World Congress of Brachytherapy 10-12 May, 2012 - Estro-events.org

WCB
World Congress of Brachytherapy
10-12 May, 2012
Barcelona, Spain

Cover photo: © Fotolia / Hugues Argence

WCB
World Congress of Brachytherapy
10-12 May, 2012 • Barcelona, Spain

WCB 2012 content
Thursday 10 May 2012
Symposium
Welcome and introduction
Modern brachytherapy: role of new image modalities (Abs. 1-6)
Panel session
Prospective trials for partial breast irradiation (Abs. 7-11)
Award lecture
Marie Curie medal presentation (Abs. 12-13)
Panel session
Prostate 1: Is there a role for primary focal therapy? (Abs. 14-17)
Physics 1: Dose to water calibration (Abs. 18-20)
Gynaecology 1: Are we decreasing morbidity with image-guided brachytherapy? (Abs. 21-23)
Proffered papers
Prostate 1 (Abs. 24-29)
Prostate 2 (Abs. 30-38)
Gynaecology 1 (Abs. 39-47)
Friday 11 May 2012
Symposium
Radiobiological modelling in brachytherapy: clinical relevance? (Abs. 48-50)
Proffered papers
Miscellaneous (Abs. 51-56)
Debate
Key controversies on patient selection for partial breast irradiation (Abs. 57-58)
Panel session
2: A perspective on health economics in brachytherapy (Abs. 59-64)
Proffered papers
Physics 1 (Abs. 65-70)
Poster
Poster highlights (Abs. 71-78)
Panel session
Prostate 2: Salvage treatment after brachytherapy failure (Abs. 79-80)

Proffered papers
Gynaecology 2 (Abs. 81-86)
Breast 1 (Abs. 87-92)
Panel session
Physics 2: Uncertainties in brachytherapy and how to report them? (Abs. 93-95)
Symposium
How to improve safety in brachytherapy? Practical examples (Abs. 96-97)
Saturday 12 May 2012
Symposium
New opportunities with robotic, endoscopic and radiological interventions (Abs. 98-100)
Role of IAEA and UICC in brachytherapy training (Abs. 101-102)
Skin brachytherapy (Abs. 103-105)
Panel session
Gynaecology 2: Emerging evidence for image-based brachytherapy in cervical cancer (Abs. 106-109)
Proffered papers
Physics 2 (Abs. 110-115)
Panel session
Physics 3: The advantages and criticalities of new dose calculation algorithms (Abs. 116-118)
Poster discussion
Session 1 (Abs. 119-128)
Panel session
Gynaecology 3: Optimal adjuvant treatment for intermediate risk endometrial cancer (Abs. 129-130)
Proffered papers
Breast 2 (Abs. 131-136)
Panel session
3: Repeat breast conservation with brachytherapy (Abs. 137-138)
Proffered papers
Physics 3 (Abs. 139-144)
Symposium
One hundred years of prostate brachytherapy (Abs. 146)
Posters
Prostate (Abs. 147-233)
Gynaecology (Abs. 234-310)
Breast (Abs. 311-325)
Physics (Abs. 326-362)
Miscellaneous (Abs. 363-420)

1
INTRODUCTION
C.HaieMeder
Institut Gustave Roussy, Radiation Oncology, Villejuif, France
Target volume determination is probably one of the most challenging
issues in radiation oncology, at the era of highly targeted
radiotherapy. BT has to face this challenge, even in a more accurate
way, as BT physical and biological properties provide the most
conformal and normal tissue sparing radiotherapy technique. To reach
this goal, BT has benefited from recent advanced imaging
technologies. The use of 3D techniques for BT dosimetry has increased
during the recent years, mainly CTbased, but also using MRI, PETCT
and ultrasound. Image guidance improves tumor and organs at risk
visualization, and their relationship with the applicator (in
gynecological tumors), representing the basis for 3D and 4D BT
treatments plans.
Prostate BT was developed using ultrasound guidance. The accuracy
of seed placement and dosevolume parameters has significantly
improved with more sophisticated imaging modalities. Emerging
techniques in ultrasound and MRI modalities, including functional
imaging, as well as 3D digital mapping, allow for more accurate
disease characterization with improvement in staging and
management of the tumor. This issue represents the basis for dose
painting.
In cervical cancer BT, MRI based adaptive BT enables 4D target
volume optimization with appropriate dosevolume constraints for
organs at risk. First clinical series report an improvement in local
control which seems to translate into a survival benefit. Ultrasound is
an evolving field and is currently under study. The value of functional
MRI or PETCT is also under investigation.
In endometrial cancer, postoperative BT has become the new
standard in intermediaterisk patients. In this situation, there is a
potential for imagebased individualization which is under
investigation.
Apart from these two main tumor sites, BT using new imaging
modalities has been developed in other fields, such as breast, head
and neck and endoluminal (bronchus, oesophagus).
In the last decade, the use of imaging modalities integrated into the
BT procedure has led to a significant increase of BT all over the world.
The use of images also led to the development of BT guidelines,
allowing multiinstitutional studies, contributing to clinical research
and scientific publications.
2
ROLE OF FUNCTIONAL IMAGING
B. Carey 1
1
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Radiology, Leeds, United Kingdom
The evolution of the art of brachytherapy into a precision form of
scientifically based radiation therapy owes much to major
developments in imaging and computer technology over the past
decade. Brachytherapy offers the most conformal of all forms of
radiotherapy and is designed largely around the intricate relationships
between radiation dose delivered, target volume and fractionation
regimes. Traditional brachytherapy planning techniques have
benefited enormously from morphological imaging techniques such as
Computed Tomography, Magnetic Resonance Imaging and Ultrasound.
Tumour volumetricbased radiation planning based on better anatomy
has much improved our ability to target malignant tissue whilst
sparing nonmalignant tissues. 3D target localisation has been
successfully modelled around a hierarchy of expanding treatment
volumes based on the demonstrable tumour morphology as well as
allowing for technical imperfections and variations in treatment
delivery. A new paradigm for treatment planning and radiation
delivery is now becoming possible with the ability of medical imaging
to define areas of varying functional activity within the presumed
tumour mass.
A new probability envelope is emerging based on our recognition of
the altered biological and molecular processes occurring in tumour
tissue. A biological target volume can be identified generally as a
subset or subsets of the morphological target volume and offers a
potentially modified approach for brachytherapy. These new
functional maps of the tumour provide the basis for a very innovative
approach to radiation treatment using much more selective planning
and treatment delivery techniques. Locating and quantifying areas of
cellular and molecular disruptions within the tumour mass offer the
potential to individualise the radiotherapy treatment and the highly
conformal and adaptive nature of brachytherapy perhaps stands to
gain most from these new functional imaging techniques.
FDGPET has become an established imaging technique in oncology
and is becoming increasingly integrated into treatment planning
processes for several common tumour sites. Newer isotopes are being
developed to further expand the depth and range of our knowledge of
tumour behaviour and will offer future targets for brachytherapy dose
delivery and modifications. Functional MRI is providing us with
additional physiological surrogate targets for dose modifications.
Newer developments in functional Ultrasound and CT will also
enhance the information available to the radiation oncologist and
yield a much more detailed map of tumour architecture and function.
The inherent goal of brachytherapy is to safely deliver adequate
radiation to those areas of tumour tissue that are considered
necessary based on our current understanding of tumour biology and
radiation response. Functional imaging offers us a way forward in
identifying subvolumes of tumour that may benefit from different
radiation regimes based on different measurements of tumour
response. Furthermore, we have the future potential to noninvasively
assess these treatment responses in terms of altered cellular and
molecular processes as well as altered tumour morphology. These are
exciting times for functional imaging based brachytherapy.
3
PET IMAGING IN BRACHYTHERAPY
V. Lowe 1
1 Mayo Clinic, Brachytherapy, Rochester, USA
Positron Emission Tomography (PET) is now being widely in the
evaluation of many types of malignancy. Multiple studies have
demonstrated the utility of PET in oncologic imaging in better staging
of disease, earlier treatment response assessment and better
characterization of recurrent disease over what can be done with
anatomic imaging methods alone. The availability metabolic
substrates other than FDG makes PET imaging attractive in some
tumors that have been otherwise poorly evaluated by FDG. This talk
will discuss the use of Choline PET imaging with discussion of how it
can be used in conjunction with brachytherapy
While prostate cancer cells have not ubiquitously shown FDG avidity,
increased choline uptake has been a more consistent finding on PET
imaging. Cancer cells have more rapid cell proliferation than normal
cells. New cells require the building blocks for cell membranes.
Choline is a watersoluble essential nutrient grouped with B
complex vitamins—that is vital for a) cell membrane structure and
signaling b) synthesis of neurotransmitters and c) general metabolism.
[ 11 C]choline is a synthetic form of choline that releases positrons by
beta decay that can be visualized by PET. [ 18 F]choline is another
radionuclide version of choline that can also be used in PET imaging.
The increased accumulation of these agents by prostate cancer in any
part of the body is a reliable way to determine the extent of prostate
cancer.
Choline PET can be use in two different treatment time points in
prostate cancer related to brachytherapy. At initial staging,
confirmation of localized disease to the prostate bed can be
performed using choline PET. Choline PET provides high accuracy for
the detection of distant metastasis. This can aid in treatment
planning. Choline PET may be most useful in the situation of
definitively treated prostate cancer with the discovery of biochemical
recurrence. One of the clinical dilemmas of biochemical recurrence of
prostate cancer is the how to decide on an optimal treatment

S2 World Congress of Brachytherapy 2012
strategy. Assessment of the prostate bed post brachytherapy is
accurately performed by Choline PET. In this situation other imaging
modalities are modestly compromised. This assessment by choline Pet
of the treatment outcome of brachytherapy of the prostate is
probably best performed after the PSA nadir postbrachytherapy.
Choline PET imaging in prostate cancer is one example of how PET
imaging can be used to assess treatment planning and outcome of
brachytherapy.
4
MRI: IMPACT ON BRACHYTHERAPY
I.M. JürgenliemkSchulz 1
1 U.M.C. Utrecht, Radiation Oncology, Utrecht, The Netherlands
The combined key words “MRI” and “brachytherapy (BT)” give PubMed
hits from 1984 onwards. Since then the amount of positive hits is
increasing, reflecting the relevance of MR information for BT
developments. Nowadays MRI is especially used for BT treatment
planning and/or optimization in prostate, cervix and brain tumors. In
other tumor sites like head and neck, sarcomas, breast, endometrial
and rectal cancer MRI is catching up. During the years we see a
development from low magnetic field strength machines and
anatomical imaging to high field equipment allowing more precise
anatomical and additional functional sequences. And approaches for
interventional MR imaging during BT procedures are coming up.
The aim of all this effort is to optimize treatment strategies so that
better control and outcome can be obtained by radiotherapy. MRI is
used for improvement of all steps in the BT chain, which are: defining
and contouring tumor targets and OAR at time of BT; reconstruction
of source carriers (applicators/needles/tube/seeds); (pre) treatment
planning optimization; monitoring application/implant quality;
monitoring application/implant stability during treatment; monitoring
regression and deformation during treatment; evaluation of treatment
outcome (responses, control and related side effects).
MRI does not completely replace clinical investigation and other
imaging modalities, but its superior soft tissue contrast often helps to
better define target volume extension and tumor stage at time of
diagnosis, at time of BT and for treatment planning purposes. It
facilitates BT in developing volume based treatment planning
concepts comparable to EBRT. One of these concepts, for example is
published as GEC ESTRO recommendations for MRI guided gyn BT.
Repeated MRI imaging during and after EBRT helps to individually
determine the amount of tumor regression, allowing if necessary
individualized planning of the BT boosts. In these cases, but also when
BT is the primary treatment approach, preBT MR information can
influence the choice for applicators, amount of needles, tubes or
seeds, their insertion depths and spatial distributions.
During the last years new MR sequences and MR markers have been
developed that provide possibilities for direct source carrier
reconstructions making additional CT scans or Xray investigations
unnecessary. Additionally, MRI allows more detailed monitoring the
quality of BT applications and implants. Applicator induced
perforations or suboptimal needle insertions for example, can easily
be detected and corrected if necessary and feasible. Repeated MRI
imaging helps to monitor the robustness of applications and implants
during treatment. It allows to detect changes in the position of
applicators/needles/tubes with respect to the targets and OAR and to
recalculate DVH parameters. These changes can occur as inter or
intrafraction variations, can change the dose volume parameters and
can influence treatment outcome. Detection of these uncertainties
will help to better understand the relations of dose volume
parameters with tumor control and treatment complication
probabilities. Target volume response and control monitoring is also
possible with MRI. In case of recurrences it helps to find relations with
spatial dose distributions and treatment field borders. There are
indications that especially functional MRI is valuable in early detection
of (recurrent) tumor and focal salvage treatments. Functional MRI
sequences help to better understand differences in tumor biology and
the relations between dose and response in a more individualized
way.
In conclusion, during the last years we see a development towards MR
guided BT in different tumor sites. Anatomical and functional MRI
information supports the different parts of the BT chain, helps to
optimize and individualize BT approaches and allows more detailed
evaluation of treatment outcome.
5
MODERN BRACHYTHERAPY: ROLE OF ULTRASOUND
P. Hoskin 1
1
Mount Vernon Hospital, Radiation Oncology, Northwood Middlesex,
United Kingdom
Ultrasound is not a new imaging modality but the recent
developments in image guided brachytherapy have found that
ultrasound is an ideal tool for many of the requirements these new
techniques demand. The advantages of ultrasound are that it has no
radiation exposure, and it is readily available, portable and can be
used as a real time imaging modality during implantation. Whilst it
may not achieve the levels of normal tissue definition, now achieved
with modern CT and MRI, image fusion techniques enable the
advantages of ultrasound to be combined with other more
sophisticated imaging techniques.
In brachytherapy ultrasound has a role in prostate, gynaecological and
interstitial brachytherapy at other sites. Developments in ultrasound
were fundamental to the rise in activity seen in prostate
brachytherapy in recent years based on the transrectal ultrasound
guided transperineal implant technique. As the technique has matured
further developments in ultrasound technology with three dimensional
imaging and integration with modern dosimety algorithms which has
been incorporated into routine prostate brachytherapy.
In gynaecological brachytherapy, transabdominal ultrasound provides
excellent imaging of the uterus during placement of an intrauterine
tube and vaginal sources. This ensures accurate and safe implantation
whilst minimising the risk of perforation. In recent years, image
guided brachytherapy for cervical cancer has become established as
the standard of care. Whilst the GEC ESTRO recommendations are
based on MR and CT imaging, it has been found that high quality
ultrasound based 3D imaging is equally effective enabling
individualised dosimety to a defined CTV based on ultrasound
appearances fulfilling the GEC ESTRO dose volume requirements.
Interstitial brachytherapy remains an important treatment modality
for many sites including the vagina, vulva, anal canal, rectum and
breast. In these sites ultrasound is again an important imaging
modality enabling accurate placement of afterloading catheters with
real time imaging during the implant procedure.
There are continued efforts to improve the technology behind the use
of ultrasound and optimisation of the imaging parameters is essential.
In prostate brachytherapy use of bi plane ultrasound transducers with
transverse and longitudinal modes is now routine and optimal imaging
parameters have been defined to obtain accurate needle insertion
depth with reduced beam width artefacts. The role of contrast
agents is also important with studies showing improved accuracy in
definition of urethral anatomy using air filled gel. Other new
developments include elastography which may prove beneficial in
indentifying tumour bearing areas distinct from normal prostate gland
based on the tissue stiffness.
Access to high quality ultrasound should be a fundamental component
of any brachytherapy programme. It provides high quality real time
imaging resulting in accurate high quality implants which will
translate into good patient outcomes.
6
CONCLUSION IMAGEGUIDED BRACHYTHERAPY FUTURE AND
EVALUATION
J. Dimopoulos 1
1 Metropolitan Hospital, Radiation Oncology, Athens, Greece
During the last two decades there were numerous attempts to
integrate modern imaging (CT, PET, PETCT, MRI, MRS, US) into the
brachytherapy treatment chain. It is evident that advanced imaging
was the driving force for the entire evolution process of
brachytherapy as it is applied for different sites.
The rationale of imageguided brachytherapy was to use images to
define the target of brachytherapy prior to any treatment and prior to
the brachytherapy intervention. The placement, with high accuracy,
of the brachytherapy applicators (e.g. interstitial needles) was guided
by the acquisition of images by either utilizing a “step by step”
World Congress of Brachytherapy 2012 S 3
procedure (e.g. CT, MRI) or by utilizing a “real time” approach (e.g.
US). The subsequent aim was to maximize the dose to the targets and
to minimize the dose to any adjacent organ at risk. The latter was
realized with the integration of images into the treatment planning
procedure. Finally, the generation of dosevolume parameters for the
targets and the organs at risk and the correlation of these DVH
parameters with measurable clinical outcome parameters enabled the
prediction of disease control probability and normal tissue
complication probability.
Ultrasound is the imaging modality of choice for the treatment of
prostate cancer patients with low and high dose rate brachytherapy.
Its unique position has to be ascribed to its capability to provide “real
time” images during the implantation procedure. The development of
dedicated treatment planning systems supported the exploitation of
the potential of this approach. The development of a systematic
methodology and the collection of clinical experience with treatment
results on thousands of patients established the procedure as the
golden standard.
Recent investigations studied the issue of using MR spectroscopy
information for treatment planning of prostate cancer brachytherapy.
The aim was to detect the topographic position of malignant lesions
within the prostate in order to use this information for dose escalation
purposes. The majority of these studies employed 1 H MRS due to the
development of efficient water and fatsuppression techniques. It
seems that further improvement regarding signaltonoise ratio with
smaller voxel dimension, improved spatial resolution and more precise
metabolite maps is required. MR spectroscopyguided adaptive
brachytherapy for prostate cancer is however, not widely available
yet and will eventually be used in future studies to evaluate the
clinical advantages of this treatment approach.
The integration of functional imaging, mainly PET and PETCT, into
the brachytherapy treatment planning procedure was mainly
restricted to patients with cervical cancer. Preliminary data from
dosimetric studies showed that the method is feasible, but its clinical
impact is not yet clearly defined.
MRIguided adaptive brachytherapy of cervical cancer represents,
besides USguided brachytherapy of prostate cancer, the most
extensively studied imageguided brachytherapy approach. The
method was developed systematically and each of the above
mentioned steps of imageguidance was carefully integrated into the
procedure. The clinical impact for the patients was remarkable, local
control for locally advanced disease was ~90%, with less than 5%
serious late adverse effects. As a consequence, the procedure was
considered as the golden standard for these patients.
The wide application of brachytherapy for accelerated partial breast
irradiation allowed the systematic application of CTguidance for
breast brachytherapy. It seems, however, that further research is
needed to clarify some issues regarding the methodology of this
approach.
Future clinical studies will have to determine whether the integration
of advanced imaging (e.g. biological and functional imaging) into the
different steps of the brachytherapy treatment chain as applied for
different sites will result into a significant clinical benefit for the
patient. Until then US and MRI which are widely applicable and
systematically utilized for prostate and cervical cancer, respectively
will represent the golden standard.
7
EUROPEAN EXPERIENCE
C. Polgár 1
1 National Institute of Oncology, Radiotherapy, Budapest, Hungary
Accelerated partial breast irradiation (APBI) is an attractive treatment
approach which shortens the course of radiotherapy (RT) to less than
a week. There has been great interest in Europe in treating selected
patients with earlystage breast cancer with APBI using different
techniques. Among these we review the results of European studies
using brachytherapy (BT), and teletherapy techniques. The results of
clinical trials using intraoperative RT (ELIOT and TARGIT) for
delivering APBI will be presented separately by others.
Six early studies had local recurrence (LR) rates of 637% yielding
annual LR rates ranging from 1.4% to 6.2% with 5083% of patients
having excellent or good cosmetic results, reflecting suboptimal
patient selection, target definition, and quality assurance procedures
(Table 1.). Twelve more recent studies performed using much more
stringent approaches have had LR rates of 011% yielding annual LR
rates ranging from 0% to 1.1% with 56100% of patients having
excellent or good cosmetic results (Table 1.).
The 10year results of a singleinstitution phase III study and
preliminary results on early toxicities of the GECESTRO multicentric
phase III APBI trial will be presented later during the World
Brachytherapy Congress.
Recently, two other European phase III trials (the IMPORT LOW and
the Florence University trials) have been initiated using IMRT in the
APBI arm. As data from these and other trials mature, they will
address and refine issues of patient selection, target volume
definition, total dose, and fractionation and hopefully support the
implementation of APBI into the routine clinical practice.
8
NORTH AMERICAN EXPERIENCE
D.W. Arthur
Virginia Commonwealth University, Richmond, VA, USA
The North American accelerated partial breast irradiation (APBI)
experience will be represented in this presentation by review of
select prospective single institutional, multiinstitutional and
randomized studies. In addition, clinical investigations evaluating how
to expand and improve the present use of APBI will be discussed.
Outcome data from William Beaumont Hospital, Virginia
Commonwealth University, RTOG and the American Society of Breast
Surgeons Registry trial, all now with extended followup of 512 years,
continue to support the use of APBI in selected patients. Acceptable
inbreast control and toxicity rate are reported from these trials and
lay the foundation for the use of APBI. To further validate the use of
APBI, the results of two large phase III randomized trials are awaited.
The Canadian trial randomized between standard whole breast and
3Dconformal external beam partial breast has completed accrual and
data maturation is awaited. The American NSABP B39/RTOG 0413
trial continues to accrue and is approaching anticipated conclusion in
early 2013. This phase III trial has included a wide range of patients
who have been randomized between standard whole breast irradiation
and APBI that can be delivered with mulitcatheter interstitial
technique, intracavitary technique or 3DConformal external beam
radiotherapy. It is the only phase III trial that is evaluating the
boundaries of patient selection. As these important trials come to a
close and we await results, further acceleration of treatment delivery

S4 World Congress of Brachytherapy 2012
and the use of partial breast treatment for reirradiation are being
investigated. Two ongoing trials that are evaluating these concepts
will be presented. A multiinstitutional trial investigating a twoday
treatment delivery scheme has become the focus of study allowing
the APBI treatment device to be inplace for only 23 days and an
RTOG trial is evaluating the role of partial breast reirradiation in
those patients experiencing an inbreast failure after whole breast
irradiation.
9
TARGIT
D.J. Joseph 1
1 Sir Charles Gairdner Hospital, Radiation Oncology, Perth, Australia
: After breastconserving surgery (BCS), 90% of local
recurrences (LR) occur within the index quadrant despite the
presence of multicentric cancers elsewhere in the breast. Thus,
restriction of radiation therapy to the tumour bed during surgery
might be adequate for selected patients. We compared targeted
intraoperative radiotherapy (IORT) utilizing the Intrabeam Device,
with conventional whole breast external beam radiotherapy (EBRT).
IORT involves an xray source small enough to be placed inside a
tumour bed to deliver its treatment. A series of applicators of varying
diameters allows the correct size to be chosen for any surgical cavity
after BCS. Low energy 50 kilovolt xrays are produced which have
limited penetration, so deliver a dose that is relatively high at the
applicator surface but falls off rapidly with distance. We prescribe a
dose of 20Gy at the applicator surface, given in a single treatment.
The procedure lengthens theatre time by 2030 minutes, but
otherwise there are few logistical issues.
: Having safely piloted the technique of IORT, Sir Charles
Gairdner Hospital (SCGH) and the Peter MacCallum Cancer Institute
joined the international TARGITA trial in 2003. In this prospective,
randomised, noninferiority trial, women aged 45 years or older with
invasive ductal breast carcinoma undergoing BCS were enrolled from
28 centres in nine countries. Participating centres were able to define
stricter eligibility criteria, and the two Australian centres chose to
include only postmenopausal women over 50 due to their lower risk
of LR. Patients were randomly assigned to receive targeted IORT or
EBRT. Postoperative discovery of predefined factors (eg, lobular
carcinoma) could trigger addition of EBRT to IORT (in an expected 15%
of patients). The primary outcome was LR in the conserved breast.
The predefined noninferiority margin was an absolute difference of
2 5% in the primary endpoint.
: 387 patients have been registered on the trial in Australia.
Analysis of the first 1113 patients randomly allocated to IORT and
1119 allocated to EBRT was performed in early 2010. Of 996 patients
who received the allocated treatment in the IORT group, 854 (86%)
received IORT only and 142 (14%) received IORT plus EBRT. 1025 (92%)
patients in the EBRT group received the allocated treatment. At 4
years, there were six LRs in the IORT group and five in the EBRT
group. The KaplanMeier estimate of LR in the conserved breast at 4
years was 1 20% (95% CI 0 53–2 71) in the IORT group and 0 95% (0 39–
2 31) in the EBRT group. The frequency of any complications and
major toxicity was similar in the two groups. Radiotherapy toxicity
(Radiation Therapy Oncology Group grade 3) was lower in the IORT
group (six patients [0 5%]) than in the EBRT group (23 patients [2 1%];
p=0 002). Recent blinded analysis has shown no significant change in
LR for the total cohort. A further unblinded analysis is planned for
late 2012. Recruitment is ongoing as it was continued beyond the
initial target to allow further centres to join the trial. Long term
followup is planned.
: In accordance to ASCO literature and discussion with
the data monitoring and safety committee and local specialists, IORT
is now considered a standard treatment option for women over 70
with low risk disease in Western Australia.
10
ELIOT TRIALS IN MILAN: RESULTS
R.Orecchia
European Institute of Oncology, Milan, Italy
Abstract not received
11
LONG TERM RESULTS AND ONGOING TRIALS OF PERMANENT BREAST
SEED IMPLANT
J. Pignol 1 , S. Doggett 2 , J. Crook 3 , M. Trombetta 4 , J.M. Caudrelier 5 , P.
Fried 6 , S. Hussein 7 , A. Dagnault 8 , N. Pervez 9 , W. Sauerwein 10
1
Sunnybrook Health Sciences Centre University of Toronto, Radiation
Oncology, Toronto, Canada
2
Tustin Hospital and Medical Centre, Radiation Oncology, Tustin, USA
3
BCCA Center for the Southern Interior University of British
Columbia, Radiation Oncology, Kelowna, Canada
4
Allegheny General Hospital Temple University School of Medicine,
Radiation Oncology, Pittsburgh, USA
5
Ottawa Hospital Cancer Centre University of Ottawa, Radiation
Oncology, Ottawa, Canada
6
The Jewish Hospital, Radiation Oncology, Cincinnati, USA
7
Tom Baker Cancer Centre University of Calgary, Radiation Oncology,
Calgary, Canada
8
Centre Hospitalier Universitaire de Quebec, Radiation Oncology,
Quebec, Canada
9
Cross Cancer Institute, Radiation Oncology, Edmonton, Canada
10
University Hospital, Radiation Oncology, Essen, Germany
Permanent Breast Seeds Implant (PBSI) is a form of partial breast
irradiation technique involving the permanent implantation of 103 Pd
stranded seeds under ultrasound guidance and light anaesthesia in a
single one hour procedure. PBSI delivers the radiation treatment over
several weeks and is hence low dose rate brachytherapy.
The technique has been prospectively tested in a Phase I/II clinical
trial. From 2004 to 2007, early stage breast cancer patients referred
to a single cancer centre for adjuvant radiotherapy were offered PBSI.
Eligible patients included those over 45 years old diagnosed with an
infiltrating ductal carcinoma £ 3 cm, margins ≥ 2 mm, no grade III, no
lobular components, no extensive in situ carcinoma, no
lymphovascular invasion, and negative lymph nodes. In 2009, when
mature data showed good tolerance and the absence of local
recurrence at 5 years, a multicentre registry trial was activated
offering PBSI to the same population but aged 50 or higher. Finally in
2010 a multicentre Phase II trial of adjuvant PBSI for selected DCIS
was activated in Canada.
Overall 111 patients have received PBSI, including 98 with infiltrating
ductal carcinoma (IDC), one patient with mixed infiltrating lobular
and ductal carcinoma, and 12 patients with DCIS. The median age at
time of surgery was 61 years [range 41 to 80 years]. The median
tumour size was 1.0 cm [0.2 to 3.0 cm]. Regarding the 99 patients
with invasive tumour, all were node negative but one, the median
free surgical margin size was 5 mm [1 to 40 mm], half of the tumour
were MSBR grade I and the other half were grade II, 83/99 patients
received adjuvant antihormone therapy and 12/99 chemotherapy.
The median followup for the entire cohort is 62 months [5 to 98
months]. At 80 months the overall survival is 97.3% ± STD 1.9%, and
the recurrence free survival was 91.9% ± STD 3.9%. Three patients
presented with ipsilateral breast recurrence; two IDC at 5.5 and 7
years and one DCIS at 6.5 years post surgery. Three patients also
presented with contralateral breast cancers, two IDC and one DCIS.
The single patient with a positive node developed a regional
recurrence at 6 years, and one patient presented with lung metastasis
after 4 years. Two patients died of diabetic complications unrelated
to the implant?. Two year tolerance data are available for 78 patients
and none presented with a toxicity of grade II ( NIH CTCAE 4.0; local
intervention required and/or limiting instrumental activity of daily
life) or higher. Twenty four patients presented with grade I side
effects (30%) including grade I telangiectasia in fourteen patients
(18%) and induration in eleven patients (14%). Fifty four patients are
showing no or minimal evidence of radiation treatment. Reviewing
postimplant quality assurance data, telangiectasia appears to be
preventable if the skin receives less than 85% of the prescribed dose.
Finally PBSI is associated with a rate of 96.9% good or excellent
cosmetic results at 3 years.
These limited data compare favourably with external beam adjuvant
radiotherapy for early stage breast cancers and other techniques of
partial breast irradiation. PBSI present the advantage to be realised in
a single outpatient procedure compared to 5 to 6 days for HDR
brachytherapy. Also using a low energy source, the faster dose fall off
enable a dramatic total body dose reduction especially regarding
World Congress of Brachytherapy 2012 S 5
heart and lung exposures. As of February 2012 the PBSI technique is
offered in three centres in North America, two additional centres
have obtained IRB approval for the Registry study, and IRB approval is
pending for five centres. In May 2011 the FDA approved an
implantation device and a treatment planning system enabling PBSI.
12
INTRODUCTION
C. HaieMeder 1
1 Institut Gustave Roussy, Radiation Oncology, Villejuif, France
Carlos A. Perez is an outstanding internationally recognized radiation
oncologist. He was born in Medellin, Colombia and earned his medical
degree at the University of Antioquia School of Medicine in
1960.Carlos Perez came to the United States at Washington University
School of Medicine. He spent three years as a radiation oncology
resident at Mallinckrodt Institute of Radiology in SaintLouis Missouri
and a oneyear fellowship in radiotherapy at M.D. Anderson Hospital
and Tumor Institute in Houston Texas. He then returned to
Mallinckrodt as an instructor in radiology.
In 1966 Carlos Perez initiated a program for the specific training of
radiation therapy technologists.
Carlos Perez was named a professor of radiology in 1972. In 1976 he
became the director of the Radiation Oncology Center, at Mallinckrodt
Institute of Radiology. Under his leadership, the Radiation Oncology
Center developed a strong research with significant contributions to
cancer treatment, with the enhancement of radiation effects with
concomitant chemotherapy. In 2001 Carlos Perez assumed the first
chairmanship of the Center which became a separate academic
department of the Washington University School of Medicine. Carlos
Perez held this position until2004.
Since 2004 Carlos Perez is a Professor Emeritus. He also served as the
President of the American Society of Therapeutic Radiation in 1982.
He is well known for his major contributions to the clinical
management of patients, especially those with gynecologic tumors
and carcinoma of the prostate and of the breast. His contribution in
the brachytherapy field has been very important, especially in
patients with gynecological cancers. Carlos Perez has been motivated
by understanding the disease as well as the psychological care of his
patients. Heis a cofounder of the Cancer Information Center (CIC),
the first United States resource facility that provided medical
information, resources and emotional support to cancer patients.
He is the recipient of many honors. He was awarded the ESTRO
Honorary Member at the 30 th ESTRO anniversary in London in 2011,
CRILA Gold Medal in 2000, the Gold Medal of the American College of
Radiology in 1997, and the Gold Medal of the American Society for
Therapeutic Radiology and Oncology in 1982.
Carlos Perez has published over 300 scientific articles, a lot of them
dealing with brachytherapy. He is coeditor of the most
comprehensive text on radiation oncology, Principles and Practice of
Radiation Oncology, now in its sixth edition. In addition, he is co
editor of two other outstanding textbooks – Principles and Practice of
Gynecologic Oncology and Radiation Oncology: Management Decisions.
On behalf of GECESTRO, ABS and all brachytherapy societies, it is a
great honor and a great pleasure to award Carlos Perez the GEC
ESTRO Marie Curie medal during the 4 th world brachytherapy meeting
in Barcelona.
13
BRACHYTHERAPY IN CANCER: ART AND SCIENCE ACCOMPLISHMENTS
IN OVER A CENTURY
C. Perez 1
1
Washington University Medical Center, Radiation Oncology, St. Louis,
USA
Brachytherapy has been used in the treatment of patients with a
variety of malignant lesions since the turn of the XX century, shortly
after the discovery of radioactivity by Marie and Pierre Curie and
Antoine Henri Becquerel, recognized by the Nobel Prize in Physics,
bestowed to the three of them in 1903. Initially, and for many years
brachytherapy was more of an Art: 226Ra needles or sources in
rudimentary applicators (cylinders) 'were inserted in the tumor and
dose prescription was empirical'. Pioneers in Radiation Oncology
designed applicators to achieve better dose distributions. Afterloading
devices with selective shielding, and flexible catheters, initially
loaded manually and later through remote devices provided welcome
radiation safety protection.
Our colleagues in Physics established dosimetry procedures and rules
to more accurately determine radiation doses (Patterson Parker,
Quimby, the Paris dosimetry methodology). 226Ra has been replaced
by other radionuclides with more appealing physical characteristics
(energy, specific radioactivity, half life, etc) and safety for the
patients and the operator, such as 137Cs, 192Ir, 169Yb, 241Am and
others.
Innovative technology has advanced brachytherapy into more
scientific grounds. Sophisticated computational methods and imaging
(ultrasound, CT scanning, etc) enhanced our ability to do more
precise 3D treatment planning and increased our capabilities for
dosimetry verification. Recently MRI and PET scanning have allowed
precise identification of target volumes and rapid imaging plus robust
computational techniques have made it possible to carry out real time
imageguided 3D/4D volumetric dose optimization (inappropriately
called 'dose painting', which would apply to a surface).
Radiation Biology investigation has also contributed to advance the
scientific basis of brachytherapy. With better understanding of the
cellular kinetics and the acute and late effects of radiation in normal
tissues it was possible to introduce different dose rate devices into
clinical practice, and in many countries the traditional Low Dose Rate
(LDR) has been progressively replaced by Mid or High Dose Rate (MDR,
HDR) techniques, with substantial reduction in cost of treatment and
improved radiation safety for providers and patients. Pulsed Dose Rate
combines the technological advantages of HDR with the biological
effects of LDR. Recently low keV xray electronic brachytherapy
systems have been introduced, with specific applications, such as
partial breast irradiation.
These modalities , combined with sophisticated treatment planning
algorithms, enhance the flexibility for 3D dose modulation and
optimization, by manipulating source dwelling times and patterns.
Relativedosehomogeneity Index, Dose nonuniformity Ratio and
Conformality Index are tools quite useful to achieve dose
optimization. Modern brachytherapy represents in many respects a
classic mode of conformational adaptive radiation therapy. Cloud
computing will facilitate realtime planning and dose optimization,
enhancing the precision in dose delivery. Whereas brachytherapy
continues to be a mainstay in the treatment of carcinoma of the
uterine cervix and other gynecological tumors, there has been a major
increase in the application of permanent seed implants (125I, 103Pa)
or HDR in the treatment of patients with prostate cancer, with results
equivalent to radical prostatectomy or advanced external beam

S6 World Congress of Brachytherapy 2012
techniques. On the other hand, a reduction in the use of
brachytherapy in the treatment of patients with cancer of the head
and neck has taken place. Breast brachytherapy has been reenacted
with the introduction of accelerated partial breast irradiation, the
efficacy and safety of which is being tested in several clinical trials.
As in any aspect of radiation therapy, quality assurance, safety,
protection and compliance with all regulatory requirements are
critical to the appropriate use of brachytherapy.
There is a critical need to emphasize the teaching of brachytherapy in
Radiation Oncology Residency programs and to foster prospective
clinical trials to expand its role in the management of many patients
with cancer.
14
UNDERSTANDING THE PATHOLOGICAL FEATURES OF PROSTATE CANCER
AS A FOUNDATION FOR FOCAL TARGETED BT
D. Bostwick 1
1 Bostwick Laboratories, Research, Glen Allen, USA
: Focal therapy is emerging as a reasonable clinical
compromise treatment for select men with early stage prostate
cancer between definitive therapy (potential overtreatment with
morbidity) and active surveillance (potential undertreatment). This
report examines the pathological features from biopsies that assist in
guiding patient selection for this novel form of therapy.
: We undertook a systematic literature review to determine
(1) What are the limitations of transrectal and transperineal biopsy
protocols; and (2) How accurately can we define and predict
pathologic selection factors prior to therapy such as final grade,
volume, unifocality, unilaterality, and stage (extent) for the
individual patient?
: Significant variance exists in practice by pathologists and
urologists that results in differences in cancer yield on biopsies.
Transperineal sector or mapping biopsies appears to be a safe
alternative to transrectal biopsies that can more accurately grade
(undergraded in 10% or more of patients with transrectal biopsies),
stage (understaged in 25% or more of patients with transrectal biopsy)
and sample (in up to 20% of patients with transrectal biopsy, the
index cancer may not be the determinant of behavior).
: Not all prostate biopsies are created (or handled)
equally. The quality and method of biopsy has a significant impact on
cancer yield as well as pathologic selection factors for focal therapy
such as cancer grade, volume, unifocality, unilaterality, and stage
(extent). Transperineal sector or mapping biopsies appear to be
superior to transrectal biopsies for patient selection for focal
brachytherapy.
15
PRIMARY FOCAL THERAPY OF PROSTATE CANCER: ROLE OF DIAGNOSTIC
IMAGING
F.V. Coakley 1
1
UCSF Comprehensive Cancer Center, Radiology and Urology, San
Francisco, USA
: Focal therapy of prostate cancer represents an entirely
new paradigm for the management of this disease, offering a novel
'middle way' between the nihilistic approach of active surveillance and
the morbid approach of traditional definitive treatment with radical
prostatectomy or radiation. While conceptually attractive, widespread
adoption of focal therapy for prostate cancer will require accurate
identification of appropriate patients, credible proof of longterm
efficacy, and precise and effective tumor targeting and ablation.
Imaging is likely to play a central role in many important aspects of
focal therapy for prostate cancer, including patient selection, tumor
localization, and outcome evaluation.
: Prostate cancer represents
an organ and a disease that is difficult to image locally. A a
substantial body of evidence has emerged in the last two decades to
indicates that multiparametric MRI, while not a perfect approach,
represents the best available method for local imaging of this
condition. Multiparametric MRI refers to standard T2 weighted MR
imaging with the addition of some combination of diffusion, perfusion,
or spectroscopic MR imaging. Prostate cancer is characterized by low
T2 signal intensity, restricted diffusion, rapid intense enhancement
with washout, and elevated choline to citrate ratio. The optimal
combination of these parameters for prostate cancer detection and
characterization is currently unknown and remains under
investigation.
: Multiparametric MRI has been
shown to improve tumor targeting prior to focal therapy. In
particular, a visible lesion and T2weighted imaging associated with at
least 0.54 cm³ of spectroscopic abnormality is likely to represent a
dominant (greater than 0.5 cm³) treatable focus of disease.
Preliminary data from our institution suggests that a noncapsular
margin of 5 mm results in adequate tumor coverage of such treatable
foci of disease.
: Prostate cancer progression, as evaluated by
serial multiparametric MRI is correlated with PSA progression,
suggesting that this modality could be used to follow disease being
managed by active surveillance or focal therapy. Serial multi
parametric MRI studies have also demonstrated that prostate cancer
usually recurs within the gland at the same location as the dominant
primary tumor. This is a critical observation, since focal therapy only
makes conceptual sense if treatment failure is a manifestation of
inadequate local control at the site of initial dominant disease.
MR guided high intensity focus ultrasound (HIFU) : MR guided HIFU
offers several major advantages as a method of tumor ablation,
including precise targeting, accurate thermometry for realtime
monitoring during ablation, and tumor treatment within a stereotactic
environment. Animal and early human studies are encouraging.
However, additional research will be required to validate this
technology before it can enter routine clinical practice.
: Focal therapy has the potential to offer a new
therapeutic option to the management of patients with prostate
cancer; imaging with multiparametric MRI is likely to be of major
importance in allowing focal therapy to achieve its full promise in the
care of these patients.
16
TECHNICAL POSSIBILITIES OF RADIOTHERAPY IN PRIMARY FOCAL
THERAPY OF PROSTATE CANCER
G. Kovács 1 , A. Schlaefer 2
1
Universität Lübeck, Interdisciplinary Brachytherapy Unit, Lübeck,
Germany
2
Universität Lübeck, Institute of Robotics and Cognitive Systems,
Lübeck, Germany
: Considering the potential morbidity of radical therapy
(prostatectomy, radiation therapy) there are an increasing number of
critics who argue that lowrisk prostate cancer is currently being
overtreated. Focal therapy is different from a whole gland treatment:
focal means to not target bladder, sphincter, neurovascular bundles,
and bowel and should spare continence, erectile function, and overall
quality of life. Because of similarities between prostate cancer and
breast cancer, the procedure may be called as the 'lumpectomy' of
the man. This growing segment has led to increased interest in less
aggressive strategies and treatment options. Several developments in
urology (vascular targeted photodynamic therapy –VTP, focal
cryoablation, focal electroporation, highintensity focal ultrasound –
HIFU, etc.) offer the tool of partial prostate gland treatments and
prospective clinical investigations are already underway.
: The pool of different modern radiotherapy
options (intensity modulated radiotherapy IMRT, image guided
radiotherapy IGRT, simultaneous integrated boost SIB, robotic
radiotherapyCK, as well as seed & HDR brachytherapy techniques)
were analyzed in order to prove the potential of radiotherapy in
primary partial prostate therapy. These different forms of radiation
techniques are compared to each other in terms of accuracy of target
definition, of inter and intrafraction movements, of possibility the
target dose painting, as well as of low dose volumes, of dose on
organs at risk and of invasivity. The potential of new technical
developments like the use of interstitial tissue separators is discussed.
In brachytherapy technology (LDR, HDR or PDR) the potential of
developing focal imaging needles using optical coherence tomography
and a robotic needle drivers will be highlighted.
World Congress of Brachytherapy 2012 S 7
: Modern radiotherapy especially interstitial brachytherapy and
Cyber Knife technology (Figure 1) combined with interstitial tissue
separators between prostate and rectum have the technical potential
for successfully performance of partial prostate treatments with
cancer ablative dose levels. However, following the actual discussion
in the urological community regarding definition and diagnosis of a
prostate focal lesion which results in difficulties in target definition
for radiotherapy, further clinical work and interdisciplinary consensus
is needed to define standard procedures for partial treatments in
localized prostate cancer.
: Following an interdisciplinary consensus on target
definition for radiotherapy, prospective and controlled multicentric
investigations are needed to define the potential and feasibility of
radiotherapy in partial prostate treatments.
Figure 1
Potential of different radiotherapy technologies in partial prostate
cancer treatment
*better with the use of image fusion
17
IS THERE A ROLE FOR FOCAL THERAPY IN PROSTATE CANCER NON
RADIATION TECHNIQUES?
T. de Reijke
Academic Medical Center, Amsterdam, The Netherlands
Due to widespread use of PSA, urologists face an increasing number of
patients with small volume, low grade prostatic carcinoma seeking for
the optimal therapeutic approach. Concerns about overdiagnosis of
prostate cancer and consequently overtreatment of clinically
insignificant tumours in combination with the significant morbidity
that traditional therapies carry, have questioned the need for radical
treatments for selected groups of patients with lowrisk cancer.
Recently, due to technological advances, focal therapy has been
developed to optimize control while minimizing the adverse events of
whole gland therapy and the anxiety associated with delayed
treatment.
The concept of organ sparing treatment has proven its efficacy for
selected tumors of the breast, skin, bladder and kidney. Four
modalities appear to have the most clinical promise for prostate
cancer focal therapy, including high intensity focused ultrasound
(HIFU), cryotherapy, radiation therapy and photodynamic therapy
(PDT). Several approaches can be found including local application of
therapy to a specific focus, ablation of onehalf of the prostate
(hemiablation) and ablation of nearly the entire prostate (neartotal
ablation).
Cryotherapy has a "freeze rupture" mode of action. leading to necrosis
and vascular thrombosis using TRUS or MRI and is the best studied
focal therapy option. HIFU induces a thermal protein denaturation and
coagulative necrosis and uses either TRUS or MRI and only some
feasibility studies have been reported. PDT ha a light activated,
oxygendependent cytotoxic and vasculotoxic mode of action using
also TRUS or MRI and only Phase I/II studies have been reported.
The problem with these focal techniques is a lack of standardized
followup protocols for patients with focal therapy. As a variable
amount of prostate tissue is left untreated in focal therapy, absolute
values of PSA will be insufficient for verifying and monitoring
treatment success. The position of followup biopsies should be
determined, in addition, MRI/MRS may identify the lesion created by
ablation and may have a potential in followup
18
20 EURAMET PROJECT: NEW CALIBRATION STANDARDS IN BRACHY
THERAPY
T. Sander 1 , M.P. Toni 2 , I. AubineauLanièce 3 , J. de Pooter 4 , A.S.
Guerra 2 , T. Schneider 5 , H.J. Selbach 5
1
National Physical Laboratory (NPL), Radiation Dosimetry,
Teddington, United Kingdom
2
Istituto Nazionale di Metrologia delle Radiazioni Ionizzanti (ENEA
INMRI), Radiation Dosimetry, Rome, Italy
3
Laboratoire National Henri Becquerel (LNELNHB), Radiation
Dosimetry, GifsurYvette, France
4
Van Swinden Laboratorium (VSL), Radiation Dosimetry, Delft, The
Netherlands
5
PhysikalischTechnische Bundesanstalt (PTB), Radiation Dosimetry,
Braunschweig, Germany
Brachytherapy dosimetry for gamma ray sources is currently based on
source calibrations in terms of reference air kerma rate (RAKR) or air
kerma strength (AKS). However, the quantity of interest is the
absorbed dose rate to water at a distance of 1 cm from the source
centre (DRw,1cm), which is currently calculated from RAKR or AKS by
applying the AAPM Task Group 43 formalism [1,2]. As for external
beam radiotherapy dosimetry, there is now growing need for accurate
brachytherapy source dosimetry traceable to national absorbed dose
primary standards.
One of the aims of the project “T2.J06, Increasing cancer treatment
efficacy using 3D brachytherapy” (a joint research project within the
European Association of National Metrology Institutes, EURAMET e. V.)
was the development of absorbed dose standards which would allow
more direct calibrations of brachytherapy sources in terms of
absorbed dose rate to water at a distance of 1 cm, DRw,1cm , compared
to the current air kermabased calibration method, where DRw,1cm is
determined as the product of the measured air kerma strength and
the dose rate constant, Λ, resulting in overall standard uncertainties
of around 5%.
Of the ten European National Metrology Institutes, which contributed
to the joint research project T2.J06 between July 2008 and June
2011, five developed a total of seven independent absorbed dose to
water primary standards for brachytherapy. Three standards, based
on ionometry, were developed for low dose rate (LDR) brachytherapy
sources and four standards, based on either water or graphite
calorimetry, were developed for the measurement of high dose rate
(HDR) brachytherapy sources. The objective was to measure DRw,1cm
with an overall uncertainty of less than 2% (with a coverage factor of
k = 1, which is equivalent to one standard deviation).
The presentation will describe the design of the new absorbed dose
standards and summarise the results of DRw,1cm measurements made
with LDR 125 I and HDR 192 Ir brachytherapy sources. The same
brachytherapy sources were also measured with existing air kerma
standards in terms of reference air kerma rate. Combining both
measurements yielded experimentally determined dose rate constants
for different brachytherapy source types with standard uncertainties
of less than 2.6% for LDR sources and standard uncertainties of less
than 2% for HDR sources. This is a significant improvement compared
to the 5% standard uncertainty currently achievable with
measurements based on thermoluminescent dosimeters (TLDs). The
measured dose rate constants compared well with published
consensus values [3] within the stated uncertainties.
Both LDR and HDR brachytherapy sources can now be calibrated more
directly in terms of absorbed dose rate to water and traceable to
primary standards. Improvements in the accuracy of absorbed dose
rate measurements and treatment delivery result in higher survival
rates and better quality of life for cancer patients.
References
[1] Nath R, Anderson L L, Luxton G, Weaver K A, Williamson J F and
Meigooni A S, Dosimetry of interstitial brachytherapy sources:

S8 World Congress of Brachytherapy 2012
Recommendations of the AAPM Radiation Therapy Committee Task
Group No. 43. Med. Phys. 22 (1995), 209234
[2] Rivard M J, Coursey B M, DeWerd L A, Hanson W F, Saiful Huq M,
Ibbott G S, Mitch M G, Nath R and Williamson J F, Update of AAPM
Task Group No. 43 Report: A revised AAPM protocol for brachytherapy
dose calculations, Med. Phys. 31 (2004), 633674
[3] ESTRO European Society for Radiotherapy and Oncology,
http://www.estro.org/estroactivities/Pages/TG43BTDOSMETRICPARA
METERS.aspx (accessed 23 January 2012)
19
BRACHYTHERAPY CALIBRATION STANDARDS IN THE USA
L. De Werd 1
1 University of Winsconsin, Brachytherapy, Madison, USA
Brachytherapy sources in the USA are characterized by the dosimetric
quantity known as the air kerma strength. The division of the
standards is along the line of energy and dose rate. For example, Low
Dose Rate (LDR) sources at low energy are calibrated using the Wide
Angle Free Air Chamber (WAFAC). A description of the primary
standard and the transfer to the Accredited Dosimetry Calibration
Laboratories (ADCL) will be described. This standard is then
transferred to the clinical physicist. A summary of this process will be
given. The High Dose Rate (HDR) highenergy sources are calibrated
with the “7 distance technique.” A comparison of the various sources
on the market will be described and their comparison will be given.
The air kerma strength for each of the sources is within 1% of each
other. This standard is also transferred to the clinic via a well
ionization chamber. Finally, the calibration standard related to a HDR
low energy xray source will be described. Each of these sources is
traceable to a primary standard with data obtained for the last 20
years.
20
RAMIFICATIONS OF DOSERATE TO WATER CALIBRATIONS ON CLINICAL
DOSIMETRY FOR PHOTONEMITTING BRACHYTHERAPY SOURCES
M.J. Rivard 1 , F.A. Siebert 2 , J.L.M. Venselaar 3 , L.A. DeWerd 4
1
Tufts University, Radiation Oncology, Boston, USA
2
Universitatsklinikum SchleswigHolstein, Clinic of Radiotherapy,
Kiel, Germany
3
Instituut Verbeeten, Medical Physics, Tilburg, The Netherlands
4
University Wisconsin, Medical Physics, Madison, USA
For several decades, the radiotherapy community has utilized
reference airkerma rate (RAKR) as the only traceable quantity for
brachytherapy (BT) source strength U. This quantity is used in place of
apparent activity, milligram radium equivalent, and other antiquated
quantities. A new quantity, doserate to water at 1 cm perpendicular
to the source long axis, is under consideration in the European
metrology laboratories. This presentation will examine the current
practice of clinical dosimetry for photonemitting BT sources using
source strength calibrations based on RAKR, with community impact
and quantitative comparisons of source strength calibrations based on
doserate to water at 1 cm.
The BT source calibration chain is complex and has evolved to include
several constituents [DeWerd et al. 2004]. It is initiated by BT source
manufacturers producing a new source type. The radiological
properties of this source are determined by academic researcher(s)
who typically characterize the dose distribution using measurements
and Monte Carlo (MC) methods of radiation transport simulations. An
important part of this characterization is to determine the doserate
constant Λ, which is the ratio of the doserate to water at 1 cm from
the source center on the transverse plane of the source to the source
strength as in Λ = D(r,θ)/Kr. The source strength is to be measured at
a primary standards dosimetry laboratory (PSDL) having a calibration
standard for that radionuclide. PSDL measurement of the source
strength permits calibration of reentrant welltype ionization
chambers at secondary standards dosimetry labs (SSDLs) and for the
BT source manufacturer.
In BT practice within the United States, the clinical medical physicist
has their reentrant welltype ionization chamber calibrated by an
SSDL (Accredited Dosimetry Calibration Lab) for PSDL (National
Institute of Standards and Technology) traceability. In Europe, SSDLs
are not prevalent and physicists calibrate their own dosimetry
equipment against a PSDLtraceable chamber for that particular
source model. When ordering BT sources for a patient, the physicist
measures the source strength for intercomparison with the source
strength on the certificate provided by the manufacturer [Butler et al.
2008]. The physicistmeasured source strength may then be entered
into the BT treatment planning system (TPS), along with the
consensus Λ value for that particular source model, for clinical dose
calculations. The product of Λ and RAKR yields the doserate to water
at 1 cm from the source center on the transverse plane. Additional BT
dosimetry parameters are used for derivation of dose distributions
following the AAPM TG43 dose calculation formalism [Rivard et al.
2004]. This process is well established.
The joint AAPM/GECESTRO TG138 report determined uncertainties
for this dose calculation process, starting with BT source calibrations
[DeWerd et al. 2011]. For lowenergy photonemitting sources such as
125 I, clinical procedures usually utilize many sources in which
manufacturerprovided source strengths are determined in 7% wide
groupings from a nominal value and the physicistmeasured source
strengths are determined from a subset of the total batch.
Consequently, the uncertainty attributed to source strengths for low
energy sources is larger than that initially measured at the PSDL. For
highenergy photonemitting sources such as HDR 192 Ir, clinical
procedures utilize a single source in which the manufacturer and
physicist calibration uncertainties are smaller than for lowenergy
seeds.
Development of a source strength calibration standard based on dose
rate to water at 1 cm is a new concept, and aims to remove the step
associated with Λ derivation so that physicists would calibrate source
strength in terms of doserate to water at 1 cm instead of RAKR
[Rivard et al. 2009]. Source strength calibration uncertainties
associated with each step in the current (RAKR) and proposed (dose
rate to water) methods are examined. While it is not apparent that
the new/proposed calibration method is superior to the established
method based on RAKR, an action plan and resources required to
guide the BT community to the proposed new calibration standard are
discussed.
21
CLINICAL RESULTS
R. Pötter 1
1
Medical University of Vienna, Comprehensive Cancer Centre, Vienna,
Austria
: Imageguided adaptive brachytherapy (IGABT) is
increasingly implemented as new treatment option for cervix cancer
applying the GYN GEC ESTRO recommendations. This approach allows
for balancing target coverage/dose and dose volume constraints for
OARs. With 2D conventional treatment planning (fixed point (A)
prescription) only some adaptation of OAR dose points is possible.
Dosimetric studies comparing 2D and 3D dose planning have provided
evidence for better OAR sparing using 3D. Therefore it is expected
that IGABT will result in decrease of BT related morbidity.
Clinical evidence for this expectation is provided by retrospective
evaluation of mono and multicentre experience (RetroEMBRACE) and
some upcoming prospective multicentre comparative and
observational studies (STIC/EMBRACE). The outcome data indicate a
decrease of morbidity, however, they are not straightforward. The
value of historical comparisons with 2D data is also limited due to
retrospective (multicentre) data collection for morbidity assessment
with even different scoring systems being applied.
: There are single
institution reports after IGABT on late morbidity showing rectal
morbidity (mainly rectal bleeding) ranging between 1242%. In a small
selected patient population (Georg 2009), endoscopic changes and
clinical symptoms were observed after HDR BT in 77% (27/35) and in
37% (13/35). The probability from dose effect analysis for Vienna
rectoscopy score (VRS) changes ≥3 was 10%/50% at 59/68 Gy (all doses
in EQD2) for rectal D2ccm and 10%/50% for rectal side effects G24 at
65/76 Gy D2ccm. This number (selected patient group) contrasts with
World Congress of Brachytherapy 2012 S 9
results from a larger patient population (Georg 2010, 2011). Based on
dose effect analysis there is 10% probability for a D2ccm of 73 Gy.(G14)
and 78 Gy (G24), resp. Clinical rectal side effects were actuarial 12%
(11/141) for any grade (8/141 for G24) for a mean rectal D2ccm of 65
Gy (med foll.up 51 mths). Overall, G3/G4 actuarial rates were 4% for
bladder, 2% for rectum, and 2% for sigmoid.
Rectoscopic changes (VRS score ≥ 2) were reported with a 50%
incidence after HDR BT for a D2ccm of 75 Gy (Koom 2007). Clinical
rectal bleeding from the same authors (mean rectal D2ccm 70.4 Gy)
showed actuarial 42% for any grade of rectal bleeding (RTOG/EORTC)
with only 2% severe bleeding (G34) after 3D BT compared to 13%
after 2D BT (Kang 2010).
The number of adverse events of preop 3DLDR BT without EBRT was
20 for grade 12 and 0 for grade 34 in 13/39 patients with a follow up
of 4.4 years (HaieMeder 2009). Late overall toxicity of MRI based 3D
PDR BT plus EBRT was 21/45 G12, 1/45 G3 (0 G4) with follow up of 26
mths after .mean D2ccm of 61 Gy and 72 Gy for rectum and bladder,
resp (Chargari 2009).
Preliminary data from retroEMBRACE from 417 patients shows 96 GU,
143 GI and 161 vagina late adverse events at 3 years after median
D2ccm of 73 Gy for bladder and 63 Gy for rectum and sigmoid (Fokdal
2011).
The first
prospective multicenter study was performed in France (STIC) as non
randomised trial comparing 2D vs. 3D PDR BT (mainly CT based). The
cumulative actuarial incidence of overall G3G4 morbidity at 2 years
(GI, GU, Gyn) was 2.6% vs. 22.7% in the 3D vs. 2D arm in 117 vs. 118
patients (p=0.002) with definitive treatment (EBRT+IGABT) delivering
mean 73 Gy EQD2 to the HR CTV (3D arm) and mean D2ccm of 68 Gy to
rectum and 64 Gy to bladder (CharraBrunaud 2012).
EMBRACE, a prospective multicentre observational study, investigates
MRI based IGABT. The mean follow up of 1 year in overall 600 patients
accrued by 3/2012 does not allow any valid estimates of late toxicity.
: IGABT for definitive treatment in locally advanced
cervical cancer as practiced in single and multicentre settings results
in low rates of grade 3 and 4 and moderate rates of G1 and G2 toxicity
after limited follow up. There is some (limited) evidence that these
rates seem to be lower than after traditional 2D BT confirming the
dosimetric evidence. More mature data from prospective clinical trials
is needed to support these first observations.
22
DVH PARAMETER ANALYSIS
K. Tanderup 1
1 Aarhus University Hospital, Medical Physics, Aarhus C, Denmark
With the advent of image guided adaptive brachytherapy (BT), it has
become possible to define a common language to communicate
information in a valid, reliable and reproducible way about dose and
volumes, and thus to facilitate a better understanding dose volume
relations and dose volume effects. In 2006 GEC ESTRO
recommendations for reporting and recording of dose parameters
were published for BT in cervical cancer (Pötter et al 2006). A new
ICRU report is currently in progress on “Dose and volume reporting in
brachytherapy in cervical cancer”, and the presentation will outline
the recommendations with regard to DVH parameter reporting.
Due to the rapid dose falloff near the BT sources there is a large dose
inhomogeneity in OARs. The organ walls adjacent to the applicator
(sources), like the anterior rectal and sigmoid (bowel) walls, inferior
and mid–posterior bladder wall, or the vaginal wall adjacent to the
cervix and vaginal applicator, are irradiated with doses of 50%100+%
of prescribed BT dose in a typical scenario for definitive cervix cancer
radiotherapy. On the contrary, the more distant organ, like the
posterior rectosigmoid (bowel) walls, the superior–anterior bladder
wall, or the inferior vagina, are irradiated by BT with much lower
doses (

S10 World Congress of Brachytherapy 2012
OC24
TENYEAR OUTCOMES FOR PATIENTS WITH GLEASON 810 TREATED
WITH HIGH DOSE RATE BRACHYTHERAPY BOOST
A. Martinez 1 , C. Shah 2 , N. Mohammed 2 , J. Demanes 3 , R. Martinez
Monge 4 , H. Ye 2 , R. Galalae 5
1
Michigan Healthcare Professionals, Radiation Oncology, Farmington
Hills, USA
2
Beaumont Health System, Radiation Oncology, Royal Oak, USA
4
Universidad de Navarra, Radiation Oncology, Pamplona, Spain
5
Kiel University, Radiation Oncology, Kiel, Germany
: To report long term multiinstitutional outcomes
for Gleason 8–10 prostate cancer patients treated with external beam
radiotherapy (EBRT) and high dose rate (HDR) brachytherapy boost.
Between 1987 and 2002, 483 patients with
Gleason 810 disease were treated for localized prostate cancer at
William Beaumont Hospital (WBH), the California Endocurietherapy
Center (CET), Kiel University, and the Universidad de Navarra on four
prospective HDR boost trials. Conformal EBRT was delivered to the
pelvis (dose range 36 Gy–50.4 Gy) along with HDR boost for a
combined biologic equivalent dose (BED) of 215–366 Gy (α/β=1.2).
Conformal intensity modulated HDRBT was planned and treatment
was delivered using online transrectal ultrasound (TRUS) images at
WBH. At CET, Kiel University, and Navarra University, HDRBT
treatment planning was CT based. Biochemical control (BC) was
defined according to the Phoenix criteria (freedom from PSA rise of
2ng/ml above nadir).
: Mean patient age was 68.4 years with mean initial PSA (iPSA)
of 18.8 ng/ml. Mean followup was 6.1 years. 10year outcomes were:
biochemical control (BC) 53.5%, distant metastases (DM) 22.1%,
clinical failure (CF) 25.6%, cause specific survival (CSS) 82.6% and
overall survival (OS) 62.7%. Hormones were given in 69.9% of patients
but did not significantly improve BC, DM, CSS, or OS. 10year
outcomes stratified by iPSA (40 ng/ml) were improved for all
outcomes with lower iPSA including BC (57.4% v. 10.3%, p

S12 World Congress of Brachytherapy 2012
204 patients were identified as having a high risk anatomic prostate
gland (50cc, or history of prior TURP). 46 patients were
identified as having ultrasound prostate volume of ≤20 cc at the time
of the implant (median, 17.8cc, range 6.7cc20cc; lower quartile,
6.7cc15.5cc). 121 patients were identified as having ultrasound
prostate volume of ≥50 cc at the time of the implant (median, 61cc,
range 50cc116cc; upper quartile 74cc116cc). 37 patients were
identified as having a history of a prior TURP. In the standard risk
group there were 443 patients, the median ultrasound prostate
volume was 32.8cc (range, 20.249.8).
Neoadjuvant hormone therapy was not routinely recommended unless
the initial ultrasound prostate volume suggested significant pubic arch
interference or the patient's Gleason score and or prostate specific
antigen placed the patient in either intermediate or high risk
categories. Patients received HDR brachytherapy as a boost either
before or after 4500 cGy of external beam radiotherapy (3D conformal
until 2006 and IMRT thereafter). Boost brachytherapy doses ranged
from 1600 1900 cGy, given in 23 fractions, with the most common
fractionation schedule being 950 cGy in two daily fractions given on
the same day as the implant with a minimum 6 hours interval between
fractions.
: The dosimetric findings are as follows:
Patient
Group
D90 V100 V150 D5 rectum D5 urethra
50cc Median106.2% 95.1% 18.2% 55.4% 109.7%
N=121 Range 95117% 9099% 3.335% 3771% 103121%
TURP Median 107.8% 94.7% 19.3% 54.2% 107.8%
N=37 Range 102.5117% 87.9100% 5.332% 3474% 101121%
Standard Median 107.5% 95.5% 18% 51% 110%
N=443 Range 94117% 83100% 336.5% 2473% 97122%
*High risk groups in bold
With a median of 5.1 years, there have been nine grade II urethral
strictures (CTCAE v.3) for the entire cohort. Four of these occurred in
the anatomic high risk group and five occurred in the standard risk
group. There was one grade II incontinence in the high risk group and
one grade I incontinence in the standard risk group. There was only
one grade II or higher toxicities found in the high risk group as well as
only a single grade II gastrointestinal toxicity in the standard group.
: In our experience, cases traditional deemed as
unsuitable for prostate brachytherapy (50cc, prior TURP) are
well managed with HDR brachytherapy with the expectation of
excellent dosimetric coverage acceptable long term toxicities.
OC29
SALVAGE HDR BRACHYTHERAPY FOR RECURRENT PROSTATE CANCER
AFTER PRIOR DEFINITIVE RADIOTHERAPY: FIVE YEAR OUTCOMES
C.P. Chen 1 , V. Weinberg 2 , K. Shinohara 3 , M. Nash 1 , A. Gottschalk 1 , M.
Roach III 1 , I. Hsu 1
1
UCSF Comprehensive Cancer Center, Radiation Oncology, San
Francisco, USA
2
Helen Diller Family Comprehensive Cancer Biostatistics Core,
Biostatistics, San Francisco, USA
3
University of California San Francisco, Urology, San Francisco, USA
: Evaluate the efficacy and toxicity of salvage high
dose rate brachytherapy (HDRB) for locally recurrent prostate cancer
after definitive radiotherapy (RT).
: From November 1998 to June 2009, we
retrospectively analyzed 52 consecutively accrued patients undergoing
salvage HDRB for locally recurrent prostate cancer after prior
definitive RT. After pathologic confirmation of locally recurrent
disease, all patients received 36 Gy in 6 fractions. Twentyfour
patients received neoadjuvant hormonal therapy prior to salvage
whereas no patients received adjuvant hormonal therapy.
Determination of biochemical failure (bF) after salvage HDRB was
based on the Phoenix definition. The 5 year probability estimates of
overall survival (OS) and bF were calculated using KaplanMeier
method. Univariate analyses were performed using the log rank test
for categorical variables and Cox’s proportional hazards model for
continuous variables to identify predictors of bF. Based on the
Common Terminology Criteria for Adverse Events (CTCAE version 4),
acute (less than 3 months postsalvage) and late (more than 3 months)
genitourinary (GU) and gastrointestinal (GI) toxicities were
documented.
: Median followup after salvage HDRB was 59.6 months
(range, 5.9 – 154.7 months). The 5year KaplanMeier estimate of OS
was 92% (95% confidence interval (CI) 8097%) without median survival
yet reached. Fiveyear biochemical control after salvage was 51% (95%
CI 3466%). Median PSA nadir postsalvage was 0.1 (range 0 – 7.2) for
all patients. However, patients who were bNED had median PSA nadir
of 0.025 (range 0 – 0.6) whereas those who recurred after salvage had
a median nadir (PSA) of 0.49 (range 0 – 7.2). On univariate analysis,
disease free interval after initial definitive radiotherapy (p=0.07),
interval from 1 st recurrence to salvage HDRB (p=0.09), and preHDRB
PSA (p=0.07) were of borderline significance in predicting bF after
salvage HDRB.
Fortysix patients are alive (27 NED) and 6 patients have died (2 NED).
Overall, after salvage HDRB, 22 patients developed disease
recurrence with 16 having biochemical failure without pathologic or
radiographic confirmation of recurrence, 3 with pathologic local
recurrence, 2 with regional recurrence, and one with distant
metastasis.
Overall there were no Grade 4 or 5 toxicities and very few Grade 3
acute or late symptoms. Acute and late grade 3 GU toxicities were
observed in only 2% and 2%, respectively. There was minimal GI
toxicity with no Grade 2 or higher acute events and only 4% grade 2
late events.
: We present the largest series of patients treated with
salvage HDR brachytherapy for locally recurrent prostate cancer after
prior definitive RT. Prostate HDR brachytherapy is an effective
salvage modality with few toxicities. We provide potential predictors
of biochemical control for prostate salvage HDR brachytherapy.
World Congress of Brachytherapy 2012 S 13
OC30
RESULTS OF I125 STRANDS + EBRT +ADT IN LOCALIZED PROSTATE
CANCER COMPARED TO KATTAN (2002) NOMOGRAM PREDICTIONS
J. Zimmermann 1 , P. Zimmermann 2 , C. Moustakis 3
1
Praxiszentrum Alstertal, and Interdisziplinäres Prostatazentrum
Kath. Marienkrankenhaus, Hamburg, Germany
2
Praxiszentrum Alstertal, Hamburg, Germany
3
Institut für Medizinische Physik, Klinik für Strahlentherapie,
Münster, Germany
: To evaluate the 5year biochemical progression
free survival after prostate brachytherapy with I125 strands +EBRT+
ADT and compare the results to pretherapeutic prediction tools.
Furtheron evaluation of TURP and clinical proctitis after treatment.
: Between 01/2004 and 12/2007, n=604
consecutive patients with localized prostate carcinoma (N0M0) were
treated in curative intention with iodine 125 strands (145 Gy
Mono/108 Gy with EBRT). N=71 patients had EBRT 45 Gy, n=153 ADT.
Intraop preplanning in 2004 and 2005, intraop online planning in 2006
and 2007. N=7 were lost to follow up, n=597 evaluable. N=313 had low
risk (LR), n=204 intermediate risk (IR) and n=80 high risk (HR) disease
according to the d´Amico classification. Mean follow up was 60,01
months (392). The endpoint was freedom from biochemical
progression (FFBP) according to the Phoenix criteria. The analysis
evaluates this endpoint for risk grouping, initial PSA level, Gleason
score, age, prior TURP, mean seed activity, additional ADT and more.
Furtheron we looked at side effects (TURP, proctitis). The results are
compared to the patient related averaged 5yearpredictions from the
Kattan/MSKCC nomogram (2002) in order a. to compare the results to
internationally established outcome predictions for RPX, EBRT and
Brachy +EBRT (BE), b. to normalize the subgroup results and c.
therefore to identify potential good or weak spots for quality
assurance.
: Overall FFBP was 93.3%. FFBP was 96.49% in LR group
(Kattan: RPE 90%/EBRT88%/BE 89%), 90,2% in IR (Kattan: RPE
75%/EBRT 77%/BE 80%) and 88,88 % in HR group (Kattan: RPE
62%/EBRT 56 %/BE 81%). PSA < 10 ng/ml showed a FFBP of 94.35%,
PSA 10 20 ng/ml of 95,24 (!) %. FFBP in Gleason =8 87.5%. After TURP for
LR patients, FFBP was 86.7% (Kattan: RPE 90%/EBRT 90%/BE 89%) ,
after TURP for IR patients 88.89 % (Kattan: RPE 77%/EBRT 79%/BE
84%) and after TURP for HR patients 75% (Kattan: RPE 62%/EBRT
56%/BE 83%) . FFBP in patients < 65 years was 93.79%, 6574 years
92.33% and in patients > 75 years 97.06 %. Patients without ADT had
FFBP of 94.37% (Kattan: RPE 84%/EBRT82%/BE 86%), patients with ADT
90.2% (Kattan: RPE 75%/EBRT74%/BE 80%).
Activity per seed 0.7 mCi of 95.24%.
After brachytherapy alone, TURP rate was 3,9%, rate of proctitis
I/II/III was 2.1%. After brachytherapy and EBRT, TURP rate was 6.5%
and proctitis I/II/III rate 8.7 %.
:
1. FFBP in all risk groups after a mean follow up of 60 months is
excellent and compared to the patient related predictions from 2002
Kattan/MSKCC nomograms signifantly better than predictions for RPX
and EBRT as well as for Brachy+EBRT.
2. It is possible to normalize the patients outcome in subgroups with
the individual progression risks, which is especially interesting for
analysis of subgroups with special aspects or individual risks.
3. Thus, comparing results with the subgroup related averaged
nomogram predictions might be a promising tool for intra/and
interinstitutional quality assurance or clinical trials.
OC31
COMPARISON OF DISTANT METASTASES FOR PROSTATE CANCER
PATIENTS TREATED WITH PROSTATECTOMY, BRACHYTHERAPY OR IMRT
M. Zelefsky 1 , J. Eastham 2 , P. Scardino 2 , X. Pei 1 , M. Kollmeier 1 , B.
Cox 1 , Y. Yamada 1
1
Memorial SloanKettering Cancer Center, Radiation Oncology, New
York, USA
2
Memorial SloanKettering Cancer Center, Urology, New York, USA
: To compare the longterm distant metastases
free survival outcomes (DMFS) for patients with clinically localized
prostate cancer treated with radical prostatectomy (RP),
brachytherapy (BRT) or intensity modulated external beam
radiotherapy (IMRT).
: Between 1993 and 2009, 5316 patients with
clinical stages T1cT2c were treated with RP (n=2870), BRT (n=1344)
or IMRT (n=1102). In the BRT cohort, 910 patients were treated with
monotherapy, and 434 patients with higherrisk disease were treated
with a combined modality approach which utilized supplemental IMRT
to a dose of 4550.4 Gy. Patients treated with IMRT alone were
treated to > 81 Gy. Patients were classified according to the NCCN
risk group classification. The median follow up was 4.8 years (range:
217 years).
: The 7year DMFS for the RP, BRT and IMRT groups were 1.5%,
0.8% and 3.6 % (p< 0.001). In the low risk group no significant
differences were observed between the treatment cohorts ; the 7
year DMFS rates were 0.7%, 0% and 1.2% for RP, BRT and IMRT groups
(overall p value=1.0). For the intermediate risk cohort, IMRT patients
experienced a higher incidence of distant metastases compared to the
other cohorts; the 7year DMFS rates were 2.5%, 2.5% and 4.9% for RP,
BRT and IMRT groups (p= 0.02). Cox regression analysis revealed the
following variables to be associated with an inferior DMFS: higher
clinical stage (p=0.004), biopsy Gleason score 7 vs 6 (p

S14 World Congress of Brachytherapy 2012
(p=0.08). The bladder maximum dose and D2 cc were not significantly
different between arms.
: HDR achieves significantly higher intraprostatic doses to
the prostate while significantly decreasing the maximum rectal dose
with our best achievable SBRT treatment planning. This was shown
with patients treated with HDR monotherapy and using the plans and
dosimetry to create a best achievable SBRT plan. This should be the
standard to compare these modalities rather than the reverse, and is
a strength to our study. Whether SBRT will provide benefit over
brachytherapy clinically has yet to be demonstrated, and future
studies comparing the two modalities will help gain insight into the
role of each treatment.
OC33
COMPARATIVE COSTEFFECTIVENESS OF SALVAGE BRACHYTHERAPY VS.
HORMONAL TREATMENT OF RECURRENT PROSTATE CANCER
L. Steuten 1 , M. Piena 1 , M. Peters 2 , M. van Vulpen 2
1
University of Twente, Health Technology and Services Research,
Enschede, The Netherlands
2
University Medical Centre Utrecht, Radiation Oncology, Utrecht, The
Netherlands
: To estimate the incremental cost per Quality
Adjusted Life Year (QALY) of focal and total salvage using
brachytherapy compared to each other and to hormonal treatment in
patient with recurrent prostate cancer.
: A decision analytic model comparing costs
and QALYs associated with focal salvage, total salvage and hormonal
therapy was developed. The analysis considered a 1 year time horizon
and adopted a hospital perspective on costs. Probabilities for severe
urogenital, severe gastrointestinal, nonsevere toxicity and their
impact on healthrelated quality of life (SF36) were derived from a
clinical study of the University Medical Centre Utrecht (UMCU) and
complemented with literature data where required. Cost data were
gathered from the UMCU and complemented with available national
cost data. Probabilistic sensitivity analysis, using 10000 Monte Carlo
simulations, was performed to quantify the joint decision uncertainty
at the recommended willingness to pay threshold of €80k / QALY.
: Focal and total salvage with brachytherapy both have higher
expected effectiveness than hormonal treatment but also higher costs
(see table). Generating one additional QALY with focal salvage
brachytherapy costs €93299 compared to hormonal therapy. However,
the model indicates large decision uncertainty between these two
treatments with circa 40% probability for focal salvage brachytherapy
to be costeffective. Focal salvage dominates total salvage as it has
higher expected effectiveness and lower expected costs. Decision
uncertainty between these two alternatives is small, with circa 80%
probability for focal salvage to be costeffective compared to total
salvage. In both comparisons, the main drivers of decision uncertainty
are the probabilities for severe toxicity and impact on healthrelated
quality of life.
Therapy Cost Incremental
cost
QALYs Incremental
QALYs
Hormonal €1840 0.83
Focal
salvage
brachyth.
Total
salvage
brachyth.
€6683 + € 4843 (vs.
hormonal)
€10945 + € 4263 (vs.
focal)
Incremental
cost / QALY
0.88 +0.05 (vs. €93299
hormonal)
0.87 0.01 (vs.
focal)
Dominated by
focal salvage
: Focal salvage using brachytherapy is likely to dominate
total salvage as it is both more effective and less costly. Based on
current data, hormonal treatment of recurrent prostate cancer seems
more costeffective than focal salvage with brachytherapy.
Substantial decision uncertainty exists between focal salvage and
hormonal treatment, driven by uncertain probabilities for urogenital
and gastrointestinal toxicity and impact on healthrelated quality of
life. Therefore, further clinical trials comparing toxicity patterns and
healthrelated quality of life following focal salvage brachytherapy or
hormonal treatment among patients with recurrent prostate cancer
are recommended as most valuable to inform future decisionmaking.
OC34
A NOVEL METHOD TO QUANTIFY PROSTATE SEED IMPLANT PLAN
QUALITY BY PERFORMING INDIVIDUAL SEED DISPLACEMENT ANALYSIS
Y. Le 1 , R. Alexander 2 , E. Armour 1 , D. Song 1
1
Johns Hopkins University, Radiation Oncology, Baltimore MD, USA
2
Southern University, Physics, Baton Rouge LA, USA
: We report on a novel method to quantify the
treatment plan quality for prostate seed implant by performing
Individual Seed Displacement Analysis (ISDA). The clinical relevance of
this method was also investigated.
: A software tool was developed to calculate
dose parameters using seed locations and organ contours exported
from a brachytherapy treatment planning system. ISDA analysis is
defined as the following: for a plan with N seeds used, N additional
plans are automatically generated by removing one individual seed at
a time to simulate the impact of a seed being displaced far enough to
have minimum effect on local dose. The dosimetric impact of
removing each seed is quantified by the reduction of V100 in each
new plan. Although this approach assumes the extreme case in which
a seed is completely missing, the result reflects the dosimetric
sensitivity of positioning error for each individual seed. 'Critical
seeds', defined as those whose displacement resulted in greater than
0.5% V100 reduction, are identified. The number of 'critical seed' per
plan can be used to quantify robustness of treatment plans. To
demonstrate this tool, a planning study and a retrospective case study
were conducted. For planning study, 48 treatment plans were created
independently by 3 experienced planners using ultrasound images
from 8 patients (volumes 28 to 53cc; mean 39cc) and same dosimetric
requirements. Each planner created one I125 plan (145Gy,
0.5U/seed) and one Pd103 plan (125Gy, 2.5U/seed) for each patient.
ISDA analysis was performed for all plans. For retrospective patient
case study, 73 patients' OR preplans were analyzed and number of
'critical seed' for each plan obtained. The postimplant CT dosimetry
results were used to test the correlation between number of 'critical
seed' and actual dosimetry outcome.
: The results of the planning study are shown in the table 1a.
The dose perturbation caused by displacing 'critical seed' is more
significant than average seed, indicating the plans with more 'critical
seeds' are more susceptible to seed displacement error during the
seed implantation. Among 73 patients analyzed using ISDA, 52
patients' plans had less than 5 'critical seeds' and 21 patients' plan had
5 or more 'critical seeds'. The average postimplant CT V100 and D90
from both patient groups are shown in the table 1b. Plans with more
'critical seeds' showed statistically significant correlation with inferior
dosimetric results.
: A method and software tool to perform ISDA was
developed and demonstrated on prostate seed implant cases. 'Critical
seeds' could exist in both I125 or Pd103 based plans and number of
'critical seed' in clinical plans shows direct correlation to the
dosimetric outcome. This tool can be utilized to guide the treatment
planning process to develop more robust plans and therefore to
minimize the potential effect of seed displacement errors.
World Congress of Brachytherapy 2012 S 15
OC35
CBCT GUIDED INTRAOPERATIVE DYNAMIC DOSIMETRY SIGNIFICANTLY
IMPROVES DOSIMETRY FOR I125 PROSTATE BRACHYTHERAPY
R. Westendorp 1 , J. Immerzeel 2 , R. Kattevilder 2 , C. Hoekstra 2 , S. van
de Pol 2 , T. Nuver 1 , A. Minken 1
1
RISO, Physics, Deventer, The Netherlands
2
RISO, Radiotherapy, Deventer, The Netherlands
: To report the dosimetry results and the clinical
experience obtained with routine Cone Beam CT (CBCT) guided intra
operative dynamic dosimetry for 900 prostate patients.
: 900 Patients received transperineal 125 I
brachytherapy for prostate cancer over a period of 5 years. Treatment
was performed as 145 Gy monotherapy (82%) or as a boost (110 Gy)
with external beam radiotherapy. Several weeks prior to the
implantation procedure a volume study was performed to assess the
number of seeds needed. At the same time four fiducial markers were
implanted.
The implantation procedure took place in the operating theater, seeds
were placed under TransRectal UltraSound (TRUS) guidance with
interactive planning. After implantation of the seeds, a TRUSscan was
obtained to contour the prostate and organs at risk. The positions of
the implanted seeds were determined using a CBCTscan that was
merged with the TRUS images using the fiducial markers as landmarks.
Dose calculation was performed on this combined imageset. If
dosimetry was deemed inadequate due to underdosage in critical
areas a correction plan was made and remedial seeds were implanted.
Final dosimetry was performed on new TRUS and CBCT images. The
effect of this procedure was assessed on Day 0 and Day 30 by
analyzing D90 and V100 for the prostate and the dose to the organs at
risk.
The effect of the remedial seeds was quantified by excluding their
dosecontribution at the postimplant plans and compare the resulting
dosimetry with the real postimplant dosimetry.
: Immediately after implantation for 181 (20%) of the patients
a critical underdosage was observed and remedial seeds were placed.
In 2007 in 25% of the cases remedial seeds were placed, that reduced
to 11% in 2011. On average 3.9 (st dev 1.6) seeds were added.
Directly after correction, the mean D90 increased from 96% to 108%,
V100 increased from 85% to 95%.On Day 30 the dosimetry was adequate
for all patients, indicating effective adaptation of initially underdosed
areas in the prostate. With remedial seeds excluded in the corrected
cases on Day 30, the simulated mean D90 and V100 decreased with 12%
and 4% respectively. Without the reimplantation procedure on Day 30
11% of all patients would have had a lower V100 or D90 than we
intended.
The reimplantation procedure took on average 10 minutes of extra
time.
: Intraoperative dynamic dosimetry with CBCT allows
improvement of dosimetry for a considerable group of patients at Day
0 and Day 30. This reduces the need to correct the implants after
finishing the operating theater procedure. The presented procedure is
used routinely and takes about 10 minutes of additional time.
OC36
VALIDATION STUDY OF USBASED HDR PROSTATE BRACHYTHERAPY
PLANNING COMPARED TO CT GOLD STANDARD
M. Gaztanaga 1 , J. Crook 1 , C. Araujo 2 , M. Schmidt 2 , F. Bachand 1 , D.
Batchelar 2
1
British Columbia Cancer Agency, Department of Radiation Oncology,
Kelowna, Canada
2
British Columbia Cancer Agency, Department of Radiation Physics,
Kelowna, Canada
: The use of US in a onestep procedure to both
guide and plan HDRBT for prostate is growing. Phantom studies have
favourably compared the accuracy of US needle tip reconstruction to
the gold standard of CT. We seek to determine the accuracy of US
needle tip reconstruction in vivo using conebeam CT (CBCT) as our
reference standard
: Treatment comprised 46 Gy/23 fractions of
EBRT plus 20Gy/2 HDRBT fractions, replacing the EBRT on days 5 and
15. Each BT fraction was performed under general anesthetic with
paralysis. A median of 16 needles (range 1618) were placed and their
tips identified using live TRUS images and Varian's Vitesse software.
Needle protrusion length from the template was recorded as each tip
was located. This allowed for reverification prior to capturing images
for planning. The needles remained locked in the template which
remained fixed to the stepper while a set of 3D TRUS images was
acquired to reconstruct the needle paths and plan the HDRBT
treatment. Following treatment, the legs were lowered from 90° to
40° to acquire a set of CBCT images. Needles were continuously
monitored on live US to rule out any SUPINF needle displacement
while repositioning legs.
Needles were reconstructed postoperatively in the CBCT images using
Varian's BrachyVision TPS. CTidentified needles were also adjusted
for protrusion length if ≥2mm displacement was observed. The
coordinates of each needle tip in either CT or US were recorded from
the TPS. As the origin of the coordinate system was unique to each
individual image set, the tip of a needle positioned directly above the

S16 World Congress of Brachytherapy 2012
US probe was chosen as a reference point for each pair of USCBCT
images. The cranialcaudal position of each needle tip was then
determined relative to this point in each image set. Finally, the US
based needle tip position was compared to the CTbased position. 21
sets of needles from 12 consecutive patients have been analyzed. The
data from the reference needles was excluded.
: 318 needle tip positions have been compared between TRUS
and CBCT. Of these 205 (64.5%) agreed within 1mm, 84 (26.4%) agreed
within 12mm, and 21 (6.6%) agreed within 23mm. For 8 needles the
discrepancy between tip positions in the 2 modalities was more than
3mm (2.6%).
: US needle tip identification in vivo is at least as
accurate as CT identification, while providing all the advantages of a
onestep procedure.
OC37
THE PROSTATE TUMORLET PROJECT. CRITICAL ANALYSIS OF D90:
TILTING AT WINDMILLS?
D. Todor 1 , P.S. Lin 1 , I. Barani 2 , M. Axente 1 , M.P. Hagan 1 , M. Anscher 1
1
Virginia Commonwealth University, Department of Radiation
Oncology, Richmond VA, USA
2
University of California, Department of Radiation Oncology, San
Francisco CA, USA
: In the PSA era, the small volume of disease and
relatively small number of tumor foci (mean 2.5) prompted the idea
of focal therapy. This work is a focibased analysis of LDR
brachytherapy treatments designed for the whole prostate. We aim to
identify the relationship between prostate D90 parameter and
tumorlets' dose, and to describe the dose received by tumorlets in
traditional whole prostate cancer treatments.This information will be
used to create prescription guidelines for focal therapy.
: A software platform was built to create in
silico prostate tumorlets, of specified morphology, volume and
location. Actual knowledge of tumorlet location was replaced with
statistical inference. Pre and postimplant plans for 14 patients,
using Pd103 and I125, with prostate sizes from 2361 cm 3 were used.
Tumorlets were grown in 9 volume categories from 0.1 to 10cm 3 with
1000 random tumorlets per category. Each tumorlet was superimposed
over the 3D dose distribution and positional, morphological,
dosimetric and radiobiological quantities were computed. The
sensitivity of results to radiobiological parameters was assessed using
two sets of parameters. A treatment reference was established using
the BED EBRT equivalent of a 78Gy regimen (2Gy/fx).
: The preplans were consistent, despite variations in prostate
size, seeds number and planner. With D90=118.9 ±2.4%, the whole
prostate EUBED was on average 135.8Gy3. By comparison, BEDo for the
EBRT regimen was ~130Gy3. In all preplan scenarios, tumorlet
parameters were virtually immune to volume, location or morphology
variations. EUBED and gBEUD told very similar stories, with 98100% of
all tumorlet volumes receiving a gBEUD and EUBED > BEDo. When
separated in 'small' (0.11cc) and 'large' (210cc) volumes, the small
tumorlets were a bit more likely to get an EUBED > BEDo than large
tumorlets (by ~6%). Unlike preplans, the CT based postimplant
evaluations told a dramatically different story (see example in Fig 1).
Uncorrelated with their high D90 (range 91.7125.5%), the probability
of any tumorlet to have EUBED > BEDo was on average only 60% with
the 'small' tumorlets having a significant advantage, 79% vs. 46%, over
'large' ones. While trends were similar, EUBED and gBEUD were
significantly different, with an average probability of values greater
then BEDo of 60% according to EUBED and 83% based on gBEUD.
: Biological dose received by tumorlets in prostate shows
that the D90 parameter is more meaningful for a highly organized
seed implant (true for preplans and maybe stranded seeds). For
poorly structured or disorganized implants, even a D90 > 125% can
produce suboptimal results at the level of foci of disease. A smaller
α/β will further amplify this effect. Also, I125 implants seems more
impacted than Pd103.These results indicate that the architecture of
the implant likely plays an important role and D90 alone is limited in
meaning. Smaller than prostate subvolumes are likely to be the true
target explaining the positive clinical outcome in these cases.
OC38
BIOCHEMICAL DISEASE FREE SURVIVAL OF 3D IMAGE GUIDED
BRACHYTHERAPY BOOST WITHIN A PERMANENT SEED IMPLANT.
A.G. Martin 1 , S. Aubin 1 , N. Varfalvy 1 , E. Vigneault 1 , E. Vigneault 1 , L.
Beaulieu 1 , P. Després 1
1
Centre Hospitalier Universitaire de Québec L'HôtelDieu de Québec,
Radio Oncologie, Quebec, Canada
: This study looks at the biochemical disease free
survival of a Real Time Intraoperative Planned (RTIOP) 3D Image
Guided Brachytherapy Boost within a Permanent Seed Implant (PSI)
and compares to our standard RTIOP approach. Could an inverse
planned focalized boost to the known pathologic disease sites improve
local DFS while protecting sensitive zone within the GTV?
: Using a high precision 3D US implant
guidance, we planned and implanted a boost area to multiple core
biopsies sites within the prostate. 1617 localized prostate cancer
patients (median age = 64 years old), were consecutively treated with
RTIOP/PSI. Starting in 2003, 203 (BG) had prostate topographic biopsy
results and a boost was delivered to the dominant involved lesion
(DIL). 1414 patients were treated without boost. Treatment delivery
was made using an integrated system with 3D ultrasound, RTIOP
dosimetry and robotic seed delivery (FIRST, Nucletron). Plans were
generated using a simulated annealing inverse planning algorithm
(IPSA). The planning objectives are a dose coverage of 144 Gy (PD)
with margin of 34 mm. V150 (V200) covers ≤ 2/3(1/3) of the prostate
volume. The urethra D10 should received ≤216 Gy and the D5 should
be ≤220 Gy. Finally, the boost volume (BV) is to be covered by 216 Gy.
Toxicities were reported, compared and published. Biochemical
disease free survival is presented and pattern of failure is described.
: 203 (BG) localized prostate cancer were treated using a boost
with RTIOP. They consisted in low risk for the majority. 7,9% being
intermediate risk tumor according to D'Amico's risk definition. At
42,97 (579) months median, only 3 failures were reported (cure rate
of 98,5%). All 3 were metastatic disease at recurrence. One of them
had prostatic biopsy, which did not reveal cancer. As compared to our
World Congress of Brachytherapy 2012 S 17
reference cohort of 1414 patients, 95,4% were cured at a median
followup of 57 (1194) months median. (Figure 1)
: Considering a shorter followup, usage of a DIL Boost in
permanent prostate cancer has proven to equally tolerate and may
well prove to give a better local control on the long run.
OC39
OUTCOME OF IMAGE GUIDED ADAPTIVE BRACHYTHERAPY IN LOCALLY
ADVANCED CERVICAL CANCER
J.C. Lindegaard 1 , L. Fokdal 1 , S.K. Nielsen 2 , L.L. Røhl 3 , E.M. Pedersen 3 ,
L.K. Petersen 4 , E.S. Hansen 5 , K. Tanderup 6
1
Aarhus University Hospital, Department of Oncology, Aarhus,
Denmark
2
Aarhus University Hospital, Department of Medical Physics, Aarhus,
Denmark
3
Aarhus University Hospital, Department of Radiology, Aarhus,
Denmark
4
Aarhus University Hospital, Department of Gynecology, Aarhus,
Denmark
5
Aarhus University Hospital, Department of Pathology, Aarhus,
Denmark
6
Aarhus University Hospital Aarhus University, Department of
Oncology Institute of Clinical Medicine, Aarhus, Denmark
: Clinical outcome data are sparse on imaging
guided adaptive brachytherapy (IGABT) in locally advanced cervical
cancer. We report the results of our first 5 year experience with MRI
based IGABT using the GEC ESTRO guidelines.
: From 20062010 a total of 145 consecutive pts
(median age 55 [2784]) were treated with IGABT. Five pts were
excluded: 3 pts with aberrant histology/uncertain origin (2 clear cell,
1 transitio cell) and 2 pts with distant progression during treatment.
Histology of the 140 included pts showed squamous cell carcinoma in
83%, adenocarcinoma in 12% and adenosquamous carcinoma in 5%.
FIGO stage distribution was: IB 11%, IIA 4%, IIB 55%, IIIA 5%, IIIB 19%,
IVA 4% and IVB 2%. All pts received external beam radiotherapy (EBRT)
4550 Gy/2530 fx. Concomitant weekly cisplatin was used in 110 pts
(79%). Neoadjuvant chemotherapy (24 courses of cisplatin, 5FU &
ifosfamide) was employed in 8 pts with very advanced locoregional
disease. PDRBT was given with 23 implants delivering 1020 hourly
pulses per BT fraction. Of the 300 implants, 188 (63%) were pure
tandemring intracavitary implants and 112 (37%) consisted of a
combined intracavitary/interstitial implant using the ring as template
for transvaginal implantation of needles. A BT applicator guided
stereotactic IMRT boost was used in 2 pts. Dose planning was based on
1.5 or 3T MRI. Planning aim for the cumulative dose of EBRT+BT
calculated as equivalent dose in 2 Gy fractions was a D90 ≥ 85 Gy for
high risk clinical target volume (HR CTV) (α/β=10, repair half time
1.5h). For OAR the DVH constrains were 90 Gy for the minimal dose to
the D2cc of bladder and 7075 Gy for the D2cc of rectum, sigmoid and
bowel (α/β=3, repair half time 1.5h).
: Planning aim for HR CTV was reached in 89% of the pts (Table
1). The bladder constrain was respected in all pts whereas the 70 Gy
constraint for rectum, sigmoid and bowel was realised in 87%, 79% and
92% of the pts, respectively. D2cc > 75 Gy for rectum and sigmoid was
found in 1% and 2% of the pts. Median followup time was 31 months.
Five pts had persistent disease and 5 pts developed local recurrence.
Local control (LC), cancer specific (CSS) and overall survival (OS) at 3
years was 91%, 86% and 78%, respectively. HR CTV D90 ≥ 90.4 Gy
(median) was prognostic for LC (p=0.0004), CSS (p=0.027) and OS
(p=0.024) in univariate analysis. HR CTV volume < 29.6 cc (median)
was prognostic for LC (p=0.006) and CSS (P=0.016) but not for OS.
Influence of HR CTV dose and HR CTV volume on LC is shown in Figure
1. Actuarial late G3G4 morbidity (CTCv3.0) for bladder, rectum,
sigmoid and/or bowel was 5% (3 pts). Vaginal G3 morbidity (stenosis)
was seen in 4 pts with vaginal involvement at diagnosis.
DVH Parameter Mean (Gy, EQD2) SD
HR CTV D90 91.0 5.9
IR CTV D90 67.5 6.5
Bladder, ICRU point 65.9 9.2
Bladder D2cc 71.0 6.3
Rectum, ICRU point 65.9 6.8
Rectum D2cc 64.0 5.4
Sigmoid D2cc 65.3 6.0
Bowel D2cc * 60.8 6.6
*
D2cc for bowel only systematically reported since September 2008
(72 pts)
: We confirm that MRI guided IGABT provides a high dose
to the tumour and a low dose to OAR resulting in excellent local
control and survival with very limited late morbidity even in extensive
disease.
OC40
IMAGE GUIDED BRACHYTHERAPY ENDS THE DEBATE OF SYSTEMATIC
RADICAL HYSTERECTOMY IN LOCALLY ADVANCED CERVICAL CANCER
R. Mazeron 1 , J. Gilmore 1 , I. Dumas 2 , J. Champoudry 2 , J. Goulart 1 , B.
Vanneste 1 , A. Tailleur 1 , P. Morice 3 , C. HaieMeder 1
1 Institut Gustave Roussy, Radiation Oncology, Villejuif, France
2 Institut Gustave Roussy, Medical Physics, Villejuif, France
3 Institut Gustave Roussy, Surgical Oncology, Villejuif, France
: To evaluate the outcomes of 3D image guided
brachytherapy (IGABT) after concomitant chemoradiation (CCT) in
locally advanced cervical cancer.
: As part of the retroEMBRACE revisory group,
clinical data from patients treated at Institut GustaveRoussy from
2004 to 2009 with curative intent IGABT after CCT were reviewed.
Patients received pelvic +/ paraaortic CCT (4550.4 Gy) followed by
MRI or CT guided pulsed dose rate BT. BT was performed according to
GECESTRO guidelines. Additional nodal or parametrial EBRT boosts
were performed when indicated. In a first period, stage I or II patients
systematically underwent radical hysterectomy or were offered a
randomized study comparing hysterectomy versus observation in case
of complete remission. Following the results of this trial,
hysterectomy was limited to salvage treatment.
: Of 163 patients identified, 27% had stage 1B, 6% IIA, 51% IIB,
3% IIIA, 9% IIIB and 3% IVA. At diagnosis, median tumour volume was 55
cm 3 This abstract forms part of
the official conference media programme
and will be available on the day of presentation.
(3269). Squamous cell carcinoma was the commonest histological
subtype (87%). Nodal involvement was noticed in 37% of the patients;
among them, 15% had para aortic involvement. Ninety percents
received concomitant chemotherapy and 18% received pelvic plus
paraaortic EBRT. BT was based on MRI in 88% of the cases and on CT

S18 World Congress of Brachytherapy 2012
for the remaining 12%. Vaginal personalized mould was used in the
majority of applications (95%), with an intracavitary technique in all
cases except two. The doses delivered (EBRT + BT, in EqD2) were
67.1+/6.4 Gy (α/β=10) to 90% of the IRCTV, 78.1+/9.6 Gy (α/β=10)
to 90% of the HRCTV. The D2cc for the bladder, rectum and sigmoid
were 67.8+/6.7 Gy, 58.8+/5.9 Gy and 58.3 Gy+/5.7 (α/β=3)
respectively. Sixtyone patients (37%) underwent a radical
hysterectomy. Macroscopic residual disease was found in 13 cases.
With a median followup of 36 months (579), 45 patients had
relapsed. Twelve local relapses were reported (5 central and 7 lateral
+/ central), of which 4 were isolated. There were 22 nodal failures
(10 pelvic and 12 paraaortic) and 28 metastatic relapses. At the time
of failure, 70.4% of the patients had distant metastasis, and this was
isolated in more than a half. The 3 year OS and DFS were 84% and 73%
respectively. Local control was 92% and pelvic control was 86%. Local
control decreased in relation to the initial tumour width: 97% for

S20 World Congress of Brachytherapy 2012
obtain comparable doses to the target volumes. Dose deescalation
and normalisation to a HR CTV D90 of 85 Gy resulted in low point A
doses in a significant number of patients. Studying dose deescalation
for small tumours at BT and reducing the vaginal loading may be a
further step for better therapeutic gain. This hypothesis needs to be
tested in a prospective clinical study.
OC45
FEASIBILITY OF ADC MAPPING IN ASSESSMENT OF TUMOR RESPONSE IN
MRIBASED HDR BRACHYTHERAPY FOR CERVICAL CANCER
K. Hosseinzadeh 1 , M.S. Rajagopalan 2 , S. Beriwal 2
1
University of Pittsburgh Medical Center, Radiology, Pittsburgh PA,
USA
2
University of Pittsburgh Cancer Institute, Radiation Oncology,
Pittsburgh PA, USA
: GECESTRO recommends T2weighted MRI for
assessment of residual disease and 3D high doserate brachytherapy
(HDRBT) planning for cervical cancer. It can be difficult to distinguish
radiation changes from residual tumor on this sequence. Diffusion
weighted imaging (DWI) is sensitive to diffusion of water molecules in
tissue and has shown promise in characterizing pathological processes
at a microscopic level. Tumor cell death and corresponding changes in
water homeostasis are reflected in increased apparent diffusion
coefficients (ADC) on DWI. The goal of this study was to determine the
feasibility of ADC mapping with ring and tandem applicator in place
and to compare the response to therapy with conventional T2
weighted sequence.
: Patients diagnosed with cervical cancer
underwent MRIbased HDRBT. PreEBRT MRI (preRT MRI) was
compared to the final treatment planning MRI during HDRBT (postRT
MRI). Patients without T2 signal abnormality on any postRT MRI were
excluded from the study. All studies were interpreted by a board
certified radiologist experienced in pelvic MRI. Signal intensity was
measured in the tumor volume (T2Tumor) and in the psoas muscle
(T2Psoas) by drawing a regionofinterest. In a similar fashion,
corresponding tumor ADC values were measured. The T2 signal of the
tumor was then normalized by calculating the ratio between T2
Tumor and T2Psoas (T2Ratio). Treatment response was determined
using a paired ttest for T2 Tumor, T2ratio, and ADC values.
: 11 patients with both preRT and postRT MRI performed at
the same institution were included. Average age was 48.9 years and
91% had squamous cell histology. In the postRT images, T2Tumor
was significantly lower than that in the preRT images (418.5 vs.
605.6, p=0.03) and there was no difference in T2Psoas. T2Ratio
demonstrated a statistically significant decrease with treatment (1.7
vs. 2.6, p=0.04). In three patients in whom the T2Tumor increased in
the postRT study (mean: +37.8%), the T2Ratio decreased (mean:
38.4%). ADC values demonstrated a highly significant increase with
treatment (1509.9 vs. 1037.0, p

S22 World Congress of Brachytherapy 2012
Spain
4 Clinica Universitaria de Navarra, Oncologia Medica, Pamplona, Spain
: To determine the impact of implant sequence
(perioperative vs. postoperative) in patients with resected squamous
cell head and neck cancer treated with adjuvant HDR brachytherapy.
: From 2000 to 2011, 78 patients (57 men and
21 women, median age 57 years, range, 3293) were implanted either
at the time of surgery (Perioperative Group) or at a variable length of
time after surgery (Postoperative Group). Both groups were well
matched with regards to the quality of the surgical margins. One third
of the cases received HDR brachytherapy as the only adjuvant to a
total dose of 32 Gy in 8 b.i.d treatments for R0 resections and 40 Gy
in 10 b.i.d treatments for R1 resections. Twothirds of the cases
received HDR brachytherapy to a total dose of 16 Gy for R0 resections
and 24 Gy in 6 b.i.d treatments for R1 resections combined with a
median of 45Gy of External Irradiation (EBRT) or chemoradiation.
: The entire treatment length (surgery to end of irradiation)
was shorter in perioperative patients than in postoperative patients
(71 days vs. 98.5 days; p=0.0001). The rate of Grade ≥3 RTOG
complications in perioperative and postoperative patients were 44.2%
and 23.1%, respectively (p=0.088). After a median followup of 7.1
years (0.610.9), the 10year actuarial local control rates in
perioperative and postoperative patients were 85.4% and 73.3%,
respectively (p=ns) and the 10year actuarial locoregional control
rates were 78.2% and 45.2%, respectively (p=0.01). Diseasefree
survival rates in perioperative and postoperative patients at 10 years
were 54.1% and 15.8% (p=ns) and overall survival rates at 10 years
were 62.4% and 15.5%, respectively (p=ns).
: The use of perioperative brachytherapy allows an earlier
completion of the adjuvant irradiation program. This may be an
advantage in terms of locoregional control although at the expense of
an increased toxicity.
OC53
FROM LOW DOSE RATE TO HIGH DOSE RATE BRACHYTHERAPY IN LIP
CARCINOMA: SAME RESULTS BUT LESS COMPLICATIONS
J.L. Guinot 1 , L. Arribas 1 , M.I. Tortajada 1 , M. Carrascosa 1 , M. Santos 1 ,
P. Soler 1 , A. Mut 1 , C. Pesudo 1 , M.L. Chust 1
1
Instituto Valenciano Oncologia, Department of Radiation Oncology,
Valencia, Spain
: Low dose rate (LDR) brachytherapy (BT) has been
used during several decades to treat lip carcinomas. Nowadays it has
been replaced by high dose rate (HDR) but very few cases have been
reported in the literature. We compare our experience with LDR and
HDR in lip carcinoma in a single institution.
: From 1990 to 1997, 99 patients with invasive
lip carcinoma were treated with LDR BT and from 1999 to 2010, 104
consecutive patients were treated with HDR BT. Mean age was 67 and
72 years old. Distribution by stage T1, T2, T3, T4 was 53.5%, 15.1%,
3.1%, 28.3% with LDR and 52.9%, 32,7%, 0%, 14,4% with HDR. N0 were
92.9% and 92.3% respectively. Some cases were treated after surgery
with positive margin (34.3% with LDR and 16.3% with HDR) and with
external beam radiation therapy plus BT (8.1% vs 2.9%). Parallel
metallic needles in a triangle shape fixed with templates were used in
100% of HDR and 76% of LDR cases, and plastic tubes in 24% of LDR
cases. All HDR patients were treated in five days, most of them with 9
fractions of 4.55 Gy at 90% isodose, twice a day, to a total dose of
40.545 Gy.
: The median followup was 63 and 51 months with LDR and
HDR BT. Five patients suffered local relapse in each group. Overall
local control, in T1, T2 and T4 were 94.9%, 100%, 86.6%, 89.3% with
LDR and 95.2%, 100%, 94.1%, 80% with HDR. With surgical salvage,
definitive local control was 97% and 98.1% respectively. Disease free
survival was 95.9% vs 94.2%. Soft tissue necrosis and bone necrosis
were 15.1% and 1% with LDR but with HDR there was no case of
necrosis. A fair or bad cosmetic result was described in 11.1% of LDR
cases but none of HDR cases.
: Both series are similar in characteristics. HDR BT with
rigid needles is a simple technique with very good long term results
and very few complications with nine fractions during five days. Local
control and disease free survival are just the same with LDR and HDR,
but late complications are minimal with HDR and less than with LDR
BT. Cosmetic results are better due to the excellent dose
homogeneity, therefore HDR BT can be recommended as a standard in
lip carcinoma with this treatment regimen.
OC54
LONG TERM OUTCOMES OF INTERSTITIAL BRACHYTHERAPY IN SOFT
TISSUE SARCOMAS
S. Laskar 1 , A. Puri 2 , A. Gulia 2 , B. Rekhi 3 , S. Juvekar 4 , S. Desai 3 , S.
Desai 4 , S. Gupta 5 , J. Ghosh 5 , N. Jambhekar 3
1
Tata Memorial Hospital, Radiation Oncology, Mumbai, India
2
Tata Memorial Hospital, Surgical Oncology, Mumbai, India
3
Tata Memorial Hospital, Pathology, Mumbai, India
4
Tata Memorial Hospital, Radiology, Mumbai, India
5
Tata Memorial Hospital, Medical Oncology, Mumbai, India
: To evaluate the clinical outcomes & long term
adverse effects of interstitial brachytherapy (BRT) for adult patients
with soft tissue sarcomas (STS).
: From July 1990 to June 2008, 198 patients
(median age 42 years, range 1890) with STS received BRT as part of
locoregional treatment at our institute. There were 128 males and 70
females, majority (n=138, 69.6%) had primary lesions. Spindle cell
sarcoma (26%) was the commonest histological type, and 52.5% had
highgrade sarcomas. Treatment included wide local excision followed
by BRT with or without external beam radiotherapy (EBRT). Eighty one
patients (41%) received BRT alone.
: The 10year local control (LC), diseasefree survival (DFS),
and overall survival (OS) were 77.1%, 62.6%, and 70.8%, respectively.
Patients receiving a combination of BRT and EBRT had comparable LC
to those receiving BRT alone (76.1% vs. 81.6%, p=0.081). There was no
significant difference in LC for patients receiving LDR vs. HDR BRT
(75.1% vs. 80.9%, p=0.120). Postbrachytherapy, surgical wound
healing complications was seen in 26 (13.1%) patients
(delay/dehiscence: n = 15, wound infection: n =11). The 5yr
cumulative incidence (CI) of RT related late toxicity was 28.5%
(Subcutaneous fibrosis: 26.4%, limb oedema 7.4%, joint
stiffness/arthritis: 6.6%, osteoradionecrosis: 2.4%, fracture: 2.4%).
There was a trend towards reduction in late toxicity with the use of
BRT alone (5yr CI: 19.5% vs. 32.4%, p=0.081). One patient developed a
second cancer (OGS). There were no BRT related vascular or nerve
injuries.
: Interstitial BRT with or without EBRT results in excellent
outcome for patients with STS. Radical BRT alone, when used
judiciously in select group of patients, results in excellent local
control and functional outcome with reduced treatmentrelated
morbidity.
OC55
LONGTERM RESULTS OF PDR BRACHYTHERAPY AS A BOOST IN
SQUAMOUS CELL CANCERS OF THE ANAL CANAL
D.P. Peiffert 1 , A. Haddad 1 , L. Rangeard 1 , I. Buchheit 2 , S. Huger 2 ,
A.S. Baumann 1 , S. Oldrini 1
1
Centre Alexis Vautrin, Radiation Oncology, Vandoeuvre les Nancy,
France
2
Centre Alexis Vautrin, Medical Physics, Vandoeuvre les Nancy, France
: Squamous cell cancers of the anal canal are
generally managed with sphincterpreserving external beam
radiotherapy with or without chemotherapy. The boost to the primary
tumour can be given with brachytherapy, thereby decreasing dose and
toxicity to the tissues surrounding the anal canal. Previously, a
National multicenter study demonstrated the feasibility of
brachytherapy using pulseddose rate delivery. We hereby report the
longterm results of a large cohort of patients treated with this
technique at a single center.
: 99 patients with squamous or basaloid
histology were treated between 1996 and 2007 in a sphincter
preserving schedule by pelvic irradiation with a PDR brachytherapy
boost. Cancers of the anal margin or with other histology were not
included in this study. External beam radiotherapy of the pelvis
delivered 45 Gy in 25 fractions of 1.8 Gy ( range 36 to 50.4 Gy with
1,8 to 3,0 Gy per fraction). After a mean gap of 25 days, a PDR
brachytherapy boost delivered a dose of 20 Gy (range 1020Gy) with
0.5 Gy per pulse every hour using a ring template with one plane of 3
World Congress of Brachytherapy 2012 S 23
to 6 needles spaced at 10mm . 58% of patients also received
chemotherapy during the initial phase of treatment. Charts were
retrospectively evaluated for local tumour control and long term
toxicity.
: Median followup for this cohort was 54 months. Clinical
exam was performed by the brachytherapist every 3 months during
the 2 first years, and every 6 months later. 85% of patients were
female, and mean age was 62 years. Stage distribution was 15%, 69%,
12% and 4% for T1, T2, T3 and T4, respectively. AJCC TNM staging was
14%, 56% and 30% for stage I, II and III, respectively. Most commonly
used chemotherapy regimen was cisplatinum and 5FU delivered
during weeks 1 and 5 of the irradiation. 15 local recurrences were
recorded, of which 6 were isolated. Recurrence rates by T stage were
7%, 15% and 25% for T1, T2 and T3/4 tumours. Of 37 patients with T1
2N0 tumours who did not undergo prophylactic inguinal irradiation, 5
(14%) inguinal failures were recorded. Late grade 3 or 4 toxicity was
as follows: 1 stool incontinence, 1 anal stenosis, and 11 soft tissue
necrosis. The actuarial colostomy free survival and prognostic factors
will be presented.
: Treatment of anal canal squamous carcinomas by PDR
brachytherapy boost after external beam radiotherapy results in good
local control rates comparable to historical series. The afterloading
setup for PDR delivery is a safer alternative in terms of radiation
exposure, and makes it the technique of choice to prescribe the dose
rate and optimise the dose distribution, and is used in routine in our
department.
OC56
BLADDER SPARING APPROACH WITH BRACHYTHERAPY IN 1040
PATIENTS
B. Pieters 1 , L. Blank 1 , C. Koedooder 1 , R. van Os 1 , M. van de Kar 1 , E.
Jansen 1 , E. Geijsen 1 , C. Koning 1
1
AMC, Radiation Oncology, Amsterdam, The Netherlands
: Several French, Belgian and Dutch radiation
oncologists have reported good results with the combination of
limited surgery followed by external beam radiotherapy and
brachytherapy in early stage muscleinvasive bladder cancer. This
approach has seldom been followed by others. This retrospective
observational study investigates treatment outcome in the largest
cohort of patients treated by brachytherapy for early stage muscle
invasive bladder cancer.
: Data from 12 out of 13 departments in The
Netherlands using this approach have been collected and imported in
a multicenter database The number of patients of this cohort was
1040.
Patients were treated by external beam radiotherapy (1055 Gy) and
brachytherapy (2540 Gy and 5060 Gy). In 247 cases a partial
cystectomy was performed.
Results were analyzed according to tumor stage and diameter,
histology grade, age and brachytherapy technique (Continuous Low
Dose Rate (CLDR) and Pulsed Dose Rate (PDR)).
: The age of patients ranged from 28 to 92 years. The gender
distribution was 811 males and 229 females. There were 2 pT0, 126
pT1, 797 pT2, 100 pT3, 1 pT4, and 8 pTx tumors. The distribution of
differentiation grade was 13 well, 167 moderately, 824 poorly, and 16
undifferentiated.
At 1, 3, and 5 years local control rates were 91%, 80%, and 75%,
metastasisfree survival rates were 91%, 80%, and 74%, diseasefree
survival rates were 85%, 68%, and 61% and overall survival rates were
91%, 74%, and 62%, respectively. There were 136 patients with local
recurrences only, 94 with both local recurrence and distant
metastases and 145 with distant metastases only. Of the 232 local
recurrences 49 were muscle invasive, 90 were nonmuscle invasive, 31
both invasive and noninvasive, and 62 were unknown. Cystectomy as
salvage treatment was performed in 60 patients.
The differences in outcome between the contributing departments
were small. After multivariate analysis the only factor influencing the
local control rate was the brachytherapy technique in favor of PDR
(HR 0.46; P = 0.004).
: External beam radiotherapy followed by brachytherapy,
combined with limited surgery offers good results in terms of local
control and bladder sparing for selected groups of patients suffering
from earlystage muscle invasive bladder cancer. These patients
should be counseled on the possibility for a bladder sparing procedure
by the use of brachytherapy.
All participating centers are acknowledged for the contribution:
University Medical Center Utrecht, University Medical Center
Groningen, Medical Center Haaglanden, Medisch Spectrum Twente,
Institute Verbeeten, Radiotherapeutic Institute RISO, The Netherlands
Cancer Institute / Antoni van Leeuwenhoek Hospital, University
Medical Center Leiden, Catharina Hospital Eindhoven, Arnhem
Radiotherapeutic Institute, Radiotherapeutic Institute Friesland,
Academic Medical Center Amsterdam
57
PARTIAL BREAST IRRADIATION: FROM THE US SIDE
R. Kuske 1
1 Arizona Cancer Specialists, Brachytherapy, Scottsdale, USA
Brachytherapy was the first method of breast irradiation. Radium
needle brachytherapy was successfully used to treat breast cancer
more than 50 years prior to the widespread use of linear accelerators
to treat the entire breast. Indeed, Geoffrey Keynes, British Surgeon
and brother to the famous economist John Maynard Keynes, published
his breastpreserving outcomes in 1938 in the British Medical Journal.
His patients were treated with radium needles during the 1920s and
1930s. His remarkable conclusion was stated in this historically
important manuscript: “These results (with radium needle breast
brachytherapy) compare favorably with the classic Halsted radical
mastectomy.”
In the US, modern breast brachytherapy began at the Ochsner Clinic in
New Orleans, LA, in 1991. In our multidisciplinary clinic, a
Venezuelan woman with T2N0M0 right breast cancer insisted upon a
treatment option that “can return me to work and my family in one
week.” Drawing on our brachytherapy experience with soft tissue
sarcoma after a compartmental resection, we delivered 45 Gy in 4
days with low doserate Iridium192 to a target volume 2 cm beyond
the surgical cavity edge.
Pleased with the results in this original patient, we wrote a Phase II
prospective clinical trial investigating 45 days widevolume breast
brachytherapy as an alternative to conventional 6week whole breast
irradiation in select breast cancers. This study accrured 162 patients
and was initially reported in a matchedpair analysis.
Two years later, William Beaumont Hospital in Michigan initiated a
similar prospective Phase II clinical trial that has been widely
published with similar longterm outcomes. In 1995, I designed and
wrote RTOG 9517, the first modern multiinstitutional phase II
clinical trial with interstitial bracytherapy PBI. This trial accrued
briskly with excellent local control rates of 96% at 5 years and 95% at
7 years. Current investigators do not give any credence to the earlier
Guy’s Hospital Trial (Fentiman) or the Christie Hospital trial (Ribeiro)
because of poor patient selection and absent quality control of
bracytherapy/electron beam dosimetry or target volume coverage.
Interstitial brachytherapy was considered by many to be too skill
dependent and invasive. These concerns spawned the MammoSite
balloon catheter in 2002. The simplicity of this singlechannel single
entry brachytherapy device popularized PBI in the US. Other single
entry devices, such as the multichannel SAVI and Contura catheters,
soon came into practice across the US, allowing more refined dose
shaping. The ability to pull the brachytherapy dose cloud away from
the skin is considered a major improvement, and further increased PBI
use in the US. It is currently estimated that up to 20% of eligible
patients are receiving PBI in many areas of the US.
The ultimate test of a new treatment or potential paradigm shift is
considered to be the prospective randomized clinical trial. NSABP B
39/RTOG 0413 has accrued 4050 out of a planned 4300 women as of
January 2012. This study may close in January, 2013. There are
currently 9 phase III clinical trials investigating PBI across the world,
attesting to the significance of this concept to patients and
oncologists alike. Singledose intraoperative methods of delivering
PBI, such as Intrabeam and intraoperative electrons, are also under
investigation.

