This document discusses high-dose-rate brachytherapy (HDR BT) and its clinical applications, with a focus on its use for prostate cancer. It defines HDR BT and compares it to low-dose-rate BT. It outlines many clinical sites where HDR BT is used and describes the procedure for prostate HDR BT in detail, including imaging, catheter placement, treatment planning, and common schedules. Complications are discussed. HDR BT is described as being commonly used as a boost with external beam radiotherapy or as monotherapy for prostate cancer.
A review of advances in Brachytherapy treatment planning and delivery in last decade or so, with main focus on brachytherapy for Prostate cancer, Breast cancer and Cervical cancer
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
A review of advances in Brachytherapy treatment planning and delivery in last decade or so, with main focus on brachytherapy for Prostate cancer, Breast cancer and Cervical cancer
The vmat vs other recent radiotherapy techniquesM'dee Phechudi
VMAT is a new type of intensity-modulated radiation therapy (IMRT) treatment technique that uses the same hardware (i.e. a digital linear accelerator) as used for IMRT or conformal treatment, but delivers the radiotherapy treatment using a rotational or arc geometry rather than several static beams.
This technique uses continuous modulation (i.e. moving the collimator leaves) of the multileaf collimator (MLC) fields, continuous change of the fluence rate (the intensity of the X rays) and gantry rotation speed across a single or multiple 360 degree rotations
This ppt explains about Electronic Brachytherapy which is a very special type of Brachytherapy in Radiation therapy. This presentation also demonstrates classifications of brachytherapy, Sources used for Brachytherapy, Advantages and disadvantages of electronic Brachytherapy, Different companies providing Electronic Brachytherapy machines and it portraits working method and components of Electronic Brachytherapy Machine.
Brachytherapy-A Brief Review with focus on Carcinoma Cervixiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
the role of brachytherapy in oral cavity carcinoma.
physics of brachytherapy
radiobiology of brachytherapy
clinical application in tongue, buccal mucosa cancer
This ppt explains about Electronic Brachytherapy which is a very special type of Brachytherapy in Radiation therapy. This presentation also demonstrates classifications of brachytherapy, Sources used for Brachytherapy, Advantages and disadvantages of electronic Brachytherapy, Different companies providing Electronic Brachytherapy machines and it portraits working method and components of Electronic Brachytherapy Machine.
Brachytherapy-A Brief Review with focus on Carcinoma Cervixiosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
the role of brachytherapy in oral cavity carcinoma.
physics of brachytherapy
radiobiology of brachytherapy
clinical application in tongue, buccal mucosa cancer
Economical, low cost, successful brachytherapy surgery in India an advantage for oversea patients coming through IndianMedGuru a leading medical tourism company.
IORT uses a high single-fraction radiation dose (10-30 Gy) is delivered during surgery to a surgically-exposed tumour bed, immediately after a chunk of the tumour has been surgically excised. This slide includes topics like APBI, IOERT, IOHDR.
Evolving Role of Radiation Therapists & Concernment of Risk Management in Mod...Subrata Roy
Radiation therapists, also known as therapeutic radiographers, work with oncology teams in order to determine the best course of radiation treatment for patients. They work under the guidance of a radiation oncologist and play a pivotal role in the planning and execution of radiation treatments. With additional training and experience, a therapist can become a certified medical dosimetrist. A dosimetrist calculates the correct dose of radiation treating cancer patients. Other therapists advance to administrative positions or to management positions such as a chief therapist or education director.
Calypso Medical's Prostate Cancer Treatment: Imaging Technology NewsCalypso Medical
A thorough explanation of image guided radiation therapy for prostate cancer, prostate cancer side effects associated with prostate radiation treatment, and how Calypso GPS for the Body technology greatly reduces the risk of side effects.
Mi primera vez como ponente en unas jornadas hablando de un blog como Carpe Diem, donde se habla de radioterapia, oncología, cuidados paliativos, pacientes... y de mí
Atlas de drenaje ganglionar cervical, muy útil para los oncólogos radioterápicos a la hora de delimitar los volúmenes de tratamiento en los tumores de cabeza y cuello
El QUANTEC nos ayuda a los oncólogos radioterápicos a la hora de aprobar un tratamiento con sus tablas con "constraints" de los órganos de riesgo (los límites de dosis que pueden recibir los órganos sanos situados entorno al tumor que queremos tratar).
PD: Las tablas se encuentran en las páginas 15-17
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
4. Definition
Brachytherapy (BT), from the Greek language, means “ therapy at a short
distance”.
