eISSN: 2081-2841
ISSN: 1689-832X
Journal of Contemporary Brachytherapy
Current Issue Archive Supplements Articles in Press Journal Information Aims and Scope Editorial Office Editorial Board Register as Author Register as Reviewer Instructions for Authors Abstracting and indexing Subscription Advertising Information Links
SCImago Journal & Country Rank

vol. 11
Case report

Image-guided high-dose-rate interstitial brachytherapy for recurrent rectal cancer after salvage surgery: a case report

Bei Yanping
1, 2
Naoya Murakami
Satoshi Shima
Kana Takahashi
Koji Inaba
Kae Okuma
Hiroshi Igaki
Yuko Nakayama
Jun Itami

Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
Department of Radiation Oncology, Lihuili Hospital, Ningbo Medical Center, China
J Contemp Brachytherapy 2019; 11, 4: 343–348
Online publish date: 2019/08/03
Article file
- Image-guided.pdf  [0.37 MB]
Get citation
JabRef, Mendeley
Papers, Reference Manager, RefWorks, Zotero


In rectal cancer, with the implementation of the total mesorectal excision (TME) and addition of neoadjuvant chemoradiotherapy (CRT), significant improvements have been reported in local control (LC) of approximately 5-10% [1,2,3,4,5,6]. Without a treatment, patients with local recurrence have a median survival of approximately 8 months only. Even after salvage treatment, 30-50% of patients will eventually die of locally recurrent disease [7,8].

Surgery is the most widely accepted standard curative salvage treatment option, and it has an acceptable quality of life (QoL). Complete surgical resection is associated with the best outcome in previously published series [9,10,11]. However, pelvic control after salvage surgery remains unsatisfactory between 40-50% [12,13]. The LC achieved is heavily dependent on additional therapies given with surgery. Use of intraoperative radiation therapy (IORT) resulted in improved LC and overall survival (OS) in recurrent colorectal cancer [14,15]. Surgery is just not always feasible, and to determine a treatment strategy for such patients is quite difficult.

Irradiation is another salvage treatment option for locally recurrent rectal cancer (LRRC), especially suitable for patients who have already received salvage resection, and who are medically and surgically inoperable. Irradiation with an external beam radiation therapy (EBRT) with or without concurrent use of chemotherapy can be considered, in general, as less invasive therapy than surgery. However, the total dose is generally limited to sub-curative doses because of dose limitation of surrounding organs such as small bowel, sigmoid colon, the rectum itself and bladder. Therefore, EBRT is considered to be a useful treatment just for symptom relief, but it has a small impact on long-term outcome [16].

In terms of optimizing radiotherapy effect, the tumor should receive a higher tumoricidal total dose while sparing the surrounding normal tissue to avoid severe toxicity. In this context, image-guided high-dose-rate interstitial brachytherapy (HDR-ISBT) might be a promising treatment option because it delivers a higher dose focally to the tumor while reducing the dose to organs at risk (OARs) in comparison to EBRT. There are only few publications in the literature on the application of HDR-ISBT for recurrent rectal cancer suggesting that it could be an effective alternative method for locally recurrent rectal cancer worth considering [17,18,19]. Here, we present a case report to illustrate the treatment effect of image-guided HDR-ISBT for LRRC after salvage surgery. Written informed consent was obtained from the patient.

Case description

A 61-year-old male LRRC patient after salvage surgery who initially underwent laparoscopic high anterior resection (LAP-HAR) D3 regional lymph node dissection for primary rectal cancer (pT3N0M0, stage II, well-differentiated adenocarcinoma), with no adjuvant chemotherapy or radiotherapy was presented at our institute. Local recurrence was noted eight months after initial surgery, for which he underwent abdominoperineal resection (APR) as a salvage treatment, followed by adjuvant 8 cycles of XELOX (capecitabine and oxaliplatin) chemotherapy. Fifteen months post-salvage surgery, he developed local recurrence determined by positron emission tomography-computed tomography (PET-CT) measuring 23 × 25 mm close to the sigmoid colon in pelvis (Figure 1). Considering the third surgery as a technically challenging and intolerable, it was refused by the patient. The patient was referred to our department for the possibility of HDR-ISBT, and the combination of image-guided HDR-ISBT and EBRT was proposed.

