6%). In the study by Llacer et al. (28), LDR or PDR as monotherapy (45 Gy) or in combination with EBRT (20 Gy BT and 45 Gy EBRT) was used. All tumors involved the neurovascular structures (45.6% positive margins). The 5-year LC was 90%. Late complications related to lesion PS-341 concentration location in the lower limb, the number of catheters, and treatment thickness of 20 mm or more. They did not evaluate a difference between the two techniques. Muhic et al. (52) reported a reoperation rate of 10% for patients receiving 20 Gy PDR and 50 EBRT. This result is comparable to reports in the LDR literature. Therefore, PDR is

also considered a suitable source loading method for STS. All the described BT dose rate delivery systems, with their various advantages, are valid alternatives (Table 3). Studies are not available to separate outcome benefits for one dose rate over another. The extent of the disease, quality of the implant, case selection, and use of external beam are equally and perhaps more important outcome Belnacasan datasheet variables. The impact of BT on acute and chronic complications is somewhat unclear because treatment is usually multimodal. Factors that influence the complication rates

include tumor stage, disease location, the nature and extent of the resection, and previous or planned EBRT or chemotherapy. Wound complication rates range from 7% to 59% [10], [21], [23], [24], [27], [28], [38], [42], [51] and [52]. Delayed wound healing is the most common acute complication. The MSKCC randomized trial reported no significant difference in the wound complication rate as Histamine H2 receptor a consequence of BT (24% BT vs. 14% no BT; p = 0.13), but the rate of wound reoperation was significantly higher in the BT arm (10% vs. 0%; p = 0.006)

(34). The rate of reoperation reported in the literature is 2.3–13.8% (23). Strategies to decrease wound healing complications include waiting for several days before source loading and the use of free flaps to decrease the wound tension [53] and [54]. The literature indicates that BT is safe when performed in association with free tissue transfer [55], [56], [57] and [58]. Wound complication rates after LDR BT are affected by various factors such as time to source loading more than 5 days (34) and good implant geometry (27), which are both associated with lower morbidity. The number of BT catheters or wires (>10) and treatment thickness >20 mm have also been reported to impact on vascular toxicity (28). Toxicity associated with HDR appears to be related to total radiation dose, total BT dose, HDR fraction size, and the volume encompassed by the 150% isodose line [23], [27] and [50]. Aronowitz et al. (50) have recommended that boost HDR BT be given at doses <15 Gy in three to four fractions (<4.5 Gy/fraction) given twice daily. Wound healing with HDR and LDR BT appears to be similar.