Combined Interstitial and Intracavitary High-Dose Rate Brachytherapy of Cervical Cancer

High-dose-rate brachytherapy by remote afterloading is now performed under three-dimensional image guidance by CT or MRI. Three-dimensional image-guided brachytherapy in cervical cancer disclosed that the traditional intracavitary brachytherapy by Manchester method cannot deliver an adequate dose to the large tumor with resulting local recurrence. To improve the local control rate, combined interstitial and intracavitary (hybrid) brachytherapy can increase the dose to the large parametrial involvement without increasing the dose to the rectum and bladder. Whether hybrid brachytherapy can be performed safely on a multi-institutional basis remains to be studied. From 2015, phase I/II study of hybrid brachytherapy was launched in Japan, and it was revealed that hybrid brachytherapy can be performed safely and with a high quality of radiation dose distribution in a multi-institutional study. In Japan, the number of patients undergoing hybrid brachytherapy in cervical cancer is rapidly rising. Education and clinical trial are very important to establish hybrid brachytherapy in the management of cervical cancer.

FLASH Radiotherapy Using Single-Energy Proton PBS Transmission Beams for Hypofractionation Liver Cancer: Dose and Dose Rate Quantification

PurposeThis work aims to study the dose and ultra-high-dose rate characteristics of transmission proton pencil beam scanning (PBS) FLASH radiotherapy (RT) for hypofractionation liver cancer based on the parameters of a commercially available proton system operating under FLASH mode.Methods and MaterialsAn in-house treatment planning software (TPS) was developed to perform intensity-modulated proton therapy (IMPT) FLASH-RT planning. Single-energy transmission proton PBS plans of 4.5 Gy × 15 fractions were optimized for seven consecutive hepatocellular carcinoma patients, using 2 and 5 fields combined with 1) the minimum MU/spot chosen between 100 and 400, and minimum spot time (MST) of 2 ms, and 2) the minimum MU/spot of 100, and MST of 0.5 ms, based upon considerations in target uniformities, OAR dose constraints, and OAR FLASH dose rate coverage. Then, the 3D average dose rate distribution was calculated. The dose metrics for the mean dose of Liver-GTV and other major OARs were characterized to evaluate the dose quality for the different combinations of field numbers and minimum spot times compared to that of conventional IMPT plans. Dose rate quality was evaluated using 40 Gy/s volume coverage (V40Gy/s).ResultsAll plans achieved favorable and comparable target uniformities, and target uniformity improved as the number of fields increased. For OARs, no significant dose differences were observed between plans of different field numbers and the same MST. For plans using shorter MST and the same field numbers, better sparing was generally observed in most OARs and was statistically significant for the chest wall. However, the FLASH dose rate coverage V40Gy/s was increased by 20% for 2-field plans compared to 5-field plans in most OARs with 2-ms MST, which was less evident in the 0.5-ms cases. For 2-field plans, dose metrics and V40Gy/s of select OARs have large variations due to the beam angle selection and variable distances to the targets. The transmission plans generally yielded inferior dosimetric quality to the conventional IMPT plans.ConclusionThis is the first attempt to assess liver FLASH treatment planning and demonstrates that it is challenging for hypofractionation with smaller fractional doses (4.5 Gy/fraction). Using fewer fields can allow higher minimum MU/spot, resulting in higher OAR FLASH dose rate coverages while achieving similar plan quality compared to plans with more fields. Shorter MST can result in better plan quality and comparable or even better FLASH dose rate coverage.

Dose Distribution of 192Ir HDR Brachytherapy Source Measurement using Gafchromic® EBT3 Film Dosimeter and TLD-100H

This study aims to measure the radial dose function and anisotropy function F(r, θ) of high Dose Rate (HDR) 192Ir source in a fabricated water-equivalent phantom using Gafchromic® EBT3 film and TLD-100H and to compare the results obtained with the MCNP5 calculated values. The phantom was fabricated using Perspex PMMA material. For, the EBT3 films with a required dimension and TLD-100H chips were placed at r=1, 2, 3, 5, and 10 cm from the source. The F(r, θ) measurements were carried out at r=1, 2, 3, 5, and 10 cm with the angle range from 10° to 170°. The result of from EBT3 film and TLD-100H was in good agreement (2.10%±1.99). Compared to MCNP5, the differences are within 0.31% to 11.47% for EBT3 film and 0.08% to 10.58% for TLD-100H. For the F(r, θ), an average deviation with the MCNP5 calculation is 4.94%±2.7. For both and F(r, θ), the effects are prominent at r=10 cm. At this distance, the response of both Gafchromic® EBT3 film and TLD-100H shows less sensitivity as the dose followed the inverse square law. This work demonstrates that Gafchromic® EBT3 film dosimeter and TLD-100H are suitable dosimeters in 192Ir dosimetric measurements at a radial distance of ˂5 cm

