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Kamio Y, Roy MÈ, Morgan LA, Barkati M, Beauchemin MC, DeBlois F, Basaric B, Carrier JF, Bedwani S. The Montreal split ring applicator: Towards highly adaptive gynecological brachytherapy using 3D-printed biocompatible patient-specific interstitial caps. J Contemp Brachytherapy 2023; 15:453-464. [PMID: 38230395 PMCID: PMC10789156 DOI: 10.5114/jcb.2023.133676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose The addition of interstitial (IS) needles to intra-cavitary (IC) brachytherapy applicators is associated with improved outcomes in locally advanced cervical cancers involving parametrial tumor extensions. The purpose of this work was to validate a clinical workflow involving 3D-printed caps for a commercial IC split ring applicator that enable using IS needle trajectories tailored to each treatment. Material and methods A dedicated software module was developed in this work allowing users to design patient-specific IS caps without knowledge of computer-aided design (CAD) software. This software module was integrated to 3D Brachy, a commercial software developed by Adaptiiv Medical Technologies Inc. For validation of the workflow, CAD models of ground truth caps with five IS needle trajectories were designed with Fusion 360™, 3D-printed, assembled with a split ring applicator, and CT-scanned with radio-opaque markers. 3D Brachy was then applied to generate a replica based on trajectories reconstructed from the radio-opaque markers. A comparison between ground truth and replicated IS needle trajectories was done using intersection points with planes at the level of the cervix (z = 0 cm) and a representative needle depth (z = 3 cm). Results Prototypes of interstitial caps 3D-printed in both BioMed Amber and BioMed Clear SLA resins were tested to be functional both pre- and post-sterilization for IS needles with obliquity angles ≤ 45°. Distance-to-agreement at z = 0 cm and 3 cm as well as deviations in pitch and yaw angles of the five IS needle trajectories were found to have mean values of 3.3 ±2.1 mm, 7.3 ±2.0 mm, 2.9° ±2.3°, and 7.0° ±7.0°, respectively. Conclusions The clinical workflow for image-guided adaptive cervical cancer brachytherapy using the Montreal split ring applicator was validated.
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Affiliation(s)
- Yuji Kamio
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Pharmacologie et Physiologie, Université de Montréal, Montréal, QC, Canada
| | - Marie-Ève Roy
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | | | - Maroie Barkati
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | | | - François DeBlois
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
| | - Borko Basaric
- Adaptiiv Medical Technologies Inc., Halifax, NS, Canada
| | - Jean-François Carrier
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
| | - Stéphane Bedwani
- Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
- Centre de Recherche du CHUM (CRCHUM), Montréal, QC, Canada
- Département de Physique, Université de Montréal, Montréal, QC, Canada
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Brunnhoelzl D, Hanania AN, Echeverria A, Sunde J, Tran C, Ludwig M. Paracervical blocks facilitate timely brachytherapy amidst COVID-19. Brachytherapy 2020; 20:284-289. [PMID: 32891569 PMCID: PMC7413110 DOI: 10.1016/j.brachy.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE The COVID-19 pandemic presents serious challenges for brachytherapists, and in the time-sensitive case of locally advanced cervical cancer, the need for curative brachytherapy (BT) is critical for survival. Given the high-volume of locally advanced cervical cancer in our safety-net hospital, we developed a strategy in close collaboration with our gynecology oncology and anesthesia colleagues to allow for completely clinic-based intracavitary brachytherapy (ICBT). METHODS AND MATERIALS This technical report will highlight our experience with the use of paracervical blocks (PCBs) and oral multimodal analgesia (MMA) for appropriately selected cervical ICBT cases, allowing for completely clinic-based treatment. RESULTS 18 of 19 (95%) screened patients were eligible for in-clinic ICBT. The excluded patient had significant vaginal fibrosis. 38 of 39 intracavitary implants were successfully transitioned for entirely in-clinic treatment utilizing PCBs and oral MMA (97% success rate). One case was aborted due to inadequate analgesia secondary to a significantly delayed case start time (PO medication effect diminished). 95% of patients reported no pain at the conclusion of the procedure. The median (IQR) D2cc for rectum and bladder were 64.8 (58.6-70.2) Gy and 84.1 (70.9-89.4) Gy, respectively. Median (IQR) CTV high-risk D90 was 88.0 (85.6-89.8) Gy. CONCLUSIONS In a multidisciplinary effort, we have successfully transitioned many ICBT cases to the clinic with the use of PCB local anesthesia and oral multimodality therapy in direct response to the current pandemic, thereby mitigating exposure risk to patients and staff as well as reducing overall health care burden.
