title: Image and laparoscopic guided interstitial brachytherapy for locally advanced primary or recurrent gynaecological cancer using the adaptive GEC ESTRO target concept.
abstract: OBJECTIVE
  To retrospectively assess treatment outcome of image and laparoscopic guided interstitial pulsed dose rate brachytherapy (PDR-BT) for locally advanced gynaecological cancer using the adaptive GEC ESTRO target concept.
  
  
  METHODS
  Between June 2005 and December 2010, 28 consecutive patients were treated for locally advanced primary vaginal (nine), recurrent endometrial (12) or recurrent cervical cancer (seven) with combined external beam radiotherapy (EBRT) and interstitial PDR-BT. Treatment was initiated with whole pelvic EBRT to a median dose of 45 Gy followed by PDR-BT using the Martinez Universal Perineal Interstitial Template (MUPIT). All implants were virtually preplanned using MRI of the pelvis with a dummy MUPIT in situ. The GEC ESTRO high risk clinical target volume (HR CTV), intermediate risk clinical target volume (IR CTV) and the organs at risk (OAR) were contoured and a preplan for implantation was generated (BrachyVision, Varian). The subsequent implantation was performed under laparoscopic visualisation. Final contouring and treatment planning were done using a post-implant CT. Planning aim of PDR-BT was to deliver 30 Gy in 50 hourly pulses to HR CTV. Manual dose optimisation was performed with the aim of reaching a D90>80 Gy in the HR CTV calculated as the total biologically equivalent to 2 Gy fractions of EBRT and BT (EQD2). Dose to the OAR were evaluated using dose volume constraints for D(2cc) of 90 Gy for bladder and 70 Gy for rectum and sigmoid.
  
  
  RESULTS
  For HR CTV the median volume was 26 cm(3) (7-91 cm(3)). Coverage of the HR CTV was 97% (90-100%) and D90 was 82 Gy (77-88 Gy). The D(2cc) for bladder, rectum, and sigmoid were 65 Gy (47-81 Gy), 61 Gy (50-77 Gy), and 52 Gy (44-68 Gy), respectively. Median follow up was 18 months (6-61 months). The actuarial 2 years local control rate was 92% (SE 5), while disease-free survival and overall survival were 59% (SE 11) and 74%, respectively (SE 10). No complications to the laparoscopic guided implantation were encountered. Late grade 2 (CTC v 3.0) complications were recorded in nine (32%) patients. One patient had a grade 3 vaginal complication. No grade 4-5 complications have been recorded so far.
  
  
  CONCLUSIONS
  Image and laparoscopic guided interstitial PDR-BT using the GEC ESTRO target concept is applicable for locally advanced primary vaginal or recurrent endometrial and cervical cancer resulting in an excellent local control rate and limited morbidity.
authors.affiliation: Department of Oncology, Aarhus University Hospital, Denmark. larfok@rm.dk
authors.forename: Lars
authors.initials: L
authors.lastname: Fokdal
authors.forename: Kari
authors.initials: K
authors.lastname: Tanderup
authors.forename: Søren Kynde
authors.initials: SK
authors.lastname: Nielsen
authors.forename: Henrik Kidmose
authors.initials: HK
authors.lastname: Christensen
authors.forename: Lisbeth
authors.initials: L
authors.lastname: Røhl
authors.forename: Erik Morre
authors.initials: EM
authors.lastname: Pedersen
authors.forename: Niels Kim
authors.initials: NK
authors.lastname: Schønemann
authors.forename: Jacob Christian
authors.initials: JC
authors.lastname: Lindegaard
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000379:methods*; D012809:Colon, Sigmoid / Q000528:radiation effects; D019583:Dose Fractionation, Radiation; D005260:Female; D005500:Follow-Up Studies; D005833:Genital Neoplasms, Female / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D010535:Laparoscopy; D053783:Magnetic Resonance Imaging, Interventional; D008875:Middle Aged; D064847:Multimodal Imaging; D009364:Neoplasm Recurrence, Local / Q000532:radiotherapy*; D009367:Neoplasm Staging; D049268:Positron-Emission Tomography; D015641:Radiography, Interventional; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted; D012007:Rectum / Q000528:radiation effects; D012189:Retrospective Studies; D015996:Survival Rate; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D001743:Urinary Bladder / Q000528:radiation effects