PURPOSE: Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment. METHODS AND MATERIALS: Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical'' anesthesia technique. RESULTS: A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred. CONCLUSION: With a 70% success rate (correct implant with mean pain and anxiety scores 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea. (C) 2020 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.

You have accessJournal of UrologyProstate Cancer: Advanced (including Drug Therapy) III (PD34)1 Sep 2021PD34-02 THE KEY ROLE OF PSA DOUBLING TIME IN PATIENTS TREATED WITH SALVAGE RADIATION THERAPY AFTER RADICAL PROSTATECTOMY: IMPLICATIONS FOR THE EXTENT OF RADIATION AND THE CONCOMITANT USE OF HORMONAL THERAPY Nicola Fossati, R Jeffrey Karnes, Stephen A Boorjian, Giovanni Motterle, Alberto Bossi, Tami Kumar, Nadia Di Muzio, Cozzarini Cesare, Barbara Noris Chiorda, Elio Mazzone, Daniele Robesti, Giorgio Gandaglia, Detlef Bartkowiak, Shahrokh Shariat, Gregor Goldner, Steven Joniau, Hendrick Van Poppel, Charlien Berghen, Gert De Meerleer, Francesco Montorsi, Thomas Wiegel, and Alberto Briganti Nicola FossatiNicola Fossati More articles by this author , R Jeffrey KarnesR Jeffrey Karnes More articles by this author , Stephen A BoorjianStephen A Boorjian More articles by this author , Giovanni MotterleGiovanni Motterle More articles by this author , Alberto BossiAlberto Bossi More articles by this author , Tami KumarTami Kumar More articles by this author , Nadia Di MuzioNadia Di Muzio More articles by this author , Cozzarini CesareCozzarini Cesare More articles by this author , Barbara Noris ChiordaBarbara Noris Chiorda More articles by this author , Elio MazzoneElio Mazzone More articles by this author , Daniele RobestiDaniele Robesti More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Detlef BartkowiakDetlef Bartkowiak More articles by this author , Shahrokh ShariatShahrokh Shariat More articles by this author , Gregor GoldnerGregor Goldner More articles by this author , Steven JoniauSteven Joniau More articles by this author , Hendrick Van PoppelHendrick Van Poppel More articles by this author , Charlien BerghenCharlien Berghen More articles by this author , Gert De MeerleerGert De Meerleer More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , Thomas WiegelThomas Wiegel More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002038.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: A clear consensus regarding the clinical target volume for salvage radiation therapy (SRT) has not been achieved yet. The oncological profile of patients affected by PSA relapse is heterogeneous, and the addition of concomitant hormonal therapy (HT) may be spared to patients with less aggressive disease. As such we aimed at assessing the role of PSA doubling time (PSADT) to identify patients who would benefit from the addition of concomitant HT and extended field to SRT. METHODS: The study included 477 patients who received SRT at five tertiary referral centres for rising PSA after RP. All patients received local radiation to the prostatic and seminal vesicle bed. Concomitant HT administration and radiation field [prostatic fossa (PF) vs. whole pelvis radiotherapy (WPRT)] were left at the discretion of the treating physician. The outcome consisted of clinical recurrence (CR) after SRT identified by imaging. Multivariable Cox regression analysis was used to predict CR. Predictors consisted of pT stage (≤pT3a vs. ≥pT3b), Gleason score (≤7 vs. ≥8), PSA level at SRT, and PSADT. The interaction test was used for the hypothesis that the impact of concomitant HT and WPRT varied significantly according to PSADT. RESULTS: Median PSADT was 8 (IQR: 4, 16) months. Concomitant HT was administered to 222 (47%) patients for a median duration of 6 (IQR: 6, 17) months. Radiation field consisted of PF in 366 (77%) patients, whereas the remaining 111 (23%) received WPRT. At a median follow-up of 113 months, 80 (17%) patients developed CR. At multivariable analysis, ≥pT3b stage (HR: 5.00; p <0.0001), Gleason score ≥8 (HR: 4.21; p <0.0001), PSA level (HR: 1.29; p=0.001), and PSADT (HR: 0.98; p=0.026) were significant predictors of CR. Benefits of concomitant HT and WPRT became significant when PSADT was <6 months (p <0.0001 by interaction test). The use of concomitant HT (Figure 1A) and WPRT (Figure 1B) reduced the risk of CR at 8 years from 25% to 17% in patients with a PSADT <6 months. On the contrary, this effect was not significant in patients with longer PSADT. CONCLUSIONS: PSADT was a significant predictor of CR after SRT. In this large multi-institutional series, the threshold of 6 months was the optimal cut-off to identify patients who benefit from concomitant HT and WPRT. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e582-e583 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicola Fossati More articles by this author R Jeffrey Karnes More articles by this author Stephen A Boorjian More articles by this author Giovanni Motterle More articles by this author Alberto Bossi More articles by this author Tami Kumar More articles by this author Nadia Di Muzio More articles by this author Cozzarini Cesare More articles by this author Barbara Noris Chiorda More articles by this author Elio Mazzone More articles by this author Daniele Robesti More articles by this author Giorgio Gandaglia More articles by this author Detlef Bartkowiak More articles by this author Shahrokh Shariat More articles by this author Gregor Goldner More articles by this author Steven Joniau More articles by this author Hendrick Van Poppel More articles by this author Charlien Berghen More articles by this author Gert De Meerleer More articles by this author Francesco Montorsi More articles by this author Thomas Wiegel More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Loading ...

