Analysis of the planned, delivered dose distributions and quality assurance for helical tomotherapy and volumetric modulated arc therapy in locally advanced non-small cell lung cancer.

BACKGROUND: With full access to both helical tomotherapy (HT) and volumetric modulated arc therapy (VMAT), we compared locally advanced non-small cell lung cancer (LA-NSCLC) treatment plans and verified the plans using patient-specific pretreatment quality assurance (PSQA). MATERIALS AND METHODS: For each of the seventeen patients included in the study, two treatment plans (i.e. HT and VMAT) were created. Optimized plans were evaluated following the ICRU 83 criteria. Planned quality indexes and dosimetric parameters were compared. Lastly, all plans were subjected to PSQA assessment by determining the gamma passing rate (GPR). RESULTS: All dosimetry results obtained from the planning target volume passed the ICRU 83 criteria. With regard to similar homogeneity indices, VMAT produced better conformity number values than HT (0.78 vs. 0.64), but differences in the values were insignificant. Furthermore, VMAT was associated with a significantly shorter mean treatment time (1.91 minutes vs. 6.66 minutes). For PSQA assessment, both techniques resulted in adequate GPR values (> 90% at the 3%/3 mm criteria). CONCLUSION: Both HT and VMAT techniques led to the generation of clinically satisfactory and reliable radiotherapy plans. However, the VMAT plan was associated with a non-significantly better degree of conformity and a significantly shorter treatment time. Thus, VMAT was determined to be a better choice for LA-NSCLC.

Intermediate-term results of trans-abdominal ultrasound (TAUS)-guided brachytherapy in cervical cancer.

OBJECTIVES: To report the intermediate-term results of trans-abdominal ultrasound (TAUS)-guided brachytherapy in cervical cancer. MATERIALS AND METHODS: Ninety-two patients with cervical cancer (stage IB-IVA, according to FIGO staging), were treated by curative radiotherapy from February 2012 to June 2015. All patients were treated with whole pelvic radiotherapy to 50 Gy in 25 fractions and central shielding after 44 Gy, in combination with TAUS-guided brachytherapy, in order to escalate the total dose (EQD2) to the minimal dose at cervical points (in EQD2 concepts) defined by TAUS, while maintaining low doses to ICRU bladder and rectal points. The treatment results and toxicity profiles were reported. RESULTS: At median follow-up time of 41.2 months (range 8 to 61 months) the pelvic control, disease-free survival, and overall survival rates were 84.8%, 75%, and 88%, respectively. The mean applied doses to cervix, bladder, and rectal points were 83.5, 72.3, and 76.5 Gy, respectively. Eight patients developed grade 2 Gastrointestinal toxicity. CONCLUSION: The 3-year results demonstrated that TAUS-guided brachytherapy is feasible and associated with excellent tumor control/toxicity rates in cervical cancer.

Evaluation of Deformable Image Registration (DIR) Methods for Dose Accumulation in Nasopharyngeal Cancer Patients during Radiotherapy.

INTRODUCTION: Deformable image registration (DIR) is used to modify structures according to anatomical changes for observing the dosimetric effect. In this study, megavoltage computed tomography (MVCT) images were used to generate cumulative doses for nasopharyngeal cancer (NPC) patients by various DIR methods. The performance of the multiple DIR methods was analysed, and the impact of dose accumulation was assessed. PATIENTS AND METHODS: The study consisted of five NPC patients treated with a helical tomotherapy unit. The weekly MVCT images at the 1st, 6th, 11th, 16th, 21st, 26th, and 31st fractions were used to assess the dose accumulation by the four DIR methods. The cumulative dose deviations from the initial treatment plan were analysed, and correlations of these variations with the anatomic changes and DIR methods were explored. RESULTS: The target dose received a slightly different result from the initial plan at the end of the treatment. The organ dose differences increased as the treatment progressed to 6.8% (range: 2.2 to 10.9%), 15.2% (range: -1.7 to 36.3%), and 6.4% (range: -1.6 to 13.2%) for the right parotid, the left parotid, and the spinal cord, respectively. The mean uncertainty values to estimate the accumulated doses for all the DIR methods were 0.21 ± 0.11 Gy (target dose), 1.99 ± 0.76 Gy (right parotid), 1.19 ± 0.24 Gy (left parotid), and 0.41 ± 0.04 Gy (spinal cord). CONCLUSIONS: Accuracy of the DIR methods affects the estimation of dose accumulation on both the target dose and the organ dose. The DIR methods provide an adequate dose estimation technique for observation as a result of inter-fractional anatomic changes and are beneficial for adaptive treatment strategies.

