April, 2019
A Message From the President
Welcome to the April 2019 edition of the American Brachytherapy Society’s  BrachyBlast  newsletter.  

Registration for the 2019 Annual Meeting at the InterContinental in Miami, Florida is now open! Don’t forget to mark your calendars and register today ! For brachytherapy practitioners, this is the conference of the year to attend - join your colleagues, along with brachytherapy pioneers from around the country and the world, as the latest patient studies, brachytherapy techniques and brachytherapy equipment are discussed.

In this month’s BrachyBlast our Social Media Committee will introduce us to #ThisIsBrachytherapy.
This month we are also featuring an article by Ronny Kalash and Sushil Beriwal introducing HDR prostate brachytherapy with tips for those interested in making the transition from LDR to HDR prostate brachytherapy.
I look forward to seeing you all at the 2019 Annual Meeting in six weeks and celebrating all things brachytherapy with you. Remember to use the Annual Meeting hashtag #ABSBRACHY19 on all social media as you prepare to attend the meeting and while you are in Miami!

Thank you,  
Peter F. Orio III, DO, MS 

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3 Month Low Dose Rate Brachytherapy Fellowship
The ABS is implementing a 10-year strategy called 300 in 10. 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 including raising public awareness, working to change ACGME brachytherapy requirements, fostering advances in simulation training, developing brachytherapy curricula for residents, and establishing centers of excellence to augment brachytherapy training – in particular, 3-month brachytherapy fellowship opportunities. The Chicago Prostate Cancer Center has been chosen by the ABS as the first site to offer the first 3-month LDR prostate brachytherapy experience as they have extensive experience. We are offering 2 residents out of training, generously co-sponsored by Theragenics Corporation , an LDR prostate 3-month fellowship starting in July of 2019. Residents will have hands on experience and will become proficient LDR brachytherapists once done.

·    This fellowship is designed to instruct physicians in the evolving techniques of low dose rate prostate brachytherapy. Basic instructions will be provided for the novice who has never performed this procedure, as well as, advanced training for those who have experience. Our intention is to match, then exceed, the physician’s experience level.
·    Training will include interactive lectures that challenge the attendee’s current concepts regarding prostate brachytherapy. Live patient interviews and case presentations will address the spectrum of patients suitable for this procedure.   

·    Additionally, much time will be devoted to live brachytherapy demonstration utilizing a pre-planned, preloaded needle technique. Emphasis will be placed on progressive thinking and participants are encouraged to share ideas and clinical cases from their own practice. Special breakout sessions will be available for ultrasound volume studies, medical physics/dosimetry treatment planning and for patient management.

·    Finally, there will be an opportunity and expectation to participate in ongoing research projects within Prostate Cancer Foundation of Chicago’s research and education department. Opportunities include data collection, literature review, abstract and manuscript writing focusing on cure rates and quality of life outcomes.

·    Approximately 7:00 am – 3:00 pm each day.
·    Monday: Consultations, Follow-ups, Volume studies, Research, Physics
·    Tuesday: Implants, Consultations, Volume studies, follow-ups, physics
·    Wednesday: Implants, Consultations, follow-ups, physics
·    Thursday: Implants, Consultations, follow-ups, research
·    Friday: Implants, Consultations, follow-ups, physics

·    Identify clinical appropriateness (low, intermediate, high risk patients)
·    Identify and utilize the latest techniques
·    Realize the roles of each team member in the treatment process
·    Detail the risk and management of post implant complications
·    Explain the concept and importance of radiation safety
·    Participants will have the research opportunities

·    3-month fellowship compensation: $18,000.00

Questions or concerns about fellowship details can be directed to:

Executive Director
American Brachytherapy Society

Your application should include the following: 
·    Curriculum Vitae
·    Supporting letter from your department chair or program director
·    Personal statement describing your brachytherapy experience and future goals, including if you plan on implementing a prostate LDR program
·    Preference will be given to applicants who plan on starting a prostate brachytherapy practice as this is the primary goal of the 300 in 10 strategy.
·    ABS Member

Transition from LDR to HDR Prostate Brachytherapy:
What to Know & Tips for Success
Ronny Kalash DO, John Vargo MD, Sanjeev Bahri MD, Ryan Smith MD, Sushil Beriwal MD
Department of Radiation Oncology - University of Pittsburgh Medical Center, Pittsburgh, PA

