Dr. Upasna Saxena presented on brachytherapy. Brachytherapy involves placing radioactive sources close to or inside the tumor. It has advantages like high localized dose and sparing of surrounding tissues. Intracavitary brachytherapy is commonly used to treat cervical cancer using applicators like tandems and ovoids. Key planning points include Point A which is 2cm lateral and 2cm superior to the cervical os. Dose to organs at risk like bladder and rectum are also important. Proper placement and geometry of applicators is important for adequate dose coverage and sparing of organs at risk.

1. PRESENTER – DR UPASNA SAXENA
MODERATOR – DR SHEH RAWAT

2.  EVOLUTION
 ADVANTAGES
 TYPES
 ICRT
 PRESCRIPTION
POINTS
 APPLICATORS
 PROCEDURE
 2D PLANNING
 3D PLANNING
•VAGINAL CUFF
BRACHYTHERAPY
•VAGINAL MOULD
•INTERSTITIAL
BRACHYTHERAPY
•INDICATIONS
•ADVANTAGES
•APPLICATORS
•PROCEDURE
•PLANNING
•ABS GUIDELINES OF
DOSES AND
SCHEDULING

3.  ‘Brachy’ Greek word for ‘short distance‘
 The term brachytherapy proposed first time by
Forsell in 1931
 Form of radiation treatment in which radiation is
delivered by small sealed radioactive sources
arranged in a geometric fashion in & around
tumor.

4.  Radioactivity was described by Becquerel in 1896
 Marie curie extracted radium from pitchblende ore
in 1898
 Danlos and Bloc performed first radium implant
(1901)
 First “schools” of brachytherapy were at
Stockholm , Memorial Salon Kettering and the
Holt Radium Institute (Paris).
 Ra & Rn –two radioactive sources used extensively
in the early years

5.  From 1940 – 1970s , Co⁶⁰, Cs¹³⁷, Ir¹⁹² first used in
brachytherapy
 Cs¹³⁷ began to replace Ra²²⁶
 Wickham-The father of radium treatment of
uterine cancer treated 1000 cases from 1906-1910
 1953-Afterloading technique- Henschke. He was
also first to use Ir192
 LDR brachytherapy became the gold standard.

6.  Rules for implantation were
made
 1970 -Emergence of remote after
loading system ( selectron
machine – LDR machine)
 HDR became widely accepted
after a long struggle particularly
for Ca Cervix
 PDR has now been developed
 Now with more sophisticated
imaging, hardware and software
: image assisted and image
guided brachytherapy coming
up
Intracavitary
Brachytherapy:
Stockholm system
(1914)
Paris System (1926)
Manchester System
(1938)
Interstitial
Brachytherapy:
Manchester system
Quimby System
Paris system

7. 7
Advantages of brachytherapy
• A high localized radiation dose to a small volume
--higher local control
•Spares surrounding normal organs and tissues
•Ultimate form of conformal radiotherapy
•Shorter treatment time- convenient, prevents tumour
proliferation
•Non-homogenour dose distribution to tumour targeting the
hypoxic central core

8.  Invasive
 Needs expertise and experience and equipment
 Time consuming
 Difficult to maintain uniformity across various
centres

9.  According to method of source loading :
 Preloading
 Afterloading
 Manual afterloading
 Remote afterloading
 According to type of application :
 Intracavitary
 Interstitial
 Intraluminal – cylinders/ moulds

10. 10
•According to dose rate
•Ultra-low dose rate (ULDR): 0.01-0.3 Gy/hour
•LDR- 0.4-2 Gy/hr  Cs-137
•MDR- 2-12 Gy/hr
•HDR- > 12Gy/hr  Ir-192
•PDR- dose rate as HDR, But delivered in pulses ,
say for 10-15 minutes every hour

11. 11
Microselectron HDR
Selectron LDR
Microselectron PDR

12. Between the period 1910-1950 three preloading
systems were devloped for CA cervix
 Paris System
 Stockholm System
 Manchester System
Subsequently remote after loading technique was
developed which overcame the hazards of
preloaded sources.

