Brachytherapy in Treating Cervical Cancer: An Overview of Image Guided Techniques

This article provides an annotated bibliography of three research papers on the benefits of image guided brachytherapy in treating cervical cancer. The papers discuss the evaluation and staging of patients, comparison of high and low dose rate brachytherapy, and the use of 3D image guided procedures. The studies show improved survival rates and decreased toxicity with the use of image guided brachytherapy. The article also discusses the challenges and opportunities for improvement in the field.

Running head: BRACHYTHERAPY IN TREATING CERVICAL CANCER
BRACHYTHERAPY IN TREATING CERVICAL CANCER
Name of the Student
Name of the university
Author’s note

1BRACHYTHERAPY IN TREATING CERVICAL CANCER
Introduction
Brachytherapy is a form of cancer treatment where radioactive compounds sealed in a
wire, pellet or capsule is introduced into the body with the help of a catheter in order to damage
the DNA of the cancer cells. It has a wide spread of application in the treatment of prostate
cancer and cervical cancer. The benefits of brachytherapy are that it allows an augmented dose of
radiation in a limited area unlike the other types of the radiation treatments. It actually helps to
lessen the damage to the surrounding tissues due to radiation. The last two papers are about
improving the image guided brachytherapy techniques in the treatment of cervical cancers. Two
of my chosen papers are related to the same, as IGBT helps in a more accurate treatment and
lesions that are too large for applying the other treatment techniques. Significant improvements
have occurred in the last three decades due to the use of the 3-D image guided procedures.
Incorporation of the transrectal US in the image guided brachytherapy have been found to be
effective in centers that have do not access to MRI. The commonly used method in the treatment
of the cervical cancer is the Manchester Point A system. But the 2-D X ray image shows no
contract of the soft tissues. Image guided brachytherapy helps to target the desired tissue. There
had been increasing evidence of the benefits of the image guided brachytherapy in cervical
cancer, which is the main rationale behind the chosen papers.

2BRACHYTHERAPY IN TREATING CERVICAL CANCER
Annotated Bibliography
1. Banerjee, R., & Kamrava, M. (2014). Brachytherapy in the treatment of cervical
cancer: a review. International journal of women's health, 6, 555.
Summary
The objective of this paper is to give an overview of the gynecologic brachytherapy, with
a focus on the recent advancements and their implications on the cervical cancer in women. The
paper describes about the evaluation and the staging of the patient, According to this paper the
initial stages of evaluation includes the cervical biopsy of the hystopathological diagnosis.
According to the FIGO recommendations, patients with who would be receiving the radiation
treatment should have a planning of the CT stimulation before the initiation of the EBRT.
The paper also brings about a comparison between the high dose rate brachytherapy and
low dose rate brachytherapy. Previously LDR was used exclusively for treating the cancer by
using a cesium -137 isotope. Since 2000s, the utilization of the HDR has increased considerably.
The HDR employs a remote after loading technology allowing a small iridium source connected
to the end of a cable that is robotically driven via the multiple channels ceasing at the dwell
positions for different span of time. The article also refers to a third type of treatment that is
commonly not used in the US known as the pulse dose rate (PDR) brachtherapy. The paper also
gives an account of the choices, by which cervical brachytherapy can be performed, namely the
intracavitary, interstitial, or a combinatory approach. A cohort study was done in order to

3BRACHYTHERAPY IN TREATING CERVICAL CANCER
measure the clinical outcomes of the image guided brachytherapy. The study compared the 2D
versus the 3D IGBT . In the patients treated with both the EBRT plus chemotherapy followed by
a brachytherapy could show a local relapse free survival 74 % of the selected patients. Similar
improvement was found in another study containing patients from Vienna.
Impression
It can be understood from the paper that brachytherapy can improve the local control,
reduce the toxicity and improve the overall survival rate of cervical cancer in women. The study
of the paper also enables one to understand that the disadvantage of brachytherapy is that, it is
invasive. The randomized control study involving 2D planning and 3D planning in selected
patients showed better results in patients being treated with image guided brachtherapy. The
paper also gave an account of the appropriate treatment target volume, the appropriate dose and
the fractionation scheme.
Application to practice
Although the progression from the 2D- 3D based imaging and the treatment planning for the
cervical cancer has increased the overall survival of the women. Further data from the 3-D based
treatment is required associated with the decrease in the toxicity of the technique.

4BRACHYTHERAPY IN TREATING CERVICAL CANCER
2. Rijkmans, E. C., Nout, R. A., Rutten, I. H. H. M., Ketelaars, M., Neelis, K. J.,
Laman, M. S., ... & Creutzberg, C. L. (2014). Improved survival of patients with
cervical cancer treated with image-guided brachytherapy compared with
conventional brachytherapy. Gynecologic oncology, 135(2), 231-238.
Summary
The previous paper focused on the effectiveness of overall brachytherapy in cervical
cancer, but this article will aim to focus on the advantages of using imaging brachytherapy over
conventional methods of brachytherapy. The paper involves a retrospective analysis of the
outcomes in patient suffering from stage IB-IVA cervical cancer treated with primary radiation
therapy. The outcome measures were the relapse free survival of the patient, distant metastasis,
pelvic control and other adverse events related to the treatment. 126 patients have been analyzed
out of which 43 patients have been treated with CBT between the years 2000-2007, and 83
patients have been treated with IGBT between the years 2007- 2012. The conventional
bracgytherapy involved the application of the low dose brachytherapy and high dose rate
brachytherapy was used after 2005. The standard brachytherapy applicators used were
intracavatary ovoids and tandem. From 2011, interstitial needles can be introduced in to the
ovoids for optimizing the dose distribution around the neoplasia. All the records of the adverse
events were recorded if prompted by the signs and the symptoms. The results concluded that
cervical cancer survival rates have increased with the introduction of IGBT.
Impression
The application of the MRI based adaptive IGBT technique was found to be useful for
the patients with stage IB-IVA cervical cancer. The overall survival rate was found to improve