Intermediate-term results of image-guided brachytherapy and high-technology external beam radiotherapy in cervical cancer: Chiang Mai University experience.

OBJECTIVE: To evaluate the outcomes of image-guided brachytherapy combined with 3D conformal or intensity modulated external beam radiotherapy (3D CRT/IMRT) in cervical cancer at Chiang Mai University. METHODS: From 2008 to 2011, forty-seven patients with locally advanced cervical cancer were enrolled in this study. All patients received high-technology (3D CRT/IMRT) whole pelvic radiotherapy with a total dose of 45-46 Gy plus image-guided High-Dose-Rate intracavitary brachytherapy 6.5-7 Gy × 4 fractions to a High-Risk Clinical Target Volume (HR-CTV) according to GEC-ESTRO recommendations. The dose parameters of the HR-CTV for bladder, rectum and sigmoid colon were recorded, as well as toxicity profiles. In addition, the endpoints for local control, disease-free, metastasis-free survival and overall survival were calculated. RESULTS: At the median follow-up time of 26 months, the local control, disease-free survival, and overall survival rates were 97.9%, 85.1%, and 93.6%, respectively. The mean dose of HR-CTV, bladder, rectum and sigmoid were 93.1, 88.2, 69.6, and 72 Gy, respectively. In terms of late toxicity, the incidence of grade 3-4 bladder and rectum morbidity was 2.1% and 2.1%, respectively. CONCLUSIONS: A combination of image-guided brachytherapy and IMRT/3D CRT showed very promising results of local control, disease-free survival, metastasis-free survival and overall survival rates. It also caused a low incidence of grade 3-4 toxicity in treated study patients.

Development of a quality assurance system in radiation oncology: A 12-year experience in a University Hospital.

PURPOSE: This study aimed to report 12 years of experience in the development of a quality assurance system in radiation oncology in a university hospital. MATERIAL AND METHODS: We developed the Quality Assurance Program in Radiation Oncology (QUAPRO) in 2008 to detect treatment deviation in the radiotherapy (RT) process with three steps of near-miss detection: simulation and prescription (primary check, PC), treatment planning (secondary check, SC), and treatment delivery process (tertiary check, TC). We transferred our paper-based medical records to electronic-based radiotherapy information systems (RTISs) in 2013. QUAPRO was completely integrated into RTIS in 2017. Since then, electronic-based incident reporting has been conducted. The program is called the Radiation Incident Learning System (RILS). The near-miss rates were compared during the three time periods: 2008-2012, 2013-2017, and 2017-2020. RESULTS: Five years of paper-based QUAPRO for 2008-2012 demonstrated a fluctuation in the checking ratio, with a gradually increasing rate of near misses of 3.5-19.7%. After electronic-based medical records were developed in 2013, the results revealed a dramatic increase from a rate of 2.7 to 4.2 in the number of checks per patient and achieved an increased rate of near misses of 24.7% for PC, SC, and TC. The rate of near misses gradually decreased to 5.3% after 2017 because of RT workflow improvement. CONCLUSION: The analysis of 12 years in near-miss data reflected the effectiveness of our quality assurance program. The QUAPRO system can detect near-miss incidents in the whole RT workflow and illustrate the detection improvement when integrated into electronic-based medical records. Regular feedback and exploration of near-miss reporting are recommended for proper RT workflow improvement.

The advantages of abdominal compression with shallow breathing during left-sided postmastectomy radiotherapy by Helical TomoTherapy.

