HDR and LDR brachytherapy in the treatment of lip cancer: the experience of the Catalan Institute of Oncology

Purpose: lip cancer can be treated by surgery, external radiotherapy, and/or brachytherapy (BT). In recent years, BT has become increasingly favored for this type of cancer. The aim of the present study was to analyze local control and survival of patients treated at our institution between July 1989 and June 2008. Material and methods: we performed a retrospective study of 121 patients (109 males and 12 females) who underwent lip cancer brachytherapy from July 1989 to June 2008. Median age was 67 years and median follow-up was 31.8 months (range 20-188 months). Out of 121 patients, 100 (82.6%) were treated with low dose rate (LDR) BT while the remaining 21 patients (17.4%) received high dose rate (HDR) BT. Results: the most common cell type was squamous cell carcinoma (115 cases; 95%) and most tumors were located on the lower lip (107 patients; 88.4%). Most cases were either stage T1 (62 patients; 51.2%), or T2 (44 cases; 36.4%). After 15 years of follow-up, overall survival was 89.5%, cause-specific survival 97.8%, and disease-free survival 86.6%. Local, regional, and distant control at 15 years were 90%, 92%, and 98.8%, respectively. Grade 3 mucosal toxicity was observed in 23% of patients treated with LDR compared to 33% of HDR patients, and grade 4 mucosal toxicity in 9% versus 0% in the HDR group. Conclusions: our findings confirm that brachytherapy is an effective treatment for lip cancer. The results from our series are in line with those published elsewhere. Based on our limited data, HDR appears to be equally as good as LDR, although this needs to be confirmed by further studies

Comparative analysis of thermoplastic masks versus vacuum cushions in stereotactic body radiotherapy

Background: To compare thermoplastic masks (TMP) and vacuum cushion system (VCS) to assess differences in interfraction set up accuracy in patients treated with stereotactic radiotherapy (SBRT) for oligometastatic lung cancer. Secondarily, to survey radiotherapy technologists to assess their satisfaction with the two systems. Methods: Retrospective study of patients treated with lung SBRT between 2008 to 2012 at our institution. Immobilization was performed for 73 treatment sessions (VCS = 40; TMP = 33). A total of 246 cone-beams were analysed. Patients considered ineligible for surgery with a life expectancy ≥6 months and performance status > 1 were included. Target lesion location was verified by cone beam computed tomography (CBCT) prior to each session, with displacements assessed by CBCT simulation prior to each treatment session. Couch shifts were registered prospectively in vertical, longitudinal, and latero-lateral directions to obtain Kernel coordinates (3D representation). Technologists were surveyed to assess their satisfaction with indexing, positioning, and learning curve of the two systems. Setup displacements were obtained in all patients for each treatment plan and for each session. To assess differences between the immobilization systems, a t-test (Welch) was performed. Results: Mean displacements for the TMP and VC systems, respectively, were as follows: session one, 0.64 cm vs 1.05 cm (p = 0.0002); session two, 0.49 cm vs 1.02 cm (p < 0.0001), and session three, 0.56 vs 0.97 cm (p = 0.0011). TMP resulted in significantly smaller shifts vs. VCS in all three treatment sessions. Technologists rated the learning curve, set up, and positioning more highly for TMP versus VCS. Conclusions: Due to the high doses and steep gradients in lung SBRT, accurate and reproducible inter-fraction set up is essential. We found that thermoplastic masks offers better reproducibility with significantly less interfractional set up displacement than vacuum cushions. Moreover, radiotherapy technologists rated the TMP system higher. Taken together, these two findings suggest that TMP may be preferable to VCS. However, more research is needed to determine both inter- and intrafraction error to identify the optimal immobilisation system for use in lung SBRT

The use of an interstitial boost in the conservative treatment of breast cancer: how to perform it routinely in a radiotherapy department

