January, 2019
A Message From the President
Welcome to the January 2019 edition of the American Brachytherapy Society’s  BrachyBlast  newsletter.  
“I am only one, but I am one. I cannot do everything, but I can do something. And because I cannot do everything, I will not refuse to do the something that I can do.”   
- Edward Everett Hale  
I promise to continue to advocate unapologetically for all things brachytherapy. We have an exciting year ahead of us in 2019, with ambitious goals for the organization set forth by our dedicated leadership team. Each one of us can do something to support ABS in 2019, and I am excited to share with you the initiatives we will focus on so that we can all do our part and we can collectively achieve success.   
Direct Patient Awareness Campaigns  
  • Our campaign to bring awareness on brachytherapy’s efficacy for all disease sites through press releases directly to the public in 2018 was very successful. We focused on ProstateGynecological and Breast cancers this past year. All the campaigns were well received and as such the Board of Directors has approved the creation of three more “Know Your Options” press releases in 2019. Reach out to us if you would like to participate in writing one of these educational pieces during a specific cancer awareness month. 

Consensus Statement Updates   
  • Dr. Petereit and the Board of Directors are working diligently to formulate guidelines for authorship on all the forthcoming consensus statement updates. Stay tuned and look out for next month’s BrachyBlast for more information on how to participate in this process.  

Continued Collaboration with GEC-ESTRO and ASTRO  
  • The Spring 2019 edition of ASTRO's quarterly member magazine, ASTRONews, will be entirely focused on brachytherapy. Past ABS President, Akila Viswanathan, and I wrote a piece on the factors competing against the utilization of brachytherapy in GYN and Prostate cancers and ways to reverse this ethically concerning trend as we strive to provide our patients the best treatments possible. Many ABS members are also authoring pieces on the role of brachytherapy in treating many types of cancer, so look out for the fruits of our labor in collaborating with ASTRO soon! 

  • The ABS International Committee continues to work with our international sister societies as we begin to plan for the 2020 World Congress of Brachytherapy. Reach out if you want to participate in these endeavors.  

300 in 10  led by Dr. Petereit  
  • The ABS is implementing a 10-year strategy called 300 in 10 under the direction of incoming President-Elect Dan Petereit. The goal of this initiative is to ensure the training of 30 competent brachytherapists per year over the next 10 years through a multi-faceted approach. More details on this will be released in the February 2019 BrachyBlast and the Spring ASTRONews.  

Continue to Educate Practitioners and Work on the Creation of Radiation Oncology Alternative Payment Models (RO-APMs) 
  • RO-APMs are here to stay, and as a specialty we must be ready. ABS continues to work in conjunction with ASTRO and other radiation oncology organizations to define the best path forward. There is much to be gained for brachytherapy as a cost-effective, efficient and effective tool in these models and we look forward to the success of this work in 2019 and beyond.   

Continuing Our Website Redesign   
  • Our website currently houses a comprehensive member directory, however, in 2019 we plan to strengthen this directory with individual physician practice and disease site specialty information. In doing this, we will facilitate patients being able to easily locate qualified brachytherapy practitioners in their geographical area to pursue consultation and treatment.  

  • In 2019 the ABS will commission videos demonstrating brachytherapy techniques to feature on the website. These videos will be practitioner and patient friendly and will highlight brachytherapy techniques and efficacy to further drive knowledge and awareness.  

  • Reach out to us if you are interested in helping with the physician finder process, creating videos or generating other content for the new website.  

  • Redesign of the Annual Meeting Structure to Include More Hands-On Learning Opportunities  

  • Remember to register for the Annual Meeting, being held at the Intercontinental Hotel in the exciting city of Miami from June 13-15, 2019. More details on revamped interactive and hands on sessions will be released soon and the March BrachyBlast will be focused on the highlights of this year’s meeting.  

  • A record number of abstracts have been received for presentation at the 2019 Annual Meeting, demonstrating the enthusiasm and importance of continued research and novel technologies surrounding brachytherapy.  

  • I promise an exciting meeting where we focus on having fun with the science. Brett Cox and Kristen Bradley have developed a dynamic and exciting program filled with fresh ideas, networking opportunities, industry engagement and an evening event to celebrate all things brachytherapy, unapologetically. Don’t miss out as this will be a meeting to remember! 