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Affiliation(s)
- Daniel Brunnhoelzl
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center Baylor College of Medicine, Houston, TX
| | - Alexander N Hanania
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center Baylor College of Medicine, Houston, TX
| | - Alfredo Echeverria
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center Baylor College of Medicine, Houston, TX
| | - Jan Sunde
- Department of Gynecologic Oncology, Baylor College of Medicine, Houston, TX
| | - Connie Tran
- Department of Anesthesia, Baylor College of Medicine, Houston, TX
| | - Michelle Ludwig
- Department of Radiation Oncology, Dan L. Duncan Comprehensive Cancer Center Baylor College of Medicine, Houston, TX.
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Zhang D, Yang Z, Jiang S, Zhou L, Zhou Z, Wang W. Individualized and inverse optimized needle configuration for combined intracavitary-interstitial brachytherapy in locally advanced cervical cancer. J Cancer Res Ther 2020; 15:1589-1596. [PMID: 31939442 DOI: 10.4103/jcrt.jcrt_292_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives The aim of this study is to address the limitation of combined intracavitary-interstitial (IC/IS) brachytherapy (BT) in locally advanced cervical cancer using standardized applicators and to determine the optimal dose distribution in patients with challenging tumors, innovative methods of customizing and optimizing the IS needle configuration for combined IC/IS BT are proposed and investigated. Materials and Methods A software module that could customize the IS needle configuration and subsequently generate the digital model of guiding template for three-dimensional printing was developed and integrated into our in-house treatment planning system for BT. The inverse optimization method based on the technique of mixed-integer linear programming was introduced to determine the needle tracks out of a candidate pool and dwell times at corresponding locations to best meet dose objectives. A treatment planning study was conducted to evaluate the feasibility and performance of the proposed methods. Results The workflow for combined IC/IS BT with customized and inverse optimized IS needle configuration was presented. Dosimetric results of the treatment planning study showed that sufficient target coverage could be obtained with the customized IS needle configuration for challenging cases. The proposed dose-based optimization method for IS needle configuration was feasible and effective. Improved target coverage and organ-at-risk sparing were achieved using the inverse planning method. Conclusions Using the proposed methods of customizing and optimizing the IS needle configuration, the limitation in the standardized design of combined IC/IS applicators can be addressed, and sufficient target coverage is obtained in cervical cancer patients with unfavorable tumor topography and/or extra lateral expansion.
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Affiliation(s)
- Daguang Zhang
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Zhiyong Yang
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Shan Jiang
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Lin Zhou
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Zeyang Zhou
- School of Mechanical Engineering, Tianjin University, Tianjin, China
| | - Wei Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
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Ying W, Liang L, Wang Y, Qi GH. Error analysis of applicator position for combined internal/external radiation therapy in cervical cancer. Oncol Lett 2018; 16:3611-3613. [PMID: 30127968 PMCID: PMC6096106 DOI: 10.3892/ol.2018.9061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 09/04/2017] [Indexed: 11/05/2022] Open
Abstract
The aim of this study was to analyze the error variation in the applicator placement during the first and second radiotherapy session for cervical cancer. We recruited 22 patients with cervical cancer treated with radiotherapy. According to the image output in the first and second CT-Sim inspection, we conducted comparative analysis of image fusion to accurately measure the errors in applicator position in the horizontal (X-), longitudinal (Y-) and vertical (Z)-axes. The calibration processing was implemented in accordance with the data error measured and the location parameters, such as the angle and depth of the applicator. Electronic portal imaging technology (EPID) was used to calibrate posture change amplitude for the extracorporeal irradiation of patients, and dynamic measurement with applicator position was used to describe the error of the parameters. Finally, the data from two measurements in CT-Sim, digital reconstruction radiography (DRR) and EPID were compared. After calibration, the mean value of error of the applicator were significantly smaller. Image registration planning for error parameter calibration of applicator position can effectively reduce the applied horizontal spatial position error in radiotherapy treatment, and improve the accuracy and effectiveness during treatment.
