Outcomes of Computed Tomography-Guided Image-Based Interstitial Brachytherapy for Cancer of the Cervix Using GEC-ESTRO Guidelines

Locally advanced cancer of the cervix is treated by concurrent chemoradiation followed by brachytherapy. Interstitial brachytherapy is used to treat large tumors with involvement of parametrium, post-hysterectomy, and narrow, conical vagina. The GYN GEC-ESTRO working group described target volume delineation and also 3D image-based planning using MRI and 3D dose-volume parameters for brachytherapy of carcinoma cervix. CT-based as compared to MR-based image-guided brachytherapy (IGBT) is much more feasible and practical because MR access is still difficult for most departments. This is a retrospective study done to assess the local control in cancer of the cervix, treated based on these guidelines and dose received by 2 cm³ of the rectum as defined by the GEC-ESTRO guidelines and its correlation with long-term toxicity. Sixty-three patients of cancer of the cervix received 45 Gy/25 fractions of external beam radiotherapy with concurrent weekly cisplatin followed by interstitial brachytherapy. A central tandem was inserted into the uterine cavity. The needles were inserted based on the concept of gross tumor volume (GTV), high-risk clinical target volume (HRCTV), and intermediate-risk CTV (IR CTV) as defined by the GYN GEC-ESTRO guidelines. All patients underwent CT-based planning. A dose of 6.5 Gy × 4 fractions was delivered in two sessions such that the HRCTV received a total dose of 26 Gy. Dose optimization was done to prevent 2 cm³ of rectum from receiving > 400 cGy (60% of prescribed dose) per fraction and 2 cm³ of bladder from receiving 500 cGy per fraction. At a median follow-up of 41.5 months (range 6–106 months), 74.6% (47/63) of the patients were alive, with no local, loco-regional, or distant metastasis. Loco-regional control rate was 88% (56/63). Eight percent (5/63) of the patients developed grade I proctitis which was managed conservatively. There was no grades II, III, or IV proctitis. There was no bladder or sigmoid toxicity. GEC-ESTRO guidelines can be modified for CT-based planning also with very minimal late toxicity without compromising local control.