Increase the Organization’s Social Media Presence    
  • Under the direction of our Social Media Committee the ABS has made great strides in the last year towards creating a strong web presence, and we need your help to keep the momentum going! Follow us on twitter (create your own twitter account if you don’t already have one!) and regularly share content. Reach out to our social media guru if you need some help!  

Increase Membership’s Participation in Committees 
  • Over the past decade the ABS has thoughtfully formed a robust committee structure to tackle our work. These committees only succeed because of a dedicated membership who choose to harness their strengths to provide service to the organization. If you want to participate on a committee in 2019, we ask that you reach out to the Chair and Co-Chair of that committee and offer your service.  
To kick us off in the new year, this month’s Guest Editor Scott Glaser has a featured article on Brachytherapy as a Means for Re-Irradiation and Chirag Shah and Jessica Schuster give us an exciting preview of the 2019 Annual Meeting’s breast brachytherapy sessions.   

Remember, although we are ALL only one person individually, we will be unstoppable if we compile our individual efforts for the good of ABS collectively. Let’s all stand up and be counted.   
Thank you,  
Peter F. Orio III, DO, MS 

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Brachytherapy as Reirradiation
Scott Glaser, MD
City of Hope Medical Center
The majority of cases that we as radiation oncologists consider for brachytherapy typically fall into one of two categories; upfront definitive management (prostate, cervix, high-intermediate endometrial, breast), or salvage therapy for those without prior radiotherapy (vaginal cuff recurrence). Another context in which that brachytherapy should be given consideration, is the setting of reirradiation. In this month’s brachytherapy blast, we will briefly discuss the topic of reirradiation with brachytherapy, broken down by disease site.
Locoregional recurrence of malignancy following gynecologic radiotherapy is fairly uncommon. Still, treatment options for such patients remain limited as R0 surgical resection is often difficult, could require complete exenteration, or be entirely impossible. Additional radiotherapy poses increased risk to previously irradiated normal tissue, though recent advancements have generated a renewed interest in reirradation with brachytherapy. 

One of the largest series of such patients comes out of the group from the University of Kentucky. Dr. Feddock and colleagues reported in the red journal in 2017 on a cohort of 42 patients who underwent salvage LDR brachytherapy for recurrent, previously irradiated pelvic malignancy [1]. They performed permanent LDR seed implant using primarily Cesium-131 with a mix of single- and double- plan implants as well as template-guided implants depending on tumor location and size. Paterson-Parker planer implant rules were used when prescribing dose and only the gross tumor was implanted. Additional details on implant technique were given in their earlier publication on safety and efficacy [2]. Their patient population was fairly diverse in terms of primary tumor, histology, initial treatment, and location of recurrence. Median D90 was 53 Gy and D2cc for the rectum and bladder were 28 and 34 Gy respectively. With a median follow up of 16 months local control was 73% and for those with 4 or more years of follow-up the cumulative incidence of local failure was 33%. Disease-free survival was 38%. The rate of grade 3-4 toxicty was 17%, primarily mucosal or skin necrosis.

Other series have utilized HDR brachytherapy in a similar setting [3-6]. A phase II trial from Spain, also with a diverse patient population, demonstrated similar rates of toxicity and efficacy as the LDR data [3]. In this trial, with a median follow-up of 2.8 years, the rate of grade 3+ toxicity was 20% and the disease-free survival was 40%. The dose delivered was a median of 38 Gy in 8 fractions over 4 days. At the 2018 ABS annual meeting a multi-institutional study of single modality interstitial HDR brachytherapy was presented [4]. A total of 27 patients with recurrent, previously irradiated gynecological cancer were included. The dose delivered was 5-7 Gy per fraction x 3-6 fractions with the dose selected based upon normal tissue tolerance. With a median follow-up of 20 months, disease-free survival was 37% and there were 2 instances of grade 3 toxicity, but no grade 4+ toxicity.