S24 World Congress of Brachytherapy 2012
In summary, a 21year experience with PBI in the US has inspired a
plethora of scientific endeavors. Lumpectomy, sentinel node
mapping, and PBI may offer women with select breast cancers the
highest quality of life and breast conservation.
58
PARTIAL BREAST IRRADIATION: FROM THE EUROPEAN SIDE
E. Van Limbergen
University Hospital Gasthuisberg, Leuven, Belgium
Abstract not received
59
HOW CAN BRACHYTHERAPY BE MORE SYSTEMATICALLY USED IN
EMERGING COUNTRIES
R. Bilimagga 1
1
Bangalore Institute of Oncology, Radiation Oncology, Bangalore,
India
This can be broadly divided into
a) Resources (Equipment and Manpower)
b) Policies
c) Strategies
a) RESOURCES (Equipment and Manpower)
In view of the financial resource crunch in these countries, we have to
consider several factors to help brachytherapy be used more
systematically in the emerging economies. Some of these
considerations would be :
1 ) Identifying common cancers occurring in a specific geographic
location helps in choosing an appropriate brachytherapy equipment
for a defined population.
2) Choosing a long halflife brachytherapy isotope will reduce the
number of source change expenses (Eg : Cobalt≈Iridium).
3) Efficacy of Xray based brachytherapy to reduce the cost
4) Number of channels in HDR (3≈18 or more) Lower channels can be
selected.
5) In areas where the patient volume is less, LDR (Low dose rate)
brachytherapy can be used & HDR (High dose rate) can be used where
high volume is present.
6) Cost of the manpower training can be reduced by imparting local
onsite training through collaborations with the vendors or through
professional associations like IBS (Indian Brachytherapy Society).
7) The use of an ultrasound machine instead of CT scanner for imaging
can substantially reduce the cost wherever CT Scanner installation is
not cost effective.
b) POLICIES
Certain Government policies will be helpful in reducing the costs.
a) Optimum use of space can be achieved by the use of Teletherapy
room for Brachytherapy also.
b) Life saving equipments like brachytherapy machines must be
exempted from import duty.
c) Accessories can be manufactured locally with guidance from
Vendors instead of importing them.
d) Cost to the patients can be subsidized through national insurance
health policies and by participating philanthropists.
e) Portable brachytherapy machines which can be moved between
different centers will help in resource sharing.
f) The life of the HDR source can be extended by using it as a PDR
(Pulsed dose rate) and LDR (Low dose rate) source, after the activity
comes down.
g) Brachytherapy facility costing must be included upfront in the
initial Radiotherapy oncology project planning.
c) STRATEGIES
The Government, vendors, private organizations, NGO’s and medical
schools can adopt important cost saving strategies.
a) Networking of cancer centers can be done through HUB and spoke
model.
b) Equipment and sources can be procured by the government (3 tier
model).
c) Free standing brachytherapy facility in cities with a centralized
treatment planning will be helpful in a resource sharing model.
60
NORTH AMERICA
D. Beyer
Arizona Oncology Services, Scottsdale, USA
Abstract not received
61
AUSTRALIAN PROSTATE BRACHYTHERAPY
J. Miller
Alfred Health, Radiation Oncology, Melbourne, Australia
Australia is 95% of the size of the continental USA, but has a
population of 23,000,000. About twothirds of this population live in
the eight capital cities of each of the component Australian States or
Territories. Australia has a higher GDP per capita than the United
States. The health care system in Australia is a mixed private and
public scheme: a Federal Governmentfunded insurance scheme
(Medicare Benefits Scheme, or MBS) provides funding for universal
cover delivered by a public hospital system overseen by each State
or by subsidising care to patients in a private inpatient or ambulatory
setting, independent of the individual Staterun "public hospitals". To
supplement and support this Government system, about 45% of
Australians purchase private health insurance in a competitive
market, allowing these people funded access to a private hospital and
to a private health careprovider system.
There are almost 20 000 cases a year of prostate cancer in Australia,
and 3000 deaths. About 5000 men a year have low risk disease at
diagnosis. Most treatment modalities are available for men with
prostate cancer in Australia: active surveillance, radical
prostatectomy (including robotassisted), external beam radiotherapy,
both high and low doserate brachytherapy, hormonal and
chemotherapy treatments. Proton treatment is not available; HIFU
and cryotherapy are available but not common.
In the period 7/20096/2010 there were over 6000 prostatectomies in
Australia, while there were about 1200 I125 seed implants.
Transperineal TRUSguided permanent seed implants commenced in
Australia in 1997, in Perth. No Governmentinsurance funding was
available until the procedure was approved for men with NCCN low
risk disease in 2001, after an expert panel review of the evidence for
safety and efficacy. In 2006 a further similar review extended the
allowable indications for seed brachytherapy to include men with GS 7
disease. The growth in numbers and brachytherapy centres has been
steady, to now include 15 centres nationally, in most states or
territories. Only iodine125 permanent seeds are easily available for
clinical use in Australia; palladium and caesium are not used.
The procedure is not, however, available freeofcharge to men in the
public hospital system in all States, and is effectively rationed where
it is available. The majority of men implanted in Australia are
privatelyinsured patients, having procedures in private hospitals, and
bearing significant outofpocket costs above the fixed MBS subsidy.
The calculated cost to the MBS, other government agencies, and by
either the patient or private insurer in Australia for treatment and
10 years followup is very similar in either the private or public
sectors, and between modalities, ranging from AUS$ 12,900 for EBRT
(and no androgen deprivation), through AUS$ 13,100 for a seed
implant, to AUS$ 14,800 for a radical prostatectomy (nonrobot).
There is, however, a major difference in the allocation of costs, with
inpatient costs being the driver for RP, and the seed cost the driver
for brachytherapy.
Seed brachytherapy has become a standard of care treatment for men
with lowrisk or "good" intermediaterisk disease in Australia, but is
unevenly available for reasons that relate to history, economics, the
regulatory arrangements of the Australian health care system,
allocation of costs, and the number and distribution of prostate
cancer specialists in the various disciplines.
World Congress of Brachytherapy 2012 S 25
62
EUROPE
Y. Lievens
University Hospital Gasthuisberg, Leuven, Belgium
Abstract not received
63
SOUTH AMERICA
M. de la Torre
CeDeTe, Buenos Aires, Argentina
Abstract not received
64
THE ROLE OF INDUSTRY IN DEVELOPING COSTEFFECTIVE
BRACHYTHERAPY
E. Rosenblatt 1
1
IAEA International Atomic Energy Agency, Applied Radiation Biology
and Radiotherapy Section, Vienna, Austria
Brachytherapy has become increasingly popular and highly tied to
technological development. The increasing popularity of
brachytherapy is a direct consequence of its effectiveness in the cure
or palliation of various forms of cancer. But also, the increasing
dependence of brachytherapy on complex technology, determines a
corresponding increase in costs.
Costeffectiveness analyses relate the additional cost to its
incremental impact on any clinically relevant measure of benefit.
Because one of the primary uses of economic analysis is to allocate
limited resources among diverse interventions, benefit has to be
measured in units that are universally applicable to all interventions.
“Yearsoflifesaved” is the most commonly used measure. When
calculating “costeffectiveness” then, only cost and survival must be
measured. A treatment’s costeffectiveness ratio is calculated by
dividing its incremental cost by its incremental impact on survival as
compared to the most reasonable alternative treatment. The result of
this rate is then expressed in dollars per yearsoflifesaved.
Interventions costing less than an additional U$ 50.000 per yearof
lifesaved are considered “costeffective”.
The industry has traditionally had a key role in the development of
brachytherapy as we know it today. The brachytherapy industry now
mostly gravitates around two main lines of production; [1] high dose
rate (HDR) remote afterloaders and accessories, and [2] prostate
brachytherapy systems. Demand by patients and physicians for
innovations to help cancer patients, drives investment in
biotechnologies given the potential profits. From the industry
perspective, pricing of new cancer innovations is influenced by
development costs (including risk at each stage of development)
production costs, potential market size, pricing of comparables, and
ultimately the novelty and value of the new product in the
marketplace.
Innovation in the brachytherapy field has to pay close attention to a
number of issues such as the international basic safety standards as
well as standards of safety determined by the ICRP, source
characterization protocols, IEC compliance and compliance with the
requirements of specific national or regional regulatory bodies such as
the FDA in the US and the EURATOM Directives in the EU.
The introduction of HDR brachytherapy allowed treatments to be
given in minutes rather than days, replace hospital admissions by
ambulatory treatments and eliminate the need for spinal or general
anaesthesia, in other words; more costeffective brachytherapy.
Economic analysis have shown that in departments that treat more
than 300 new cases of cervical cancer per year, the use of HDR
brachytherapy is clearly costeffective as compared with LDR. The
equivalence of HDR vs. LDR in terms of clinical outcomes and
toxicities has already been established in levelI evidence studies
carried out in developed as well as developing countries.
The miniaturisation of Cobalt60 sources, making them the same size
of previously used Ir192 sources, was a clear and significant step
towards a more costeffective brachytherapy. Other strategies to be
discussed are accelerated partial breast irradiation (APBI) and
electronic brachytherapy.
One possible approach that has been promoted by the IAEA through
the AGaRT (“Advisory Group for increasing access to Radiotherapy
Technology”) process is encouraging the manufacturers to develop
packages of equipment fully compatible and which are sold at
accessible prices. A typical package may include for example: the
afterloader, a number of sources, a BT treatment planning system
with software, connectors and applicators, an imaging device, a
service maintenance contract and training. Manufacturers have
responded positively to this challenge, and the process moves
forward.
To make brachytherapy more costeffective then, the industry must
come up with either treatments strategies or techniques that are
more effective, resourcesparing or both, while at the same time
keeping the high standards of safety that are the norm today.
OC65
DEVELOPMENT OF A WATER CALORIMETER AS A PRIMARY STANDARD
FOR ABSORBED DOSE TO WATER FOR HDR BRACHYTHERAPY SOURCES
L.A. de Prez 1 , J.A. de Pooter 1
1 VSL Ionizing Radiation Standards, Delft, The Netherlands
: Currently, dosimetry for brachytherapy sources is
based on airkerma standards. In the framework of the iMERAplus JRP
6, VSL is developing a water calorimeter for high dose rate (HDR)
brachytherapy sources to measure directly the absorbed dose to
water, Dw. Water calorimetry for HDR sources differs from water
calorimetry for external beams on two main aspects. Firstly, due to
the selfheating of the source an undesired temperature rise appears.
Secondly, the radiation induced temperature signal is very sensitive to
small variations in the HDRsource to thermistor distance. Methods to
reduce these effects were implemented in the design of the
calorimeter.
: The developed water calorimeter is based on
the existing water calorimeter for external beams with a newly
developed high purity cell (HPC, see figure). The HDR source is
positioned centrally inside the HPC. A nylon catheter on the central
axis of the HPC is used for positioning of the source. The HPC is
cylindrically shaped with two opposing thermistors on each side of the
catheter. The distance between the thermistors and the centre of the
catheter is 2.0 cm. To decrease the uncertainty of the temperature
signal as a result of variations in the distance between catheter and
thermistors, the measured temperature increase is averaged over the
two thermistors. A cylindrical aluminum heat sink in a concentric
configuration with the HPC is used to reduce the influence of the
source selfheat on the temperature signal. The heat sink is separated
from the inside of the HPC by the central PEEK cylinder. Due to the
enhanced heat transport in the longitudinal direction of the heat sink,
less heat generated in the HDR source (selfheat) reaches the
thermistors. Monte Carlo (PENELOPE) and heat transport simulations
(Comsol Multiphysics TM ) were performed to determine the amount of
source selfheat and resulting excess temperature effects.
: Measurements performed with a Nucletron microSelectron V2
HDR source showed good agreement with the modeled excess
temperature effects for an initial temperature of source and cable of
respectively 13 °C and 17 °C. The resulting measured and modeled
calorimeter drifts are shown in the figure. Presently the relevant
correction factors are being examined in order to determine the
aborbed dose rate and its final uncertainty budget.
: The model calculations for the HDR water calorimeter
are in good agreement with measurements. After establishing suitable
correction factors with their final uncertainty budget, the calorimeter
can be used for absorbed dose measurements of HDR brachytherapy
sources.

S26 World Congress of Brachytherapy 2012
OC66
QC OF LOWENERGY PHOTON BT SOURCES: RECOMMENDATIONS OF
THE NETHERLANDS COMMISSION ON RADIATION DOSIMETRY (NCS)
A. Rijnders 1 , A. Aalbers 2 , M. De Brabandere 3 , C. Koedooder 4 , M.A.
Moerland 5 , B. Schaeken 6 , B. Thissen 7 , A. van 't Riet 8 , S. Vynckier 9
1
Europe Hospitals Sint Elisabeth, Radiotherapy, Brussels, Belgium
2
Van Swinden Laboratorium, Dosimetry, Delft, The Netherlands
3
UZ Leuven, Radiotherapy, Leuven, Belgium
4
AMC Amsterdam, Radiotherapy, Amsterdam, The Netherlands
5
UMC Utrecht, Radiotherapy, Utrecht, The Netherlands
6
URA Antwerpen, Radiotherapy, Antwerpen, Belgium
7
CHU Liège, Radiotherapy, Liège, Belgium
9
UCLSt Luc, Radiotherapy, Woluwe, Belgium
: In Belgium (BE) and The Netherlands (NL)
permanent prostate brachytherapy (PPBT) using 125 I seeds is a widely
used treatment modality. The strong increase in the number of
patients treated prompted the NCS board in 2004 to set up a working
group in order to study the clinical and dosimetry aspects related to
the use of lowenergy photon (LEP) sources and to publish guidelines
and recommendations on QC with respect to this use.
: The clinical practice regarding QC of LEP
sources used in BT was studied by sending a questionnaire to all
institutes in both countries. From this survey a large variability in the
QC procedures applied was observed. In about 40% of the institutes
the source strength of the LEP sources was not routinely verified.
Table 1 gives an overview of the measurement equipment available in
the institutions. Only 3 devices were calibrated at an ADCL, 4 other
were calibrated by the manufacturer.
Table 1: Measurement equipment in use in Be and Nl
Be Nl Total
None 5 1 6
PTW SourceCheck 9 1 10
SI (HDR1000/IVB1000) 4 4 8
NA 34070 3 3 6
Capintec (CRC10/CRC15R) 2 1 3
Veenstra VDC303 1 1
Sun Nuclear 100840 1 1
In a second step, onsite visits were performed in all participating
institutes (31). The source strength for a limited number of seeds
(typically 3) was measured by the NCS visit team and compared to the
value stated on the source certificate and, if available, to the value
determined by the local physicist.
During the onsite visits the accuracy of the TPS used for PPBT was
evaluated with 5 basic tests. The AAPM TG43 update and consensus
data or otherwise published data on the source dosimetry parameters
were used as reference. The tests revealed variations in dose
calculation results due to incorrect application of the anisotropy
model by the user and to the use of source data which were since
2004 no longer recommended. Most TPSs underestimate the volumes
in DVH calculations.
These results have been presented earlier (Boston 2008).
: The survey and onsite visits identified a need for guidelines
on the QC of LEP BT sources. Taking into account the
recommendations from other organizations such as IAEA, ICRU, IPEM,
ESTRO and AAPM, the subcommittee decided to adopt the latter and
recommends to verify the source strength on a sample of sources prior
to the implantation procedure. Dedicated instruments should be used,
and these should be traceably calibrated at a 2 year interval.
The ultrasound (US) machine grid and template alignment should be
verified at a 3 months interval (tolerance 2 mm). The accuracy of
source position reconstruction by the TPS should be tested for all
imaging modalities that are applied (accuracy < 2 mm). Dose
calculation accuracy should be verified to be < ±2%.
: The NCS subcommittee endorses the recommendations
of the AAPM to perform a measurement on a sample of sources prior
to the implantation procedure, using dedicated and traceably
calibrated instruments.
The subcommittee stresses the importance of using consensus data as
input in the TPS and presents recommendations for the QC of this TPS
and of the US system that is used for PPBT.
OC67
AAPM PRACTICE GUIDELINES FOR COMS EYE PLAQUE BRACHYTHERAPY
S.T. ChiuTsao 1 , M.A. Astrahan 2 , P.T. Finger 3 , D.S. Followill 4 , A.S.
Meigooni 5 , F. Mourtada 6 , M.E. Napolitano 7 , R. Nath 8 , M.J. Rivard and
C.S. Melhus 9 , D.W.O. Rogers and R.M. Thomson 10
1
Quality MediPhys LLC, Physics, Denville NJ, USA
2
University of Southern California, Radiation Oncology, Los Angeles
CA, USA
3
The New York Eye Cancer Center, Ophthalmology, New York NY, USA
4
University of Texas M.D. Anderson Cancer Center, Radiological
Physics Center, Houston TX, USA
5
Comprehensive Cancer Center of Nevada, Radiation Oncology, Las
Vegas NV, USA
6
Christiana Health Care System, Radiation Oncology, Newark DE, USA
7
Elekta Inc., Physics, Norcross GA, USA
8
Yale University School of Medicine, Therapeutic Radiology, New
Haven CT, USA
9
Tufts University School of Medicine, Radiation Oncology, Boston MA,
USA
10
Carleton University, Physics, Ottawa, Canada
: A report has been prepared on quality practice
recommendations for COMS eye plaque brachytherapy which have
been endorsed by the ABS. The forthcoming report includes reference
coordinates for seeds positioned in COMS plaques, fundus diagrams for
eyes, a clinical literature review, and estimates of dose changes when
heterogeneity corrections are made to the TG43 dose calculation
formalism. A summary of the dosimetry and quality practice aspects is
provided if a decision is made to adopt heterogeneity corrections.
: A literature search was performed to
evaluate dosimetry studies and clinical practices. A 2011 multi
institutional COMS plaque dosimetry study was evaluated as a basis for
practice recommendations and to estimate behavior of different
treatment planning techniques with and without heterogeneity
corrections.
: The TG43 formalism does not account for material
heterogeneities. A prescription dose of 85 Gy (based on homogeneous
water assumption) at 5 mm depth actually delivers 76 Gy and 67 Gy
for 125 I (model 6711) and 103 Pd (model 200) sources, respectively, after
accounting for COMSplaque heterogeneities. Factor of 10 dose
changes occur between homogeneous and heterogeneous medium
calculations for offaxis anatomic structures. The plaque treatment
planning system and ultrasound unit should be commissioned
preceding clinical use. The prescription should include a retinal
diagram that indicates the affected eye, tumor location, tumor
dimensions, and proximity to critical normal ocular structures. Doses
to fovea, optic disc, lens, opposite eye wall, and sclera should be
calculated. Seed strengths shall be verified prior to plaque assembly
and loading patterns confirmed using autoradiography, photography,
or visual inspection. The plaque placement should be verified
World Congress of Brachytherapy 2012 S 27
intraoperatively. Intraoperative ultrasonographic imaging, scleral
depression, and/or transillumination techniques are widely used to
verify plaque placement accuracy for posterior tumors. Different dose
calculation algorithms can result in significant dose differences which
can complicate evaluations of radiation dose response and
intercomparisons with other modalities.
: Accurate dose calculations are the foundation upon
which meaningful intercomparisons can be performed amongst
different radiation modalities and for variations such as the use or
nonuse of Silastic inserts, gold 'seedguides,' seed slots, notches,
plaqueslots, and custom plaque designs. Thus, as more accurate
methods for dose calculation become available, these methods should
be adopted clinically even though it may require changes in
prescription doses. Practice guidelines are also provided outlining
specific tasks towards unifying the widespread practice of eye plaque
brachytherapy. A joint AAPM/ABS/ESTRO Task Group has been
established and will examine similar aspects that are specific to non
COMS plaques.
OC68
DOSIMETRIC CHARACTERIZATION OF SURFACE APPLICATORS USED WITH
BRACHYTHERAPY SOURCES
R. Fulkerson 1 , J. Micka 1 , L. DeWerd 1
1
University of Wisconsin School of Medicine and Public Health,
Medical Physics, Madison, USA
: This investigation was performed to develop a
quantitative method of output verification for surface applicators
used with HDR brachytherapy sources. Specifically applicators
manufactured by Varian Medical Systems (Palo Alto, CA) for use with
the VariSource TM iX and GammaMedplus iX HDR 192 Ir afterloader
systems, as well as applicators manufactured by Xoft Inc (an iCAD
company) (Sunnyvale, CA) for use with the Axxent ® source. Current
dosimetry protocols available from the AAPM cannot be applied
directly for these kinds of surface applicators. The standard
interstitial brachytherapy dosimetry protocol (TG43) was intended
for treatments assuming full homogenous backscatter, with a
reference point 1 cm from the perpendicular bisector of a
cylindrically symmetric source. Another dosimetry protocol of interest
(TG61) was developed to determine absorbed dose to water at a
point of interest through airkerma rate measurements with a NIST
traceable ionization chamber for lowenergy superficial xray beams.
The geometric and scatter conditions of the Varian and Xoft
applicators do not fully meet the requirements described in either
protocol, and this work aims to provide a transition within the
underlying issue of brachytherapy sources being used as external
beam sources.
: Conical surface applicators with diameters
ranging from 1 cm to 5 cm are available for the conformal treatment
of superficial lesions. To ensure the correct dose is delivered to the
patient, the output of each applicator must be characterized and
calibrated using a NISTtraceable dosimetric standard. Airkerma rate
measurements for each applicator were performed using a variety of
ionization chambers. To obtain a dose to water from the airkerma
rate measurements, a number of correction factors were applied
including Monte Carlo determined backscatter factors (Bw) and
chamber stem correction factors (Pstem). Additional measurements of
the relative surface dose distributions and depth dose curves in water
were determined for all applicators and compared to the Monte Carlo
calculated values.
: Measured airkerma rates for the Varisource iX are shown in
Table 1, decay corrected to a reference date. Measurements for all
applicators agreed to within 5%. Measured and calculated depth dose
curves for the Varisource iX and GammaMed iX agreed to within 3% for
all applicators. Similar results were observed for the Axxent surface
applicators.
: This work will create a surface applicator specific
dosimetry protocol based on airkerma rate measurements with a
NISTtraceable small volume parallelplate chamber. Through
measured and calculated chamber correction factors and relative dose
distribution information, users will have a clinically relevant
methodology for output verification, minimizing the uncertainty
associated with patient dose delivery.
OC69
BRINGING INVIVO FIBERCOUPLED BRACHYTHERAPY DOSIMETRY TO
THE PATIENT
G. Kertzscher 1 , C.E. Andersen 1 , J.C. Lindegaard 2 , L.U. Fokdal 2 , M.
Paludan 2 , S.K. Nielsen 3 , K. Tanderup 4
1
Technical University of Denmark, Center for Nuclear Technologies,
Roskilde, Denmark
2
Aarhus University Hospital, Department of Oncology, Aarhus,
Denmark
3
Aarhus University Hospital, Department of Medical Physics, Aarhus,
Denmark
4
Aarhus University, Institute of Clinical Medicine, Aarhus, Denmark
: The clinical use of invivo brachytherapy (BT)
dosimetry is limited partly by operative complexities and
measurement and detector positioning uncertainties. These
limitations compromise the detection of BT treatment errors. Fiber
coupled dosimetry systems have demonstrated capacity for accurate
realtime BT dosimetry. The purpose of this study was to develop
tools and methods that increase possibilities to perform routine and
precise fibercoupled BT dosimetry in the clinic.
: Invivo fibercoupled Al2O3:C dosimetry was
performed during four pulsed dose rate (PDR) BT treatments of locally
advanced cervical cancer. Each patient underwent 20 hours of
intracavitary PDR BT using tandemring applicators ± interstitial
needles. Tools developed for improved probe placement stability,
minimal calibration time, and insignificant optical interference were
evaluated. A procedure to light seal the fibercable using black
polyethylene terephthalate heatshrink tubing was developed. The
dosimeter probe was placed inside a catheter which was fastened to
the tandem applicator (see Figure). Reference dose rates were
calculated according to the TG43 protocol using MR reconstructed
dosimeter probe and source dwell positions. Measured dose rate
discrepancies with respect to the first BT pulse were obtained for
each tandem applicator dwell position during the treatments.
Dosimeter position shifts were deduced by minimizing the difference
between measured and numerically simulated dose rate
discrepancies.
: Measured dose rate discrepancies during treatments 1, 3, and
4 corresponded to a 1.5 mm maximum dosimeter position shift with
respect to the position during the initial treatment pulse (see Figure).
As an example, in one treatment pulse, a 2.5 % (1.5 %) dose rate
discrepancy at the 52 mm (13 mm) sourcetodetector distance,
corresponded to a 0.4 mm (0.2 mm) position shift in the longitudinal
dosimeter probe direction. The 4 mm position shifts observed during
the second treatment, were ascribed to a poor probe connection. The
dry calibration procedure took less than 15 min, including the time
required to setup the afterloader, powering the computer, etc. Heat
shrink tubing kept the outer diameter of the dosimeter smaller than
1.1 mm, and reduced the light interference by two orders of
magnitude to the readout electronics background level.

S28 World Congress of Brachytherapy 2012
: Utilities necessary to facilitate routinebased and time
efficient invivo BT dosimetry is presented. The measured 1.5 mm
probe position stability provides a crucial dose rate uncertainty
component during both PDR and HDR BT dosimetry. The thin and light
tight dosimeter probe allows for both easy probe insertion and sub
mm stability measurements.
OC70
A REVOLUTIONARY MULTIPOINT PLASTIC SCINTILLATION DETECTOR
FOR IN VIVO DOSIMETRY IN HDR BRACHYTHERAPY.
F. TherriaultProulx 1 , L. Archambault 2 , S. Beddar 1 , L. Beaulieu 2
1
UT MD Anderson Cancer Center, Department of Radiation Physics,
Houston, USA
2
HotelDieu de Quebec, Departement de RadioOncologie, Quebec,
Canada
: There is a growing interest for in vivo dosimeters
in high dose rate brachytherapy (HDR). If plastic scintillation
detectors (PSDs) have been shown to possess advantageous
characteristics, they require a coupling to an optical guide for each
point of measurement. In brachytherapy the space for dosimeter
insertion is often limited (e.g. in catheters). The necessity of an
optical guide for each scintillating element then often limits the
measurement to a single point per region of interest. The purpose of
our study is to develop a PSD capable of measuring dose at multiple
points along a same optical transmission line for Ir192 HDR/PDR
brachytherapy and to demonstrate additional potential applications
for such a detector.
: A multipoint PSD composed of three
different scintillating elements (2 mm long x 1 mm diameter, 25 mm
apart) and a single collection plastic optical fiber (20 m long x 1 mm
diameter) was built, as depicted in figure 1. Optical spectra (Spec.)
were acquired at the output of the collection optical fiber. The
emission spectra from the scintillating elements were obtained using a
well collimated xray source. The light spectrum of the stem effect
generated in the clear optical fiber was obtained through irradiation
using the Ir192 HDR brachytherapy source. A novel approach allowed
us to calculate the individual contribution (CX) of each lightemitting
component (see equation 1). The dose to a specific scintillating
element can be calculated from equation 2 by using at least one
knowndose condition to this element.
: Dose measurements were performed with the multipoint
detector placed at radial distances (r) of 1.0 cm and 2.0 cm from the
source inside a polystyrene phantom and compared to data from the
treatment planning system (TPS). Figure 1 shows the dose integrated
by the detector by each scintillating element for each source positions
along the z axis together with the expected dose as calculated by the
TPS. There is a (4.6±1.0)% average difference between the measured
dose and the dose from the TPS for individual dwell positions. The
summation of measurements for all dwell positions differs from the
dose calculated across the entire catheter by only (2.1±1.0)%. On top
of their use for simultaneous multipoint dosimetry, we showed that
the scintillating elements were capable of determining the source
position along the zaxis with a (0.8±0.2) mm accuracy.
: This study shows for the first time it is possible to
measure accurately dose at multiple positions in HDR brachytherapy
using a waterequivalent detector with a single line of signal
World Congress of Brachytherapy 2012 S 29
transmission. This will be useful for spatially constrained applications
and will decrease the need for additional catheter implants. Together
with its capacity to determine accurately the source position in space
and all the other advantages known to PSDs, the multipoint PSD has a
bright future and should lead to the development of various
applications in HDR/PDR brachytherapy for both in vivo dosimetry and
pretreatment quality assurance.
OC71
SINGLE NUCLEOTIDE POLYMORPHISMS (SNP'S) ASSOCIATED WITH LATE
RADIATION TOXICITY AFTER PROSTATE BRACHYTHERAPY
N. Leong 1 , M. Parliament 1 , K. Martell 2 , S. Ghosh 3 , N. Pervez 1 , J.
Pedersen 1 , D. Yee 1 , A. Murtha 1 , J. Amanie 1 , N. Usmani 1
1 Cross Cancer Institute, Radiation Oncology, Edmonton, Canada
2 University of Alberta, Faculty of Medicine, Edmonton, Canada
3 University of Alberta, Oncology, Edmonton, Canada
: Excessive toxicity from prostate brachytherapy
treatment may be related to increased radiosensitivity from genetic
polymorphisms. This study was designed to identify particular single
nucleotide polymorphisms (SNP's) that were associated with high
toxicity after therapy in order to determine possible markers for
increased radiation sensitivity
: 349 patients treated with prostate
brachytherapy at the Cross Cancer Institute between 1998 and 2010
provided saliva samples from which DNA was extracted for this
research ethics board approved study. In the cohort of patients with
at least 2 years of followup, 41 patients were identified as having
high late toxicity (≥ RTOG grade 2 GI or GU toxicity), and 110 patients
were identified as controls without high late toxicity. We analyzed 15
SNP's from 13 genes (MSH6, GSTA1, SOD2, NOS3, GSTP1, ATM, LIG4,
XRCC1, XRCC3, RAD51, TP53, TGFβ1, ERCC2) for correlation with
increased late toxicity. Patient factors and dosimetric parameters
were also collected for the analysis.
: All 15 proposed SNP's demonstrated polymorphism within the
study population. We implemented a univariate analysis, with
Bonferroni correction, to examine the correlation between variant
allele SNP's (versus wild type) and the presence of increased toxicity.
This revealed a statistically significant relationship in 3 of the SNP's
(p

S30 World Congress of Brachytherapy 2012
urethral dose to 0.1 cm 3 , 1 cm 3 , and 2 cm 3 was on average 76.2 Gy
(range: 49.4 – 111.2 Gy), 48.9 Gy (range: 43.2 – 68.1 Gy) and 46.1 Gy
(range: 43.2 – 51.8 Gy) respectively. 2 of the 6 patients who had
urethral involvement developed urethral necrosis after HDRBT. The
D90 for these 2 patients was 76.8 Gy (range: 70.7 – 83.0 Gy). The
average urethral dose to 0.1 cm 3 , 1 cm 3 , and 2 cm 3 for these patients
was 95.1, 45.8, and 45.8 Gy respectively. Those that developed
severe urethral toxicity had a trend to higher mean equivalent dose to
the urethra (95.1 Gy vs. 73.4 Gy, p=0.1) and significantly higher dose
per fraction of HDRBT to 0.1 cm 3 volume of the urethra (5.7 Gy vs.
3.7 Gy, p=0.02) when compared to those who did not develop severe
urethral toxicity.
: This is the first study to assess urethral dosimetry for
patients treated with HDR interstitial brachytherapy. The feasibility of
contouring the urethra as a critical structure and monitoring its dose
is demonstrated. Patients who received over 5 Gy/fraction to 0.1 cm 3
of urethra (approximate equivalent dose of 85 Gy) are at significantly
increased risk of severe urethral toxicity. Since the total urethral
volume was small, the point dose appears of greater clinical
importance. Thus while sometimes high doses are necessary to
adequately treat tumor with urethral involvement, the dose to the
urethra should be monitored and reduced to decrease the likelihood
of morbidity.
OC74
DOES PARTIAL BREAST BRACHYTHERAPY DECREASES SCATTERED FETAL
DOSE IN PREGNANT WOMEN?
A. Youssef 1 , T. LaCouture 1 , N. Pahlajani 1 , L. Hughes 1 , Y. Chen 1 , L. An 1 ,
P. Potrebko 1 , N. Kramer 1 , S. Asbell 1
1 Cooper University Hospital, Radiation Oncology, Camden, USA
: More than 4000 pregnant women per year would
need radiation therapy during pregnancy. Many studies had been
made on calculation and measurement of the fetal dose from breast
radiotherapy for pregnant women. The purpose of this study is to
investigate if the fetal dose can be lowered using Partial Breast
Brachytherapy.
: The scattered dose to the anterior abdominal
wall of 4 patients treated with Partial Breast Brachytherapy (PBB)
treatments were recorded using film badges placed at anterior
abdominal wall around the umbilicus. PBB used SAVI devices, two
cases used SAVI size (61), one case used SAVI size (81) and one used
SAVI size (101). The dose was measured during 5 out of the 10
treatments given. The dose per treatment was 340 cGy to 1 cm
around the lumpectomy cavity. One cm bolus was added on top of the
film badges. No shielding was attempted. The scattered dose was also
measured the same way for 2 patients treated with IMRT to the whole
breast. The dose prescribed was 180 cGy per fraction using inverse
and forward IMRT. Again no shielding was attempted. The film badges
were placed at the anterior abdominal wall with one cm bolus on top.
The doses were recorded for only five treatments.
: The measured dose was analyzed and multiplied by 2 for PBB
(to get a total dose of 34 Gy), and by 5 for whole breast IMRT (to
calculate for a total dose of 45 Gy to the whole breast in 25
fractions). The following table simplifies the results
Treatment
type
Calculated total
treatment dose
Patient height in
inches
Case #1 SAVI (61) 9.754 cGy 61
Case #2 SAVI (61) 3.65 cGy 68
Case #3 SAVI (81) 8.528 cGy 63
Case #4 SAVI (101) 14.878 cGy 60
Case #5 IMRT
forward
28.305 cGy 62
Case #6 IMRT
inverse
20.815 cGy 67
Our data showed that PBB treatment lowered the dose scattered to
the fetus during pregnancy. The average dose for PBB was 9.2 cGy vs.
24.5 cGy for IMRT. The dose of PBB was directly related to the size of
the SAVI and inversely proportional to the distance between the
device and the point of measurement on the anterior abdominal wall.
: Although our data does not show that PBB is safe to
treat pregnant women, we believe that PBB contributes with fewer
doses to the fetus during pregnancy and further investigation should
show that PBB can be used safely if special techniques are used to
limit fetal dose.
OC75
CTGUIDED INTERSTITIAL IODINE125 SEED IMPLANTATION IN THE
TREATMENT OF SPINAL AND PARASPINAL MALIGNANCIES
C. Liu 1 , H.S. Yuan 1 , J.J. Wang 2 , N. Meng 2 , Y.Q. Ma 1 , S.B. Han 1 , C.N.
Pang 1
1
Peking University Third Hospital, Radiology, Beijing, China
2
Peking University Third Hospital, Oncology, Beijing, China
: To investigate the clinical benefits of CTguided
interstitial iodine125 seed implantation in the treatment of
metastatic or primary spinal and paraspinal tumors.
: 38 patients (with 43 lesions) of metastatic or
primary spinal and paraspinal tumors, with no surgery or external
beam radiotherapy opportunity, were underwent implantation
procedure. Treatment planning system (TPS) was used to formulate
the seeds distribution and assess radiation dosimetry preoperation and
to obtain quality evaluation postoperation. Needles placement under
CTguidance were performed according to TPS. The mean minimal
peripheral doses of implantation was 120Gy (ranged from 90140Gy).
The mean number of seeds was 79.3 (ranged from 10224), The mean
specific activity per seed was mCi 0.7 (ranged from 0.500.80 mCi).
Visual analogue scale (VAS) and Ambulatory function score (AFS) was
used to evaluate pain relief and limb function.
: All patients tolerated the procedures well. No complications
occurred. The mean followup was 15.3 months (ranged from 1 to 96
months). The local control rate was 76.3% (29/38). The mean local
control time and survival time was 14.2 months and 15.3 months. The
1, 2, 3, and 5year local controls were 79.5%, 72.2%, 72.2% and
72.2%, respectively. The 1, 2, 3, and 5year survival rates were
62.4%, 35.8%, 21.5% and 14.3%, respectively. The mean VAS pre and
postoperation was 8.08±2.12 and 3.96±2.00, respectively (P

S32 World Congress of Brachytherapy 2012
: The obtained results show that the proposed detector is
suitable for in vivo realtime dosimetry in high dose rate
brachytherapy. Further studies are currently in progress for the
application of this dosimeter in urethral dose measurements during
interstitial brachytherapy treatments of the prostate.
79
PERMANENT PERINEAL IMPLANT (PPI) SALVAGE OF PPI FAILURES: IS
LESS MORE IN HIGHLY SELECTED PATIENTS
M. Roach
Department of Radiation Oncology UCSF, San Francisco, CA, USA
Helen Diller Family Comprehensive Cancer Center, San Francisco, CA,
USA
It has been estimated that 15 to 75% of men treated with radiotherapy
(RT) will fail biochemically (Agarwal et al, Cancer 2008; 1230714).
Specifically given the outcomes of series reported by experienced
Practitioners upwards of 30% of men undergoing permanent perineal
implants (PPI) for prostate cancer fail within 10 years. Thus it is likely
that failure rates are higher in the community where less experienced
physicians. Based on a “back of the envelope” calculation I would
estimate that it is likely that well over 100,000 men who have
undergone are experiencing a rising PSA after PPI in the USA alone.
Among the men with rising PSAs post PPI some are failing distantly
and some locally. Given the typical selection criteria and the
likelihood of poor quality implants in the community performed by
low volume practitioners it seem probable that at least as many of
these recurrences are local as occurs after a radical prostatectomy
(RP). Since the vast majority of men undergoing salvage external
beam radiation (EBRT) after RP respond, it is also likely that a
relatively large number of men failing PPIs might benefit from
additional local treatment.
Currently nearly 95% of men failing any form of RT are managed with
androgen deprivation therapy (ADT) (Agarwal et al, Cancer 2008; 12
30714). Unfortunately this is not a curative intervention and it is
associated with a host of side effects. Previous series have
documented suboptimal control rates and significant morbidity when
PPI salvage has been attempted (Moman et al. Brachytherapy 9: 119
25, 2010, Nguyen et al. Cancer 110:1485 92, 2007 and Nguyen et al.
Brachytherapy 8:34552, 2009). However these series tended to treat
the entire gland to near full doses. Of note however, most clinically
significant local recurrences after RT appear to occur at the initial
site of the primary tumor (Pucar et al. IJROBP 69: 629, 2007). Thus
subsets of patients who are failing locally can be identified who might
be candidates for local therapy.
At UCSF we assessed feasibility of MRplanned focal partial prostate
salvage PPI (psPPI).
Our hypothesis going into this intervention was
based on several principles:
If the seeds were not distributed as planned but they were placed into
the prostate then we did not have to worry about cold spots
elsewhere and there was not need to retreat previously treated areas.
Patients who had limited disease to start out with who appeared to
have recurred in sites of previous disease where ideally suited for
psPPI.
An otherwise negative multiparametric MRI, supported by a care set
of biopsies combined with #2 above set the criteria for the ideal
patient for psPPI.
Most importantly, develop a strategy that maximized the chances that
our treatment would “at least do no harm”. To this end composite
plans combining the previous dose distribution and “salvage plan” had
to be “safe”.
The potential types of patients who might be considered for salvage
local therapies are shown diagrammatically in Figure 1. The typical
patients we at UCSF selected for psPPI belong to categories 3 and 4 as
shown in Figure 1 below.
From 20032009, fifteen patients without metastases underwent
MRI/MRS to identify coincident areas of recurrence following iPPI
(N=14 I 125, 144Gy, N=1 Pd103, 125Gy) underdosage in preparation
for possible psPPI (without hormone therapy). For the psPPI planning
the mean D90 CTV (focal recurrent disease) was set at 142Gy resulting
in a whole prostate gland doses of 37Gy and a mean V100 rectum of
0.5% (0.07cc) and urethra dose of 12% (0.3cc).
Although the followup definition following psPPI for PSA failure was
chosen as the Phoenix Definition (PSAF = nadir + 2.0) or the first
ASTRO definition (ASTROPSAF = three consecutive rises) we expected
substantially lower values to be reflective of success. Toxicity was
scored using CTCAE v4.0.
At psPPI the median age was 68, and the median PSA=3.5ng/mL
(range:0.9 5.6 ng/mL). Most patients (71%) had Gleason Score 6 or
less but 39% had Gleason Scores of ≥7. Only 40% had abnormal MRI/S
with one (80%) or two (20%) abnormal foci. The median interval
between iPPI and psPPI was 69mos (range 28132).
At median followup of 23.3mos (range 888), two patients (13%)
failed biochemically at 26 and 35mos however both underwent a
second psPPI with followup PSA at 11.7 and 26.4 mos of 0.6 and
0.7ng/mL, respectively. Counting these two patients as failure the
ASTROPFS at 1, 2 and 3 years was 86.7%, 78.4%, and 62.7% with 5
failures (N=3 with negative TRUSbiopsy). In contrast, the PhoenixPFS
at 1, 2, and 3years were 100%, 100%, and 71.4%. psPPI PSA
nadir 12 months is associated
with a low risk of systemic progression and 92% remain metastasis
free at 5 years.
Surgical technique
Nowadays with most patients undergoing EBRT, perineal low or high
dose brachytherapy the standard retropubic approach is preferred for
salvage RPE. Depending on the type of radiation technique there are
different anatomical areas in which the surgical procedure might be
complicated (table 1) and deserves specific experience.
Complications: Rectal injury has been described in 6% to 19% of
patients in former series whereas it is reported in only 25% of
patients in modern series.
Anastomotic strictures occur more frequently in 832%
The incidence if urinary stress incontinence is higher than in series of
primary RPE. Complete continence can be achieved in about 50%,
another 20% to 30% require only 1 pad per day. The radiation
technique used appears to be associated with the frequency of
incontinence: in the author’s experience a high continence rate of
90% could be achieved in patients having undergone LDR
brachytherapy.
Cancer control following SRP
The 5year progressionfree rates have improved and the results are
similar to those of standard RPE in cases of similar pathological
stages. The 10year cancer specific and overall survival rates are in
the range of 70% to 75% and 60% to 66% in contemporary series. In
most contemporary series, organconfined disease, negative surgical
margins and the absence of seminal vesicle and/or lymph node
metastases are favourable prognosticators associated with a better
diseasefree survival of approximately 7080%.
: With the advantage of PSA screening at regular followup
intervalls following RT, most local failures will be detected by an
asymptomatic PSA increase. Patients with PSA levels < 10 ng/ml, no
palpable disease, negative findings on CT and bone scans are most
suitable candidates for SRP. Contemporary series of SRP demonstrate
excellent local control, good longterm cancer specific survival rates,
minimal complication rates and a good health related quality of life.
SRP represents the therapeutic option if choice in well selected
patients with locally recurrent PCA preventing significant local
complications. Based on our most recent findings on 117 patients SRP
should only be performed at tertiary referral centres with an
extensive experience not only in radical prostatectomy but especially
in salvage surgery.
OC81
A MULTICENTRE COMPARISON OF INTER AND INTRAFRACTIONAL
ORGAN MOVEMENT IN CERVIX CANCER BT AND ITS DOSIMETRIC IMPACT
N. Nesvacil 1 , K. Tanderup 2 , T. PaulsenHellebust 3 , A. De Leeuw 4 ,
C. Anderson 5 , S. Mohamed 2 , R. Pötter 6 , C. Kirisits 6
1
Medical University of Vienna, Department of Radiotherapy and
Oncology Comprehensive Cancer Center, Vienna, Austria
2
Aarhus University Hospital, Department of Oncology, Aarhus,
Denmark
3
Oslo University Hospital, Department of Medical Physics Division of
Cancer and Surgery, Oslo, Norway
4
University Medical Center Utrecht, Department of Radiation
Oncology, Utrecht, The Netherlands
5
Mount Vernon Cancer Centre, Clinical Physics Department,
Northwood Middlesex, United Kingdom
6
Medical University of Vienna, Department of Radiotherapy and
Oncology Comprehensive Cancer Center & Christian Doppler
Laboratory for Medical Radiation Research for Radiation Oncology,
Vienna, Austria
: Inter and intrafractional organ motion plays an
important role in multifractional brachytherapy treatment when one
dose plan is used for multiple fractions, or when organ movement
happens in between imaging and dose delivery. The dosimetric impact
of such motions has been reported previously in singleinstitutional
studies.
The aim of this study is to compare the dosimetric impact of organ
position variations by a retrospective multicentre analysis with
different application techniques and fractionation schemes.
: Data from 5 centers in the GYNGEC ESTRO
Network using intracavitary (tandem/ovoid or tandem/ring)
applicators +/ interstitial needles were collected.
To assess dosimetric effects of the motion of critical organs (bladder,
rectum, sigmoid) between treatment fractions, multiple image scans
(MRI or CT) were analysed. OAR were contoured on images at the time
of BT planning as well as on a subsequent image series acquired prior
to treatment of a subsequent HDR or PDR fraction. Dose plans
generated by using the 1 st image series were superimposed onto the
subsequent image sets and DVH parameters were calculated.
DVH data for a total of 96 patients was available (323 image/contour
sets, 254 MRI, 69 CT). DVH data for 16 fractions were available for
each patient. The average time between consecutive image
acquisitions varied between centers, from several hours to several
days (mean 73 h, median 22 h, range 5 h – 22 d).
: For each patient, D2cc for bladder, rectum and sigmoid were
calculated based on images and contour sets acquired at different
times during the BT treatment (at time of planning (D2cc_1) + at time

S34 World Congress of Brachytherapy 2012
of subsequent imaging (D2cc_2)), using one dose plan for both image
acquisitions. Data on sigmoid was only reported in 3 centers.
In order to compare DVH parameters from treatment plans based on
different fractionations and dose prescription, the relative changes in
D2cc (physical dose) between two subsequent imaging acquisitions,
(D2cc_2D2cc1)/D2cc_1, were computed.
The median, average +/ standard deviation of the relative D2cc
variations were 0.2%, 2.3+/21.7 % for bladder, 3.3%, 7.2+/24% for
rectum, and 2.1%, 2.3+/26.1% for sigmoid.
The data showed no statistically significant increase of the variation
with increasing time between two image acquisitions, even not for
those cases where the applicators had been removed and reinserted
between two fractions.
: Although in clinical routine sigmoid is observed to be the
most mobile OAR in cervix cancer BT, the dosimetric effect to the
recorded DVH parameters is comparable to the results for rectum and
bladder. Other influencing factors, which were not recorded in these
retrospective data, remain unclear. In particular, contouring
uncertainties may be a significant contributor to the evaluated
uncertainties. Proposals for standardized data collection and/or
prospective study protocols are currently being developed.
OC82
PREPLANNING IMPROVES FEASIBILITY OF INTRACAVITARY/INTERSTITIEL
BRACHYTHERAPY IN CERVICAL CANCER.
L. Fokdal 1 , K. Tanderup 2 , S.B. Hokland 2 , L. Røhl 3 , E.M. Pedersen 3 , S.K.
Nielsen 2 , J.C. Lindegaard 1
1
Aarhus University Hospital, Department of Oncology, Aarhus,
Denmark
2
Aarhus University Hospital, Department of Medical Physics, Aarhus,
Denmark
3
Aarhus University Hospital, Department of Radiology, Aarhus,
Denmark
: Combined intracavitary/interstitial (IC/IS)
brachytherapy (BT) techniques are increasingly being used for
treatment of locally advanced cervical cancer. The aim was to
investigate clinical feasibility and dosimetric gain of combined IC/IS
pulsed dose rate BT for locally advanced cervical cancer based on full
3D MRI preplanning with a tandem/ring IC applicator in situ.
: Twentyfour consecutive patients (pts)
included in the EMBRACE study from our institution were analysed. All
pts had large volume cervical cancer and were treated with 2 IC/IS BT
fractions (BT1 and BT2) combined with radiochemotherapy (4550
Gy/2530 fx and weekly cisplatin). Overall treatment time was 7
weeks with BT1 and BT2 delivered in week 6 and 7. A preplanning
procedure with US guided insertion of a tandem/ring applicator in
general anaesthesia and MRI was performed in week 5 (BT0).
Optimised preplans were generated off line for both IC and IC/IS
including predefined virtual needle insertion points and implant depth
through the ring as well as free needles. The IC/IS preplan was used
as template for the actual IC/IS implants. MRI was repeated at BT1
and BT2 and the dosimetric gains associated with the IC/IS implants
were investigated and compared to IC BT0. Geometric reproducibility
of the virtual needles from preplan to the actual implanted needles,
time consumption, and assessment of acute toxicity and early
morbidity (CTC v.3.0) were investigated.
: Time in general anaesthesia for IC/IS implantation at BT1 and
BT2 was 1530 min longer compared to the IC implant at BT0 (p

S36 World Congress of Brachytherapy 2012
: While overall changes in D2cc for R, B, and S are small,
a clinically relevant increase in R and B was observed in some cases.
The effect is likely due to changes in organ filling. An overall decrease
in S D2cc was observed and was likely due to an overall catheter shift
in the caudal direction. Further investigation on a larger patient
sample will be conducted to validate our conclusions and to asses the
effect of possible cranial catheter shifts on S D2cc.
OC87
BREASTCONSERVING THERAPY WITH PARTIAL OR WHOLE BREAST RT:
10YEAR RESULTS OF THE BUDAPEST RANDOMIZED TRIAL
C. Polgár 1 , T. Major 1 , J. Fodor 1 , Z. Sulyok 2 , Z. TakacsiNagy 1 , G.
Nemeth 1 , M. Kasler 3
1
National Institute of Oncology, Department of Radiotherapy,
Budapest, Hungary
2
National Institute of Oncology, Department of Surgery, Budapest,
Hungary
3
National Institute of Oncology, Director General, Budapest, Hungary
: To report the 10year results of a randomized
study comparing the This survival abstract and cosmetic forms results part of
breastconserving
treatment the with official partial conference breast irradiation media (PBI) programme
or conventional whole
breast and irradiation will be (WBI). available on the day of presentation.
: Between 1998 and 2004, 258 selected
patients with T1 N01mi, Grade 12, nonlobular breast cancer
without presence of extensive intraductal component and resected
with negative margins were randomized after breastconserving
surgery to receive 50 Gy WBI (n=130) or PBI (n=128). The latter
consisted of either 7 x 5.2 Gy highdoserate (HDR) multicatheter
brachytherapy (BT; n=88) or 50 Gy electron beam (EB) irradiation
(n=40).
: At a median followup time of 122.5 months, the 10year
actuarial rate of local recurrence was 5.9% and 5.1% in PBI and WBI
arms, respectively (p=0.77). There was no significant difference in the
10year probability of overall survival (80% vs. 82%), cancerspecific
survival (94% vs. 92%), and diseasefree survival (85% vs. 84%), either.
The rate of excellentgood cosmetic result was 81% in the PBI, and
63% in the control group (p=0.0015).
: PBI delivered by interstitial HDR BT or EB for a selected
group of earlystage breast cancer patients produces similar 10year
results to those achieved with conventional WBI. Significantly better
cosmetic outcome can be achieved with carefully designed HDR
multicatheter implants compared with the outcome after WBI.
OC88
FIRST CLINICAL RESULTS OF THE GECESTRO BREAST WG PHASE III
MULTICENTRIC APBI TRIAL.
V. Strnad 1 , O.J. Ott 1 , G. Hildebrandt 2,3 , R. Pötter 4 , R. Fietkau 1,2 , J.
Lyczek 5,8 , W. Uter 6, , T. Major 7 , M. Lotter 1 , C. Polgar 7
1
University Hospital Erlangen, Radiation Oncology, Erlangen, Germany
2
University Hospitals Rostock, Radiation Oncology, Rostock, Germany
3
University Hospital Leipzig, Radiation Oncology, Leipzig, Germany
4
University Hospital AKH, Radiotherapy and Radiobiology, Vienna,
Austria
5
Institute of Oncology, Brachytherapy, Warsaw, Poland
6
Institute for Medical Informatics, Biometry and Epidemiology,
Erlangen, Germany
7
National Institute of Oncology, Radiotherapy, Budapest, Hungary
8
Podkarpacki Regional Cancer Center, Radiation Oncology, Brzozów,
Poland
: Several Phase II trials have shown that Accelerated Partial
Breast Irradiation (APBI) leads to similar local control rate with lower
toxicity as whole breast irradiation (WBI) after breast conserving
surgery in a selected subgroup of breast cancer patients. The primary
objective of this randomized multicentric Phase III trial is to compare
multicatheter brachytherapy (BT) alone to WBI in a lowrisk group of
invasive breast cancer or ductal carcinoma in situ and to affirm the
hypothesis that local control rates in each arm are equivalent. The
secondary outcome measures include treatmentrelated toxicities,
cosmesis, quality of life (QoL) and survival rates. This study is
registered at ClinicalTrials.gov: NCT00402519. The rationale, study
design, patients’ and treatment characteristics, and early toxicities
are reported.
: Between May 2004 and July 2009, 1195
eligible patients with nodenegative Stage 0/I/II breast cancer were
prospectively enrolled on the protocol. Patients allocated to the
standard arm received 50 Gy WBI in 1.82.0 Gy fractions followed by a
tumor bed boost of 10 Gy in 2 Gy fractions. Patients in the
experimental arm were treated with APBI using multicatheter
interstitial BT up to 32.0 Gy/8 fractions or 30.3 Gy/7 fractions (HDR
BT) or up to 50 Gy/0.600.80 Gy (1 pulse/hour, 24 hours/day; PDR
BT). The side effects of therapy were documented according Common
Toxicity Criteria for Adverse Events v3 and RTOG/EORTC Late
Radiation Morbidity Scoring Scheme. The cosmetic outcome was
judged by digital photographs, for the assessment of QoL, repeated
QoLquestionnaires (EORTC QLQC30 including the Breast cancer
module QLQBR23) were used.
: We report on the prospectively collected data from 1195
patients randomized in the GECESTRO APBI Phase III trial who were
eligible and treated according study protocol (WBI: n = 568 vs. APBI: n
= 624). At the time of analysis complete followup documentation of
early toxicities was available for 98.2% (1170/1192) of the patients.
Both WBI and APBI were well tolerated with moderate early toxicities
at the end of therapy: acute dermatitis (Grade 1: 49.4% vs. 18.4%,
Grade 2: 35.7% vs. 2.1%, Grade 3: 7.1% vs. 0.2%; p 2 mm in 83% of
patients. Seventy per cent had T 01 tumors and 85% were ER positive.
Seventyone per cent of patients were node negative, with 12% N1, 3%
N0 (i+), and 1.5% N1mic. According to the ASTRO Consensus Guidelines
for use of APBI (2009) none of these patients would be classified as
suitable based upon age criteria.
: Median age was 48 years (range 39 – 50). With a median
followup of 6.2 years (range 1.6 – 16.9) the 5year actuarial local
recurrence rate (LR) was 3%; no regional recurrences (RR) were
documented. Additionally, no distant metastases were seen. Median
time to LR was 7.0 years. On univariate analysis, there were no
factors significant for LR, this including close/positive margins, ER/PR
status, age, nodal status, tumor size, histology, grade, hormonal
therapy or chemotherapy. The 5year actuarial cause specific,
diseasefree, and overall survivals were 100%, 97%, and 100%,
respectively.
: This cohort of young aged patients who have undergone
APBI has yielded excellent localregional control rates and survival
outcomes comparable to more traditional whole breast irradiated
patients. Continued followup along with accrual of additional
patients into such protocols as the NSABP B39/RTOG 0413 (which
continues to enroll young patients) will be needed to assess the long
term efficacy of breast cancer patients aged 50 or younger treated
with APBI.
OC91
LONG TERM OUTCOMES AND RECURRENCE PATTERN FOLLOWING
ACCELERATED PARTIAL BREAST IRRADIATION USING MAMMOSITE
A. Ravi 1 , C. Sison 2 , A. Osian 3 , S. Lee 4 , D. Nori 1
1
New York Hospital Queens Weill Cornell Medical College, Radiation
oncology, Flushing NY, USA
2
Feinstein Institute for Medical research North Shore LIJ health
System, Biostatistics, Manhasset, USA
3
New York Hospital Queens, Radiation Oncology, Flushing, USA
4
New York Hospital Queens, Surgery, Flushing, USA
: To evaluate: 1. The incidence of locoregional
recurrence in early breast cancer treated by APBI using the
MammoSite device in patients grouped according to ASTRO consensus
panel 'suitable 'and 'cautionary' category.
2. The recurrence pattern in patients with 'triple negative tumor' (TN)
(negative Estrogen, Progesterone receptor and Human Epidermal
Growth factor (HER2)) and the association and outcomes of African
American, Hispanic ethnicity and ER negative tumor.
: Between June 2003 and December 2009, 83
postmenopausal patients:76 invasive ductal carcinoma (IDC), 7 ductal
carcinoma in situ (DCIS), with diagnosis of early stage breast cancer
and node negative status met our inclusion criteria for APBI using the
single lumen MammoSite balloon catheter. Following a CT scan based
3D plan a dose of 3400cGy was prescribed in 10 fractions at distance
of 1 cm from surface of balloon delivered twice daily, 6 hours apart
using the high dose rate system. Patients were categorized as 4
groups: ASTRO consensus 'suitable', 'cautionary', TN and TN plus Her2
positive ('High Risk'). Data on treatment outcome with for ipsilateral
breast tumor recurrence (IBTR), tumor bed area failure (TBF),
elsewhere failure in the same breast (EF), ipsilateral axilla failure
(IAF) was analyzed.
: There were 42/83 (51%) patients in the 'suitable' and 41/83
(49%) in the 'cautionary' group. TN was 11% (8/76) and 'High risk' was
24% (18/76) of invasive cancer patients. Mean age of invasive cancer
patients was 72 years. Median followup for all 83 patients was 61
months; 'cautionary' group= 61 months; triple negative= 59; 'suitable'
group=61 and 'High risk'= 59. Adjuvant chemotherapy was given in 18%
(14/76) and hormones in 85% ER+ IDC patients. The locoregional
control was 98.6%. IBTR that was EF occurred in 2/83 (2.4%) patients;
one from the 'cautionary' group (ER, HER2+) and another from the
'suitable' group (ER+, HER2). IAF was seen in the first patient. There
was a significant association between tumor grade and ethnicity with
grade 3 tumors seen more in Hispanic and black women as compared
to others (31% vs. 8%; p=0.03) in the invasive group.
There was a higher proportion of ERnegative tumors seen among
African American and Hispanics compared to other ethnicities (56.25%
vs. 8.33%; p

S38 World Congress of Brachytherapy 2012
: There was very low occurrence of IBTR at a median
follow up of 5 years in 'suitable', 'cautionary', TN and 'High risk' group
of postmenopausal node negative early breast cancer patients
treated with APBI using the MammoSite balloon device. Long term
outcomes of APBI in AA and Hispanic patients with TN tumors should
be further investigated.
OC92
IMPACT OF MARGIN STATUS AFTER APBI: AN ANALYSIS OF THE
AMERICAN SOCIETY OF BREAST SURGEONS MAMMOSITEÆ REGISTRY
TRIAL
J.B. Wilkinson 1 , C. Shah 1 , M. Keisch 2 , P. Beitsch 3 , D. Arthur 4 , M.
Lyden 5 , F.A. Vicini 6
1
Oakland University William Beaumont School of Medicine, Radiation
Oncology, Royal Oak MI, USA
2
Cancer HealthCare Associates University of Miami Hospital,
Radiation Oncology, Miami FL, USA
3
Dallas Surgical Group, Breast Surgery, Dallas TX, USA
4
Virgina Commonwealth University Massey Cancer Center, Radiation
Oncology, Richmond VA, USA
5
Biostat International Inc., Statistics, Tampa FL, USA
6
Michigan Healthcare Professionals, Radiation Oncology, Pontiac MI,
USA
: At this time, data regarding the impact of close
or positive surgical margins on ipsilateral breast tumor recurrence
(IBTR) is limited to traditional breastconserving therapy (BCT) using
whole breast irradiation (WBI). This study examines the impact of
margin status on IBTR for patients who received applicatorbased
accelerated partial breast irradiation (APBI) as part of the American
Society of Breast Surgeons (ASBrS) MammoSite ® Breast Brachytherapy
Registry Trial.
: 1449 cases of earlystage breast cancer were
prospectively treated with BCT on the ASBrS MammoSite ® Registry
Trial. The MammoSite ® singlelumen Radiation Therapy System (RTS)
(Bedford, MA) was used to deliver adjuvant APBI to the tissue
surrounding the lumpectomy cavity (34 Gy in 3.4 Gy fractions, BID).
1255 cases (87%) had invasive breast cancer (median size = 10mm) and
194 cases had DCIS (median size = 8mm). Patients were stratified by
margin status into negative (n=1326), close (< 2mm) (n=110), and
positive (n=13) categories with the IBTR rates compared between
groups.
: One hundred and twenty three ASBrS MammoSite ® Registry
cases (8.5%) had close or positive final margins. In general, the two
groups were well balanced except that patients with close/positive
margins had larger median tumor sizes (11.016.5mm vs. 10.0mm;
p=0.03, p=0.04) and were more likely to be ER negative (13.615.4%
vs. 9.2%, p=0.01, p=0.03). Positivemargin patients were also more
likely to be node positive (15.4% v. 2.5%, p=0.01) as compared to the
marginnegative cohort. With a median follow up of 58.6 months, the
sixyear rate of IBTR was double for patients with close margins
compared to that of marginnegative patients (8.7% v. 4.1%, p=0.10)
and over threefold higher in patients with positive margins (14.3% v.
4.1%, p=0.41). When both groups were pooled, a trend towards
increased IBTR was noted for women with close/positive margins
compared with the negativemargin cohort (9.3% v. 4.1%, p=0.07).
Cases of pure DCIS with involved margins had statistically higher IBTR
rates vs. those with negative margins (15.717.6% vs. 4.2%, p=0.01).
No differences emerged in other clinical outcomes by margin status
including regional failure, distant metastasis, diseasefree survival,
causespecific survival, or overall survival.
: Good clinical outcomes were seen in patients undergoing
APBI regardless of margin status. However, trends for increased rates
of IBTR were noted in patients with close or positive margins; similar
to what is observed with WBI. This analysis supports the
recommendation to obtain margins of 2mm or greater prior to
adjuvant application of APBI. Further prospective studies are required
to validate these results and assist in the definition of appropriate
margin status for patients treated with accelerated partial breast
irradiation.
93
TG138 REPORT: UNCERTAINTIES IN PHOTON EMITTING
BRACHYTHERAPY SOURCE DOSIMETRY
B. Thomadsen 1 , L. DeWerd 1 , G. Ibbott 2 , A. Meigooni 3 , M. Mitch 4 , M.
Rivard 5 , K. Stump 6 , J. Venselaar 7
1
University of Wisconsin School of Medicine and Public Health,
Medical Physics, Madison Wisconsin, USA
2
M.D. Anderson Cancer Center, Radiation Physics, Houston Texas, USA
3
Comprehensive Cancer Center of Nevada, Radiation Oncology, Las
Vegas Nevada, USA
4
National Institute of Standards and Technology, Radiation Division,
Gaithersburg Maryland, USA
5
Tufts University School of Medicine, Radiation Oncology, Boston
Massachusetts, USA
6
Costal Radiation Oncology Group Inc, Santa Maria Radiation Oncology
Center, Santa Maria Califronia, USA
7
Instituut Verbeeten, Medical Physics and Engineering, Tilburg, The
Netherlands
The report of Task Group (TG) 138 of the American Association of
Physicists in Medicine (AAPM), in collaboration with the Groupe
Européen de Curiethérapie – European Society for Therapeutic
Radiology and Oncology (GECESTRO) [Medical Physics 38: 782801,
2011], studied the uncertainty in dose delivered to a point in an
infinite water phantom from a single, photonemitting brachytherapy
source, following the recommendations of the AAPM’s Task Group 43
(TG 43.) The investigation began with the uncertainties associated
with the calibration of sources at the national standards laboratory
and followed through the determination of the dosimetric parameters
by measurement and Monte Carlo simulations. The uncertainty
analysis considered those parameters classified by the International
Organization for Standardization as Type A, those amenable to
statistical analysis, and Type B, those requiring different sorts of
assessment. The relative uncertainties in the individual components of
the dose calculation were combined in quadrature. The analysis
included the effects of phantom construction and composition on
measurements, and interaction data on simulations. Each of the TG 43
parameters was considered as well as the transfer of the calibration
from the primary standards laboratory to secondary labs and to the
user. The final results for the equivalent of one standard deviation
(k=1) in percentage uncertainty are given below. The first values are
for lowenergy sources, while those in parentheses are for highenergy
sources.
Source strength (SK) 1.3 (1.5)
Measured dose 3.6 (3.0)
Monte Carlo 1.7 (1.6)
Interpolation 3.8 (2.6)
Total uncertainty (k=1) 4.4 (3.4)
Expanded Uncertainty (k=2) 8.8 (6.8)
94
SYSTEMATIC OVERVIEW AND REPORTING GUIDELINES FOR
UNCERTAINTIES IN CLINICAL BRACHYTHERAPY
C. Kirisits 1 , M.J. Rivard 2 , F.A. Siebert 3
1
on behalf of the GECESTRO uncertainties BRAPHYQS subgroup &
Medical University of Vienna, Dept. of Radiotherapy Comprehensive
Cancer Center, Vienna, Austria
2
Tufts University School of Medicine, Department of Radiation
Oncology, Boston, USA
3
UK SH Campus Kiel, Clinic of Radiotherapy, Kiel, Germany
The essential result of any study on uncertainties of clinical
brachytherapy is the impact on absorbed dose. However, only a
couple types of uncertainties (i.e. source strength and afterloader
timer) are independent of clinical disease site and location of
administered dose. Therefore, it is not possible to perform an overall
generalized quantitative ranking. While for low energy sources or
situations close to the skin the influence of medium on dose
calculation is significant, it is of minor importance for high energy
World Congress of Brachytherapy 2012 S 39
sources in the pelvic region. The level of uncertainties due to target,
organ, applicator, and/or source movement in relation to the
geometry assumed for treatment planning is highly dependent on
fractionation and the level of imageguided adaptive treatment. The
choice of the complexity for such techniques could be based on a
cost/benefit analysis, which needs detailed results from uncertainty
studies. Such studies should report the results in a manner that allows
reproduction and further comparison with other studies:
1. Clearly distinguish between variations, uncertainties, and errors.
2. Quantify Type A and Type B uncertainties, and describe the
approach taken.
3. Present data on the analyzed parameter (distance shifts, volume
changes, source or applicator position, etc…), and also their influence
on absorbed dose for clinicallyrelevant dose parameters (e.g. target
parameters such as D90 or OAR doses).
4. This reporting also can include uncertainties for total dose of the
entire treatment course (including several fractions and external
beam dose if applicable) and in terms of biological weighted dose as
EQD2.
These comprehensive investigations are important to obtain a general
impression on uncertainties and may help to assess which elements in
the brachytherapy treatment chain need improvement towards
diminishing their dosimetric uncertainties.
95
UNCERTAINTIES IN IMAGE GUIDED BRACHYTHERAPY: ECONOMICAL AND
LOGISTICAL ASPECTS
J.A. Polo Rubio
Hospital Ramon y Cajal, Madrid, Spain
Abstract not received
96
IS HIGH SAFETY IN BRACHYTHERAPY A RESULT OF ADVANCED
TECHNIQUES AND ADVANCED IMAGING?
D. Baltas
Klinikum Offenbach GmbH, Offenbach am Main, Germany
Abstract not received
97
STRATEGIES TO PREVENT ERRORS IN BRACHYTHERAPY: LEARNING
FROM OUR MISTAKES
R. Lee 1
1
Duke University Medical Center, Department of Radiation Oncology,
Durham NC, USA
PrecisThis brief session will describe the nature of reported errors in
brachytherapy and discuss strategies to prevent errors.
When establishing methods for preventing errors, information on what
errors have occurred in the past proves valuable in directing attention
to aspects of a procedure posing the greatest risk. The lecture will
begin with examples of reports in the lay press about brachytherapy
errors. The lecture will continue with a description of multiple
publications that describe examples of errors in brachytherapy
reported to the United States Nuclear Regulatory Commission (NRC)
and the International Atomic Energy Agency (IAEA). The specifics
from the events at Philadelphia VA will be reviewed as well. The
lecture will finish with practical recommendations that may prevent
brachytherapy errors in the future.
98
ROBOT ASSISTED MESH BRACHYTHERAPY AFTER SUBLOBAR RESECTION
FOR EARLY STAGE LUNG CANCER
D. Khuntia 1 , G.H. Dunnington 2 , C. Platta 3 , R.R. Patel 1
1
Western Radiation Oncology, Radiation Oncology, Mountain View,
USA
2
Stanford University, Thoracic Surgery, Palo Alto, USA
3
University of Wisconsin, Human Oncology, Madison, USA
Lobectomy has long been the standard of care for the management of
patients with early stage lung cancer. More recently, this has been
challenged as advanced radiotherapy techniques are showing
excellent long term local control approaching that of lobectomy.
However, the latter makes assumptions about nodal disease and
occasionally histology, that can dramatically affect the impact on
adjuvant therapy. Recently, there has been resurgence in the United
States of the use of sublobar resections for patients that are not able
to tolerate a lobectomy. However, sublobar resection does result in a
a staple line that has a non – trivial risk of local recurrence. Methods,
such as mesh brachytherapy have been explored and have shown in
single institution series the ability to dramatically decrease the local
recurrences. Prospective trials are underway to further quantify this
benefit. One of the downsides of using mesh brachytherapy is that
there is radiation exposure to the team handling the mesh. Novel
methods, utilizing robotic technology, have allowed us to improve the
safety and precision of this procedure. In this lecture we will describe
both the rationale and methods for robot assisted mesh brachytherapy
after sublobar resection.
99
RIGID RECTOSCOPY TO IMPROVE RADIATION TARGETING AND
INDIVIDUALISE MANAGEMENT OF RECTAL CANCER
J.P. Gérard 1
1 Centre Antoine Lacassagne, Radiation Oncology, Nice, France
: In rectal cancer most of the time radiotherapy (RT) is given
front line and the identification of the GTV is important to target
properly the beams. Assessment of the GTV (and CTV) can be made
with imaging(CT scan, MRI, ERUS, PetCT etc…) . Clinical examination
with Digital examination (DE) and endoscopy is essential for GTV
evaluation. Endoscopy can be performed in different way (flexible
colo or sigmoidoscopy). Rigid rectoscopy (RR) is a relevant alternative
: RR is performed on an ambulatory basis, in the knee chest
position. A small bowel preparation is necessary. A disposable plastic
rectoscope is used with cold light, insuflation and succion. The
diameter of the RR is 2.5 cm. Biopsy can be taken with forceps.
Fiducial marker can be implanted to localize the tumor. Pictures of
the tumor can be taken with a camera. This examination is lasting 2
to 5 minutes and can be easily repeated at each visit.
:
1 With RR it is possible to see the tumor and localize it precisely in
the rectum which is important for proper delineation on the planning
CT scan. The tumor response is evaluated according to RECIST
criteria. RR can be performed each week during RT and after
treatment to evaluate the CLINICAL RESPONSE (CR) which as strong
predictive and prognostic value (1). A complete CR after neoadjuvant
treatment is defined as no visible tumor and a rectal wall supple or
with a slight non suspicious induration.
If a CCR is achieved the surgeon may reapraize his initial decision and
move to a more conservative type of surgery (1).
2 To perform contact XRay (CXRT) it is mandatory to use RR which is
necessary to position the XRay tube in contact to the tumor under
vision control. The diameter of this applicator is usually 3 cm ; with
the Papillon 50 TM it is possible to use applicators of 2.5 or 2.2 cm easy
to introduce.
The merit of CXRT is to safely increase (50 to 110 Gy in 3 to 4
fractions) the dose to the rectal tumor. The randomized trial Lyon
R9602 has shown that CXRT+EBRT was increasing significantly the
CCR (29%) and the rate of colostomy free 10 year survival (60%) (2).

S40 World Congress of Brachytherapy 2012
CXRT alone or combined with external beam RT can definitively
control 80 to 90% of T1 or T2 N0 tumors not exceeding 4 cm in
diameter (3).
: Clinical examination of the tumor with RR is an essential
step of the management of rectal cancer with radiotherapy. It is
simple and fast to perform but need some clinical practice. Radiation
oncologists treating rectal cancers (and all surgeons) should become
familiar with RR and use it on a routine basis.
References:
Ortholan C et al. Dis Colon Rectum 2006;49:30210.
Gérard JP et al. IJRBOP 2011 ;81(2) : abstract 191
Gérard JP et al. Lancet Oncol 2003 ;4(3) :15866.
100
RADIOLOGICAL INTERVENTION
G. Gademann 1 , J. Ricke 2
1
OttovonGuerickeUniversität, Department of Radiotherapy,
Magdeburg, Germany
2
OttovonGuerickeUniversität, Department of Radiology and Nuclear
Medicine, Magdeburg, Germany
: The new possibilities of image guidance by
interventional radiology enable very advanced treatments by
interstitial brachytherapy. Tumors or metastases at almost any
anatomical site may be targeted. In this talk, the spectrum of
indications will be demonstrated. Clinical and oncological properties
and results will be discussed accordingly.
: Positioning of the catheters is carried out by CT
or MRI guidance. The Seldinger technique is applied to place sheaths
in the target volume, which ultimately host the brachytherapy
catheter. Proper localization and a sufficient number of catheters are
important to achieve an adjusted dose distribution. In specific cases
this is supported by preplanning using virtual catheters in the
treatment planning system set by a radiooncologist. HDR
brachytherapy with a 192Ir source is dependent on a close inter
disciplinary cooperation of radiooncologist and radiointerventionalist.
Since August 2006 1573 patients with liver tumors have been treated,
as well as 163 patients with lung tumors and metastases, 44
retroperitoneal malignancies, 15 renal tumors and 110 patients with
tumors in other locations.
: Prospective data is available on HCC as well as colorectal
carcinoma. Outside the liver, prospective data is available on lung and
retroperitoneal treatments. A prospective phase II trial with 83
brachytherapy application for lung malignomas resulted in a local
control rate of 92% after 12 months (1 – 21). Minor pneumothorax
occurred in 6 patients (21 %), only in 1 patient a chest tube was
necessary (2 %). There were no changes in the postinterventional vital
capacity.
For the patients with retroperitoneal tumors the results regarding
local control are similar, the complication rate and GI toxicity are
negligible.
: Interventional CT/MRI assisted brachytherapy is typically
an interdisciplinary approach. In almost every anatomical site where
the interventional radiologist may place a catheter brachytherapy is
able to deliveran adequate dose usually as a single fraction. Our
results demonstrate CT guided brachytherapy is safe and highly
effective. It is important to further define appropriate indications
with regard to a) alternative therapeutic approaches such as
extracerebral stereotactical irradiation with hypofractionation
schemes and b) general oncological considerations. The lecture will
provide facts for this discussion.
101
BRACHYTHERAPY: THE IAEA VISION AND POLICY.
E. Fidarova 1 , E.H. Zubizarreta 1 , J. Wondergem 1 , I. Stojkovski 1 , E.
Rosenblatt 1
IAEA, Applied Radiation Biology and Radiotherapy Section, Vienna,
Austria
In the field of Human Health and radiotherapy in particular, the
International Atomic Energy Agency (IAEA) has an objective to
enhance Member States’ (MS) capabilities to establish sound policies
for radiotherapy and cancer treatment, to improve access to
radiotherapy worldwide and to ensure the effective and safe
application of radiotherapy technologies.
Brachytherapy (BT) is an essential component of cancer treatment
and activities in this field have always been among IAEA’s priorities.
The IAEA has a number of possibilities to address the needs of MS
related to BT. Technical Cooperation (TC) Programme comprises
national and regional projects, with either bilateral cooperation
between individual MS or between a group of MS in the region and
IAEA. These projects are unique vehicles through which a MS may
obtain knowledge, skills or technology from the Agency or other MS.
Typical examples of TC projects are the initiation of a highdose rate
(HDR) BT unit, upgrade of BT department or introduction of a new BT
technique.
The IAEA conducts radiotherapy and radiobiology multicentre
international trials under Coordinated Research Project (CRP)
Programme. They are designed to answer scientific questions relevant
to the radiation oncology community and applicable in busy
radiotherapy departments within limited resource setting. Additional
benefit for participating institutions includes research capacity
building and gaining expertise in conducting radiotherapy trials. Two
of 12 currently running CRPs are randomised studies on oesophageal
and cervical cancer investigating clinical outcome and toxicity of a
resourcesparing schedule of radiotherapy with BT component. The
results of CRPs are usually published as IAEA documents with free
access and/or in scientific peerreviewed journals.
The IAEA places a lot of emphasis on training and education both in BT
and in external beam radiotherapy. This is achieved through
producing learning and educational materials, making them available
in IAEA official languages, organizing and conducting training courses
and workshops, assistance in planning and implementation of long
term training and education programmes at the national or regional
level. Recent publications include a full series of syllabi for the
training and education of radiotherapy professionals. The IAEA
develops clinical guidelines for management of selected types of
cancer or clinical situations that are very common in low and middle
income MS. Described approach and techniques are intended to be
simple, feasible and resource sparing to the extent that is possible
when dealing with a complex treatment modality. Such clinical
guidelines on cervical and prostate cancers are in press and will be
available later this year. Another important publication
“Implementation of HDR BT in limited resource setting” is planned to
be published in 2012/2013. The document covers a broad range of
relevant subjects, as necessary infrastructure, requirements for
personnel and training, quality assurance, radiation safety and current
applications of HDR BT.
The Division of Human Health supports and promotes elearning and
mlearning. The recently launched Human Health Campuswebpage
and its mobile version are educational and informational portals for
professionals in radiation medicine. Development of learning
resources was performed in close collaboration with professional
educationalists. Among available educational tools are recorded
lectures, interactive case studies and videos containing guide
questions and answers.
It is worth emphasizing that Agency’s policy in reference to
brachytherapy promotes resourcesparing approaches with support of
HDR brachytherapy, Co 60 brachytherapy, short fractionation schedules,
and the use of fixedgeometry applicators (e.g. tandemring).
Having more than half a century history of promoting and supporting
of radiotherapy and BT in treatment of cancer, the IAEA is proud of its
success stories. One of the recent examples is establishing a HDR BT
unit in ElSalvador.
102
UICC: RADIATION THERAPY IN THE WORLD
M. Gospodarowicz 1
1
Princess Margaret Hospital, Department of Radiotherapy, Toronto,
Canada
Radiotherapy is a critical ingredient of comprehensive cancer
treatment. It has been estimated that anywhere from 40 to 50
World Congress of Brachytherapy 2012 S 41
percent of all cancer patients would benefit from receiving
radiotherapy in course of their illness. Radiotherapy can be used as a
sole curative therapy, in combination with surgery and/ or
chemotherapy as part of the initial curative treatment approach, in
the management of recurrent disease, and as a powerful tool for
palliation.
Currently, the supply of radiotherapy services falls short of demand in
many parts of the world including many of high income countries.
However, the shortage is so pronounced in low and middle income
countries that it precludes radiotherapy from being considered as part
of cancer management. In fact, there are many countries in Africa
with no access or access limited to one or two centres. It is estimated
that in Africa, only 18% of the published need of the minimal need of
one treatment unit per million population in Africa. In Indonesia,
available radiotherapy resources represent less than 10% of national
need. This in spite of a large number of cervical cancer cases best
managed with curative radiotherapy. Large gaps also exist in high
income countries that face not only shortages of equipment, staff, but
also limited access to new technologies. Radiotherapy is one of the
most cost effective and safe cancer treatments available today. To
execute treatment process safely and effectively, an initial
investment into facility, equipment, staff training and ongoing
investment in quality programs is required.
The IAEA has developed a number if guidelines for safe deployment of
radiation therapy programs. The IAEA has also developed a
Programme for Action for Cancer Therapy (PACT) whose mission is to
contribute to the improvement in cancer survival in developing
countries by integrating radiotherapy investment into health system.
PACT integrates radiotherapy within a comprehensive cancer strategy
within the framework of a National Cancer Control Plan. However, in
spite of a number of partner organizations, the resources available to
IAEA and PACT Programme are limited. If we are going to witness
improvement in access to radiotherapy in the world, we must change
the current strategy of reliance on WHO and IAEA to solve the
problem. The UICC is working together with WHO, IAEA, and its
member organizations to put cancer on the global agenda to secure
improved funding. However, cancer requires complex interventions
and there will be numerous priorities for the use of funds.
The national and international radiation therapy organizations should
consider their role in global advocacy for cancer control, especially in
advocacy for radiation therapy. More complete data are required
describing radiotherapy resources including required manpower and
technology for optimal deployment of radiotherapy. Many countries
do not recognize medical physicists and radiation therapists as
essential medical personnel. Information regarding infrastructure
required for equipment operation (power supply, service, availability
of parts, etc) is frequently incomplete. Resource rich countries should
offer training and assistance to those less resources not only in
providing personnel and medical training but also advocacy and
implementation science support. This help should not be limited to
northsouth help or westeast but also east east and southsouth
help. In addition, the radiotherapy industry should join forces with
other partners to develop affordable sources of radiotherapy
equipment coupled with sustainable service provision.
Global radiation oncology community must join forces to assist the
governments in making rational choices in identifying best strategies
to improves cancer control; strategies that include radiotherapy.
103
WHAT ARE THE BEST INDICATIONS FOR BRACHYTHERAPY IN NON
MELANOMA SKIN CANCERS?
M. Delannes 1
1 Institut Claudius Regaud, Radiation Oncology, Toulouse, France
Non melanoma skin cancers are highly curable tumors mostly located
in sun exposed areas, with an increased incidence in elderly. The goal
of the treatment is to obtain cure with the best achievable cosmetic
and functional results. Different modalities have been applied:
dermatologic treatments, surgery alone or in combination with
external beam radiotherapy, or interstitial low dose rate (LDR)
brachytherapy. More recently, high dose rate (HDR) brachytherapy
have been proposed with specific, customized or not, surface
applicators.
Surgery remains the treatment of choice if it can be used simply and
safely, when negative microscopic margins can be achieved without
compromising cosmesis or function.
External beam irradiation with electrons can be indicated in locally
advanced lesions (size or thickness), not accessible to other treatment
modalities.
In the other situations, brachytherapy is an excellent option. The
greater experience have been gained with LDR interstitial
treatments, specially for periorificial lesions. The flexibility and
thinness of the Iridium wires, the adaptation of their longer to the
lesions offer personalized treatments easy to perform with minimally
traumatic implants. The limitation of this approach is that patient
isolation is required for several days.
HDR could be used as interstitial as well, but necessitates to use
thicker catheters to allow the passage of the HDR Ir source, limiting
its use in fragile areas, such as eyelid. Surface applicators can
overcome this problem, but seem to be more suitable for flat
surfaces, and have some technical limitations, particularly in case of
thick lesions or necessity of placement of bent catheters. This
technique can be particularly convenient for the elderly patients,
allowing outpatient treatments.
The acute tolerance of brachytherapy is excellent, with grade1 to 2
skin toxicity resolving in 4 to 6 weeks with topical treatments.
Cosmetic and functional results are reported as excellent, with local
control rate comparable to surgery or external beam radiotherapy.
During the lecture, brachytherapy indications will be illustrated with
clinical examples.
104
PHYSICS REQUIREMENTS FOR SKIN BRACHYTHERAPY
J. PerezCalatayud 1
1 Hospital Universitario La Fe, Radiotherapy, Valencia, Spain
Skin or superficial brachytherapy is the modality in which the sources
are set outside, or in contact with, the patient skin. In this
presentation we will focus on the widely extended HDR superficial
brachytherapy. There are two main techniques available:
The first one consists on a simple plane implant using parallel
catheters typically spaced 1 cm following the skin surface. This
configuration is preserved using moulds or flaps, i.e., Freiburg Flap,
depending on the skin curvature. Flaps are designed to keep the
distance between catheters. Typically, the prescription depth is 5
mm. The second technique uses specific applicators, i.e., Leipzig or
Valencia, where the typical prescription depth is 3 mm.
Several physics aspects should be considered in this modality for
treatment planning calculation and will be discussed on this
presentation.
Most of the available TPS perform calculations based on the TG43
method assuming full scatter conditions. In the mould/flap cases,
there is significant lack of scatter that could influence the uncertainty
on the dose rate distribution and prescribed dose. In this presentation
deviations between TG43 derived dose distributions and realistic ones
obtained using Monte Carlo methods are evaluated for different
source disposition (involved area), distance to skin (in contact to
several mm), prescription depth (typically 5 mm), use of backscatter
tissue equivalence material (typically up to 2 cm), and HDR
radionuclide (Ir192, Co60 and Yb169).
Dose distribution for treatment planning with Leipzig or Valencia
applicators cannot be obtained with the conventional calculation TG
43 approach existing on most of the current TPS. Monte Carlo
obtained data are used as will be included in this presentation.
Alternative techniques as the Tufts Technique (Rivard 2009) and
modern algorithms will be discussed.
In clinical practice, special attention should be focused on shielding
and leakage for these applicators. We will illustrate this issue on this
presentation. Similarly, depth evaluation methodology using specific
ultrasound techniques will be addressed.
Commissioning of these applicators will be discussed, including
acceptance, source positioning, flatness/symmetry, output, % depth
dose, etc. Finally, it will be complemented with patient specific
aspects as setup of the applicators and quality assurance.

S42 World Congress of Brachytherapy 2012
105
SKIN BRACHYTHERAPY FROM THE DERMATOLOGIST SIDE
J. Strasswimmer
Mohs Surgery Institute of Excellence of the Dermatology Associates,
Department of Dermatology, Delray Beach, USA
Abstract not received
106
GLOBAL PERSPECTIVE ON GYNECOLOGIC BRACHYTHERAPY:
CHALLENGES AND DEVELOPMENTS
A. Viswanathan 1
1
Brigham and Women's Hospital, Department of Radiation Oncology,
Boston, USA
The management of locally advanced cervical cancer has undergone
several fundamental shifts over the past 20 years. With the advent of
threedimensional (3D) imaging, the implementation of CT and MRI in
treatment planning for external beam and brachytherapy has resulted
in many improvements in patient outcomes. In this talk, an overview
of the state of the art technologies related to imaging for cervical
cancer will be summarized and novel technologies reviewed. In
particular, the role of imageguided brachytherapy worldwide and its
implications for patient care will be assessed.
107
MULTICENTER STUDIES WITH IMAGE GUIDED BRACHYTHERAPY IN
CERVICAL CANCER
J.C. Lindegaard 1 , C. CharraBrunaud 2 , A. Sturza 3 , C. HaieMeder 4 , C.
Kirisits 3 , K. Tanderup 5 , R. Pötter 3
1
Aarhus University Hospital, Department of Oncology, Aarhus C,
Denmark
2
Centre AlexisVautrin, Department of Radiotherapy, Vandoeuvreles
Nancy, France
3
Medical University of Vienna, Department of Radiotherapy, Vienna,
Austria
4
Service de Curiethérapie, Institut GustaveRoussy, Paris, France
5
Aarhus University Hospital Aarhus University, Department of
Radiotherapy Institute of Clinical Medicine, Aarhus, Denmark
The GEC ESTRO guidelines for image guided adaptive brachytherapy
(IGABT) in cervical cancer incorporate the use of 3D imaging with
applicator in situ and a 4D target concept (volume & time) including
both tumour extent at diagnosis (Intermediate Risk Clinical Target
Volume [IR CTV] and at time of brachytherapy (High Risk Clinical
Target Volume [HR CTV]). Several monoinstitutional reports show
significant improved DVH parameters and clinical outcome compared
to historical standard 2D intracavitary BT but higher level clinical
evidence has so far not been published.
Current multicentre studies encompass a completed French non
randomised study comparing 2D and 3D BT (STIC), an ongoing
international prospective observational study (Embrace) and a parallel
retrospective study (retroEmbrace). In STIC planned surgery was used
in 407 patients (group 1 and 2) leaving 235 patients treated with
definitive radio(chemo)therapy (group 3) and 117 of these were
treated with 3D IGABT. STIC was open for accrual 20052007. Since
2008 Embrace has recruited about 600 patients and a similar number
of patients treated before 2008 have been registered in the
retroEmbrace. The primary endpoint is local control and morbidity is
assessed with CTCAE v3.0 in all 3 studies. Health related quality of
life is in addition used in Embrace (EORTC C30+CX24). Currently the
FIGO stage distribution in STIC group 3, Embrace and retroEmbrace is
similar with 910% in stage IB1, 6669% in stage IB2IIAIIB and 2425%
in stage IIIIV. Median dose of EBRT is also identical (45 Gy/25 fx) in
all 3 studies, but more patients are receiving concomitant
chemotherapy in Embrace (91%) compared to STIC (77%) and
retroEmbrace (83%). In STIC the imaging modality used for 3D planning
of BT is mainly CT (82%), IR CTV is used in all patients for BT dose
prescription and 3D BT is delivered with PDR via pure intracavitary
(IC) implants. MRI is the main imaging modality in retroEmbrace (86%)
and Embrace (100%) and in both studies HR CTV is used in 85% of the
patients for BT dose prescription. Dose rate is at the moment 34% HDR
versus 66% PDR in retroEmbrace and 47% HDR versus 53% PDR in
Embrace. In retroEmbrace combined intracavitary/interstitial (IC/IS)
implants is used in 14% of the patients increasing to 19% in Embrace.
Reporting of dose volume parameters follow the GEC ESTRO guidelines
in all 3 multicentre studies by calculating the equivalent dose in 2 Gy
fractions (EQD2) using a/b=10 for tumour, a/b=3 for OAR and a repair
halftime of 1.5 h (Table 1). The dose received by 90% (D90) of the
target (HR CTV and IR CTV) is systematically being reported and for
OAR the minimal dose to the most exposed 2 cm 3 of the organ (D2cc)
is calculated. The mean volume of HR CTV is stable across the 3
studies (3536 cm 3 ). In contrast, there are remarkable differences in
the D90 values between STIC and the Embrace studies reflecting both
different planning aims in terms of cumulative EQD2 and the
difference in target volume used for dose prescription (IR CTV versus
HR CTV). The increasing use of combined IS/IC implants in
retroEmbrace and Embrace may also contribute to this difference and
may also explain that only a modest increase of 27 Gy in the D2cc
values are observed even with a 1115 Gy increase in D90 of HR CTV
when comparing STIC and the Embrace studies.
With regard to outcome the STIC study is able to show a significant
decrease in G3G4 morbidity from 23% to 3% and an improved local
control when the 2D and 3D arm of the study is compared. Morbidity
data is not yet mature for the Embrace studies, but interestingly it
seems that the increase in D90 of HR CTV is accompanied by an
increase in 2 year local control from 79% with STIC to about 90% in the
Embrace studies.
In conclusion, CT based IGABT according to GEC ESTRO guidelines may
significantly lower the G34 morbidity in a multicentre setting. MRI
based IGABT, use of HR CTV for dose prescription and use of IC/IS
implants in selected cases may further improve the dose distribution,
resulting in even higher rates of local control with no apparent loss in
the therapeutic index.
Table 1 HR CTV
HR
CTV
volume mean,
cm 3
D90
EQD2
IR
CTV
D90
EQD2
Bladder Rectum Sigmoid
D2cc
EQD2
D2cc
EQD2
D2cc
EQD2
STIC 3D, group
35
3
73 62 70 61 58
retroEmbrace 36 84 68 76 63 63
Embrace 35 88 69 77 64 63
108
UPCOMING ICRU/GEC ESTRO RECOMMENDATIONS FOR BRACHYTHERAPY
IN CANCER OF THE CERVIX (1)
R. Pötter 1 , C. Kirisits 1
1 on behalf of the ICRU 38 revision committee & Medical University of
Vienna, Comprehensive Cancer Center Dept. of Radiotherapy, Vienna,
Austria
The first ICRU report on intracavitary brachytherapy (38) was
published in 1985. In 1999 an ICRU committee was initiated to
perform a revision due to various developments in the fields, as e.g.
imaging, treatment planning, dose rates. No agreement could be
found during the following years. A new committee was constituted in
2009 with the task to finalize a report as soon as possible based on the
Gyn GEC ESTRO Recommendations which had become wide spread and
widely accepted in the international community.
The current report draft has a strong focus on the 3D image based and
4D adaptive approach. It also includes traditional concepts for 2D
planning which are linked to the 3D world as much as possible both for
target and OAR. The 3D concepts are based on the Gyn GEC ESTRO
recommendation with some further evolution.
The GTV and CTV concepts follow the classical ICRU traditions with a
special focus on the change of CTV during treatment. This has lead to
the introduction of a High Risk CTV which represents residual GTV and
surrounding areas assumed to carry a high risk for residual cancer
cells. The HR CTV is identified at a certain time point during
treatment by clinical examination and imaging, which is e.g. after 40
World Congress of Brachytherapy 2012 S 43
45 Gy EBRT plus chemotherapy in advanced cervical cancer. An
additional Intermediate Risk CTV is suggested representing the area of
tumour spread at diagnosis and/or a surrounding area around the HR
CTV. Uncertainties for CTV definition and contouring are subsumed
under the CTV. Uncertainties due to internal motion and due to set up
are recognized in the PTV concept. As the applicator is fixed to the
target by the intracavitary/vaginal applicator, no compensation seems
to be necessary according to current evidence. Also set up
uncertainties seem to be minimal according to current knowledge, if
applicator reconstruction is performed appropriately. In any case, the
addition of margins (as in EBRT) is not recommended after
application, in particular not orthogonal to the longitudinal axis of the
sources. If margins due to such uncertainties are considered, the
suggestion is to design them in the phase of planning the application
and to adapt the application as appropriate.
Adjacent (hollow) OARs like rectum, sigmoid, adjacent bowel and
bladder are delineated along their walls and limited absolute
volumes/areas of risk are defined, e.g. 2 cm³ and 0.1 cm³. Due to
contouring uncertainties this contouring approach is at present not
recommended for the vagina. Uncertainties due to internal motion are
present for OARs but should not be compensated with adding shell
margins like in EBRT, but rather assessed and individually corrected
for through repetitive imaging.
Dose (rate) per fraction is reported as physical absorbed dose and is
also calculated and reported as isoeffective dose, which is assumed
to correspond to a dose of 2 Gy per fraction, EQD2. The total dose in
one value both for the target and for OARs can only be given as EQD2.
The underlying model chosen for these calculations in this report is
the linearquadratic model. Its use is encouraged for the treatment
planning process and for the overall reporting. The limitations of this
model are well recognized, and its use has to be mainly understood
from pragmatic reasons. For the calculation of the tumour effect a
common α/β value of 10 Gy is proposed, for OAR a value of 3 Gy. For
doses above 56 Gy per fraction the calculated value seems to
overestimate the effect.
The upcoming ICRU report is based on experiences from 2D and 3D/4D
treatment planning. It summarizes and further evolves the Gyn GEC
ESTRO recommendations as applied so far and proposes these
concepts and terms to create a common language for future efficient
communication within the community to promote research and
development and to improve quality of care in the upcoming years.
(For concepts and terms for dose volume parameters and for
the treatment planning process see the following abstract
of Kirisits, Pötter on upcoming ICRU/GEC ESTRO
recommendations (2))
109
UPCOMING ICRU/GEC ESTRO RECOMMENDATIONS FOR BRACHYTHERAPY
IN CANCER OF THE CERVIX (2)
C. Kirisits 1 , R. Pötter 1
1 on behalf of the ICRU 38 revision committee & Medical University of
Vienna, Comprehensive Cancer Center Dept. of Radiotherapy, Vienna,
Austria
(For concepts and terms for target and OAR definitions and
biological dose modelling see the preceding abstract of
Pötter, Kirisits on upcoming ICRU/GEC ESTRO
recommendations (1))
The main parameter for reporting dose to target volumes is D90, which
is already well established and widely reported in singlecenter
experiences as well as for dose response studies. During clinical use of
D100 it became evident, that DVH sampling introduces major
uncertainties leading to nonreproducible D100 calculations. Therefore,
using the same arguments as in ICRU 83 for IMRT dose reporting, the
D98 is now proposed as an alternative to report the “near” minimum
target dose. In order to quantify high dose volumes within the CTVs
the D50 is included.
In contrast to the initial ICRU 38 report it is recommended to use
point A for dose reporting, which is defined based on the applicator
geometry. It will allow reproducible dose assessment for the 2D
approach, but also consistency and comparability for the 3D approach.
The TRAK, already proposed in ICRU 38 remains an essential reporting
parameter.
For normal tissues D2cm³ and D0.1cm³ are the main parameters for the 3D
approach. The use of D1cm³, proposed in the GEC ESTRO
recommendations is not continued as it contains only redundant
information for the dose region already fixed by D2cm³ and D0.1cm³.
Additional parameters for the mid and low dose region are suggested,
mainly reflecting the contribution of EBRT. While for bladder, rectum,
sigmoid and bowel DVH parameters are proposed, the situation is
different for the vagina. Due to inherent uncertainties in vaginal wall
delineation and DVH assessment, a point concept is proposed similar
to what has been recommended by ABS, with additions. Especially for
the 2D approach the dose points for rectum and bladder remain from
ICRU 38, but for bladder an additional point cranial to the original
point is proposed.
Beside parameters for evaluation it is underlined in this report that
also the spatial dose distribution within the target and OARs has to be
taken into account. Furthermore, dose to not explicitly contoured
organs at risk has to be considered. The concept of reference volume
and treated volume as suggested in ICRU 38 and other ICRU reports
has been replaced by “isodose volumes” which may be linked to
certain dose values selected for various reasons. These values can be
used e.g. for planning aims within a department or for inter
institutional comparisons.
Dedicated sections of the report contain recommendations and
information on treatment planning, applicator reconstruction, 3D dose
summation, inter and intrafraction uncertainties, source strength
specification and dose calculation.
A new concept, already proposed in ICRU 83, is introduced for
brachytherapy treatment planning: The “planning aim” is defined
upfront representing a certain “treatment schedule” for a specific
clinical scenario and includes a given set of dose and volume
parameters for a specific applicator. During the optimization
treatment planning process, adaptations are performed according to
dose volume constraints for the target and OARs. “Prescription” is
based on the final set of parameters which presents the treatment
plan finally sent to the afterloader for irradiation.
The upcoming ICRU report is based on experiences from 2D and 3D/4D
treatment planning. It summarizes and further evolves the Gyn GEC
ESTRO recommendations as applied so far and proposes these
concepts and terms to create a common language for future efficient
communication within the community to promote research and
development and to improve quality of care in the upcoming years.
OC110
FUNCTIONAL MRI GUIDED HDR PROSTATE BRACHYTHERAPY TUMOUR
BOOST: A FEASIBILITY STUDY
J. Mason 1 , B. AlQaisieh 1 , P. Bownes 1 , D. Wilson 1 , D.L. Buckley 2 , D.
Thwaites 3 , B. Carey 4 , A. Henry 5
1
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Department of Medical Physics, Leeds, United Kingdom
2
University of Leeds, Division of Medical Physics, Leeds, United
Kingdom
3
University of Sydney, Institute of Medical Physics School of Physics,
Sydney, Australia
4
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Radiology, Leeds, United Kingdom
5
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Clinical Oncology, Leeds, United Kingdom
: For standard HDR prostate brachytherapy in
combination with EBRT, a single 15Gy fraction is delivered to the
whole prostate. Tumour control may be improved if regions most
likely to contain higher tumour cell density within the prostate can be
identified and given a higher dose. In this study, the feasibility of
identifying these tumour regions using MRI, image registration of MRI
to treatment planning transrectal ultrasound (TRUS) and dose
optimisation to deliver increased dose to tumour regions while
maintaining existing urethral and rectal dose constraints is
investigated.

