Educational article Outpatient combined intracavitary and interstitial cervical brachytherapy: barriers and solutions to implementation of a successful programme – a single institutional experience

Abstract

Involvement of parametrial disease in locally advanced cervical patients poses a challenge for women undergoing brachytherapy. Current use of the Fletcher suit applicator may not adequately cover the high risk clinical target volume (HR CTV), especially in the parametrial region due to the physical qualities of brachytherapy from the inverse square law and the need to respect organs at risk (OAR) constraints, and leads to lower local control rates. Combined intracavitary and interstitial brachytherapy with the use of 1 or 2 interstitial needles allows adequate coverage of the HR CTV and the clinical evidence have demonstrated a correlation with better clinical results. This procedure is often resource intensive, requiring inpatient stay and magnetic resonance imaging (MRI) planning. In departments where such resources are limited, there is a poor uptake of interstitial brachytherapy. This article discusses the technique of combined intracavitary and interstitial brachytherapy in an outpatient setting, and explores the issues and barriers for implementation and suggestions to overcome such barriers.

The role of interstitial brachytherapy in the management of primary radiation therapy for uterine cervical cancer

“…Hybrid brachytherapy is much easier to perform compared with ISBT because it only requires a few interstitial needles and could be performed in outpatient setting [11]. In contrast, ISBT demands time and labor, and forces the patients to lay on the bed overnight during treatment period.…”

“…Small tumors, which are within isodose line generated by conventional intracavitary brachytherapy (ICBT), consisted of intrauterine (tandem) and vaginal (ovoid/ring) sources, calculated based on the traditional Manchester principles [3, 4], can be well controlled. Tumors, which are slightly larger than isodose volume created by ICBT, can be well treated by image-guided adaptive brachytherapy (IGABT) [5, 6, 7, 8] with or without additional interstitial needle insertion (hybrid brachytherapy – HBT) [9, 10, 11, 12]. On the other hand, guidelines from the American Brachytherapy Society recommends high-dose-rate (HDR) interstitial brachytherapy (ISBT) for cervical cancer patients in certain clinical situations such as bulky lesions, a narrow vaginal apex, inability to enter the cervical os, extension to the lateral parametria or pelvic sidewall, and lower vaginal extension [1].…”

Optimum organ volume ranges for organs at risk dose in cervical cancer intracavitary brachytherapy

“…For all cases, the CTV HR was the cervix with no parametrical extension at time of brachytherapy. Therefore, all of these patients were candidates for intracavitary HDR tandem-ovoid brachytherapy without interstitial needles [ 18 ]. These patients were in different stages (IB2, IB, IIB) according to the FIGO staging [ 19 ].…”

Model assessment of individual tumor control rate and adverse effects in comparing locally advanced cervical cancer treatment using intracavitary with and without interstitial brachytherapy

“…This development modified the standard loading pattern to conform the target shape or to avoid dose to OAR [3], and facilitated the development of inverse planning processes in gynecologic cases [4, 5, 6]. For bulky and asymmetrical tumors with residual parametrial involvement at the time of BT, the use of intracavitary combined with interstitial brachytherapy (IC/IS BT) [7, 8, 9] has offered another option to improve the dose coverage for locally advanced cervical cancer. However, its implementation has not been widespread and the clinical results in terms of using IC/IS are yet to be determined.…”