BACKGROUND: Left-sided post-mastectomy radiotherapy (PMRT) certainly precedes some radiation dose to the cardiopulmonary organs causing many side effects. To reduce the cardiopulmonary dose, we created a new option of the breathing adapted technique by using abdominal compression applied with a patient in deep inspiration phase utilizing shallow breathing. This study aimed to compare the use of abdominal compression with shallow breathing (ACSB) with the free breathing (FB) technique in the left-sided PMRT. MATERIALS AND METHODS: Twenty left-sided breast cancer patients scheduled for PMRT were enrolled. CT simulation was performed with ACSB and FB technique in each patient. All treatment plans were created on a TomoTherapy planning station. The target volume and dose, cardiopulmonary organ volume and dose were analyzed. A linear correlation between cardiopulmonary organ volumes and doses were also tested. RESULTS: Regarding the target volumes and dose coverage, there were no significant differences between ACSB and FB technique. For organs at risk, using ACSB resulted in a significant decrease in mean (9.17 vs 9.81 Gy, p<0.0001) and maximum heart dose (43.79 vs 45.45 Gy, p = 0.0144) along with significant reductions in most of the evaluated volumetric parameters. LAD doses were also significantly reduced by ACSB with mean dose 19.24 vs 21.85 Gy (p = 0.0036) and the dose to 2% of the volume (D2%) 34.46 vs 37.33 Gy (p = 0.0174) for ACSB and FB technique, respectively. On the contrary, the lung dose metrics did not show any differences except the mean V5 of ipsilateral lung. The positive correlations were found between increasing the whole lung volume and mean heart dose (p = 0.05) as well as mean LAD dose (p = 0.041) reduction. CONCLUSIONS: The ACSB technique significantly reduced the cardiac dose compared with the FB technique in left-sided PMRT treated by Helical TomoTherapy. Our technique is uncomplicated, well-tolerated, and can be applied in limited resource center.

Effect of Deformation Methods on the Accuracy of Deformable Image Registration From Kilovoltage CT to Tomotherapy Megavoltage CT.

INTRODUCTION: The registration accuracy of megavoltage computed tomography images is limited by low image contrast when compared to that of kilovoltage computed tomography images. Such issues may degrade the deformable image registration accuracy. This study evaluates the deformable image registration from kilovoltage to megavoltage images when using different deformation methods and assessing nasopharyngeal carcinoma patient images. METHODS: The kilovoltage and the megavoltage images from the first day and the 20th fractions of the treatment day of 12 patients with nasopharyngeal carcinoma were used to evaluate the deformable image registration application. The deformable image registration image procedures were classified into 3 groups, including kilovoltage to kilovoltage, megavoltage to megavoltage, and kilovoltage to megavoltage. Three deformable image registration methods were employed using the deformable image registration and adaptive radiotherapy software. The validation was compared by volume-based, intensity-based, and deformation field analyses. RESULTS: The use of different deformation methods greatly affected the deformable image registration accuracy from kilovoltage to megavoltage. The asymmetric transformation with the demon method was significantly better than other methods and illustrated satisfactory value for adaptive applications. The deformable image registration accuracy from kilovoltage to megavoltage showed no significant difference from the kilovoltage to kilovoltage images when using the appropriate method of registration. CONCLUSIONS: The choice of deformation method should be considered when applying the deformable image registration from kilovoltage to megavoltage images. The deformable image registration accuracy from kilovoltage to megavoltage revealed a good agreement in terms of intensity-based, volume-based, and deformation field analyses and showed clinically useful methods for nasopharyngeal carcinoma adaptive radiotherapy in tomotherapy applications.

Dosimetric verification of radiotherapy treatment planning systems: results of IAEA pilot study.

BACKGROUND AND PURPOSE: The methodology developed by IAEA for dosimetric quality control of treatment planning systems has been tested in different hospitals through a pilot study. The aim was to verify the methodology and observe the range of deviations between planned and delivered doses in 3D conformal radiotherapy in situations close to a clinical setting. MATERIAL AND METHODS: The methodology was based on an anthropomorphic phantom representing the human thorax, and simulates the whole chain of external beam radiotherapy treatment planning activities. The phantom was scanned using computed tomography and eight test cases were planned on treatment planning systems which imitate different irradiation geometries found in conformal radiotherapy. The doses were measured with ion chambers, and the deviation between measured and treatment planning system calculated doses was reported. This methodology, which employs the same phantom and the same set of test cases, was tested in 17 different hospitals which were using 14 different algorithms/inhomogeneity correction methods implemented in different treatment planning systems. RESULTS: A total of 53 clinical test case datasets for different energies and calculation algorithms were produced. Most of the systems with advanced algorithms complied with predefined agreement criteria. Dose differences more than 20% were discovered for some of the simple algorithms and high energy X-ray beams. The number of deviations outside agreement criteria increases with the beam energy and decreases with advancement of the treatment planning system calculation algorithm. CONCLUSIONS: Large deviations exist in some simple dose calculation algorithms, therefore more advanced algorithms would be preferable and therefore should be implemented in clinical practice. The test cases that could be performed in reasonable time would help the users to appreciate the possibilities of their system and understand its limitations.