A common question in the radiation oncology clinic from men with prostate cancer is, “what are the options if radiation doesn’t work?” This question generally seems to be prompted by previous conversations with urology in which the patient has been told something along the lines of, “if the PSA rises or the cancer returns after prostatectomy, radiation is a back-up option” (in contrast to upfront radiation for which prostatectomy generally isn’t consider a feasible salvage option). So, while the recurrence of prostate cancer within the irradiated field is uncommon, the topic does come up in conversation with patients fairly often. Additionally, in the era of prostate cancer specific imaging (Fluciclovine PET, PSMA PET) we may begin to detect in-field recurrences of prostate cancer with greater frequency.

The data for reirradiation of the prostate with brachytherapy is primarily limited to single institution retrospective series, although some phase 2 data dose exist [7]. A nice review article by Ramey et al . published in 2013, summarizes 18 series using brachytherapy to treat recurrent prostate cancer which had been previously irradiated [8]. There is indubitably a large degree of heterogeneity among the studies, with a mix of techniques (LDR vs HDR, dose, volume), various inclusion criteria (palpable recurrence, MRI detected recurrence, LN+ vs LN-, etc.), and various definitions of failure (ASTRO definition, Phoenix definition, palpable abnormality). Still, when taken as a whole, the series demonstrates a 5-year median bPFS of about 50-60% and a DSS of 85-90%. Toxicity is not insignificant and primarily consists of GU toxicity, with median rates of grade 3 toxicity in the 20-30% range and grade 4 toxicity in the 5-10% range.

Another more recent series from the Switzerland demonstrates the need for caution and a larger scale prospective trial in this patient population [9]. In their series of 14 patients (10 of whom had salvage EBRT+brachy, and 4 brachy alone) with the entire gland retreated to a median EQD2 dose of 85 Gy, there was no grade 3+ acute toxicity. However, with longer follow-up 4 patients (29%) had grade 4 GU/GI toxicity and the 5-year bPFS was only 35%, although the CSS was 100%. It should be noted however, that others have described lower rates of long-term toxicity [10].

A future brachyblast will discuss “the role of brachytherapy in the management of soft tissue sarcomas in the era of IMRT and preoperative radiotherapy”. So, I will not go into as much detail here regarding sarcoma reirradiation. For those who are interested, the 2017 ABS consensus statement for sarcoma brachytherapy by Naghavi et al. ( https://www.ncbi.nlm.nih.gov/pubmed/28342738 ) provides a thorough summary of reirradiation on page 480 [11].
Repeat breast conserving therapy following in breast recurrence (repeat lumpectomy and reirradiation with partial breast radiotherapy) was studied on the RTOG 1014 protocol [12, 13]. The radiotherapy in this protocol was EBRT to a dose of 45 Gy in 1.5 Gy per fraction BID. While, not specific to brachytherapy, the trial supports the concept of partial breast reirradiation for recurrent disease.  The 3-year rate of ipsilateral breast recurrence was 4% and the rate of grade 3 late toxicity was 7% with no grade 4 toxicity. A review article by Sedlmayer et al. published in Breast in 2013 identified 12 published series between 2002 and 2012 with a cumulative of 310 patients treated with partial breast-reirradiation for local recurrence [14]. Of these patients, 82% were treated with brachytherapy. The authors note that oncologic outcomes were excellent with local control rates from 76-100%, and DFS and OS rates similar to salvage mastectomy series. They also describe a low rate of toxicity with cosmetic outcome scored as excellent or good in 60-80% of patient and very low rate of grade 3+ toxicity. While there are limitations to these data, the results are encouraging and should lead to an increased interest in protocol development involving brachytherapy for this patient population.

