d109 - braquiterapia - passado ou futuro

8/7/2019 D109 - Braquiterapia - Passado Ou Futuro

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PORTO, 27-29

JANEIRO 2011


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CABEA E PESCOO - UPDATE.BRAQUITERAPIA:

PASSADO OU FUTURO

ANGELES ROVIROSA

Oncologa RadioterpicaHospital Clnic Barcelona

Espaa


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BRAQUITERAPIA EN EL CNCER DE CABEZA Y CUELLO.

PASADOPRESENTE

FUTURO?


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DIFERENTES TCNICAS


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TRATAMIENTO EFECTIVO

VENTANA NASAL LABIO LENGUA SUELO DE BOCA BASE DE LENGUA

AMGDALA MUCOSA YUGAL NASOFARINGE


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TRATAMIENTO CONSERVADOR

TRATAMIENTO EXCLUSIVO O ASOCIADO A RTE

IGUAL CONTROL LOCAL Y SUPERVIVENCIA

PRESERVACIN DE LA ANATOMA Y FUNCIN DELRGANO O ESTRUCTURAS ANATMICAS

EVITAR PROBLEMAS ESTTICOS

MEJOR CALIDAD DE VIDA


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BRAQUITERAPIA EN CNCERDE CABEZA Y CUELLO.

Una de las tcnicamente ms difciles. Estructuras sanas vecinas con riesgo de

complicaciones importante. Las complicaciones graves, son de difcil

solucin y causan gran disconfort en el

paciente; y en ocasiones el mdico se sienteimpotente ante ellas.

REQUIERE DE EQUIPOS MUY ENTRENADOS


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BRAQUITERAPIA EN EL CNCER DECABEZA Y CUELLO HA OFRECIDO:

EN ESTADIOS TEMPRANOS:Iguales resultados en control local y supervivencia que la ciruga.Tratamiento conservador de rgano y del funcionalismo.

EN ESTADIOS AVANZADOS:Permite un incremento de la dosis a nivel del seno del tumor y evitar tratamientosmutilantes.

EN POSTOPERATORIOS CON MRGENES AFECTOS:Una solucin a exresis ms amplias.

TRATAMIENTO DE RECIDIVAS DESPUS DE OTROS TRATAMIENTOS.


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ESTRO GUIDELINES.


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ASTRO GUIDELINES.


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PRESENTE DESAPARICIN PROGRESIVA DEL IRIDIO 192 DE BAJA TASA.

POCOS BRAQUITERAPUTAS FORMADOS EN TCNICAS DE ORL. IMPLEMENTACIN LENTA DE LAS TCNICAS DE ALTA TASA.

EXPERIENCIA DE LA LITERATURA EN ALTA TASA NO SUFICIENTE EN.

NO SUFICIENTES BRAQUITERAPUTAS ENTRENADOS EN LAS TCNICASDE ALTA TASA.

FALTA DE DIFUSIN DE LA TCNICA POR LOS RADIOTERAPUTAS.

TENDENCIA MAYOR DE LOS CIRUJANOS A OPERAR, A SU VEZFACILITADA POR LOS RADIOTERAPUTAS CON POCA EXPERIENCIA ENBRAQUITERAPIA.

PREDOMINIO DE LOS TRATAMIENTOS CON RADIOQUIMIOTERAPIA ENLOS ESTADIOS AVANZADOS.


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TAC: 33% 61%RNM: 5% 16%


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GRUPO I: Austria, Blgica, Dinamarca, Finlandia, Francia, Alemania, Grecia, Islandia, Irlanda italia, Holanda, Noruega, Portugal,Espaa, Suecia, Suiza y Gran Bretaa.

GRUPO II: Chipre, Repblica Checa, Estonia, Hungaria, Lituania, Malta, Polonia, Eslovaquia y eslovenia.

GRUPO III: Albania, Armenia, Belarus, Bosnia, Herzegovina, Bulgaria, Croacia, Georgia, Israel, Macedonia, Moldova, Rumania,

Montenegro, Servia y Turquia.


