To report outcomes of combined intracavitary/interstitial (IC/IS) image-guided brachytherapy (IGBT) in locally advanced cervical cancer, and to compare its dosimetric parameters with intracavitary-only (IC) brachytherapy in a first-in-country experience. Between January 2021 and September 2022, a total of 160 insertions were done in 40 patients with FIGO IB3-IVA cervical cancer undergoing IGBT using a hybrid (Utrecht) applicator. Corresponding treatment plans for IC brachytherapy were generated during treatment, and optimized. A preplanned comparison of dosimetric parameters, defined in GEC-ESTRO was conducted. The clinical use of a hybrid IC/IS applicator was feasible in all insertions. An average of 14 needles were inserted in each patient over four fractions. Mean HR-CTV D90 and D98 was 86 (SD 1.9) Gy and 75.7 (SD 2.3) Gy using hybrid applicator, and 80 (SD 5.4) Gy and 69.8 (SD 5.2) Gy using IC applicator, with a mean dose gain of 6.0 (SD 5.0) Gy and 5.9 (SD 4.7) Gy (p <0.001), respectively. Likewise, mean D2cc for bladder and sigmoid were significantly lower in the hybrid technique. Mean contribution of brachytherapy to total HR-CTV D90 (in absolute EQD2 Gy) was 41.7 Gy using IC/IS applicator while 35.7 Gy for IC-only applicator (p = 0.027). Clinical response at 12 weeks showed an overall response rate (ORR) and complete response (CR) rates of 92.5% and 77.5%, respectively. IGBT using a hybrid IC/IS applicator showed excellent tolerability and yielded favorable results, resulting in significant dosimetric improvement in terms of primary target dose, and sparing OARs.

An electromagnetic tracking device (EMT) has been integrated in an HDR 3D ultrasound guidance system for prostate HDR. The aim of this study was to compare the efficiency of HDR workflows with and without EM tracking. A total of 58 patients with a 15 Gy HDR prostate boost were randomized in two arms and two operation room (OR) procedures using: (1) the EMT investigational device, and (2) the Oncentra prostate system (OCP). OR times were compared for both techniques. The overall procedure median time was about 20% shorter for EMT (63 min) compared to OCP (79 min). The US acquisition and contouring was longer for OCP compared to EMT (23 min vs. 16 min). The catheter reconstruction's median times were 23 min and 13 min for OCP and EMT respectively. For the automatic reconstruction with EMT, 62% of cases required no or few manual corrections. Using the EM technology in an OR environment was challenging. In some cases, interferences or the stiffness of the stylet introduced errors in the reconstruction of catheters. The last step was the dosimetry with median times of 11 min (OCP) and 15.5 min (EMT). Finally, it was observed that there was no learning curve associated with the introduction of this new technology. The EMT device offers an efficient solution for automatic catheter reconstruction for HDR prostate while reducing the possibility of mis-reconstructed catheters caused by issues of visualization in the US images. Because of that, the overall OR times was shorter when using the EMT system.

We sought to assess the impact of bladder neck dose (BND) on patient reported urinary toxicity, and feasibility of relative urethral sparing technique in prostate brachytherapy (PB). We retrospectively identified bladder neck as a point dose on post-implant CT scans in patients treated with 131Cs PB. Urinary symptoms were assessed through EPIC questionnaires. Patient cohorts were identified based on mean BND as a percentage of prescription dose with toxicity assessment at each time point. In our cohort of 542 patients, BND was associated with clinically significant acute urinary symptoms and chronic symptoms, as patients receiving >70% of the prescription dose had significantly worse overall EPIC scores than patients receiving ≤70% of prescription dose. There was no difference in bDFS between patients receiving BND ≤70% (96% bDFS) and >70% (94% bDFS) at a median follow up of 57 months. BND has a significant impact on both acute and chronic urinary symptoms, with reduced symptoms reported with BND <70% of prescription dose. With a median follow up of 4.7 years, excellent bDFS has thus far been achieved with relative urethral and bladder neck sparing. Utilizing this constraint should improve urinary symptoms without impacting disease control.

To determine cardiac dose received by patients treated with high dose rate interstitial brachytherapy. Patients with early-stage, node negative breast cancer can be treated using multi-catheter interstitial brachytherapy accelerated partial breast irradiation (MIB-APBI), with the benefit of reduced treatment volumes and favorable toxicity. We conducted a retrospective review of left-sided breast cancer patients treated using MIB-APBI at our institution since 2014. The mean heart dose (MHD) was calculated using the Oncentra 3.2 planning system. The minimum distance between the planning target volume (PTVeval) and heart contour was measured manually. 81 patients were included. The upper outer quadrant was the most common site. The MHD was 97.8 cGy (EQD2a/b=2) (range 22-229 cGy). MHD significantly correlated with the closest distance between PTVeval and heart contour (correlation coefficient -0.823, p <0.001); size of PTVeval (cc) and quadrant location did not. Appropriately selected women with early-stage, low-risk, left-sided breast cancer who received MIB-APBI had acceptable MHD. There was a strong correlation between the distance of PTVeval and MHD. Quadrant breast tumor is in cannot be used as a surrogate for MHD in brachytherapy. Our findings contribute to the growing evidence of the utility and safety of MIB-APBI.