S44 World Congress of Brachytherapy 2012
: 15 patients underwent T2weighted (T2W),
diffusion weighted (DWI) and dynamic contrastenhanced (DCE) MRI
scans the day before HDR prostate brachytherapy treatment. For this
feasibility study, all patients were treated using the standard protocol
and the analysis described here was carried out after treatment had
been delivered. Tumour delineation was performed by a radiologist.
Regions suspicious for tumour on all 3 MRI datasets were classed as
gross tumour volume (GTV), regions suspicious on at least one MRI
dataset were classed as clinical target volume (CTV). MRI GTV and
CTVs were manually registered to treatment planning TRUS images. A
margin of 3mm was applied to each CTV to allow for contouring and
image registration uncertainties. Dose optimisation was investigated
by comparing the dose delivered to the GTV, CTV and CTV + margin
for (i) the delivered treatment plan and (ii) a modified version of the
delivered plan optimising dose to the CTV in a clinically realistic
manner, maintaining urethral and rectal dose at a similar level to the
delivered plan, adding additional HDR needles to target the tumour
area where appropriate.
: In general the suspicious areas on T2W, DWI and DCE MRI
were different but had regions of overlap. GTVs were identified in 11
patients with mean volume 0.52 cc (range 0.01 – 1.7 cc). CTVs were
identified in all patients with mean volume 2.6 cc (range 0.123.6 cc).
Though no patient had more than 1 GTV, 5 patients had more than
one CTV. Averaged results for the first 5 patients included in the dose
optimisation study are shown in Table 1. DVH statistics are relative to
100% dose = 15Gy.
Table 1: Mean DVH parameters from dose optimisation study.
D90 (Gy) V150 (%) V200 (%) D10 (Gy) D2cc (Gy)
(limit 17.5) limit 11.8
Plan:
1 2 1 2 1 2 1 2 1 2
1 delivered
2 optimised for
boost
Prostate (whole 17.0 17.2 24.7 36.2 5.7 9.0
including
CTV)
GTV,
GTV 20.4 29.5 36.0 100.0 3.9 74.9
CTV 18.6 25.9 26.6 93.8 4.3 54.7
CTV+margin 18.0 21.9 27.3 82.5 4.8 29.7
Urethra 17.1 17.2
Rectum 8.2 8.7
: Functional MRI guided HDR prostate brachytherapy
tumour boost is feasible it is possible to identify tumour regions
within the prostate in the majority of patients, and it is possible to
achieve significant increased dose to those regions without violating
urethral and rectal dose constraints. The level of dose escalation
varies from patient to patient and is lower if there are multiple
tumour regions, the tumour volumes are large or the tumour regions
are close to either the urethra or rectum.
OC111
IMPROVED APPLICATOR VISUALISATION FOR MRGUIDED BRACHY
THERAPY OF CERVIX
G.P. Liney 1 , C.J. Horsfield 1 , T.J. Murray 1 , A.W. Beavis 1
1
Queens Centre for Oncology Castle Hill Hospital, Radiation Physics,
Hull, United Kingdom
: Following GECESTRO guidelines we are utilising
MRI for Image Guided Brachytherapy (IGBT) planning of cervix cancer.
The softtissue contrast from these images is excellent at depicting
the high risk volume and organs at risk. However, one limitation is the
poor visualisation of the intrauterine (IU) tube and ring arising from
the use of MRcompatible materials (e.g. titanium or plastic) which do
not exhibit a proton signal and appear isointense. Potential remedies
using catheters of MRvisible solution have proved unsuccessful;
current practice is to register MRI with CT in which the definition of
the applicator is much clearer, although the planning system does not
subsequently use the CT numbers. It would be desirable to move
towards MRonly planning removing the repeated use of ionising
radiation and as a first step the poor applicator visualisation needs to
be addressed.
The purpose of this work was to develop an imaging protocol and
associated postprocessing software that can be used to produce a
single MRI dataset providing softtissue contrast and improved
applicator visualisation.
: A modification to the standard planning
sequence was investigated whereby a dualecho technique was used
to provide two images at every slice location; the first using a short
echo time (TE = 17 ms), to provide protondensity weighting in order
to enhance the contrast between tissue and applicator; the second
image acquired at a longer echo time (TE = 100 ms) to provide the
required T2weighted contrast for contouring. Furthermore, the short
TE image has a reduced susceptibility artefact meaning the signal void
more accurately represents the applicator.
Images were automatically processed (MATLAB) to identify the
hypointensity from the central portion of the short TE image using an
adaptive histogram threshold with additional morphological
manipulation. These pixels are then 'burnt in' as hyperintensities in
the inherently registered long TE images and converted into a
new DICOM series to be imported into the planning system for
analysis.
The protocol was acquired in a cohort of cervix patients to examine
the efficacy of introducing the technique into clinical practice.
:
Figure 1 (A) above demonstrates the specific benefits from dualTE
imaging. (B top & bottom) shows a 'burntin' dataset as displayed in
Flexiplan. This combines the T2weighting plus improved visualisation
of the ring and IU tube to position the applicator template.
Localisation of the applicator was much faster and easier without the
need of CT registration. Excellent positional agreement was achieved
when compared to using CT alone (C) and plans were unaltered.
: This study describes a simple but effective technique of
providing image guidance with the combined advantages of both MR
and CT from one single MRI acquisition. Scan time is not extended and
the new dataset is created within a few seconds. The method
described could be used to replace CT entirely and adopt MRonly
planning.
OC112
DOES INTERFRACTION CATHETER MOTION AFFECT HRCTV COVERAGE
IN GYNECOLOGIC INTERSTITIAL BRACHYTHERAPY?
A. Damato 1 , R. Cormack 1 , A. Viswanathan 1
1 Brigham and Women's Hospital, Radiation Oncology, Boston MA, USA
: In this preliminary work we estimated the effect
on HRCTV coverage of cranial/caudal interfraction catheter
displacements observed in gynecologic interstitial implants performed
in our clinic.
: Records of 12 patients recently treated in our
clinic with multifraction gynecologic interstitial brachytherapy were
retrospectively analyzed. The patients received between 5 and 9
World Congress of Brachytherapy 2012 S 45
fractions twice a day, with reference dose (RX) between 3 Gy and 7.5
Gy per fraction. A clinical plan (CLINICAL) was created on a CT scan
acquired immediately after implantation. The optimization was
performed by manually adjusting dwell times until a satisfactory
compromise was found between HRCTV coverage (maximization of
V100, D90) and sparing of OAR (minimization of D2cc of rectum,
bladder and sigmoid). A subsequent CT scan (D2_Scan) acquired 4872
hours after implantation was registered to the planning scan based on
rigid fusion of the pubic symphysis. The registered D2_Scans were
used to measure the catheter shifts and the offsets (i.e., catheter
slipping into or out of the patient) in the cranial (+) / caudal () (CC)
direction. HRCTV V100 and D90 in absolute value and as a percentage
of RX were also calculated on two modifications of the catheter
digitization of CLINICAL: by adjusting the location of the catheter tips
to reflect the measured CC shifts (D2_ACTUAL), and by adjusting the
location of the catheter tips to emulate the CC shift on the D2_Scan if
catheter offsets are corrected (D2_CORRECTED).
: The overall mean of mean shift per patient was 0.2±4.7 mm
(range [rg], 5.3 to 11.9 mm). Singlecatheter shifts between 16.3
mm and 20.0 mm were observed. CLINICAL HRCTV V100 was
86.9±13.0% (rg, 62.5% to 99.6%); D90 was 4.6±2.1 Gy (rg, 1.9 to 9.4
Gy); as a percentage of RX this was 99.6±25.9% (rg, 54.1% to 126.6%).
D2_ACTUAL HRCTV V100 was 85.7±13.7% (rg, 57.0% to 99.2%); D90
was 4.5±2.1 Gy (rg, 1.7 to 9.4 Gy); as a percentage of RX this was
96±25.5% (rg, 52.1% to 125.4%). D2_CORRECTED HRCTV V100 was
85.8±13.8% (rg, 60.5% to 99.2%); D90 was 4.5±2.1 Gy (rg, 2.0 to 9.4
Gy); as a percentage of RX this was 97.2±25.5% (rg, 48.3% to 125.5%).
The largest difference between CLINICAL and D2_ACTUAL in D90, from
119% to 105% of RX, was observed in a patient without a rectum with
a mean shift of 11.9 mm (rg, 8.8 to 20.0 mm). The results per patients
are summarized in the Table.
: Interfraction catheter displacements had a small effect
on HRCTV coverage in the patients analyzed. D90 was observed to
degrade in a patient with large cranial shifts; the resulting D90 was
still clinically acceptable. Large interfraction catheter offsets were
observed, resulting in large shifts of single catheters. These large
singlecatheter shifts did not affect the HRCTV coverage. Further
investigation on a larger patient sample will be conducted to validate
our conclusions.
OC113
DYNAMIC MODULATED BRACHYTHERAPY (DMBT): CONCEPT, DESIGN,
AND SIMULATIONS
W. Song 1 , M. Webster 1 , D. Han 1 , J. Einck 1 , D. Scanderbeg 1 , T. Vuong 2 ,
S. Devic 2
1
University of California San Diego, Radiation Medicine and Applied
Sciences, La Jolla, USA
2
McGill University, Radiation Oncology, Montreal, Canada
: Colorectal cancer is the third most diagnosed and
third leading cause of cancer death among men and women in the US.
In particular, patients with rectal cancer present a wide range of
disease burden, from very limited mucosal disease to quite advanced
and metastatic disease. Brachytherapy offers considerable advantages
over externalbeam RT for this site. With judiciously designed high
doserate (HDR) brachytherapy applicators, high conformality can be
achieved to the tumor volume with significant sparing to healthy
tissues. However, all currently available HDR brachytherapy
applicators are limited by their static designs. By allowing a shielded
applicator to dynamically modulate radiation, far better results can
be achieved. Our system, built from groundsup, named dynamic
modulated brachytherapy (DMBT), uses linear and rotational
modulation of a well collimated radiation profile to deliver extremely
conformal dosages.
: Our proposed system utilizes a high density
cylindrical tungsten shield, which houses an 192 Ir HDR source, to
generate a highly collimated radiation profile (Figure 1). Dosimetric
properties of the system are obtained by simulations in the Monte
Carlo NParticle (MCNP) package. An inhouse coded, gradient
projection optimization algorithm calculates the optimal dwell times
for each potential dwell position of the system based on the patient
geometry and userassigned weightings. The treatment plans are to be
carried out by a high precision robotic arm. We performed a
treatment plan quality comparison study using a previously treated
clinical data of 35 total fractions from 12 patients that were treated
using the Intracavitary Mold Applicator (ICMA).
Figure 1. Prototype DMBT system.
: The results show a striking advantage of DMBT over ICMA.
Table 1 shows the dosimetric characteristics of the two applicators
averaged over all patient plans. While keeping the prescription dose
constant to 10Gy, the DMBT produced significantly lower dosages to
all normal structures analyzed for every patient. In addition, the
DMBT system had significantly smaller lateral dose spills. Currently,
the DMBT’s only drawback is its longer total delivery time (i.e., three
times that of ICMA). However, the times are still well within the
patient tolerances and we are working to reduce them.
Table 1. Dosimetric characteristics of the 35 plans between ICMA and
DMBT.
: The dosimetric properties of the novel DMBT device
have been investigated using the MCNP simulations and directly
compared to the ICMA using treated patient plans. The translational
and rotational ability of the DMBT device gives it a clear advantage
over ICMA for rectal tumors. It allows for more uniform coverage to
the GTV while significantly increasing sparing to the surrounding
healthy tissues. Considering ICMA is currently the gold standard for
intracavitary brachytherapy, our DMBT system is clearly a great step
forward in HDR brachytherapy of rectal cancer.
OC114
ROBOTGUIDED DELIVERY OF BRACHYTHERAPY NEEDLES ALONG NON
PARALLEL PATHS TO AVOID PENILE BULB PUNCTURE
J.A.M. Cunha 1 , A. Garg 2 , T. Siauw 2 , N. Zhang 1 , Y. Zuo 3 , K. Goldberg 2 ,
D. Stoianovici 3 , M. Roach III 1 , J. Pouliot 1
1
University of California (UCSF), Radiation Oncology, San Francisco
CA, USA
2
University of California, Industrial Engineering and Operations
Research, Berkeley CA, USA
3
Johns Hopkins University, Urology, Baltimore MD, USA
: It has been shown in silico that both PPI and HDR
brachytherapy (BT) plans using nonparallel penilebulbavoiding

S46 World Congress of Brachytherapy 2012
needle geometries can meet all the standard clinical dose objectives.
This work demonstrates the implantation of these patterns into pelvic
phantoms using a robotic brachytherapy device.
: Custom pelvic phantoms (prostate, urethra,
bladder, pubic arch, rectum, & penile bulb) were built and CT used to
generate planning images. Structure vertices were transferred from
the Oncentra planning system to a custom needle optimization engine
to generate a candidate needle set (CNS) within the robot workspace.
The CNS excluded all needles that would puncture nontarget
structures and included both parallel and angulated needles (up to 53
deg. from parallel).
For HDR BT, a custom integer program was built to choose a subset of
the CNS to be implanted (smallest subset such that every voxel of the
target organ is within a userspecified distance from a needle). The
resulting planned needle configuration (PNC) was passed to the dose
optimization engine, Inverse Planning by Integer Program (IPIP), for
verification that the PNC supports a clinically viable dose plan. For
PPI, the CNS was passed to Inverse Planning Simulated Annealing
(IPSA), which returns a PNC and seed coordinates.
AcubotRND is a 7DoF stereotactic robot with a remote center of
motion (RCM) allowing needle pivot around the RCM point. Its
reference frame was calibrated to the phantom for registration to the
planner frame using a CTopaque marker. The robot geometry was
used to calculate an analytic inverse kinematic solution to map every
point in the robot workspace: from 3D coordinate system of the
planner to 7D coordinate system of the robot. The PNC coordinates
were transferred via a software interface that translates the two
coordinate systems to Acubot for insertion. After insertion, the
needles were released in place by the automated needle grippers of
the robot. Needle stylets were passed through the needle and
deposited in the phantom during needle retraction by the human user
making the implanted needle configuration (INC).
: An input system for Acubot was developed that allowed
digital input of needle coordinates. A postimplant CT was obtained,
and for HDR BT the INC was digitized for treatment plan generation.
For PPI, the stylets represent a string of seeds and spacers, which
were visible for postimplant dose evaluation. Visual inspection of the
INC with respect to PNC verified that the penile bulb and pubic arch
were not punctured. (Figure. Top right: PNC. Top left: INC.) Post
implant CT images verified avoidance of urethra puncture.
Satisfaction of clinical dose objectives of Prostate V100>90%,
V150

S48 World Congress of Brachytherapy 2012
brachytherapy practice. Model based dosimetry should not be
considered a simple investment on a new treatment planning system
mandated by recommendations or current trend, but rather as an
opportunity for concerted, interdisciplinary effort to reach improved
levels of care quality in the near future.
118
THE ADVANTAGES AND CRITICALITIES OF NEW DOSE CALCULATION
ALGORITHMS: WHEN PRESCRIPTION DOSES SHOULD CHANGE?
J.L. Guinot 1
1
Instituto Valenciano Oncologia, Department of Radiation Oncology,
Valencia, Spain
Prescription dose is one of the main points to give an adequate dose
in Brachytherapy. But we do not use always the same language.
Radiation oncologists have to explain the radiation physicists what we
really need to give the right dose to the right place. Traditionally dose
has been prescribed to points, as in the Manchester system for
cervical cancers, what can be called prescription 1D. When several
points are required in one plane as in the Paris system we can call
prescription 2D. Nowadays brachytherapy tends to be prescribed to
volumes based on image from computed tomography (CT), magnetic
resonance (MRI) or ultrasound (US). This is the 3D prescription. Last
recommendations suggest that this should be the best way to do the
prescription dose, but we can get some troubles that will be
described.
Four situations can happen with 3D prescription: A) When CTV is clear
and target is well defined, as in cervix with MRI or in prostate with
US, D90 is a good prescription, but doses inside the implant can be
very high and inhomogeneous. Moreover, if a cold spot involves GTV,
this can be a reason for failure at that point. B) When target is not
well defined a prescription dose to a volume can get big differences
depending on the person who draws the target, as it happens in
cervix, prostate or breast with CT. A prescription to points or isodoses
is required and D90 is useful to compare and be sure that the volume
is well covered. C) Sometimes a CTV cannot be drawn on the CT
slides, as in breast with closed cavity, tongue tumours that are
removed, or cavum with complete response. Target is defined by the
implant catheters. If the prescription dose to the target is given to
volume at a certain distance from the implant, big differences of real
dose can be achieved depending on the chosen distance, therefore a
calculation by the modified Paris system is mandatory. D) In cases
when there is no target because no image system is used, as in lip
carcinoma and boost breast with needles, modified Paris System is
used to prescribe to an isodose, and calculation should avoid
increased doses at the margins of the implant.
In 2D prescription doses are given to a certain distance due to the
sharp gradient, as it happens with a single applicator as esophageal,
bronchial brachytherapy and vaginal cylinders, with two catheters in
endometrium and cavum, and with more in contact brachytherapy to
treat skin tumours. CT can be used to test if prescription doses cover
the volume, but high doses on the surface of the applicators must be
taken into account and limit the chance of modifying doses. An
agreement is required to prescribe doses at a certain distance of the
applicator for every tumoral location.
1D prescription can be useful in some cases of choroidal melanoma,
esophageal and bronchial brachytherapy, but no longer in cervical
carcinoma.
In all these situations radiation physicists will calculate the isodoses
with different algorithms that can change homogeneity and dose
distribution, and a good communication with radiation oncologists will
always be required. New modelbased dose calculation techniques will
change our view of the standard dosimetries. A step forward is
needed, years after ICRU 38 and 58, to adapt the prescription doses to
the 3D, even 4D brachytherapy if we consider the changes in volume
between fractions.
: Prescription is a medical decision. 2. We need to use a
common language to compare different series. 3. With one or two
catheters there is a high gradient of dose, and distance must be
carefully chosen. 4. With three or more catheters, prescription
should be done to volume. 5. If the target is not visible, modified
Paris system and prescription to an isodose related to the implant
should be used. 6. If target is not well defined by imaging methods,
prescription can be done to volume but it must be compared with
standard prescription to points. 7. If target is well defined,
prescription should always be done to volume but taking into account
the previous experience of prescription to points. 8. The tendency is
the prescription to volume (3D) with imaging systems as it is in EBRT.
9. A common policy regarding prescription should be achieved in all
tumoral locations.
PD119
REALTIME SOURCE POSITION VERIFICATION FOR MRGUIDED SINGLE
FRACTION HDR PROSTATE BRACHYTHERAPY.
M.A. Moerland 1 , H. de Leeuw 2 , M. van Vulpen 1 , C.J.G. Bakker 2 , P.R.
Seevinck 2
1
U.M.C. Utrecht, Department of Radiotherapy, Utrecht, The
Netherlands
2
U.M.C. Utrecht, Image Sciences Institute, Utrecht, The Netherlands
: Single fraction HDR brachytherapy as a
monotherapy requires safe dose delivery, e.g. by realtime source
position verification. Since MRI provides superior visualization of
prostate, tumour and critical organs, an MRIguided single fraction
HDR brachy monotherapy for localized prostate cancer is being
developed in our institute. In a dedicated treatment suite equipped
with an HDR afterloader and a 1.5 T MR scanner, patient treatment
and imaging can be combined. Objects like an Ir192 source in a steel
capsule cause MR image artefacts, which may be exploited to detect
the position of the source in the MR image. The purpose of this in
vitro study is to investigate the feasibility of realtime Ir192 source
position verification using MRI.
: For realtime position verification we applied
the coRASOR (centerout RAdial Sampling OffResonance) technique.
This special MR imaging technique allows signal distortion around a
perturber to be focused into its exact center by applying a specific
frequency offset [1]. We applied the offset during reconstruction of
the data. An HDR source was introduced in a plastic needle, which
was inserted parallel to B0 in a 7 cm thick inhomogeneous piece of
porcine tissue. The source consists of a nonradioactive Ir192 cylinder
(0.65x3.6 mm) in an AISI 316L steel capsule (0.9x4.5 mm) connected
to a ferromagnetic steel cable (diameter 0.7 mm). The phantom was
imaged on a CT scanner with 1 mm slices at 120 kV and 450 mAs for
comparison. Multislice 2D coRASOR imaging was performed on a 1.5T
MR scanner using a large excitation bandwidth (5.4 kHz), field of view
192x192 mm 2 , resolution 2 mm isotropic, reconstruction 1 mm, single
coronal and sagittal slice, slice thickness 10 mm, echo time 0.75 ms,
repetition time 2.9 ms, flip angle 20 o , readout bandwidth 890
Hz/voxel, NSA 2, scan duration 2.9 s. The images reconstructed at the
optimal frequency were thresholded and the resulting positive
contrast images were merged with the onresonance acquired images.
MR and CT images were registered using rigid registration.
: Results of coRASOR imaging of the HDR source in the
inhomogeneous porcine tissue are shown in Figure 1. The high signal
spot in the coRASOR images corresponds within 1 mm to the tip of
the source, as measured in the registered CT images. The two 2D
images allow tracking of the source tip in 3D. Acquisition of the 2
orthogonally placed MRI slices was performed within 3 seconds. Off
resonance reconstruction increased the total acquisition and
reconstruction time by less than one second. Hereby the total tracking
could be performed within 4 s, which is within the range of the source
dwell times in a single fraction monotherapy HDR prostate treatment.
: coRASOR MR imaging of 2 orthogonal slices allows
source tracking within 4 s, making realtime source position
verification in HDR prostate treatment feasible.
[1] P.R. Seevinck et al. MRM, 65:146–156, 2011
World Congress of Brachytherapy 2012 S 49
PD120
FIDUCIAL MARKERS IN COMBINED EBRTLDR THERAPY OF PROSTATE
CANCER: INFLUENCE ON LDR DOSE
G. Landry 1 , B. Reniers 1 , L. Lutgens 2 , L. Murrer 3 , H. Afsharpour 4 , D. de
HaasKock 2 , P. Visser 3 , F. van Gils 2 , F. Verhaegen 1
1
MAASTRO clinic, Physics Research, Maastricht, The Netherlands
2
MAASTRO clinic, Radiotherapy, Maastricht, The Netherlands
3
MAASTRO clinic, Clinical Physics, Maastricht, The Netherlands
4
Centre Hospitalier Universitaire de Quebec, RadioOncologie,
Quebec, Canada
: When performing combined modality
radiotherapy treatment of intermediate or highrisk prostate cancer
with external beam radiotherapy (EBRT) and low dose rate (LDR)
brachytherapy, gold fiducial markers (FM) implanted at the EBRT
stage are present during LDR seed implantation and subsequent dose
delivery. These FM will create dose shadows perturbing the LDR dose
distribution, to a greater extent than in EBRT, given the lower photon
energies. The purpose of this study was to perform an initial
investigation into the perturbations of the LDR brachytherapy dose
distribution introduced by the presence of FM in the prostate, by
investigating phantom and patient cases.
: A virtual water phantom was designed
containing a single FM. Single and multi source scenarios were
investigated by performing Monte Carlo dose calculations, along with
the influence of varying orientation and distance of the FM with
respect to the sources. Three prostate cancer patients treated with
LDR brachytherapy for a recurrence following external beam
radiotherapy with implanted FM were studied as surrogate cases to
combined EBRTLDR therapy. FM and brachytherapy seeds were
identified on post implant CT scans and Monte Carlo dose calculations
were performed with and without FM. The dosimetric impact of the
FM was evaluated by quantifying the magnitude of dose shadows and
the volume of cold spots for both phantom and patient scenarios.
: Large dose shadows are observed in the single sourceFM
scenarios, and the shadows are dependent on sourceFM distance (see
Fig. 1 AE) and orientation. Large dose reductions are observed at the
distal side of FM, while at the proximal side a dose enhancement is
observed (Fig. 1 D). In multi source scenarios, the importance of
shadows is mitigated, although FM at the periphery of the seed
distribution caused underdosage (

S50 World Congress of Brachytherapy 2012
wall). Conformity Indexes (CI), related to reported air/seroma and
invagination volumes, were also evaluated.
: Lumpectomy cavity volumes averaged 8.3±0.9cc. PTV_EVAL
and PTV volumes averaged 43.2±9.0cc and 49.5±3.8cc, respectively.
V90 values averaged 98.5±1.9% (TG) and 98.0±2.3% (AC) of the
PTV_EVAL volume. Similarly, V95 averaged 97.4±2.8% (TG) and
96.5±3.1% (AC), and V100 averaged 95.3±3.4% (TG) and 94.1±3.9%
(AC) across the entire cohort of patients. The V150 'hotspots' averaged
24.4±4.7cc (TG) and 23.9±5.4cc (AC), while V200 averaged 14.1±2.9cc
(TG) and 13.8±2.8cc (AC). The average minimum skin distance was
11.9mm, but the applicator was used in patients where the skin
bridge was as low as 1mm. The average maximum skin dose was 76.3%
(TG) and 73.2% (AC) of the prescription dose. The average minimum
rib bridge was 15.7mm, with the shortest 20 days) was
3.3%. Prolonged AUR in the first 500 implanted patients was 6.2% vs.
1.1% in the last cohort. The order of implant was considered to be a
significant factor (p = 0.0002).
Overall acute RTOG grade 0, 1, 2 and 3 urinary toxicity rates were
12.3%, 45.2%, 34.2 % and 8.1%. The rates of late RTOG grade 0, 1, 2
and 3 urinary toxicity were 47.5%, 34.25, 15.1% and 3.1%. There were
no acute or late RTOG grade 4 urinary events. The rate of acute
toxicity (RTOG grade ≥ 2) in the first 500 implanted patients was
51.5% vs. 31.7% in the last cohort. The order of implant was
considered to be a significant factor (p

S52 World Congress of Brachytherapy 2012
regrowth of tumor. This might be the result of an inadequately
covered target volume. The use of MRIguided brachytherapy would
allow for accurate treatment planning due to precise tumor
delineation and catheter reconstruction. To determine the potential
benefit of MRIguided brachytherapy for esophageal cancer, we
evaluated the dose distribution of the current brachytherapy
technique on MR images.
: 5 patients with inoperable esophageal cancer
were treated with HDR brachytherapy with a dose of 1012Gy in one
fraction. The proximal and distal tumor borders were visualized with
endoscopy and the position of the catheter controlled by fluoroscopy.
The dose was prescribed at 1 cm from the middwell position and the
active length encompassed the visible tumor with a 2 cm margin
proximal and distal.
After treatment the applicator and active treatment length were
reconstructed on MR images using the anatomical structures and
reference markers on the Xray images. T2w MR images in transversal,
coronal and sagittal plane were acquired on a 1.5 T scanner
approximately one week before brachytherapy and used to delineate
the tumor (Fig 1a). The reconstructed dose distribution enabled
calculation of the dose to 90% of the tumor volume (D90%) and the
volume of the tumor receiving 95% of the prescribed dose (V95%).
Furthermore, the distance between the borders of the tumor and the
100% isodoseline along the applicator was measured to determine the
actual treatment margin.
: For all patients the extension of the tumor documented by
fluoroscopy was smaller than the tumor length delineated on the MR
images (Table 1). The intended treatment margin of 2 cm was only
reached for 2 of the 10 tumor borders. For two patients the 100%
isodoseline was on the distal border of the tumor and one patient
even demonstrated 7 mm of mucosal tumor to be outside the 100%
isodoseline (Fig 1 b). Due to the axial tumor extension beyond 1 cm,
the tumor volume was underdosaged in all patients with an average
V95% of 50% and D90% of 6.1 Gy (Table 1).
Table 1: Tumor length along the applicator as documented on the X
ray images and delineated on the MR images, the treatment margins
and dose coverage based on the reconstructed dose distribution on
the MR images.
Patient tumor
length
on Xray
(mm)
tumor
length
on MRI
(mm)
Proximal margin
(mm)
Distal
margin
(mm)
V95% D90%
(%) (Gy)
1 70 90 24 0 63 7.7
2 100 114 15 0 25 3.7
3 70 89 10 23 53 7.3
4 60 90 7 16 38 4.0
5 60 85 12 9 69 8.0
: Endoscopic/Xray based brachytherapy for esophageal
cancer seems to underestimate the extension of the mucosal tumor.
Even with a large treatment margin of 2 cm underdosage of the
mucosal tumor occurs. Accurate MRIguided brachytherapy, allowing
for conformal treatment planning with a small margin, has the
potential to improve tumor coverage while sparing healthy esophageal
wall along the length direction.
PD127
VAGINAL BRACHYTHERAPY FOR INTERMEDIATE RISK ENDOMETRIAL
CARCINOMA FROM SINGLE INSTITUTION
A. Jhingran 1 , A. Klopp 1 , P. Allen 1 , P. Soliman 1 , C. Levenback 1 , J.
Brown 1 , P. Ramirez 1 , P. Eifel 1
1
U.T. M.D. Anderson Cancer Center, Radiation Oncology Unit 1202,
Houston TX, USA
: To review the outcome and patterns of recurrence for
patients treated with postoperative vaginal apex brachytherapy for
intermediaterisk endometrial cancer.
: Two hundred and fortyfive patients with
endometrial carcinoma were treated from 4/199911/2009 with
adjuvant vaginal brachytherapy alone +/ chemotherapy. All patients
were treated using a Delclos dome cylinder to a total dose of 30 Gy in
5 fractions prescribed to the vaginal surface; only the apex of the
vagina was treated, usually with 4 dwell positions. The mean follow
up of the patients was 57 months (range 1 157 months). The median
age of the patients was 63 yrs. (range 3189 yrs.). All patients had a
TAH/BSO and most had lymph node sampling. Nineteen percent
(46/245) of patients received adjuvant chemotherapy consisting of
carboplatin, taxol or a combination of the two.
: Sixtyseven percent (164/245) of the patients had
endometrioid adenocarcinoma, 14% (34/245) had serous carcinoma,
9% (21/245) had clear cell carcinoma and 10% (24/245) had MMMT.
Two patients had other histologies. Of the patients with
adenocarcinoma, 7% (11/164) had grade 1 disease, 72% (119/164) had
grade 2 disease and 21% (34/164) had grade 3 disease. Most patients
had FIGO 1988 stage I (75%, 184/245), however, 15% (37/245) had
stage II and 10% (24/245) had stage III. Lymph vascular space invasion
was seen in 42% (101/245) of the specimens.
At 4 years, the rates of overall survival (OS), disease free survival
(DFS) and vaginal control (VC) for 245 patients were 88%, 86% and
95%, respectively. There were 13 vaginal recurrences, 7 patients
recurred at the apex and 6 patients recurred distal to the radiated
vagina. Of the 6 patients that recurred distally, 4 were salvaged with
radiation therapy and chemotherapy. Of the apical recurrences, only
one patient was salvaged with surgery and chemotherapy. Most of the
patients who had apical recurrences had large pelvic masses or distant
metastasis at the same time as the apical recurrence. Factors that
correlated with poorer DFS were LVSI (p=0.025), grade 3 (p=0.002),
stage III (p=0.005), and MMMT/serous histology (p < 0.0001). Grade 3
histology (p = 0.05) and LVSI (p = 0.02) predicted for vaginal
recurrence.
: Excellent vaginal control was achieved while treating
only the vaginal apex with brachytherapy in this group of patients
with endometrial carcinoma. Recurrences distal to the area of
treatment are rare and often can be successfully salvaged. For
patients with grade 3 tumors the addition of chemotherapy should be
explored to try to achieve better local control and diseasefree
survival.
PD128
DOSE CONTRIBUTION TO INVOLVED PELVIC NODES WITH 3D
BRACHYTHERAPY FOR CERVIX CANCER; COMPARISON OF TWO CANCER
CENTERS
W. van den Bos 1 , L. Velema 2 , S. Beriwal 3 , A.A.C. de Leeuw 1 , I.M.
JürgenliemkSchulz 1
1
U.M.C. Utrecht, Radiation Oncology, Utrecht, The Netherlands
2
Erasmus Medical Center, Radiation Oncology, Rotterdam, The
Netherlands
3
University of Pittsburgh Cancer Institute, Radiation Oncology,
Pittsburgh, USA
: Imageguided brachytherapy (IGBT) has
beenincreasingly adopted in the treatment of advanced cervical
cancer. Mainadvantage is the doseoptimization to target volumes
with reduced dose tocritical organs. It also offers the opportunity to
measure the dose to pelviclymph nodes visible on T2 weighted MR
images with a short axis diameter of ≥ 5mm (pLNN). The goal of this
study was to measure and compare the pLNN dose fromtwo different
cancer centers.
: Twentyseven and fifteen patients with
cervical cancer and pLNNtreated with HDRIGBT and PDRIGBT
World Congress of Brachytherapy 2012 S 53
respectively at two different institutions wereanalyzed. HDRIGBT
dose was 5.06.0 Gy x five fractions using CT/MRI
compatibletandem/ring applicator with intracavitary technique. PDR
IGBT dose was 32x60cGy x two fractions using Utrechttandem/ovoid
applicator with intracavitary/interstitial technique. PLNN seenon
pretreatment PET/CT or MRI were contoured on all BTplans. D90
(dose to 90%of each node volume) was calculated from dosevolume
histograms. Both theabsolute dose and percentage of prescription
dose to the node volume wascalculated for each fraction. For each
involved node the total dose for allfractions was calculated,
expressed in biological equivalent doses of 2 Gyfractions (EQD2). The
D90 as percentage of prescription dose and as EQD2 werecompared.
: 57(HDR) vs. 40 (PDR) pLNN were contoured. In the HDR and
PDR groups, the nodaldistributions were 4 vs. 1 in common iliac region
(CI), 14 vs. 11 in internaliliac region (II), 31 vs. 18 in external iliac (EI)
region 8 vs. 5 in obturatorregion (OB) and 0 vs 5
inparametrial/miscellaneous area. The mean percentage of dose to
the nodes was10.8% (5.725.1 %) vs. 20.5% (6.893.3%) of the
prescribed dose to HRCTV inthe two centers, respectively (p

S54 World Congress of Brachytherapy 2012
the med group compared to lat; for N0 med: 77.8% vs. lat: 85.5%, p =
0.0038.
: The use of a HDR source in boosting the primary tumour
site after external beam radiotherapy with a dose of 10 Gy in 1
fraction is a routine procedure. The local relapse rate and survival
data are very similar to those reported in literature. More than 95% of
the patients live with their preserved breast. When comparing two
time periods, an improvement both in the local recurrence rate and
the disease free survival rate occurred.
We therefore hypothesize that after BCS ± ST and RT, patients with
medial tumour locations are at higher risk, in particular in N0
patients. The reason may lie in the fact that the pathologic stage of
the IMC is unknown, and that patients with medial tumour locations
and negative axillary nodes neither received radiation treatment to
IMC nodes nor systemic therapy, while in lateral tumours all patients
with positive axillary nodes underwent systemic therapy and (in part)
supraclavicular irradiation.
Thorough diagnostic examination and more aggressive treatments are
to be considered for patients with medial tumour location and axillary
N0 status.
OC132
EXCELLENT COSMESIS AFTER APBI: DOES DOSE TO THE DERMAL
VOLUME PROVIDE A BETTER PREDICTIVE CONSTRAINT THAN SKIN
DMAX?
R. Vera 1 , D. Todor 1 , N. Bennion 1 , N. Mukhopadyay 2 , D.W. Arthur 1
1
Virginia Commonwealth University, Radiation Oncology, Richmond,
USA
2
Virginia Commonwealth University, Biostatistics, Richmond, USA
: Our goal was identify an anatomic structure and
its associated dosevolume constraints that correlate with excellent
longterm cosmesis for breast cancer patients treated with adjuvant
accelerated partial breast radiation (APBI) delivered with
brachytherapy. A comparative analysis of TG43 and Acuros variables
was done to identify the best discriminator of cosmetic outcome.
: From 20002005, 45 patients, treated with
balloon and multicatheter brachytherapy, had dosevolume histogram
(DVH) reconstruction that was electronically available. Clinical follow
up was at regular intervals and included history, physical exam, and
mammography. Overall cosmesis was a physiciangraded evaluation
using the Harvard scale from excellent, good, fair or poor. Additional
toxicities, in the form of hyperpigmentation, telangectasia, and
fibrosis, were graded on the RTOG scale of 04. These patients were
further divided into two populations of acceptable cosmesis (AC) and
unacceptable cosmesis (UC). The AC group included patients who had
excellent and good overall cosmesis without any other described
toxicity. The UC group consisted of 5 patients with either a fair or
poor overall cosmesis, or a good overall cosmesis and documented
toxicity of at least grade 1 hyperpigmentation, telangectasia, or
fibrosis.
In an attempt to include vascular networks to the skin, a new dermal
structure, extending from the skin surface to a 5mm depth, was
created for each plan. Dose rate, maximum skin surface dose, V90,
V100, V150 and V200 to this dermal structure was evaluated and
analyzed. A tree regression analysis was used to compare the
predictative capabilities of TG43 and Acuros planning models.
: For the 45 patients with available DVH analysis, there was a
median follow up of 35.2 months. The AC group had a mean Dmax to
the skin surface of 2.66Gy (SD= 0.47Gy), and the UC group had a mean
Dmax to the skin surface of 2.98Gy (SD= 1.01Gy). Based on statistical
analysis, the maximum dose to skin surface did not differentiate
between the two groups. The mean dermal V90 for the AC group was
4cc (SD=2.6cc), and the mean dermal V90 for the UC was 7cc (SD
2.4cc).
The dermal V90 distinguished between the two groups with statistical
significance. Moreover, a threshold value for a dermal V90 of

S56 World Congress of Brachytherapy 2012
Georgia, USA
5
Boca Raton Community Hospital, Radiation Oncology, Boca Raton
Florida, USA
6
Texas Cancer Clinic, Radiation Oncology, San Antonio Texas, USA
7
First Coast Oncology, Radiation Oncology, Jacksonville Florida, USA
8
Arizona Breast Cancer Specialists, Radiation Oncology, Phoenix
Arizona, USA
9
Putnam Cancer Center, Radiation Oncology, Palatka Florida, USA
: Noninvasive imageguided breast brachytherapy
(NIBB) is a mammographybased (AccuBoost ® , Billerica, MA),
brachytherapy system whereby the treatment applicators are
centered on the planning target volume (PTV) to direct 192 Ir emissions
along orthogonal axes. This study reports early clinical results on the
use of NIBB for breast tumor bed boost with external beam whole
breast radiation therapy (WBRT) as part of postlumpectomy
radiation.
: A privacyencrypted online data registry was
created to collect information from 9 independent academic and
communitybased institutions. Data were collected from consecutive
247 individual women with early stage breast cancer (59% invasive)
after breast conserving surgery, who received adjuvant WBRT (mean
47.9Gy in 26±2 fractions) and tumor bed boost (mean 12.6Gy in 6±2
fractions) with NIBB between Jun 2007 and Dec 2011. NIBB was
delivered before, during, or after WBRT in 46%, 48%, or 5% of pts. Pt
age and tumor size ranged from 1988yr and 0.15cm. Toxicity and
cosmesis were evaluated after radiation therapy and graded according
to the Common Toxicity Criteria (v3.0) and the Harvard scale. Mean
follow up was 7 months (range 0.2542).
: There were no locoregional recurrences in the cohort. There
was no association noted of cosmetic outcomes with type of surgery
(2% oncoplasty, 74% standard or 24% unknown), presence of re
excision (29%), presence of tumor bed clips (42%) or tumor size. Grade
12 skin toxicity was observed in 44%, 36%, and 16% during the acute
(13wks), intermediate (426 wks), and lateintermediate (>26wks)
periods. There was no grade 35 skin toxicity event and no poor
cosmesis reports. Overall, cosmeses were excellent, good, fair in 50%,
46%, and 4% (Figure).
Interval time (months)
Cosmesis (CTC v3.0) 0 to1 >1 to 6 >6 to 12 >12
Fair (%) 0 7 3 6
Good (%) 75 41 54 29
Excellent (%) 25 52 43 65
: These data support that NIBB can be consistently
implemented with minimal shortterm toxicity and no evidence of
early local failure in both community and academic settings. The
overall cosmetic outcome appears to be stable beyond 12 months
(Table).
137
REPEAT BREAST CONSERVATION THERAPY: USA EXPERIENCE
R. Patel
University of Wisconsin, School of Medicine and Public Health,
Madison, USA
Abstract not received
138
SECOND CONSERVATIVE TREATMENT FOR IPSILATERAL BREAST CANCER
RECURRENCE: GECESTRO BREAST WG STUDY
J. HannounLevi 1 , D. KauerDorner 2 , J. Gal 3 , V. Strnad 4 , P. Niehoff 5 , K.
Loessl 6 , G. Kovacs 7 , E. Van Limbergen 8 , C. Polgar 9
1
Centre Antoine Lacassagne, Radiation Oncology, Nice, France
2
Medical University of Vienna, Radiation Oncology, Vienna, Austria
3
Centre Antoine Lacassagne, Biostatistic Unit, Nice, France
4
University ErlangenNuremberg, Radiation Oncology, Erlangen,
Germany
5
University Hospital SH, Radiation Oncology, Kiel, Germany
6
University Hospital Bernes, Radiation Oncology, Bernes, Switzerland
7
University of Luebeck and University Hospital of SchleswigHolstein,
Radiation Oncology, Luebeck, Germany
8
University Hospital Gasthuisberg, Radiation Oncology, Leuven,
Belgium
9
National Institute of Oncology, Radiation Oncology, Budapest,
Hungary
In case of ipsilateral breast cancer recurrence (IBCR), radical
mastectomy represents the treatment option frequently proposed to
the patient. A second conservative treatment has been proposed using
either lumpectomy alone or associated with a second irradiation of
the tumor bed. However, in both clinical situations, the proof level of
such therapeutic approaches remains low, based on casedseries or
retrospective studies (level C).
In order to analyze the clinical outcome of a second conservative
treatment (SCT) using lumpectomy and multicatheter interstitial
brachytherapy (MIB) for IBCR, the GECESTRO Breast Working Group
retrospectively analyzed the results of 217 patients (pts) with an IBCR
treated between 09/2000 and 09/2010 in 8 European institutions by
lumpectomy and MIB (low LDR, pulse – PDR, or highdose rate
HDR). Survival rates without 2 nd local and metastatic progression,
disease free survival (DFS) and specific and overall survivals were
analyzed as well as late tissue breast complications and cosmetic
results. Dosimetric data were reported according to the dose rate
used. Univariate and multivariate analysis were performed to find
local, metastatic and/or DFS progression prognostic factors.
With a median followup of 14.5 years [3.538.2] and 3.9 years [1.1
10.3] from primary tumour and IBCR respectively and a median delay
of 9.4 years [1.135.4] between primary and IBCR, 20.7% of the local
recurrence were observed at distance from the primary tumour.
Median tumour sizes were 15 mm [160] and 11 mm [140] for the
primary and IBCR respectively. Sixteen percent of the patients
presented a positive lymph node dissection for the primary tumour
while 69.1% did not undergo new axillary dissection at the time of
IBCR. Median radiotherapy dose for the primary was 56 Gy [3069.6].
Positive hormonal receptor status for IBCR was 72.8% while 65% and
19.8% received hormonal and chemotherapy respectively as adjuvant
therapy for the IBCR. MIB for IBCR used LDR (12.4%), PDR (40.6%) and
HDR (47%) with a median delivered dose of 46 Gy [3055], 50.4 Gy [49
50] and 32 Gy [2236] for LDR, PDR and HDR respectively. Five and 10
year actuarial 2 nd local recurrence rates were 5.6% [1.59.5] and 7.2%
[2.112.1] respectively. Five and 10year actuarial metastatic
recurrence rates were 9.6% [5.715.2] and 19.1% [7.828.3]
respectively. Five and 10year actuarial DFS rates were 84.6% [78.9
90.6] and 77.2% [67.588.3] respectively. Five and 10year actuarial
overall/specific survival rates were 88.7% [83.194.8] and 76.4% [66.9
87.3] respectively. One hundred and forty one pts developed 193
complications. Fibrosis was the most frequent complication with 11%
of G34 complications. Cosmetic result was jugged as excellent/good
World Congress of Brachytherapy 2012 S 57
in 85%. Univariate and Multivariate analysis for prognostic factors of
2 nd local recurrence, metastatic recurrence and DFS are reported in
the table 1. The results of this study suggest that in case of IBCR, a
SCT combining lumpectomy plus MIB is feasible with an overall
survival rate at least equivalent to those obtain after salvage
mastectomy. The rate of complication remains acceptable with
encouraging cosmetic results.
The data provided by the literature analysis suggest that the rate of
second local recurrence is about 10% (ranged from 3 to 32%), about
25% (ranged from 7 to 36%) and about 10% (ranged from 2 to 26%),
after salvage mastectomy, salvage lumpectomy alone or combined
with a second irradiation of the tumor bed respectively. However, the
5year overall survival rates after salvage mastectomy and SCT seem
to be equivalent (≈ 75%) mainly influenced by distant metastatic
progression.
To go forward in terms of Evidence Based Medicine, different options
can be discussed such as Phase III or II randomized trials comparing
salvage mastectomy versus SCT, retrospective studies based on a
matchedpair analysis or observatory studies. All of the study designs
have their own advantages and disadvantages and need to be carefully
analyzed to be able to propose new treatment options for women who
experience an IBCR.
OC139
A FAST AND ACCURATE GPUBASED PRIMARY+SCATTER ALGORITHM FOR
LDRBRACHYTHERAPY
A. Bourque 1 , P. Després 1 , L. Beaulieu 1
1
Centre Hospitalier Universitaire de Québec, L'HôtelDieu de Québec,
Radiation Oncology, Quebec, Canada
: To improve the accuracy while maintaining fast
execution of TG43 dose calculations with a fast GPUbased ray
tracing algorithm integrating a point to point scatter dose kernel that
handles medium heterogeneities.
: The method developed derives from the TG
43 formalism. An incremental version of Siddons’s raytracing
algorithm is first used to compute radiological distances from sources
to dose calculation points. Then, a regular TG43 dose calculation is
performed, with an added correction factor for medium attenuation.
Finally, a scatter dose kernel spread the SCERMA energy value around
every voxel based on the Thompson approximation of the Compton
scattering. Interseed attenuation (ISA) effects and the presence of
numerous materials on dosimetry were assessed for both regular and
modified TG43 calculations in virtual phantom geometries, and
compared to Monte Carlo (MC) simulations with GEANT4, acting here
as a gold standard. The 125 I SelectSeed from Nucletron was used for
validation on a NVIDIA Tesla C2050 GPU. Calculations were tested for
geometries of 20x20x20cm 3 and a fine resolution with voxels of 1mm 3 .
: An execution time of 2.3 s/seed was obtained, representing
an acceleration factor (AF) of 5427x over a regular CPU
implementation (Table 1). We expect further reduction of execution
time to less than one second per seed for clinical geometries. With a
1cm range for scatter dose, the modified TG43 algorithm was able to
reduce ISA errors from 45% to less than 10% for some dose calculation
points. The TG43 algorithm improved the accuracy of dose deposited
through various materials. At 3cm from the seed, dose corrections of
up to 2Gy, corresponding to errors of more than 100%, were obtained
for adipose and cortical bone tissues. Furthermore, considering dose
to medium, the D95 deviation with MC was reduced by 4% in a 56cc
calcified prostate implant simulation. The relative dose around every
calcification was adequately corrected to an error less than 5% (Figure
1), which is within uncertainties conceded by the TG43 formalism.
Stage
Execution time on
CPU
(s/seed)
Execution time on
GPU
(s/seed)
Raytracing algorithm 3366 0.5 6732
Primary dose calculation 0.428 0.6x10 3 713
Scattered
calculation
dose
9117 1.8 5065
Total dose calculation 12483 2.3 5427
Monte Carlo simulation
11520
(2E9 γ)
Table 1 Acceleration factor (AF) for every step in the improved TG
43 dose calculation
: TG43 dose calculations were improved with a modified
algorithm integrating attenuation and scatter corrections while
maintaining fast executions. This algorithm still considers the medium
to be homogeneous for scattered radiation and the range is
underestimated to maintain clinically compatible execution times.
Future work will address these issues to further increase accuracy of
the dosimetries.
OC140
INFLUENCE OF HIGH ATOMIC NUMBER ELEMENTS IN HUMAN TISSUE IN
DOSIMETRY FOR LOW ENERGY PHOTON BRACHYTHERAPY
S.A. White 1 , G. Landry 1 , F. Van GIls 1 , F. Verhaegen 1 , B. Reniers 1
1 Maastricht University Medical Center, Department of Radiation
Oncology (MAASTRO) GROW School for Oncology and Developmental
Biology, Maastricht, The Netherlands
: Low energy brachytherapy sources such as I125,
Pd103 and electronic brachytherapy sources (EBS) interact with
AF

S58 World Congress of Brachytherapy 2012
tissue via the photoelectric effect, which is highly dependant on
atomic number (Z) of the tissue. Tissue is composed mostly of H, C, N,
and O with higher Z trace elements (weight fraction below 1%), like
Na, P and K. The amount of trace element varies not only from tissue
to tissue but also from person to person. Cancerous tissue has shown a
tendency to contain a higher concentration of trace elements
compared to healthy tissue (Kwiatek et al., 2005). We aimed to
determine the dosimetric impact of these trace elements in human
tissues for low energy photon sources used in brachytherapy.
: Monte Carlo dose calculations were used to
investigate the dosimetric effect of trace elements present in normal
and cancerous human tissues. The effect of individual traces (atomic
number Z=11 to 30) was simulated in a commonly cited healthy soft
tissue composition (Woodard and White, 1986) for 3 low energy
sources where a fixed concentration (0.5% w/w) of each trace
element was added. Three other tissue types (prostate, adipose and
mammary gland) were also simulated with each of their trace
components excluded alternately to quantify the contribution of each
trace to the dose distribution. Finally, the dose differences between
cancerous and healthy prostate tissue compositions were calculated,
using more precise trace compositions(Kwiatek et al., 2005). All
results were compared against a zerotrace tissue composition (HCNO
only). All calculations were reported as dose to medium.
: The presence of traces in a tissue produces a difference in
the dose profile versus distance from the source that is dependent on
Z, the trace concentration and the source type. Pd103 was the most
sensitive source to concentration change, while the EBS was the least.
LowZ traces (Na) had a negligible effect (3%). There is a considerable
difference in the dose profile between cancerous and healthy prostate
(figure 1).
: Trace elements have a nonnegligible effect on the dose
in tissues irradiated with low energy photon sources. This study
underlines the need for further investigation into accurate
determination of the trace composition of tissues associated with low
energy brachytherapy. Alternatively, trace elements could be
incorporated as a source of uncertainty in dose calculations.
References:
Kwiatek W M, Banas A, Gajda M, Galka M, Pawlicki B, Falkenberg G
and Cichocki T 2005 Cancerous tissues analyzed by SRIXE Journal of
Alloys and Compounds 401 17377
Woodard H Q and White D R 1986 The composition of body tissues Br J
Radiol 59 120918
OC141
QUANTIFYING THE INTERSOURCE ATTENUATION IN A DUALSOURCE
HDR/PDR AFTERLOADER TREATMENT UNIT
M. Plamondon 1 , L. Beaulieu 1
1
Centre Hospitalier Universitaire de Québec, Département de Radio
oncologie, Québec, Canada
: Much discussions are ongoing in the community
on the commercial availability of HDR (high dose rate) afterloaders
which can drive two sources simultaneously, reducing the duration of
treatments up to a factor 2. The sourcesource and sourcecable
attenuations are not taken into account by current planning systems.
The purpose of this work is to try and characterize this effect and its
overall impact on clinically relevant treatment configurations.
: An Ir192 Flexitron source is modeled in
GEANT4 and its dose profile in water is evaluated in a grid up to 10
cm. A second source is placed parallel at various distances in order to
quantify the attenuation due to its presence. This pedagogical case is
then transposed to a typical prostate treatment planning. Various
catheter loading patterns (using an actual clinical HDR prostate
geometry) are simulated and compared to the nominal treatment
using a single source. The worst (the two sources always travelling in
two closely located catheters) and best (two sources far from each
other) case scenarios give a respective estimate of the upper and
lower bounds of the deviations. A measure proportional to the dwell
times and R 2 , where R is the intersource separation, is used to
determine these configurations. Random and minimal deadtime
configurations are also studied for comparison.
: Figure 1 shows the profile of the deposited energy for inter
source separations ranging from 5 to 20 mm. A maximal effect of the
order of 20% is observed at small distance and a shadow region with at
least 10% decrease extends up to 10 cm. A similar study considering a
parallel steel cable instead shows the same behavior but with an
initial dropping of less than 10%. The global impact on actual
treatments is obtained by superimposing the contributions from
catheter pairs simulating the dualsource loading. No significant
deviation is observed in all aforementioned configurations except the
worst case scenario. In that case, a narrow region showing a 5 mm. These effects become negligible
in reallife treatments when source insertions in nearby catheters is
avoided.
OC142
DOSIMETRY FOR HDR HEAD AND NECK BRACHYTHERAPY PATIENTS
USING A GRIDBASED BOLTZMANN SOLVER
F. Siebert 1 , S. Wolf 1 , G. Kovacs 2
1
University Hospital SH Campus Kiel, Radiotherapy, Kiel, Germany
2
University of Luebeck and University Hospital of SchleswigHolstein,
Brachytherapy, Luebeck, Germany
: The aim of this study is to compare dosimetric
results of gridbased Boltzmann solver (GBBS) calculations with
treatment plans computed by the TG43 formalism for high dose rate
(HDR) head and neck brachytherapy (BT) patients. The expected
differences between the standard TG43 and the GBBS dose
calculations, particularly in the head and neck region, is due to
reduced backscattering effects and bony structures close to the
catheter locations. The GBBS uses the electron densities of the
World Congress of Brachytherapy 2012 S 59
computed tomography (CT) scans and is able to take tissue
heterogeneities into account.
: For this study CTbased 3D BT treatment
plans of 49 head and neck patients were analyzed. The patient cohort
(15 female, 34 male) was treated with an HDR VariSource afterloader
(Varian Medical Systems, Palo Alto, CA) between 2001 and 2009 using
an Ir192 source. A single dose of 2.5 Gy was applied to each patient.
The mean age of the patients was 57.1 years and the mean plastic
catheters used was 5.1 (SD=2). The diagnoses comprised mainly floor
of mouth, larynx, and parotis carcinoma. The patient’s treatment
plans were calculated with the BrachyVision v8.8 (Varian Medical
Software, Palo Alto, CA) software using the TG43 formalism and the
commercial GBBS Acuros module of BrachyVision.
The dosimetric indices D90, V100, V150, as well as the dose
homogeneity index (DHI) were evaluated and compared between the
two dose calculation methods. Due to the fact that no target outline
could be clinically identified in many cases, the 100% prescription
dose outline of the TG43 calculation was converted into a 3D contour
and used as an artificial CTV.
: The collected data are presented in table 1. Median D90 and
V100 for TG43 calculation are about 3% higher than for GBBS. The
V150 dose parameter shows a 1.6% increase from GBBS to TG43.
Nevertheless, these are median parameters and clinical assessment
must be performed individually for each patient. The fluctuations of
the minimum and maximum values of the dose parameters are
remarkably higher for the GBBS than for the TG43 calculations. The
dosehomogeneity index DHI is almost constant for both calculation
methods used in this study. An example isodose distribution for both
calculation methods is demonstrated in figure 1.
: The presence of air and bony structures close to the
target volume in head and neck HDR BT implants affects results of
dosimetric calculations of gridbased Boltzmann solver techniques.
The extend at which this impacts prescription doses or the
assessments of toxicities is still unknown at this time.
OC143
COMPARISON OF DIFFERENT FRACTIONATION SCHEDULES IN HDR
BRACHYTHERAPY AS MONOTHERAPY FOR LOWRISK PROSTATE CANCER
P. Mavroidis 1 , N. Milickovic 2 , N. Tselis 3 , Z. Katsilieri 2 , V. Kefala 2 , N.
Zamboglou 3 , D. Baltas 2
1
Karolinska Institutet and Stockholm University, Medical Radiation
Physics, Stockholm, Sweden
2
Klinikum Offenbach GmbH, Strahlenklinik Medical Physics &
Engineering, Offenbach, Germany
3
Klinikum Offenbach GmbH, Strahlenklinik, Offenbach, Germany
: The selection of a proper fractionation scheme is
still an issue of debate when moving towards to less fractions of HDR
brachytherapy as monotherapy for lowrisk prostate cancer. The aim
of the present study is the investigation of different fractionation
schemes in order to estimate their clinical impact. For this purpose,
widely applied radiobiological models and dosimetric measures are
employed in order to associate their results with clinical findings.
: The dose distributions of 12 clinical HDR
brachytherapy implants for prostate that were produced by an inverse
optimization algorithm (HIPO) are evaluated regarding different
fractionation schedules. The fractionation schedules that are
compared are: a) 1 fraction of 20 Gy; b) 2 fractions of 14 Gy; c) 3
fractions of 11 Gy; and d) 4 fractions of 9.5 Gy. These fractionation
schemes have been previously found to be equivalent based on the
BED for the prescription dose levels. The quality of the different
fractionation schemes was evaluated by examining common dose
volume indices for the prostate and the organs at risk (OARs). Their
clinical effectiveness was estimated through the complicationfree
tumor control probability, P+, the biologically effective uniform dose
(BEUD), which were calculated using the Poisson and the relative
seriality models, and the generalized equivalent uniform dose (gEUD)
index.
: For the different fractionation schemes examined, the tumor
control probabilities are 98.2% in 1x20Gy, 98.6% in 2x14Gy, 97.6% in
3x11Gy and 98.0% in 4x9.5Gy. Similarly, the corresponding total
normal tissue complication probabilities are 9.3% in 1x20Gy, 14.9% in
2x14Gy, 11.3% in 3x11Gy and 16.0% in 4x9.5Gy. Finally, the
complicationfree tumor control probabilities are 89.0% in 1x20Gy,
83.7% in 2x14Gy, 86.3% in 3x11Gy and 82.1% in 4x9.5Gy. The mean
dose, gEUD, mean dose converted to 2Gy per fraction, gEUD
converted to 2Gy per fraction, response probability and BEUD for the
different organs and fractionation schemes are shown in the Table.
Keeping the fractionation scheme 4x9.5Gy as standard, the iso
effective schemes regarding tumor control for 1, 2 and 3 fractions are
1x19.91Gy, 2x13.81Gy and 3x11.11Gy. Finally, the optimum
fractionation schemes for 1, 2, 3 and 4 fractions are 1x19.4Gy with a
P+ of 91.5%, 2x13.7Gy with a P+ of 88.1%, 3x10.7Gy with a P+ of 88.7%
and 4x9.1Gy with a P+ of 87.6%.
: The present analysis shows that among the fractionation
schemes of 1x20Gy, 2x14Gy, 3x11Gy and 4x9.5Gy the first scheme is
more effective. However, after performing a radiobiological
optimization to the different fractionation schemes individually, it is
shown that the 1x19.4Gy scheme is overall more effective, whereas
the 4x9.1Gy scheme is the least effective one. Based on our results, it
appears that an improvement in the effectiveness of the optimized
HDR dose distributions can be achieved if a radiobiological evaluation
and optimization could be applied.

S60 World Congress of Brachytherapy 2012
OC144
DOSIMETRIC AND RADIOBIOLOGICAL EVALUATION OF MANUALLY AND
INVERSELY OPTIMIZED BRACHYTHERAPY TREATMENT PLANNING
T. Palmqvist 1 , A.D. Wanderås 2 , A.B.L. Marthinsen 2 , M. Sundset 3 , I.
Langdal 2 , S. Danielsen 2 , I. TomaDasu 1
1
Stockholm University and Karolinska Institutet, Medical Radiation
Physics, Stockholm, Sweden
2
St. Olav’s Hospital, Department of Oncology, Trondheim, Norway
3
St. Olav’s Hospital, Department of Gynaecological Oncology,
Trondheim, Norway
: To compare five inverse treatment planning
techniques with the conventional manually optimized planning
approach for brachytherapy of cervical cancer with respect to
dosimetric and radiobiological parameters.
: Eighteen cervical cancer patients treated
with external radiotherapy (2Gy x 25) and MRI guided HDR
brachytherapy (5Gy x 4) were included in this study. For each patient
six plans were created: one manually optimized and five inversely
planned for each of the four HDR brachytherapy fractions. Three
inverse planning simulated annealing (IPSA13) approaches, using
different dose objectives not only for the target but also for the
organs at risk were investigated and compared to plans created with
equal dwell times and prescription to target points. The dose was
prescribed to the surface of the target volume. The resulting dose
volume histograms were analyzed and compared from the dosimetric
and the radiobiological point of view by quantifying specific
dosimetric parameters D90, D100, COIN, and D2ccm for rectum, bladder
and the sigmoid colon, and the probability of complication free cure,
P+, respectively.
: A summary of the results showing the average dose and
volume parameters for all the six plans performed for each patient is
given in the table below. IPSA led to superior target coverage and
similar COIN values compared to the manual optimization. The manual
optimization led to the better results with respect to the dose to the
most exposed 2 cm 3 volume, D2ccm for the organs at risk. Nevertheless,
the radiobiological evaluation of the plan rendered comparable
probabilities of complication free cure within the uncertainties
originating from the radiobiological parameters. Overall, the best
results were obtained with manual optimization and IPSA3 with
volumetric constraints.
Dose and volume parameters for the manually optimized plan and the
inverse planning techniques (average for all patients)
Manual
optimization
Inverse planning technique
IPSA1 IPSA2 IPSA3
Equal Target
Dwell Time Points
CTV:
78.3±8.5 87.5±7.9 91.7±6.0 82.5±9.6 64.8±9.6 74.2±6.7
V100 (%)
CTV: D90
4.07±0.65 4.81±0.74 5.23±0.70 4.38±0.83 3.22±0.52 3.74±0.51
(Gy)
CTV:
D100
(Gy)
Bladder
D2ccm
(Gy)
Rectum
D2ccm
(Gy)
Sigmoid
D2ccm
(Gy)
2.13±0.52 2.64±0.63 2.88±0.66 2.36±0.66 1.69±0.41 1.97±0.46
4.77±0.64 5.06±0.50 5.47± 0.64 4.82±0.60 4.88±1.20 4.96±0.92
3.14±0.72 3.37±0.55 3.69±0.67 3.23±0.54 2.47±0.70 2.50±0.59
3.69±0.64 4.02±0.67 4.41±0.73 3.81±0.73 3.19±0.80 3.74±0.84
COIN 0.59±0.08 0.57±0.07 0.55±0.07 0.58±0.07 0.50±0.07 0.57±0.07
CTV:
24.4±5.6 29.4±6.6 34.6±7.2 26.4±6.5 22.5±4.8 27.1±3.5
V200 (%)
: Inverse planning simulated annealing with proper dose
objectives is a good choice when it is necessary to minimize staff
workload and treatment planning time. However, the dose to organs
at risk must be inspected thoroughly and manually adjusted if
exceeding the recommended organ dose limits. Nevertheless,
dosimetric and radiobiological criteria are similarly fulfilled with
manual or inverse optimization approaches indicating the potential of
inverse planning simulated annealing for brachytherapy.
146
ONE HUNDRED YEARS OF PROSTATE BRACHYTHERAPY
J.N. Aronowitz 1
1 University of Massachusetts, Radiation Oncology, Worcester MA, USA
Beginning in 1908, clinicians (urologists, radiologists, and radiation
oncologists) have treated prostate cancer with natural (radium,
radon), reactorgenerated (radiogold, iridium), and kcapture ( 125 I,
103 Pd, 131 Cs) radionuclides. There have been intracavitary (urethral,
rectal) and interstitial (suprapubic, retropubic, transperineal)
implants. Source placement has been directed by touch, fluoroscopy,
sonography, and MR.
This review examines the techniques and personalities that have
shaped prostate brachytherapy over an eventful century.
World Congress of Brachytherapy 2012 S 61
PO147
SECTOR ANALYSIS OF I125 PROSTATE IMPLANTS PROVIDES AN
EFFECTIVE METHOD IN COMPARING PRE AND POSTIMPLANT
DOSIMETRY
A.B. Mohamed Yoosuf 1 , M.M. O'Toole 1 , M. Straney 1 , R. Verghis 2 , E.
Napier 3 , D.M. Mitchell 4 , G. Workman 1
1
Northern Ireland Cancer Centre, Radiotherapy Medical Physics
Section, Belfast, United Kingdom
2
Royal Group of Hospital Trust, Clinical Research Support Centre,
Belfast, United Kingdom
3
Northern Ireland Cancer Centre, Department of Radiology, Belfast,
United Kingdom
4
Northern Ireland Cancer Centre, Department of Clinical Oncology,
Belfast, United Kingdom
: To evaluate 12 sector analysis in the assessment
and comparison of pre and post implant dosimetric parameters
during the development of an I125 permanent prostate
brachytherapy (PPB) service.
: 50 consecutive men treated with PPB had
dose volume analysis in 12 sectors of their preimplant ultrasound
(PIUS) and postimplant CT (PICT) volumes using a Variseed TM 8.0
treatment planning system. PIUS dosimetry was performed 2 weeks
prior to implantation and PICT dosimetry 4 weeks post implant.
Individual sectors were created by dividing the craniocaudal prostate
length into 3 equal lengths creating prostate base (PB), midgland (PM)
and apex (PA). Each of these volumes was then divided into four axial
sectors (right and left anterior, right and left posterior). The prostate
volume (PVOL), dose to 90% (D90) and 50% (D50) of prostate, volume
enclosed by 100% (V100), 150% (V150) and 200% (V200) dose were
recorded in each sector for PIUS and PICT. Differences in individual
sectors on PIUS and PICT were evaluated. Implant quality was evaluated
by measuring conformity index (CI=V100/PVOL) in base, midgland and
apex regions. Adjacent sectors uniformity on PIUS was assessed as
were adjacent sectors on PICT.
: Statistically significant differences between PIUS and PICT
were noted in prostate volume, particularly in PB with PICT >PIUS as
shown in figure (1a). When individual sectors on PIUS and PICT were
compared, statistically significant differences were noted in the
majority of dosimetric parameters. The dose in the anterior PB and
PM were significantly lower on PICT (p value < 0.001) and significantly
higher at the posterior PM and PA (p value < 0.05). These changes
were consistent across all analysed parameters. In particular,
significant absolute differences in D90 in equivalent sectors on PIUS
and PICT were seen as shown in figure (1b). Sector analysis in PICT
showed a lower degree of conformity in the base sectors (0.71 ± 0.2)
when compared to midgland (0.97 ± 0.1) and apex (0.96 ± 0.1)
regions. Adjacent sector analysis demonstrated uniformity in all
sector sets of PIUS and the majority of sector sets of PICT.
:12 sector analysis allows rapid assessment of, PIUS and
PICT, dose and volume homogeneity. It offers a scientific method of
identifying areas of relative over and under dosing on PICT when
compared with PIUS providing both clinicians and physicists with a
learning tool to refine dosimetric analysis and highlight sectors where
implant quality could be improved.
PO148
OUTCOME AND TOXICITY AFTER SALVAGE PROSTATECTOMY,
CRYOSURGERY AND BRACHYTHERAPY FOR PROSTATE CANCER
RECURRENCES
M. Peters 1 , M.R. Moman 1 , H.G. van der Poel 2 , H. Vergunst 3 , I.J. de
Jong 4 , P.L.M. Vijverberg 5 , J.J. Battermann 1 , S. Horenblas 2 , M. Vulpen 1
1
University Medical Center, Department of Radiation Oncology,
Utrecht, The Netherlands
2
Netherlands Cancer Institute, Department of Urology, Amsterdam,
The Netherlands
3
CanisiusWilhelmina Hospital Nijmegen The Netherlands,
Department of Urology, Utrecht, The Netherlands
4
University Medical Center Groningen The Netherlands, Department
of Urology, Utrecht, The Netherlands
5
St. Antonius Hospital Nieuwegein The Netherlands, Department of
Urology, Utrecht, The Netherlands
: Current salvage treatments for recurrent cancer
of the prostate after primary radiation therapy include radical
prostatectomy, cryosurgery and brachytherapy. Because toxicity and
failure rates are considerable, salvage treatments are not commonly
performed. As most centers perform only one preferred salvage
technique, literature only describes single center outcomes from a
single salvage technique with a limited number of patients. In this
overview, five high volume Dutch centers describe their toxicity and
outcome data using different salvage techniques. This provides a view
on how salvage is performed in clinical practice in the Netherlands.
: 129 patients from 5 different centers in the
Netherlands were retrospectively analyzed. Biochemical failure was
defined as PSA > 0,1 ng/ml for the salvage >prostatectomy group (n =
44) and PSA nadir + 2,0 ng/ml (Phoenix definition) for the salvage
cryosurgery (n = 54) and salvage brachytherapy group (n = 31).
Toxicity was scored according to the Common Toxicity Criteria for
Adverse Events (CTCAE v3.0).
: Biochemical failure occurred in 25 (81%) patients in the
brachytherapy group (mean followup 29±24 months), 29 (66%)
patients in the prostatectomygroup (mean followup 22± 25 months)
and 33 (61%) patients in the cryosurgery group (mean followup 14± 11
months). Severe (grade >3) genitourinary and gastrointestinal toxicity
was observed in up to 30% of patients in all three groups (table 1).
: This overview shows clinical practice of prostate cancer
salvage. Significant failure and toxicity rates are observed, regardless

S62 World Congress of Brachytherapy 2012
of salvage technique. Patients should be selected with great care
before offering one of these salvage treatment strategies.
PO149
DEVELOPMENT OF A PRACTICAL PROSTATE BRACHYTHERAPY TRAINING
PHANTOM
K. Forsythe 1 , A. Svoboda 1 , R.G. Stock 1
1
Mount Sinai Medical Center, Dept. Radiation Oncology, New York,
USA
: Training in prostate brachytherapy remains non
standardized and a suitable training phantom for practicing fully
simulated implants does not exist. The only commercially available
training phantom is prohibitively expensive (~$400) and its brittle gel
matrix cannot withstand the trauma of needlesticks without suffering
permanent needle track scars which render it incompatible with TRUS
imaging. Our objective was to develop a reusable training phantom
that was 1) composed of hydrocolloids with rheological properties
resilient to repeated needle sticks, 2) compatible with both TRUS and
CT imaging, 3) composed of inexpensive materials, and 4) can be
made relatively easily by hand.
: The phantom’s basic model consists of a gel
based prostate with a Foley catheter as standin for the urethra and a
gelbased rectum, both of which are encompassed by a gelbased
perineum. Two sets of molds are made for casting the prostate and
rectum, and once casted they are embedded within the surrounding
gelbased perineum. After construction, the phantom is fixed to the
procedure table and the user may perform a fully simulated TRUS
guided implant. After completion of the implant, the phantom may
undergo CT imaging so that postimplant dosimetry can be performed
and the quality of the implant may be evaluated by standard dose
metrics (D90, V100, RV100, UrethraV150, etc.)
For the construction of the prostate mold, rectal wall mold, and
phantom container: NSP Soft clay ($4.25/lb), Van Aken clay
($5.22/2lbs), Mold Star 15 Silicone ($30.99/pint), foam core poster
board ($0.64/sq ft), 1’ of ¾' PVC pipe ($0.99), 1’ of 1½'' PVC pipe
($0.99), ¾' PVC pipe coupling adaptor ($0.49), 1½' PVC pipe coupling
adaptor ($0.89), Propoxy Epoxy ($7.55/4.8oz), 6' plastic funnel
($1.82), 1 gallon Rubbermaid container ($9.42). Reagents for gel
based components: Foley catheter ($2.00), Barium Sulfate
($1.50/30g), agar powder ($2.34/55g), glycerine ($0.27/20g).
: The phantom’s container and casting molds are all durable
products which may be reused indefinitely and have a subtotal cost
of $62.85. The gelbased components of the phantom have a subtotal
cost of $6.11 and may be discarded after each use or remelted and
recast into refurbished gelbased components. The gelbased
components of the phantom are compatible with performing a fully
simulated TRUSguided implant without the troublesome permanent
needle track scars of commercially available phantoms; the gelbased
components are also easily distinguishable on CT imaging which
permits postimplant dosimetry. Repeated practice with the phantom
can yield increased proficiency as measured by standard dose metrics
which can be plotted to document a user's learning curve for the
procedure.
: This reusable phantom has a significantly lower cost
than commercially available phantoms. It is also the only training
phantom that is both TRUS and CT compatible, which permits users to
practice fully simulated implants and to objectively evaluate their
performance. As a training aid, this phantom can help improve the
quality of prostate brachytherapy implants on a wide scale.
PO150
THE IMPACT OF GEOMETRIC INACCURACIES ON RESULTING DOSE
DISTRIBUTION DURING HDR PROSTATE BRACHYTHERAPY
P. Paluska 1 , M. Hodek 1 , L. Kasaova 1 , I. Sirak 1 , M. Zouhar 1 , M. Vosmik 1 ,
J. Petera 1
1
University Hospital Hradec Kralove, Department of Oncology and
Radiotherapy, Hradec Kralove, Czech Republic
: Highdose rate interstitial brachytherapy (BT) can
be applied as a boost treatment in combination with external beam
radiation therapy (EBRT) of prostate cancer. Transrectal ultrasound
(TRUS) guided transperineal temporary brachytherapy using an
iridium192 stepping source and a remote afterloading technique
represents the standard of interstitial prostate BT. Simplified model
of parallel linear guide needles in the planning software doesn’t
represent the real implant precisely. The purpose of our study was to
evaluate the impact of needles’ representation inaccuracies and
changes in anatomy during implantation on resulting dose distribution.
: The implantation starts with acquisition of
axial TRUS images in steps of 5 mm distance from base to apex of
prostate. TRUS images are transferred to planning software, where
CTV, urethra and rectum are delineated. Initial needle geometry,
prepared during preplanning one day before implantation, is
reproduced. After insertion of each guide needle, the needle
coordinates are corrected based on it’s position on central transversal
TRUS image, but the needles are still represented as linear and
parallel. Volume optimization of the target dose distribution is
performed to achieve the best possible CTV coverage by 8 Gy isodose,
urethral doses < 10 Gy and rectal doses < 6.4 Gy.
For the purpose of this study, TRUS images were acquired after the
implantation of all the needles. Postimplant TRUS images were fused
with preimplant ones based on template invariable geometry. CTV,
urethra and rectum were delineated and contours’ positions were
World Congress of Brachytherapy 2012 S 63
compared with positions on preimplant images. The implant model
was corrected according to the real situation of nonparallel needles,
as visible on postimplant images. The irradiation plan was
recalculated with the original dwell times. CTV dose coverage and
maximal urethral and rectal doses were compared with the original
ones.
: Eleven applications on six patients were analyzed. Maximal
urethra contour changes varied between 2 and 7 mm, median 4 mm.
Maximal observed change in the needle position was 5 mm.
Differences in CTV dose coverage varied between 3.7 % and 0.3 %,
with a mean result of 1.1 %. Differences in maximal rectal dose
varied between 0.1 Gy and 1.7 Gy, in 9 cases from 11 total the
maximal rectal dose was higher than the original one. Differences in
maximal urethral dose varied between 1.4 Gy and 1.9 Gy, in 7 cases
from 11 total the maximal urethral dose was higher than the original
one.
: Inaccurate implant model assuming parallel linear guide
needles and rigid anatomy can lead to a significant underestimation of
urethral and rectal doses. Especially needles close to urethra and
rectum should be modeled with a special care.
PO151
LONG TERM RESULTS OF HDR BRACHYTHERAPY IN MEN OLDER THAN 75
WITH LOCALIZED CARCINOMA OF THE PROSTATE
R. Soumarova 1 , L. Homola 1 , H. Perkova 1
1 Radioterapie a.s., radiation oncology, Novy Jicin, Czech Republic
: Prostate cancer is an illness with a high
incidence, especially among older men. The choice of treatment
option among men above 75 years is however not clear. Radical
prostatectomy in this age group is connected with a relatively high
morbidity. A further possibility of curative treatment is radiotherapy,
which can be administered in the form of external beam or in
combination with high dose rate (HDR) brachytherapy. The aim of our
work was to ascertain how HDR brachytherapy is tolerated among men
older than 75 and how associated diseases can influence the tolerance
to this treatment. Of interest to us were the treatment results and
mortality from other diseases.
: We analysed a sample of 20 men above 75
years old (median 77 years), who were undergoing treatment by a
combination of external radiotherapy and brachytherapy. 16 (80 %) of
them had prostate cancer with a intermediate and high risk of
recurrence, 4 had low risk prostate cancer. Most patients – 14 (70 %)
had less than two comorbidities.
: The median observation period was 57 months. No
perioperative complications were recorded. Acute genitourinary
toxicity (GU) to a maximum grade of 12 manifested in 60% of cases.
Acute gastrointestinal toxicity (GIT) was observed only at grade 1, and
in 25% of cases. Late GU toxicity occurred in 35% of patients, with
only one such of grade 3; late GIT toxicity was recorded at grade 1
only in 3 patients (15%). 70% of the men lived posttreatment longer
than 3 years, 50% at present live more than 5 years. Longterm
biochemical remission was achieved in 18 patients (90%).
: HDR BRT is possible and welltolerated in older men
above 75 years in good condition and without serious intercurrence.
Wellselected older patients with higherrisk tumours and without
serious comorbidities undoubtedly benefit from radical treatment
when compared with watchful waiting.
PO152
EXPLORING THE DOSIMETRIC AND RADIOBIOLOGICAL EFFECTS OF
PROSTATE SEED LOSS AND MIGRATION
C. Knaup 1 , C. Esquivel 1 , P. Mavroidis 2 , S. Stathakis 1 , N. Papanikolaou 1
1 University of Texas Health Science Center at San Antonio, Cancer
Therapy & Research Center, San Antonio, USA
2 Karolinska Institutet, Medical Physics, Stockholm, Sweden
: Low doserate brachytherapy is commonly used
to treat prostate cancer. However, once implanted, the seeds are
vulnerable to loss and movement. Ideally, the postimplant evaluation
would quantify these effects. However, many clinicians opt for day 0
postimplant scanning based on logistical issues and patient
convenience. Therefore a general estimation of these effects may be
useful for making patient care decisions when seeds are lost after the
postimplant scan. The goal of this work was to explore the dosimetric
and radiobiological effects of the types of seed loss and migration
commonly seen in prostate brachytherapy. The results may be a
useful guide for clinicians confronted with the problem of seed loss
following implantation.
: Five patients were used in this study. For
each patient three treatment plans were created using Iodine125,
Palladium103 and Cesium131 seeds. The three seeds that were
closest to the urethra were identified and modeled as the seeds lost
through the urethra. The three seeds closest to the exterior of
prostatic capsule were identified and modeled as those lost from the
prostate periphery. The seed locations and organ contours were
exported from Prowess and used by inhouse software to perform the
dosimetric and radiobiological evaluation. The radiobiological
evaulation was based on the linearquadratic model. Seed loss was
simulated by removing 1, 2 or 3 seeds near the urethra 0, 2 or 4 days
after the implant or removing seeds near the exterior of the prostate
14, 21 or 28 days after the implant.
: Loss of one, two or three seeds through the urethra results in
a D90 reduction of 2%, 5% and 7% loss respectively. Due to delayed loss
of peripheral seeds, the dosimetric effects are less severe than for
loss through the urethra. However, while the dose reduction is modest
for multiple lost seeds, the reduction in tumor control probability was
minimal.
Table 1. Results of the dosimetric and radiobiological effect of central
seed loss through the urethra for implants with I125 seeds.
125
I Missing Dmin (Gy) D50 (Gy) D80 (Gy) D90 (Gy) V100 (%) V150 (%) TCP (%)
Day 0 1 1.4 ± 1.4 4.0 ± 0.7 3.7 ± 1.0 2.8 ± 0.7 1.8 ± 1.7 2.0 ± 0.4 0.0 ± 0.0
2 4.4 ± 3.2 7.7 ± 1.3 7.0 ± 1.5 5.9 ± 1.0 4.2 ± 3.4 3.3 ± 0.6 0.1 ± 0.1
3 8.7 ± 4.3 10.4 ± 2.1 9.7 ± 1.3 9.1 ± 2.7 5.9 ± 4.0 4.1 ± 0.7 0.4 ± 0.3
Day 2 1 1.4 ± 1.4 3.9 ± 0.7 3.5 ± 1.0 2.7 ±0.7 1.7 ±1.6 1.9 ± 0.5 0.0 ± 0.0
2 4.2 ± 2.9 7.5 ± 1.3 6.7 ± 1.5 5.6 ±1.0 4.0 ± 3.4 3.2 ± 0.6 0.1 ± 0.1
3 8.0 ± 4.0 10.2 ± 2.0 9.3 ± 1.4 8.7 ± 2.6 5.7 ± 3.9 4.0 ± 0.7 0.3 ± 0.4
Day 4 1 1.4 ± 1.3 3.8 ± 0.7 3.4 ± 0.9 2.6 ± 0.7 1.6 ± 1.5 1.9 ± 0.5 0.0 ± 0.0
2 4.0 ± 2.7 7.4 ± 1.2 6.5 ± 1.4 5.4 ± 1.0 3.9 ± 3.2 3.1 ± 0.6 0.1 ± 0.1
3 7.3 ± 3.8 9.9 ± 2.0 9.0 ± 1.4 8.4 ± 2.5 5.5 ± 3.8 4.0 ± 0.7 0.3 ± 0.3
: The goal of this work was to explore the dosimetric and
radiobiological effects of the types of seed loss and migration
commonly seen in prostate brachytherapy. The results presented show
that loss of multiple seeds can cause a substantial reduction of D90
coverage. However, for the patients in this study the dose reduction
was not seen to reduce tumor control probability.
PO153
PROSPECTIVE MULTICENTRE DOSIMETRY STUDY OF I125 PROSTATE
BRACHYTHERAPY PERFORMED AFTER TURP
C. Salembier 1 , A. Rijnders 1 , A. Henry 2 , P. Niehoff 3 , F.A. Siebert 3 , P.
Hoskin 4
1
Europe Hospitals Site StElisabeth, Department of Radiation
Oncology, Brussels, Belgium
2
St James', Institute of Oncology, Leeds, United Kingdom
3
UHSH, Klinik für Strahlentherapie und Radiooncologie, Kiel,
Germany
4
Mount Vernon, Cancer Center, Northwood, United Kingdom
: To evaluate in a multicentre setting the ability of
centres to perform preimplant permanent prostate brachytherapy
planning using Iodine125 fulfilling dosimetric goals and constraints
based on GECESTRO guidelines in the setting of implantation after
prior TURp.
: A reference transrectal ultrasound image set
of the prostate gland from a patient who had undergone TURp having
a significant residual cavity was used. Contouring of the prostate,

S64 World Congress of Brachytherapy 2012
clinical target volume and organs at risk was performed by the co
ordinating centre before image export. This was based on the existing
GECESTRO guidelines but with small adaptations given the postTURp
setting. Goals and constraints regarding the dosimetry were defined.
: 17 centres participated in this study. The mean number of
needles used was 18 ( min10 max 25). Mean number of seeds was 52
(min 27 max 63). 8 out of the 17 centres applied a classical seed
spacing with regular 1 cm seed centretocentre in the majority of
their needles, whereas 9 centres used specially loaded needles that
differed by having extra spacing between seeds. The mean seed
strength used was 0,486 U (range 0,458 – 1,0 U) or 0,383 mCi (range
0,361 – 0,787 mCi). The mean activity of the total implant was 27,8 U
(range 25,7 – 33,9 U) or 21,9 mCi (range20,2 – 26,7 mCi). All centres
fulfilled the requested dosimetry constraints for the prostate volume.
The mean Vp100 was 98 % (range 97,06 99,94%), the mean Dp90
was 187 Gy (range 159 219 Gy), the mean Vp150 was 73% (range 42
90%) and the mean Vp200 was 35 % (range 18 56%). All but 2 centres
fulfilled the CTV dosimetric constraints and these two centres
deviated from the requirements by only a small amount which could
have been corrected by movement of one or two seeds by a few
millimetres. The mean V100 for the CTV was 96,5 % (range 94
99,41%), mean V150 was 62 % (range 41 – 75,4%) and mean D90 was
171 Gy (range 157 – 186 Gy). In terms of urethral dosimetry, all but 2
institutions were able to fulfil the protocol requirements. These 2
centres exceeded the Du30 constraint achieving 133 Gy and 134 Gy
in contrast to the protocol constraint of ≤130Gy). The mean Du30 was
118 Gy (min 99 – max 134 Gy) and the mean Du10 was 124 Gy (min 104
– max 148 Gy). All centres achieved the required rectal dose
constraints. Sector analysis was performed for all plans. Given the
small prostatic volume, eight segments were defined. The typical
postTURp defect results in very small anterior segments. For each
segment, D90 and V100 were calculated. 3 centres showed perfect
coverage for D90 and V100 for all defined segments. Four centres had
a clear underdosage in the basal anterior segments and fourteen
centres had an underdosage in the apical anterior segments.
: Consistent preimplantation planning with adherence to
protocol guidelines is feasible in a postTURp setting. This study
validates the proposed standardized contouring in this specific
anatomical setting and the proposed dose goals and constraints. A
prospective study evaluating the outcome of prostate I125
brachytherapy performed after transurethral resection of the prostate
can therefore be undertaken with an expectation of consistent
dosimetry in the multicentre setting.
PO154
FOCAL BRACHYTHERAPY FOR PROSTATE CANCER: A PILOT STUDY
J.M. Cosset 1 , X. Cathelineau 2 , N. Pierrat 1 , D. Hajage 1 , G. Wakil 1 , F.
Rozet 2 , E. Barret 2 , G. Vallancien 2
1 Institut Curie, Radiotherapy, Paris, France
2 Institut Mutualiste Montsouris, Urology, Paris, France
: Permanent implant prostate brachytherapy (using
Iodine125 seeds) is now recognized as one of the standard therapies
for lowrisk localized prostate cancer. For strictly selected patients,
focal therapy is nowadays increasingly proposed to limit toxicity and
permit easier salvage in case of failure. Brachytherapy, which is able
to treat a welldefined partial prostate volume at a welldefined dose
level, appears to be particularly well adapted to focal prostate
therapy.
: Focal brachytherapy was initiated by our
group in February 2010, according to a protocol approved by our local
ethics committee, with all patients signing an informed consent.
Patient selection is based on (at least) two series of prostate biopsies
and on a highresolution MRI. Only patients with very limited and
localized tumors, according to strict criteria, were selected for the
procedure. The technique is directly derived from the 'realtime'
procedure with the implantation of 'free' Iodine125 seeds, with
dynamic dose calculation (continuous feedback as per the real
positioning of each seed). We chose to deliver to the focal volume the
dose usually recommended by GECESTRO for the whole prostate (145
Gy).
: To date, 12 focal implantations were performed. The treated
volume corresponded to a mean value of 34 % of the total prostatic
volume (range 2048 %). For the focal volume, mean D90 was 182 Gy (
range 176188 Gy), and the mean V100 was 99.6 % ( range 98.899.9
%). In our experience, the technique could be performed without any
problem in approximately an hour and a half, that is to say not
significantly different from a usual 'whole prostate' brachytherapy. On
our very preliminary results, early urinary toxicity seems to be inferior
to what is usually observed after brachytherapy of the whole prostate,
particularly for the focal 'apex only' cases. Incontinence score (ICS)
was nil in all cases, as well as rectal toxicity. As for sexual toxicity,
IIEF5 scores only showed very limited and transitory changes.
: Focal treatment by brachytherapy is easily feasible with
apparently little acute toxicity. Further investigation is needed to
assess the results in terms of tumor control and toxicity.
PO155
DOSIMETRIC CONSTRAINT OPTIMIZATION IN INTRAOPERATIVE
TREATMENT PLANNING OF PERMANENT SEED IMPLANTATION (PSI)
K.U. Kasch 1 , P. Wust 2 , F. Kahmann 3 , T. Henkel 3
1
Beuth University for Applied Sciences Berlin,
Mathematics/Physics/Chemistry, Berlin, Germany
2
Charité – University Medicine, CVK, Berlin, Germany
3
Outpatient Prostate Brachytherapy, Ullsteinhaus, Berlin, Germany
: Today, PSI is an established treatment modality
for (earlystage) prostate cancer. In comparison to alternatives the
method often results in lower toxicity at equal tumor control. Current
systems for the necessarily inverse treatment planning limit both type
and number of available dosimetric constraints. Considering these
limitations this study aims at a set of robust dosimetric constraints
that translate into optimal clinical outcome.
: The results presented here are based on the
experience of about 2000 implantations performed by the authors of
this study. For a subgroup of about 400 patients both CTbased post
implantation analyses were performed and standardized patient
questionnaires were evaluated. Subsequently, first the
correspondence of intraoperatively achieved dosimetric constraint
values and those showing in the postimplant analysis was analyzed.
Secondly, a possible correlation of dosimetric constraint values and
clinical outcomes concerning acute and subacute toxicities was
investigated. Finally, a set of robust dosimetric constraints was
derived.
This set was used by a supervised group of 20 medical physics master
students to retrospectively (re)plan more than 300 patients (different
from the above subgroup). The results were evaluated utilizing a
quadratic score function for the dosimetric constraints as well as
dosevolumehistograms (DVH) for prostate, urethra and rectum.
Planning time and score function value as a function of the
(increasing) number of patients planned by an individual student were
interpreted in a learning curve.
: The above derived set of dosimetric constraints results in a
significant correlation between score function (physics) and DVH
(clinical outcome). This, in conjunction with a steep learning curve in
the planning process itself clearly indicates the clinical usefulness and
robustness of the constraints found. The results can be used with
commercially available treatment planning systems and do not depend
on the seed activity.
: Evaluation of postimplant analyses in conjunction with
well designed patient questionnaires results in an optimized set of
dosimetric constraints. This, besides the growing experience with an
increasing number of implantations, significantly contributes to the
improvement of clinical outcome in PSI.
PO156
URINARY MORBIDITY RELATED TO PROSTATE BRACHYTHERAPY WITH
OR WITHOUT EXTERNAL BEAM RADIATION THERAPY
M. Ishida 1 , K. Kanao 1 , A. Sugawara 2 , R. Ohara 1 , S. Kashiyama 3 , M.
Katayama 3 , N. Tsukamoto 3 , Y. Nakajima 1
1 Saiseikai Yokohamashi Tobu Hosipital, Urology, Yokohama, Japan
2 Keio University School of Medicine, Radiology, Tokyo, Japan
3 Saiseikai Yokohamashi Tobu Hosipital, Radiology, Yokohama, Japan
: A combination of permanent seed implantation
brachytherapy (BT) and external beam radiation therapy (EBRT) is one
of the treatment options for localized prostate cancer with
intermediate or high risk. As for the difference of radiation field and
World Congress of Brachytherapy 2012 S 65
radiation dose between the cases treated with BT alone or BT
combined with EBRT (BT + EBRT), the divergence of posttreatment
urinary morbidity may be seen. This study is to clarify the difference
of urinary morbidity in the cases treated with BT alone or BT + EBRT.
: Seventyseven histologically confirmed
prostate adenocarcinoma patients underwent iodine125 seed BT in
our institute between October 2009 and June 2011. Among those
patients, 10 with incomplete data were excluded from this study. The
median age was 72, ranged from 45 to 81. Of those 67 patients
included in this study, 43 (64.2%) were treated with BT alone with
prescription dose of 160 Gy and the other 24, who were evaluated as
intermediate or high risk under D’Amico classification, were treated
with 110 Gy of BT followed by 45 Gy (1.8 Gy x 25) of EBRT.
International Prostate Symptom Score (IPSS) was obtained from those
67 patients before BT (baseline) and 3 months (3M) after BT or BT +
EBRT to evaluate voiding condition. To characterize urinary morbidity
related to BT, changes of the scores from the baseline and the
difference of the scores between two treatment groups were
statistically analyzed with MannWhitney Utest.
: Prostate volume was same in both treatment groups (BT
alone: 26.7 ± 6.5 cc, BT+EBRT: 25.2 ± 11.8 cc, p = 0.16). There was
no significant difference in total Biochemical Effective Dose (BED)
between two groups, but BED of brachytherapy was higher in BT alone
group (BT alone: 216.2 ± 25.1 Gy, BT+EBRT: 137.4 ± 17.7 Gy, p <
0.01). There were no significant differences in total IPSS and
obstructive urinary symptom score between the two treatment groups
at baseline, however, irritative urinary symptom score was higher in
BT+EBRT group (BT alone: 4.8 ± 2.8, BT+EBRT: 6.3 ± 3.2, p < 0.05).
The changes of total IPSS from baseline revealed difference between
the two treatment groups (BT alone: 8.7 ± 6.4, BT+EBRT: 0.6 ± 5.3, p
< 0.01) showing that BT+EBRT had better voiding condition. The
changes of obstructive urinary symptom score between the two
treatment groups showed significant difference (BT alone: 5.6 ± 3.9,
BT+EBRT 0.2 ± 3.3, p < 0.01). There was a significant difference
between the two treatment groups on the changes of irritative urinary
symptom score (BT alone: 3.0 ± 3.2, BT+EBRT 0.8 ± 2.8, p < 0.01).
Urinary retention was not observed in both treatment groups.
: According to the results of this study, urinary morbidity
during the first 3 months after BT was lower in cases treated with BT
combined with EBRT compared with cases treated with BT alone. It
suggests that urinary morbidity is rather related to the radiation dose
of implanted seeds than total BED.
PO157
RECTAL BALLOONS AND THE RISK OF SECONDARY RECTAL CANCER
AFTER COMBINED MODALITY PROSTATE RADIATION
R.J. Burri 1 , J. Ng 2 , D.P. Horowitz 2 , J.A. Cesaretti 3 , M. Terk 4 , J. Kao 5 ,
T. Stephens 5 , K.S.C. Chao 2 , D.J. Brenner 6 , I. Shuryak 6
1
Tampa Bay Cancer Center, Radiation Oncology, Sun City Center FL,
USA
2
Columbia University Medical Center, Radiation Oncology, New York
NY, USA
3
Tampa Bay Cancer Center, Radiation Oncology, Tampa FL, USA
4
Florida Radiation Oncology Group, Radiation Oncology, Jacksonville
FL, USA
5
Tampa Bay Cancer Center, Radiation Oncology, Brandon FL, USA
6
Columbia University Medical Center, Center for Radiological
Research, New York NY, USA
: An increased risk of secondary rectal malignancy
is an established problem following definitive external beam radiation
therapy (EBRT) for prostate cancer. Many highrisk, and some
intermediaterisk, patients are currently treated with combined
brachytherapy and EBRT, usually with an intensitymodulated
radiation therapy (IMRT) plan to 45 Gy. In this study, a biologically
based carcinogenesis model was used to quantitate and compare the
predicted risk of secondary rectal cancer in men treated with or
without a rectal balloon in place during the IMRT portion of combined
modality therapy.
: Treatment plans were developed for ten
clinically localized prostate cancer patients using CT scans obtained
both with and without a rectal balloon in place. Target volumes
(prostate and proximal 1.5 cm of seminal vesicles) and normal
structures were contoured, and dosevolume histograms (DVHs) for
these organs were determined with a planned IMRT dose of 45 Gy. A
biologicallybased mathematical model of spontaneous and radiation
induced carcinogenesis was used to determine the excess absolute risk
of secondary rectal malignancies both with and without the rectal
balloon in place. These risks were then compared to one another and
to the baseline population.
: Treatment with a rectal balloon in place resulted in a
significantly lower mean rectal wall dose in all patients compared
with treatment without a rectal balloon. The average mean rectal
wall dose with a rectal balloon in place was 17.2 Gy versus 20.7 Gy
without the rectal balloon (p=0.001). A significantly higher risk of
secondary rectal cancers was predicted for patients treated without
rectal balloons when compared with patients treated with balloons in
place (p=0.001, relative risk 1.22; 95% confidence interval 1.101.34).
: For prostate cancer patients treated with combined
brachytherapy and external beam radiation therapy, the use of a
rectal balloon during the IMRT portion of treatment is associated with
a significant reduction in the predicted risk of secondary rectal
malignancy.
PO158
PHASE II TRIAL OF HIGHDOSE RATE BRACHYTHERAPY AND EXTERNAL
RADIATION FOR INTERMEDIATERISK PROSTATE CANCER
I. Tsukiyama 1 , R. Kobayashi 1 , J. Hiratsuka 2 , S. Kariya 3 , S. Uehara 4 , T.
Dokiya 5 , H. Sekine 6 , T. Sato 7
1
Aidu Central Hospital, Radiology, Fukushima, Japan
2
Kawasaki Medical College, Radiation Oncology, Kurashiki, Japan
3
Kochi University, Diagnostic Radiology and Radiation Oncology,
Kochi, Japan
4
Kyushu Cancer Center, Radiology, Fukuoka, Japan
5
Saitama Medical University, Radiation Oncology, Hidaka, Japan
6
Jikei University School of Medicine, Radiation Oncology, Tokyo,
Japan
7
Kitasato University, Urology, Kanagawa, Japan
: To estimate the rate of early and late Grade 3 or
greater genitourinary and gastrointestinal adverse events after
treatment with external beam radiotherapy and prostate highdose
rate (HDR) brachytherapy.
: Patients with locally confined T2b,T2c or
10ng/ml < PSA ≤ 20ng/ml or Gleason score=7 prostate cancer were
eligible for the present study. All patients were treated 39 Gy in 13
fractions using external beam radiotherapy and one HDR implant
delivering 18 Gy in two fractions. All adverse event were graded
according to the Common Terminology Criteria for Adverse Event,
version 3.0. Early adverse events were those occurring less than 9
months and late adverse events were those occurring more than 12
months from the start of the protocol treatment. Primary endpoint of
this study is rate of late Grade 3 or later adverse event. Secondary
endpoints are rate of early Grade 3 adverse event and PSA failure
rate.
: A total of 92 patients from 5 institutions were enrolled in the
present study. Of the 92 patients, 84 were eligible. Each rate of early
adverse events of Grade 1 after three, six and nine months from the
irradiation was 63%, 70% and 37% respectively, and that of Grade 2
was 9%, 5%, and 3% respectively. Each rate of late adverse events of
Grade 1 after 12, 18 and 24 months from the irradiation was 28%, 73%
and 0% respectively, and that of Grade 2 was 4%, 0%, and 0%
respectively. No adverse events of Grade 3 or greater were observed.
Among 84 cases, only one patient caused PSA failure. The patient was
treated with endocrine therapy.
: As a result of highdose rate brachytherapy combined
with external irradiation for intermediaterisk prostatic cancer, early
and late adverse events of Grade 3 or greater did not occur, and only
one patient had biochemical failure among the 84 patient. The
technique and doses used in the present study resulted in acceptable
level of adverse events.
PO159
LONG TERM TOXICITY FOLLOWING CS131 PROSTATE BRACHYTHERAPY
R.P. Smith 1 , S. Beriwal 1 , R.M. Benoit 2
1
University of Pittsburgh, Radiation Oncology, Pittsburgh, USA
2
University of Pittsburgh, Urology, Pittsburgh, USA

S66 World Congress of Brachytherapy 2012
: Cesium131 is a newer radioisotope now being
used in prostate brachytherapy (PB). We have noted a median
duration of acute symptoms of 36 months following PB with Cs131.
There is however, no data on long term urinary or bowel toxicity with
this isotope, which this study addresses.
: Patients undergoing PB with Cesium131 at
our institution were asked to complete the Expanded Prostate Cancer
Index Composite (EPIC) and IPSS survey preoperatively and at 2
weeks, 1, 3, 6, 9 and 12 months and every 6 months thereafter
following the implant. This report is based on the first 100 patients
with at least 3 years of follow up, so that long term toxicity can be
described. Scores in the EPICs range from 0 to 100, with higher scores
corresponding to improved quality of life. A difference of > 10 points
is noted to be a significant difference. The IPSS obviously indicates
relative urinary morbidity while the EPIC notes morbidity in the
following subscales: Urinary summary, urinary function, urinary
bother, urinary incontinence, urinary irritative/obstructive, bowel
summary, bowel function, and bowel bother.
: There was no difference when comparing prebrachytherapy
function to function at the 3 year mark in any of the EPIC subscales or
in the IPSS score, indicating that PB with Cs131 carries little to no
risk of long term morbidity to patients as a whole. In every subscale
studied, however, there were patients who did not return to baseline.
The median number who did not return to baseline in the different
subscales studied was 21 (hence 21%). This was balanced by a number
of patients who actually had an improvement in their function, with a
median number improved in the different subscales being 19 patients
(19%). Predictors of longterm toxicity were studied, including
prostate volume, # seeds, seed activity, D90, V100, V150, V200, V150
urethra, V100 urethra, Bladder neck D max, R100, type of therapy,
+/ ADT, the use preoperative alpha blockers, preoperative EPIC
scores, age, and the need for a postoperative catheter. The only
consistent predictor of worsening function at the 3 year mark was a
better prebrachytherapy EPIC score.
: Most patients undergoing PB with Cs131 have no urinary
or bowel toxicity at the three year postbrachytherapy mark. Those
that do have a worsening in function are balanced by those who
actually have an improvement in function after PB with Cs131. The
only consistent predictor for selfreported 3 year toxicity is better
prebrachytherapy urinary and bowel function.
PO160
DAILY NEEDLE APPLICATOR DISPLACEMENT DURING HIGHDOSERATE
PROSTATE BRACHYTHERAPY USING DAILY CT EXAMINATIONS
T. Takenaka 1 , K. Yoshida 2 , M. Ueda 1 , H. Yamazaki 3 , S. Miyake 1 , E.
Tanaka 4 , M. Yoshida 4 , Y. Yoshimura 1 , T. Oka 5 , K. Honda 1
1
Osaka national hospital, Radiology, Osaka, Japan
2
Osaka national hospital, Radiation Oncology and Institute for Clinical
Research, Osaka, Japan
3
Kyoto prefectural university of medicine, Radiology, Kyoto, Japan
4
Osaka national hospital, Radiation Oncology, Osaka, Japan
5
Osaka national hospital, Urology, Osaka, Japan
: To improve treatment conformity for prostate
cancer, we investigated daily applicator displacement during high
doserate interstitial brachytherapy (HDRISBT).
: Between May 2007 and March 2009, 35
patients at the National Hospital Organization Osaka National Hospital
were treated with HDRISBT as monotherapy using our ambulatory
technique. All patients received a treatment dosage of 49 Gy in 7
fractions over 4 days. For dose administration, we examined 440
flexible applicators (1320 points) using our unique ambulatory implant
technique. Using CT images with a 3mm slice thickness, we
calculated the relative coordinates of the titanium markers and the
tips of the applicators. We calculated the distance between the
center of gravity of the markers and the tips of the catheters, and
compared the distances measured on the day of implantation and the
second (21 hours), third (45 hours), and fourth (69 hours) treatment
days.
: The mean displacement distance for all applicators was 4.4 ±
3.4 mm, 4.8 ± 4.1 mm, and 6.2 ± 4.5 mm at 21, 45, and 69 hours after
initial planning CT. We used a 15mm margin for needle displacement
and only 5 points (0.4%) of 3 patients (9%) exceeded this range.
Almost patients (86%) showed the largest displacement within the first
21 hours. The relative doses that covered 100% of CTV (D100(CTV))
values compared with the initial treatment plan were reduced to
0.96±0.07, 0.95±0.08 and 0.92±0.1 at 21, 45 and 69 hours. However,
the relative D90(CTV) values kept acceptable levels (1.01±0.02,
1.01±0.03 and 0.96±0.05).
: Cranial margin of 15 mm seems to be effective to keep
D90(CTV) level if we do not do corrective action for 4 days of
implantation. However, corrective action should be performed to
keep D100(CTV) level and to reduce cranial margin and bladder neck
complication.
PO161
LDR PROSTATE DOSIMETRY AND DOCUMENTATION FOCUS STUDY
E. Cirino 1 , I. Iftimia 1 , L. Xiong 1 , H. Mower 1 , A. Mahadevan 1 , T. Lo 1
1 Lahey Clinic, Radiation Oncology, Burlington, USA
: This work is a retrospective review of twenty five
low dose rate prostate (I125 seed) treatment plans. The objective is
to evaluate our criteria for determination of plan quality relative to
current standards and to review our compliance with the definition of
medical events for brachytherapy.
: Several references were reviewed to
establish planning objectives (prostate and organs at risk) for both
intraoperative and one month postimplant plans. Our Radiation
Oncologists reviewed a summary of these guidelines and in
consideration of their historic practice and outcomes established
updated criteria for our clinic. The new DVH criteria were used for
the retrospective review.
In a recent publication, an ASTRO working group recommended that
the definition of a medical event for prostate permanent
brachytherapy should be based on the implanted source strength and
not dose. The recommendation was reviewed by our Radiation
Oncologists then compared with local regulatory guidelines. It was
agreed that this definition could be adopted in our clinic. The twenty
five cases were reviewed to determine written directive compliance
based on this definition.
: Twenty four of the twenty five cases reviewed met the
revised DVH guidelines. One of the twenty five cases had a one month
postimplant prostate D90 less than 80%. This particular case showed
an enlarged prostate volume and prompted further evaluation. The
evaluation resulted in a revised process that triggers the physician to
review the case in detail and document the review if a postoperative
prostate D90 is less than 80% of the written directive target dose. The
planning printouts are now customized to include the established
criteria.
A medical event is now based on greater than 20% of the source
strength prescribed in the written directive being implanted outside
the planning target volume in the one month postimplant evaluation.
All of the study cases reviewed were compliant with the ASTRO
recommended definition for written directive. The one month
postimplant planning document was edited to reflect evaluation of
the source strength and therefore written directive compliance.
: Updated planning DVH objectives were established
based on literature review, used for the retrospective study, and
implemented in our practice. The study showed good agreement with
the updated objective for both the intraoperative plans and the one
month postimplant plans.
The ASTRO working group definition of a medical event based on
verification of implanted source strength rather than dose was used
for the retrospective review and adopted for future cases. Based on
this definition all plans were in compliance.
Future work will include a more detailed evaluation of the one month
postimplant cases where prostate D90 is less than 80% to determine
any predictors that could prompt modification during the
intraoperative planning.
PO162
IMPACT OF DOSE ON INTERMEDIATERISK PROSTATE CANCER PATIENTS
TREATED WITH BRACHYTHERAPY ALONE OR BOOST
A. Yorozu 1 , K. Toya 1 , K. Yoshida 1 , N. Koike 1 , A. Takahashi 1 , S. Saito 2 ,
T. Nishiyama 2 , Y. Yagi 2 , R. Namidome 2 , A. Ashikari 2
1
Tokyo Medical Centre NHO, Department of Radiation Oncology,
Tokyo, Japan
2
Tokyo Medical Centre NHO, Department of Urology, Tokyo, Japan
World Congress of Brachytherapy 2012 S 67
: To assess the impact of radiation dose on
biochemical failure in intermediaterisk prostate cancer patients
treated with brachtherapy (BT) alone or combined with external beam
irradiation (EBRT).
: From a prospectively collected database of
1290 men treated at Tokyo Medical Center from 2003 to 2009 with I
125 BT for prostate cancer, 688 men with intermediaterisk patients
with either one or more intermediaterisk features (PSA level 1020
ng/mL, Gleason score 7, or Stage T2b/2c) were identified who had a
minimum followup of 24 months. Patients with lowtier of
intermediate risk (PSA < 10 ng/mL and Gleason score 3+4 with positive
core rates less than 1/3 ) were treated with BT alone and the rest
uppertier patients were treated with BT followed by EBRT. Gleason
score was 7 in 76% of patients. PSA ranged from 1.4 to 20 ng/mL
(median, 7.6 ng/mL). Seventy per cent of patients received
neoadjuvant hormone therapy (median, 7 months) while 30 % of
patients did not. Biologically effective dose (BED) values were
calculated to compare doses of treatment regimens. BED ranged from
105 to 250 Gy2 (median, 206 Gy2). Patient and treatmentrelated
factors were analyzed with respect to freedom from biochemical
failure (FFbF). The effects of multiple variables were tested by log
rank and linear regression.
: The median followup was 60 months (range, 24–100 months).
The overall FFbF using the ASTRO definition for all patients was 93 %
at 5 years and 91 % at 7 years. Of the eight factors tested (age, T
stage, PSA levels, Gleason score, positive core rate, use of hormone,
use of EBRT, and BED), only BED (BED 180 Gy2) was
found to be significant (p=0.003). To analyze the effect of increasing
BED on FFbF, patients were devided in to three BED dose groups. The
dose groups were 180210 Gy2 (n=368), and >210
Gy2 (n=254). The 7year FFbF rate for BED groups was 81%, 91% and
94%, respectively (p=0.010). Cox regression revealed that Tstage
(p=0.049), Gleason score (p=0.018) and BED (p=0.007) were significant
predictors of FFbF when age, PSA, Tstage, Gleason score, positive
core rate, hormone and BED were considered continuous variables.
: Radiation dose is an important predictor of 5year FFbF
in intermediaterisk prostate cancer. With the use of high BED
radiotherapy setting, neoadjuvant hormone therapy did not have a
significant impact on 5year FFbF rates. Individualized treatment
using I125 brachytherapy alone or boost should be a good option for
intermediaterisk prostate cancer patients.
PO163
PSA RESPONSE TO TRIMODALITY PREDICTS BIOCHEMICAL
PROGRESSION FREE SURVIVAL IN LOCALIZED PROSTATE CANCER
M. Aoki 1 , K. Miki 2 , Y. Yamamoto 2 , M. Kido 2 , S. Takaki 1 , M. Kobayashi 1 ,
C. Kanehira 1 , S. Egawa 2
1
Jikei University School of Medicine, Department of Radiology,
Minatoku, Japan
2
Jikei University School of Medicine, Department of Urology, Minato
ku, Japan
: High dose rate (HDR) brachytherapy combined
with external beam radiation therapy (EBRT), neoadjuvant androgen
suppression therapy (NAST) and adjuvant androgen suppression
therapy (AAST) (Trimodality) have been used to treat localized high
risk prostate cancer. To define prognostic factors of biochemical
relapse free survival (bRFS), an analysis of patients treated with Tri
modality were performed.
: Between May 2005 and Oct. 2008, 109 high
risk prostate cancer patients (D'Amico classification) were treated
with NAST prior to HDR brachytherapy combined with
hypofractionated EBRT. Among 108 patients, 107 patients (99%) had
completed AAST for 24 months after whole radiotherapy. The median
age was 69 years (range, 5982). The median initial PSA was 23.5
ng/ml (range, 3.9365). The median Gleason score was 8 (GS
6/7/8/9/10 : 7/23/35/23/4). The median follow up was 52 months
(range, 3674). The median NAST was 9 months (range,129). The
median AAST was 24 months (range, 324). 74 patients:HDR
brachytherapy (PTV: 5Gy, 6Gy, 2fx/day) and hypofractionated EBRT
(45Gy : 3Gy×15fx/3weeks). 35 patients:HDR brachytherapy (PTV: 9Gy,
9Gy, 2fx/day) and hypofractionated EBRT (40Gy :
2.5Gy×16fx/3weeks). Hypofractionated EBRT was performed 1weeks
after HDR brachytherapy. 66 patients were given total androgen
suppression and 16 patiennts were given LHRH only as NAST.
: With a median follow up of 52 months, bRFS of all patients
was 81%(70mons). bRFS of high dose arm and low dose arm were 100%
(48 mon) and 79.5%(76mon) respectively(p=0.24). On multivariate
analysis of factors predicting bRFS, dose of HDR and PreHDR PSA level
were significant respectively (p=0.0003, 0.005). However age, initial
PSA, Gleason score, duration of NHT were not significant respectively
(p=0.68, 0.065, 0.40, 0.62). Patients in the PreHDR PSA0.1 group (87.9% vs. 68.2%, p=0.014). On multivariate analysis of
factors predicting PreHDR PSA level, although the term of NAST was
not significant (p=0.076), initial PSA tend to be significant (p=0.052).
: For highrisk prostate cancer patients treated with Tri
modality (NAST, HDR plus EBRT, AAST), Dose of HDR and PreHDR PSA
were important prognostic factors (p=0.0003, 0.005 respectively).
Patients in the PreHDR PSA0.1 group (p=0.014). A
further study is needed to confirm the importance of PreHDR PSA in
Trimodality treatment.
PO164
SEED MIGRATION IN PROSTATE BRACHYTHERAPY DEPENDS ON
EXPERIENCE AND TECHNIQUE
G. Delouya 1 , D. Taussky 1 , C. Moumdjian 1 , R. Larouche 1 , D. Béliveau
Nadeau 1 , C. Boudreau 1 , Y. Hervieux 1 , D. Donath 1
1 CHUM Hôpital NotreDame, Radiation Oncology, Montréal, Canada
: To determine the rate of seed loss and pulmonary
migration over time in permanent seed prostate brachytherapy (PB).
: The first 495 patients treated at our
department were analyzed. All patients were treated with loose
I 125 seeds using an automated seed delivery system and realtime
intraoperative planning. Pelvic fluoroscopic imaging was done 30 days
following the implant. Patients were divided into five groups of 100
patients each according to the order treated. The five groups were
compared using Chisquare test and Oneway analysis of variance
(ANOVA).
: A total of 22.8% of patients lost at least one seed. The
highest percentage of patients losing any number of seeds was in the
first group of 100 patients. At least one seed was lost in 38% of the
patients. This number decreased gradually and reached a rate as low
as 9% in the last group of one hundred patients (patients 400 to 499).
The mean total seed loss rate (number of seeds lost/number of seeds
implanted) changed significantly over time (p

S68 World Congress of Brachytherapy 2012
: 15 patients with local recurrent prostate
cancer after primary radiotherapy were treated with focal salvage I
125 brachytherapy. Location of recurrent tumor was defined on T2
weighted MRI and Dynamic Contrast Enhanced (DCE)MRI, in
combination with systematic 10core prostate biopsy. Goal was to
deliver 145Gy to the gross tumor volume (GTV) while maintaining dose
limitations for organs at risk. Toxicity was scored by the Common
Terminology Criteria for Adverse Events (CTCAE3.0). Quality of Life
(QoL) was measured by SF36 Health Survey, European Organization of
Research and Treatment of Cancer (EORTC) C30+3 and PR25
questionnaires. Feasibility was defined as treating >90% of patients
within prescription limits and severe toxicity (>grade 3) in
: In 13 patients >95% of the GTV was covered with the
prescribed dose. Mean D90 was 198Gy (range 150330). In 14 patients
rectum and bladder doses were within limits. The D2cc for bladder
and rectum were respectively 42Gy (1969) and 63Gy (1896). For
urethra, median D10 was 133Gy (100240). With a minimum followup
of 6 months one patient suffered from grade 3 gastrointestinal (GI)
and genitourinary (GU) toxicity. Grade 2 occurred in 4 (GU) and 0 (GI)
patients. Erectile dysfunction at baseline and after 6 months was seen
in 6 patients. Quality of life significantly decreased with regard to
social and pain measures. In 12 patients PSA declined during follow
up.
:
Focal therapy for prostate cancer recurrences seems feasible and
toxicity and influence on quality of life are acceptable.
PO166
PERMANENT PROSTATE BRACHYTHERAPY IN JAPANESE PATIENTS WITH
SMALL PROSTATE GLANDS
K. Kobayashi 1 , K. Okihara 2 , K. Kamoi 2 , T. Iwata 2 , T. Tsubokura 1 , N.
Aibe 1 , N. Kodani 1 , T. Miki 2 , H. Yamazaki 1
1
Kyoto Prefectural University of Medicine, Department of Radiology,
Kyoto, Japan
2
Kyoto Prefectural University of Medicine, Department of Urology,
Kyoto, Japan
: To investigate the dosimetric and treatment
related morbidity for brachytherapy in Japanese patients with
prostate glands < 20cm 3
: From April 2005 to December 2010, a total of
300 patients were treated by brachytherapy without EBRT in our
institute. About 50% of 300 (151) patients had small prostate < 20cm 3 .
We compared the two groups, Small prostate < 20cm 3 dosimetric
quality assesment we useds Day 30 CT with MRI. We compared the two
groups, Small prostate 20 cm3
(nS). The implant technique was Hybrid interactiverealtime with Mick
Aplicator method. Prescription dose was 145Gy. For assessment of
prostate volulme, we performed transrectal ultrasound (TRUS), MRI
(one day before procedure day, Day1 and Day30). Dosimetric quality
assessment was Day 30CT with MRI. Dosimetric quality was reported in
terms of the following parameters: D90, V100, V150, rectalV100,
urethralD90. For the evaluation of treatmentrelated morbidity, we
used CTCAE ver.4.
: DVH parameters (S vs. nS) were D90 (170.2 vs. 171.5 Gy),
V100 (97.6 vs. 97.4 %), V150 (54.5 vs. 53.7%), rectalV100 (0.02 vs.
0.08ml) and urethralD90 (166.3 vs. 161.7Gy). The median age were
(68.5 vs. 70y.o.), follow up length were (42 vs. 39 months). All
parameters showed no significant difference. There were no acute
Grade 2 urinary retention in the S group, but there were 5 patients
who experienced Grade 2 retention in nS group (p=0.02). Acute Grade
2 micoic pain was one case in both groups. Grade 2 incontinence was
one case in S group (No significant difference). Late Grade 3 urinary
toxicity of retention which needed transurethral resection of the
prostate (TURP) was one case in nS group, and grade 2 retention were
2 case in nS group. Grade 2 hematuria was occurred one case in both
groups. There were no grade 3 rectal complications. Only one case of
grade 2 rectal hemorrhage was occurred in both groups. PSA failure
determined by nadir +2 (except PSA bounce) was occurred one case in
S group.
: Our results demonstrate that bracytherapy for Japanese
small prostate volumes is also highly effective, excellent post
dosimetry and acceptable treatmentrelated morbidity. Regarding
acute urinary retention it is unlikely to cause adverse events in small
prostates.
PO167
IMPACT OF EMBEDDED SEEDS ON DOSE DISTRIBUTIONS IN XRAY
RADIOTHERAPY: A PHANTOM STUDY WITH MONTE CARLO CALCULATION
K. Shiraishi 1 , A. Sakumi 1 , A. Haga 1 , T. Onoe 1 , K. Yamamoto 1 , K.
Okuma 1 , K. Yoda 1 , K. Nakagawa 1
1 University of Tokyo, Department of Radiology, Tokyo, Japan
: In the multidisciplinary therapy era for high risk
prostate cancer, external beam radiation therapy is often combined
with brachytherapy boost. We have investigated the impact of
implanted seeds on dose distributions in xray radiotherapy by way of
Monte Carlo calculation.
: Iodine125 seeds, OncoSeed (Oncura, USA),
were implanted into a prostate training phantom for brachytherapy,
Model 053 (CIRS, USA), and the phantom was positioned in water with
an acrylic enclosure. A dose of 100 MU with a photon energy of 6 MV
and a field size of 5 x 5 cm2 was unidirectionally delivered to the
phantom and the projected image was acquired by a portal imager,
iViewGT (Elekta, UK). A Monte Carlo based TPS, Monaco (Elekta, USA)
was used to calculate the dose distributions inside the phantom with
the identical radiation parameters. Another Monte Carlo code,
EGSnrc, was also employed for comparison. Monaco was also used to
calculate dose distributions when the same beam was delivered to the
phantom from four directions of 0, 90, 180 and 270 degrees.
:
Figure 1(a) shows a projected image on the iViewGT panel, where
seeds were clearly observed. Figure 1(b) shows dose perturbation
caused by backscattering from each seed.
Figure 1(c) shows another verification result done by the EGSnrc code
under the same radiation parameters except for a field size of 3 x 3
cm2 to reduce computation time. Again the dose fluctuation in space
was clearly observed. Finally Figure 1(d) demonstrates that the above
dose perturbation is not observed when multiple beams were
delivered to the phantom including seeds. Good result was also
obtained in dose verification
World Congress of Brachytherapy 2012 S 69
:
We have observed that seeds implanted in the phantom are
acceptably visible in EPID and affect dose distributions in xray
radiotherapy when a single beam is delivered. However, beams from
multiple directions may cancel the dose perturbation by spatial
averaging. These results encourage us to use seeds for tumor
registration in 3D CRT, IMRT, and VMAT. Furthermore, especially in
VMAT delivery after radioactive seed implantation, which has already
been clinically employed as shown in Figure 2, there may be little
deleterious effect by the seeds on dosimetric evaluation.
PO168
VALIDITY OF INTRAOPERATIVE INTERACTIVE PLANNING TECHNIQUE
BASED ON ANATOMIC DISTRIBUTION OF PROSTATE CANCER
O. Keisei 1 , N. Kohno 2 , Y. Okinaka 1 , Y. Okada 1 , K. Murata 2
1
Shiga University of Medical Science, Department of Urology, Otsu
shi, Japan
2
Shiga University of Medical Science, Department of Radiology, Otsu
shi, Japan
: Modern prostate brachytherapy is a highly
effective treatment for localized prostate cancer. To obtain a high
cure rate by prostate brachytherapy, it is important to provide a
sufficient radiation dose everywhere cancer cells exist. There have
been reports of lower radiation dose on anterior base. This has been
justified because of the rare location of prostate cancer at the
anterior base. We reviewed whole mounted prostatectomy specimens
in our series to see the anatomic distribution of prostate cancer.
Based on these results, we evaluated the validity of our current
interactive intraoperative technique.
: A total of 69 men with clinically localized
prostate cancer were treated with radical prostatectomy at Shiga
University of Medical Science between 2008 and 2011. Whole mounted
prostatectomy specimens were analyzed for anatomic distribution of
prostate cancer. Extraprostatic extensions (EPE) and resection
margins (RM) were studied, and their locations were classified into
four quadrants [anteriorsuperior quadrant (ASQ), posteriorsuperior
quadrant (PSQ), anteriorinferior quadrant (AIQ), posteriorinferior
quadrant (PIQ)], and apex. Based on the results of the anatomical
distribution of prostate cancer, we evaluated our current interactive
intraoperative technique by investigating postimplant dosimetry for
four different regions of the prostate gland.
: Among the 69 prostatectomy cases, EPE and/or RM were
present in 33 cases (47.8%). The locations of EPE and/or RM were
distributed with 11 cases (33.3%) in ASQ, 12 cases (36.3%) in AIQ, one
case (3.0%) in PSQ, six cases (18.1%) in PIQ and three cases (9.0%) in
apex. The postimplantation dose obtained by our current interactive
intraoperative technique was: The mean V100±95% confidence
interval for the whole prostate, 97.5±0.5%; for ASQ, 96.2±1.3%; for
PSQ, 97.6±0.7%; for AIQ, 99.0±0.7%; for PIQ, 97.7±0.9%. The mean
D90±95% confidence interval for [or] the whole prostate, 180.4±4.4Gy;
for ASQ, 175.0±6.9Gy; for PSQ, 181.2±6.6Gy; for AIQ, 202.2±7.6Gy; for
PIQ, 181.2±5.5Gy.
: The present data demonstrate the importance of
including treatment of the anterior portions of the prostate, not only
AIQ, but also ASQ. Our current interactive intraoperative technique
allows us to provide high quality implants covering the entire prostate
with minimal morbidity.
PO169
BRACHYTHERAPY FOR YOUNG PROSTATE CANCER PATIENTS. WHAT IS
DIFFERENT FROM ELDER PATIENTS?
Y. Yagi 1 , A. Ashikari 1 , R. Namitome 1 , T. Nishiyama 1 , K. Toya 2 , A.
Yorozu 2 , S. Saito 1
1
National Hospital Organization Tokyo Medical Center, Urology,
Tokyo, Japan
2
National Hospital Organization Tokyo Medical Center, Radioncology,
Tokyo, Japan
: This study is to evaluate clinical outcomes of
brachytherapy (BT) with I125 seed implantation in young prostate
cancer patients.
: Between July 2005 and December 2008, 771
patients underwent BT for cT13N0M0 prostate cancer at our
institution. Of the total number of patients, 86 (11.2%) were aged 60 years old (elder
group). Kaplan Meier analysis was performed to evaluate the
biochemical progressionfree survival rate (BPFS), clinical progression
free survival rate (CPFS) and overall survival rate (OS). The Phoenix
definition was used to determine biochemical failure. Prostate
specific antigen (PSA) bounce was defined as a rise of at least 0.4
ng/ml with a spontaneous return to the prebounce level or lower.
Expanded Prostate Cancer Index Composite (EPIC) was used to
investigate healthrelated quality of life (HRQOL).
:
The followup period was 6.4 to 75.1 (median 51.1) months. The BPFS
rate in the young and elder groups at 5year was 82.1% and 92.5%,
respectively (P = 0.006). The CPFS rate in the young and elder groups
at 5year was 97.5% and 94.7%, respectively (P = 0.450). Of the 86
patients in the young group, 13 patients matched the Phoenix
definition of biochemical failure, however, only 2 patients showed
clinical progression and the others were defined as PSA bounce. The
PSA bounce rate in the young and elder groups at 3year was 46.7%
and 26.1%, respectively (P = 0.027). The OS rate in the young and
elder groups at 5year was 100% and 95.9%, respectively (P = 0.082).
No one died of prostate cancer in young group and only one died elder
group. HRQOL analysis with EPIC showed that urinary incontinence
and sexual function were better in the young group than those in the
elder group. Bowel and hormonal function were similar in both
groups. A total of 52 patients in the elder group suffered from second
primary cancer (SPC) after BT, but no SPC was seen in the young
group. Nine out of 52 patients in the elder group were bladder or
rectal cancer, which arose between 33 to 65 months after BT.
: BT was equally effective in young prostate cancer
patients under age of 60, but PSA bounce was more often observed in
the young group. EPIC analysis showed that the young group had