Accuracy of eight deformable image registration (DIR) methods for tomotherapy megavoltage computed tomography (MVCT) images.

INTRODUCTION: The application of deformable image registration (DIR) to megavoltage computed tomography (MVCT) images benefits adaptive radiotherapy. This study aims to quantify the accuracy of DIR for MVCT images when using different deformation methods assessed in a cubic phantom and nasopharyngeal carcinoma (NPC) patients. METHODS: In the control studies, the DIR accuracy in air-tissue and tissue-tissue interface areas was observed using twelve shapes of acrylic and tissue-equivalent material inserted in the phantom. In the clinical studies, the 1st and 20th fraction MVCT images of seven NPC patients were used to evaluate application of DIR. The eight DIR methods used in the DIRART software varied in (i) transformation framework (asymmetric or symmetric), (ii) DIR registration algorithm (Demons or Optical Flow) and (iii) mapping direction (forward or backward). The accuracy of the methods was compared using an intensity-based criterion (correlation coefficient, CC) and volume-based criterion (Dice's similarity coefficient, DSC). RESULTS: The asymmetric transformation with Optical Flow showed the best performance for air-tissue interface areas, with a mean CC and DSC of 0.97 ± 0.03 and 0.79 ± 0.11 respectively. The symmetric transformation with Optical Flow showed good agreement for tissue-tissue interface areas with a CC of (0.99 ± 0.01) and DSC of (0.89 ± 0.03). The sequences of target domains were significantly different in tissue-tissue interface areas. CONCLUSIONS: The deformation method and interface area affected the accuracy of DIR. The validation techniques showed satisfactory volume matching of greater than 0.7 with DSC analysis. The methods can yield acceptable results for clinical applications.

University Cooperation Platform (UCP) between Christian-Albrechts-University Kiel (Germany) and Chiang Mai University (Thailand): implementation of image-guided gynecological brachytherapy.

Starting in 1999, the University Cooperation Platform (UCP) implemented an exchange program of researchers and clinicians/physicists between the Christian-Albrechts-University Kiel in Germany and Chiang Mai University in Thailand, to initiate a sustainable base for long-term development of image-guided brachytherapy and in general for high-technology radiotherapy in Chiang Mai. A series of UCP protocols, based constructively on each other, were performed and evaluated at intermediate term follow-up. The first protocol, addressing computed tomography (CT)-optimized brachytherapy for advanced cervical cancer (n = 17), showed a significant reduction of D2cc for the bladder and sigmoid (p < 0.001) while maintaining a very high dose in D90 high-risk clinical target volume (HR-CTV) in comparison with standard point-based planning. In addition, after a follow-up of 19 months no tumor relapse was observed. The second UCP protocol, testing the impact of magnetic resonance imaging (MRI) guidance (n = 15) in patients with cervical cancer, proved significantly smaller D2cc doses for the bladder, rectum, and sigmoid (p = 0.003, p = 0.015, and p = 0.012), and secured highly curative mean doses in D90 HR-CTV of 99.2 Gy. The acute and late toxicity was excellent without any observed grade 3 or higher morbidity. In the third protocol, the combination of image-guided brachytherapy (IGBT) and whole pelvis intensity-modulated external beam radiotherapy (WP-IMRT) (n = 15) reaffirmed the significant reduction of D2cc doses for the bladder, rectum, and sigmoid (p = 0.001 or p < 0.001) along with high equivalent dose at 2 Gy (EQD2) in the HR-CTV, and demonstrated very low acute therapy-related toxicity in absence of grade 3 morbidity. The implementation of transabdominal ultrasound (TAUS) was the focus of the fourth UCP project aiming a more generous potential use of image-guidance on long-term, and enhancing the quality of soft tissue assessment complementary to conventionally planned gynecological brachytherapy. Analyses in 29 patients revealed significantly reduced OARs doses in bladder with a total EQD2 > 80 Gy for bladder in only 17.2% versus 62.1% in conventional planning, and in rectum EQD2 > 75 Gy in 44.8% versus 79.3%, respectively. In conclusion, analyses revealed excellent results for the high-dose-rate IGBT in patients with advanced gynecological cancer both by using CT and MRI, and/or the combination with WP-IMRT. They also define MRI as gold standard for soft tissue assessment and to determine more accurately HR-CTV. The use of TAUS-guidance adds quality aspects to the "classical" conventional X-ray based planning, especially in terms of real-time measures and adequate soft tissue information, and may lower significantly the dose in OARs. The review of all UCP-results reconfirms the importance of the established program that will continue to operate with subsequent projects.