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PRESENTE

Jubilacin de los grandes referentes en estostratamientos. Menor nmero de publicaciones en cabeza y

cuello por los autores referentes previos. Autores referentes actuales estn centrados

en otras reas de braquiterapia. Aumento de las publicaciones en los Pases

del Este, China, India y Japn.


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Strahlenther Onkol. 2004 Dec;180(12):776-82.Late effects of post-high-dose-rate brachytherapy for oropharyngeal carcinoma: arethey severer than post-low-dose-rate?

Nose T, Peiffert D, Lapeyre M, Hoffstetter S, Koizumi M, Nishiyama K.Department of Radiation Oncology, Osaka Medical Center, Osaka, Japan. [email protected]

AbstractBACKGROUND: . Late effects by high-dose-rate (HDR) brachytherapy have been believed severer thanlow-dose-rate (LDR) provided tumor control was constant. Local control of oropharyngeal carcinoma

HDR vs LDR

w t at sa a e ca enter was compara e to ser es rom entre ex s autr n 82%,

79.5%, respectively). To assess the feasibility of HDR brachytherapy, the late effects were compared.PATIENTS AND METHODS: . The data of 29 HDR and 24 LDR patients (median follow-up of 27 and 29.5months, respectively; p = 0.89) were collected. The HDR schedule was 21 Gy/3.5 fractions/2 daysfollowing 46 Gy/23 fractions external beam, while 25 Gy/3 days following 50 Gy/25 fractions externalbeam was for LDR. Late changes were evaluated using RTOG/EORTC late morbidity scoring scheme. Forsubclinical late changes, mucosa chapter of Dische score was modified for brachytherapy. Scores werediscussed through photos and were agreed on by authors. Late sequelae were estimated, by reviewing

charts, concerning frequency, severity, and duration of mucosal damages (erosion and ulcer).RESULTS: . Late changes were of no difference (p = 0.12 for EORTC/RTOG, and p = 0.45, 0.47, 1.00, 0.12,0.16, 0.95, 0.27, 0.21 for erythema, ulceration, edema, thinning, pallor, telangiectasia, mobility impairmentof tongue/faucial pillars, respectively, of the modified Dische score). Late sequelae showed nodifferences (p = 0.90, 0.12, 0.40 for frequency, severity, duration, respectively, of mucosal damages).CONCLUSION: . The late effects by HDR were not severer than by LDR. HDR oropharyngeal

brachytherapy is as safe as LDR.


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APLICADORES HDR


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LABIO


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Int J Radiat Oncol Biol Phys. 2001 Sep 1;51(1):171-5.Phase III trial of high- vs. low-dose-rate interstitial radiotherapy for early mobiletongue cancer.Inoue T, Inoue T, Yoshida K, Yoshioka Y, Shimamoto S, Tanaka E, Yamazaki H, Shimizutani

K, Teshima T, Furukawa S.Division of Multidisciplinary Radiotherapy, Biomedical Research Center, Osaka UniversityGraduate School of Medicine, Suita, Osaka, Japan.

Abstract

LENGUA

(ISRT). We carried out a Phase III trial to compare the treatment results of low-dose-rate(LDR) ISRT and high-dose-rate (HDR) ISRT for early mobile tongue cancer.METHODS AND MATERIALS: From April 1992 through October 1996, 59 patients withcancer of the early mobile tongue were registered in this Phase III study. Eight patients wereexcluded from the evaluation because of violations of the requirements for this study. Of 51eligible patients, 26 patients were treated with LDR-ISRT (70 Gy/4-9 days) and 25 patients

with HDR-ISRT (60 Gy/10 fractions/1 week). For the hyperfractionated HDR-ISRT, the timeinterval between 2 fractions was more than 6 h.RESULTS: Five-year local control rates of the LDR and HDR groups were 84% and 87%respectively. Nodal metastasis occurred in 6 patients in each group. Five-year nodal controlrates of the LDR and HDR groups were 77% and 76%, respectively.CONCLUSION: Hyperfractionated HDR-ISRT for early mobile tongue cancer has the samelocal control compared with continuous LDR-ISRT. Hyperfractionated HDR-ISRT is analternative treatment for continuous LDR-ISRT.


