The context for writing this textbook is that of a dedicated division of brachytherapy in a large urban teaching hospital with three core missions: excellence in clinical care of patients, excellence in teaching, and excellence in research. This textbook addresses all three goals. This textbook should be a practical source to clinical teams answering two basic questions, why and how. Ten clinical disease site chapters are preceded by chapters on practical radiobiology, practical physics considerations, and followed by a final chapter of organizational practical considerations. Chapters 3 to 12 on clinical disease sites flow generally in a cephalocaudal order. These vignette descriptions will help contextually orient the reader.
The chapter on head and neck brachytherapy was contributed by the Beth Israel NY group, led by Peter Han and Ken Hu under the direction of Lou Harrison. Lou's influence over how head and neck radiation therapy is practiced is without parallel. His unstinting commitment to excellence continues to inspire. This chapter features a very nice concise history of brachytherapy, as befits the first clinical chapter. Patient selection, techniques, and results form the backbone of the various clinical sites. Nasopharynx, lip, oral tongue, base of tongue, floor of mouth, buccal mucosa, faucial arch, tonsil, recurrences and additional techniques are covered well. There are many useful clinical pictures, including various films of implants and applicators. The chapter finishes with some of my own clinical cases with novel applications of high dose rate (HDR) surface applicator technology for superficial head and neck targets.
The central nervous system (CNS) chapter comes out of hospital in Boston, the Massachusetts General Hospital (MGH). Arnab Chakravarti, with the assistance of Tom DeLaney and Jay Loeffler, has given a broad overview of the CNS and included novel approaches. The chapter reviews radiobiology and physics pertinent to temporary or permanent Iodine-125 (125I) implants, as well as colloidal 125I for temporary intracavitary balloon implantation, I-emitting isotopes for dural plaque therapy, monoclonal tagged antibodies for gliomas, and also for surface applicator technology and permanent seed implant technology for spinal dura. For the additional clinical images provided by Normand Laperriere, Jim Welsh, and David Larson.
The chapter on breast brachytherapy was born out of the Virginia Commonwealth University program by Joe Kelly under the leadership of Doug Arthur and with guidance from Frank Vicini at the William Beaumont Hospital. These latter two senior doctors have changed the face of breast conserving radiation therapy and, as leaders in the national randomized trial, are fully committed to teaching these methodologies. There is a thorough review of the history of breast conservation, the rationale for less than whole breast irradiation, and the various techniques. Interstitial and intracavitary techniques are reviewed in detail including indications, techniques, and results. Future directions are dealt with carefully and with insight. In this chapter, additional clinical information on novel uses of HDR surface applicator technology for postmastectomy immediate reconstruction scar boost have added.
The chapter on thoracic brachytherapy was developed in Boston. Subhakar Mutyala has shown a strong interest in learning more about this, and has enthusiastically taken these methodologies to his new practice in the Bronx at Montefiore where he has begun to teach fellows in a cross-town collaboration with Lou Harrison. Esophagus, lung and mesothelioma, endobronchial disease are carefully reviewed for indications, technique, dose, in the setting of early stage, locally advanced stage, as well as palliation. Over 50 clinically relevant references augment this chapter. Intraoperative radiation therapy and combining brachytherapy with novel techniques complete this chapter.
Brian Czito and Chris Willett, now both Duke University gastrointestinal radiation oncologists, have provided a very comprehensive core GI chapter that is augmented by recent innovations in biliary combined modality therapy and hepatic radioactive sphere therapy in collaboration with Nasir Siddiqi and Harvey Mamon from our own center. This chapter comprehensively reviews the literature, indications, suggested treatment schemas, for definitive and palliative brachytherapy for esophagus, pancreatic, biliary, colorectal and liver metastases. Over 60 appropriate clinical references support this and further aid clinicians. It may be that the buzz previously seen about coronary artery brachytherapy may return for this last subject. Novel collaborations with interventional radiology, nuclear medicine, and radiopharmacy colleagues may prove to be not only an additional radiation therapy to aid a group of liver disease patients who were previously not referred to us, but also a very satisfying opportunity to expand the horizons of our specialty.