13. INTRACAVITARY
BRACHYTHERAPY

14.  ICRU specified dose specification system that relates dose
distribution to target volume, instead of dose to specific point.
 Also includes information on various treatment parameters.
DOSIMETRIC INFORMATION FOR REPORTING
 Complete description
 Technique
 Time-dose pattern
 Treatment prescription
 Total Reference Air Kerma
 Dose description
 Prescription points/surface
 Reference dose in central plane
 Mean central /peripheral dose
 Volumes: Treated/ point A/ reference volume
 Dose to Organs at Risk : bladder, rectum

15.  the dose should be prescribed & assessed at a
representative point.
 Point A, lies in the paracervical triangle.
 Chosen initially because
 Believed to be a good index of normal tissue tolerance which is the dose
limiting factor
“High dose in the paracervical tissues, where the uterine vessels are crossed by the
ureter, produces dangerous extrinsic reactions”
 And comparable from case to case, not too variable with application
(textbook by Paterson)
 ABS recommends this point as it falls within the portion of the
isodose distribution with little cephalocaudal gradient.

16.  Definition
 Original – 2cm lateral to the central canal of the
uterus, and 2cm up from the mucous membrane of
the lateral fornix in the axis of the uterus.

17.  Although point A was defined
in terms of important
anatomical structures, these can
not be revealed on a
radiograph.
 So point A definition was
modified in 1953.
 “2 cm superior from lower end
of central radium tube and 2 cm
lateral from uterine canal in
radiograph of radium insertion.
 Variant – beginning at the
flange abutting the cervical os.
Manchester cont

18.  Tandem and ovoid - Draw a
line connecting middle of
sources in vaginal ovoids on
A-P radiograph and move 2
cm plus the radius of ovoid
superiorly along the tandem
from intersection of this line
with intrauterine source line
and then 2 cm lateral on
either side of the tandem.

19.  Vaginal ring applicator – use line connecting lateral
most source dwell points on the ring and then
extend 2 cm superiorly (along the tandem from
where the line intersects the tandem) and then 2 cm
laterally on either side
 Tandem and cylinders – extend 2 cm along tandem
from the flange, and then 2 cm laterally from it on
each side

21.  Is at same level as point A, but 5
cm from the midline.
 Depicts dose delivered to
obturator nodes.
 Indicates rate of fall-off of
dosage laterally.
 Dose to point B is ~ 20-25% of
dose at point A.
 Depends upon total amount of
radium used

22.  is used by
Mallinckrodt
Institute of
Radiology System
to specify minimum
dose to pelvic
lymph nodes.
 It is 6 cm to Rt and
Lt of patient
midline in same
plane as of classical
point A.

23.  Description of reference volume i.e the tissue volume
encompassed by a reference isodose surface is
proposed for specification in reporting
 An absorbed dose level of 60 Gy was widely accepted
as reference level
 Reference volume described is pear shaped co-incident
with intra-uterine sources

24.  This Reference volume is defined by 3 dimension:
1) Height(dh): Maximum dimension along the intrauterine
source, measured in oblique frontal plane.
2) Width (dw): Maximum dimension perpendicular to the
intra-uterine source, measured in oblique frontal plane.
3) Thickness (dt): Maximum dimension perpendicular to the
intrauterine source and is measured in saggital plane.

25. ICRU 38 Cont

26. 47
BLADDER REFERENCE
POINT: Foley balloon
with 7 cc contrast pulled down .
•On lateral x-ray-
•Anteroposterior line drawn
through the centre of balloon
.A point on this line on the
posterior surface of the
balloon
•AP x-ray
•at the centre of the balloon
•There are some articles that suggest
that dose at bladder base and bladder
neck should be recorded

27.  RECTAL REFERENCE POINT:
• Lateral x-ray-an anteroposterior line drawn from the lower
end of intra uterine source (or middle of intra vaginal
sources). Point located on this line 5 mm behind the post
vaginal wall
• AP x-ray-this at the lower end of intrauterine source or at the
middle of intravaginal sources
• Some articles show that rectal dose along several points over the length of
the implant

