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Only scarce data are available on the possibility to reduce rectal dose by controlling rectum filling before HDR (high dose rate) IGABT (image-guided adaptive brachytherapy) in LACC (locally advanced cervical carcinoma) patients. We compared dosimetric outcomes before and after the evacuation of gasses using a rectum emptying tube.Sixty CT (computed tomography) scans from 30 consecutive patients with cancer of the cervix undergoing HDR IGABT after EBRT were reviewed. Patients who underwent at least one gas evacuation were included in the analysis. The three-dimensional dosimetric data of the dosimetric plan performed before and after gas evacuation were compared. Primary endpoint was the difference between D2cc of the rectum before and after the procedure. Expected probability of grade 2-4 overall rectum morbidity was assessed using a probit model from the prospective multicenter EMBRACE study.Thirty five (58.3%) CT scans from 23 patients (76.7%) requiring gas evacuation were analysed. The mean rectum volume, before and after gas evacuation, was 123.1 cc (sd, ± 60.4) and 66.4 cc (sd, ± 34.8), respectively. For each patient, the volume of the rectum after gas evacuation was lower than before. No major complication occurred during and after the procedure. After gas evacuation, a significant reduction in rectal dose per fraction was observed, on average -4.3 Gy (-38.4%, p0.001) for D0.1cc and -1.9 Gy (-30.6%, p0.001) for D2cc. Estimated mean probability to develop a grade 2-4 rectum morbidity was significantly lower after gas evacuation, 6.9% (sd,± 1.94) versus 9.5% (sd,± 3.17), p0.001.Gas evacuation using a rectal emptying tube in selected LACC patients treated with HDR BT after chemoradiotherapy, allowed a substantial reduction in the dose to the rectum. Such procedure could be of particular interest when a dose escalation strategy is being considered.

Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment.Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical" anesthesia technique.A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred.With a 70% success rate (correct implant with mean pain and anxiety scores 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea.

Purpose Esophageal cancer is characterized by its propension to local evolution, which conditions prognosis and quality of life. Brachytherapy may be a therapeutic option for all stages of esophageal cancer. Methods and Materials This retrospective unicentric study included all consecutive patients treated for an esophageal high-dose-rate brachytherapy in our institution from 1992 to 2018. Results Ninety patients were included. They were treated in four distinct indications: exclusive (7 patients), boost after external beam radiotherapy (41), reirradiation (36), or palliative aim (6). Most frequently prescribed schemes were 3 × 5 Gy (boost) or 6 × 5 Gy (exclusive treatment and reirradiation) at applicator's surface or at 5 mm. At the end of follow-up, 50% of patients had presented with local recurrence. Seventeen percent of patients had a metastatic relapse. Median overall survival was 15 months in the whole cohort: 22 months in the boost setting, 25 months for exclusive brachytherapy, 15 months for reirradiation, and only 2 months for palliative treatment. Tumor length at brachytherapy, brachytherapy dose, and interfraction response were significantly associated to overall survival. 40% of patients presented with grade 2+ toxicity, mostly esophagitis, including three toxic deaths. Conclusions Although local control outcomes are still poor, one must remember that patients are unfit for any curative therapeutic option and that palliative chemotherapy offers mediocre results. The most promising setting probably is reirradiation because brachytherapy offers a remarkable dose gradient allowing best organ at risk sparing, with an encouraging rate of long survivors (19% at 2 years). Esophageal brachytherapy deserves to be further investigated because some patients, even unfit, may benefit from it, with acceptable toxicity.

Purpose To examine the feasibility of using diffusion-weighted images (DWIs) coregistered with T2-weighted (T2w) sequence in treatment planning system to improve target delineation for image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer patients. Methods and Materials We retrospectively examined the records of consecutive patients who were referred to our institution for pulse-dose-rate IGABT between May and December 2015 after concurrent chemoradiation. An MRI with T2w and DWI sequences with a maximum diffusion factor of 1000 s/mm2 on a 1.5 or 3.0-T MR scanner was performed after placement of the vaginal mold applicator. T2w defined gross tumor volume (GTVT2) and diffusion volume on DWI sequences (CTVDWI) were retrospectively delineated, if achievable, by radiologist and radiation oncologist. Concordances between CTVDWI and GTVT2, high-risk and intermediate-risk clinical target volumes (CTVHR and CTVIR) were evaluated. Results Forty-four patients were identified: 23 patients (52%) had a GTVT2 delineated, CTVDWI was delineated in 42 patients (95%). Intraobserver and interobserver conformity indexes were Conclusions These results suggest that DWI images as anatomical sequence without apparent diffusion coefficient mapping might have led to CTVHR modifications. Still, interobserver and intraobserver variations in delineation are substantial, and artifacts make it difficult to implement.