1. Feddock J, Cheek D, Steber C, et al. Reirradiation using permanent interstitial brachytherapy: A potentially durable technique for salvaging recurrent pelvic malignancies. Int J Radiat Oncol Biol Phys . 2017;1225-1233.
2. Wooten C, Randall M, Edwards J, et al. Implementation and early clinical results utilizing Cs-131 permanent instestitial implants for gynecologic malignancies.  Gynecol Oncol . 2014;133:268-273.
3. Martinez-Monge R, Cambeiro M, Rodriguez-Ruiz M, et al. Phase II trial of image-based high-dose-rate interstitial brachytherapy for previously irradiated gynecologic cancer. Brachytherapy . 2014;13:219-224.
4. Raziee H, D’Souza D, Velker V, et al. Multi-institutional study of salvage irradiation with single-modality interstitial brachytherapy for the treatment of recurrent gynecological tumours in the pelvis. Brachytherapy . 2018;17:S28-29.
5. Mahantshetty U, Kalyani N, Engineer R, et al. Reirradiation using high-dose-rate brachytherapy in recurrent carcinoma of the uterine cervix. Brachytherapy . 2014;13:548-553.
6. da Silva V, Diniz A, Martins J, et al. Use of interstitial brachytherapy in pelvic recurrence of cervical carcinoma: Clinical response, survival, and toxicity. Brachytherapy . 2018; epub ahead of print . https://doi.org/10.1016/j.brachy.2018.11.002
7. Nguyen P, Chen M, D’Amico A, et al. Magnetic resonance image-guided salvage brachytherapy after radiation in select men who initially presented with favorable-risk prostate cancer: a prospective phase 2 study. Cancer . 2007;110:1485-1492.
8. Ramey S, Marshall D. Re-irradiation for salvage of prostate cancer failures after primary radiotherapy. World J Urol . 2013;6:1339-1345.
9. Zilli T, Benz E, Dipasquale G, et al. Reirradiation of prostate cancer local failures after previous curative radiation therapy: Long-term outcome and tolerance.  Int J Radiat Oncol Biol Phys. 2016;96:318-322.
10. Chen C, Weinberg V, Shinohara K, et al. Salvage HDR brachytherapy for recurrent prostate cancer after previous definitive radiation therapy: 5-year outcomes. Int J Radiat Oncol Biol Phys . 2013;86:324-329.
11. Naghavi A, Fernandez D, Mesko N, et al. American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy . Brachytherapy . 2017;16:466-489.
12. Arthur D, Winter K, Kuerer H, et al. NRG Oncology-radiation therapy oncology group study 1014: 1-year toxicity report from a phase 2 study of repeat breast-preserving surgery and 3-dimensional conformal partial-breast reirradiation for in-breast recurrence. Int J Radiat Oncol Biol Phys . 2017;98:1028-1035.
13. Arthur D, Moughan J, Kuerer H, et al. NRG Oncology/RTOG 1014: 3 Year efficacy report from a phase II study of repeat breast preserving surgery and 3D conformal partial breast re-irradiation for in-breast recurrence. Int J Radiat Oncol Biol Phys . 2016;96:941.
14. Sedlmayer F, Zehentmayr F, Fastner G. Partial breast re-irradiation for local recurrence of breast carcinoma: Benefit and long term side effects. Breast . 2013;22:S141-146.
What is Happening at #ABSBRACHY19
The 2019 Annual Meeting is fast approaching! It will be held from June 13-15, 2018 in Miami, Florida. We have secured a fabulous meeting venue, the Intercontinental Miami, which will provide a fresh, modern feel to the academic proceedings. The B reast Committee is excited to   present a preview of our  SESSIONS  at the meeting. Recently NSABP B-39 and several other studies have been presented, offering a new take on partial breast irradiation and breast brachytherapy. The ABS Annual meeting breast session will have experts to provide prospective, literature update, and implications for the future to our members. Additionally, there will be comparison of the many different techniques for delivery of partial breast radiotherapy and expert review of patient selection and target delineation. Finally a practical session on challenging breast radiation cases such as reconstruction, oncoplastic surgery  and many others. We look forward to seeing you there!

