American Brachytherapy Society Task Group Report: Combined external beam irradiation and interstitial brachytherapy for base of tongue tumors and other head and neck sites in the era of new technologies

GEC-ESTRO recommendations for head & neck cancer brachytherapy (interventional radiotherapy): 2nd update with focus on HDR and PDR

Modern brachytherapy (BT) is playing an important role in the multidisciplinary treatment of Head and Neck (H&N) cancer, as an organ- and function-preserving therapy. Low-dose-rate (LDR) technology has been replaced by modern remote afterloading and stepping source equipment using pulsed dose rate (PDR) or high dose rate (HDR) sources, improved image guidance and 3D treatment planning systems. This is an update of the previous GEC-ESTRO recommendations for H&N tumors, mainly applied to squamous carcinomas. Indications, results and recommended doses for different tumor sites are presented according to the published studies.

An end-to-end deep convolutional neural network-based dose engine for parotid gland cancer seed implant brachytherapy

BACKGROUND

Seed implant brachytherapy (SIBT) is a promising treatment modality for parotid gland cancers (PGCs). However, the current clinical standard dose calculation method based on the American Association of Physicists in Medicine (AAPM) Task Group 43 (TG-43) Report oversimplifies patient anatomy as a homogeneous water phantom medium, leading to significant dose calculation errors due to heterogeneity surrounding the parotid gland. Monte Carlo Simulation (MCS) can yield accurate dose distributions but the long computation time hinders its wide application in clinical practice.

PURPOSE

This paper aims to develop an end-to-end deep convolutional neural network-based dose engine (DCNN-DE) to achieve fast and accurate dose calculation for PGC SIBT.

METHODS

A DCNN model was trained using the patient's CT images and TG-43-based dose maps as inputs, with the corresponding MCS-based dose maps as the ground truth. The DCNN model was enhanced based on our previously proposed model by incorporating attention gates (AGs) and large kernel convolutions. Training and evaluation of the model were performed using a dataset comprising 188 PGC I-125 SIBT patient cases, and its transferability was tested on an additional 16 non-PGC head and neck cancers (HNCs) I-125 SIBT patient cases. Comparison studies were conducted to validate the superiority of the enhanced model over the original one and compare their overall performance.

RESULTS

On the PGC testing dataset, the DCNN-DE demonstrated the ability to generate accurate dose maps, with percentage absolute errors (PAEs) of 0.67% ± 0.47% for clinical target volume (CTV) D90 and 1.04% ± 1.33% for skin D0.1cc. The comparison studies revealed that incorporating AGs and large kernel convolutions resulted in 8.2% (p < 0.001) and 3.1% (p < 0.001) accuracy improvement, respectively, as measured by dose mean absolute error. On the non-PGC HNC dataset, the DCNN-DE exhibited good transferability, achieving a CTV D90 PAE of 1.88% ± 1.73%. The DCNN-DE can generate a dose map in less than 10 ms.

CONCLUSIONS

We have developed and validated an end-to-end DCNN-DE for PGC SIBT. The proposed DCNN-DE enables fast and accurate dose calculation, making it suitable for application in the plan optimization and evaluation process of PGC SIBT.

Automatic planning for head and neck seed implant brachytherapy based on deep convolutional neural network dose engine

BACKGROUND

Seed implant brachytherapy (SIBT) is an effective treatment modality for head and neck (H&N) cancers; however, current clinical planning requires manual setting of needle paths and utilizes inaccurate dose calculation algorithms.

PURPOSE

This study aims to develop an accurate and efficient deep convolutional neural network dose engine (DCNN-DE) and an automatic SIBT planning method for H&N SIBT.

METHODS

A cohort of 25 H&N patients who received SIBT was utilized to develop and validate the methods. The DCNN-DE was developed based on 3D-unet model. It takes single seed dose distribution from a modified TG-43 method, the CT image and a novel inter-seed shadow map (ISSM) as inputs, and predicts the dose map of accuracy close to the one from Monte Carlo simulations (MCS). The ISSM was proposed to better handle inter-seed attenuation. The accuracy and efficacy of the DCNN-DE were validated by comparing with other methods taking MCS dose as reference. For SIBT planning, a novel strategy inspired by clinical practice was proposed to automatically generate parallel or non-parallel potential needle paths that avoid puncturing bone and critical organs. A heuristic-based optimization method was developed to optimize the seed positions to meet clinical prescription requirements. The proposed planning method was validated by re-planning the 25 cases and comparing with clinical plans.