The current protocol for use of the image-guided adaptive brachytherapy (IGABT) procedure entails transport of a patient between the treatment room and the 3-D tomographic imaging room after implantation of the applicators in the body, which movement can cause position displacement of the applicator. Moreover, it is not possible to track 3-D radioactive source movement inside the body, even though there can be significant inter- and intra-fractional patient-setup changes. In this paper, therefore, we propose an online single-photon emission computed tomography (SPECT) imaging technique with a combined C-arm fluoroscopy X-ray system and attachable parallel-hole collimator for internal radioactive source tracking of every source position in the applicator. In the present study, using Geant4 Monte Carlo (MC) simulation, the feasibility of high-energy gamma detection with a flat-panel detector for X-ray imaging was assessed. Further, a parallel-hole collimator geometry was designed based on an evaluation of projection image quality for a 192Ir point source, and 3-D limited-angle SPECT-image-based source-tracking performances were evaluated for various source intensities and positions. The detector module attached to the collimator could discriminate the 192Ir point source with about 3.4% detection efficiency when including the total counts in the entire deposited energy region. As the result of collimator optimization, hole size, thickness, and length were determined to be 0.5, 0.2, and 45 mm, respectively. Accordingly, the source intensities and positions also were successfully tracked with the 3-D SPECT imaging system when the C-arm was rotated within 110° in 2 seconds. We expect that this system can be effectively implemented for online IGABT and in vivo patient dose verification.

Uncertainties in postimplant quality assessment (QA) for low-dose-rate prostate brachytherapy (LDRPBT) are introduced at two steps: seed localization and contouring. We quantified how interobserver variability (IoV) introduced in both steps impacts dose-volume-histogram (DVH) parameters for MRI-based LDRPBT, and compared it with automatically derived DVH parameters. Twenty-five patients received MRI-based LDRPBT. Seven clinical observers contoured the prostate and four organs at risk, and 4 dosimetrists performed seed localization, on each MRI. Twenty-eight unique manual postimplant QAs were created for each patient from unique observer pairs. Reference QA and automatic QA were also performed for each patient. IoV of prostate, rectum, and external urinary sphincter (EUS) DVH parameters owing to seed localization and contouring was quantified with coefficients of variation. Automatically derived DVH parameters were compared with those of the reference plans. Coefficients of variation (CoVs) owing to contouring variability (CoVcontours) were significantly higher than those due to seed localization variability (CoVseeds) (median CoVcontours vs. median CoVseeds: prostate D90-15.12% vs. 0.65%, p < 0.001; prostate V100-5.36% vs. 0.37%, p < 0.001; rectum V100-79.23% vs. 8.69%, p < 0.001; EUS V200-107.74% vs. 21.18%, p < 0.001). CoVcontours were lower when the contouring observers were restricted to the 3 radiation oncologists, but were still markedly higher than CoVseeds. Median differences in prostate D90, prostate V100, rectum V100, and EUS V200 between automatically computed and reference dosimetry parameters were 3.16%, 1.63%, -0.00 mL, and -0.00 mL, respectively. Seed localization introduces substantially less variability in postimplant QA than does contouring for MRI-based LDRPBT. While automatic seed localization may potentially help improve workflow efficiency, it has limited potential for improving the consistency and quality of postimplant dosimetry.

The global cervical cancer burden is disproportionately high in low- and middle-income countries (LMICs), and outcomes can be governed by the accessibility of appropriate screening and treatment. High-dose-rate (HDR) brachytherapy plays a central role in cervical cancer treatment, improving local control and overall survival. The American Brachytherapy Society (ABS) and Indian Brachytherapy Society (IBS) collaborated to provide this succinct consensus statement guiding the establishment of brachytherapy programs for gynecological malignancies in resource-limited settings. ABS and IBS members with expertise in brachytherapy formulated this consensus statement based on their collective clinical experience in LMICs with varying levels of resources. The ABS and IBS strongly encourage the establishment of HDR brachytherapy programs for the treatment of gynecological malignancies. With the consideration of resource variability in LMICs, we present 15 minimum component requirements for the establishment of such programs. Guidance on these components, including discussion of what is considered to be essential and what is considered to be optimal, is provided. This ABS/IBS consensus statement can guide the successful and safe establishment of HDR brachytherapy programs for gynecological malignancies in LMICs with varying levels of resources.