Brachytherapy for rectal cancer

Rectal cancer occurs when cells in the rectum mutate and grow out of control. The disease may also develop when polyps on the inner wall of the rectum develop and become cancerous. Rectal cancer is among the common malignancies globally, frequently affecting patients older than 50-years-of-age. 1 Colorectal cancer is the third most common cancer and the second leading cause of cancer death globally, with rectal cancer accounting for one-third of these cases. 2

Although total mesorectal excision (TME) combined with EBRT with or without chemotherapy is the standard management of this condition, treatment with high dose rate (HDR) brachytherapy has demonstrated promising response rates. 3-9

Doctor and patient

The value of brachytherapy for rectal cancer

High-dose rate (HDR) brachytherapy is an image-guided brachytherapy treatment for individuals diagnosed with rectal cancer. The treatment is based on tumor imaging with MRI in particular, which is used to select eligible patients and enhance the visualization of tumors. Treatment planning is performed using 3D CT simulation. This inpatient or outpatient treatment is delivered with a rectal applicator and requires minimal local anesthesia. 1 HDR brachytherapy is an attractive alternative to surgery (total mesorectal excision [TME]) – which can result in decreased quality of life – and to EBRT alone, which uses a lower therapeutic dose and a higher risk of radiation side effects in organs-at-risk, such as the prostate, bladder and small bowel.

In the preoperative setting, HDR brachytherapy, alone or combined with EBRT, has resulted in superior pathological complete response rates compared to EBRT alone. 1-2 With its superior conformality to the target, HDR brachytherapy enables better sparing of normal tissues surrounding the tumor during treatment, while delivering higher doses to the tumor. 3 This decreases the number and severity of side effects and results in a more effective treatment. 1-2,4

  1. American Cancer Society . Cancer Facts & Figures 2017. American Cancer Society; Atlanta, GA, USA: 2017.
  2. Siegel R.L., Miller K.D., Fuchs H.E., Jemal A. Cancer statistics, 2021. CA Cancer J. Clin. 2021;71:7–33. doi: 10.3322/caac.21654. - DOI - PubMed
  3. Vuong T, Garant A, Vendrely V, et al. Image-Guided Brachytherapy for Rectal Cancer: Reviewing the Past Two Decades of Clinical Investigation. Cancers (Basel). 2022 Oct 4;14(19):4846. doi: 10.3390/cancers14194846. PMID: 36230770; PMCID: PMC9563024.
  4. Vuong T, Garant A, Vendrely V, et al. Clinical applications of high dose rate endorectal brachytherapy for patients with rectal cancer. Cancer Radiother. 2022 Oct;26(6-7):879-883. doi: 10.1016/j.canrad.2022.07.001. Epub 2022 Aug 26. PMID: 36031497.
  5. Gerard J-P, Barbet N, Schiappa R, et al. Neoadjuvant chemoradiotherapy with radiation dose escalation with contact x-ray brachytherapy boost or external beam radiotherapy boost for organ preservation in early cT2–cT3 rectal adenocarcinoma (OPERA): a phase 3, randomised controlled trial. Published: February 16, 2023. https://www.thelancet.com/journals/langas/article/PIIS2468-1253(22)00392-2/fulltext.
  6. Garant A, Vasilevsky CA, Boutros M, et al. MORPHEUS Phase II-III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results. Cancers (Basel). 2022 Jul 28;14(15):3665. doi: 10.3390/cancers14153665. PMID: 35954329; PMCID: PMC9367346.
  7. Fleischmann, M., Diefenhardt, M., Trommel, M. et al. Image-guided high-dose-rate brachytherapy for rectal cancer: technical note and first clinical experience on an organ-preserving approach. Strahlenther Onkol 198, 654–662 (2022). https://doi.org/10.1007/s00066-022-01931-4.
  8. Cheng T, Peng R, Qu A, Wang H. High-dose rate endorectal brachytherapy for rectal cancer: A state-of-the-art review. Cancer Sci. 2023 Nov;114(11):4145-4156. doi: 10.1111/cas.15959. Epub 2023 Sep 13. PMID: 37702196; PMCID: PMC10637059.
  9. Vuong T, Devic S. High-dose-rate pre-operative endorectal brachytherapy for patients with rectal cancer. J Contemp Brachytherapy. 2015 Apr;7(2):183-8. doi: 10.5114/jcb.2015.51402. Epub 2015 May 6. PMID: 26034500; PMCID: PMC4444460.

HDR brachytherapy effectiveness

With the use of CT or MRI for better visualization of tumors and for treatment planning, HDR brachytherapy is safe and effective in achieving a high tumor regression rate and was well tolerated in a phase II multicenter study and two matched-pair studies. 4

The modality is presently explored as a phase III dose-escalation study in the nonoperative management (NOM) of patients with operable rectal cancer. 4 The aim of this study is to validate the value of HDR brachytherapy in patients with operable stage II rectal cancer. The preliminary interim toxicity analysis of the first 40 patients showed favorable toxicity post-operative data and potential benefits from HDR brachytherapy boost in the NOM of rectal cancer. Patients were randomized 1:1 to receive either an EBRT boost of 9 Gy in five fractions (Arm A) or three weekly adaptive brachytherapy boosts totaling 30 Gy (Arm B) There was a 50 percent complete clinical response (Arm A) and 90 percent complete clinical response (Arm B). 5