RESULTS

The absolute percentage error in the TG-43 calculation for CTV V100 and D90 was reduced from 5.4% and 13.2% to 0.4% and 1.1% with DCNN-DE, an accuracy improvement of 93% and 92%, respectively. The proposed planning method could automatically obtain a plan in 2.5 ± 1.5 min. The generated plans were judged clinically acceptable with dose distribution comparable with those of the clinical plans.

CONCLUSIONS

The proposed method can generate clinically acceptable plans quickly with high accuracy in dose evaluation, and thus has a high potential for clinical use in SIBT.

Status of head and neck brachytherapy in Spain in 2022

PURPOSE

Brachytherapy (BT) has been used for many years for disease control in tumours of the head and neck area (H&N). It is currently performed with high dose rate (HDR) or pulsed dose rate (PDR), but its use has been reduced due to the implementation of new non-invasive external beam radiotherapy techniques such as intensity modulation (IMRT) and volumetric modulated arc therapy (VMAT) and the improvement of surgical techniques.

METHODS

The Spanish Brachytherapy Group (GEB) has carried out a survey to find out the number of centres in Spain that continue to use BT in H&N and its indications and expectations for the future.

RESULTS

The results were presented at the XX GEB Consensus Meeting held on October 21, 2022, in Valencia (Spain) and it was confirmed that, although there are fewer and fewer centres that use BT in H&N, there are still units with extensive experience in this technique that should be positioned as referral centres.

CONCLUSION

It is necessary to carry out continuous work with other specialities involved, such as H&N surgeons, and other radiation oncologists, to improve the training of residents, both oncologists and medical physicists.

Interstitial Brachytherapy for Lip Cancer: Technical Aspects to Individualize Treatment Approach and Optimize Outcomes

Primary radiation therapy using interstitial brachytherapy (IBT) provides excellent local tumor control for early-stage squamous cell carcinoma of the lip. Technical aspects of treatment are important to optimize outcomes. In this report, we discuss patient selection criteria, procedural details, and dosimetric considerations for performing IBT for cancers of the lip. Catheters are inserted across the length of tumor entering and exiting approximately 5 mm beyond the palpable tumor extent. A custom mouthpiece is fabricated to facilitate normal tissue sparing. Patients undergo computed tomography imaging, the gross tumor volume is contoured based on physical examination and computed tomography findings, and an individualized brachytherapy plan is generated with the goals of achieving gross tumor volume D90% ≥ 90% and minimizing V150%. Ten patients with primary (n = 8) or recurrent (n = 2) cancers of the lip who received high-dose-rate lip IBT using 2.0- to 2.5-week treatment regimens are described (median prescription: 47.6 Gy in 14 fractions of 3.4 Gy). Local tumor control was 100%. There were no cases of acute grade ≥4 or late grade ≥2 toxicity, and cosmesis scores were graded as good to excellent in all patients. IBT represents an excellent treatment option for patients with lip squamous cell carcinoma. With careful attention to technical considerations furthered described in the present report, high rates of tumor control, low rates of toxicity, and favorable esthetic and functional outcomes can be achieved with IBT for lip cancer.

Nursing management of patients receiving interstitial brachytherapy for head and neck malignancies

Brachytherapy is a type of radiation therapy in which the radioactive source is directly delivered to the tumor and is used to treat a variety of malignancies. Although the local control effect of brachytherapy is higher than that of external beam radiation therapy (EBRT), it is often the case that brachytherapy is more invasive than conventional EBRT. As a result, patients receiving head and neck brachytherapy confront several physical, nutritional, and pain management issues. The nurses caring for patients with head and neck cancer receiving high-dose rate interstitial brachytherapy (ISBT) should have a thorough understanding of radiation therapy principles, technology, applicator management, and the acute and chronic side effects of ISBT. However, there are no appropriate textbooks or review articles regarding nursing care for head and neck patients undergoing ISBT. The purpose of this article is to provide radiation oncologists and nurses who want to start head and neck ISBT with a comprehensive guide regarding nursing care and to help the wide spread of this treatment strategy.