Purpose To evaluate the usefulness of reporting the point A dose in patients with locally advanced cervical cancer treated with image-guided adaptive brachytherapy (IGABT). Methods and Materials Dosimetric data from patients treated with a combination of chemoradiation and intracavitary IGABT were examined in light of their outcomes. Prescribing followed the Groupe Europeen de Curietherapie–European Society for Radiation Oncology recommendations. All doses were converted in 2-Gy equivalent. The relationships between the D90 high-risk clinical target volume (CTV HR ) and intermediate-risk clinical target volume (CTV IR ) and point A doses were studied. Dose-effect relationships based on the probit model and log-rank test were assessed. Results Two hundred twelve patients were included with a median followup of 53.0 months. A total of 28 local relapses were reported, resulting in a local control rate of 86.6% at 3 years. Mean D90 CTV HR , CTV IR , and point A doses were: 79.7 ± 10.4 Gy, 67.4 ± 5.8 Gy, and 66.4 ± 5.6 Gy, respectively. The mean D90 were significantly different and independent from the mean point A dose, even in bulky tumors at diagnosis or in large CTV HR lesions. Point A dose appeared correlated with TRAK, and finally with the D90 CTV HR through a complex formula including the CTV HR volume (R 2 = 0.55). Whereas significant relationships between the probability of achieving local control and the D90 CTV HR and CTV IR ( p = 0.08 and 0.025) were observed, no similar relationship was found with point A dose except a trend of an inverse relation. After sorting patients according to three dose levels, highest local control rates were observed in patients with D90 CTV HR ≥85 Gy, whereas those with point A doses ≥70 Gy had the worst outcomes. Conclusions In patients treated with IGABT, point A dose is not predictive of local control but a surrogate of the irradiated volume. Its relationships with the D90 CTV HR are indirect and complex rising the question of relevance of its reporting in routine.

Purpose There are only scarce data on the place of brachytherapy (BT) for treatment of vulvar carcinoma. Our institutional experience of interstitial BT for vulvar carcinoma patients is reported. Methods and Materials Clinical records of patients receiving low-dose-rate or pulsed-dose-rate BT as part of the primary treatment for primary/recurrent vulvar squamous cell carcinoma or as part of postoperative treatment between 2000 and 2015 were included. Patients, tumors, and treatment characteristics as well as clinical outcome were examined. Results A total of 26 patients treated with BT were identified. BT was delivered as part of primary intent treatment for locally advanced/recurrent cancer in 11 patients and as part of postoperative treatment in 15 patients. Median age at time of BT was 63 years (range, 41–88 years). Pulsed-dose-rate and low-dose-rate were used in 15 patients and 11 patients, respectively. BT was performed as a boost to the tumor bed following external beam radiotherapy ( n = 13) or as the sole irradiation modality ( n = 13). Total median dose at the level of primary tumor was 60 GyEQD2 (range, 55–60 GyEQD2). With mean followup of 41 months (range, 5 months–11.3 years), 11 patients experienced tumor relapse, and in two of them, site of relapse was only local. Three-year estimated disease-free survival and overall survival rates were 57% (95% confidence interval: 45–69%) and 81% (95% confidence interval: 72–90%), respectively. All toxicities were Grade 2 or less. Conclusions Interstitial BT used as part of the primary or postoperative treatment of vulvar carcinoma is feasible with a satisfactory toxicity profile. Prognosis remains, however, dismal, with a high frequency of failures in patients with locally advanced tumors.