Chirag Shah, MD
Scientific Program Chair, Breast

Jessica Schuster, MD
Scientific Program Co-Chair, Breast
Patient Safety Corner
ABS Medical Event Case 004
Sarah Price & Panagiota Galanakou
Graduate Students, Florida Atlantic University
Zoubir Ouhib, MS
Boca Raton Community Hospital
Hello Brachyblast readers! We hope that your holidays were full of good memories and that you had a chance to spend it with family and friends. We were again pleased with the responses received regarding Case 0003 presented in the October Brachyblast, and the follow up in the November Brachyblast. Our hope is that this peer review will help reduce the occurrence of medical events in the coming years. We would again like to thank you for your participation and encourage you to continue to share your thoughts as your feedback is valuable and could make a difference in someone’s outcome by preventing a medical event. In all presented cases, we have made every effort not to modify the text as listed by the regulatory agency. Information that might identify the institution or individuals that were involved in the event was removed.
 “Dose error on second day of electronic brachytherapy treatment”   

Introductory Information : Reported to the SAFRON incident report system. This medical event took place in 2014 and it is related to a patient who received electronic brachytherapy treatment with the Xoft Axxent system. The radiation oncologist discovered the incident during a regular chart check.
Below is the original text describing the medical event that was submitted to SAFRON :
 “On the first day of the electronic brachytherapy treatment with the Xoft Axxent system, the calculations were performed and double checked by the physicist. The treatment was delivered correctly, according to the prescription, for 500 cGy (5 Gy). On the 2nd day of the treatment, the operator inadvertently treated the patient with 436.6 sec (instead of 230.7 sec). Upon review of the treatment log file the Physician called the physicist to investigate the situation, and the physicist determined the reason to be incorrect source strength measurement before the patient treatment. The physicist checked the machine and all the patients treated for the day. Everything was in the correct working order and so the reason for this event is attributed to be that the source was not inserted all the way into the well chamber for the source strength measurement before this patient’s treatment. Therefore, the weekly dose is about 145% of the prescribed weekly dose. Over the whole course of the treatment if we don’t do any changes to the remaining treatment the delivered dose will be 112.5% of the prescription dose (the dose will not exceed 20% of the prescribed dose).”

What preventive action(s) could stop reoccurrence of a similar event? Consider both corrective (immediate and long term) and preventive actions.

Please send corrective action suggestions before January 15, 2019 to: PreventMedEvent@gmail.com including the title of the event (or case #), your name, your institution (optional), and your profession (Med. Phys., Rad. Onc., etc.). We intend to acknowledge all individuals who provided feedback. Please include in your response whether you approve of this recognition.

Please feel free to contact us ( PreventMedEvent@gmail.com ) with any questions or inquiries regarding this case.

Happy new year to all!

For more information, please email bradleyl@theragenics.com
REMINDER: ABS Culture of Safety Practice Survey
This 5-minute survey will query several important features of your practice including types of brachytherapy and departmental policies, your perception of brachytherapy safety culture, meaningful use of incident reporting and learning systems, and what is important to you to understand how the ABS can best improve your practice.
We are excited to have you participate in the Culture of Safety Practice Survey. Your participation is voluntary. Answers are anonymous and held in the strictest confidence.
Neil K. Taunk, MD, MS
University of Pennsylvania

Zoubir Ouhib, MS, DABR
Lynn Cancer Institute

Timothy N. Showalter, MD, MPH
University of Virginia
ABS Quality and Safety Committee

2019 Membership Renewals are Underway
If you have not renewed your ABS membership, it expired on December 31, 2018 and you are now within your membership grace period . We are at watershed moment and we must all come together to continue to advocate for brachytherapy. The ABS is committed to promoting the highest possible standard for the practice of brachytherapy. We are committed to education, innovation, ensuring access, developing future leaders, and promoting brachytherapy to ensure the best outcomes for our patients. The strength of the association relies on individual members like you, who are committed to making an impact in the field of brachytherapy
The online renewal process is fast and easy. Click here to log into your members only portal on ABS’s new website. While you are there, be sure to review and update your member profile.
To pay by check, please request an invoice for your dues before mailing your payment.
2018-2019 ABS Board of Directors

Peter F. Orio, III, DO, MS , President
Daniel G. Petereit, MD, President Elect
Firas Mourtada, PhD, Vice President
Ann Klopp, MD, PhD, Treasurer
Zoubir Ouhib, MS, Secretary
Catheryn Yashar, MD, Chairwoman of the Board
Steven J. Frank, MD, Past Chairman of the Board

Sushil Beriwal, MD
Christopher L. Deufel, PhD
Peter J. Rossi, MD
Timothy Showalter, MD

Meetings and Workshops of Interest