The chapter on prostate brachytherapy was more than any other, a complex team effort. Books have been and will continue to be written on prostate brachytherapy alone. Caroline Holloway, Michele Albert, and Warren Suh have sought to strike the right balance for this disease site in the context of a general brachytherapy textbook. The chapter summarizes the basic Seattle technique and then examines interesting innovations in implant technology including MRI-guided implants, automated seed loading, and HDR. Advanced inverse planning software is featured for both very low dose rate (VLDR) and HDR techniques. Inverse planning techniques for seed implants from Centre Hospitalier Universitaire de Québec with André-Guy Martin and HDR from University of California San Francisco (UCSF) with Joe Hsu are demonstrated.
Gynecologic brachytherapy is one of the mainstays of this subspecialty and is another huge area to be covered. The chapter is a comprehensive review of the brachytherapy for cervix, endometrial vaginal and vulvar cancer and beautifully covers classic low dose rate (LDR) techniques and modern HDR and pulsed dose rate (PDR) adaptations. Cervix cancer is first reviewed with the anatomy, imaging, and modern adaptations to the role of imaging in the care of this disease site. Dose rate considerations specific to the cervix are reviewed, including modern PDR strategies. Practical instructions are provided for every aspect of the implant from preprocedural preparation, through anesthesia, operating room (OR) considerations, applicator selection, placement, packing, recovery, postoperative orders, treatment planning, isotope loading/HDR/PDR dose and fractionation schemes, applicator removal, quality assurance specific to cervix cancer care, potential for complications, and follow-up care. Endometrial, vaginal and vulvar cancers are also treated in a similar detailed manner including cylinder, double tandem, and interstitial therapies. Palliative care is also addressed. Ninety-five references and over 50 figures and tables aid in this excellent offering. Although books have been and will continue to be written on the subject, this offering has a unique place on your bookshelf, for the most practical review that will guide your practice.
Another splendid collaboration is that between Chan Raut and Michele Albert, who have joined the dynamic influences of their training from the MGH, Memorial Sloan-Kettering Cancer Center (MSKCC), and MD Anderson Hospital Cancer Center (MDAHCC) schools of sarcoma brachytherapy. This chapter leads off with an excellent review of contemporary management strategies and a comparison of beam versus brachytherapy approaches. Evidence-based management of extremity sarcoma with varying combinations of surgery and radiation are pertinently reviewed. A broad range of elements including patient selection, techniques, and dose-rate considerations leads to additional considerations for the management of recurrences, retroperitoneal sarcoma, desmoids, keloids, and low-grade disease. Quality of life and comparative considerations between external beam radiation therapy and brachytherapy are reviewed. This chapter is supported by 75 clinically important references, over 40 figures and tables and the three clinical vignettes make this a most useful adjuvant for sarcoma.
For the vascular brachytherapy chapter was developed in Scripps Clinic in La Jolla as the American birthplace. Huan Giap and Prabhakar Tripuraneni have given a complete review of this subject and left to the future what role may persist or return. Much was learned from this short sojourn into the world of interventional cardiology and radiology. To Radiation Oncology's great credit, this modality was rapidly mobilized, staffs trained, QA procedures created and schedules altered to cover the unpredictable cath lab schedules. No doubt, there were mutual sighs of relief, when Radiation Oncology was asked to step down in favor of the drug-eluting stent technology. Newer collaborations with the medical technology industry will continue at heightened levels as a result of this short but intense experience.
The chapter on pediatric brachytherapy was written by Tom Merchant and Matt Krasin of St. Jude Children's Research Hospital in Memphis. Their whole approach to the use of brachytherapy for children with cancer is set in the appropriate context of an infrequently employed modality. Nonetheless, they have given a thorough review of the use of brachytherapy in Wilms tumor, neuroblastoma, hepatoblastoma, Ewing sarcoma, osteosarcoma, soft tissue sarcoma, rhabdomyosarcoma, retinoblastoma, and craniopharyngioma. Intraoperative radiation therapy, fractionated HDR therapy, permanent radioactive seed therapy and eye plaque therapy are nicely reviewed. Throughout, case reports and clinical scenarios are embedded to highlight indications as well as benefits and potential risks. Fifty-eight clinically pertinent references and excellent figures support this important contribution.