It involves the precise placement of radiation sources near the site of the
cancer cells. Because the absorbed dose falls off rapidly with increasing
distance from the sources, high doses may be delivered safely to a
localized target region over a short time. (1)
Compared to external beam radiotherapy (EBRT), brachytherapy has the
advantage of delivering a high dose to the tumor while sparing the
surrounding normal tissues. (1)
5. History
It was increasingly used in the treatment of
malignant tumors shortly after the discovery
of radium – 226 (226Ra) by Marie Curie in
1898. (2)
Sustained a rapid growth with the
development of afterloading devices
(treatment with radioactive sources controlled from a distance)
and the introduction of artificial
radionuclides. (2)
6. Types (3)
Source placement
Interstitial
Intracavitary (e Intraluminal)
Superficial (surface applicators)
Duration of dose delivery
Temporary
Permanent
Dose rate
Low-dose rate (LDR): rate of up to 2 Gy/h. (Iodine 125 (125I) or Palladium 103 (103Pd))
Medium-dose rate (MDR): rate between 2 Gy/h to 12 Gy/h
High-dose rate (HDR): rate > 12 Gy/h. Iridium-192 (192Ir):
Is the most commonly used isotope for HDR.
Has an average energy of 380 KeV, a half-life of 73,8 days and a half value layer of 2,5 mm of lead.
7. HDR VS LDR
While LDR BT has been examinated and assesed the most and become a
standard treatment option, HDR brachytherapy has recently gained
momentum as an alternative.
8. Advantages Disadvantages
Radiation protection.
• HDR eliminates radiation exposure hazard for care givers and visitors.
• HDR eliminates source preparation and transportation.
• Since there is only one source, there is minimal risk of losing a radioactive source.
Radiobiological.
• The short treatment times do not allow for the repair of
sublethal damage in normal tissue or the redistribution of
cells within the cell cycle or reoxygenation of the tumor
cells; hence, multiple treatments are required.
Allows shorter treatments times.
• There is less patient disconfort since prolonged rest is eliminated.
• It is posible to treat patients who may not tolerate long periods of isolation and those who are at high
risk for pulmonary embolism due to prolonged bed rest.
• There is less risk of applicator movement during therapy.
• There are reduced hospitalization costs since outpatient therapy is posible.
• HDR may allow greater displacement of nearby normal tissues (by packing or retraction) which could
potentially reduce morbidity.
• It is posible to treat a larger number of patients in instutions that have a high volumen of BT patients
but insufficient inpatient facilities.
• Allow intraoperative treatments, wich are completed while patient is still in the operating room.
Limited experience.
• Few centers in the United States have long-term (>20 years)
experience.
• Until recently, standarized treatment guidelines were not
available; however, the American Brachytherapy Society
(ABS) has recently provide guidelines for HDR at various
sites (http://www.americanbrachytherapy.org/guidelines/)
HDR sources are of smaller diameter than the cesium sources that are used for
intracavitary LDR.
• This reduces the need of dilatation of the cervix and therefore reduces the need for heavy sedation or
general anesthesia.
• High-risk patients who are unable to tolerate general anesthesia can be more safely treated.
• HDR allows for intesrtitial, intraluminal, and percutaneus insertions.
The economic disadvantage
• The use of HDR BT as compared to manual afterloading
techniques requiers a large initial capital expenditure since
the remote afterloaders cost about $ 300000.
• There are aditional cost for a shielded toom and personnel
cost are higher as the procedures are more labor intensive
HDR makes treatment dose distribution optimization possible.
• Variations of the dwell times of a single stepping source allow an almost infinite variation of the
effective source strengths, and the source position allows for greater control of the dose distribution
and potenctially less morbidity
Greater potential risks
• Since a high activity source is used, there is greater
potential harm if the machine malfunctions or if ther is a
calcualtion error. The short treatment times, compared to
LDR, allow muchs less time to dectect and correct errors(1) Halperin, Edward C; Brady, Luther W; Perez, Carlos A; Wazer, David E (2013) Perez & Brady's Principles and Practice of Radiation Oncology (6th ed)
9. CLINICAL APPLICATIONS
HDR BT has been used in almost every site in the body, generally as a
component of multimodality treatment (4)
10. 1. Cervical cancer
2. Endometrial cancer
3. Prostate
4. Breast
5. Skin
6. Bronchus/Trachea
7. Bile duct
8. Esophagus
9. Head and neck
10. Soft tissue sarcoma
11. Pediatric tumors
12. Intraoperative brachytherapy
13. Anorectal
14. Other indications:
Penis
Bladder
Urethra
Ocular
Blood vessels (coronary and peripheral arteries)…
11. 1. Cervical cancer
2. Endometrial cancer
3. Prostate
4. Breast
5. Skin
6. Bronchus/Trachea
7. Bile duct
8. Esophagus
9. Head and neck
10. Soft tissue sarcoma
11. Pediatric tumors
12. Intraoperative brachytherapy
13. Anorectal
14. Other indications:
Penis
Bladder
Urethra
Ocular
Blood vessels (coronary and peripheral arteries)…
13. Introduction
Multiple treatment options are available for clinically localized prostate cancer:
Radical prostatectomy, EBRT, BT, EBRT + BT….
