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We report an updated analysis of the outcomes and toxicities of MRI-based brachytherapy for locally advanced cervical cancer from a U.S. academic center. A retrospective review was performed on patients treated with MRI-based brachytherapy for cervical cancer. EBRT was standardly 45 Gy in 25 fractions with weekly cisplatin. MRI was performed with the brachytherapy applicator in situ. Dose specification was most commonly 7 Gy for 4 fractions with optimization aim of D90 HR-CTV EQD2 of 85–95 Gy α/β=10 Gy in 2 implants each delivering 2 fractions. Ninety-eight patients were included with median follow up of 24.5 months (IQR 11.9–39.8). Stage IIIA-IVB accounted for 31.6% of cases. Dosimetry results include median GTV D98 of 101.0 Gy (IQR 93.3–118.8) and HR-CTV D90 of 89 Gy (IQR 86.1–90.6). Median D2cc bladder, rectum, sigmoid, and bowel doses were 82.1 Gy (IQR 75.9–88.0), 65.9 Gy (IQR 59.6–71.2), 65.1 Gy (IQR 57.7–69.6), and 55 Gy (IQR 48.9–60.9). Chronic grade 3+ toxicities were seen in the bladder (8.2%), rectosigmoid (4.1%), and vagina (1.0%). Three-year LC, PFS, and OS were estimated to be 84%, 61.7%, and 76.1%, respectively. MRI-based brachytherapy demonstrates excellent local control and acceptable rates of high-grade morbidity. These results are possible in our population with relatively large volume primary tumors and extensive local disease. • Local control, overall survival, and progression-free survival at our institution are similar to larger studies. • Dose planning limits to organs-at-risk were met in a population with a higher proportion of stage IIIA-IVB patients. • Chronic grade 3+ toxicities were seen in 13.3% of patients, mostly in stage IIIB and IVA patients. [ABSTRACT FROM AUTHOR]

Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018–2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes. • Curative-intent radiotherapy for cervical cancer in the US may include external beam radiotherapy and brachytherapy. • This is the first assessment of physician practice pattern of curative-intent brachytherapy for cervical cancer in the US. • Most patients received HDR intracavitary brachytherapy and completed their radiotherapy as prescribed. • Patient ethnicity, insurance, and facility type are significantly associated with number of HDR brachytherapy fractions. [ABSTRACT FROM AUTHOR]

Uterine serous carcinoma is a rare but aggressive subtype of endometrial adenocarcinoma. Our objective was to compare adjuvant treatment strategies for patients with early stage uterine serous carcinoma. This multi-institutional, retrospective cohort study evaluated patients with early stage uterine serous carcinoma. Patients with FIGO Stage IA-II disease after surgery, whose tumors had serous or any mixed serous/non-serous histology were included. Patients with carcinosarcoma were excluded. Clinical data were abstracted from local medical records. Summary statistics, Fisher's exact, and Kruskal-Wallis tests were used to analyze demographic and clinical characteristics. Univariable and multivariable analyses were performed for recurrence-free and overall survival. There were 737 patients included. Most patients had Stage IA disease (75%), 49% of which had no myometrial invasion. Only 164 (24%) tumors had lymphatic/vascular space invasion. Adjuvant treatment varied: 22% received no adjuvant therapy, 17% had chemotherapy alone, 19% had cuff brachytherapy, 35% had cuff brachytherapy with chemotherapy, and 6% underwent pelvic radiation. Adjuvant treatment was significantly associated with a decreased risk of recurrence (p = 0.04). Compared with no adjuvant therapy, patients who received brachytherapy or brachytherapy/chemotherapy had improved recurrence-free survival (HR 0.59, 95% CI 0.40–0.86; HR 0.65, 95% CI 0.49–0.88, respectively) and overall survival (HR 0.53, 95% CI 0.35–0.79; HR 0.49, 95% CI 0.35–0.69, respectively). Improved survival with brachytherapy and brachytherapy/chemotherapy persisted on multivariable analyses. Chemotherapy alone was also associated with improved overall survival compared with no adjuvant treatment (HR 0.55, 95% CI 0.37–0.81). Adjuvant therapy was associated with a decreased risk of recurrence relative to observation alone. Adjuvant cuff brachytherapy with and without chemotherapy was associated with improved survival outcomes in patients with early stage uterine serous carcinoma. • Treatment approaches for patients with early stage uterine serous carcinoma vary. • Use of adjuvant therapy is associated with decreased risk of recurrence relative to surveillance. • Vaginal cuff brachytherapy both with and without chemotherapy is associated with improved survival outcomes. • Patients with early stage uterine serous carcinoma should be offered vaginal cuff brachytherapy. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the clinical outcome in locally advanced cervical cancer (LACC) after image-guided adaptive brachytherapy (IGABT) with combined intracavitary and interstitial (IC/IS) techniques using the hybrid Venezia applicator (Elekta AB, Sweden). LACC patients (UICC Stage IIB – IVB) treated with radiochemotherapy followed by IGABT with the hybrid IC/IS Venezia applicator at a single institution were retrospectively analyzed. Treatment comprised EBRT of the pelvis with 45 Gy and concomitant weekly cisplatin chemotherapy (40 mg/m2) followed by MRI-based IGABT. Dosimetry, oncological outcome and toxicity were investigated. Forty-six patients underwent a total of 184 fractions of IGABT between 2017 and 2020. Median follow-up was 24 months. Combined IC/IS techniques were used in 40 patients (87%). The median HRCTV volume was 31.2 cm3 and the median HRCTV D 90% was 92.3 Gy (EQD2 10). The median D 2cm 3 was 74.8 Gy for bladder, 57.9 Gy for rectum, 60.0 Gy for sigmoid and 52.2 Gy for bowel (EQD2 3). The 3-yr actuarial rates were 97.6% for local control, 97.6% for pelvic control, 59.9% for distant metastasis-free survival and 81.6% for overall survival. The crude rate for G2 and G3 late toxicity was 21.7% and 4.3%. IGABT with the hybrid Venezia applicator and a pronounced use of a combined IC/IS technique achieved high target doses, while maintaining low doses to organs at risk, leading to excellent local control and overall survival rates with acceptable toxicity. • Combined intracavitary and interstitial brachytherapy achieves high target doses. • This leads to excellent local control. • Toxicity with this combined approach is acceptable. • Distant recurrence is common; improvements in distant control are warranted. [ABSTRACT FROM AUTHOR]