Fig. 1

Axial (A) and sagittal (B) images of PET-CT images of recurrent rectal carcinoma in the presacral area closed to the sigmoid colon


The technique of salvage image-guided HDR-ISBT for recurrent pelvic malignancies has been described elsewhere [20,21]. Eleven plastic 5F ProGuide® needles (Nucletron, an ELEKTA company, ELEKTA AB, Stockholm, Sweden) were inserted through a perineal Prostate Stepper Template® (Nucletron, an ELEKTA company, ELEKTA AB, Stockholm, Sweden) beyond the prostate. Trans-rectal ultrasound was not used in this case to guide the needle insertion, as the patient’s anus was closed during salvage APR. There was calcification inside of the recurrent tumor, which was visible with C-arm fluoroscopy. Initially, four needles were inserted toward the calcification based on fluoroscopy and trans-abdominal ultrasound guidance; then, CT was taken. It was found that one needle penetrated the tumor, and this needle was used as a landmark; the rest of the needle was inserted by fluoroscopy, CT, and trans-abdominal ultrasound guidance. After the needle insertion, a planning computed tomography was completed and dose calculation was performed using Oncentra® Brachy version 4.5.1 (Nucletron, an ELEKTA company, ELEKTA AB, Stockholm, Sweden). Clinical target volume (CTV) was contoured based on CT, and no planning treatment volume (PTV) margin was added since the needles moved with the tumor. Dose calculation was performed so that 100% isodose line covered the CTV. Prescribed dose per fraction was 6 Gy and the total prescribed dose was 30 Gy/5 fractions/3 days, applied twice-daily, with an inter-fractional interval of at least 6 hours. EBRT was performed after HDR-ISBT, with 39.6 Gy in 22 fractions. Figure 2 shows the isodose dose distribution of the HDR-ISBT. The sigmoid D2cc, bladder D2cc, and CTV D90 was 272 cGy, 212 cGy, and 840 cGy per fraction, respectively. Brachytherapy was carried out using an 192Ir remote after-loading system (RALS, MicroSelectron v2r® HDR Ir-192 source, Nucletron, an ELEKTA company, ELEKTA AB, Stockholm, Sweden).

Fig. 2

The isodose dose distribution of the interstitial brachytherapy. From a dosimetric point of view, the sigmoid D2cc was 272 cGy, bladder D2cc was 212 cGy, and CTV D90 was 840 cGy per fraction, respectively


One week after HDR-ISBT, 39.6 Gy in 22 fractions of EBRT by 4-fields box technique was started. Figure 3 shows the isodose dose distribution of the EBRT. Radiotherapy-related toxicity was measured using the Radiation Therapy Oncology Group (RTOG) radiation morbidity scoring schema [22]. Post-treatment, the patient had grade 1 acute radiation-related diarrhea, and no late radiation-related toxicity of any grade was observed.

Fig. 3

The isodose dose distribution of the external beam radiation therapy with 4-fields box technique


Two months post-HDR-ISBT, MRI detected shrinkage of the recurrent pelvic tumor, and follow-up MRIs detected no tumor progression on five, eight, and fourteen months thereafter (Figure 4). The CEA level decreased sharply from 24.5 ng/ml before HDR-ISBT to 0.7 ng/ml 4 months after whole salvage radiotherapy, and the CEA level sustained within the normal range during follow-up until now.

Fig. 4

The magnetic resonance imaging (MRI) scan showing complete response taken 14 months after interstitial brachytherapy



In rectal cancer patients, local pelvic relapse is one of the major failure patterns, which creates a major therapeutic dilemma. It can lead to a devastating condition such as intractable pain, pelvic infection, and bowel obstruction, which has a significant impact on the patient’s health-related QoL, and eventually ending up being a fatal condition [23]. The goals of treatment for locally relapsed rectal cancer are palliation of symptoms with a better QoL and if possible, achieving cure with low treatment-related complications. Therapeutic modalities such as repeated surgery, radiotherapy (EBRT, IORT, or intraoperative brachytherapy [IOBT]), chemotherapy, or combinations of these modalities can be proposed as salvage strategies, and the choice is dependent on the previous treatment and patient’s health condition as well as the balance between benefits and morbidity.