S70 World Congress of Brachytherapy 2012
better outcomes of HRQOL. Concerning the incidence of SPC after BT,
longer followup is necessary to reach the conclusion.
PO170
EXCLUSIVE IODINE 125 PROSTATE BRACHYTHERAPY. EXPERIENCE OF
INSTITUT BERGONIÈ
L. Thomas 1 , A. Chemin 1 , S. Belhomme 1 , O. Lasbareilles 1 , J.
Mendiboure 2 , N. Houédé 3 , E. Descat 4 , D. Monnin 5 , P. Richaud 1
1
Institut Bergonié, Radiation Oncology, Bordeaux, France
2
Institut Bergonié, Biostatistics, Bordeaux, France
3
Institut Bergonié, Medical Oncology, Bordeaux, France
4
Institut Bergonié, Radiology, Bordeaux, France
5
Institut Bergonié, Anesthesiology, Bordeaux, France
: Retrospective analysis of pts with prostate cancer
treated with Iodine permanent implant. To describe biochemical
failure free survival (BFFS), genitourinary toxicity and erectile
dysfunction.
: 302 patients (pts) with prostate cancer were
treated at Institut Bergonié with permanent Iodine implant between
June 2002 and December 2009. Patients were selected for
brachytherapy according to usual criterias admitted (international and
national recommendations). At the beginning, strand I125 seeds
'ONCURA' after intraoperative dosimetry with spot Nucletron were
inserted manually with 'Utrecht' wings for 65 pts. From May 2005, a
seed projector after 3D dosimetry peroperative treatment planning
'First technique' was used for 237 pts. Inverse planning optimized
dosimetry was incorporated (IPSA) since September 2006. Prescribed
dose at the planning target volume (prostate) was 145 Gy. Every
patient had a clinical and biochemical followup. Genitourinary and
rectal toxicity were classified according to CTCAE V3 (Common
Toxicities Criteria for Adverse Events) and using IPSS score
(International Prostate Symptoms Score).
: Mean age of pts was 64.6 years and mean pretreatment PSA
was 6.97 ng/ml; 79.8% of pts (241 pts) were low risk prostate cancer,
19.5% (59 pts) were intermediate risk and 2 pts were high risk; 83.2%
(251 pts) were T1c, 15.6% (47 pts) T2a. Gleason score was less or
equal to 6 in 88.8% (268 pts) and Gleason score was 7 (3+4) in only
10.9% (33 pts). Mean IPSS score was 3.21 (014) and only 12 pts (4%)
had an IPSS score > 10 < 15. Before treatment with brachytherapy,
hormone deprivation was administered during a mean of 4 months for
cytoreduction in 68 pts (22.5%). Dosimetric quality criterias fullfilled
recommendations and intraoperative D90 Prostate was 180 Gy (mean
and median) and D90 Prostate on CT scan at 30 days was respectively
for mean and median dose 153.56 Gy and 156 Gy. Retention rate was
6% (18 pts) during the period of the study and is evaluated to 2% per
year since 2007. Overall urinary toxicity ³ G3 was reported in 8.6% (26
pts), with only 1.6% G3 (4 pts) at 12 months after brachytherapy and
1% G3 (2 pts) at 24 months after brachytherapy. Since 2007, no
urinary toxicity G3 is reported. Incontinence rate was 0.5% at 24
months (1 pt) after treatment. IPSS score at 6 months after treatment
was > 10 in 22.5% (46 pts). Rectal toxicity G2 and G3 was recorded in
overall 2.4% (7 pts). At 2 years after treatment, erectile dysfunction
was present in 27.6% (43 pts). Followup is 45 months (IC 95%), 95.3%
(286 pts) are alive without disease, 0.7% (2 pts) are dead cancer
prostate related, 1.3% (4 pts) have presented distant metastasis and
2.3% (7 pts) have presented a local relapse which has been salvaged
for 5 pts by cœlioscopy robotic prostatectomy. Biochemical failure
free survival at 36 and 48 months were respectively 95.8% and 94.7%
according to Phoenix definition.
: Iodine 125 monotherapy yields excellent results for pts
with prostate cancer carefully and highly selected with acceptable
urinary toxicity and relatively low erectile dysfunction.
PO171
DNA PLOIDY BASED ON ARCHIVED BIOPSY MATERIAL MAY CORRELATE
WITH PSA RECURRENCE AFTER PROSTATE BRACHYTHERAPY
M. Keyes 1 , M. MacAulay 2 , M. Hayes 3 , J. Korbelik 2 , D. Garner 2 , J.W.
Morris 1 , B. Palcic 2
1
B.C. Cancer Agency Vancouver Centre, Department of Radiation
Oncology, Vancouver BC, Canada
2
B.C. Cancer Agency Vancouver Centre, Department of Cancer
Imaging, Vancouver BC, Canada
3
B.C. Cancer Agency Vancouver Centre, Department of Pathology,
Vancouver BC, Canada
: It has been postulated that DNA ploidy status as
measured by Diagnostic DNA Image Cytometry (DNAICM) can predict
the therapeutic outcome in prostate cancer. The objective of this
study was to further explore whether DNA ploidy of prostate cancer
cells can distinguish between patients with PSA failures and non
failures treated with prostate Brachytherapy.
: 1006 uniformly selected low and intermediate
risk patients received prostate brachytherapy between 20/7/98 to
23/10/03 at the BCCA. Median followup is 73 months, and PSA
recurrence at 7 years is 5.6%. Neither of the recognized dosimetry
quality assurance factors (V100 or D90) were able to distinguish
between PSA failures and non failures. 47 patients with PSA failure
were identified from this cohort and 47 controls matched using age,
iPSA, clinical stage Gleason Score and use of hormone therapy and
length of follow up. Out of the 90 specimens received from pathology
departments across BC, 79 were successfully processed. 27 controls
and 20 failures contained more than 100 tumor cells, and these were
used for the final analysis. Tumor location in the tissue blocks was
marked by a pathologist, the tissue prepared as a cell monolayer, and
scanned.
DNA content of each individual cell was determined by measuring
their integrated optical densities (IOD). The nuclei for each case were
separated into 13 separate previously validated ploidy groups (P1P13)
based on their DNA content. The percentage of cells in each group
was used to classify the samples. Linear discriminate function analysis
was used for the statistical analysis.
: Age, iPSA, clinical stage Gleason Score and use of hormone
therapy and length of follow up between failures and non failures
were well matched (Ttest, all p values NS). Non failure group
however, had larger proportion of cores involved with cancer (Ttest
p=0.0021). Using a single feature P2 (frequency of cells with DNA
Index of 0.95 to 1.0) we could correctly recognise 70% of controls and
80% of failures (MannWhitney U test p=0.0022).
: DNA ploidy can correctly classify the majority of failures
and nonfailures in this study. This suggests the possibility of failure
patients likely having a different amount of genomic alterations, and
potentially a more aggressive disease. The question arises whether
knowing this information before brachytherapy, may call for more
aggressive treatment upfront. DNA ploidy may be useful for
separating patients for active surveillance from those warranting
active management. A larger sample of prostate cancer cohort
patients and validation on an external cohort will be necessary to
further confirm our hypothesis.
PO172
CURRENT RISK CLASSIFICATION FOR PROSTATE CANCER DOES NOT
ACCURATELY PREDICT SURVIVAL AFTER I125 BRACHYTHERAPY
L. Kerkmeijer 1 , E. Monninkhof 2 , M. Van Vulpen 1
1
U.M.C. Utrecht, Radiation Oncology, Utrecht, The Netherlands
2
U.M.C. Utrecht, Julius Center for Health Sciences and Primary Care,
Utrecht, The Netherlands
: Prediction of outcome in prostate cancer patients
is usually based on risk classification systems including a low, medium
and high risk category based on Tstage, PSA at diagnosis and Gleason
score. The available risk classification systems are subject of
discussion, since outcome is based on biochemical recurrence rather
than survival. Furthermore, these systems do not take into account
the individual contribution of each clinical risk factor on outcome.
The objective of the present study is to develop a model based on the
individual clinical pretreatment parameters to predict survival in
prostate cancer patients after I125 prostate brachytherapy more
accurately.
: From 1989 to 2008, 1694 patients were
treated with I125 brachytherapy. For 1645 patients, all clinical
pretreatment parameters and survival outcome were known. In the
statistical package of R, clinical parameters including Tstage (T1,
T2a, T2b and T2c), grade (1, 2 and 3), pretreatment PSA (continuous
parameter) and age (continuous parameter) were related to the
hazard of mortality by means of multivariate Cox regression analysis.
To assess the discriminative accuracy of the model for prediction of
World Congress of Brachytherapy 2012 S 71
overall and disease specific mortality, the cstatistic was calculated
and compared to the discriminative ability of the risk classification
system described by Ash et al.
: Of the 1645 patients analysed, 1441 (87.6%) were alive at
time of the censor date (December 2008), 61 (3.7%) died of prostate
carcinoma and 143 (8.7%) died of nonprostate carcinoma related
death. Median followup time was 4.2 years. The cstatistic of our
preliminary model for prediction of disease specific mortality was
0.81 (SD 0.055), compared to 0.77 (SD 0.046) for the risk classification
system by Ash et al. Our model showed a cstatistic of 0.69 (SD 0.047)
for overall mortality against 0.61 (SD 0.045) for the system of Ash et
al.
: Current risk classification systems do not predict survival
accurately. This is probably caused by the fact each clinical
pretreatment factor in these systems has the same weight. Better
prediction of survival can be achieved by enabling a different
contribution to the predicted outcome of each clinical risk factor in
the model, by using PSA as a continuous variable, and by adding
patient age. This new model is a promising tool for physicians to
predict prostate cancer related mortality prior to treatment. The
predicted risks of mortality derived from the new model will be
compared with the observed risks of mortality for calibration
purposes. After internal validation, we will develop a nomogram for
prediction of survival based on the abovementioned clinical
pretreatment parameters.
PO173
IODINE125 (I125) LOW DOSE RATE (LDR) BRACHYTHERAPY FOR
HIGHER RISK (HR) PROSTATE CANCER
R. Conroy 1 , J. Malik 1 , P. Mandell 1 , R. Swindell 1 , P. Hoskin 2 , D.
Bottomley 3 , J. Logue 1 , J. Wylie 1
1
The Christie NHS Foundation Trust, Clinical Oncology, Manchester,
United Kingdom
2
Mount Vernon Cancer Centre, Clinical Oncology, Middlesex, United
Kingdom
3
St James' Institute of Oncology, Clinical Oncology, Leeds, United
Kingdom
: LDR brachytherapy offers dose escalation when
compared to external beam radiotherapy alone. It is well established
as monotherapy for patients with low risk (LR) prostate cancer with
10year biochemical relapse free survival (bRFS) in different series of
around 90% with acceptable toxicity. It has been used increasingly in
intermediate risk (IR) prostate cancer, but is not standard of care for
high risk (HR) disease. We report the outcomes for a cohort of men
with higher risk prostate adenocarcinoma treated with LDR
brachytherapy in a multiinstitutional UK practice.
: Data on patient demographics, dosimetry and
biochemical outcome was obtained from the multiinstitutional
prospective database for patients with higher risk disease treated
between 20032007. High risk was defined as patients with ≥ 2
D’Amico intermediate risk factors (PSA 1020, GS 7 or clinical T2c) or
≥1 high risk factor (PSA > 20, GS ≥ 8).
KaplanMeier methods were used to estimate bRFS defined using both
ASTRO Phoenix and ASTRO consensus definitions. A univariate analysis
was performed to assess the significance of Gleason score, PSA, T
stage, pre or postimplant dosimetry, and additional hormones on
BRFS.
: Two hundred and seventeen men with histologically
confirmed adenocarcinoma of prostate were identified with median
age 65 years (range 4379). Median follow up was 62 months (range
14102). All patients were treated with I125 LDR brachytherapy;
67(31%) patients had additional hormone treatment, median duration
7 months (range 3 – 22), and no patients had additional EBRT.
Preimplant dosimetry median V150 59.6 %( 43.789.8), medianV200
20.1 %( 11.636) and postimplant dosimetry on 75 cases (35%),
showed median D90 132.8Gy (range 75192Gy).
The 3 and 5 year bRFS as defined by ASTRO Phoenix were 85.4% and
74.4% and as defined by ASTRO consensus were 76.6% and 69.8%.
On univariate analysis there were no statistically significant predictors
of outcome.
: These results show that good bRFS can be obtained with
LDR brachytherapy alone. There was no additional benefit of adjuvant
hormone therapy. These results appear comparable to other
treatment modalities available to these patients. To determine the
optimum therapy comparing LDR, HDR and other hypofractionated
doseescalation regimes for these higher risk patients, randomised
trials are required
PO174
HDR BRACHYTHERAPY BOOST FOR LOCALISED PROSTATE CANCER: THE
FIRST 150 PATIENTS FROM THE SYDNEY CANCER CENTRE.
D. Whalley 1 , N. Patanjali 1 , M. Jackson 1 , G. Perez 1 , M. Whittaker 1 , M.
Chatfield 2 , G. Hruby 1
1
Royal Prince Alfred Hospital, Radiation Oncology, Sydney NSW,
Australia
2
University of Sydney, NHMRC Clinical Trials Centre, Sydney NSW,
Australia
: To report the toxicity and early efficacy of high
dose rate brachytherapy (HDR) as a boost to external beam radiation
(EBRT) in the treatment of localised prostate cancer.
: Between December 2002 and July 2010, 150
consecutive patients with intermediate or high risk prostate cancer
were treated with EBRT (46Gy in 23 fractions) plus an HDR boost. The
HDR boost was initially delivered over a 24 hour period in three
fractions of 6.5Gy each via a single implant; this was subsequently
modified to a twofraction outpatient scehdule with separate implants
two weeks apart. All but five patients also received androgen
deprivation therapy for between 3 and 24 months.
: Our cohort included 103 intermediate risk and 47 high risk
patients. 83 patients received the three fraction regime and 67 two
fractions. The dose of the twofraction brachytherapy course was
escalated over the time interval such that the initial patients received
17Gy (8.5Gy per fraction), and the last five patients received 19Gy
(9.5Gy per fraction). Median follow up was 52 months, at which time
87% of patients were free from failure. The 4 year disease free
survival (DFS) for intermediate and high risk groups was 95% and 69%
respectively. Two patients developed metastatic disease. Three
patients died during the follow up period, none of prostate cancer.
Significant acute treatment toxicities included clot retention requiring
overnight catheterisation and irrigation (15 patients), two traumatic
urethral injuries, one case of retention requiring suprapubic catheter
placement, and one case of new onset atrial fibrillation. Three cases
of pulmonary emboli were also documented, all of which occurred in
patients receiving the three fraction inpatient regime, despite
prophylaxis with enoxaparin. At 4 years, the rate of late grade 2 or
worse genitourinary (GU) toxicity was 13%; four patients experienced
grade 3 GU toxicity. Five patients had grade 2 late GI toxicity. No late
grade 3 or 4 gastrointestinal (GI) toxicity was observed. Potency was
preserved in 64% of those patients reporting normal pretreatment
sexual function.
: Our series of patients treated with an HDR boost for
localised prostate cancer reveals promising efficacy results at a
median follow up of 4.3 years. The side effect profile, with a
predominance of GU rather than GI toxicity, is similar to other
published reports.
PO175
CATHETER POSITION CONTROL IN HIGH DOSE RATE BRACHYTHERAPY
OF PROSTATE CANCER
P. Marolt 1 , R. Hudej 1 , A. Bernik 2
1
Institute of Oncology, Brachyradiotherapy, Ljubljana, Slovenia
2
University of Ljubljana, Faculty of Health Sciences, Ljubljana,
Slovenia
: The success of fractionated high dose rate
brachytherapy depends on the precise implantation and reproducible
catheter positioning. Catheter displacements are often observed
during fractionated treatments of prostate cancer, usually because of
periprostatic edema, which can be discovered with control imaging.
The purpose of this study was to analyze catheter displacement during
HDR brachytherapy of prostate cancer.
: 25 patients were included in this study. Total
number of cathethers was 377. On average, 15 needles were
implanted per patient (range 11 to 19). All patients were imaged with
MR for planning and with CT for the catheter position check before
the last fraction. Distance from the tip of each catheter to gold

S72 World Congress of Brachytherapy 2012
marker along the catheter line was measured on MR and CT images.
Catheter displacement was calculated as a difference between both
measurements in caudal and cranial directions.
: Absolute median value of catheter displacement was 1,9 mm
(range: 15,1 to +8,7 mm; minus and plus signs indicate caudal and
cranial directions, respectively) with 2,2 mm standard deviation. In
one patient all catheter displacements were larger than the tolerance
of 3 mm. In this case, patient accidentally pulled catheters out of
prostate. In ten patients the displacements of all catheters were
smaller than tolerance.
With our results we can confirm the results of other studies, that the
majority of displacements are in the caudal direction. In our case 64%
of catheters were shifted in caudal and 36% in the cranial direction.
The shifts may be caused by physiological movements (e.g., amount
of water in the bladder), pathology (edema) or artificially induced
(template shifts, patient movements). Calculated values for
displacements presumably include reconstruction errors as well.
Particularly unreliable are catheter reconstructions on MR images in
areas with low cathetertissue contrast, e.g., proximity of bladder
wall. However, in the study this was not separately analyzed.
In 84% of the patients no out of tolerance average catheter shifts
were observed. In 12% of the patients it was necessary to correct a
plan or shift catheters, in 4% of patients complete implant was
removed because shifts were too large to correct and the
implantation was repeated 7 days later.
: Catheter displacement is critical for treatment with high
dose rate brachytherapy of prostate and should not be ignored.
Without correction and replanning we risk under dosage of tumor and
over dosage of organs at risk. This study showed that 3D imaging is an
important factor in planning and correcting the position of
brachytherapy catheters. Together with proper fixation, large
catheter displacements can be avoided.
PO176
EFFICACY, TOXICITY AND DOSIMETRIC ASPECTS OF HDR
BRACHYTHERAPY IN PROSTATE CANCER PATIENTS: 5 YEARS
EXPERIENCE
T.M. Filipowski 1 , A. SzmigielTrzcinska 1 , J. TopczewskaBruns 1 , B.
PancewiczJanczuk 2 , W. Nowik 2
1 Bialostockie Centrum Onkologii, Radiotherapy, Bialystok, Poland
2 Bialostockie Centrum Onkologii, Physics, Bialystok, Poland
: To analyze efficacy, toxicity profile and
dosimetric aspects of radical brachytherapy HDR +/ teleradiotherapy
in prostate cancer patients.
: Between December 2006 and December 2011
190 patients (pts) with prostate cancer (T1 –T2c) underwent
conformal HDR brachytherapy (HDRBRT) with a temporary implant.
The mean age of pts was 68 years, while mean PSA – 11,069 [ng/ml].
Gleason score was observed from 3 to 7 and most of the patients
received androgen deprivation. 60 patients received 30 Gy in 2
fractions of HDR brachytherapy (21 days interval) and were treated to
a dose of 30 Gy in 15 fractions with 3D external beam radiotherapy (3
to 5 fields) on to the prostate region.130 patients were treated with
exclusive HDRBRT 45 Gy in 3 fractions (21 days interval). HDR
brachytherapy was delivered using an Iridum192 source
(MicroSelectron, Nucletron) and treatment planning system: SWIFT
2.11.8 and Oncentra Prostate 3.0.9/4.0 realtime treatment planning
software SWIFT incorporates inverse planning optimization. Dose
volume constraints for this inverse planning system included: prostate
V 100 ≥95 %, maximal urethral dose ≤ 120% and average rectal dose
≤85% of the prescription dose. Patient were monitored weekly during
radiotherapy and 1, 3, 6, 9, 15 months after the end of treatment and
then at three months interval. Followup visit included clinical
examination and PSA value assessment. The acute toxicities were
graded according to the EORTC/RTOG scales.
: Median follow up was 18 (603) months with 95% diseasefree
survival rate. The most common urinary symptoms were: urinary
urgency, urinary frequency, dysuria and nocturia in both treatment
options. The rectal symptoms (rectal urgency, frequency and
tenesmus) were rare. No grade 3 and 4 acute toxicities were
recorded. Two death cases were reported during treatment. Overall
survival and late toxicity data need longer followup.
: HDRBRT is a valid treatment modality for patients with
localized prostate cancer. HDRBRT has an important role in achieving
dose escalation for the radical treatment of prostate cancer patients.
The treatment was well tolerated by majority of patients with
acceptable degree of acute toxicities. However, overall survival and
late toxicity data need longer followup.
PO177
HISTOSCANNING BASED DOSE ESCALATION FOR PROSTATE CANCER AS
MICROBOOST USING BRACHYTHERAPY A PHASE IITRIAL
S. Lettmaier 1 , S. Kreppner 1 , M. Lotter 1 , R. Fietkau 1 , V. Strnad 1
1
University Hospital of Erlangen, Dept. of Radiation Oncology,
Erlangen, Germany
: The aim of this study is to selectively escalate
the dose in tumour areas inside the prostate exploiting the
capabilities offered by imageguided interstitial PDR/HDR
brachytherapy for finetuned dosepainting that allow the creation of
microboost volumes. The definition of tumour areas is based on a
novel ultrasound approach HistoScanning TM . We report our first
experiences regarding feasibility of this new approach.
: Between the end of August 2011 and January
2012 a total of 19 patients with prostate cancer have been treated
according to the study protocol at our institution. Nonmetastatic
patients with prostate cancer of any level of risk according to the D’
Amico definition are eligible for inclusion. Depending on risk group
temporary interstitial brachytherapy is used either as sole treatment
(low risk) or in combination with EBRT (intermediate and high risk).
The brachytherapy dose prescribed at the prostate capsule was 70 Gy
(100x 0,7Gy) or 38 Gy (4x 9,5 Gy) for sole PDR or HDRbrachytherapy,
respectively and 35 Gy (50x 0,7Gy) or 19 Gy (2x 9,5 Gy) if PDR/HDR
brachytherapy was used as boost following EBRT with 50,4 Gy. Dose
escalation within the tumour areas as defined by HistoScanning (HR
CTV ~ high risk CTV) aiming for V120/HRCTV> 90% was always performed
respecting the dose constraints of organs at risk. Side effects will be
assessed using the CTCVers.3, IPSS and IEFF scores as well as the
QOL30 quality of life questionnaire. Tumour control will be
monitored through regular PSA checks using the Phoenix definition to
determine failure and correlated to HistoScanning reevaluations.
Trial registration: This trial is registered at ClinicalTrials.gov:
NCT01409876.
: Analyzing the treatment plans of patients from the first 6
months following the start of patient recruitment we can establish as
fact, that dose escalation meeting the requirement that V120/HRCTV be
greater than 90% is possible. The median prostate volume was 30,8
cm³ (range 16,5 71,2cm³); the median volume of tissue identified as
tumour by HistoScanning (HRCTV) was 2,9cm³ (range 0,73 4,9cm³).
The median values of V100 and D90 for the prostate were 99% (range
90 100%) and 112% (range 100 122%), respectively. For the high risk
areas as defined by HistoScanning (HRCTV) we obtained the following
median values: D90=124%, V120=94% and V130=85%. A D90/HRCTV value
of 124% equates to physical dose values of 43,4 Gy and 11,8 Gy for a
single PDR or HDR brachytherapy session (PDR 35 Gy, HDR 9,5 Gy),
respectively. The corresponding total biological doses expressed as
EQD2 and assuming α/ß=1 for HRCTV therefore range above 100 Gy.
Early followup data up to 3 months fortunately document excellent
tolerability without significant acute side effects – in particular there
were no grade ≥3 toxicities.
: Preliminary data show that using imageguided
interstitial PDR/HDRbrachytherapy a significant dose escalation as
microboost to the tumour regions of the prostate is possible while
meeting stringent dose constraints for the adjacent organs at risk.
There seems to be no excessive acute toxicity. The study will
continue.
PO178
PREDICTION OF ERECTILE DYSFUNCTION FOLLOWING PROSTATE
BRACHYTHERAPY: A DOSE VOLUME ANALYSIS OF PENILE STRUCTURES
C. Beaufort 1 , B. Hindson 1 , E. Paul 2
1
William Buckland Radiotherapy Centre, The Alfred, Melbourne,
Australia
2
Monash University, Department of Epidemiology and Preventative
Medicine, Melbourne, Australia
World Congress of Brachytherapy 2012 S 73
: To identify if the dose to penile structures is a
potential causative factor for severe erectile dysfunction following
low dose rate brachytherapy (LDRB) for prostate cancer in men with
normal pretreatment erectile function.
: The post brachytherapy dosimetry CT
datasets for 69 men with low risk prostate cancer treated between
April 2004 and November 2007 were used. Patients with pre
treatment moderate or poor erectile dysfunction were excluded. The
penile bulb (PB), neurovascular bundle (NVB) and the penile crura
(PC) were retrospectively volumed in a standardised manner and
dosevolumetric parameters were generated.
All patients had low or intermediate risk disease and received LDRB
monotherapy. Four patients received hormone therapy. The dose
prescribed was 145Gy and the dosimetery CT was undertaken at 4
weeks post brachytherapy. All patients were followed prospectively
using the International Index of Erectile Function (IIEF)
questionnaires.
For the analysis the patients were divided into a severe erectile
dysfunction group (IIEF

S74 World Congress of Brachytherapy 2012
keep the maximum value of recommendations, therefore becoming
135%.
SPOTPRO and SeedSelectron from Nucletron were used to plan and
automatically build and deliver the trains of seeds and spacers.
Inverse planning using the implemented IPSA algorithm with minor
manual adjustments were performed.
DVH parameters of 50 patients treated with prostate permanent
brachytherapy with 160 Gy of prescription dose are included. Volume
ranges from 17.261.8 cc (average 31.4 std 9.5). D90 of prostate and
D10 together with Dmax for urethra have been analyzed.
: For the urethra, D10 results in 121.1% (average) with range
99.1%140.4% and std 8.5%. Urethra Dmax is significantly higher, in
average 135.3%, with range and std of 104.5%189.5% and 15.3%,
respectively.
For the prostate, D90 results in significantly higher than 100%, being
in average 115%, with range 101.7%128.9% and std 8.5%.
Despite the implemented dose escalation, the urethra D10 constraint
is maintained according to ESTRO Recommendations, even with a
prostate coverage larger than 100%. The advantage of the
combination of non regular trains with loosed seeds using the
SeedSelectron plus the IPSA inverse planning makes it feasible. It is
pointed out by evaluating the ratio Urethra D10 vs. Prostate D90
resulting in average 1.05 with range and std of 0.881.23 and 0.06
respectively.
: Dose escalation at 160Gy while keeping the ESTRO
recommended values in coverage and urethra constraint is feasible
and efficient on clinical practice.
PO182
INTRAOPERATIVE REALTIME PLANNED PERMANENTSEED PROSTATE
BT: IMPACT OF TRAINING PROGRAM AND LEARNING CURVE
T. Zilli 1 , M. Alizadeh 1 , D. Taussky 1
1 CRCHUM Centre de Recherche du Centre Hospitalier de l’Université
de Montréal Hôpital Notre Dame, Radiation Oncology, Montréal,
Canada
: To assess the influence of two different
fellowship training programs and the effect of learning curve on
dosimetric outcome and genitourinary toxicity in threedimensional
(3D) intraoperative (IO), permanentseed prostate brachytherapy
(PB).
: Between 2005 and 2011, 115 patients with
localized prostate cancer were implanted by two investigators (I1 and
I2) using TRUSguided, 3D IOinteractive planning with virtual needle
guidance, robotic seed delivery, and needle retraction system. Eighty
two percent of the patients (n=94) had a lowrisk and 18% (n=21)
intermediaterisk prostate cancer. Median age at implant was 66 years
(range 5178). PSA was

S76 World Congress of Brachytherapy 2012
kinetics, biochemical failurefree survival, life quality and
intraoperative and postimplant dosimetry results.
: From 2009 to 2011, we treated 56 patients
diagnosed of lowrisk prostate adenocarcinoma with LDRBT as
monotherapy, using permanent seeds under spinal anesthesia, using
First System (Nucletron seedSelectron), with perineal insertion
guided by transrectal ultrasound and real time planning. The
prescribed dose for PTV (prostate + 5 mm margin) is 145 Gy.
Ultrasound verification. Postimplant control by CT at 24 hours and
dosimetry at 30 days. Patients are discharged the next day after the
implant. Followup through quarterly PSA levels and life quality
control (QLQ PR25) pre and postimplant.
:With a mean followup of 20 months, the biochemical failure
free survival rate is 98.2%/year, (biochemical relapse occurred in one
patient, M1 bone) with an average number of seeds per implant: 67.51
(5492); mean activity of 0,5317 cGy/cm2/h (0,46730,6110); D 90:
118.23% (94,68 % 128,67 %), V100: 97.5% (87,42 % 122,55 %), V150:
69.4% (49,64% 82,67 %); Uretra_V150: 0; Rectum D2cc: 63.31% (44,47
% 127,76 %). Acute toxicity (

S78 World Congress of Brachytherapy 2012
toxicities at 1 and 6 months after the boost regarding the
fractionation scheme applied is presented in the Table 1.
Table 1: Analysis of GU and GI complications observed at 1 and 6
months after HDRB boost regarding the complication grade (CTCv3.0)
and the different fractionation schemes.
Complications GU GI
Grades
1 mth 6 mths 1 mth 6 mths
0 59% 65% 83% 76%
1 34% 35% 17% 23%
2 6% 0% 0% 1%
3 0% 0% 0% 0%
4 1% 0% 0% 0%
Fract. schemes
G1 (18 Gy/3f) 24%* 65% 6% 50%
G2 (18 Gy/2f) 56% 35% 53% 50%
G3 (14 Gy/1f) 20% 41%
p value 0.53 0.86 0.21 0.34
* Percentages of complication among patients who developed GU
and/or GI complications.
GU: genitourinary complications; GI: gastrointestinal complications;
Fract. Schemes: fractionation schemes.
: From 02/2009 to 09/2011, while a significant physical
dose escalation was performed (33% and 10% between G1 vs G3 and
G2 vs G3 respectively), no significant increasing of the GU and GI
acute toxicities was observed.
PO193
HIGH DOSE RATE BRACHYTHERAPY AS MONOTHERAPY FOR EARLY
STAGE PROSTATE CANCER: TOXICITY AND EARLY RESULTS
S. Aluwini 1 , P. van Rooij 1 , J. Praag 1 , P. Jansen 1 , C. Jauns 1 , W. Kirkels 2 ,
I. KolkmanDeurloo 1
1
Erasmus Medical Center Rotterdam, Radiation Oncology, Rotterdam,
The Netherlands
2
Erasmus Medical Center Rotterdam, Urology, Rotterdam, The
Netherlands
: The use of HDR Brach therapy (HDRBT) as
monotherapy for early stage prostate cancer (PC) patients is
increasing worldwide. We report our results on toxicity and clinical
outcome after this regimen.
: Between 2007 and 2011, 93 consecutive
patients were treated with HDRBT for earlystage PC. Total dose was
38 Gy in 4 fractions within 36 hours. Toxicity and Quality of life (QoL)
was assessed prospectively using validated questionnaires.
Biochemical Failure (BF) was determined according to the Phoenix
definition.
: Median FU was 25 months. Median pretreatment prostate
volume was 32 cc. Median number of needles was 17. No Surgical
complications were reported. The constraints regarding bladder,
rectum, and urethra were well met.
Biochemical failure occurred in 2 patients. The 3year actuarial
biochemical control rate was 98%. Mean nadir PSA was 0.4 ng/ml.
Median International prostate symptoms score (IPSS) was 6 before
treatment and showed a median increase of 5 after 3 months, and
remained stable afterward. The EORTC/RTOG toxicity scales showed
grade ≥ 2 rectal toxicity, in 7%3%2%2% after 3122436 months,
respectively. Grade 3 rectal toxicity was reported in 3% at 3 months.
There was no instance of late grade 3 rectal toxicity. Genitourinary
(GU) grade ≥2 toxicity was seen in 7% 23%19%17% after 3122436
months, respectively. A grade 3 GU toxicity was seen in 6%3%2%,2%
after 3122436 months, respectively. Seven patients needed a
temporary catheter shortly after the treatment. The 3 assessed
domains (urinary, bowel and sexual) of the PR25 questionnaire did
recover with the time.
: HDRBT as monotherapy for favourablerisk prostate
cancer was well tolerated with acceptable acute and late toxicity and
excellent biochemical control after 3 years. Longer FU is still required
to evaluate the efficacy
PO194
ULTRASOUNDCT FUSION COMPARED TO MRCT FUSION FOR POST
IMPLANT DOSIMETRY IN PERMANENT PROSTATE BRACHYTHERAPY
J.M. Crook 1 , C. Araujo 2 , M. Gaztanaga 1 , D. Batchelar 2 , D.M. Bowes 3
1
British Columbia Cancer Agency Center for the Southern Interior,
Radiation Oncology, Kelowna B.C., Canada
2
British Columbia Cancer Agency Center for the Southern Interior,
Radiation Physics, Kelowna B.C., Canada
3
Nova Scotia Cancer Center, Radiation Medicine, Halifax, Canada
: Postplan evaluation is essential for quality
assurance in prostate brachytherapy (BT). MRI has demonstrated
greater interobserver consistency in prostate contouring compared
with CT. Although a valuable tool in postimplant assessment, MRI is
costly and not always available. Our purpose is to compare dosimetry
obtained using fusion of postimplant CT to preimplant transrectal
ultrasound (TRUS) vs. CTMR fusion.
: 20 patients receiving permanent I125 seed
prostate BT underwent preimplant TRUS with urethrography, one
month CT with a Foley catheter, and one month MRI. No patient
received androgen deprivation or external beam radiotherapy. The
prescription dose of I125 implant monotherapy was 144 Gy. The pre
implant TRUS and postimplant CT images were fused based on
urethral position, and the CTTRUS images were subsequently fused to
the MRI using a seedtoseed match. Dosimetric parameters for the
USderived and MRderived prostate contours were compared.
: There were no significant differences in D90, V100, V150,
and V200 when comparing dosimetry obtained using MRI and CTTRUS
fusion. The mean absolute difference between dosimetry from MR
imaging or CTTRUS fusion for D90 was 3.2% and in V100 was 1.2%.
Only 1 patient had a difference in MR and USderived D90 of > 10%
(11.4%) and only one had a difference in V100 of > 5%. There were no
implants in this group in which the D90 was less than 110% of the
prescription dose. Although volume differences appeared more
substantial (11/20 > 10%), the actual magnitude of the difference was
small with a mean absolute difference as calculated between MR and
US of only 3.0 cc (maximum 7.5 cc).
Median value (IQ range) CTTRUS fusion CTMR fusion
Volume 32.8 cc (25.8, 42.6) 31.1 cc (25.8, 37.6)
D90 120.0% (117.4, 132.2) 122.8% (115.0, 132.4)
V100 97.8% (95.4 ,98.9) 97.8% (94.9, 98.8)
V150 71.5% (64.7, 75.6) 72.6% (62.7, 77.5)
V200 37.2% (28.9, 41.2) 36.0 (26.6, 42.4)
: Fusion of preimplant TRUS with 1month postimplant
CT appears to lead to acceptable agreement with MRbased
dosimetric parameters in postplan evaluation. TRUS based contours
may be a reasonable option when MR is not available.
PO195
BIOCHEMICAL RESULTS FOR HIGH RISK PROSTATE CANCER AFTER HIGH
DOSERATE BRACHYTHERAPY WITH EXTERNAL RADIOTHERAPY
E. Arrojo Alvarez 1 , P.J. Prada 1 , L. Méndez 1 , J. Fernández 2 , H.
González 1 , I. Jiménez 1
1
Hospital Universitario Central de Asturias, Radiation Oncology,
Oviedo, Spain
2
Hospital Universitario Central de Asturias, Radiation Physics, Oviedo,
Spain
: We analyzed the longterm oncologic outcome for
patients with high risk prostate cancer who were treated using high
doserate conformal brachytherapy combined with external
irradiation.
: From June 1998 to August 2006, 252 patients
with localized high risk prostate cancer were treated. The median
World Congress of Brachytherapy 2012 S 79
followup was 74 months. Freedom from biochemical failure rates
were calculated using the Phoenix definition. Toxicity was reported
according to the Common Toxicity Criteria for Adverse Event, Version
4.0.
: The biochemical control was 84% and 78% (SD ±2%) at 5 and
10 years respectively. The 10year actuarial biochemical control was
89% for patients with two intermediate risk criteria, 80% with one high
risk criteria and 72% for patients with 23 high risk criteria (P = 0. 04).
The 10 year cause specific survival was 93% (SD ±2%) and the overall
survival was 88% and 78% (SD ±4%) at 5 and 10 years respectively. The
multivariate Cox regression analyses identified, Gleason score as
independent prognostic factors for biochemical failure and distant
metastases.
: External beam radiation therapy with conformal high
dose rate brachytherapy boost for patients with high risk localized
prostate cancer represents a considerable improvement over standard
surgical and radiotherapy modalities.
PO196
NATURAL DOSE VOLUME HISTOGRAM: RELATION WITH VOLUME OF
TARGET AND SEEDS PER NEEDLE IN PERMANENT PROSTATE IMPLANTS
R. Martinez Cobo 1 , E. Rivin del Campo 2 , J.M. Roldán Arjona 1 , A.
Palacios Eito 2
1
Reina Sofía University Hospital, Department of Physics and
Radiologic Protection, Cordoba, Spain
2
Reina Sofía University Hospital, Department of Radiation Oncology,
Cordoba, Spain
: The Natural Dose Volume Histogram (NVDH)
allows the evaluation of the implant quality (homogeneity of dose
distribution and underdosage or overdosage of treated volume).
This is a retrospective and descriptive analysis of results found when
comparing different indexes obtained from NDVH (Uniformity Index
(UI), Quality Index (QI) and Natural Dose Ratio (NDR)) with the volume
of the target and the number of seeds per needle. The objective of
this study is to find differences in these indexes in relation to the
volume of the target and the number of seeds per needle used in the
implant.
: The reviewed data belongs to treatments
performed between 20072012. The prescribed dose to the volume of
the target was 145 Gy and the V150 to urethra was restricted to 0.00
cm 3 . The manufacturer of the radioactive sources (I125) provides 14
possible source activities, of which only four types have been used.
The equipment used in the implants is known as FIRST (Nucletron).
This system has a planning program (SPOT PRO v3.0) with which the
parameters of NDVH and volumes of the target have been calculated.
To study the relationship between the indexes obtained from the
NDVH with both the volume of the target and the number of seeds per
needle, implants were divided into three groups according to the
values of these two parameters. The chosen cutoff values allowed a
similar distribution of individuals in each group. For the volume of the
target, the first group included target volumes under 21 cm 3 , the
second group between 21 and 28 cm 3 and the third group above 28
cm 3 . Regarding the number of seeds per needle, the first group
contains individuals with a less than 2.75, the second group between
2.75 and 3.1 and the third group above 3.1.
: The results for the mean value of each parameter of NDVH
depending on the volume of the target are shown in Table 1. The
results for the mean value of each parameter of NDVH in relation to
the number of seeds per needle are represented in Table 2.
: These results indicate that there is a statistically
significant difference in NDVH depending on the volume of the target,
finding the best results in both homogeneity of spatial dose
distribution and in coverage of the volume of the target in larger
volumes of the target. These differences could be considered
selection criteria to determine the best candidates for a permanent
prostate implant. In the case of the number of seeds per needle, the
value of the NDR in NDVH is significantly different depending on the
group considered, obtaining better values when the number of seeds
per needle increases. A trend towards a better implant quality was
found, based on the QI and UI results, when the number of seeds per
needle is higher.
PO197
HIGH DEFINITION CUSTOMISED BRACHYTHERAPY FOR PROSTATE
CANCER BASED ON TRANSPERINEAL SECTOR MAPPING BIOPSIES
S.L. Morris 1 , M. McGovern 2 , R. Tsung 3 , S.L. Aldridge 2 , B. Challacombe 3 ,
R.B. Beaney 1 , R.B. Popert 3
1 Guys Hospital London UK, Clinical Oncology, London, United Kingdom
2 Guys Hospital London UK, Physics, London, United Kingdom
3 Guys Hospital London UK, Urology, London, United Kingdom
: Customised dose prescription for prostate LDR
brachytherapy is possible and it has been shown that higher doses
improve biochemical control. Transperineal sector mapping biopsies
(TPSMB) can identify areas of dominant intraprostatic involvement.
This planning study investigates the feasibility of dose escalation
during brachytherapy planning to the dominant involved sectors
: This study was carried out on the
brachytherapy plans of 10 patients treated with our real time dynamic
dose feedback (4D) technique. All patients with low risk prostate
cancer underwent a pre implant MRI scan and Transperineal sector
mapping biopsy (TPSMB) to assess their suitability for either Active
Surveillance or Brachytherapy and to exclude any adverse features not
identified on the Transrectal biopsy. The TPSMB provides information
on the apico to basal and medial to lateral distribution of tumour
within the prostate based upon 8 sectors. The dynamic plans were
created using the Variseed 8 software. A protocol for outlining the
sectors biopsied; right and left apex, right and left mid gland in
anterior and posterior sectors and right and left base was developed
to match the sector mapping technique. Depending upon the
histological involvement dominant sectors were boosted to > 200Gy,
whilst maintaining the conventional prostate brachytherapy dose
constraints.
: The planning study showed that dominant sectors can be
boosted to > 200Gy while keeping within the standard constraints. The
example below is of a patient where the right posterior sector showed
the highest number of cores and % of core involvement on biopsy. The
customised plan allowed boosting of this sector to a D90 of 248.8Gy,
while the whole Prostate D90 was 180.9Gy, V200 of 32.9%, Rectal
V100 of 0.8cc, D2cc of 122.8Gy, D0.1cc of 184Gy and Urethral V140 of
0.01%, D30% of 127.8Gy, D10% of 130.9Gy.

S80 World Congress of Brachytherapy 2012
Fig 1 Dose distribution of sector boost mid prostate:
: Customised dose escalation to dominant sector
involvement in the prostate with brachytherapy is possible and needs
to be tested in the clinical setting.
PO198
COMPARISON OF TREATMENT PLAN PARAMETERS IN BRACHYTHERAPY
OF PROSTATE CANCER IN DIFFERENT SCHEDULES
M. Kanikowski 1 , J. Skowronek 1 , A. Chichel 1
1 Greater Poland Cancer Centre, Brachytherapy, Poznan, Poland
: Radiotherapy (EBRT and HDRBT) in prostate
cancer treatment seems to be nowdays as effective as surgery
procedure. High dose rate brachytherapy (HDRBT) can be applied as a
single modality treatment in patients from low and intermediate risk
group with localized tumors. High dose rate brachytherapy (HDRBT) is
very usefull in high risk group patients, in increasing prostate dose
after EBRT (boost) which shortens whole radiation treatment. There is
no clear recommendations about doses and schemes of combined
radiation treatment (EBRTBT). The aim of this work was to make
comparison of dosevolume parameters beetween (HDRBT) fractions,
in patients prostate cancer treated in two combined with external
beam radiotherapy schedules and one monotherapy.
: 103 patients were enrolled to the study and
divided to groups according to radiation schemes (I – EBRT 50 Gy/BRT
1 x 15 Gy, II – EBRT 46 Gy/BRT 2 x 10 Gy, III – BRT 3 x 15 Gy) Group I,
II, III consisted of 37 (35,92%), 36 (34,95%), 30 (29,13%) patients
respectively. The mean value of D90 (reference dose given to 90% of
volume) was 90,86%, 88,23% and 92,03% respectively to each group.
Hot spots parameters in target volume (V200, V150, V120, Dmax) were
found respectively: I – 15,22%, 41,48%, 69,47%, 1192,46%, II – 16,31%,
40,09%, 66,61%, 1906,19%, III 14,97%, 39,3%, 67,53%, 1182,16%. Mean
urethral D10 (dose given to 10% of urethral volume) was estabilished
on respectively: 122,32%, 123,48% and 120,37%. Mean values of high
doses parameters for urethra (Dmax, V100, Dmean) were as follows
respectively for I group: 143,18%, 53,76%, 90,23%, for II: 144,7%,
53,76%, 97,34% and for III: 140,79%, 46,57%, 86,79%. Mean rectal D10
dose was estimated as 62,19% (I), 63,8 (II), 65,21% (III). According to
parameters Dmax (90,76% I, 90,85% II, 84,68% III), V100 (0,43% I,
0,23% II, 0,18% III), Dmean (46,06% I, 46,27% II and 49,35% III)
were found as a hot spots in rectum volume. Comparison of dose
volume parameters was done by KruskalWallis and MannWhitney
tests.
: After statistical comparison we observed higher values of
high target doses (V200, Dmax) in the second group of patients.
Parameter V120 was the only one with statistical significance in
KruskalWallis test (p=00264). According to these changes, parameters
of target doses like D90 (87,76%) and V100 (82,5%) were lower in II
than the other groups (without statistical significance). The urethral
high dosevolume parameters were much higher in 46/ 2 x 10 Gy
group D10 (123,48%), Dmean (97,69%), V100 (54,2%), also without
statistical significance. In the second group parameter Dmax (90,95%)
for another organs at risk (rectum) was the highest and with smallest
value of SD parameter (10,83%) can increase risk of serious
complications in this localization.
: 1. HDR brachytherapy parameters in prostate cancer
treatment are not statistically different in most treatment schedules.
2. HDR brachytherapy schedule with two lower doses fractions was
less correct in terms of treatment planning system constraints. 3. To
confirm differences between each treatment schedule a comperative
investigation in larger groups is needed. 4. To confirm value of
treatment parameters comparison observation of results and
complications is also needed.
PO199
PROSTATE VOLUMEBASED NOMOGRAMS FOR PROSTATE SEED
IMPLANTS: CUSTOMIZING FOR A RANGE OF SEED ACTIVITIES
S.J. Gardner 1 , K.L. Chapman 1 , A.P. Dicker 1 , T.N. Showalter 1 , L.A.
Doyle 1
1
Jefferson Medical College of Thomas Jefferson University, Radiation
Oncology, Philadelphia, USA
: The use of a nomogram to predict the number of
seeds needed for an intraoperative prostate seed implant is common
in radiation oncology. One such nomogram for I125 implants,
developed by Wu et al., relates prostate volume to I125 activity
without specifying the activity per seed. In this study, we evaluate
treatment plans for 22 consecutive patients, with one plan for each of
4 seed activities (0.3, 0.4, 0.5, and 0.6 mCi; 88 total plans), to
determine appropriate nomograms across a range of seed activities.
: Treatment plans were generated for 22
patients using intraoperative ultrasound images. Treatment plans
were generated using Variseed 8.0.1 software and Bard STM 1251 I
125 seeds, using four activities (0.3 mCi, 0.4 mCi, 0.5 mCi, and 0.6
mCi) with a modified peripheral loading technique. The seed
activities were chosen based on the normal range of seed activity for
permanent prostate seed implants (0.30.8 mCi), as specified by AAPM
Task Group 64. The dose calculation was performed according to 1D
TG43 formalism. The nominal treatment prescription dose was 145
Gy to greater than 98% of the prostate. Additional planning
constraints included D_PTV(90%)>170 Gy, D_PTV(150%)

S82 World Congress of Brachytherapy 2012
: Permanent 125 I seed BT is a successful and established
treatment of earlystage prostate cancer. Although this sample
represents the learning curve of our institution the outcomes are
similar to the literature.
PO202
LONG TERM RESULTS WITH MULTIMODALITY RADIOTHERAPY (3D, IGRT,
LDRBT, HDRBT) IN PROSTATE ADENOCARCINOMA
S. Rodríguez Villalba 1 , M. Santos Ortega 1 , M. Deppiagio 1 , J. Pérez
Calatayud 1 , J. Richart 1 , F. Ballester 2
1
Clinica Benidorm, Radiation Oncology, Benidorm, Spain
2
Valencia University, Atomic Molecular and Nuclear Physicist,
Valencia, Spain
: A retrospective analysis is made evaluating the
toxicity and efficacy of different multimodality radiotherapy
approaches for organ confined prostate cancer in our Institution with
a minimum followup of 12 months.
: From September 2004 to December 2010 we
have treated in our Department with a radical treatment 262
patients. Our protocol has been based with uniformity on the risk
classification of prostate adenocarcinoma. It includes external
radiotherapy (extRT)(3D or IGRT) or LDRBT in low risk patients, IGRT
or combined treatment (3D over prostate and seminal vesicles+
LDRBT) in intermediate risk patients and IGRT or combined treatment
(IMRT over pelvis and HDRBT) in high risk patients. 48 p (18.3%) have
been treated with extRT3D, 58p(22%) with IGRT, 68p (26%) with
LDRBT, 59 p (22.5%) with combined 3D + LDRBT and 29p (11.1%) with
combined IMRT and HDRBT. Median age 71 years (4687 y). Median PSA
at diagnostic 9.74 ng/ml (2.5 500 ng/ml). Median Gleason 6 (29). 75
p (29%) were included in low risk (LR), 97 (37%) intermediate risk (IR)
and 90 (34%) in high risk (HR).
: The local control have been reach in 254 p (97%). All patients
treated with IGRT, 3D+ LDRBT and IMRT + HDRBT are under local
control. Two patients treated with 3D and 6 p (9%) treated with
LDRBT exclusively have local failure. The local failure have been
produced in 1 patient treated with 7200 cGy and 1p treated with 7560
cGy.
Biochemical failure have been reached in 8p (3%). 2p (0.8%) of LR, 4
(1.5%) IR and 2p (0.8%) of HR
We have evidenced lymph node failure in 6p (2%). One p (0.4%) of IR
and 5p (1.9%) of HR. 3p treated with extRT3D (1%), 2p IGRT (0.8%) and
1 p with 3D+ LDRBT (0.4%).
Distance failure in 13p (5%).5p (1.9%) of IR and 8 p (3.1%) of HR. 6 p
treated with extRT3D (3.3%), 4 with IGRT (1.6%), 1 with LDRBT (0.4%)
and 2 with 3D+ LDRBT (0.8%).
The toxicity evaluated is:
GENITOURINARY (GU) TOXICITY # TREATMENT
GRADE 3
Hematuria 4 p 3 p IGRT and 1p with 3D+
(1.5%) LDRBT
Cystitis 1p IGRT
(0.4%)
Urinary obstruction 3p 1p IGRT and 2p LDRBT
(1.1%)
Urethral stenosis 4p
(1.5%)
Increased of the urinary frequency 2p
(0.8%)
Urinary retention 2p
(0.8%)
GASTROINTESTINAL (GI) TOXICITY
GRADE 3
Diarrhea 1p
(0.4%)
Rectitis 23p
(8.8%)
2p IGRT and 2p 3D +
LDRBT
1p IGRT and 1p 3D +
LDRBT
IMRT and HDRBT
IGRT
IGRT
Median time for GU toxicity 3 months (148 months).
Median time for GI toxicity 10.5 months (040 months).
Only one patient treated with 3D+ LDRBT had rectitis grade 3. This
patient was treated previously of an embolism of an iliac aneurism
several years ago with changes in the vascular drainage).
At the end of the followup, December of 2010, 216 p (82%) are alive
without any evidence of disease, 4 p (1.5%) are alive with Biochemical
failure, 18 (7%) have died of an intercurrent disease, 4 (1.5%) have
loose of control, 13 p (5%) live with active prostate disease and 7 (3%)
have died of prostate tumor. The median followup is 35.5 months (5
88 months)
: Despite the good outcomes obtained with the different
radiotherapy approaches our results shows a better disease control
with more intensive radiotherapy doses. In our experience,
combination modalities with BT techniques achieve more intensity
treatments with lesser toxic events, mainly related to gastrointestinal
damage.
PO203
RECTUM PRESERVATION BY BOLUS HYALURONAN INJECTION INTO
PERI/PARA RECTAL SPACE DURING HDRBT OF PROSTATE CANCER
K. Kishi 1 , M. Sato 1 , Y. Noda 1 , T. Sonomura 1 , S. Shirai 1 , R. Yamada 2
1
Wakayama Medical University, Radiation Oncology, Wakayama City,
Japan
2
Kishiwada Tokushukai Hospital, Urology, Kishiwada City, Japan
: To evaluate feasibility and effectiveness of
nativetype hyaluronate gel injection (HGI) to reduce the rectal dose
during high dose rate interstitial brachytherapy (HDRBT) of prostate
cancer, by comparing HGI and control groups.
: From Jun 2006 to September 2008, 40
patients with T2aT3a prostate cancer were treated with a combined
schedule of 50Gy of external beam radiotherapy (EBRT) followed by
HDRBT. 17 patients underwent bolus HGI into anterior part of
perirectal space. The other 23 including 17 with matched prostate
size were randomly sampled for control from database in the same
period.
: The HGI procedure was easily performed and took approx.
ten minutes. There were no procedurerelated complications. By HGI,
the rectum was shrunken and shifted posteriorly. The minimum
rectoprostate distance was increased from 0.3±0.4 to 2.6±0.7cm
(mean ±sd) after gel injection, and shrunk the rectum volume behind
the prostate level decreases to 21.7±7.6% of the original size, and
further gas inflation of the rectum was blocked. 12.46Gy±2.14 bid was
prescribed in control group and 14.52Gy±2.0 in single fraction in HGI
group (p

S84 World Congress of Brachytherapy 2012
hypofractionated radiotherapy or highdoserate brachytherapy (HDR
BT) regimens using appropriate radiation doses are expected to
improve the local control rate for localized prostate cancer. However,
the increase in the total biological effective dose (BED) may cause an
increase in the severity and incidence of normal tissue complications.
The purpose of this study was to investigate if the clinical and
dosimetric factors affected the incidence of rectal bleeding after
HDRBT combined with external beam radiotherapy (EBRT).
: The records of 150 patients with localized
prostate cancer treated by HDRBT combined with EBRT at Kochi
Medical School Hospital between November 2004 and December 2008
were analyzed. The fractionation schema for HDRBT and EBRT was
prospectively changed. The distribution of the fractionation schema
used in the patients was as follows: 9 Gy x 2 + 2 Gy x 20 (BED1.5 = 219
Gy, BED3 = 139 Gy) in 59 patients (Group 1); and 9 Gy x 2 + 3 Gy x 13
(BED1.5 = 243 Gy, BED3 = 150 Gy) in 91 patients (Group 2). The median
followup duration was 49months (range 24 – 61 months). The
toxicities were graded based on the National Cancer Institute
Common Terminology Criteria for Adverse Events v3.0. The clinical
and dosimetric factors affecting the incidence of Grade 2 or worse
late rectal bleeding were analyzed by statistical analyses.
: Fifteen (10.0 %) and 2 (1.3 %) patients developed Grade 2 and
3 rectal bleeding, respectively. Seven out of 59 (11.9 %) patients
belonged to Group 1 and 10 out of 91 (11.0 %) patients belonged to
Group 2 developed Grade 2 or worse rectal bleeding. There was no
statisticallysignificant correlation between the incidence of Grade 2
rectal bleeding and dose escalation. Regarding the correlation with
dosimetric factors, no significant differences were found in the means
of V10, V30, V50, V70, V75, V90, D0.1cc, D0.2cc, D0.5cc, D1cc, D2cc,
D5cc, and D10cc between those with bleeding and those without in
each Group. Grade 2 or worse rectal bleeding occurred in 6 out of 31
(19.4 %) patients receiving the antiplatelet therapy, while it occurred
in 11 out of 119 (9.2%) patients without a history of antiplatelet
therapy, and Grade 2 or worse rectal bleeding occurred much more in
the patients receiving the antiplatelet therapy than those without a
history of antiplatelet therapy, however it was no statistically
significant difference between two groups.
: Dose escalation could be performed without severe
rectal bleeding in HDRBT combined with EBRT. HDRBT combined
with EBRT is possible to perform to even the patient receiving the
antiplatelet therapy. However, further investigation will be needed.
PO208
QUALITY OF HDR BRACHYTHERAPY OF FAVORABLE LOCALIZED
PROSTATE CANCER AND NUMBER OF IMPLANTED NEEDLES
E. Slobina 1 , D. Kozlovsky 1 , A. Soroka 1 , Y. Ezhgurova 2
1
N.N. Alexandrov National Cancer Center of Belarus, Radiotherapy,
Minsk, Belarus
2
Minsk Regional Oncology Dispensar, Radiotherapy, Minsk, Belarus
: To assess the dependence of quality of 192 Iridium
HDR interstitial imageguided brachytherapy of localized prostate
cancer with favorable prognostic factors from number of implanted
needles.
: Between February 2007 and December 2011 a
total of 60 previously healthy patients, Table 1, with favorable
prognostic factors (Gleason score ≤ 7, PSA ≤ 10 ng/ml) and biopsy
proven adenocarcinoma. HDR brachytherapy was performed by
conformal imageguided transperineal HDR brachytherapy with real
time planning.
Mean age (years) 69
Age range (years) 4581
Stage T2N0M0 60
Histology
Adenocarcinoma 60
Gleason score 3 20
4 5
5 31
6 4
Median pretreatment PSA 8.2 ng/ml
Table 1. Study population.
The total dose was 34.5 Gy/3 fractions (3 consecutive fractions with 2
week gap between of each were performed), the dose per fraction
was 11.5 Gy. The median followup was 16 months (range 3 44
months). 12 patients received temporary androgen deprivation
starting 29 month before brachytherapy.
Cumulative dosevolume histograms of 180 plans were evaluated. The
plans were divided into 3 groups in dependence of number of
implanted active needles: < 16 (1 st group); 16–18 needles (2 nd group);
> 18 (3 rd group). Dose volume parameters for target and quality
indices were calculated. Maximal dose in reference points for urethra
and rectum were determined.
: There was no evidence of distant metastases, biochemical or
clinical failure. All 60 patients experienced some degree of acute
urinary toxicity, Table 2. However, chronic reactions are absent. The
median first posttreatment PSA was 0.89 ng/ml (range 2.860.04
ng/ml).
Acute toxicity Number of
patients
RTOG grade I 35
RTOG grade II 25
RTOG grade III 0
RTOG grade IV 0
Table 2. Acute urinary toxicity results.
Mean of maximal dose in reference points for urethra was 117.78% –
1 st group, 115.4% – 2 nd , 116.19% – 3 rd group. Mean of maximal dose in
reference points for rectum was 82.44% – 1 st group, 82.2% – 2 nd , 84.48%
– 3 rd group. The difference between groups were observed in following
parameters: more needles was implanted in inverse dependence from
volume of prostate (Vpr) for three groups (mean Vpr: 81,46 cm 3 , 60,73
cm 3 , 51,9 cm 3 , respectively). There were no significant difference in
other parameters.The number of 16–18 implanted needles in most
cases provide optimal dosimetric acceptable volumetric dose
distribution in HDR brachytherapy plan.
: The treatment by interstitial HDR brachytherapy of
patients with favorable prognostic prostate cancer factors results in
low toxicity and in excellent functional results. Number of implanted
needles depends not only of prostate volume, but and individual
anatomy of patients. By our results the number of 16–18 implanted
needles usually provide optimal dosimetric acceptable volumetric
dose distribution in HDR brachytherapy plan.
PO209
RESCUE TREATMENT IN PROSTATE CANCER FOR LOCAL RELAPSE AFTER
RADIOTHERAPY WITH HIGHDOSE RATE BRACHYTHERAPY
K. Quispe Santibáñez 1 , E. Martínez Pérez 1 , J. Pera Fàbregas 1 , C.
Gutiérrez Miguélez 1 , F. Pino Sorroche 2 , M. Ventura Bujalance 1 , J.F.
Suárez Novo 3 , A.M. Boladeras Inglada 1 , F. Ferrer González 1 , F. Guedea
Edo 1
1
Institut Català d'Oncologia, Radiation Oncology, L'Hospitalet de
Llobregat, Spain
2
Institut Català d'Oncologia, Medical Physics, L'Hospitalet de
Llobregat, Spain
3
H. Bellvitge, Urology, L'Hospitalet de Llobregat, Spain
: To evaluate our institutional results in terms of
biochemical progression free survival (BPFS), diseasefree survival
(DFS) and toxicity of rescue treatment in prostate cancer for local
relapse (RESCPROST) with HighDose Rate brachytherapy (HDRBT).
: Between November 2004 and June 2011, 36
patients with local failure were included in RESCPROST protocol at our
institution. The mean interval between primary and salvage treatment
was 70 months (range 27131). All patients underwent biopsy to
confirm local relapse. Patients were evaluated to rule out metastatic
or regional disease. The mean PSA before salvage treatment was 5.03
ng/ml (CI 95%, 4.06.0). Upon local relapse, 10 patients had
unfavorable Gleason grade 89 and 2 had advanced stage (T3). A total
of 35 patients were treated with HDRBT (1 patient was excluded due
to technical problems). The primary treatment was external beam
radiotherapy in 27 cases and low dose rate brachytherapy (LDRBT) in
7. The prescribed dose was 38 Gy in 4 fractions of 9.5Gy, delivered in
World Congress of Brachytherapy 2012 S 85
two separate implants performed 2 weeks apart. Adjuvant hormonal
therapy was used in 5 patients (14.3%). Patients were followedup
every six months by physical exam and PSA. If Biochemical
progression, complementary exams to rule out distant disease were
performed.
: The survival and the risk of local relapse were calculated
using the KaplanMeier method and toxicity was graded using CTCAE
v3.0. Median followup after RESCPROST was 21 months (range, 673).
After 21 months there are 12 patiens at risk of failure. Overall and
specific survival: 2 patients died of prostate cancer at 20 and 36
moths. There were 2 cases of local relapse at 22 and 32 months. The
risk of regional relapses was 22 % at 2 years. Three patients developed
distant bone metastasis at 10, 14 and 43 months, respectively. Three
patients underwent genitourinary (GU) grade 3 toxicity and 1 patient
presented grade 4 toxicity: all of these patients had received
permanentseed brachytherapy previously. No cases of
gastrointestinal (GI) toxicity grade 3 or 4 were observed. The patients
that relapsed were treated with androgen deprivation therapy. Two
patients received chemotherapy and 2 palliative radiotherapy.
: HDRBT yields a good local control for local prostate
cancer recurrence after radiotherapy. Most of the relapses ocurr in
bone or in lymph nodes. The greatest GU toxicity was observed in
patients treated initially with LDRBT.
PO210
URINARY ENGRAILED2: A NOVEL BIOMARKER FOR FOLLOW UP POST
RADICAL TREATMENT FOR PROSTATE CANCER
S. Javed 1 , E. Chadwick 2 , A. Michael 3 , R. Morgan 3 , H. Pandha 3 , R.W.
Laing 2 , S.E.M. Langley 1
1
The Royal Surrey County Hospital NHS Foundation Trust, Urology,
Guildford, United Kingdom
2
The Royal Surrey County Hospital NHS Foundation Trust, Oncology,
Guildford, United Kingdom
3
Post graduate medical school University of Surrey Guildford. U.K.,
Oncology, Guildford, United Kingdom
: Engrailed2 (EN2) is a homeodomaincontaining
transcription factor that is expressed in embryonic development. It is
subsequently reexpressed and secreted by prostate cancer cells but
not by normal prostate cells. These secretions may be detected in a
patient's urine without the need for prior digital rectal examination
(DRE). The presence of EN2 in urine is highly predictive of prostate
cancer, with a sensitivity of 66% and a specificity of 88.2%.
: In this pilot study, we randomly selected 10
patients successfully treated with low dose rate brachytherapy from a
prospectively collated database with over 2000 patients. All patients
were hormone naïve with +5 years follow up and a PSA ≤ 0.1 ng/ml.
The EN2 level was measured in patient's firstpass urine sample,
without prior DRE, using ELISA.
: The results showed that 9/10 patients had an EN2 level
below the standard cut off of 42.5 ng/ml (range 032.7, median=4.3).
One patient had a raised EN2 level of 406 ng/ml, which was
confirmed on a repeat urine sample. To investigate this further, a
diagnostic flexible cystoscopy was performed on this patient.
Interestingly, he was found to have a small asymptomatic superficial
transitional cell carcinoma (TCC) of the bladder. EN2 staining of the
tissue taken at the time of transurethral resection of bladder tumour
(TURBT) confirmed that EN2 was present in the TCC specimen, but not
in the normal bladder biopsies. A urine sample following TURBT
showed an EN2 level of 0 ng/ml.
: This preliminary study suggests that EN2 may be a
useful surveillance marker in patients who have undergone radical
treatment for prostate cancer. Further studies with larger sample
sizes are currently in progress to further validate this potential in
patients who have undergone various other forms of radical
treatment. Secondly as EN2 is also secreted in TCC of the bladder,
studies are under way to validate its diagnostic potential in TCC of the
bladder.
PO211
PROSTATE BRACHYTHERAPY USING AN AUTOMATIC SEED
AFTERLOADER: PRELIMINARY EXPERIENCE IN 1037 PATIENTS
P. Pommier 1 , M. Delannes 2 , L. Thomas 3 , S. ServagiVernat 4 , G.
Crehange 5 , D. Williaume 6 , C. Llacer 7 , M. Untereiner 8 , A. Bajard 9
1
Centre Léon Bérard, Department of Radiation Oncology, Lyon,
France
2
Centre Claudius Regaud, Department of Radiation Oncology,
Toulouse, France
3
Institut Bergognié, Department of Radiation Oncology, Bordeaux,
France
4
CHU Besançon, Department of Radiation Oncology, Besançon, France
5
Centre GF Leclerc, Department of Radiation Oncology, Dijon, France
6
Centre E Marquis, Department of Radiation Oncology, Rennes, France
7
Centre Valdorel, Department of Radiation Oncology, Montpellier,
France
8
Centre F Baclesse, Department of Radiation Oncology, Eschsur
Alzette, Luxembourg
9
Centre L Bérard, Department of Biostatistics, Lyon, France
: To prospectively assess toxicity outcome in
prostate exclusive brachytherapy with the use of an automatic seed
afterloader (seedSelectron, Nucletron R )
: Since November 2002, 1156 patients treated
with the seedselectron for a localized prostate adenocarcinoma have
been included in a prospective multicentric survey database (7
centers in France and 1 in Luxembourg). Data for 1035 pts with at
least immediate toxicity data are reported. Median age was 66 y. [46
80]. Mean PSA value was 6.7 ng/l (SD 2.3); 76% were classified as T1C,
19.7% as T2a and 1.1% as T2B (T1a in 1 and T3a in 1 pt); Gleason Score
was < 6 in 84.5%; 7=3+4 in 15.3% (4+3 in 2; 8 in 1 pts).
RESULTS: For the whole population, a urinary obstruction occurred in
31 patients (3%), immediately after the removal of the urinary
catheter in 12; within the first week in 5; within the first 8 weeks in 7
and after 3 mo. in 7 pts. A urinary resection was performed in 6 pts.
The maximal urinary toxicity CTCv3 grade was quoted as 3 in 4.5%; 2
in 39% and 01 in 53%. The maximal IPPS value (available in 931
patients) was > 25 in 3.4%; 20

S86 World Congress of Brachytherapy 2012
: The mean age was 63.93 years (4488); means pretreatment
PSA was 6.34 ng/mL (0,67 33.09); 88.20% of patients ha initial PSA
less 10 ng/mL; 83.28 had Gleason score

S88 World Congress of Brachytherapy 2012
regular seeds migrated (were lost) out of the pelvis compared to 1
AnchorSeed (8/114 vs. 1/126 p=0.015)
: Coated AnchorSeeds were found to have a significant
anchoring effect which was effective in reducing the number of apical
seeds that were lost from the pelvis.
PO218
125I BRACHYTHERAPY AS A CURE FOR EARLY STAGE PROSTATE CANCER
IN PATIENTS UNDER 65 YEARS OF AGE
T. Palloni 1 , F.P. Mangiacotti 2 , A. Petrucci 2 , G. Bakacs 3 , M. Martini 3 , R.
Consorti 2 , P. Soldini 1 , D. Cuccoli 4 , M. Sereni 5 , M.A. Mirri 1
1
San Filippo Neri Hospital, Radiotherapy, Roma, Italy
2
San Filippo Neri Hospital, Medical Physics, Roma, Italy
3
San Filippo Neri Hospital, Urology, Roma, Italy
4
San Filippo Neri Hospital, Anesthesia, Roma, Italy
5
San Filippo Neri Hospital, Surgical Unit, Roma, Italy
: Nowadays, greater public awareness of prostate
cancer and the implementation of routine PSA screening have resulted
in a decrease in patient age of the time of first diagnosis 1 . Young age
has traditionally been viewed as a negative prognostic factor 2 . Many
physicians believed that younger patients (pts) are better suited for
surgery rather than radiation as primary treatment 2,3 . However, data
literature supporting this traditional view are very limited 456789 .
Longterm results 10 show that 125 I BT represents an effective and safe
treatment with satisfying results in terms of biochemical progression
(BP) and of overall survival, also in hormone naïve pts ≤60 years (yrs)
with freedom from biochemical failure (FFbF) 92% at 8 yrs 411 . In
addition literature reports that younger pts tolerate BT well, with
favorable quality of life and low morbidity even in late follow up
(FUP) 1213 . It appears evident that the efficacy and morbidity of BT,
regardless of patient’s age 6 , are strongly correlated to patient
selection, multidisciplinary management and implant quality 1415 . The
purpose of this study was to report our results in pts younger than 65
years treated with 125 I BT.
: 125 I BT was proposed to pts with PSA ≤ 10,
Gleason Score (GS) ≤ 7 (3+4), T1T2 stage, good urinary functionality
and prostate volume ≤ 55 gr 16 . The prescription dose was 145 Gy. One
month after the implant, the pts underwent CTbased dosimetry: a
D90 (the dose delivered to 90% of the prostate volume) ≥ 140 Gy was
considered the measure of good implant quality 17 . We recorded the
following data: post implant dosimetric parameters, acute and late
genitourinary (GU) and gastrointestinal (GI) toxicity, erectile function
(EF), urinary continence preservation and PSA levels.
: Between February 2009 and December 2011, 41 pts
underwent the 125 I BT in our institution, 19 of which younger than 65
yrs with a median age of 56 yrs. In the cohort of younger pts the mean
prostate volume was 35,5 cm 3 and the 1month mean D90 was 149,7
Gy . At a median FUP of 12,5 mts, the toxicity was low with no acute
or late urinary obstruction. The toxicity was 47,4% and 10,5% grade 1
(G1) and grade 2 (G2) acute GU, respectively, and only 5,3%
developed G1 acute GI toxicity; 31,6% and 10,5% of pts presented G1
and G2 late GU toxicity. At the moment urinary continence and EF are
preserved in the whole group. All pts are free from BP and local
recurrence with mean PSA values reduced of 74,2%, 85,2%, 73,0% and
89,6% at 3, 9, 18 and 24 months, respectively.
: Our data confirm 125 I BT to be an effective cure also in
younger than 65 yrs pts. 125 I BT is particularly suitable for men
motivated to maintain EF, urinary continence and asking to rapidly
return to normal work and social life. Outcome seems strongly related
to a multidisciplinary approach, to high implant quality and technical
ability of dedicated team, as well as to the selection of the patients.
PO219
IMPLEMENTATION OF INTRAOPERATIVE ULTRASOUND BASED REALTIME
ADAPTIVE PLANNING FOR PROSTATE BRACHYTHERAPY
D. D'Souza 1 , N. Patil 1 , H. Mosalaei 2 , M. Mulligan 2 , K. Jordan 2 , C.
Lewis 2 , T. Murray 3 , L. Derrah 3 , G. Bauman 1
1
The London Regional Cancer Program, Radiation Oncology, London
Ontario, Canada
2
The London Regional Cancer Program, Medical Physics, London
Ontario, Canada
3
The London Regional Cancer Program, Nursing, London Ontario,
Canada
: Improvements in the quality of radiation
delivered for several sites has been achieved by the use of dynamic
planning. This is particularly relevant to prostate brachytherapy (PB)
with organ swelling and movement, difficulty in reproducing the pre
plan positioning of needles and seed placement. However such an
approach can be resourceintensive.
: This study prospectively evaluated the effect
of implementing intraoperative realtime adaptive planning for PB
with respect to implant quality and procedure time. From Jul/10 –
Nov/11, 22 patients underwent I125 PB using IBTBebig loose seeds
and Mick applicator. Intraoperative realtime adaptive planning was
performed using Variseed 8.0 and evaluated with ultrasound.
However, we compared the standard dosimetric parameters using Day
30 CT with 23 patients undergoing I125 PB using stranded seeds using
traditional preplanning during the same time period.
:
Median Preplan (n=23) Intraoperative (n=22)
TRUS Volume (cc) 30.5 (range: 20 50) 34.0 (range: 15 57)
Post plan V100 (%) 91.5 (range: 75 99) 95.1 (range: 86 100)
Post plan V200 (%) 16.7 (range: 9 35) 34.5 (range: 13 63)
Post plan D90 (Gy) 141.9 ( range: 116 – 155) 165.4 (range: 132 216)
The median procedure time was 158 minutes (range 100225).
However there was a significant reduction in time from the 1 st
quartile (205) to the last quartile (120).
: Intraoperative ultrasound based realtime adaptive
planning for PB is associated with improvement in standard implant
quality parameters compared to preplanning. Acute toxicity is
favourable, however longer followup is required to assess clinically
relevant outcomes.
PO220
DOSE ESCALATION TO 160 GY IN I125 PROSTATE IMPLANTS. EARLY
CLINICAL RESULTS
A. Tormo 1 , E. Collado 1 , S. Roldán 1 , F.J. Celada 1 , J.C. Morales 1 , V.
Carmona 2 , M.C. GarcíaMora 1 , O. Pons 1 , F. Lliso 2 , J. PérezCalatayud 2
1 Hospital La Fe, Radiation Oncology, Valencia, Spain
2 Hospital La Fe, Radiation OncologyPhysics, Valencia, Spain
: The aim of this dose escalating study (from
D90>144 Gy to D90>160 Gy) is to analyze the biochemical recurrence
free survival (bRFS) and toxicity profile of prostate cancer patients
treated with I125 seeds implant.
: From January´08 to December´10 219 low
risk and one factor intermediaterisk patients were chosen for 160 Gy
I125 therapies. Previous MRI, urinary flowmetry an IPSS questionnaire
were realized. Using realtime intraoperative interactive planning,
prescribed dose was 160 Gy, keeping the same urethral and rectal
constraints as when 144 Gy was the prescribed dose. One month post
implant CT and MRI were realized for postplanning. Median age was
68 years old (range 4179), median PSA 7.7 ng/ml (range 233) and
median Gleason 6. 79 patients were treated with hormone therapy
(media duration 4 months). Median US prostate volume was 35 cc
(range 1072). Retrospectively maximal acute and chronic toxicity,
using CTCv4.0 and RTOG scales, and bRFS, using Phoenix definition,
were evaluated.
: The incidence of grade 34 acute toxicity was 2% (6 patients
required urinary catheter because of acute retention, all solved with
medical treatment). No grade 34 chronic toxicity was observed. 74%
of patients remained potent. 2% patients presented biochemical
failure with negative complementary exams, including transperineal
prostate saturation biopsy.
: Dose escalation to 160 Gy in I125 prostate implants
don’t give rise more toxicity than 144 Gy. Clinical results are good,
but with a short followup.
PO221
HDR BRACHYTHERAPY BOOST AND EXTERNAL RADIOTHERAPY FOR
UNFAVORABLE PROSTATE CANCER PATIENTS
I. Monteiro Grillo 1 , F. Pina 1 , V. Mendonça 1 , A. Amado 1 , J. Melich
Cerveira 2 , G. Marcelino 1 , P. Marques Vidal 3
1 University Hospital of Santa Maria, Radiotherapy, Lisboa, Portugal
2 Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
World Congress of Brachytherapy 2012 S 89
3
Institute of Social and Preventive Medicine, University Hospital of
Lausanne, Lausanne, Switzerland
: To evaluate the outcome of prostate cancer
patients treated with a combination of HDR Brachytherapy boost
(HDRBT) and 3D conformal external pelvic radiotherapy (EBRT) in a
dose escalation study.
: 162 patients were followed between
November 2004 and December 2010 . Two different dose escalation
groups were done: group 1 (n= 92), 1 fraction HDR boost (910 Gy )
followed by EBRT (60 Gy in 6 weeks) – BED: 203216 Gy and group 2
(n=70): 2 fraction HDR boost (1819 Gy), 6 hours interval between
fractions, followed by EBRT (46 Gy in 4.5 weeks) BED: 233.3 247 Gy;
116 pts (71.6%) received concomitant androgen deprivation. Patients
were classified according to the MSKCC criteria into high (N=137) and
intermediate (N=25) risk. Phoenix biochemical failure definition was
used. Toxicity was scored by Radiation Morbidity Scoring Criteria
(RTOG)
: The mean followup was 41 (range 784) months. The 7 years
cancerspecific and overall survival was 100% an 92%, respectively.
The 7 years actuarial biochemical control rate was 89% and 100% for
group 1 and 2, respectively. One patient from group 1 and two
patients from group 2 never reached a low nadir. Two patients
developed distant metastases 12 and 16 months after the treatment.
In a multivariate Coxregression analysis neither treatment nor risk
group (intermediate vs. high risk) were associated with increased risk
for biochemical failure. The RTOG grade 3 genitourinary early toxicity
was 1.0% and 8.5% while gastrointestinal/genitourinary late toxicity
was 7.6% and 1.4% for group 1 and 2, respectively
: HDR BT boost followed by EBRT appears to be a safe,
feasible and effective treatment for patients with unfavorable
localized prostate cancer. This study shows a beneficial effect on
biochemical control in group 2 pts, however without statistical
significance. Higher radiation doses (BED 233.3247 Gy) do not seem
to carry extra toxicity.
PO222
A NEW DIMENSION TO THE TREATMENT OF LOCALIZED PROSTATE
CANCER: 4D BRACHYTHERAPY
S. Langley 1 , E. Chadwick 2 , S. Javed 1 , R.W. Laing 2
1
Royal Surrey County Hospital, Urology, Guildford, United Kingdom
2
Royal Surrey County Hospital, St Lukes Cancer Centre, Guildford,
United Kingdom
: LDR prostate brachytherapy has been performed
at our centre for the last 12 years. Data for patients have been
collected on a bespoke, prospective database. During this time, we
have made significant modifications to the technique, culminating in a
new onestage realtime procedure, which utilizes the benefits of
stranded and loose seeds. After an initial learning curve, data for
cohorts of patients from sequential techniques are compared here.
: In 1999, implants were performed using the
Seattle technique, with loose seeds in a modified uniform
distribution. From 2005, seeds were implanted as a combination of
stranded seeds placed peripherally, and loose seeds placed centrally,
with a Mick applicator. This was termed the 'Guildford Hybrid
technique'. By 2007, implants were still preplanned, but realtime
planning allowed intraoperative plan modifications, 'Realtime
optimization'. In 2008, a nomogram for seed and strand ordering was
developed so that implants could be performed as a 1stage
procedure. All planning now takes place intraoperatively. The plans
are developed iteratively, in response to realtime dosimetric
feedback. This technique is termed '4D Brachytherapy'.
:
The table describes demographics and dosimetry. The D90, %D90 (D90
as a percentage of the prescribed dose) and V100 were all
significantly higher for the three modifications to the procedure
compared with the original Seattle series (p

S90 World Congress of Brachytherapy 2012
: Between July 1999 up to December 2011 446
patients with low and intermediate risk prostate cancer were treated
with permanent seed implantation. 128 patients received Palladium
103, 329 received Iodine125. The median follow up for the entire
group is 48 months (mean 53.36 months, min 1/ max 144 months).
Pretreatment low risk criteria were as follows: PSA level < 10 ng/ml,
Gleason score < 7, intermediate risk: PSA level >10 < 20 ng/ml or
Gleason 7. In exceptional cases we also treated patients with high risk
features (PSA level > 20 ng/ml or Gleason > 8).
In order to exclude patients with extraprostatic disease, between
2002 and 2004 we routinely performed a MRT +/ endorectal coil.
Since 2004 we only recommended pretreatment erMRT for patients
with higher risk for stage T3 tumours (patients in the intermediate
risk group, with positive biopsies in both prostate lobes or high risk
patients). To evaluate side effects, validated questionnaires, as IPSS,
EORTC QLQC30(+3), IIEF 5/15 and individual parameters like
maximum urinary flow rates and residual urine volume were assessed
before implantation and every three month within the first two years.
Irritative and obstructive interferences were monitored and analysed.
For quality assurance four weeks after the procedure a postplan was
calculated in all cases.
: Every procedure was performed without major
complications. Mild to moderate acute genitourinary side effects
included obstructive and/or irritative symptoms. Rectal side effects
like mild to moderate proctitis also occurred, but gradually resolved
in most patients. Biochemical relapse free survival (bNED) according
to nadir +2 ng/ml for the entire cohort is 93.73%. Low / intermediate
/ high risk patients represented a bNED of 92.3, 97.7 and 97%
respectively (figure 1).
: Prostate brachytherapy with Palladium103 and Iodine
125 permanent implantation is a feasible, minimal invasive, highly
effective procedure for curative treatment for low and intermediate
risk prostate cancer.
PO224
LONG TERM EXPERIENCE OF HDR BOOST FOR LOCALIZED PROSTATE
USING INVERSE PLANNING WITH SIMULATED ANNEALING
E. Vigneault 1 , P. Despré 1 , A.G. Martin 1 , W. Foster 1 , S. Aubin 1 , L.
Beaulieu 1
1
Centre Hospitalier Universitaire de Québec L'HôtelDieu de Québec,
Department of Radiotherapy, Quebec, Canada
: The purpose of this study is to report PSA failure
free survival (Phoenix) in localized prostate cancer patients treated
with external beam radiation therapy (EBRT) followed by HDR (high
dose rate) boost using inverse planning with simulated annealing
(IPSA).
: Since 1999, 731 prostate cancer patients
were treated with 4044 Gy of EBRT followed by HDR boost using
inverse planning with simulated annealing (IPSA). The HDR boost
evolved from 3 fractions (6 Gy X 3) technique to two fractions ( 9510
Gy X 2) technique and more recently in a one fraction technique (15
Gy X 1). Patients were followed prospectively. Only patients with a
minimum followup of 6 months were analyzed and presented in this
study. We define the PSA failure free survival using Phoenix
definition. Chisquare test was used to compare PSA failure free
survival between the three risk groups and different dose / fraction
regimens.
: Out of the 731 patients, 640 had a minimum followup of 6
months. Pretreatment PSA was< 10 ng/ml in 75% of patients, 1020
ng/ml in 22% and > 20 ng/ml in 3% respectively. The mean age of
patients at presentation was 65.9 year with an average clinical follow
up of 36 months (range 6130 months). 82% of patients presented with
a clinical stage T1T2a, 16% T2bc and 2 % > T3. 18% had a Gleason
Score ≤ 6 /10 and 75% Gleason score 7 and 7% Gleason score ≥ 8. 59%
were low risk, 39% intermediate risk and 7% high risk prostate cancer
patients. In our population 80% did not received androgen deprivation
therapy (ADT) while 20% received short / long term (high risk patient)
ADT. For the whole group of patients the 5 year PSA failure free
survival (Phoenix) is 98.7%. The 5 year PSA failure free survival was
not statistically different between the three risk group (low,
intermediate and high) and between the different HDR
dose/fractionation used.
: The use of HDR brachytherapy boost in localized
prostate cancer gives impressive 5 year PSA failure free survival using
Phoenix definition even in intermediate and high risk group. These
results are comparable with other single institution series. These
excellent results should be compared to high dose EBRT in a
multicentre Phase III study.
PO225
PLANNED TURP PRIOR TO LDR PROSTATE BRACHYTHERAPY DOES NOT
CAUSE INCONTINENCE
E. Chadwick 1 , S. Javed 2 , R.W. Laing 1 , S.E.M. Langley 2
1
Royal Surrey County Hospital, St Lukes Cancer Centre, Guildford,
United Kingdom
2
Royal Surrey County Hospital, Urology, Guildford, United Kingdom
: Historically, patients with a high IPSS (>15), or a
recent transurethral resection of the prostate (TURP), have been
excluded from brachytherapy due to concerns regarding urinary
incontinence, urinary outflow obstruction and the ability to achieve
acceptable dosimetry. However, since 2006, a limited TURP/bladder
neck resection (BNR) has been offered to patients with significant
obstructive symptoms (poor urinary flow or poor bladder emptying)
before their implant. The dosimetry, subsequent urinary function and
biochemical relapse free survival (bRFS) are described here.
: 65 Preimplant brachytherapy patients with
at least 32 months follow up, with obstructive uroflowmetry or large
postvoid residuals, together with a high bladder neck due to median
lobe hypertrophy on transrectal ultrasound (TRUS) were offered a BNR
/ limited TURP 6 weeks before their implant, as these patients are
known to experience significant postimplant urinary toxicity. 9
patients received neoadjuvant hormones and 4 patients received
EBRT in combination with their implant. IPSS scores were recorded
prospectively on a bespoke database. A questionnaire based on the
Expanded Prostate Cancer Index Composite (EPIC) questionnaire was
sent to patients retrospectively to assess incontinence, described
below:
Over the past 4 weeks, how often have you leaked urine?
Which of the following best describes your urinary control during
the last 4 weeks?
How many pads or adult nappies per day did you usually use to
control leakage during the last 4 weeks?
: The mean follow up was 47 months. The 4 year bRFS was
97%. The mean postimplant D90 as a percentage of the prescribed
dose was 112%. The mean V100 and V150 were 94 and 56Gy respectively.
The mean urethral V150 was 6%.
Urinary morbidity is described in the table below. 1 patient developed
a urethral stricture at 18 months. No patient went into urinary
retention or required intermittent selfcatheterisation. The mean
score for the EPIC incontinence domains was 93% and in particular no
one was using pads.
Months FU
PreBNR /
Urinary morbidity
12 24 36
TURP
Mild IPSS 08 55% 53% 66% 77%
Moderate IPSS 916 35% 41% 25% 20%
Severe IPSS 1735 9% 7% 9% 3%
: A limited TURP / BNR is a procedure which can be
World Congress of Brachytherapy 2012 S 91
performed on patients with urinary outflow obstruction who might not
otherwise have been offered brachytherapy, and is preferable to a
postimplant TURP when tissue healing is less predictable and patients
will have inevitably endured significant urinary symptoms prior to
surgery. A preimplant TURP does not cause urinary incontinence and
is associated with low urinary morbidity. The dosimetry and bRFS in
this series demonstrate that the oncological management is not
compromised.
PO226
INCORPORATING EDEMA IN PROSTATE SEED IMPLANT DOSIMETRY USING
A CLINICALLYINFORMED EDEMA MODEL
D. Liu 1 , T. Monajemi 2 , R. Sloboda 1
1
Cross Cancer Institute, Medical Physics Department, Edmonton,
Canada
2
McGill University Health Center, Medical Physics Unit, Montreal,
Canada
: To calculate preplan and postimplant dosimetric
quantifiers for prostate seed implants using a new spatially
anisotropic linearly timeresolving edema model.
: 10 patients treated with I125 permanent
prostate brachytherapy were studied retrospectively. On preplan US
and postimplant CT scans, dose distributions incorporating edema
were calculated (Med Phys 2011, 38:22892298) and compared with
TG43 point source calculations. The edema model parameters
(magnitude = 0.2 and resolution time = 28 days) were chosen based on
previously published results (Brachytherapy 2010, 9:354361).
Dosimetric quantifiers were calculated for the preplan PTV and the
postimplant prostate using CERR, an opensourced radiotherapy
software. For one preplan case, representative edema effects were
also determined for Pd103 and Cs131 implants using the same seed
distribution with adjusted source strength.
: The dose when incorporating edema was consistently lower
than the TG43 dose. The relative error expressed as a percent (RE%)
was calculated between the two dose distributions. The maximum RE%
within the structure boundary was 2.7. The mean RE% was 2.02
[range: 1.95 – 2.12] for the preplan PTV and 2.10 [range: 2.04 – 2.17]
for the postimplant prostate. There was no significant difference in
mean RE% between the prostate and its subregions (i.e. urethra, near
bladder, prostate surface). The ~2% reduction in dose when
accounting for edema was similarly reflected in several dose metrics,
as shown in the table. Postimplant results exhibited similar
differences. All differences in dose metrics were found to be
correlated with prostate volume (R 2 > 0.6; p < 0.01).
Preplan dose metric Incorporating edema TG43
Mean dose 282 Gy 286 Gy
D90 188 Gy 192 Gy
V200 27.8 % 29.7 %
V150 69.3 % 72.4 %
V100 (145 Gy) 99.6 % 99.7 %
The dosimetric differences were greater for Pd103 and Cs131
compared to I125, as shown in the DVH figure. The mean RE% were
2.0, 6.0, and 7.5 for I125, Pd103, and Cs131, respectively.
: The dosimetric effects of edema for 10 I125 implants
were determined using an anisotropic edema model with clinically
based parameters. The mean dose was ~2% lower when accounting for
edema and this difference was observed with little variation across
different regions of the prostate, between pre and postplans, and
between patients. Similar reductions were observed for the mean
dose, D90, V200, and V150. The effects of edema were substantially
greater for Pd103 and Cs131 compared to I125.
PO227
C4 MARKERS FOR MRIBASED PROSTATE BRACHYTHERAPY
S. Frank 1 , T. Madden 2 , D.A. Swanson 3 , K. Martirosyan 4 , R.
Uthamanthil 5 , J. Stafford 6 , M. Gagea 5 , T.J. Pugh 1 , R. Kudchadker 7 ,
M.J. Johansen 2
1
U.T. M.D. Anderson Cancer Center, Radiation Oncology, Houston TX,
USA
2
U.T. M.D. Anderson Cancer Center, Experimental Therapeutics,
Houston TX, USA
3
U.T. M.D. Anderson Cancer Center, Urology, Houston TX, USA
4
University of Texas Brownsville, Chemical and Biomolecular Imaging,
Houston TX, USA
5
MD Anderson Cancer Center, Veterinary Medicine and Surgery,
Houston TX, USA
6
MD Anderson Cancer Center, Imaging Physics, Houston TX, USA
7
MD Anderson Cancer Center, Radiation Physics, Houston TX, USA
: To establish the invivo safety and efficacy of a
permanently implantable cobalt chloride complex contrast agent (C4)
to localize radioactive seeds for MRIbased prostate brachytherapy.
: To support evaluation of the extent of
complexation and stability of the complexed material, a LC/MS
method using diethyl dithiocarbamate (DDTC) derivitization quantified
free cobalt in C4 solutions and in plasma spiked with C4. The extent
of complexation and stability of C4 complexes in water and plasma
were then evaluated over 5 days at 37°C. Ninemicroliter doses
(equivalent to leakage from 120 C4 MRI markers in a man) of vehicle
control, 1% and 10% C4 solution, were injected into the prostates of
male SpragueDawley rats via laparotomy. Cobalt disposition in
plasma, tissues, feces and urine was evaluated along with both gross
and microscopic evidence of organ toxicity. C4 MRI markers with I125
stranded seeds were inserted into both prostate phantoms and an in
vivo canine prostate for seed localization under 1.5 and 3T MRI (TR
1500/TE 30).
: At physiologic pH in plasma, the C4 solutions were found to
contain a consistently low amount of free cobalt over the 5day period
thereby demonstrating nearly complete complexation formation with
available cobalt in the solutions. The mean free cobalt measured on
Day 0, 2, 4 and 5 ranged from 6.08.8%. The pharmacokinetics
analyses revealed no treatmentrelated morbidity or mortality among
60 rats. Cobalt was detected in the plasma only transiently (at 560
minutes, mean peak concentration 1.40 g/mL); in the urine (60
minutes6 hours, mean peak concentration 11.6 g/mL at 6 hours);
and in the feces (3.28 g/g at 624 hours), but only in the highdose
(10% C4) group. Findings confirmed the expected dual renalhepatic
elimination of this compound. Toxicity data demonstrating the rapid
elimination of cobalt in animals administered the C4 solution. No
adverse clinical signs and no histopathologic lesions were noted in any
dose group. The C4 MRI markers could be visualized under both 1.5T
and 3T MRI and localize the implanted seeds invivo.
: In summary, these data demonstrate the formulation
used for the C4 MRI Marker contains complexes as identified. 10% C4 is
the noadverseeffectslevel in this setting and is therefore expected
to be safe as an MRI marker for prostate cancer treatment. The C4
MRI marker was able to localize implanted seeds under 1.5 and 3T T1
weighted MRI in phantoms and within invivo canine prostates.
PO228
PROSPECTIVE EVALUATION OF PHARMACOLOGIC PENILE REHABIL
ITATION FOLLOWING PROSTATE BRACHYTHERAPY
T.J. Pugh 1 , D.A. Swanson 2 , R.J. Kudchadker 3 , T.L. Bruno 3 , M.F.
Munsell 4 , S.J. Frank 1
1
University of Texas MD Anderson Cancer Center, Radiation Oncology,
Houston TX, USA
2
University of Texas MD Anderson Cancer Center, Urology, Houston
TX, USA
3
University of Texas MD Anderson Cancer Center, Radiation Physics,

S92 World Congress of Brachytherapy 2012
Houston TX, USA
4 University of Texas MD Anderson Cancer Center, Biostatistics,
Houston TX, USA
: To describe patient reported sexual quality of life
in men treated with prostate brachytherapy and prophylactic
tadalafil.
: Between 20052011, we prospectively
measured outcomes reported by 237 patients before and after
prostate brachytherapy monotherapy. All patients were prescribed
tadalafil 10 mg tablets by mouth twice weekly starting 2 weeks prior
to brachytherapy implant. No patient had previously used a 5
phosphodiesterase inhibitor for erectile enhancement. The expanded
prostate index composite (EPIC) was completed prior to any
intervention (baseline) and at each followup assessment. The change
in EPIC sexual domain, sexual function, and sexual bother scores was
calculated. Preservation of potency was assessed through subgroup
analysis of men declaring 'erections firm enough for intercourse' at
baseline versus posttreatment evaluation.
: The mean sexual domain, sexual function, and sexual bother
scores at baseline were 57.4, 50.9, and 72.8 respectively. Sexual
domain and sexual function scores decreased significantly from
baseline at each time interval assessed (Range 148 months). The
mean change in sexual domain and sexual function score from
baseline to 24 months was 5.5 (p = 0.013) and 6.1 (p = 0.007)
respectively. Sexual bother scores were not significantly different at
24 months. The mean change in sexual bother score was 4.4 (p =
0.219). Sixtythree percent of men reported full potency at baseline.
At 24 month followup, 75% of men with baseline potency reported
potency preservation.
: This is the first ever report of prophylactic 5
phosphodiesterase inhibitor use for preservation of erectile function
in men treated with prostate brachytherapy. These results compare
favorably to published outcomes with brachytherapy alone or
alternative management strategies for localized prostate cancer. A
randomized trial of prophylactic tadalafil is warranted.
PO229
ACUTE AND CHRONIC TOXICITY ASSOCIATED WITH THREE HIGHDOSE
RATE BRACHYTHERAPY MONOTHERAPY SCHEDULES
J. Dilworth 1 , H. Ye 1 , M. Ghilezan 1 , M. Wallace 1 , C. Shah 1 , D. Krauss 1 ,
G. Gustafson 1 , A. Martinez 1
1 William Beaumont Hospital, Radiation Oncology, Royal Oak, USA
: To report the acute and chronic toxicity profiles
associated with three highdoserate brachytherapy (HDR) regimens
used as monotherapy for favorablerisk prostate cancer.
: 482 patients with T stage T2b or less, Gleason
score 7 or less, and pretreatment PSA value 18 ng/mL or less were
treated with HDR. 317 patients received 38 Gy in four fractions; 72
received 24 Gy in two fractions; 93 received 27 Gy in two fractions.
Chisquare, ttest, ROC, and univariate analyses were conducted to
compare patient characteristics and clinical outcomes. Acute and
chronic toxicities were defined as those occurring within or after the
first six months following treatment, respectively, and graded using
the CTCAE, v3.0.
: Median followup was 3 years for all patients. Clinical
outcomes were similar among groups, with 3yr actuarial rates of 91%
(biochemical failurefree survival, p=0.76), 99% (overall survival,
p=0.83), and 100% (causespecific survival). Acute and chronic
toxicities are listed in Table 1. All acute gastrointestinal (GI) toxicities
were similar among groups. The majority of acute genitourinary (GU)
symptoms was similar among groups, with urinary retention and
urinary incontinence rates being higher in the 38 Gy group. All chronic
GU toxicities were similar among groups. The majority of chronic GI
toxicities was similar among groups, with chronic diarrhea being lower
in the 38 Gy group. Nine patients (2%) developed urethral strictures
requiring surgical dilation. Patients receiving prebrachytherapy
hormonal therapy (HT) experienced higher acute GI and GU toxicities
(20% and 70%) then hormonenaïve patients (10% and 53%)(p=0.03 and
0.02). In a separate analysis of patients who did not receive HT, the
relative rates of acute and chronic GU and GI toxicities were
comparable. Gland volume did not predict acute or chronic toxicity.
Table 1. Acute and chronic toxicities (all patients)(A.T.=acute
toxicity, C.T.=chronic toxicity)
All (n=415) Toxicity 38/4
(n=256)
24/2
(n=68)
27/2 (n=91) p
value
G1 G2 G3 G1 G2 G3 G1 G2 G3 G1 G2 G3
A.T. 33% 12% 1% Freq./Urg. 34% 11% 2% 31% 13% 0% 30% 13% 0% 0.56
20% 3% 0% Dysuria 23% 3% 0% 14% 4% 0% 14% 1% 0% 0.11
12% 6%

S94 World Congress of Brachytherapy 2012
PO232
ARE URETHRAL TOXICITIES CORRELATED WITH DOSE AFTER
INTERSTITIAL HDR BOOST BRACHYTHERAPY FOR PROSTATE CANCER?
R. Broksch 1 , F.A. Siebert 1 , N. Brüske 1 , B. Kimmig 1 , R. Galalae 2
1 University Hospital SH Campus Kiel, Radiotherapy, Kiel, Germany
2 University Hospital SH Campus Kiel, Medical Faculty, Kiel, Germany
: HDR brachytherapy as boost technique for
prostate cancer patients is in our clinic a well established technique.
Study aim was a volumetric evaluation stratified by anatomyrelated
urethral segmentation in correlation with urethral toxicities.
: HDRBT prescription prostate dose was 2x15
Gy to peripheral zone (CTV1) and 8.5 Gy to the whole prostate gland
(CTV2), using 8 ± 1 (SD) implant needles. Dosimetric analyses were
performed in 70 consecutive patients i.e. 140 HDRBTfractions,
treated in 2003. Intraoperative technique based on TRUS images was
applied. The echo of an inserted catheter plus 2 mm margin was
digitized as urethra structure, and was digitally divided into three
anatomical distinct parts. Two very basal TRUSimages + one cranial
additional were defined as 'basal urethra', and two very apical slices +
one distal additional as 'apical urethra'. The remaining mid part was
labeled 'pars prostatica'. For each partial volume D5 and D0.1cc were
calculated using the TG43 formalism and the mean dose indices over
the two fractions were used for evaluation. Late urethral toxicities
were analyzed for each patient according to RTOG/EORTC
classification and compared against the computed urethral doses of
the three segments.
: For basal urethra, the D5 was 10.1 ±3.8 Gy (SD), and for
D0.1cc 8.6 ±2.9 Gy. Similar values were measured in the apex: D5
10.2 ±2.8 Gy and D0.1cc 8.4 ±2.3 Gy, while pars prostatica showed
higher D5 with 12.4 ±3.7 Gy and D0.1cc 11.6 ±3.7 Gy.
Late toxicities of grade 3 cystitis were found in 6%. One patient with
grade 4 toxicity developed a bladder fistula. First results show no
correlations between dose indices in the distinct urethra segments
and toxicities.
: Dosimetric differences in three sequential anatomy
related urethral segments were detected. Nevertheless, no
correlation between dose and late toxicities in the urethra could be
found is this study.
PO233
INTENSITY MODULATED HIGHDOSERATE BRACHYTHERAPY AS
MONOTHERAPY FOR CLINICALLY LOCALIZED PROSTATE CANCER
N. Tselis 1 , D. Baltas 2 , U.W. Tunn 3 , T. Buhleier 1 , T. Martin 4 , N.
Milickovic 2 , S. Papaioannou 2 , H. Ackermann 5 , N. Zamboglou 1
1
Klinikum Offenbach GmbH, Department of Radiation Oncology,
Offenbach am Main, Germany
2
Klinikum Offenbach GmbH, Department of Medical Physics and
Engineering, Offenbach am Main, Germany
3
Klinikum Offenbach GmbH, Department of Urology, Offenbach am
Main, Germany
4
Klinikum Bremen Mitte, Department of Radiation Oncology, Bremen,
Germany
5
J.W. Goethe University of Frankfurt, Institute of Biostatistics,
Frankfurt am Main, Germany
: To report the clinical outcome of intensity
modulated (IM) high dose rate (HDR) brachytherapy (BRT) as sole
treatment (monotherapy) for localized prostate cancer.
: Between January 2002 and December 2009,
718 consecutive patients with localized prostate cancer were treated
with transrectal ultrasound (TRUS) guided IMHDR monotherapy. Three
biologically equivalent treatment protocols were applied; 141 patients
received 38 Gy using one implant at 4 fractions of 9.5 Gy with
computed tomography based treatment planning [Group A], 351
patients received 38 Gy in 4 fractions of 9.5 Gy using two implants (2
weeks apart) and intraoperative TRUS realtime treatment planning
[Group B], and 226 patients received 34.5 Gy using three single
fraction implants of 11.5 Gy (3 weeks apart) and intraoperative TRUS
realtime treatment planning [Group C]. Biochemical failure was
defined according to the `Phoenix consensus´ and toxicity evaluated
using the Common Toxicity Criteria for Adverse Events version 3.
: The median followup was 52.8 months. For the entire
cohort, the 36, 60 and 96 months biochemical control (BC),
metastasisfree survival, and overall survival rates were 97 %, 94 %, 89
% and 99 %, 98 %, 97 % as well as 98 %, 96 % and 95 %, respectively.
For Group A (n=141) and Group B (n=351) the 36, 60 and 96 (80)
months BC rates were 97 %, 94 %, 89 % (96 months) and 99 %, 98 %,
and 97 % (80 months), respectively. For Group C (n=226), the 12, 24
and 35 months BC rates were 100 %, 98 % and 95 %, respectively.
Toxicity was scored per event with 5.4 % acute Grade 3 genitourinary
and 0.2 % acute Grade 3 gastrointestinal toxicity. Late Grade 3
genitourinary and gastrointestinal toxicity were 3.5 % and 1.6 %,
respectively. Two patients developed Grade 4 genitourinary toxicity.
No other instance of Grad 4 or greater acute or late toxicity was
reported.
: Our results confirm IMHDRBRT to be a safe and
effective monotherapeutic treatment modality for clinically organ
confined prostate cancer.
PO234
DOSE OPTIMIZATION OF INTRAVAGINAL BRACHYTHERAPY USING
DIFFERENT MULTICHANNEL APPLICATORS
H. Kuo 1 , K. Mehta 1 , R. Yaparpalvi 1 , L. Hong 1 , A. Wu 1 , D. Mynampati 1 ,
W. Bodner 1 , M. Garg 1 , S. Kalnicki 1
1 Montefiore Medical Center, Radiation Oncology, Bronx NY, USA
: An inflatable applicator (Capri TM , Varian, USA)
with thirteen lumens is designed with the advantage of reducing air
pocket, and conforming dose to patient tissues. It is arranged in two
concentric rings (with six lumens each) surrounding a central lumen.
This study investigates the dose distribution in intravagina between
applicators of Capri, multichannel cylinder, Contura balloon, and
Mammosite balloon (Figure 1).
: Plans for Capri (injected water of 30 cc, 40
cc, and 60 cc which corresponding to 3.5 cm, 3.7 cm, and 4.2 cm
respectively) were configured with central lumen activated only (C),
middle ring lumens activated only (M), outer ring lumens activated
only (O), all lumens activated (CMO), outer ring lumens activated
combined with selective dwell positions in middle ring lumens
activated (mO). The goals were dose prescribed to 5mm depth (PTV)
from surface of each applicator (D90>90%) with minimum dose at
normal tissue (OAR) which is another 5mm away. To study the
difference of dose to the apex of the vagina and dose to the body of
vagina, plans were evaluated at the proximal 2 cm length vagina
[PTV_A(V150) & OAR_A(V80)] and the rest of treatment length at
vagina body [PTV_B(V150) & OAR_B(V80)].
: Compares similar size (3.5cm diameter at midbody) of
different applicators, Contura and Mammosite have lowest
OAR_B(V80) but have maximal PTV_B(V150) (12%) as well. Capri
planned with 'O' loading or 'mO' loading has slightly better OAR_B(V80)
and reasonable PTV_B(V150) (~5%) compared to multichannel
cylinder. At apical vagina, Contura & Mammosite have similar
PTV_A(V150) and have better OAR_A(V80) comparing to Capri. Muliti
channel cylinder has the highest value in both of PTV_A(V150) and
OAR_A(V80). The sizes of the Contura and Mammosite limit their
treatment length to the vaginal body. Compares different
configurations of activated lumens in Capri with different sizes, plans
in 'C' or 'M' loading show better at PTV( V150) but worse at OAR(V80);
on the contrary, plans in 'O' loading show better at OAR( V80) but
worse at PTV(V150). Plans in 'CMO' loading have PTV(V150) close to
plans in 'C' & 'M' loading but the OAR(V80) are not optimum. To
minimize PTV(V150) and OAR(V80) simultaneously, plan in 'mO' loading
is the best choice for each size. It offers the least amount of OAR(V80)
which is close to plan in 'O' loading yet with moderate value of
PTV(150).
: Postoperative endometrial brachytherapy using Capri
applicator which has the potential of eliminating airsurface interface
results in excellent intravagina dose coverage. A modifiedperipheral
loading of the total 13 lumens provides tolerable dose to mucosa of
vagina, good coverage to vaginal treatment depth, and the best dose
sparing at normal tissue.
World Congress of Brachytherapy 2012 S 95
PO235
CLINICAL OUTCOME AND DOSIMETRIC PARAMETERS OF MRIGUIDED
BRACHYTHERAPY IN CERVICAL CANCER PATIENTS
C.N. Nomden 1 , A.A.C. de Leeuw 1 , J.M. Roesink 1 , J.H.A. Tersteeg 1 ,
M.A. Moerland 1 , I.M. JürgenliemkSchulz 1
1 U.M.C. Utrecht, Radiotherapy, Utrecht, The Netherlands
: To report and evaluate the dosimetric
parameters and clinical outcome of our first patients treated with a
combination of external beam radiotherapy (EBRT) ± chemotherapy
and MRI guided brachytherapy (BT).
: Fortysix cervical cancer patients treated
between January 2006 and October 2008 were analysed. EBRT dose
was 45Gy in 25 fractions and concomitant monotherapy cisplatin was
given weekly (40 mg/m 2 ). PDR (n=39), HDR (n=5), or combined
HDR/PDR (n=2) MRIguided BT was delivered using either an
intracavitary (IC) or combined intracavitary/interstitial (IC/IS)
approach. The aim of BT treatment was to increase the D90 HRCTV
while taking into account the dose volume constraints for bladder,
rectum, sigmoid, and bowel (D2cc < 90, 75, 75, and 75Gy EQD2,
respectively). Outcome was evaluated in terms of tumour control and
survival. Additionally, late morbidity was scored using CTCAE v3.0.
: Thirtytwo patients (70 %) were treated with the IC approach
and 14 (30 %) with IC/IS using the Utrecht interstitial CT/MR
applicator. Median HRCTV volume was 45.1 cm 3 (12–182) at time of
the first BT application. Mean total D90 HRCTV was 84±9 Gy EQD2,
with a D2cc for bladder, rectum, sigmoid, and bowel of 83±7, 66±6,
61±6, and 64±9 Gy EQD2, respectively. Figure1 shows that higher D90
HRCTV values were easier achieved in smaller tumour volumes. No
significant relation was found between delivered dose and local
recurrences (only 3 cases). Median followup was 41 months for all
patients. Local control, progression free survival, and overall survival
at 3 years were 93, 72, and 65%, respectively. Failures occurred in 13
patients (28%): 3 local and 6 regional failures (persistent disease and
recurrences), 5 paraaortic failures, and 10 distant metastases. Table1
shows the progression free survival (PFS) and the failures in relation
to the FIGO stages.
Eighteen late morbidities (grade 35) were observed in 6 of 46
patients. Gastrointestinal toxicity: 2 rectal bleedings (G3), 2 proctitis
(G3), 1 diarrhoea (G3), 1 rectal incontinence (G4), 1 radiation
enteritis (G4), and 1 rectovaginal fistula (G4). Sexual/ reproductive
toxicity: 1 vaginal stenosis (G3) and 1 vagina mucositis (G4).
Renal/genitourinary: 1 ureter stenosis (G3).Musculoskeletal fibrosis
(G3) was seen in one patient, abdominal epidermolysis (G3) in one,
and one patient had anaemia (G3). Finally, one patient with vaginal
top necrosis (G4) and underlying coagulation disorder due to alcohol
related liver failure died because of vaginal bleeding (G5).
: The addition of MRI guidance to the treatment of
advanced cervical cancer results in high local control rates. Future
work should focus on the prevention of regional and distant failures
and the reduction of late toxicity.
PO236
3D IMAGE BASED VS. POINT BASED DOSIMETRY FOR CERVICAL CANCER:
EARLY OUTCOME ANALYSIS
N. Kannan 1 , H. Kim 2 , C. Houser 2 , S. Beriwal 2
1 University of Pittsburgh, School of Medicine, Pittsburgh, USA
: Currently, most of the published outcomes data
for cervical cancer brachytherapy utilizes pointbased dosimetry,
where the goal is to deliver 100% ± 5 % of the prescription dose to the
designated 'point A'. The last ABS survey, conducted in 2007, revealed
that 55% of the respondents used CTbased planning. Of these
respondents, 76% still prescribed to Point A instead of using a 3D
derived tumor volume. Radiation oncologists may be reluctant to
accept 3D imageguided brachytherapy (IGBT) plans for patients in
whom the point A dose is significantly lower than prescription dose
because of concerns for inferior outcomes. But using a fixed
prescription point can result in greater than necessary doses to the
adjacent bowel and bladder and a correspondingly greater risk of
serious treatment complications. The goal of our study was to look at
the response rates and outcomes of patients who were treated with
IGBT with CT or MRI based planning and had a point A dose that was
less than 90% of prescription dose.
: We have treated 103 patients from January
2007 to June 2011 with IGBT with the dose optimized to the HRCTV.
Of these patients, 30 with FIGO stage IB1 to IIIB had a point A dose
less than 90% of the prescription dose and were included in the study.
Eleven patients had pelvic and/or periaortic nodes visualized on
PET/CT. The median pretreatment tumor size was 4 (0.9 to 9.0) cm
and 11 patients had a tumor size ≥ 5 cm. The median age was 56
(range 2286). 22 patients had an MRIbased plan and 8 patients had a
CTbased plan for HDR brachytherapy. The brachytherapy dose was
5.5 Gy x 5 fractions (25 pts) and 5 Gy x 5 (5 pts). At planning, the goal
was to achieve D90 (dose to 90% of HRCTV) of ≥100% of prescription
dose. The point A dose was recorded but not used for prescription or
treatment. The median point A dose was 85 (50 to 89)% of the
prescription dose. The median HRCTV treated was 28.9 (15.338.5)
cc. The median EQD2 D90 HRCTV and median EQD2 Point A were
82.3 ( 75.989.8) Gy and 73.9 (58.074.9) Gy ( p