28. On lateral radiograph
 A line is drawn from junction of S1-S2 to the
top of symphysis pubis
 Then a line is drawn from the middle of that
line to the middle of anterior aspect of L4

29.  A point 6 cm lateral to the midline at the inferior end is
used to estimate dose rate to mid-external illiac nodes
 At the top of trapezoid points 2 cm lateral to midline at
L4 level gives an estimate to dose of Para-aortic nodes
 Midpoint of line connecting to these to points is used to
estimate the dose to common illiac node

30. 51
LYMPHATIC TRAPEZOID

31.  This point represent the absorbed dose to distal part of
parametrium and obturator nodes
 On frontal radiograph, the pelvic wall reference point
is intersected by 2 line, a horizontal line tangential to
the highest point of acetabulum and a vertical line to
the inner aspect of acetabulum
 On lateral radiograph highest point of Rt & Lt
acetabulum is joined and pelvic reference point is at
the mid-distance of these 2 points

32. 53
PELVIC WALL POINTS

33. DRAWBACK OF ICRU
38

34.  Lack of information about correlation between
 Applicator and tumour
 Applicator and OAR
 Tumour and OAR
 OAR anatomic boundaries not very clear, estimated based
on contrast
 Dose to target and OARs is not reliable
 All doses reported are a point dose which do not depict the
actual dose delivered to entire structure
 Points do not correlate with local control or toxicity

35.  It relates to position of sources and not
to specific anatomic structure.
 It is very sensitive to position of ovoid
sources relative to tandem sources
which should not be determining factor
in deciding on implant duration.
 Depending on size of cervix point A
may be inside or outside of tumor.
Manchester cont

36.  A & B are not anatomic sites
 A &B varies with applicator type
 A is not in paracervical triangle
 A is not a reliable indicator of minimum tumor
dose
 B does not always represent obturator node

38. 59
Loose Tandem & Ovoids
Stockholm
Paris or London colpostat
Manchester system
Fixed applicators
Fletcher-suit-Delclos
Manchester
Vienna ring
INTRACAVITARY
APPLICATORS

39.  Loose system.
 Intrauterine applicator
 Rubber tubing, with flange at end.
 Varying length, can take – 1,2,3 radium tubes in line.
 Ovoids
 Rubber or nylon
 Shape follows the distribution in 3-D space of the
isodose curves around the contained radium tube,
ensuring homogenous dose on its surface.

40. LOOSE APPLICATORS

41. 62
STOCKHOLM SYSTEM PARIS SYSTEM

42. STOCKHOLM
APPLICATOR

43. 64
MANCHESTER SYSTEM
Point A : 2 cm lateral to the central canal of the uterus and 2 cm up from the
mucous membrane of the lateral fornix in the axis of the uterus.( In practice,2 cm
up from the flange and 2cm lateral from the central axis)
Point B : Being in the transverse axis through points A , 5 cm from midline

45. RIGID APPLICATORS

46.  Tandems of angles 0, 15, 30 and 45 degress
 Length is adjustable with a flange placed
according to length of the uterus to prevent
perforation and mark the external os on
radiograph

47.  Ovoids
 3 sizes
 Small –shortest dia – 2cm
 Medium – dia – 2.5cm
 Large – dia – 3cm.
 Pairs of ovoids held apart by a “SPACER” .
 Fixes at a distance of 1 cm.
 “WASHER” – holds the ovoids in position in narrow
vagina.
 Range of ovoid pair – 4-7cm.

48.  Select the longest possible intra-uterine applicator and
the largest possible size of ovoids, which can be placed
snugly.
 Carries the ovoid closer to point B
 Gives better proportional depth dose.
 Pushes the isodose of lethal damage as laterally as
possible.
 Longer tandem – more contribution to pt B
 Bigger ovoid – vaginal surface dose falls by 35%

49.  Intact uterus should always have a tandem
placed
 Supracervical hysterectomy- short tandem
 Intact uterus with extensive disease – tandem
with interstitial needles

50.  INTERSTITIAL – large lesions, lower vaginal
disease, applicators not fitting
 TANDEM + CYLINDER – upper vaginal
stenosis/narrowing, superficial disease (5mm thick) in
lower vagina
 TANDEM + RING – shallow fornices