Dose escalation via brachytherapy in prostate cancer treatment has been shown to deliver a more durable biochemical control outcome 1 . The current radiation oncology practice landscape shows the majority of prostate brachytherapy practices currently utilize an LDR-based approach 2 . HDR-based brachytherapy represents a treatment modality to potentially capitalize upon a growing understanding of the α/β ratio of prostate cancer cells (range of 1.5-3). Further, comparative studies indicate an improved rate of acute and late urinary discomfort/urgency/frequency and acute rectal pain with HDR vs. LDR-based treatment 3 . Finally, HDR brachytherapy delivers several advantages including; enhanced radiation safety - by limiting exposure to both staff and the general population, dosimetric planning consistency and flexibility – with no post-implant seed migration and real-time dose optimization, as well as cost-savings - by using one source to treat multiple patients and disease-sites. As the momentum of HDR prostate brachytherapy training/utilization and reported outcomes move in opposite directions, the importance of improving both accessibility and awareness of HDR prostate brachytherapy continues to grow. This discussion aims to highlight the workflow and practices involved in successfully developing a prostate HDR practice, or transitioning from an LDR to HDR approach.

Clinical Workflow
Our institution follows similar American Brachytherapy Society/NCCN clinical practice guidelines when selecting prostate brachytherapy patients for either low or high dose rate treatment. An overlapping pre-treatment workup includes a pre-implant prostate ultrasound volume study. Traditional ABS guidelines caution against LDR in patients with large prostate gland size, however data indicate HDR can provide effective target coverage and acceptable toxicity when performed in patients with a prostate gland volume >50cc 4 .

Dose Schedule / Staffing
Multiple safe and effective HDR fractionation schedules have been reported in both the monotherapy/boost setting 5-7 . HDR fractionation schedules typically include normal tissue organ constraint recommendations for the rectum and urethra that are more stringent than those reported with LDR 8 . If multiple fractions are required it is feasible to deliver multiple fractions following either a single-insertion or multi-insertion schedule. While single-insertion provides convenience, multiple insertions may yield advantages regarding target/normal tissue dose distribution. This decision requires consideration of whether a practice is capable of prolonged admission or observation/holding to allow a minimum of 6 hours in-between fractions. This also requires access to nursing/anesthesia monitoring to periodically collect vitals and provide pain control while the implant remains inserted.

Day of Insertion:
Insertion and delivery of HDR brachytherapy requires a practice layout and workflow that differs from that of LDR brachytherapy. Both HDR and LDR procedures start with the patient undergoing a trans-perineal template-guided catheter placement into the prostate under general anesthesia and ultrasound guidance. Permanent LDR sources are planned and immediately inserted in the same OR suite, followed by a CT afterwards to assess post-implant dosimetry. Multiple HDR brachytherapy workflows exist following catheter insertion. The most common involves fixation of the template to the patient, followed by patient recovery and transfer to CT to identify/adjust catheter position, followed by planning of temporary source dwell time while the patient is monitored and finally transferred to a reinforced/protected radiation vault that houses a remote afterloader sync’d with a brachytherapy delivery platform. Some departments have modified this workflow by incorporating MRI into treatment planning to improve accuracy, while others have begun utilizing real-time TRUS based planning to improve efficiency. Some have streamlined the workflow by delivering the treatment in the same location as the catheter insertion. This can be done by either providing anesthesia in the radiation oncology department or treating in a shielded operating room. Each additional step requires available support staff dedicated to maintaining an efficient workflow throughout the day.

HDR brachytherapy treatment planning also requires unique steps following target and normal tissue delineation. A physicist and dosimetrist must digitize the identified catheters within the treatment planning software. This often requires manual review to confirm accuracy before planning treatment, and a second-check verification. Next, dwell times are calculated to meet target coverage and meet normal tissue constraints recommended by large multi-institution consortium series 9 . Finally QA must be completed to verify the integrity of the afterloader and the sustained patency of the implant catheters prior to final delivery. Institutions have reported an improved efficiency of this workflow by having physicians and physicists work simultaneously to complete each step of treatment planning and utilizing standard national protocol plan optimization goals 10 .