To report long-term results of an outpatient template-based high-dose-rate interstitial brachytherapy (HDR ISBT) program for the treatment of gynecologic malignancies. Patients treated between 2006 and 2020 at an academic hospital with outpatient template based HDR ISBT without spinal or general anesthesia were reviewed. Patients who had previously received HDR ISBT were excluded. Baseline patient, tumor, and treatment characteristics, such as tumor size, histology, and/or total EQD2 including prior external beam radiation therapy (EBRT) were recorded. Local control and overall survival were estimated using the Kaplan-Meier method, and factors associated with local control and overall survival were evaluated using Cox regression analyses. 150 patients received HDR ISBT for a gynecologic tumor and the median follow-up time was 2.98 years (0.89–4.82). Of those, 74/150 (49%) were treated definitively, 69/150 (46%) were treated for tumor recurrence/persistence, and 7/150 (5%) were treated for durable palliation. Median tumor size was 3.00 cm (1.50–4.00). 124/150 (83%) patients received EBRT prior to HDR ISBT. Median HDR ISBT dose was 18 Gy delivered in eight fractions. Local control was 71% (64%–79%), 58% (50%–68%), and 57% (48%–67%) at one, three, and five years, respectively. On multivariate analysis, non-endometrial adenocarcinoma histology (HR = 2.423, 95% CI = 1.011–5.808, p = 0.047) and tumor size ≥ 3 cm (HR = 2.903, 95% CI 1.053–3.441, p = 0.033) were associated with lower local control. The majority of patients who received outpatient-based twice daily HDR ISBT had long-term local control. Larger tumor size and non-endometrial adenocarcinoma histology were detrimental to local control. • HDR ISBT for vaginal, vulvar, cervical, and urethral tumors yielded durable local control. • 150 patients were treated definitively, for tumor recurrence, or for durable palliation. • Local control for all patients was 71%, 58%, and 57% at one, three, and five years. • Tumor size ≥3 cm and non-endometrial adenocarcinoma histology were detrimental to local control on multivariate analysis. [ABSTRACT FROM AUTHOR]