S96 World Congress of Brachytherapy 2012
: All thirty patients completed the planned course of radiation
treatment. All but two were available for assessment of response. All
28 patients had complete clinical response. Twentythree patients had
a followup PET/CT at 3 months posttreatment, and all showed
complete metabolic response in the cervix. One patient had residual
uptake in the leftexternal iliac node, but this was decreased when
compared to a pretreatment PET/CT. At the median followup time
of 7.2 months (334 months) ,one patient has developed recurrence
with bone metastases at 29 months. One patient developed a RTOG
grade 3 complication of enterovaginal fistula at 10 months post
therapy requiring surgical intervention. This patient’s point A % dose
was 85%, D90 HDR CTV 84 Gy (108%), and D2cc bladder, rectum, and
sigmoid colon doses were 79.5 Gy, 59.2 Gy, and 70.9 Gy respectively.
: Our early results suggest that the 3D dosimetry
translated into excellent response rate and early outcome in these
patients. The decrease in point A dose did not cause any detrimental
effects and should be reassuring to the treating clinician. We need
both interim and longterm outcome data with this approach for wider
adoption of this technique.
PO237
DOSIMETRIC EFFECTS OF RECTAL FILLING ON VAGINAL CYLINDER
BRACHYTHERAPY
S. Sabater 1 , I. Andres 1 , V. de la Vara 2 , M.J. Muñoz 2 , E. Jimenez 1 , M.V.
Carrizo 1 , A. Martos 1 , R. Berenguer 1 , A. Nuñez 1 , M. Arenas 3
1 Hospital General de Albacete, Radiation Oncology, Albacete, Spain
2 Hospital General de Albacete, Radiation Physics, Albacete, Spain
3 Hospital Sant Joan de Reus, Radiation Oncology, Reus, Spain
: Bladder filling variations have shown dosimetric
consequences on organs of risk on patients referred for vaginal
brachytherapy. Fewer reports have been focused on the effect of
rectal filling when treating such patients despite this subject has
received great attention on external irradiation. The aim of this study
was to evaluate the variation of rectal dose related to the rectal
distension, on patients treated postoperatively with vaginal cylinder
brachytherapy related to rectal distention.
: Retrospective brachytherapy evaluation was
done for seventeen patients with endometrial cancer treated with
fractionated postoperative HDR vaginal cuff cylinders (MicroSelectron)
alone or after an external radiotherapy course. Identical cylinder on
each insertion was used. A CTscan was done on each fraction.
Bladder was catheterized and filled with 50cc (5 cc of iodine contrast
dissolved in 45 cc of saline water during CT. No special instructions
were given to patients except for attempting to evacuate prior to
come to the hospital. Barium rectal contrast (50cc) was administered
in some fractions at discretion of the treating physician. 3D dose
planning was performed with PLATO v14.2.6. External surfaces of the
rectum and bladder were countered; bladder was contoured on all CT
scans. The rectum was contoured from 1 cm above the tip of cylinders
to the caudal well position level. Documented rectal doses were D0.1cc,
D1cc, D2cc, D5cc and D10cc. Doses were recorded as percentages from the
prescribed dose to 0.5 cm from the cylinder surface. Cross sectional
area (CSA) was also calculated
: Seventyfour CTseries were reviewed, 3 to 6 series per
patient (mean 4.7, median 4). Barium rectal contrast was
administered on the 16% of fractions. Percentages of fractions with
barium per patient fluctuate between 0% and 50%. Rectal volumes and
dosimetric results are tabulated in table 1. Independent non
parametrical test showed significance in all rectal level doses
analysed.
Mean Mean no barium Mean barium p
Rectum volume (cc) 47.32 45.34 57.73 .155
CSA 9.17 8.83 10.87 .083
D Rectum 0.1 cc (%) 118.26 115.1 134.81 .000
D Rectum 1 cc (%) 96.83 93.93 112.07 .000
D Rectum 2 cc (%) 87.56 84.61 103.02 .000
D Rectum 5 cc (%) 71.45 68.54 86.70 .000
D Rectum 10 cc (%) 56.03 53.37 69.93 .000
: Our preliminary results shown a dismal effect related to
the barium contrast enema. A significant increment of rectal doses
was evident over the full length of the rectal DVH related to such
intervention. Despite we could see as the rectal volume and CSA
increased as well, the first didn’t reached a statistically significance
and the second remained borderline. Our data attract attention to
avoid maneuvers that distend rectum and, if the data are confirmed,
could warrant to empty the rectum before any vaginal cuff
brachytherapy fraction.
PO238
DOSIMETRIC COMPARISON OF OPTIMISATION METHODS FOR
MULTICHANNEL INTRACAVITARY VAGINAL BRACHYTHERAPY
C. Lapuz 1 , C. Dempsey 2 , P. O'Brien 2
1
Peter MacCallum Cancer Centre, Division of Radiation Oncology,
Melbourne, Australia
2
Calvary Mater Newcastle, Department of Radiation Oncology,
Newcastle, Australia
: To compare dose distributions generated by
inverse planning simulated annealing (IPSA), dose point optimisation
(DPO) and graphical optimisation (GrO) for vaginal cancers treated
with high dose rate (HDR) brachytherapy using a multichannel
intracavitary vaginal cylinder.
: CT data sets were obtained for five
consecutive patients with recurrent vaginal cancers treated with
multichannel intracavitary HDR brachytherapy. Treatment plans were
generated using DPO, GrO, surface optimisation with IPSA (surf IPSA),
and volume optimisation with IPSA (vol IPSA). The plans were
evaluated for target coverage, conformal index (COIN), dose
homogeneity index (DHI) and dose to organs at risk (OARs).
: Vol IPSA and surf IPSA achieved the best target coverage with
mean V100 values of 95.46% (range: 90.56–98.81%) and 93.04% (range:
87.94–97.70%) respectively. Mean D90 was similar for GrO, surf IPSA
and vol IPSA plans. Rectal D2cc was within tolerance for all
optimisation methods. Vol IPSA plans resulted in slightly higher
bladder D2cc for some patients and higher vaginal mucosa D0.5cc for
all patients. Surf IPSA and DPO provided the greatest homogeneity
within the target volume with mean DHIs of 0.81 (range: 0.79–0.83)
and 0.81 (range: 0.78–0.83) respectively. Surf IPSA and GrO had the
highest conformity with mean COINs of 0.74 (range: 0.64–0.85) and
0.71 (range: 0.67–0.80) respectively. Vol IPSA plans had inferior
homogeneity and conformity with mean DHI of 0.55 (range: 0.48–0.68)
and mean COIN of 0.54 (range: 0.39–0.74).
: Surf IPSA was user friendly for the generation of
treatment plans and achieved good target coverage, conformity and
homogeneity with acceptable doses to OARs. Vol IPSA plans provided
good target coverage but resulted in higher doses to the vaginal
mucosa and lower COIN and DHI. DPO plans provided inadequate
coverage of the target volume. GrO resulted in acceptable plans but
at the expense of increased planning times.
World Congress of Brachytherapy 2012 S 97
PO239
THE ROLE OF VAGINAL BRACHYTHERAPY IN THE TREATMENT OF STAGE
I PAPILLARY SEROUS OR CLEAR CELL ENDOMETRIAL CANCER
B. Barney 1 , I. Petersen 1 , M. Haddock 1
1
Mayo Clinic, Academic Department of Radiation Oncology,
Rochester, USA
: International Federation of Gynecology and
Obstetrics (FIGO) Stage I papillary serous (PS) and clear cell (CC)
endometrial histologies were excluded or underrepresented on
practicedefining endometrial cancer trials, resulting in confusion
regarding the optimal adjuvant therapy for patients with these
tumors. Because they are at a high risk for both local and extrapelvic
relapse, adjuvant chemotherapy is commonly administered to these
women; however, recommendations for adjuvant radiotherapy vary
widely. We report on the largest singleinstitution experience using
adjuvant highdose rate (HDR) vaginal brachytherapy (VBT)
for patients with FIGO Stage I PS or CC endometrial cancer.
:From 1998 to 2011, 103 women with FIGO
2009 Stage I PS (n=74, 72%), CC (n=21, 20%), or mixed PS/CC (n=8, 8%)
endometrial cancer underwent surgical staging followed by adjuvant
HDR VBT. Surgery consisted of, at a minimum, total abdominal
hysterectomy and bilateral salpingooophorectomy (TAH/BSO), and
nearly all patients (n=98, 95%) also underwent extended lymph node
dissection, with a median number of nodes dissected of 45 (range, 0
to 100). Other common surgical procedures included peritoneal fluid
washings (n=92, 89%), omentectomy (n=83, 81%), and random
peritoneal biopsies (n=63, 61%). All VBT was performed with a multi
channel vaginal cylinder, treating to a dose of 21 Gy in 3 fractions.
The treatment volume consisted of the entire vaginal mucosa
extending from the vaginal cuff to within 1 to 2 cm of the urethral
meatus. Thirtyfive patients (34%) also received adjuvant platinum
based chemotherapy, either prior to (n=7, 20%) or after (n=28, 80%)
HDR VBT.
: At a median followup of 36 months (range, 1 to 146 months),
2 patients had experienced a vaginal recurrence (VR), and the 5year
Kaplan Meier (KM) estimate of VR was 3%. Rates of isolated pelvic
(PR), locoregional (LRR, VR + PR), and extrapelvic (EPR, including
intraabdominal) recurrence were similarly low, with 5year KM
estimates of 4, 7, and 10%, respectively. Estimates for 5year disease
free survival (DFS) and overall survival (OS) were 88 and 84%,
respectively (see Figure). On univariate analysis, having nonPS
histology was associated with an increased risk of VR (p=0.02).
: Vaginal brachytherapy is effective at preventing vaginal
relapse in women with Stage I PS or CC endometrial cancer. In this
cohort of surgically staged patients, the risk of isolated pelvic or
extrapelvic relapse was low, implying more extensive adjuvant
radiotherapy is likely unnecessary.
PO240
DAILY HDR BRACHYTHERAPY IN THE POSTOPERATIVE SETTING OF
ENDOMETRIAL CARCINOMA
A. Rovirosa 1 , I. Valduvieco 1 , A. Herreros 1 , C. Bautista 1 , I. Romera 1 , I.
Rios 1 , M. Arenas 2 , A. Biete 1
1 Hospital Clinic i Universitari, Radiation Oncology, Barcelona, Spain
2 Hospital Sant Joan de Reus, Radiation Oncology, Tarragona, Spain
: To analyze the preliminary results of HDR
brachytherapy (HDRBT) administered daily on local control and
toxicity in postoperative endometrial carcinoma (EC).
: From January 2007 to September 2010, 112
patients with FIGO Stage 24IA, 48IB, 14II, 12IIIA, IIIIIB, 8IIIC1 and
4IIIC2, were treated with HDRBT after surgery. Pathology: 99/112
endometrioid and 23/112 other types. Radiotherapy. Group 1: 70/112
External beam irradiation (EBI) + HDRBT (2 fractions 56Gy); Group 2:
42/112 HDRBT alone (4 fractions 56Gy). Toxicity evaluation: RTOG
scores for bladder and rectum; Objective criteria of LENTSOMA for
vagina. Statistics: Chisquare and Fisher exact test.
: With a mean followup of 29.5 months (range 9.653.6) no
patients developed vaginalcuff relapse. Toxicity. Group 1: early G1
G2 appeared in 9% in rectum, 8.5% bladder, 1.4% in vagina (stenosis);
late problems appeared in 8.5% in rectum (all G12 but 1 G3) and 25%
in vagina (all G12 but 1G4). Group 2: Early G12 toxicity 9.4% in
bladder, 6.9% in vagina; late problems appeared in 2.3% in rectum
(G1) and 6.9% in vagina (G12).
: Daily HDRBT using 2 fractions of 5Gy after EBI and 4
fractions of 5Gy as exclusive treatment was a safe regime in terms of
local control and toxicity; Group 1 had a higher incidence of late
vaginal toxicity. This regime allows all the treatment to be performed
in a lower overall interval time and is less resource consuming than
other regimes with a greater number of fractions.
PO241
THREEDIMENSIONAL IMAGE GUIDED PULSED DOSE RATE
BRACHYTHERAPY BOOSTING BULKY CERVICAL CANCER
T. Refaat 1 , W. Small Jr 1 , N. Lotfy 2 , A. Elsaid 2 , E. Lartigau 3 , P. Nickers 3
1
Northwestern University, Radiation Oncology, Chicago, USA
2
Alexandria University, Clinical Oncology, Alexandria, Egypt
3
Centre Oscar Lambret and University Lille II, Academic Radiation
Oncology Department, Lille, France
: Concomitant radiotherapy and platinumbased
chemotherapy is the standard of care for patients with locally
advanced cervical cancer. Pulsed Dose Rate (PDR) Brachytherapy
rather than High Dose Rate (HDR) Brachytherapy may decrease normal
tissue toxicity due to radiobiological advantages while maintaining the
ability to optimize dose distribution. This study aimed to determine
the feasibility, tolerance and effectiveness of Image Guided PDR
brachytherapy after External Beam Radiotherapy (EBRT) and weekly
cisplatin for cervix cancer.
: Forty female patients with histologically
confirmed Stage IB2 or II cervical cancer and treated with
concomitant EBRT and cisplatin followed by a PDR brachytherapy
boost were identified. All patients were initially evaluated with EUA,
CT, MRI, and laparoscopic lymphadenectomy or PET scan. Patients
received 45 50 Gy EBRT to the pelvis with concomitant weekly
cisplatin 40mg/m 2 for 56 cycles. All patients then underwent
reimaging with CT or MRI prior to brachytherapy. The brachytherapy
boost was accomplished with one insertion using an MRI compatible
tandem and ovoid applicator. A PLATO treatment planning system
using MRI imaging and target definition based on GEC ESTRO
guidelines was used. 0.5 Gy per fraction was delivered every hour for
a duration of 6070 hours to a total dose of 3035 Gy to the HR CTV
and 1015 Gy to the IR CTV. Dose to organs at risk (OAR), rectum,
bladder, and sigmoid was limited to

S98 World Congress of Brachytherapy 2012
The disease free survival was 92.5%. Acute toxicity was as follows:
10% grade 3 anemia, 2.5% grade 3 neutropenia and thrombocytopenia,
12.5% grade 3 diarrhea, 5% grade 2 and 2.5% grade 3 proctitis.
: There are few reports of PDR brachytherapy boost using
imageguidance in stage IB2 and II cervix cancer. In this study, a PDR
brachytherapy boost using MRI image guidance after external beam
radiotherapy and cisplatin was welltolerated. Although follow up was
relatively short, local control and toxicity appear comparable, and
possibly superior, to that in studies using imageguided HDR
brachytherapy. The advantages of PDR brachytherapy include a
reduction in medical resources by requiring only a single admission to
the operating room and reduction in physics time by requiring only
one treatment planning, reduction of total treatment time possibly
improving local control, reducing treatment induced toxicities and
minimal risk of radiation exposure to patient and medical personnel
PO242
125I SEED PERMANENT IMPLANTATION FOR PELVIC RECURRENT
GYNECOLOGICAL MALIGNANCIES AFTER MULTIPLE THERAPY
W. Jiang 1 , J. Li 1 , L. Zhu 1 , P. Jiang 1 , H. Wang 1 , J. Wang 1 , C. Liu 2 , H.
Yuan 2 , W. Ran 3
1
Peking University Third Hospital, Radiation Oncology, Beijing, China
2
Peking University Third Hospital, radiology department, Beijing,
China
3
Peking University Third Hospital, Ultrasound, Beijing, China
: To assess the feasibility, efficacy, and morbidity
of imageguided radioactive iodine 125 ( 125 I) seed implantation for
pelvic recurrent gynecological malignancies after multiple therapies.
: From July 2005 to July 2010, 11 patients with
125
pelvic recurrent gynecologic malignancies received I seed
implantation guided by computerized tomography (CT) or ultrasound.
The primary cancers were cervical cancer (n = 8), endometrial cancer
(n = 2), and leiomyosarcoma of the uterus (n = 1). Ten patients had
undergone surgery, EBRT and chemotherapy before seed implantation,
one had undergone only surgery and EBRT, and the median total dose
was 68 Gy (range, 50102 Gy). Seven patients were suffering from
pain. Six masses were treated by CTguided, one by intraoperative
ultrasound, two by ultrasound, two by transvaginal ultrasound, and
two by transrectal ultrasound. A median of 29 seeds per patient
(range, 10109) were implanted, with a median activity of 0.7 mCi
(range, 0.40.8 mCi). The actuarial median D90 is 13290cGy (5455.3
17110cGy)
: After a median followup of 13.6 months (range, 336
months), 85.7% (6/7) patients received relief from pain. Median local
control was six months (95% CI, 4.47.6 months). The 1 , 2, and 3
year local control rates were 18.2%, 18.2%, and 18.2%, respectively.
Median overall survival was 13.6 months (95% CI, 8.618.6 months).
The 1, 2, and 3year actuarial overall survival rates were 63.6%,
11.4%, and 11.4%, respectively. One patient (9.1%) developed grade 1
acute toxicity of the urinary system.
: Interstitial 125 I seed implantation guided by CT or
ultrasound is a safe and effective palliative therapy for patients with
pelvic recurrent gynecological malignancies after surgery and external
beam radiotherapy.
PO243
LATE TOXICITY AND TOLERANCE OF THE VAGINAL VAULT TO
INTRACAVITARY HIGH DOSE RATE BRACHYTHERAPY
O. KaidarPerson 1 , R. AbdahBortnyak 1 , A. Amit 2 , A. Nevelsky 1 , A.
Berniger 1 , R. Bar – Deroma 1 , S. Billan 1 , R. Ben Yosef 1 , A. Kuten 1
1
Rambam Health Care Campus Faculty of Medicine Technion,
Oncology Insitute, Haifa, Israel
2
Rambam Health Care Campus Faculty of Medicine Technion,
Gyneconcology unit, Haifa, Israel
: The tolerability of the vaginal vault to
radiotherapy is high; however, this was estimated only in studies using
intracavitary LDR brachytherapy. There are many differences between
HDR treatment plans making it challenging to evaluate its true
biologicalclinical effects; therefore, there is a need for a spectrum of
maximal surface doses that are safe without causing vaginalvault
necrosis combined with acceptable long term complication rates.
The aim of this study was to evaluate the late effects and tolerance of
the vaginal vault after concomitant chemotherapy with pelvic
irradiation and intracavitary HDR brachytherapy.
: A retrospective review of the medical records
of all consecutive patients who were treated between 1998 and 2002
was undertaken. Analyzed parameters included radiation dose and
treatment–associated late sequelae of the vaginal vault, rectum and
bladder. Vaginal, rectal and bladder toxicity was graded according to
the Common Terminology Criteria for Adverse Events (CTCAE) Version
4.0. The HDR vaginal mucosal dose was calculated for 4 central
reference points on the surface of the ovoids. The maximal vaginal
surface dose was defined as the sum of the physical doses of the
maximal HDR dose (out of the 4 reference points) and the external
irradiation dose.
: Fifty patients were included in the study; the average age at
diagnosis was 54 (range 30 – 87) years. There were no records of acute
grade IV toxicity during treatment. Seven patients were lost to follow
up. The maximal HDR vaginal surface dose was 103 Gy. The maximal
combined external and HDR vaginal surface dose was 148 Gy. There
were no cases of vaginal necrosis or fistulas. There were no cases of
grade IV late vaginal, rectal or bladder toxicity. No correlation was
found between the maximal vaginal surface dose and vaginal, rectal
or bladder toxicity.
: Concomitant chemoradiotherapy including pelvic
radiotherapy and HDR intracavitary brachytherapy is safe in the
definitive treatment of advanced uterine cervix carcinoma. The
tolerance dose of the vaginal vault using HDR brachytherapy and
pelvic irradiation exceeds 148 Gy.
PO244
A DOSIMETRY PHANTOM FOR GYNEOCOLOGICAL BRACHYTHERAPY
M. Nazarnejad 1 , D.R. Mahdavi 2
1 Medical Radiation Engineering Science and Research Branch Islamic
Azad University Tehran Iran, Medical Radiation Engineering, Tehran,
Iran Islamic Republic of
2 Tehran University of Medical Sciences Science and Research Branch
Islamic Azad University Tehran Iran, Medical physics, Tehran, Iran
Islamic Republic of
: Dosimetric accuracy is a major issue in the
quality assurance program of treatment planning systems (TPS). An
important contribution to this process has been a proper dosimetry
method to guarantee the accuracy of delivered dose to the tumor. In
brachytherapy (BX) of gyneocological (Gyn) cancer it is usual to insert
combination of tandem & ovoids applicators with a complicated
geometry which makes their dosimetry verification difficult and
important. Therefore, evaluation and verification of dose distribution
is necessary for accurate dose delivery to the patients.
: The solid phantom was made from Perspex
slabs as a tool for intracavitary brachytherapy dosimetric quality
assurance. Film dosimetry (EDR2) was done for a combination of
ovoids and tandem applicators introduced by Flexitron brachytherapy
World Congress of Brachytherapy 2012 S 99
system. Treatment planning was also done with Flexiplan 3DTPS to
irradiate films sandwiched between phantom slabs. Isodose curves
obtained from treatment planning system and film were compared
with each other in 2D and 3D manners.
: The brachytherapy solid phantom was constructed with slabs.
It was possible to insert tandem and ovoids and after loaded with
radioactive source of Ir192. Relative error was between 38.6% and
average relative error was 5.08% in comparison between film and TPS
isodose curves.
: Our results showed that the difference between TPS and
measurement is well in tolerance limits and below the action level
according to AAPM TG.45. Our findings showed that this phantom
after minor corrections can be used as a method of choice for inter
comparison analysis of TPS and to fill the existed gap for accurate
quality assurance program in intracavitary brachytherapy. Constructed
phantom also showed can be a valuable tool for verification of
accurate dose delivery to the patients as well as training for
brachytherapy residents and physics students.
PO245
EFFECT OF BLADDER DISTENSION ON DOSIMETRY OF ORGAN AT RISK IN
CT BASED PLANNING OF HDR ICBT FOR CERVICAL CANCER
K. Sazzad Manir 1 , P. Niladri B 1 , B. Swapnendu 2 , G. Jyotirup 3 , K. Apurba
K 1 , S. Shyamal K 1 , B. Kallol 1 , G. Kaushik 2
1
Medical College Kolkata, Dept of Radiotherapy, Kolkata, India
2
R.G.Kar Medical College Kolkata, Dept of Radiotherapy, Kolkata,
India
3
Wset Bank Hospital, Dept of Radiotherapy, Howrah, India
: Distension and shape of urinary bladder may vary
during ICBT for cervical cancer, significantly affecting doses to
bladder, rectum and sigmoid colon and consequently late radiation
toxicities.
To evaluate the effects of fixed bladder distension with different
volumes on dosimetry, assessed by three dimensional image based
planning techniques, in bladder, rectum and sigmoid colon in cancer
cervix patients during ICBT.
: Forty seven patients of cervical cancer (stage
IB to IVA) were taken for ICBT following EBRT (50Gy in 25 fractions,
5days a week).
Patients were grouped in 4 different groups:
Group A :Empty bladder group (defined as no extra saline or contrast
material given after Foleys catheter insertion, gentle evacuation of
bladder done by Foleys catheter)
Group B(upto 40ccinstillation)
Group C(41cc80cc instillation)
Group D(81cc and above instillation).
Planning CT scans were performed after insertion of applicators and
three dimensional treatment planning was done on Brachyvision
treatment planning system (Varian Medical Systems, Palo Alto, CA).
Dose volume histograms were analysed. Bladder, rectum, sigmoid
colon doses were collected for individual plans and compared, based
on the amount of bladder filling .
Dose volume data from the different groups were compared using
Multivariate Regression Model (ANOVA, Post Hoc test). A pvalue of
less than 0.05 was considered statistically significant. Adjustment for
potential confounders [including parity, tumor stages, and type of
applicator used] was performed in multiple linear regression models.
: Mean dose to the bladder significantly decreased with
increased bladder filling.
On Post Hoc test analysis and multivariate analysis during multiple
comparisons among each groups it was found that mean dose of
bladder was significantly decreased in Group D in comparison with
group A (p value 0.001)and also with group B (p value 0.038)..(Mean
value of mean dose of bladder were 3.2Gy in Group A, 2.9Gy in Group
B, 2.8 Gy in Group C and 2.2 Gy in Group D.). This finding was also
validated by Kruskal Wallis test (Monte Carlo significance was 0.02)
and Mann Whitney U test.
However, doses to the small volumes (0.1cc, 1cc,2cc) which are
relevant for brachytherapy, did not change significantly with bladder
filling for bladder, rectum or sigmoid colon.
On analysing covariable factors such as parity, stage, applicator type
(multivariate analysis) it has been found that maximum dose of
bladder along with two DVH parameters (0.1ml,1ml volume dose) are
increased in higher parity groups and the change is statistically
significant (average p value was 0.0025) and weak positive correlation
exists.
: There is no significant change in the bladder, rectum
and sigmoid colon dosimetric parameters with bladder distention.
Though mean bladder dose decreaseswith distension of bladder there
is no change of small volume dose parameters (o.1cc, 1cc,2cc) which
are actually important for late toxicities in ICBT patients. A larger
study with clinical correlation of late toxicities is needed to is needed
to evaluate this strategy.
PO246
OVERALL SURVIVAL RATES IN LOCALLY ADVANCED CERVIX CANCER A
BRAZILIAN EXPERIENCE
C. Campos 1 , J.V. Salvajoli 2 , P.E. Novaes 3 , M.G.C. da Silva 4 , J.A.A.
Oliveira 5 , F.J.M. Neto 5
1
Hospital Haroldo Juacaba, Radiatio, Fortaleza, Brazil
2
Instituto do Cancer do Estado de Sao Paulo ICESP, Radiation
Oncology, Sao Paulo, Brazil
3
Instituto Santista de Oncologia ISO, Radiation Oncology, Sao Paulo,
Brazil
4
Hospital Haroldo Juacaba, Epidemiology, Fortaleza, Brazil
5
Universidade do Estado do Ceara UECE, Medicine, Fortaleza, Brazil
: Evaluate the overall survival rates in locally
advanced cervix cancer patients and determine the clinical and
treatment prognostic factors for local control and overall survival
rates.
: A retrospective cohort study was carried out
with 261 patients stage IIIB, 164 patients received 54 Gy RT to the
pelvis and 30 Gy of HDR without chemotherapy and 97 patients
received 54 Gy RT to the pelvis and 30 Gy of HDR with weekly
cisplatin 40mg/m2 IV (CDDP) from August 1998 to June 2004 in
Hospital Haroldo Juacaba, a Brazilian northeastern hospital. The mean
followup time was 50 months (2185 months) and the KaplanMeier
method was used to calculate survival curves. The nonnormal
distributions were evaluated by nonparametric tests, Cox regression
was used to evaluate multivariate analysis and P values =< 0, 05 were
considered significant.
: Local control rates were 39.6% for exclusively radiation and
50.5% for chemoradiation. There was no statistically significant
difference between groups (p = 0.19). The overall median 5year
survival rate for exclusively radiation was 38.4% and 47.4% for
chemoradiation. The results were not statistically significant (p =
0.36). The mean treatment time was 61 days (39 to 210 days). Both
local control and overall survival rates were affected by age,
parametrial involvement and the timing of brachytherapy (p0.05). But less than six cycles of chemotherapy improved
local control rates better than six or more cycles (55.1% versus 44.9%
p = 0.02).
: The bilateral parametrium infiltration (hazard ratio=
2.96 95% CI 1.306.76 p=0.009) and age

S100 World Congress of Brachytherapy 2012
: To assess feasibility and implementation of
Interstitial implant using thermoplastic Poly Ether Etherketone
(PEEK) catheters for MRIbased brachytherapy of advanced cervical
cancer in the absence of MR compatible applicators.
: Brachytherapy in cervical cancer is integral
part of the treatment. Gynecological (GYN) GECESTRO introduced
concepts and terms in 3D image based 3D treatment planning in cervix
cancer brachytherapy with emphasis on MRI assessment of GTV and
CTV and given the recommendations.
We have treated few cases of stage IIIB cervical cancer first with
external beam radiotherapy to a dose of 50 Gy in 25 fractions to
whole pelvis using 3D conformal therapy. In our center we lack the MR
Compatible Brachytherapy Applicators, but we use to treat them with
interstitial brachytherapy using stainless steel needles with CT
imaging. To overcome this we did implant using semiflexible
thermoplastic PEEK catheters with Syed Neblett template. These
catheters are biocompatible and whole applicator set is MR
compatible. Dicom images of MRI T1 and T2 sequences were imported
to Varian brachyvision. With the help of MRI we were able to
reconstruct these catheters and volume were delineated in
accordance with the GEC ESTRO recommendations. We have
delineated GTV, HR CTV on T2 weighted images.
: We prescribed the dose of 6Gy X4# to HR CTV. Volume
optimization was done in Varian Brachyvision. Dose–volume histograms
were calculated to evaluate doses to tumour, target volumes and
organs at risk. Dose values were biologically normalised to equivalent
doses in 2 Gy fractions (EQD2, equivalent to 50 cGy/h low dose rate)
applying the linearquadratic model. The average tumor volume was
58.8cc.The 3D dose volume parameters were D90 (6.65Gy) 87 EQD2,
D100 (5.25Gy) 77Gy EQD2, V15028.4cc, V200 15.67cc and the Dose
to 2cc Rectum79 Gy EQD2, bladder 81Gy EQD2.
: MR Based Interstitial Brachytherapy using PEEK catheters
and GYN GECESTRO Guidelines is feasible. Further refinement and
improvement in dose volume parameters especially rectum for pure
interstitial HDR brachytherapy needs to be defined.
PO248
GYNAECOLOGICAL BRACHYTHERAPY: USING A SPREADING APPLICATOR
TO INDIVIDUALIZE DOSE TO THE VAGINAL APEX
J. Biesta 1 , L. KwakkelHuizenga 1 , T. Stam 1 , P. Koper 1 , T. Oorschot
van 1 , M. Mast 1 , E. Kouwenhoven 1
1
Radiotherapy Centre West, Radiotherapy, Den Haag, The
Netherlands
: When using a standard applicator, the dose to the
mucosa of the vaginal apex is often too low, since the vaginal fold at
the top is generally wider than in the lower part. We, therefore,
developed a vaginal applicator which can be expanded thus providing
an optimal coverage of the mucosa of the vagina. Purpose of the study
is to investigate the mucosal coverage using this applicator.
: The spreading applicator consists of two
identical parts that hinge at 7 cm from the top. The applicator is
covered by a condom to ensure that no vaginal tissue will be caught
between the two spreading parts.
In ten patients two CTscans were made, one with the applicator
closed and one with the applicator fully opened. In both scans vaginal
contrast was used.
The volume of contrast and air around the applicator was delineated
in both scans and compared, see the figure. These volumes were
determined for the cranial 5 cm of the vagina.
: In the table the air/contrast volumes of both scans are
presented.
Patient Opened (cm 3 ) Closed (cm 3 )
1 2.8 7.5
2 3.6 10.3
3 0.3 0.5
4 0.0 0.0
5 0.0 0.2
6 0.6 3.7
7 1.3 2.2
8 0.7 2.1
9 0.0 0.0
10 0.0 0.6
Mean 0.9 2.7
SD 1.3 3.5
: In 7 of the 10 patients we demonstrated that the
mucosal coverage by the closed applicator was less optimal than by
the opened applicator. This could lead to an underdosage of the
vaginal mucosa. Further research will be performed and presented to
show the effect on the isodose pattern using both applicator types.
PO249
HDR BRACHYTHERAPY BOOST IN GYNAECOLOGICAL CANCERS, WHAT'S
THE PERFECT TIMING TO PREVENT VAGINAL STENOSIS?
F. Piro 1 , D. Cosentino 1 , P. Indrieri 1 , P. Ziccarelli 1 , L. Ziccarelli 1 , L.
Marafioti 1
1 Mariano Santo, Radiotherapy, Cosenza, Italy
: To evaluate the best timing schedule, after or
before 3D conformal radiotherapy (ERT), of high dose rate
brachytherapy boost (BBRT) in gynaecological cancers in an
experience of the unique regional Center performing BBRT.
World Congress of Brachytherapy 2012 S 101
: From January 2009 196 pts. with endometrial
cancer were treated with BBRT plus ERT in postoperative setting as
out patients. The treatment schedule was 18 Gy in 3 fractions as
boost before ERT to pts. of our Center (group A), to pts. by others
Centers BBRT (group B) was performed after ERT (conformal 3D
radiotherapy in both cases) the dose was prescribed to 5 mm from the
surface of the applicator 3 cm the active length of the source. The
implant optimisation was performed recognizing the bladder dose and
the rectal dose as average of almost 3 points for each critical organ
with a semi3D technique aided by simulator, the optimal targetdose
volume was determined with radiopaque marker into the rectum and
Foley catheter balloon in the bladder. We measured the lenght and
the diameter of each vaginal cilinder so we calculated the volume of
treated vagina. By these data we enrolled a third observational group
(C) consisting of only 10 pts. from our center with volume of treated
vagina measured before and after ERT and finally underwent to BBRT.
: In the group A we enrolled 116 pts. the others 70 in group B.
The median lenght, diameter and volume of both groups resulted the
same, while the recorded ranges of each parameter were different
expecially for measured volume ( 7.530 cm³ for A versus 530 cm³ for
B ).In the B group we also recorded pain during the introduction of
vaginal cilinder and acute toxicity G1G2 of bladder and rectum,
requiring supportive care by ERT; so the vaginal introduction of
complete cilinder was more difficult than group A. In group C the
median reduction of the measured volume of vagina resulted 25% (10
35%).In the group A the vaginal lenght at the first follow up after the
treatment completation was the nearest to the lenght during the
simulation. In the B group the BBRT was performed 23 weeks after
the completation of ERT.
: The use of HDR Brachitherapy to boost gynaecological
cancers is widely accepted. Vaginal stenosis by Radiotherapy is an
acute toxicity that starts at the beginning of treatment and increases
using small vagynal cilinder, so to obtain a perfect timing for boost
after ERT we need more collaboration with the neighbouring centers.
Boost before ERT increases pts. compliance to treatment and probably
reduces geographic missing.
PO250
CONCURRENT CHEMORADIOTHERAPY WITH HDR INTRACAVITARY
BRACHYTHERAPY FOR CERVICAL CANCER: A PHASE II STUDY
T. Toita 1 , R. Kitagawa 2 , T. Hamano 3 , K. Umayahara 4 , Y. Hirashima 5 , Y.
Aoki 6 , M. Oguchi 7 , M. Mikami 8 , K. Takizawa 4
1
University of Ryukyus, Radiology, Okinawa, Japan
2
NTT Medical Center Tokyo, Obstetrics and Gynecology, Tokyo, Japan
3
Kitasato University, Biostatistics, Tokyo, Japan
4
Cancer Institute Hospital, Gynecology, Tokyo, Japan
5
Shizuoka Cancer Center Hospital, Gynecology, Shizuoka, Japan
6
University of Ryukyus, Obstetrics and Gynecology, Okinawa, Japan
7
Cancer Institute Hospital, Radiation Oncology, Tokyo, Japan
8
Tokai University School of Medicine, Obstetrics and Gynecology,
Kanagawa, Japan
: A multicenter phase II trial was conducted to
assess the efficacy and toxicity of concurrent chemoradiotherapy
(CCRT) with highdoserate intracavitary brachytherapy (HDRICBT)
using a low cumulative dose schedule in patients with locally
advanced uterine cervical cancer.
: The Japanese Gynecologic Oncology Group
(JGOG) study JGOG1066 enrolled patients with FIGO stage IIIIVA
cervical cancer who had no paraaortic lymphadenopathy (> 10mm) as
assessed by CT. Patients received definitive radiotherapy consisting of
wholepelvis external beam radiotherapy (EBRT), pelvic EBRT with
midline block, and HDRICBT. The cumulative linear quadratic
equivalent dose (EQD2) was 6265 Gy prescribed at point A. Three
dimensional planning using CT/MRI was not applied. Cisplatin (40
mg/m 2 weekly) was administered concurrently with radiotherapy for 5
courses. All patients received individual case review of radiotherapy
quality assurance.
: Of the 72 patients registered from 25 institutions between
March 2008 and January 2009, 71 patients were eligible. Median age
of the patients was 57 years. FIGO stages were IIIA in 3 patinets, IIIB
in 64 patients, and IVA in 4 patients. Median tumor diameter, as
assessed by MRI, was 55 mm. With a median followup of 28 months,
21 patients had pelvic failure (primary=14, node=6, other=1), and 17
patients developed distant metastases (paraaortic=11, lung=2,
other=4). The 2year pelvic disease progressionfree rate (PDF) was
73% (95% CI, 61% to 82%). The 2year progressionfree survival rate
and overall survival rate were 66% (95% CI, 54% to 76%), and 90% (95%
CI, 80% to 95%), respectively. The 2year cumulative late complication
rates by grades were 24% for all grades, 9% for grade 1, 12% for grade
2, 3% for grade 3, and 0 for grades 4/5.
: Despite a limited followup period, the JGOG1066 study
demonstrated that CCRT using HDRICBT with a low cumulative RT
dose schedule achieved comparable pelvic disease control to that
achieved with global dose schedules (EQD2=85Gy), with a lower
incidence of late toxicity for patients with locally advanced uterine
cervical cancer.
PO251
IMPACT OF BLADDER DISTENSION ON ORGANS AT RISK IN 3D
INTRACAVITARY BRACHYTHERAPY FOR GYNECOLOGICAL CANCER
H. Bajwa 1 , K. Rehman 1 , I. Niazi 2 , M. Ali 2 , I. Haider 1 , S. Usman 1 , A.
Masood 1
1
Shaukat khanum Memorial Cancer Hospital, Radiotherapy, Lahore,
Pakistan
2
Shaukat khanum Memorial Cancer Hospital, Radiology, Lahore,
Pakistan
: To determine the effects of bladder distension on
organs at risk (OAR) in intracavitary brachytherapy (ICBT) for
gynecological cancer with 3D Image Based Planning
: Thirtytwo patients with gynecological cancer
were treated with highdose radiation (HDR) brachytherapy, out of
which twentyeight were diagnosed with cervical cancer and treated
with 700 cGy/fraction for 4 fractions and the remaining four were
diagnosed with endometrium cancer and treated with 600
cGy/fraction for 2 fractions. Pelvic CT scans were obtained from
patients with indwelling catheters in place defined as empty bladder)
and from patients who received 200 cc injections of sterile water in
their bladders (defined as full bladder) for threedimensional (3D)
analysis. Regions of Interest (ROI) were drawn by a radiologist for four
organs at risk (OAR): bladder, rectum, sigmoid colon and small bowel.
All planning parameters including dwell positions and dwell times
were kept constant for both plans. Dose Volume Histograms (DVHs)
were used to compare the maximum dose and the mean dose of the
OAR when the patient had empty bladder (Emax and Emean
respectively) with the maximum dose and mean dose when the
patient had full bladder (Fmax and Fmean respectively).
: The Emean of bladder was 277cGy and the Fmean was
208cGy (P = 0.000) and Emax of bladder was 1710 cGy and Fmax was
2298cGy (P = 0.000).
The Emean of rectum was 196cGy and the Fmean was 198cGy (P =
0.000) and Emax of rectum was 986cGy and Fmax was 951cGy (P =
0.058).
The Emean of sigmoid colon was 135cGy and the Fmean was 107cGy (P
= 0.000) and Emax of sigmoid colon was 1792cGy and Fmax was
899cGy (P = 0.000).
The Emean of small bowel was 104cGy and the Fmean was 67cGy (P =
0.000) and Emax of small bowel was 1469cGy and Fmax was 609cGy (P
= 0.000).
: This study shows that treating patients with full bladder
results in reduced organexposure in the case of sigmoid colon and
small bowel. Although the maximum bladder dose was higher, the
mean dose was less, reducing thereby the risk of complications. The
rectal dose, however, was not affected by the bladder state.
PO252
ADJUVANT CARBOPLATIN/PACLITAXEL AND INTRAVAGINAL RADIATION
FOR STAGE III SEROUS ENDOMETRIAL CANCER
A. Kiess 1 , S. Damast 2 , V. Makker 3 , M.A. Kollmeier 1 , G.J. Gardner 4 , N.R.
AbuRustum 4 , R.R. Barakat 4 , K.M. Alektiar 1
1
Memorial SloanKettering Cancer Center, Dept of Radiation
Oncology, New York NY, USA
2
Yale School of Medicine, Dept of Therapeutic Radiology, New Haven
CT, USA
3
Memorial SloanKettering Cancer Center, Gynecologic Medical
Oncology Service, New York NY, USA

S102 World Congress of Brachytherapy 2012
4 Memorial SloanKettering Cancer Center, Gynecology Service, New
York NY, USA
: The optimal management for early stage high risk
endometrial cancer is evolving. The purpose of this study is to report
a single institution experience with concurrent adjuvant intravaginal
radiation (IVRT) and carboplatin/paclitaxel chemotherapy for early
stage serous endometrial cancer.
: From 10/2000 to 12/2009, 41 women with
stage III (FIGO 2009) serous endometrial cancer were treated with
surgery followed by high dose rate IVRT using Ir192 (median dose of
21 Gy in 3 fractions) and concurrent carboplatin (AUC=5) and
paclitaxel (175 mg/m2) given every three weeks for six planned
cycles. Each IVRT fraction was given in between cycles of
chemotherapy with an interval of at least 1 week between
treatments. Patients with positive peritoneal cytology were excluded.
Toxicities were recorded by CTCAE criteria (version 3). KaplanMeier
methods were used to estimate survival, and the logrank test was
used for comparison.
: The mean age was 67 years (range, 5180 years). Surgery
consisted of hysterectomy (TAH/BSO in 51%, LAVH/BSO in 49%),
peritoneal washing, omental biopsy, pelvic lymph node dissection
(median 16 nodes), and selective paraaortic node sampling (in 93%,
median 6 nodes). Thirty patients had stage IA disease (73%), 4 had
stage IB (10%), and 7 had stage II, i.e. cervical stromal invasion (17%).
Histology was pure serous in 68% and mixed in 32% of patients. Thirty
five patients (85%) completed all 6 cycles of carboplatin/paclitaxel
and 3 IVRT treatments. Six patients did not complete therapy due to
allergy (1), physician preference (2), or toxicity (3). All toxicities (of
all grades) are presented in Table 1.
With a median followup time of 58 months, the 5year diseasefree
and overall survival rates were 85% (95% CI, 7396) and 90% (95% CI,
80100), respectively. The 5year actuarial recurrence rates were 9%
in the pelvis, 5% in the paraaortic nodes, and 10% at distant sites.
None of the patients developed vaginal recurrence. Of the 4 patients
with pelvic recurrence, 2 had isolated disease and were successfully
salvaged. Patients with stage II disease had significantly lower
diseasefree survival (71% vs 88%; p=0.017) and overall survival (71% vs
93%; p=0.001) compared to patients with stage I disease.
Table 1. Toxicity of combined adjuvant therapy.
: Based on this study, concurrent adjuvant
carboplatin/paclitaxel and IVRT provide excellent outcome for
patients with early stage serous endometrial cancer. The subset of
patients with cervical stromal invasion (stage II) still represents a
therapeutic challenge. The question of whether adjuvant IVRT and
chemotherapy are superior to standard pelvic radiation will require
further confirmation from the ongoing international randomized trial.
PO253
VAGINAL VAULT HDR BRACHYTHERAPY AS SOLE ADJUVANT THERAPY
FOR ENDOMETRIAL CANCER
A. Stillie 1 , M. Zahra 1
1
Western General Hospital, Clinical Oncology, Edinburgh, United
Kingdom
: To evaluate the effectiveness and toxicity of HDR
vaginal vault brachytherapy as sole adjuvant therapy, following
hysterectomy, for high intermediate risk endometrial cancer.
: HDR vaginal vault brachytherapy was
introduced in this centre in January 2009. Between 30/1/2009
29/10/2010 a total of forty patients, treated with adjuvant HDR
vaginal vault brachytherapy as sole adjuvant therapy for endometrial
cancer, were identified. Patients were treated with a single line
source vaginal applicator (Varian Medical Systems) to deliver a dose of
7Gy per fraction to a depth of 5mm from the applicator surface. A
total of three fractions were administered once a week with an
overall treatment time of 14 days to deliver 21Gy in 3 fractions.
: The median age of patients at diagnosis was 69. Patients
were managed surgically with a TAH or TLH, BSO, and washings. One
patient did not undergo resection of the cervix due to perioperative
complications associated with their elevated BMI. The majority of
patients (65%) had FIGO Stage IB disease. Ten patients (25%) had
involvement of the cervical glands. At a median follow up of 22
months two patients (5%) have died from disseminated endometrial
cancer. High risk features were present at diagnosis in one patient
(LVSI, Grade 3, Clear Cell histology) however due to advanced age and
significant medical co morbidities additional adjuvant therapy in the
form of systemic chemotherapy and pelvic radiation therapy was not
administered. The other patient had no high risk features present at
diagnosis and developed pulmonary metastases, but no loco regional
recurrence, within 6 months of adjuvant treatment. A third patient
developed loco regional relapse and remains alive with stable disease
following a course of palliative chemotherapy. In this case the initial
pathology was reported as a grade 2 adenocarcinoma with no high risk
features. Biopsy of the vaginal vault recurrence demonstrated a
degree of serous papillary differentiation. A pathology review of the
original specimen, following the diagnosis of relapse, confirmed no
evidence of high risk features.
Toxicity data was recorded at each clinic visit for all patients, there
were no significant toxicities identified. Grade 1 vaginal stenosis was
reported in a small proportion of patients.
: HDR vaginal vault brachytherapy for high intermediate
risk endometrial cancer is a well tolerated treatment associated with
high rates of pelvic control.
PO254
HDR BRACHYTHERAPY FOR HIGH GRADE VAGINAL INTRAEPITHELIAL
NEOPLASIA
S.H. Mhlanga 1 , L. Pule 1 , F. Mohammed 2 , J.A. Kotzen 2
1
Charlotte Maxeke Hospital, Medical Physics, Johannesburg, South
Africa
2
Charlotte Maxeke Hospital, Radiation Oncology, Johannesburg, South
Africa
: To determine the efficacy and safety of High
Dose Rate (HDR ) Brachytherapy for High GradeVaginal Intraepithelial
Neoplasia.
: A retrospective study of patients treated with
HDR Brachytherapy at Johannesburg hospital from 2007 to 2011 was
performed by reviewing patient charts.There were 6 patients . A Dose
of 54 Gy in 18 twice daily fractions of 3.0 Gy each was delivered to
5mm from the surface of a personalized vaginal mould.
: No patients have relapsed. There was one case of severe
mucositis.
: Fractionated HDR Brachytherapy appears to be an
effective modality for controlling High Grade Vaginal Intraepithelial
Neoplasia, with an acceptable complication rate.
PO255
HIGH DOSERATE INTERSTITIAL BRACHYTHERAPY FOR GYNECOLOGICAL
MALIGNANCIES
N. Murakami 1 , T. Kasamatsu 2 , K. Takahashi 1 , K. Inaba 1 , Y. Kuroda 1 , M.
Morota 1 , H. Mayahara 1 , Y. Ito 1 , M. Sumi 1 , J. Itami 1
1 National Cancer Center, Radiation Oncology, Tokyo, Japan
2 National Cancer Center, Gynecologic Oncology, Tokyo, Japan
: The purpose of this study is to retrospectively
analyze the results of high doserate interstitial brachytherapy
(HDRIBT) for gynecological malignancies.
World Congress of Brachytherapy 2012 S 103
: We reviewed the records of 39 patients with
histologically confirmed gynecological malignancies who were treated
by HDRIBT between 2008 and 2011 in our institution. Primary lesion
was cervix in 21, vagina in 11, corpus in 4, ovary in 2, and vulva in 1.
Thirteen patients were treated as a primary treatment, 18 as salvage
for recurrence after prior surgery, 4 for residual lesion after surgery,
and 4 as salvage for recurrence after prior radiation therapy.
Squamous cell carcinoma was seen in 23, adenocarcinoma in 13, and
the remaining 3 had other histologies. Median tumor size was 3.7cm
(range 18cm). Thirty one patients were treated by radiation therapy
alone and 8 patients were irradiated concurrent with chemotherapy.
In the patients without prior radiation therapy, pelvic external
irradiation was performed before HDRIBT. Median dose of pelvic
irradiation was 30 Gy (range 2650 Gy). Either metallic or plastic
needle applicators were used for HDRIBT. Median number of
applicators was 15 (range 529). Dose per fraction for HDRIBT was
either 4 or 6 Gy and median fraction of brachytherapy was 4 (range 3
9). Median clinical target volume (CTV) was 35.5 ml (range 2.4142.1
ml), median CTV D90 was 6.16 Gy (range 4.388.15 Gy), median
rectum D2cc was 3.47 Gy (range 0.995.81 Gy), and median bladder D2cc
was 3.69 Gy (range 1.015.88 Gy). Median followup period was 16.3
months (range 6.038.1 months). We calculated treatment result of
local control (LC), progression free survival (PFS), overall survival
(OS). We also tried to identify the prognostic factors of LC and
treatment complications using univariate analysis.
: The 2year LC, PFS, OS for all patients were 73.8%, 51.9% and
69.6% respectively. The frequency of local recurrence and distant
metastasis was 23.1% (9/39 pt.) and 20.5% (8/39 pt.). Vaginal ulcer
was seen in 3 patients, 2 of them were recurrence case after prior
radiation therapy. Treatment indication as primary treatment, no
prior chemotherapy, performance of pelvic irradiation combined with
brachytherapy, and usage of concurrent chemotherapy showed
tendency for good LC (p=0.103, 0.06, 0.115 and 0.111). Regarding
vaginal ulcer, prior radiation therapy before treatment was a
statistically significant prognostic factor(p=0.034)
: HDRIBT for gynecologic cancers both for primary and
salvage treatment yields good result. Attention must be paid
regarding vaginal ulcer for patients who had experience of prior
radiation therapy and dose parameter predicting vaginal morbidities
must be sought.
PO256
CT IMAGE GUIDED LOW DOSE RATE BRACHYTHERAPY FOR CERVICAL
CANCER: TRANSITIONING FROM 2D TO 3D, ARE WE THERE YET?
C. Nelson 1 , V. Narra 1 , S. Motwani 1 , M. Gabel 1
1
Robert Wood Johnson Medical School, Department of Radiation
Oncology, New Jersey, USA
: Traditional lowdoserate (LDR) brachytherapy
for cervical cancer utilizes 2D imaging and reference points
approximating target dose and organs at risk (OAR). Recent image
guided brachytherapy (IGBT) advances with MRI compatible LDR
applicators allow for 3D planning but are limited to facilities with MRI
machines. For those facilities with CT simulators, the CTcompatible
Henschke applicator (Mick RadioNuclear Instruments, Inc; Mount
Vernon, NY) provides IGBT capabilities for LDR cervical
brachytherapy. We report our initial institutional experience using CT
guided LDR for cervical cancer.
: Between December 2009 and September
2011, definitive LDR brachytherapy was delivered in 19 consecutive
treatments to 11 patients at Robert Wood Johnson University Hospital.
All patients received 4547.6 Gy (median 45 Gy) of external beam
radiotherapy to the whole pelvis. Intracavitary insertions were
performed twice for 9 patients and a single insertion for 2 patients.
CT scans were obtained and the intended dose prescribed to Point A
was 90 Gy. OAR volumes for bladder, rectum, sigmoid and small bowel
were contoured and the 1, 2 and 5 cc organ volumes were compared
to ICRU reference point dose estimates.
: Total Point A doses ranged from 84.7 to 92.9 Gy, with mean
dose of 88.8 Gy. The mean rectal point dose (57.0 Gy) was 64% of the
Pt A dose, compared to the 1, 2, and 5 cc rectal volume doses of 78%
(69.3 Gy), 76% (67.4 Gy) and 72% (64.0 Gy) respectively. Mean mid
Foley balloon point dose (64.7 Gy) was 73% of Pt A compared to 95%
(84.1 Gy), 91% (80.6 Gy), and 84% (74.6 Gy) to 1, 2, and 5 cc of
bladder respectively. Mean rectosigmoid point dose approximation
(58.3 Gy) was 66% of Pt A compared to 1, 2, and 5 cc of sigmoid
volumes doses of 76% (67.6 Gy), 73% (64.8 Gy) and 69% (61.1 Gy)
respectively. Mean dose to small bowel was 81% of Pt A dose to 1 cc
(72.3 Gy), 79% (70.6 Gy) to 2cc, and 75% (66.8 Gy) to 5 cc of bowel.
The volumetric doses consistently exceeded ICRU point dose estimates
to rectum, bladder and sigmoid by 118%, 125% and 111% respectively.
With median follow up of 11.4 months, 9% of patients reported Grade
12 urinary toxicity, 18% Grade 2 dyspareunia and 27% reported pelvic
pain requiring medication.
: CT based imageguided brachytherapy allows for precise
tumor and normal tissue dose calculations for LDR brachytherapy.
However, traditional ICRU point estimates to predict rectal, bladder
and sigmoid doses consistently underestimate volumetric doses to
these organs. In this series, CT imaging revealed small bowel adjacent
to the uterus in the majority of cases that received substantial
radiation dose. When transitioning from 2D to 3D brachytherapy
planning, GECESTRO and ABS dose guidelines should be followed
closely to minimize potential for organ toxicity. Target delineation
and organ dose limits for CT based planning for LDR should build on
the growing experience with MRI based LDR to define safe and
effective dosing.
PO257
DEEP VENOUS THROMBOSIS (DVT) RATES IN PATIENTS RECEIVING
BRACHYTHERAPY FOR CERVICAL CANCER
A. Caley 1 , A. Hickman 1 , K. Frantzeskou 1 , E. Hudson 1 , K. Parker 1 , I.
Appadurai 2 , R. Rayment 3 , S. Noble 4 , L. Hanna 1
1 Velindre Cancer Centre, Clinical Oncology, Cardiff, United Kingdom
2 University Hospital of Wales, Anaesthetics, Cardiff, United Kingdom
3 University Hospital of Wales, Haematology, Cardiff, United Kingdom
4 Royal Gwent Hospital, Palliative Care, Newport, United Kingdom

S104 World Congress of Brachytherapy 2012
: Patients with pelvic malignancy have an
increased risk of DVT but the incidence of DVT associated with
brachytherapy for cervical cancer is unknown. A study was undertaken
to assess the rate of DVT in this population.
: Since April 2010 all patients having
brachytherapy for cervical cancer at our cancer centre have
undergone weekly bilateral Doppler ultrasound scans (DUSS) of the
lower limb veins for three weeks, at the time of each scheduled
insertion. Patients receive mechanical thromboprophylaxis with TED
stockings. The case records of the last 52 patients to have undergone
brachytherapy prior to the introduction of DUSS were also examined
to assess the incidence of significant thromboembolic events.
: 32 patients were planned to have brachytherapy for cervical
cancer. One patient developed a large pulmonary embolus during
external beam chemoradiotherapy and did not have brachytherapy,
and five others (16%) were found to have below knee DVTs at the
time of their first brachytherapy insertion. Of the 31 patients who
underwent brachytherapy, 3 (10%) developed asymptomatic below
knee DVTs after one insertion and a further 3 (10%) after two
insertions. Of the six positive cases at week 3, 3 had repeat DUSS at
6weeks and all had resolved. All those with DVTs were treated with
low molecularweightheparin as per local practice; one had clot
progression to the popliteal vein and one developed bleeding
requiring transfusion. Of 52 patients who received brachytherapy prior
to the introduction of DUSS, 2 developed significant thromboembolic
events (1 ileofemoral DVT and 1 bilateral pulmonary embolism) at 4
months and 1 year respectively, both coinciding with significant
disease progression.
: There is a high incidence of asymptomatic below knee
DVTs in this population but their clinical significance is uncertain.
There are no guidelines to help with the management. The low
incidence of symptomatic thromboses in the 52 patients prior to the
introduction of DUSS suggests that most asymptomatic DVTs do not
lead to adverse outcomes.
PO258
CLINICAL RESULTS OF VAGINAL BRACHYTHERAPY DELIVERED WITH A
RING APPLICATOR FOR ENDOMETRIAL CANCER
P. Meijnen 1 , N. Bijker 2 , C. Koedooder 2 , B.R. Pieters 2
1
The Netherlands Cancer Institute Antoni van Leeuwenhoek
Hospital, Radiation Oncology, Amsterdam, The Netherlands
2
Academic Medical Centre, Radiation Oncology, Amsterdam, The
Netherlands
: Vaginal brachytherapy (VBT) delivered with a
cylinder applicator (figure 1), with the reference isodose covering the
proximal half of the vagina has become the standard treatment after
surgery for highintermediate risk endometrial cancer. Since most
recurrences develop in the vaginal vault we advocate the use of a ring
applicator (RA) (figure 1) with the reference isodose covering the
vaginal vault at 5 mm from the surface. Minimization of radiated
volume would preferably lead to less vaginal toxicity and a better
quality of life. In this report we analysed the number of vaginal,
pelvic and distant failures after VBT delivered with a RA.
Figure 1. cylinder and ring applicator
: Between 2001 and 2009, 112 patients were
referred to our department for VBT after surgery for a stage IA or IB
(FIGO 2009) intermediate risk endometrial cancer. Surgery consisted
of a total abdominal hysterectomy and bilateral salpingo
oophorectomy without routine lymphadenectomy. Medical files were
retrospectively analysed. The KaplanMeier method was used for
failure analysis.
: VBT was delivered with a RA in 100 (89%) patients by LDR (26
patients) or PDR brachytherapy (74 patients) to a total dose of 30 or
28 Gy, respectively. 82 patients were diagnosed with high
intermediate risk and 18 patients with lowintermediate risk
endometrial cancer. 79 patients had stage IB (FIGO 2009) disease
based on a least 50% myometrial invasion, 77 patients were 60 years
or older, and 44 and 20 patients had grade 2 and 3 disease,
respectively. Vascular invasion was present in four patients while five
patients were diagnosed with a clear cell carcinoma. 15 patients had
a history of previous malignant disease. Lymphadenectomy was
performed in 13 patients. Median age at diagnosis was 65 years.
Ninety percent of the patients underwent VBT within 10 weeks after
surgery. At a median followup of 37 months (range 1107) six (6%)
patients showed failures. Three patients developed an infield
recurrence in the vaginal vault 2, 30, and 101 months after VBT. One
of these recurrences was isolated while the other two showed
simultaneous pelvic and/or distant failure. A fourth patient developed
an outfield recurrence in the posterior vaginal wall of the proximal
half of the vagina including pelvic and distant failure. Two other
patients showed only distant failure. The estimated 3year cumulative
rate of any vaginal recurrence was 2.6% (95% CI, 06.3%). A total of
four (4%) patients died after disease progression within 3 to 13
months.
: VBT with the use of a RA covering the vaginal vault
results in acceptably low vaginal failure rates. Since only one vaginal
recurrence developed outfield of the vaginal vault, VBT delivered
with a cylinder applicator with coverage of the proximal half of the
vagina might be overtreatment resulting in unnecessary toxicity.
PO259
REEXAMINING ABS RECOMMENDATIONS FOR HDR VAGINAL
BRACHYTHERAPY FOR UPSC OR CLEAR CELL ENDOMETRIAL CANCER
M. Yondorf 1 , K. Holcomb 2 , D. Gupta 2 , T. Caputo 2 , P. Desai 1 , L.
Nedialkova 1 , K.S.C. Chao 1 , B. Parashar 1 , D. Nori 1 , A.G. Wernicke 1
1
Weill Cornell Medical Center of Cornell University, Radiation
Oncology, New York NY, USA
2
Weill Cornell Medical Center of Cornell University, GYN Oncology,
New York NY, USA
: The ABS recommends treating full length of the
vagina (FLV) after hysterectomy in patients with Stage I and IIA (with
less than 50%myometrial invasion) papillaryserous (UPSC) or clear cell
(CC) endometrial cancer. We compare the rates of vaginal recurrence
and acute toxicities in these patients treated with adjuvant HDR
brachytherapy to FLV versus partial length of the vagina (PLV) [upper
half or upper two thirds].
: After obtaining an IRB approval, we
conducted a retrospective analysis of 48 patients who underwent
hysterectomy and complete surgical staging and were found to have
Stages I or IIA (with less than 50% myiometrial invasion)UPSC or CC
endometrial cancer and were treated with highdose rate (HDR)
adjuvant brachytherapy between 2004 and 2010. These patients also
received platinumbased adjuvant chemotherapy. The total HDR dose
was 21Gy, in 7Gy per fraction, prescribed to depth of 0.5cm.
Prescribed treatment length was FLV between January 2004 and
October 2007, and PLV between October 2007 and January 2010.
Follow up was every 3 months during 2 years and subsequently every 6
months for 3 years and then annually after completion of treatment.
Vaginal recurrences were assessed by physical exam and Pap smears.
Acute toxicity was evaluated using the RTOG scale. Statistical
considerations included logrank analysis and a paired ttest.
: Of 48 patients in this study, 25/48 (52%) were treated with
FLV and 23/48 (48%) were treated with PLV brachytherapy. The
majority of subjects had Stage I disease: 88% and 86% in the FLV and
PLV groups, respectively. There was a statistically significant
difference in mean treatment lengths between 2 groups: 10.5cm for
FLV and 5.0cm for PLV (p

S106 World Congress of Brachytherapy 2012
and NAG were 1.91 Gy (27% of Point A dose) and 1.85 Gy (26% of point
A) respectively with a p value of 0.7. Mean Point BL doses in the AG
and NAG were 1.89 Gy (27% of Point A dose) and 1.82 Gy (26% of Point
A dose) respectively. The mean dose to rectal reference point was
higher in the AG than NAG (5.09 Gy vs 4.49 Gy, p value 0.01). The
mean dose to bladder reference point in the AG and NAG was 5.03 Gy
and 4.90 Gy respectively (p value 0.6).
Table 1. Dosimetric comparison with and without anesthesia.
Numbers in parentheses represent standard deviation.
: The results of our study reveal that HDRICBT dosimetry
with and without anesthesia are comparable and therefore lack of
anesthesia does not compromise the HDRICBT dosimetry in cervical
carcinoma patients.
PO263
DOSEVOLUME PARAMETERS IN CTBASED IMAGEGUIDED BRACHY
THERAPY FOR CERVICAL CANCER
K. Ando 1 , S. Kato 2 , M. Wakatsuki 3 , H. Kiyohara 1 , Y. Ohkubo 4 , K.
Karasawa 3 , T. Nakano 1 , T. Kamada 3
1
Gunma University Graduate School of Medicine, Department of
Radiation Oncology, Maebashi, Japan
2
Saitama Medical University International Medical Center,
Department of Radiation Oncology, Saitama, Japan
3
National Institute of Radiological Sciences, Research Center Hospital
for Charged Particle Therapy, Chiba, Japan
4
Saitama Cancer Center, Department of Radiology, Saitama, Japan
: To evaluate the efficacy of the dosevolume
parameters as predictor for local tumor control and late complications
in cervical cancer patients treated with computed tomography (CT)
based image guided brachytherapy (IGBT).
: Fiftytwo patients treated with CTbased
IGBT between June 2008 and August 2010 were analyzed. Median age
was 65 years (range, 30–89 years). The FIGO stages of their disease
were stage I in 11 patients, II in 18, III in 12 and IV in 11. Cervical
tumor size ranged from 1.4 cm to 9.8 cm (median; 5.0 cm). All
patients were treated with a combination of external beam
radiotherapy (EBRT) and CTbased IGBT with or without cisplatin (40
mg/m 2 of body surface per week for 5 weeks). The median total dose
of EBRT was 49.6 Gy (range, 39.6–50.6 Gy). IGBT was performed once
a week, with the median total dose to point A of 24 Gy in 4 fractions
(range, 10–29 Gy). 3D dosevolume parameters of the highrisk and
intermediaterisk clinical target volumes (HRCTV and IRCTV, D100
and D90) and organs at risk (D0.1cc, D1cc, D2cc of the rectum,
sigmoid colon, and bladder) were calculated from the dosevolume
histograms according to the GECESTRO recommendation. The
relationships between the 3D dosevolume parameters and the local
tumor control or late complications were analyzed.
: The median followup duration of all patients was 21 months
(range 440 months). The 2year overall survival and local control
rates for all patients were 94.9% and 78.8%, respectively. The 2year
local control rate for patients with tumor size < 4 cm was 100%.
Among patients with tumor size > 4 cm, the 2year local control rates
for patients receiving HRCTV D90 > 60 Gy, and those with HRCTV
D90 < 60 Gy were 81.4% and 58.2%, respectively (p = 0.02). For IR
CTV, no statistically significant differences were observed in all DVH
parameters. Eight (15.4%) patients developed late rectum
complication and 3 (5.8%) developed late bladder complication. All
complications were classified as Grade 1 or 2. For bladder, the
median values of D2cc for patients with and without late complication
were 86.9 GyEQD2 and 61.0 GyEQD2, respectively (p = 0.01). For
rectum, no statistically significant differences were observed in all
DVH parameters between the patients with and without late
complication.
: In the current study, it was suggested that 3D dose
volume parameters of the HRCTV and bladder were effective
predictors for local tumor control and late complication.
PO264
INITIAL CLINICAL FOLLOWUP ON THE USE OF A CO60 HDR SOURCE
FOR CERVICAL CANCER BRACHYTHERAPY
Y. Nagar 1 , A. Palmer 2 , L. Ioannou 3 , O. Hayman 3
1
Portsmouth Hospital NHS Trust, Clinical Oncology Department,
Portsmouth, United Kingdom
2
Portsmouth Hospital NHS Trust (& Faculty of Engineering and
Physical Science University of Surrey), Medical Physics Dept.,
Portsmouth, United Kingdom
3
Portsmouth Hospital NHS Trust, Medical Physics Dept., Portsmouth,
United Kingdom
: There is no published clinical data on the use of
Co60 sources for HDR brachytherapy, compared to the more
widespread Ir192 sources. This work reports initial clinical results
using a Co60 HDR brachytherapy source for cervical cancers.
: Retrospective data was analysed for 14 HDR
brachytherapy patients treated with a Co60 source, who also
received external beam radiotherapy +/ concurrent chemotherapy:
50% stage IIb, 21% stage III, 29% stage IV. Patients were treated from
June 2010 to August 2011, with follow up to January 2012 (11 patients
> 1 year). Response rate and acute and late toxicity were analysed.
Treatment plans were analysed to determine mean and range GEC
ESTRO dosimetric parameters, with assessment of correlation
between plan and toxicity.
Brachytherapy treatment was delivered using the Eckert & Ziegler
BEBIG HDRMultisource.
: Complete response in 64% of patients, partial response in
29%, and no response in 7% (n=1). Table 1 presents the recorded
toxicities for the patient group.
Table 1: Acute and late toxicities for 14 patients treated with EBRT &
Co60 HDR brachytherapy for cervical cancer
The mean APoint dose was 8.1 Gy, D90 5.7 Gy, V100 71.8%, V150
45.7%, bladder D2cc 86.1%, and rectum D2cc 71.3%. There was no
statistically significant correlation between dosimetric metrics and
toxicities in our limited data.
: Brachytherapy using Co60 source results in acceptable
acute and late toxicities, with excellent response rates in our early
experience with a limited number of patients. We propose to present
more mature data in 35 years.
PO265
CLINICAL CONSEQUENCES OF HDR SOURCE ANISOTROPY IN VAGINAL
CYLINDER TREATMENTS
S.J.E.A. Bus 1 , G.H. Olijve 1 , B.J. Oosterveld 1 , T.G. Janssen 1 , E.M. van
der SteenBanasik 1
1
ARTI Arnhems RadioTherapy Inst., Radiation Oncology, Arnhem,
The Netherlands
: To evaluate whether compensation of the
anisotropy of the HDR source used in the Flexitron afterloader has
clinical relevance for dosimetric issues in vaginal vault brachytherapy
applied with a vaginal cylinder.
: In our institute postoperative vaginal
brachytherapy is applied with a vaginal cylinder. The diameter of the
cylinder is selected by clinical examination and the application is CT
guided to avoid air gaps and to estimate D2cc of OAR.
Treatment plans are made for 7 Gy prescribed at 5 mm from the
cylinder surface and cylinder apex with 100% isodose around the
cylinder from apex to the proximal half of the vagina. Previously, we
World Congress of Brachytherapy 2012 S 107
used to work with a microSelectron PDR but after installation of the
Flexitron HDR we found significant differences in the dose
distributions due to source anisotropy caused by the larger HDR
source. We compared PDR treatment plans (Plato BPS) with HDR
treatment plans (Flexiplan) with various cylinder diameters (range 24
cm), using the same dwell positions and dwell times and choosing the
same dose points. We observed approximately 28% underdosage at the
vaginal top in HDR plans compared to PDR plans, with a size at the
surface of the cylinder depending on the diameter of the cylinder.
It has always been assumed that positioning differences of the
cylinder in regard to the vaginal mucosa for every fraction would
average out the underdosage due to anisotropy. To evaluate the
positioning of the vaginal mucosa in relation to the cylinder surface
one haemoclip was sutured at the top of the vagina in the area where
anisotropic dose is expected. Each fraction of HDR was preceded by a
CT with corresponding slices. We repeated this procedure in 3
patients, making 3 corresponding CTscans in each patient.
: We found that in the CTscans made in 3 patients only one
image showed a haemoclip shift >1.5 mm. Because of these findings
we believe to have found sufficient evidence to assume that between
fractions there is no significant change of the position of the mucosa
in relation to the cylinder surface which could compensate for the
underdosage in the anisotropy area.
: We conclude that in HDR treatment underdosage due to
source anisotropy at the vaginal top is a relevant clinical issue.
Therefore we decided to optimize the dose in the anisotropy area by
adjusting the dwell positions and dwell times in such a way that the
maximum dose at the surface of the cylinder is the same as with the
PDR treatments. The remaining small areas of under and overdose
respectively at the top and laterally from the top have to be
accepted.
PO266
IS AN MRI REQUIRED ON EACH FRACTION? AN EXPERIENCE WITH MRI
GUIDED BRACHYTHERAPY FOR CERVICAL CANCER
J. Chino 1 , J. Maurer 1 , B. Steffey 1 , J. Cai 1 , J. Adamson 1 , O.
Craciunescu 1
1
Duke University Medical Center, Radiation Oncology, Durham NC,
USA
: MRI guidance has shown great promise at
improving target definition and predictive dosimetric indices for the
use of brachytherapy for cervical cancer. It is unclear, however, if use
of MRI beyond the first fraction is useful in clinical practice. We
examined our experience of using MRI with every fraction for
variations among fractions that would suggest a meaningful difference
in dose to tumor or normal tissue.
: We retrospectively identified 6 patients
treated with a combined total of 29 fractions in whom MRI guidance
was used for treatment planning from 20112012 at Duke University
Medical Center. Treatments were given twice a week after completing
whole pelvic radiation with concurrent chemotherapy, with a median
of five fractions planned. 27 fractions were delivered with a tandem
and ring applicator, 2 fractions were delivered with tandem and
ovoids. On each fraction, a CT and MRI were obtained with the
applicator in place, fused, and contoured as per the GECESTRO
recommendations for target delineation (HRCTV) as well as for organs
at risk (OARs). Each plan was first generated using a theABS
recommended reference lines then modified as necessary with a goal
to meet the GECESTRO recommendations for HRCTV D90 and OAR
D2cc. The total time for the treatment plan process was also
recorded.
: The median time from start of imaging to treatment delivery
was 3.6 hours, not including insertion time (IQR 3.3 – 3.9 hours). The
median HRCTV volume was 27cc (IQR 2231cc). Among individual
women, the range of HRCTV volumes (maximum – minimum) among
their fractions were 37 73% of the woman’s median (1028cc
absolute range). In a subset of 20 MRI images sets, the HRCTVs were
recontoured in a single sitting, with a range of 1043% of the woman’s
median (511cc absolute range). The median dose to HRCTV D90 was
699cGy, and among individual women, the range of HRCTV D90 doses
were 413% of the woman’s median (2686cGy absolute range). The
median plan called for 311.4 sec nominal, and among individual
women, the range was between 337% of the woman’s median (12.6
84.2 sec absolute range).
: The HRCTV volumes were variable between fractions,
and resulted in variability in the plans developed to meet GECESTRO
dose goals. This variability was less with retrospective 'single sitting'
recontouring, but was still up to 43% of the median volume in some
women. We feel that this was largely due to deformation of the target
due to variations in applicator placement, rather than a change in the
target volume due to treatment. However, MRI based treatment
planning also requires significant time and resources, which should be
factored into the decision to implement for all fractions.
PO267
3D DOSIMETRY OF THE BLADDER FILLING IN HDR VAGINAL CUFF
BRACHYTHERAPY
J. Kobzda 1 , E. CikowskaWozniak 1 , M. Michalska 1 , R. Makarewicz 2
1
Euromedic International Oncotherapy Center in Poznan,
Brachytherapy Department, Poznan, Poland
2
Chair and Clinic of Oncology and BrachytherapyCentre of Oncology
in Bydgoszcz N.Copernicus University in Torun, Brachytherapy
Department, Bydgoszcz, Poland
: The aim of the study was to asses the bladder
doses during vaginal cuff brachytherapy, to examine the effect of
bladder filling on normal tissue dosimetry using computed tomography
and to establish standards of treatment.
: A total number of 40 women were enrolled in
a prospective clinical trial. Patients were treated in the lithotomy
position using single source vaginal cylinder to deliver a dose of 6 7,5
Gy per fraction to one third of the vagina at a depth of 0,5cm from
the cylinder surface. A total dose was 30Gy in 4 fractions when alone
high dose rate brachytherapy was used or 18Gy in 3 fractions when
brachytherapy was combined with external beam irradiation. The
cylinders' diameters were in a range of 2,53,5 cm. Patients were
asked to consume 400ml of water 40 minutes before CT scans were
taken. No contrast to the bladder was given. For each patient two
treatment plans in 3D Flexitron Planning System were performed: one
with full bladder and the other one when the bladder was emptied.
Organs at risk and CTV were contoured by one physician and checked
by another. While the OAR were contoured, the following rules were
preserved: the bladder and rectum were delineated as the whole
organs; all the bowels (including sigmoid) visible 2cm above the
cylinder and around it on the whole length of the cylinder. The dose
volume histogram for all OAR as well as the parameters recommended
by GECESTRO were reported.
: As the most useful values for evaluation, the following
parameters were taken into account for both, full and empty bladder:
mean volume, V50, V80, D0.1cc, D2cc, D2cc of the bowels (Table 1).
However, the dose to the bowels is only an estimate because of their
high mobility and the difficulty in defining their borders.
32 patients received a lower dose to the empty bladder than to the
filled organ.
8 patients received a lower dose to the full bladder than to the empty
one. However, in this case the difference was only 0,25 Gy in average.
Additionally, it was observed that in empty state of the bladder, the
bowels were receiving a higher dose (comparing to the full state) as
they were located closer to the cylinder. No correlation between the
diameter of the cylinder and the dose to the bladder in full or empty
state was found.
: The results of this paper have shown, that in most cases
the dose to the empty bladder is lower than when it is full. However,
in the empty state of the bladder, the bowels receive higher dose.
Early and late bowel toxicity should be investigated to establish clear

S108 World Congress of Brachytherapy 2012
standards of treatment. In order to control and evaluate the dose to
OAR, CTbased vaginal cuff brachytherapy may be used. The outcomes
confirm other studies.
PO268
NOVEL MRIMARKERFLANGE FOR MRIGUIDED BRACHYTHERAPY FOR
GYNECOLOGICAL CANCER
J. Schindel 1 , A. Eagle 2 , M. Hewitt 2 , T. Stockman 2 , M.
Muruganandham 1 , C. Pigge 3 , Y. Kim 1
1
University of Iowa, Radiation Oncology, Iowa City, USA
2
University of Iowa, Electrical Computer Engineering, Iowa City, USA
3
University of Iowa, Chemistry, Iowa City, USA
: To develop a novel MarkerFlange that can be
used in titanium or plastic applicators of tandemandring or tandem
andovoid and evaluate its feasibility using seven different MRI marker
agents.
: A novel MarkerFlange was developed in
house. A 5 L phantom (Figure 1.A) was used in combination with three
MarkerFlanges placed around three titanium tandems (Varian). The
phantom was filled with 4L of 3% Agarose Gel (AGEL: 3g Agarose
powder/ 100 mL distilled water). A total of seven different MRI
marker agents were tested: Saline, Conray60 (Mallinckrodt medical),
CuSO4 (1.5g/L), liquid Vitamin E, fish oil, 1% AGEL, and a cobalt
chloride complex contrast (C4) (CoCl2: Glycine=4:1) which was
synthesized inhouse. A high resolution (3T) MRI was used. Clinical MRI
scan protocols for GYN HDR were used: T1 and T2weightedMRI
(T1MRI and T2MRI) of 1 mm and 3 mm slice thickness, respectively.
The signal intensities of each MarkerFlange were then compared to
the signal intensity of the 3% AGEL background using ImageJ software.
:
The MarkerFlange showed hypersignals of > 500% with CuSO4 or C4 on
T1MRI and of > 400% with Saline on T2MRI. Sourcereconstruction is
recommended on T1MRI—the signals of CuSO4 and C4 on T1MRI were
771 ± 187% and 558 ± 197%, respectively. The effect of artifacts
caused by titanium was minimal. Five agents showed signals of > 100%
on T1MRI: CuSO4, C4, Vitamin E, Conray60, and fish oil. All agents
but C4 showed signals of > 100% on T2MRI. The signals on T1MRI
showed better geometric accuracies in cranialcaudal direction when
compared to those on T2MRI that show signal blurring of 4.64 ± 1.7
mm due to 3 mm slice thickness. Further studies on the geometric
accuracy of MarkerFlange signals, when compared to CT datasets, are
planning to be followed. When combining with the use of the
applicator library, the hypersignals of the MarkerFlange are
expected to improve applicatorreconstruction accuracy for MRI
guided brachytherapy for gynecological cancer, especially for, but not
limited to, titanium applicators.
: The use of the novel MarkerFlanges for MRIguided GYN
HDR brachytherapy seems feasible. The markers of CuSO4 and C4
showed considerably high signals on T1MRI, as Saline did on T2MRI.
However, on T1MRI CuSO4 had the highest average signal intensity
throughout the flange, and C4 had the highest maximum intensity
readings, so future research will be done on these two promising MRI
markers. The geometrical accuracy of the MarkerFlanges with 1 mm
slice thickness was also promising and seemed to minimally affected
by the artifacts that can be created by the titanium applicators.
PO269
EXTERNAL BEAM RADIOTHERAPY AND BRAQUITHERAPY ASSOCIATED
CHEMOTHERAPY,IN IIBIV CANCER OF THE CERVIX
Z. Mercedes 1 , I. Tovar 1 , J.A. Bullejos 2 , R. Guerrero 1 , P. Vargas 1 , M.A.
Gentil 1 , I. Linares 1 , M. Martínez 1 , P. Expósito 1 , R. Del Moral 1
1
Hospital Universitario Virgen de las Nieves, Radiotherapy Oncology,
Granada, Spain
2
Hospital Universitario Virgen de las Nieves, Medical phisics, Granada,
Spain
: Introduction: External beam radiotherapy (EBRT)
and braquitherapy (BQT) associated with chemotherapy (CT) are
standard treatment in cancer of the cervix.
The use of HDR BQT has allowed the optimization of dosimetry and its
application outpatient basis.
Objectives: To analyze the clinical results of our study and evaluate
the toxicity of this treatment.
: From May 2005 to May 2011 were treated in
our center fortyseven patients with a mean age of 51 years (3770)
with this disease by chemoradiotherapy (45 50.4 Gy) plus HDR BQT
overprint probe uterine central. Each patient received 4 or 5
applications of BQT HDR.
Tumor stage: 1E1, 2 E IIA, 34 IBD B, 3E III B, 3 EIIIC, and 4E IV. The
maximum average diameter of the tumor is 5.7 cm
We need a description of the GTV (gross target volume) and CTV
(clinical target volume) prior to each treatment modification. The
effective biological dose in GTV and organs at risk, rectum and
bladder was 67.32 Gy and 75.63 half 76.97 Gy respectively.
: With a median follow more 2years we get a 81.8% pelvic
control and overall survival of 99%. The toxicity was observed:
Acute:18% proctitis, 27% cystitis and late: 9% stenosis vaginal.
: Concomitant chemoradiotherapy followed by BQT HDR is
feasible and effective treatment for patients with advanced cervical
cancer. It allows complete coverage of the GTV and CTV which is
crucial for local control.
PO270
COMPARING CLASSIC AND MULTICHANNEL CYLINDRICAL VAGINAL
APPLICATORS IN INTRACAVITARY GYNAECOLOGIC BRACHYTHERAPY
A. Cerrotta 1 , M. Carrara 2 , M. Borroni 2 , C. Tenconi 3 , E. Pignoli 2 , C.
Fallai 1
1
Fondazione IRCCS Istituto Nazionale Tumori, Radiotherapy 2, Milan,
Italy
2
Fondazione IRCCS Istituto Nazionale Tumori, Medical Physics, Milan,
Italy
3
Uiversità degli Studi di Milano, Physics, Milan, Italy
: To compare dose distributions obtained by means
of the 'classical' cylindrical and the multichannel vaginal applicator in
intracavitary gynaecologic brachytherapy treatments.
: Eight patients with primary or recurrent
vaginal cancer were treated at the Fondazione IRCCS Istituto
Nazionale dei Tumori with high dose rate (HDR) brachytherapy (BRT).
The prescribed BRT doses to the target were of 2000cGy (BRT as
boost) and 3500cGy or 4200cGy (exclusive BRT), which were delivered
in fractions of 500cGy or 600cGy, respectively. Out of 37 treatment
fractions, a total of 24 were performed by means of a 'homemade'
multichannel vaginal intracavitary applicator which contains a central
catheter and five or six lateral tubes that are equally spaced around
the surface of the cylinder. Retrospectively, a theoretical BRT
treatment was planned on the same images adopting only the central
catheter, simulating the use of the 'classical' cylindrical vaginal
applicator which is commonly recommended as the standard
applicator for vaginal treatments. Dosimetric distributions were
obtained fulfilling for each single fraction the constrains of V2cc

S110 World Congress of Brachytherapy 2012
PO273
DETERMINING DOSIMETRIC FACTORS RELATED TO LOCAL CONTROL IN
CTBASED BRACHYTHERAPY
S. Kaplan 1 , K. Townamchai 1 , C. Newhouse 1 , A. Viswanathan 1
1 Brigham and Women's Hospital, Radiation Oncology, Boston MA, USA
: To determine the relationship between local
recurrence (LR) and dosimetric values for cervicalcancer patients
treated using CTguided, highdoserate brachytherapy.
: A total of 124 patients were treated for
cervical masses using CTplanned brachytherapy between 4/2004 and
3/2011. Of these, 5 patients with primaries that were noncervical or
of unclear origin and 4 with Stage IV disease at diagnosis were
excluded.
A total of 595 fractions were analyzed. Each patient had a median of
5 fractions (range [rg] 3 – 10). Median perfraction prescription (Rx)
dose was 5.5 Gy (rg 39). Twentytwo patients were treated with a
tandem and ovoid applicator, 36 tandem and ring, 6 tandem and
cylinder, 16 interstitial +/ tandem, and 35 with a combination.
KaplanMeier progressionfree (PFS), diseasespecific (DSS) and overall
(OS) survival estimates were calculated. To analyze dosimetric
relationships, median average point A, median D90, and median Rx
dose per patient were used to calculate several ratios: Rx/Point A,
Rx/D90, and D90/Point A. Mean ratios were compared using 2tailed
Ttests.
: Stages were IA (n=2; 1.7%), IB (n=25; 21.7%), IIA (n=24;
20.9%), IIB (n=49; 42.6%), IIIA (n=2; 1.7%), IIIB (n=11; 9.6%) and IVA
(n=2; 1.7%). Staging for interstitial patients was: IB (1), IIA (2), IIB (5),
IIIA (2), IIIB (4) and IVA (2).
Median total external beam (EB) cervical dose in EQD2 was 44.3 Gy (rg
42.560.3). Median cumulative Rx brachytherapy dose was 42.6 Gy (rg
25.675). Median combined EB + brachytherapy dose was 86.9 Gy (rg
67.3102.9). Median cumulative CTD90 in EQD2 was 81.8 Gy (rg 38.3
114.7). Median cumulative doses to 0.1cc (D0.1cc) and 2cc (D2cc)
were 88.5 Gy3 and 72.8 Gy3 for the bladder, 75.1 Gy3 and 63.0 for
rectum and 74.8 Gy3 and 63.1 Gy3 for sigmoid.
Median followup time was 21.8 months. The 2year LR rate was 6.9%
overall, 4.0% for the 99 noninterstitial patients and 18.8% for the 16
patients treated with interstitial alone. For all patients, 2year PFS
was 79%, DSS was 83% and OS was 78%.
As seen in the table, the Rx/point A and D90/Point A ratios were
significantly lower for patients with LR than for all others. This
implies that patients who relapsed had larger tumors with the Rx dose
close to Point A, and that Point A is a good approximation for tumor
dose. CT is most beneficial for optimizing the normaltissue doses.
LR Not LR P value
Rx/Point A MR=1.002; n=9 MR=1.140; n=101 0.001*
(rg 0.891.15) (rg 0.76–2.11)
Rx /D90 MR=1.024; n=8 MR=1.016; n=84 0.882
(rg 0.91 1.28) (rg 0.672.36)
D90 / Point A MR=1.020; n=7 MR=1.214; n=80 0.004*
(rg 0.89 1.25) (rg 0.672.72)
*MR=mean ratio
: Dosimetric ratios incorporating point A may be useful
metrics for clinics attempting to transition from plain film to CT
and/or for those seeking a metric to determine adequate dosing to
the CTCTV.
PO274
DOSIMETRIC IMPACT OF CTS WITH EACH FRACTION ON ORGANS AT RISK
FOR HDR VAGINAL CYLINDER BRACHYTHERAPY
L. Zhu 1 , O. Craciunescu 2 , J. Cai 2 , B. Steffey 2 , J. Adamson 2 , J. Chino 2
1 Peking University Third Hospital, Radiation Oncology, Beijing, China
2 Duke University Medical Center, Radiation Oncology, Durham, USA
: To investigate the relevance of CTbased
planning with every fraction versus first fraction CTbased planning on
organs at risk (OARs) for highdose rate vaginal cylinder brachytherapy
(HDR VBT).
: Fifty patients (201 fractions) who underwent
HDR VBT for postoperative endometrial or cervical cancer were
retrospectively analyzed in the study. CTbased 3D planning was
performed at each fraction with prescription dose of 400700 cGy
prescribed to 0.5 cm from the cylinder surface and for a treatment
length of 46 cm. Two crude dose summation plans were made for
each patient: (1) by multiplying the number of fractions and the
treatment plan metrics of the first fraction (Sum1), and (2) by
summing treatment plan metrics of all fractions (Sum2). D0.1cc, D2cc,
and D10cc of bladder, rectum, sigmoid, and small bowel were
collected and compared between Sum1 and Sum2. All data were also
converted to equivalent dose at 2Gy per fraction (EQD2) for
comparison. For 18 patients who had urinary catheterization in all
fractions, ICRU 38 bladder and rectum points were also defined
(PDICRU, B, PDICRU, R) and compared between Sum1 and Sum2. All
statistical analyses were performed using paired t test.
: For bladder and small bowel, the means of Sum1 were
significantly greater than those of Sum2 (p

S112 World Congress of Brachytherapy 2012
: Radical and salvage radiotherapy with brachytherapy
achieves an acceptable locoregional control rates in patients with
localized / locally advanced vulval cancers.
PO279
RADIOTHERAPY AND MULTIMODALITY TREATMENT FOR PATIENTS WITH
LOCALLY ADVANCED UTERINE CERVIX CANCER
T. Litvinova 1 , I. Kosenko 1 , O. Matylevich 1 , L. Furmanchuk 1 , G.
Kostevich 1
1
N.N.Alexandrov National Cancer Center of Belarus, Department
Gynaecological Surgery, Minsk, Belarus
: Comparing the outcomes of multimodality
treatment and radiotherapy in LAUCC patients.
: The study enrolled 88 LAUCC patients. In
group 1 (36 women) the treatment started with multidrug
chemotherapy (MDCT) courses of cisplatin, gemcitabine or
doxorubicin. The patients presenting resectable tumours (41.7%) were
administered a brachytherapy (BT) treatment at a dose of 10 Gy and
type III hysterectomy or pelvic exenteration, the rest of the patients
received combination radiotherapy (CRT). Group 2 (52 women) were
treated with splitcourse CRT and cisplatin. The treatment started
with externalbeam radiotherapy (EBRT) at a dose of 30 Gy. After an
interval, 32 patients received BT at point A 5 Gy twice a week up to
30 Gy and EBRT up to 20 Gy. The remaining 20 patients, also after an
interval, continued the treatment with only EBRT up to a total dose of
20 Gy. The basic characteristics of patients in the both groups were
comparable.
: In group 1, 80% of the patients underwent radical surgery,
and 20% received nonradical surgical treatment. Postoperative
morbidity rate was 6.7%. In the course of 3year followup, only 2
(13.3%) patients developed relapses. Observed overall survival (OOS)
was 0.90±0.09, recurrencefree survival (RFS) was 0.89±0.1,
metastasisfree survival (MFS) was 1.0. Among the patients
administered MDCT and CRT, recurrence occurred in 1 (4.8%) patient,
and metastases in 6 (28.6%). Threeyear OOS was 0.26±0.02, RFS was
0.99±0.07, MFS was 0.39±0.18.
In group 2, of 32 patients treated with CRT, 10 (31.3%) presented with
uncured tumour, and of the remaining 20 patients, such cases
amounted to 15 (75%), the number of women with relapses and
metastases among them exceeding by 43.7%. Threeyear OOS was
0.62±0.09 and 0.30±0.1, RFS was 0.90±0.06 and 0.74±0.1, MFS was
0.70±0.08 and 0.63±0.1 respectively.
: CRT for LAUCC patients, being a stardard treatment in
Belarus, produces high rates of OOS, RFS and MFS, compared to EBRT
alone without BT.
The novel multimodality technique is more beneficial than CRT but it
can be performed only in 41.7% of LAUCC patients.
PO280
PRELIMINARY INVESTIGATION OF DOSE SUM OF PELVIC TOMOTHERAPY
AND HDR BRACHYTHERAPY TREATMENT FOR CERVICAL CANCER
S. Garelli 1 , S. Agostinelli 1 , A. Bellini 1 , F. Giannelli 2 , D. Doino 2 , S.
Barra 2 , G. Taccini 1
1
IRCCS AOU San Martino IST, U.O.C. Fisica Medica, Genova, Italy
2
IRCCS AOU San Martino IST, U.O.S. Radioterapia Infantile e
Tecniche Speciali, Genova, Italy
: To evaluate the feasibility of dose summation of
tomotherapy whole pelvic irradiation (TWPI) with simultaneously
integrated boost (SIB) and the high dose rate (HDR) intracavitary
brachytherapy boost treatment for locally advanced cervical cancer.
: Three patients with FIGO IIIIIIVA uterine
cervix cancer received concurrent chemoradiation with pelvic helical
tomotherapy (HiArt) irradiation including SIB to parametrium and
involvedatdiagnosis lymph nodes followed by HDR intracavitary
brachytherapy boost. TWPI dose was 45 Gy delivered in 25 fractions
with a 57.50/53.7 Gy SIB, while the sequential HDR intracavitary (3
channels Fletcher) brachytherapy boost dose was 2430 Gy/45
fractions twice a week. For external radiotherapy, delineation of
target volumes was made according to ICRU Report 50 and 62. The
ORs bladder, rectum, intestine and femoral heads were contoured.
For brachytherapy all patients at every treatment session underwent a
MR or a CT scan. HR and IR CTVs were delineated according to the
Recommendations from GYN GECESTRO Working Group and ORs
bladder, rectum and intestine were contoured in the CT scan. Given
that the CTVs and ORs are displaced during the brachytherapy
treatment because of the insertion of the intracavitary applicator the
image fusion, and hence the dose summation, of the external
tomotherapy plan with the brachytherapy plan is not trivial. We
evaluated the feasibility of image fusion/dose summation of the two
plans using MIM v.5.2 (MIM software inc.) by looking how well the
fused structures contoured on the brachytherapy plan matched with
the ones contoured on the TWPI plan.
: In the examined cases we tested the available MIM rigid
image fusion tools (rigidassisted, boxbased, contourbased and
pointbased) and found that no rigid fusion tool can provide an
acceptable fusion. On the other hand the deformed image fusion
provided improved and consistent results with overall good
correspondence of the fused CTV and bladder volumes, while the
match of the rectum volume was only fair. Deformed brachytherapy
dose distribution was in general reasonable, but we noticed
unacceptable strong distortion at the level of the cranial periphery of
the brachytherapy plan.
: In our preliminary investigation we found that the
deformed CTCT image fusion implemented in MIM 5.2 software
provides a powerful tool to experiment dose summation of external
beam and brachytherapy treatments. While the resulting deformed
image and dose distribution seem 'reasonable', strong distortion of
certain areas can be present. In conclusion we can say that MIM’s
deformed fusion proved to be a good starting point, but we think that
for this demanding task the deformed fusion tool should be further
improved maybe adding userdriven or pointbased deformation
guidance. In progress the improvement of patients number to obtain
also a quantitative analysis.
PO281
THE EFFECT OF BODY MASS INDEX ON MAXIMUM RECTAL DOSE IN HIGH
DOSE RATE BRACHYTHERAPY FOR CERVICAL CANCER
J. Lim 1 , B. Durbin Johnson 2 , R. Valicenti 1 , R. Stern 1 , M. Mathai 1 , J.
Mayadev 1
1 University California Davis, Radiation Oncology, Sacramento, USA
2 University California Davis, Biostatistics, Sacramento, USA
: The impact of body mass index (BMI) on rectal
dose delivered in high dose rate brachytherapy for cervical cancer is
unknown. We investigated the role of BMI in volumetric rectal dose
delivery during 3D CT based planning for locally advanced cervical
cancer.
: Between 2007 and 2010, there were 51
patients treated with high dose rate brachytherapy for locally
advanced cervical cancer. A retrospective chart review was conducted
using the electronic medical record to determine the patients’ BMI. 97
brachytherapy treatment planning CT scans from 51 patients with
locally advanced cervical cancer were reviewed. The rectum was
manually contoured from the ischial tuberosity to the pubic
symphysis. Using the treatment planning software, a volumetric
measurement of the maximum, mean, dose to 2cc, dose to 1cc of the
rectum was calculated. The ICRU rectal point was recorded, and a
dose volume histogram was referenced. Linear mixed effect models
were used to determine the effect of BMI, tandem angle, and other
factors on dose while adjusting for the presence of multiple
observations per patient.
: The average BMI (kg/m2) was 28.5 with a range of 17.247.6.
Of the study population, 6% were morbidly obese, 28% were obese,
28% were overweight, 36% were normal weight and 2% were
underweight. The mean D1cc, D2cc, mean rectal dose (%), and
maximum rectal dose (%), and ICRU rectum was 304Gy, 278 Gy, 60%,
and 20%, respectively. In multivariate analysis controlling for tandem
angle, surface area, and maximum distension, there was a significant
decrease in the D1cc rectal dose, p = 0.017, and D2cc rectal dose,
p=0.016, ICRU rectal point dose, p=0.022, and mean rectal dose
percentage, p=0.021 with an increase in BMI.
: Obesity decreases the rectal dose given in high dose rate
brachytherapy for locally advanced cervical cancer. The increase in
fatty tissue in the retrouterine space may possibly contribute to
sparing of rectal dose.
World Congress of Brachytherapy 2012 S 113
PO282
RADIOCHEMOTHERAPY AND HDR BOOST IN CERVICAL CANCER:
ANALYSIS ON TOXICITY, A 10 YEARS SINGLE INSITUTION EXPERIENCE
A. Colombo 1 , R. D'Amico 1 , C. Frigerio 2 , S. Sacco 1 , G. Sangalli 2 , F.
Declich 2 , F. Placa 1
1 A.O. della Provincia di Lecco, S.C. Radioterapia, Lecco, Italy
2 A.O. della Provincia di Lecco, Fisica Sanitaria, Lecco, Italy
: To evaluate the data of toxicity and relapses in
patients with cervical cancer treated by a definitive regimen of
radiotherapy ± chemotherapy + high dose rate brachytherapy (HDR
BRT) boost.
: Patients affected by cervical cancer, every
histotype and every stage, according to the results of multiple
randomized clinical trials, were treated by a radiotherapy schedule,
with or without chemotherapy, according to stage, age, and
performance status of the patient. All patients were addressed to a
HDR BRT boost.After the treatment the patients were followed by a
clinical examination every six months, and an imaging evaluation (MRI
or PETTC) every six months for the first two years.
: Between 01/07/2000 and 30/06/2010 190 patients affected
by cervical cancer (different hitotypes) were treated in our
institution.40 were classified stage Ib1IIA1, 68 were stage IB2IIA2, 38
were stage IIb, 35 were stage III, 9 were stage IVA. Pelvic limphnodes
were positive in 56 patients (29.4%), and lomboaortic limphnodes (±
pelvic nodes) were positive in 19 patients (10%).The median follow up
was 29 months (range 1136.5).The schedule included a wholepelvic
external beam radiotherapy of 45 Gy in 25 fractions with parametrial
boost (when parametrial or sidewall disease and/or pelvic
lymphadenopathy present) of 9 Gy and a HDR BRT boost, dose 2131
Gy in 36 fractions, delivered to PTV. Every single BRT fraction was
plannified by CT. A chemotherapy regimen of weekly cisplatin
(40mg/mq) was used, according to disease stage and patient
PS.Outcome measures included the toxicity (CTCAE 3.0), disease free
survival (DFS) and local control.The gastrointestinal G2 toxicity was
observed in 6.3% of patients and the G3 GI toxicity was observed in
1%. We observed 1 case of G4 GI toxicity (0.5%).We found a
relationship between EQD2 of 77Gy to 2cc of rectum and GI≥2
(p=0.043) (fig.1).
The genitourinary G2 toxicity was observed in 3.1 % and the G3 GU
toxicity was observed in 1%. No G4 GU toxicity was reported.We
reported one case of cutaneous toxicity and one case of G4
neurological toxicity.The overall survival was 61% (116/190). The
diseasefree survival was 64% (121/190). The local control was 84.7%
(161/190).The mean time to local recurrence was 38 months (range 1
135 months). The mean time to distant recurrence was 36 months
(range 2135 months).
: The radiochemotherapy and BRT schedule as a definitive
treatment is widely used for cervical cancer. The results in terms of
toxicity and DFS are comparable with the results of the literature; in
clinical practise we adopted the limit of D2cc to rectum ≤ 77Gy.A
detailed analysis must be done about the relationship between the
sites of recurrence and the delivered dose, considering for the future
BRT dose escalations, using Image Guided Adaptive BRT (IGABT).
PO283
NEOADJUVANT OR ADJUVANT BRACHYTHERAPY FOR CORPUS UTERI
CANCER PATIENTS AT LOW RISK
S. Mavrichev 1 , V. Suslova 2 , I. Kosenko 1
1
N.N.Alexandrov National Cancer Center of Belarus, Department
Gynaecological Surgery, Minsk, Belarus
2
N.N.Alexandrov National Cancer Center of Belarus, Department
Radiotherapy/Brachytherapy, Minsk, Belarus
: Evaluating the efficacy of neoadjuvant and
adjuvant brachytherapy (BT) for stage I corpus uteri cancer (CUC)
patients at low risk.
: In 2011 our Centre started a prospective
randomized study to evaluate the efficacy of neoadjuvant (group A)
and adjuvant BT (group B) for stage I CUC patients at low risk. All the
patients underwent surgical intervention: hysterectomy with bilateral
salpingooophorectomy. Sixtyfour patients were administered the
treatment; 27 in group A and 37 in group B.
Neoadjuvant BT consisted of one traction at a single target dose of
13.5 Gy using Rotte Endometrial Applicator. The dose was delivered to
the middle of endometrium. The application was performed the day
before or on the operation day. For adjuvant BT, singlechannel
colpostat was used. The dose of 8.5 Gy was delivered to the depth of
5 mm from vaginal mucosa. A total of two fractions was delivered
with 7day interval, the total target dose being 17 Gy. The patients of
the both groups were treated at high dose rate on microSelectron
HDR.
: All the 64 patients received the prescribed treatment. One to
12 months followup found no severe radiation morbidity in vaginal
mucosa. The vaginal stump healed by first intention.
: Further accumulation of clinical material and followup
of the patients are needed to evaluate early and late radiation
toxicity caused by the two BT techniques.
PO284
OUR EXPERIENCE IN INITIAL 20 CASES OF CERVICAL CANCER WITH CT
IMAGE BASED BRACHYTHERAPY TREATMENTS
L. Carvalho 1 , A. Pereira 2 , R. Pirraco 2 , T. Viterbo 2 , M. Gomes 2 , L.
Salgado 1 , L. Trigo 1 , J. Lencart 2
1
Instituto Português de Oncologia, Serviço Braquiterapia, Porto,
Portugal
2
Instituto Português de Oncologia, Serviço Fisica, Porto, Portugal
: Our institution has a big experience in the
treatment of cervical cancer, since the early 70´s, with
brachytherapy as major component of the treatment plan. We began
with radio implants, with hand calculations and in the 80’s we moved
to cesium tubes, and then moved to cesium pelets using a Selectron
137Cs, with treatment planning system calculations based in
orthogonal images. Since 2003, we began to use a MicroSelectron
Pulse Dose Rate (PDR), with the same type treatment planning.
In 2011, we started CT based planning with CTMR compatible utero
vaginal applicators. Dose prescription guidelines, dose points
prescription and organs at risk dose (OAR’s) derived from the
Manchester System are described in the ICRU Report Nº38. Although
this method has provided a large clinical experience, it presents big
limitations that have been well documented. The implementation of
3D imagebased treatment planning systems, with target and OAR’s
volumes delineation allows a better understanding of the tumour
spatial configuration and provides a better target coverage and OAR’s
dose evaluation. In this study we analyse our initial 20 cases of
cervical cancer brachytherapy treatments with 192Ir PDR using a CT
image based planning, and the changes we felt it introduced in our
technique, in terms of prescription points and OAR´s dose constraints.
: 20 patients were treated with pelvic 3DC
external irradiation, followed by a brachytherapy boost. Patients were
treated with MicroSelectron V2 or with Flexitron PDR, and all plans
were CT imagebased, using Oncentra Masterplan 4.1. All patients had
a bladder catheter inserted, with the balloon filled with contrast, and
a rectum catheter, containing a radiopaque marker. Target volume,
rectum, rectal catheter, bladder wall and bladder balloon were
delineated. The normal Manchester A points prescription was
modified, following the coverage of target volume. Plans were

S114 World Congress of Brachytherapy 2012
analysed by DVH. The 0.1cc dose for bladder balloon, rectum
catheter, bladder and rectum were calculated and compared.
: The prescription dose points were changed in 40% of cases
from the Manchester system to modified dose prescription points. The
width of the 100% isodose at the level of classical point A varied
between 1.6 and 2cm. The OAR´s 0.1cc dose was higher in the CT
imagebased plans when compared with maximum dose points in the
orthogonal image based plans, with the mean variations for bladder of
+26% (0 – 66) and rectum of +20% (0 – 37), respectively.
: When gynaecological brachytherapy applications are
performed using CT imagebased planning, the prescription dose may
change and surrounding tissues are better spared. The physicians have
a clear vision of what it is the real target volume and isodose
distributions may be conformed to that target. The OAR’s doses are
well known and the DVH analysis allows us to compare results, and
also analyse other volumes of interest as D1cc and D2cc for rectum
and bladder.
PO285
3D COMPUTED TOMOGRAPHY GUIDED IMAGE BASED INTERSTITIAL
BRACHYTHERAPY FOR CANCER OF CERVIX
S. Sharma 1 , S. Rishi Kartik 1 , R.C. Alva 1 , P. Deka 1
1 Manipal Hospital, Radiation Oncology, Bangalore, India
: To evaluate the local control and toxicities in
patients with locally advanced cancer of cervix undergoing interstitial
brachytherapy planned with computed tomography (CT) imaging.
: Between January 2008 and December 2010,
29 consecutive clinically staged patients of carcinoma of cervix FIGO
stages IBIIIB treated at our institution with curative radiation were
analysed. None of the patients underwent Magnetic Resonance
imaging as part of work up. All the patients received 45 Gy in 25
fractions of whole pelvic external beam radiation planned by 3DCRT
concurrent with weekly Cisplatinum 40mg/m 2 . A week later, patients
underwent interstitial brachytherapy using Syed Neblett Gyn 3
perineal template combined with intrauterine tandem insertion and
two fractions of 6.5 Gy each were delivered by high dose rate
brachytherapy system. The same was repeated after another week.
CT scans were obtained after each application with 50 ml of dilute
contrast injected into bladder and 20 ml into rectum. The outer
boundary of the needles was used to define clinical target volume
(CTV). The first application and CTV delineation was done according
to the disease extent at diagnosis. Second application and the CTV
delineation covered the disease extent present at the time of
brachytherapy. Thus the second CTV received 4 fractions of 6.5 Gy
each (EqD2 = 80.1Gy). Rectum, bladder and sigmoid were contoured
according to GECESTRO guidelines. Employing dose volume
adaptation, dose to 2cc of bladder, rectum and sigmoid was restricted
to 5, 4 and 4 Gy respectively ( EqD2 = 69.5, 63 and 63 Gy
respectively). Although every effort was made to ensure that at least
90% of CTV received the prescription dose, OAR constraints were
strictly respected, even if that resulted in inferior CTV coverage.
Clinical outcomes evaluated were locoregional disease control and
toxicity.
: The median age of this patient population was 54 (range 25
72) years. All 29 had squamous cell carcinoma histology. Stage
distribution : IB2 3, IIA – 3, IIB –13 and IIIB –11. At a median followup
of 19 (range 642) months, 28 (96.5%) patients had locoregional
disease control as assessed by clinical examination. One patient each
developed lung metastasis and second malignancy (breast cancer) at
17 and 14 months respectively but were locoregionally controlled.
Three (10.6%) patients developed RTOG grade I rectal toxicity. No
patient reported bladder or sigmoid toxicity. Grade III late vaginal
effects occurred in all patients and grade III in 4 (13.8%).
: CT based interstitial brachytherapy of cervical cancer is
feasible and results in excellent clinical outcomes providing very high
locoregional control of disease with very low rates of treatment
related toxicity.
PO286
ASSESSMENT OF "OLD FASHION" GYNAECOLOGIC HIGHDOSERATE
BRACHYTHERAPY STARTING POINT TO MODERN BT TECHNIQUES
A. Vasconcelos 1 , M. Ferreira 1 , V. Mendonça 1 , M. Jorge 1 , I. Monteiro
Grillo 1
1 Hospital Santa Maria, Radiation Oncology, Lisboa, Portugal
: Carcinoma of the uterine cervix is the second
most common cancer and the third leading cause of cancer death
among women. For some decades combination of external beam
radiotherapy (EBRT) and intracavitary brachytherapy (ICBT) has
become a Radiotherapy standard treatment modality for cervix
cancer. The purpose of this study is to assess dosimetry plan outcomes
with highdoserate (HDR) ICBT planning orthogonal radiographs. For
pts with cervix cancer throughout treatment prescription to standard
Point A dose in the Manchester system.
: Between December 2001 to November 2009,
106 pts with cervix cancer, were treated with EBRT and concomitant
Chemotherapy + ICBT. Pts staged with FIGO staging system (6th ed.
2002). Authors report a retrospective analysis of 94 patients (pts), 12
pts did not complete ICBT. Pts presented stage IB in 11%, 14% for
stage IIA, 66% for stage IIB and 10% for stage IIIB disease. Initially
treated with EBRT dose (box technique) between 41,450,4 Gy
(1,8Gy/fx) with concomitant weekly CT (cisplatin 40 mg/m 2 ). Dose
escalation was obtain with HDR ICBT prescription to point A 24Gy
(6Gy/fx) within 34 weeks (EQD2=32Gy). With Intracavitary Rotte 'Y'
applicators technique. Dosimetry study was performed with
orthogonal radiographs and PLATO ® planning system. Local recurrence
and two year disease free survival (Kaplan Meier model) were
determinate. Major acute and late toxicity was evaluated with
EORTCCTC.
: Within this group of 94 pts, median age was 54 yearsold
(range 2984). Cervix lesions size had median diameter 40 mm (range
1080). Lesion was localized in 77% pts in exocervix, 17% pts in
endocervix and 2 pts with both involved. Pathology determined 81%
squamous cell carcinoma and 18% adenocarcinoma. Applicators with
median tandem length of 7 cm (range 48cm) and median vaginal
ovoids diameter 25mm (range 1530 cm). Dose variations observed in
rectum median Dmax. 315cGy (range 155509) and bladder median
Dmax. 418cGy (range 234531). Median total treatment time was 10
weeks (range 320). With a median followup 45 months (range 7–98),
4 pts had local recurrence and 14% distant metastasis. The twoyear
disease free survival was 81%; 3 pts with acute grade 3/4 toxicity;
Late toxicity: 9 pts with grade 3/4 gastrointestinal and 8 pts with
grade 3/4 genitourinary toxicity (Dmax rectum 297486cGy and
bladder 367460cGy).
: Single point dose estimation using the reference point
on orthogonal radiographs will underestimate the maximum bladder
and rectum dose. However 3D entire intracavitary evaluation,
underdosage regions can be recognized and optimize. These outcomes
will endorse new era in ICBT, with CT imaging and dosimetric
planning, following GECESTRO guidelines. Since individualized HDR
ICBT treatment is recommended for all clinical stages of cervix
cancer.
PO287
VOLUME RELATED HRCTV COVERAGE USING MRI BASED OPTIMISED
TREATMENT PLANS FOR HDR BRACHYTHERAPY CERVIX TREATMENTS
S. Aldridge 1 , M. Naeem 1 , N. Bozic 1 , A. Winship 2
1
Guy's and St.Thomas' Hospital NHS Foundation Trust, Department of
Medical Physics, London, United Kingdom
2
Guy's and St.Thomas' Hospital NHS Foundation Trust, Department of
Clinical Oncology, London, United Kingdom
: Intracavitary brachytherapy (BT) plays a crucial
role in the therapeutic management of patients with locally advanced
cervical carcinoma. MRI is the gold standard for target and organ at
risk (OAR) delineation for BT cervix treatments enabling the dose
distribution to be conformed to the target for individual patients. We
implemented MRI based 3D treatment planning for HDR BT cervix
treatments following the GYN GECESTRO recommendations in May
2010 and have now treated 25 patients. This work assesses the ability
to cover the HRCTV with respect to volume size without exceeding
World Congress of Brachytherapy 2012 S 115
the critical structure doses by using plan optimisation without
interstitial needles.
: Each patient received 3 individual applicator
insertions. MR and CT scans were acquired for every BT fraction. The
3D image sets were then fused; the MR images were used to delineate
the target and critical structures (OAR), and the CT images were used
for applicator reconstruction (Rotterdam). A standard plan was then
viewed. The plan was optimised as required to keep the OAR doses
below tolerance and to achieve the required target doses.
: To optimise our plans we used a variety of techniques;
removal of dwell positions from the top of the IUT, moving the dwell
positions in the ovoids, using asymmetric dwell times in the ovoids or
asymmetric ovoid sizes, and changing the normalisation value at point
A. In the majority of treatments these optimisation techniques
resulted in reduced OAR doses with the desired HRCTV D90 coverage.
The graph below compares the HRCTV volumes against the LQ doses
for the total treatment (including the EBRT dose) for the HRCTV D90
and the corresponding D2cc doses for the OAR. The tolerance dose lines
indicate the doses that are considered to be acceptable for the
different OAR.
HRCTV volumes up to 40cc were treated adequately (>75Gy but
ideally >84Gy) without exceeding the OAR tolerance doses in 88% of
our cases.
: Individual optimisation of treatment plans per fraction is
required to account for differences in applicator position, organ at
risk location and tumour response/position. Volumes greater than
40cc are difficult to cover adequately with optimisation alone without
exceeding the OAR doses. The addition of interstitial needles to our
intracavitary technique may have increased the HRCTV dose in 12% of
our patients. Our results with a volume of 40cc are comparable with
that stated by the GECESTRO group for plan optimisation without
needles.
PO288
A NOVEL COMPUTER PROGRAM TO SUPPORT MRGUIDED GYNECOLOGIC
BRACHYTHERAPY
J. Egger 1 , X.C. Chen 1 , T.K. Kapur 1 , A.N.V. Viswanathan 2
1
Brigham and Women's Hospital, Department of Radiology, Boston
MA, USA
2
Brigham and Women's Hospital, Department of Radiation Oncology,
Boston MA, USA
: To describe a novel computer program designed
and implemented to provide an overall system for supporting MR
guided gynecologic brachytherapy.
: From September 2011 to January 2012, 10
gynecologiccancer patients requiring brachytherapy underwent
imageguided applicator insertion in a multimodal operating suite with
integrated MR scanner, ultrasound and PET/CT scanner. In order to
increase the physician's speed and monitor the consequences of
inserting interstitial catheters in real time, a novel computer program
was designed and implemented and is described here.
: The overall system starts with preimplant imaging and the
integrated software permits measurement of relevant sizes for
intervention leading to automatic inventory control and specific
applicator request. Next, a device is selected (e.g., tandem and
ring/ovoid +/ interstitial needles or interstitial needles alone) that is
modeled in the preoperative images. Virtual modeling and
visualization of several instruments for direct device comparison is
enabled to identify the optimal one. In the intraoperative stage, the
patient is imaged using 3 Tesla MRI with legs in the insertion position.
The computervisualized template allows guidance to an optimal
position for dose delivery. Serial imaging examinations are
superimposed on the visualization of the modeled device. With this
interactive novel software program, the physician can select which
interstitial needles may best benefit the patient, and at what depth
they should be inserted, as determined by the MRI image viewed
during the insertion process. The physician then inserts the correct
interstitial needle into the necessary applicator hole based on the
tumor location as visualized on intraoperative 3T MRI (see Figure).
: Novel software was developed that aids in the
integration of preoperative assessment, intraoperative 3T imaging and
applicator insertion. Novel features include 1) linking a diagnostic
imaging set in realtime to a 3D CAD model of a medical device; 2)
precise identification of catheter location in the 3D imaging model
with realtime imaging feedback and 3) the ability to perform patient
specific preimplant evaluation by assessing in the computer the
placement of interstitial needles prior to an intervention via virtual
template matching with a diagnostic scan.
PO289
MULTICHANNEL VAGINAL BRACHYTHERAPY: OVERKILL OR NECESSITY?
S. Park 1 , J. Demanes 1 , M. Steinberg 1 , M. Kamrava 1
1
David Geffen School of Medicine at UCLA, Radiation Oncology, Los
Angeles CA, USA
: Singlechannel cylinder applicators are most
commonly used to treat early stage endometrial cancers. Multichannel
applicators have been developed to reduce the dose to organs at risk
(OARs) while optimizing dose to the target. The Capri (Varian Medical
Systems) is a vaginal applicator with 13 channels. It is not clear how
best to utilize all these channels for treatment planning. We
conducted a dosimetry study using this device to determine the
dosimetric advantages/disadvantages in utilizing various combinations
of channels.
: The Capri consists of a single central catheter
(R1), an inner array of six catheters (R2), and an outer array of six
catheters (R3). A total of 78 plans were generated by using 6 different
catheter arrangements (R1, R2, R12, R13, R23, and R123). The target
volume was defined as a 2 mm circumferential shell extending 4 cm in
length around the Capri device. A urinary catheter and contrast were
used to assist in contouring bladder, rectum, and urethra. 3D plans
were generated with the Nucletron Oncentra MasterPlan to deliver 6.0
Gy per fraction to the target. An inverse planning simulated annealing
optimization algorithm was applied to ensure the prescription dose
covered >99% of the target and minimized dose to the OARs. Target
coverage and OAR doses of the various catheter arrangements were
compared. Statistical significance was evaluated with a twotail
paired ttest to ruleout the null hypothesis that there is no difference
between the reference plan R123 (all 13 channels) and the various
other plans.
: Target Dose Coverage: Figure shows on average all plans had
the same target coverage V100 and D90 (p>0.05). Target hot spot: The
V150 for R123 (2.3%), R2 (1.5%), and R23 (2.7%) were similar (p=0.2).
The R12 had the smallest hot spot (1.1%, p=0.001). The R1 was larger

S116 World Congress of Brachytherapy 2012
(8.1%, p=0.02) and R13 was the largest (25.0%, p0.05). They were statistically better than all the
other plans (p10 on their pre treatment PET scan. 60% of
distant metastases occurred in patients with a nodal SUV >4 on pre
treatment PET scan. In patients with 3 month post treatment PET scan
(54%), 75% of patients with a SUV >4 suffered a local recurrence. 30
month estimates for local control, disease free survival, metastasis
free survival, and overall survival using KM curves are 80%, 30%, 42%
and 65% respectively.
: MRI based interstitial brachytherapy for locally advanced
cancers of the cervix and vagina results in a high rate of local control.
Additionally, a HRCTV D90 > 95%, an initial staging PETCT SUV max
>10 and a 3 month posttreatment SUV of >4 correlate well with local
control. A pretreatment PETCT nodal SUV >4 may be a better
predictor for distant metastasis than an SUV >10 of the primary.
Though longer followup is required, MRI based planning appears to
provide initial excellent local control and distant metastasis free
survival.
PO293
OUTCOMES FOR RECURRENT ENDOMETRIAL CANCER WITH HDR
INTERSTITIAL BRACHYTHERAPY UTILIZING MRI BASED PLANNING
M.C. Biagioli 1 , J.M. Freilich 1 , A. Cruz 1 , A.S. Saini 1 , D.C. Hunt 1 , J. Shi 1 ,
D.C. Fernandez 1
1
H. Lee Moffitt Cancer Center, Radiation Oncology, Tampa Florida,
USA
: Recent data has emerged demonstrating
significant advantages to MRI based planning over CT based planning
in the brachytherapy treatment of cancer of the cervix. The purpose
of this study is to evaluate our experience utilizing MRI based
brachytherapy treatment planning for patients with recurrent
endometrial cancers who underwent an interstitial implant as part of
there treatment.
: A retrospective review was conducted of all
endometrial cancer recurrences treated at Moffitt Cancer Center from
20092011 where 1.5 T contrast enhanced MRI based high dose rate
(HDR) interstitial brachytherapy was part of their treatment plan. 12
patients were identified and local recurrence, disease free survival,
metastasis free survival, and overall survival were analyzed in the
whole group and based on prognostic features and treatment plans.
: Mean followup was 10 months (range 216). 92% of patients
had recurrent disease, 17% received chemotherapy and 83% received
external beam radiation therapy with a median dose (range) of 4920
cGy (43205500). Median (range) brachytherapy total dose and dose
per fraction was 2500 cGy (22003500) and 500 cGy (450600),
respectively. Local recurrence rate was 16.7% with estimated mean
time to local recurrence of 13 months. In patients with the CTV D90
greater than 95%, local recurrence was 10% versus 50% if less than or
equal to 95%. Disease free survival was 67% with estimated mean time
to event of 9 months. Metastasis free survival was 80% in patients
without metastatic disease on presentation with estimated mean time
to metastasis of 7 months. Overall survival was 67% with estimated
mean time to death of 9 months. 15 month estimates for local
control, disease free survival, metastasis free survival, and overall
survival using KM curves are 70%, 62%, 62% and 62%, respectively.
: MRI guided interstitial brachytherapy results in a high
level of local control in patients with pelvic recurrences after primary
treatment for endometrial cancer. Though initial followup is short
this local control appears to result in a high level of DFS. Of the 2
local failures there was no pretreatment PET information available.
Additionally, patient number was too small to determine the utility of
3 month posttreatment PET as a predictor for local or distant
failures.
PO294
BRACHYTHERAPY
TURKEY
EXPERIENCE IN GYNAECOLOGICAL TUMORS IN
I. Aslay 1 , B.W.G. Brachytherapy Working Group 2
1
Istanbul University Oncology Institute, Radiation Oncology, Istanbul,
Turkey
2
Oncology Institutes, Radiation Oncology, Istanbul, Turkey
: This study is conducted to evaluate the
brachytherapy experience in gynaecological tumors in Turkey.
: Gynaecological brachytherapy data of 11
medical faculty, one government hospital and two private hospitals
between 19702011 was collected. Ovarian cancer was not included.
Median brachytherapy (BrT) experience of the centers was 12 (141)
years. The total number of the patients (pts) was 297124 and 7% of
them was gynaecological tumor (except ovary). The ratio of the
tumors was %49 in cervix carcinoma (CC), %46 in endometrium
carcinoma (EC), %1 in vagina carcinoma (VaC), %3 in vulvar carcinoma
(VuC).
: For curative treatment of CC concomitant chemotherapy
(CCh) 40mg/m2 weekly was standard procedure in all centers. In
postoperative CC , Cch was given if poor prognostic factors present
such as positive margin, positive lymph node, bulky tumor, positive
parametrium. Adjuvant Ch to radiotherapy was not given in any
center. The incidence of the pts treated with curative intent in EC
and VuC was low. Ch was given in EC pts if advanced stage or poor
hystology was present. In VuC, Ch was given due to comorbidities of
the pts and also BrT was not applicated as a treatment component
except in salvage therapy. VaC was treated mostly with the same
protocol of CC. Salvage treatment was done with external
radiotherapy (ERT) and/or BrT in two centers, with only ERT in 3
centers and with cyberknife in one center. Eight centers have no
salvage treatment experience. ERT technigues were 3D and IMRT in
three centers, 3D in 7 centers, 2D and 3D in 4 centers. Except two
centers with two and one center with 5 BrT machines all the others
have one HDR treatment unit. BrT technigue was 3D in 6 , 2D in 8
centers. Two centers also have LDR experience. ERT, BrT and total
treatment doses are listed in table 1.

