Hyaluronate gel injection for rectum dose reduction in gynecologic high-dose-rate brachytherapy: initial Japanese experience

Tairo Kashihara, Naoya Murakami, Nikolaos Tselis, Kazuma Kobayashi, Keisuke Tsuchida, Satoshi Shima, Koji Masui, Ken Yoshida, Kana Takahashi, Koji Inaba, Rei Umezawa, Hiroshi Igaki, Yoshinori Ito, Tomoyasu Kato, Takashi Uno, Jun Itami, Tairo Kashihara, Naoya Murakami, Nikolaos Tselis, Kazuma Kobayashi, Keisuke Tsuchida, Satoshi Shima, Koji Masui, Ken Yoshida, Kana Takahashi, Koji Inaba, Rei Umezawa, Hiroshi Igaki, Yoshinori Ito, Tomoyasu Kato, Takashi Uno, Jun Itami

Abstract

Perirectal hyaluronate gel injection (HGI) appears to be a promising technique for healthy tissue dose sparing in pelvic radiotherapy. In this analysis, we report our initial experience of HGI in gynecologic brachytherapy, focusing on its safety and effectiveness for dose reduction to the rectum. Between July 2013 and May 2014, 36 patients received HGI for primary/salvage gynecologic brachytherapy. Dosimetric effect analysis was based on pre- and post-HGI computed tomography dataset registration with corresponding dose-volume histogram evaluation. The maximum dose to the most exposed 0.1 cm3 (D0.1cm3) and 2.0 cm3 (D2.0cm3) were used as index values for rectum and bladder dose evaluation. The dose indexes for target volume (TV) coverage were TV D90/V100. In all cases, HGI was well tolerated, with no acute or late adverse events documented at a median follow-up of 220 days (range, 18-1046 days). Rectum D2.0cm3 and D0.1cm3 were significantly decreased by HGI (P < 0.001 and P = 0.003, respectively), with no significant impact on dosimetric parameters of bladder and TV coverage. Factors correlating negatively with the dosimetric effect of HGI were an increasing number of interstitial catheters (P = 0.003) as well as Lcranial100% (P = 0.014) and Lcranial80% (P = 0.001) [i.e. the length from the anal verge to the most cranial point at which the 100% and 80% isodose lines, respectively, crossed the rectum]. The concept of HGI for gynecologic brachytherapy is plausible, and our initial experience indicates it to be an effective technique for rectal dose reduction in radiotherapy of intrapelvic tumours.

Keywords: brachytherapy; gynecologic malignancies; high-dose rate; hyaluronate gel.

© The Author(s) 2019. Published by Oxford University Press on behalf of The Japan Radiation Research Society and Japanese Society for Radiation Oncology.

Figures

Fig. 1.
Fig. 1.
Hyaluronate gel injection (HGI) is performed under real-time transrectal ultrasound (TRUS) guidance. (A) Sagittal TRUS image obtained before HGI. (B) Sagittal TRUS image obtained during HGI. An application needle is inserted between the vagina and rectum via a transperineal approach, and hyaluronate gel is being injected into the pararectal space. Sagittal CT images before HGI (C) and after HGI (D) are also shown. The red line marks the hyaluronate gel and the brown line the rectum.
Fig. 2.
Fig. 2.
Pre-HGI CT image in sagittal view. The length from the anal verge to the most cranial point at which the 100% and 80% isodose line crossed the rectum on the pre-HGI image were defined as Lcranial100% and Lcranial80%, respectively. The red line indicates the 100% isodose line and the green line the 80% isodose line. The brown dotted line marks the rectum.
Fig. 3.
Fig. 3.
Correlation diagram of Rectum D2.0cm3 and the number of implanted catheters. It shows that with an increase in the number of catheters used, the dosimetric effect of HGI reduces.
Fig. 4.
Fig. 4.
Correlation diagram of Rectum D2.0cm3 and LCranial100% and Lcranial80%. It shows that the more cranial the high-value isodose lines overlapping the rectum, the less is the dosimetric effect of HGI.

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