BT can deliver a highly localized radiation dose to the tumor.
While LDR BT has been examined and assessed the most, and become a standard
treatment option (permanent implantation 125I or 103Pd (1)), HDR BT has recently gained
momentum as an alternative (5-6):
Most commonly as a dose escalating boost delivered in combination with EBRT.
There is also increasing experience in HDR BT used alone to deliver a radical dose radiation and as a
salvage treatment to local recurrence.
Recomendations on temporary transperineal prostate BT, were first published on
behalf of GEC/ESTRO-EAU Prostate Brachytherapy Group (PROBATE) in 2005 (7)
14. Advantages Disadvantages
It is possible to individualise the source positions over the full
lenght of the prostate based on a defined planning target volume
and organs at risk. Dose distribution optimisation by inverse
planning enables highly conformal dose delivery.
Use of a fractionated schedule results in more work
load per patient and logistic issues related to quality
assurance across several radiation exposures
The use of image guide catheter or needle placement enables
accurate implantation which can be extended to include
extracapsular disease and seminal vesicles.
The treatments must be executed carefully because
the short treatment times do not allow any time for
correction errors, and mistakes can result in harm to
patients
The fixation of the prostate by the implant and rapid radiation
delivery minimises the problems of target and OAR movement.
During multifractionated HDR treatment, catheter
migration could cause degradation of dosimetry.
The use of high dose per fraction has a biological dose advantage
for tumors with a low alpha beta ratio of which prostate is a
common example.
Temporary BT using a stepping source does not need any source
preparation time and there is good radiation protection for
personnel.
The use of a single source for all patients using a multipurpose
facility makes HDRBT highly cost effective.
(6)(5-6)
16. Equipment
Operating room or brachytherapy suite suitable for sterile procedures and access to anaesthetic support.
HDR afterloader.
TRUS unit with template, the ultrasound should be capable of both transaxial an sagital image acquisition.
TRUS fixation and stepping unit.
Intestitial implant catheters of a suitable design compatible with the TRUS based template; They should
also be CT or MR compatible if this imaging method is to be used. Rigid steel or flexible catheters can be
used for the implant procedure. The advantage of flexible catheters is that the may be seen to bend
around the pubic arch and then regain their plane in the more anterior aspects of the prostate gland.
Appropiate software to enable importation of post implant TRUS or CT or MR imaging with image fusion.
A planning system which can achieve accurate implant reconstruction and 3D dosimetry.
A brachytherapy suite with adequate shielding to perform the HDR treatment, according to national
radiation protection rules.
Access to appropriate imaging post implant with either TRUS, CT or MR.
17.
18. General Considerations
Brachytherapy is done under spinal anesthesia.
The patient is placed in the lithotomy position and a
urinary catheter is placed into the urinary bladder.
The skin is prepared and full sterile theater
precautions should be used.
TRUS is now the standard means of guiding
applicators. Setting up of the TRUS prior to
implantation is very important.
The position of the patient and the template position
are critical before implantation is commenced:
The urethra should be identified and positioned along the central
row of the template (usually row D)
The inferior row of applicator positions must reflect the lowest part
of the gland to be implanted and if seminal vesicles are to be
included in the PTV it is essential these are also considered in the set
up.
19. Catheter insertion
The applicators are inserted transperineally under
direct US control.
When homogenous cover of the gland is required then
catheters should be placed with no greater tan 1 cm
intervals between applicators.
Peripheral coverage is most important so it is vital to
have a ring of catheters around the edge of the
peripheral zones, with a distance of about 3 mm from
the prostate CTV border. It is advantageous start to
implant with the anterior catheters.