Conventional dose versus dose escalated radiotherapy including high-dose-rate brachytherapy boost for patients with Gleason score 9–10 clinical localized prostate cancer

As several recent researches focus on the importance of Gleason 9–10, we examine the role of radiotherapy dose escalation in those patients. We analyzed 476 patients with Gleason score 9–10 prostate cancer treated with radiotherapy. Of them, 127 patients were treated with conventional-dose external beam radiotherapy (Conv RT) and 349 patients were treated with high-dose radiotherapy (HDRT; 249 patients received high-dose-rate brachytherapy boost + external beam radiotherapy [HDR boost] and 100 patients received intensity-modulated radiotherapy [IMRT]). We compared these treatment groups using multi-institutional retrospective data. The patients had a median follow-up period of 66.3 months. HDRT showed superior biochemical disease-free survival (bDFS) rate (85.2%; HDR boost 84.7% and IMRT 86.6%) to Conv RT (71.1%, p < 0.0001) at 5 years, with a hazard ratio of 0.448. There were borderline difference in prostate cancer-specific mortality (PCSM; 4.3% and 2.75%, p = 0.0581), and distant metastasis-free survival (DMFS; 94.4% and 89.6%, p = 0.0916) rates at 5-years between Conv RT and HDRT group. Dose escalated radiotherapy showed better bDFS, borderline improvement in PCSM, and equivocal outcome in DMFS in with clinically localized Gleason 9–10 prostate cancer.

Is There Still a Place for Brachytherapy in the Modern Treatment of Early-Stage Oral Cancer?

Brachytherapy (BT) involves the direct application of radioactive sources to the tumour. This technique is characterised by a steep dose gradient, the delivery of high-dose radiation to the target volume centre, and the sparing of surrounding healthy tissues. Low-dose-rate (LDR) BT and manual afterloading played an important role in the treatment of early-stage oral cancer, with treatment outcomes that were comparable to surgery. Interest in BT as a primary treatment for oral cancer has declined in recent years due to the emergence of better surgical techniques, the switch from LDR BT to high-dose-rate (HDR) BT (which has a higher risk of complications), and to advances in external beam radiotherapy (EBRT). At present, the main indications for BT are in the postoperative setting due to the superior dose conformity and better quality of life offered by BT versus EBRT. Postoperative BT can be administered as monotherapy in early-stage (T1N0) cancers and in combination with elective neck dissection or EBRT to treat larger or deeper tumours. BT yields excellent results for lip carcinoma in older patients and in tumours with unfavourable localisations. BT is an effective salvage therapy for local recurrences in previously-irradiated areas. Despite its many advantages, brachytherapy is a complex treatment requiring meticulous technique and close cooperation between the radiation oncologist, physicist, and surgeon.

Stray radiation produced in FLASH electron beams characterized by the MiniPIX Timepix3 Flex detector

This work aims to characterize ultra-high dose rate pulses (UHDpulse) electron beams using the hybrid semiconductor pixel detector. The Timepix3 (TPX3) ASIC chip was used to measure the composition, spatial, time, and spectral characteristics of the secondary radiation fields from pulsed 15–23 MeV electron beams. The challenge is to develop a single compact detector that could extract spectrometric and dosimetric information on such high flux short-pulsed fields. For secondary beam measurements, PMMA plates of 1 and 8 cm thickness were placed in front of the electron beam, with a pulse duration of 3.5 µs. Timepix3 detectors with silicon sensors of 100 and 500 µm thickness were placed on a shifting stage allowing for data acquisition at various lateral positions to the beam axis. The use of the detector in FLEXI configuration enables suitable measurements in-situ and minimal self-shielding. Preliminary results highlight both the technique and the detector’s ability to measure individual UHDpulses of electron beams delivered in short pulses. In addition, the use of the two signal chains per-pixel enables the estimation of particle flux and the scattered dose rates (DRs) at various distances from the beam core, in mixed radiation fields.