High dose rate (HDR) interstitial brachytherapy (ISBT) boost is integral for definitive radiation treatment of primary vaginal cancer. Technological advances with CT or MRI guidance provide improved precision and ability to treat more extensively invasive tumors over historical techniques, but reported experience is limited. We sought to provide updated outcome and toxicity data for women with primary vaginal cancer undergoing treatment with a modern ISBT technique. Databases of primary vaginal carcinoma patients treated at two Canadian academic cancer institutions were combined including patient, tumor and treatment characteristics, and survival outcomes and toxicity data. Descriptive statistics, survival estimates based on the Kaplan-Meier method, and univariable/multivariable Cox proportional hazards regression analyses are reported. Between 2002 and 2017, 67 women with primary vaginal cancer were treated with 3D HDR ISBT. FIGO stage distribution was I (22.4%), II (50.8%), III (17.9%), IVa (9.0%). All patients received external beam radiotherapy and HDR ISBT of 500–750 cGy per fraction over 2–4 fractions. Median follow-up was 2.68 years (95% confidence interval: 2.04–6.04). Cumulative rate of grade 3–4 genitourinary/gastrointestinal toxicity was 10.4%. Four patients developed vaginal fistula. Progression-free survival at 2 and 3 years was 73.5% and 66.4% for all patients, 78.3% and 75.0% for stage I-II and 61.6% and 46.2% for stage III-IVa, respectively (log-rank p = 0.252). Use of 3D image-guided HDR ISBT boost was safe and resulted in improved survival outcomes compared to historical rates in this series of primary vaginal cancer patients. Prospective study is warranted to better define clinical and dosimetric predictors of local control. • Multicenter series providing outcome/toxicity data relevant to patients receiving modern brachytherapy treatment • Interstitial brachytherapy boost resulted in 84.5% local control at 3 years. • Concurrent chemotherapy was associated with significantly improved OS. [ABSTRACT FROM AUTHOR]

Since dose escalation allowed by image-guided adaptive brachytherapy (IGABT) in locally advanced cervical cancer (LACC), local relapses have become a rare event. Only scarce data are available on the outcome of patients experiencing a local relapse after IGABT. Between 2004 and 2016, all consecutive patients treated at Gustave Roussy Institute for LACC and receiving concomitant chemoradiation and IGABT were analysed. Clinical and treatment-related prognostic factors for survival after local relapse were searched, in order to potentially identify patients requiring salvage treatment. Two hundred and fifty-nine patients were treated during this period. With a median follow-up of 4.1 years, 10.8% (n = 28) had a local relapse. Among these patients, 53.6% had synchronous lymph nodes or distant metastatic relapse and only 13 patients (5% of all patients) had isolated local relapse. After local relapse, median survival was 47 months and three patients were alive at last follow-up. Only three patients with local relapse could receive salvage surgery (10.7%). Metastases occurrence and pelvic wall involvement were the main contraindications (67.9%) for salvage surgery. Among the three patients treated with surgery, two are still alive at last follow-up without significant complication. Improved survival was observed among the two patients who could have surgery (p =.02). Local progression led to serious symptoms in 75% of patients. Only the time interval between brachytherapy and relapse (<1 year) was prognostic for 2-year overall survival (p =.005). Salvage surgery is feasible in a very low number of highly selected patients with local relapse following IGABT. Local failure is a major cause of severe local symptoms, confirming that every effort should be done to achieve long-term local control through dose escalation. • In locally advanced cervical cancer, local relapse is a rare event due to dose escalation allowed by brachytherapy. • Feasibility of salvage surgery is uncertain and is feasible in a low number of highly selected patients. • Salvage surgery, however, appears to improve overall survival without significant complication. [ABSTRACT FROM AUTHOR]