51.  TANDEM + OVOIDS – barrel shaped cervix,
using largest ovoid. To cover cervix, uterus, medial
parametrium and upper 1-2 cm of vagina
 TANDEM + RING/OVOIDS +
INTERSTITIAL NEEDLES – large bulky
tumours (for tumour coverage and OAR sparing),
vaginal extension of disease, fistulae, pelvic side
wall invasion
 OVOIDS OR CYLINDERS ALONE – for post op
cases

57. 78
ICRT STEPS
 Anesthesia / sedation
Positioning - Lithotomy
 Cleaning & draping
 Bladder catheterization—7 cc radio opaque
contrast in balloon. If US guided procedure
planned, 100-120 cc saline infused into the
bladder
 EUA
 Dilatation of os
Uterine sounding to assess length
Insertion of tandem and ovoids
 Posterior and anterior vaginal packing

58. 79

59. 80
A COMPLETED HDR ICRT
APPLICATION

60. 81
AN HDR OVOID APPLICATION

61.  After the application – patient is shifted for
imaging
 AP and orthogonal x-rays for 2-D planning.
 Planning CT scan for 3-D planning
 MRI based planning – 1.5-T MR sequence maybe
used that allows the needle tip to appear as a
balloon on saggital image and cross on axial image

63. 84
SIMULATION
Markers
Markers Orthogonal radiographs

64.  Potish et al used linear least-square regression
to show that although there was good
correlation between the milligram-hours and
colpostats and the dose to point A, it was
markedly affected by the position of the
tandem and colpostats
 MD Anderson quatified the acceptable implant
geometry

65.  Tandem should be
 4 cm from sacrum
 1/3 distance between pubis and sacrum
 Midway betweem sacrum and bladder
 Tandem should bisect the ovoids in AP & lat films
 Distance between vaginal ovoids and cervical marker
seeds was 7mm

66.  Superior tip should be below promontry (in the pelvis)
 The bladder and rectum should be packed away from
the implant with no packing above the ovoids
 Packing was within a line 5mm behind the line along
posterior surface of ovoids, running parallel to the
tandem

68.  Ovoids should fill the
vaginal fornices – largest
ovoid size to be used.
- should be separated by
0.5 –1.0 cm, admitting the
flange on the tandem with
no inferior displacement
-should be against the
cervix (marker seeds)
 The axis of the tandem
should be central between
the ovoids
 Should be bisected by the
tandem

69.  RTOG 0116 and 0128 studied 103 patients (both LDR
and HDR).
 They concluded that unacceptable geometry had
higher LR (HR=2.67, 95%CI=1.11 to 6.45; p=0.03)
 Displacement of ovoids in relation to the cervix and
inappropriate packing also resulted in a lower DFS

71.  Check proper application
 Proper delineation of OARs
 More reliable dose distribution
 Kim et al found that dose to point A is significantly lower
than D90 of HRCTV. Though dose to point A should be
reported
 Himmelman et al described individualized computer
treatment optimization of source position and dwell time

72. Modern Intracavitary Techniques
Covering the target volume with prescribed dose ( )
Standard loading
Mid-coronal view
target V
A

73. Modern Intracavitary Techniques
Covering the target volume with prescribed dose ( )
Modified loading
Mid-coronal view
target V
A

74.  Advantages
 Acceptability due to wide use
 Checks applicator geometry or perforation
 Easy delineation of applicator
 OARs position
 Disadvantage
 Artifacts due to metal applicator
 Overestimate the tumour contours as compared to MRI
 Can not distinguish sigmoid well as there is no contrast
 Can not distinguh cervix from uterus – hence both are
contoured in CT based guidelines

75.  Advantages
 Better for tumour and parametrial visualization
 Can distinguish sigmoid colon and also cervix from
uterus
 Disadvantage
 Needs specific titanium & zirconium applicators
 Poor bony anatomy distinction
 Necessary to fuse CT scan with MRI for planning
 Inconvenient & Expensive