20. Imaging for dosimetry
TRUS
Obtained whilst the patient remains in the
lithotomy position under anaesthetic or
sedation. The whole prostate should be covered
and in addition at least 5 mm cranially and
caudally outside the gland.
CT or MRI
Obtained following recovery from anaesthetic
and transfer to the imaging deparment:
CT acquisition should be at no more tan 3 mm intervals
T2 will provided optimal anatomical definition but T1 will
provide more accurate catheter reconstruction.
Image fusion may be used to maximise information. Fiducial
markers are placed in the prostate to compare catheter
localited prior to each treatment.
21. Volumes for treament plannig
CTV is defined by:
The prostate capsule.
Plus any macroscopic extracapsular
disease or seminal vesicle involvement
identified on diagnostic images expanded
by 3 mm. (Usually constrained posteriorly to the
anterior rectal wall and superiorly to the bladder base.)
Organs at risk (OAR):
Rectum.
Urethra: Should extend from bladder
base to 5 – 50 mm bellow the prostatic
apex.
OAR dose constraints
Urethra: Dmax ≤ 120%
Rectum: V70 < 1cc
22. Planning aim and dose prescription
Once satisfactory dose distribution has
been obtained, this will be transfered into
the HDR control program as a series of
dwell times for each catheter.
Typical treatment times are very short,
most catheters having total treatment
times for the implant being of the order of
10 – 15 min, depending upon the total
number of catheters.
23. Complications and toxicity
This technique is well tolerated.
Perineal presure after catheter removal will minimize the risks of
hematoma formation. Antibiotics, steroid medications and α blockers can
be prescribed.
Genitourinary:
Acute urinary irritative symptoms (urgency, frequency…) are common and usually resolve with time.
Urinary retention occurs in < 5% of cases and can be managed with catheterization.
Urinary strictures are reported in up to 15% of patients (most commonly in bulbomembranous urethra). TURP
should be avoided after HDR prostate BT, but there is no absolute contraindication to a properly
performed procedure.
Prolonged urinary incontinencee is extremely rare, < 2%.
25. Complications and toxicity
Gastrointestinal:
Rectal irritation causing rectal urgency or frequency is more likely when HDR is use in
conjunction with EBRT.
Late rectal bleeding may occur and is usually not clinically significant.
Serius complications, such as a rectal fistula, are extremely rare, and seen in < 1%.
Sexual dysfunction:
Erectile dysfunction has been reported in up to 40% of men who were fully potent at
baseline but approximately 80% respond to pharmacologic agents .
5 – year probability of impotence 49% LDR and 21% HDR (p = 0,006) (2)
26. USES OF HDRBT IN PROSTATE CANCER
Boost with EBRT, Monotherapy or Salvage treatment to local recurrence
27. BOOST with EBRT
HDRBT as a boost with EBRT is now estabilished as an effective means of
dose escalation in the radical treatment of prostate cancer supported by
level 1 evidence from one randomised trial (10) and a large body of
published series.
Represents a succesful treatment of choice and results in excellent bNED,
local control and survival rates.
28. Patient Selection Criteria
Stages T1b to T3b prostate cancers, any Gleason
Score and any PSA level are candidates for HDR
as a boost to EBRT
Relative Contraindications:
Large glande size (>60cc)
Significant urinary obstructive symptons
Recent TURP within the last 6 months
Large TURP defects
Pubic arch interference
Rectum-prostate distance on TRUS of < 5 mm
Absolute Contraindications: (9)
Preexisting rectal fistula.
Lithotomy position or anesthesia not possible
No proof of malignancy
GEC-ESTRO/EAU 2005
GEC/ESTRO 2013
29. Treatment Schedules
It is not possible to make a firm recommendation on plannig aim dose
EBRT:
45 Gy in 25 fx, 46 Gy in 23 fx; 35,7 Gy in 13 fx; 37,5 Gy in 15 fx…
Before currently with or after HDRBT.
Minimum volumen treated should include the entire prostate and vesicles with
margin +/- pelvic lymph nodes.
HDR:
Is given in multiple fractions, generally twice a day with a minimum of 6 h between
fractions, in 1 – 3 implant procedures.
15 Gy in 3 fx; 11 – 22 Gy in 2 fx; 12 – 15 Gy in 1 fx… A single dose of 15 Gy is gaining
increasing acceptance (11)
31. A single dose of 15 Gy
1. HDR Brachytherapy 2. EBRT (IMRT)
Pelvic lymph nodes: 45 Gy
Prostate + vesicles: 54 Gy
32. MONOTHERAPY
First proposed by Yoshioka et al, almost 2 decades ago (12).