Function Preservation in Head and Neck Cancers

The treatment of head and neck cancers can have a significant impact on function and appearance, which results in impairment of quality of life. Various long-term sequelae of treatment include speech and swallowing difficulty, oral incompetence, trismus, xerostomia, dental caries and osteoradionecrosis. Management has evolved from single modality treatment of either surgery or radiation to multimodality treatment to attain acceptable functional outcomes. Brachytherapy, also known as interventional radiotherapy, with its ability to deliver high doses centrally to the target, has been shown to improve local control rates. Due to the rapid fall-off of the dose of brachytherapy there is better organ at risk sparing as compared with that of external beam radiotherapy. In the head and neck region, brachytherapy has been practiced in various sites, including the oral cavity, oropharynx, nasopharynx, nasal vestibule and paranasal sinuses. Additionally, brachytherapy has also been considered for reirradiation as a salvage. Brachytherapy can also be considered as a perioperative technique together with surgery. Close multidisciplinary cooperation is required for a successful brachytherapy programme. In oral cavity cancers, depending on the location of the tumour, brachytherapy has been shown to preserve oral competence, maintain tongue mobility, maintain speech, swallowing and the hard palate. Brachytherapy in oropharyngeal cancers has been shown to reduce xerostomia and also reduce dysphagia and aspiration post-radiation therapy. For the nasopharynx, paranasal sinus and nasal vestibule, brachytherapy preserves the respiratory function of the mucosa. Despite such an incomparable impact on function and organ preservation, brachytherapy is an underutilised technique for head and neck cancers. There is a strong need to improve brachytherapy utilisation in head and neck cancers.

Clinical features and treatment outcomes for primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder: a retrospective cohort study from the Dana-Farber Cancer Institute and updated literature review

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (PCSM-TCLPD) was reclassified in 2016 as a rare benign entity with an excellent prognosis, yet its clinical features and best treatments remain poorly defined. We collected clinical data, treatments, and treatment-responses from our institution's patients with PCSM-TCLPD through September 2018 and an identical PubMed review through June 2021. Among 36 cases (median-age 54 years; 58.3% head/neck), diagnostic biopsy resulted in sustained complete remission (CR) in 13/33 punch/shave biopsies and 3/3 excisional biopsies. The remaining 20 patients further required topical corticosteroids (n = 5); intralesional corticosteroids (n = 1); surgical-excision (n = 5); electron-beam-radiation (n = 6); or brachytherapy (n = 3). All patients ultimately achieved CR, excluding one patient continuing treatment at end-of-study. 57/59 (96.6%) of institutional and literature-reported radiation-treated patients experienced CR. No institutional cases progressed beyond skin; 5/209 (2.4%) literature-reported cases progressed to systemic/extracutaneous involvement, all pre-reclassification. PCSM-TCLPD responds well to local-directed therapy including radiation, and only rarely if ever progresses.

The efficacy and safety of 125I brachytherapy combined with pre-operative transarterial chemoembolization in patients with locally advanced head and neck cancer

Objective

To evaluate the safety and effectiveness of Iodine-125 (¹²⁵I) brachytherapy combined with pre-operative transarterial chemoembolization in patients with locally advanced head and neck cancer.

Methods

In this study, a total of thirty-seven individuals suffering from locally advanced head and neck cancer were involved. The patients were subjected to transarterial chemoembolization as well as implantation of ¹²⁵I seeds under the guidance of CT and ultrasonography. Follow-up was conducted for 36 months to study the following parameters: the local control rate, survival rate, and clinical complications.

Results

In total, thirty-six patients at the end of three months showed an objective response rate of 69.8% and disease control rate of 93.0%, respectively. The 1, 2, and 3-year cumulative overall survival rate was 89.2%, 73.0%, and 45.9%, respectively. The adverse events of the treatment included infection (n=1, Grade III), radiation brachial plexus injury (n=1, Grade III), leukopenia (n=1, Grade III), cerebrovascular embolism (n=1, Grade IV).

Conclusion

The combination of ¹²⁵I brachytherapy and pre-operative transarterial chemoembolization was safe and effective in patients with locally advanced head and neck cancer.

Results of sole postoperative interstitial, high-dose-rate brachytherapy of T1–2 tongue tumours

Purpose

To describe the results of treating tongue cancer patients with single postoperative interstitial, high-dose-rate (HDR) brachytherapy (BT) after resection.

Methods

Between January 1998 and April 2019, 45 patients with squamous cell histology, stage T1–2N0–1M0 tongue tumours were treated by surgery followed by a single HDR BT in case of negative prognostic factors (close or positive surgical margin, lymphovascular and/or perineural invasion). The average dose was 29 Gy (range: 10–45 Gy) and rigid metal needles were used in 11 (24%) and flexible plastic catheters in 34 cases (76%). Survival parameters, toxicities and the prognostic factors influencing survival were analysed.

