Background: A significant portion of head-and-neck cancer patients will develop persistent or recurrent disease after definitive treatment. Radiation therapy is often used as definitive therapy or as an adjunct to surgery. Recurrent cancer of the head and neck in the previously irradiated field is, thus, a common occurrence and poses a therapeutic challenge. Some studies have evaluated low-dose-rate (LDR) brachytherapy as a therapeutic option, including a large case series with long-term follow-up by our own institution. High-dose-rate (HDR) brachytherapy offers therapeutic advantages over LDR brachytherapy. This study evaluates the local control and outcomes of patients with previously irradiated recurrent head-and-neck cancer treated with HDR interstitial brachytherapy.Methods and Materials: Between 1997 and 2002, 30 patients who received prior radiation therapy for primary tumors of the head and neck were treated for biopsy-proven recurrent disease. All patients received previous radiation as definitive therapy alone or as adjunct to surgery. All patients were inoperable, refused surgery, or had gross residual disease after salvage surgery for their recurrent disease. Thirty-six sites on the 30 patients were implanted by application of high-dose-rate interstitial brachytherapy techniques with mean tumor dose of 34 Gy (18-48 Gy) in twice daily fractions of 300 to 400cGy per fraction.Results: At a minimum follow-up of 12 months, local tumor control was achieved in 69% of implanted sites. Disease-specific survival at 1 and 2 years was 54% and 45%, respectively. Overall survival at 1 and 2 years was 56% and 37%, respectively. Grade 3/4 late complications occurred in 16% of the patients. No fatal complications occurred.Conclusion: HDR brachytherapy can play an important role in the salvage treatment of previously irradiated recurrent head-and-neck cancer. This study shows that comparable results are obtained by HDR brachytherapy with fewer late complications than were indicated by previously reported data for LDR brachytherapy. (c) 2005 Elsevier Inc.

Purpose: To analyze the outcome of permanent I-125 interstitial radiotherapy for unresectable retroperitoneal recurrences of gynecologic malignancies.Methods and Materials: A retrospective review of 20 patients treated between 1979 and 1993 was performed to evaluate survival and morbidity associated with the interstitial I-125 technique.Results: Nineteen tumors were located on the lateral pelvic wall and one in the para-aortic region. Eight patients, not previously irradiated, received external beam radiotherapy (EBRT) along with I-125 interstitial implants placed at the time of celiotomy. Nineteen (95%) are dead of disease at 1-69 months of follow-up. The median survival was 7.7 months for patients treated with I-125 alone and 25.4 months for those treated with both I-125 and EBRT. One patient is alive without evidence of disease 69 months after I-125 implantation. Fistulas, bowel obstructions, and fatal complications occurred only among patients previously irradiated.Conclusions: When used in a previously irradiated field, I-125 interstitial radiotherapy has major morbidity and is unlikely to be associated with cure or long-term survival. In radiotherapy-naive patients with unresectable isolated recurrent gynecologic malignancies, I-125 implants and EBRT are feasible and occasionally may contribute to long-term disease-free survival. (C) 2002 Elsevier Science Inc.

Purpose: Recurrent cancers of the head and neck within previously irradiated volume pose a serious therapeutic challenge. This study evaluates the response and long-term tumor control of recurrent head-and-neck cancers treated with interstitial low-dose-rate brachytherapy.Methods and Materials: Between 1979 and 1997, 220 patients with prior radiation therapy with or without surgery for primary tumors of the head and neck were treated for recurrent disease or new primary tumors located within previously irradiated volumes. A majority of these patients had inoperable diseases with no distant metastasis. There were 136 male and 84 female patients, and median age was 56 years. All patients had previously received radiation therapy as the primary treatment or adjuvant treatment following surgery, with a median dose of 57.17 cGy (range, 39-74 cGy). The salvage brachytherapy consisted of a low-dose-rate, afterloading Iridium(192) implant, which delivered a median minimum tumor dose of 53 Gy to a mean tumor volume of 68.75 cm(2). Sixty percent of the patients also received interstitial hyperthermia, and 40% received concurrent chemotherapy as a radiosensitizing and potentiating agent.Results: At a minimum 6-month follow-up, local tumor control was achieved in 77% (217/282) of the implanted tumor sites. The 2, 5, and 10-year disease-free actuarial survival rates for the entire group were 60%, 33%, and 22%, respectively. The overall survival rate for the entire group at 5 years was 21.7%. Moderate to severe late complications occurred in 27% of the patients.Conclusion: It has been estimated that approximately 20-30% of head-and-neek cancer patients undergoing definitive radiation therapy have recurrence within the initial treatment volume. Furthermore, similar percentages of patients who survive after successful irradiation develop new primary tumors of the head and neck or experience metastatic neck disease. A majority of such patients cannot be treated with a repeat course of external beam irradiation because of limited normal tissue tolerance, leading to unacceptable morbidity. However, in a select group of these patients, salvage interstitial brachytherapy may play an important role in providing patients with durable palliation and tumor control, as well as a chance for cure. (C) 2001 Elsevier Science Inc.