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LENGUABrachytherapy. 2010 Jul-Sep;9(3):227-34. Epub 2010 Jan 29.

Efficacy of high-dose-rate interstitial brachytherapy in patients with oral tonguecarcinoma.Guinot JL, Santos M, Tortajada MI, Carrascosa M, Estells E, Vendrell JB, Muelas R, Chust ML, Mengual JL,Arribas L.Department of Radiation Oncology, Fundacin Instituto Valenciano de Oncologa (IVO), Valencia, [email protected]

AbstractPURPOSE: To evaluate the results of hi h-dose-rate HDR -interstitial brach therap ISBT in oral ton uecarcinomas.

METHODS AND MATERIALS: Between September 1999 and August 2007, 50 patients were treated for oraltongue carcinoma with HDR-ISBT. The patient's mean age was 58 years. Forty-two patients were in T1-2 stageand 8 patients were in T3 stage; 16 patients were in N+ stage and 34 patients in N0 stage. Exclusive ISBT wasgiven to 17 patients (34%) in T1-2 N0 stage and complementary to external beam radiotherapy (EBRT) to 33patients (66%). A perioperative technique was performed on 14 patients. The median total dose was 44 Gy whenHDR was used alone (4 Gy per fraction) and 18 Gy when complementary to 50 Gy EBRT (3 Gy per fraction).RESULTS: The median followup was 44 months. Actuarial disease-free survival rates at 3 and 5 years were 81%

and 74%, respectively. Local failure developed in 7 patients. Actuarial local control (LC) rates were 87% and 79%at 3 and 5 years in T1-2 stage 94.5% and 91% and T3 stage 43% and 43% (with salvage surgery). Exclusive HDRcases showed LC in 100% of the cases, and the combined group (EBRT+HDR) showed LC in 80% and 69% ofthe cases at 3 and 5 years (p=0.044). Soft-tissue necrosis developed in 16% and bone necrosis in 4% of thecases.CONCLUSIONS: HDR brachytherapy is an effective method for the treatment of oral tongue carcinoma in low-risk cases. Doses per fraction between 3 and 4 Gy yield LC and complication rates similar to low-dose rate. The

perioperative technique promises encouraging results


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SUELO DE BOCAInt J Radiat Oncol Biol Phys. 1998Apr 1;41(1):53-8.

High dose rate versus low dose rate interstitial radiotherapy for carcinoma of thefloor of mouth.Inoue T, Inoue T, Yamazaki H, Koizumi M, Kagawa K, Yoshida K, Shiomi H, Imai A, Shimizutani K, Tanaka E,Nose T, Teshima T, Furukawa S, Fuchihata H.Department of Radiation Oncology, Biomedical Research Center, Osaka University Medical School, Suita, Japan.

AbstractPURPOSE: Patients with cancer of the floor of mouth are treated with radiation because of functional andcosmetic reasons. We evaluate the treatment results of high dose rate (HDR) and low dose rate (LDR)

interstitial radiation for cancer of the floor of mouth.METHODS AND MATERIALS: From January 1980 through March 1996, 41 patients with cancer of the floor ofmouth were treated with LDR interstitial radiation using 198Au grains, and from April 1992 through March1996 16 patients with HDR interstitial radiation. There were 26 T1 tumors, 30 T2 tumors, and 1 T3 tumor. For21 patients treated with interstitial radiation alone, a total radiation dose of interstitial therapy was 60 Gy/10fractions/6-7 days in HDR and 85 Gy within 1 week in LDR. For 36 patients treated with a combination therapy,a total dose of 30 to 40 Gy of external radiation and a total dose of 48 Gy/8 fractions/5-6 days in HDR or 65 Gy

within 1 week in LDR were delivered.RESULTS: Two- and 5-year local control rates of patients treated with HDR interstitial radiation were 94% and94%, and those with LDR were 75% and 69%, respectively. Local control rate of patients treated with HDRbrachytherapy was slightly higher than that with 198Au grains (p = 0.113). For late complication, boneexposure or ulcer occurred in 6 of 16 (38%) patients treated with HDR and 13 of 41 (32%) patients treated withLDR.CONCLUSION: HDR fractionated interstitial brachytherapy can be an alternative to LDR brachytherapy forcancer of the floor of mouth and eliminate radiation exposure for the medical staff


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BASE DE LENGUAStrahlenther Onkol. 2004 Dec;180(12):768-75.