76. 3D imaging
Contouring
Reconstruction of applicator
3D dose planning
Dose delivery
Applicator insertion

77.  Cervix and GTV can not be differentiated, so uterus
along whole tandem should be included in CTV
 The top dwell position is optimized off the sigmoid
 Uterosacral ligaments, if detected, should be included
in the CTV contours

78.  First guidelines published in 2004 by ABS (Nag et al)
 Guidelines of GEC-ESTRO (Groupe European
Curietherapy-European Society for Therapeutic
Radiation Oncology) issued guidelines for MRI based
brachytherapy in 2005 (Haier-meder et al, Poetter et al)
 In july 2005, ABS and GEC-ESTRO agreed to follow
GEC-ESTRO guidelines

79.  GEC-ESTRO guidelines are followed-
 GTV – include all T2 bright area of enhancement
 HRCTV(high risk CTV) – entire cervix, any regions
of high to intermediate signal intensity in the
parametria, uterus and vagina and any residual
disease clinically
 IRCTV (intermediate risk CTV) – subtracts the OAR
from the GTV at the time of diagnosis and a 1cm
margin to the HRCTV

81. 102
cervix
cervix
HR-CTV
Initial tumour extension
(at diagnosis)
IR-CTV
Complete remission
Partial remission
Stable disease
Residual disease
10 mm
cervix
cervix
10 mm
Legend
10 mm
CTV BT

82. 103

83. 104

84. 105

85. Either based on
 Point A as per ICRU and ABS guidelines
 Volume based prescription

86. 107
PLANNING
ICRT isodose curves

87. 108
OVOID ISODOSE CURVES

90. It is early to draw definitive conclusions
BUT
First results show that systematic MRI based
treatment planning enables prospective control and
maybe reduction of morbidity
DIRECT COMPARISON
G3-G4 gastrointestinal and urinary late morbidity
(Pötter et al R&O 2007)
10% in 1998–2000 and 2% in 2001–2003
G3 gastrointestinal and urinary late morbidity
(Haie-Meder et al R&O 2009,2010, Chargari et al Int J Radiat Oncol Biol Phys 2009 )
5% in 2000–2004 and 2% in 2004–2006
Outcome of 3D-Image Based Gynaecological
Brachytherapy
Morbidity: Rectum, Sigmoid, Bladder, Vagina

91. 112
Eliminates RT exposure hazard for caregivers, visitors; eliminates source
prepration and transportation
Allows shorter treatment time
Less patient discomfort
Possible to trt patients who can’t tolerate long periods of isolation
Less risk of applicator movement during therapy
Due to OPD procedure results in cost shifting
Allows greater displacement of nearby normal tissues by packing
Possible to treat large number of patients
Allows use of smaller diameter sources than are used in LDR
Reduces the need of dilatation
Reduces the need of GA
High risk who don’t tolerate GA
Physically easier to insert applicator into the cervix
Makes dose distribution optimization possible
Allows integration of EBRT & HDR, which can lead to a shorter overall Rx
duration & better tumor control
HDR vs. LDR IN CA CERVIX -ADVANTAGES

92.  Limited experience
 Requires infrastructure
 Maintenance is costly
 Potential for more late effects in non-
fractionated HDR

93.  Similar outcomes in LDR vs HDR
 Recommended to use 3D imaging for HDR
 For larger tumours (>4cm)using HDR early on during
treatment, results in poor outcome
 Displacing the bladder and rectum away while short HDR
treatment may overcome the disadvantage of toxicity
associated with fewer no of HDR fractions
 Newman et all treated 115 patients , 87 LDR, 30 HDr. No
significant differences were found in the local control and
toxicity

94. 115
HDR (%) LDR (%)
5 yr Dis Sp. Sur ST II 69 87
ST III 55 60
5 yr Pelvic RFS ST II 89 100
ST III 69 70
Distant Metastases 25 24
Pelvic R/E 18 13
Para aortic Recurrence 10 11
Overall 5yr compli 10 13
ST II 5 12
ST III 7 13
Rectum 3.5 8.7
Small Bowel 2.4 1.6
Bladder 4 7.5
P= ns
P= ns
Hareyama et al. Cancer 2002.

