Novel portable apparatus for outpatient high-dose-rate (HDR) brachytherapy in penile cancer



      Penile squamous cell carcinoma (PSC) is traditionally treated with surgical resection with significant morbidity. Penile sparing approaches, such as brachytherapy, require expertise, prolonged inpatient stays, poor patient convenience, and heterogenous plans with variable long-term toxicity. In this study, we describe the protocol for novel portable apparatus created for PSC, allowing outpatient hybrid interstitial/surface brachytherapy, improving homogeneity and patient convenience.


      A portable brachytherapy apparatus was developed utilizing a foley catheter, prostate template, 6F interstitial catheters, 5 mm bolus, and a jock strap. The apparatus allowed for internal and external catheter placement housed in a jock strap to allow mobility and defecation without affecting the implant. High-dose-rate brachytherapy was performed as an outpatient.


      The apparatus was then used on a 62-year-old male with cT2pN0M0 (stage IIA) PSC with bilateral glans and urethral meatus involvement, who elected for definitive brachytherapy (4000cGy in 10 fractions over 5-days). Given external dwell positions, heterogeneity correction of the template was calculated (AAPM TG186) with <2% variation. Patient had minimal impact on his active lifestyle during treatment and had complete clinical response at 3-months. Grade 2 skin desquamation resolved at 2-months, with no necrosis. At 6-months, he was able to resume sexual intercourse, and at 12-months, he remained disease-free with sexual and urinary function intact.


      Novel portable implant allows for improved patient convenience, reduced inpatient stay, capable of optimizing dosimetry with hybrid brachytherapy. This outpatient treatment allows the opportunity to increase fractionation, offering high local-control and lower toxicity. Future studies utilizing this apparatus for more fractionated regimens with further lower dose-per-fraction (∼3 Gy/fraction) is recommended.


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      1. Howlader N, Noone AM, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA, (eds). SEER Cancer Statistics Review, 1975-2018, National Cancer Institute. Bethesda, MD,, based on November 2020 SEER data submission, posted to the SEER web site, April 2021.

