American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: High-dose-rate brachytherapy

doi:10.1016/j.brachy.2011.07.002

Brachytherapy

Volume 11, Issue 1, January–February 2012, Pages 47-52

https://doi.org/10.1016/j.brachy.2011.07.002 Get rights and content

Abstract

Purpose

This report presents an update to the American Brachytherapy Society (ABS) high-dose-rate (HDR) brachytherapy guidelines for locally advanced cervical cancer.

Methods

Members of the ABS with expertise in cervical cancer formulated updated guidelines for HDR brachytherapy using tandem and ring, ovoids, cylinder, or interstitial applicators for locally advanced cervical cancer. These guidelines were written based on medical evidence in the literature and input of clinical experts in gynecologic brachytherapy.

Results

The ABS affirms the essential curative role of tandem-based brachytherapy in the management of locally advanced cervical cancer. Proper applicator selection, insertion, and imaging are fundamental aspects of the procedure. Three-dimensional imaging with magnetic resonance or computed tomography or radiographic imaging may be used for treatment planning. Dosimetry must be performed after each insertion before treatment delivery. Applicator placement, dose specification, and dose fractionation must be documented, quality assurance measures must be performed, and followup information must be obtained. A variety of dose/fractionation schedules and methods for integrating brachytherapy with external-beam radiation exist. The recommended tumor dose in 2-Gray (Gy) per fraction radiobiologic equivalence (normalized therapy dose) is 80–90 Gy, depending on tumor size at the time of brachytherapy. Dose limits for normal tissues are discussed.

Conclusion

These guidelines update those of 2000 and provide a comprehensive description of HDR cervical cancer brachytherapy in 2011.

Introduction

Brachytherapy is an important component in the curative management of carcinoma of the cervix, and significantly improves survival [1], [2]. High-dose-rate (HDR) and low-dose-rate (LDR) brachytherapy seem to be relatively equivalent treatments in terms of survival outcomes based on existing retrospective and prospective studies [3], [4], [5], [6], [7], [8], [9], [10], [11]. Advantages of HDR brachytherapy include opportunities for outpatient treatment, avoidance of exposure to staff from the radiation source, consistent and reproducible applicator positioning, and dose optimization attained with a variable dwell-time stepping source (3). Virtually all modern clinical trials for cervical cancer allow either HDR or LDR brachytherapy.

The use of HDR brachytherapy for cervical cancer has substantially increased over the past 10 years in the United States and internationally. The most recent Quality Research in Radiation Oncology (formerly Patterns of Care) survey from 2007 to 2009 shows that 62% of surveyed facilities use HDR compared with 13% in the 1996–1999 survey (12). A total of 85% of respondents to surveys in the United States (13) and internationally (14) use HDR brachytherapy. Nevertheless, with HDR brachytherapy, there is a significant variation of the total tumor dose, the dose delivered per fraction and the proportion of tumor dose delivered with external-beam radiotherapy (EBRT) vs. brachytherapy (14).

Given the potential for short- and long-term injury to normal tissues from large HDR doses per treatment, the radiation oncologist must carefully assess and minimize normal-tissue doses administered per fraction, and must calculate the summative total dose of EBRT and brachytherapy. To assess the normal-tissue doses per fraction accurately, computer-assisted tomography or magnetic resonance imaging with the brachytherapy apparatus in place is recommended.

This article will present current concepts in HDR brachytherapy for cervical cancer including three-dimensional (3D) image-based dose-specification methods and review standard practice recommendations.

Section snippets

Methods

Gynecologic radiation oncology experts in the United States were surveyed regarding their willingness to serve as authors for these guidelines. Those responding affirmatively reviewed and updated the 2000 guidelines of the American Brachytherapy Society (ABS) (15). These authors evaluated the relevant literature, identified established and controversial topics via conference calls, and supplemented this information with their clinical experience to formulate the current guidelines. A consensus

External-beam radiation therapy issues related to HDR brachytherapy

Treatment with EBRT and brachytherapy should be completed in less than 8 weeks, as better local tumor control and survival can be expected with relatively shorter treatment courses [16], [17]. The HDR brachytherapy may be interdigitated with EBRT to shorten the total treatment duration, with the latter typically given in 1.8-Gy fractions to 45 Gy. Many institutions administer as much EBRT as possible first to minimize the amount of residual disease, ensure that the lymph-node regions of the

Conclusions

This ABS report recommends that 3D imaging with ultrasound, computer-assisted tomography, or magnetic resonance imaging be performed when feasible to estimate the cervical tumor dimensions and ensure adequate coverage of the tumor. Normal-tissue dosimetry using 3D parameters results in a more accurate reflection of doses administered and may provide more reliable indicators of the risk of toxicity.