Interstitial high-dose-rate brachytherapy in the treatment of base of tonguecarcinoma.Takcsi-Nagy Z, Polgr C, Oberna F, Somogyi A, Major T, Remenr E, Fodor J, Ksler M, Nmeth G.

Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary. [email protected]

AbstractBACKGROUND AND PURPOSE: . To date none of the studies examined the feasibility and efficacy of interstitialhigh-dose-rate (HDR) brachytherapy in the treatment of carcinoma of the tongue base. Therefore the aim of thisstudy was to contribute to this issue.

: . e ween an pa en s mean age years w - an -

carcinoma of the base of tongue were presented. Neck dissection was carried out in twelve cases (32%). 30patients with advanced stage received brachytherapy boost after 50-66.5 Gy (mean, 60 Gy) locoregional externalbeam irradiation (EBI) and 7 patients with early stage (T1-2, N0) were managed locally with wide tumor excisionand sole brachytherapy. 4 of them underwent neck dissection and the others were subjected to 50 Gy regionalEBI. The mean dose of boost and sole brachytherapy was 18 Gy and 28 Gy, respectively.RESULTS: . The median follow-up time for surviving patients was 51 months. The 7 sole brachytherapy patientsare living with no evidence of disease. For patients treated with EBI and brachytherapy boost, the 5-yearactuarial rate of local, locoregional recurrence-free and overall survival was 60%, 52% and 46%, respectively. Forall patients in univariate analysis larger tumor size (T4 vs. T1-3) was significant negative predictor of local (RR:7.23) and locoregional control (RR: 3.87), but nodal involvement was not. Delayed soft tissue ulceration andosteoradionecrosis occurred in 4 (13%) EBI and brachytherapy treated patients. None of the sole brachytherapypatients experienced severe late radiation toxicity.CONCLUSION: . EBI combined with interstitial HDR brachytherapy boost result in acceptable local tumor controlwith low incidence of late side effects in patients with advanced disease. Fractionated sole HDR brachytherapyfollowing tumor excision is a feasible treatment option for patients with early stage cancer and gives excellent

local results


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BASE DE LENGUAMagy Onkol. 2004;48(4):297-301. Epub 2005 Jan 17.Teletherapy versus teletherapy and "boost" brachytherapy in the treatment of baseof tongue tumors: 5-year results.[Article in Hungarian]Takcsi Nagy Z, Oberna F, Somogyi A, Polgr C, Major T, Plus K, Fodor J, Nmeth G.

Orszgos Onkolgiai Intzet, Budapest, 1122, Hungary. [email protected]

AbstractAIM: To study the importance of high-dose-rate (HDR) boost brachytherapy (BT) afterpercutaneous irradiation of base of tongue tumors.

of tongue were treated with primary radiation therapy. Fourty patients received a mean dose of61 Gy (range, 50-72 Gy) external beam irradiation, and afterwards 30 patients were treated witha mean dose of 18 Gy (range, 12-30 Gy) boost HDR BT. Prognostic factors were analyzed in uni-and multivariate model.RESULTS: At a median follow-up of 56 (16-108) months, boost BT increased the incidence oflocal tumor control (LTC) from 38% to 67% (p=0.0145). The 5-year probability of LTC was 60%vs. 36% (p=0.0188), the locoregional tumor control 52% vs. 34% (p=0.0753) and the overallsurvival (OS) 46% vs. 26% (p=0.0545), respectively, in favor of the boost group. Serious, grade4 radiation toxicity occurred in 5% (2/40) and 13% (4/30) without or with boost treatment,respectively (p=0.2110). In multivariate analyses for LTC, tumor size (p=0.0042) and boost(p=0.0444), and for OS tumor size (p=0.0047) and nodal status (p=0.0163) had a significanteffect.CONCLUSION: Boost BT after teletherapy improves LTC significantly without considerable

increase in the risk of side-effects.


