Transition from 2D to 3D Image Guided Brachytherapy for Cervical Carcinomas in a Developing Country: Challenges and Early Results

Abstract

We review our experience with the introduction of 3D Image Guided Brachytherapy (IGBT) for cervical cancer at our institution, along with early results of the treated patients. It is an attempt to present potential challenges and solutions applicable for radiation oncology departments in developed and developing nations alike. We describe the 4-month multi-disciplinary planning phase to initiate an IGBT program for cervical cancer. We describe the specific challenges that were encountered prior to treating our first patient, and we also report on the outcome of the treated patients between November 2015 and December 2017. We describe the solutions that were realized and executed to solve the clinical and physics challenges that we faced to establish IGBT program within the context of our available institutional resources. In the planning phase we established a team with defined job description for each member. We emphasize detailed coordination of care, planning, and communication to make the workflow feasible, and ensure proper education of the team members and collaborators from other departments about every aspect of IGBT. We present the imaging and radiation physics solutions to ensure a safe delivery of IGBT before having the first patient on table. For this purpose, a 3D brachytherapy plan with just the applicator was created, delivered and analyzed using radiographic films. CT based planning was used for all the fractions. Due to limited resources, one MRI was obtained for target volume definition with the applicator in situ for the first fraction, and fused with subsequent CTs for the remaining fractions. Volume definition and brachytherapy planning were in accordance with GEC-ESTRO guidelines for 3D IGBT. The strategies that were developed to overcome the challenges and the experience that was built over the time represented a learning curve for all the members, thus resulting in a decrease of the total time from about 7 hours to 4 hours for each fraction. Nine patients were treated so far with a median follow up time of 11 months (range 6 – 17). The median external beam radiotherapy dose was 50.4Gy with concurrent Cisplatin, and the brachytherapy dose was 28Gy/4Fx. 7 patients achieved complete remission in the primary, but one of them died of liver metastases 7 months after treatment completion. Of the remaining two, one died of progressive local and distant disease soon after treatment completion, and one is alive with evidence of disease in the pelvis. None of these 9 patients developed more than grade 2 GI or GU toxicities This review represents a detailed report on establishing a safe and efficient 3D IGBT service, and it addresses important lessons learned from a successful establishment of a sophisticated radio-therapeutic modality in developing countries.