Surgery is often advocated as the most effective way to treat patients with LRRC. However, there is still a high incidence of a second local recurrence after repeated surgery of approximately 40-50% [12,13]. Additional therapies given along with surgery such as IORT could improve LC and OS in recurrent colorectal cancer [14,15]. Third time surgery is more aggressive and challenging, with higher morbidity and mortality rate than previous operations and tend to be refused by most of patients. Therefore, under such circumstances, radiotherapy or CRT is often the preferred salvage approach of treatment.

In terms of optimizing radiotherapy, the tumor should receive a higher tumoricidal total dose while sparing the surrounding normal tissue to avoid radiotherapy-related severe late toxicities. There are several articles, which proposed radiotherapy to be an optimal palliative procedure for recurrent rectal cancer [24,25,26,27,28]. Because of the poor perfusion in the recurrent tumor, LRRC is considered to be potentially radio-resistant. Since EBRT requires margins, which accounts for tumor/organ movement and set-up error, an application of high doses of EBRT is associated with a high-risk of radiation damage to surrounding normal structures such as gastrointestinal tracts or bladder [29,30]. Therefore, in general, only sub-curative doses can be delivered using EBRT and it is often used for palliative treatment. Because of the lower efficiency of EBRT, some novel radiotherapy techniques such as stereotactic body radiation therapy (SBRT), a proton or carbon-ion radiotherapy are under investigation for LRRC [31,32,33,34,35,36].

HDR-IBT is also a promising treatment option for LRRC; it delivers exceptionally high doses concentrated to the tumor compared to doses delivered with EBRT. Moreover, its steep dose gradient offers the protective property for surrounding critical OARs, which enables to safely deliver high tumoricidal dose to the target. It is expected that it can provide better clinical results than those offered by EBRT alone.

The use of brachytherapy in the treatment of LRRC was first reported in 1997 by Goes et al. [37]. Kolotas et al. [28] described HDR-ISBT as a valuable tool for delivering high doses and achieved effective symptom palliation in recurrent rectal carcinoma patients. As the radiation sources are implanted directly into the tumor in HDR-ISBT, the dose can be escalated to a level that is biologically lethal for all tumor cells. With the development of brachytherapy technology, image-guided HDR-ISBT is used in many institutions. Visualization of not only the CTV, but also the OARs by CT images integrated with a computerized system for implant planning and evaluation allows optimized dose distributions to be indexed based on individual anatomy [38]. Image-guided HDR-ISBT is used in many institutes for different tumor sites such as gynecologic, breast, or head and neck malignancies [39,40,41,42,43], but a lesser number of cases has been reported about CT-guided implantation of interstitial catheters in pelvis for the treatment of LRRC.

In our study, we have delivered image-guided HDR-ISBT followed by EBRT as a curative treatment for LRRC after failure from definitive and salvage surgery. An excellent clinical and biochemical results was noticed with a sharp decrease in CEA level from 24.5 ng/ml to 0.7 ng/ml in 4 months after implant. The tumor regressed considerably, as identified by MRI, two months after the whole salvage radiotherapy treatment, and no evidence of progression were noted until 14 months after radiotherapy. No radiation-related late toxicity was reported. The clinical and biochemical results of this salvage HDR-ISBT for LRRC are very encouraging, and a combination of EBRT with image-guided HDR-ISBT has the potential to be a valuable treatment option for this kind of patients.


This study was partially supported by the Japan Agency for Medical Research and Development, AMED, the National Cancer Center Research and Development Fund (26-A-18 and 26-A-28).

Statement of ethics

Written informed consent was obtained from the patient and this case report was approved by the Institutional Review Board of National Cancer Center Hospital (the approved number is 2017-331), according to the Declaration of Helsinki.


Authors report no conflict of interest.