Purpose With the increasing use of simultaneous integrated boost in the treatment of cervical cancer, there is a need to anticipate the brachytherapy (BT) contribution at the level of the pathologic pelvic lymph nodes. This study aimed to report the dose delivered at their level during BT. Methods and Materials Patients with pelvic nodal involvement and treated with a combination of chemoradiation followed by image-guided adaptive pulsed-dose-rate BT were selected. On per BT three-dimensional images, pelvic lymphadenopathies were delineated, without planning aim. For the purposes of the study, D100, D98, D90, and D50 were reviewed and converted in 2-Gy equivalent doses, using the linear quadratic model with an α/β of 10 Gy. Results Ninety-one patients were identified, allowing evaluation at the level of 226 lymphadenopathies. The majority of them were external iliac (48%), followed by common iliac (25%), and internal iliac (16%) regions. The 2-Gy equivalent doses D98 were 4.4 ± 1.9 Gy, 5.4 ± 3.1 Gy, and 4.3 ± 2.1 Gy for the obturator, internal iliac, and external iliac, respectively, and 2.8 ± 2.5 Gy for the common iliac. The contribution to the common iliac nodes was significantly lower than the one of external and internal iliac (p Conclusions BT significantly contributes to the treatment of pelvic nodes at the level of approximately 5 Gy in the internal, external, and obturator areas and 2.5 Gy in the common iliac, allowing the anticipation of nodal boost with the simultaneous integrated boost technique. However, important individual variations have been observed, and evaluation of the genuine BT contribution should be recommended.

PURPOSE Correct tandem implantation for cervix cancer intracavitary brachytherapy may be challenging. We investigated whether suboptimal implantation can be related to patient and disease characteristics and may result in subsequent underutilization of brachytherapy in cervical cancer. METHODS AND MATERIALS Consecutive cervix cancer patients referred for intracavitary brachytherapy after external beam radiation therapy performed in several general hospitals from 2013 to 2017 were included. Results In 172 patients having 301 procedures, 95 implantations were suboptimal (15% inadequate tandem insertions, 10% subserosal insertion, and 6% uterine perforation on postimplant CT scan). Risk factors were age, myometrium invasion, and uterine retroversion. Median followup was 21 months. Three-year local control and survival rates were 72% and 85%, respectively. Forty-seven patients (27%) failed to receive brachytherapy. Failure to perform brachytherapy was associated with poorer local control (OR = 0.34 [0.17–0.67], p = 0.001). By contrast, suboptimal implantation did not increase local failure or toxicity rates in patients undergoing brachytherapy. No peritoneal carcinomatosis occurred after uterine perforation in our cohort. CONCLUSIONS Suboptimal implantation was frequent. In the absence of image guidance during implantation, conversion to other treatment modalities (including external beam radiation therapy) due to insertion difficulties resulted in worse local control. With optimization, however, suboptimal brachytherapy implantation did not result in suboptimal dose coverage or poorer local control. Failure to perform a brachytherapy boost correlates with increased local failure risk in patients with cervix cancer, whereas tandem malposition does not. Real-time intraoperative ultrasound guidance may be useful to reduce uterine perforation rates and thus increase brachytherapy use.

Image-guided adaptive brachytherapy is a high precision technique that allows dose escalation and adaptation to tumor response. Two monocentric studies reported continuous dose-volume response relationships, however, burdened by large confidence intervals. The aim was to refine these estimations by performing a meta-regression analysis based on published series.Eligibility was limited to series reporting dosimetric parameters according to the Groupe Européen de Curiethérapie-European SocieTy for Radiation Oncology recommendations. The local control rates reported at 2-3 years were confronted to the mean D90 clinical target volume (CTV) in 2-Gy equivalent using the probit model. The impact of each series on the relationships was pondered according to the number of patients reported.An exhaustive literature search retrieved 13 series reporting on 1299 patients. D90 high-risk CTV ranged from 70.9 to 93.1 Gy. The probit model showed a significant correlation between the D90 and the probability of achieving local control (p0.0001). The D90 associated to a 90% probability of achieving local control was 81.4 Gy (78.3-83.8 Gy). The planning aim of 90 Gy corresponded to a 95.0% probability (92.8-96.3%). For the intermediate-risk CTV, less data were available, with 873 patients from eight institutions. Reported mean D90 intermediate-risk CTV ranged from 61.7 to 69.1 Gy. A significant dose-volume effect was observed (p = 0.009). The D90 of 60 Gy was associated to a 79.4% (60.2-86.0%) local control probability.Based on published data from a high number of patients, significant dose-volume effect relationships were confirmed and refined between the D90 of both CTV and the probability of achieving local control. Further studies based on individual data are required to develop nomograms including nondosimetric prognostic criteria.