Radiobiological considerations, which asume a low α/β for prostate
cancer, predict a significant advantage for HDRBT alone delivered in a
small number of very large fractions in terms of total biologically effective
dose over EBRT and LDRBT.
Advantages relating to dosimetry and radioprotection.
Demands higher degree of technical and planning expertise than boost.
33. Patient Selection Criteria
Hot debate (5):
Reported by several institutions, largely for low-risk, but also for low-to-
intermediate-risk patients.
For high-risk patients should be considered investigational. However,
recently published reports revealed excellent biochemical control rates,
even for intermediate- and high-risk patients (13-15)
As yet, no guidelines or recommendations have been established .
34. Treatment Schedules
Long term date are not yet available.
34 Gy in 4 fx (1 implant)
36-48 Gy in 4 fx (1 implant)
38 Gy in 4 fx (2 implants)
34,5Gy in 3 fx (3 implants)
31,5 Gy in 3 fx (1 implant)
26 Gy in 2 fx (1 implant)
19 Gy in 1 fx (1 implant)
Gunderson (2)
36. SALVAGE TREATMENT TO LR
Locally recurrent prostate cancer following RT represent a clinical challenge (16).
Surgery, cryotherapy and BT are among the most frequently used salvage
treatment options (17)
Several aspects unique to HDR BT make it ideally suite or use as a salvage
procedure (18):
Delivers high dose radiation directly to the target tissue.
Results in very little treatment related uncertainty.
Is well suited to hypofractionated treatment schedules.
EBRT is not able to achieve either the high doses to the prostate or the dose sparing effect on normal
tissues that HDR BT is able to achieve (19)
37. Patient Selection Criteria
Have a biospy-proven recurrence after definitive EBRT, with no evidence of
disease elsewhere.
Treatment schedules
36 Gy in 6 fx (20)
21 Gy in 3 fx (21)
30 Gy in 2 fx after 30 – 40 Gy
EBRT (post prostatectomy) (22)
There is limited experience and this is no
recommended outside a formal prospective
study. OAR constraints are critical in this setting (6)
38. HDRBT 36 Gy in 6 fx (2 implants, 1 week apart)
Mediam followup 18,7m: bNED 89% with 14% G3-4 toxicity. (20)
Mediam followup 60m: bNED 51% with 4% G3-4 toxicity. Suggestig that, with
further time, G3 complicantions trend to improve. (23)
40. HDRBT is a vehicle for dose escalation that has resulted in high tumor control and
low toxicity rates.
With proper selection and delivery technique, HDRBT has great promise and
convenience because of avoidance of radiation exposure, short treatment times,
and outpatient therapy.
The development of well-controlled randomized trials addressing issues of efficacy,
toxicity, quality of life and costs versus benefits will ultimate define the role of HDR
BT in the therapeutic armamentarium.
With excellent tumor control and a favorable side-effect profile, HDR BT is now an
established and important treatment for prostate cancer.
42. 1. Halperin, Edward C; Brady, Luther W; Perez, Carlos A; Wazer, David E (2013). Perez & Brady's Principles and Practice of Radiation
Oncology (6th ed) . Philadelphia: Lippincott Williams & Wilkins.
2. Gunderson ,Leonard L; Tepper, Joel E (2012). Clinical Radiation Oncology (3rd ed). Philadelphia: Elsevier Saunders.
3. Guinot, JL; Lanzós, E; Muñoz, V; Polo, A; Ramos, A (2008). Guía de Braquiterapia. Madrid: SEOR.
4. Erickson BA, Demanes DJ, Ibbott GS, et al. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR)
practice guideline for the performance of high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 2011 ;79: 641 – 649.
5. Yoshioka Y, Suzuki O, Otani Y, et al. High-dose-rate brachytherapy as monotherapy for prostate cancer: technique, rationale and
perspective. J Contemp Brachytherapy 2014; 6: 91 – 98.
6. Hoskin PJ, Colombo A, Henry A et al. GEC/ESTRO recomendations on high dose rate afterloading brachytherapy for localised prostate
cancer: an update. Radiother Oncol 2013; 107: 325 – 332.
7. Kovacs G, Potter R, Loch T, et al. GEC-ESTRO EAU recommendations on temporary brachytherapy using stepping sources for localized
prostate cancer. Radiother Oncol 2005; 74: 137 – 148.