Dowdall JF, Maguire D, McAnena OJ , authors. Experience of surgery for rectal cancer with total mesorectal excision in general surgical practice. Br J Surg. 2002. 89:p. 1014–1019


Heald RJ, Ryall RD , authors. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986. 1:p. 1479–1482


Sauer R, Becker H, Hohenberger W, et al. , authors. Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med. 2004. 351:p. 1731–1740


Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. , authors. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001. 345:p. 638–646


Sebag-Montefiore D, Stephens RJ, Steele R, et al. , authors. Preoperative radiotherapy versus selective postoperative chemoradiotherapy in patients with rectal cancer (MRC CR07 and NCIC-CTG C016): a multicentre, randomised trial. Lancet. 2009. 373:p. 811–820


Bakx R, Visser O, Josso J, et al. , authors. Management of recurrent rectal cancer: a population based study in greater Amsterdam. World J Gastroenterol. 2008. 14:p. 6018–6023


Mannaerts GH, Rutten HJ, Martijn H, et al. , authors. Comparison of intraoperative radiation therapy-containing multimodality treatment with historical treatment modalities for locally recurrent rectal cancer. Dis Colon Rectum. 2001. 44:p. 1749–1758


Suzuki K, Dozois RR, Devine RM, et al. , authors. Curative reoperations for locally recurrent rectal cancer. Dis Colon Rectum. 1996. 39:p. 730–736


Bouchard P, Efron J , authors. Management of recurrent rectal cancer. Ann Surg Oncol. 2010. 17:p. 1343–1356


You YN, Skibber JM, Hu CY, et al. , authors. Impact of multimodal therapy in locally recurrent rectal cancer. Br J Surg. 2016. 103:p. 753–762


Schrempf M, Anthuber M , authors. Importance of surgical treatment for recurrent rectal cancer. Chirurg. 2017. 88:p. 974


Sagar PM, Pemberton JH , authors. Surgical management of locally recurrent rectal cancer. Br J Surg. 1996. 83:p. 293–304


Boyle KM, Sagar PM, Chalmers AG, et al. , authors. Surgery for locally recurrent rectal cancer. Dis Colon Rectum. 2005. 48:p. 929–937


Wallace HJ, Willett CG, Shellito PC, et al. , authors. Intraoperative radiation therapy for locally advanced recurrent rectal or rectosigmoid cancer. J Surg Oncol. 1995. 60:p. 122–127


Abuchaibe O, Calvo FA, Azinovic I, et al. , authors. Intraoperative radiotherapy in locally advanced recurrent colorectal cancer. Int J Radiat Oncol Biol Phys. 1993. 26:p. 859–867


Wong CS, Cummings BJ, Brierley JD, et al. , authors. Treatment of locally recurrent rectal carcinoma – results and prognostic factors. Int J Radiat Oncol Biol Phys. 1998. 40:p. 427–435


Sakurai H, Mitsuhashi N, Harashima K, et al. , authors. CT-fluoroscopy guided interstitial brachytherapy with image-based treatment planning for unresectable locally recurrent rectal carcinoma. Brachytherapy. 2004. 3:p. 222–230


Morimoto M, Isohashi F, Yoshioka Y, et al. , authors. Salvage high-dose-rate interstitial brachytherapy for locally recurrent rectal cancer: long-term follow-up results. Int J Clin Oncol. 2014. 19:p. 312–318


Kolotas C, Röddiger S, Strassmann G, et al. , authors. Palliative interstitial HDR brachytherapy for recurrent rectal cancer. Implantation techniques and results. Strahlenther Onkol. 2003. 179:p. 458–463


Umezawa R, Murakami N, Nakamura S, et al. , authors. Image-guided interstitial high-dose-rate brachytherapy for locally recurrent uterine cervical cancer: a single-institution study. Brachytherapy. 2018. 17:p. 368–376


Murakami N, Kato T, Miyamoto Y, et al. , authors. Salvage high-dose-rate interstitial brachytherapy for pelvic recurrent cervical carcinoma after hysterectomy. Anticancer Res. 2016. 36:p. 2413–2421


Cox JD, Stetz J, Pajak TF , authors. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys. 1995. 31:p. 1341–1346


Camilleri-Brennan J, Steele RJ , authors. The impact of recurrent rectal cancer on quality of life. Eur J Surg Oncol. 2001. 27:p. 349–353


Cohen A, Gunderson L, Welch C , authors. Radiation therapy of rectal cancer. World Jurg. 1982. 6:p. 560–568


Rao AR, Kagan AR, Chan PY, et al. , authors. Effectiveness of local radiotherapy in colorectal carcinoma. Cancer. 1978. 2:p. 1082–1086