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Cited by (416)

Safe dose escalation and reduction of the fraction number of uterine cervical brachytherapy using a gel spacer in the rectovaginal and vesicouterine septum: A planning study
2024, Brachytherapy
To evaluate the possibility of dose escalation and reduction of fraction number in cervical brachytherapy using a gel spacer.
Twenty patients with uterine cervical cancer treated with image-guided adaptive brachytherapy (IGABT) were selected. Hyaluronic acid gel injection (HGI) was performed in the rectovaginal and vesicouterine septum for 10 patients. The other ten patients were not with HGI. Both groups were treated with IGABT involving tandem/ovoid or cylindrical applicators along with additional interstitial needles. Dose distributions approved by radiation oncologists were retrospectively analyzed, and a dose summation of 45 Gy/25 of external beam radiation therapy and IGABT was performed. Dose constraints for D_2cc of bladder, rectum, and sigmoid were 80, 70, and 70 Gy, respectively. Equivalent dose in 2-Gy fractions calculations used α/β = 10 Gy for high-risk clinical target volume (CTV_HR) D₉₀ and α/β = 3 Gy for organs at risks (OARs). As a planning study, dose distribution rescaling was conducted to deliver as much dose to CTV_HR D₉₀ as possible within the dose constraint limitation for OARs when IGABT was performed for four, three, and two fractions in both groups.
The median CTV_HR D₉₀ was >80 Gy in the non-HGI group and >85 Gy in the HGI group for virtual two and three fractions. Rectum D_2cc was significantly lower in the HGI group for three fractions (p < 0.01).
In the HGI group, adequate dose delivery to CTV_HR could be achieved with a reduced IGABT fraction number while meeting the dose constraints of OARs.
Effects of pain management using nonsteroidal anti-inflammatory drug suppositories during brachytherapy for cervical cancer: A single-center prospective observational study
2024, Brachytherapy
No standardized pain management protocol exists for intracavitary brachytherapy, and various methods of analgesia have been used in different countries and institutions. This study aimed to investigate the effects of pain management during intracavitary brachytherapy using nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen suppositories.
In this single-center, prospective, observational study, patients undergoing intracavitary brachytherapy for cervical cancer completed a questionnaire survey after each brachytherapy session, which comprised questions regarding pain intensity, satisfaction with analgesia, and desire for effective anesthesia.
Data analysis was performed using data from 100 brachytherapy sessions of 27 patients. The median numerical rating scale (NRS; 0–10) score for each intracavitary brachytherapy session was 3–4. The median satisfaction scale score for analgesia (5-point scale, 1–5) for each session was approximately 4. Eight patients (29.6%) answered that they desired anesthesia more effective than suppositories at any session of brachytherapy. A comparison of the high (NRS $\geq$ 4) and low (NRS $\leq$ 3) NRS groups during the first session revealed that the high NRS group tended to have higher NRS scores and lower satisfaction with analgesia during all sessions. A positive correlation was observed between tumor size and the NRS score during the first brachytherapy session.
The NRS score was approximately 3–4, and satisfaction with analgesia was approximately 4 out of 5 when NSAIDs or acetaminophen suppositories were used as analgesics during intracavitary brachytherapy for cervical cancer. Although the current pain management protocol is clinically acceptable, inadequate analgesia is indicated in approximately 30% of patients.
Design approach and benefits of the 3D-printed vaginal individualized applicator (VIA)
2024, Brachytherapy
Interstitial gynecologic brachytherapy necessitates precise needle placement, requiring time and expertise. We aimed to simplify interstitial procedures and facilitate optimal needle distribution with individualized vaginal templates to guide interstitial needles.
We developed the 3D-printed vaginal individualized applicator (VIA), a cylindrical template containing individualized internal channels that guide interstitial needles to cover the tumor extent. Eight patients underwent VIA only interstitial implants (VIA only), and five intact cervical cases were treated using tandem and customized VIA (VIA + T). Procedure length, number of needles utilized and dosimetric measures were evaluated.
VIA was successfully designed and used clinically for 24 procedures (8 VIA only, 16 VIA + T). Average procedure needle insertion time reduced from 80.9 min for traditional interstitial to 42.9 min for VIA only, approximately 47% shorter with a similar mean high risk CTV volume (28.3 cc VIA only vs. 32.4 cc) and excellent dosimetry with average CTV V100% (94.3% and 94.4%). VIA + T was particularly useful in patients with small vaginal canals and large tumor size. For the five VIA + T patients average tumor size was 68.0cc (range 26.6–143.5 cc). VIA + T procedures were approximately 20% shorter than hybrid procedures with other applicators with mean length of 20.1 min and an average of 6.8 needles (range 3–12).
Our novel 3D-printed VIA facilitates gynecologic interstitial brachytherapy by simplifying needle placement, reducing procedure time, and maintaining excellent dosimetry. VIA can be customized for various clinical scenarios, particularly beneficial for large tumors or small vaginal canals.
The impact of a positive COVID-19 test on timeliness of radiation in patients receiving brachytherapy
2024, Brachytherapy
Delays in initiating and completing brachytherapy may have adverse oncologic outcomes for patients with cervical, uterine, and prostate cancer. The impact of the COVID-19 pandemic on brachytherapy in the United States has not been well-characterized.
We aim to evaluate how a positive COVID-19 test affected timeliness of treatment for patients undergoing brachytherapy for cervical, uterine, and prostate cancer.
