Ring Versus Ovoids and Intracavitary Versus Intracavitary-Interstitial Applicators in Cervical Cancer Brachytherapy: Results From the EMBRACE I Study

Şerban, M; Kirisits, Christian; Leeuw, Astrid de; Pötter, Richard; Jürgenliemk-Schulz, Ina M.; Nesvacil, N.; Swamidas, Jamema; Hudej, R.; Lowe, Gerry; Hellebust, Taran Paulsen; Menon, Geetha; Oinam, Arun S; Bownes, Peter; Oosterveld, B.J.; Brabandere, Marisol De; Koedooder, Kees; Marthinsen, Anne Beate Langeland; Whitney, Diane; Lindegaard, J.C.; Tanderup, Kari

doi:10.1016/j.ijrobp.2019.12.019

Cited by 54 publications

(27 citation statements)

References 35 publications

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“…Ultimately, data from EMBRACE1 available in a recent publication (20) with an indirect comparison of intracavitary and IC/IS implants in an international study showed increased target dose and lower bladder and rectal dose for the hybrid approach similar to our findings. They also demonstrated a similar HR-CTV size of 35 cc for benefit for the hybrid approach.…”

Section: Discussionsupporting

confidence: 88%

“…When splitting the patient data into groups based on tumor volume, the local control benefit was more obviously seen in the patient group with HR-CTV volume $35 cc, which was 4.1% ( p 5 0.0013) as compared with 0.8% increase of local control rate for the group with HR-CTV volume less than 35 cc. The cutoff value 35 cc was chosen to follow the same setup in a previous study (20). In terms of RR, using needles significantly improved local control rate in both groups with RR $ 2.0 and RR !…”

Section: Hr-ctv Coverage and Local Control Ratementioning

confidence: 99%

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Predicting which patients may benefit from the hybrid intracavitary+interstitial needle (IC/IS) applicator for advanced cervical cancer: A dosimetric comparison and toxicity benefit analysis

et al. 2021

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The purpose of this study is to compare the predicted rate of local control and bladder and rectum toxicity rates for image-guided adaptive brachytherapy plans using a tandem and ovoid (T/O) applicator versus using a simulated hybrid intracavitary/interstitial tandem and ring applicator with needles (T/R þ N) for patients with locally advanced cervical cancer (LACC). METHODS AND MATERIALS: Patients with $ FIGO Stage IIB locally advanced cervical cancer treated with T/O from a single institution were included. Simulated treatment plans were created with a T/R þ N applicator for the best high-risk clinical target volume (CTV) coverage and minimal dose to organs at risk. Three-year local control rate was estimated using published dose-volume effect relationships. Next, the high-risk CTV EQD2 D90 of T/R þ N plans were calculated, and bladder and rectum toxicity rates were estimated. Analysis was performed in subpatient groups defined based on tumor volume and ratio of maximal and minimal tumor radii (RR) that reflects tumor shape asymmetry. RESULTS: Improvements in predicted local control rate for the T/R þ N were 0.8, 4.1, 1.6, and 3.9% for groups with tumor volume !35 cc, $35 cc, RR ! 2.0, and $2.0, respectively, with the latter three being statistically significant. Predicted reductions in Grade 2e4 toxicity rates of bladder and rectum were significant in all groups except bladder toxicity in tumor volume ! 35 cc, when T/R þ N plans were normalized to the same CTV coverage as the T/O plans. Comparing unnormalized T/R þ N plans and T/O plans, predicted toxicity reductions were significant in all groups except rectum toxicity in RR $ 2.0. Predicted reduction of toxicity rate was larger for patients with large tumor or large tumor RR, although some reductions were relatively small.

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Section: Discussionsupporting

confidence: 88%

Section: Hr-ctv Coverage and Local Control Ratementioning

confidence: 99%

Predicting which patients may benefit from the hybrid intracavitary+interstitial needle (IC/IS) applicator for advanced cervical cancer: A dosimetric comparison and toxicity benefit analysis

et al. 2021

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“…In the literature, the addition of interstitial component escalated target coverage without increasing doses to OARs, and enhanced a therapeutic window by an average of 4 to 8 Gy EQD 2 [4,5,25]. This has been confirmed recently in the large prospective trial EMBRACE I, where for a HR-CTV volume of 60 cm 3 , which is comparable to the patients included in our study, mean HR-CTV D90% was 5.4 Gy (95% CI: 2.7-8.1) higher for ovoids-IC/IS compared with ovoids-IC centers, and 8.9 Gy (95% CI: 7.0-10.7) higher for ring-IC/IS compared with ring-IC centers [26].…”

Section: Discussionsupporting

confidence: 78%

Venezia applicator with oblique needles improves clinical target volume coverage in distal parametrial tumor residue compared to parallel needles only