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RECIDIVASInt J Radiat Oncol Biol Phys. 2005Aug 1;62(5):1444-50.

Salvage high-dose-rate (HDR) brachytherapy for recurrent head-and-neckcancer.Hepel JT, Syed AM, Puthawala A, Sharma A, Frankel P.Department of Internal Medicine, University of California at Irvine, Orange, CA 90806, USA. [email protected]

AbstractBACKGROUND: A significant portion of head-and-neck cancer patients will develop persistent or recurrent diseaseafter 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 posesa 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 ofpatients 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 forprimary tumors of the head and neck were treated for biopsy-proven recurrent disease. All patients receivedprevious radiation as definitive therapy alone or as adjunct to surgery. All patients were inoperable, refusedsurgery, or had gross residual disease after salvage surgery for their recurrent disease. Thirty-six sites on the 30patients were implanted by application of high-dose-rate interstitial brachytherapy techniques with mean tumordose of 34 Gy (18-48 Gy) in twice daily fractions of 300 to 400 cGy 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 was56% and 37%, respectively. Grade 3/4 late complications occurred in 16% of the patients. No fatal complicationsoccurred.CONCLUSION: HDR brachytherapy can play an important role in the salvage treatment of previously irradiatedrecurrent head-and-neck cancer. This study shows that comparable results are obtained by HDR brachytherapywith fewer late complications than were indicated by previously reported data for LDR brachytherapy.


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PDRInt J Radiat Oncol Biol Phys. 2000 Jan 1;46(1):27-30.

Early results of pulsed-dose-rate interstitial brachytherapy for head and neckmalignancies after limited surgery.Strnad V, Lotter M, Grabenbauer G, Sauer R.

Department of Radiation Therapy, University Erlangen-Nrnberg, Erlangen, [email protected]

AbstractPURPOSE: The aim of this study was to evaluate the relative incidence of toxicity and local control in patientswith head and neck mali nancies who underwent interstitial pulsed-dose-rate PDR brach therap iBT .PATIENTS AND METHODS: From October 1997 to December 1998, 61 patients underwent interstitial PDR

brachytherapy procedures in our department; 47 were patients with head and neck cancer. Forty patientsreceived brachytherapy as part of their curative treatment regimen, and 7 patients were implanted for palliativepurposes and excluded from the analysis of therapy efficacy. Twenty-four patients had interstitialbrachytherapy procedures alone with D(REF) = 50 Gy; in 23 patients, iBT procedures were performed withD(REF) = 24 Gy in combination with external radiation. A dose per pulse (dp) of 0.5 Gy was prescribed for 38/47patients, and a dp = 0.7 Gy for 9/47 patients. The pulses were delivered 24 h a day, with a time interval of 1 hbetween two pulses, resulting in an effective dose rate of 0.5 Gy/h or 0.7 Gy/h. A follow-up of the patients was

done to analyze acute and delayed toxicity, local control, and survival. The analysis was performed aftermedian follow-up of 12 months (5-18 months).RESULTS: After a median follow-up of 12 months, soft tissue necrosis was seen in one patient and bonenecrosis in another. No other serious side effects were observed. Permanent locoregional tumor control wasachieved in 37 of 40 patients. No distant metastases were observed.CONCLUSIONS: PDR interstitial brachytherapy with 0.5-0.7 Gy/h is a safe therapy. These preliminary resultssuggest that PDR interstitial brachytherapy of head and neck cancer is comparable with low-dose-rate (LDR)brachytherapy.


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PDR

PDR


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PDRStrahlenther Onkol. 2005 Dec;181(12):762-7.

Role of interstitial PDR brachytherapy in the treatment of oral and oropharyngealcancer. A single-institute experience of 236 patients.Strnad V, Melzner W, Geiger M, Zenk J, Waldfahrer F, Lotter M, Ott O, Seeger A, Iro H, Sauer R.Department of Radiation Oncology, University Erlangen-Nuremberg, Erlangen, Germany. [email protected]

AbstractPURPOSE: To evaluate the role of pulsed-dose-rate interstitial brachytherapy (PDR IBT) in patients with head-and-neck malignancies.