95.  HIGHER TOXICITY grade>2 seen for higher
values of D2cc (Koom et al)
For interstitial, EQD2 of <62 Gy is recommended
and it is further reduced as the length of vagina
treated increases

96.  EVOLUTION
 ADVANTAGES
 TYPES
 ICRT
 PRESCRIPTION
POINTS
 APPLICATORS
 PROCEDURE
 2D PLANNING
 3D PLANNING
•VAGINAL CUFF
BRACHYTHERAPY
•VAGINAL MOULD
•INTERSTITIAL
BRACHYTHERAPY
•INDICATIONS
•ADVANTAGES
•APPLICATORS
•PROCEDURE
•PLANNING
•ABS GUIDELINES OF
DOSES AND
SCHEDULING

98.  Used in post op cases of carcinoma cervix (>=4weeks
postop)
 Less than radical hysterectomy
 Close/positive margins
 Large or deeply invasive tumours
 Parametrial/vaginal involvement
 Extensive LVI
 Intact uterus with narrow vagina, in combination with
a tandem
Ovoids alone can also be used, but cylinders are more
effective to treat the ‘dog ears’ of the vault and whole
length of vagina

99. Dog ears of vaginal vault

100.  3-5 cm proximal vagina is treated
 Whole length treated only if -
 Papillary serous/clear cell
 Grade 3 disease
 Extensive LVI
 Prescription at 0.5 cm from vaginal surface as 95%
lymphatics are located within 3mm of the mucosa
(Choo J et al)

101.  ABS suggests
 If only upper length of vagina is to be treated, cylinder
should not extend to introitus
 If whole vagina is to be treated, cylinder should extend
beyond introitus
 Condoms should be placed on the cylinders to facilitate
cleaning and for applicator longevity
 Single channel or multiple channel applicators are
used
 Single channel – low dose to mucosa with larger size
cylinders
 Multiple channel – risk of higher dose to the mucosa has
to be guarded

102. 123
HDR SORBO APPLICATOR SET

103. 124
ASSEMBLED HDR SORBO

104. 125
SORBO-PROCEDURE

105. The vaginal cylinder is 30 mm in diameter with
cylinder sleeves of 35 and 40 mm.

108.  IMAGING
 X-ray
 CT scan
 MRI
 If imaging shows significant soft tissue above
apex of vagina, EBRT maybe preferable

109. 130
SORBO ISODOSE CURVES

118.  Form of brachytherapy where sealed radioactive
sources are directly implanted into the tumour in a
geometric fashion
 First suggested in USA by Alexander Graham Bell
(1903)
 At same time independently being used in France
& Germany
 First case treated for an inoperable Parotid
Sarcoma

119. 140
Indications of interstitial implantation in ca
cervix
• Extensive residual disease(not likely to be taken care of by
intracavitary application)
• Os not negotiable
• Fistulae
• Adjacent organ invasion
• Extensive parametrial +/- sidewall invasion
• Vaginal extension
• Recurrent disease (post RT/post surgery)
• Narrow vagina
• Prior supracervical hysterectomy

120. 141
Intracavitary
brachytherapy
Interstitial brachytherapy
More accumulated
experience
Relatively new technique
Easy to perform Requires expertise
Less invasive More invasive
Dose to cervix and
adjacent paracervical
areas
Dose to cervix, paracervical and
parametrial tissues
Lesser possibilities of
optimisation of dose
Owing to many number of needles,
more possibilities of dose
optimisation
Used in most cases Used with special indications

121. SYSTEMS
•Manchester system
•Quimby system
•Paris system
•Stepping source
dosimetry

122.  The Paris System lead to a Stepping Source Dosimetry System
(SSDS) for HDR
 Dose points are placed midway between the catheters, not only in
the central plane but along all catheters
 Dwell times are optimized such that the same dose is delivered to
all dose points; dwell times in the outer ends of the catheters are
increased substantially

123. 147
• History
• Clinical examination
• CT / MRI
• PAC clearance of the patient
• Admit the patient 48 hours prior to the implant
PATIENT EVALUATION