Purpose: We used clinical patient data to examine implant displacement between high dose rate (HDR) brachytherapy fractions for prostate cancer to determine its impact on treatment delivery.Materials and Methods: We analyzed the verification films taken prior to each fraction for 96 consecutive patients treated with HDR brachytherapy boosts as part of their radiation therapy for definitive treatment of organ-confined prostate cancer at our institution. Patients were treated with 18-24 Gy in 4 fractions of HDR delivered in 40 hours followed by 36-39.6 Gy external beam radiation to the prostate. We determined the mean and maximum displacement distances of marker seeds placed in the prostate and of the implanted needles between HDR fractions.Results: Mean and maximum displacement distances between fractions were documented up to 7.6 mm and 28.5 mm, respectively, for the implant needles and 3.6 mm and 11.4 mm, respectively, for the gold marker seeds, All displacement of implant needles occurred in the caudal direction. At least 1 cm caudal displacement of needles occurred prior to 15.5% all fractions. Manual adjustment of needles was required prior to 15% of fractions, and adjustment of the CLP only was required in 24%. Most of the displacement for both the marker seeds and needles occurred between the first and second fractions.Conclusions: There is significant caudal displacement of interstitial implant needles between HDR fractions in our prostate cancer patients. Obtaining verification films and making adjustments in the treatment volume prior to each fraction is necesary to avoid significant inaccuracies in treatment delivery. (C) 2000 Elsevier Science Inc.

Purpose: We evaluated treatment outcomes of patients with mostly locally advanced primary and recurrent cancer of the nasopharynx managed with interstitial and intraluminal brachytherapy.Methods and Materials: This is a retrospective analysis of 56 patients with cancer arising from the nasopharynx treated with interstitial and intracavitary afterloading brachytherapy from 1978 to 1997. Patients were divided into three treatment groups: 15 patients with primary cancer (Group 1), 34 patients with recurrent or persistent disease (Group 2), and 7 patients with cancer in the nasopharynx who had history of previous definitive radiation therapy to the nasopharynx for head and neck cancer (Group 3). Fifty-three percent of patients in Group 1 had 1992 AJCC Stage IV disease, and 49% of patients in Groups 2 and 3 had extensive disease (defined as T3, T4, or parapharyngeal extension. Group 1 received megavoltage radiation to 50-60 Gy followed by a boost to the primary site and neck tin cases of persistent neck disease) with a combination of interstitial and intracavitary brachytherapy (mean dose 33-37 Gy). Five patients received chemotherapy, and 6 patients received hyperthermia. Groups 2 and 3 patients were treated with brachytherapy implants (mean dose 50-58 Gy) without external beam radiation. Twenty-five patients received chemotherapy either before or during radiation, and 21 patients received hyperthermia.Results: The overall survival at 2, 5, and 10 years for patients in Group 1 was 79%, 61%, and 61%, respectively, and for patients in Groups 2 and 3 combined was 48%, 30%, and 20%, respectively. Cause-specific survival at 2, 5, and 10 gears was 87%, 74%, and 74%, respectively, for patients in Group 1; and 82%, 60%, and 60%, respectively, for patients in Groups 2 and 3. Local control at 2, 5, and 10 years was 93%, 93%, and 77%, respectively, for patients in Group 1; and 81%, 59%, and 49%, respectively, for patients in Groups 2 and 3. Control in the neck at 2, 5, and 10 gears was achieved in 93%, 93%, and 93% of patients, respectively, in Group 1; and 88%, 81%, and 81%, respectively, for patients in Groups 2 and 3. Disease-free survival was 87%, 74%, and 62%, respectively, for patients in Group 1, and 56%, 41%, and 34%, respectively, for patients in Groups 2 and 3. There were 1 peri-operative deaths. One death (2%) was attributable to the development of late complications. Forty-five percent of patients experienced some form of late complications.Conclusion: Interstitial afterloading brachytherapy can provide effective treatment for nasopharyngeal cancers, especially for locally persistent/recurrent and locally extensive lesions. (C) 2000 Elsevier Science Inc.

