28 April 2019

28 April 2019
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  Uterus & Cervix combined  100 Gy
 Upper vagina  238 Gy
 Lower Vagina  98 Gy

 Rectum  60 Gy
 U Bladder  65 Gy
 Intestine  45 Gy Emami B,IJROBP’91l;
Hintz JL,IJROBP’80;
Hall EJ,5th edn;
Grigsby PW,RadiotherOncol’03]
28 April 2019
  Brachytherapy must be included as a
component of the definitive radiation for
cervical carcinoma.

[ IJROBP’00(48):201-11]

28 April 2019
  Conformity 
 Highly localised to tumor
 Sharp dose fall off

 Hypoxic tumor cells 

 High dose at center

 Reoxigenation 
 LDR

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 I

 EBRT II  Brachy

III

Ratio of EBRT dose to Brachy dose

depends on volume & stage of the disease

28 April 2019
 GOAL
Total treatment duration to be less than 8 wks
Lanciano RM,IJROBP’93,25;391-97

Perez CA,IJROBP’95,25;391-97
INTENT
Adequate intracavitary insertion so that 

 Geometry of insertion must prevent underdosage

 Sufficient dose must be delivered to paracervical areas
 Vaginal mucosal, bladder, rectal tolerance doses must be
respected

28 April 2019
Tumor response should be evaluated with periodic
pelvic examination to determine best time to
deliver brachytherapy

Interdigitate the implants during EBRT

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  Pre-loaded vs. After-loading
 Manual vs. Remote
 HDR vs. LDR

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 Conscious sedation
 Largest ovoid dia & longest tandem
 Asymm. or absent fornix- Ring applicator
 Cx markers
 Packing
 Treatment planning/Dosimetry
 IBU

[ABS Recommendations for HDR Brachytherapy

in cancer cervix, IJROBP’00(48):201-11]
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  Fletcher Suit

 Cylinder

 Ring Applicator

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  Rotterdam Applicator

 Interstitial Ring Appl

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Isotope Half life

Radium 226 1626 yrs

Cesium 137 30 yrs

Iridium 192 73.8 days

Cobalt 60 5.26 yrs

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  First to use applicators & loadings to satisfy
specific dosimetric constraints

 First to use Pt A rather than mg-hr to specify

treatment

 .53 Gy/hr to Pt A, 80 Gy in 144 hrs

28 April 2019
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“The radiation necrosis is not the result of direct
effects of radiation on bladder & rectum, but high
dose effects on the area in medial edge of broad
ligament where uterine vessels cross ureter.”

[Meredith WJ, Radiation dosage: Manchester System,1967]

Dose rate at this point is not too sensitive to small

variation in applicator position
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 Classical Pt A
 Difficult to localise surface of ovoids in
radiograph

Revised Pt A
 2cm up from lower end of last I U source &
2cm lateral in plane of uterus

28 April 2019
 Wide Variation in Rev. Pt A dose wrt ovoids:

28 April 2019
 Dependence on size of cervix:

28 April 2019
 Ra being replaced by Cs137, Ir192
 Old systems unsuitable for new sets of sources
available
 SI units, now being widely used
 Use of computers for calculation & dose distribution

28 April 2019
 An absorbed dose level of 60 Gy is accepted as the
appropriate reference level for conventional LDR therapy.

 When 2 or more IC applications are performed, the

absorbed dose to consider is that resulting from all
applications.

28 April 2019
  When ICRT is combined with EBRT, the isodose level
to be considered is the difference between 60 Gy & the
dose delivered at same location by EBRT.

 For ICRT at MDR/HDR, the rad onc has to indicate the

dose level which he/she believes to be equivalent to 60
Gy delivered at LDR.

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 No guidance for dose prescription

 How to correlate reference volume dimensions

with clinical outcome ?

 No explanation for selecting 60 Gy as ref isodose

level

 Whether absorbed dose at reference points

accurately indicates the absorbed dose in volume
of interest?