To analyze the clinical outcomes and the safety of radiochemotherapy (RCT) and image-guided adaptive brachytherapy (IGABT) and to evaluate the impact of hysterectomy (HT) as completion of treatment for cervical cancer. 145 patients with locally advanced cervical cancer were treated at our institution. Patients underwent RCT and IGABT, then hysterectomy (HT) as completion of treatment was performed, with the exception of patients with surgical contraindications, para aortic metastatic disease or patients who refused surgery. Clinical outcomes and morbidity were retrospectively reviewed in both groups. Local relapse free survival (LRFS), pelvic relapse free survival (PRFS) and overall survival (OS) were analyzed. Completion HT was performed in 90 (62.1%) patients. Complete histological response and microscopic disease were found in 77 patients (85.6%). Local relapse was observed in 14 patients (9.6%) without differences between completion HT group and the definitive RCT and IGABT group (Odds Ratio OR = 1.73 [0.57–5.23], p = 0.33). The estimated 3-year LRFS and PRFS for the entire population were respectively 90% [84%–94%] and 93% [87%–96%], with no significant differences between them (respectively Hazard Ratio HR = 0.57 [0.20–1.64], p = 0.30 and HR = 0.37 [0.10–1.31], p = 0.12). The estimated 3-year OS rate for the whole population was 84% [75%–91%] with no significant differences between groups (HR = 0.81 [0.32–2.06], p = 0.65). Regarding morbidity, grade ≥ 2 vaginal toxicity was more frequent in the definitive RCT and IGABT group (43.6% vs 26.7%, p = 0.04). All grade 4 toxicity events were reported in the completion HT group. Due to high severe toxicity, RCT and IGABT with dose escalation followed by completion hysterectomy don't seem compatible. No benefit and increased severe late morbidity were observed. Combined intracavitary/interstitial technique is mandatory in large target volume at brachytherapy. • Locally advanced cervical cancer in the modern era of Image-guided adaptive brachytherapy. • Impact of hysterectomy as completion of treatment. • Incompatibility of treatments: high grade toxicity without clinical benefits. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the efficacy, feasibility and safety of image-based, inversely and adaptively planned high-dose rate interstitial brachytherapy (HDR-ISBT) to treat advanced primary or recurrent gynecologic malignancy in a single implant, three-consecutive-day regimen. Methods Clinical demographics and outcome data were abstracted from all patients with primary and recurrent gynecologic malignancies who received HDR-ISBT boost from 2014 to 2017. Treatment consisted of a single implant (~7 Gy × 4 fractions) of interstitial needles using the Syed-Neblett template over a three-day hospital admission. CT-based (3D) simulation with inverse and adaptive planning was utilized for each fraction. MR prior to and MR immediately after external beam therapy were fused for HDR-ISBT target delineation. Results Forty women with an overall median follow-up of 18 months (range: 6–54 months) received an HDR-ISBT boost. Of the 30 primary cases (83% cervix, 10% vaginal, 7% uterine), 44% had organ invasion (bladder, rectal or both) on MRI. Median coverage and dose are reported (V 100 : 98%, HR-CTV EQD 2 : 85.1 Gy, D 90 : 92 Gy). A significant association existed between rectal doses exceeding GEC-ESTRO recommendations (D 2cc < 75 Gy) and the development of grade 3 gastrointestinal toxicity with a relative risk of 1.4 [1.1–1.8] (p =.046). Actuarial two-year overall survival (OS), local control (LC) and progression-free survival (PFS) were 81%, 81% and 64%, respectively. Conclusions A four fraction, inversely and adaptively planned, single-implant approach of image-based HDR-ISBT provides excellent coverage, minimal toxicity and effective local control in patients with advanced and recurrent disease. Graphical abstract Unlabelled Image Highlights • A condensed regimen of single implant interstitial brachytherapy is safe and effective. • An inverse and adaptive planning technique for each fraction is feasible. • One of the most locally advanced gynecologic cohorts treated with brachytherapy [ABSTRACT FROM AUTHOR]

Objective The purpose was to compare local control (LC), overall survival (OS) and dose to the organs at risk (OAR) in women with locally advanced cervical cancer treated with MR-guided versus CT-guided interstitial brachytherapy (BT). Methods 56 patients (29 MR, 27 CT) were treated with high-dose-rate (HDR) interstitial BT between 2005–2015. The MR patients had been prospectively enrolled on a Phase II clinical trial. Data were analyzed using Kaplan-Meier (K-M) and Cox proportional hazards statistical modeling in JMP® & R®. Results Median follow-up time was 19.7 months (MR group) and 18.4 months (CT group). There were no statistically significant differences in patient age at diagnosis, histology, percent with tumor size > 4 cm, grade, FIGO stage or lymph node involvement between the groups. Patients in the MR group had more lymphovascular involvement compared to patients in the CT group ( p < 0.01). When evaluating plans generated, there were no statistically significant differences in median cumulative dose to the high-risk clinical target volume or the OAR. 2-year K-M LC rates for MR-based and CT-based treatments were 96% and 87%, respectively (log-rank p = 0.65). At 2 years, OS was significantly better in the MR-guided cohort (84% vs. 56%, p = 0.036). On multivariate analysis, squamous histology was associated with longer OS (HR 0.23, 95% CI 0.07–0.72) in a model with MR BT (HR 0.35, 95% CI 0.08–1.18). There was no difference in toxicities between CT and MR BT. Conclusion In this population of locally advanced cervical-cancer patients, MR-guided HDR BT resulted in estimated 96% 2-year local control and excellent survival and toxicity rates. [ABSTRACT FROM AUTHOR]