Urdaneta-Lafee N, Klingerman MM, Knwolton AH , authors. Evaluation of palliative irradiation in rectal carcinoma. Radiology. 1972. 104:p. 673–677


Stearns MW Jr, Whiteley HW Jr, Leaming RH, et al. , authors. Palliative radiation therapy in patients with cancer of the colon and rectum. Cancer. 1970. 25:p. 343–346


Kolotas C, Röddiger S, Strassmann G, et al. , authors. Palliative interstitial HDR brachytherapy for recurrent rectal cancer. Implantation techniques and results. Strahlenther Onkol. 2003. 179:p. 458–463


Moran MR, Rothenberger DA, Lahr CJ, et al. , authors. Palliation for rectal cancer. Resection? Anastomosis? Arch Surg. 1987. 122:p. 640–643


Aleman BM, Bartelink H, Gunderson LL , authors. The current role of radiotherapy in colorectal cancer. Eur J Cancer. 1995. 31A(7-8):p. 1333–1339


Ie M, Yamaguchi T, Kinugasa Y, et al. , authors. Complete response of locally recurrent anorectal cancer to proton beam therapy alone – a case report. Gan To Kagaku Ryoho. 2014. 41:p. 2623–2625


Kim MS, Choi C, Yoo S, et al. , authors. Stereotactic body radiation therapy in patients with pelvic recurrence from rectal carcinoma. Jpn J Clin Oncol. 2008. 38:p. 695–700


Murata K, Kitahara T, Nushijima Y, et al. , authors. An 85-year-old man with lymph node metastasis of recurrent rectal cancer treated using proton beam therapy. Gan To Kagaku Ryoho. 2016. 43:p. 1473–1475


Defoe SG, Bernard ME, Rwigema JC, et al. , authors. Stereotactic body radiotherapy for the treatment of presacral recurrences from rectal cancers. J Cancer Res Ther. 2011. 7:p. 408–411


Yamada S, Kamada T, Ebner DK, et al. , authors. Carbon-ion radiation therapy for pelvic recurrence of rectal cancer. Int J Radiat Oncol Biol Phys. 2016. 96:p. 93–101


Shinoto M, Yamada S, Okamoto M, et al. , authors. Carbon-ion radiotherapy for locally recurrent rectal cancer: Japan Carbon-ion Radiation Oncology Study Group (J-CROS) Study 1404 Rectum. Radiother Oncol. 2019. 132:p. 236–240


Goes RN, Beart RW Jr, Simons AJ, et al. , authors. Use of brachytherapy in management of locally recurrent rectal cancer. Dis Colon Rectum. 1997. 40:p. 1177–1179


Martel MK, Narayana V , authors. Brachytherapy for the next century: Use of image based treatment planning. Radiat Res. 1998. 150 5 Suppl:p. S178–188


Pötter R, Haie-Meder C, Van Limbergen E, et al. , authors. Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy-3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology. Radiother Oncol. 2006. 78:p. 67–77


Sekii S, Murakami N, Kato T, et al. , authors. Outcomes of salvage high-dose-rate brachytherapy with or without external beam radiotherapy for isolated vaginal recurrence of endometrial cancer. J Contemp Brachytherapy. 2017. 9:p. 209–215


Murakami N, Kobayashi K, Kato T, et al. , authors. The role of interstitial brachytherapy in the management of primary radiation therapy for uterine cervical cancer. J Contemp Brachytherapy. 2016. 8:p. 391–398


Strnad V, Major T, Polgar C, et al. , authors. ESTRO-ACROP guideline: Interstitial multi-catheter breast brachytherapy as Accelerated Partial Breast Irradiation alone or as boost – GEC-ESTRO Breast Cancer Working Group practical recommendations. Radiother Oncol. 2018. 128:p. 411–420


Ott OJ, Strnad V, Hildebrandt G, et al. , authors. GEC-ESTRO multicenter phase 3-trial: Accelerated partial breast irradiation with interstitial multicatheter brachytherapy versus external beam whole breast irradiation: Early toxicity and patient compliance. Radiother Oncol. 2016. 120:p. 119–123

Copyright: © 2019 Termedia Sp. z o. o. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.
Quick links
© 2020 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.
PayU - płatności internetowe