title: MRI-guided 3D optimization significantly improves DVH parameters of pulsed-dose-rate brachytherapy in locally advanced cervical cancer.
abstract: OBJECTIVE
  To compare dose-volume histogram parameters of standard Point A and magnetic resonance imaging-based three-dimensional optimized dose plans in 21 consecutive patients who underwent pulsed-dose-rate brachytherapy (PDR-BT) for locally advanced cervical cancer.
  
  
  METHODS
  All patients received external beam radiotherapy (elective target dose, 45 Gy in 25-30 fractions; tumor target dose, 50-60 Gy in 25-30 fractions). PDR-BT was applied with a tandem-ring applicator. Additional ring-guided titanium needles were used in 4 patients and a multichannel vaginal cylinder in 2 patients. Dose planning was done using 1.5 Tesla T(1)-weighted and T(2)-weighted paratransversal magnetic resonance imaging scans. T(1)-weighted visible oil-containing tubes were used for applicator reconstruction. The prescribed standard dose for PDR-BT was 10 Gy (1 Gy/pulse, 1 pulse/h) for two to three fractions to reach a physical dose of 80 Gy to Point A. The total dose (external beam radiotherapy plus brachytherapy) was normalized to an equivalent dose in 2-Gy fractions using alpha/beta = 10 Gy for tumor, alpha/beta = 3 Gy for normal tissue, and a repair half-time of 1.5 h. The goal of optimization was dose received by 90% of the target volume (D(90)) of > or =85 Gy(alpha/beta10) in the high-risk clinical target volume (cervix and remaining tumor at brachytherapy), but keeping the minimal dose to 2 cm(3) of the bladder and rectum/sigmoid at <90 and <75 Gy(alpha/beta3), respectively.
  
  
  RESULTS
  Using three-dimensional optimization, all dose-volume histogram constraints were met in 16 of 21 patients compared with 3 of 21 patients with two-dimensional library plans (p < 0.001). Optimization increased the minimal target dose (D(100)) of the high-risk clinical target volume (p < 0.007) and decreased the minimal dose to 2 cm(3) for the sigmoid significantly (p = 0.03). For the high-risk clinical target volume, D(90) was 91 +/- 8 Gy(alpha/beta10) and D(100) was 76 +/- 5 Gy(alpha/beta10). The minimal dose to 2 cm(3) for the bladder, rectum, and sigmoid was 73 +/- 6, 67 +/- 6, and 69 +/- 6 Gy(alpha/beta3), respectively.
  
  
  CONCLUSIONS
  The results of our study have shown that magnetic resonance imaging-guided optimization of PDR-BT for locally advanced cervical cancer significantly improved the dose-volume histogram parameters.
authors.affiliation: Department of Oncology, Aarhus University Hospital, Aarhus, Denmark. jlind@as.aaa.dk
authors.forename: Jacob C
authors.initials: JC
authors.lastname: Lindegaard
authors.forename: Kari
authors.initials: K
authors.lastname: Tanderup
authors.forename: Søren Kynde
authors.initials: SK
authors.lastname: Nielsen
authors.forename: Søren
authors.initials: S
authors.lastname: Haack
authors.forename: John
authors.initials: J
authors.lastname: Gelineck
mesh_terms: D000328:Adult; D001918:Brachytherapy / Q000379:methods*; D019583:Dose Fractionation, Radiation; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods*; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008279:Magnetic Resonance Imaging / Q000379:methods*; D011881:Radiotherapy, Computer-Assisted / Q000379:methods*; D016896:Treatment Outcome; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000532:radiotherapy*