To establish dose-volume effect correlations for late small bowel (SB) toxicities in patients treated for locally advanced cervical cancer with concomitant chemoradiation followed by pulsed-dose rate MRI-guided adaptive brachytherapy.Patients treated with curative intent and followed prospectively were included. The SB loops closed to CTV were delineated, but no specific dose constraint was applied. The dosimetric data, converted in 2-Gy equivalent, were confronted with the occurrence of late morbidity assessed using the CTC-AE 3.0. Dose-effect relationships were assessed using mean-dose comparisons, log-rank tests on event-free periods, and probit analyses.A total of 115 patients with a median followup of 35.5 months were included. Highest grade per patient was: Grades 0 for 17, 1 for 75, 2 for 20, and 3 for 3. The mean [Formula: see text] and [Formula: see text] were, respectively, 68.7 ± 13.6 Gy and 85.8 ± 33.1 Gy and did not differ according to event severity (p = 0.47 and p = 0.52), even when comparing Grades 0-1 vs. 2-4 events (68.0 ± 12.4 vs. 71.4 ± 17.7 Gy; p = 0.38 and 83.7 ± 26.4 vs. 94.5 ± 51.9 Gy; p = 0.33). Log-rank tests were performed after splitting the cohort according to four [Formula: see text] levels: >80 Gy, 70-79 Gy, 60-70 Gy, and

Purpose Although dose–volume parameters in image-guided brachytherapy have become a standard, the use of posterior–inferior border of the pubic symphysis (PIBS) points has been recently proposed in the reporting of vaginal doses. The aim was to evaluate their pertinence. Methods and Materials Nineteen patients who received image-guided brachytherapy after concurrent radiochemotherapy were included. Per treatment, CT scans were performed at Days 2 and 3, with reporting of the initial dwell positions and times. Doses delivered to the PIBS points were evaluated on each plan, considering that they were representative of one-third of the treatment. The movements of the applicator according to the PIBS point were analysed. Results Mean prescribed doses at PIBS −2, PIBS, PIBS +2 were, respectively, 2.23 ± 1.4, 6.39 ± 6.6, and 31.85 ± 36.06 Gy. Significant differences were observed between the 5 patients with vaginal involvement and the remaining 14 at the level of PIBS +2 and PIBS: +47.60 Gy and +7.46 Gy, respectively (p = 0.023 and 0.03). The variations between delivered and prescribed doses at PIBS points were not significant. However, at International commission on radiation units and measurements rectovaginal point, the delivered dose was decreased by 1.43 ± 2.49 Gy from the planned dose (p = 0.019). The delivered doses at the four points were strongly correlated with the prescribed doses with R2 ranging from 0.93 to 0.95. The movements of the applicator in regard of the PIBS point assessed with the Digital Imaging and Communications in Medicine coordinates were insignificant. Conclusion The doses evaluated at PIBS points are not impacted by intrafractional movements. PIBS and PIBS +2 dose points allow distinguishing the plans of patients with vaginal infiltration. Further studies are needed to correlate these parameters with vaginal morbidity.

Objective To examine the outcome of patients receiving interstitial pulsed-dose-rate brachytherapy (PDR-BT) after pelvic radiation therapy for treatment of an anal squamous cell carcinoma. Methods and Materials Twenty-one patients were identified: 13, six, and two with stages I, II, and III tumors, respectively. After receiving received pelvic irradiation +/− concurrent chemotherapy, patients were delivered a PDR-BT boost to the residual tumor, with intention to deliver a minimal total dose of 60 Gy. The greatest dimension of residual tumor at the time of brachytherapy procedure was 12.5 mm (range: 0–20 mm). Brachytherapy implantation was performed according to the Paris system, only one plane implant being used. Results Median dose delivered through BT was 20 Gy (range: 10–30 Gy). Median number of pulses was 48 (range: 20–80 pulses). Median treated volume was 9 cm 3 (range: 5–16 cm 3 ). Median dose per pulse was 40 cGy (range: 37.5–50 cGy). No Grade 3 or more acute toxicity was reported. No Grade 3 or more delayed toxicity was seen among 18 patients with more than 6 months follow-up. Median followup was 47 months (range: 6–73 months). Twenty patients (95%) were alive at last follow-up. Tumor relapses were experienced in four patients (19%), including local relapse in three patients (14%). Conclusion With almost 4 years median followup, this study confirms previous data suggesting that PDR-BT is effective and safe in this indication. Local control rate and toxicity were in the range of what was seen with continuous low-dose-rate BT.

