cet cancer center oakland california high dose rate (hdr) brachytherapy gynecological cancer d....
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CET Cancer CenterOakland California
High Dose Rate (HDR) BrachytherapyGynecological Cancer
D. Jeffrey Demanes [email protected]
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Brachytherapy
Intracavitary Interstitial
Low Dose Rate High Dose Rate
CET
Radiation is given directly to target
Gradient effect– relatively little dose to surrounding tissue
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Robotic High Dose Rate (HDR) Brachytherapy
Source position x Time = Effective Source Strength
HDR is given in 1-2 sessions per day
Radiation is confined to patient
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Applicator PlacementApplicator Placement
High Dose Rate Robotic TreatmentHigh Dose Rate Robotic Treatment
3 Dimensional Scan Imaging3 Dimensional Scan Imaging
Virtual Image Computer DosimetryVirtual Image Computer Dosimetry
CET
A Four Step Process
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Intracavitary Multi-Channel Vaginal Cylinder
Decreases dose to bladder and rectum by 15%
*IJROBP Vol. 44, No. 1, pp.211-219, 1999
Cylinder cross section
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CET
Intracavitary Tandem and Ovoids
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HDR Interstitial
Direct tissue access
Catheter scaffolding ‘matrix’
Encompass extensive disease
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CET
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CET
2 Scan 3D Image with Implant
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CET
3) Virtual Image of Implant
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CET
3) Another Patient with CT Dosimetry
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Recurrent Pelvic Sidewall Cervix Cancer
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3) Virtual Image viewed from above
Left Pelvic Sidewall
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4) HDR Treatment Delivery
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4 HDR Treatment Delivery
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CET Protocol Gynecologic Cancer
External Beam Radiation Therapy
Small Tumors Large Tumors Metastatic
36 Gy 39.6 Gy 45-50 Gy
50.4 Gy minimum to pelvic lymph nodes
HDR Brachytherapy 5.5 - 6.0 Gy
5-6 sessions
(1 or 2 implants 1 week apart)
CET
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Dose Constraints
Anterior rectum: 75 % Posterior bladder and urethra: 80%
3 Dimensional Dosimetry
Normal Tissue
Transluminal View Rectum
CET
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Applicator Selection
.
Intracavitary (T&O, Vaginal cylinders etc.)
Small lesion, good response to EBRT, adequate anatomy
If applicator fits
Interstitial (Template etc.)
Bulky disease, parametria or vaginal involvement
Anatomy not suitable for intracavitary
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Cervical CancerRadiation and Chemotherapy
ChemotherapyCisplatinum weeklyNot given during HDR
Acute ChemoRadiation ToxicityHypokalemiaDehydrationPancytopenia
CET
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Previously Untreated Cervix 5 Year Results 204 Pts 1991-
1999 FIGO Stage Pathology Scan
IB1 36 (18%) Squam 82% Nx 4%
IB2 45 (22%) Adeno 12% N0 85%
II2a 21 (10%) AdenoSq 6% N1 11 %
II2b 59 (29%)
IIIa 12 (6%) BT Method IC = 36% IS = 64%
IIIb 24 (12%) Hysterectomies 14.5%
IVa 7 (3%) Chemotherapy 16%
[email protected] age 55
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5 Year Results Cervix CancerLocal Control by Stage
0
10
20
30
40
50
60
70
80
90
100
Patient Group
%
85%
ALL IB1 1B2 IIA IIB IIIA IIIB IVA
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Patient Group
CET Cervix 5 Year Results
Patient Group
0
10
20
30
40
50
60
70
80
90
100
%
85%
LocalControl
PelvicControl
81%
DM
22%
66%
DFS
60%
OS
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Chronic Morbidity Cervix
Site Grade 3 Grade 4
Bladder 3 2
Rectal 5 1
Gyn 5 0
Total Bladder and Rectal = 11/204 (5%)
CET
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Previously Untreated Vagina Cancer
8 Year Results 53 Patients 1991-2001
FIGO Pathology CT Scan
I 11% Squamous 78% Nx 9%
II 76% Adeno 20% N0 78 %
III 11% AdenoSq 2% N1 13 %
IVa 2% Chemotherapy 15%
Intracavitary 15% Interstitial 85%
[email protected] age 64
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Patient Group
CET Vagina 5 Year Results
Patient Group
0
10
20
30
40
50
60
70
80
90
100
%
87%
LocalControl
PelvicControl
83%
DM
17%
62%
DFS
52%
OS
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Site Grade 3 Grade 4
Bladder 0 1
Rectal 0 3
GYN 4 0
Total Bladder and Rectal = 4/53 (7.5%)
Chronic Morbidity Vagina Ca