S118 World Congress of Brachytherapy 2012
: In gynaecological tumors BrT is an impotant component
of the radiotherapy. In this study we found that there is a variability
in the BrT techniques and doses between centers in Turkey. The
Brachytherapy Working Group is continuing to collect data for further
studies.
PO295
DOSIMETRIC GAIN OF UTRECHT INTERSTITIAL CT/MRI APPLICATOR IN
CERVICAL CANCER HDRBRACHYTHERAPY
C. Camacho 1 , F. Celada 2 , S. Roldán 2 , A. Tormo 2 , J.C. Morales 2 , V.
Carmona 1 , M.C. GarciaMora 2 , F. Lliso 1 , S. Rodríguez 3 , J. Pérez
Calatayud 1
1
Hospital Universitario La Fe, Radiation OncologyPhysics, Valencia,
Spain
2
Hospital Universitario La Fe, Radiotherapy (Phy), Valencia, Spain
3
Clínica Benidorm, Radiation Oncology, Benidorm, Spain
: The purpose of this study is to check the
potential gain, in dosimetric terms, of the Utrecht
intracavitary/interstitial CT/MR applicator over the Fletcher
intracavitary (Nucletron®) applicator for MRI imaging—guided HDR
brachytherapy in cervical cancer patients.
: Ten applications, using 6 needleUtrecht
applicator, were analyzed in this study. For each application two
theoretical different HDRplans were elaborates, manually optimized
in MRI: (1) with needles and (2) without needles (Fletcher
intracavitary applicator). Considering 45 Gy external beam, four ~7 Gy
fractions were prescribed according to GECESTRO recommendations.
After assessing DVHs for highrisk clinical target volume (HRCTV),
intermediaterisk clinical target volume (IRCTV), bladder, rectum and
sigmoid and doses converting to the equivalent dose in 2 Gy (EQD2),
D90/D2cc quotients as HRCTV as IRCTV, for all OARs of two plans
were obtained for comparison between them. Then D90/D2cc
quotient of needleplan versus no needleplan was obtained.
: Quotient of needleplan versus no needleplan were: in case
of HRCTV 1,30[1,790,95], 1,21[2,110,81] and 1,07[1,420,77] for
bladder, rectum and sigmoid, and in case of IRCTV 1,46[1,971,15],
1,33[1,671,08] and 1,19[1,461,01] respectively.
: Although always according to GECESTRO
recommendations, not all needleplans show a favorable ratio
between HRCTV coverage and OARS doses. But as we are assessing IR
CTV, all needleplans are favorable. In such cases, that planning is
conditioned by a small HRCTV (e.g. complete remission after EBRT)
and a wide IRCTV because of diagnosesGTV, interstitialBT is useful
for right coverage of microscopic disease. The benefit of interstitial
BT is shown in all other needleplans for both HRCTV and IRCTV.
Sigmoid benefits the least from interstitialBT, but average is
favorable. Bladder is most favored. On the basis of our results all
patients benefit from the using Utrecht intracavitary/interstitial
CT/MR applicator for MRI imaging—guided HDRbrachytherapy, so, in
our institution, all cervical cancer patients are treated with Utrecht
applicator.
PO296
CLINICAL AND DOSIMETRIC RESULTS OF HDR BRACHYTHERAPY GUIDED
WITH MRI
P. Antonini 1 , A. Tormo 1 , S. Roldán 1 , F. Celada 1 , C. Camacho 1 , V.
Carmona 1 , J.C. Morales 1 , M.S. Rodríguez 1 , F. Lliso 1 , J. Pérez
Calatayud 1
1 Hospital Universitario La Fe, Radiation Oncology, Valencia, Spain
: Summarize and report oncologic and dosimetric
results of cervical cancer patients treated with magnetic resonance
image (MRI) guided highdoserate brachytherapy (HDR BT).
: Retrospective review of the records of
cervical cancer patients treated in our institution from September 07
to march 2010. To be included in the study, the treatment had to
fulfil the criteria: (1) include a previous treatment of at least 45 Gy of
external radiation (RTE) to the pelvis concomitant with cisplatin (2)
the BT boost consisted in insertion of a Fletcher intracavitary
(nucletron®) applicator under spinal anaesthesia and individualized
MRI planning. Each treatment was composed of 2 applications (7 days
apart), with 2 separated fractions of ~7 Gy (in 24 hours). All patients
had squamous cervix cancer staged with FIGO’s 2009 classification for
primary tumour size and AJCC 2006 classification for lymph node
status. Tumour volume was also analyzed using EMBRACE protocol
definitions. Toxicity scores were defined by CTCAE v 3.0.
: 43 patients were found. The mean follow up for the entire
group was 12 months (636). Mean patient age was 56 years. 82 %
patients had FIGO tumours IIbIIIb and 76 % of them were N0 cases. 88
% of patients had what EMBRACE defines as 'small tumours' or 'large
tumours with good response to RTE'. The mean total cumulative dose
was 76,2 Gy with mean D90 doses exceeding 85 and 65 Gy for HRCTV
and IRCTV. ICRU in vesical and rectal points, maximal cumulative
doses in 2 cm3 of bladder, rectum and sigmoid were, respectively:
78.5; 82; 79.3; 61.2 and 58.2 Gy: Mean dose to H point was 71,7 Gy.
Major (G3 or more) genitourinary and gastrointestinal toxicities were
present in 2 and 4 % respectively. Three (7 %) patients had local
persistent disease, all of them with large tumour nonresponsive to RT
and 2 of them also with uncontrolled systemic disease.
: MRIguided HDRbrachytherapy, in accordance with GEC
ESTRO recommendations, is a safe technique in terms of local control
and toxicity. These clinical and dosimetric results compare favourably
with traditional technique.
PO297
IMAGEGUIDED BRACHYTHERAPY FOR THE TREATMENT OF CERVICAL
CANCER: RESULTS ON DIFFERENT PACKING TECHNIQUES
B. Libby 1 , K. Ding 1 , E. Crandley 1 , K.A. Reardon 1 , B.F. Schneider 1
1 University of Virginia, Radiation Oncology, Charlottesville, USA
Historically, gynecological brachytherapy
applicators have been placed in an operating room, with gauze
packing used to both immobilize the applicator and to reduce dose to
bladder and rectum by increasing their distance from the applicator.
The patient is then moved to a CT scanner for 3D imaging, and then to
the radiation oncology department for treatment. If the packing is
inadequate, the treatment will either be suboptimal or will need to
be aborted. With the advent of image guided brachytherapy (IGBT)
suites with dedicated imaging systems, inadequate packing can be
assessed and corrected prior to treatment. In this investigation we
present the effectiveness in reducing critical structure doses and
overall procedure time of IGBT by providing optimal packing and
planning for cervical cancer patients treated with HDR.
: Patients undergoing HDR brachytherapy had
tandem and ovoid applicators placed in the IGBT suite, which has an
operating room couch with carbon fiber insert, full anesthesia
capabilities, a Siemens Somatom CT on rails, and a Varisource HDR
unit. Vaginal packing was accomplished with either gauze or the
Alatus balloon system. Before planning, the CT images were
evaluated to determine whether the packing or balloon placement
was optimal. For cases in which the packing was suboptimal, the
packing was redone and the patient was scanned again for treatment
planning. Patients remained in the scanning position during planning
and treatment. For this evaluation of varying packing techniques all
doses were prescribed to Point A, with the dose to the ICRU 38
bladder and rectal points determined, as well as the D2cc and D1cc of
the bladder and rectum.
:
We present a range of dosimetric results for both gauze and balloon
packing in Table 1. For a patient in which the Alatus system was
World Congress of Brachytherapy 2012 S 119
used, the first insertion of the balloons was suboptimal, thus the
predicted doses to the bladder and rectal points were suboptimal. Re
insertion of the balloons was performed for optimal treatment. A CT
scan after balloon removal also demonstrated their utility in reducing
bladder and rectal doses. For a patient in which gauze packing was
used, differences between optimal and suboptimal packing that occur
during the procedure are shown. Optimal packing reduced the average
time from applicator insertion to treatment to an average of 54
minutes, as opposed to 70 minutes for suboptimal packing which
would require being corrected before treatment. The reduced
planning time allows use of less anesthesia for the patient.
: Dedicated IGBT suites allow for the correction of
suboptimal vaginal packing, and a reduction in overall treatment
planning and delivery time. In the context of IGBT, in which the
applicator is placed and the treatment planning scans and treatment
occur without movement of the patient, use of balloon packing
systems may allow for more optimal packing than gauze packing.
PO298
ESTIMATION OF BOWEL DOSE FOR ENDOMETRIAL CARCINOMA TREATED
BY HIGH DOSE RATE BRACHYTHERAPY ALONE INITIAL RESULTS
A. Zuchora 1 , L. Fahy 1 , M. Pomeroy 2
1
University Hospital Galway, Department of Medical Physics, Galway,
Ireland Republic of
2
University Hospital Galway, Radiotherapy Department, Galway,
Ireland Republic of
: To analyze the results of an initial study using
oral contrast to improve the estimation of the dose received by the
bowel during HDR brachytherapy (BT) treatment alone for
endometrial carcinoma after total abdominal hysterectomy bilateral
salpingooophorectomy (TAO/BSO).
: The protocol for treatment endometrial
carcinoma at Radiotherapy Department at University Galway Hospital
is to use BT alone with total dose 25Gy in five fractions prescribed to
0.5 cm from the vaginal surface with standard active lengths of 4 cm.
BT treatment is delivered twice weekly. Since the beginning of 2011
all patients treated with HDR cylinder insertion have been
administered oral contrast. This analysis deals only with patients with
BT treatment alone, without previous External Beam. Seven patients
were included in this analysis, 5 patients FIGO I and 2 patients FIGO II.
Brachytherapy was performed with vaginal cylinders (Varian) with
diameters dependent on patient anatomy. Before each insertion 10 ml
oral contrast Gastrografin (Bayer Schering Pharma 37 ml Iodine per
100ml) in a cup of water was administrated. The cylinder was inserted
approximately 45 min1 hour later and Computer Tommography (CT)
scanning using ACQsim Philips Medical System for dose planning with 3
mm slice thicknesses was done. Contouring of Organs at Risk (OAR)
and planning were prepared in the Brachyvision System Planning
version 10.0.34 after every insertion. Doses at Bladder, Rectum and
Bowel in 0.1,1 and 2cc volume and point doses based on ICRU report
38 were reported and recalculated to 2Gy Equivalent Dose(EQD) base
on the radiobiological linearquadratic model(LQM).
: Oral contrast administration is an easy procedure which is
well tolerated by the patient. Organs in pelvic area can change the
position after a TAO/BSO surgical procedure. The CT verification scan
is used to contour the OARs and doses can be monitored using Dose
Volume Histograms (DVH) tools. The bowel position is more clearly
visible when oral contrast has been administered and 3D dose
distribution can be calculated. This additional information can be
used to modify the treatment if necessary to maintain OAR dose
tolerances. For two patients in the study individual vacpack
immobilization was used after the first fraction to move the bowel
away from the high dose area, in this way decreasing the bowel dose
during the subsequent treatments.
Analysis of patients data shows the doses in 2 cc bowel volume were:
Bowel average dose for one fraction 2.5 ± 1.3Gy
Bowel average dose in 2Gy EQD for one fraction 3.1 ± 2.2Gy
Bowel average total dose for full treatment in 2Gy EQD2 15.6 ± 8Gy
: This simple procedure can help with estimation of the
dose in bowel and possibly decrease late bowel symptoms. In some
cases CT verification gives the option to change patient position using
individual immobilization devices and move the bowel from the high
dose region.
PO299
3D MRIBASED HDRBRACHYTHERAPY PLANNING AND IMRT FOR THE
TREATMENT OF CERVICAL CANCER
P.T. Dyk 1 , A.J. Apicelli 1 , B. Sun 2 , C. Bertelsman 1 , J. Kavanaugh 2 , J.
Rolfingsmeier 1 , T.A. DeWees 1 , J.L. GarciaRamirez 2 , J.K. Schwarz 2 ,
P.W. Grigsby 2
1
Barnes Jewish Hospital, Radiation Oncology, St. Louis, USA
2
Washington University in St. Louis, Radiation Oncology, St. Louis,
USA
: To evaluate dose volume parameters for targets
and organsat risk (OAR) using MRIbased HDRbrachytherapy
treatment planning and IMRT in a series of patients treated at a large
volume academic cancer center in the United States.
: Between December 2009 and July 2011, 50
patients with stage Ib1IVa cervical cancer were diagnosed and
treated using definitive radiation therapy, with or without
chemotherapy. Treatment consisted of external radiation therapy
using IMRT directed at the cervical mass and pelvic lymph nodes using
the PETCT simulation technique. All patients received 6 weekly HDR
brachytherapy treatments beginning week 1 of IMRT. MRI simulation
was used for each HDR fraction. The gross tumor volume (GTV) at
each fraction was delineated using diffusion weighted and/or T2
weighted images. Subsequent symmetrical expansions were made at
3, 5, 7, and 10 mm to form highrisk clinical tumor volumes (HR CTV),
avoiding the rectum, bladder, and sigmoid. Doses in 2 Gy equivalent
fractions (EQD2) to the 90% and 100% volumes for each fraction were
recorded and summed. Doses to the 2cc OAR's were recorded and
summed. The mean dose from the IMRT plan for each OAR was
summed to the 2cc dose. The D90 and D100 of the cervical mass from
the IMRT plan was summed to the D90 and D100 for the GTV and HR
CTV expansions. Patients were followed for local control and toxicity
until censored or lost to follow up.
: Median follow up was 9.7 months. Platinumbased
chemotherapy was administered in 86% of the patients. All 50 patients
completed the planned 6 brachytherapy fractions. The median dose to
the cervical tumor and lymph nodes from IMRT was 20 Gy and 50.4 Gy
in 28 fractions. Three of the 50 patients did not complete EBRT. There
were 5 local failures at a median time of 4.4 months after diagnosis.
The median D90/D100 EQD2's for the patients who failed vs. those
who did not for the GTV, HR CTV 3, 5, 7, and 10 volumes are listed in
the table below:
Failed
locally
Did NOT fail
locally
GTV
(D90/D100)
HR CTV
3mm
39.4/60.5 Gy 34.4/49.9
Gy
71.9/103.1
Gy
59.5/83.7
Gy
HR CTV
5mm
32.1/46.8
Gy
55.2/78.2
Gy
HR CTV 7
mm
30.4/44.1
Gy
38.1/55.7
Gy
HR CTV
10mm
27.7/39.8
Gy
33.7/49.1
Gy
There were 4 late grades 3 or 4 toxicities at a median of 10 months
following diagnosis. These were a rectosigmoid perforation, a recto
vaginal fistula, and 2 vesicovaginal fistulaes. The median EQD2 2cc
bladder dose was 85.0 Gy for those with a bladder complications
compared to 92.2 Gy for those without. Both patients with VV
fistulaes had initial IVa disease invading the bladder. The median
EQD2 2cc doses for the rectum were 80.4 Gy for the 2 patients who
suffered G3+ rectal complications compared to 70.8 Gy for those who
did not. The EQD2 2cc for the sigmoid in the patient with the
rectosigmoid perforation was 80.0 Gy vs. 68.4 Gy for the remaining
patients.
: Longer follow up and a greater number of patients will
be needed to determine which dosevolume parameters best predict
local control, and bladder, rectal, and sigmoid toxicity using our
technique in the treatment of cervical cancer.
PO300
DOSIMETRIC COMPARISON OF 2D AND 3D BRACHYTHERAPY PLANNING
G. Kemikler 1 , I. Aslay 2 , S. Kucucuk 2 , I. Özbay 1
1
Istanbul University Oncology Institute, Radiophysics, Istanbul, Turkey
2
Istanbul University Oncology Institute, Radiation Oncology, Istanbul,
Turkey

S120 World Congress of Brachytherapy 2012
: To compare dosimetrically 2D and 3D
brachytherapy planning in the curative treatment of cervix carcinoma.
: With the guidance of MR images that were
taken before and after the external radiotherapy, CT based
brachytherapy planning was performed in 5 patients.The CTMR
compatible Fletcher applicators were used. Two different dose
perscription and fractionation schedules were used for comparison of
2D Point A and 3D HRCTV. One radiation oncologist who is
experienced in brachytherapy deliniated the target (HRCTV, IMRCTV)
and OAR (rectum, bladder, sigmoid) volumes on CT images. In 2D
planning normalization to Point A was done without
optimisation.However in 3D planning reference dose was given to
HRCTV with normalization and optimisation . Oncentra 3.1 version of
TPS was used. Dose schedules were 7Gy/ 3 fractions (EQD2=29,75Gy)
and 6 Gy/4 fractions (EQD2=32Gy). Doses at 2 cc of OAR volumes were
calculated. Paired ttest was used in statistical analyses.
:
The results are given in table1.
HRCTV
90%
IMRCTV
90%
Rectum 2cc (Gy) Bladder 2cc (Gy)
Sigmoid
2 cc
(Gy)
Point
196±26 133±36 14±5
A 7x3
20±3 15±4
Point
171±43 125±39 16±5
A 6x4
23±3 18±5
p:NS p:NS p:0,003 p:0,000 p:0,007
Point
196±26 133±36 14±5
A 7x3
20±3 15±4
HRCTV
101±1
7x3
65±9 7±3 10±3 7±1
p:0,022 p:0,019 p:0,021 p:0,006 p:0,005
Point
171±43 125±39 16±6
A 6x4
23±3 18±5
HRCTV
101±1
6x4
67±7 9±3 12±3 9±1
p:0,020 p:0,023 p:0,031 p:0,006 p:0,007
HRCTV
101±1
7x3
65±9 7±3 10±3 7±1
HRCTV
101±1
6x4
67±7 9±3 12±3 9±1
p:NS p:NS p:0,014 p:0,006 p:NS
: In this study it was found that HRV, IMRV and OAR doses
were higher in 2D (Point A) planning than in 3D (HRCTV) optimized
planning. Thus, fewer side effects would be expected with 3D
planning. In 3D planning, between 7x3 and 6x4 fractionation similar
HRCTV 90% and IMRCTV 90% were found . But, significantly higher
rectum and bladder doses were found in 6x4 fractionation. Therefore,
7x3 fractionation can be prefered especially by busy clinics.
PO301
SOURCE POSITION LOCALIZATION FOR ICBT TANDEM & OVOID
APPLICATORS UTILIZING ONCENTRA BRACHY APPLICATOR MODELING
J. Kemp 1 , M. Price 1
1
Mary Bird Perkins Cancer Center, Medical Physics, Baton Rouge LA,
USA
: Nucletron’s Oncentra Brachy Applicator
Modelingplugin (AMp) may facilitate HDR cervical brachytherapy
treatment planning whenimage quality inhibits dwell position
localization. When registered with a ICBTpatient’s CT/MR, the AMp
utilizes a 3D CAD rendering of the corresponding applicatorto define
possible source dwell positions. As such, imaging artifacts thatwould
normally inhibit the accurate selection of dwell positions
viaintercolpostatic dwell position markers or measurement from an
applicatorbasedlandmark will be of little consequence. Heretofore,
literature has lacked anyverification of the accuracy or utility of the
AMp. The purpose of this studyis to compare the equivalence of
source localization within a CT/MRFletchertype tandem and ovoid
applicator utilizing current clinical practiceand Oncentra’s AMp in a
water phantom containing OAR surrogate structures.
: KVCT image sets with 0.976mm x 0.976mm x
1.25mm voxelswere acquired of a water phantom following clinical
protocol containing bladderand rectum surrogates as well as an
assembled Nucletron’s Fletcher CT/MRapplicator with various ovoid
sizes (20, 25, 30mm) and a 30 o tandem.Using the Oncentra Brachy
TPS, OARsurrogates were segmented and catheters
werereconstructed using (1) institutional clinical protocols for T&O
basedbrachytherapy (i.e. usingintercolpostatic dwell position markers)
and (2) using the AMp. Treatment plans were then generated
followingclinical protocol, which ensures a dose of 600cGy to the ICRU
38defined PointA. The coordinates corresponding to the center of
each active dwell position,resulting from each method, were spatially
compared. The dosimetric impact ofthese differences was quantified
by determining D0.1cc, D1ccand D2cc for the surrogate OARs.
: Preliminary results obtained for the 25mm ovoid/ 30 o tandem
applicator demonstrate 80% of dwell positions definedutilizing clinical
protocol and the AMp agree within 1mm with a maximum deviationof
1.17mm, both less than the resolution of the kVCT scan. Differences
insource position definitions resulted in an increase of 2.9%, 0.48% and
0.3% and0.66%, 0.87%, and 0.59% for D0.1cc , D1cc and D2ccfor the
bladder and rectumsurrogates, respectively, when utilizing the
AMprather than clinical protocol for source position localization. This
limiteddata indicates that use of the AMp for dwell position
localization isequivalent to our clinical practice.
: Preliminary resultsindicate that source dwell position
localization utilizing Nucletron’sApplicator Modeling plugin and our
clinical protocol results in equivalentdosimetry for the simple, water
phantom geometry investigated. Currently we are investigating the
validityof this conclusion utilizing ovoids of different sizes as well as
aCT/MRcompatible vaginal cylinder.
World Congress of Brachytherapy 2012 S 121
PO302
COMBINATION OF EXTERNAL BEAM IRRADIATION AND LOWDOSE RATE
BRACHYTHERAPY FOR INOPERABLE ENDOMETRIAL CARCINOMAS
A. Baumann 1 , C. CharraBrunaud 1 , S. Hoffstetter 1 , D. Peiffert 1
1 Centre Alexis Vautrin, Radiotherapy, Vandoeuvre les Nancy, France
: The standard treatment for early stage
endometrial carcinoma is total abdominal hysterectomy and bilateral
salpingooophorectomy. However 3 to 9% of patients are inoperable
because of comorbidities or age. Such patients can be treated with a
combination of external beam radiation therapy (EBRT) and
brachytherapy. The goal of this study was to update our experience of
combining EBRT and intracavity lowdose rate (LDR) brachytherapy for
inoperable endometrial carcinomas.
: The files of 56 patients treated at the Centre
Alexis Vautrin between 1995 and 2010 for inoperable endometrial
carcinoma were reviewed. Seventyone per cent were stage I tumor
(based on the 1971 FIGO classification), 11% stage II, 16% stage III and
2% stage IV. The mean age of the patients was 70.1 years, and the
mean BMI was 35.8 kg/m 2 . The EBRT dose to the pelvis was 30 Gy in
the absence of involved nodes on imaging and 45 to 50 Gy in case of
involved nodes. The brachytherapy CTV was defined as the whole
uterus plus the upper third of the vagina; most patients had 3D
dosimetry based on CT imaging. The prescribed dose was 15 to 30 Gy
to obtain a total CTV dose on the CTV of 60 to 65 Gy including EBRT
dose.
: At 5 years, local control, diseasespecific survival and overall
survival were 84.4 %, 59.5 % and 36.8 % respectively. For Stage I
histologic grade 1 patients, diseasespecific survival was 79.6 %.
Eighteen patients (33 %) showed progressive disease, 12 of whom had
an initial stage ≥ II. Only one patient with a stage I tumor developed a
local recurrence.
One patient presented with an acute toxicity grade 3 after EBRT. No
severe acute brachytherapy side effects were observed. One patient
suffered a thromboembolic event immediately after brachytherapy.
Late effects of grade 3 or higher were seen in 5 patients, 1 rectal
toxicity and 5 vaginal toxicities.
: The combination of EBRT and LDR brachytherapy as
exclusive treatment of medically inoperable patients with
endometrial cancer is welltolerated and results in excellent local
control rate. It should be recommended as an alternative treatment
for stage I inoperable patients.
PO303
ANISOTROPIC DOSE MODEL OF INTRACAVITARY VAGINAL
BRACHYTHERAPY USING MULTIRING INFLATABLE APPLICATOR
H. Kuo 1 , R. Yaparpalvi 1 , K. Mehta 1 , L. Hong 1 , A. Wu 2 , D. Mynampati 1 ,
W. Bodner 1 , M. Garg 1 , S. Kalnicki 1
1
Montefiore Medical Center, Radiation Oncology Department, Bronx,
USA
2
Thomas Jefferson University, Department of Radiologic Science,
Philidelphia, USA
: An inflatable applicator (Capri TM , Varian, Palo
Alto, USA) with thirteen lumens is designed with the advantage of
reducing air pocket, and conforming dose to patient tissues. It is
arranged in two concentric rings (with six lumens each) surrounding a
central lumen. This study investigates the efficacy of dose shielding to
normal tissue with anisotropic planning models.
: Anisotropic dose plans for Capri with 1/4,
1/2, 3/4 treatment sectors were designed with sparing structures at
0.5cm to 1cm depth from Capri surface on the opposite 1/4 sectors
(OAR) (Figure 1). Reference plan with isotropic dose distribution with
central lumen activated only (C) was also created. Planning target
volume (PTV) was defined as 0.5cm depth from the surface of Capri
enclosed within the treatment sector. Capri applicators sizes were
varied by injecting 30cc, 40cc and 60cc water which corresponding to
diameters 3.5cm, 3.7 cm and 4.2cm respectively. Plans were done
with different configurations of activated lumens within the
treatment sector, with lumens only in the outer ring (O), or only in
the middle ring (M), or combination of outer and middle ring (OM).
Planning goal was to minimize PTV(V150) and OAR(2cc) with D90 of
PTV > 90%. Doses to points A, B and C, which was located in the
sparing structure at the surface, 0.5 cm and 1.0 cm depth of the Capri
respectively, were calculated for all plans. The ratio of doses to those
points from anisotropic plans to the reference plan was defined as
effective transmission (ET).
: The ET depends on the treatment sector length and the
location of activated lumens. It varied from 0.2, 0.4 and 0.7 for 1/4,
1/2 and 3/4 treatment sector, respectively. The dose to OAR strongly
correlates to ET. They are 20%, 40% and 60% of the prescribed dose
for 1/4, 1/2 and 3/4 treatment sector, respectively. PTV(V150),
however, is inversely correlated to ET. PTV (V150) varied from close
to 25%, higher than 15% and less than 15% for ¼, 1/2 and 3/4
treatment sectors, respectively. With same treatment sector length,
plans with OM lumens can reduce PTV (V150) by 5% but with increased
OAR dose by 2% compared with plans with O loading. For OM loading,
middle lumen could be weighted more heavily to reduce high dose to
vagina mucosa without increasing too much dose to OAR. For 1/4
treatment sector, plan with middle lumen only could reduce
PTV(V150) in vaginal mucosa.
: Postoperative endometrial brachytherapy using Capri
applicator can optimize anisotropic dose distribution by using variable
configuration of lumens. A combination of outer ring and middle ring
planning model provides tolerable dose to mucosa of vagina, good
coverage to vaginal treatment depth, and the best dose sparing at
normal tissue.
PO304
EVALUATION OF 3D MRI CUBE TECHNIQUE FOR HDR CERVICAL CANCER
TREATMENT
H. Kim 1 , C. Houser 1 , S. Beriwal 1
1
University of Pittsburgh Cancer Institute, Radiation Oncology,
Pittsburg PA, USA
: Recently 3D image guided high dose rate (HDR)
brachytherapy for cervical cancer treatment has been quickly evolved
by using either CT or MRI images. Gold standard for the treatment
planning is to use MRI images for each fraction of treatment due to
the superior quality in accurate target delineation. However, MRI scan
for HDR brachytherapy has not been popular because of the limitation
of access to the scanner, the longer scan acquisition time than CT and
longer planning time due to difficulty in reconstruction of applicators.
Newly introduced 3D MRI CUBE sequence technique has been
implemented to the MRI scanners and it offers a 3D high definition and
better resolution with a shorter total scan time. We compared total
scan time, visualization and reconstruction of applicator in the
treatment planning with MR CUBE technique to the planning with
conventional MR images.
: 20 cervical cancer patients who were treated
with MRI based plan using HDR Ring and Tandem applicator were
analyzed. All patients had 5 fractions after external beam was
completed and each HDR fraction was replanned for treatment with
Nucletron Plato 14.5 system. Ten patients had MRI scans using

S122 World Congress of Brachytherapy 2012
conventional method of T2 true axial with 5.0mm slice spacing and
the other 10 patients had scans with T2 CUBE by 2mm spacing and
reformatted to 0.8mm spacing in true axial slices. Xray film based
plans were taken as reference plans for reconstruction of applicators
for each fraction for all patients. Total 100 fractions were analyzed.
Reference plan was generated based on orthogonal Xray films by
digitizing the dummy seed markers inside applicators and prescribing
dose to point A. MRI based plan was generated by tracking the
applicator shape using coordinates of applicator and dwell positions in
a reference plan. Comparisons between reference plan and MR based
plans were involved as following: i) overall conventional and cube MR
scan time , ii) dwell time for weighting 1.0 and iii) geometrical source
dwell position coordinate.
: Total scan time was 30 minutes and 8 minutes for
conventional and CUBE technique respectively. Dwell time variation
was 1.9 to 8.1% with a SD of 3.6% and 0.1 to 3.0% with a SD of 0.9% for
conventional MR and CUBE sequence respectively. Variations from the
reference plan in applicator reconstruction showed 1.8 mm with a
standard deviation (SD) of 0.8 mm and 1.1mm with a SD of 0.5 mm for
ring and tandem applicator respectively in conventional MR image. In
T2 CUBE image, variation was 0.7 mm with SD of 0.4 mm and 0.3 mm
with SD of 0.2 mm for ring and tandem applicator respectively.
: MRI CUBE scan provides shorter scan acquisition time,
better accuracy of applicator reconstruction in the planning with high
resolution. It can help utilizing MRI based planning for HDR cervical
cancer treatment and will improve the quality of planning process.
PO305
3D BALANCED STEADYSTATE FREE PRECESSION (3DBSSFP) MRI
INTERSTITIAL CATHETER IDENTIFICATION
A. Viswanathan 1 , T. Kapur 2 , A. Damato 1 , E. Schmidt 2
1
Brigham and Women's Hospital, Department of Radiation Oncology,
Boston, USA
2
Brigham and Women's Hospital, Department of Radiology, Boston,
USA
: To determine the utility of a 3DbSSFP Magnetic
Resonance (MR) sequence to identify interstitial catheters after
insertion used for gynecologic interstitial brachytherapy in an MR
environment
: A pressing problem in MRguided interstitial
brachytherapy is difficulty with precisely locating the catheters during
the insertion process. Therefore, we sought to identify an MR
sequence which could be used to reproducibly identify each catheter
after insertion. A series of 3 patients underwent MRguided catheter
placement in a multimodality operating room with a 3 Tesla MR
scanner used for intraoperative visualization of the tumor and
interstitial catheters. In order to visualize and distinguish the
catheters from each other, multiple contrast MR sequences (3DbSSFP,
3DFSE, 3DGRE) were acquired. After the first catheter was inserted,
a 3DbSSFP scan was performed in the sagittal plan, and an attempt
made to identify the tip of the catheter. After a series of
modifications to reduce the size of the ballooning at the tip, an ideal
sequence was developed. Subsequently, additional catheters were
inserted and scanned using this sequence, and catheters were
identified as unique entities using the images obtained. Needle
positions were compared to CTbased identification of the needles.
: A sequence using 3DbSSFP in a 3 Tesla MR scan was
identified as the best sequence for catheter identifications with
ballooning artifact at the tip. It was confirmed on CT and showed
accurate placement (Figure). The needleartifact size, shaped as a
cross centered on the needle, was controlled by changing the 3D
bSSFP bandwidth and repetitiontime (TR). Best results were achieved
with TR/TE/θ=4.6 ms/2.3 ms/30 0 , bandwidth= 600 Hz/pixel,
0.9x0.9x1.6 mm 3 resolution, 160 mm superiorinferior coverage, 1.2
minutes/acquisition. The most accurate identification was confirmed
with this optimized 3DbSSFPP series, with the 3DGRE signaltonoise
ratio being lower; an equivalentresolution 3DFSE required 5minute
scans. Accurate identification of the catheter tip during the insertion
process allows proper placement and ensures that catheters are not
unintentionally inserted into the normal tissue structures.
: A novel sequence for MR catheter identification is
proposed and validated in a clinical series of patients undergoing
interstitial catheter placement for gynecologic brachytherapy.
PO306
FROM 2D RADIOGRAPHBASED TO 3D CTBASED PLANNING IN CERVICAL
CANCER BRACHYTHERAPY WARSAW EXPERIENCE
M. Dabkowski 1 , M. Kawczynska 2 , A. ZolciakSiwinska 1 , E.
Gruszczynska 2 , B. Czyzew 2
1
The Maria SklodowskaCurie Memorial Cancer Center, Department of
Brachytherapy, Warsaw, Poland
2
The Maria SklodowskaCurie Memorial Cancer Center, Medical
Physics Department, Warsaw, Poland
: To investigate the differences in dose distribution
between twodimensional radiographbased planning and three
dimensional CTbased planning in cervical cancer brachytherapy.
: We investigated 160 HDR brachytherapy plans
from two groups of patients treated at our deparment for cervical
cancer stages IBIIIB. The first group consisted of 20 consecutive
patients treated with 2D HDR brachytherapy, with dose prescription to
point A. In the second group of 20 successive patients a 3D CTbased
approach was used with dose prescription to target volume. In both
groups the ICRU Report 38 recommendations were used for reporting
the dose distribution. For each patient we analyzed 4 plans (one plan
for every fraction).
: The analysis revealed moderate to significant differences
between 2D and 3Dbased planning in terms of dose distribution. CT
based treatment planning resulted in lower volumes of prescribed
isodose, lower doses to points A, B, rectal and bladder points.
: 3D CTbased brachytherapy planning with dose
prescription to target volume results in significantly lower treatment
volumes. Further clinical follow up is needed for evaluation of clinical
relevance of new treatment planning method in terms of local control
and acute and late toxicity.
World Congress of Brachytherapy 2012 S 123
PO307
RESULTS OF CT BASED BRACHYTHERAPY PLANNING FOR IIBIVA
CERVICAL CANCER PATIENTS
M. Garipagaoglu 1 , E.T. Tezcanli 1 , M. Sengoz 1 , O. Senkesen 1 , H.
Kucucuk 1 , E.O. Goksel 1 , M. Yilmaz 1 , I. Aslay 2
1 Acibadem University Med, Radiation Oncology, Istanbul, Turkey
2 Istanbul University, Oncology Institute, Istanbul, Turkey
: To evaluate the treatment results and morbidity
of stage IIBIVA cervical carcinoma patients treated with combination
of external radiotherapy (ERT) and 3 dimensional (3D) high dose rate
(HDR) brachytherapy (BT).
: Thirtyseven cervical carcinoma patients with
inoperable stage IIBIVA, tumor size ≥5cm, treated between July 2005
December 2010 were included. 3D conformal technique was used for
pelvic ERT to total doses of 4550Gy, parametrial boost was added for
selected cases. Paraaortic ERT performed using simultaneous
integrated boost technique with macroscopic disease receiving 60 Gy
was used for 8 patients. Median BT fraction dose was 6 Gy (58) Gy
and fraction number was 5 (35). Concurrent 40mg/m 2 of weekly
cisplatin was administered during ERT. BT was started at least after
completion of 4 th week of ERT. Computerized tomography (CT) and
magnetic resonance (MR) compatible applicators were used. CT
images were taken after the placement of applicators and 3D
brachytherapy planning (BTP) was performed. Beside CT images, MR
images were obtained for selected patients. Targets such as residual
GTV, high risk CTV (HRCTV) and intermediate risk CTV (IRCTV) and
OARs namely rectum (R) and bladder (B) were delineated. 3D BTP,
dose calculation and optimizations (manual and volume) were
performed considering target and OAR doses. According to our in
house protocol 90% of HRCTV were required to receive prescription
dose (PD) and D2cc for B and R needed to be less than 80% of PD.
Treatment was done using HDR Varisource 200 device containing Ir 192
sources. Patients were followed up with 3 month intervals. The effect
of stage, tumor size, ERT dose, BT fraction and total dose, residual
tumor size after ERT, left and right point A doses, V100 and D90 for
GTV to local control and survival were studied. Moreover the relation
of toxicity and dosevolume parameters such as ICRU38 R, percent and
absolute R volume receiving PD and 80%of PD, rectal length receiving
80%PD, D2cc, D1cc, D0.1 cc for rectum and mean rectal doses were
investigated.
: All patients completed the planned treatment receiving
median 5 (46) times weekly cisplatin. Stage distribution was IIB: 21,
IIIA: 2, IIIB: 7, IVA: 7 patients and median largest tumor diameter was
5.6 (5 11) cm. After completion of ERT, measured median GTV
volume was 3.9 (067) cc. Five year local control and survival for
whole group and IIB were 87% 66.3% and 95% 90% respectively.
Stage was the only significant factor for both local control and
survival. No bladder toxicity was observed. However, chronic rectal
toxicity was seen in 5 patients (Grade 3 in 2 patients, grade2 in 2
patients and grade1 in 1 patient). No relation between dose volume
parameters and rectal side effects was found.
: Although, 3D BTP provided better local control and
survival, the patients with large tumor size and advanced stage
disease failed to show improvement in rectal toxicity.
PO308
HDR BRT IN ENDOMETRIAL CANCER: EXPERIENCE OF TWO
FRACTIONATION SCHEDULES AND RESULTS OF 14 YEARS WITH 57
PATIENTS
S. Gribaudo 1 , M. Tessa 2 , E. Madon 3 , V. Richetto 3 , D. Masenga 4 , U.
Monetti 1 , A. Mussano 1 , A. Urgesi 1 , D. Nassisi 2 , S. Cosma 5
1
O.I.R.M. S. Anna Hospital, Radiotherapy, Torino, Italy
2
Cardinal Massaia Hospital, Radiotherapy, Asti, Italy
3
O.I.R.M. S. Anna Hospital, Physics, Torino, Italy
4
Cardinal Massaia Hospital, Physics, Asti, Italy
5
University of Turin, Gynecology, Torino, Italy
: Endometrial cancer is the mainly gynecologic
malignancy that is, in 8085%, in stage I at the time of diagnosis. The
standard primary treatment for early stage endometrial cancer
remains TAH&BSO, with appropriate surgical staging. The
epidemiology of this disease favours elderly, obese women with
multiple medical problems (hypertension, diabetes, cardiovascular
diseases, coagulation disorders, respiratory disorders) that render
some of them medically inoperable. Radiation alone is the only
efficient option for these women. Brachytherapy is the main
component of radiation management in this cohort of patients.
: Staging was based on clinical examination,
TVUS, MR or CT scan and fractionated curettage. From September
1997, to July 2011, 57 patients were treated with BRT HDR alone. The
median age was 79 years (range 5793). There were 19 patients in
Stage Ia, 35 in Stage Ib, and 3 in Stage II. Overall, diseasespecific
survival, local control and late side effects were analyzed
retrospectively. Followup over 10 years (mean 52 months) is
reported. BRT HDR was performed with Rotte endometrial 'Y'
applicator and in stage II by adding an endovaginal cylinder
applicator. Dose prescription: we use ‘‘uterine points’’ that are two
points located 1 cm over the centre of a line drawn between the tips
of the two ends of the Rotte applicator and a series of points placed
laterally to the tandem according to the pretreatment imaging data.
The entire length of the uterus was treated so as to ensure coverage
of the fund. TPS optimization was performed to maintain the bladder
and rectal maximum point doses below 100% of the prescribed dose;
the same plan was used for each fraction of treatment. From 1997 to
2002 BRT was performed four to five times (weekly) and mean dose
was 29 Gy (range 1835 Gy); from 2003 (30 patients) we deliver 30 Gy
in five fractions of 6 Gy each b.i.d. schedule, 6 hours interval
between fractions.
: At 5 years, overall survival, diseasespecific survival, and
local control were 47.4%, 86%, and 89.5% (Stage Ia: 50%, 86.4%, and
90.9%; Stage Ib: 46.9%, 87.5%, and 90.6%; and Stage II: 33.3%, 66.7%,
and 66.7%). Disease specific survival was not affected by tumour
grade or age. The local control rate is related to the size of the uterus
but not to the tumour grading. One patient showed progressive
disease, 6 (10,6%) developed recurrence after a median of 13 months
(3 with distant metastases), 2 (3,5%) developed a lymph node
recurrence with distant metastases. One patient have a GE grade III
late side effect (1.8%) at 5 years, not related with rectal dose.
: At Stages Ia, Ib, and II, HDR BRT with Rotte 'Y' applicator
is a very effective treatment modality with good local control rates
and suitable diseasespecific survival for patients who are not fit for
surgery.This method has proven to have a low risk of acute
complications and longterm side effects. Longer followup will be
required to document the incidence of late effects using the b.i.d.
fractionated HDR approach. In the short term, it seems that this
approach is a feasible way to limit the number of procedural
complications and length of hospital stay and bed rest.
PO309
DOSIMETRIC IMPACT OF INTERFRACTION CATHETER MOVEMENT IN MRI
CT GUIDED HDR INTERSTITIAL BRACHYTHERAPY FOR GYN CANCER
F. Rey 1 , C. Chang 1 , C. Mesina 1 , N. Dixit 1 , K. Teo 1 , L. Lin 1
1 University of Pennsylvania, Radiation Oncology, Philadelphia, USA
: To determine the dosimetric impact of catheter
movement for MRI/CT image guided high dose rate (HDR) interstitial
brachytherapy (ISBT) for gynecologic cancers and investigate feasible
alternatives for optimal dose delivery.
: Between January and September 2011, 8
patients were treated with HDR ISBT using the SyedNeblett template.
Disease sites included: cervical (4), vaginal (2), vulvar (1), and
endometrial (1). All patients received EBRT (median 50.4 Gy). Needles
were placed according to a preplan based on CTV assessment using
MRI and CT. The Eclipse treatment planning system and the Varian
GammaMedPlus ix were used for planning and delivery, respectively.
The CTV and organs at risk were contoured and the catheters were
digitized using a postimplant MRI and CT. The prescribed dose was
3.75 – 4 Gy per fraction for a total of 5 fractions delivered twice daily
on 3 consecutive days with a single implantation. Planning goals were
a dose homogeneity index ≥ 0.65 and CTV D90 ≥ 90%. The treatment
plan for the first fraction was created and delivered on day 1 (d1). An
MRI and CT were performed prior to the second and fourth fraction.
All image sets were coregistered to the initial CT and MRI. The CTV of
the d1 MRI was transferred, OARs were drawn and catheters were
digitized on the d2 and d3 CT. Three scenarios were modeled. 1) The
d1 plan (same dwell positions/times) was applied to the d2 and d3 CT,
using the updated catheter positions and compared to the d1 plan. 2)

S124 World Congress of Brachytherapy 2012
Based on the same optimization objectives of the d1 plan, replanning
was performed with the actual catheter positions for d2 and d3.
Dosimetry was analyzed for each plan and compared to the d1 dose
distribution. 3) We further applied the dwell positions/times from the
d2 replan over the d3 CT and compared the dosimetric goals with a d3
CT replan.
: 1) When we used the d1 plan on the d2 and d3 CT with the
updated catheter positions, the mean CTV V100 decreased from 83.7%
to 80.1% (p=0.16) and 79.2% (p=0.03), respectively. The coverage of
the mean CTV D90 was reduced from 92.3% on d1 to 88.9% (p=0.19) on
d2 and to 87.5% (p=0.009) on d3. 2) The replanning on d2 and d3
compensated for catheter movement with no significant difference
with the initial plan, mean CTV V100 of 85% (p=0.25) and D90 of 94.2%
(p=0.12) on d2 and V100 of 84.5% (p=0.3) and D90 of 92.7% (p=0.76)
on d3. 3) When we compared the replan of d2 applied on the d3 CT vs
the d3 replan, there was no significant difference in coverage, V100
of 82% (p=0.22) and D90 of 89.7% (p=0.25).
: Interfraction catheter movement significantly decreases
the CTV coverage over 3 days, compromising CTV coverage for the
fourth and fifth fractions. Rather than replanning on both days prior
to treatment, replanning on the day 2 CT for day 3 treatment would
give an optimal solution that would compensate for interfraction
catheter displacement. This is a feasible and time effective technique
using a single replanning.
PO310
CLINICAL FEASIBILITY OF COBALT 60 HDR INTRACAVITARY
BRACHYTHERAPY IN CARCINOMA CERVIX : A PRELIMINARY REPORT
A. Basu 1 , S. Basu 1 , K. Ghosh 1 , S.N. Mullick 1 , S. Datta 1
1
R.G. Kar Medical College Kolkata, Department of Radiation
Oncology, Kolkata, India
: 60 Co sources with identical dimensions to 192 Ir
have recently been made available for use in HDR brachytherapy. We
present one of the first clinical data of our initial single institutional
experience with 60 Co HDR remote afterloading brachytherapy in
gynaecological malignancies.
: Patients of locally advanced carcinoma cervix
were accrued for this single institutional prospective observational
study to test the clinical feasibility and safety of using 60 Co HDR
brachytherapy. All patients were more than 18 years of age and had
biopsy proven squamous cell ca cervix (FIGO stage IIB – IVA). They had
normal baseline hematological, biochemical and renal profile and
ECOG PS 0 or 1. They received upfront EBRT of 50.4 Gy in 28 fractions
over 5.5 weeks to the pelvis using standard portals with weekly Inj.
Cisplatin 40 mg/m 2 . All patients then received HDR intracavitary
brachytherapy with the Multisource remote afterloading machine
using 60 Co source and the HDR Plus software v2.6 (Eckert & Ziegler
BEBIG GmbH, Germany). All fractions were planned using CT imaging.
Planning parameters mandated dose prescription to point A. Dose
cutoffs of < 75 Gy EQD2 to 2cc volumes of rectum and sigmoid colon
and < 90 Gy EQD2 to 2cc volume of bladder were aimed for and the
D90 HRCTV and D90 IRCTV were planned to receive > 87 Gy and > 60
Gy. Treatment was planned to be completed within 8 weeks. Initial
response and toxicity were assessed.
: From October 2010 to December 2011, 167 patients of
carcinoma cervix were treated at our centre. The median age was 54
years (range 28 – 76 yrs). Majority of the patients were in FIGO stage
IIIB (63%). 93% of patients received chemoradiation and majority (84%)
completed treatment on time. Most of the patients (88%) received 9
Gy in 2 fractions to point A. CT based planning was done for all
fractions and GTV B, HRCTV and IRCTV were delineated using clinical
findings and / or T2w MR imaging. The median EQD2 for D90 HRCTV
was 88 Gy (range 67.3 – 124.7 Gy) and D90 IRCTV was 65.5 Gy (range
50 – 92.9 Gy). The median EQD2 for D2cc Rectum was 71.9 Gy (range
54.3 – 85.2 Gy), D2cc Bladder was 80.75 Gy (range 54– 109.4 Gy) and
D2cc Sig Col was 65.85 Gy (range 49.1 – 85.1 Gy). The acute toxicity
was acceptable and no G3 or higher acute bladder or bowel toxicities
were noted. Till January 15 th , 2012, there have been no locoregional
failures and only 2 late rectal toxicities (bleeding), both of whom
received D2cc rectal doses > 85 Gy EQD2.
: HDR brachytherapy using 60 Co sources for carcinoma
cervix is clinically feasible and safe with favourable short term
response and toxicity, comparable to historical data using 192 Ir. This
represents a viable option for HDR brachytherapy with added benefits
of lower constraints on logistics, resources and perhaps cost because
of the longer half life of 60 Co. However, larger studies with more
number of patients and long term follow up are required in future.
PO311
HDRAFTERLOADING FOR BREAST IORT USING A BALLOON CATHETER
APPLICATOR
U. Schleicher 1 , E. Bosch 1 , W. Hürter 1 , L. Paas 2 , M. Türker 2
1
Strahlentherapie GP DürenMechernich, Strahlentherapie Düren,
Düren, Germany
2
Krankenhaus Düren, Gynaecology, Düren, Germany
: We developed an intraoperative treatment for
breast cancer using an HDR brachytherapy unit with 192Iridium and a
balloon catheter with a single therapy lumen.
: From February to December 2011, we treated
40 patients aged 36 to 85 (median 62) years by intraoperative HDR
afterloading brachytherapy intended as a tumour bed boost.
Preoperative indication for boost irradiation was G2 or G3
differentiation in the biopsy specimen. Patients were eligible for the
method with cT1 (n=31) or small cT2 (n=9) tumours, no
multicentricity, and a skintumourdistance of > 1.5 cm. After tumour
excision and balloon catheter implantation (filling volumes 3550 ml,
median 35 ml) into the tumour bed, the wound is temporarily closed
with close adaptation of tissue to the balloon, leaving only the
connecting catheter outside, and covered with sterile transparent
drape. Accompanied by breast surgeon and anaesthesiologist, the
patient is transferred in anaesthesia to the brachytherapy unit, and
treated with an applicator surface dose of 20 Gy using standard plans
calculated for different applicator volumes. Skin dose close to the
applicator is monitored by in vivo dosimetry. After treatment, the
patient is brought back to the operation theatre, the applicator is
removed and oncoplastic surgery finished. Percutaneous whole breast
radiotherapy was started 33 to 63 (median 42) days after IORT in
patients not receiving chemotherapy. In the case histology reveals
indications for chemotherapy whole breast radiotherapy is done
thereafter.
: Prolongation of anaesthesia due to irradiation time and
transport was 40 minutes in mean. Balloon volumes ranged from 3550
ml, resulting in 8.89.5 Gy in 1cm depth. Measured skin dose ranged
from 1.381 to 8.8 Gy. Acute and subacute side effects were mild to
moderate and consisted mainly in erythema, oedema or induration of
the surgical site. Major haematoma leading to intervention or
infection was not observed. Incidence of seroma was not higher than
usual. Four patients withdrew their consent to percutaneous therapy
after IORT and thus received no further treatment. During further
followup, no difference in toxicity was seen compared to
percutaneous 3Dplanned boost after whole breast radiotherapy.
: This IORT method is easily feasible and does not lead to
severe specific side effects. Being an IORT procedure, it avoids
geographic miss of the tumour bed. In patients receiving
chemotherapy, the IORT boost of 20 Gy may lead to better local
control. The structural requirements (architecture, brachytherapy
unit) given, it offers the possibility of breast IORT for departments
with small numbers of eligible patients on a pay per performance
basis (only the patientdependent cost of the catheters).
PO312
OUTCOME OF TRIPLE NEGATIVE (TN) BREAST CARCINOMA AFTER
BREAST CONSERVATION WITH RADIOTHERAPY
U. Masood 1 , M. Bukhari 2 , A. Masood 1 , I. Haider 1 , T. Mehmood 1 , A.
Muhammad 1 , M. Shah 1 , A. Rasheed 1
1
Shaukat Khanum Memorial Cancer Hospital & Research Centre,
Department of Radiation Oncology, Lahore, Pakistan
2
Shaukat Khanum Memorial Cancer Hospital & Research Centre,
Department of Surgical Oncology, Lahore, Pakistan
: Triplenegative (TN) breast cancer, by definition
estrogenreceptor, progesteronereceptor and HER2 negative, does
not have as many treatment options as other breast cancers. The
World Congress of Brachytherapy 2012 S 125
current study was performed to determine the relationship of breast
conservation with radiotherapy in TN breast cancer.
: Total 109 triple negative breast cancer
women underwent breast conservation (WLE, lumpectomy,
quadrentectomy) followed by radiation 60GY in 30 fraction
(200cGy/day 5 days a week). Chemotherapy was given either in neo
adjuvant or adjuvant setting in all patients
: Median follow up after treatment was 36months.Median age
of the patients was 43 years (2673). 90% patients were early stage
and 10 % were locally advanced while 62% were node negative and
38% were node positive. Locoregional recurrence was seen in only
3.7% patients (total 3, chest wall 1) while Distant metastasis was seen
in 22.9% patients. At 4.38 years Kaplan Meier estimated disease free
survival was 54% and overall survival was 81%.
: Patients with TN breast cancer are not at significantly
increased risk for isolated LRR at 5years so remain appropriate
candidates for breast conservation. There is increased risk of distant
failure even in early stage disease associated with poor disease free
survival .Targeted therapies are required in clinical trials to find new
and better ways to treat it.
PO313
EVALUATION OF IN VIVO DOSIMETRY IN BREAST CANCER
BRACHYTHERAPY USING MOSFET DETECTORS
D. Nahajowski 1 , E. Byrski 1 , R. Kudzia 1 , D. Dybek 1 , A. Dziecichowicz 1 ,
T. Dabrowski 1 , A. Kukielka 1
1
Centre of Oncology Institute MSC Kraków, Cancer Centre, Krakow,
Poland
To evaluate MOSFET detectorbased in vivo skin
dose in breast cancer brachytherapy performed using the Breast
Template Set TM (Nucletron) needle applicator technique.
: In vivo measurements, using TN502 RDM
(Best Medical System) MOSFET detectors were made for 81 female
patients undergoing breast cancer brachytherapy by the Breast
Template Set (NUCLETRON) needle applicator technique. Prior to
patient exposure using the NUCLETRON MicroSelectron HDR system,
the MOSFET detectors were positioned between the templates and
breast skin at two locations, shown in Fig. 1: at the tipend template,
and at the connectorend template, in both cases along the inner
(transfer tube) sides of the templates. Calibration of the MOSFET
detectors was performed in a breast fantom made of bolus gel,
specially prepared to imitate the clinical conditions. Values of
absorbed dose measured by these detectors were compared with
values calculated at the detector positions by the PLATO TPS
(NUCLETRON).
: The mean absolute difference between 81 pairs of measured
and planned dose values were 2.1% ± 5.9% (1 SD), for the tip end
location and 1.2% ± 6.0% (1 SD) for the connector end location. The
observed differences between the MOSFETmeasured and TPSplanned
dose values may be due to uncertainties in measuring the needle
lengths, instability of MOSFET detectors, inaccuracies of detector
calibration and inaccuracies in the TPS calculations of the planned
dose at detector locations.
: The described method of MOSFETbased in vivo
dosimetry applied in breast brachytherapy, by providing an
adequately accurate evaluation of dose delivered to the breast skin, is
able to effectively assess the dose delivered to the target area.
PO314
PRESCRIPTION DOSE EVALUATION FOR APBI WITH NONINVASIVE
BREAST BRACHYTHERAPY USING EQUIVALENT UNIFORM DOSE
K.L. Leonard 1 , D.E. Wazer 2 , M.J. Rivard 1 , S. Sioshansi 3 , J.R. Hiatt 4 ,
C.S. Melhus 1 , J.T. Hepel 4
1
Tufts Medical Center Tufts University School of Medicine, Radiation
Oncology, Boston MA, USA
2
Tufts Medical Center Tufts University School of Medicine and Rhode
Island Hospital Warren Alpert School of Medicine of Brown University,
Radiation Oncology, Boston MA and Providence RI, USA
3
UMass Memorial Medical Center, Radiation Oncology, Worcester MA,
USA
4
Rhode Island Hospital Warren Alpert School of Medicine of Brown
University, Radiation Oncology, Providence RI, USA
: A Phase I/II APBI trial using a noninvasive breast
brachytherapy device (NIBB) was initiated. Calculations of equivalent
uniform dose (EUD) were performed to identify the appropriate NIBB
dose.
: APBI plans were developed for 24 patients: 5
with 3Dconformal APBI (3DCRT), 5 with multilumen intracavitary
balloons (MIBB), 4 with singlelumen intracavitary balloons using
multiple dwell positions (SMIBB), 5 with singlelumen intracavitary
balloons using a single dwell position (SSIBB), and 5 simulated in the
prone position with compression paddles for both the craniocaudal
(CC) and mediolateral (ML) orientations simulating NIBB treatment
(Figure).
PTV_eval was contoured for 3DCRT and IBB techniques per the NSABP
B39 protocol. For NIBB, PTV_eval was contoured on both the CC and
ML scans and comprised the tumor bed with a 1 cm margin limited by
the chestwall and 5 mm from the skin surface. Prescription doses of
34 Gy and 38.5 Gy were delivered in 10 fractions for IBB and 3DCRT,
respectively. Prescription doses ranging from 3438.5 Gy were
considered for NIBB, with plans generated using firstgeneration round
applicators in the CC and ML orientations. Dose for each axis
contributed equally to total dose. This method does not model tissue
deformation and composite dosimetry between axes, which may
influence EUD calculations. All plans were generated in Pinnacle
treatment planning systems. DVH data from all 3DCRT, MIBB, and
NIBB plans were used to calculate the biologically effective EUD and
corresponding EUD to the PTV_eval using the following equation: EUD
= EUBED/[n(1 + EUD/α/β)]. EUD was calculated for SSIBB and SMIBB
using the equation EUD = 10{[v(40BEDtrue/α/β) – 10]/(20/α/β)}. An α/β
= 10 Gy or 4.6 Gy (as per the START trial) was assumed for breast
tumor. For 3DCRT, generalized EUD (gEUD) was also calculated in
Pinnacle with local control (a = 7.2) as the endpoint. EUDs for varying
NIBB prescription doses were compared to EUDs for the other APBI
techniques.

S126 World Congress of Brachytherapy 2012
: Mean PTV_eval volume was largest for 3DCRT (454 cm 3 ) and
was similar for NIBB and MIBB (86.8 and 87.2 cm 3 , respectively).
Mean gEUD was similar to calculated EUD for 3DCRT plans (38.8 and
38.4 Gy, respectively). For MIBB, calculated EUD ranged from 33.1 –
40.3 Gy, reflecting differences in treatment plan geometry. Changing
α/β from 4.6 to 10 increased EUD by 2% on average. The Table
displays the mean EUD for each treatment modality.
EUDα/β = 10 (std dev)
3DCRT (38.5 Gy) 38.4 (0.9)
M–IBB (34 Gy) 35.7 (3.0)
SMIBB (34 Gy) 38.0 (0.3)
SS–IB (34 Gy) 38.8 (0.9)
NIBB (34 Gy) 34.1 (0.4)
NIBB (35 Gy) 35.1 (0.4)
NIBB (36 Gy) 35.9 (0.2)
NIBB (37 Gy) 37.0 (0.4)
NIBB (38.5 Gy) 38.5 (0.4)
: For APBI, 3638 Gy prescribed to the 100% isodose line
delivered with NIBB using firstgeneration round applicators is the
uniform dose equivalent of 34 Gy in 10 fractions delivered with IBB
techniques and of 38.5 Gy in 10 fractions delivered with 3DCRT.
Alternatively, 34 Gy with NIBB can be prescribed to the 95% isodose
line.
PO315
CAN WE IMPROVE THE DOSE DISTRIBUTION FOR SINGLE OR MULTI
LUMEN INTERSTITIAL BREAST BALLOON USED FOR APBI?
G. Bieleda 1 , G. Zwierzchowski 1 , A. Chichel 2 , M. Kanikowski 2 , M.
Dymnicka 1 , J. Skowronek 1
1 Great Poland Cancer Centre, Medical Physics, Poznan, Poland
2 Great Poland Cancer Centre, Brachytherapy, Poznan, Poland
: The aim of the study was to verify dose
distribution parameters for Contura and artificially created single
lumen balloon applicator application for the same patient using two
optimisation algorithms: Inverse Planning Simulated Annealing (IPSA)
and dose point optimisation with distance option.
: Group of 24 patient with Contura multilumen
balloon applied were investigated. Each had tenfraction treatment
with prescribed dose of 3.4 Gy per fraction. For every patient 4
treatment plans were prepared. First for fivelumen balloon optimized
with IPSA algorithm, with optimization parameters adjusted for each
case. Second for the same applicator optimized with dose point
optimisation with distant option. Two other plans were prepared for
singlelumen applicator, created by removing four peripheral lumens,
optimized with both algorithms.
: The highest D95 parameter was obtained for plans of Contura
patients optimized with IPSA algorithm, mean value 99,32 percent of
prescribed dose, and it was significantly higher than Contura plans
optimized with dose point algorithm (mean= 83,50%, p

S128 World Congress of Brachytherapy 2012
:To report five years results with single dose (7 Gy)
HDRBT boost for highrisk breast cancer patients treated with breast
conserving therapy.
: Between June 2005 and December 2010, 139
breast cancer patients (pTis: 7,1%, pT1: 66,9%, pT2: 28,4%, pT3: 2,1%)
received a single fraction HDRBT boost after breastconserving
surgery and whole breast external beam radiation therapy (EBRT).
Median age: 53,7 years (range: 2577). Pathologic features:
intraductal carcinoma (6.5%), ductal carcinoma (79.9%), lobulillar
carcinoma (5%), others histologies (8,6%). 33,8 % of patients with
infiltrating carcinoma had axillary positive nodes. Mean tumor sized:
16,4 mm. (range:170). Linfovascular invasion: 14.4%. Perineural
invasion: 8.6%. 22.3% of patients had grade 3 tumors. After
completion of EBRT (median dose 4550 Gy), the patients received a
singlefraction HDRboost of 7 Gy, using the Nucletron
(Microselectron) afterloading system. In all patients rigid needles
were used, with a catheter spacing of 16 mm.
: At a median followup of 54,59 months (range: 1887), 6
patients (4,3 %) with a disease free survival of 95,7 %. The overall
survival was 96,4 %. One patient had hematoma at the implant site 8
hours after removal the needles, and required surgery and two
patients had mild fat necrosis, controlled with local treatment,
without needing surgery. There were no other adverse events.
: Breast conservation radiation therapy utilizing
interstitial HDRBT boost implant with a single fraction of 7 Gy, seems
a safe and well tolerated therapy, have good control local, and have
few late side effects.
PO321
DOSIMETRIC COMPARISON BETWEEN 2D DOSE POINT AND 3D CT BASED
VOLUME OPTIMIZATION IN BREAST BOOST HDR BRACHYTHERAPY
E. Gruszczynska 1 , M. Dabkowski 2 , M. Kawczynska 1 , B. Czyzew 1 , M.
Bijok 1 , A. Kulik 2
1
The Maria SklodowskaCurie Memorial Cancer Center, Department of
Medical Physics, Warsaw, Poland
2
The Maria SklodowskaCurie Memorial Cancer Center, Department of
Brachytherapy, Warsaw, Poland
: The aim of this study was to evaluate differences
between two optimization methods of HDR breast boost
brachytherapy planning. In the first method the localization of tumor
bed was based only on clinical judgement, with no imaging of breast
implant. The dose was prescribed to reference points 5mm from
interstitial needles using dose point optimization (DPO). The second
method is based on CT imaging of tumor bed and volume optimization
(VO). These methods are compared in terms of conformity and
homogeneity parameters.
: Ten patients treated with HDR boosting of
breast tumor bed were evaluated. For each patient two separate
plans were prepared. The first plan was based on CT imaging: breast
tumor bed, planning target volume (PTV) and skin were delineated
and volume optimization was used.
In the second plan no imaging was applied and the active length of
the implant was decided by clinician. The dose was optimized
typically on points 5mm from interstitial needles. For comparing of
these planning methods the information from 2D planning on CT
images were used for the 3D planning mode. Dosevolume histograms
were calculated for all volumes of interest along with conformity and
homogeneity parameters.
: Both optimization methods yielded almost similar dose to the
skin (mean D0.01cc 46 % DPO v. 49% VO). The treated volume
encompassed by the reference isodose using VO was reduced (mean
V100 62cc with DPO vs 39cc with VO, p=0.031 ). Volume optimization
offered better conformity index than DPO (mean CI 17%, p=0.015).
With DPO high dose volumes were for V150 ( mean 18cc with DPO vs
21cc with VO) and V200 (mean 7cc with DPO vs 12cc with VO). The
mean conformation number CN was 0.23 for DPO vs 0.55 for VO,
p=0.0156. The mean value for DNR for implant was bigger for VO
about 0.23 (p=0.0156).
: CTbased planning with volume optimization offers more
conformal dose distribution and lowers irradiated volumes at the
expense of less homogeneous implants. Both methods are good
enough for sparing skin from excessive doses.
PO322
ACCELERATED PARTIAL BREAST IRRADIATION WITH HYBRID
BRACHYTHERAPY APPLICATORS: FAVORABLE OUTCOMES AT FOUR
YEARS
C. Yashar 1 , R.R. Kuske 2 , C.A. Mantz 3 , C.A. Quiet 2 , M.B. Snyder 2 , A.G.
Sadeghi 2 , Y.J. Graves 1 , D. Scanderbeg 1
1
UCSD Moores Cancer Center, Radiation Oncology, La Jolla CA, USA
2
Arizona Breast Cancer Specialists, Radiation Oncology, Phoenix AZ,
USA
3
21st Century Oncology, Radiation Oncology, Ft Meyers FL, USA
: Accelerated partial breast irradiation (APBI) using
various intracavitary applicators has become increasingly popular.
There are currently a number of brachytherapy applicators on the
market for use in treating patients with APBI. However, there is a
need for long term followup with these applicators. A multi
institutional research group, The StrutBased Brachytherapy Research
Group, has been formed to study the long term outcomes of those
treated with APBI using strutbased applicators. At the time of
abstract deadline, we present data on 50 women treated at three
institutions using strutbased applicators with median followup of
approximately 46 months.
: A total of 50 patients were treated at 3
institutions with accelerated partial breast irradiation using the hybrid
(nonballoon based) breast brachytherapy device with conventional
dose and fractionation (340 cGy x 10 fractions twice daily). All
patients successfully completed treatment and had no serious adverse
events during treatment. Patients were followed regularly and graded
on disease status, cosmesis, hyperpigmentation, seroma, induration,
erythema, fibrosis, telangiectasias, fat necrosis and breast symmetry
based on the CTCAE v3.0 (common terminology critera for adverse
events, version 3.0).
: Overall, the strutbased applicator was tolerated well by the
patients and the results are summarized in the chart below.
: With nearly four years of median followup the strut
based brachytherapy device appears to be a welltolerated, effective
treatment with minimal acute and few adverse late toxicities,
although followup remains fairly modest. With APBI likely an
acceptable treatment for a proportion of women with early breast
cancer, the strutbased device is a facile and versatile device in the
armamentarium.
PO323
COSMETIC OUTCOME AFTER INTRAOPERATIVE RADIOTHERAPY FOR
EARLY BREAST CANCER IN WOMEN OVER 50 YEARS
N. Williams 1 , M. Keshtgar 1 , T. Corica 2 , C. Saunders 3 , M. Bulsara 4 , D.J.
Joseph 2 , on behalf of the TARGIT Trialists' Group 1
1
University College London, Division of Surgery and Interventional
Science, London, United Kingdom
2
Sir Charles Gairdner Hospital, Department of Radiotherapy, Perth,
Australia
3
Sir Charles Gairdner Hospital, Department of Surgery, Perth,
Australia
4
University of Notre Dame, Institute of Health and Rehabilitation
Research, Fremantle, Australia
: The randomised controlled TARGIT Trial was
designed to determine noninferiority between the novel technique of
TARGIT [intraoperative radiotherapy with Intrabeam® (Carl Zeiss,
Germany)] and conventional external beam radiotherapy (EBRT) in
women with early breast cancer. The main outcome objective is risk
of local relapse within the treated breast. We report here data from a
subprotocol assessing cosmesis in 114 women over 50 years of age
participating in the TARGIT Trial from one centre (Perth, Australia).
World Congress of Brachytherapy 2012 S 129
: Frontal digital photographs from were
assessed, blind to treatment, using specialist software (BCCT.core
2.0, INESC Porto, Portugal) which produces a composite score based
on symmetry, colour and scar. Statistical analysis was by generalised
estimating equations (GEE) on all of the data, and logistic regression
analysis at year 1.
: 114 patients have been assessed, median age at
randomisation 62 years (IQR 56 to 68). Photographs were taken at
baseline (before surgery) and one, two, three and four years after
initial breast conserving surgery; none had subsequent breast surgery.
The scores were dichotomised into Excellent and Good (EG), and Fair
and Poor (FP). There was a nonsignificant 45% increase in the odds of
having an outcome of EG for patients in the TARGIT group relative to
the EBRT group (OR=1.45, 95%CI 0.78 – 2.69, p=0.245) after adjusting
for tumour size. The results were similar when adjusted for tumour
grade and age of the patient. For year 1 only there was a statistically
significant 2.35 fold increase in the odds of having an outcome of EG
for patients in the TARGIT group relative to the EBRT group (OR=2.35,
95%CI 1.02 – 5.45, p=0.047) after adjusting for age of the patient,
tumour size and grade.
: These results confirm a significantly better cosmetic
outcome with TARGIT compared to EBRT in the first year after
surgery.
PO324
CONTRAINDICATIONS TO BREAST INTERSTITIAL BRACHYTHERAPY AFTER
CONSERVATIVE SURGERY
N. Stas 1
1 Instituto Português de Oncologia, Brachytherapy, Porto, Portugal
: All the patients included were operated at I.P.O.,
Porto or at some of the northen refering hospitals, since we're the
only one performing breast interstitial brachytherapy (IBT). As it
refers to a great number of patients, and since they were operated
differently before being addressed for IBT, contraindication criteria
must be set in order to get the best benefit for the patients
: During 2010, 347 out of 432 patients were
treated with a IBT boost of the closed tumour bed, with pre and post
operatory mammography, the last one always done at our institution.
IBT boost was performed 1 3 weeks after the end of ERT. 649
fractions were distributed as follows: 25 patients treated with PDR
Selectron of Nuclétron with a 1520 Gy dose, 0,8 Gy/ hour; 312
patients treated with HDR Selectron of Nuclétron with 2 x 5 Gy/12h.
85 patients were excluded. 25 patients treated with partial IBT were
also excluded, since they have specific contraindications.
: Contraindications (CI): In 2010, 85 (19,08%) patients selected
for brachytherapy were excluded. Most of these exclusions (3 and 4)
are illustrated with breast photograph and mammography.
1. CI related to the patient general condition
Physical or mental condition occurring after surgery or chemotherapy
2. CI related to the breast pathology
Great extension of in situ DC/LC, around limited invasive carcinoma,
multifocal carcinoma in other quadrant
3. CI related to the surgery performed (picture and mammography)
Most patients now desire surgery to be excellent according to
oncological and aesthetical standards in the same operative time,
regardless of age. More and more contralateral breast reductions,
breast repositions, and peri nipple, arcuate, sub mammal, T reversed
and almost invisible scars are seen, as well as prosthesis. These
obstacles may be overcome by placing surgical clips in the tumour bed
(forgotten in up to 50% of the cases) or by tri dimensional
reconstruction on pre and post operative mammography. A number of
patients had a non complex surgery and a simple scar over the tumour
site. Post operative infections, multipunctured seromas and mammal
celulitis may occur weeks or months after surgery.
4. CI related to the anatomy of the operated breast
Lack of breast volume. Axilary, supra sternal, sub mammal, sub
clavicular, supra costal locations. All locations where hypodermic
needles and plastic tubes would disturb the patient during the IBT
treatment.
5. Associated different CI
6. Patient refusal
: Early stage breast carcinoma patients represented 13,8%
of the patients treated by the Radiotherapy Dpt of the I.P.O. Porto, in
2010. It was in the 3 and 4 CI groups that we had most difficulties,
and in spite of the more frequent usage of surgical clips, this is still a
most forgotten procedure, that forces us to use reconstruction
imaging techniques like mammography and even MRI which are much
more expensive. In 2011 we had a new Radiotherapy Dpt, new PDR
and HDR Selectrons and new imaging techniques, so that we’ll be able
to work more, always standing for our quality standards.
PO325
HIGHDOSE RATE BRACHYTHERAPY FOR EARLY BREAST CANCER:
DOSIMETRIC DATA AND COSMETIC EFFECT
M. Italiani 1 , M. Casale 1 , L. Chirico 1 , L. Draghini 1 , E. Buono 1 , M. Muti 1 ,
L. Basagni 1 , E. Maranzano 1
1 "S.Maria" Hospital, Radiotherapy, Terni, Italy
: To evaluate the dosimetric parameters in a group
of patients with lowrisk early breast cancer treated with HDRBRT on
a prospective phase II trial and analyze the correlation with cosmetic
oucome.
: From May 2005 to January 2010, aseries of 74
patients (pts), median age 66 years (range value 4285) with early
breast cancer were treated with HDRBRT after conservative surgery.
The implant was afterloaded with HDR Ir192 with a Nucletron remote
unit and the interstitial implant are based about 23 layers of parallel
catheters in trapezoidal symmetry. The treatment schedule was 4 Gy
twice a day for a total dose of 32 Gy with a minimum interval of 6 h
between the 2 daily fractions. No external beam radiotherapy was
given. Clinical endpoints evaluated included: acute and late toxicity
(according to RTOG/EORTC scoring criteria), infield and extrafield
relapse, regional control, disease free survival, overall survival.
Cosmetic outcome was evaluated at each followup visit and
dichotomized as excellent and good/poor. Dosimetric parameters,
calculated with PlatoNucletron treatment planning system, were
volumes receiving definite relative isodose (V100, V150, V200)
homogeneity index (DHI) and skin dose.
: During the followup 71 pts (96%) and 3 pts (4%) developed
acute skin G1 and G2 toxicity, respectively. No patients had G34
toxicity. Of the series, 45 (61%) had a G0 late toxicity, 25 (34%) G1,
and 3 (4%) G2 toxicity. In no case grade G34 late toxicity was
reported. No infield and/or extrafield relapse was registered after
HDRBRT. Whereas, there were no local relapses, 4 patients
developed distant (3 liver and 1 bone) metastases. At last followup,
in 49 (66%) pts the cosmetic outcome was rated as excellent, in 17
(34%) as good, only in 11 as poor. V100 mean is 114.5cc. V100 is
always inferior than 30% of breast volume. DHI mean are 0.75. Skin
dose significatevely conditionated cosmetic outcome which resulted
excellent in 81% and 44% of pts receiving ≤55% and >55% of
prescripted dose, respectively (p=

S130 World Congress of Brachytherapy 2012
singledwell dose kernels that can later be used for optimization.
bGPUMCD can also simulate previously optimized plans, taking in
consideration all dwell positions and dwell times of the plan. To
establish the accuracy of the platform, singlesource dosimetry for
the microSelectron V2 source was compared to published reference
data. Three clinical cases were also used: a prostate case, a breast
case and a case with a shielded applicator. Timing and accuracy
benchmarks were performed on these cases for singledwell dose
calculations and multipledwell clinical dose distributions and
compared to reference dose distributions computed with GEANT4 and
using the same simulation parameters. Dosimetric values, voxels per
voxels differences and 1%2mm gamma criteria were used to
characterize the accuracy.
: Singlesource dosimetry, compared to reference data for the
microSelectron V2 source, was within 2% for the radial function and
within 14% for the anisotropic function. By comparing D90 and V100
values of the clinical plans, bGPUMCD was within 1% or 2% of the
reference distributions, depending on the case. The average of the
absolute value of the difference for voxels within the target was near
or below 2%. 90% of the target voxels passed the 1%2mm gamma
criteria for all three cases. For timing experiments, the computation
of a singledwell position dose distribution took between 0.25 and 0.5
seconds for a 2% statistical uncertainty and the computation of the
optimized plan, with multiple dwell positions, was approximately 2
seconds for a 2% statistical uncertainty, as seen in the included data
table.
Prostate Breast Shielded applicator
(s) (s) (s)
Single dwell position 0.29 0.27 0.46
Full plan recalculation 1.45 2.01 2.00
: bGPUMCD has the potential to allow for fast and
accurate Monte Carlo simulations in all phases of HDR brachytherapy
treatment planning, including its use by inverse planning algorithms.
PO327
MIXED INTEGER PROGRAMMING FOR DOSE AND DOSEVOLUME BASED
OPTIMIZATION IN PROSTATE HDRBRACHYTHERAPY
B.L. Gorissen 1 , D. Den Hertog 1 , A.L. Hoffmann 2
1
Tilburg University, Econometrics and Operations Research, Tilburg,
The Netherlands
2
MAASTRO Clinic, Medical Physics, Maastricht, The Netherlands
: Current inverse treatment planning methods that
optimize both catheter positions and dwell times in prostate HDR
brachytherapy use surrogate linear or quadratic objective functions
that have no direct interpretation in terms of DVHcriteria, do not
solve to optimality or have long solution times. The aim is to enhance
existing methods to solve in clinically acceptable time and to
formulate a new dosevolume based model that solves to optimality
while satisfying preset DVHcriteria.
: Existing dosebased linear programs (LP) with
integer variables and quadratic programs (QP) have the advantage
that a dwell time modulation restriction or total dwell time constraint
can be added easily and solved using a stateoftheart MILP or MIQP
solver. Modifications are implemented to decrease the solution times.
For the quadratic model, an iterative procedure is proposed to allow
the optimal target dose to be an interval, while retaining
independence between the solution time and the number of
calculation points. The methods are evaluated on three clinical cases.
: For existing dosebased models to be solved to optimality,
our modifications allow to optimize over more than 40 candidate
catheter positions. An average speedup of 75% can be obtained by
stopping the solver at an early stage, without deterioration of the
clinical plan quality. For a fixed catheter configuration, dosebased LP
solves the dwell time optimization problem to optimality in less than
15 seconds, which confirms earlier results obtained by others. The
iterative procedure for QP is comparable in speed, but produces
better plans than the noniterative QP. Our dosevolume based model
optimizes both catheter positions and dwell times in 5 minutes (range:
0.315 minutes), gives better DVH statistics than dosebased models
and requires less a posteriori dwelltime adaptation by a human
expert. The solutions have a relatively large surrogate objective
value, suggesting that the correlation between objective value and
clinical plan quality is weak in existing dosebased models.
: Our modifications decrease the solution time of existing
dosebased models for inverse treatment planning of both catheter
positions and dwell times. Extending the quadratic model to include
an iterative procedure to find the optimal target dose improves the
plan quality. The new dosevolume based model allows simultaneous
optimization of both catheter positions and dwell times in clinically
acceptable time and produces treatment plans that better match pre
set DVHcriteria than existing dosebased models.
PO328
NEW DESIGN OF THE VALENCIA APPLICATORS TO REDUCE RADIATION
LEAKAGE
D. Granero 1 , J. PerezCalatayud 2 , F. Ballester 3 , Z. Ouhib 4 , J. Vijande 3 ,
J. Richart 5
1
ERESA Hospital General Universitario, Department of Radiation
Physics, Valencia, Spain
2
Hospital La Fe, Physics Section. Radiotherapy Department, Valencia,
Spain
3
University of Valencia, Department of Atomic Molecular and Nuclear
Physics, Burjassot, Spain
4
Lynn Cancer Institute of Boca Raton Regional Hospital, Radiotherapy
Department, Boca Raton, USA
5
Hospital Clinica Benidorm, Radiotherapy Department, Benidorm,
Spain
: The Valencia applicators are designed to treat
skin lesions with the microSelectronHDR afterloader. Although the
radiation is highly directed to the treatment area, radiation might
leak through the backside of the applicator. Recently, the
manufacturer has introduced a new applicator design to reduce such
radiation leakage. This new design consists mainly in the addition of
about 4 mm of tungsten in the backside of the applicator making it
thicker. The purpose of this study is to evaluate by means of the
Monte Carlo method the radiation leakage of this new design and to
evaluate whether this modification affects the dose rate distributions
in the treatment area.
: The complete geometry of the new
applicators has been introduced in the Monte Carlo code GEANT4. The
applicators have been located on the surface of a cylindrical water
phantom following a methodology similar to the used in the original
study of the Valencia applicators by Granero et al [Med.Phys 2008
35:495503]. Kerma in the water phantom and kerma in air outside
the phantom have been evaluated to estimate the radiation leakage
of the new designed Valencia applicators.
: The Monte Carlo simulations of the new applicators show that
the radiation leakage has been reduced significantly from the previous
design. The largest radiation leakage of this design is now about 30%
of the dose at the prescription point and about 10% at 1 cm from the
backside of the applicators. The dose rate distributions in the area of
treatment have not changed.
: In this study the radiation leakage of the new design of
the Valencia applicators has been obtained. The radiation leakages
have been largely reduced from the previous design without
compromising dose rate distributions in the treatment area.
PO329
DOSIMETRIC ANALYSIS OF A THERMOBRACHYTHERAPY APPLICATOR IN
THE CONTEXT OF A POSITIONING REPRODUCIBILITY STUDY
J. Sánchez Mazón 1 , K. Arunachalam 2 , R. McMahon 3 , B. Steffey 3 , P.
Stauffer 3 , J. Chino 3 , O. Craciunescu 3
1
Hospital Universitario Marques de Valdecilla, Oncología
Radioterápica, Santander, Spain
2
Indian Institute of Technology, Engineering Design, Madras, India
3
Duke University Medical Center, Radiation Oncology, Durham, USA
: A thermobrachytherapy surface applicator (TBSA)
has been developed for simultaneous heat and brachytherapy
treatment of chestwall (CW) recurrent breast cancer. The purpose of
this project is to assess variation in radiation dose due to movement
World Congress of Brachytherapy 2012 S 131
of the TBSA relative to the target volume, as recorded during a
volunteer protocol investigating TBSA comfort and secure fit.
: The TBSA combines an 2cm spaced array of
brachytherapy catheters with a printed circuit board microwave
antenna array coupled to the skin surface with a temperature
controlled conformal 8 mm thick water bolus. Breath hold MRI scans
of postmastectomy volunteers with the TBSA wrapped around the CW
were acquired every 15 min for 90 min, a period during which the
volunteers changed position several times. A planning target volume
(PTV) representing a 5 mm skin strip was generated on each scan. An
HDR plan to deliver 400cGy to the PTV using catheters spaced 2 cm
apart was created on the Baseline scan of each volunteer using the
volume optimization in BrachyVision 8.10. The plan was then
reproduced on each subsequent scan. The following metrics were
calculated for each plan: the coverage index V(x), with x = 100, 130,
140, homogeneity index HI(x) = V(100)V(x) for x = 130, 140, spill ratio
SR = (Volume of normal tissue receiving 100% dose or more)/(Total
volume receiving 100% dose or more), skin overdose OD = 100%(Dskin
Dtarget)/Dtarget (with Dskin and Dtarget the dose at skin and 5 mm depth),
and ipsilateral (i) and contralateral (c) mean lung dose MLD. For one
of the patients, an electron plan was also generated in Eclipse for
comparison, using two 20x20 cones, mixed 9 and 12 MeV, 1 cm bolus,
and calculated with the Electron Monte Carlo algorithm (v. 10.0.28).
: Three volunteers were fitted with a rectangular (500 cm 2 )
TBSA and two with a Lshaped (875 cm 2 ) TBSA. The mean PTV volume
was 118.1 ± 0.1 cm 3 . The mean baseline ± STDEV of each metric is
reported followed in parantheis by the maximum % variation between
baseline and the 90 min scan: V(100) =96.2% ± 0.9 (4.3%), HI(130) =
91.8% ± 5.2 (6.4%), HI(140) = 94.6% ± 2.1 (5.1%), SR = 18.8 %± 5.4
(15.6%), skin OD = 13.8 %± 1.5 (1.8%), MLDi = 1.064 Gy ± 0.2 (1.2%),
and MLDc = 0.34 Gy ± 0.05 (3.4%). In contrast, the electron plan was
inferior in target coverage, V(100) = 86.1%, had lower HIs, HI(130) =
80.4%, HI(140) = 83.1%, and larger spill ratio of 37%. Lung doses were
lower, MLDi = 0.6 Gy and MLDc = 0.04 Gy, but might become
comparable if a comparable V100 was targeted.
: The dosimetric impact of applicator displacements
relative to the skin and target volume measured in this study are
small, and changes in dosimetry due to these displacements are not
clinically significant. The advantages of using this applicator for
extensive CW disease include the potential for enhanced effect from
simultaneous heat and radiation, and superior dose metrics compared
to electron therapy.
PO330
INTEREST OF THE MONTE CARLO SIMULATIONS FOR DOSIMETRIC
EVALUATION OF THE 50 KVP DEVICE "PAPILLON50"
O. Croce 1 , S. Hachem 1 , E. Franchisseur 2 , J.P. Gérard 3 , S. Marcié 3
1
University of Nice SophiaAntipolis, Radiotherapy Lab., Nice, France
2
Dosisoft, Radiotherapy, Cachan, France
3
Centre Antoine Lacassagne, Radiotherapy, Nice, France
: We presents a dosimetric study concerning the
system named 'Papillon 50' used in the department of radiotherapy of
the Centre AntoineLacassagne, Nice, France. The machine provides a
50 kVp Xray beam, currently used to treat the cancers of skin, eyelid
or rectum. The system can be mounted with various applicators of
different diameters or shapes. These applicators can be fixed over the
main rod tube of the unit in order to deliver the prescribed dose into
the tumour with an optimal dose distribution.
: We have analyzed depth dose curves and
dose profiles for the naked tube and for a set of three applicators
with SSD of 28.7mm, 32.3mm and 38.3mm. Dose measurements were
made with an ionization chamber (PTW type 23342) and Gafchromic
films (EBT2). We have also compared the measurements with Monte
Carlo simulations (code PENELOPE) which have been used with a
detailed geometrical description of the experimental setup.
: The depths of the 50% isodose in water for the various
applicators are respectively 6.0, 6.6 and 7.1 mm. Results showed a
good agreement between simulations and physical measurements.
Simulations are able to provide an accurate evaluation of the dose
delivered. The following figure illustrates the close correlation
between the measurements performed with a PTW ion chamber and
the data from Monte Carlo PENELOPE simulations for depth dose curve
using a 3 cm straight end applicator.
Moreover, we design a specific software named 'MC2Plan' that uses a
precalculated dose distribution data from Monte Carlo simulations.
MC2Plan can be useful to display isodoses when combining contact X
rays radiotherapy and external beam radiotherapy in order to help
radiation oncologists to optimize treatments.
: The Monte Carlo PENELOPE simulations are in
accordance with the measurements for a 50 kV Xray system.
Simulations are able to confirm the measurements provided by
Gafchromic films or ionization chambers. Results also demonstrate
that Monte Carlo simulations could be helpful to validate the future
applicators designed for other applications such as intraoperative
radiotherapy (IORT) for breast cancer. Furthermore, Monte Carlo
simulations could be a reliable alternative for a rapid evaluation of
the dose delivered by such a system that uses multiple designs of
applicators.
PO331
SIMPLE PHANTOM SETUP FOR ULTRASOUND GUIDED PROSTATE HDR
BRACHYTHERAPY QUALITY ASSURANCE PROCEDURE
T. Ribeiro Nuno Ramos 1 , M.E.R. Poli 1
1 Hospital Santa Maria, Medical Physics Unit, Lisbon, Portugal
: To develop a simple and low cost phantom setup
to be used in a quality assurance procedure for ultrasound guided
prostate high dose rate (HDR) brachytherapy that encompasses the
tests of the AAPM TG 128 report, geometry tests based on IAEA TRS
430 and additional image fusion and dose verification tests.
: The materials used were: a table tennis ball,
three Nucletron's 6F needles for prostate implant, a Siemens
ultrasound equipment, a Nucletron's HDR prostate brachytherapy
system and a MOSFET dosimeter. The tennis table ball was selected
for this setup because it is an object of known dimensions, good
image contrast, low cost and easy to get. The phantom setup consists
of inserting the three needles through the template and the table
tennis ball in a triangular shape. The phantom and the transrectal
ultrasound probe are then fixed to the stepper and inserted into a
small water tank (Figure 1). The first set of image tests, based on
AAPM TG 128 report, were (1) grayscale visibility, (2) depth of
penetration, (3) axial and lateral resolution, (4) axial and lateral
distance measurement accuracy, (5) area measurement accuracy, (6)
volume measurement accuracy, (7) needle template/ electronic grid
alignment, (8) treatment planning system (TPS). A new image test was
developed to evaluate the TPS image fusion (9). CT and MR images of
the phantom were made to allow volume measurements in both image
sets and manual fusion tests with the ultrasound based images.
Geometrical tests, based on IAEA TRS 430, for (10) needle
reconstruction accuracy and (11) source position accuracy were also
made. Finally, a dose verification test (12) was performed inserting a
MOSFET dosimeter, through a catheter previously placed in the
phantom parallel to the needles.

S132 World Congress of Brachytherapy 2012
Figure 1 – Phantom setup.
: Table 1 presents a summary of the results. The AAPM TG 128
required tests (1 to 8) were accomplished with the setup used and the
results were within the action limits. In test 6, the table tennis ball
volume calculated by the ultrasound system was 2% higher than the
actual volume. CT and MR images volume measurements, test 9, were
about 1% lower than actual value. The fusion tests also showed a good
matching between the images. The geometrical tests (10 and 11) were
also accomplished and the results were less than 1 mm.
The final dose verification test (12) result, comparing TPS and
measured values, was less than 2%.
Table 1 – Results of the tests.
: The phantom setup and methodology presented in this
study allows the completion of AAPM TG 128 required tests as well as
other tests recommended either by IAEA TRS 430 and the authors.
A final note is that this setup only uses a table tennis ball and
material that normally exists in a department with ultrasound guided
prostate brachytherapy.
PO332
IS HDR EQUIPMENT PERFORMANCE SUITABLE FOR MODERN
BRACHYTHERAPY? POSITIONAL ERRORS, DOSIMETRIC IMPACT & CASE
STUDY
A. Palmer 1 , O. Hayman 2 , L. Ioannou 2 , Y.S. Nagar 3
1
Portsmouth Hospitals NHS Trust (& University of Surrey Faculty of
Engineering and Physical Science), Radiotherapy Physics, Portsmouth,
United Kingdom
2
Portsmouth Hospitals NHS Trust, Radiotherapy Physics, Portsmouth,
United Kingdom
3
Portsmouth Hospitals NHS Trust, Clinical Oncology, Portsmouth,
United Kingdom
: To study the effect of simulated HDR source
dwell position errors on the dose to the clinical target volume (HR
CTV) and organs at risk in cervix cancer. Determine the clinically
relevant positional accuracy requirement; inform QC needs and
treatment uncertainty estimates. Interpret the performance of an
HDR unit using this data.
: Simulated dwell position errors, 0.2 to 10.0
mm, were introduced in eight HDR cervix plans and the dosimetric
effect on ICRU and GECESTRO DVH parameters calculated. CT plans
on the Eckert & Ziegler BEBIG (EZ) HDRplus planning system, with Co
60 source and IUT/splitring applicator were used throughout. Two
error modes were simulated: (a) systematic proximal shift (away from
HDR unit) position calibration error; (b) source cable takeup lag,
possible with older EZ software, first dwell unaffected and others
shifted distally [1].
Video source position tests for the EZ HDR MultiSource were used with
the above simulation data to predict effect on clinical dose delivery.
: Figure 1 shows the relationship between systematic errors in
source dwell positions, mode (a), and the % change in DVH metrics,
D90 and D2cc. The mean and interquartile range from eight plans is
provided. There is an approximate linear relationship; errors of 1.0
mm result in 2.0 % change, 4.0 mm error 10.0 % change. ICRU A pt.
exhibits less change than DVH metrics, 0.4% and 0.7% respectively.
Bladder doses increase while rectum, sigmoid and HRCTV decrease
due to the proximal shift direction of dwells. This would be reversed
for distal shifts. Table 1 gives additional detailed DVH data for 0.2 to
2.0 mm position errors for both modes. Previous software version of
the EZ unit had the potential for small dwell position errors due to
curvature of the transfer tube: This effect on dose delivery
uncertainty is given in Table 1(b). This is eliminated with new
software.
Thirty QC test results of source position were collated for the EZ HDR
World Congress of Brachytherapy 2012 S 133
unit. 13% were recorded within 0.25 mm error, 64% within 0.5 mm,
and 23% within 1.0 mm.
Figure 1. Effect of systematic proximal dwell position shifts, 0.2 to 6.0
mm, mode (a), on DVH metrics. Data is the mean and interquartile
range from eight cervix plans.
Table 1. Effect of dwell position shifts on dose delivery metrics, 0.2 to
2.0 mm; modes (a) and (b), see text.
: An accuracy of at least 1.0 mm in dwell positions is
required to limit the effect on clinically relevant dose delivery
parameters to within an acceptable level of 3.0%. Only at 0.2 mm
accuracy are the effects all within 1.0%. A QC action level of 0.5 mm
is proposed, with 1.0 mm maximum tolerance. All recorded QC
position results for the EZ unit were within the clinically relevant
accuracy level. Errors due to source cable takeup lag, with potential
DVH uncertainty up to 6%, have been eliminated with the new
software.
[1] Palmer A et al. Performance assessment of the BEBIG multisource high dose rate brachytherapy treatment
unit. Phys Med Biol 2009:54;74177434
PO333
PARTICULARITIES OF I125 SEED CALIBRATION FOR PROSTATE
INTERSTITIAL PERMANENT BRACHYTHERAPY
A. TorneroLópez 1 , F. Simancas 1 , S. RuizArrebola 1 , M. GazdicSantic 2 ,
D. Guirado 1
1 Universitary Hospital San Cecilio, Radiophysics, Granada, Spain
2 Clinical Centre of Sarajevo University, Department of Medical
Physics and Radiation Safety, Sarajevo, Bosnia and Herzegovina
: For the measuring of I125 seeds, we have
available the plane parallel chamber SourceCheck (PTW), calibrated
by PTW Laboratory Calibration Center, and the well chamber HDR1000
(Standard Imaging), calibrated by the Wisconsin University. These
chambers show a discrepancy of 6% between its simultaneous
measurements of the same I125 seed. We also found a difference of
about 3% of each chamber measurement from the value provided by
the manufacturer for that particular seed. It is essential to find out
the cause of these differences to guarantee the AAPM 1 and ESTRO 2
recommendations for the QA procedure in brachytherapy (figure 1).
Motivated by this scenario, we aim to establish a user protocol
yielding to a fulfillment of the recommendations.
: After doing an optimal statistical monitoring
of both chambers, we have carried out several lines of work:
1. The well chamber lecture is corrected by an additional pressure
dependent factor 3 . As other hospitals, ours is located at a quite high
altitude above the sea level. This fact compels us to apply correction
factors as big as 3.03.5%, besides the usual tp correction. We
performed an experiment to verify that this correction yields to
coherent results. We took measurements at different altitudes,
spanning pressures from 596 up to 770 mmHg.
2. To have a set of consistent calibrated chambers, we opted for
calibrating them all in our hospital using a calibration source provided
by an ADCL. This possibility is included in the AAPM protocol for
braquitherapy 4 .
A monitoring procedure has been developed to control the deviation
between the user measured distribution and the manufacturer one:
periodic measurement of a sample of at least 10 seeds combined with
the sporadic measurement of an individual seed calibrated by the
manufacturer.
: We confirm that the pressuredependent correction factor is
correctly applicable to our well chamber. However, we find out that
instead of applying a potential function correction, a simpler linear
one yields to equivalent results.
We measured the Air Kerma Strength (AKS) distribution of 10 sets of a
mean of 20 seeds. We observed a systematic deviation of 2.5% from
the manufacturing distribution. A similar difference is found with
respect to the value of an individual calibrated seed.
: The differences found in the measurements of the well
chamber HDR1000, the SourceCheck and the manufacturer equipment
are presumably due to discrepancies between their calibrations.
We remark the need of a consistent cross calibration of the user’s
available ionometric setups.
We also suggest the realization of a statistical monitoring of the
systematic difference between the manufacturing and user
distributions of the AKS.
1. Butler et al. Med Phys 2008;35:38605.
2. Venselaar JLM, PérezCalatayud J. ESTRO Booklet No 8.
ESTRO;2004.
3. Griffin et al. Med Phys 2005;32: 1103114
4. Rivard et al. Med Phys 2004;31:63374.
PO334
DOSIMETRIC CONSEQUENCES OF ROTATIONAL ERRORS WITH DIRECT
SIMULATION FOR PARTIAL BREAST IRRADIATION USING CONTURAÔ
J. Peng 1 , M. Ashenafi 1 , K. Vanek 1 , J. Harper 1 , J. Jenrette 1
1
Medical University of South Carolina, Radiation Oncology,
Charleston, USA
: The purpose was to determine dosedelivery
errors resulting from systematic rotational positioning errors of the
Contura multilumen balloon catheter for Accelerated Partial Breast
Irradiation (APBI) using direct simulation in the 3D imaging
registration system (VelocityAl).
: Twenty patients who received APBI had dose
distributions reevaluated to assess the impact of systematic
rotational positioning errors. The dosimetric effect of rotational

S134 World Congress of Brachytherapy 2012
errors was simulated by rotating 3D dose cloud manually using the 3D
imaging registration system (VelocityAI), as shown in figure. The
rotational errors of ± 1°, ± 3°, ± 5°, ± 7° , ± 10° , ± 30°,± 45° and ±
90 ° along each axis were simulated. Dosimetric effects of the rotated
plans were compared with the original plans. In previous study, the
balloon to skin/chest wall distance, (BtoS Dist.) was the most critical
factor to affect the treatment results. Results for two groups of
patients were analyzed: (1) BtoS Dist. ≤ 7mm (the small BtoS group) ;(
2) BtoS Dist.>7mm (the large BtoS group).
: A comparison of various dosimetric parameters is presented
in the Table. The mean volume of PTV_Eval (1cm rind of breast tissue
outside of the balloon) that received the prescription dose decreased,
for the small BtoS group, from 1.7% ± 2.2% (less than 10°) to 28.1% ±
25.9% (up to 90°); for the large BtoS group, from 0.7% ± 0.5% (less
than 10°) to 3.3% ± 3.4% (up to 90°). In general, the increase in the
volumes of the organs at risk (OARs) receiving the tolerance doses was
small and did not exceed the tolerance, except for cases where the
OARs were in close proximity to the balloon (3% tumor coverage loss and >36%
maximal dose increase to the OARs, for the small and large BtoS
groups, respectively. However, for small BtoS Dist. ≤ 3mm targets
with the elliptical shape of dose cloud, the target coverage and dose
of OARs decreased significantly as rotational errors of 3° or more
were present.
: Rotational errors should be evaluated carefully for
clinical cases involving small balloon to skin/chest wall distance and
for dose cloud with elliptical shape. For the best dosimetric results,
APBI treatments using Contura should have rotational errors ≤ 3° (BtoS
Dist. ≤ 3mm), ≤ 10° (BtoS Dist.≤ 7mm) and ≤ 45° (BtoS Dist.> 7mm)
PO335
INVERSE PLANNING OF CONFORMAL HDRPROSTATE BRACHYTHERAPY
BOOST TECHNIQUE USING TWO CTVS
S. Wolf 1 , G. Bockelmann 1 , F.A. Siebert 1
1 University Hospital SH Campus Kiel, Radiotherapy, Kiel, Germany
: Ultrasoundbased intraoperative HDRprostate
brachytherapy (BT) as boost technique is a well established method in
our clinic. To date the treatment planning is performed manually as
conventional planning technique (CP). Despite the success of this
method, the introduction of inverse planning techniques (IP) is hoped
to reduce planning time and to decrease user dependency of the
planning process itself. In this study the clinical implementation and
evaluation of inverse planning for HDR prostate BT is presented. In
contrast to other HDR prostate techniques the target structure is
segmented into two parts: the peripheral zone of the prostate (CTV2)
and the whole prostate gland (CTV2).
: For the patient cohort considered in mean 12
needles were implanted in the typical ushape form. Using 38
different clinical treatment plans appropriate dose constraints for the
IP algorithm (BrachyVision v8.8, Varian Medical Systems, Palo Alto,
CA) were identified. Prescription doses for CTV1/CTV2 were 15/8.5
Gy. Doses in urethra and rectum should be lower than 10 and 8 Gy,
resp. Because the CTV1 is often badly visible with ultrasound after
insertion of the implant needles, the CTV1 was geometrically defined
by a threedimensional 0.5 cm hull around the implanted needles.
After establishing a general template of dose constraints and their
appropriate weightings, applicable to all patient anatomies, all
treatment plans were calculated according the TG43 formalism using
identical start conditions as well: three seconds dwell times in all
dwell positions, calculation time for the IP algorithm in the treatment
planning system was one minute, a maximum dwell time of 10 seconds
was allowed, and dwell time smooth function was set to maximum
100%. IP results were compared against the existing clinical CP by
using D90CTV1/2, V200CTV1/2, D2ccrectum, D0.1ccurethra, and COIN index.
Significant statistical differences (pvalue < 0.05) were analyzed by
the MannWhitney rank sum test.
: The inverse planning results in this study were available after
one minute. In contrast to this an experienced medical physicist needs
about 10 to 15 minutes per treatment plan. The results of this study
are summarized in table 1. Dosimetric indices are very similar
between CP and IP techniques. Only V200CTV1 is significantly lower for
CP. Moreover the IP technique fairly reduced (not statistical
significant) the D0.1ccurethra.
: This study showed that the usage of IP algorithms for
HDR prostate boost techniques with a complex CTV arrangement can
yield similar dosimetric results as a CP technique. Nevertheless
dosimetric results of an inverse planning must be checked by an
expert physicist before patient treatment.
World Congress of Brachytherapy 2012 S 135
PO336
BRACHYTHERAPY ACTIVITIES IN THE FRAMEWORK OF THE EUROPEAN
METROLOGY RESEARCH PROGRAMME
T. Schneider 1 , U. Ankerhold 1 , J. Solc 2
1
Phys. Techn. Bundesanstalt (PTB), Dosimetry for Radiation Therapy,
Braunschweig, Germany
2
Czech Metrology Institute, Inspectorate for Ionizing Radiation,
Praha, Czech Republic
: The European Metrology Research Programme
(EMRP) enables European metrology institutes to collaborate with
industrial organisations and academia on joint research projects
within specified fields. The EMRP is implemented by EURAMET e.V.,
organised by 22 European National Metrology Institutes (NMIs),
supported by the European Union and has a budget of 400 M€ over an
approximately seven year period. In 2011 a new Joint Research
Project (JRP) in the field dosimetry of ionizing radiation was initiated
and approved after a review conference. A part of this project covers
the recent developments in brachytherapy. In this presentation an
outline of the planned activities for dosimetry in brachytherapy will
be given.
: The work within the new JRP addresses the
establishing of miniature xray tubes for the treatment with low
energy photons as well as the work in the community of medical
physicists to bring up the treatment modality and treatment planning
to the level already achieved in External Beam Radiation Therapy,
manifested in the work of the AAPM TG 186 task group members in
close cooperation with the European society ESTRO.
: The dosimetry system of two miniature xray tubes will be
investigated: one from the vendor Carl Zeiss called 'Intrabeam ® ' and
another one from the vendor Xoft called 'Axxent ® ' tube. The
calibration procedures offered by the vendors are totally different.
The Axxent system uses a well type chamber calibrated in terms of Air
Kerma Strength (AKS) for the radiation field of I125. Calibration
factor in AKS for the Axxent field are under development (NIST,
Univ. Wisconsin). For the Intrabeam device the calibration is based on
measurements in a water phantom in terms of absorbed dose to water
with a soft xray ionization chamber. As no NMI offers calibrations in
terms of absorbed dose to water DW in a certain depth in a water
phantom in the respective radiation field, this calibration factor is
derived from Air Kerma calibrations and a conversion into DW
according to ICRU 17. The goal of the first part of the brachytherapy
work is to characterize the sources, to establish a primary standard in
terms of absorbed dose to water and to give recommendations on a
calibration chain.
: In most publications the results of treatment planning
are compared only to MonteCarlo calculations and not to
experimental data. It is the topic of the second part of the work to
overcome this problem by developing measuring techniques to canvass
the results of treatment planning systems in the presence of clinical
applicators. For NMIs this means a step apart from the standard fields
usually applied to a complex field close to clinical conditions. The
applied measuring devices will be characterized to achieve an
absolute uncertainty below 2% (k=1) in this irregular, nonstandard
field and the uncertainty of the positioning will be below 30 m.
PO337
MAPPING OF RELATIVE DOSE RATE DISTRIBUTION UNCERTAINTY OWING
TO SOURCE CONSTRUCTION
K. Zourari 1 , E. Pantelis 1 , L. Sakelliou 2 , E. Georgiou 1 , P. Papagiannis 1
1
University of Athens, Medical School Medical Physics Laboratory,
Athens, Greece
2
University of Athens, Physics Department Nuclear and Particle
Physics Section, Athens, Greece
: A joint AAPM/GECESTRO report 1 recommends
that brachytherapy source dosimetry investigators using Monte Carlo
simulation (MC) should determine the effect of type B uncertainties
on the quantities proposed for clinical use. This work presents results
of a method to map the total uncertainty owing to source construction
related type B uncertainties based on the ISO Guide to the Expression
of Uncertainty in Measurement 2 and MC.
: Calculations were performed for one
commercially available 125 I LDR seed. 3 Information on the dimensions
of the cylindrical silver marker, the thickness of its radioactive silver
halide coating, and the dimensions of the titanium encapsulation,
were available 3 as: xi±axi. Corresponding standard uncertainties were
calculated assuming uniform probability distributions. Let be a
point in the 2D matrix of dose rate per unit air kerma strength on a
plane including the source long axis.
is a function of xi (i.e. ) and, assuming f is
approximately linear and no correlation exists between xi, its standard
uncertainty can be calculated according to the law of uncertainty
propagation 2 : . MC simulations were
performed to obtain the 2D distribution of around the nominal
source design, as well as source designs where each of the quantities
xi was individually varied, assuming values of xiaxi or xi+axi. This
allowed for the forward and backward finite difference
approximations of the partial derivatives in the above equation, and
hence the calculation of 2D maps of the total standard uncertainty
owing to source construction and the partial contributions to it.
: The figure presents the overall % relative standard
uncertainty of around the source (left) compared to the
corresponding type A MC uncertainty (right). As expected, radioactive
coating thickness, followed by end weld radius, were the major
uncertainty contributors affecting mainly points close to the source
longitudinal axis. Uncertainty results at these points are comparable
to the uncertainty of NIST traceable SK calibration of seeds delivered
to the clinic. 1 The former however is position dependent and
therefore subject to smoothing out when multiple sources are used.
: Results support recommendations 1 that detailed
information on the source should be openly provided by
manufacturers and considered by dosimetry investigators. The
proposed 2D mapping method facilitates the overview of total
uncertainty while providing all the input necessary for the calculation
of uncertainty of TG43 quantities. The brute force implementation of
MC could be replaced by methods of improved computational
efficiency or physically intuitive models.
Acknowledgments
Kiveli Zourari was supported by Irakleitos II.
References
1. L. De Werd et al. Med. Phys. 38, 782801, 2011.
2. Guide to the expression of uncertainty in measurement, ISO, JCGM
100, 2008.
3. P. Karaiskos et al. Med. Phys. 28, 1753–1760, 2001.