Purpose To evaluate the efficiency and potential implications of the lowest dose evaluated in the maximally exposed 2cm 3 of the bladder/dose evaluated at the International Commission for Radiation Units and Measurements (ICRU) bladder point (D2cm 3 /DICRU) ratio as surrogate to locate the D2cm 3 in patients treated with MRI-guided adaptive brachytherapy for cervical cancer. Methods and Materials The D2cm 3 area of the bladder was located in 69 patients, using the Digital Imaging and Communications in Medicine coordinates of its barycenter, with respect to the ICRU bladder point. The D2cm 3 /DICRU ratio was correlated with the longitudinal coordinate of the D2cm 3 . Afterward, the ratio was used in a retrospective cohort of 216 patients to evaluate its impact in dose–effect analyses for late urinary incontinence. Results The mean position of the D2cm 3 was 1.73 ± 0.98 cm cranially, 0.59 ± 0.65 cm backwardly, and 0.02 ± 0.89 cm to the right of the ICRU point. It was located above the ICRU point in 95.7% of the patients. Its position was lower in patients with vaginal involvement at diagnosis ( p = 0.03). The D2cm 3 /DICRU ratio was correlated with the position of the D2cm 3 ( R ² = 0.716, p −6 ). In speculating that a ratio greater than one would predict a D2cm 3 located above the ICRU point, the sensibility, specificity, positive, and negative predictive values were 95.2%, 100%, 100%, and 66.8%, respectively. Among the retrospective cohort, 85 patients had a ratio lower than 1.1, reflecting a D2cm 3 located in the lower bladder. In these patients, analyses showed significant dose relationship with Grade 2–4 incontinence ( p = 0.017), whereas no correlation was demonstrated in the remaining patients. Conclusions The D2cm 3 /DICRU ratio is a relevant surrogate to estimate the localization of the D2cm 3 . Significant dose–effect correlations for incontinence were established in patients with low values for this ratio.

Purpose Primary vaginal cancer is a rare disease for which treatment has been modeled based on cervical cancer. We report our experience in the use of image-guided adaptive brachytherapy (IGABT) in this indication. Methods and Materials Patients treated for vaginal cancer with a combination of external beam radiation therapy and IGABT were identified through electronic search. The Groupe Europeen de Curietherapie–European Society for Radiotherapy and Oncology recommendations for cervical cancer have been extrapolated with the definition of two clinical target volumes (CTVs) corresponding to the residual disease after external beam radiation therapy (CTVBT), assessed from clinical and imaging findings, and the so-called CTVi, comprising the CTVBT with directional margins and at least the initial disease at diagnosis. Results Twenty-seven patients were identified. MRI was used for brachytherapy guidance in 82% of the cases. An interstitial component was used in 59% of the cases. The D90 CTVBT and D90 CTVi were 73.1 ± 12.8 Gy and 66.6 ± 6.7 Gy, respectively. After a median followup of 40.1 months, nine recurrences in 8 patients were observed of which four were local. Local relapses occurred within the CTVBT. Three-year local control and disease-free rates were 82% and 65%, respectively. At 2 years, the Grade 2–4 gastrointestinal or urinary morbidity accrual rate was 9%. Twelve patients experienced late sexual morbidity, including three patients with Grade 3 stenosis. Conclusion IGABT is feasible in vaginal cancer with promising outcomes. Harmonizing the definition of CTVs is required to allow comparisons between experiences and to perform multicenter studies.

