A unique approach to high-dose-rate vaginal mold brachytherapy of gynecologic malignancies

Nilsson, Sanna; Moutrie, Zoë; Cheuk, Robyn; Chan, Philip; Lancaster, Craig M.; Markwell, Tim; Dawes, Jodi; Back, Phil

doi:10.1016/j.brachy.2014.10.004

Cited by 11 publications

(15 citation statements)

References 36 publications

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“…Nilsson et al offered a customizable applicator with mold material when traditional cylindrical or dome-type applicators could not be used or provided inadequate dose coverage of target. [22] Our data of 10 years experience presented satisfactory clinical results with the practice of IH-MCA. The rigid type MCA was used for most patients owing to its convenience and simplicity for VBT.…”

Section: Discussionmentioning

confidence: 76%

Outcomes of intermediate-risk to high-risk stage I endometrial cancer

Hou

et al. 2019

Chinese Medical Journal

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Background: There are only very few reports on clinical outcomes using multi-channel applicators (MCA) for patients with endometrial cancer (EC) in China. We aimed to evaluate the clinical experience of treating intermediate-risk (IR) to high-risk (HR) stage I EC using in-house made multi-channel applicators (IH-MCA) in a single institution. Methods: Three hundred and ninety patients with stage I IR to HR EC were treated with hysterectomy and adjuvant radiotherapy from 2003 to 2015. All patients received post-operative vaginal cuff brachytherapy (VBT) alone or as a boost after external beam radiotherapy (EBRT). The prescriptions were 500 cGy per fraction for a total of 5 to 6 fractions with brachytherapy alone or 400 to 600 cGy per fraction for 2 to 3 fractions if it was combined with EBRT. Two types of applicators including a traditional rigid IH-MCA and a recent model custom-made with 3 dimension printing technology were used for treatment. The Kaplan-Meier method was used to calculate survival rate. Results: Follow-up rate was 92.8% and the median follow-up time was 48 months (range 4–172 months). The 5-year overall survival (OS), progression-free survival, local recurrence, and distant metastasis rates for all patients were 96.3%, 92.1%, 2.9%, and 4.8% respectively. Two patients had isolated relapse in vagina outside the irradiated volume. The univariate and multivariate analysis showed that age and grade were the prognostic factors correlated with OS (hazard ratio: 0.368, 95% confidence interval [CI]: 0.131–1.035, P = 0.048; hazard ratio: 0.576, 95% CI: 0.347–0.958, P = 0.026,). Conclusions: For patients with IR to HR stage I EC, adjuvant VBT alone or in combination with EBRT using IH-MCA led to excellent survival and recurrence rates. Age and grade were the prognostic factors correlated with OS.

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Section: Discussionmentioning

confidence: 76%

Outcomes of intermediate-risk to high-risk stage I endometrial cancer

Hou

et al. 2019

Chinese Medical Journal

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“…There are also different methods reported to produce customized moulds. Nilsson et al used a two-part putty [55]. However, further work is warranted investigating the use of 3D printing in the treatment of vaginal malignancies [56,57].…”

Section: Discussionmentioning

confidence: 99%

A single-institution review of image-guided brachytherapy for vaginal malignancies using customized molded applicators and interstitial needles