S136 World Congress of Brachytherapy 2012
PO338
VAGINAL CUFF BRACHYTHERAPY USING OVOIDS: COMPARISON OF
POINT BASED AND TARGET BASED PRESCRIPTION
S. Sharma 1 , D. Manigandan 1 , A.K. Gandhi 1 , D.N. Sharma 1 , V.
Subramani 1 , P.K. Julka 1 , G.K. Rath 1
1
All India Institute of Medical Sciences (AIIMS), Radiation Oncology,
Delhi, India
: To compare the treatment plans with point based
and target dose point based prescription methods for vaginal cuff
brachytherapy with two ovoids.
: Twenty previously treated sessions of post
operative carcinoma uterine cervix patients were studied. For all the
patients, application was done by using two Fletcher ovoids under
sedation. After application, CT scan was done at 3mm slice thickness.
The target volume was contoured and it assumed to be around the
applicator, however, in some cases, modification was done according
to the clinical and planning CT findings. Similarly, organs at risk (OAR)
i.e. bladder and rectum were contoured. The ICRU38 bladder and
rectum points were also marked on CT images. Applicators were
reconstructed using 2.5mm source step size and plans were generated
for Nucletron HDRV2 machine using PLATO planning system. In both
the ovoids, first four dwell positions were activated and dose
prescription was done by using two different prescription methods.
One is conventional point dose (PD) based and the second is target
dose point (TDP) based. For conventional PD method, the dose
prescription point was at 5mm above the superior surface of mid
dwell position of two ovoids. For TDP based method, target dose
points were created 5mm around the target. No optimization was
done after prescription. For comparison purposes, dose was
prescribed at 100cGy. For plan evaluation, following dose volume
indices were used: Volume of target that receive 100% (V100), 95%
(V95), and 90% (V90) of prescription dose, coverage index
(CI=V100/Target volume) and overdose volume index (OI=V200/V100). For
bladder and rectum, doses received by 0.1cc (D0.1cc), 1cc (D1cc), 2cc
(D2cc), 5cc (D5cc), and 10cc (D10cc) of volumes were noted. The ICRU38
bladder and rectum point doses were also noted to correlate with
volumetric doses.
: The plan comparison is summarized in Table.1. Volumetric
evaluation shows that target coverage was lower in PD based plans
than the TDP based plans. However, the OI index shows that high dose
volume was more in TDP based plans compared to PD plans. In
addition, the OAR doses were higher in TDP based method than the PD
based. In the both TDP and PD methods, the bladder doses received
by 0.1cc, 1cc, 2cc and 5cc volumes were higher compared to ICRU38
bladder point doses and doses to 10cc bladder volume were in closer
agreement with the ICRU38 bladder points. Similarly, for rectum, the
doses received by 0.1cc, and 1cc volumes were higher compared to
ICRU38 rectum point doses and doses to 2–5cc volume of rectum were
in closer agreement with the ICRU38 rectum points.
: In the CT guided PD prescription method, lesser target
coverage and lower OAR doses were observed. In TDP based
prescription, target coverage was higher and resulted in higher OAR
doses. Doses received by 10cc of bladder and 2–5cc of rectum were
closer to ICRU38 bladder and rectum points, respectively.
PO339
MRIDUMMY MARKERS OF MRIGUIDED HDR BRACHYTHERAPY FOR
INTERSTITIAL PROSTATE AND INTRACAVITARY GYN CANCERS
J. Schindel 1 , M. Muruganandham 1 , A. Eagle 2 , M. Hewitt 2 , T.
Stockman 2 , C. Pigge 3 , Y. Kim 1
1
University of Iowa, Radiation Oncology, Iowa City, USA
2
University of Iowa, Electrical Computer Engineering, Iowa City, USA
3
University of Iowa, Chemistry, Iowa City, USA
: Compare seven different MRIdummy markers for
interstitial prostate and intracavitary GYN HDR brachytherapy.
: Seven markers were used: Saline, Conray60
(Mallinckrodt medical), CuSO4 (1.5g/L), liquid Vitamin E, fish oil, 1%
Agarose gel (AGEL: 1g Agarose powder/ 100 ml distilled water), and a
cobaltchloride complex contrast (C4) (CoCl2: Glycine=4:1). Interstitial
and intracavitary phantoms were designed. The interstitial phantom
consisted of eight flexi needles (outer/inner diameter of
1.98mm/1.45mm) that were filled with each MRImarker and
embedded in 450 mL of 3% AGEL. The intracavitary phantom consisted
of 4L of 3% AGEL, a plastic tandem and ring applicator (Varian), and
MRIdummy catheters (outer/inner diameter of 2.66mm/1.87mm).
Clinical 3T MRI protocols (both T1weightedMRI (T1MRI:1mm slice
thickness) and T2weightedMRI scans (T2MRI: 3mm slice thickness))
were used. Signal intensities for each marker were characterized as
percentages compared to the 3% AGEL background using ImageJ
software.
: Some interstitial markers, even though small agent volume,
could generate favorable signals (> 100%), implying their feasibility for
MRIguided prostate HDR. The markers of CuSO4, C4, and Vitamin E on
T1MRI and 1% AGEL, Saline, and fish oil on T2MRI showed higher than
100% signals on both phantoms. The volume effect on signals was
found due to different marker volumes in the different dummy
catheters. The markers of CuSO4 and Saline showed highest signals on
T1MRI and T2MRI, respectively. Sourcereconstruction is
recommended on T1MRI, so CuSO4 and C4 markers have great
potentials as a dummy marker for both interstitial and intracavitary
brachytherapy.
: The use of interstitial markers for MRIguided prostate
HDR seems feasible. The markers of CuSO4 and C4 showed
considerably high signals on T1MRI, as did Saline on T2MRI, for
interstitial needles for prostate HDR and for a tandemandring
applicator for GYN.
World Congress of Brachytherapy 2012 S 137
PO340
DOSIMETRIC IMPACT OF NOT CORRECTING FOR THE DISTAL SHIFT
REPORTED IN VARIAN TANDEM AND RING (T&R) APPLICATORS
O. Craciunescu 1 , J. Sánchez Mazón 2 , L. Lan 3 , J. Maurer 1 , B. Steffey 1 ,
J. Cai 1 , J. Adamson 1 , J. Chino 1
1
Duke University Medical Center, Radiation Oncology, Durham NC,
USA
2
Hospital Universitario Marqués de Valdecilla, Servicio de Radiofísica
y Protección Radiológica, Santander, Spain
3
Duke University Medical Center, Department of Biostatistics and
Bioinformatics, Durham NC, USA
: Studies have shown that source stop positions
within Varian’s HDR CT/MR compatible ring applicators can deviate
from the intended positions by several millimeters, and that a
corrective shift has to be applied to limit the effect of these inherent
offsets. The purpose of this study was to investigate the dosimetric
impact of NOT applying this correction.
: Twentyseven HDR T&R clinical plans (cP)
from six different patients treated for cervical cancer in our clinic
were used in this study. Both CT and MR were acquired for each plan.
The dose per fraction was 5.5 Gy. GECESTRO guidelines were
followed for HRCTV and organs at risk (OARs): bladder, rectum,
sigmoid. ICRU 38 points A were also defined. The planning was done in
BrachyVision with a hybrid volume optimization method based on
HRCTV and ABS recommended reference lines. Depending on the
shape of the HRCTV, the posterior ring dwell positions were allowed
in the optimization for 5 patients. For 1 patient, a standard ring
loading that mimicks ovoid placement was used. To show the
dosimetric impact of NOT applying distal corrections, plans were
generated by shifting the dwells in the ring in the opposite direction
incrementally by 1 5 mm. The plans were calculated using the TG43
formalism and ACUROS, a modelbased analytical solver that
accounts for inhomogeneities. To establish clinical significance, the
mean percent difference between all metrics in each of the shifted
plans and the cP were calculated. The Wilcoxon signedrank test was
used to determine if the differences have any statistical significance,
for all cases together, but also separating patients depending on the
ring dwells activated.
: For brevity, only D2cc results for OARs for all 27 plans are
presented. Ring loading strategy did not impact the dosmetric results.
The mean percent differences between the largest shift (5mm) and
the cP for the D2cc bladder, rectum and sigmoid were 1.6, 1.7, 2.5%
for TG43, and 1.2, 1.8 and 1.4 % for ACUROS. The Wilcoxon rank sum
pvalues were > 0.05 for all the OAR metrics, shift amounts, and
method of calculation. For A_RT, A_LT and HRCTV D90, the mean
percent differences were 0.8, 0.5 and 0.6 %, and 0.6, 0.8 and 0.9 %
for TG43 and ACUROS, respectively. However, the Wilcoxon signed
rank pvalues for Point A_RT were < 0.05 for both TG43 and ACUROS,
for all shifts. Only when using ACUROS, the pvalues for HRCTV D90
were < 0.05 for all shifts.
: The dosimetric impact of NOT applying corrective shifts

S138 World Congress of Brachytherapy 2012
measurements. The dose rate was calculated following a modification
of the AAPM Task Group 61 protocol.
: Azimuthal anisotropy measurements performed with film and
TLD show good agreement as shown in Figure 1c. The TLD polar
anisotropy measurements agree well with the MCNP5 predicted values
as also shown in Figure 1d, but exhibit slight anisotropy not predicted
by MCNP5. The DRC, as measured with the Exradin A16 chamber and
corrected with egs_chamber simulations, was 0.536 cGyh 1 U 1 , which is
8% higher than the previously measured TLD value.
Figure 1: a. Film insert. b. Polar TLD insert. c. Azimuthal anisotropy
results. d. Polar anisotropy results.
: This phantom allows a convenient and practical means
to measure azimuthal and polar anisotropy. It was also possible to
measure the doserate constant with an ionization chamber, provided
the appropriate corrections are made. This phantom allows users of
the Axxent system to easily verify the absorbed dose to water
parameters of TG43 without the use of liquid water.
PO343
COMPARISION OF TG43 AND ACUROS DOSE CALCULATION ALGORITHM
FOR VARIOUS APPLICATORS USED IN HDR GYN BRACHYTHERAPY
J. Swamidas 1 , U. Mahantshetty 2 , S.K. Shrivatava 2 , D.D. Deshpande 1
1 Tata Memorial Hospital, Medical Physics, Mumbai, India
2 Tata Memorial Hospital, Radiation Oncology, Mumbai, India
: The current brachytherapy dose calculation
formalism assumes a homogeneous water medium that doesnot
incorporate the effect of radiation scatter, tissue or applicator
heterogeneities. The purpose of this study was to quantify the
dosimetric effects of tissue heterogeneities and various applicator
materials used in HDR Gynaecological Brachytherapy
: Three series of CT images of patients
undergoing HDR brachytherapy for cancer of uterine cervix were used
for this retrospective analysis. Each of the CT image series was
selected to have different applicator material. The applicators were
a) Ring applicator made of stainless steel (SS) material b) Vienna
Applicator made of plastic/polymer material and c) Tandem/Ovoid
applicator made of Titanium. CT images of each of these applicators
were transferred to the Treatment Planning System (Brachyvision
v10). High Risk CTV, rectum, bladder and sigmoid were delineated
based on GEC ESTRO recommendations. Two plans with 7Gy as dose
prescription to HRCTV were generated for each image series. Dose
calculation was carried out using TG43 and ACUROS dose calculation
algorithm for Iridium192 HDR classic source (Nucletron). Dose volume
parameters recommended by GEC ESTRO recommendations were
calculated. In addition, volume receiving 50%, 100%, 200% and 400%
isodose lines also were calculated to evaluate low and high dose
variations. Dose to Point A, ICRU bladder and rectal point also were
determined and used for this comparative analysis.
: The table below shows the variation in dose to water in
water as compared to heterogeneity corrected dose to tissue in tissue
for different types of applicators. Average variation of all the dose
volume parameters for applicator made from SS and Titanium
material is 3.3 (±0.9)% and 3.1(± 1.1)% respectively as compared to
polymer applicator of 1.2(± 0.9)% with ACUROS as compared to TG43.
Also, the low dose region (V50%) has more variation as compared the
high dose regions (V400%). For all the three applicators, it was found
that TG43 formalism over estimates the dose as compared to ACUROS
dose calculation algorithm.
Parameters SS Polymer Titanium
HRCTV D90 3.0 0.5 3.0
HRCTV D100 3.1 0.3 2.9
HRCTV V100 1.3 0.3 2.1
BLD2cc 3.9 0.8 1.7
RD2cc 3.4 0.5 4.5
SD2cc 3.5 1.2 3.3
ICRU BL 2.4 1.5 2.9
ICRU R 3.9 3.0 4.0
V50% 4.8 0.5 4.5
V100% 4.1 0.5 4.2
V200% 3.6 1.7 3.8
V400% 4.0 3.0 2.8
PTA RT 2.8 1.5 1.8
PTA LT 2.0 1.7 1.2
: The present study is an attempt to quantify the
applicator and tissue heterogeneities for commonly used applicators
in realistic conditions related to HDR Gynecological Brachytherapy.
The TG 43 algorithm overestimates the doses as compared to ACUROS.
The magnitude of variation depends on the applicator material with
highest for applicators made of stainless steel and titanium and least
for polymer material. Defining applicator material and incorporating
anticipated variations may further add to existing quality assurance
program for GYN Brachytherapy planning.
PO344
INVIVO DOSIMETRY IN HDR BRACHYTHERAPY: THE EFFECT OF
TEMPERATURE VARIATION AND SIMULATED POSITION CHANGES
O. Hayman 1 , A. Palmer 2 , S. Williams 1
1
Queen Alexandra Hospital, Medical Physics Department, Portsmouth,
United Kingdom
2
University of Surrey, Medical Physics Department & Faculty of
Engineering and Physical Science, Guildford, United Kingdom
: Invivo dosimetry provides real time feedback on
patient set up and organ at risk dosimetry for both rectum and
bladder at treatment. Clinical studies had demonstrated the need for
further characterisation and a full understanding of the diode system
functionality. [1]
This study aimed to characterise the use of diodes in Co60 cervical
cancer treatment using the HDR MultiSource (Eckert & Ziegler BEBIG)
with integrated diodes (PTW). Temperature dependence of the diode
response was assessed at typical calibration (room) temperature
(22.8 o C) and internal rectal temperature (34.4 – 37.8 o C) for bladder
and rectal dosimetry systems. Effects of positional uncertainty were
evaluated with a treatment planning study correlating measured and
predicted doses.
[1] Invivo dosimetry for gynaecological brachytherapy: physical and
clinical considerations, Wadhäusl C et al 2005
: 20 patient's CT images were used to
determine the mean position of the rectal and bladder invivo diodes.
corresponding to planning ref points, in relation to the HDR
applicator. An inhouse jig was designed for the Eckert & Ziegler split
ring and IUT applicator in water. The stability and reproducibility of
the rectal and bladder diode system was assessed at calibration
temperature of 22.8 o C. The temperature was elevated to a maximum
37 o C and change in response of the rectal and bladder probes
determined. The diode immersion time at the higher temperature was
representative of clinical use within the patient. A treatment planning
study was conducted to assess the maximum position uncertainty,
using the range of dose difference established in the rectal and
bladder diode measurements. Each diode's dose range was plotted
separately and compared with the volume doses for both rectum and
bladder.
World Congress of Brachytherapy 2012 S 139
: The mean rectal diode dose was 2.8 Gy (sd 0.04) compared
to planned dose 2.5Gy. The mean bladder diode dose was 4.0 Gy (sd
0.05) with planned dose 3.9 Gy. At the elevated body temperature,
rectal dose was 2.8 Gy (sd 0.01) and bladder dose 4.1 Gy (sd 0.05).
The difference in predicted to measured readings ranged from 0.2 to
0.4 Gy for the bladder and rectal diodes individually. Applying this
dose range to each diode position on the treatment plan, the largest
positional uncertainty was ±7.5mm with a dose range of ±0.3Gy.
The bladder diode dose correlated well with the D2cc for the bladder
of 3.9Gy but the rectal diodes correlated better with D5cc of 3.3Gy.
: Stability and reproducibility are clinically acceptable for
this integrated diode system. No diode sensitivity variation with
temperature was observed in typical clinical conditions. The
Positioning of the diodes is of primary concern for accurate use and
correlation to treatment planning reference points. Image guidance
during treatment and retrospective planning using DRRs must be
utilised to fully exploit the usefulness of the diodes.
PO345
INTERSEED ATTENUATION IN PROSTATE I125 SEED IMPLANT
BRACHYTHERAPY: EXPERIMENTAL AND CLINICAL INVESTIGATION
P. Bownes 1 , J. Mason 1 , B. AlQaisieh 1 , A. Henry 2 , D. Thwaites 3
1
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Department of Medical Physics, Leeds, United Kingdom
2
St James Institute of Oncology The Leeds Teaching Hospitals NHS
Trust, Clinical Oncology, Leeds, United Kingdom
3
University of Sydney, Institute of Medical Physics School of Physics,
Sydney, Australia
: In prostate permanent seed implant
brachytherapy the actual dose delivered to the patient may be less
than that calculated by TG43 due to interseed attenuation (ISA). In
this study Monte Carlo (MC) simulation is used to quantify ISA.
Experimental verification of MC simulation results is performed using
a MOSFET dosimeter. 15 post implant treatment plans are simulated
to quantify the clinical effects of ISA. Results for the Oncura 6711 and
Thinseed seed models are compared. Thinseed has the same design as
the well known 6711 model but has 0.5mm diameter compared to
0.8mm for 6711 and a correspondingly thinner radioopaque marker.
: Dose measurements using a MOSFET in a
Perspex phantom for an implant of 36 seeds were compared to MC
simulation results. For the clinical study, 15 recently treated CT based
post implant plans were simulated using both 6711 and Thinseed. 7
patients were treated with standard activity seeds (0.458U) and 8
patients were treated with lower activity seeds (average 0.396U). ISA
was quantified by comparing DVH values for full MC simulation
(includes the ISA effect) to an MC superposition dose calculated using
single seed MC simulation results (ignores the ISA effect). DVH
calculation code was benchmarked by comparing MC superposition
dose to output from Variseed using source data calculated from single
seed MC simulation, and to output from Variseed using TG43U1
consensus source data.
: MC simulation results were validated by MOSFET
measurements although difficulties included variability in repeat
readings at low dose rates and drift in MOSFET calibration response.
The mean ISA effect on DVH parameters (calculated from the
difference between full MC simulation and MC superposition), for the
15 clinical post implant plans using the 6711 seed was prostate: D90
2.8%, V100 1.4%, V150 5.3%; urethra D10 2.5%, V150 14%; rectum
D2cc 4.4% V100 25%. For the Thinseed the ISA effect was lower with
mean values for prostate: D90 1.6%, V100 0.8%, V150 3.2%; urethra
D10 1.4%, V150 8%; rectum D2cc 2.5% V100 15%. DVH benchmarking
work showed that that the difference between single source MC
simulation and TG43U1 consensus parameters for the 6711 seed had a
slightly larger effect on DVH parameters than ISA: for example for the
prostate average differences were D90 4.2%, V100 2.0%, V150 7.6%.
There was little difference in ISA effects between the standard
activity and lower activity groups of patients.
: Experimental validation of MC simulation of complex I
125 seed arrangements is feasible. ISA causes DVH values for clinical I
125 seed implants to be lower compared to TG43 dose calculations.
ISA effects are reduced for a seed model that is less attenuating.
PO346
MEASUREMENTS AROUND AN ELECTRONIC BRACHYTHERAPY SOURCE
USING LITHIUM FORMATE EPR DOSIMETERS AND GAFCHROMIC FILM
E. Adolfsson 1 , S. White 2 , G. Landry 2 , G. Alm Carlsson 1 , H. Gustafsson 1 ,
E. Lund 1 , B. Reniers 2 , F. Verhaegen 2 , A. Carlsson Tedgren 3
1
Linköping University, Department of Medical and Health Sciences
(IMH) Radiation Physics, Linköping, Sweden
2
Maastricht University Medical Center, Department of Radiation
Oncology (MAASTRO) GROW School for Oncology and Developmental
Biology, Maastricht, The Netherlands
3
Swedish Radiation Safety Authority, (SSM), Stockholm, Sweden
: In this work, the aim was to test two different
dosimetry systems, lithium formate EPR dosimeters and GafChromic
film for dose verification measurements around a 50 kV Xoft Axxent
source.
Use of electronic xray brachytherapy sources (EBS) has increased as
an alternative to radionuclides in brachytherapy. The low energy (50
kV) in combination with the steep dose gradient around the EBS makes
it difficult to perform accurate dose verification measurements. It is
of great interest to identify dosimetry systems that are capable of
performing absolute dosimetric measurements around such sources.
One option is to use solid state detectors which can be made small
enough to resolve the gradients. Both lithium formate EPR (electron
paramagnetic resonance) dosimeters and GafChromic film are
potentially suitable for this purpose.
To determine absorbed dose to water, calibration in a well known
radiation quality that provides traceability to a primary standard is
needed. The calibration radiation quality can be similar to that under
investigation but is most often a MV or 60 Co field as suggested by the
AAPM TG43U1 for absolute dosimetry using LiF TLDs. When
calibrating dosimeters in a different radiation quality than used for
measurements, a correction for the different intrinsic response, fLET
(caused by different ionization densities (LET) of the secondary
electrons) is needed for highest accuracy in results.
: Measurements were performed in a PMMA
phantom. Four EPR dosimeters (cylinders with height 5 mm, diameter
4.5 mm) were positioned radially with their centers at 3 and 5 cm
from the EBS. GafChromic film was positioned on top of the EPR
dosimeters. The EPR dosimeters were calibrated in a MV photon beam
and the film in a well characterized 50 kV xray beam.
The dose to film was evaluated with the triple channel method using
an Epson v700 film scanner and the manufacturer’s (ISP) software,
FILMQA pro. The EPR dosimeters were read out in a BRUKER EleXsys
E580 spectrometer with a standard cavity ER 4102ST.
To determine absorbed dose to water in the PMMA phantom at a
certain distance r from the source, correction for the volume
averaging effect in the EPR dosimeters was obtained from Monte Carlo
(MC) simulations. MC simulations were also used to account for the
different positions of the EPR dosimeters and the Gafchromic film in
the phantom.
: Absorbed doses to water in the phantom determined by the
lithium formate EPR dosimeters agreed with the absorbed doses
determined by the films within the estimated uncertainties and
differences were less than 10%.
: The results from the two dosimetry systems conform to
a high degree of certainty which indicates that they are suitable for
this application.
PO347
ARE TISSUE AND APPLICATOR HETEROGENEITIES EFFECT IMPORTANT IN
BRACHYTHERAPY TPS? A REAL CASE
A. Pereira 1 , R. Pirraco 1 , T. Viterbo 1 , L. Salgado 2 , L. Carvalho 2 , L.
Trigo 2 , J. Lencart 1
1
Instituto Português de Oncologia, Fisica Médica, Porto, Portugal
2
Instituto Português de Oncologia, Serviço Braquiterapia, Porto,
Portugal
: The aim of this work is to quantify the difference
in delivered dose when different types of cylindrical applicators are
used in gynaecological brachytherapy, considering that the Treatment
Planning System (TPS) algorithm do not have heterogeneities
correction.
: In our department endometrial tumours are

S140 World Congress of Brachytherapy 2012
treated with two types of commercial cylindrical applicators: the
Vaginal Applicator Set and the Shielded Cylindrical Applicator Set for
high dose rate brachytherapy, from Nucletron. The former type has
massive structure and the later is hollow, allowing the introduction of
tungsten shielding (which we do not normally use). CT image based
plans are performed and the dose prescription points are located at
0,5 cm from the applicator surface. As our TPS (Oncentra Masterplan
4.1) does not take into account medium heterogeneities, there is a
difference between the calculated and delivered doses at the
prescription points when either type of applicator is used.
To evaluate these differences, we performed the HDR treatments
(Nucletron microSelectron V3) on a phantom, with both types of
cylinders, with 3,0 cm and 3,5 cm diameters, and measured the
delivered dose along the prescription points with a five Mosfet array
(TN 252LA5 MOSFET, Best Medical Canada).
: We observed a difference between the doses delivered at the
prescription points with the Vaginal Applicator Set and Shielded
Cylindrical Applicator of 5.4% for the 3.0cm cylinders and 5.2% for the
3.5cm cylinders.
: The obtained results suggest that further investigations
are made, specially if we consider using the tungsten shielding. The
use of an algorithm with heterogeneity correction is of high
importance.
Further work will be done in order to validate these results with
Monte Carlo simulations.
PO348
EVALUATION OF THE TRACHEA INHOMOGENETY EFFECT ON DOSE
CALCULATIONS OF ESOPHAGUS HDR BRACHYTHERAPY
S.M. Hosseini Daghigh 1 , R. Jaberi 2 , S.R. Mahdavi 2 , S.M.R. Aghamiri 1 , H.
Baghani 1 , E. Boroghani 3 , R. Eidi 1
1
Shahid Baheshty University, Radiation Medicine, Tehran, Iran Islamic
Republic of
2
Tehran University of Medical Science, medical physics, Tehran, Iran
Islamic Republic of
3
Guilan University, physics, Tehran, Iran Islamic Republic of
: Dose calculations in esophagus High Dose Rate
(HDR) Brachytherapy treatment planning systems (TPS) are greatly
based on TG43 protocol which in, all materials are considered to be
water equivalent.
Regarding to Locating the trachea near the esophagus and considering
the air inside it equivalent to water in TPS may introduce a
considerable error in dose calculations.
The aim of this research is surveying the effect of air within trachea
on dose calculations of Flexiplan TPS in esophagus HDR
brachytherapy.
: To do so, we used a cylindrical PMMA
phantom with a tube in the center (esophagus equivalent) with 20mm
diameter and a tube in 24mm distance from the center (trachea
equivalent) with 18mm diameter and the PMMA cylinders with
external diameter of 20mm and a hole with diameter that was equal
to the external diameter of each applicator was created within it, so
that the thickness of the thinnest part of the wall in each cylinder was
1 mm. the structure of described phantom has been shown in
following figure.
Esophagus brachytherapy applicators with various diameters (6, 8, 10
and 20mm) were placed into related cylinders and finally inserted in
esophagus tube. The irradiation was performed using Flexitron remote
afterloading system. In this system, HDR implants are achived by
moving a single high strength Ir192 source. Associated Treatment
planning system with this afterloading unit is Flexiplan that was used
to design treatment plan that loads a special dose at interested
points.
EDR2 radiography films were used for dosimetry at reference point in
esophagus HDR brachytherapy (between esophagus and trachea wall
14mm distance from center) and posterior wall of trachea (33mm
distance from center).
: The results of treatment planning and practical dosimetry (2
times measurements) in mentioned positions have been showed in the
following table. Difference between acquired results has been showed
too.
: The results show that there is a meaningful difference
between practical dosimetry and treatment planning results (Pvalue

S142 World Congress of Brachytherapy 2012
measurements which however showed much reduced values (in
Sv/hr) are a consequence of structural shielding by concrete walls
and leadembedded doors.
: It is essential to include checks of radiation levels in
treatment and control rooms in daily quality assurance tests.
Measurements while source position indicator was in use were
comparable to corresponding irradiation values with ring applicators
in patients. Therefore, radiation readings during source visual test
should be given necessary attention as typical of likely measurements
when brachytherapy irradiation of patients is actually in progress.
PO352
MODULATION RESTRICTIONS DO NOT NECESSARILY IMPROVE
TREATMENT PLAN QUALITY FOR HDR PROSTATE BRACHYTHERAPY
M. Balvert 1 , B. Gorissen 1 , D. den Hertog 1 , A. Hoffmann 2
1
Tilburg University, Dept. Econometrics and Operations Research,
Tilburg, The Netherlands
2
MAASTRO Clinic, Medical Physics, Maastricht, The Netherlands
: Inverse optimization algorithms in interstitial
HDR prostate brachytherapy may produce solutions with large dwell
time variations within catheters. An undesirable property is that
dominant dwell positions result in selective highdose volumes (i.e.,
hot spots). A dwell time modulation restriction (DTMR) has been
suggested and is used in planning software to eliminate this problem.
Additionally, such DTMRs are used to reduce the sensitivity for
uncertainties in dwell positions that inevitably result from catheter
reconstruction errors and source positioning inaccuracy of the
afterloader. The aim of this study is to quantify the reduction of hot
spots and the robustness against these uncertainties by applying a
DTMR to templatebased HDR prostate brachytherapy implants.
: For catheter reconstruction, the
measurement error in defining the tip was estimated to be 2 mm in
any direction. An additional error due to the source positioning
inaccuracy of the afterloader (±1 mm) was considered separately.
Three different DTMRs were consecutively applied to existing dose
based and dosevolume based optimization models, limiting the
relative differences, absolute differences, or summed squared
differences between neighboring dwell positions. The models were
solved for various restriction levels, ranging from no restriction to
uniform dwell times within catheters. The errors were simulated
uniformly at least 1.000 times on representative clinical cases. For
each resulting dose distribution, hot spot indices and DVH statistics
for the PTV, rectum and urethra were computed. These indices
comprise global and local measures, respectively given by the dose
homogeneity index (DHI) computed as (V100V150)/V100, and the newly
introduced V150c, being the largest contiguous volume receiving 150%
of the prescribed dose.
: None of the DTMRs could improve the nominal value,
simulated sample mean or variance of DHI or V150c without
simultaneously reducing V100. Moreover, the simulated sample
variance of V100 was not decreased by any DTMR. Preliminary results
for the afterloader inaccuracy are consistent with these results.
: No improvement in robustness against uncertainty in
dwell position measurement and afterloader precision was obtained
by applying a DTMR for the dosebased and dosevolume based
optimization models. We recommend not to use any of the three
DTMRs for inverse treatment planning optimization in HDR prostate
brachytherapy implants.
PO353
CLINICAL ASSESSMENT OF THE HDR CAPRIÔ APPLICATOR
B. Steffey 1 , O. Craciunescu 1 , J. Cai 1 , J. Adamson 1 , J. Chino 1
1
Duke University Medical Center, Radiation Oncology, Durham NC,
USA
: The Capri applicator (Varian Corp.) is a new
HDR CTcompatible brachytherapy (BT) applicator marketed to better
sculpt the radiotherapy dose and improve patient comfort. It is a 13
catheter balloon that is inflated upon insertion to conform to patient's
anatomy. In this study we characterize this applicator by investigating
the dosimetry as it compares with a stump vaginal cylinder, and the
manufacturer's stated relative catheter positions.
: Six patients received HDR brachytherapy
using the Capri applicator for the treatment of vaginal (4), recurrent
endometrial (1), and recurrent ovarian (1) cancers involving the
vagina. All patients received external beam radiation therapy
followed by 5 Gy x 45 fractions of HDR BT. For each insertion,
MR/CTbased HRCTV volumes were delineated for treatment planning.
GECESTRO guidelines were followed for dose volume constraints for
the organs at risk (OARs): bladder, rectum, sigmoid and bowel. The
planning was done in BrachyVision using the volume optimization
technique. Depending on the HRCTV shape and location, 411
catheters were used. Plans were calculated using the TG43 formalism
and with ACUROS, a modelbased analytical solver that accounts for
tissue inhomogeneities. Retrospectively, for dosimetry comparison,
planning was also done using a 3.5 cm stump cylinder(SC) with the
dose prescribed at 0.5 cm in tissue. HRCTV D90, bladder, rectum,
sigmoid and bowel D2cc were compared between the two plans
(CAPRI vs SC). Twentyeight CAPRI applicators were imaged after
TX and the relative positions between the distal ends of the catheters
were measured and compared to manufacturer's stated values: 2 mm
from central catheter to outer ring, and 10 mm from outer ring to
inner ring.
: The 3.5 cm SC could be used on only 22/29 fractions. The
mean percent differences in HRCTV D90, and D2cc for bladder,
rectum, sigmoid and bowel between the Capri, used as reference,r
and SC were, respectively: 19%±14, 39%± 29, 59%±44, 58%±37, and
41%±32 for TG43. Similar differences were found when ACUROS was
used. For the Capri plans, the mean differences between TG43 and
ACUROS for the same metrics were: 1.8%±0.5, 2.3%±0.6, 2.6%±0.6,
3.5%±1.1, and 3.4%±1.5 The distal measurements ranged 2.0 to 7.0
mm (avg 4.1 mm) from central catheter to outer ring, and 7.1 to 10.2
mm (avg 8.3 mm) from outer ring to inner ring.
: The new CAPRI applicator has several advantages: 1)
better dose coverage for asymmetric and deep (> 0.5 cm) targets; 2)
better OARs sparing; 3) increased patient comfort and immobilization
due conformity to the vaginal vault. For catheter identification
purposes, it is important for the user to be aware of the differences
between the manufacturer's stated relative positions of the catheters
and individual production CAPRIs. Air in the balloon, when accounted
for with ACUROS, impacts modestly on the dose metrics.
PO354
DOSIMETRIC IMPACTS OF UPGRADING FROM PLATO TO
ONCENTRABRACHY IN A HIGH VOLUME PROSTATE HDR BRACHY
THERAPY CENTER
F. Lacroix 1 , J. Morrier 1 , M.C. Lavallée 1 , S. Aubin 1 , W. Foster 1 , A.G.
Martin 1 , E. Vigneault 1 , N. Varfalvy 1 , L. Beaulieu 1
1 CHUQ, Radiooncologie, Québec, Canada
: To investigate the dosimetric impacts of
upgrading from Plato to OncentraBrachy for HDR prostate planning.
: CHUQ is one of the highest volume prostate
HDR brachytherapy centers in North America today. More than 800
prostate cancer patients have been treated with an HDR
brachytherapy boost at HôtelDieu de Québec (CHUQ) since 1999 and
more than 200 in 2011 only.
Our current procedure involves the insertion of 1617 flexible plastic
needles using ultrasound guidance. Computed tomography imaging is
used for contouring. Planning was performed using Plato (Nucletron,
BV, The Netherlands) until june 1 2011 but is now performed using
OncentraBrachy. Inverse planning simulated annealing optimization is
used for all cases. 81 patients were accrued from January 1 2011 to
June 1 2011 and treated with Plato and 112 patients were treated
from June 15 2011 to November 8 2011 using Oncentra. In this period,
there were no modifications in the implant procedure itself, to the
prescription dose, the contouring methods, or in the personnel
performing the implant. Student’s ttest was performed on relevant
dosimetric indices of the distributions to determine whether the
averages of the distributions were different between the two periods.
An Ftest was also performed to determine whether the standard
deviation of the distributions were significantly different. In addition,
where differences where statistically significant (p

S144 World Congress of Brachytherapy 2012
PO357
DOSIMETRIC IMPLICATIONS TO VAGINAL SURFACE DOSE OF PLANNING
OPTIMIZATION METHODS
A. Damato 1 , K. Townamchai 1 , A. Viswanathan 1
1
DanaFarber Cancer Institute and Brigham and Women's Hospital,
Radiation Oncology, Boston, USA
: Highdoserate vaginal cylinder (VC)
brachytherapy is a widely used technique for the management of
postoperative endometrial cancer. Differences exist in prescription
and optimization methodologies for VC brachytherapy. This is a
dosimetric evaluation of two common VC brachytherapy optimization
techniques.
: Records of 15 postoperative endometrial
cancer patients who recently received adjuvant VC brachytherapy in
our clinic were retrospectively analyzed. For all patients, a dose of 4
Gy per fraction was prescribed to the surface of the VC; 4 to 6
fractions were administered. The CT scan of the first fraction was
used to generate 2 3D plans: 1 with optimization dose points along the
surface of the VC and tapered along the dome (TP), and 1 with dose
points at a fixed distance from the cylinder center (NTP) equal to the
cylinder radius. The dwell times were automatically optimized in the
Oncentra Brachy Planning System so that average dose to the dose
points was equal to 4 Gy. The source step size was 0.5 cm. Organs at
risk (OARs) (i.e., bladder [BD], rectum [R], sigmoid [S] and bowel
[BW]) were contoured when present in the CT scan and the D0.1cc
and D2cc per fraction were calculated. Dose per fraction to the dome
(DD) was calculated at the most superior dose point along the VC
dome for both TP and NTP. Significance was evaluated with a paired
student Ttest; pvalues

S146 World Congress of Brachytherapy 2012
segmentation of the target volume and of organs at risk (OAR).
Cornea, eye lens, sclera, papilla, optic nerve and lacrimal gland were
considered.
: In order to simulate an actual treatment it was assumed that
the plaques in each of the positions were irradiating 4 mm height
tumours. A dose of 700 Gy to the sclera was prescribed. As an
example, the DVHs obtained for the papilla are presented in the
figure. The lines from right to left correspond to CCA in posterior
position, CCB equatorial, CCA equatorial and CCA anterior.
: For the first time it has been possible to simulate an
accurate geometry of an eye plaque inside the voxelised geometry of
a patient. This mixed quadric and voxelised geometry simulation
approach, together with a segmented CT, allows calculating DVHs for
relevant anatomical structures of the eye and the orbit obtaining
unprecedented accurate information on absorbed dose applied to
OARs. This is an important step for further optimization of
brachytherapy of ocular tumours.
PO362
QUALITY ASSURANCE OF TREATMENT PLANS IN HDR/PDR
BRACHYTHERAPY. A METHOD OF VERIFYING CALCULATED TREATMENT
TIMES
A. With 1 , L. Karlsson 1
1 Örebro University Hospital, Medical Physics, Örebro, Sweden
: In brachytherapy there are many different
treatment sites, e.g uterine cervix, head & neck and breast. For each
afterloading technique there are variations in implant size, number of
catheters and type of applicators used, as well as the number of
active dwell positions. With every unique implant the configuration of
catheters varies; singlelayered, multilayered, different separations
etc. Different optimization techniques such as geometrical and
anatomical are available. There are also various ways of
normalization, choice of prescription points and different dose
prescriptions. In a clinical situation, usually with little time between
planning and delivery, estimation of the validity of the total
treatment time given by the planning software can prove difficult.
The aim of this study was to develop a method for quick verification
that the treatment time for an implant dose calculation is reasonable
within ± 15% (2σ).
: Material consisting of data from 395
treatments, both HDR (150 uterine cervix) and PDR (45 lip, 125 base
of tongue & 75 breast) were evaluated. All PDRimplants were
performed with flexible plastic tubes and for the HDR treatments of
the uterine cervix the ring applicator with or without needles was
used. The volume encompassed by the 100% isodose was analyzed
together with the prescribed dose D (Gy), total radiation time T
(seconds) and reference air kerma rate RAKR (mGy m 2 h 1 ) at the time
of treatment. The data was normalized to 1 Gy and a RAKR of 40.7
mGy m 2 h 1 . Parametric fits were applied to each group individually as
well as a common fit for all the data. A nonlinear equation of the
form f(x)=a x b was used in each case. Using the relations TRAK=a Vol b
and TRAK=T RAKR/3600 we end up with the expression T=
3600 a Vol b /RAKR relating treatment time with isodose volume.
: Considering the common fit, approximately 95% (2σ) of the
data points falls within ±11%. For the individual treatment sites, lip,
base of tongue, breast and uterine cervix, the differences between
individual fits and the common fit were negligible. The deviation from
the common fit was ±12%, ±7%, ±14% and ±6% respectively. The R
square values of the fits were 0.99 (all data) and 0.98, 0.99, 0.94,
0.99 individually. The coefficients for the common fit were a=7.82 10
4
and b = 0.634 which yields the final
T=114.5 Vol 0.634 D/RAKR.
: For future HDR/PDR treatments, it is possible to verify
the calculated treatment time within 15% (95% confidence level) using
a parametric fit from earlier treatment data. The expression for the
common fit can be used for all implants.
PO363
BRACHYTHERAPY IN THE HEAD AND NECK REGION USING INDIVIDUAL
APPLICATORS A TECHNICAL NOTE
M. Niewald 1 , S. Richard 1 , N. Licht 1 , M.H. Schneider 2 , K. Bumm 3 , J.
Fleckenstein 1 , C. Ruebe 1
1
Saarland University Hospital, Dept. of Radiotherapy and
Radiooncology, Homburg/Saar, Germany
2
Epithetic Institute, Dept.Zweibrücken, Zweibruecken, Germany
3
Saarland University Hospital, Dept. of Otorhinolaryngology,
Homburg/Saar, Germany
: The dose that can be applied safely especially to
the upper nose or the nasopharynx is often limited due to the
tolerance of critical structures like eye, optic nerve or optic chiasm.
Furthermore, air within the nose or the paranasal sinuses prevents an
exact planning of dose distribution. Thus, we combined 3D or IMRT
percutaneous radiotherapy with brachytherapy using individual
applicators.
: Impressions of the region to be irradiated are
taken by a epithetician, if necessary under general anesthesia.
Silicone applicators are formed from these impressions with the
brachytherapy lines inserted in the predefined position .Usually after
completion of percutaneous radiotherapy the applicators are inserted.
The brachytherapy lines are marked by metal wires, a CT is
performed, after identification of the lines and coutouring of the PTV
the 3Disodose distribution is computed by the physicist (mainly
Masterplan, Nucletron BV, Venendaal, The Netherlands). The tubes
are connected to the radiotherapy device (mainly MicroSelectron,
Nucletron BV, Venendaal, The Netherlands), radiotherapy is applied.
Finally, the applicators are removed.
: 15 patients have been treated using individual applicators.
The target volume consisted of the nasopharyxnx in 7 patients, the
nose in further 5, the remaining patients were treated for tumors of
the orbit (1), the paranasal sinuses (1) and the external ear (1). After
a percutaneous radiotherapy of 5060Gy (single fractions of 2Gy) a
brachytherapy dose of 10 – 20Gy in 2 – 4 daily fractions to the isodose
surrounding the PTV was applied.
The applicators fitted well to the patients´ target regions. The 3D
plan showed that the dose distribution could be easily tailored to the
tumor localization and the patient´s individual anatomy so that a
highquality implant could be achieved in all patients. The vast
majority of the patients coped well with this therapy, the anesthetic
procedures could be performed without problems. The costs for an
applicator amount to € 800 – 1200.
: To our opinion this method is suitable for difficult
brachytherapy applications to the head and neck region and may be
superior to commercially available nasopharynx applicators.
Nevertheless, we have to admit that the method is rather time
consuming and costly.
World Congress of Brachytherapy 2012 S 147
PO364
FIRST EXPERIENCE WITH HIGHDOSE RATE INTERSTITIAL BRACHY
THERAPY IN THE TREATMENT OF PENILE CARCINOMA
J. Petera 1 , I. Sirak 1 , L. Kasaova 1 , P. Paluska 1
1 Charles University Medical School and Teaching Hospital in Hradec
Kralove, Department of Radiotherapy, Hradec Kralove, Czech
Republic
: Interstitial lowdose rate (LDR) brachytherapy
allows a conservative treatment of T1T2 penile carcinoma. Highdose
rate (HDR) brachytherapy is often considered as a dangerous method
for interstitial implants because of higher risk of complications.
However, numerous reports suggest that results of HDR brachytherapy
may be comparable to LDR. We present our first experience with HDR
brachytherapy in the treatment of penile cancer.
: Thirteen patients with early penile carcinoma
were treated by interstitial HDR brachytherapy at the dose of 18
times 3 Gy twice daily between years 2002 and 2011. Breast
interstitial brachytherapy template was used for fixation and precise
geometry reconstruction of stainless hollow needles. Median follow up
was 37 months (4.5 – 115).
: Our brachytherapy technique and fractionation schedule was
well tolerated by all patients. Acute reaction consisted predominantly
of penis edema and grade 2 radiation mucositis which dissolved during
8 weeks after the treatment. We didn’t observe any postradiation
necrosis nor urethral stenosis. The worst late side effects recorded
were mild telenagiectasias in the treatment region. The local control
with brachytherapy was achieved in 12 patients, one patient recurred
9 months after brachytherapy and was salvaged by partial
amputation.
: HDR interstitial brachytherapy with 18 times 3 Gy per
fraction twice daily is a promising method in selected patients of
penile carcinoma and deserves further evaluation in a larger
prospective study.
PO365
PHASE II STUDY: CTGUIDED INTERSTITIAL 60COHDRBRACHYTHERAPY
WITH MRI FUSION FOR BOOST HEAD AND NECK PATIENTS
A. Lozhkov 1 , T.M. Sharabura 1 , A.S. Aladin 2 , A.G. Zhumabaeva 3 , A.V.
Turbina 1 , E.Y. Mozerova 1 , O.N. Davidova 1
1
Chelyabinsk Regional Oncol.Centre, Department for Radiotherapy
and RadioOncology, Chelyabinsk, Russian Federation
2
Chelyabinsk Regional Oncol.Centre, Department of Head and Neck
Surgery, Chelyabinsk, Russian Federation
3
Chelyabinsk Regional Oncol.Centre, Department of Medical Physic,
Chelyabinsk, Russian Federation
: To evaluate the efficacy and safety of CTguided
interstitial 60CoHDRBrachytherapy with MRI fusion for boost head
and neck patient.
: In the period from February to August 2010
ten patients with squamous cell carcinoma of head and neck( I1, II4,
III3, IV2) received external beam irradiation to the primary and the
neck to a total dose of 50 Gy. After 3 4 weeks was carried out
brachytherapy for boost. The brachytherapy dose of 24 Gy delivered
in eight equal fractions BID to the primary site+1 cm. Definition of
GTV was carried out by fusion MRI with contrast done prior to the
start of treatment and the CT with interstitial plastic needles.
Insertion of plastic needles, using rules of the Paris system, but for
planning, using inverse methods.
: Locoregional tumor control at one years was 80%. For the
entire group with one year diseasefree survival of 60%. 2 patients
have recurrence after 6 and 9 months after treatment. Acute
mucositis grade 3 had no place. Two patients underwent preventive
tracheostomy
: The use CTguided interstitial HDRBrachytherapy with
MRI fusion improving the accuracy and safety of radiation treatment
PO366
HIGHDOSERATE INTERSTITIAL BRACHYTHERAPY AS A MONOTHERAPY
FOR ANTERIOR MOBILE TONGUE CANCER
K. Yoshida 1 , T. Takenaka 2 , H. Akiyama 3 , H. Yamazaki 4 , M. Yoshida 5 , M.
Kano 6 , H. Yamamoto 6 , T. Arika 6 , Y. Koretsune 7 , E. Tanaka 5
1
Osaka national Hospital, Radiation Oncology and Institute for Clinical
Research, Osaka, Japan
2
Osaka National Hospital, Radiology, Osaka, Japan
3
Osaka Dental University, Oral Radiology, Osaka, Japan
4
Kyoto Prefectural University of Medicine, Radiology, Kyoto, Japan
5
Osaka National Hospital, Radiation Oncology, Osaka, Japan
6
Osaka National Hospital, Oral Surgery, Osaka, Japan
7
Osaka National Hospital, Institute for Clinical Research, Osaka,
Japan
: We had been used treatment doses of 60 Gy in 10
fractions for highdoserate interstitial Brachytherapy (HDRISBT) as a
monotherapy for anterior mobile tongue cancer previously. However,
to reduce the treatment duration, we started to use the treatment
doses of 54 Gy in 9 fractions in 2001. In this study, we investigated
the feasibility of this dosefractionation schedule.
: During eight years (20012009), eighteen
N0M0 anterior mobile tongue cancer patients were enrolled at
National Hospital Organization Osaka National Hospital. The median
age of the patients was 61 years (range; 3484 years) and median
followup time was 61 months (range; 21116 months). Using the UICC
classification 2002, 3 patients were classified as T1, 11 patients as T2
and 4 patients as T3. We implanted treatment applicators with the
assistance lugol’s iodine staining and metal marker implantation for
superficial lesion and intraoral ultrasonography for deep lesion.
Treatment plans were optimized using metal marker and computed
tomography as needed, and total treatment doses were 54 Gy in 9
fraction.
: The 2 and 5year local control rates were both 82%,
respectively. The 2year local control rates were 100%, 72% and 100%
for T1, T2 and T3. Technical error was suspected as a cause of local
recurrence for two of three patients. One was inadequate shielding by
leadblock and the other was tongue edema during implantation. The
2 and 5year causespecific survival rates were 83% and 74%. The 2
year causespecific survival rates were 67%, 90% and 75% for T1, T2
and T3. Acute severe complication was aspiration of sputum that was

S148 World Congress of Brachytherapy 2012
necessary to be managed by respirator transiently for one patient.
Five patients (28%) showed soft tissue necrosis or mandible
complication as moderate to severe late severe complication. One of
5 patients received partial sequestrectomy and the other symptoms
were improved by drug and/or hyperbaric oxygen.
: Our treatment result of HDRISBT as a monotherapy of
54 Gy in 9 fractions for anterior mobile tongue cancer is feasible.
Technical improvement should be investigated to prevent local
recurrence by technical error.
PO367
THE DIFFERENT BIOLOGICAL EFFECTS OF SINGLE, FRACTIONED AND
CLDR IRRADIATION IN CL187 COLORECTAL CANCER CELLS
H. Wang 1 , J. Wang 1
1 Peking University Third Hospital, Cancer Center, Beijing, China
: To identify the different effectiveness of single,
fractioned and continuous low dose rate irradiation on the human
colorectal cancer cell line CL187 in vitro and explore the relevant
molecular mechanisms.
: The CL187 cells were exposed to radiation of
6 MV Xray at high dose rate of 4Gy/min and 125 I seed at low dose rate
of 2.77 cGy/h. There were three groups: single dose radiation group
(SDR), fractioned dose radiation group (FDR) by 2Gy/f and continuous
low dose rate radiation group (CLDR). The radiation doses were 0, 2, 4
and 8Gy, respectively. Radiation responses to radiation of tumor cells
were evaluated by colonyforming assay. Cell cycle arrests were
detected by flow cytometry after propidium iodide (PI) staining.
Apoptosis was detected by Annexin and PI staining. The expressions of
DNAPKcs, Ku70 and Ku80 were determined by Western blotting.
: The relative biological effect (RBE) for 125 I seeds compared
with 6 MV Xray was 1.41. At 48h after 0, 2, 4 and 8 Gy irradiation,
the percentage of G2/M phase of CLDR group were 4.92±0.02%,
13.67±1.67%, 16.41±2.19% and 23.81±1.61%, respectively. Irradiated
by 4Gy, the percentage of the G2/M phase cell cycle arrest of CLDR
group increased significantly(CLDR vs. SDR, t=6.03, p=0.026; CLDR vs.
FDR, t=13.98, p=0.005). After 0, 2, 4 and 8 Gy irradiation, early
apoptosis rates of CLDR group at 48h were 1.28±0.25%, 1.87±0.06%,
6.54±0.88% and 7.62±0.39%, respectively. The percentage of early
apoptosis of 4Gy in CLDR group increased significantly(CLDR vs. SDR,
t=31.22, p=0.001; CLDR vs. FDR, t=7.01, p=0.02). At 48h after 0, 2, 4
and 8 Gy irradiation, late apoptosis rates of CLDR group were
1.19±0.05%, 7.86±0.08%, 9.72±0.85% and 5.76±0.63%, respectively.
The percentage of late apoptosis of 4Gy in CLDR group increased
significantly(CLDR vs. SDR, t=15.08, p=0.004; CLDR vs. FDR, t=11.99,
p=0.007). DNAPKcs and Ku70 expression level of CLDR group
decreased compared with SDR and FDR groups.
: 125 I seeds continuous low dose rate irradiation showed
more effective inhibition than that of 6 MV Xray high dose rate
irradiation on CL187 cells. Apoptosis and G2/M phase cell cycle arrest
were the main mechanism of cellkilling effects under low dose rate
irradiation. 125 I seeds continuous low dose rate irradiation could
influence the DNA repair of cells via DNAPKcs and Ku70 pathways.
PO368
ULTRASOUNDGUIDED PERCUTANEOUS IODINE125 SEED IMPLANTATION
FOR TREATING LIVER MALIGNANCIES
S.Q. Ttian 1 , J.J. Wang 1 , Y.L. Jiang 1 , W.J. Jiang 1 , P. Jiang 1 , W.Q. Ran 1 ,
N. Meng 1
1
Peking University Third Hospital, Department of Radiation Oncology
Cancer Center, Beijing, China
: To investigate the therapeutic efficacy of
ultrasoundguided 125 I seed implantation for treatment of liver cancer.
: A total of 18 patients (84 male, 13 female;
mean age 53.4 years, range 24–74 years) with liver cancer were
included in this study. The diagnosis of each case was verified by CT,
MRI and biopsy. A median number of 28 125 I seeds (rang, 856) per
patient were implanted into liver cancer by ultrasoundguided needle
puncture. The specific activity of 125 I ranged from 0.60 to 0.80 mCi per
seed and the median D90 was 120 Gy (rang, 90140 Gy). Patients were
followedup by examination and by contrastenhanced computed
tomography (CT) to evaluate treatment responses. Survival was
analyzed using the Kaplan–Meier method.
: During a median followup period was 24 months (range: 4–
37months), the response rate of tumor was 83.0%. Overall median
control time was 11.0 months (95% CI, 8.4–14.3). The local control
rate was 59.9% at 1 year and 20.5% at 2 years. The overall median
survival was 15 months (95% CI, 9.6–20.3), while the overall 1, 2 year
survival rates were 61.9%, 27.1%, respectively. No serious
complications were observed postoperatively and during the followup
period
125
: Ultrasoundguided brachytherapy using I seed
implantation was a safe and effective therapeutic technique for
treating liver cancer.
PO369
COMPARISON OF 60 GY AND 54 GY IN HIGHDOSERATE INTERSTITIAL
BRACHYTHERAPY FOR EARLY ORAL TONGUE CANCER
H. Akiyama 1 , K. Yoshida 2 , K. Shimizutani 1 , H. Yamazaki 3 , M. Koizumi 4 ,
Y. Yoshioka 4 , N. Kakimoto 5 , S. Murakami 5 , S. Furukawa 5 , K. Ogawa 4
1
Osaka Dental University, Department of Oral Radiology, Osaka,
Japan
2
National Hospital Organization Osaka National Hospital, Department
of Radiation Oncology, Osaka, Japan
3
Graduate School of Medical Science Kyoto Prefectural University of
Medicine, Department of Radiology, Kyoto, Japan
4
Osaka University Graduate School of Medicine, Department of
Radiation Oncology, Osaka, Japan
5
Osaka University Graduate School of Densitry, Department of
MaxilloFacial Radiology, Osaka, Japan
: To compare the results between total dose 60
Gy/ 10 fractions (bid) and 54 Gy/ 9 fractions of Highdoserate
interstitial brachytherapy (HDRISBT) for early oral tongue cancer.
: We made a matchedpair analysis of early
oral tongue cancer (T12N0M0) patient treated by 60 Gy and 54Gy
between 1996 and 2004 at Osaka University Hospital. 17 patients
treated by 54Gy and 34 matched pair control arm treated by 60Gy
were extracted and analyzed.
: Local recurrence occurred in two patients treated with 54 Gy
arm and five in 60 Gy arm. Two and 5year local control rates were
both 88% for 54 Gy arm and 88% and 84% for 60Gy arm (n.s.). Nodal
metastases occurred in 13 and 9 patients for 60 Gy and 54 Gy arms
Fiveyear overall survival rates of 60 Gy and 54 Gy arm were 84% and
66%, respectively. One and 2year actuarial complication free rates in
the 60 Gy arm were 97 and 91%, respectively, and those in the 54 Gy
arm was both 83% (n.s.). There were no significant associations
between the total dose and local control rate and late complications.
: A dose of 54 Gy in 9 fractions showed compatible
outcome to 60 Gy/ 10 fractions for early oral tongue cancer.
PO370
PERCUTANEOUS ULTRASOUNDGUIDED IODINE125 IMPLANTATION AS A
SALVAGE THERAPY FOR RECURRENT LYMPH NODE METASTASES
J.J. Wang 1 , L.E.I. Lin 1 , Y. Jiang 1 , N.A. Meng 1 , W. Ran 1 , S. Tian 1 , R.
Yang 1 , Y.A.N. Yu 2
1
Peking University Third Hospital, Department of Radiation Oncology,
Beijing, China
2
Thomas Jefferson University, Department of Radiation Oncology,
Beijing, USA
: Esophageal cancer is generally associated with a
poor prognosis, particularly in the recurrent cervical lymph node
metastases after radial therapy. This study aimed to assess the
efficacy and feasibility of percutaneous 125 I seed implantation for the
management of recurrent lymph node metastases in esophageal
carcinoma.
: 27 lesions in 16 patients with cervical lymph
node metastases who had undergone ultrasoundguided 125 I seed
implantation were reviewed. The local control and survival rates were
evaluated by the KaplanMeier method
: Prior to seed implantation, all patients had undergone
surgery, EBRT with/without chemotherapy: one patient had previously
undergone cervical lymph nodes dissection and EBRT twice; two
patients had undergone surgery once; 13 patients had received EBRT
(9 patients received EBRT once, 4 received EBRT twice). The total
cumulative doses of EBRT were 47143 Gy, with a median of 64 Gy.
World Congress of Brachytherapy 2012 S 149
Four patients had received 13 cycles of chemotherapy, with a median
of 1 cycle. The activity of 125 I seeds implanted ranged from 0.5 mCi to
0.8 mCi (median: 0.69 mCi). The total number of seeds implanted
ranged from 9 to 84 (median: 27). The actuarial D90 ranged from 142
Gy to 218 Gy (median: 218 Gy). The median time of local diseasefree
progression was 7 months (95% CI, 3.3 – 10.7), and the 1 and 2year
local control rates were 20.1% and 13.4%, respectively. The 1 and 2
year survival rates were 20.6% and 13.8%, respectively (median: 7
months; 95% CI, 3.3 – 10.7). In the patients with two or more lymph
nodes metastases, seven of the nine (78%) patients survived no more
than 10 months. Four of seven (57%) patients who had single lymph
node metastases lived longer than 10 months. Of the 16 original
patients, one was still alive at the time of data analysis. The other
patients had died from cancerrelated cachexia (n = 8, 50%),
pneumonia (n = 3), the primary tumor (n = 3), and heart disease (n =
1). One patient experienced a grade I skin reaction. Treatment
related blood vessel damage and neuropathy were not observed.
: In esophageal carcinoma patients with recurrent cervical
lymph node metastases after radical therapy, treatment with
permanent percutaneous 125 I seed implant is an alternative salvage
treatment, which appears to be effective and welltolerated.
PO371
IMAGEGUIDED IODINE125 PERMANENT IMPLANTATION AS SALVAGE
THERAPY FOR RECURRENT HEAD AND NECK CARCINOMA
J. Wang 1 , L. Zhu 1 , Y. Jiang 1 , N.A. Meng 1 , W. Ran 1 , H. Yuan 1 , C.H.E.N.
Liu 1 , A.N.G. Qu 1 , R. Yang 1
1
Peking University Third Hospital, Department of Radiation Oncology,
Beijing, China
: To preliminarily assess the feasibility, efficacy,
and morbidity of 125 I seed implantation under imageguidance for
recurrent head and neck carcinoma after both surgery and external
beam radiotherapy.
: Nineteen patients with recurrent head and
neck carcinomas underwent 125 I seed implantation under ultrasound or
ComputedTomography (CT) guidance. The actuarial D90 of 125 I seed
implantation ranged from 90 to 160 Gy (median, 131 Gy). The follow
up ranged from 3 to 44 months (median, 11 months).
: The median local control was 24 months (95%CI, 10.2–37.8).
The 1 year 2 year and 3 year local controls were 73.3%, 27.5% and
27.5%, respectively, whereas the 1 year, 2 year and 3 year
survival rates were 53.0%, 18.2% and 18.2%, respectively, and the
median survival was 13 months (95% CI, 6.6–19.4). 26.3% of patients
(5/19) died of local recurrence and 21.1% of patients (4/19) died of
metastases. No bone, soft tissue necrosis and carotid artery damages
were noted.
: 125 I seed implantation is feasible and safe as a salvage
treatment for patients with recurrent head and neck cancers. The
high local control results and low morbidity merits further
investigation.
PO372
EVALUATION OF BIODEGRADABLE MAGNESIUM ALLOY AZ31 AS A NEW
CONNECTING MATERIAL FOR IODINE125 BRACHYTHERAPY
Z. Fu Jun 1
1
Sun Yatsen University Cancer Center, Department of Imaging and
Interventional Radiology, Guangzhou, China
: To evaluate the in vivo degradation
characteristics and tissue compatibility of new I 125 seed chains
connected with the biodegradable magnesium alloy AZ31 in New
Zealand rabbits.
: Thirty New Zealand rabbits were randomly
divided into three groups. In group A, magnesium alloy radioactive I 125
seed chains were implanted into VX2 tumors; in group B, magnesium
alloy nonradioactive I 125 seed chains were implanted into normal
muscle; group C served as an untreated control group. The mass loss
of the AZ31 magnesium alloy connecting material was measured in the
two groups at different time points after implantation of the I 125 seed
chains. Morphological and histological changes at the implantation
site and in organs were monitored using light microscopy, and seed
displacement was assessed using regular Xray and computed
tomography (CT) scanning. Blood and urine samples were collected
from all experimental animals to measure changes in magnesium ion
concentrations.
: The new I 125 seed chains made with AZ31 magnesium alloy
began to degrade during the first week after implantation. On day 21,
the degradation rate was 81% in muscle tissue and 83% in tumor
tissue; these degradation rates are not statistically significant. Shortly
after implantation, a mild local inflammatory response and gas
production were induced; the gas disappeared 21 days after
implantation. Blood magnesium ion concentrations after implantation
were relatively stable, but urine magnesium concentrations increased
and fluctuated over a larger range. Pathological inspection of the
liver, kidney, heart, and spleen of all animals implanted with I 125 seed
chains revealed no significant abnormalities. At 7 days after the
implantation of magnesium alloy radioactive I 125 seed chains into
tumors, the connecting material showed good connecting and fixing
function. At 21 days after implantation, the seeds had separated from
each other, displacement had occurred, and the radioactive seeds had
aggregated in concordance with tumor shrinkage.
: Iodine125 seed implants connected with AZ31
magnesium alloy have rapid degradation characteristics and good
biocompatibility when implanted into rabbits,the results suggest that
magnesium alloy AZ31 might be a potential and attractive connecting
material for permanently iodine125 brachytherapy.
PO373
HDR BRACHYTHERAPY BOOST FOR LOCALLY ADVANCED RECTAL
CARCINOMA FOLLOWING EBCRTCLATTERBRIDGE EXPERIENCE
A. Sun Myint 1 , A. Montazeri 1 , F. Jelly 1 , M. Snee 1 , H. Wong 1
1
Clatterbridge Centre for Oncology, Clinical Oncology, Bebington
Merseyside, United Kingdom
: Preop chemoradiotherapy is now standard of
care for the locally advanced rectal carcinomas with threatened CRM.
Clear resection margin is not always possible and advanced surgical
techniques have to be used with increase morbidity and mortality. We
present our experience on patients treated at brachytherapy unit in
Clatterbridge.
: From Jan 2003Dec 2010, patients with
locally advanced low rectal cancer were treated with preoperative
chemoradiotherapy (CRT) using 45Gy /25#/5 weeks with oral
capecitabine (MonFri) during RT. A total of 53 patients of whom 42
(79.2%) were males. Median age was 65 years (range3983). Preop
MRI staging was mandatory. Stages were T3 = 43 (81.1%), T4= 6
(11.3%) others 4 (7.5%) . HDR rectal brachytherapy was carried out
within 24 weeks after completion of CRT using OncoSmart multi
channel applicator delivering 10Gy at 10mm from the surface of the
applicator. Restaging MRI scan was carried out at 4 weeks (8wks from
CRT). Surgery was carried out 46 weeks later.
: Only patients proceeded to surgery were analysed. Median
follow up was 18 months (range 0.0370). Type of surgery were APR
35(66%), and AR 17(32.1%). Only one patient had palliative resection.
Complete resection (R0) was achieved in 45(84.9%), R1 in 8 pts
(15.1%). Significant down staging occurred in 19 pts (35.8%) out of
which 12 (22.6%) has no residual tumour. Thirty three patients with
either N1 19(35.8%) or N2 14 (26.4%) were down staged to no residual
tumour (N0) in the lymph nodes. There was only one patient initially
staged N0 has evidence of disease (N1). No significant increased in
surgical morbidity was encountered (detailed surgical paper to
follow).
: HDR brachytherapy can be offered to locally advance
rectal cancer following preop CRT. This could down staged the
tumour further and improve R0 resection rate which reduces the
chance of relapse at a later date. Those patients who achieved down
staging can be identified with MRI restaging scans. After MDT
discussion, major surgery can be avoided in those patients suitable for
watch policy to reduce morbidity and mortality especially in elderly
and those with increased surgical risk.

S150 World Congress of Brachytherapy 2012
PO374
PROSPECTIVE DOSEESCALADE STUDY OF ADJUVANT HIGHDOSERATE
BRACHYTHERAPY FOR SOFT TISSUE SARCOMAS
G. Kacso 1 , L. Florea 2 , D. Eniu 3
1
Institute of Oncology Prof. Dr. I. Chiricuta, Brachytherapy, Cluj
Napoca, Romania
2
Institute of Oncology Prof. Dr. I. Chiricuta, Medical Oncology, Cluj
Napoca, Romania
3
Institute of Oncology Prof. Dr. I. Chiricuta, Surgery, Cluj Napoca,
Romania
: Prospective nonrandomized doseescalade study
of adjuvant highdoserate brachytherapy (HDR BT) for completely
resected high grade soft tissues sarcomas of extremities or superficial
trunk (STRESs)
: From November 2004 to February 2008, 15
patients with nonmetastatic pT12R0 G23 STRESs consented to
participate and were given adjuvant Iridium 192 HDRBT on 3 dose
levels: 12 fractions of 3 Gy, bid (regimen A), 14 fractions of 3 Gy, bid
(B) and 12 fractions of 3.5Gy, bid (C). Prior stratification according to
the topography (upper vs. lower limb vs. trunk) and to the size (< 5cm
vs. 510 cm vs. >10 cm) ensured equal distribution between dose
subgroups. Single plan equidistant catheters (stainless needles or
plastic tubes depending on the anatomy) were implanted per
operatively, with BT starting no sooner than the fifth day after the Ro
resection. The dose was prescribed at 1 cm from the cathethers axis.
Nine patients (60%) received also adjuvant chemotherapy. BT toxicity
was assessed on the CTC3.0 scale, whereas efficacy by local control or
histological proven local recurrence.
: The local treatment (surgery + BT) was delivered between 11
and 20 days (mean 14.5 days). With a median followup of 46 months
(13 to 84 months), the local failure was 40% (2 patients) vs. 20 % (1
patient) vs. none in C vs. B vs. A subgroup. One single acute wound
dehiscence and one other severe late toxicity (subcutaneous fibrosis)
was noticed in the 14frx 3Gy group and in the 3.5Gy/fr dose level,
respectively. The ≤ G2 late toxicity (skin, neurologic and/or functional
impairment) was recorded more frequently in the high dose arms (B &
C).
: For this STRESs group of patients, there seems no
benefit of dose escalade with adjuvant HDR BT from 3 Gy to 3.5 Gy/fr
or from 12 fr to 14 fr bid. In our study, the 12fr x 3 Gy bid regimen
offers the best therapeutic index, with 100% local control and no
severe toxicity at almost 4 years median followup. The short overall
treatment time favours BT as compared to external beam
radiotherapy.
PO375
THE CLINICAL VALUE AND SAFETY OF TRANSSUPERIOR VENA CAVA
BRACHYTHERAPY FOR METASTATIC MEDIASTINAL LYMPH NODES
Y. Li 1 , B. Liu 1 , Y. Wang 1 , W. Wang 1 , Z. Li 1 , X. Song 1
1
Second Hospital of Shandong University, Interventional therapy,
Jinan, China
: To investigate the clinical value and safety of
trans superior vena cava brachytherapy in treating metastatic lymph
nodes of mediastinum under CTguidance.
: From November 2009 to January 2011, 15
patients with 27 metastatic mediastinal lymph nodes received 125 I
brachytherapy.The diameter of these lymph nodes ranged from 1.0 to
4.0cm. The diameter of these metastatic lymph nodes ranged from
1.0 to 4.0cm; 15(55.56%) of them with diameter ofT>0.01 day.
BEDVHs were generated for all ROIs using these T values and
correspondingly reduced prescription doses. Objective functions were
created to evaluate the BEDVHs as a function of both implant duration
vs. T=7 and radionuclide selection vs. R= 125 I.
: Reducing T from 7 to 0.01 day for a 10 mm plaque produced
a BED benefit of 26%, 20%, and 17% for 103 Pd, 125 I, and 131 Cs,
respectively, across all treatment positions considered. Results were
somewhat positiondependent for the larger plaques. For all positions,
T, and plaque sizes, we calculated a 16%35% BED benefit for 103 Pd vs.
125 131 125
I and a 3%7% BED detriment for Cs vs. I. Additionally, the
corresponding OAR physical doses were lowest for 103 Pd under all
circumstances.
: Shorter implant durations may correlate with more
favorable outcomes compared to 7 day implants when treating small
or medium intraocular lesions. Results also indicate that implant
duration may be safely reduced if the prescription physical dose is
103
appropriately diminished, and that Pd offers a substantial
radiobiological benefit over 125 I and 131 Cs irrespective of plaque
position, implant duration, and tumor size.
PO379
ENDOLUMINAL HIGH DOSE RATE BRACHYTHERAPY FOR EARLY STAGE
AND RECURRENT ESOPHAGEAL CANCER
M.R. Folkert 1 , G.N. Cohen 2 , A.J. Wu 1 , H. Gerdes 3 , M.A. Schattner 3 , E.
Ludwig 3 , D.H. Ilson 4 , K.A. Goodman 1
1
Memorial SloanKettering Cancer Center, Radiation Oncology, New
York NY, USA
2
Memorial SloanKettering Cancer Center, Medical Physics, New York
NY, USA
3
Memorial SloanKettering Cancer Center, Gastroenterology, New
York NY, USA
4
Memorial SloanKettering Cancer Center, Medical Oncology, New
York NY, USA
: The management of locally recurrent esophageal
cancer (EC) after definitive chemoradiotherapy or early stage EC in
patients who are poor surgical candidates is complex. Endoluminal
highdoserate (HDR) brachytherapy utilizing a wide range of
techniques and dosing regimens has been used with mixed results in
terms of toxicity and local control. In this study we examine the
outcomes and toxicities in early stage and locally recurrent EC
patients treated with a consistent HDR technique.
: Between 8/2008 and 7/2011, 14 patients with
EC were treated with HDR intraluminal brachytherapy, 10 (71.4%) with
recurrent disease after chemoradiotherapy and 4 (28.6%) with
previously unirradiated lesions. 12 (85.7%) patients had
adenocarcinoma and 2 (14.3%) had squamous cell carcinoma. Of the
previously treated patients, median dose of prior radiotherapy was
5040 cGy (range 45005600 cGy). HDR treatments were performed
under general anesthesia in conjunction with a gastroenterologist. At
the time of the procedure, tumor extent was defined endoscopically
and radioopaque markers were placed on the skin surface to
demarcate the proximal and distal tumor and facilitate catheter
positioning. Treatments were delivered in 3 fractions over 3 weeks to
a median dose of 1200 cGy (range 10001500 cGy); dose was
prescribed to a median depth of 7mm (range 410mm) with mucosal
surface dose limited to 8001000 cGy. 6 (42.9%) patients also received
concurrent chemotherapy (capecitabine, 1000 mg BID) during the 3
week course of brachytherapy. Patients were followed with serial
imaging and esophagoscopy every 23 months.
: Overall median followup was 9.7 months; 1 year local
progressionfree (PFS) and overall survival (OS) were 48.8% (95% CI:
22.375.9%) and 88.9% (95% CI: 58.298.8%) respectively. For patients
with recurrent disease, median followup was 6.7 months; 1 year PFS
and OS were 32.4% (95% CI: 8.668.3%) and 80% (95% CI: 42.296.9%)
respectively. For patients with previously unirradiated disease,
median followup was 21.9 months; 1 year PFS and OS were 75.0% (95%
CI: 21.998.7%) and 100.0% (95% CI: 39.6100.0%) respectively. 1
patient (7.1%) with recurrent squamous cell carcinoma developed
distant metastases 8.5 months after treatment. 8 of 14 (57.1%)
patients had Grade 1 acute adverse effects; 6 of 14 (42.9%) patients
had chronic Grade 1 adverse effects; 2 of 14 (14.3%) patients
developed Grade 1 strictures noted on endoscopy (both with recurrent
disease). There were no Grade 2 or higher complications.
: HDR brachytherapy with or without concurrent
chemotherapy is a safe and welltolerated treatment for both early
stage, previously untreated and recurrent EC. Given the high rate of
local recurrence and minimal toxicity in these patients, we are
planning a prospective dose escalation trial for recurrent EC to
determine the optimal brachytherapy regimen.
PO380
THE “CLAWS” : A GOLD APPLICATOR LOADED WITH I125 SEEDS FOR
LOCALIZED WHOLE EYE RADIOTHERAPY
C.J. Trauernicht 1 , G.J. Maree 1 , E.R. Hering 1 , F.C.P. Du Plessis 2 , C.
Stannard 3 , K. Lecuona 4 , R. Munro 1 , S. Tovey 1
1
Groote Schuur Hospital, Medical Physics, Cape Town, South Africa
2
University of the Free State, Medical Physics, Bloemfontein, South
Africa
3
Groote Schuur Hospital, Radiation Oncology, Cape Town, South
Africa
4
Groote Schuur Hospital, Ophthalmology, Cape Town, South Africa
: This applicator (Fig. 1) is a specially designed
gold applicator which is loaded with I125 seeds. The applicator is
used to mainly treat children with retinoblastoma, who require whole
eye radiotherapy.
: Under general anaesthesia, a pericorneal ring
is attached to the 4 extraocular muscles, and 4 appendages, each
loaded with I125 seeds, are inserted beneath the conjunctiva in
between each pair of muscles and attached anteriorly to the ring. The
applicator has an inside diameter of 22 mm.

S152 World Congress of Brachytherapy 2012
Fig 1: The 'Claws'
: The applicator irradiates the eye with minimal dose to the
surrounding bony orbit, extraocular optic nerve, eyelids and lacrimal
gland. Certain seeds may be omitted to reduce the dose to the
unaffected parts of the eye. A typical treatment prescription is 40 Gy
given over 4 days to the centre of the eye. General anaesthesia is also
required for the removal of the applicator.
55 eyes in 49 patients were treated from 1987 – 2006. According to
the Intraocular Group Classification of Stage 0 cancers, there were 9
group B, 4 group C, 38 group D and 4 group E patients. 19 patients
were treated with ≤ 34 Gy, 36 received ≥ 35 Gy. The median followup
was 33 months, the range 2 – 205 months. Tumour control was
achieved in 35 out of 55 patients (64 %) (groups B / C: 85 %; group D:
58 %), the eye survived in 26 out of 55 patients (47 %) (groups B / C:
85 %, group D: 39 %) and vision was retained in 23 out of 55 patients
(42 %) (groups C / D: 85 %; group D: 32 %).
: There is good local control for groups B and C. Local
control in group D is improved with chemotherapy. Cosmesis is
excellent.
The applicators are costeffective because they can be reused, and
the I125 seeds are regularly used for other eye plaques and implants.
A current project is underway to do the dose calculations using Monte
Carlo simulations.
PO381
PREDICTIVE MODEL OF COMPLICATIONS AFTER PERIOPERATIVE HIGH
DOSE RATE BRACHYTHERAPY
I. San Miguel 1 , M. RodriguezRuiz 2 , A. Olarte 2 , M. Cambeiro 2 , J.
Aristu 2 , J. GarcíaFoncillas 1 , M. San Julián 3 , J. Alcalde 4 , M. Jurado 5 , R.
MartinezMonge 2
1
Clinica Universitaria de Navarra, Medical Oncology, Pamplona, Spain
2
Clinica Universitaria de Navarra, Radiation Oncology, Pamplona,
Spain
3
Clinica Universitaria de Navarra, Orthopedic Surgery, Pamplona,
Spain
4
Clinica Universitaria de Navarra, Otolaryngology, Pamplona, Spain
5
Clinica Universitaria de Navarra, Gynaecology, Pamplona, Spain
: To discover which patient, tumor, and treatment
factors determine toxicity after perioperative high doserate
brachytherapy (PHDRB).
: Patients (n=329) enrolled in several PHDRB
prospective Phase III studies conducted at the Clínica Universidad de
Navarra were analyzed. Two hundred and twelve patients received
one course of primary PHDRB +/ EBRT, and 117 patients received
PHDRB after one or several EBRT or brachytherapy courses.
: The median followup was 2.3 years (range, 0.1 – 10.2). The
highest toxic event observed was grade ≥ 3 in 105 cases (31.9%), grade
≥ 4 in 54 cases (16.4%), and grade 5 in 12 cases (3.6%). The first grade
≥ 3 and ≥ 4 events occurred at a median time of 3.8 months and 3.0
months after surgery, respectively. Multivariate analysis showed that
Grade ≥ 3 complications increased with TV150 ≥ 13 cc (p=0.004),
lifetime Eq2Gy ≥ 80Gy (p=0.013), and time to loading ≥ 5 days
(p=0.034). Grade ≥ 4 complications also increased with TV150 ≥ 13 cc
(p=0.035), lifetime Eq2Gy ≥ 95Gy (p=0.001), and time to loading ≥ 5
days (p=0.041). The combination of the three variables increased the
predictive ability of the model for grade ≥3 complications (AUC =
0.619; p=0.0001) and grade ≥4 complications (AUC = 0.663; p=0.0001).
: Grade ≥ 3 and grade ≥ 4 complications observed after
surgery + PHDRB are multifactorial in origin and are mainly dependent
upon treatment factors (TV150, lifetime Eq2Gy and time to loading).
PO382
DOSIMETRIC COMPARISON OF 131CS VERSUS 125I INTRAOPERATIVE
BRACHYTHERAPY FOR THE TREATMENT RESECTED BRAIN TUMORS
A.G. Wernicke 1 , T.H. Schwartz 2 , P. Stieg 2 , J.A. Boockvar 2 , S.
Pannullo 2 , L. Nedialkova 1 , A.M. Sabbas 1 , B. Parashar 1 , D. Nori 1 , K.S.C.
Chao 1
1
Weill Cornell Medical Center of Cornell University, Radiation
Oncology, New York, USA
2
Weill Cornell Medical Center of Cornell University, Neurosurgery,
New York NY, USA
: A prospective ongoing trial assesses feasibility of
131
Csbased intraoperative brachytherapy in patients undergoing
maximally safe neurosurgical resection of brain tumors. Intra
125
operative I brachytherapy was previously established in
neurosurgically resected brain tumors with up to 26% radiation
necrosis (UCSF) until 131 Cs emerged as a novel radioisotope with more
favorable physical and radiobiological characteristics. In this analysis,
we created 2 plans for each patient so as to compare dosimetric
profiles of 125 I and 131 Cs.
: After obtaining an IRB approval, a total of 17
patients were prospectively accrued to an ongoing trial and treated
with 131 Csbased brachytherapy (10 with newly diagnosed solitary
brain metastases and 7 with recurrent high grade tumors) between
September 2010 and September 2011. Median age at diagnosis was 55
years (range, 4784 years). A dose of 80 Gy was prescribed to the
tumor surface, using median activity of 131 Cs 2.87 U (range, 2.11
3.08 U). The patients were treated with 131 Cs. A separate plan was
created for each patient where a dose of 120Gy was prescribed to the
tumor surface, with activity of 125 I implants 0.70 U (0.55 mCi) based
on experience from UCSF. V100 represents the volume delineated by
the seeds which is the CTV. A dose distribution to the healthy brain
tissue was determined as the median difference of volumes (V) at 3
levels of isodose lines in all patients: 80100%, 50100%, and 30100%.
A statistical analysis employed ttest to perform comparisons of the
dosimetric profiles of the two isotopes.
: The median implanted tumor cavity volume was 8.98 cc
(range, 1.75 76.63 cc). The median number of seeds placed into the
neurosurgical cavity was 12 (range, 550). For 131 Cs implants compared
to 125 I implant, median V80% was 11.93cc vs. 16.89cc (p=0.002);
median V50% was 21.56 cc vs. 29.11 cc (p=0.004); median V30% was
40.69cc vs. 52.11cc (p=0.01). The corresponding delta volumes were
median V80100%: 3.13cc vs. 3.85cc (p=0.009); median V50100%:
12.84cc vs. 16.07cc (p=0.03); median V30100%: 32.69cc vs. 39.08cc
(p=0.06).
: 131 Csbased intraoperative brachytherapy can be used to
achieve a more compact dose distribution than the previously
established 125 Ibased approach, thus potentially predisposing less
normal tissue to toxicity such as radiation necrosis. A prospective
clinical study is in progress to assess local control, toxicity and
survival outcomes using this treatment modality in patients with
neurosurgically resected brain tumors.
World Congress of Brachytherapy 2012 S 153
PO383
CESIUM131 BRACHYTHERAPY FOR HEAD AND NECK CANCERS: FIRST
REPORT OF OUTCOMES, TOXICITY AND RADIATION EXPOSURE
B. Parashar 1 , S. Arora 1 , A. Pavese 2 , D. Kutler 3 , W. Kuhel 3 , S. Trichter 1 ,
A.G. Wernicke 1 , D. Nori 1 , K.S.C. Chao 1
1
New York Hospital/Cornell Med.Cente, Radiation Oncology, New
York, USA
2
New York Hospital/Cornell Med.Cente, Health Physics, New York,
USA
3
New York Hospital/Cornell Med.Cente, Otorhinolaryngology, New
York, USA
: Cesium131 is an encapsulated radioactive
isotope that is approved for head and neck cancer (HNC)
brachytherapy. It has a shorter halflife (9.7 days) but similar energy
to Iodine125 (I125). Recurrent HNC are common and pose a
significant therapeutic challenge. This report evaluates the outcomes,
toxicity and radiation exposure in patients with high risk and
recurrent HN cancers treated with surgery followed by Cs131
brachytherapy.
: Eighteen Cs131 implants were performed in
14 patients from 20092011. There were 6 males and 8 females. Most
common histology was squamous cell carcinoma. Other histologies
were merkel cell carcinoma, carcinosarcoma and osteosarcoma.
Twelve patients had previously received a full course of radiation
therapy. Of the patients without prior RT, one received a neck
implant after surgery for tonsil primary since he refused external
radiation. Another patient with Merkel cell skin cancer received a
neck implant after nodal disease progression during adjuvant
radiation. After surgical resection, Cs131 seeds were placed 0.51cm
apart on the tumor bed to deliver 80Gy at 0.5 cm (based on Cs131
nomogram). Lead shields and gowns were used by radiation
oncologists and surgeons. Dosimetric CT scan was performed within a
week of the implant. Patients were followed by clinical exam and
imaging. Local control was defined as no clinical/radiological
evidence of recurrence in the area of implant. In keeping with Nuclear
Regulatory Commission (NRC) guidelines, exposure rate at 1 meter (m)
was measured following the procedure using a Keithley survey counter
(ion chamber).
: Median age was 71y (range 2288y). Primary tumors that
were included were those of oral cavity, oropharynx, paranasal sinus
and skin with neck nodes. Seventeen of eighteen implants were
performed in recurrent tumor after surgical resection. Median number
of seeds were 21 (Range 1058). Median seed activity was 2.4 Gy
m 2 /h (range 0.952.5). Median followup was 10 months (range 224
months). Local control was 77.7% (14/18 implants). Four patients
(28.5%) developed distant metastasis. Four patients have died at the
time of last followup due to distant metastasis. There was no RTOG
grade 3 or 4 toxicity related to the implants. The median RT exposure
rate at 1 meter postimplant was 2.3mrem/hr postimplant
(recommended limits to radiation exposure to professionals5000
mrem/y for stochastic effects, 15000 mrem/yr for lens of the eye and
and 50,000mrem/yr for all others).
: Cs131 LDR brachytherapy is a safe and effective option
for high risk Head and neck cancers. It produces high control rates,
limited toxicity and is safe for health personnel in terms of radiation
exposure.
PO384
COMBINED EXTERNAL BEAM RADIOTHERAPY AND INTRALUMINAL
BRACHYTHERAPY IN THE TREATMENT OF ESOPHAGEAL CANCER
D. Scepanovic 1 , M. Pobijakova 1 , P. Lukacko 1 , M. Masar 1 , Z. Dolinska 1 ,
A. Masarykova 1
1 National Oncology Institute, Radiation Oncology, Bratislava, Slovakia
: The main objective of treatment for locally
advanced esophageal cancer remains palliation of dysphagia.
Radiotherapy for palliation can be external beam alone, intraluminal
brachytherapy (ILBT) alone, or a combination of both.
The purpose of our study was to compare the effect of combined
external and intraluminal radiation treatment versus external beam
radiotherapy alone (EBRT).
: Between 2006 and 2010, 66 patients (pts)
with locally advanced esophageal cancer received radiation therapy
(RT) with/without chemotherapy (CT). Patients without evidence of
metastatic disease were identified. Combined EBRT/ILBT and EBRT
alone were performed in 26 and 40 pts, respectively. ILBT with high
doserate Ir192 source was applied after pts completed EBRT as a
boost therapy. The external radiation was performed with a median
total dose of 46Gy given in 23 fractions. On the average a week after
the external radiation a median total dose of 10Gy ILBT was given in 2
fractions. The longterm outcomes were investigated with a median
followup time of 20 months.
: The overall cumulative survival rate was 10% at 5 years for
whole group of pts. The cause specific survival rate at 5 years was 4%
in the external irradiation alone group and 22% in ILBT combined
group. There was statistically significant difference between two
groups of patients regarding overall survival (OS) (p = 0.0002). The
incidence of early and late complications did not differ according to
whether ILBT was used.
: The usefulness of ILBT, as additional irradiation in large
advanced tumors has been shown similar results for dysphagiafree
survival, stenosis, and fistulas and is equally effective in palliation of
advanced esophageal cancer. ILBT as a boost treatment seems to
contribute to the prolonged survival of these pts (p=0.0279).
PO385
SUBLOBAR RESECTION AND BRACHYTHERAPY FOR NON SMALL CELL
LUNG CANCER IN PATIENTS WITH HISTORY OF PRIOR MALIGNANCY
A. Jain 1 , C. Connery 2 , F. Bhora 2 , W. Choi 1 , A. Evans 1
1
St. Luke'sRoosevelt Hospital, Department of Radiation Oncology,
New York, USA
2
St. Luke'sRoosevelt Hospital, Department of Surgery, New York, USA
: Patients with a history of malignancy and a new
diagnosis of early stage lung cancer can pose a challenging clinical
problem. Previous oncologic treatments or comorbidities may limit
the use of conventional treatment options. Patients in this group who
are not candidates for lobectomy have been offered sublobar
resection plus brachytherapy at our institution and clinical outcomes
are reported here.
: Records of patients who underwent sublobar
resection plus brachytherapy for a new diagnosis of early stage lung
cancer from 2006 to 2011 at our institution were reviewed to identify
patients with prior malignancies. Patients were determined by pre
treatment evaluation to have T1 or T2 lung cancer with tumors

S154 World Congress of Brachytherapy 2012
Median age was 76. There were a total of 20 prior malignancies in this
group; 6 Lung, 4 Breast, 4 Gastrointestinal, 3 Prostate, 1 Head and
Neck, 1 Lymphoma, and 1 Skin. 4 patients had previous lobectomy, 3
patients had previous thoracic radiation, and 1 patient had both
lobectomy and thoracic radiation for treatment of prior malignancy.
Final pathologic staging showed T1N0 disease in 13 patients, T2N0
disease in 3 patients, and T2N2 disease in 1 patient. Median follow up
was 13.3 months (range 3.652.3 months). Local control at last follow
up was 100% and regional control was 87.5%. Disease specific survival
for lung cancer was 94% and overall survival was 76%. Postoperative
complications were seen in 4 patients including readmission for
inpatient rehabilitation, pneumothorax, acute pulmonary embolism
(PE) and death due to pneumosepsis. Among the group of 8 patients
with previous lobectomy and/or thoracic radiation the procedure was
well tolerated with one acute PE as the only postoperative
complication seen. At last follow up, there was one death in this
group, from progressive lung cancer.
: Sublobar resection plus brachytherapy is a feasible
option in appropriately selected patients with early stage non small
cell lung cancer and a history of prior malignancy. Previous lobectomy
or thoracic radiation for prior malignancy should not be considered
exclusion criteria for this procedure.
PO386
ENDOBRONCHIAL BRACHYTHERAPYAS ADJUVANT TREATMENTIN
PRIMARY BRONCHIAL N.S.C.L.C TUMORS
K. Papalla 1 , B. Polizoi 2 , I. Tsalafoutas 3 , D. Bisirtzoglou 4 , A. Zettos 4 , B.
Anastasakos 4 , G. Politis 4 , I. Katsilieris 1
1 St. Savvas Anticancer Institute, 3rd Radiotherapy, Athens, Greece
2 St. Savvas Anticancer Institute, Radiotherapy, Athens, Greece
3 St. Savvas Anticancer Institute, Medical Physics, Athens, Greece
4 St. Savvas Anticancer Institute, Pulmonary Disease, Athens, Greece
: Currently, lung cancer is characterized by
increasing incidence rate and minimal improvement in mortality rate.
For this reason its therapeutic management is concidered to be one of
the most difficult tasks. About 40%of all lung cancers are
adenocarcinoma, and about 1520% are nonsmall cell lung
cancer(NSCLC) with squamous cells. In these cases,surgery offers the
best chance for cure. A 75% of the patients present locally advanced
non resectable disease. For these patients Chemotherapy and/or
External Radiation Therapy(ERT) are the treatments of choice,
however,this therapeutic approach is associated with low survival and
high rates of local recurrence. Recently EBBT has been applied in
combination with ERT as the curative treatment of choice in selected
primary bronchial and tracheal tumors. These treatment starts in our
department since March 2010, for observing symptomatic response
rates, duration of symptoms palliation, obstruction scores, quality of
life outcomes and complications in various patients groups.
: Under bronchospopic quidance, a
polyethelene catheter with a guide wire was placed into the involved
airway and it was advanced until its edge passed by the lower end of
the tumor. The bronchoscope and guidewire were then removed,
leaving the catheter in place. A radiopaque insert with marker pellets
(dummy) was placed into the catheter to indicate the source positions
of the high dose rate(HDR) Iridium source. This was fastened
externally to the patient, after its proper placement had been
confirmed fluoroscopically. Utilizing the bronchoscopic findings
concering the tumor load and location, the radiation oncologist
determined the radiation dosing. Two radiographs (anteroposterior
and lateral) were acquried for treatment planning purposes
(irradiation length and dwell time of the iridium source at various
positions) using specialized software. Fortyfive patients were
treated, using a total EBBT dose of 16Gy, delivered in two by 8 Gy
fractions, one fraction per week. Group A (patients with primary lung
tumors), received 3050 Gy by ERT and two by 8 Gy EBBT fractions.
Group B (patients with recurent or metastatic tumors), received two
by 8 Gy EBBT fractions after ERT for palliative treatment of acute
respiratory symptoms.
: The overall symptomatic responce rates were 91% for
dyspnea, 84% for cough, 94% for hemoptysis and 83% for obstructive
pneumonia. There was no significant difference between the two
groups. The median time to relapse of symptoms was 48 months for
all symptoms and the median time for symptoms progression was 611
months.
: Endobronchial brachytherapy is an established modality
for the palliation of advanced nosmall cell lung cancer, in the case of
endobronchial recurence after ERT, used for centrally localized lung
cancer alone or in combination with ERT.
PO387
MANCHESTER SYSTEM TREATMENTS TO THE SKIN SURFACE; FROM
RADIUM TO IRIDIUM HDR (1953 TO 2012)
D. Wood 1 , S. Baker 1 , E. Allan 2 , H. Farrow 3
1
The Christie Hospital, Brachytherapy, Manchester, United Kingdom
2
The Christie Hospital, Clinical Oncology, Manchester, United
Kingdom
3
The Christie Hospital, C.M.P.E., Manchester, United Kingdom
: Skin surface mould treatments have been carried
out using the classical Manchester system tables presented by
Meredith in 1953, the only change since being the move to SI units.
The tables provide for a given area and treatment height, the total
source activity needed to give a unit of prescription dose at the skin
surface, assuming a uniform distribution of sources around the
treatment area, in accordance with Manchester system rules. The aim
of this work is to assess how typical treatments using HDR, differ from
that calculated assuming uniform source arrangements and flat
geometry as in the classical Manchester system approach.
: Manchester system distribution rules were
used to determine source positioning for a variety of geometric
phantom arrangements and patient treatments, and the treatment
times calculated. The dose distributions were then assessed using
Oncentra Brachy v4.0. against an array of surface dose points.
: Air gaps were quantifiable in CT scans taken of the mould
when fitted to the patient, this led to a reduction to dose at the skin
surface by up to 15% for a 2mm air gap, and 32% for a 5mm air gap
compared with assumed optimal treatment geometry.
The arrangement of dwell positions around a near semicylinder or
around an irregular area can lead to significant variation of the dose
received at the skin surface compared with that for a flat treatment
area considered to be equivalent in the system approach.
a) Manchester system treatment times b) Optimised treatment times
The Manchester tables are calculated assuming only inverse square
law dose dependence. The additional effects of dose fall off due to
source anisotropy and absorption and scatter in water as per TG43
calculations are significant, particularly for greater treatment
distances above the skin surface.
: It is advisable to correct calculation methodologies to
account for individual treatment geometries, the assessment of air
gaps, and more accurate source modelling, otherwise the treatment
dose delivered at the skin surface may be significantly inaccurate.
However, it is important when following a well established system
approach to assess the treatment dose typically received before
making informed modifications to individual treatment plans.
PO388
CONTACTHERAPY FOR CARCINOMA OF THE EYELID: A REPORT OF 29
CASES.
K. Benezery 1 , R. Natale 1 , A. Courdi 1 , M.E. Chand 1 , J. Lagier 2 , D.
Flores 2 , S. Marcie 1 , M. Gauthier 1 , J. Feuillade 1 , J.P. Gerard 1
1
Centre Antoine Lacassagne, Radiotherapy, Nice, France
2
CHU St ROCH, Ophtalmologie, Nice, France
: To assess the tolerance and efficacy of contact x
ray therapy (CXR) in the management of eyelid tumours.
: 29 patients were treated from February 2009
to December 2011, using a RT 50 Philips or the new PAPILLON 50 unit
World Congress of Brachytherapy 2012 S 155
delivering a 50kV maximal energy Xray beam. Out of a total of 28
patients, one had two synchronous tumours. Age ranged from 48 to 94
years (median: 77.3), with a male female ratio of 1. Site: lateral
canthus = 3 %, medial canthus = 31%, lower eyelid = 45 %, upper eyelid
= 21 %. There were 80 % (23) basal cell carcinomas, 17% (5) squamous
cell carcinoma, 3% (1) melanoma. No tumour exceeded T1b. Five
patients were referred for radical radiotherapy treatment (first event)
and twentyfour patients for postoperative treatment: among them,
R0 excision = 2 (1 first event, 1 recurrence), R1 excision = 22 (15 first
events, 7 recurrences). They were treated according to 2 schemes: 42
Gy in six fractions of 7 Gy (23 %) for radical treatment, 35 Gy in 5
fractions of 7 Gy (77 %) in case of postoperative treatment.
: Followup ranged from 2 to 24 months. Five patients were
lost to followup. One local relapse occurred 2 months after
treatment, outside the treated area. Side effects: All patients had
Grade I (55%) or II (45 %) erythema and loss of the eyelashes in the
treated area during treatment. 17% had GI eye watering, 10% suffered
from a GII conjunctivitis, and 3% had a G II pilo sebaceous gland
infection. Sequelae: persistent watering of the eye for 21%, xerosis for
14%, one ectropion, one definitive loss of eyelashes and one with
slightly depigmented skin. No cataract was observed. Majority of
patients assessed were more than satisfied with both the cosmetic
and function that followed radiotherapy.
: CXR therapy of the eyelid for skin carcinoma is an
effective treatment, with no local relapse except one outside the
treated area, with few significant side effects or sequelae in this
elderly population.
PO389
INTERSTITIAL PERMANENT IMPLANTATION OF 125 I SEEDS FOR
REFRACTORY CHEST WALL MATASTASIS OR RECURRENCE
P. Jiang 1 , J. Wang 1 , Y. Jiang 1 , W. Jiang 1 , N.A. Meng 1 , R. Yang 1
1
Peking University Third Hospital, Radiotherapeutic Department,
Beijing, China
: To evaluate the efficacy and safety of 125I seeds
implantation for refractory chest wall matastasis or recurrence under
CT guidance. In addition we assessed initial data obtained on the
therapeutic response for refractory chest wall matastasis or
recurrence.
: A retrospective review of 20 patients ( from
Jul,2004 to Jan, 2011) who underwent interstitial permanent
implantation of 125 I seeds under CT guidance. All patients had ever
received at least one modality treatment before 125I seeds
implantation and had been reviewed by the surgeons and radiation
oncologists, that they were considered not suitable for salvage surgery
and external beam radiation therapy again or the patients refused to
receive. The tumor volumes were measured using CT scans at 5mm
intervals 35days before seed implantation.Postoperative dosimetry
was routinely performed for all patients. The D90 (the doses delivered
to 90% of the target volume de?ned by CT using dosevolume
histogram) of the implanted 125 I seeds ranged from 100Gy to 160Gy
(median:130Gy). The activity of 125 I seeds ranged from 0.5mCi to
0.78mCi (median: 0.71mCi). The total number of seeds implanted
ranged from 8 to 269 (median: 53). The followup period ranged from
3 to 54 months(median: 11.5months). The survival and local control
probabilities were calculated by the KaplanMeier method.
: The 1 ,2,3and 4year tumor control rates were all 88.7%
respectively. The 1 and 2,3,4year cancer specific survival rates
were 56.5% and 47.1%, 47.1%, 47.1% respectively. The 1 and 2,3,4
year overall survival rates were 53.3% and 35.6%, 35.6%, 35.6%
respectively, with a median survival of 15 months (95% CI,7.0–22.9).
Mild brachial plexus injury was seen in one patient, grade 1 or 2 skin
reactions were seen in 6 patients (30%) who had received external
beam radiation therapy before. No grade 3 and 4 skin side effects
were found. Rib fracture, ulceration, pneumothorax or
hemopneumothorax were not seen.
: Interstitial permanent implantation of 125 I seeds under
CT guidance is feasible, efficacy and safe for refractory chest wall
matastasis or recurrence.
PO390
INTRAOPERATIVE AND PERCUTANEOUS IR192 BRACHYTHERAPY FOR
MULTIPLY IRRADIATED LESIONS OF THE SPINE
Y. Yamada 1 , M.R. Folkert 1 , G.N. Cohen 2 , M. Zaider 2 , J. Chiu 2 , E. Lis 3 ,
G. Krol 3 , M.H. Bilsky 4
1
Memorial SloanKettering Cancer Center, Radiation Oncology, New
York NY, USA
2
Memorial SloanKettering Cancer Center, Medical Physics, New York
NY, USA
3
Memorial SloanKettering Cancer Center, Neuroradiology, New York
NY, USA
4
Memorial SloanKettering Cancer Center, Neurosurgery, New York
NY, USA
: While advances in stereotactic external beam
radiation therapy have improved local control of spine metastases,
progression of disease is still a significant problem and repeat
irradiation is complicated by normal tissue tolerance, particularly that
of the spinal cord. Intraoperative and percutaneous highdose rate
brachytherapy techniques have been developed to address this issue
and improve local control, pain control, and prevent progressive
neurological deficits.
: A series of patients were identified with
progressive disease at multiply irradiated sites in the spine; 2 patients
subsequently received intraoperative HDR brachytherapy using
catheters placed in the vertebral bodies during surgery and 1 patient
was treated with percutaneously implanted catheters with the
assistance of interventional radiology. In all cases catheter placement
was performed under general anesthesia; using either direct
visualization or fluoroscopic guidance, trocars were placed into the
vertebral body and pedicles, after which flexible afterloader

S156 World Congress of Brachytherapy 2012
catheters were placed through these trocars and the position of the
catheters was confirmed by fluoroscopic imaging. A planning CT scan
was taken in the treatment position; using this intraoperative CT scan
and preoperative imaging, the patient's spinal cord/cauda, gross
tumor volume and a clinical volume were contoured. A treatment plan
was generated and following plan review and approval, the patients
were treated with radiation delivered in a single fraction using high
doserate Ir192 brachytherapy. All treatments were performed using
a GammaMed Plus HDR Unit, after which the catheters were removed.
Patients were reassessed clinically at 24 weeks and then with serial
imaging and clinical assessment.
: In all cases treatment was successfully delivered with no
brachytherapyrelated complications. At a median followup of 5.7
months, there has been no local progression of disease. Median dose
delivered was 1400 cGy (range 12001800 cGy) with a median GTV V90
of 57% (range 4089%). In all cases the spinal cord/cauda maximum
dose constraints were met. 2 patients (66.7%) had significant pain
relief 14 weeks following treatment.
: Intraoperative and percutaneous Ir192 HDR spine
brachytherapy is not associated with complications or acute toxicity;
while these therapeutic methodologies are in the early investigational
stages, they may provide a safe and effective means of treating
multiply irradiated sites of disease progression in the spine. In
addition, use of the percutaneous technique provides a novel salvage
treatment modality for patients who are not appropriate surgical
candidates.
PO391
INTRAOPERATIVE BRACHYTHERAPY FOR THORACIC MALIGNANCIES
RESECTED WITH CLOSE OR POSITIVE MARGINS
A.J. Wu 1 , G.N. Cohen 2 , K.E. Rosenzweig 3 , M.J. Zelefsky 1 , M.S. Bains 4 ,
A. Rimner 1
1
Memorial SloanKettering Cancer Center, Radiation Oncology, New
York NY, USA
2
Memorial SloanKettering Cancer Center, Medical Physics, New York
NY, USA
3
Mount Sinai Medical Center, Radiation Oncology, New York NY, USA
4
Memorial SloanKettering Cancer Center, Thoracic Surgery, New York
NY, USA
: Local recurrence is a significant problem after
surgical resection of thoracic malignancies, particularly when close or
positive margins are anticipated. As intraoperative radiotherapy can
deliver radiation directly to the threatened margin, we used this
technique in an attempt to reduce local recurrence, particularly for
patients who had already received external beam radiation. We
reviewed our experience with thoracic intraoperative brachytherapy
to assess disease control and toxicity outcomes.
: We performed a retrospective review of
patients undergoing permanent I125 mesh placement or temporary Ir
192 afterloading therapy during surgical resection of primary or
metastatic thoracic tumors between 2001 and 2011. In general, for I
125 brachytherapy, iodine seeds were sutured into a mesh at 1cm
intervals to form a planar implant delivering 100150Gy to the MPD,
which was then sutured onto the atrisk site. For Ir192
brachytherapy, a HAM applicator was apposed to the atrisk site, then
connected to the afterloader to deliver 1215Gy to a depth of 0.5cm
from the applicator surface.
: Fortyone procedures (33 permanent, 8 temporary) were
performed on 40 patients (2874 years old, median 57). Histology of
tumors was NSCLC (n=19), sarcoma (n=12), mesothelioma (n=2),
thymic carcinoma (n=7) and metastatic renal cell carcinoma (n=1).
Treated sites were lung (n=16), chest wall/paraspinal (n=16), and
mediastinum (n=9). Twentysix patients had previously received EBRT
to the area (median 50.4 Gy). Final margins were microscopically
negative in 20 cases (49%) and positive or not assessable in the
remainder. The median size of the treated area was 25cm 2 (range: 4
70cm 2 ). The median followup was 30 months. Actuarial local control
at 1 and 2 years was 74% and 67% respectively. Overall survival at 1
and 2 years was 86% and 75% respectively. No perioperative deaths
occurred. There was no significant difference in local control
according to margin status or brachytherapy technique. Seven
patients (17%) experienced toxicity possibly related to brachytherapy:
4 patients required reoperation for empyema, 1 patient developed
apparent bronchopleural fistula, and 1 patient developed possible
radiation pneumonitis. One patient, who also had a distant history of
mantlefield irradiation for lymphoma, died from complications of SVC
syndrome possibly related to radiation fibrosis, four years after
brachytherapy.
: Intraoperative brachytherapy is associated with good
local control after resection of thoracic tumors felt to be at very high
risk for recurrence due to close or positive margins. There does not
appear to be an excessive rate of severe toxicity attributable to
brachytherapy. Intraoperative brachytherapy should be considered in
situations where the oncologic completeness of thoracic tumor
resection is in doubt.
PO392
POSTOPERATIVE INTERSTITIAL PULSEDDOSERATE (PDR) BRACHY
THERAPY IN THE TREATMENT OF THERAPYRESISTANT KELOIDS
R. Davila Fajardo 1 , R. Van Os 1 , O. Lapid 2 , R. Noordanus 3 , B. Pieters 1
1
Academic Medical Center, Radiation Oncology, Amsterdam, The
Netherlands
2
Academic Medical Center, Plastic Surgery, Amsterdam, The
Netherlands
3
Flevoziekenhuis Hospital, Plastic Surgery, Almere, The Netherlands
: To evaluate the results of pulseddoserate (PDR)
brachytherapy after excision of the therapyresistant keloids treated
between 2007 and 2011 in our institution.
: Between July 2007 and December 2011, 24
consecutive patients (11 male, 13 female), with 28 keloids were
treated in our department with immediate adjuvant brachytherapy
after surgical excision. Most of them appeared to be caused by
previous trauma, surgery or infection. Histological keloid confirmation
was obtained in 14% of the cases. In 91% of the patients the
Fitzpatrick scale grade was recorded. Sixty four percent of the keloids
had been previously treated either by surgical excision or intralesional
steroid injections (KenacortA®), the rest conservatively. The median
followup time was 7.2 months [range 034.4]. All keloids underwent
surgical excision under local anaesthetic, placing of a plastic catheter
(Best®) and the wound was primarily closed with subcutaneous
suture. The irradiation was performed with a PDR afterloader device
using an Ir192 source. One single fraction of 13Gy was administered
with a 100% reference isodose line at the surface of the skin (47mm)
in the central plane. Biologically effective dose (BED) 29.9Gy
(α/β=10). Recurrence was defined as a growing nodular pruritic scar
infield or beyond the surgical and irradiated area.
: Recurrence free survival at 12 months was 80% (figure 1.
KaplanMeier curve). The median time to recurrence was 5.3 months
[range 034.4]. Four patients developed pruritus in a flat scar and
they were treated with steroid injections with no growing nodular scar
in the followup. These patients are not included in the recurrence
group. Multivariate analysis showed the gender as significant factor
for recurrence free survival to the detriment of male condition
(p=0.04). While Fitzpatrick scale grade and location of the keloid
were no significant factors for recurrence free survival (p=0.27 and
p=0.54, respectively).Three patients developed hyperpigmentation of
the scar, grade1 as toxicity of the irradiation, probably also related to
the use of steroids, and one hypopigmentation of the scar grade 1,
(CTC 4.0). No second malignancy has been described.
World Congress of Brachytherapy 2012 S 157
: Surgical excision followed by postoperative irradiation in
the form of brachytherapy of the therapyresistant keloids offers a
reasonable good local control in the literature reviewed.
Traditionally LDR and most recently HDR brachytherapy schemes have
been reported with BED ≈30Gy, showing low recurrence rate.
This comfortable PDR scheme consisting of 13Gy in a single fraction
and one pulse provides a similar recurrence free survival to previous
described, with a low toxicity rate.
PO393
125I SEEDS BRACHYTHERAPY TO TREAT MALIGNANT SUBLINGUAL
GLAND TUMORS
Y. Shi 1 , M.W. Huang 1 , L. Zheng 1 , S.M. Liu 1 , J. Zhang 1 , J.G. Zhang 1
1
Peking University School of Stomatology, Oral & Maxillofacial
Sugery, Beijing, China
: The goal of the study is to conclude local control
rate, survival rate of brachytherapy using 125 I radioactive seeds for
treating malignant sublingual gland tumors.
: Twentyone patients of sublingual gland
derived malignant tumor, including nine males and twelve females,
median age 51, were collected in the study. There were 16 adenoid
cystic carcinoma, 3 mucoepidermoid carcinoma, 1 adenoid carcinoma
and 1 malignant pleomorphic adenoma. Twenty patients were treated
by surgical resection, eleven were local tumor resection and nine
were composite procedures, including four segmental
mandibulectomy and five marginal jaw resection. Selective neck
resection was performed in 7 patients. These twenty patients
received 125 I seeds interstitial brachytherapy after surgery. One
patient couldn’t afford surgery and received brachytherapy alone.
Brachytherapy were designed by treatment planning system. Patients
were implanted a mean amount of 39.8 seeds, ranging from 8~92. The
total seeds activity is 31.0mCi (1147MBq) on average. The prescription
dose ranged from 60~120Gy. Each patient received quality verification
and was followed up.
: Twentyone patients were followed up for 16~113 months
(median 44 months). There were one local recurrence and four distant
metastasis, including two died of lung metastasis. No severe
complications such as osteomyelitis were observed. The local control
rate is 95.2%. Oneyear and threeyear survival rate is 100% and
85.8%. Threeyear survival rate with and without distant metastasis
are 100% and 50% respectively (P

S158 World Congress of Brachytherapy 2012
up of the patients was done to analyze acute and late toxicity, local
control and survival.
: After a median follow up of 12 months (range 2 28 months),
soft tissue necrosis was seen in one patient, dysphaia and hemorrhage
in another. No other serious side effects were observed. All the tumor
mass of 10 cases disappeared within 6 months, regional metastases
was observed in one patient and distant metastases was observed in
another. Seven of 10 patients survived till the date of investigation.
: External beam radiotherapy plus I125 seeds
implantation is a safe and effective therapy regimen for patients with
unresectable head and neck cancers.
PO396
I125 BRACHYTHERAPY FOR LOCALLY RECURRENT PAROTID GLAND
CANCER IN PREVIOUSLY IRRADIATED PATIENTS
L. Zheng 1 , J.G. Zhang 1 , J. Zhang 1 , T.L. Song 1 , M.W. Huang 1 , G.Y. Yu 1
1
The Stomotology School and Hospital of Peking University, Oral and
Maxillofacial Surgery Department, Beijing, China
: This study analyzed the treatment of recurrent
parotid gland cancers with radioactive iodine (125I) seed
implantation.
: Fifteen patients with recurrent previously
irradiated parotid gland cancers were treated with postoperative 125I
seed implantation between April 2004 and June 2009. Local control,
survival rates and side effects were retrospectively reviewed.
: The 3 and 5year local control rates were 67% and 53.6%,
and the overall survival rates were 76.2% and 66.7%, respectively.
Four HouseBrackman grade IV patients recovered to grade II during
followup. Four patients (26.7%) developed grade IV skin ulceration.
Two patients (13.3%) developed moderate fibrosis of the subcutaneous
tissues, and two (13.3%) suffered hearing loss for 1 year after
brachytherapy. There were no severe late toxicities.
: This study showed improved local control and survival
rates in patients who received 125I brachytherapy. These findings
should be interpreted cautiously due to the small number of patients.
PO397
32PFOILS FOR RADIOACTIVE IMPLANTS IN LOWDOSERATE (LDR)
BRACHYTHERAPY
W. Assmann 1 , M. Bader 2 , J. Schirra 3 , C. Schäfer 3 , R. Sroka 4 , C. Stief 2
1
Ludwig Maximilians Universtät München, Fakultät für Physik,
Garching, Germany
2
LMU Klinikum Großhadern, Urologische Klinik, München, Germany
3
LMU Klinikum Großhadern, Medizinische Klinik II, München, Germany
4
LMU Klinikum Großhadern, Laserforschungslabor, München, Germany
: LDR brachytherapy can modulate wound healing
avoiding hyperproliferation and benign stenosis of endogenous tubular
structures such as bile duct or urethra. Till now, however, there is no
suited applicator available. The aim of this project was to develop a
new polymer based foil containing radioactive 32P which fits to the
usual urethra catheter or bile duct stent, but would be also suitable
for similar other applications.
: Polymer foils filled with up to 10% 31P have
been produced and tested for their radiation resistance during
neutron activation of 31P to 32P, washout behavior and dose
distribution. The therapeutic range of the pure electron emitter 32P
(Emax = 1.7 MeV, T1/2 = 14.3 d) is known to be only a few millimeters
delivering minimal dose to the healthy tissue surrounding the treated
stenosis. Measured dose distributions were confirmed by Geant4
simulation. Within a feasibility study on rabbits and swine, a benign
stenosis was induced endoscopically by laser or heat in the urethra
and the common bile duct, respectively. After activation radioactive
32Pfoils were wrapped around and fixed on usual implants (catheter,
stent), and inserted after balloon dilatation to locally irradiate the
wounded stenosis tissue. For radiation protection, a 10 mm thick
plexiglass enclosure of the implants was sufficient.
: The novel radioactive 32Pfoil allows for the usual stent or
catheter application with additional LDRbrachytherapy to prevent
stenosis formation. Animal tests applying 0, 15 and 30 Gy within 7
days have not shown adverse dose effects in histology of the target
tissue, but dose finding studies have to be made. Handling and
radiation protection was found to be very easy, and no radioactive
contamination has been measured.
: This newly developed 32Pfoil offers a simple and save
way to irradiate very precisely tissue with a dose up to some 60 Gy,
therefore after animal studies now clinical tests for the urethra are in
preparation. These flexible and thin radioactive foils can be applied in
a lot more cases, where hyperproliferation causes problems, and even
in radiobiological experiments. To cover a wider dose range, for
example to irradiate malign proliferation, foils containing 192Ir are
under development.
PO398
RADIOACTIVITY SEEDS INTERSTITIAL BRACHYTHERAPY TREATING
MALIGNANT SALIVARY GLAND TUMORS
J. Zhang 1 , L. Zheng 1 , M.W. Huang 1 , L.F. Jia 1 , Y. Shi 1 , G.Y. Yu 1 , J.G.
Zhang 1
1
The Stomotology School and Hospital of Peking University, Oral and
Maxillofacial Surgery Department, Beijing, China
: To detect the efficacy of radioactive seeds
implanting treating malignant salivary gland tumors.
: Fortythree patients with malignant salivary
gland tumors of head neck were treated at Peking University
stomatologic hospital with radioactivity seeds brachytherapy between
the years 2001 and 2008. These patients were implanted 125I with
dose of 120160Gy. The treatment response, local control rate and
survive rate were evaluated and the adverse events were observed.
: Tumors of twentynine patients were got complete
remission(CR), tumors of seven patients were partial remission(PR),
the response rate was 83.7%. The patients were followed up 848
months (median 21 months), local control rate was 79%, total survival
rate was 76.7%. No serious side radiotherapeutic effect was observed.
: Radioactivity seeds interstitial brachytherapy is an
effective form of treatment for patients with unresectable malignant
salivary gland tumors.
PO399
HDR INTENSTINAL BRACHYTERAPY AS A SALVAGE TREATMENT IN
RECTAL ADENOCARCINOMA PATIENTS
T. Filipowski 1 , W. Markiewicz 2 , D.E. Kazberuk 1 , A. SzmigielTrzcinska 1 ,
M. Niksa 1 , B. PancewiczJanczuk 3 , W. Nowik 3
1
Comprehensive Cancer Center Bialystok, Radiation Oncology,
Bialystok, Poland
2
Comprehensive Cancer Center Bialystok, Oncological Surgery,
Bialystok, Poland
3
Comprehensive Cancer Center Bialystok, Physics, Bialystok, Poland
: To analyze efficacy and toxicity profile of salvage
intenstinal brachytherapy HDR in rectal Anenocarcinoma patients
after tumorectomy who refused or was not classified to the radical
resection.
: Between April 2009 and July 2011, 8 patients
(pts) with rectal Adenocarinoma underwent conformal HDR
brachytherapy (HDRBRT) with a temporary intenstinal implant ( 35
cathetters) The mean age of pts was 71years,. 6 of patients received
30 Gy in 5 days 3 Gy per fraction twice daily, one of patients received
24 Gy in 4 days, 4 Gy per fraction, one of the patient received 10 Gy
single fraction. The plan was prepared in 3D based on CT and
Oncentra Master plan and PLATO planning software. Dose volume
constraints for this planning system included for target: V 100,
V150,V200, D90. Patient were monitored weekly during radiotherapy
and 1, 3, 6, 9, and 15 months after the end of treatment and then at
three months interval. Followup visit included clinical and surgical
examination, radiology exam (Ultrasoun of abdomen and liver and
World Congress of Brachytherapy 2012 S 159
chest Xray) and CEA value assesment. The acute toxicities were
graded according to the EORTC/RTOG scales.
: Median follow up was 8 months (153) with 100% diseasefree
survival rate. The most common symptoms were: pain, swelling,
bleeding, thin stool, rectal urgency, frequency and tenesmus and
acute proctitis was observed. 20 % grade 4 acute toxicities were
recorded. However overall survival data need longer followup.
: HDRBRT is a valid anal sphincter sparing treatment
modality for selected patients. HDRBRT has an important role in
achieving dose escalation for some patients. The treatment was well
tolerated by majority of patients with acceptable degree of acute
toxicities. Overall survival data need longer followup.
PO400
THE CLINICAL APPLICATIONS OF SURFACE HDR LEIPZIG APPLICATORS
I. Ozbay 1 , S. Kucucuk 2 , M. Fayda 2 , B. Serarslan 2 , A. Kizir 2 , E.N. Oral 2 ,
E.K. Saglam 2 , A. Fathalizadeh 2 , G. Kemikler 1 , I. Aslay 2
1
Istanbul University Oncology Institute, Medical Physics, Istanbul,
Turkey
2
Istanbul University Oncology Institute, Radiation Oncology, Istanbul,
Turkey
: The purpose of this study is to evaluate our initial
experience with surface Leipzig applicators of microSelectronHDR
afterloader (Nucletron).
: Between January 2011 and January 2012, 15
patients with 18 lesions were treated with Leipzig applicators at our
institution. The median age of patients was 69 (2690). Skin tumors
were the main indication for treatment with 7 basal cell cancer (BCC),
6 squamous cell cancer (SCC), 3 Kaposi’s sarcoma, one keloid and one
hemangioma cases treated. Another patient was treated for two
buccal mucosa tumors. Initial management was incisional biopsy in 13
cases, excision with positive margins in 3 cases, total excision before
RT in one keloid case and one lip hemangioma case with no prior
treatment. Five lesions were treated previously. One keloid case was
removed three years prior, one skin cancer case had cryotherapy,
another skin lesion was externally irradiated six months previously and
two oral cavity lesions were externally irradiated prior to using the
surface applicator. All of the lesions were on the head except two
cases of Kaposi’s sarcoma involving the toes. In 12 cases, the patients
were treated with 3 fractions per week, in 4 cases, 5 fractions per
week, one case used 2 fractions per week, and one of the keloid cases
was treated BID in three consecutive days. The characteristics of the
treatments are provided in the table. The typical use of the Leipzig
applicator is shown (see photo).
Median MinMax
Age 69 2690
Size of the lesion (cm) 1.4 0.52.5
Leipzig applicator dimension (cm) 2 13
Reference depth (mm) 3 35
Dose per fraction (Gy) 4 2.510
Number of fractions 10 314
Total dose (Gy) 37 967.5
No. of fraction per week 3 (mode) 25
Followup (months) 3 111
: All of the patients tolerated the treatment very well. The
median followup time was 3 (111) months. Four patients had grade 2
acute mucositis, two patients had grade 1 skin reactions and one
patient had grade 3 mucositis treated with topical steroids. Most of
the acute reactions resolved within the first month. One case
experienced hypopigmentation and the patient with two oral cavity
lesions developed necrotic tissue on the treated areas. The overall
tumor response was 95% for patients with gross tumors at a six week
followup.
: The treating of small targets especially on the face is
associated with some difficulties. Cosmetic results in this area are of
great importance. The dosimetric uncertainties of the small fields
should be managed individually especially during external beam
radiation with electrons. The longer treatment time is not easily
tolerated by elderly patients with multiple comorbidities. The surface
Leipzig applicators of microSelectronHDR afterloader may help to
irradiate superficial small tumors located on the skin and mucosal
surfaces by using larger fraction sizes allowing for the use of fewer
fractions. Long term followup is needed to evaluate long term local
control and cosmetic results.
PO401
MRIBASED RECTAL APPLICATOR RECONSTRUCTION IN HDR RECTAL
BRACHYTHERAPY
A. BeikiArdakani 1 , A. Simeonov 1 , R. Wong 2 , J. Jezioranski 1
1 Princess Margaret Hospital, Radiation Physics, Toronto, Canada
2 Princess Margaret Hospital, Radiation Oncology, Toronto, Canada
: To date, only CT images are used for treatment
planning in High Dose Rate (HDR) rectal Brachytherapy (BT). The
major challenge of MRIbased HDR rectal BT has been the lack of
adequate visualization of the HDR applicator and catheter.
Consequently, CT is generally used for catheter reconstruction in the
treatment planning system. One disadvantage of using two imaging
modalities MR for target delineation and CT for catheter
reconstruction is patient motion between the two scans, which may
create a large uncertainty in image fusion. The purpose of this study
was to assess the performance of a 3D volumetric interpolated breath
hold sequence (VIBE) for both target delineation and catheter
reconstruction in HDR rectal BT.
: Recently, the 3D VIBE sequence (a modified
fast 3D gradientecho sequence), has been used to acquire T1
weighted images in a clinical wholebody MRI. This sequence may
provide isotropic or nearisotropic resolution in three dimensions,
while preserving wide anatomic coverage in a short acquisition time.
Motion artifacts and accompanying partial volume averaging effects
are also reduced by the rapid data acquisition, resulting in high
quality 3D MR images. We obtained T1weighted images through the
rectal applicator using the VIBE sequence and then used Nucletron
reconstruction software to generate 3D MR images of the HDR rectal
applicator. MRI was performed on a 3T MR unit (Siemens Medical
Solutions) using a phasedarray body coil. T1weighted images of the
rectal applicator in both phantom and a test patient were obtained
using VIBE (TR/TE, 4.75/2.53; flip angle, 15°; field of view, 400 mm;
slice thickness, 3 mm; section gap, 0–0.5 mm; number of slices, 30–40;
image matrix, 256 [interpolation, 512]; bandwidth, 490 Hz/pixel; 1
signal acquisition; scanning time, 60 seconds). Using the 3D VIBE
sequence we were able to not only visualize the tumor and Organs at
Risk (OARs) but also the rectal applicator as well as the catheter
channels for purposes of treatment planning (Fig 1). The validity of
the 3D VIBE sequence was evaluated using T2 weighted MR and CT
images in a specially designed phantom as well as a test patent.