The book begins with two preparatory chapters, the first on practical radiobiology and the second on practical physics considerations. The first chapter is a very lucid collaboration between a great student and a great teacher. Alex Stewart and Bleddyn Jones, who had been her mentor at the Charing Cross Hospital, have assembled a very clear concise review of the core of radiobiology as it pertains to the clinical tasks of brachytherapy. The chapter starts with a very clear explanation of the basics of this subject, through the explanation of radiobiologic equivalence, to the four R's of radiobiology. Embedded are examples, straightforward equations, practical pearls, and an excellent integration of the important literature. Included are considerations of dose-rate effects and the integration of chemotherapy and other biologic therapies. Eight worked practical examples in problem format illustrate the need to consider not only the equivalent dose, but also to distinguish the needs and thresholds for tumor control as well as the risk of acute and late toxicities. Various practical needs that may be encountered in clinical care are reviewed; a need to replace intended external beam dose with a low dose rate implant, the need to replace a low dose rate implant with high dose rate fractions, how to deal with interrupted dose and a time delay, how to correct for errors of the omission of a decay factor and the delivery of prescribed dose. In all this the goal to evaluate the biologically intended dose, the currently delivered dose, and the calculation of the remainder of dose to be given are elegantly demonstrated. The chapter ends with a tidy comparison of the RBED's of three common fractionation schemes for vaginal vault brachytherapy.
The second chapter is an excellent in-house team effort lead by Robert Cormack with Jorgen Hansen, Desmond O'Farrell, and Alex Stewart. The goal of this chapter is entirely practical. Starting off with the needs for personnel, imaging equipment, and treatment planning, the chapter goes on to cover the facilities and equipment, written procedures, the Quality Management Program, calibration, and emergency contingencies for both HDR and LDR brachytherapy. The chapter provides examples of clinical forms that stood the test of time as necessary and sufficient to record the various components of brachytherapy so as to minimize the risk of misunderstanding and misadministration. Floor plans for an idealized brachytherapy suite as well as the necessary physics equipment for the safe handling of radioactive sources can further assist in the development of new programs.
The final chapter of the book returns to a supportive, rather than a purely clinical subject. This chapter reviews strategic planning for brachytherapy comprehensively. The various resources, people, space, time, and equipment are reviewed in the matrix of timelines, patient care flow charts, the population to be served, the community, and potential competition. The chapter details the elements of a successful business plan, again in the complicated matrix of time, resources, and potential reimbursement.The final section of the chapter places the proposal for the development of a brachytherapy service squarely in the realities of 2006 reimbursement constraints in the United States. They have provided web-based resources and useful appendices. Key financial indicators commonly used in medical practices are reviewed for the evaluation of the success of a brachytherapy program.
About the Editor
Phillip M. Devlin MD is Chief Division of Brachytherapy, Dana-Farber Cancer Institute, Brigham and Women's Hospital; Assistant Professor of Radiation Oncology, Harvard Medical School, Boston, Massachusetts.
Contents
1 - Radiobiologic Concepts for Brachytherapy
2 - Technical Physics Support for Brachytherapy
3 - Head and Neck Brachytherapy
4 - Central Nervous System Brachytherapy
5 - Breast Brachytherapy
6 - Thoracic Brachytherapy
7 - Gastrointestinal Brachytherapy
8 - Prostate Brachytherapy
9 - Gynecologic Brachytherapy
10 - Soft Tissue Sarcoma Brachytherapy
11 - Vascular Brachytherapy
12 - Role of Brachytherapy in Pediatrics
13 - Establishing a Brachytherapy Practice