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Affiliation(s)
- Wei Ying
- Radiotherapy Center, Sichuan Cancer Hospital and Institue, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
| | - Li Liang
- Radiotherapy Center, Sichuan Cancer Hospital and Institue, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
| | - Yu Wang
- Radiotherapy Center, Sichuan Cancer Hospital and Institue, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
| | - Guo-Hai Qi
- Radiotherapy Center, Sichuan Cancer Hospital and Institue, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan 610041, P.R. China
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Off-line magnetic resonance imaging navigation of cervix cancer brachytherapy in patients with risk factors for uterine perforation. J Contemp Brachytherapy 2018; 9:519-526. [PMID: 29441095 PMCID: PMC5807993 DOI: 10.5114/jcb.2017.71912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/06/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose There are no reports on pre-insertion identification of cervix cancer patients at risk for uterine perforation during brachytherapy (BT). Our aim was to assess the incidence of risk factors in our patient cohort, and assess feasibility of a novel technique of magnetic resonance imaging (MRI)-guided navigation for applicator insertion (NAI) in high-risk cases. Material and methods All patients with locally advanced cervical cancer, treated with image guided adaptive BT at our department between October 2013 and June 2017 were considered for analysis. Tumor characteristics on initial MRI (MRIinitial), pre-BT MRI (MRIpre-BT), and BT MRI (MRIBT) were assessed. Frequency of risk factors (age above 60 years, retroverted/retroflected uterus, tumor necrosis, non-visible cervical orifice, distorted cervical canal) was recorded. Patients with two or more factors underwent MRI guided NAI. Time needed for NAI was estimated and procedure feasibility score assigned using a three-tiered scoring system. Results Twenty-seven patients (98 insertions) were included. Mean tumor volume was 70.2 (± 47.9), 17.8 (± 18.9), and 10.3 (± 9.1) cm3 on MRIinitial, MRIpre-BT, and MRIBT1, respectively (p < 0.05). In 16 (59%) cases, ≥ 1 perforation risk factor was found on MRIpre-BT: distorted canal in 12 (44%), necrosis in 9 (33%), retroverted/retroflected uterus in 8 (30%) cases. Nine (33%) patients had ≥ 2 risk factors and underwent MRI guided NAI. Additional time to perform NAI was estimated at 105 minutes, and feasibility score was 1 in all cases. There were no cases of uterine perforation. Conclusions Using pre-insertion MRI, we found ≥ 2 risk factors for uterine perforation in 1/3 of patients. Off-line MRI navigation was feasible and enabled non-complicated insertion in all cases. Further studies with larger sample size are warranted to assess its clinical efficacy.