28 April 2019
 Dose Specification- Point H

 Nominal Bladder Point-

 Nominal Rectal Point-

Std ICRU Defenition

 Dose to Nominal Bladder & Rectal Pts <80% of Pt H

 Regional Lymph Nodes-

Pelvic Wall Pts
Not to use Pt B
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  Join the mid dwell position of two ovoids

 Find the point where this line intersects the

tandem

 Follow the tandem 2 cm superiorly

 2 cm perpendicular to the tandem

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  Advantages
 Less variability with tumor shrinkage
 Not popular

28 April 2019
  > 2005
 GEC ESTRO
 ABS GOG
 Consensus report adopted GEC ESTRO
 MRI based
 GTV, CTV
 To report in conjunction with pt. A dose

28 April 2019
 Contouring of volume of cervix, bladder, rectum

 Dose calculations in 3D volume

 DVH of cervix, bladder, rectum

 Max bladder, rectum dose & min cervix dose

28 April 2019
Volumes Description

GTV- D GTV at diagnosis

GTV-B1, B2, B3 GTV at every application

HR CTV – B1, B2, B3 High risk CTV at every application,

includes paracervical region

IR CTV – B1, B2, B3 HR CTV + 5-15 mm margin

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 Max dose to bladder, rectum grossly underestimated
by ICRU ref. pts.

 Min dose to cervix overestimated by point A

[Ling etal,Keppe etal,Schoeppel etal]

 Still in Infancy

28 April 2019
 LDR Brachytherapy
(Traditional Std of Care)

HDR Brachytherapy

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 Long History of Use
 Ability to predict rate of late complications
 Improved chances of catching tumor in
radiosensitive cell cycle phase
 Favorable dose rate effect on normal tissue
repair
 Long isotope T1/2

28 April 2019
  No long term bed confinement
 No indwelling catheter
 Avoid severe anesthesia (possibly)
 Maintain position of sources during treatment.
 No specialized nursing
 High output of pts/machine
 Short treatment time
 Minimum radiation protection problem
 Dose Distribution : Optimization
28 April 2019
 Author Stage LDR HDR
Charoonsantikul II B 88.3 80.6
(IJROBP ‘04) IIIB 92.8 93.7
Koito etal II 100 89
(Cancer ‘02) III 70 69
I 88-100 87-100
Patel etal
II 78-82 73-82
(IJROBP ‘93)
III 76 71
Shigematsu II B + III 77 90
etal (’83)

28 April 2019
 Author Stage LDR HDR
Charoonsantikul II B 73.8 64.5
(IJROBP ‘04) IIIB 62.9 70.8
I 73 78
Patel etal
II 62 64
(IJROBP ‘93)
III 50 43
Shigematsu etal II B + III 55 55
I 89 66
Teshima et al
II 73 61 (p=0.0002)
(cancer ’93)
III 45 47

28 April 2019
Author Gr I Gr II Gr III Gr IV
LDR HDR LDR HDR LDR HDR LDR LDR
Charoonsantikul
19 10 15 7 1 4 0 1
(IJROBP ’04)
Patel et al 33 11 10 3 1 1 5 0 (p>0.05)

28 April 2019
Author Gr I Gr II Gr III Gr IV
LDR HDR LDR HDR LDR HDR LDR LDR
Charoonsantikul
11 7 12 9 2 1 1 0
(IJROBP ’04)
Patel et al 9 8 0 1 0 0 0 0

28 April 2019
 Flange
•Placed at varying lengths
Central Tandem
•Diiferent Angulations

Ovoids
•Different sizes

28 April 2019
  Patient preparation
 Enema, Shaving & Surgical part preparation
 Thorough pelvic examination

 Conscious sedation / Short anesthesia

 Propofol
 Muscle relaxant

28 April 2019
  Sounding / dilating the os
 Creates passage for tandem
 Measures UCL (tandem length)

 Insertion of Smith’s Sleeve

 Easier repeat application
 Foreign body

 Insertion of Tandem
 Flange placement
 Angulation: 0, 15, 30
28 April 2019
  Ovoids insertion
 Largest that the vagina can accommodate
 Splay according to tumor size
 Tandem intersects the ovoids

 Packing of vagina
 Posteriorly and anteriorly
 Spacing of bladder and rectum (Bladder < Rectum)
 Holds application in position

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  Dose point optimization
 Volume optimization

Dwell Time
Dwell Position

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  Minor OT
 Radioluscent Couch
 Multiaxial C-Arm
 Filmless Imaging
 Online TPS
 Integrated Treatment
Delivery

 No more popular

28 April 2019
  For relapsed/residual
 Central/parametrial
 HDR
 Individualised
28 April 2019
  Syed Neblett Template
 Martinez Universal Pelvic Interstitial Template
(MUPIT)

28 April 2019
  Image based
 Computerised
 DVH

28 April 2019
Skilled use of intracavitary brachytherapy is the
most crucial to a successful outcome in cancer
Cervix

Implementation of HDR brachythearpy should

follow careful planning of treatment regimens and
dose distribution.

28 April 2019
 Thanks

28 April 2019