Purpose: to demonstrate the utility of a boost with interstitial brachytherapy (BT) in breast-conserving therapy (BCT) by doing a thorough review of the literature and describing in detail our technique for delivering this boost. Material and methods: our department has been delivering the boost with interstitial BT since 1989, in most cases with rigid needles and a theoretical dosimetry. In the early years, we used low-dose-rate (LDR) with iridium-192 wires. The dose administered was 15 Gy if there were no risk factors for local relapse or 20-25 Gy in the presence of risk factors. The risk factors considered were the presence of a close margin (less than 10 mm) and an extensive intraductal component (more than 25%). After 2002, we switched to high-dose-rate (HDR); using the linear quadratic model we changed the low dose to 3 fractions of 4.5 Gy in the case of no risk factors for local relapse or to 3 fractions of 5 Gy in the presence of risk factors. Results: in 79 consecutive boost patients treated in our department between 2010 and 2011, with a median follow-up of 46 months, the local control rate was 97.47%. With respect to cosmesis, fibrosis occurred in 17 cases (21.5%) and hyperpigmentation in 26 cases (32.9%). Our hospital's results are comparable in terms of local control and cosmesis to those of other authors. Conclusions: this educational article describes our department's boost technique with rigid needles and comments briefly on our results using this technique in a group of consecutively treated patients in our department. A review of the literature and the published results on local control and cosmesis is also described

Advantages of intraoperative implant for interstitial brachytherapy for accelerated partial breast irradiation either frail patients with early-stage disease or in locally recurrent breast cancer

Purpose: to describe the intraoperative multicatheter implantation technique for accelerated partial breast irradiation (APBI) delivered with high-dose-rate brachytherapy (HDR-BT). Secondarily, to evaluate outcomes and toxicity in a series of 83 patients treated with this technique at our institution. Material and methods: retrospective analysis of a series of patients treated with HDR-BT APBI after intraoperative multicatheter interstitial implant between November 2006 and June 2017 at our institution. We assessed cosmesis, toxicity, overall survival (OS), and disease-free survival (DFS). Results: eighty-three patients were included: 59 patients (71.1%) with primary early-stage breast cancer and 24 (28.9%) with locally recurrent breast cancer. Tumorectomy was performed in all cases, with intraoperative tumor margin assessment and sentinel node biopsy. Median age was 82 years (range, 44-92). The total prescribed dose was 32 Gy (8 treatment fractions) in 60 patients (72.3%), and 34 Gy (10 fractions) in 23 patients (27.7%). Median follow-up was 40 months (range, 1-136 months). Three-year OS and DFS in the recurrent and primary cancer groups were 87% vs. 89%, and 96 % vs. 97.8%, respectively. Five patients died from non-cancer related causes. No local relapses were observed. Rates of acute and late toxicity were low in both groups. The cosmesis was good or excellent in most of patients treated for primary disease; in patients who underwent salvage brachytherapy for local recurrence, cosmesis was good in 49 patients and fair in 6. Conclusions: this technique, although time-consuming, achieves good local disease control with a satisfactory toxicity profile in both early-stage and local recurrent breast cancer patients. It may be especially suitable for frail patients

Second breast-conserving therapy with interstitial brachytherapy (APBI) as a salvage treatment in ipsilateral breast tumor recurrence: a retrospective study of 40 patients

Purpose: breast-conserving treatment (BCT) have emerged as an alternative to mastectomy in patients with ipsilateral breast tumor recurrence (IBTR). We evaluated survival outcomes and treatment-related toxicity in a series of 40 patients with IBTR, who underwent tumorectomy plus interstitial brachytherapy (APBI) as a salvage treatment. Material and methods: retrospective analysis included 40 patients diagnosed with IBTR and treated with intraoperative (26 patients) or post-operative (14 patients) multicatheter brachytherapy for APBI at our institution between June 2002 and October 2017. We assessed cosmesis, toxicity, overall survival (OS), and cancer-specific survival (CSS). Results: tumorectomy was performed in all cases, including intraoperative tumor margin assessment and sentinel node biopsy. Median age was 65 years (range, 41-92). The total prescribed dose was 32 Gy (8 fractions) in 19 patients and 34 Gy (10 fractions) in 20 patients. One elderly patient (age 92) received a single fraction of 16 Gy. Median follow-up was 61.5 months (range, 6-153). A median of 14 tubes were inserted. Mean treated V100 was 115 cc. Two patients developed a second relapse at 3 and 5 years after salvage treatment: one patient underwent salvage mastectomy and remains alive 10 years after brachytherapy, and the second one developed both local relapse and bone metastasis. The disease is stable at present. Five-year OS and CSS rates were 85.3% and 97.5%, respectively. Two patients died from cancer-related causes. Acute and late toxicity rates were low; seven patients developed acute infectious mastitis. Late fibrosis > grade 3 and late mastitis were observed in 14 and 6 cases, respectively. Conclusions: second BCT with APBI as a salvage treatment in ipsilateral breast recurrence achieves good local disease control, with a satisfactory toxicity profile compared to mastectomy. This approach seems to be safe and effective, although more data from randomized trials are needed