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Focal boost to residual gross tumor volume in brachytherapy for cervical cancer—A feasibility study. Brachytherapy 2018; 17:181-186. [DOI: 10.1016/j.brachy.2017.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 09/04/2017] [Accepted: 09/18/2017] [Indexed: 11/18/2022]
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Fredman E, Traughber B, Podder T, Colussi V, Zheng Y, Russo S, Herrmann K, Paspulati R, Waggoner S, Zanotti K, Nagel C, Nakayama J, Machtay M, Ellis R. 3T multiparametric MRI-guided high-dose-rate combined intracavitary and interstitial adaptive brachytherapy for the treatment of cervical cancer with a novel split-ring applicator. Brachytherapy 2017; 17:334-344. [PMID: 29097137 DOI: 10.1016/j.brachy.2017.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/13/2017] [Accepted: 09/22/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the role of 3T-MRI-guided adaptive high-dose-rate (HDR) combined intracavitary and interstitial brachytherapy for cervical cancer using a novel intracavitary split-ring (ICSR) applicator adapter. METHODS AND MATERIALS We retrospectively reviewed all HDR brachytherapy cases from 2013 to 2015 using an ICSR applicator. Initial optimization was performed using 3T multiparametric MRI (mpMRI) series with an applicator in place. The mpMRI series were discretionarily acquired before subsequent fractions for possible target adaptation. When necessary, interstitial needles (ISNs) were inserted through a novel ICSR adapter or freehand. Dosimetric parameters, clinical outcomes, and toxicities were compared between groups. RESULTS Seventeen patients were included, with a mean followup of 32 months. An mpMRI series preceded each initial fraction and 52.9% of patients underwent ≥1 additional pretreatment mpMRI. Among these subsequent fractions, the high-risk clinical target volume was reduced in 80% vs. 41% without pretreatment mpMRI. Five patients had ISN placement (seven insertions) to improve extracervical target coverage. Mean D90 (Gy) per fraction to the high-risk clinical target volume and intermediate-risk clinical target volume with and without an ISN were 7.51 ± 1.07 vs. 6.14 ± 0.52 (p = 0.028) and 6.35 ± 0.75 vs. 5.21 ± 0.49 (p = 0.007), respectively. Mean fractional D2cc (Gy) for organs at risk was comparable. No Grades 3-4 toxicity was reported. Disease-free survival and local control for the ICSR-ISN and ICSR-alone groups were 29.8 months/80.0% and 31.2 months/83.3%, respectively. CONCLUSIONS The mpMRI acquisition with ICSR applicator in place immediately before HDR brachytherapy for cervical cancer guided successful adaptive treatment optimization and delivery. Our initial experience with a novel interstitial adapter for the split-ring applicator demonstrated excellent target coverage without compromising organs at risk, resulting in good local control and disease-free survival.
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Affiliation(s)
- Elisha Fredman
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH.
| | - Bryan Traughber
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Tarun Podder
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Valdir Colussi
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Yiran Zheng
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Suzanne Russo
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Karin Herrmann
- Department of Radiology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Raj Paspulati
- Department of Radiology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Steven Waggoner
- Department of Gynecologic Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Kristin Zanotti
- Department of Gynecologic Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Christa Nagel
- Department of Gynecologic Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - John Nakayama
- Department of Gynecologic Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Mitchell Machtay
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
| | - Rodney Ellis
- Department of Radiation Oncology, Seidman Cancer Center, University Hospitals, Cleveland Medical Center, Cleveland, OH
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Pre-plan technique feasibility in multi-interstitial/endocavitary perineal gynecological brachytherapy. J Contemp Brachytherapy 2017; 9:472-476. [PMID: 29204168 PMCID: PMC5705827 DOI: 10.5114/jcb.2017.70710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/22/2017] [Indexed: 11/17/2022] Open
Abstract
Purpose To present the implementation of a magnetic resonance imaging (MRI) pre-planning technique in multi-interstitial perineal and endocavitary gynecological brachytherapy. Material and methods We used a new fully MRI-compatible applicator that is capable to engage titanium needles, and an intrauterine tandem, developed in our department for the treatment of gynecological cervical cancer patients. This applicator is an attempt to combine the technical advantages of the Martinez universal perineal interstitial template (MUPIT) with the improvement in dose distribution by adding an intrauterine probe with the imaging advantages of MRI-based brachytherapy, thus preserving the stability, geometry, and robustness of the implant, avoiding possible errors of free-hand needle placement. A pre-brachytherapy MRI T2 acquisition is carried out with the template in place 3-5 days before the implant. On this image set, clinical target volume (CTV) is drawn. The required needles and their depths are selected accordingly to encompass the CTV (as conformal as possible). To facilitate this task, a Java based application linked to the treatment planning system has been developed. From this procedure, each needle identification and its depth are obtained previously to the implantation. With this information, the radiation oncologist proceeds with implant and then, a post-implant MRI is carried out, in which the contouring, needles, tandem reconstruction, and optimization are established. Results This pre-planning procedure has been successfully applied in 10 patients. An excellent reproduction of the virtual pre-planning has been achieved. Conclusions We describe a virtual pre-planning technique using a multi-interstitial and endocavitary perineal template. It is based on a virtual work with MRI images. This procedure has shown to be feasible and efficient in clinical practice by facilitating the work of specialists, and reducing uncertainties of the application.