Results

During a mean follow-up of 103 months (range: 16–260 months) for surviving patients, the 10-year local and regional control (LC, RC), overall survival (OS), and disease-specific survival (DSS) probabilities were 85, 73, 34 and 63%, respectively. The incidence of local grade 1, 2 and 3 mucositis was 23, 73 and 4%, respectively. As a serious (grade 4), late side effect, soft tissue necrosis developed in 3 cases (7%). In a univariate analysis, there was a significant correlation between lymphovascular invasion and RC (p = 0.0118) as well as cervical recurrence and DSS (p < 0.0001).

Conclusion

Sole postoperative HDR brachytherapy can be an effective method in case of negative prognostic factors in the treatment of early, resectable tongue tumours. Comparing the results of patients treated with postoperative BT to those who were managed with surgery or BT alone known from the literature, a slightly more favourable LC can be achieved with the combination therapy, demonstrating the potential compensating effect of BT on adverse prognostic factors, while the developing severe, grade 4 toxicity rate remains low.

Gel spacer to protect carotid artery and reconstructed jejunum in image-guided interstitial brachytherapy for recurrent hypopharyngeal cancer: a technical report

In this technical report, patient with total pharyngolaryngectomy and jejunum interposition experienced lymph node metastasis in the reconstructed mesenteric lymph nodes. Because this patient received 45 Gy of whole neck radiation therapy 24 years ago and small bowel's tolerance dose of the reconstructed jejunum was considered to be low, spacer gel injection was applied during image-guided interstitial brachytherapy to decrease doses to the reconstructed jejunum and previously irradiated carotid artery.

Brachytherapy and non-cancer mortality in patients with oral cavity and oropharynx SCCs

BACKGROUND

Oral cavity and oropharyngeal squamous cell cancers (OC-OPSCC) display high cancer-specific mortality and increased non-cancer mortality. We examined cause of death in patients treated for OC-OPSCC with brachytherapy, chemotherapy, external beam radiation, surgery, or combination of modalities. We hypothesized that brachytherapy does not increase non-cancer mortality comparably with external beam radiation.

METHODS

A database was constructed from institutional tumor registry and electronic medical record data from all patients with first OC-OPSCC diagnosis at our institution between 2000 and 2010, excluding patients with a second primary cancer at diagnosis. The primary outcome was association between treatment modality and non-cancer mortality.

RESULTS

Of 693 eligible patients, 460 were deceased; 84 from primary malignancy and 96 from a non-primary cancer cause, including 24 with a second primary cancer. 193 patients received brachytherapy. Cox proportional hazards regression was performed on treatment regimen, stratified by AJCC stage, race, and sex. Age, smoking history, and alcohol had HRs for death of 1.05 (p < 0.005), 1.37 (p = 0.106), and 2.24 (p < 0.005), respectively, while brachytherapy had a 0.53 HR (p < 0.005) for death. Non-smoking OPC patients had an 88% 5-year OS, suggesting these were largely HPV-driven cancers. In smoking OPC patients, 5-year OS was 61%. Non-cancer mortality HR of 0.36 for brachytherapy-treated patients.

CONCLUSION

We report non-cancer mortality from a cohort of curatively treated OC-OPSCC and show a significant correlation between brachytherapy and non-cancer survival, independent of remission status. The impact of brachytherapy in OPC was strongest in smokers.

The Accuracy of Individualized 3D-Printing Template-Assisted I125 Radioactive Seed Implantation for Recurrent/Metastatic Head and Neck Cancer

Purpose

To evaluate the accuracy of individualized 3D-printing template-assisted I¹²⁵ radioactive seed implantation (3D-PT assisted I¹²⁵ RSI) for recurrent/metastatic head and neck cancer.

Materials and Methods

From February 2017 to January 2020, clinical data of 41 patients (mean age, 58.5 ± 16.1 years; 28 males) with recurrent (48.8%)/metastatic (51.2%) head and neck cancer underwent individualized 3D-PT assisted I¹²⁵ RSI under CT guidance in a single institute were retrospectively reviewed. Total 430 seed needles [mean, 10.5 (range 3–17) per patient] were inserted.