Localized prostate cancer in Norway, the United States, and Spain: between-country differences of variables before treatment among patients eligible for curative treatment

Between-country differences in medical and sociodemographic variables, and patient-related outcomes (PROs) before treatment might explain published variations of side effects after radical prostatecomy (RP) or radiotherapy (RAD) for prostate cancer (PCa). This hypothesis was tested among 1908 patients from the United States, Spain, and Norway. Significant between-country differences were observed for most factors investigated before treatment. The observations should be considered in comparison of the frequency and severity of internationally published studies. Background: In men with PCa, large variations of PROs after RP or high-dose RAD might be related to betweencountry differences of medical and sociodemographic variables, and differences in PROs before treatment in the sexual and urinary domains. Patients and Methods: In 1908 patients with localized PCa from Norway, the United States, or Spain, the relation between medical (prostate-specific antigen, Gleason score, cT-category) and sociodemographic variables (age, education, marital status) before treatment was investigated. Using the Expanded Prostate Cancer Index Composite questionnaire, PROs before treatment within the sexual and urinary domains were also considered. Results: Compared with the European patients, American patients were younger, fewer had comorbid conditions, and more had a high education level. Fifty-three percent of the US men eligible for RP had low-risk tumors compared with 42% and 31% among the Norwegian and the Spanish patients, respectively. Among the Spanish RAD patients, 54% had had low-risk tumors compared with 34% of the American and 21% of the Norwegian men planned for RAD, respectively. Compared with the European patients, significantly fewer US patients reported moderate or severe sexual dysfunction and related problems. In most subgroups, the number of patients with sexual or urinary dysfunction exceeded that of patients with bother related to the reported dysfunction. Conclusion: Statistically significant between-country differences were observed in medical and sociodemographic variables, and in PROs before treatment within the sexual and urinary domains. Large differences between reported dysfunction and related problems within the sexual and urinary domains indicate that dysfunction and bother should be reported separately in addition to calculation of summary scores. The documented differences, not at least regarding PROs, might in part explain the large variation of side effects after treatment evident in the medical literatur

Preliminary Study of the Effect of Stereotactic Body Radiotherapy (SBRT) on the Immune System in Lung Cancer Patients Unfit for Surgery: Immunophenotyping Analysis

An immunophenotyping analysis was performed in peripheral blood samples from seven patients with lung cancer unfit for surgery treated with stereotactic body radiotherapy (SBRT). The objective was to characterize the effect of SBRT on the host immune system. Four patients received 60 Gy (7.5 Gy x 8) and three 50 Gy (12.5 Gy x 4). Analyses were performed before SBRT, 72 h after SBRT, and at one, three, and six months after the end of SBRT. Of note, there was a specific increase of the immunoactive component of the immune system, with elevation of CD56(+high)CD16+ natural killer (NK) cells (0.95% at baseline to 1.38% at six months), and a decrease of the immunosuppressive component of the immune system, with decreases of CD4+CD25+Foxp3+CDA5RA- regulatory T cells (4.97% at baseline to 4.46% at six months), granulocytic myeloid-derived suppressor cells (G-MDSCs) (from 66.1% at baseline to 62.6% at six months) and monocytic (Mo-MDSCs) (8.2% at baseline to 6.2% at six months). These changes were already apparent at 72 h and persisted over six months. SBRT showed an effect on systemic immune cell populations, which is a relevant finding for supporting future combinations of SBRT with immunotherapy for treating lung cancer patients

Association between inflammatory bowel disease and uveal melanoma: case report of two young adults and a literature review