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Petric P, Hudej R, Al-Hammadi N, Segedin B. Virtual modelling of novel applicator prototypes for cervical cancer brachytherapy. Radiol Oncol 2016; 50:433-441. [PMID: 27904452 PMCID: PMC5120583 DOI: 10.1515/raon-2016-0048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 08/29/2016] [Indexed: 11/22/2022] Open
Abstract
Background Standard applicators for cervical cancer Brachytherapy (BT) do not always achieve acceptable balance between target volume and normal tissue irradiation. We aimed to develop an innovative method of Target-volume Density Mapping (TDM) for modelling of novel applicator prototypes with optimal coverage characteristics. Patients and methods. Development of Contour-Analysis Tool 2 (CAT-2) software for TDM generation was the core priority of our task group. Main requests regarding software functionalities were formulated and guided the coding process. Software validation and accuracy check was performed using phantom objects. Concepts and terms for standardized workflow of TDM post-processing and applicator development were introduced. Results CAT-2 enables applicator-based co-registration of Digital Imaging and Communications in Medicine (DICOM) structures from a sample of cases, generating a TDM with pooled contours in applicator-eye-view. Each TDM voxel is assigned a value, corresponding to the number of target contours encompassing that voxel. Values are converted to grey levels and transformed to DICOM image, which is transported to the treatment planning system. Iso-density contours (IDC) are generated as lines, connecting voxels with same grey levels. Residual Volume at Risk (RVR) is created for each IDC as potential volume that could contain organs at risk. Finally, standard and prototype applicators are applied on the TDM and virtual dose planning is performed. Dose volume histogram (DVH) parameters are recorded for individual IDC and RVR delineations and characteristic curves generated. Optimal applicator configuration is determined in an iterative manner based on comparison of characteristic curves, virtual implant complexities and isodose distributions. Conclusions Using the TDM approach, virtual applicator prototypes capable of conformal coverage of any target volume, can be modelled. Further systematic assessment, including studies on clinical feasibility, safety and effectiveness are needed before routine use of novel prototypes can be considered.
