- Email: [email protected]
Integrating Permanent Interstitial Brachytherapy Using Cesium-131 into the Primary Management of Gynecologic Malignancies: Bringing Back the Old School
S60
Abstracts / Brachytherapy 14 (2015) S11eS106 2
1 1
Lea, MD , Kevin Albuquerque, MD, MS, FRCS . Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, USA; 2Gynecological Oncology, UT Southwestern Medical Center, Dallas, TX, USA. Purpose: Brachytherapy is an essential component of definitive treatment for locally advanced gynecological malignancies (GM). In the past 3 decades, there has been a disturbing decrease in the utilization of brachytherapy, contrary to established standards of care and compromising patients’ chance for cure. While many outpatient centers (OPC) are capable of delivering the radiation component of brachytherapy, they are not associated with or are remote from an operative center for implant placement, limiting the ability to deliver appropriate care. In this study, we report on our experience with noncolocated implant placement and radiation delivery, and the impact of patient stabilization improvements on patient safety. Materials and Methods: Between 9/2010 and 11/2014, 25 patients with GM underwent implantation at a remote inpatient facility and were then transported daily via ambulance to and from an OPC for HDR brachytherapy treatment; median of 10 transports (range 6-12). From 9/ 2010-10/2012, patients (n58) were transported using a standard ambulance stretcher; from 11/2012-11/2014, patients were placed on a Slessinger board (n515) (Figure 1) or a ‘‘waffle’’ support (n52). These allowed transfer of patients onto the bariatric ambulance stretcher used for transport to OPC, with reproducible patient stabilization and reduced needle/template movement during patient transfers. Potential transport-associated toxicity was assessed (lacerations/trauma to tissues near the implant, infection, and ulcers). Association between standard and augmented transport types and toxicity was performed using Spearman’s rank correlation coefficient (Rs). Results: From 9/2010-11/2014, 234 transports were performed. Average distance traveled per treatment course was 8.8 miles (range 4.2-14.4). At our institution, transport from the inpatient hospital to OPC was associated with an average cost of $186.04 per transfer, or an average of $1771 per course of treatment (range $900-$2783). All patients underwent interstitial implantation, 14 (56%) also had tandem placed. 4 (16%) patients had recurrent disease, 1 (4%) Stage 1, 4 (16%) Stage II, 14 (56%) Stage III, and 2 (8%) Stage IVA. Histologies included 9 (36%) vaginal, 14 (56%) cervical, and 2 (8%) endometrial malignancies. There were 14 (6%) potential transportation-associated toxicities, including 2 (0.8%) lacerations/local trauma, 3 (1.3%) infections, and 9 (3.8%) ulcers; 7 (3%) were Grade 3. Comparing transport using the
Figure 1. HDR treatment couch with Slessinger board in place and sacral support cushion.
two stretcher types, there was no association between stretcher type and laceration/trauma or ulcer, but the transports using the Slessinger or ‘‘waffle’’ support were associated with significantly fewer overall toxicities (Rs 5 -.490, P5.013) and Grade 3 toxicities (Rs 5 -.718, P!.001), and fewer infections (Rs -.538, P5.006). Conclusions: Non-colocated implantation and treatment is safe and facilitates optimal therapy for women with GM. Toxicities potentially associated with transport are minimal, and appear to be reduced by use of augmented stabilization. Transportation from inpatient unit to OPC is associated with some economic cost, but is justified by the need for appropriate therapy that meets standard of care. Understanding that this is a reasonable way to deliver brachytherapy may allow more stand-alone centers to deliver high quality care for patients and improve gynecological cancer outcomes in the US.
