5) was 57.0% vs. 54.3% (p<.05), and the maximum skin point dose per fraction was 312.2 and 273.6cGy (p<.05) for the MS and CP methods, respectively. CONCLUSIONS: The MS and CP methods of PBI offer comparable target volume coverage; however, the CP device achieves increased normal tissue sparing.

Recommendations for permanent prostate brachytherapy with (131)Cs: a consensus report from the Cesium Advisory Group.

PURPOSE: Published clinical information on the safety and efficacy of (131)Cs implants is limited. We provide consensus recommendations for (131)Cs prostate brachytherapy based on experience to date. METHODS AND MATERIALS: The Cesium Advisory Group (CAG) consists of experienced (131)Cs users. Recommendations are based on three clinical trials, one of which has completed accrual and has been published in the peer reviewed literature, and combined CAG experience of more than 1200 (131)Cs implants. RESULTS: We recommend using 1.059cGyh(-1)U(-1) as the dose rate constant for the IsoRay source. The prescription for monotherapy implants is 115Gy and when combined with 45-50Gy external beam it is 85Gy. Suggested individual source strength ranges from 1.6 to 2.2U. The release criterion for (131)Cs implants is 6mRh(-1) at 1m. (131)Cs brachytherapy should be performed differently from (125)I and (103)Pd brachytherapy: source placement is further from the urethra and rectum; the prostate V(150) should be < or =45%; sufficient margins may be obtained while limiting source placement to the capsule or close to the capsule. The increased dose rate may cause degradation of postimplant quantifiers due to edema. However, large variability in the magnitude and rate of resolution of edema make determination of the most representative postoperative imaging time impossible. The CAG recommends postimplant imaging on the day of the implant. Recommended postimplant evaluation goals include prostate D(90) greater than the prescription dose; maintaining D(u)(,30)<140% of the prescription dose and keeping V(r)(,100)<0.5cm(3). CONCLUSION: It was the consensus of the CAG that optimal (131)Cs implants should be performed differently from those performed with (125)I or (103)Pd. Guidelines have been established to allow for safe and effective delivery of (131)Cs prostate brachytherapy.

Clinical outcome analysis in "high-risk" versus "low-risk" patients eligible for national surgical adjuvant breast and bowel B-39/radiation therapy oncology group 0413 trial: five-year results.

PURPOSE: To report the local control and overall survival outcomes after lumpectomy followed by accelerated partial breast irradiation in high-risk patients as defined by the current inclusion criteria for the National Surgical Adjuvant Breast and Bowel B-39/Radiation Therapy Oncology Group 0413 Intergroup trial. METHODS AND MATERIALS: Between 2000 and 2005, 273 women with early-stage breast cancer were treated using either multicatheter interstitial brachytherapy (n=247) or MammoSite (n=26). Patients received 32-34 Gy in 8-10 twice-daily fractions using high-dose-rate 192Ir brachytherapy. All patients met the initial inclusion criteria for the Intergroup trial and were separated into two groups: high-risk patients (representing the cohort that remained eligible for the Intergroup trial) who satisfied one or more of the "high-risk" criteria (age<50 years, estrogen receptor negative, and/or positive lymph nodes; n=90), and low-risk patients who comprised the remainder of the cohort (n=183). The outcomes of the two cohorts were analyzed and compared. RESULTS: The median follow-up of the entire cohort was 48.5 months. No significant difference was found in outcomes at 5 years between the low- and high-risk groups, with a local control rate of 97.8% vs. 93.6%, crude local recurrence rate of 2.2% (n=4) vs. 4.4% (n=4), and overall survival rate of 92.1% vs. 89.5%, respectively. CONCLUSION: At 5 years, no statistically significant difference was found in outcomes for patients deemed to be at greater risk in the current National Surgical Adjuvant Breast and Bowel B-39/Radiation Therapy Oncology Group 0413 Intergroup trial. These clinical data support the inclusion of this "high-risk" population in this important ongoing study.

The use of directional interstitial sources to improve dosimetry in breast brachytherapy.

The purposes of this study were to investigate the feasibility of improving dosimetry with temporary low-dose-rate (LDR) multicatheter breast implants using directional 125I (iodine) interstitial sources and to provide a comparison of a patient treatment plan to that achieved by conventional high-dose-rate (HDR) interstitial breast brachytherapy. A novel 125I source emitting radiation in a specified direction has been developed. The directional sources contain an internal radiation shield that greatly reduces the intensity of radiation in the shielded direction. The sources have a similar dose distribution to conventional nondirectional sources on the unshielded side. The treatment plan for a patient treated with HDR interstitial brachytherapy with 192Ir (iridium) was compared with a directional 125I treatment plan using the same data set. Several dosimetric parameters are compared including target volume coverage, volume receiving 50%, 100%, and 150% of the prescription dose (V50, V100, and V150, respectively), dose homogeneity index (DHI), and the skin surface areas receiving 30%, 50%, and 80% of the prescription dose (S30, S50, and S80, respectively). The HDR and LDR prescription doses were 34 Gy in ten fractions delivered over five days and 45 Gy in 108 h, respectively. Similar and excellent target volume coverage was achieved by both directional LDR and HDR plans (99.2% and 97.5%, respectively). For a 170 cm3 target volume, the dosimetric parameters were similar for LDR and HDR: DHI was 0.82 in both cases, V100 was 214.4 cm3 and 225.7 cm3, and V150 was 39.1 cm3 and 40.4 cm3, respectively. However, with directional LDR, significant reductions in skin dose were achieved: S30 was reduced from 100.6 to 62.5 cm2, S50 from 50.6 to 16.1 cm2, and S80 from 2 cm2 to zero. The reduction in V50 for the whole breast was more than 100 cm3 (386.1 cm3 for LDR versus 489.2 cm3 for HDR). In this case study, compared with HDR, directional interstitial LDR 125I sources allow similar dose coverage to the subcutaneous target volume while lowering the skin dose due to a more conformal dose distribution and quicker falloff beyond the target. The improved dose distribution provided by directional interstitial brachytherapy might enable partial breast treatment to tumors closer to the skin or chest wall or in relatively small breasts.