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Affiliation(s)
- Primoz Petric
- National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar; Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Robert Hudej
- Institute of Oncology Ljubljana, Ljubljana, Slovenia
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Rodríguez Villalba S, Richart Sancho J, Otal Palacín A, Perez-Calatayud J, Santos Ortega M. Development and clinical implementation of a new template for MRI-based intracavitary/interstitial gynecologic brachytherapy for locally advanced cervical cancer: from CT-based MUPIT to the MRI compatible Template Benidorm. Ten years of experience. J Contemp Brachytherapy 2016; 8:404-414. [PMID: 27895682 PMCID: PMC5116450 DOI: 10.5114/jcb.2016.63187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/22/2016] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To study outcome and toxicity in 59 patients with locally advanced cervix carcinoma treated with computed tomography (CT)-based Martinez universal perineal interstitial template (MUPIT) and the new magnetic resonance imaging (MRI)-compatible template Benidorm (TB). MATERIAL AND METHODS From December 2005 to October 2015, we retrospectively analyzed 34 patients treated with MUPIT and 25 treated with the TB. Six 4 Gy fractions were prescribed to the clinical target volume (CTV) combined with external beam radiotherapy (EBRT). The organs at risk (OARs) and the CTV were delineated by CT scan in the MUPIT implants and by MRI in the TB implants. Dosimetry was CT-based for MUPIT and exclusively MRI-based for TB. Dose values were biologically normalized to equivalent doses in 2 Gy fractions (EQD2). RESULTS Median CTV volumes were 163.5 cm3 for CT-based MUPIT (range 81.8-329.4 cm3) and 91.9 cm3 for MRI-based TB (range 26.2-161 cm3). Median D90 CTV (EBRT + BT) was 75.8 Gy for CT-based MUPIT (range 69-82 Gy) and 78.6 Gy for MRI-based TB (range 62.5-84.2 Gy). Median D2cm3 for the rectum was 75.3 Gy for CT-based MUPIT (range 69.8-132.1 Gy) and 69.9 Gy for MRI-based TB (range 58.3-83.7 Gy). Median D2cm3 for the bladder was 79.8 Gy for CT-based MUPIT (range 71.2-121.1 Gy) and 77.1 Gy for MRI-based TB (range 60.5-90.8 Gy). Local control (LC) was 88%. Overall survival (OS), disease free survival (DFS), and LC were not statistically significant in either group. Patients treated with CT-based MUPIT had a significantly higher percentage of rectal bleeding G3 (p = 0.040) than those treated with MRI-based TB, 13% vs. 2%. CONCLUSIONS Template Benidorm treatment using MRI-based dosimetry provides advantages of MRI volume definition, and allows definition of smaller volumes that result in statistically significant decreased rectal toxicity compared to that seen with CT-based MUPIT treatment.
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Affiliation(s)
| | | | | | - Jose Perez-Calatayud
- Radiotherapy Department, Hospital Clínica Benidorm, Benidorm, Alicante; Radiotherapy Department, La Fe University and Polytechnic Hospital, Valencia, Spain
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Petric P, Kirisits C. Potential role of TRAns Cervical Endosonography (TRACE) in brachytherapy of cervical cancer: proof of concept. J Contemp Brachytherapy 2016; 8:215-20. [PMID: 27504131 PMCID: PMC4965497 DOI: 10.5114/jcb.2016.60502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 05/09/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Magnetic resonance imaging (MRI) is the gold standard for image guided adaptive brachytherapy (BT) of cervical cancer. Ultrasound is an attractive alternative with reasonable costs and high soft tissue depiction quality. This technical note aims to demonstrate the proof of principle for use of TRAns Cervical Endosonography with rotating transducer in the context of brachytherapy (TRACE BT). MATERIAL AND METHODS TRACE BT presentation is based on a single stage IIB cervical cancer patient. Prior to second BT implant, rotating US transducer (6.9 mm diameter) was inserted in cervical canal and axial images obtained at 10 MHz, focal range of 30 mm, and axial resolution of 0.4 mm. Size and topography of hypo-echoic areas were assessed and optimal positions of interstitial needles were determined. Finally, intracavitary applicator was placed and needles inserted through vaginal ring-template according to TRACE pre-plan. MRI-based high risk clinical target volume (CTVHR) dimensions were compared with hypoechoic areas on TRACE. Topography of parametrial needles on post-insertion MRI was compared with TRACE pre-plan. RESULTS Insertion of rotating mechanism into cervico-uterine cavity was safe, feasible and fast. The 360° imaging in axial plane enabled real-time assessment of cervix, uterus, and adjacent parametria. Qualitative comparison of TRACE with post-insertion MRI revealed favorable agreement of findings. In-plane size of CTVHR on MRI was comparable to hypoechoic areas on TRACE. Needle positions on post-insertion MRI corresponded to TRACE-based pre-plan. Main limitation of TRACE was gradual deterioration of image quality due to coupling gel removal. CONCLUSIONS Present proof of concept demonstrates potential role of TRACE-BT for cervical cancer as an attractive high-tech approach with reasonable costs. Prior to investigation of its clinical role, further development of TRACE methodology is needed. This includes reliable transducer-tissue coupling, applicator reconstruction, imaging range, limitations in extensive tumors, US-based contouring concepts, registration with other imaging methods, organ dose-assessment, real-time dosimetry, etc.
