Cervical Cancer Brachytherapy:

From Stockholm to GEC ESTRO

Case
28F C-section October 2013
Pap smear completed for abnormal looking cervix
HSIL

Multiple cervix biopsies (6/6)

Extensive high grade dysplasia w/o invasive disease

Referred to GyneOnc for management

EUA (cervical cone bx) and Laparascopic LSO (for left
quadrant pain)
Invasive SCC and Left ovary mature cystic teratoma

~4cm mass in cervix, with ~1cm extension into vagina,

clinical right parametrial extension

Stage: FIGO IIB

Case
GyneHx:
G1P1, no OCP use, ?prior Pap smear

PMHx:
Right synovial cell sarcoma of anterolateral thigh age 12
Adjuvant RT 1998 Total dose 64Gy
Insufficiency fracture 2007

Plan:
1. Concurrent CRT: EBRT 46Gy/23# + Cisplatin
Ovarian transposition prior to treatment

2.

Intracavitary Brachytherapy 30Gy/5# prescribed

to Point A

Case: Pre-treatment MRI

Brachytherapy
brachys (short) and therapeia (treatment)
therapeutic use of encapsulated radionuclides (ionizing
radiation) applied at the surface (intracavitary) or placed
within (interstitial) tumour or area at risk
Intracavitary
Interstitial
Intraluminal
Intravascular
Surface Applications
Permanents Seed (Prostate)

Brachytherapy
Advantages

High dose of radiation to target

Rapid dose fall-off to surrounding normal tissues due
to ISL
Lower energy photons

Disadvantages

Limited by access to tumour or area at risk

Afterloading vs. Manual loading
Source decay/storage/replacement

Intracavitary: Evolution
CLASSICAL:
-

Stockholm (1914), Paris (1910-1920)

Dose to specific point
Dose not accurately known
Based on source, strength, geometry and application
method

STOCKHOLM:

- Fractionated 226Ra
- 3#/1 month, each # ~20-30h
- Applicators:
- Intravaginal: Pb or Au
- Intrauterine: flexible rubber
- Unequal loading of uterus and
vagina
- Uterus: 30-90mg of radium
- Vagina: 60-80mg
- Dose = mg of 226Ra x hours
- Total dose ~ 6500-7100mg-h
- ~4500mg-h (vaginal

Intracavitary: Evolution
CLASSICAL:
-

Stockholm (1914), Paris (1910-1920)

Dose to specific point
Dose not accurately known
Based on source, strength, geometry and application
method

PARIS:
- Single fraction of 226Ra inserted for 5 days
- Equal loading of uterus and vagina
- Applicators:
- Intravaginal: 2 cylindrical cork colopostats
- Intrauterine: tube
- Dose = 7000-8000mg-h

Intracavitary: Revolution
MANCHESTER (2D)
- Radiograph based treatment planning
- 1st system to define dosimetry related to reference points
- Calculate dose at a specified distance for particular
geometry
- Point A
Revolution:
- Standardize treatments
- Correlate dose to Point A with clinical results

Intracavitary: Manchester
Dose:
- Delivered in 2 #; using 226Ra
- Each session: 72 hours, Interval ~ 4-7 days (No
EBRT)
- < dose to point A from vaginal sources
- Uniform dose in treated volume
- Goal: dose variation < 10%
Applicators
- Rubber Tandem
- 2 ellipsoid ovoids

Loading Scheme:
- Create same dose rate irrespective of applicator
arrangement
- Non-uniform distribution of source strength
- Tandem: 10 +10+15 (long); 10+15 (medium), 20mg
(short) 226Ra

Point A, B

Point A

2cm superior to external cervical os

2 cm lateral of midline
medial edge of broad ligament
Intersection of uterine vessels and ureter

Dose = 80Gy, Prescription point

Point B

2 cm superior to external cervical os

3 cm lateral of midline
pelvic side wall
Parametria/obturator nodes

Dose = to dose of Point A

Intracavitary: ICRU 38
(1985)
Recommendations:
Point A
Located in region of high dose gradient
Result in larger uncertainties in absorbed doses at this point

Defined target volume

Anatomically, contains soft tissue to be treated to specific dose

Dose
60Gy dose volume (EBRT +brachytherapy)

Bladder Point
Posterior surface of foley ballon on lateral x-ray
Foley filled 7cm3 radiopaque fluid and pulled down against urethra

Rectal Point
5mm behind posterior vaginal wall between ovoids
at inferior point of last intrauterine tandem source or mid-vaginal
source

ABS HDR Brachytherapy:

Point H

Point H

Intersection of mid-dwell positions of ovoids

2cm superior along tandem + radius of ovoid
2cm perpendicular to tandem
2cm from top of ovoids

Why?
Difficult to see Point A on radiographs
Point A was in high dose gradient

Intracavitary: CT Planning
(3D)

CCSEO- Ortho. Radiograph

Image-Based HDR
Brachytherapy Treatment

GEC-ESTRO: 3D Planning (2005)

Why?
GTV CTV, PTV, OARs & use of DVHs standardized
Delineation of GTV, CTV and PTV and critical organs
impacts Brachytherapy planning
MRI soft tissue delineation!!