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from 51% to 83% with the shift from conventional brachytherapy to imaging brachytherapy. The
study confirmed that there had been a significant decrease in the distant metastasis in the group
treated with IGBT. The pelvic control rates were also found to be improved in the IGBT group.
Data obtained from the patient’s record found that the IGBT patients were more likely to
complete the chemotherapy faster than the patients’ receiving the conventional brachytherapy.
Application to practice
The use of IGBT in the primary chemo radiation of the cervical cancer is superior to the CBT
and should be considered as the new standard of care. It can be known from the paper that there
is a requirement of improvement of the nodal and the PAN tumor control, using the PET-CT and
the lessening of the adverse events in both the standard and the adaptive IMRT. A 3D MRI based
image guided brachytherapy have been found to reduce the toxicity as discussed in the previous
paper. The objectives of the paper were realistic. One of the limitations of the paper is that the
sample population of the cohort was not large. Although there are several studies that have
actually provided the evidences of imaging brachytherapy.
3. Otter, S., Franklin, A., Ajaz, M., & Stewart, A. (2016). Improving the efficiency of
image guided brachytherapy in cervical cancer. Journal of Contemporary
Brachytherapy, 8(6), 557–565. http://doi.org/10.5114/jcb.2016.64452
Summary
Brachytherapy is an essential component for the treatment of the cervical cancers that
have progressed locally. It allows the dose of the tumor to be amplified sparing the nearby

6BRACHYTHERAPY IN TREATING CERVICAL CANCER
tissues. Image guided brachytherapy have found to lessen the local recurrence. The article
focuses on how the 3D conformal brachytherapy can be used in a hospital setting and how the
brachytherapy services can be improved. The radiological studies operative parameters and
patient workflow and intensive therapy planning can pose challenge to the clinical resources. The
paper also discuses about the translational research opportunities in the field of brachytherapy.
One of the concerns is that some proportion of the tumor will display biological resistance to the
radiations and even to brachytherapy.
Impression
The objective of the paper was to find new advancement in the field of imaging-
brachytherapy. Hence the paper had been appropriate in stating the recent advancements in the
radiotherapy techniques like the intensity modulated radiotherapy (IMRT) and the stereotactic
body radiotherapy (SBRT). This research paper also enables one to understand the demerits of
the therapy, such as IMRT had been unsuccessful in achieving the target volume doses unlike
that of the image guided brachytherapy.
Application to practice
The paper informs that IGBT is more time consuming and requires individual planning
and contouring. Additional resources such as MRI/CT scans and the compatible applicators are
required. The cost of setting up an IGBT is about 10-15 % more than that of the conventional
procedures of brachytherapy. In a clinical setting with IGBT facilities there should be provisions
for an intrauterine brachytherapy applicator as most of the patients will be having an intact
uterus, which will require the placement of an intrauterine tube.

7BRACHYTHERAPY IN TREATING CERVICAL CANCER
Summary and conclusion
It can be understood from all the three papers that image guided brachytherapy makes 3D
models by using the cross sectional image. It should be mentioned that the points of similarities
between the three papers were much more than the differences as all the three papers focused on
the advancements in the field of brachytherapy in treating cervical cancers and the advantage of
using image dependant brachytherapy over the conventional treatment of the brachytherapy. The
difference between the three papers is that the last two papers focused more on the improvements
in the image guided brachytherapy. The last papers exclusively mentioned the advancements
rather than just comparing with the conventional standards.
Various retrospective studies and the cohort studies described in the three papers have
showed better survival rates in patients with cervical cancer. Among the three papers my choice
of paper was the first one as it had elaborately stated the difference between the new techniques
and the old ones such as the difference between the HDR brachytherapy and the LDR
brachytherapy, the selection of the applicator. It further gives information about the intracavity
brachytherapy, interstitial brachytherapy. An appropriate treatment planning was mentioned.
This assignment has not only aided us to know about the different image guided brachytherapy
techniques but have also informed us with the procedures undertaken in brachytherapy.

8BRACHYTHERAPY IN TREATING CERVICAL CANCER
References
Banerjee, R., & Kamrava, M. (2014). Brachytherapy in the treatment of cervical cancer: a
review. International journal of women's health, 6, 555.
Otter, S., Franklin, A., Ajaz, M., & Stewart, A. (2016). Improving the efficiency of image
guided brachytherapy in cervical cancer. Journal of Contemporary Brachytherapy, 8(6),
557–565. http://doi.org/10.5114/jcb.2016.64452
Rijkmans, E. C., Nout, R. A., Rutten, I. H. H. M., Ketelaars, M., Neelis, K. J., Laman, M. S., ...
& Creutzberg, C. L. (2014). Improved survival of patients with cervical cancer treated
with image-guided brachytherapy compared with conventional brachytherapy.
Gynecologic oncology, 135(2), 231-238.