124. 148
One day prior to the implant
Clear liquid diet from 24 hours prior to the implant
Shave and clean perineum
Start antibiotic
Peglec 1 sachet diluted in I litre of water to drink till evening
Proctoclysis enema / soap water enema at 10 PM
Carry out anesthetic pre op orders
Nil orally after 10 PM
On day of implant
Proctoclysis enema/ soap water enema early morning
Slow iv fluids started in the morning
PRE OP PREPARATION

125. 149
Martinez Universal Perineal Interstitial
Template

128. 152
TRUS GUIDANCE

130.  Implant Orientation and Needle identification is very
important

131. 155
IMAGING

132. •Visible target and OAR
•Easy reconstruction of the
needles
•Optimization program

134.  D90, D100, V100 for HRCTV
 V150, V200 may be reported
 OAR reporting – same as in image based ICRT

135. 159
POST OP
•Carefully observe for any bleeding per rectum/hematuria
•Maintain frog leg position
•Maintain continuous infusion of epidural anaesthesia
IMPLANT REMOVAL
•Each needle to be removed separately
•Apply tincture benzoin at the bleeding points
•Advise perineal sitz baths and vaginal douches 2-3 times 3
hours apart after implant removal

137. 161
TEMPLATE RESULTS
Syed , Puthawala et al- IJROBP Sep 2002
• N=185
• EBRT-5040 cGy-----Template LDR 40-50 Gy in 2 applications
• 5YDFS- IB-65%, II-67%, III-49%, IV-17 %
• Grade 3,4 late complications- 10%
Demanes et al- IJROBP Aug 1999, CEC ,1991-96
• N=62 ,locally advanced , early with abn anatomy
• EBRT-50Gy ----Template 5.5 - 6 Gy X 6 #
• 5YDFS - I-81%, II-47% III-39%, IV-0%
• LC rate- I-100% (12/12), II- 93% (25/27) III- 95% (18/19) IV- 75% (3/4)
• Grade 3-4 late complications -6.5 %

138.  Image guided insertion resulted in lesser risk of
inadvertent insertion into surrounding organs and
accurate placement of catheters
 In face of inadvertent insertion into a normal organ,
need not remove it, just do not load the needle
 Optimization by PDR or HDR improves target
coverage and OAR avoidance
 Mikami et al reported displacement of 1-2mm cranio-
caudal, replanning for >3mm displacemnt (daily CT
scans)

139.  Damatao et al reported <1cm displacement occurred
over the course of treatment
 Shukla et al reported these shifts for alternate fraction
CT imaging
 Cranial – 2.5mm
 Caudal – 17.4mm
 Anterior- 1.7mm
 Posterior – 2.1mm
 Right – 1.7 mm
 Left - 0.6mm

141.  Essential part of treatment (along with EBRT)
of carcinoma cervix stage IB2-IV A
 Maybe used alone for stage IA-IB1

142.  Staging evaluation before starting EBRT and before
commencing brachytherapy
 Imaging – CT scan +/- MRI
 Whole treatment (EBRT + brachy) within 8 weeks.
 Delay decreases LC and survival 1% per day
 Patients at risk of DVT should receive heparin +/-
compression stockings or calf compression devices

143.  Trimethoprim-sulphamethoxazole should be used for
coverage
 Fiducial seeds to mark cervical os and extent of disease,
possible
 Smitt sleeve may be used
 Rectal separator reduced the rectal dose substantially.
Acc to Lee et al, it applied only when target received
>70% of prescribed dose

144.  Van Dyk et al and Mahantshetty et al compared US
and MRI guided target and OAR delineation and
found them comparable
 A study showed that local recurrence when dose to
HRCTV of >87 Gy vs <87Gy was 4% vs 20%
 LC of >95% for HRCTV D90 >87Gy
(Dimopoulous JC
et al)