GEC-ESTRO: 3D planning (2005)

Definitions:
GTV

Diagnosis GTVD
Defined for each fraction i.e. GTVB1, GTVB2
Clinical exam at diagnosis & at BT
On MRI (T2-weighted sequence) at diagnosis & at BT

High Risk CTV (HR CTV) = residual microscopic tumour

Major risk of LR because of macroscopic residual disease
Defined for each fraction HR CTVB1

Intermediate Risk CTV (IR CTV) = microscopic disease

Receive at least 60Gy
Defined for each fraction IR CTVB1

MR-HDR Brachytherapy PMCC

MRI to assess tumour response to EBRT EUA
Treatment (HDR/PDR) for each fraction

MRI with intrauterine applicator

MRI Dosimetrist define of GTV, HR CTV, IR CTV, CARs
RO approves contours
Physicists creates treatment plan
RO approves treatment plan

PDR:
36-40Gy at 60-80cGy/h

HDR:
30Gy in 5#

MR-HDR Brachytherapy

Implementing GEC-ESTR0
COSTS!
MRI dedicated for Radiation Oncology
OR time for EUA
MRI compatible tandems, ovoids/ring

TIME!

Dosimetrist
Physicist
Radiation Oncologist
Patient

Cancer Care Ontario

Recommendations:
MRI for delineation of target volumes and planning
CT planning acceptable if MRI not available
CT provides inferior soft-tissue delineation and cannot
accurately delineate target volumes
No high quality studies showing clinical superiority of 3D
over 2D planning

Ultrasound-guided insertions of uterine applicator

Program in Evidence Based Care: The Delivery of Brachytherapy for Cervical Cancer
Organizational and Technical Advice to Facilitate High-Quality Care in Ontario

Cancer Care Ontario

Recommendations:
MRI for delineation of target volumes and planning
CT planning acceptable if MRI not available
CT provides inferior soft-tissue delineation and cannot
accurately delineate target volumes
No high quality studies showing clinical superiority of 3D
over 2D planning

Ultrasound-guided insertions of uterine applicator

Program in Evidence Based Care: The Delivery of Brachytherapy for Cervical Cancer
Organizational and Technical Advice to Facilitate High-Quality Care in Ontario

Cancer Care Ontario

Recommendations:
Evidence supports use of 3D planning with CT or
MRI over 2D planning
MRI preferred imaging method
However high-quality clinical studies have not been
performed to demonstrate clinical superiority of 3D
versus 2D planning

Program in Evidence Based Care: The Delivery of Brachytherapy for Cervical Cancer
Organizational and Technical Advice to Facilitate High-Quality Care in Ontario

Cancer Care Ontario

Recommendations:
Fluoroscopy
Widely available, usually accessible in BT suite
Localize applicators, opaque packing and radiation
source (bony landmarks)
No visualization of target or OARs

CT availability and accessibility are variable

Program in Evidence Based Care: The Delivery of Brachytherapy for Cervical Cancer
Organizational and Technical Advice to Facilitate High-Quality Care in Ontario

EMBRACE
MRI guided BT in LACC
Prospective observational study
DVH parameters for clinical target volumes and OARs
with outcome

Develop prognostic and predictive models for

clinical outcomes
QOL Study
Accrual target: 1000
1000th patient enrolled November 6th 2013

Ernational study on MRI-guided BRachytherapy in locally Advanced CErvical can

References
Dr. C. Joshis lecture notes
Clinical Radiation Oncology, 3rd Edition, 2007 Gunderson, L.
GEC-ESTRO

1.
2.
3.
i.

ii.

Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (I):

concepts and terms in 3D image based 3D treatment planning in cervix cancer
brachytherapy with emphasis on MRI assessment of GTV and CTV
Recommendations from Gynaecological (GYN) GEC-ESTRO Working Group (II):
concepts and terms in 3D image based treatment planning in cervix cancer
brachytherapy 3D volume parameters and aspects of 3D image-based anatomy,
radiation physics, radiobiology

Cancer Care Ontario: Program in Evidence Based Care (PEBC) Radiation Therapy

4.
i.

Brachytherapy for Cervical Cancer Expert Working Group (BCCEWG)

EMBRACE

5.
i.

http://clinicaltrials.gov/ct2/show/NCT00920920