S160 World Congress of Brachytherapy 2012
Fig 1: Left: T2 vs 3D VIBE, minimal shift was observed for central
channel in applicator for test patient. right; CT vs 3D VIBE with
horizontal frequency encoding causing 1mm applicator shift to right
: The 3D VIBE sequence introduces a maximum 1 mm chemical
shift of the Rectal Applicator relative to surrounding soft tissue
equivalent material (both in phantom and test patient) in the
direction of frequency encoding relative to CT and T2 weight MR
images. This shift can be corrected during catheter reconstruction or
reduced by using a higher bandwidth acquisition.
: Our study has shown that the 3D VIBE sequence can be
used for both target delineation and catheter reconstruction for
treatment planning of HDR rectal BT, with a maximum spatial
uncertainty of 1mm.
PO402
HDR BRACHYTHERAPY GIVES RAPID TUMOR RESPONSE AND LOW
NORMAL TISSUE TOXICITY IN NONMELANOMA SKIN CANCER OF THE
FACE
R. Kumar 1 , R. Hobbs 1 , A. HackerPrietz 1 , H. Quon 1 , A. Wild 1 , T. Wang 2 ,
E. Armour 1 , J.M. Herman 1
1
The Johns Hopkins University, Radiation Oncology and Molecular
Radiation Sciences, Baltimore, USA
2
The Johns Hopkins University, Dermatology, Baltimore, USA
: Nonmelanoma skin cancer (NMSC) is the most
common malignancy in the United States with over 2,000,000 cases
diagnosed in 2010. Electron beam radiation has been historically used
in poor surgical cases. In this study, we analyzed the dosimetry of HDR
brachytherapy (HDR BT) vs electron beam irradiation in the treatment
of NMSC of the bilateral face.
: Our patient is a 66 year old male with a
history of rheumatoid arthritis on chronic immunosuppression, and a
long history of multiple NMSC lesions, including those on the bilateral
face. Multiple biopsies and resections had been performed, but his
disease was refractory to MOHS resection, topical agents, and oral
agents. CT simulation was performed with immobilization achieved by
an aquaplast mask. The visible lesions were marked with radioopaque
wire and BB. A Freiburg® flap was applied under the mask and molded
to maintain contact with the patient's skin. Catheters were inserted
into the flap and connected to a remote source. The patient was
treated with 400 cGy fractions of HDR BT to a total of 10 fractions
(total dose of 4000 cGy). A dosimetric comparison was simultaneously
performed using the Pinnacle® planning system. The comparison dose
was with a 6MV electron beam using a 5 mm tissue bolus to a dose of
55 Gy in 20 fractions (2.75 Gy/fraction). The BED10Gy was 70.13 Gy for
electrons vs 56.00 Gy for brachytherapy; the BED3Gy was 105.4 Gy for
electrons vs 93.33 Gy for brachy. The dose to head and neck critical
structures was compared between the two treatment plans.
: The patient experienced visible clinical improvement by
fraction 4 of the HDR BT. Nearcomplete resolution of his bilateral
cheek disease was observed by fraction 8. Treatment was completed
on a 23 doses/week fractionation schedule. A treatment break of 5
days was provided after fraction 4 to the patient to allow for toxicity
improvement. Only grade 2 skin erythema was noted, no other acute
toxicity was described. Resimulation of the patient was performed on
treatment day 3 to ensure accurate patient alignment in the
immobilization system. Less than 1 mm of patient motion was
observed.
Electron (Gy) HDR Brachy (Gy)
Left GTV 51.30 51.00 (avg)
Right GTV 52.87 54.37 (avg)
Brain 40.28 17.74 (max)
Thyroid 3.30 1.12 (avg)
Mandible 32.16 20.80 (max)
Oral cavity 44.42 20.10 (max)
Left Parotid 26.07 16.99 (avg)
(Right parotid previously excised)
Left Globe 52.99 15.94 (max)
Right Globe 1.29 8.63 (max)
Left Cochlea 0.97 7.78 (avg)
Right Cochlea 0.93 8.06 (max)
Left masseter 59.45 25.64 (max)
Right masseter 59.57 29.23 (max)
: The clinical response of our patient was dramatic (image
below). The potential dosimetric advantage of this technique over
electron beam irradiation is significant in terms of both acute and late
radiation toxicity, especially when the relatively higher BED of the
electron plan is noted. Additionally, the fractionation of the HDR BT
method may theoretically allow for increased normal tissue repair.
However, longterm follow up is necessary to address the potential
late toxicity of this treatment method, and the comparison of HDR BT
to electron beam irradiation should be addressed prospectively.
PO403
ENDOSCOPIC GUIDED BRACHYTHERAPY (EGBT)FOR SINONASAL AND
NASOPHARYNGEAL RECURRENCES
F. Bussu 1 , L. Tagliaferri 2 , M. Rigante 1 , F. Miccichè 2 , N. Dinapoli 2 , R.
Autorino 2 , G. Almadori 1 , G. Paludetti 1 , V. Valentini 1 , G. Kovacs 1
1
Università Cattolica del Sacro CuorePoliclinico A. Gemelli,
Otorhinolaryngology, Rome, Italy
2
Università Cattolica del Sacro CuorePoliclinico A. Gemelli,
Radiotherapy, Rome, Italy
: In recurrences of a nasopharyngeal or sinonasal
malignancy after a full course of radiotherapy second clinically
effective dose of external beam radiotherapy leads to high toxicity
rates. Brachytherapy may improve the outcome with a more
World Congress of Brachytherapy 2012 S 161
conformed dose. Endoscopic surgery offers advantages as it is
minimally invasive, however, still not fully validated, especially for
recurrences, and exceptionable for issues about radicality. In this
setting the possibility to deliver an adjuvant irradiation by catheters
positioned on the high risk areas of the surgical bed under direct
endoscopic vision may definitely increase the chances for local
control. In the present work we evaluate the outcome of combined
endoscopic surgery and perioperative brachytherapy.
: Local recurrences following a full course of
radiotherapy were resected by an endoscopic approach and plastic
tubes were intraoperatively fixed to the surgical bed. In the
nasopharyngeal cases we stabilized the blind tubes by suturing them
on the nasal packing and the 2ways catheters by through stitches on
the cartilaginous septum. In sinonasal cases we stabilized the blind
catheters passing them through tunnels drilled in the maxillary bone,
pushing them to adhere to the target area by nasal packing under
endoscopic vision and then suturing them to the skin. The irradiation
dose was 30 Gy in 12 fractions, 2.5 Gy each, twice a day, in 6 days.
The nasal packing and the catheters were removed at the end of
irradiation course. We calculated the overall and relapse free survival
starting from the day of the procedure.
: We enrolled 3 patients with recurrences of sinonasal
malignancies (2 adenocarcinomas, 1 adenoidcystic carcinoma),
already treated by surgery and adjuvant irradiation, and 2 patients
with recurrent nasopharyngeal SCC, both treated by
chemoradiotherapy (70 Gy+ cis q21). Median follow up was 8 months.
4 out of 5 patients are still alive with no evidence of disease. 1 of
them (nasopharyngeal SCC) is dead for massive bleeding 2 months
after the procedure. In 1 case (recurrence of an adenoid cystic
carcinoma of the coana) we had a transient deficit of the VI cranial
nerve, totally solved after 2 weeks of steroids.
: Combination of the endoscopic approach for removal of
recurrence and perioperative brachytherapy seems to be an effective
option for treating local recurrences. The morbidity of the endoscopic
approach is minimal, perioperative radiation can start the day after.
The endoscopic approach allows an optimal catheter positioning with
an extraordinary exposure and anatomic detail; on the other hand the
combination with brachytherapy may lead to enlarge the indications
for an endoscopic approach in the salvage of sinonasal recurrences.
PO404
VOXELIZED DOSERESPONSE STUDY IN HIGH DOSE RATE (HDR) 192IR
BRACHYTHERAPY FOR RECTAL CANCER
R.F. Hobbs 1 , Y. Le 1 , E.P. Armour 1 , J. Efron 2 , N. Azad 3 , L. Diaz 3 , H.
Qiu 3 , G. Sgouros 4 , S.L. Gearhart 2 , J.M. Herman 1
1 Johns Hopkins University, Radiation Oncology, Baltimore MD, USA
2 Johns Hopkins University, Surgery, Baltimore MD, USA
3 Johns Hopkins University, Oncology, Baltimore MD, USA
4 Johns Hopkins University, Radiology, Baltimore MD, USA
: Doseresponse studies in radiation therapy are
typically using single response values for tumors across ensembles of
tumors. Using the HDR treatment plan dose grid and voxelized pre
and posttherapy FDGPET images, we show correlations between
voxelized dose and FDG uptake response in individual tumors.
: Five patients were treated for localized
rectal cancer using 192 Ir high dose rate (HDR) brachytherapy in
conjunction with surgery. FDGPET images were acquired before HDR
therapy and 68 weeks after treatment (prior to surgery). Treatment
planning was done on a commercial workstation and the dose grid was
calculated. The two PETs and the treatment dose grid were registered
to each other. The difference in PET SUV values before and after HDR
was plotted versus absorbed radiation dose for each voxel (left
figure). The voxels were then separated into bins for every 400 cGy of
absorbed dose and the bin average values plotted similarly (right
figure)
: Four of the five patients showed a significant positive
correlation (R 2 = 0.18, 0.70, 0.81, 0.82 and 0.89, respectively)
between PET uptake difference in the targeted region and the
absorbed dose for the binned voxels (see figure).
: By considering larger ensembles of voxels, such as organ
average absorbed dose or the dose bins considered here, valuable
information may be obtained. The doseresponse correlations as
measured by FDGPET difference potentially underlines the
importance of FDGPET as a measure of response, as well as the value
of voxelized information.
PO405
EARLY INTERVENTION WITH SELECTIVE INTERNAL RADIATION THERAPY
(SIRT) IMPROVES SURVIVAL AND LOCAL/SYSTEMIC OPTIONS
N. Sharma 1 , E.M. Nichols 1 , S. Grabowski 1 , P. Amin 1 , M. Garofalo 1 , A.
Hanlon 2 , N. Hanna 3 , R. Patel 4 , M. Horiba 5 , F. Moeslein 4
1 University of Maryland, Radiation Oncology, Baltimore MD, USA
2 University of Pennsylvania, Biostatistics, Baltimore MD, USA
3 University of Maryland, Surgical Oncology, Baltimore MD, USA
4 University of Maryland, Interventional Radiology, Baltimore MD, USA
5 University of Maryland, Medical Oncology, Baltimore MD, USA
: Hepatic brachytherapy with selective internal
radiation therapy (SIRT) using Y90 resin microspheres (SIRSpheres)
has been extensively described in the treatment of metastatic
colorectal cancer (mCRC). However, its application as a treatment
modality in other tumor types has been documented primarily through
small case series and data regarding optimal timing of treatment and
patient selection are still emerging. We reviewed our large single
institutional experience with this modality in patients with adequate
staging and multidisciplinary oncologic management.
: Records of all patients undergoing SIRT after
determination of appropriate eligibility by our multidisciplinary
hepatobiliary tumor board between 3/2002 4/2011 were reviewed on
an IRB approved protocol. Appropriate laboratory and imaging workup
was performed to determine liver function, tumor burden and extent
of extrahepatic disease. Hepatic angiography and macroaggregated
albumin perfusion scans were performed to assess liver anatomy and
lung shunting. Meticulous coil embolization of collateral vesselsat
risk was performed. Patients were typically treated with initial
infusion to the hepatic lobe with more extensive disease followed by
treatment to the contralateral lobe 34 weeks later using an
individualized dose of Y90. Followup imaging was performed 3
months later and systemic therapy was as per the treating medical
oncologist. Uni and multivariable statistical analyses were
performed to determine variables associated with OS.
: 112 patients with complete data were evaluated with the
following tumor types: Colorectal cancer (N=64, 57%), hepatocellular
(N=9), esophageal (N=7), neuroendocrine (N=6), breast (N=5) and
other (N=21). Mean patient age was 59 (12.6), 58 (11.0) for CRC
cancer patients. Median OS for the entire cohort was 29 months from
initial diagnosis and 8 months from date of 1st Y90 treatment. Log
Rank analysis demonstrated rate of death in patients with ≥5 lesions
was twice that in patients with

S162 World Congress of Brachytherapy 2012
survival and allows, more importantly, for more extensive systemic
management through delivery of more chemotherapy cycles.
PO406
NON MELANOMA SKIN CANCER TREATED WITH SUPERFICIAL
BRACHYTHERAPY (BQT) OF HIGH DOSE RATE (HDR) WITH LEIPZIG OR
MOULD
M. VillavicencioQueijeiro 1 , B.H.Y. Bautista Hernandez Yicel 1 , M.M.J.
Montoya Monterrubio Juan 1 , L.C.P. Lujan Castilla Pomponio 1 , F.M.S.
Fuentes Mariles Sonia 1 , R.V.D. Ruesga Vazquez Daniel 1
1
Hospital General de Mexico (Goverment), Département de Radio
Oncologie, DF, Mexico
: : Non melanoma skin cancer is one
of five causes of dead in men and women like the result of the
epidemiological change in the world
: To compare the local control in CPNM with superficial
brachytherapy (BQT) of high dose rate (HDR) with Leipzig or mould.
: Retrospective research in 98 patients with
CPNM in head and neck area, treated only with BQT, superficial HDR,
in the BQT Department of the Radiotherapy Service in Hospital
General de Mexico from April 1 st 2005 to December 31 st 2011.
Patients were divided into 5 nonhomogeneus groups (nose, eye, face,
hand and ear). In the table 1 are the results of the different
localizations and the type of applicator.
In all the cases the prescribed dose was 5064cGy in 12 fractions, 3
times a week (Monday, Wednesday and Friday) for 4 weeks. In the
applicator's choice the type of surface was essential. In homogeneus
surfaces, Leipzig applicators were used while in the inhomogeneus
surface the mould applicator was chosen to guarantee the dose
prescription.
: It was found that in the 5 groups the local control is similar
with the 2 types of applicators, except for the external ear canal in
which the local failure is presented in up to 20%.
Table 1. Caracteristics of the Group in the differents areas of
treatment. Hospital General de Mexico from April 1st 2005 to
December 31st 2011
Baso: Basocelular carcinoma, Squam: Squamous carcinoma. * The time
of follow are in months
: In CPNM head and neck area local control is up to 95%
with the superficial brachytherapy (BQT) use of high dose rate (HDR).
The surface type must be taken into account in the applicators choice
(Leipzig or mould). The late toxicity percentage (hypopigmentation)
was lowest with Leipzig than with mould. Specially the follow of the
patients it´s difficult for the age and the conditions of them, so we
have problems with the follow in the time. The superficial BQT could
be an option for the patients with CPNM in stages I and II, with good
results in local control and cosmetic results.
PO407
CTGUIDED INTERSTITIAL HDRBRT FOR RECURRENT MALIGNANT
GLIOMAS: FIFTEEN YEARS SINGLE INSTITUTE EXPERIENCE
N. Tselis 1 , C. Kolotas 2 , G. Birn 3 , E. Archavlis 3 , G. Chatzikonstantinou 4 ,
E. Zoga 4 , T. Papavasileiou 4 , B. Rogge 5 , D. Baltas 5 , N. Zamboglou 4
1
Klinikum Offenbach GmbH, Department of Radiation Oncology,
Offenbach am Main, Germany
2
Hirslanden Clinic, Department of Radiotherapy, Aarau, Switzerland
3
Klinikum Offenbach GmbH, Department of Neurosurgery, Offenbach,
Germany
4
Klinikum Offenbach GmbH, Department of Radiation Oncology,
Offenbach, Germany
5
Klinikum Offenbach GmbH, Department of Medical Physics and
Engineering, Offenbach, Germany
To assess the efficacy of computed tomography
(CT)guided interstitial highdoserate (HDR) Brachytherapy (BRT) in
the local treatment of recurrent malignant gliomas.
: Between January 1995 and December 2010,
179 consecutive patients were treated for recurrent malignant
gliomas located within previously irradiated volumes. Sixtyseven
patients were female and 112 male. Of those, 126 patients had an
initial diagnosis of glioblastoma multiforme (GBM) and 53 a non
glioblastoma histologic primary (13 astrocytoma grade II and 40
astrocytoma grade III) which transformed into a higher grade glioma
at recurrence. In all patients primary treatment consisted of surgery
and postoperative external radiotherapy up to 60 Gy. Adjuvant
chemotherapy was administered in 110 (61.4 %) patients.
Brachytherapy was performed for inoperable recurrent disease with
progression under palliative chemotherapy. The median implanted
tumour volume was 49 cm 3 (2207 cm 3 ) for primary GBM (n=126), 46
cm 3 (10110 cm 3 ) for initial nonglioblastoma recurring as confirmed
glioma grade IV (n= 25) and 29 cm 3 (6200 cm 3 ) for recurrences
presented as astrocytoma grade III (n= 28). The interstitial HDRBRT
was performed using CTguided catheter implantation under local
anesthesia and delivered a median dose of 40 Gy at twicedaily
fractions of 5.0 Gy to a CTbased planned volume.
: After a median followup of 8.8 months, three (1.6 %)
patients were alive. The median postBRT survival was 37.7 weeks for
primary GBM, 42.5 weeks for initial nonglioblastoma recurring as
glioma grade IV, and 46.1 weeks for astrocytoma grade III. The
corresponding median survival from diagnosis was 82.4 weeks, 53.5
months, and 54.8 months, respectively. Seven out of 179 (3.9 %)
patients experienced symptomatic radiation necrosis and 3 (1.6 %)
bacterial meningitis. In addition, there were 4 (2.2 %) cases of
intracerebral hemorrhages, one (0.5 %) of fatal extend. No other
procedurerelated deaths occurred.
: For patients with inoperable recurrences of malignant
gliomas within previously irradiated volumes, CTguided interstitial
HDRBRT is a feasible and effective additional palliative treatment
option.
PO408
HIGH DOSE RATE 3DIMENSIONAL TOPOGRAPHIC APPLICATOR BRACHY
THERAPY FOR SKIN CANCER ABOVE CLAVICLE: EARLY OUTCOMES
S. Vyas 1 , R. Weinberg 2 , N. Thawani 1 , S. Mutyala 1
1 Scott and White Healthcare, Radiation Oncology, Temple, USA
2 Scott and White Healthcare, Radiation Physics, Temple, USA
: Nonmelanoma skin cancers (NMSC) accounts for
nearly half of all cancers in the US with an estimated incidence of 2
million new cases/year. Surgery is the treatment of choice for most
sites. Radiation is recommended as frontline therapy for Head and
Neck (HN) skin cancers which has poor functional and cosmetic
outcomes after surgical excision with negative margins. External beam
radiation leads to inaccurate dosimetry and non homogeneity
secondary to skin surface complexity. Brachytherapy is the most
conformal form of radiation. There are few reports in published
literature for use of brachytherapy for skin cancers. We present our
single institution experience for feasibility, acute toxicity and early
outcomes of definitive treatment of skin cancers in the head and neck
using 3dimensional Topographic Applicator Brachytherapy (3TAB).
: Patients with localized, nonmetastatic,
NMSC above clavicle were treated with customized thermoplastic
masks molded to the skin contour and either H.A.M. (Mick Radio
Nuclear Instruments, Inc.) or Freiburg flap (NucletronElekta)
applicators in contact with the skin lesion(s). The number of catheters
used depended on the size and location of the lesions, with a 0.51cm
margin. The prescription dose was 40 Gy in 8 fractions of 5 Gy each,
delivered twice a week, to a depth of approx 3mm from the skin
surface. Dose calculations comprised of determining the volume
receiving 90% (V90), 100% (V100), and 135% (V135) of the prescribed
dose. Treatment toxicity was recorded and graded by RTOG criteria.
Patients were followed at two weeks posttreatment and then every 3
months with evaluation of response to treatment as well as acute and
World Congress of Brachytherapy 2012 S 163
late toxicities. Local and regional relapsefree survival was analysed
after generation of Kaplan Meier curves.
: A total of 81 lesions on 54 consecutive patients received 3
TAB between July 2010 to Dec 2011. The demographic and treatment
parameters of the patients are shown in Table.
PARAMETERS N=81
value(%) mean median range
SITE
nose 26(32.1)
cheek 19(23.5)
ear 17(21)
forehead 7(8.6)
others
HISTOLOGY
12(14.8)
basal 55(67.9)
squamous 23(28.4)
mixed 2(2.5)
bowens
STAGE
1(1.2)
I 68(84)
II 13(16)
VOL(CC)
1.8 1.3 0.39.4
# CATHETERS
5 5 113
V90 (%)
70.1 83.7 38.6100
V135(%)
2.3 0.2 0.0153
Mean follow up was 19 weeks (median 13 weeks, range 064), and 78
of the 81 lesions received the full treatment course. The complete
response rate at last followup was 95%(77/81). Local failure was seen
in 3.7%(3/81) and regional failure was seen in 1.2% of 81 lesions.
Three patients with 7 lesions were lost to followup. The KM local
relapsefree survival was 88.4% and locoregional relapsefree survival
was 83.5% at 64 weeks. There were no Grade 3 or Grade 4 toxicity,
49% patients had Grade 2 dermatitis and 51% had Grade 1 skin
changes. There was complete resolution of skin toxicity by 3 months.
One patient developed a persistent ulcer after subsequent biopsy for
suspected recurrence.
: 3TAB is feasible treatment for HN skin cancers, with
low acute toxicity. Early outcomes show good local control and low
long term toxicity, but longer follow up is warranted.
PO409
LOCAL EXCISION AND BRACHYTHERAPY FOR SPHINCTER PRESERVATION
IN RECTAL CANCER: RESULTS ON A COHORT OF 70 PATIENTS
L. Grimard 1 , H. Stern 2
1
The Ottawa Hospital Regional Cancer Centre, Department of
Radiotherapy, Ottawa, Canada
2
Montreal Jewish General Hospital, Department of Surgery, Montreal,
Canada
: From Nov 1991 to March 2011, 70 patients (Pts)
were entered in a cohort combining local excision (LE), brachytherapy
(Ir192), and external beam radiotherapy (EBRT) for Pts at higher risk
of nodal disease. Long term results are presented.
: Seven Pts could not be treated as planned: 4
did not have a LE, and 3 did not have Ir192. There were 4 local
recurrences (LR) in this subgroup and they are excluded from this
analysis. There were 63 Pts treated as intended, 34 males and 29
females. Their age ranged from 33 to 88 with a median of 70, and 25
Pts (40%) were over 75 years old. There were 61 adenocarcinomas (18
WD, 35 MD, 6 PD, 2 unknown), one melanoma, and one
neuroendocrine carcinoma. Tumor was located in the rectum in 34 Pts
and at the anorectal junction in 29 Pts. Ir 192 dose was 4550 Gy
(Paris System) using single or double plane implant in the tumor bed
and 20 Gy after EBRT. There were 21 T1, 33 T2, and 9 T3 Pts. Two of
the T3 Pts had M1 disease. Ir 192 was used alone in 21 T1, and 20 T2
Pts. EBRT and Ir192 was used in 13 T2 and all T3 Pts. Chemotherapy
was given with EBRT in 2 T2 and 7 T3 Pts.
: Following LE, margins were negative (R0) in 16 T1, 18 T2, 1
T3 and positive (R1) in 5 T1, 15 T2, and 8 T3 Pts. There were 14 LR,
including one in the perirectal nodes: 4 T1 (19%), 8 T2 (24%), and 2 T3
(22%) Pts. There was no increased risk for T1 and T2 of LR with
regards to margins. There were 8 LR in the 34 R0 Pts (23%) and 4 LR in
the 20 R1 Pts (20%). There were 6 salvage surgeries in 3 T1 and 2 T2
Pts: three are NED at 3, 7, 10 years, one is alive with disease at 3
years, and 2 died of metastatic disease. Two patients required a
colostomy because of radionecrosis. Two patients had significant
incontinence. There were 16 deaths from disease, including the two
patients expected with Stage IV, and 7 died from other causes.
: This approach is promising for frail and elderly Pts at
high surgical risk for a major resection. Adjuvant Ir192 is a valid
alternative to major resection in some Pts with positive margins after
LE.
PO410
TRANSLATIONAL NEOADJUVANT HIGH DOSE RATE ENDORECTAL
BRACHYTHERAPY FOR RECTAL ADENOCARCINOMA
J. Herman 1 , J. Efron 2 , N. Azad 3 , E. Wick 2 , E. Shin 4 , I. Kamel 5 , A.
Singh 6 , L. Diaz 3 , A. HackerPrietz 1 , S. Gearhart 2
1 Johns Hopkins University, Radiation Oncology, Baltimore MD, USA
2 Johns Hopkins University, Surgical Oncology, Baltimore MD, USA
3 Johns Hopkins University, Medical Oncology, Baltimore MD, USA
4 Johns Hopkins University, Gastroeterology, Baltimore MD, USA
5 Johns Hopkins University, Radiology, Baltimore MD, USA
6 Johns Hopkins University, Pathology, Baltimore MD, USA
: Neoadjuvant chemoradiation therapy (NCRT) is
the standard of care for TxN12, T34N0, rectal adenocarcinoma.
Previous studies have shown improved local control and reduced
toxicity with NCRT compared to adjuvant therapy. NCRT consists of
approximately 56 weeks of external beam radiation with concurrent
5Fluorouracil. Intensity Modulated Radiation Therapy (IMRT) has been
studied in attempt to further limit dosing and toxicity to surrounding
normal tissue, but length of treatment does not differ. The addition
of more aggressive chemotherapy to NCRT has increased acute
toxicity rates, yet failed to improve response rates. Therefore a novel
approach using high dose rate endorectal brachytherapy (HDREBT)
given in 4 fractions (6.5Gy/day) on a pilot study was investigated.
Preliminary results of the first seven patients on protocol were
reviewed.
: Cases of the first 7 patients enrolled on HDR
EBT pilot study, who underwent surgical resection, were reviewed. All
patients had tumors 28%. Out of
the 7 patients, 3 had node negative disease at resection, 2 patients
had 1 positive node. All patients were margin negative and 6 had
sphincter preserving surgery, (other patient chose to have APR due to
age). 3 of 7 patients (43%) had a pathologic complete response (pCR)
of their primary tumors. Toxicity assessments showed only 1 patient
with grade 3 proctitis posttherapy, all others were grade 2 or less
consisting of proctitis and pain that resolved following surgery.
: HDREBT is a novel approach for rectal cancer that
reduces neoadjuvant treatment length, allows pts to undergo
resection sooner, and shows favorable tumor response
radiographically, pathologically, and biochemically. Preliminary
results appear encouraging to guide future studies and assist with
determining the efficacy of this modality.
PO411
BRACHYTHERAPY WITH IODINE 125 OR RUTHENIUM 106 FOR
TREATMENT OF CHOROIDAL MELANOMAS MEASURING 57 MM IN
THICKNESS

S164 World Congress of Brachytherapy 2012
L. Tagliaferri 1 , D. Smaniotto 1 , M.A. Blasi 2 , M. Pagliara 2 , A. Villano 2 , E.
Balestrazzi 2 , L. Azario 3 , S. Luzi 1 , V. Valentini 1
1
Università Cattolica del Sacro Cuore Policlinico A. Gemelli,
Department of Radiotherapy, Rome, Italy
2
Università Cattolica del Sacro Cuore Policlinico A. Gemelli,
Department of Ophthalmology, Rome, Italy
3
Università Cattolica del Sacro Cuore Policlinico A. Gemelli,
Institute of Physics, Rome, Italy
: Plaque radiotherapy is one of the most common
treatment modalities for uveal melanoma and the Collaborative
Ocular Melanoma Study found no significant difference between
enucleation and plaque radiotherapy with respect to patient survival.
The main aim of this study is compare Iodine 125 (I125) and
Ruthenium 106 (Ru106) plaque radiotherapy for uveal melanomas
measuring 57 mm in thickness with regard to treatment
complications and tumor control.
: Each case was evaluated at the weekly
multidisciplinary meeting with ophthalmologists, radiotherapists and
medical physicists. Treatment planning was performed by physicists
and validated by radiotherapists and ophthalmologists. For this
analysis we selected from our database, Patients with tumor thickness
of 57 mm presented between February 2007 and October 2010 and
treated with I125 (group A) or RU106 plaque +/ Transpupillary
thermotherapy (group B) plaque. We always prescribed respectively a
dose of 85 Gy (Group A) or 100 Gy (Group B) at tumor apex The
clinical data were then analyzed with regard to four outcomes of
radiation maculopathy, enucleation, local tumor recurrence, and
metastasis.
: The patieents of group A are 14 pts and group B are 12 pts.
Clinical and ultrasound data of group A and group B were as follow:
mean age (67 vs 65 years, range 4282) , mean tumor thickness (6.43
vs 5.34mm, range 5.06.9), mean tumor largest basal diameter (11.85
vs 11.33mm, range 7.5314.40). Mean follow was 24.2 months (range
14.338.7) in group A and 30.2 months (range 7.648.3) in group B .
Treatment with I125 resulted in higher rate of radiation maculopathy
(14.3% vs 8.3% respectively), lower rate of enucleation (7.1% vs 8.3%
respectively), lower rate of tumor recurrence (7.1% vs 8.3%
respectively), and lower rate of metastasis (0% vs 25% respectively).
The differences were not significant on univariate level (P > 0.05),
except for metastasis rate. The mean interval between treatment and
onset of metastatic disease was 30.5 months.
: The management of choroidal melanoma with a
thickness of 57 mm is controversial. Iodine seems to provide higher
local tumor control, while Ruthenium induces less radiation
complications. Although there are several limitations to our study, we
found that I125 represents a better option in these subgroup of
tumors, especially for preventing metastatic disease.
PO412
BRACHYTHERAPY OF THE ORBIT IN YOUNG CHILDREN
W. Sauerwein 1 , C. Stannard 2 , E. Biewald 3 , L. Brualla 1 , L. Lüdemann 1 ,
B. Timmermann 4 , N. Bornfeld 3 , A. Wittig 5
1
Universitätsklinikum Essen, Department of Radiotherapy, Essen,
Germany
2
Groote Schuur Hospital and University of Cape Town, Department of
Radiation Oncology, Cape Town, South Africa
3
Universitätsklinikum Essen, Department of Ophthalmology, Essen,
Germany
4
WPE gGmbH, Proton Therapy, Essen, Germany
5
University Hospital Marburg, Department of Radiation Oncology,
Marburg, Germany
: The most common ocular tumor in the childhood
is retinoblastoma. Uveal melanoma at this age is extremely rare. As
the survival probability of patients drops dramatically if the tumor has
invaded the sclera or the resection line of the optic nerve, or
macroscopic tumor has invaded the orbit these patients are managed
with radiotherapy to the orbit and (in the case of retinoblastoma)
with systemic chemotherapy. External beam radiotherapy, although
excellent in preventing a recurrence, interferes with growth of the
orbital bones in children resulting in very poor cosmesis, thus
requiring multiple surgical interventions. To avoid these
complications, several techniques were used with the goal to irradiate
the orbital contents, while shielding the bony orbit and eyelids.
: From 1992 to 2010 we saw 8 children (2 girls
6 boys) in the age range from 1 to 8 years (mean 2.5 y), suffering from
retinoblastoma (6 unilateral, 1 bilateral) and uveal melanoma with
involvement of the orbit. In 1992, two cases were treated by HDR
afterloading brachytherapy with Ir192 giving 2 daily fractions of 1.3 –
2 Gy up to a total dose of 40 Gy. In 2005, one child was irradiated by
protons (1 single field 4 x 2 Gy/week up to 50 Gy). Since 2007, five
children received LDR brachytherapy using I125 (technical details in
Strahlenther. Onkol. 187, 322327, 2011). This treatment consists of 6
trains of I125 seeds placed around the periphery of the orbit, and a
metal disc, loaded with seeds, placed beneath the eyelids.
: In all cases a longterm local tumor control could be
achieved. One child died 3 months after the treatment for rapidly
progressive intracerebral metastases. The follow up for the other 7
children is 219 years (mean 5 y). The children treated with HDR
brachytherapy and proton radiotherapy had a very poor cosmetic
outcome: In all of them a severe shrinking of the orbital socket and
fibrosis of the lids requested plastic surgery. The bones of the mid
face show an asymmetric growth, which however is less pronounced
as it was in former cases irradiated by external photon beam
radiotherapy. In contrast, the children after LDR brachytherapy have
a normal and symmetric growing of the bones of the face. In all
except one the ocular prosthesis can be worn without problems. The
only patient, who may need plastic surgery in this group had a tumor
infiltration of the lower lid, which had to be included in the target
volume.
: In the rare situation where in young children an
irradiation of the orbit has to be performed, best cosmetic results and
excellent tumor control can be achieved by LDR brachytherapy using
I125 implants. The irradiation should be designed in such a way as to
reduce the dose to the eyelids and the growing orbit in children.
External beam radiotherapy including proton irradiation should be
avoided. HDR brachyterapy using Ir192 it also leads to an unfavorable
dose distribution especially to the lids and cannot be recommended.
PO413
HDR BRACHYTHERAPY IN ADVANCED ESOPHAGEAL CANCER:
IMPROVEMENT OF DYSPHAGIA IN A COHORT OF 108 PATIENTS
M.L. Reisner 1 , R.Z. Grazziotin 2 , L. Morikawa 1 , H. Salmon 1 , A.A. Rosa 2 ,
T.M. Carneiro 2 , I.M. Veras 2 , M.A. Ferreira 2 , C.M. Viegas 2 , C.M. Araujo 2
1
Clinicas Oncológicas Integradas, Radiation Oncology, Rio de Janeiro,
Brazil
2
Instituto Nacional de CancerINCA, Radiation Oncology, Rio de
Janeiro, Brazil
: Most patients with esophageal cancer are
inoperable at presentation and dysphagia is one of the main symptoms
interfering with quality of life.
The purpose of this study was to estimate the improvement in
dysphagia and complication rate using HDR (highdoserate)
brachytherapy.
: Between August 1997 and July 2008, 108
patients with advanced esophageal cancer underwent HDR
brachytherapy with a total dose of 1500cGy in 3 fractions of 500cGy.
Tumors located in upper esophagus were also eligible to
brachytherapy. Tracheoesophagic fistula by bronchoscopy was
considered an absolute contraindication. Dysphagia was graded as 0
(absent), 1 (to solids), 2 semisolids, 3 liquids. The improvement after
brachytherapy was measured in a scale of points: 1 point
(improvement in 1 grade of dysfaghia) and 2 or 3 points (improvement
of 2 or 3 grades, respectively).
: After 8 weeks after brachytherapy, significant improvement
in dysphagia was observed in 36 % of patients and 42% remained
stable. An improvement of 1 point was observed in 21% patients, with
an improvement of 2 and 3 points in 10.5% and 4.7 % of patients,
respectively.
Complete clinical response by endoscopy was observed in 21%, greater
than 50% response in 18%, less than 50% response in 12% and disease
progression in 47% of the patients.
Overall, esophageal stenosis occurred in 39% of patients, bleeding in
6%, and fistula in 7%. Esophageal dilatation was performed in 29% of
cases and prosthesis was implanted in 11%. Complications based on
World Congress of Brachytherapy 2012 S 165
tumor location (upper, middle and lower esophagus) like stenosis
were observed in 46.1%, 37.8% and 42.8% of patients, respectively.
: Brachytherapy seems to be very effective in palliating
dysphagia on those patients with esophageal advanced disease.
Moreover, it is feasible even in upper esophagus.
PO414
A CASECONTROL STUDY OF PATIENTS WITH HEAD AND NECK
SQUAMOUS CELL CARCINOMA TREATED WITH PDR BRACHYTHERAPY
A. Haddad 1 , D. Peiffert 1 , V. Harter 2 , J.F. Betala 2 , I. Buchheit 3 , P.
Graff 1 , M. Lapeyre 4
1
Centre Alexis Vautrin, Department of radiotherapy, Vandoeuvreles
Nancy, France
2
Centre Alexis Vautrin, Department of medical statistics,
VandoeuvrelesNancy, France
3
Centre Alexis Vautrin, Department of physics, VandoeuvrelesNancy,
France
4
Centre Jean Perrin, Department of radiotherapy, Clermont Ferrand,
France
: PDR brachytherapy combines the radiobiological
benefits of lowdose rate delivery with the radioprotection and
optimization advantages of HDR brachytherapy. Practice in our
department has been progressively shifting away from continuous LDR
Iridium 192 wires to PDR dose delivery. We set out to evaluate the local
control and toxicity outcomes of this technique in patients with head
and neck squamous cell carcinoma.
: 36 consecutive head and neck patients
treated with PDR brachytherapy were randomly matched to 72 control
patients treated with LDR brachytherapy. Patients were excluded if
they were previously irradiated to the same site. Patients were
matched based on T stage (1/2 Vs 3/4), tumour site (oral cavity Vs
oropharynx), and use of surgery and/or external beam radiotherapy as
part of the management strategy. Local control and the incidence of
soft tissue and osteonecrosis were retrospectively evaluated and
compared between the two groups.
: Baseline patient and tumour characteristics were well
balanced between the two groups. Male to female ratio was 3:1, and
mean age was 57 yrs. Oral cavity cancers predominated at 81%.
Overall Tstage distribution was 46, 44, 6 and 3% for T1, 2, 3 and 4,
respectively. 75% of patients received brachytherapy postoperatively,
either alone or as a boost after external beam radiotherapy (EBRT),
while 14% underwent curative EBRT followed by a brachytherapy
boost and 11% were treated with brachytherapy exclusively. PDR
patients received a slightly lower mean dose than LDR patients, but
had a slightly higher rate of R0 resections. Median followup was 59
and 30 months for LDR and PDR patients, respectively. 3yr actuarial
local control rates were 97 and 94% for LDR and PDR patients,
respectively. Crude rates of soft tissue and osteonecrosis were 33%
and 22% for LDR and PDR, respectively, although KaplanMeier
estimates at 3 yrs found that this difference was not statistically
significant. Dose rate however was correlated with the incidence of
late necrosis for both groups: each increase of 1 cGy per hour (or per
pulse) was associated with a 34% increase in the relative risk of such
toxicity.
: We conclude that PDR brachytherapy in head and neck
squamous cell carcinoma yields comparable results to LDR treatment.
However, the ability to prescribe the desired dose rate and to
optimize the dose distribution may result in lower complication rates.
Furthermore, this technique decreases the exposure risk to medical
personnel, altogether making it the technique of choice in our
department.
PO415
LOCAL CONTROL, SURVIVAL AND COMPLICATIONS OF SOFT TISSUE
SARCOMAS TREATED WITH LOW OR HIGH DOSE RATE BRACHYTHERAPY
A. Paul 1 , E. Melian 2 , M. Surucu 2 , M. Kwasny 3 , M. Shoup 4 , C. Godellas 4 ,
D. Vandevender 4 , A. Sethi 2 , G. Aranha 4
1
Loyola University Medical Center and Rosalind Franklin University of
Medicine and Science, Radiation Oncology, Maywood IL, USA
2
Loyola University Medical Center, Radiation Oncology, Maywood IL,
USA
3
Northwestern University, Department of Preventive Medicine,
Chicago IL, USA
4 Loyola University Medical Center, Surgery, Maywood IL, USA
: Soft tissue sarcomas (STS) are rare tumors and
radiation therapy has played a major role in their treatment. This
retrospective analysis reviews the rates of local control, survival, and
significant complications (acute and chronic) of patients who received
low dose rate (LDR) or high dose rate (HDR) brachytherapy (BRT) at
our institution.
: From 1993 to 2011, 33 adult (median age =
58) patients with STS received LDR BRT (n= 9) or HDR (n = 24) as part
of initial or salvage local treatment. All patients had radical excision
with goal to remove tumor enbloc and simultaneous catheter
placement. BRT was started 45 days post surgery. LDR was used from
19932003 and HDR from 20042011. BRT was given with (18) or
without (15) external beam radiation (EBRT). Doses for BRT alone
were LDR 45 Gy or HDR 3437 Gy in 10 fractions given twice daily.
When BRT was given with EBRT doses were LDR 1520 Gy over 4 days
or HDR 13.620.4 Gy in 46 fractions given with 4550.4 Gy in 2528
fractions EBRT. KaplanMeier estimates of local control (LC), overall
survival (OS), and disease specific survival (DSS) are presented.
Association between LC, acute severe complications (ASC;

S166 World Congress of Brachytherapy 2012
brachytherapy.
: Regional recurrences following a full course
of radiotherapy were resected by an external approach and plastic
tubes were intraoperatively fixed to the surgical bed. The tubes were
fixed in a grossly parallel direction to cover all the high risk areas of
the surgical bed, both on the tissues to irradiate, by reabsorbable
stitches, and to the skin, by buttons and nylon. The irradiation started
in the 3rd postoperative day. In cases with a previous dissection of the
carotid to avoid the risk of a boost on the carotid wall we carefully
checked the distance from the tubes by a postoperative contrast
enhanced CT. The irradiation dose was 30 Gy in 12 fractions, 2.5 Gy
each, twice a day, in 6 days. The nasal packing and the catheters
were removed at the end of irradiation course. We calculated the
overall and relapse free survival starting from the day of the
procedure.
: We enrolled 5 patients, 3 with a neck recurrence from a
supraglottic SCC, 1 from a parotid dedifferentiated acinic cell
carcinoma, 1 with a locoregional recurrence of hypopharyngeal SCC.
All the cases with the exception of the hypopharygeal one, had
already undergone a neck dissection. 3 cases had undergone primary
surgery, the oher 2 (1 larynx and the hypopharynx) primary
radiochemotherapy (70 Gy+ cis q21). In 3 cases, reconstructed by a
microvascular free flap, the recurrence involved the skin. In 1 case a
pectoralis major flap was raised to protect the carotid in a previously
irradiated neck in which jugular vein, SCM muscle and spinal nerve
had been sacrificed (Crile operation). Median follow up was 7 months.
All the patients are still alive, 3 out of 5 with no evidence of disease.
No significant acute and late morbidities were recorded.
: Combination of extensive salvage surgery and
perioperative brachytherapy seems to be an effective option for
treating regional recurrences of head and neck malignancies. The
great conformation of the dose of brachytherapy and the
reconstructive surgery contribute to reduce morbidity. The main
problem in this cases is to avoid boosts on the carotid wall while
delivering an effective dose to the high risk area. For this aim both a
rational catheter positioning and a careful dose painting maximally
exploiting the possibilities offered by the modern IMBRT are
fundamental.
PO417
A PHASE I FEASIBILITY STUDY FOR HDR INTERSTITIAL BRACHYTHERAPY
USING 60CO FOR DIFFERENT SITES
S. Basu 1 , A. Basu 1 , K. Ghosh 1 , S. Datta 1 , S. Mullick 1
1
R.G. Kar Medical College Medical College, Department of
Radiotherapy, Kolkata, India
: 60 Co60 source with similar geometric and
dosimetric properties to 192 Iridium are now available. We present our
experience with 60 Co HDR remote afterloading brachytherapy in
interstitial implants/ surface moulds for different sites.
: Patients of different sites were accrued for this
phase I study to test the clinical feasibility and safety. Those included
in the study had been treated with radical brachytherapy or a boost
after EBRT with flexible or rigid interstitial implants or surface
moulds. They had flexible or rigid implants using plastic catheters or
steel needles using a Syed template respectively under general
anesthesia.Skin cancer patients had surface moulds using flexible
catheters fixed on thermoplastic devices. All patients then received
HDR brachytherapy with the Multisource remote afterloading machine
using 60 Co sources (Eckert & Ziegler BEBIG GmbH, Germany) and CT
based planning in the HDR Plus software v2.6. Planning parameters
mandated dose prescription to CTV. Initial response, local and distant
failures and toxicity were assessed every monthly for the first 3
months then two monthly.
: From October 2010 to December 2011, 31 patients of
carcinoma of different sites were treated at our centre with HDR
brachytherapy with interstitial implants or surface moulds with or
without EBRT. The diagnoses and the dose prescription are
summarized in Table 1. Till January 2012 only one prostate cancer
patient amongst those treated had a bone metastasis, no other
locoregional failures were observed. Amongst all the skin cancer
patients and 50% of the soft tissue sarcoma patients had acute G3 skin
toxicities at the 3 rd or 4 th week which resolved by 2 months. The only
breast cancer patient has slight telengectasia at the end of 1 year of
followup.
: HDR brachytherapy interstitial implants or surface moulds
using 60 Co sources for different sites is clinically feasible and safe with
favourable short term response and toxicity. It is also a very viable
option for economically strained regions as for the half life of
60
Cobalt. A long term larger study based on different subsites is
needed to draw a conclusion though.
PO418
HYPOFRACTIONATED ACCELERATED CTGUIDED INTERSTITIAL HIGH
DOSERATE BRACHYTHERAPY FOR LIVER MALIGNANCIES
N. Tselis 1 , G. Chatzikonstantinou 1 , C. Kolotas 2 , N. Milickovic 3 , D.
Baltas 3 , B. Rogge 3 , N. Zamboglou 1
1
Klinikum Offenbach GmbH, Department of Radiation Oncology,
Offenbach am Main, Germany
2
Hirslanden Medical Center, Institute for Radiotherapy, Aarau,
Switzerland
3
Klinikum Offenbach GmbH, Department of Medical Physics and
Engineering, Offenbach am Main, Germany
: To report our results of computed tomography
(CT)guided interstitial (IRT) highdoserate (HDR) brachytherapy
(BRT) in the local treatment of inoperable primary and secondary liver
malignancies.
: Between 2000 and 2009, 31 patients
underwent a total of 42 BRT procedures for 36 hepatic lesions
exceeding 4 cm and located adjacent to the liver hilum and bile duct
bifurcation. In all patients treatment was performed for progressive or
World Congress of Brachytherapy 2012 S 167
locally recurrent disease after failure of previous antitumor
therapies. Eight patients (26 %) received BRT for primary tumors
(hepatocellular carcinoma and intrahepatic cholangiocellular
carcinoma) and 23 (74 %) for metachronous metastatic disease. The
median tumor volume was 99 cm 3 (range, 461348 cm 3 ). The median
age was 64 years (range, 2785 years). The HDRBRT delivered a
median total physical dose of 13.0 Gy (range, 7.032.0 Gy) in twice
daily fractions of median 7.0 Gy (range, 4.010.0 Gy) in 14 patients
and in oncedaily fractions of median 8.0 Gy (range, 7.014.0 Gy) in 17
patients.
: The median followup was 13.3 months with an overall
survival rate of 66 % at one year. The overall local control (LC) was 82
% at one year, 57 % at two years and 57 % at three years. The LC rate
for patients with metastatic lesions was 79 %, 59 % and 59 %, and for
the subgroup with primary hepatic tumors 88 %, 50 % and 50 % at one,
two and three years, respectively. Seven mild and two major adverse
events occurred acute in 42 procedures with no procedurerelated
deaths. Mild adverse events were pain, nausea, and vomiting and
were treated symptomatically. The two severe events were
intraabdominal hemorrhages following catheter removal requiring
blood transfusions but no invasive intervention.
: Our results confirm CTguided IRTHDRBRT to be an
effective modality for the palliative treatment of inoperable liver
malignancies unsuitable for thermal ablation.
PO419
INTRAOPERATIVE HIGH DOSE RATE INTERSTITIAL BRACHYTHERAPY IN
THE MANAGEMENT OF SOFT TISSUE SARCOMAS
L. Varela Cagetti 1 , A. Polo Rubio 1 , A. Montero Luis 1 , R. Hernanz de
Lucas 1 , R. Colmenares 1 , D. Perez Aguilar 2 , I. Sanchez del Campo 2 , A.
Ramos Aguerri 1
1 Hospital Ramon y Cajal, Radiation Oncology, Madrid, Spain
2 Hospital Ramon y Cajal, Orthopedic Surgery, Madrid, Spain
: In a retrospective analysis we evaluated the
Ramon y Cajal Hospital experience of locoregional control, survival,
and complications of highdoserate (HDR) brachytherapy (BT) for soft
tissue sarcomas (STS) of the extremities, delivered in combination
with external beam radiation therapy (EBRT) and adjuvant
chemotherapy.
: Between 2007 and 2011, 10 patients with
biopsy proven STS (primary or recurrent), were managed with
conservation surgery (S) and intraoperative placement of plastic tubes
(11 implants) for HDR adjuvant BT delivery followed by EBRT.
Brachytherapy was performed with Ir192 High Dose Rate afterloader,
Brachytherapy dose calculation was based on the spatial
reconstruction of the implant from a CT image set. EBRT was
administered at the end of brachytherapy, once the healing process
was complete. The total dose of the combination of brachytherapy
and EBRT was calculated using the linearquadratic formulation
(EQD2). Chemotherapy was added in high grade tumors. Descriptive
statistics were calculated. A dosimetric and volumetric analysis was
performed. Survival analysis was performed according to the Kaplan
Meier method.
: Eleven implants were performed in ten patients. Median age
was 30 y. (range 13 86). Median largest tumor diameter was 6 cm
(range 219 cm). T stage was as follows: T1b, 4; T2a, 1; T2b, 6. Tumor
grade: I, 2; II, 4; III, 5. R0 resection was achieved in 4 patients, R1 in
6 patients and R2 in 1 patient. Median number of vectors was 8 (range
3 11). Median interval between S and start of irradiation was 12
days. Chemotherapy was administered in 5 patients.
Dosimetric and volumetric analysis is shown in table 1.
Median Range
BT Physical dose 19.8 Gy 17.5 54.0 Gy
BT Dose per fraction 3.4 Gy 3 6.5 Gy
BT Number of fractions 6 5 12
BT EQD2 21 Gy 19.5 65 Gy
EBRT Physical dose 46 Gy 45 46
Total EQD2 65 Gy 62 67 Gy
BT Reference volume 132 cc 38 271 cc
BT V150 43.9 cc 13.6 81 cc
BT V200 19.6 cc 6.0 37.0 cc
Median followup was 18.5 months (range 3.6 40.6 months). Three
year actuarial local relapse free survival (LRFS) was 88.8%. Local
relapse occurred in one patient, nodal relapse occurred in one patient
and distal relapses in three patients. In relation with the status
disease, in our series we found 7 patients with NED (no evidence of
disease), 2 patients AWD (alive with disease) and 2 patients DOD
(death of disease). Wound complication Grade 3 was observed in 36 %
of patients.
: The integration of HDRBT in the multidisciplinary
management of STS is feasible in a General Hospital. It offers
excellent local tumour control with an acceptable rate of
complications. Further followup is required to confirm our long term
results.
PO420
IMAGEGUIDED INTERSTITIAL HDRBRACHYTHERAPY IN THE LOCAL
TREATMENT OF INTRATHORACIC MALIGNANCIES
N. Tselis 1 , K. Ferentinos 1 , C. Kolotas 2 , J. Schirren 3 , D. Baltas 4 , H.
Ackermann 5 , N. Zamboglou 1
1
Klinikum Offenbach GmbH, Department of Radiation Oncology,
Offenbach am Main, Germany
2
Hirslanden Medical Center, Institute for Radiotherapy, Aarau,
Switzerland
3
Horst Schmidt Kliniken, Department of Thoracic Surgery, Wiesbaden,
Germany
4
Klinikum Offenbach GmbH, Department of Medical Physics and
Engineering, Offenbach am Main, Germany
5
J.W. Goethe University of Frankfurt, Institute of Biostatistics,
Frankfurt, Germany
: Imageguided interstitial (IRT) brachytherapy
(BRT) is an effective therapeutic option as part of a multimodal
approach to the treatment of intrathoracic tumors. In this study we
report our results of computed tomography (CT)guided IRT highdose
rate (HDR) BRT in the local treatment of inoperable primary and
secondary intrathoracic malignancies
: Between January 1997 and December 2010,
65 consecutive patients underwent a total of 102 interventional
procedures for a total of 77 lesions. All patients were not surgical
candidates and BRT was performed for progressive or locally recurrent
disease after failure of previous antitumor therapies. Fortyfive
patients received BRT for primary intrathoracic tumors and 20 for
metastatic disease. Fortyfive patients were male and 20 female with
a median age of 66 years (range, 2393 years). The median tumor
volume was 160 cm 3 (range, 24633 cm 3 ). The IRTHDRBRT delivered a
median dose of 25.0 Gy (range, 10.035.0 Gy) in twicedaily fractions
of 4.015.0 Gy in 30 patients, and a median dose of 10.0 Gy (range,
7.032.0 Gy) in oncedaily fractions of 4.020.0 Gy in 35 patients.
: The median followup was 13 months (range, 149 months).
The overall survival rate was 61 % at one year, 24 % at two years and 6
% at three years. The overall local control (LC) rate was 87 % at one
year, 83 % at two years and 78 % at three years. The LC rate for
metastatic tumors was 95 %, 88 % and 88 %, and for primary
intrathoracic cancers 84 %, 77 % and 73 % at one, two and three years,
respectively. Pneumothoraces occurred in 8 % of interventional
procedures, necessitating postprocedural drainage in one patient.
: Our results confirm CTguided IRTHDRBRT to be an
effective modality for the palliative treatment of inoperable
intrathoracic malignancies

S168 World Congress of Brachytherapy 2012
Aalbers, A. OC066
AbdahBortnyak, R. PO243
AbuRustum, N.R. PO252
Ackerman, S. OC136
Ackermann, H. PO420, PO233
Adamson, J. PO353, PO274, PO340, PO266
Adolfsson, E. PO346
Afsharpour, H. PO215, PD120
Aghamiri, S.M.R. PO348
Agostinelli, S. PO280
Aguero, E.G. OC134
Aibe, N. PO166
Akiyama, H. PO369, PO366
Aladin, A.S. PO365
Albert, M. PO349
Albitskiy, I. PO187
Alcalde, J. PO381, OC052
Aldridge, S. PO287, PO197
Alektiar, K. OC046, PO252
Alexander, R. OC034
Ali, M. PO251
Alizadeh, M. PO182
Allan, E. PO387
Allen, C. PO260
Allen, P. PD127
Alm Carlsson, G. PO346
Almadori, G. PO416, PO403
Alonzi, R. OC025
AlQaisieh, B. OC110, PO345
Aluwini, S. PO193
Alva, R.C. PO285
Amado, A. PO221
Amanie, J. OC071
Amin, P. PO405
Amit, A. PO243
An, L. OC074
Anand, V. OC076
Anastasakos, B. PO386
Andersen, C.E. OC069
Anderson, C. OC081
Andikyan, V. OC046
Ando, K. PO263
Andres, I. PO237
Ankerhold, U. PO336
Anscher, M. OC037
Antonini, P. PO296
Aoki, M. PO163
Aoki, Y. PO250
Apicelli, A.J. PO299
Appadurai, I. PO257
Apurba K, K. PO245
Aranha, G. PO415
Araujo, C. PO217, OC036, PO194
Araujo, C.M. PO413
Archambault, L. OC070
Archavlis, E. PO407
Arenas, M. PO240, PO237
Arias, F. OC052
Arika, T. PO366
Aristu, J. PO381
Arm, J. PO260
Armour, E. PO402, OC034
Armour, E.P. PO404
Arnold, A.A. PO356
Aronowitz, J.N. 146
Arora, S. PO383
Arribas, L. OC053
Arrojo Alvarez, E. PO195
Arthur, C. PO230, OC026
Arthur, D. OC136, OC092, 8, OC132
Arunachalam, K. PO329
Asbell, S. OC074
Ashenafi, M. PO334
Ashida, S. PO207
Ashikari, A. PO169, PO162
Asín Felipe, G. PO214
Aslay, I. PO307, PO300, PO294, PO400
Assmann, W. PO397
Astrahan, M.A. OC067
Atsushi, N. PO190
Aubin, S. PO224, OC038, PO354
AubineauLanièce, I. 18
Autorino, R. PO416, PO403
Axente, M. OC037
Azad, N. PO410, PO404
Azario, L. PO411
Bachand, F. OC036
Bader, M. PO397
Baghani, H. PO348
Bains, M.S. PO391
Bajard, A. PO211
Bajwa, H. PO251
Bakacs, G. PO218
Baker, S. PO387
Bakker, C.J.G. PD119
Balestrazzi, E. PO411
Ballester, F. PO204, PO202, PO181, PO328
Ballo, M. PD124
Balm, A.J.M. PD125
Baltas, D. PO420, PO418, PO233, PO407,
OC143
Balvert, M. PO352
Bar – Deroma, R. PO243
Barakat, R.R. PO252
Barani, I. OC037
Barney, B. PO239
Barra, S. PO280
Barret, E. PO154
Basagni, L. PO325
Basu, A. PO310, PO417
Basu, S. PO310, PO417
Batchelar, D. PO217, OC036, PO194
Batel, V. PO360
Battermann, J.J. PO165, PO148
Bauman, G. PO219
Baumann, A. PO302
Baumann, A.S. OC055
Bautista Hernandez Yicel, B.H.Y. PO406
Bautista, C. PO240
Beaney, R.B. PO197
Beaufort, C. PO178
Beaulieu, L. OC141, OC070, PO224, PO215,
OC038, PO354, OC139, PO326
Beavis, A.W. OC111
Beddar, S. OC070
Behera, M.K. PO376
BeikiArdakani, A. PO401
Beitsch, P. OC092
Bel, A. PO205
Belhomme, S. PO170
BéliveauNadeau, D. PO164
Bellini, A. PO280
Ben Yosef, R. PO243
Benda, R. OC136
Benedict, S.H. PO341
Benezery, K. PO388
Bennion, N. OC132
Benoit, R.M. PO159
Berenguer, R. PO237
Berger, D. OC083, OC135
Beriwal, S. PO304, PD128, OC045, OC073,
PO159, PO236
Berniger, A. PO243
Bernik, A. PO175
Bernstein, M. PO290
Bertelsman, C. PO299
Best, L. PO260
Betala, J.F. PO414
Bhagwat, M. OC086
Bhora, F. PO385
Biagioli, M.C. PO293, PO216, PO292
Bieleda, G. PO315
Biesta, J. PO248
Biete, A. PO240
Biewald, E. PO412
Biggers, R. OC028
Bijker, N. PO258
Bijok, M. PO321
Bilimagga, R. 59
Billan, S. PO243
Bilsky, M.H. PO390
Birn, G. PO407
Bisirtzoglou, D. PO386
Blank, L. OC056
Blasi, M.A. PO411
Bloom, E. PD124
Bochner, B. OC046
Bockelmann, G. PO335
Bodner, W. PO303, PO316, PO234
Boladeras Inglada, A.M. PO209
World Congress of Brachytherapy 2012 S 169
Boland, P. OC046
Bolla, M. PO180
Boockvar, J.A. PO382
Bornfeld, N. PO412
Boroghani, E. PO348
Borroni, M. OC078, PO270
Borst, G.R. PD125
Bosch, E. PO311
Bostwick, D. 14
Bottomley, D. PO173
Boudreau, C. PO164
Bourque, A. OC139
Bowes, D. PO217, PO194
Bownes, P. OC110, PO345
Bozic, N. PO287
Brachytherapy Working Group PO294
Brackett, N.C. OC134
Brader, P. PO271
Brandão, F. OC089
Bräutigam, E. OC131
Brenner, D.J. PO157
Broksch, R. PO232
Brouste, V. OC041
Brown, J. PD127
Brualla, L. PO361, PO412
Bruno, T.L. PO228
Brüske, N. PO232
Bryant, L. OC025
Buchheit, I. PO414, OC055
Buckley, D.L. OC110
Buhleier, T. PO233
Bukhari, M. PO312
Bullejos, J.A. PO269, PO186
Bulsara, M. PO323
Bumm, K. PO363
Buono, E. PO325
Burri, R.J. PO157
Bus, S.J.E.A. PO265
Bussu, F. PO416, PO403
Byrski, E. PO313
Cai, J. PO353, PO274, PO340, PO266
Caley, A. PO257
Calvo Crespo, P. PO320
Camacho, C. PO296, PO295, PO291
Cambeiro, M. PO381, OC052
Came, D. PO213
Campos, C. PO246
Caputo, T. PO259
Carey, B. OC110, 2
Carlsson Tedgren, A. PO346
Carmona, V. PO220, PO296, PO295, PO291
Carneiro, T.M. PO413
Carney, M. PO359
Carrara, M. OC078, PO270
Carrascosa, M. OC053
Carrizo, M.V. PO237
Carvalho, A.L. PO360
Carvalho, L. PO284, PO347, PO201
Casale, M. PO325
Castilho, L. PO212
Castro Gómez, E. PO320
Castro, C. PO201
Cathelineau, X. PO154
Cattani, F. PO319
Caudrelier, J.M. 11
Cavanaugh, S. OC136
Cavatorta, C. OC078
Celada, F. PO296, PO295, PO291
Celada, F.J. PO220
Cerrotta, A. PO270
Cesaretti, J.A. PO157
Chadwick, E. PO231, PO225, PO222, PO210
Challacombe, B. PO197
Champoudry, J. OC040, OC084
Chan, E.K. PD123
Chand, M.E. PO388
ChandFouche, M.E. PO183, PO192
Chang, C. PO309
Chao, K.S.C. PO383, PO382, PO259, PO157
Chapman, K.L. PO199, PO272
CharraBrunaud, C. PO302, 107
Chatfield, M. PO174
Chatzikonstantinou, G. PO418, PO407
Chaudhari, P. PO262
Chemin, A. PO170, OC041
Chen, C.P. OC029
Chen, P.Y. OC090
Chen, T. PO317
Chen, X.C. PO288
Chen, Y. OC074
Chi, D. OC046
Chicata Sutmöller, V. PO214
Chicata, V. OC052
Chichel, A. PO198, PO315
Chino, J. PO353, PO274, PO340, PO266,
PO329
Chiquita, S. PO358
Chirico, L. PO325
Chiu, J. PO390
ChiuTsao, S.T. OC067
Chng, N. PO213
Cho, Y.B. OC085
Choi, W. PO385
Chopra, S. PO278
Choudhury, A. PO230, OC026
Chuong, M.D. PO216
Chust, M.L. OC053
CikowskaWozniak, E. PO267
Cirino, E. PO161
Coakley, F.V. 15
Cohen, G. PD122, PO200
Cohen, G.N. PO391, PO390, PO379, OC032
Cohn, E. OC028
Colangione, S.P. PO319
Collado, E. PO220, PO291
Colmenares, R. PO419
Colombo, A. PO282, PO185
Comi, S. PO319
Connery, C. PO385
Conroy, R. PO173
Consorti, R. PO218
Corica, T. PO323
Cormack, R. OC112, OC086
Cornell, D.C. PO356
Cosentino, D. PO249
Cosma, S. PO308
Cosset, J.M. PO154
Courdi, A. PO388
Cox, B. OC031, PD122, PO200, OC032
Craciunescu, O. PO353, PO274, PO340, PO266,
PO329
Crandley, E. PO297, PO341
Crehange, G. PO211
Creutzberg, C.L. 130
Croce, O. PO330
Crook, J. PO217, OC036, 11
Crook, J.M. PO194
Cruz, A. PO293, PO216, PO292
Cuaron, J. PD122
Cuartero, J. OC085
Cuccoli, D. PO218
Cunha, A. OC027
Cunha, J.A.M. OC114, PO359
Czyzew, B. PO306, PO321
da Silva, M.G.C. PO246
Dabkowski, M. PO306, PO321
Dabrowski, T. PO313
Dagnault, A. 11
Damast, S. PO252
Damato, A. PO305, OC112, PO357, OC086
D'Amico, R. PO282, PO185
D'Amours, M. PO326
Danielsen, S. OC144
Datsenko, P. PO187
Datta, S. PO310, PO417
Davidova, O.N. PO365
Davila Fajardo, R. PO392
De Brabandere, M. OC066
de HaasKock, D. PD120
de Jong, I.J. PO148
de la Vara, V. PO237
De Leeuw, A. OC081, PO235, PD128
de Leeuw, H. PD119
de Pooter, J. 18, OC065
de Prez, L.A. OC065
de Reijke, T. 17
De Werd, L. 19
Declich, F. PO282, PO185
Dejean, C. PO192, PO183
Deka, P. PO285

S170 World Congress of Brachytherapy 2012
Del Moral Ávila, R. PO186
Del Moral, R. PO269
Delannes, M. PO211, 103
Delouya, G. PO164
Demanes, D.J. PO191
Demanes, J. PO289, OC024
Dempsey, C. PO260, PO238
den Hertog, D. PO327, PO352, OC077
Deo, S.V.S. OC133
Depiaggio, M. PO204, PO181, PO202
Derrah, L. OC072, PO219
Desai, P. PO259
Desai, S. OC054, OC054
Descat, E. PO170
Descotes, J.L. PO180
Deshpande, D.D. PO343
Deshpande, S. OC076
Despré, P. PO224
Després, P. OC038, OC139, PO326
Devic, S. OC113
DeWees, T.A. PO299
DeWerd, L. PO342, OC068, 93, 20
Diallo, I. OC084
Diaz, L. PO410, PO404
Dicker, A.P. PO199
Dilworth, J. PO229
Dimopoulos, J. 6
Dinapoli, N. PO416, PO403
Ding, K. PO297, PO341
Dinkla, A.M. PO205
Dixit, N. PO309
Doggett, S. 11
Doino, D. PO280
Dokiya, T. PO158
Dolinska, Z. PO384
Domínguez Domínguez, M.A. PO214
Donath, D. PO164
Doyle, L.A. PO199, PO272
Draghini, L. PO325
D'Souza, D. OC072, PO219
Du Plessis, F.C.P. PO380
Dugal, R. PO349
Dumas, I. OC040, OC084
Dunnington, G.H. 98
Durbin Johnson, B. PO281
Dutta, S. PO376
Dybek, D. PO313
Dyk, P.T. PO299
Dymnicka, M. PO315
Dziecichowicz, A. PO313
Eagle, A. PO339, PO268
Eastham, J. OC031
Ebara, T. PO206
Ebert, M. PO184, PO184
Efron, J. PO410, PO404
Egawa, S. PO163
Egger, J. PO288
Eidi, R. PO348
Eifel, P. PD127
Einck, J. OC113
Eito, C. PO214
Elliot, P. PO230
Elsaid, A. PO241
EMBRACE Study Centers, E.M. OC043
Engineer, R. PO278
Eniu, D. PO374
Erickson, B. 23
Esquivel, C. PO152
Evans, A. PO385
Expósito Hernández, J. PO186
Expósito, P. PO269
Ezhgurova, Y. PO208
Fahy, L. PO298
Fallai, C. PO270
Farrow, H. PO387
Fathalizadeh, A. PO400
Fayda, M. PO400
Federico, M. OC043
Ferentinos, K. PO420
Fernandez, D.C. PO293, PO216, PO292
Fernández, J. PO195
Ferreira, M. PO286
Ferreira, M.A. PO413
Ferreira, U. PO212
Ferrer González, F. PO209
Feuillade, J. PO192, PO388
Fidarova, E. OC083, 101
Fietkau, R. OC088, PO177
Figueira, A. PO360
Filipowski, T. PO399, PO176
Finger, P.T. OC067
Fleckenstein, J. PO363
Floquet, A. OC041
Florea, L. PO374
Flores, D. PO388
Flower, E. PO350
Flühs, D. PO361
Fodor, C. PO319
Fodor, J. OC087
Fokdal, L. OC082, OC039, OC069
Folkert, M.R. PO390, PO379
Followill, D.S. OC067
Forsythe, K. PO149
Foster, W. PO224, PO354
Franchisseur, E. PO330
Frank, S. PO227
Frank, S.J. PO228
Franken, S. PO165
Frantzeskou, K. PO257
Freilich, J.M. PO293, PO292
Fried, P. 11
Frigerio, C. PO282, PO185
Fu Jun, Z. PO372
Fuentes Mariles Sonia, F.M.S. PO406
Fulkerson, R. OC068
Furmanchuk, L. PO279
Furukawa, S. PO369
Fyles, A. OC085
Gabel, M. PO256
Gademann, G. 100
Gagea, M. PO227
Gagne, N.L. PO355, PO378
Gagne, S. PO349
Gal, J. PO192, PO183, 138
Galalae, R. PO232, OC024
Galhardo, E. PO349
Gambarini, G. OC078
Gandhi, A.K. OC042, PO338
Ganesh, K.M. PO247
GarcíaFoncillas, J. PO381
GarciaMora, M.C. PO295, PO220
GarciaRamirez, J. PO276, PO299
Gardner, G.J. PO252
Gardner, S.J. PO199
Garelli, S. PO280
Garg, A. OC114
Garg, M. PO303, PO234
Garipagaoglu, M. PO307
Garner, D. PO171
Garofalo, M. PO405
Gauthier, M. PO388, PO183
GazdicSantic, M. PO333
Gaztanaga, M. PO217, OC036, PO194
Gearhart, S. PO410, PO404
Geijsen, E. OC056
Gentil Jiménez, M.A. PO186
Gentil, M.A. PO269
Georgiou, E. PO337
Gérard, J.P. 99, PO388, PO330
Gerdes, H. PO379
German Farfalli, G.F. PO377
Gerst, S. OC046
Gherardi, F. PO319
Ghilezan, M. PO229
Ghosh, J. OC054
Ghosh, K. PO310, PO417
Ghosh, S. OC071
Giannelli, F. PO280
Gibbs, G. OC028
Gifford, K. PD124
Gilmore, J. OC040, OC084
Giraud, J.Y. PO180
Godellas, C. PO415
Godfrey, L. PO318
Godley, A. PO394
Goksel, E.O. PO307
Goldberg, K. OC114
Goldner, G. PO271
Golub, S. PO187
Gomes, M. PO284
World Congress of Brachytherapy 2012 S 171
González Patiño, E. PO320
González, H. PO195
Goodman, K.A. PO379
Gorissen, B. PO352, OC077
Gorissen, B.L. PO327
Gospodarowicz, M. 102
Gottschalk, A. OC029
Goulart, J. OC040, OC084
Grabowski, S. PO405
Graff, P. PO414
Granero, D. PO328
Graves, Y.J. PO322
Grazziotin, R.Z. PO413
Greene, T. PO318
Greskovich, J. PO394
Gribaudo, S. PO308
Grigsby, P. PO276
Grigsby, P.W. PO299
Grimard, L. PO409
Gruszczynska, E. PO306, PO321
Guedea Edo, F. PO209
Guerra, A.S. 18
Guerrero Tejada, R. PO186
Guerrero, R. PO269
Gugic, J. PO261
Guinot, J.L. OC053, 118
Guirado, D. PO333
Gulia, A. OC054
Gupta, D. PO259
Gupta, L. PO262
Gupta, S. OC054, PO278
Gustafson, G. PO229
Gustafsson, H. PO346
Gutiérrez Miguélez, C. PO209
Guyon, F. OC041
Hachem, S. PO330
HackerPrietz, A. PO410, PO402
Haddad, A. PO414, OC055
Haddock, M. PO239
Haga, A. PO167
Hagan, M.P. OC037
Haider, I. PO251, PO312
HaieMeder, C. OC040, OC083, OC084, 107, 12, 1
Hajage, D. PO154
Hajdok, G. OC072
Halperin, R. PO217
Hamano, T. PO250
Hamid, S. OC136
Hammer, J. OC131
Han, D. OC113
Han, S.B. OC075
Hanlon, A. PO405
Hanna, L. PO257
Hanna, N. PO405
HannounLevi, J. 138
HannounLevi, J.M. PO192, PO183
Hansen, E.S. OC039
Happersett, L. OC032
Harper, J. PO334
Harter, V. PO414
Hawliczek, R. PO223
Haworth, A. PO184, PO184
Hayes, M. PO171
Hayman, O. PO344, PO264, PO332
Heidenreich, A. 80
Hellebust, T.P. OC083
Henkel, T. PO155
Henrique, R. PO201
Henry, A. OC110, PO345, PO153
Hepel, J.T. PO314
Hering, E.R. PO380
Herman, J. PO410
Herman, J.M. PO404, PO402
Hernanz de Lucas, R. PO419
Herreros, A. PO240
Hervieux, Y. PO164
Hewitt, M. PO339, PO268
Heysek, R.V. PO216
Hiatt, J.R. PO314
Hickman, A. PO257
Hijazi, H. PO192, PO183
Hildebrandt, G. OC088
Hindson, B. PO178
Hirashima, Y. PO250
Hiratsuka, J. PO158
Hissoiny, S. PO326
Hobbs, R. PO402
Hobbs, R.F. PO404
Hodek, M. PO150
Hoekstra, C. OC035
Hoffmann, A. PO352, PO327, OC077
Hoffstetter, S. PO302
Hojo, H. PO189
Hokland, S.B. OC082
Holcomb, K. PO259
Homola, L. PO151
Honda, K. PO160
Hong, L. PO303, PO316, PO234
Horenblas, S. PO148
Horiba, M. PO405
Horowitz, D.P. PO157
Horsfield, C.J. OC111
Hoskin, P. PO173, OC025, PO153, 5
Hosseini Daghigh, S.M. PO348
Hosseinzadeh, K. OC045
Houédé, N. PO170
Houser, C. PO304, OC073, PO236
Hruby, G. PO188, PO174
Hsu, I. OC029, OC027
Huang, M.W. PO398, PO396, PO393
Hudej, R. PO175
Hudson, E. PO257
Huger, S. OC055
Hughes, L. OC074
Hughes, R. OC025
Hunt, D. OC027, PO293, PO292
Hürter, W. PO311
Hussein, S. 11
Ibbott, G. 93
Iftimia, I. PO161
Ilson, D.H. PO379
Immerzeel, J. OC035
Inaba, K. PO255
Indrieri, P. PO249
Ioannou, L. PO264, PO332
Ishida, M. PO156
Ishikawa, H. PO206
Isohashi, F. PO179
Italiani, M. PO325
Itami, J. PO255
Ito, Y. PO255
Itoh, K. PO206
Ivanov, S. PO187
Iwata, T. PO166
Jaberi, R. PO348
Jackson, M. PO174
Jagadesan, P. PO262
Jain, A. PO385
Jambhekar, N. OC054
Jansen, E. OC056
Jansen, P. PO193
Janssen, T.G. PO265
Janssens, G.O. OC051
Jauns, C. PO193
Javed, S. PO231, PO225, PO222, PO210
Jelly, F. PO373
Jennings, S. OC028
Jenrette, J. PO334
Jezioranski, J. PO401
Jhingran, A. PD127
Jia, L.F. PO398
Jiang, P. PO389, PO242, PO368
Jiang, W. PO389, PO242, PO368
Jiang, Y. PO389, PO371, PO370, PO368
Jimenez, E. PO237
Jiménez, I. PO195
Johansen, M.J. PO227
Jordan, K. PO219
Jorge, M. PO286
Joseph, D. PO184
Joseph, D.J. PO323, 9
Julka, P.K. OC042, PO338, PO262, OC133
Jurado, M. PO381
JürgenliemkSchulz, I. 4, PO235, PD128
Juvekar, S. OC054
Jyotirup, G. PO245
Kaanders, J.H. OC051
Kacso, G. PO374
Kahmann, F. PO155
KaidarPerson, O. PO243

S172 World Congress of Brachytherapy 2012
Kakimoto, N. PO369
Kaldas, S. PO188
Kallol, B. PO245
Kalnick, S. PO316
Kalnicki, S. PO303, PO290, PO234
Kamada, T. PO263
Kamel, I. PO410
Kaminuma, T. PO206
Kamoi, K. PO166
Kamrava, M. PO289, PO191
Kanao, K. PO156
Kanehira, C. PO163
Kanikowski, M. PO198, PO315
Kannan, N. OC073, PO236
Kannan, V. OC076
Kano, M. PO366
Kao, J. PO157
Kaplan, S. PO273
Kapur, T. PO305
Kapur, T.K. PO288
Karasawa, K. PO263
Kariya, S. PO207, PO158
Karlsson, L. PO362
Kasamatsu, T. PO255
Kasaova, L. PO364, PO150
Kasch, K.U. PO155
Kashiyama, S. PO156
Kasler, M. OC087
Katayama, M. PO156
Kato, S. PO263
Katoh, H. PO206
Katsilieri, Z. OC143
Katsilieris, I. PO386
Kattevilder, R. OC035
KauerDorner, D. OC135, 138
Kaushik, G. PO245
Kavanaugh, J. PO299
Kawakami, N. PO212, OC089
Kawczynska, M. PO306, PO321
Kazberuk, D.E. PO399
Kefala, V. OC143
Keisch, M. OC092
Keisei, O. PO168
Kemikler, G. PO300, PO400
Kemp, J. PO301
Kerkar, R. PO278
Kerkmeijer, L. PO172
Kertzscher, G. OC069
Keshtgar, M. PO323
Keyes, M. PD123, PO171
Khan, A. PO317
Khuntia, D. 98
Kido, M. PO163
Kiess, A. PO252
Kim, D. PO217
Kim, H. PO304, OC073, PO236
Kim, L. PO317
Kim, Y. PO339, PO268
Kimmig, B. PO232
Kind, M. OC041
Kirby, N. PO359
Kirchheiner, K. PO271
Kirisits, C. OC044, OC043, PO271, OC081, 108,
109, 107, 94
Kirkels, W. PO193
Kirsner, S. PD124
Kishi, K. PO203
Kitagawa, R. PO250
Kiyohara, H. PO263
Kizir, A. PO400
Klopp, A. PD127
Knaup, C. PO152
Kobayashi, K. PO166
Kobayashi, M. PO163
Kobayashi, R. PO158
Kobzda, J. PO267
Kodani, N. PO166
Koedooder, C. OC066, PO205, PO258, OC056
Kohno, N. PO168
Koike, N. PO162
Koizumi, M. PO179, PO369
Kolar, M. PO394
KolkmanDeurloo, I. PO193
Kollmeier, M. OC031, PD122, OC032 PO200,
PO252
Kolotas, C. PO420, PO418, PO407
Koning, C. OC056
Konishi, K. PO179
Koper, P. PO248
Korbelik, J. PO171
Koretsune, Y. PO366
Kosenko, I. PO283, PO279
Kostevich, G. PO279
Kotzen, J.A. PO254
Kouji, A. PO190
Kouwenhoven, E. PO248
Kovacs, A. OC086
Kovacs, G. OC142, PO403, 138, OC135, 16
Kozlovsky, D. PO208
Kramer, N. OC074
Kratochwil, A. PO271
Krauss, D. PO229
Kreppner, S. PO177
Krishnamurthy, D. OC027
Krol, G. PO390
Kucucuk, H. PO307
Kucucuk, S. PO300, PO400
Kudchadker, R. PO227, PO228
Kudzia, R. PO313
Kuhel, W. PO383
Kukielka, A. PO313
Kulik, A. PO321
Kumar, R. PO402
Kunaprayoon, D. PO200
Kunogi, H. PO189
Kuo, H. PO303, PO290, PO316, PO234
Kuroda, Y. PO255
Kuruvilla, A. OC136
Kuske & C. Quiet, R. OC136
Kuske, R. 57, PO322
Kuten, A. PO243
Kutler, D. PO383
KwakkelHuizenga, L. PO248
Kwasny, M. PO415
Labeck, W. OC131
LaCouture, T. OC074
Lacroix, F. PO354
Lagier, J. PO388
Laing, R. PO231
Laing, R.W. PO225, PO222, PO210
Lala, M. OC076
Lan, L. PO340
Landry, G. PO346, PD120, OC140
Langdal, I. OC144
Langley, S. PO222, PO231, PO225, PO210
Lapeyre, M. PO414
Lapid, O. PO392
Lapointe, V. PD123
Lapuz, C. PO238
Larouche, R. PO164
Lartigau, E. PO241
Lasbareilles, O. PO170, OC041
Laskar, S. OC054
Lavallée, M.C. PO354
Lazzari, R. PO319
Le, Y. PO404, OC034
Lecuona, K. PO380
Lee, C. PO316
Lee, L. PO275, OC047
Lee, R. 97
Lee, S. OC091
Lefkopoulos, D. OC084
Lencart, J. PO284, PO347
Leonard, K.L. PO314
Leonardi, M.C. PO319
Leong, N. OC071
Lettmaier, S. PO177
Levenback, C. PD127
Lever, F.M. PD126
Levin, W. OC085
Lewis, C. PO219
Li, J. PO242
Li, K. PO356
Li, Y. PO375
Li, Z. PO375
Libby, B. PO297, PO341
Licht, N. PO363
Lim, J. PO281
Lin, L. PO309
Lin, L.E.I. PO370
World Congress of Brachytherapy 2012 S 173
Lin, P.S. OC037
Linares Galiana, I. PO186
Linares, I. PO269
Lindegaard, J. OC043, OC069, OC044, OC082,
OC039, 107, 23
Liney, G.P. OC111
Lipman, D. OC051
Lips, I.M. PD126
Lis, E. PO390
Litvinova, T. PO279
Liu, B. PO375
Liu, C. OC075, PO242
Liu, C.H.E.N. PO371
Liu, D. PO226
Liu, S.M. PO395, PO393
Livsey, J. PO230
Llacer, C. PO211
Lliso, F. PO220, PO296, PO295, PO291
Lo, T. PO161
Loessl, K. 138
Logue, J. PO230, PO173, OC026
Lokesh, V. PO247
Lomas, H. PO216
Long, J.A. PO180
LopezPicazo, J.M. OC052
LopezYurda, M. PD125
Lorentz, W.C. PO191
Lotfy, N. PO241
Lotter, M. OC088, PO177
Lovett, A. PO188
Lowe, G. OC025
Lowe, V. 3
Lozhkov, A. PO365
Lüdemann, L. PO412
Ludwig, E. PO379
Luis Aponte Tinao, L.A. PO377
Lujan Castilla Pomponio, L.C.P.PO406
Lukacko, P. PO384
Luna Vega, V. PO320
Lund, E. PO346
Luo, C. PO349
Lutgens, L. PD120
Luzi, S. PO411
Lyczek, J. OC088
Lyden, M. OC092
Ma, Y.Q. OC075
MacAulay, M. PO171
Madan, R. OC133
Madden, T. PO227
Madersbacher, S. PO223
Madon, E. PO308
Mah, D. PO316
Mahadevan, A. PO161
Mahantshetty, U. PO278, PO343
Mahdavi, D.R. PO244
Mahdavi, S.R. PO348
Maheshwari, A. PO278
Major, T. OC088, OC087
Makarewicz, R. PO267
Makker, V. PO252
Malik, J. PO230, PO173, OC026
Malinen, E. OC083
Manchul, L. OC085
Mandall, P. PO230, OC026
Mandell, P. PO173
Mangiacotti, F.P. PO218
Manigandan, D. OC042, PO338, PO262
Mantz, C.A. PO322
Marafioti, L. PO249
Maranzano, E. PO325
Marcela de la Torre, M.T. PO377
Marcelino, G. PO221
Marcie, S. PO388
Marcié, S. PO330
Maree, G.J. PO380
Markiewicz, W. PO399
Marolt, P. PO175
Marques Vidal, P. PO221
Marshall, I.R. OC134
Martell, K. OC071
Marthinsen, A.B.L. OC144
Martin, A.G. PO224, OC038, PO354
Martin, T. PO233
Martínez Carrillo, M. PO186
Martinez Cobo, R. PO196
Martínez Pérez, E. PO209
Martinez, A. PO229, OC024
Martínez, M. PO269
MartinezMonge, R. PO381, OC052, OC024
Martini, M. PO218
Martirosyan, K. PO227
Martof, A. PO341
Martos, A. PO237
Marussi, E. OC089
Masar, M. PO384
Masarykova, A. PO384
Masayoshi, Y. PO190
Masenga, D. PO308
Mason, B. PD124
Mason, J. OC110, PO345
Masood, A. PO251, PO312
Masood, U. PO312
Mast, M. PO248
Mathai, M. PO281
Mathur, N. PO200
Matos, J. PO201
Matsui, H. PO206
Mattiucci, G. PO416
Matylevich, O. PO279
Maurer, J. PO340, PO266
Mavrichev, S. PO283
Mavroidis, P. OC143, PO152
Mayadev, J. PO281
Mayahara, H. PO255
Mazeron, R. OC040, OC084
McGovern, M. PO197
McKenzie, M. PD123
McMahon, R. PO329
Mehmood, T. PO312
Mehta, K. PO303, PO316, PO234
Mehta, K.J. PO290
Meigooni, A. 93
Meigooni, A.S. OC067
Meijnen, P. PO205, PO258
Meirelles, A. PO212
Melchert, C. OC135
Melhus, C.S. PO355, PO314
Melian, E. PO415
Melich Cerveira, J. PO221
Méndez, L. PO195
Mendiboure, J. PO170
Mendonça, V. PO221, PO286
Meng, N. OC075, PO368
Meng, N.A. PO389, PO371, PO370
Mercedes, Z. PO269
Mesina, C. PO309
Mhatre, R. OC076
Mhlanga, S.H. PO254
Miccichè, F. PO416, PO403
Michael, A. PO210
Michalska, M. PO267
Micka, J. PO342, OC068
Mikami, M. PO250
Miki, K. PO163
Miki, T. PO166
Milenin, K. PO187
Milette, M.P. PO217
Milickovic, N. PO418, PO233, OC143
Milosevic, M. OC085
Minken, A. OC035
Mirri, M.A. PO218
Mitch, M. 93
Mitchell, C.K. OC090
Mitchell, D.M. PO147
Miyake, S. PO160
Miyakubo, M. PO206
Moerland, M.A. OC066, PO235, PD119, PD126,
PO165
Moeslein, F. PO405
Mohamed Yoosuf, A.B. PO147
Mohamed, S. OC044, OC081
Mohammed, F. PO254
Mohammed, N. OC024
Moman, M.R. PO165, PO148
Monajemi, T. PO226
Monetti, U. PO308
Monnin, D. PO170
Monninkhof, E. PO172
Monroe, A. OC028
Montazeri, A. PO373

S174 World Congress of Brachytherapy 2012
Monteiro Grillo, I. PO221, PO286
Montenero, G. PO377
Montero Luis, A. PO419
Montesdeoca, N. OC052
Monti, C. PO212, OC089
Montoya Monterrubio Juan, M.M.J.
PO406
Morales, J.C. PO220, PO296, PO295, PO291
Morcovescu, S. PD121
Morgan, R. PO210
Morgia, M. OC085
Morice, P. OC040
Morikawa, L. PO413
Morota, M. PO255
Morra, A. PO319
Morrier, J. PO354
Morris, J.W. PO171
Morris, S.L. PO197
Morris, W.J. PO213, PD123
Morton, J.F.M. PD121
Mosalaei, H. PO219
Motwani, S. PO256
Moumdjian, C. PO164
Mourtada, F. OC067
Moustakis, C. OC030
Mower, H. PO161
Mozerova, E.Y. PO365
Muhammad, A. PO312
Mukhopadyay, N. OC132
Mulhall, J. PO200
Mullick, S. PO417, PO310
Mulligan, M. PO219
Muñoz, M.J. PO237
Munro, R. PO380
Munsell, M.F. PO228
Murakami, N. PO255
Murakami, S. PO369
Murata, K. PO206, PO168
Murray, T. OC072, PO219, OC111
Murrer, L. PD120
Murtha, A. OC071
Muruganandham, M. PO339, PO268
Mussano, A. PO308
Mut, A. OC053
Muti, M. PO325
Mutyala, S. PO408
Mynampati, D. PO303, PO234
Naeem, M. PO287
Nagar, Y. PO264, PO332
Nahajowski, D. PO313
Nakagawa, K. PO167
Nakajima, Y. PO156
Nakano, T. PO206, PO277, PO263
Nakashiro, M. PO189
Namidome, R. PO162
Namitome, R. PO169
Napier, E. PO147
Napoli, J. PO318
Napolitano, M.E. OC067
Narra, V. PO317, PO256
Nash, M. OC029
Nassisi, D. PO308
Natale, R. PO388
Nath, R. OC067
Naveen, T. PO247
Nazarnejad, M. PO244
Ndlovo, A. PO318
Nedialkova, L. PO382, PO259
Nelson, C. PD124, PO256
Nemeth, G. OC087
Nesvacil, N. OC081
Neto, F.J.M. PO246
Nevelsky, A. PO243
Newhouse, C. PO273
Ng, J. PO157
Niazi, I. PO251
Nichols, E.M. PO405
Nickers, P. PO241
Niehoff, P. OC135, PO153, 138
Nielsen, S.K. OC069, OC082, OC039
Niewald, M. PO363
Niksa, M. PO399
Niladri B, P. PO245
Nishioka, A. PO207
Nishiyama, T. PO169, PO162
Nkiwane, K. OC043
Noble, S. PO257
Noda, S. PO277
Noda, Y. PO203
Nomden, C.N. PO235
Noordanus, R. PO392
Nori, D. OC091, PO383, PO382, PO259
Novaes, P.E. PO246
Nowik, W. PO399, PO176
Nozomu, T. PO190
Nuñez, A. PO237
Nuver, T. OC035
O'Brien, P. PO260, PO238
O'Toole, M.M. PO147
Obed, R.I. PO351
Oberlander, A.S. OC084
Ogata, T. PO179
Ogawa, K. PO179, PO369
Ogawa, Y. PO207
Oguchi, M. PO250
Oh, S. OC085
Ohara, R. PO156
Ohkubo, Y. PO263
Ohno, T. PO277
Ohri, N. PO272
Oismueller, R. PO223
Oka, T. PO160
Okada, Y. PO168
Okihara, K. PO166
Okinaka, Y. PO168
Okonogi, N. PO277
Okuma, K. PO167
Olarte, A. PO381, OC052
Oldrini, S. OC055
Olijve, G.H. PO265
Oliveira, A. PO201
Oliveira, J. PO201
Oliveira, J.A.A. PO246
on behalf of the TARGIT Trialists' Group,
PO323
Onoe, T. PO167
Oorschot van, T. PO248
Oosterveld, B.J. PO265
Oral, E.N. PO400
Orecchia, R. PO319
Osian, A. OC091
Ostler, P. OC025
Ott, O.J. OC088
Ouhib, Z. PO328
Oyekunle, E.O. PO351
Özbay, I. PO400, PO300
Ozell, B. PO326
Paas, L. PO311
Pagliara, M. PO411
Pahlajani, N. OC074
Palacios Eito, A. PO196
Palcic, B. PO171
Palled, S. PO247
Palloni, T. PO218
Palmer, A. PO344, PO264, PO332
Palmqvist, T. OC144
Paludan, M. OC069
Paludetti, G. PO416, PO403
Paluska, P. PO364, PO150
PancewiczJanczuk, B. PO399, PO176
Pandha, H. PO210
Pang, C.N. OC075
Pannullo, S. PO382
Panshin, G. PO187
Pantelis, E. PO337
Papagiannis, P. PO337, 117
Papaioannou, S. PO233
Papalla, K. PO386
Papanikolaou, N. PO152
Papavasileiou, T. PO407
Parashar, B. PO383, PO382, PO259
Park, S. PO289
Parker, B. PO217
Parker, K. PO257
Parliament, M. OC071
Patanjali, N. PO188, PO174
Patel, R. PO405, 98
Patil, N. OC072, PO219
Patwe, P. OC076
Paul, A. PO415
World Congress of Brachytherapy 2012 S 175
Paul, E. PO178
PaulsenHellebust, T. OC081
Pavese, A. PO383
Pavlov, A. PO187
Pawlicki, T. OC115
Peddada, A. OC028
Pedersen, E.M. OC082, OC039
Pedersen, J. OC071
Pei, X. OC031, PD122, PO200
Peiffert, D. PO414, PO302, OC055
Pellejero, S. PO214
Peng, J. PO334
Pera Fàbregas, J. PO209
Pereira, A. PO284, PO347, PO201
Perez Aguilar, D. PO419
Pérez Calatayud, J. PO202
Perez, C. 13
Perez, G. PO188, PO174
PerezCalatayud, J. PO204, PO181, PO328, 104
PO220, PO296, PO295, PO291
Perkova, H. PO151
Perry, K. PD121
Pervez, N. OC071, 11
Pesudo, C. OC053
Petera, J. PO364, PO150
Peters, M. OC033, PO165, PO148
Petersen, I. PO239
Petersen, L.K. OC039
Petit, A. OC041
Petric, P. OC083, PO261
Petrucci, A. PO218
Pickles, T. PD123
Piena, M. OC033
Pierrat, N. PO154
Pieters, B. PO392, OC056
Pieters, B.R. PO205, PO258
Pigge, C. PO339, PO268
Pigneux, J. OC041
Pignol, J. 11
Pignoli, E. OC078, PO270
Pike, T. PO342
Pina, F. PO221
Pino Sorroche, F. PO209
Piro, F. PO249
Pirraco, R. PO358, PO284, PO347
Placa, F. PO282, PO185
Plamondon, M. OC141
Platta, C. 98
Pobijakova, M. PO384
Polgar, C. OC088, 138, OC087, 7
Poli, M.E.R. PO331
Politis, G. PO386
Polizoi, B. PO386
Poljanc, K. PO223
Polo Rubio, A. PO419
Pomeroy, M. PO298
Pommier, P. PO211
Pons, O. PO220
Popert, R.B. PO197
Potrebko, P. OC074
Pötter, R. OC088, OC083, OC044, OC043,
PO271, OC081, 108, 109, 107, 23, 21
Pouliot, J. OC114, PO359, OC027
Praag, J. PO193
Prada, P.J. PO195
Pramod, K.P.R. PO247
Prefontaine, M. OC072
Prestidge, B. OC136
Price, M. PO301
Pugh, T.J. PO228, PO227
Pule, L. PO254
Puri, A. OC054
Putz, E. OC131
Qiu, H. PO404
Qu, A.N.G. PO371
Quiet, C.A. PO322
Quispe Santibáñez, K. PO209
Quon, H. PO402
Rahnema, S. OC134
Rajagopalan, M.S. OC045, OC073
Rajapakshe, R. PO217
Ramirez, P. PD127
Ramos Aguerri, A. PO419
Ran, W. PO371, PO370, PO242, PO368
Rangeard, L. OC055
Rasch, C.R.N. PD125
Rasheed, A. PO312
Rasoda, R. PO213
Rath, G.K. OC042, PO338, PO262, OC133,
PO376
Rauchenwald, M. PO223
Ravi, A. OC091
Rayment, R. PO257
Read, P.W. PO341
Reardon, K.A. PO297, PO341
Reerink, O. PD126
Refaat, T. PO241
Rehman, K. PO251
Reis, L. PO212
Reis, T. PO360
Reisner, M.L. PO413
Rekhi, B. OC054
Reniers, B. PO346, PD120, OC140
Resch, A. OC135
Rey, F. PO309
Reynolds, H. PO184
Ribeiro Nuno Ramos, T. PO331
Richard, S. PO363
Richardson, S. PO276, OC115
Richart Sancho, J. PO181
Richart, J. PO204, PO202, PO328
Richaud, P. PO170
Richetto, V. PO308
Ricke, J. 100
Rico Osés, M. PO214
Rigante, M. PO416, PO403
Rijnders, A. OC066, PO153
Rimner, A. PO391
Rios, I. PO240
Rishi Kartik, S. PO285
Rivard and C.S. Melhus, M.J. OC067
Rivard, M.J. PO355, PO314, PO378, 94, 93, 20
Rivin del Campo, E. PO196
Roach III, M. OC114, OC029
Rodríguez Villalba, S. PO202
Rodríguez, M.S. PO296
Rodriguez, S. PO204, PO181, PO295, PO291
RodriguezRuiz, M. PO381, OC052
Roesink, J.M. PO235
Rogers and R.M. Thomson, D.W.O.
OC067
Rogge, B. PO418, PO407
Rohant, N. PO318
Røhl, L. OC082
Røhl, L.L. OC039
Rojas, A. OC025
Roldán Arjona, J.M. PO196
Roldán, S. PO220, PO296, PO295, PO291
Rolfingsmeier, J. PO299
Romera, I. PO240
Romero, P. PO214
Rosa, A.A. PO413
Rosa, C.C. PO358
Rosenblatt, E. 101, 64
Rosenstein, M. PO316
Rosenzweig, K.E. PO391
Roth, A. OC135
Rovirosa, A. PO240
Rozet, F. PO154
Ruebe, C. PO363
Ruesga Vazquez Daniel, R.V.D. PO406
RuizArrebola, S. PO333
Sabater, S. PO237
Sabbas, A.M. PO382
Sacco, S. PO282, PO185
Sadeghi, A.G. PO322
Saglam, E.K. PO400
Saini, A.S. PO293, PO216, PO292
Saito, S. PO169, PO162
Sakelliou, L. PO337
Sakumi, A. PO167
Salcudean, S. PO213
Salembier, C. PO153
Salgado, L. PO284, PO347
Salmon, H. PO413
Salvador Garrido, N. PO320
Salvajoli, J.V. PO246
San Julián, M. PO381
San Miguel, I. PO381, OC052
Sanchez del Campo, I. PO419

S176 World Congress of Brachytherapy 2012
Sánchez Mazón, J. PO340, PO329
Sander, T. 18
Sandhu, J. OC046
Sandler, H. OC027
Sangalli, G. PO282, PO185
Santos Ortega, M. PO202
Santos, M. PO204, OC053, PO181
Sardi Mabel, S.M. PO377
Sasai, K. PO189
Sathiyan, S. PO247
Sato, M. PO203
Sato, T. PO158
Sauerwein, W. PO361, PO412, 11
Saunders, C. PO323
Sazzad Manir, K. PO245
Scala, L.M. PO200, OC046
Scala, M. OC032
Scanderbeg, D. PO322, OC115, OC113
Scardino, P. OC031
Scepanovic, D. PO384
Schaeken, B. OC066
Schäfer, C. PO397
Schattner, M.A. PO379
Schindel, J. PO339, PO268
Schirra, J. PO397
Schirren, J. PO420
Schlaefer, A. 16
Schleicher, U. PO311
Schmid, M. PO271
Schmidt, E. PO305
Schmidt, M. OC036
Schneider, B.F. PO297
Schneider, M.H. PO363
Schneider, T. PO336, 18
Schwartz, T.H. PO382
Schwarz, J.K. PO299
Scoz, M.C. OC089
Seevinck, P.R. PD119
Seewald, D.H. OC131
Segedin, B. PO261
Sekine, H. PO158
Selbach, H.J. 18
Sempau, J. PO361
Sengoz, M. PO307
Senkesen, O. PO307
Serarslan, B. PO400
Sereni, M. PO218
ServagiVernat, S. PO211
Sethi, A. PO415
Sgouros, G. PO404
Sha, S. OC136
Shah, C. PO229, OC090, OC024, OC092
Shah, M. PO312
Sharabura, T.M. PO365
Sharma, A. PO376
Sharma, D.N. OC042, PO338, PO262, OC133
Sharma, N. PO405
Sharma, S. OC042, PO285, PO338, PO262,
OC133
Sharma, S.C. PO376
Shi, J. PO293, PO292
Shi, Y. PO398, PO393
Shimizutani, K. PO369
Shin, E. PO410
Shinohara, K. OC029
Shirai, S. PO203
Shiraishi, K. PO167
Shoup, M. PO415
Showalter, T.N. PO199, PO272
Shrivastava, S.K. PO278
Shrivatava, S.K. PO343
Shuin, T. PO207
Shukla, N.K. OC133
Shuryak, I. PO157
Shyamal K, S. PO245
Shylashree, S. PO278
Siauw, T. OC114
Siebert, F. OC142
Siebert, F.A. PO232, PO335, PO153, 94, 20
Simancas, F. PO333
Simeonov, A. PO401
Simões, F. PO212
Singh, A. PO410
Sioshansi, S. PO314
Sirak, I. PO364, PO150
Sison, C. OC091
Skowronek, J. PO198, PO315
Slobina, E. PO208
Sloboda, R. PO226
Small Jr, W. PO241
Smaniotto, D. PO411
Smith, R.P. PO159
Snee, M. PO373
Snyder, M.B. PO322
Soares, A. PO201
Sola Galarza, A. PO214
Solc, J. PO336
Soldini, P. PO218
Soler, P. OC053
Soliman, P. PD127
Somay, C. PO223
Song, D. OC034
Song, T.L. PO396
Song, W. OC113
Song, X. PO375
Sonoda, Y. OC046
Sonomura, T. PO203
Soroka, A. PO208
Soumarova, R. PO151
Spadinger, I. PO213, PD123
Spiegl, K.J. OC131
Spratt, D.E. OC032
Sroka, R. PO397
Stafford, J. PO227
Stam, T. PO248
Stannard, C. PO412, PO380
Stas, N. PO324
Stathakis, S. PO152
Stauffer, P. PO329
Steenbergen, F. OC077
Steffey, B. PO353, PO274, PO340, PO266,
PO329
Steinberg, M. PO289
Stephens, T. PO157
Stern, H. PO409
Stern, R. PO281
Steuten, L. OC033
Stief, C. PO397
Stieg, P. PO382
Stillie, A. PO253
Stock, R.G. PO149
Stockman, T. PO339, PO268
Stoeckle, E. OC041
Stoianovici, D. OC114
Stojkovski, I. 101
Straney, M. PO147
Straube, W. OC027
Strnad, V. OC088, PO177, 138
Stump, K. 93
Sturdza, A. PO271
Sturza, A. 107
Suárez Charneco, A. PO186
Suárez Novo, J.F. PO209
Subramani, V. PO338
Sugawara, A. PO156
Sugimoto, A. OC072
Sulyok, Z. OC087
Sumi, M. PO255
Sun Myint, A. PO373
Sun, B. PO299, PO276
Sun, Y. PO395
Sundset, M. OC144
Surry, K. OC072
Surucu, M. PO415
Suslova, V. PO283
Suzuki, K. PO206
Svoboda, A. PO149
Swamidas, J. PO343
Swanson, D.A. PO228, PO227
Swapnendu, B. PO245
Swindell, R. PO230, PO173, OC026
SzmigielTrzcinska, A. PO399, PO176
Taboada Valladares, B. PO320
Taccini, G. PO280
Tadahiko, K. PO190
Tagliaferri, L. PO416, PO411, PO403
Tailleur, A. OC040
TakacsiNagy, Z. OC087
Takahashi, A. PO162
Takahashi, K. PO255
World Congress of Brachytherapy 2012 S 177
Takahashi, Y. PO179
Takaki, S. PO163
Takenaka, T. PO160, PO366
Takes, R.P. OC051
Takizawa, K. PO250
Tan, I.B. PD125
Tanaka, E. PO160, PO366
Tanderup, K. OC083, OC069, OC044, OC043,
OC081, OC082, OC039, 107, 23, 22
Tanvirpasha, C.R. PO247
Taussky, D. PO182, PO164
Teliyants, A. PO187
Tenconi, C. PO270
Teo, K. PO309
Terk, M. PO157
Tersteeg, J.H.A. PO235
Tessa, M. PO308
Tezcanli, E.T. PO307
Thames, H.D. OC131
Thawani, N. PO408
TherriaultProulx, F. OC070
Thissen, B. OC066
Thomadsen, B. 93
Thomas, L. PO211, PO170, OC041
Thullier, C. PO180
Thwaites, D. OC110, PO345
Tian, S. PO370
Timmermann, B. PO412
Todor, D. OC132, OC037
Toita, T. PO250
TomaDasu, I. OC144
Toni, M.P. 18
TopczewskaBruns, J. PO176
Tormo, A. PO220, PO296, PO295, PO291
TorneroLópez, A. PO333
Torresan, R. OC089
Tortajada, M.I. OC053
Tovar Martín, M.I. PO186
Tovar, I. PO269
Tovey, S. PO380
Townamchai, K. PO357, OC086, PO275, PO273
Toya, K. PO169, PO162
Track, C. OC131
Tran, A. PO230
Trauernicht, C.J. PO380
Trichter, S. PO383
Trigo, L. PO284, PO347, PO201
Trombetta, M. 11
Tsalafoutas, I. PO386
Tselis, N. PO420, PO418, PO233, PO407,
OC143
Tsubokura, T. PO166
Tsukamoto, N. PO156
Tsukiyama, I. PO158
Tsung, R. PO197
Ttian, S.Q. PO368
Tunn, U.W. PO233
Turbina, A.V. PO365
Türker, M. PO311
Ueda, M. PO160
Uehara, S. PO158
Ulhman, E. PO212
Umayahara, K. PO250
Untereiner, M. PO211
Upasani, M. PO278
Urgesi, A. PO308
Usman, S. PO251
Usmani, N. OC071
Uter, W. OC088
Uthamanthil, R. PO227
Valduvieco, I. PO240
Valentini, V. PO416, PO411, PO403
Valicenti, R. PO281
Vallancien, G. PO154
van 't Riet, A. OC066
van de Kar, M. OC056
van de Pol, S. OC035
van den Bos, W. PD128
van der Grient, J.N. PO205
van der Heide, U.A. PO165
van der Laarse, R. PO205
van der Poel, H.G. PO148
van der SteenBanasik, E.M. PO265
van Deursen, M. PO165
van Gils, F. OC140, PD120
Van Limbergen, E. 138
van Os, R. PO392, OC056
van Rooij, P. PO193
van Vulpen, M. PO172, OC033, PD119, PD126,
PO165
van Wieringen, N. PO205
Vandevender, D. PO415
Vanek, K. PO334
Vanneste, B. OC040, PD125
Varela Cagetti, L. PO419
Varfalvy, N. OC038, PO354
Vargas Arrabal, M.P. PO186
Vargas, P. PO269
Vasconcelos, A. PO286
Vavassori, A. PO319
Vedda, A. OC078
Velema, L. PD128
Venselaar, J. 93
Venselaar, J.L.M. 20
Ventura Bujalance, M. PO209
Vera, R. OC132
Veras, I.M. PO413
Verghis, R. PO147
Vergunst, H. PO148
Verhaegen, F. PO215, PO346, PD120, OC140
Verhoef, L.C. OC051
Verry, C. PO180
Vicini, F.A. OC090, OC092
Viegas, C.M. PO413
Vigneault, E. PO224, OC038, OC038, PO354
Vijande, J. PO328
Vijverberg, P.L.M. PO148
Vila Viñas, M. PO214
Villafranca, E. PO214
Villano, A. PO411
VillavicencioQueijeiro, M. PO406
Vinikovetskaya, A. PO187
Visser, P. PD120
Viswanathan, A. PO305, OC112, PO357, OC086,
PO273, OC047, 106
PO275, PO288
Viterbo, T. PO284, PO347, PO201
Vosmik, M. PO150
Vulpen, M. PO148
Vuong, T. OC113
Vyas, S. PO408
Vynckier, S. OC066
Wakatsuki, M. PO277, PO263
Wakil, G. PO154
Wakumoto, Y. PO189
Wallace, M. PO229, OC090
Wanderås, A.D. OC144
Wang, H. PO242, PO367
Wang, J. PO191, PO389, PO371, PO242,
PO367
Wang, J.J. OC075, PO370, PO368
Wang, T. PO402
Wang, W. PO375
Wang, Y. PO375
Wang, Z. PO349
Warden, M.J. PO318
WarrenForward, H. PO260
Wazer, D. OC136
Wazer, D.E. PO314
Webster, M. OC113
Weinberg, R. PO408
Weinberg, V. OC029
Welch, S. OC072
Wernicke, A.G. PO383, PO382, PO259
Westendorp, R. OC035
Whalley, D. PO174
Whitaker, M. PO188
White, S. PO346, OC140
Whitsell, T. PD124
Whittaker, M. PO174
Wick, E. PO410
Wiebe, E. OC072
Wild, A. PO402
Wilder, R.B. PO216
Wilkinson, A. PO394
Wilkinson, J.B. OC090, OC092
Williams, N. PO323
Williams, S. PO344, PO184, PO184
Williaume, D. PO211
Wilson, D. OC110

S178 World Congress of Brachytherapy 2012
Winship, A. PO287
With, A. PO362
Wittig, A. PO361, PO412
Wolf, S. OC142, PO335
Wondergem, J. 101
Wong, H. PO373
Wong, R. PO401
Wood, D. PO387
Workman, G. PO147
Wu, A. PO303, PO316, PO234
Wu, A.J. PO391, PO379
Wust, P. PO155
Wylie, J. PO230, PO173, OC026
Xie, J. OC085
Xiong, L. PO161
Yagi, Y. PO169, PO162
Yamada, R. PO203
Yamada, Y. OC031, PD122, PO390, OC032
Yamamoto, H. PO366
Yamamoto, K. PO167
Yamamoto, Y. PO163
Yamasaki, I. PO207
Yamazaki, H. PO166, PO369, PO160, PO366
Yang, J. PO359
Yang, R. PO389, PO371, PO370
Yang, Y. PO355
Yap, M.L. OC085
Yaparpalvi, R. PO303, PO290, PO234
Yashar, C. PO322
Ye, H. PO229, OC024
Yee, D. OC071
Yilmaz, M. PO307
Yoda, K. PO167
Yondorf, M. PO259
Yorozu, A. PO169, PO162
Yoshida, K. PO162, PO369, PO160, PO366
Yoshida, M. PO160, PO366
Yoshimura, Y. PO160
Yoshioka, Y. PO179, PO369
Youssef, A. OC074
Yu, G.Y. PO398, PO396
Yu, Y.A.N. PO370
Yuan, H. PO371, PO242
Yuan, H.S. OC075
Yue, J. PO317
Zahra, M. PO253
Zaider, M. PO390
Zakikhani, R. PO349
Zamboglou, N. PO420, PO418, PO233, PO407,
OC143
Zaragoza, F.J. PO361
Zelefsky, M. OC031, PD122
Zelefsky, M.J. PO200, PO391, OC032
Zettos, A. PO386
Zhang, J. PO398, PO396, PO395, PO393
Zhang, J.G. PO398, PO396, PO395, PO393
Zhang, N. OC114, PO359
Zhang, Z. PO200
Zheng, L. PO398, PO396, PO395, PO393
Zhu, L. PO274, PO371, PO242
Zhu, Y. PO349
Zhumabaeva, A.G. PO365
Ziccarelli, L. PO249
Ziccarelli, P. PO249
Zilli, T. PO182
Zimmermann, J. OC030
Zimmermann, P. OC030
Zoga, E. PO407
ZolciakSiwinska, A. PO306
Zouhar, M. PO150
Zourari, K. PO337
Zubizarreta, E.H. 101
Zuchora, A. PO298
Zuo, Y. OC114
Zwierzchowski, G. PO315