PURPOSE:Adjuvant external beam radiotherapy (EBRT) was shown to decrease pelvic relapses in patients with an early stage cervical cancer and intermediate-risk histopathological prognostic factors, at the cost of increased bowel morbidity. We examined the feasibility and results of adjuvant brachytherapy alone as an alternative to EBRT in this situation. PATIENTS AND METHODS:Medical records of consecutive patients receiving adjuvant brachytherapy between 1991 and 2018 for an early stage cervical cancer were examined. Patients were included if they presented a pT1a2N0 or pT1b1N0 disease following radical colpohysterectomy. Adjuvant vaginal wall brachytherapy (without EBRT) was indicated because of a tumor size≥2cm and/or presence of lymphovascular space invasion (LVSI). Patients received 60Gy to 5mm of the vaginal wall, through low-dose or pulse-dose rate technique. Patients' outcome was examined for disease control, toxicities and prognostic factors. RESULTS:A total of 40 patients were included. Eight patients (20%) had LVSI, 26 patients (65%) had a tumor size≥2cm. With median follow-up time of 42.0 months, 90% of patients were in complete remission and four patients (10%) experienced tumor relapse, all in the peritoneal cavity, and associated with synchronous pelvic lymph node failure in 2/4 patients. No vaginal or isolated pelvic nodal failure was reported. At 5 year, overall survival was 83.6% (CI95%: 67.8-100%) and disease-free survival was 85.1% (CI95%: 72.6-99.9%). In univariate analysis, probability of relapse correlated with tumor size≥3cm (P=0.004). No acute or late toxicity grade more than 2 was reported. CONCLUSION:Brachytherapy alone was a well-tolerated adjuvant treatment for selected patients with intermediate risk factors. The risk of relapse in patients with tumor size≥3cm was however high, suggesting that EBRT is more appropriate in this situation.

La curiethérapie guidée par l’image est cruciale dans la prise en charge des cancers du col localement avancé et a bénéficié de progrès de l’imagerie de ces dernières décennies. Les recommandations du Groupe Européen de Curiethérapie–European Society for Radiation Oncology (GEC-ESTRO) ont permis une harmonisation des pratiques dans la définition des volumes à partir de l’imagerie par résonance magnétique (IRM) et de meilleurs résultats cliniques en termes d’efficacité et de toxicité. L’IRM après l’implantation est devenue la modalité d’imagerie de référence pour guider la réalisation de la curiethérapie. La scannographie couplée à la Tomographie par Emission de Positons (TEP) scanographie se positionne comme une alternative intéressante dans les cas où l’IRM ne serait pas réalisable. Les relations dose/effet et les valeurs pronostiques de l’IRM et de la TEP-scanographie avant curiethérapie permettent d’envisager une personnalisation de la dose délivrée en curiethérapie et de proposer une escalade de dose aux patientes qui le nécessitent vraiment et d’envisager éventuellement une désescalade chez celles ayant un très bon pronostic. Des études complémentaires sont néanmoins nécessaires pour confirmer cette attitude thérapeutique.