GSOR10 Presentation Time: 11:21 AM Integrating Permanent Interstitial Brachytherapy Using Cesium-131 into the Primary Management of Gynecologic Malignancies: Bringing Back the Old School Jonathan Feddock, MD, Charles Eric Wooten, MD, Prakash Aryal, PhD, Marcus Randall, MD. Radiation Medicine, University of Kentucky, Lexington, KY, USA. Purpose: Permanent interstitial brachytherapy (PIB) using free radiation seeds is an often forgotten modality that provides multiple distinct advantages. The relatively low initial dose rate and short half-life of Cesium-131 significantly reduces the exposure to the treating physician and involved medical staff compared to previously used permanent isotopes. Re-irradiation using Cesium-131 PIB has been described as a management option for recurrent disease. This report presents our experience incorporating its use in up-front management of Gyn malignancies. Materials and Methods: The records of 21 consecutive patients were retrospectively reviewed, all of whom were treated for a gynecologic malignancy using Cesium-131 PIB as a component of definitive therapy. Local failure was defined as a recurrence within the irradiated organ (vagina or vulva). Maximum doses to gross disease and normal tissues were calculated using equivalent dose at 2Gy per fraction (EQD2), outcomes were estimated from the time in months from the date of PIB, and toxicities were scored according to CTCAE v4.0. Results: Reasons for performing PIB included a boost to gross disease for endometrioid adenocarcinoma (EAC) of the uterus (5), squamous cell carcinoma (SCC) of the cervix (1), vaginal SCC (3), vaginal melanoma (3), and vulvar SCC (2); and as a boost for close or positive margins in EAC (4), SCC of the cervix (1), and SCC of the vulva (2). Combined with a median dose of external beam RT of 45 Gy (range 30-64.8 Gy), the median dose delivered using PIB was 22 Gy (range 15-50 Gy) using a median 13 Cesium-131 sources (range 9-30), with median strength of 0.76 u/seed. The median area of PIB was 6 cm2 (range 2 - 19.25 cm2). All patients received their procedure as an outpatient. Sedation consisted of general anesthesia in 2 patients, and local anesthesia in 19. After a median follow-up period of 10.7 months (3-26.5 mos), there has been no local failures. All patients developed acute grade 1-2 mucosal reactions, and only 1 patient has demonstrated persistent grade 3 reactions beyond 6 months. Compared to equivalent plans using vaginal cylinders, equivalent tumoricidal doses of radiation could be delivered using Cs-131 PIB, while calculated maximum doses in EQD2 to normal tissues such as rectum and bladder could consistently be reduced by as much as 20% using PIB. Conclusions: PIB using Cs-131 is an effective treatment modality for incorporation into primary management of gynecologic cancers. The technique benefits from a low rate of morbidity and a very high local control.
Abstracts / Brachytherapy 14 (2015) S11eS106 2
1 1
Lea, MD , Kevin Albuquerque, MD, MS, FRCS . Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, USA; 2Gynecological Oncology, UT Southwestern Medical Center, Dallas, TX, USA. Purpose: Brachytherapy is an essential component of definitive treatment for locally advanced gynecological malignancies (GM). In the past 3 decades, there has been a disturbing decrease in the utilization of brachytherapy, contrary to established standards of care and compromising patients’ chance for cure. While many outpatient centers (OPC) are capable of delivering the radiation component of brachytherapy, they are not associated with or are remote from an operative center for implant placement, limiting the ability to deliver appropriate care. In this study, we report on our experience with noncolocated implant placement and radiation delivery, and the impact of patient stabilization improvements on patient safety. Materials and Methods: Between 9/2010 and 11/2014, 25 patients with GM underwent implantation at a remote inpatient facility and were then transported daily via ambulance to and from an OPC for HDR brachytherapy treatment; median of 10 transports (range 6-12). From 9/ 2010-10/2012, patients (n58) were transported using a standard ambulance stretcher; from 11/2012-11/2014, patients were placed on a Slessinger board (n515) (Figure 1) or a ‘‘waffle’’ support (n52). These allowed transfer of patients onto the bariatric ambulance stretcher used for transport to OPC, with reproducible patient stabilization and reduced needle/template movement during patient transfers. Potential transport-associated toxicity was assessed (lacerations/trauma to tissues near the implant, infection, and ulcers). Association between standard and augmented transport types and toxicity was performed using Spearman’s rank correlation coefficient (Rs). Results: From 9/2010-11/2014, 234 transports were performed. Average distance traveled per treatment course was 8.8 miles (range 4.2-14.4). At our institution, transport from the inpatient hospital to OPC was associated with an average cost of $186.04 per transfer, or an average of $1771 per course of treatment (range $900-$2783). All patients underwent interstitial implantation, 14 (56%) also had tandem placed. 4 (16%) patients had recurrent disease, 1 (4%) Stage 1, 4 (16%) Stage II, 14 (56%) Stage III, and 2 (8%) Stage IVA. Histologies included 9 (36%) vaginal, 14 (56%) cervical, and 2 (8%) endometrial malignancies. There were 14 (6%) potential transportation-associated toxicities, including 2 (0.8%) lacerations/local trauma, 3 (1.3%) infections, and 9 (3.8%) ulcers; 7 (3%) were Grade 3. Comparing transport using the
Figure 1. HDR treatment couch with Slessinger board in place and sacral support cushion.