8. Joslin, C.A.F; Hall, E; Flynn, A (2001); Principles and Practice of Brachytherapy: Using Afterloading Systems. London: Arnold.
9. Yamada Y, Rogers L, Demanes DJ, et al. American Brachytherapy Society consensus guidelines for high-dose-rate prostate
brachytherapy. Brachytherapy 2012; 11: 20 – 32.
10. Hoskin PJ, Rojas AM, Bownes PJ, Lowe GJ, Ostler PJ, Bryant L. Randomised trial of external beam radiotherapy alone or combined with
high-dose-rate brachytherapy boost for localised prostate cancer. Radiother Oncol 2012; 103: 217 – 222.
11. Morton G, Loblaw A, Cheung P, et al. Is single fraction 15 Gy the preferred high-dose-rate brachytherapy boost dose for prostate
cancer?. Radiother Oncol 2011; 100: 463 – 467.
12. Hoskin P, Rojas A, Ostler P, Hughes R, et al. High-dose-rate brachytherapy alone given as two or one fraction to patients for locally
advanced prostate cancer: Acute toxicity. Radiother Oncol 2014; 110: 268 – 271.
43. 13. Rogers CL, Alder SC, Rogers RL et al. High dose brachytherapy as monotherapy for ingermediate risk prostate cancer. J Urol 2012; 187:
109 – 116.
14. Hoskin P, Rojas A, Lowe G et al. High-dose-rate brachytherapy alone for localized prostate cancer in patients at moderate or high risk of
biochemical recurrence. Int J Radiat Oncol Biol Phys 2012; 82: 1376 – 1384.
15. Zamboglou N, Tselis N, Baltas D, et al. High-Dose-Rate Interstitial Brachytherapy as Monotherapy for Clinically Localized Prostate
Cancer: Treatment Evolution and Mature Results. Int J Radiat Oncol Biol Phys 2013. 85: 672 – 678.
16. Hsu IC, Yamada Y, Assimos DG, et al. ACR Appropriateness Criteria high-dose-rate brachytherapy for prostate cancer.
Brachytherapy 2014; 13: 27 – 31.
17. Henríquez I, Sancho G, Hervás A, Guix B, et al. Salvage brachytherapy in prostate local recurrence after radiation therapy: predicting
factors for control and toxicity. Radiat Oncol 2014; 9: 102.
18. Yamada Y, Kollmeier M.A, Pei X, et al. A Phase II study of salvage high-dose-rate brachytherapu for the treatment of locally recurrent
prostate cancer after definitive external beam radiotherapy. Brachytherapy 2014. 13: 111 – 116.
19. Spratt DE, Scala LM, Folkert M, et al. A comparative dosimetric analysis of virtual stereotactic body radiotherapy to high-dose-rate
monotherapy for intermediate-risk prostate cancer. Brachytherapy 2013. 12: 428 – 433.
20. Lee B, Shinohara K, Weinberg V, et al. Feasibility of high dose rate brachytherapy salvage for local prostate cacner recurrence afteer
radiotherapy: the University of San Francisco experience. Int J Radiat Oncol Biol Phys 2007. 67: 1106 – 1112.
21. Tharp M, Hardacre M, Bennett R, et al. Prostate high dose rate brachytherapy as salvage treatment of local failure after previous
external or permanent seed irradiation for prostate cancer. Brachytherapy 2008; 7: 231 – 236.
22. Niehoff P, Loch T, Nurnber N, et al. Feasibility and preliminary outcome of salvage combined brachytherapy and external beam
radiotherapy for local recurrences after radical prostatectomy. Brachytherapy 2005; 4: 141 – 145.
23. Chen CP, Weinberg V, Shinohara K, et al. Salvage HDR brachytherapy for recurrent prostate cancer after previous definitive radiation
therapy: 5 – Year otcomes. Int J Radiat Oncol Biol Phys 2013. 86: 324 – 329.
44. ”Life is not easy for any of us. But what of that? We
must have perseverance and above all confidence in
ourselves. We must believe that we are gifted for
something and that this thing must be attained.”
Marie Curie
Editor's Notes
*Deger
15 Gy con EQD2: 70,71 Gy
54 Gy con EQD2: 56,46 Gy
EQD2total: 127,17 Gy
“La vida no es fácil, para ninguno de nosotros. Pero... ¡Qué importa! Hay que perseverar y, sobre todo, tener confianza en uno mismo. Hay que sentirse dotado para realizar alguna cosa y que esa cosa hay que alcanzarla, cueste lo que cueste”.