147.  STAGE IA
 LDR - 60Gy in one # or 75-80 Gy in 2#
 HDR – 5GY X 10#
 STAGE IB to IVA (35-45Gy following 45Gy EBRT)
 Small tumour (non bulky stage I/II ,< 4 cm diameter) –
80-85Gy to point A
Pelvic side wall dose-50-55 Gy
 Large tumour ( > 4 cm diameter or stage IIIB)
good response, point A – 85-90Gy
poor response, point A - >90Gy
Pelvic side wall dose-55-60 Gy

148. 172
• ABS recommends that OAR dose should be <80% of
prescription dose
•Keep the bladder dose below the LDR equivalent of 80 Gy
•Keep the rectal dose below the LDR equivalent of 75 Gy
(use LQ model with late tissue effect parameters-a/b -3)

149.  2 sessions
 First within 4-6
weeks of starting
EBRT
 Second 1-2 weeks
after 1st application
(to allow tumour
volume reduction)
PDR
•Same dose in pulses
•No established
guidelines about
dose per pulse and
pulse intervals
SCHEDULING

150. HDR dose LDR equivalent
6 Gy X 4 32 Gy
6Gy X 5 40Gy

151.  Optimal time-dose-fractionation scheme for HDR
brachytherapy of cervix is yet to be established
 LDR to HDR reduction factor (Orton et al)
 0.54-0.6 for 3-5 #
 0.75 for 6-8 #
 EQD2 (equivalent dose in 2Gy) obtained by
 ABS worksheet
 Isoeffect tables by Liu et al (Concluded that 2-4 # LDR is equivalent to 4-7 # of
HDR)
 Viswanathan et al found significant variations
internationally

152.  Complete/partial response with tumour <4cm - EQD2
>= 80Gy
 Non responders/residual tumour >4cm – EQD2 85-
90Gy

154.  Different schedules
 Deliver max EBRT to reduce tumour volume and
treat nodes 5days/wk  brachy
 Starting 2nd week, weekly #. No EBRT or chemo on
brachy day. Boost to nodes on non brachy day
 EBRT  5# given twice/week

157. BRACHY ALONE
 LDR dose equivalent of 60Gy
 HDR –
 PORTEC 2 – 7Gy X 3
 MD Anderson – 6Gy X 5
 Dana Farber/Bringham – 4Gy X 6

158. BRACHY AS A BOOST TO EBRT
 No disease
 LDR equivalent of 70Gy
 HDR
 RTOG 0921 – 6Gy X 3
 RTOG 0418 – 6Gy X 2
 Margin positive/ recurrence
 70-80Gy LDR equivalent

160. Treated with interstitial +/- EBRT
 PREVIOUSLY IRRADIATED - 40-45Gy by interstitial
alone/EBRT boost alone
 PREVIOUSLY SURGERY ALONE – EBRT 45-50Gy 
20-35Gy interstitial for total dose of 80Gy

161. 185
• TOLERANCE DOSES
 Cervix & uterus – 200 -300 Gy
 Vaginal mucosa – 160 -200 Gy
 Recto sigmoid & large bowel – 50 -60 Gy
 Small bowel – 45 -50Gy
 Urinary bladder – 55 -60Gy

162.  Retrospective. 7662 intracavitary procedures in 4043 patients for
FIGO I-III cervical CA (Jhingran A et al)
 Complications
 2.8% uterine perforation rate
 14% have fever >101 C during at least 1 admission
 0.1% fatal thromboembolism rate
Perforation did not affect DSS in stage I, II, but did lead to worse
prognosis in stage III.
Vaginal lacerations
– mild – no intervention
- Large – bleeding may require postponing session and control of
bleeding by pressure or suturing of mucosa

163.  Eifel PJ et al.
 Retrospective. 1784 pts, FIGO stage IB.
 Grade 3 or higher complications occurred in 7.7% at
3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year,
so at 20 yrs, 14.4% risk.
 Risk of rectal complications was the greatest, more
than urinary complications.

164.  Age did not affect the usefulness of
brachytherapy
 Always recommended whenever possible even
in elderly

165.  EBRT reports significantly inferior results than
brachytherapy
 60Gy volume is much larger and high central
tumour dose is much less in EBRT than in
brachytherapy
 Recommended only for
 Medical reasons
 Unusual anatomic configurations of the pelvis or
tumour

166. 190