Increased skin dose with the use of a custom mattress for prone breast radiotherapy.

The purpose of this study was to measure and compare the loss of buildup to the skin of the breast in the prone position due to 2 different positioning systems during tangential external beam irradiation. Two experiments were performed; one with a standard nylon-covered foam support and another with a novel helium-filled Mylar bag support. The choice of helium-filled Mylar was to reduce the contamination to as low as possible. The experiments were designed to allow a surface dose measurement and a depth dose profile with the pads placed in the path of the beam in front of the detector. All measurements were taken using a Capintec PS-033 thin-window parallel plate ionization chamber. The standard nylon-covered foam pad caused the surface dose to rise as it got closer to the skin. When the pad was directly touching the surface, the surface dose increased by 300% compared to the result when no pad was present. This loss of buildup to the surface was similar to that of a custom bolus material. The opposite effect occurred with the use of the helium-filled Mylar bag, namely the surface dose gradually decreased as the pad got closer to the phantom. When the Mylar pad was directly touching the phantom, the surface dose was decreased by 7% compared to when no pad was present. The use of a foam pad could potentially result in a significant higher dose to the skin, resulting in an enhanced acute skin reaction. Therefore, special care should be taken in this clinical scenario and further investigation of an air- or helium-based mylar support pad should be investigated in the context of definitive breast radiation treatment.

A dosimetric comparison of accelerated partial breast irradiation techniques: multicatheter interstitial brachytherapy, three-dimensional conformal radiotherapy, and supine versus prone helical tomotherapy.

PURPOSE: To compare dosimetrically four different techniques of accelerated partial breast irradiation (APBI) in the same patient. METHODS AND MATERIALS: Thirteen post-lumpectomy interstitial brachytherapy (IB) patients underwent imaging with preimplant computed tomography (CT) in the prone and supine position. These CT scans were then used to generate three-dimensional conformal radiotherapy (3D-CRT) and prone and supine helical tomotherapy (PT and ST, respectively) APBI plans and compared with the treated IB plans. Dose-volume histogram analysis and the mean dose (NTD(mean)) values were compared. RESULTS: Planning target volume coverage was excellent for all methods. Statistical significance was considered to be a p value <0.05. The mean V100 was significantly lower for IB (12% vs. 15% for PT, 18% for ST, and 26% for 3D-CRT). A greater significant differential was seen when comparing V50 with mean values of 24%, 43%, 47%, and 52% for IB, PT, ST, and 3D-CRT, respectively. The IB and PT were similar and delivered an average lung NTD(mean) dose of 1.3 Gy(3) and 1.2 Gy(3), respectively. Both of these methods were statistically significantly lower than the supine external beam techniques. Overall, all four methods yielded similar low doses to the heart. CONCLUSIONS: The use of IB and PT resulted in greater normal tissue sparing (especially ipsilateral breast and lung) than the use of supine external beam techniques of 3D-CRT or ST. However, the choice of APBI technique must be tailored to the patient's anatomy, lumpectomy cavity location, and overall treatment goals.

Targeted therapy for brain metastases: improving the therapeutic ratio.

Brain metastasis is the most common intracranial malignancy in adults. Improvements in modern imaging techniques are detecting previously occult brain metastases, and more effective therapies are extending the survival of patients with invasive cancer who have historically died from extracranial disease before developing brain metastasis. This combination of factors along with increased life expectancy has led to the increased diagnosis of brain metastases. Conventional treatment has been whole brain radiotherapy, which can improve symptoms, but potentially results in neurocognitive deficits. Several strategies to improve the therapeutic ratio are currently under investigation to either enhance the radiation effect, thereby preventing tumor recurrence or progression as well as reducing collateral treatment-related brain injury. In this review article, we discuss new directions in the management of brain metastases, including the role of chemical modifiers, novel systemic agents, and the management and prevention of neurocognitive deficits.

Image-guided breast brachytherapy: an alternative to whole-breast radiotherapy.

Lumpectomy and whole-breast radiotherapy (ie, breast-conservation treatment) are accepted as viable alternatives to mastectomy in locoregional management of breast cancer. These techniques are used to keep morbidity to a minimum, optimise cosmesis, and maintain treatment outcomes. Pathological and clinical data suggest that most recurrences of cancer in the ipsilateral breast are in the vicinity of the index lesion, and that remote recurrences are uncommon, whether or not whole-breast radiotherapy is delivered. These data lend support to the idea of partial-breast radiotherapy. Such a restricted treatment volume allows safe delivery of an accelerated hypofractionated regimen over a shortened course of 1 week. This technique differs from that of standard whole-breast tangential external-beam radiotherapy and necessitates investigation of accelerated partial-breast irradiation (APBI). Several techniques of APBI are being investigated; however, most experience, and the most favourable early outcomes, has been obtained with image-guided breast brachytherapy. This review highlights the rationale and outcomes of brachytherapy techniques.

The emergence of advanced brachytherapy techniques for common malignancies.

The recent advent and integration of sophisticated radiation planning and imaging modalities has improved the quality of brachytherapy treatments, allowing for more conformal radiation delivery. Further investigation and follow-up are necessary to demonstrate improvements in outcome and morbidity with these refined approaches.