A comparative planning study of step-and-shoot IMRT versus helical tomotherapy for whole-pelvis irradiation in cervical cancer.

The aim of this study was to compare the dosimetric parameters of whole-pelvis radiotherapy (WPRT) for cervical cancer between step-and-shoot IMRT (SaS-IMRT) and Helical Tomotherapy™ (HT). Retrospective analysis was performed on 20 cervical cancer patients who received WPRT in our center between January 2011 and January 2014. SaS-IMRT and HT treatment plans were generated for each patient. The dosimetric values for target coverage and organ-at-risk (OAR) sparing were compared according to the criteria of the International Commission on Radiation Units and Measurements 83 (ICRU 83) guidelines. Differences in beam-on time (BOT) were also compared. All the PTV dosimetric parameters (D5%, D50% and D95%) for the HT plan were (statistically significantly) of better quality than those for the SaS-IMRT plan (P-value < 0.001 in all respects). HT was also significantly more accurate than SaS-IMRT with respect to the D98% and Dmean of the CTV (P-values of 0.008 and <0.001, respectively). The median Conformity Index (CI) did not differ between the two plans (P-value = 0.057). However, the Uniformity Index for HT was significantly better than that for SaS-IMRT (P-value < 0.001). The median of D50% for the bladder, rectum and small bowel were significantly lower in HT planning than SaS-IMRT (P-value < 0.001). For D2%, we found that HT provided better sparing to the rectum and bladder (P-value < 0.001). However, the median of D2% for the small bowel was comparable for both plans. The median of Dmax of the head of the left femur was significantly lower in the HT plan, but this did not apply for the head of the right femur. BOT for HT was significantly shorter than for SaS-IMRT (P-value < 0.001). HT provided highly accurate plans, with more homogeneous PTV coverage and superior sparing of OARs than SaS-IMRT. In addition, HT enabled a shorter delivery time than SaS-IMRT.

Two-year results of transabdominal ultrasound-guided brachytherapy for cervical cancer.

PURPOSE: To report the preliminary results of transabdominal ultrasound (TAUS)-guided brachytherapy (BT) in cervical cancer. METHODS AND MATERIALS: Twenty-nine patients with cervical cancer Stage IB-IVA according to The International Federation of Gynecology and Obstetrics staging were treated by radical radiotherapy from February 2012 to December 2012. Treatment was composed of WPRT to 50 Gy in 25 fractions and central shielding after 44 Gy in combination with TAUS-guided BT to optimize the total dose (equivalent dose of 2 Gy [EQD2]) to the minimal dose at cervical points (in EQD2 concepts) defined by TAUS ≥80 Gy while maintaining low doses to the ICRU report no. 38 bladder and rectal points. The treatment results and toxicity profiles were reported. RESULTS: At median followup time of 19 months (range, 17-27), the local control and disease-free survival rates were 93.1% and 86.2%, respectively. One episode of Grade 3 vaginal toxicity was observed in this followup period. The mean applied doses to cervix, bladder, and rectal points were 82.6, 72.5, and 75 Gy, respectively. TAUS-guided planning reduced bladder (defined as >80 Gy in EQD2) and rectal overdose (defined as >75 Gy in EQD2) in 44.9% and 34.5% of patients, respectively. CONCLUSION: The 2-year results demonstrate that TAUS-guided BT is feasible and associated with excellent tumor control/toxicity rates in cervical cancer.

The using of megavoltage computed tomography in image-guided brachytherapy for cervical cancer: a case report.

We present a case of cervical cancer treated by concurrent chemoradiation. In radiation therapy part, the combination of the whole pelvic helical tomotherapy plus image-guided brachytherapy with megavoltage computed tomography of helical tomotherapy was performed. We propose this therapeutic approach could be considered in a curative setting in some problematic situation as our institution.

A dosimetric comparison of two-phase adaptive intensity-modulated radiotherapy for locally advanced nasopharyngeal cancer.