two stretcher types, there was no association between stretcher type and laceration/trauma or ulcer, but the transports using the Slessinger or ‘‘waffle’’ support were associated with significantly fewer overall toxicities (Rs 5 -.490, P5.013) and Grade 3 toxicities (Rs 5 -.718, P!.001), and fewer infections (Rs -.538, P5.006). Conclusions: Non-colocated implantation and treatment is safe and facilitates optimal therapy for women with GM. Toxicities potentially associated with transport are minimal, and appear to be reduced by use of augmented stabilization. Transportation from inpatient unit to OPC is associated with some economic cost, but is justified by the need for appropriate therapy that meets standard of care. Understanding that this is a reasonable way to deliver brachytherapy may allow more stand-alone centers to deliver high quality care for patients and improve gynecological cancer outcomes in the US.
GSOR10 Presentation Time: 11:21 AM Integrating Permanent Interstitial Brachytherapy Using Cesium-131 into the Primary Management of Gynecologic Malignancies: Bringing Back the Old School Jonathan Feddock, MD, Charles Eric Wooten, MD, Prakash Aryal, PhD, Marcus Randall, MD. Radiation Medicine, University of Kentucky, Lexington, KY, USA. Purpose: Permanent interstitial brachytherapy (PIB) using free radiation seeds is an often forgotten modality that provides multiple distinct advantages. The relatively low initial dose rate and short half-life of Cesium-131 significantly reduces the exposure to the treating physician and involved medical staff compared to previously used permanent isotopes. Re-irradiation using Cesium-131 PIB has been described as a management option for recurrent disease. This report presents our experience incorporating its use in up-front management of Gyn malignancies. Materials and Methods: The records of 21 consecutive patients were retrospectively reviewed, all of whom were treated for a gynecologic malignancy using Cesium-131 PIB as a component of definitive therapy. Local failure was defined as a recurrence within the irradiated organ (vagina or vulva). Maximum doses to gross disease and normal tissues were calculated using equivalent dose at 2Gy per fraction (EQD2), outcomes were estimated from the time in months from the date of PIB, and toxicities were scored according to CTCAE v4.0. Results: Reasons for performing PIB included a boost to gross disease for endometrioid adenocarcinoma (EAC) of the uterus (5), squamous cell carcinoma (SCC) of the cervix (1), vaginal SCC (3), vaginal melanoma (3), and vulvar SCC (2); and as a boost for close or positive margins in EAC (4), SCC of the cervix (1), and SCC of the vulva (2). Combined with a median dose of external beam RT of 45 Gy (range 30-64.8 Gy), the median dose delivered using PIB was 22 Gy (range 15-50 Gy) using a median 13 Cesium-131 sources (range 9-30), with median strength of 0.76 u/seed. The median area of PIB was 6 cm2 (range 2 - 19.25 cm2). All patients received their procedure as an outpatient. Sedation consisted of general anesthesia in 2 patients, and local anesthesia in 19. After a median follow-up period of 10.7 months (3-26.5 mos), there has been no local failures. All patients developed acute grade 1-2 mucosal reactions, and only 1 patient has demonstrated persistent grade 3 reactions beyond 6 months. Compared to equivalent plans using vaginal cylinders, equivalent tumoricidal doses of radiation could be delivered using Cs-131 PIB, while calculated maximum doses in EQD2 to normal tissues such as rectum and bladder could consistently be reduced by as much as 20% using PIB. Conclusions: PIB using Cs-131 is an effective treatment modality for incorporation into primary management of gynecologic cancers. The technique benefits from a low rate of morbidity and a very high local control.