Purpose Brachytherapy (BT) is an effective organ-preserving treatment for selected localized penile carcinoma, providing high local control rates. Long-term functional results however, are still insufficiently evaluated. Methods and Materials All consecutive patients treated with low-dose-rate or pulse-dose-rate BT in our institute for a localized penile cancer and who were in first complete remission and followed for at least 3 years were included. A self-reporting questionnaire was sent, to assess: 1/urinary function, 2/sexual function, 3/cosmetic aspect of the penis, and 4/quality of life. Results Thirty-nine patients fulfilled inclusion criteria and were sent the questionnaire. Twenty-three patients (59%) answered. Median age was 63.4 years, (interquartile range [IR]: 49.7–67.0). Median followup was 5.9 years (IR: 5.2–6.7). The urinary scores showed moderate lower urinary tract symptoms. During the followup, a urethral dilation or self-catheterization had been necessary in 30% and 13%, respectively. Sixteen (70%) patients continued to maintain a sexual activity and the erectile dysfunction was mild. Finally, quality of life was good with a median score of 80/100 (IR = 65–90) and was only impacted by pain (p = 0.02). Overall, 57% and 39% declared having none or moderate pain/discomfort, respectively. Conclusions Although this questionnaire needs to be validated in an independent cohort, our results show the moderate impact of BT on functional outcomes, confirming that it is an adequate first-intent organ-sparing strategy in patients with localized penile carcinoma.

Purpose Radiotherapy of nasal carcinomas results in cure rates comparable to surgery, with anatomic preservation and good cosmesis. Brachytherapy (BT) overcomes difficulties with dosimetric coverage and affords a localized and highly conformal irradiation. We report our experience of BT for early-stage nasal squamous cell carcinomas (SCCs). Methods and Materials Clinical data, BT parameters, and outcome of consecutive patients treated by interstitial BT in our institute between December 1982 and April 2015 for a localized nasal SCC were examined. A total of 34 patients with newly diagnosed T1-2N0-1 nasal skin ( n = 22) or nasal cavity ( n = 12) SCC were identified. Implantation and dosimetry were done according to the Paris system rules. Low-dose-rate ( n = 30) or pulsed-dose-rate ( n = 4) techniques were used. Median dose was 70 Gy (64–75 Gy). Sites of tumor recurrence, toxicity rates, and cosmesis outcome were examined. Results Median followup time was 89 months. All patients achieved complete response. Five patients experienced local failure, with a median interval of 9 months (range, 5–12 months). Grade 3 acute reactions were reported in 2 patients (6%). Most delayed complications were mild to moderate, and good or fair cosmesis was achieved in 97%. Estimated local failure-free survival and disease-free survival rates at 5 year were 85% (95% CI = 68–94%) and 76% (95% CI = 58–88%), respectively. Conclusions Interstitial BT is effective for selected nasal SCCs, with durable local control, acceptable toxicity, and good cosmesis.

To establish dose-volume effect correlations for late small bowel (SB) toxicities in patients treated for locally advanced cervical cancer with concomitant chemoradiation followed by pulsed-dose rate MRI-guided adaptive brachytherapy.Patients treated with curative intent and followed prospectively were included. The SB loops closed to CTV were delineated, but no specific dose constraint was applied. The dosimetric data, converted in 2-Gy equivalent, were confronted with the occurrence of late morbidity assessed using the CTC-AE 3.0. Dose-effect relationships were assessed using mean-dose comparisons, log-rank tests on event-free periods, and probit analyses.A total of 115 patients with a median followup of 35.5 months were included. Highest grade per patient was: Grades 0 for 17, 1 for 75, 2 for 20, and 3 for 3. The mean [Formula: see text] and [Formula: see text] were, respectively, 68.7 ± 13.6 Gy and 85.8 ± 33.1 Gy and did not differ according to event severity (p = 0.47 and p = 0.52), even when comparing Grades 0-1 vs. 2-4 events (68.0 ± 12.4 vs. 71.4 ± 17.7 Gy; p = 0.38 and 83.7 ± 26.4 vs. 94.5 ± 51.9 Gy; p = 0.33). Log-rank tests were performed after splitting the cohort according to four [Formula: see text] levels:80 Gy, 70-79 Gy, 60-70 Gy, and60 Gy. No difference was observed for Grades 1-4, Grades 2-4, or Grades 3-4 (p = 0.21-0.52). Probit analyses showed no correlation between the dosimetric parameters and probability of Grades 1-4, 2-4, or 3-4 events (p = 0.19-0.48).No significant dose-volume effect relationships were demonstrated between the [Formula: see text] and [Formula: see text] and the probability of late SB morbidity. These parameters should not limit the pulsed-dose rate brachytherapy optimization process.

