Change in image-guided planning strategies over time impacts oncologic and survival outcomes for intracavitary cervical cancer brachytherapy



      Intracavitary cervical brachytherapy (BT) has transitioned from a two-dimensional nonvolumetric (NV) dosimetry system to three-dimensional computed tomography (CT) and/or magnetic resonance imaging (MRI)-based planning techniques. The purpose of this study is to retrospectively evaluate the relative improvements in image-guided planning strategies over time with regards to dosimetry, survival, and toxicity.


      A single site retrospective review of 95 locally advanced cervical cancer patients treated with concurrent chemoradiation and high dose rate BT from 2009 to 2016 were divided into three BT planning groups: point-A based NV dosimetry using CT imaging (n = 37), CT-based volumetric dosimetry (n = 33), and MRI-based volumetric dosimetry (n = 25). Overall survival (OS), progression free survival (PFS), and pelvic control (PC) at 5 years were plotted using Kaplan–Meier curves. Univariate and multivariate (MVA) cox proportional-hazards models calculated hazard-ratios (HZ). Finally, acute and late grade 3–4 toxicities were compared between the cohorts.


      Both MRI and CT had significantly less D2cc to bowel (p < 0.001) and sigmoid (p < 0.001) compared to NV-based planning. On MVA, age (<60 vs. ≥60 years) was significant for worse 5-year OS (HZ: 2.48) and PC (HZ: 5.25). MRI, with NV as the reference, had significantly improved 5-year OS (HZ: 0.26), PFS (HZ: 0.34) and PC (HZ: 0.16). There was no significant difference in grade ≥3 toxicities between the cohorts.


      CT and MRI-based 3D planning had significantly less D2cc to bowel and sigmoid. MRI-based planning had significant improvement in 5-year OS, PFS, and LC compared to NV on MVA.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Brachytherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jemal A
        • et al.
        Global cancer statistics.
        CA Cancer J Clin. 2011; 61: 69-90
        • Haie-Meder C
        • et al.
        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.
        Radiother Oncol. 2005; 74: 235-245
        • Pötter R
        • et al.
        Recommendations from gynaecological (GYN) GEC ESTRO working group (II): concepts and terms in 3D image-based treatment planning in cervix cancer brachytherapy—3D dose volume parameters and aspects of 3D image-based anatomy, radiation physics, radiobiology.
        Radiother Oncol. 2006; 78: 67-77
        • Pötter R
        • et al.
        Present status and future of high-precision image guided adaptive brachytherapy for cervix carcinoma.
        Acta Oncol (Madr). 2008; 47: 1325-1336
        • Van Dyk S
        • Byram D
        • Bernshaw D
        ORIGINAL ARTICLE: use of 3D imaging and awareness of GEC-ESTRO recommendations for cervix cancer brachytherapy throughout Australia and New Zealand.
        J Med Imaging Radiat Oncol. 2010; 54: 383-387
        • Leborgne F.
        • et al.
        Fractionation in medium dose rate brachytherapy of cancer of the cervix.
        Intl J Radiat Oncol Biol Phys. 1996; 35: 907-914
        • Muirhead W
        • Green LS
        Carcinoma of the cervix: five-year results and sequelae of treatment.
        Am J Obstet Gynecol. 1968; 101: 744-749
        • Noyes WR
        • et al.
        Impact of “optimized” treatment planning for tandem and ring, and tandem and ovoids, using high dose rate brachytherapy for cervical cancer.
        Intl J Radiat Oncol Biol Phys. 1995; 31: 79-86
        • Zwahlen D
        • et al.
        Magnetic resonance imaging-guided intracavitary brachytherapy for cancer of the cervix.
        Intl J Radiat Oncol Biol Phys. 2009; 74: 1157-1164
        • Charra-Brunaud C
        • et al.
        Impact of 3D image-based PDR brachytherapy on outcome of patients treated for cervix carcinoma in France: results of the French STIC prospective study.
        Radiother Oncol. 2012; 103: 305-313
        • Kamran SC
        • et al.
        Comparison of outcomes for MR-guided versus CT-guided high-dose-rate interstitial brachytherapy in women with locally advanced carcinoma of the cervix.
        Gynecol Oncol. 2017; 145: 284-290
        • Viswanathan AN
        • et al.
        Computed tomography versus magnetic resonance imaging-based contouring in cervical cancer brachytherapy: results of a prospective trial and preliminary guidelines for standardized contours.
        Int J Radiat Oncol Biol Phys. 2007; 68: 491-498
        • Thomas KM
        • et al.
        Reduced toxicity with equivalent outcomes using three-dimensional volumetric (3DV) image–based versus nonvolumetric point–based (NV) brachytherapy in a cervical cancer population.
        Brachytherapy. 2017; 16: 943-948
        • Chassagne D
        • et al.
        Report 38.
        J Intl Commission Radiat Units Measurements. 1985;
        • Viswanathan AN
        • Thomadsen B
        American Brachytherapy Society consensus guidelines for locally advanced carcinoma of the cervix. Part I: general principles.
        Brachytherapy. 2012; 11: 33-46
        • Gao M
        • et al.
        3D CT-based volumetric dose assessment of 2D plans using GEC-ESTRO guidelines for cervical cancer brachytherapy.
        Brachytherapy. 2010; 9: 55-60
        • Suzumura EA
        • et al.
        Effects of 3D image-guided brachytherapy compared to 2D conventional brachytherapy on clinical outcomes in patients with cervical cancer: a systematic review and meta-analyses.
        Brachytherapy. 2021; 20: 710-737
        • Murofushi K
        • et al.
        Outcomes analysis of pre-brachytherapy MRI in patients with locally advanced cervical cancer.
        Intl J Gynecol Cancer. 2020; 30: 473
        • Sturdza A
        • et al.
        Image guided brachytherapy in locally advanced cervical cancer: improved pelvic control and survival in RetroEMBRACE, a multicenter cohort study.
        Radiother Oncol. 2016; 120: 428-433
        • Pötter R
        • et al.
        Clinical impact of MRI assisted dose volume adaptation and dose escalation in brachytherapy of locally advanced cervix cancer.
        Radiother Oncol. 2007; 83: 148-155
        • Nesvacil N
        • et al.
        Adaptive image guided brachytherapy for cervical cancer: a combined MRI-/CT-planning technique with MRI only at first fraction.
        Radiother Oncol. 2013; 107: 75-81
        • Serban M
        • et al.
        Ring versus ovoids and intracavitary versus intracavitary-interstitial applicators in cervical cancer brachytherapy: results from the EMBRACE I study.
        Intl J Radiat Oncol Biol Phys. 2020; 106: 1052-1062
        • Kim H
        • et al.
        Dose summation strategies for external beam radiation therapy and brachytherapy in gynecologic malignancy: a review from the NRG Oncology and NCTN Medical Physics Subcommittees.
        Intl J Radiat Oncol Biol Phys. 2021; 111: 999-1010