Results

All seed needles were inserted manually in a single attempt with the technical success rate of 100% without major perioperative complications. The mean needle’s entrance deviation was 0.090 cm (95% Confidence Interval, 0.081–0.098). The mean intraoperative depth and angle of the needle were consistent with that of planned (6.23 ± 0.24 vs. 6.21 ± 0.24 cm, p = 0.903; 83.14 ± 3.64 vs. 83.09 ± 3.66 degrees, p = 0.985, respectively). The mean deviation between the needle’s planned and intraoperative depth and angle was 0.168 ± 0.024 cm and 1.56 ± 0.14 degrees, respectively. The postoperative dosimetry parameters, including D90, D100, V100, V150, V200, conformity index, external index, and homogeneity index, were all well-coordinated with planned dosimetry without significant difference (p = 0.515, 0.662, 0.958, 0.865, 0.872, 0.278, 0.456, and 0.989, respectively).

Conclusions

Within the limitation of this study, individualized 3D-PT assisted I¹²⁵ RSI may be accurate in obtaining favorable postoperative dosimetry for patients with recurrent/metastatic head and neck cancer.

Clinical Trial Registration

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Results of postoperative interstitial brachytherapy of resectable floor of mouth tumors

PURPOSE

The purpose of this study was to describe the results of postoperative sole interstitial brachytherapy (BT) in patients with resectable floor of mouth tumors.

METHODS AND MATERIALS

Between January 1998 and December 2017, 44 patients with squamous cell histology, stage T1-3N0-1M0 floor of mouth tumor were treated by excision of the primary lesion with or without neck dissection followed by sole high-dose-rate tumor bed BT with an average dose of 22.7 Gy (10-45 Gy) using rigid metal needles (n = 14; 32%) or flexible plastic catheters (n = 30; 68%).

RESULTS

During a median followup time of 122 months for surviving patients, the probability of 5- and 10-year local and regional tumor control, overall survival (OS), and disease-specific survival (DSS) was 89% and 89%, 73% and 67%, 52% and 32%, 66% and 54%, respectively. In univariate analysis, lymphovascular invasion was a negative predictor of regional tumor control (p = 0.0062), DSS (p = 0.0056), and OS (p = 0.0325), whereas cervical recurrence was associated with worse DSS (p < 0.0001) and OS (p < 0.0001). The incidence of local Grade 1, 2, and 3 mucositis was 25%, 64%, and 11%, respectively. Grade 4 side effect, that is soft tissue necrosis occurred in four cases (9%).

CONCLUSIONS

Results of postoperative sole high-dose-rate BT of floor of mouth tumors are comparable with those reported with low-dose-rate BT, and this method could improve local tumor control and DSS compared with exclusive surgical treatment.

Image-guided interstitial brachytherapy boost for nasopharyngeal carcinoma: technical aspects

Nasopharyngeal cancer generally responds well to concurrent chemoradiotherapy (CCRT). However, there is a small group of patients who respond poorly to CCRT, and experience local residual tumor or local relapse. Although several attempts have been performed to such a group of patients including re-irradiation with external beam radiation therapy (EBRT) or salvage surgery, clinical results remain unsatisfactory. Intracavitary brachytherapy (ICBT) boost after CCRT with EBRT has been explored, however, its efficacy is limited to those with superficial residual tumors. For those residual tumors thickness with more than 5 mm, interstitial brachytherapy (ISBT) boost would be an appropriate modality of choice. Here, we describe technical aspects of the high-dose-rate interstitial brachytherapy (HDR-ISBT) boost for nasopharyngeal cancer (NPC) patients who responded poorly to the CCRT with EBRT.

Image guided high-dose-rate brachytherapy versus volumetric modulated arc therapy for head and neck cancer: A comparative analysis of dosimetry for target volume and organs at risk

Background The aim of the study was to present dosimetric comparison of image guided high-dose-rate brachytherapy (IGBT) with volumetric modulated arc therapy (VMAT) for head and neck cancer regarding conformity of dose distribution to planning target volume (PTV) and doses to organs at risk (OARs). Patients and methods Thirty-eight consecutive patients with T1-4 mobile tongue, floor of mouth and base of tongue cancer treated with IGBT were selected. For these patients additional VMAT treatment plans were also prepared using identical computed tomography data. OARs and PTV related parameters (e.g. V98, D0.1cm3, Dmean, etc.) were compared. Results Mean V98 of the PTV was 90.2% vs. 90.4% (p > 0.05) for IGBT and VMAT, respectively. Mean D0.1cm3 to the mandible was 77.0% vs. 85.4% (p < 0.05). Dmean to ipsilateral and contralateral parotid glands was 4.6% vs. 4.6% and 3.0% vs. 3.9% (p > 0.05). Dmean to ipsilateral and contralateral submandibular glands was 16.4% vs. 21.9% (p > 0.05) and 8.2% vs. 16.9% (p < 0.05), respectively. Conclusions Both techniques showed excellent target coverage. With IGBT dose to normal tissues was lower than with VMAT. The results prove the superiority of IGBT in the protection of OARs and the important role of this invasive method in the era of new external beam techniques.