Cervical cancer patients with a bulky high-risk clinical target volume (HR-CTV) get the largest benefit of dose escalation in terms of local control. However, the expected survival benefit could be lessened by a higher metastatic risk. We examined the patterns of relapse according to major prognostic factors: the HR-CTV volume and to the D90 HR-CTV.The clinical records of patients treated with pulsed-dose-rate image-guided adaptive brachytherapy after concurrent pelvic chemoradiation were reviewed. All patients had an optimal workup before treatment comprising a 18-fluorodeoxyglucose positron emission tomography/computed tomography and a para-aortic lymph node dissection. Patients with initial extrapelvic disease were excluded.A total of 109 patients fulfilled inclusion criteria. Median followup was 39 months. An HR-CTV volume ≥40 cm(3) was associated with a poorer local failure-free survival. There was a strong inverse correlation between the HR-CTV volume and the D90 of the HR-CTV (correlation coefficient r = -0.696; p 0.001) with increasing HR-CTV volume being associated with a decreasing D90 HR-CTV. A D90 HR-CTV85 Gy and an HR-CTV volume ≥40 cm(3) were significant univariate factors for experiencing nonlocal failure (p = 0.002 and 0.035, respectively), even after exclusion of local relapses.A lower ability to reach the target D90 HR-CTV planning and an HR-CTV volume ≥ 40 cm(3) correlated with a high propensity of relapsing at distance, these factors being interrelated. Next step of treatment personalization should design strategies integrating this risk, which is now the main cause of failure.

To evaluate the efficiency and potential implications of the lowest dose evaluated in the maximally exposed 2cm(3) of the bladder/dose evaluated at the International Commission for Radiation Units and Measurements (ICRU) bladder point (D2cm(3)/DICRU) ratio as surrogate to locate the D2cm(3) in patients treated with MRI-guided adaptive brachytherapy for cervical cancer.The D2cm(3) area of the bladder was located in 69 patients, using the Digital Imaging and Communications in Medicine coordinates of its barycenter, with respect to the ICRU bladder point. The D2cm(3)/DICRU ratio was correlated with the longitudinal coordinate of the D2cm(3). Afterward, the ratio was used in a retrospective cohort of 216 patients to evaluate its impact in dose-effect analyses for late urinary incontinence.The mean position of the D2cm(3) was 1.73±0.98 cm cranially, 0.59±0.65 cm backwardly, and 0.02±0.89 cm to the right of the ICRU point. It was located above the ICRU point in 95.7% of the patients. Its position was lower in patients with vaginal involvement at diagnosis (p=0.03). The D2cm(3)/DICRU ratio was correlated with the position of the D2cm(3) (R²=0.716, p10(-6)). In speculating that a ratio greater than one would predict a D2cm(3) located above the ICRU point, the sensibility, specificity, positive, and negative predictive values were 95.2%, 100%, 100%, and 66.8%, respectively. Among the retrospective cohort, 85 patients had a ratio lower than 1.1, reflecting a D2cm(3) located in the lower bladder. In these patients, analyses showed significant dose relationship with Grade 2-4 incontinence (p=0.017), whereas no correlation was demonstrated in the remaining patients.The D2cm(3)/DICRU ratio is a relevant surrogate to estimate the localization of the D2cm(3). Significant dose-effect correlations for incontinence were established in patients with low values for this ratio.

Purpose The importance of the quality of cervical cancer brachytherapy applicators has been reported, suggesting a direct influence of competent technical implant performance on outcome. In our institute, an original brachytherapy technique based on the use of a molded applicator for genital tract brachytherapy has been applied routinely in clinical practice. Here, we report the technical aspects of this customized applicator and perspectives on its use. Technical Aspects The first step consists of a vaginal impression that accurately shows the topography and extension of the tumor as well as the anatomy of the vagina and cervix. From this impression, an acrylic applicator is made. Then, the intended positions of the vaginal catheters are drawn on the surface of the mold by the radiation oncologist. Two plastic vaginal catheters are introduced and fixed on the internal surface of the molded applicator. A hole for the cervical os is made through which the uterine probe will be positioned. Perspectives This method allows for high specificity within the framework of a modern brachytherapy procedure, integrating the tumor topography, anatomy of the patient, and internal movements of target and critical volumes. This technique has been successfully extended to other tumor locations, such as genital tract rhabdomyosarcoma in children and postoperative endocavitary brachytherapy in patients with endometrial cancer. Conclusion Customization of a vaginal brachytherapy applicator allows for the maintenance of morphologic optimization throughout the treatment course, which better takes into account a fourth dimension: internal organ motion during the course of brachytherapy.