Purpose: To evaluate the association between pelvic bone marrow (BM) dose volume parameters and probability of acute hematological toxicity (HT), a cohort of cervical cancer patients receiving definitive chemoradiation (CRT) was assessed. Materials and methods: Medical records of patients treated by CRT (45 Gy in 25 fractions, without dose constraints applied to the BM) were reviewed. Baseline and weekly hematological parameters were collected. BM was retrospectively delineated and divided into sub-sites: iliac crests, lower pelvis, lumbosacral region. BM volumes (V) receiving 5, 10, 20, 30, 40 Gy (V5, V10, V20, V30, V40, respectively) and mean dose (Dm) were calculated. Logistic regression was used to analyze associations between HT and dose-volume histograms parameters. Results: 114 patients were included. 75.4% were treated with 3D radiation therapy and 24.6% were receiving intensity modulated radiation therapy (IMRT). Neither age, chemotherapy regimen (cisplatin vs carboplatin), number of chemotherapy cycles, performance status, body mass index, or para-aortic irradiation were associated with HT. In univariate analysis, more frequent grade 3+ leukopenia was found in the IMRT group (odds ratio [OR]: 3.5; 95% CI, 1.4-9.1; p=0.007). In multivariate analysis, grade 4 HT was associated with lower pelvis V5>95% (OR 4.1; 95% CI, 1.6-14. p=0.02), lower pelvis V20>45% (OR 3.5; 95% CI, 1.1-13.4; p=0.05), total pelvic bone V20>65%, and iliac crests Dm >31 Gy (OR 4.5; 95% CI, 1.4-14.7; p=0.02). Conclusion: The following dose constraints could be proposed to decrease acute HT risk: lower pelvis V5<95%, lower pelvis V20=45%, total pelvic bone V20<65%, and iliac crests Dm <31 Gy.

Image-guided brachytherapy is crucial in the management of locally advanced cervical cancers and has benefited from advances in imaging over recent decades. The recommendations of the European Brachytherapy - European Society for Radiation Oncology (GEC-ESTRO) have resulted in harmonized practices and improved clinical outcomes in terms of efficacy and toxicity. Post-implant magnetic resonance imaging (MRI) has become the reference imaging modality to guide brachytherapy. There is an increasing interest for other multimodal imaging in these patients. The metabolic information provided by Positrons Emission Tomography/computed tomodensitometry (PET/CT) is also very promising approach to guide personalized dose escalation strategies. The prognostic values of MRI and PET scanner before brachytherapy make it possible to consider personalizing the dose delivered in brachytherapy and to propose a dose escalation to patients who really need it and to possibly consider a deescalation strategy in patients with a very good prognosis. However, further studies are needed to confirm this approach.

According to the NCCN guidelines, Salvage Brachytherapy is a treatment option for pathologically confirmed local recurrence after EBRT or brachytherapy. We retrospectively evaluated the feasibility and the toxicity of high dose rate (HDR) brachytherapy at our institution. Between November 2013 and February 2018, 30 consecutive patients with biopsy proven intraprostatic recurrence of cancer after definitive radiation therapy underwent a salvage re-irradiation using HDR brachytherapy. Treatment regimen was 24 Gy delivered to the whole gland in 2 implants of 12 Gy performed 2-4 weeks apart. All patients had had no severe side effect of the previous radiotherapy course and underwent a rectoscopy to ascertain the absence of radiation proctitis prior to salvage procedure. Biochemical control was assessed according to the Phoenix definition. Secondary outcomes included survival and toxicities. Median age at the salvage brachytherapy was 68.5 years (range 61.3-83.2). The median interval between salvage HDR brachytherapy and the first radiotherapy course was 9.1 years (range 0.8-22.4). The median PSA at salvage brachytherapy was 4.9 ng/mL (range 1.3-40) and 6 pts (20%) were castration-resistant. After a median follow-up of 1.7 years, a total of 19 pts (63%) presented a biochemical relapse with a median time of 1.3 years (range 0.2 – 3.9) and 16 a clinical relapse (4 local only, 2 local and regional, 5 regional and metastatic and 5 metastatic only). Local relapses occurred after a median time of 2.7 y (range 0.9-4.7). Overall toxicity profile was good, with no severe grade 3 or higher acute or late gastrointestinal or genitourinary toxicity recorded. Salvage HDR brachytherapy for locally recurrent prostate cancer after radiotherapy is feasible and associated with an acceptable toxicity profile. The high rate of clinical relapse warrants further investigation to define the subgroup of patients who will benefit from salvage local therapy.