Kissel¹,

Fournier-Bidoz²,

Henry³

et al. 2021

jcb

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Purpose: Residual distal parametrial involvement after radiochemotherapy is a true challenge for brachytherapists since the width and asymmetry of high-risk clinical target volume (HR-CTV) are difficult to cover properly with a standard implant.Material and methods: Dosimetric plans of five patients treated with Venezia advanced gynecological applicator at our institution were reviewed. For each patient, we compared the original plan with a new plan where oblique needles were removed and re-optimized manually. Optimization process was halted when EQD2 10 D 90 HR-CTV reached 90 Gy, when one hard constraint to organs at risk (OARs) was reached according to the EMBRACE II protocol, or when dose-rate of one of OARs exceeded 0.6 Gy/h.Results: Tumors were large; median HR-CTV volume was 64 cc and median distance between tandem and outer contour of HR-CTV was 40 mm. For the five patients, HR-CTV EQD2 10 D 90 was superior in the plan using oblique needles, with a median difference of 6.5 Gy (range, 1.7-8.5 Gy). Median D 90 HR-CTV and intermediate-risk CTV (IR-CTV) were significantly increased with oblique needles: 85.9 Gy (range, 83.2-90.3 Gy) vs. 81.5 Gy (range, 77.4-84 Gy), and 68.7 Gy (range, 66.3-72.3 Gy) vs. 67 Gy (range, 64.3-69.1 Gy), p = 0.006 for both. There were no significant differences in the dose to OARs. Plans with only parallel needles had less favorable dose distribution, with cold spots on the outer parametria and higher vaginal activation to compensate parametrial coverage in its inferior part.Conclusions: Venezia TM applicator permits reproducible application to increase CTV coverage in patients with distal parametrial tumor residue during brachytherapy, while maintaining acceptable dose to OARs.

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“…In the retroEMBRACE study, LC improved by 10% in patients with CTV ≥ 30 cc in the IS/IC group [5]. The EBRACE I study has shown that IS/ICBT was performed in 91% of patients with parametrium involvement [19]. Jastaniyah et al reported that IS/ICBT was frequently used in patients with large tumor, tumor with poor response or tumor involvement to distal parametrium, or pelvic wall in MRI at the time of brachytherapy [20].…”

Section: Ctv -Clinical Target Volume Hr -High-risk Icbt -Intracavitmentioning

confidence: 99%

Impact of pre-brachytherapy magnetic resonance imaging on dose-volume histogram of locally advanced cervical cancer patients treated with radiotherapy including high-dose-rate brachytherapy

Murofushi

Ishida

Baba

et al. 2021

jcb

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Purpose: This study investigated the suitability of brachytherapy technique selection based on pre-brachytherapy magnetic resonance imaging (MRI) findings in cervical cancer by evaluating dose-volume histogram parameters. Material and methods: We retrospectively evaluated data from 61 patients with cervical cancer who underwent pre-brachytherapy MRI within 7 days before their first high-dose-rate brachytherapy treatment, selected according to pre-brachytherapy MRI findings. Combined intracavitary brachytherapy with interstitial techniques (IC/ISBT) or interstitial brachytherapy (ISBT) were favored treatments for poor-responding tumors after concurrent chemoradiotherapy, asymmetrical tumors, bulky parametrial extensions, bulky primary disease, and extensive paravaginal or distal vaginal involvement. Intracavitary brachytherapy (ICBT) was the preferred treatment for small tumors without extensive involvement of the vagina and parametrium. Results: The median tumor size was 58 mm on pre-treatment MRI and 38 mm on pre-brachytherapy MRI. On pre-brachytherapy MRI, 13 patients had a tumor with severe vaginal invasion, 15 patients presented with an asymmetrical bulky tumor, and 4 patients had bulky residual tumors. IC/ISBT or ISBT were administered to 26 patients (43%). Median equivalent dose in 2 Gy fractions of clinical target volume D 90 was 70.8 Gy for all patients. Median clinical target volume D 90 in each brachytherapy session exceeded the prescribed dose in both patients treated with ICBT and IC/ISBT or ISBT. Median equivalent dose in 2 Gy fractions of D 2cc to the bladder, sigmoid colon, and rectum was 69.5, 52.0, and 58.4 Gy, respectively. All cases remained within the doses recommended for organs at risk. Conclusions: Pre-brachytherapy MRI may be helpful in selecting suitable candidates for each type of brachytherapy and deliver the recommended doses to the tumor and organs at risk, particularly in cases with large tumors, poor response to concurrent chemoradiotherapy, asymmetrical tumors, severe vaginal invasion, extensive parametrial invasion, and/or corpus invasion.

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Ring Versus Ovoids and Intracavitary Versus Intracavitary-Interstitial Applicators in Cervical Cancer Brachytherapy: Results From the EMBRACE I Study

Cited by 54 publications

References 35 publications

Predicting which patients may benefit from the hybrid intracavitary+interstitial needle (IC/IS) applicator for advanced cervical cancer: A dosimetric comparison and toxicity benefit analysis

Predicting which patients may benefit from the hybrid intracavitary+interstitial needle (IC/IS) applicator for advanced cervical cancer: A dosimetric comparison and toxicity benefit analysis

Venezia applicator with oblique needles improves clinical target volume coverage in distal parametrial tumor residue compared to parallel needles only

Impact of pre-brachytherapy magnetic resonance imaging on dose-volume histogram of locally advanced cervical cancer patients treated with radiotherapy including high-dose-rate brachytherapy

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