HDR prostate brachytherapy represents an effective and safe treatment approach for radiation dose escalation. Delivery of HDR provides several clinical and practical advantages in comparison to LDR brachytherapy. Our goal is to provide insight into the logistical nuances between each approach, and continue to increase accessibility to HDR prostate brachytherapy.
1. Morris WJ, Tyldesley S, Rodda S, et al. Androgen suppression combined with elective nodal and dose escalated radiation therapy (the ASCENDE-RT Trial ): An analysis of survival endpoints for a randomized trial comparing a low-dose-rate brachytherapy boost to a doseescalated external beam boost. Radiat Oncol Biol. 2017; 98:275-285.
2. Buyyounouski MK, Davis BJ, Prestidge BR, et al. A survey of current clinical practice in permanent and temporary prostate brachytherapy: 2010 update. Brachytherapy. 2012; 11:299-305.
3. Martinez AA, Demanes J, Vargas C, et al. High-dose-rate brachytherapy: an excellent accerlerated-hypofractionated treatment for favorable prostate cancer. Am J Clin Oncol.  2010; 33(5):481-8.
4. Monroe AT, Faricy PO, Jennings SB, et al. High-Dose-Rate Brachytherapy for large prostate volumes (≥50cc)- Uncompromised dosimetric coverage and acceptable toxicity. Brachytherapy 2008; 7:7-11.
5. Hauswald H, Kamrava M, Fallon JM, et al. High-dose-rate (HDR) monotherapy for localized prostate cancer: 10 year results. Int J Radiat Oncol Biol Phys. 2016; 94:667-674.
6. Morton G, Loblaw A, Cheung P, et al. Is single fraction 15Gy the preferred high dose-rate brachytherapy boost dose for prostate cancer? Radiother Oncol. 2011; 100(3): 463-467.
7. Chen WC, Tokita KM, Ravera J, et al. Four-year outcomes of hypofractionated high-dose-rate prostate brachytherapy and external beam radiotherapy. Brachytherapy. 2013; 12(5):422-427.
8. Yamada Y., Rogers, L, Demanes J, et al. American Brachytherapy Society consensus guidelines for high-dose-rate prostate brachytherapy. Brachytherapy. 2012; 11:20-32.
9. I-Chow H, Kyounghwa Bae, Shinohara K, et al. Phase II Trial of Combined High Dose Rate Brachytherapy and External Beam Radiotherapy for Adenocarcionma of the Prostate: Preliminary Results of RTOG 0321. Int J Radiat Oncol Biol Phys. 2010; 78(3): 751-758.
10. Solanki AA, Mysz ML, Patel R, et al. Transitioning from a low-dose-rate to a high-dose-rate prostate brachytherapy program: comparing initial dosimetry and improving workflow efficiency through targeted intervention. Advances in Radiation Oncology. 2019 Jan; 4 (1):103-111
What is Happening at #ABSBRACHY19
On behalf of the American Brachytherapy Society, we warmly invite you to attend the 2019 Annual Meeting! This year’s meeting will be held in Miami from June 13-15 at the chic InterContinental Miami. The theme of the meeting is “Knowledge is Power: Generating Awareness for Patients and Practitioners”, which emphasizes the essential role of brachytherapy in modern oncology practice. We have an exciting meeting lined up with a sterling roster of nationally and internationally known experts. Each of the sessions will highlight new developments in brachytherapy as they relate to modern practice.  

The prostate sessions will focus on advances in diagnostics and patient selection, with presentations from multidisciplinary speakers on genomic classifiers, targeted biopsies, and molecular imaging, as well as dedicated sessions for both for focal and salvage therapies. The gynecology sessions will focus on the issues that are redefining modern practice, including hybrid applicators, contemporary controversies in uterine cancer treatment, and a session about custom implants and challenging case presentations with experts sharing the latest technical tips and techniques. Physics sessions include a review of modern radiobiological principles and their application to clinical practice, a critical analysis of modern brachytherapy technologies and optimization strategies, and a special “How We Do It” session with experts sharing insights on transition to ultrasound based planning for prostate HDR brachytherapy, optimizing MRI workflow in clinical practice, and software for the automation of treatment planning and plan checking.  A novel session has been added to reexamine the optimal use of anesthesia and pain management in modern brachytherapy practice. Other exciting breakouts will focus on how to build and refresh a brachytherapy practice, a roundtable entrepreneurial discussion about how to transition a novel technological idea into a finalized industry product, and updates on target dose and organ at risk constraints for all major brachytherapy treatment sites. The social media session includes some of the most well-known digital names in radiation oncology and will certainly add value to any academic or clinical practice. Socioeconomic sessions include national thought leaders from ABS and ASTRO sharing the future of the socioeconomic landscape which will define your practice – big changes are coming and you need to be ready! Finally, sessions featuring presentations from experts in brachytherapy nursing/advanced practitioners have been added. We have tailored all sessions in response to membership feedback and believe you will find them invaluable.