PATIENTS AND METHODS: From October 1997 to December 2003, 236 patients underwent PDR IBT for head-and-neck cancer at the authors' department. 192 patients received brachytherapy as part of their curativetreatment regimen after minimal non-mutilating surgery, 44 patients were treated with irradiation alone. 144patients had sole IBT (median D(REF) = 56 Gy), in 92 patients IBT procedures (median D(REF) = 24 Gy) wereperformed in combination with external irradiation. The pulses (0.4-0.7 Gy/h) were delivered 24 h a day with atime interval of 1 h between two pulses. The analysis of tumor control, survival and treatment-related toxicitywas performed after a median follow-up of 26 months (6-75 months).RESULTS: At the time of analysis permanent local tumor control was registered in 208 of 236 patients (88%).At 5 years overall survival and local recurrence-free survival of the entire group were 82-73% and 93-83% forT1/2, and 56% and 83% for T3/4, respectively. Soft-tissue necrosis was seen in 23/236 patients (9.7%) andbone necrosis in 17/236 patients (7.2%). No other serious side effects were observed.CONCLUSION: PDR IBT with 0.4-0.7 Gy/h and 1 h between pulses is safe and effective. These results confirmthat PDR IBT of head-and-neck cancer is comparable with low-dose-rate (LDR) brachytherapy - equallyeffective and less toxic


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PDRStrahlenther Onkol. 2007 Sep;183(9):512-6.Preliminary report of pulsed dose rate brachytherapy in head-and-neck cancer.Ziemlewski A, Zienkiewicz J, Serkies K, Badzio A.Department of Oral and Maxillofacial Surgery, Medical University of Gdask, Poland. [email protected]

AbstractPURPOSE: To assess the feasibility and acute/delayed toxicity of pulsed-dose-rate brachytherapy(PDR BT) in head-and-neck tumors.PATIENTS AND METHODS: 45 head and neck cancer patients underwent interstitial or contact PDR BTat a dose of 10.2-70 G median 70 G and 0.6 or 1.0 G / ulse/h. 42 atients were administered BT aspart of their curative treatment; 32 of them had sole BT. Three reirradiated patients with recurrent

tumor had palliative BT.RESULTS: PDR BT was well tolerated. Intense bleeding was the only complication associated withcatheter removal from the tongue and bucca. 44 patients who completed BT experienced acutemucositis. Grade 3 toxicity of skin and oral mucosa occurred in three (6.8%) and six patients (13.6%),respectively. At a median follow-up of 22 months (range, 2-67 months), late serious toxicity (grade 4,for soft tissue and bone) was seen in seven patients (15.9%). Among the parameters analyzed, onlydental care performed before BT had a significant impact on mucosal side effects. Acute severemucositis was observed in 23% of patients without dental care compared to 0% of those with dentalcare (p=0.044). Late severe mucositis occurred in 17.7% and 26.9% of the respective patients (p=0.035),overall in 23%. The larger the volume encompassed by the reference isodose, the more late (p=0.004)mucosal reactions were observed.CONCLUSION: PDR BT continued over a few days is a feasible and safe approach in head-and-necktumors; however, it is accompanied by some toxicity. Dental care should precede isotope application.


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PDR


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PLANIFICACIN 3D.


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Hungarian Oncology 2000; 44:109-15


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Hungarian Oncology 2000; 44:117-21

10 Pacientes


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FUTURO


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FUTURO

TCNICA EFECTIVA.

IMPLEMENTACIN DE LAS TCNICAS EN LOS

SERVICIOS.

FORMACIN DE RESIDENTES Y ESPECIALISTAS

DIFUSIN DE LAS TCNICAS Y RESULTADOS.


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CONCLUSIONES

TUVO PASADO.

TIENE PRESENTE.

PUEDE Y DEBE TENER FUTURO.


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Muito obrigada !!!

d109 - braquiterapia - passado ou futuro

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