        • Parsai S.
        • Cherian S.
        • Berglund R.K.
        • et al.
        Principles and practice of high-dose rate penile brachytherapy: planning and delivery techniques.
        Pract Radiat Oncol. 2018; 8: e386-ee91
        • Sri D.
        • Sujenthiran A.
        • Lam W.
        • et al.
        A study into the association between local recurrence rates and surgical resection margins in organ-sparing surgery for penile squamous cell cancer.
        BJU Int. 2018; 122: 576-582
        • Maddineni S.B.
        • Lau M.M.
        • Sangar V.K.
        Identifying the needs of penile cancer sufferers: a systematic review of the quality of life, psychosexual and psychosocial literature in penile cancer.
        BMC Urol. 2009; 9: 8
        • Draeger D.L.
        • Sievert K.D.
        • Hakenberg O.W.
        Cross-sectional patient-reported outcome measuring of health-related quality of life with establishment of cancer- and treatment-specific functional and symptom scales in patients with penile cancer.
        Clin Genitourin Cancer. 2018; 16: e1215-e1e20
        • Baumgarten A.
        • Chipollini J.
        • Yan S.
        • et al.
        Penile sparing surgery for penile cancer: a multicenter international retrospective cohort.
        J Urol. 2018; 199: 1233-1237
        • Romero F.R.
        • Romero K.R.
        • Mattos M.A.
        • et al.
        Sexual function after partial penectomy for penile cancer.
        Urology. 2005; 66: 1292-1295
        • Hegarty P.K.
        • Shabbir M.
        • Hughes B.
        • et al.
        Penile preserving surgery and surgical strategies to maximize penile form and function in penile cancer: recommendations from the United Kingdom experience.
        World J Urol. 2009; 27: 179-187
        • Crook J.
        Organ preserving radiation strategies for penile cancer.
        Urol Oncol. 2022; 40: 184-190
        • McLean M.
        • Akl A.M.
        • Warde P.
        • et al.
        The results of primary radiation therapy in the management of squamous cell carcinoma of the penis.
        Int J Radiat Oncol Biol Phys. 1993; 25: 623-628
        • Escande A.
        • Haie-Meder C.
        • Mazeron R.
        • et al.
        Brachytherapy for conservative treatment of invasive penile carcinoma: prognostic factors and long-term analysis of outcome.
        Int J Radiat Oncol Biol Phys. 2017; 99: 563-570
        • Crook J.M.
        • Haie-Meder C.
        • Demanes D.J.
        • et al.
        American Brachytherapy Society-Groupe Europeen de Curietherapie-European Society of Therapeutic Radiation Oncology (ABS-GEC-ESTRO) consensus statement for penile brachytherapy.
        Brachytherapy. 2013; 12: 191-198
        • Sharma D.N.
        • Joshi N.P.
        • Gandhi A.K.
        • et al.
        High-dose-rate interstitial brachytherapy for T1-T2-stage penile carcinoma: short-term results.
        Brachytherapy. 2014; 13: 481-487
        • Petera J.
        • Sirak I.
        • Kasaova L.
        • et al.
        High-dose rate brachytherapy in the treatment of penile carcinoma–first experience.
        Brachytherapy. 2011; 10: 136-140
        • D'Alimonte L.
        • Ravi A.
        • Helou J.
        • et al.
        Optimized penile surface mold brachytherapy using latest stereolithography techniques: a single-institution experience.
        Brachytherapy. 2019; 18: 348-352
        • Nath R.
        • Anderson L.L.
        • Luxton G.
        • et al.
        Dosimetry of interstitial brachytherapy sources: recommendations of the AAPM Radiation Therapy Committee Task Group No. 43. American Association of Physicists in Medicine.
        Med Phys. 1995; 22: 209-234
        • Beaulieu L.
        • Carlsson Tedgren A.
        • Carrier J.F.
        • et al.
        Report of the Task Group 186 on model-based dose calculation methods in brachytherapy beyond the TG-43 formalism: current status and recommendations for clinical implementation.
        Med Phys. 2012; 39: 6208-6236
        • Suarez-Ibarrola R.
        • Zengerling F.
        • Haccius M.
        • et al.
        Adherence to European association of urology and national comprehensive cancer network guidelines criteria for inguinal and pelvic lymph node dissection in penile cancer patients-a survey assessment in German-speaking countries on behalf of the European prospective penile cancer study group.
        Eur Urol Focus. 2021; 7: 843-849
        • Soria J.C.
        • Fizazi K.
        • Piron D.
        • et al.
        Squamous cell carcinoma of the penis: multivariate analysis of prognostic factors and natural history in monocentric study with a conservative policy.
        Ann Oncol. 1997; 8: 1089-1098
        • Kiltie A.E.