Additionally, the practical sessions have been completely revamped, expanded and updated based on YOUR feedback, with renewed emphasis on hands-on sessions, phantom work and practical clinical flow in addition to the traditional training in contouring critical for brachytherapy treatment planning. These sessions will emphasize the practical delivery of brachytherapy from both the clinician’s and physicist’s standpoint. The gynecology sessions will include new opportunities for phantom work using the latest advanced and hybrid applicators, with stations for anatomic mannequin models for practical demonstrations and attendee training. The prostate sessions will include an emphasis on intraoperative workflow including the similarities and differences between LDR and HDR. The skin workshop will continue to amaze with stations on treatment planning for HDR brachytherapy, applicators for electronic brachytherapy and custom mold making, 3D printing and the use of ultrasound. 

Finally, new opportunities for socializing with your peers and breakfast symposia have been added to enhance your conference experience.

We look forward to seeing you all in sunny Miami!

Brett Cox, MD 2019 Scientific Program Chair
Kristin Bradley, MD 2019 Scientific Program Vice Chair
Looking for Volunteers
2 days prior to the 2019 ABS Annual Meeting in Miami a joint meeting is being planned with ABS , GEC-ESTRO , and CARO to develop consensus brachytherapy contouring guidelines for recurrent endometrial cancer. The ABS is seeking volunteers as representatives to this meeting. If you are interested in participating please email Mitch Kamrava ( Mitchell.Kamrava@cshs.org )

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 would like to once again thank those who provided feedback on case 0004 from the February 2019 Brachyblast. Such feedback is valuable and hopefully leads to prevention of reoccurrence. Presented below is case 0005, please continue to share your thoughts as we work together to encourage safe brachytherapy practices.

Case 0005: Received Dose Greater than Prescribed Dose
The patient received SAVI (Strut-Adjusted Volume Implant) High Dose Rate Treatments on two separate dates. After the second treatment, it was noted that the dwell time on one catheter appeared unusual. The first treatment was then reviewed, and it was discovered that the catheters were labeled incorrectly during the initial treatment planning process. The physician was notified to review the delivered dose. Another physicist was contacted and remotely viewed the treatment plan from the first treatment and reached the same conclusion, that the catheter had been mislabeled.

The skin received a greater dose than intended for one delivered fraction. 1cc received 848 cGy, intended was 256 cGy, and 0.1 cc received 1500 cGy, intended 282 cGy. A decision was made by the physician to cancel all further radiation treatments using the SAVI device and the applicator was removed. 

This event summary was taken directly from the NRC website.

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

Please send your suggestions before May 10, 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 in the summary of the preventive/corrective actions. Please include in your response whether you approve of this recognition.
Please feel free to contact us with any questions or inquiries regarding this case.
For more information, please email bradleyl@theragenics.com
International Committee
The  National and International Observerships  Task Group of the ABS International Committee is conducting a brief survey of institutions performing brachytherapy treatments. We seek your participation on behalf of your center.
The objective of this survey is to develop a current list of institutions who might be able to host local, national and or international visitors to observe brachytherapy programs. The overall goal of this survey is to help advance brachytherapy as an essential treatment modality through provider education and outreach.
Complet ing the survey will take less than five minutes. We appreciate your time.
Beth A. Erickson, MD, FACR
Pranshu Mohindra, MD, MBBS
Mac M. Longo, MD
Umesh M. Mahantshetty, DMRT, MD
Junzo P. Chino, MD
Zoubir Ouhib, MS, DABR
On behalf of ABS International Committee

Did You Renew Your 2019 Membership?
If you have not renewed your ABS membership, it expired on December 31, 2018 and your membership benefits ended on March 3 1. 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.

Questions? Melinda Long
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