34. Uncommon indications for brachytherapy - The GEC-ESTRO Handbook of Brachytherapy

Uncommon indications for brachytherapy

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THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 30/04/2025

Neural Damage (ND) ND is a rare complication after adjuvant brachytherapy. Contemporary literature describes an overall rate of chronic neuropathy below 10% with a few severe cases (median 1.7%, range 0–7.0%). The study of nerve tolerance is limited by the difficulty in delineation of peripheral nerves. Prior LDR + EBRT reports have established 90Gy as a safe dose for tumours involving the neurovascular bundle [11]. More recent HDR reports have established the safety of relatively high doses such as 50Gy in 10 fractions b.i.d. [30]. In the absence of nerve delineation, the DVH of irradiated volumes containing a neural structure may serve as a surrogate of neural damage [28]. 6.2. Previously Irradiated Cases Some patients with locally recurrent, previously irradiated soft tissue sarcomas are candidates for surgical salvage and adjuvant irradiation. Reirradiation in this setting follows the same guidelines as other disease sites with special emphasis on dose and volume reduction. Brachytherapy can spare normal tissues and potentially reduce complications in the re-irradiation setting compared with EBRT. In spite of this potential advantage, WHC represent a major issue in the reirradiation setting with some series reporting WHC rates greater than 50% as well as higher rates of amputations due to complications associated with reirradiation [31,32]. A recent analysis revealed an all-grade WHC rate of 63.3% in a prospective study of brachytherapy-alone reirradiation delivering 32-40Gy in 8-10 fractions b.i.d. [28]. In that study, WHC correlated (p = 0.01) with lifetime cumulative radiation doses to the skin (EQD2 3 Skin 2cm 3 > 84 Gy). In cases at greatest risk of developing severe WHC a reasonable alternative to immediate wound closure or immediate reconstruction is the use of delayed or staged reconstruction. Catheters are removed before final reconstruction. Delayed reconstruction allows margin re-resection if needed and minimizes WHC compared to immediate reconstruction resulting in an improved limb preservation rate [33].