OBJECTIVE:Our purpose was to evaluate the role of interstitial brachytherapy in vulvar cancer management.STUDY DESIGN:From 1985-1992 we performed a retrospective study of patients treated at the University of California, Irvine Medical Center, and Long Beach Memorial Medical Center.RESULTS:Eleven patients received interstitial brachytherapy, with (n = 5) or without (n = 6) external beam radiotherapy, for locally advanced (n = 5) or recurrent (n = 6) vulvar cancer. Local control was achieved in all patients. Ten patients have died of disease at a mean interval of 33 months from the time of treatment, with 9 patients having maintenance of local control at death. One patient is alive without disease after 77 months of follow-up. There were 2 cases of local necrosis (18%) and 1 case of rectovaginal fistula (9%).CONCLUSION:Local control of advanced vulvar cancer can be achieved with interstitial brachytherapy, with or without external beam radiotherapy. With improved systemic therapy this treatment modality may be used to salvage women with bulky, symptomatic tumors.

Patients who develop locally recurrent uterine corpus or uterine cervix cancer after primary surgery are usually treated with radiotherapy. The optimal radiotherapeutic approach, however, has not been defined. We report the use of exploratory laparotomy, omental pedicle grafting, and intraoperative transperineal interstitial brachytherapy in the treatment of 28 such patients (10 with recurrent corpus and 18 with recurrent cervix cancer). In addition, 22 patients also received perioperative whole pelvic teletherapy while 21 also received a second closed interstitial application. Local control was achieved in 20 patients (71%), but only 10 (36%) continue to be alive without disease after a median of 44 months. Eighteen patients have died (17 of disease) a median of 13 months after open implant. Patients treated with a single implant (n = 7), with side wall involvement (n = 5), with tumors greater than 6 cm in size (n = 4), with a history of previous pelvic irradiation (n = 8), or with persistent disease after open interstitial therapy (n = 8), were not salvaged. Ten patients suffered acute morbidity which included deep venous thrombosis (n = 1), wound separation (n = 1), urinary infection (n = 2), wound infection (n = 2), pneumonia (n = 1), and fever (n = 3). Two other patients experienced chronic non-tumor-related comorbidities. These included a vesicovaginal fistula with a rectovaginal fistula in 1 patient and a small bowel obstruction with a ureteral stricture in another. A single individual suffered from both acute and chronic complications (fever, ureterointestinal fistula).(ABSTRACT TRUNCATED AT 250 WORDS)

The controversy about the treatment of carcinoma of the prostate has increased in the last decade, with most urologists favoring radical prostatectomy rather than primary irradiation. Several reports of persistent tumors in 50% to 90% of patients after external irradiation and permanent iodine-125 implantation of the prostate have been disturbing. From July 1977 to December 1985, 200 patients with adenocarcinoma of the prostate were treated by combining bilateral pelvic lymphadenectomy and temporary interstitial iridium-192 implantation of the prostate, followed by external irradiation. Seventy-four (36%) patients underwent biopsies of the prostate 4 months to 2 years after completion of the irradiation. Only 12 (16%) patients had persistent tumors. Complications were minimized subsequently by dose modifications.

Endocurietherapy (brachytherapy) is the placing of radioactive sources directly into or near a solid tumor. This technique delivers a concentrated dose of radiation to a restricted volume while minimizing radiation effects on normal tissue. We have treated 11 patients (nine sarcomas, one carcinoma, and one Wilms') with endocurietherapy procedures as part of their multimodality treatment program. Six were treated as part of the primary management, and the other five were treated for recurrent or metastatic disease. Temporary afterloaded implants using ribbons embedded with radioactive iridium192 (Ir192) seeds delivered typical tumor doses of 4,000 cGy. Six patients, including four primary cases and two recurrent cases, are currently classified as no evidence of disease (NED) without further local regional treatment (follow-up of 11-62 months; median, 38 months), and one patient treated for metastasis also remains locally controlled. Two patients are classified as alive with disease (AWD), two died of disease (DOD), and one is now NED after surgical salvage. Special considerations were given to gonadal shielding, radioprotection techniques, and psychosocial issues in this pediatric population.