  1. Vuong T, Devic S. High-dose-rate pre-operative endorectal brachytherapy for patients with rectal cancer. J Contemp Brachytherapy. 2015 Apr;7(2):183-8. doi: 10.5114/jcb.2015.51402. Epub 2015 May 6. PMID: 26034500; PMCID: PMC4444460.
  2. Buckley H, Wilson C, Ajithkumar T (2017) High-dose-rate brachytherapy in the management of operable rectal cancer: a systematic review. Int J Radiat Oncol Biol Phys 99(1):111–127. https://doi.org/10.1016/j.ijrobp.2017.05.023
  3. Tam SY, Wu VWC (2019) A review on the special radiotherapy techniques of colorectal cancer. Front Oncol 9:208. https://doi.org/10.3389/fonc.2019.00208
  4. Vuong T, Garant A, Vendrely V, et al. Image-Guided Brachytherapy for Rectal Cancer: Reviewing the Past Two Decades of Clinical Investigation. Cancers (Basel). 2022 Oct 4;14(19):4846. doi: 10.3390/cancers14194846. PMID: 36230770; PMCID: PMC9563024.
  5. Garant A, Vasilevsky CA, Boutros M, et al. MORPHEUS Phase II-III Study: A Pre-Planned Interim Safety Analysis and Preliminary Results. Cancers (Basel). 2022 Jul 28;14(15):3665. doi: 10.3390/cancers14153665. PMID: 35954329; PMCID: PMC9367346.

Rectal Applicator

The Rectal Applicator is designed to deliver high dose rate (HDR) brachytherapy for patients with rectal cancer. This single-use applicator is compatible with Elekta’s Flexitron and microSelectron afterloader systems.

Features include:

  • Ease of use
    The easy click system is designed to make assembly of the fixation element and fixation clip simple, without the need for screws or a screwdriver. The fixation element and fixation clip, as well as the insertion tool, are reusable after steam sterilization. The applicator is also is equipped with integrated kink protection. Simplified fixation element with the Easy Click system with no need for screw and tools. Also facilitated with integrated kink protection for added convenience and safety.
  • MR compatible imaging
    The applicator is safe to use with x-ray and CT, providing good imaging results without artifacts or distortion, and is also suitable for use in an MR environment (MR conditional)
  • Patient comfort
    The applicator’s flexibility offers maximum patient comfort versus a rigid applicator.
  • Accuracy
    To maximize precision, the rectal applicator provides the ability to modulate the dose to cover the tumor and spare surrounding healthy tissues. The applicator’s length markings help the user identify insertion depth and confirm that the applicator has not shifted after insertion. In addition, radiopaque catheters help users recognize and resolve applicator twist.

Treatment planning for rectal cancer

Homogeneous dose delivery on the target while sparing the OaR.

Oncentra Brachy—Comprehensive treatment planning software

Designing the optimal dose distribution can be a time-consuming job. The latest version of Oncentra Brachy offers a series of useful tools that simplify many repetitive tasks, such as contouring and reconstruction. Oncentra Brachy buys you time to focus on what counts: creating the optimal dose distribution.

Oncentra Brachy also helps you optimize treatment plan accuracy, providing easy navigation to any plane that offers the most relevant information per region of interest. Template solutions for repetitive tasks, such as the new Implant Modeling tool and the popular Applicator Modeling feature, help reduce implant reconstruction time. DVH presets and the ROI Catalog Manager can help improve accuracy and reproducibility. Powerful inverse planning optimization automates volume-based planning, making the process fast and efficient.

Treatment delivery with Flexitron

Four simple features are the basis for the Flexitron way of working, introducing a new standard in treatment delivery

  • Enhanced safety and trust
    Designed to prevent human error, enabling enhanced safety for clinicians and patients
  • Best accuracy and precision
    Enables the best accuracy and precision in the market, revolutionizing the confidence in the treatment delivery
  • Reliability and ease of use
    Continuously enhanced, allows you to treat with great ease and reliability
  • Great flexibility
    Offering personalized treatment solutions tailored to each patient's distinct needs and conditions

What is the success rate of radiation therapy for rectal cancer?

High dose rate endorectal brachytherapy is safe and effective in achieving high tumour regression rate and was well tolerated. It is presently explored in a phase III dose escalation study in the non-operative management of patients with operable rectal cancer. 1

Targeted dose escalation with the endoluminal brachytherapy technique (IGAEBT) allows safe salvage surgery to occur in the NOM management of patients with rectal cancer. 2

In the OPERA trial we found that in combination with chemoradiotherapy, when compared to a boost with external beam radiotherapy, a contact x-ray brachytherapy boost significantly increased the cCR rate and the 3-year organ preservation rate for early cT2–cT3 rectal adenocarcinomas. This is the first randomised controlled trial to show that dose escalation can result in increased organ preservation. 3

  1. https://www.sciencedirect.com/science/article/abs/pii/S1278321822001536?via%3Dihub
  2. https://www.mdpi.com/2072-6694/14/15/3665
  3. https://pubmed.ncbi.nlm.nih.gov/36801007/

Other indications

Find out about our Brachytherapy solutions for other indications.

Head and neck

Bronchus and oesophagus

Breast

Skin

Prostate

Bladder

Rectum

Gynecology

Brachy­Academy

Empowering through education

Peer-to-peer education platform for brachytherapy professionals

The BrachyAcademy comprises a complete peer-to-peer medical education library and includes programs such as clinical workshops and training visits to leading hospitals worldwide.

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We've created our online educational brachytherapy portal for patients and those who are supporting patients throughout their curative treatment, to provide key information and to help those affected gain an understanding of brachytherapy.

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