IntroductionUveal melanoma is a rare tumour caused by genetic factors and alterations in the immune response. Inflammatory bowel disease (IBD) is a multifactorial chronic inflammatory disorder characterized by an inappropriate or excessive immune response. The two main types of IBD are Crohn's disease (CD) and ulcerative colitis (UC). A diagnosis of IBD and the use of immunosuppressive drugs are both independently associated with an increased risk of developing skin melanoma. The association between IBD and uveal melanoma (UM) has not been previously described.Cases descriptionTwo young Caucasian men, aged 24 and 28, developed UM 3 and 15 years, respectively, after being diagnosed with IBD. Both received long-term treatment with immunomodulatory drugs, with periodic switching among the drugs due to the refractory nature of IBD. In both cases, melanoma was treated by brachytherapy with iodine-125 COMS plaque implant at a dose of 75Gy.DiscussionChronic inflammation can promote cell proliferation and growth. The use of immunomodulatory drugs is associated with an increased risk of developing melanoma and non-melanoma skin cancer. The two patients described in this report both had long-standing IBD treated with immunomodulatory drugs. It seems reasonable to suggest that these two factors may have promoted the development of uveal melanoma. More studies are warranted to investigate and confirm this possible association

Five-year results of accelerated partial breast irradiation: a single institution retrospective review of 289 cases

Purpose: the purpose of the study was to describe our institutional experience with accelerated partial breast irradiation (APBI) using multicatheter brachytherapy with high-dose-rate. We report 5-year survival outcomes, cosmesis, and treatment-related toxicity. Methods and materials: this included a retrospective review of patients who underwent breast-conserving surgery followed by APBI at our institution from 2004 to 2017. Results: a total of 289 patients were evaluated. Median followup was 72 months. Median age was 70 years. APBI was the only primary treatment in 86.2% of cases with early-stage breast cancer and a second conservative treatment in 13.8%. The implant was performed postoperatively in 213 patients (73.7%) and intraoperatively in 76 (26.3%). The most common radiation schemes were 10 fractions of 3.4 Gy and eight fractions of 4 Gy. Elderly or frail patients (10%) received a single 16 Gy dose. Of the 289 patients, 215 met Groupe Europ een de Curieth erapie-European Society for Radiotherapy and Oncology criteria for APBI; in this group, late side effects included Grade 2 (G2) fibrosis (14.8%), skin discoloration at the catheter points (8.8%), and telangiectasia (0.5%). The cosmetic result was considered excellent or good in 88.3% of cases. Five-year local control, disease-free, cancer-specific, and overall survival rates were 98.9%, 96.7%, 99.1%, and 95.6%, respectively. Conclusions: local control and survival outcomes at 5 years of followup in this group of well-selected patients were excellent, with low rates of treatment-related toxicity. These findings confirm the safety and effectiveness of APBI, even in elderly and frail patients. These results provide further support for the clinical use of APBI in suitable patients. 2021 Published by Elsevier Inc. on behalf of American Brachytherapy Society

Improving quality of care and clinical outcomes for rectal cancer through clinical audits in a multicentre cancer care organisation

Introduction: Colorectal cancer treatment requires a complex, multidisciplinary approach. Because of the potential variability, monitoring through clinical audits is advisable. This study assesses the effects of a quality improvement action plan in patients with locally advanced rectal cancer and treated with radiotherapy. Methods: Comparative, multicentre study in two cohorts of 120 patients each, selected randomly from patients diagnosed with rectal cancer who had initiated radiotherapy with a curative intent. Based on the results from a baseline clinical audit in 2013, a quality improvement action plan was designed and implemented; a second audit in 2017 evaluated its impact. Results: Standardised information was present on 77.5% of the magnetic resonance imaging (MRI) staging reports. Treatment strategies were similar in all three study centres. Of the patients whose treatment was interrupted, just 9.7% received a compensation dose. There was an increase in MRI re-staging from 32.5 to 61.5%, and a significant decrease in unreported circumferential resection margins following neoadjuvant therapy (ypCRM), from 34.5 to 5.6% (p < 0.001). Conclusions: The comparison between two clinical audits showed improvements in neoadjuvant radiotherapy in rectal cancer patients. Some indicators reveal areas in need of additional efforts, for example to reduce the overall treatment time