A total of 70 patients with histologically proven diagnosis of carcinoma of the base of the tongue were treated with primary irradiation between May 1974 through April 1984. Fifty-eight (83%) of these patients had locally advanced tumors (Stage T3, T4, N2, N3). Fifty-one of the 70 (73%) patients had clinically palpable neck nodes at first presentation. All patients received a combination of external and interstitial irradiation. The dose of external irradiation was limited to 45-50 Gy over 4 1/2-5 1/2 weeks. Interstitial volume implants were performed 2-3 weeks after completion of external irradiation. The primary site as well as the vallecula, epsilateral pharyngeal wall, glossopalatine sulcus, tonsillar bed, and pillars were routinely implanted to encompass contiguous spread of the disease. The doses of implant varied according to the stage of disease, that is, 2000-2500 cGy for T1 and T2 lesions, 3000-4000 cGy for T3 and T4 lesions, with typical dose rates of 50-60 cGy per hour. The neck nodes were also separately implanted to deliver additional doses of 2000-4000 cGy in 50-80 hours. Overall, local tumor control was observed in 58 of 70 (83%) patients at minimum follow-up of 2 years. An absolute 3-year disease-free survival of the entire group was 67.0%. Treatment related complications such as soft tissue necrosis and/or osteoradionecrosis occurred in 8 of the 70 (11.4%) patients. The salvage of neck failures and the local failures was feasible in 74% and 46% of the patients, respectively either by surgery or by re-irradiation using interstitial 192iridium implant alone. This treatment region is well tolerated and it preserves the functional and asthetic integrity in most patients.

Between January 1976 and March 1982, 80 patients with histologically proven diagnosis of squamous cell carcinoma of the tonsillar region were treated with definitive radiotherapy. Sixty-five (81%) of these patients had locally advanced tumors (Stage III and IV); 49% of patients had clinically palpable cervical lymphadenopathy. All patients received a combined external megavoltage and interstitial irradiation. The dose of external irradiation was limited to 4500-5000 cGy over 41/2 to 51/2 weeks. This was followed by interstitial 192iridium implants to doses of 2000-2500 cGy in 50-60 hours for T1, T2 lesions and 3000-4000 cGy in 60-100 hours for T3 , T4 lesions. The neck masses were also separately implanted to deliver additional doses of 2000-4000 cGy in 50-80 hours. Overall local tumor control was observed in 84% of patients with a minimum follow-up period of 2 years. An absolute 3-year disease free survival of the entire group was 72%. Treatment related complications such as soft tissue necrosis or osteoradionecrosis occurred in 6% (5/80) of patients. The salvage of neck failures and local failures was possible in 78 and 38% of patients, respectively, either by surgery or by re-irradiation employing interstitial 192iridium implants. Functional and esthetic integrity was well preserved in most cases.

A total of 127 patients with histologically proved diagnosis of carcinoma of the tonsillar region and soft palate were treated over the past ten years utilizing interstitial iridium-192 implants. Eighty patients were treated for primary tumors and 47 patients for either recurrent or persistent tumors after definitive irradiation and/or surgery. All patients with primary tumors were treated by a combination of external megavoltage irradiation and interstitial iridium-192 implants, whereas patients with recurrent tumors were treated by interstitial implants alone. In the primary group, 95% of patients with T1 and T2 lesions and 79% with T3 and T4 lesions achieved complete local tumor control. The three-year absolute disease-free survival rate was 72%. Seventy-five percent local tumor control was obtained in patients with recurrent disease, with two-year absolute disease-free survival of 42%. Treatment-related complications such as soft-tissue necrosis or osteoradionecrosis occurred in 6% of patients in the primary group and 23% in recurrent group. This treatment regimen offers an excellent locoregional control with no significant functional or esthetic impairment. Most patients with primary lesions who fail this regimen can be salvaged by surgery or reirradiation using interstitial implants. Reirradiation with interstitial implants is feasible and offers a good chance of long-term local tumor control in the selected group of patients with recurrent disease for whom external irradiation and/or surgery had not been successful.