Objective Present long-term outcomes in primary cervical cancer treated with external beam and high dose rate interstitial brachytherapy. Methods High dose rate (HDR) interstitial (IS) brachytherapy (BT) and external beam (EBRT) were administered from 1992 to 2009 to 315 patients who were unsuitable for intracavitary (IC) BT alone. Histology was 89% squamous cell, 8% adenocarcinoma, and 3% adenosquamous. FIGO stage was I-14%, II-47%, III-34%, and IVA-5%. Median tumor size was 6 cm. Lymph node metastases were 26% pelvic and 9.5% para-aortic. Treatment planning was 49% 2D and 51% 3D–CT. The mean doses were central EBRT EQD2 10 37.3 ± 4.3 Gy (sidewall 49.2 ± 3.6 Gy) and HDR EQD2 10 42.3 ± 5.3 Gy (nominal 5.4 Gy × 6 fractions using a mean of 24 catheters and 1 tandem). Total EQD2 10 mean target dose was 79.5 ± 5.4 Gy. Standardized planned dose constraints were ICRU points or D 0.1cc bladder 80%, rectum 75% and urethra 90% of the HDR dose per fraction. Morbidity assessment was CTCAEv3. Median and mean follow-up were 50 and 61 months (3–234). Results The 10-year actuarial local control was 87%, regional control 84%, and loco-regional control 77%. Distant metastasis free survival was 66%, cause specific survival 56%, disease free survival 54%, and overall survival 40%. The rates of late grade GU and GI toxicities were 4.8% G3 and 5.4% G4. Conclusions Template-guided interstitial can be safely performed to successfully deliver high radiation dose to locally advanced cervix cancer and avoid excessive dose and injury to adjacent vital pelvic organs. We achieved high tumor control with low morbidity in patients who were poor candidates for intracavitary brachytherapy. [ABSTRACT FROM AUTHOR]

Objectives: There are significant disparities in access to care and treatment among cervical cancer patients. Less than half of patients with locally advanced cervical cancer receive the standard of care therapy consisting of concurrent chemoradiation, followed by brachytherapy, despite significantly improved overall survival based on an analysis of the National Cancer Database. The recommended time to complete radiation therapy in advanced cervical cancer patients is < 56 days, with both pelvic control and survival decreasing when the duration of treatment is lengthened. This study explored the relationship between social vulnerability and clinical variables, including radiation treatment duration in cervical cancer patients undergoing definitive chemoradiation, including brachytherapy over a nine-year period at a single institution. Methods: By querying a cohort discovery tool, data were obtained from 108 patients with cervical cancer from 2012 to 2021 who received brachytherapy in addition to external beam radiation. Patients' census tracts were matched to indices from the Centers for Disease Control's (CDC) Social Vulnerability Index (SVI). The SVI rankings range from least vulnerable, 0, to most vulnerable, 1, for four themes: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Clinical data, such as stage, histology, and demographic factors, were investigated. Results were analyzed using the Kruskal-Wallis rank-sum test Fisher's exact test, and Spearman's correlation. Results: Of patients included, 69% were Caucasian, 20% African American, 6.5% Hispanic, 1.9% Asian, and 1.9% American Indian/ Alaskan Native. The median SVI value when comparing patients to all census tracts in the United States was 0.43 (range: 0.0001-0.9907) in this population. Median SVI values suggested that African American patients were most vulnerable with an SVI of 0.86 (Interquartile Range [IQR]: 0.77-0.94), followed by Hispanic 0.59 (IQR: 0.46-0.79), American Indian or Alaska Native 0.56 (IQR: 0.43-0.69), Asian 0.33 (IQR: 0.22-0.44), and Caucasian 0.31 (IQR: 0.11-0.53) (p <0.001). Using 2018 FIGO staging, 58% of patients were stage III. Stage IV patients had the highest social vulnerability (0.77, IQR: 0.6-0.9). In a subset analysis of radiation treatment duration, the median time from start to end of radiation was 53 days (range: 35-127 days). There was no significant difference in length of time of radiation treatment by race (p=0.3) or stage (p>0.9). There was no relationship between SVI and radiation treatment duration (Rs =0.1). Conclusions: While social vulnerability appears to impact cervical cancer patients in regards to race and stage, increased social vulnerability was not associated with increased radiation treatment duration. Other factors, such as time to diagnosis, initiation of treatment, or accessibility to follow-up, may be more reflective of social vulnerability than treatment duration when a committed team works to mitigate obstacles to care during the course of radiation. [ABSTRACT FROM AUTHOR]