        • Elwell C.
        • Close H.J.
        • Ash D.V.
        Iridium-192 implantation for node-negative carcinoma of the penis: the Cookridge Hospital experience.
        Clin Oncol (R Coll Radiol). 2000; 12: 25-31
        • Mazeron J.J.
        • Langlois D.
        • Lobo P.A.
        • et al.
        Interstitial radiation therapy for carcinoma of the penis using iridium 192 wires: the Henri Mondor experience (1970-1979).
        Int J Radiat Oncol Biol Phys. 1984; 10: 1891-1895
        • Crook J.M.
        • Jezioranski J.
        • Grimard L.
        • et al.
        Penile brachytherapy: results for 49 patients.
        Int J Radiat Oncol Biol Phys. 2005; 62: 460-467
        • Delannes M.
        • Malavaud B.
        • Douchez J.
        • et al.
        Iridium-192 interstitial therapy for squamous cell carcinoma of the penis.
        Int J Radiat Oncol Biol Phys. 1992; 24: 479-483
        • de Crevoisier R.
        • Slimane K.
        • Sanfilippo N.
        • et al.
        Long-term results of brachytherapy for carcinoma of the penis confined to the glans (N- or NX).
        Int J Radiat Oncol Biol Phys. 2009; 74: 1150-1156
        • Rozan R.
        • Albuisson E.
        • Giraud B.
        • et al.
        Interstitial brachytherapy for penile carcinoma: a multicentric survey (259 patients).
        Radiother Oncol. 1995; 36: 83-93
        • Rouscoff Y.
        • Falk A.T.
        • Durand M.
        • et al.
        High-dose rate brachytherapy in localized penile cancer: short-term clinical outcome analysis.
        Radiat Oncol. 2014; 9: 142
        • Martz N.
        • Bodokh Y.
        • Gautier M.
        • et al.
        High-dose rate brachytherapy in localized penile cancer: 5-year clinical outcome analysis.
        Clin Transl Radiat Oncol. 2021; 27: 89-95
        • Marban M.
        • Crook J.
        • Keyes M.
        • et al.
        High-dose-rate brachytherapy for localized penile cancer: evolution of a technique.
        Brachytherapy. 2020; 19: 201-209
        • Kellas-Sleczka S.
        • Bialas B.
        • Fijalkowski M.
        • et al.
        Nineteen-year single-center experience in 76 patients with penile cancer treated with high-dose-rate brachytherapy.
        Brachytherapy. 2019; 18: 493-502
        • Pohankova D.
        • Sirak I.
        • Kasaova L.
        • et al.
        High-dose rate brachyther-apy in the treatment of early stages of penile carcinoma.
        Klin Onkol. 2019; 32: 52-57
        • Kochhar R.
        • Taylor B.
        • Sangar V.
        Imaging in primary penile cancer: current status and future directions.
        Eur Radiol. 2010; 20: 36-47
        • Hakenberg O.W.
        • Comperat E.M.
        • Minhas S.
        • et al.
        EAU guidelines on penile cancer: 2014 update.
        Eur Urol. 2015; 67: 142-150
        • Robinson R.
        • Marconi L.
        • MacPepple E.
        • et al.
        Risks and benefits of adjuvant radiotherapy after inguinal lymphadenectomy in node-positive penile cancer: a systematic review by the European association of urology penile cancer guidelines panel.
        Eur Urol. 2018; 74: 76-83
        • Tang D.H.
        • Djajadiningrat R.
        • Diorio G.
        • et al.
        Adjuvant pelvic radiation is associated with improved survival and decreased disease recurrence in pelvic node-positive penile cancer after lymph node dissection: a multi-institutional study.
        Urol Oncol. 2017; 35 (e17- e23): 605
        • Johnstone P.A.S.
        • Boulware D.
        • Djajadiningrat R.
        • et al.
        Primary penile cancer: the role of adjuvant radiation therapy in the management of extranodal extension in lymph nodes.
        Eur Urol Focus. 2019; 5: 737-741
        • Yuan Z.
        • Grass G.D.
        • Azizi M.
        • et al.
        Intrinsic radiosensitivity, genomic-based radiation dose and patterns of failure of penile cancer in response to adjuvant radiation therapy.
        Rep Pract Oncol Radiother. 2019; 24: 593-599
        • Crook J.
        • Ma C.
        • Grimard L.
        Radiation therapy in the management of the primary penile tumor: an update.
        World J Urol. 2009; 27: 189-196
        • Peskircioglu L.
        • Karabulut A.
        • Deniz E.
        • et al.
        The role of pentoxifylline in the treatment of erectile dysfunction due to borderline arterial insufficiency.
        Br J Urol. 1996; 77: 563-565
        • Yang L.
        • Qian S.
        • Liu L.
        • et al.
        Phosphodiesterase-5 inhibitors could be efficacious in the treatment of erectile dysfunction after radiotherapy for prostate cancer: a systematic review and meta-analysis.
        Urol Int. 2013; 90: 339-347