The purpose of this investigation was to evaluate the potential dosimetric benefits of a two-phase adaptive intensity-modulated radiotherapy (IMRT) protocol for patients with locally advanced nasopharyngeal cancer (NPC). A total of 17 patients with locally advanced NPC treated with IMRT had a second computed tomography (CT) scan after 17 fractions in order to apply and continue the treatment with an adapted plan after 20 fractions. To simulate the situation without adaptation, a hybrid plan was generated by applying the optimization parameters of the original treatment plan to the anatomy of the second CT scan. The dose-volume histograms (DVHs) and dose statistics of the hybrid plan and the adapted plan were compared. The mean volume of the ipsilateral and contralateral parotid gland decreased by 6.1 cm(3) (30.5%) and 5.4 cm(3) (24.3%), respectively. Compared with the hybrid plan, the adapted plan provided a higher dose to the target volumes with better homogeneity, and a lower dose to the organs at risk (OARs). The Dmin of all planning target volumes (PTVs) increased. The Dmax of the spinal cord and brainstem were lower in 94% of the patients (1.6-5.9 Gy, P < 0.001 and 2.1-9.9 Gy, P < 0.001, respectively). The Dmean of the contralateral parotid decreased in 70% of the patients (range, 0.2-4.4 Gy). We could not find a relationship between dose variability and weight loss. Our two-phase adaptive IMRT protocol improves dosimetric results in terms of target volumes and OARs in patients with locally advanced NPC.

The association of rectal equivalent dose in 2 Gy fractions (EQD2) to late rectal toxicity in locally advanced cervical cancer patients who were evaluated by rectosigmoidoscopy in Faculty of Medicine, Chiang Mai University.

PURPOSE: To evaluate association between equivalent dose in 2 Gy (EQD2) to rectal point dose and gastrointestinal toxicity from whole pelvic radiotherapy (WPRT) and intracavitary brachytherapy (ICBT) in cervical cancer patients who were evaluated by rectosigmoidoscopy in Faculty of Medicine, Chiang Mai University. MATERIALS AND METHODS: Retrospective study was designed for the patients with locally advanced cervical cancer, treated by radical radiotherapy from 2004 to 2009 and were evaluated by rectosigmoidoscopy. The cumulative doses of WPRT and ICBT to the maximally rectal point were calculated to the EQD2 and evaluated the association of toxicities. RESULTS: Thirty-nine patients were evaluated for late rectal toxicity. The mean cumulative dose in term of EQD2 to rectum was 64.2 Gy. Grade 1 toxicities were the most common findings. According to endoscopic exam, the most common toxicities were congested mucosa (36 patients) and telangiectasia (32 patients). In evaluation between rectal dose in EQD2 and toxicities, no association of cumulative rectal dose to rectal toxicity, except the association of cumulative rectal dose in EQD2 >65 Gy to late effects of normal tissue (LENT-SOMA) scale ≥ grade 2 (p = 0.022; odds ratio, 5.312; 95% confidence interval, 1.269-22.244). CONCLUSION: The cumulative rectal dose in EQD2 >65 Gy have association with ≥ grade 2 LENT-SOMA scale.

The effect of central shielding in the dose reporting for cervical cancer in EQD2 era.

PURPOSE: To evaluate the cumulative dose at point A for three and four centimeters central shielding. MATERIAL AND METHODS: The plans of external beam radiotherapy plus conventional intracavitary brachytherapy were performed. Three or four centimeters central shieldings (after 44 Gy) were applied to the standard whole pelvis irradiation. Additional intracavitary brachytherapy 4 × 7 Gy at point A was prescribed, and the cumulative dose in EQD2 (α/ß = 10) of 3 cm and 4 cm central shielding were evaluated. RESULTS: The cumulative dose at point A in EQD2 (α/ß = 10) of 3 cm central shielding were 95.7 Gy for AR and 95.5 Gy for AL, while the cumulative dose at point As in EQD2 (α/ß = 10) of 4 cm central shielding were 90.8 Gy for AR and 91.2 Gy for AL. CONCLUSIONS: The 3 cm central shielding caused higher cumulative dose (in terms of EQD2 [α/ß = 10]) than 4 cm central shielding.

Image-guided brachytherapy (IGBT) combined with whole pelvic intensity-modulated radiotherapy (WP-IMRT) for locally advanced cervical cancer: a prospective study from Chiang Mai University Hospital, Thailand.