An international consensus panel has defined locally advanced cervical cancers as a high priority malignancy during the COVID-19 pandemic and recommends prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID). This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/2019 to 10/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT between 1/2019-12/2019, and peri-COVID was defined by initiation between 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05. Thirty pts were included, with 18 patients undergoing treatment pre-COVID and 12 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, three pts had delayed initiation to treatment >100 days: two related to fertility and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts completed CRT with RT: 24 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710). [Display omitted] Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in treatment parameters pre- and peri-COVID. [ABSTRACT FROM AUTHOR]

Abstract: Objective.: Brachytherapy plays a major role in the treatment of patients with carcinoma of the cervix. However, routine intracavitary brachytherapy may not be feasible or adequate to treat locally advanced disease. The purpose of this prospective study was to assess treatment outcome for patients with locally advanced gynecological malignancies treated with interstitial brachytherapy using Martinez Universal Perineal Interstitial Template (MUPIT) and to study the acute and late sequelae after treatment by this technique. Methods.: Thirty previously untreated patients with histologically confirmed carcinoma of the cervix (20 patients), vault (7 patients), and vagina (3 patients) were treated by a combination of external beam radiotherapy using megavoltage irradiation to the pelvis to a dose of 4000 to 5000 cGy followed by interstitial brachytherapy using MUPIT between June 2000 to August 2001 at Gujarat Cancer and Research Institute, Ahmedabad. Only those patients who were found unsuitable for conventional brachytherapy or in whom intracavitary radiotherapy was found to be unlikely to encompass the tumor volume were treated with interstitial template brachytherapy using MUPIT applicator and were enrolled for this study. Criteria for inclusion in this study were as follows: Hemoglobin — minimum 10 gm%; Performance Status — 70% or more (Karnofsky Scale); Histopathological confirmation; FIGO Stage — IIb–IIIb (excluding frozen pelvis). Results.: Among the 30 patients studied, 4 lost to follow-up and they were excluded from the study. With a median follow up of 9 months, local control was achieved in (20/26) 76.92% patients. The local control was better for nonbulky tumors compared to bulky tumors irrespective of stage of disease. Local control rate was better in patients with good regression of disease after EBRT. The time gap between EBRT and implant also had an impact on the outcome. Conclusion.: Interstitial template brachytherapy by MUPIT is a good alternative to deliver high-dose radiation in locally advanced gynecological malignancies where conventional brachytherapy application is either not feasible or unlikely to encompass tumor volume adequately. The locoregional control obtained is definitely better than external beam therapy alone and within the accepted range of complications. However, long-term follow-up is needed to comment on late morbidities. [Copyright &y& Elsevier]

• Seizure outcomes following ablation of hypothalamic hamartomas are heterogeneous. • Differences in surgical targeting contribute to variability in postoperative outcomes. • A preoperative high-resolution hypothalamic atlas can inform surgical targeting. Large hypothalamic hamartomas (HH) are often associated with difficult-to-treat, refractory seizures. Although magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) has emerged as a useful tool to treat these challenging lesions, postoperative outcomes are variable and potentially related to differences in surgical targeting. We sought to identify differences in the anatomic localization of laser ablations that either did or did not result in seizure freedom. Four children who underwent MRgLITT for large HH (3 seizure-free and 1 not seizure-free) were included in the analysis. Ablation volumes were segmented, normalized, and overlaid on a high-resolution hypothalamic atlas. For each lesion, the size, spatial extent, and degree of overlap with key hypothalamic nuclei and surrounding brain regions were computed and compared between ablations that did and did not result in seizure freedom. Ablation masks that resulted in seizure freedom were smaller and located more centrally than the ablation mask that did not. In addition, ablation masks that resulted in seizure freedom overlapped with regions including the paraventricular nucleus, the posterior hypothalamus and the zona incerta, fornix, and mammillothalamic tract, whereas the single non-seizure-free ablation did not. Differences in the size, position, and anatomical localization of ablation volumes may be a potential contributor to the variability in postoperative outcomes of large HH treated with MRgLITT. A novel, high-resolution MRI atlas of the hypothalamus identifies a number of regions at the interface of large HH that are preferentially disconnected in seizure-free patients. This method of anatomical localization not only serves as a potential clinical tool for surgical targeting but may also provide novel insights into the mechanisms of epileptogenesis in hypothalamic hamartomas. [ABSTRACT FROM AUTHOR]