One hundred six patients with locally advanced carcinoma of the breast underwent definitive radiation therapy for loco-regional control following incisional and/or needle biopsy. Doses of external and interstitial irradiation were 5000 rad (50 Gy) in 5 to 6 weeks, and 3000 to 4000 rad (30-40 Gy) in 60 to 80 hours, respectively. Forty-eight of 106 patients (45%) also received adjuvant systemic chemotherapy. Loco-regional control was observed in 93 of the 106 patients (88%), with five-year disease-free survival of 47%. Distant metastases developed in 59 of the 106 patients (56%). Good to satisfactory cosmetic results were obtained in the majority of these patients; morbidity was at an acceptable level. Locally advanced breast cancer can be treated adequately and satisfactorily without mastectomy by a combination of external and interstitial irradiation.

Forty patients with clinically localized adenocarcinoma of the prostate have been treated by a combination of pelvic lymphadenectomy, temporary Iridium-192 implantation, and external irradiation with follow-up of one to five years. 192Ir implant delivers a minimum tumor dose of 3,000 rad to A2 and B1 lesions and 3,500 to B2 and C lesions. Two weeks later patients receive 4,000 rad of external irradiation to the prostate over four to five weeks. Patients with pelvic nodal metastases receive 5,000 rad to the pelvis with a midline block at 4,000 rad. All patients have had a complete local response as judged by clinical criteria. Prostate needle biopsies have been performed on 16 patients one year or less after treatment, with 15 biopsies benign. The technique appears to offer excellent local control of prostatic adenocarcinoma with acceptably low morbidity.

Twenty-seven patients with the diagnosis of primary carcinoma of the vagina were treated by definitive radiotherapy. Twenty-three patients received a combination of external and interstitial iridium-192 implant irradiation and four patients received only interstitial irradiation. Twenty-one patients had squamous cell carcinoma and six had adenocarcinoma. All patients were staged according to the FIGO classification. More than 70% of patients had relatively advanced local disease and conventional intracavitary irradiation was unsuitable. Local tumor control was observed in 85% (23 of 27 patients), and 56% of the patients remain alive and free of disease for a median follow-up period of 50 months to a maximum follow-up period of 84 months. Fifteen percent of the patients suffered from treatment-related complications.

Forty-patients with locally extensive carcinoma of the anorectum were treated by a combination of external and interstitial irradiation from April 1, 1974 to January 30, 1979. Twenty-eight patients (70%) achieved complete local tumor control and two more patients with residual tumor were salvaged by surgery. Twenty-four patients remain alive with local control for an average follow up period of three years. The overall complication rate has been 20%.

Forty patients with a diagnosis of recurrent pelvic malignancy from various primary sites with no clinical evidence of distant metastasis were re-irradiated with interstitial implant. Removable after-loading 192Ir sources or permanent 125I seeds or a combination of both were used. Twenty-six of these patients received interstitial implant at the time of exploratory laparotomy. A complete local control of implanted pelvic tumors was achieved in 27 of the 40 patients (67%). Thirteen of the 40 patients (33%) remained alive and disease-free to a minimum follow-up period of two years. Serious complications such as soft tissue necrosis and fistulae occurred in 15% of the patients.

A total of 86 patients with carcinoma of the tongue were treated between May 1, 1974 and June, 1978, at the Los Angeles County-University of Southern California Medical Center and California Hospital Medical Center, Los Angeles, California. Fifty-five of these patients were treated for primary tumors and 31 of the 86 patients were re-irradiated with interstitial Ir192 implants for recurrent or persistent tumors after “radical” external irradiation and/or surgery. Primary treatment consisted of a combination of external irradiation and an interstitial after loading Ir192 implant. In the primary treatment group, patients with T1 and T2 lesions showed control rates of 69% for the anterior two-thirds of the tongue (9 of the 13 patients) and 75 % for the posterior one-third of the tongue (3 of the 4 patients). For patients with T3 and T4 lesions, the control rates were 46 % (6 of the 13 patients) and 68 % (17 of the 25 patients) for the anterior two-thirds of the tongue and the base of the tongue respectively. In the re-irradiation group, 4 of the 13 patients (30 % ) with lesions of the anterior two-thirds of the tongue and 8 of the 18 patients (44 %) with lesions of the base of the tongue achieved local control. The follow-up period for all these patients was a minimum of 24 months.