PURPOSE: A report of preliminary results and toxicity profiles using image-guided brachytherapy (IGBT) combined with whole pelvic intensity-modulated radiation therapy (WP-IMRT) for locally advanced cervical cancer. MATERIAL AND METHODS: Fifteen patients with locally advanced cervical cancer were enrolled into the study. WP-IMRT was used to treat the Clinical Target Volume (CTV) with a dose of 45 Gy in 25 fractions. Concurrent cisplatin (40 mg/m(2)) was prescribed during radiotherapy (RT) on weekly basis. IGBT using computed tomography was performed at the dose of 7 Gy × 4 fractions to the High-Risk Clinical Target Volume (HR-CTV). RESULTS: The mean cumulative doses - in terms of equivalent dose of 2 Gy (EQD2) - of IGBT plus WP-IMRT to HR-CTV, bladder, rectum, and sigmoid colon were 88.3, 85.0, 68.2 and 73.6 Gy, respectively. In comparison with standard (point A prescription) dose-volume histograms, volume-based image-guided brachytherapy improved the cumulative doses for bladder of 67%, rectum of 47% and sigmoid of 46%. At the median follow-up time of 14 months, the local control, metastasis-free survival and overall survival rates were 93%, 100% and 93%, respectively. No grade 3-4 acute and late toxicities were observed. CONCLUSION: The combination of image-guided brachytherapy and intensity-modulated radiotherapy improved the dose distribution to tumor volumes and avoided overdose in OARs which could be converted in excellent local control and toxicity profiles.

Preliminary results of MRI-guided brachytherapy in cervical carcinoma: the Chiangmai University experience.

This study was performed to evaluate the feasibility of magnetic resonance imaging (MRI) in the treatment planning of image-guided brachytherapy for cervical carcinoma. Seventeen consecutive patients with locally advanced cervical cancer were enrolled in the study. Fifteen patients could be evaluated. When comparing the tumor at diagnosis (GTV-Dx) and the tumor at the first brachytherapy (GTV-BT), 11 of 15 patients showed a tumor regression of more than 80% while only four patients had less than 80% tumor regression. The mean D90 of HR-CTV and the calculated D2cc of the bladder, rectum, and sigmoid were 99.2 ± 11 Gy, 87.7 ± 5.7 Gy, 68.4 ± 5.4 Gy and 70.3 ± 6.8 Gy, respectively. No grade 3-4 acute toxicity was observed. The MRI can be a valuable tool for evaluating tumor response after external beam radiotherapy (EBRT) and is very helpful for prognosis prediction by residual GTV evaluation. Furthermore, MRI-guided brachytherapy allowed us to optimize the dose for both the target volumes and the OARs.

Preliminary results of conformal computed tomography (CT)-based intracavitary brachytherapy (ICBT) for locally advanced cervical cancer: a single institution's experience.

Intracavitary brachytherapy using tandem and ovoids is an important component of definitive treatment for cervical cancer. In the present study, we analyzed the dose-volume histograms (DVHs) of the tumor volume and organs at risk including the sigmoid colon by CT-based treatment planning for high dose rate (HDR) intracavitary brachytherapy (ICBT) in cervical cancer. Seventeen patients with carcinoma of the cervix uteri were treated with external beam radiotherapy plus concurrent chemotherapy. For brachytherapy, the planning procedure started by performing a conventional plan which prescribed a dose of 6.5-7 Gy per fraction to point A, then optimized the dose based on CT imaging. Volumes and DVHs were calculated for the HR-CTV, bladder, rectum and sigmoid colon. The mean BED(2Gy) total doses of post-optimized plans of HR-CTV, bladder, rectum and sigmoid colon were: 89.6, 94.1, 74.0 and 69.8 Gy, respectively. For conventional plans, the calculated mean BED(2Gy) total doses of HR-CTV, bladder, rectum and sigmoid colon were 92.2, 120.1, 75.7 and 78.3 Gy, respectively. This study showed statistical significant higher BED(2Gy) total doses for bladder and sigmoid colon (p < 0.001) using conventional plans versus post-optimized, CT-based plans, while no difference between HR-CTV and rectum BED(2Gy) total doses could be detected. After a median follow-up of nineteen months, all seventeen patients had a clinical complete response. Two patients developed distant metastasis. Compared with conventional treatment, CT based brachytherapy planning was very effective in reducing doses to OARs, especially bladder and sigmoid colon whilst maintaining a high therapeutic dose for tumor target volumes in the treatment of cervical carcinoma.