We queried the National Cancer Database to identify patients diagnosed with cervical, uterine, and prostate cancer in 2019 and 2020 who received brachytherapy in their treatment. Patients who tested positive for COVID-19 between cancer diagnosis and start of radiation were compared to those who did not test positive for COVID-19. Time in days from cancer diagnosis to initiation of radiation was compared using two-sample t-tests with p < 0.05 signifying significant differences.
We identified 38,341 patients with cervical (n = 6,925), uterine (n = 18,587), and prostate cancer (n = 12,829). Rates of COVID-19 positivity were cervical cancer (n = 135; 2%), uterine cancer (n = 236; 1.3%), and prostate cancer (n = 141; 1%). Of those, 35% of cervical, 49% of uterine, and 43% of prostate cancer patients tested positive between their cancer diagnosis and initiation of radiation. Median days to radiation was significantly longer in these patients: 78 versus 51 for cervical cancer (p < 0.01), 150 versus 104 for uterine cancer (p < 0.01), and 154 versus 124 for prostate cancer (p < 0.01).
For patients with cervical, uterine, and prostate cancer diagnosed between 2019–2020, testing positive for COVID-19 after their cancer diagnosis was associated with a delay to initiation of radiation by 4–7 weeks.
Patient Experiences of Brachytherapy for Locally Advanced Cervical Cancer: Hearing the Patient Voice Through Qualitative Interviews
2024, International Journal of Radiation Oncology Biology Physics
Brachytherapy for gynecological cancer is reported to cause pain, anxiety, and distress with no clear guidance for optimizing patient experiences. The aim of this study was to explore patient experiences of brachytherapy and views on improvement.
Semistructured interviews were undertaken with patients who had received brachytherapy for locally advanced cervical cancer. Two cohorts were recruited: cohort 1 had recently had brachytherapy, and cohort 2 was a year post brachytherapy. Four recruitment sites were selected, where brachytherapy is given in different ways, some with short day case procedures and others having 1 or 2 overnight stays with applicators in place. Consecutive patients were invited to interview. Participants were asked to retell their brachytherapy story, with views on their care and ideas for improvement. Interviews were audio recorded, transcribed, and data analyzed following Braun and Clarke's method for reflexive thematic analysis.
Thirty-five interviews were conducted (20 in cohort 1 and 15 in cohort 2). Participant's ages ranged from 28 to 87 years. The interview duration ranged from 22 to 78 minutes. Difficult and traumatic experiences were reported, including periods of severe pain and perceptions of poor care. However, some participants described positive experiences and what went well.
Three themes were developed: (1) how the patient got through it, (2) unpleasantness, discomfort, and the aftermath, and (3) emotional consequences and trauma. Some aspects of medium and long duration brachytherapy were found to be more problematic compared with short duration brachytherapy. Exploring experiences at 1-year post brachytherapy has provided insights into the long-lasting impact of brachytherapy experiences.
Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimens and durations, to minimize difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations.
Dosimetric comparison of stereotactic MR-guided radiation therapy (SMART) and HDR brachytherapy boost in cervical cancer
2024, Brachytherapy
The standard of care in locally advanced cervical cancer (LACC) is concomitant chemoradiotherapy followed by high-dose-rate brachytherapy (HDR-BT). Although previous studies compared HDR-BT with stereotactic body radiotherapy (SBRT), there is scarce data regarding the dosimetric outcomes of stereotactic MR-guided adaptive radiation therapy (SMART) boost in lieu of HDR-BT.
In this single-institutional in-silico comparative study, LACC patients who were definitively treated with external beam radiotherapy followed by HDR-BT were selected. Target volumes and organs at risk (OARs) were delineated in MRI and HDR-planning CT. An HDR-BT and a SMART boost plan were generated with a prescribed dose of 28 Gy in four fractions for all patients. The HDR-BT and SMART boost plans were compared in regard to target coverage as well OARs doses.
Mean EQD2 D90 to HR-CTV and IR-CTV for HDR-BT plans were 89.7 and 70.5 Gy, respectively. For SMART, the mean EQD2 D90 to HR-PTV, HR-CTV, and IR-CTV were 82.9, 95.4, and 70.2 Gy, respectively. The mean D_2cc EQD2 of bladder, rectum, and sigmoid colon for HDR-BT plans were 86.4, 70.7, and 65.7 Gy, respectively. The mean D_2cc EQD2 of bladder, rectum, and sigmoid colon for SMART plans were 81.4, 70.8, and 73.6 Gy, respectively. All dose constraints in terms of target coverage and OARs constraints were met for both HDR-BT and SMART plans.
This dosimetric study demonstrates that SMART can be applied in cases where HDR-BT is not available or ineligible with acceptable target coverage and OAR sparing. However, prospective clinical studies are needed to validate these results.

View all citing articles on Scopus

: In formulating guidelines, it should be noted that variations in approaches to gynecologic brachytherapy, as with most medical procedures, are commonplace and may readily fall within accepted and appropriate management of cervical cancer patients. The guidelines presented are a means to aid practitioners in managing patients, but are not to be viewed as rigid practice requirements that establish a legal standard of care.

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American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part II: High-dose-rate brachytherapy

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Methods

External-beam radiation therapy issues related to HDR brachytherapy

Conclusions

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol