Innovation in the management of soft tissue sarcomas in infants and young children: high-dose-rate brachytherapy.

Abstract

The combination of conservative surgery, chemotherapy, and exclusive HDR to postchemotherapy tumor volume with a modest margin, avoiding EBRT, provided disease control in carefully selected young children, while preserving bone growth and organ function. The short duration of therapy and small volume irradiated allowed chemotherapy to be resumed shortly after brachytherapy. The use of HDR challenges the present philosophy of radiotherapy treatment volume, which holds that the prechemotherapy tumor volume should be treated with an acceptable margin. Brachytherapy should be included in multicentric clinical trials in young children.

Use of brachytherapy in children with cancer: the search for an uncomplicated cure

“…Table 3 shows the results of studies of brachytherapy in patients with rhabdomyosarcoma. 2,23,25,[28][29][30]32,33,[37][38][39][40][41][42][43][44][45][46][47] In a prospective trial of high-dose-rate brachytherapy alone, three of the 12 very young girls with rhabdomyosarcoma had grade 3-4 morbidity, and three developed grade-2 morbidity. 39,40 Vaginal stenosis developed 10 years later in one girl, and periurethral fibrosis developed 8 years later in another when they entered puberty.…”

Treatment modalities of bladder/prostate rhabdomyosarcoma: a review

“…60 The concern of the side effects of EBRT has prompted some to look at brachytherapy. 24,43,61,62 These side effects are well documented and particularly troublesome in infants. Generally, the side effects include severe growth retardation and organ deformity.…”

“…If there is extensive disease, EBRT should also be used along with brachytherapy in older children. 61 At this time, most studies invoking brachytherapy have a very small number of patients.…”

“…Such side effects of EBRT underscore the reasons that the larger multi-institutional studies avoid RT in infants less than 1 to 2 y old. Nag et al 61 explain that brachytherapy should be reserved for those with microscopic or small volume residual disease. If there is extensive disease, EBRT should also be used along with brachytherapy in older children.…”

Feasibility report of conservative surgery, perioperative high-dose-rate brachytherapy (PHDRB), and low-to-moderate dose external beam radiation therapy (EBRT) in pediatric sarcomas

“…High-dose-rate (HDR) brachytherapy alone has been used with success in the younger patients with more chemoresponsive tumors (e.g., rhabdomyosarcoma) in whom the smaller postchemotherapy tumor volume can be encompassed with an interstitial or intracavitary implant, eliminating the need for additional EBRT (9). However, older children with more extensive tumors cannot be treated with brachytherapy alone and may require EBRT.…”