Flower¹,

Zanjani²,

Busuttil³

et al. 2021

jcb

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Purpose:To review a single-institution's pattern of practice, dosimetry results, and clinical outcomes for patients with unresectable malignancies of vagina, vulva, or urethra, receiving brachytherapy using customized vaginal moulds with or without interstitial needles.Material and methods: Twenty-one consecutive patients were reviewed. Patients were treated using customized moulds with or without interstitial needles, implanted with a free-hand technique. Technical implementation, such as type of implant and imaging used were recorded. D 90 and D 98 of clinical target volume (CTV), D 0.1cc of urethra, and D 2cc and D 0.1cc of bladder and rectum were analyzed. Any adverse clinical outcomes were reported.Results: Eleven patients experienced endometrial cancer recurrences, one a cervical cancer recurrence and nine vaginal or peri-urethral primary disease. After a median follow-up of 3.5 years, local control was achieved in 14 patients (67%). Median D 98 and D 90 to CTV was 73.7 Gy and 78.3 Gy, respectively. One patient died from disease progression, one developed distant metastasis, and seven failed locally. Median D 2cc to bladder was 64.8 Gy, with low-grade toxicity reported. Median D 2cc to rectum was 62.9 Gy, with low-grade toxicity and one case of rectal proctitis was observed. Median urethral D 0.1cc was 66 Gy, with no toxicity reported. One patient suffered from a sacral insufficiency fracture. It was presumed that vaginal mucosa proximal to CTV received the total dose, with two patients developing vaginal ulcers, which both resolved; 10 patients reported mild telangiectasia, fibrosis, or stenosis.Conclusions: A review of patients treated with a customized vaginal mould and interstitial needles showed acceptable doses to CTV, with local control achieved in 67% of patients, and reasonable doses to organs at risk (OARs) and acceptable toxicity.

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“…Furthermore, the ability to offer customized brachytherapy through hydrogel used in combination with a single size, reusable applicator may provide the opportunity for cost-savings, compared to other alternatives such as stocking a range of different sizes of applicators or using commercially available disposable options for this purpose. We did not compare our strategy to vaginal mold techniques of vaginal brachytherapy [ 18 , 19 , 20 ], but one would expect mold techniques to be more conformal, with better target volume coverage and lower doses to adjacent organs as well as more time-consuming than our proposed methodology. It should be noted that the hydrogel reaction occurs very rapidly and can be removed readily after the procedure, which may provide some workflow and patient comfort advantages compared to the vaginal mold technique.…”

Section: Discussionmentioning

confidence: 99%

Development and preclinical testing of a novel biodegradable hydrogel vaginal packing technology for gynecologic high-dose-rate brachytherapy

Peach

Moore

Giles

et al. 2018

jcb

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PurposeWe evaluated the performance of a novel hydrogel-based strategy developed for clinical use as vaginal packing using phantoms and cadavers, and to compare the hydrogel to gauze and balloon packing.Material and methodsThe biocompatible hydrogel is based on a thiol-Michael addition reaction, with delivery of reagents into the vaginal cavity using a custom-made system. Soft-cured cadavers were used for soft tissue-like mechanical properties. Two cadavers with intact uteri had magnetic resonance imaging (MRI) compatible with tandem and ovoids. For one cadaver, the temperature of the vaginal canal was measured before hydrogel application, during polymerization, and after hydrogel removal. The hydrogel packing and applicator was kept in a second cadaver, which was imaged using computed tomography (CT) and MRI. The hydrogel packing and imaging was repeated for an open multichannel MRI compatible, titanium-based vaginal cylinder placed in a post-hysterectomy cadaver.ResultsThe gel reaction occurred within 90 seconds, indicating polymerization at clinical quantities with a 5°C increase in vaginal temperature. CT and MRI imaging identified the hydrogel readily and showed a conformance to anatomy with few air pockets. The entire hydrogel packing was readily retrieved upon completion of imaging.ConclusionsThe novel strategy for polyethylene glycol (PEG)-based hydrogel intra-vaginal packing was able to rapidly polymerize in human cadavers with minimal heat production. Delivery was efficient and able to fill the contours of the vaginal cavity and displace tissue away from the applicator axis. The hydrogel has favorable imaging characteristics on CT and MRI, and shows a potential for clinical use, warranting additional studies for the use in humans.

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A unique approach to high-dose-rate vaginal mold brachytherapy of gynecologic malignancies

Cited by 11 publications

References 36 publications

Outcomes of intermediate-risk to high-risk stage I endometrial cancer

Outcomes of intermediate-risk to high-risk stage I endometrial cancer

A single-institution review of image-guided brachytherapy for vaginal malignancies using customized molded applicators and interstitial needles

Development and preclinical testing of a novel biodegradable hydrogel vaginal packing technology for gynecologic high-dose-rate brachytherapy

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