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Affiliation(s)
- Primoz Petric
- National Center for Cancer Care and Research, Hamad Medical Corporation, Doha, Qatar
- Department of Brachytherapy, Sector of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Christian Kirisits
- Department of Radiotherapy, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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Choong ES, Bownes P, Musunuru HB, Rodda S, Richardson C, Al-Qaisieh B, Swift S, Orton J, Cooper R. Hybrid (CT/MRI based) vs. MRI only based image-guided brachytherapy in cervical cancer: Dosimetry comparisons and clinical outcome. Brachytherapy 2015; 15:40-8. [PMID: 26602964 DOI: 10.1016/j.brachy.2015.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/27/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE Limited access to MRI has restricted implementation of MRI-based image-guided brachytherapy (IGBT) in line with GEC-ESTRO guidelines in many centers. This work reports our experience using an alternative CT/MRI based (hybrid) approach for IGBT, dosimetry comparisons, and its impact on long-term clinical outcome and major toxicity. METHODS AND MATERIALS Seventy-six patients diagnosed with locally advanced cervical cancer between May 2008 and May 2012 treated with IGBT were analyzed. The hybrid approach is the default IGBT approach during this study period. Forty-nine had hybrid approach and 27 patients had "3-fraction conformal MRI" approach (17 within EMBRACE study). Treatment consisted of 48 Gy in 24 fractions of conformally planned external beam radiotherapy with weekly cisplatin followed by three weekly fractions of brachytherapy to high-risk clinical target volume (HR-CTV). All patients have a prebrachytherapy MRI 4 days before treatment and with the applicators in place on Fraction 1. MRI only or CT is used for subsequent fractions. Using image registration techniques and the assumption that the HR-CTV is fixed with respect to the applicator, the HR-CTV from MRI at Fraction 1 is transferred onto subsequent fraction CT image sets for the hybrid approach. RESULTS Median follow-up was 41 months (range, 23-71 months). Excellent 3-year local control, overall progression-free survival, and overall survival of 92.6%, 78.8%, and 77.7% were seen with the hybrid approach and 92.2%, 66.3%, and 69.6% with a 3-fraction conformal MRI approach, respectively. Dosimetry achieved and late toxicity rates were comparable in the two groups. CONCLUSIONS Hybrid IGBT in locally advanced cervical cancer offers an alternative approach when access to MRI restricts implementation of IGBT.
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Affiliation(s)
- Ee Siang Choong
- Department of Clinical Oncology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK.
| | - Peter Bownes
- Department of Medical Physics and Engineering, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Hima Bindu Musunuru
- Department of Clinical Oncology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Sree Rodda
- Department of Clinical Oncology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Carolyn Richardson
- Department of Medical Physics and Engineering, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Bashar Al-Qaisieh
- Department of Medical Physics and Engineering, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Sarah Swift
- Department of Radiology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Jane Orton
- Department of Clinical Oncology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
| | - Rachel Cooper
- Department of Clinical Oncology, St James's Institute of Oncology, St James's University Hospital, Leeds, UK
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Outpatient combined intracavitary and interstitial cervical brachytherapy: barriers and solutions to implementation of a successful programme - a single institutional experience. J Contemp Brachytherapy 2015. [PMID: 26207117 PMCID: PMC4499522 DOI: 10.5114/jcb.2015.52625] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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.
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