Comparison of the IPSA and HIPO algorithms for interstitial tongue high-dose-rate brachytherapy

Purpose

This study aimed to compare the inverse planning simulated annealing (IPSA) stochastic algorithm with the hybrid inverse planning and optimization (HIPO) algorithm for interstitial tongue high-dose-rate (HDR) brachytherapy.

Methods

Twenty patients who received radiotherapy for tongue cancer using interstitial HDR brachytherapy were retrospectively selected for this study. Oncentra Brachy v. 4.3 was used for IPSA and HIPO planning. Four to eight fixed catheter configurations were determined according to the target shape. During the optimization process, predetermined constrain values were used for each IPSA and HIPO plan. The dosimetric parameters and dwell time were analyzed to evaluate the performances of the plans.

Results

The total dwell time using IPSA was 4 seconds longer than that of HIPO. The number of active positions per catheter for the IPSA plans were approximately 2.5 fewer than those of the HIPO plans. The dose-volumetric parameters related to the clinical target volume with IPSA were lower than those with HIPO. In terms of the dose-volumetric parameters related to normal tissue, HIPO tended to associate with slightly higher values than IPSA, without statistical significance. After GrO, the target coverages were satisfied to clinical goal for all patients. The total dwell times was approximately increased by 10%.

Conclusions

The IPSA and HIPO dose optimization algorithms generate similar dosimetric results. In terms of the dwell time, HIPO appears to be more beneficial.

Dose-volume analysis of target volume and critical structures in computed tomography image-based multicatheter high-dose-rate interstitial brachytherapy for head and neck cancer

Purpose

To evaluate dose-volume relationships of target volume and critical structures in computed tomography (CT) image-based brachytherapy for head and neck cancer.

Material and methods

Thirty-seven patients with mobile tongue, floor of mouth, and base of tongue cancer treated with brachytherapy (post-operative alone and as a boost after external beam radiotherapy [EBRT], or definitive alone or as a boost after EBRT) were selected. Treatment plans were made using post-implant CT images. The fractionation schedule was 7-15 × 3-5 Gy for post-operative (with or without EBRT), 14-15 × 3 Gy for definitive alone, and 5-10 × 3 Gy for boost treatments. For the target volume, V₁₀₀, D₉₀, and dose non-uniformity ratio (DNR) were calculated. For the mandible, spinal cord and salivary glands doses to specified volumes were reported.

Results

The median values of V₁₀₀ and D₉₀ were 89.9% and 99.9%, respectively; the median values of DNR was 0.46. The median D_2cm³ of the mandible and spinal cord were 48.3% and 5.8%, respectively. The ipsilateral median D_2cm³ of parotid and submandibular glands were 6.4% and 12.5%, whereas on the contralateral side, the corresponding values were 5.3% and 7.0%, respectively.

Conclusions

Using conformal treatment planning, it was desirable to keep the dose to the mandible, spinal cord, and salivary glands at an acceptable level. The quantitative plan evaluation may help us find correlations between dosimetric parameters and clinical outcome, which may lead to improve the quality of the treatment, but it requires longer follow-up and results from other studies.

Vaginal cuff brachytherapy in endometrial cancer - a technically easy treatment?

Endometrial cancer (EC) is one of the most common gynecological cancers among women in the developed countries. Vaginal cuff is the main location of relapses after a curative surgical procedure and postoperative radiation therapy have proven to diminish it. Nevertheless, these results have not translated into better survival results. The preeminent place of vaginal cuff brachytherapy (VCB) in the postoperative treatment of high- to intermediate-risk EC was given by the PORTEC-2 trial, which demonstrated a similar reduction in relapses with VCB than with external beam radiotherapy (EBRT), but VCB induced less late toxicity. As a result of this trial, the use of VCB has increased in clinical practice at the expense of EBRT. A majority of the clinical reviews of VCB usually address the risk categories and patient selection but pay little attention to technical aspects of the VCB procedure. Our review aimed to address both aspects. First of all, we described the risk groups, which guide patient selection for VCB in clinical practice. Then, we depicted several technical aspects that might influence dose deposition and toxicity. Bladder distension and rectal distension as well as applicator position or patient position are some of those variables that we reviewed.