PURPOSE:Multicatheter interstitial brachytherapy for partial breast irradiation can be initiated immediately after surgery through intraoperative catheter implantation. Although the perioperative partial-breast brachytherapy (pPBB) enables a convenient single-stage breast-conserving therapy, subsequent whole-breast irradiation (WBI) may be required on the final pathology. This study evaluated clinical outcomes and dosimetric parameters in patients receiving sequential WBI. METHODS:Consecutive patients undergoing pPBB between 2010 and 2025 were analyzed. pPBB dose was delivered at 32 Gy/8 fr. or 25.2 Gy/4 fr. High-risk patients received subsequent WBI. Outcomes and toxicities were compared with those of patients receiving pPBB alone. Cumulative OAR doses were evaluated. RESULTS:Among 922 patients treated with pPBB, 26 (2.8%) subsequently received WBI. At a median follow-up of 7.2 years, 5-year rates of local-relapse-free, disease-free, and breast cancer-specific survival in the WBI after pPBB versus pPBB alone cohorts were 100% versus 98.1% (p = 0.75), 95.2% versus 97.0% (p = 0.80), and 95.2% versus 99.7% (p = 0.96), respectively. No serious adverse events were reported. The cumulative doses to OARs remained within tolerance limits. CONCLUSIONS:Risk-adapted WBI after pPBB was associated with acceptable oncologic outcomes and toxicity. This strategy appears feasible for patients who require treatment escalation after pPBB because of high-risk pathological features.
OBJECTIVE:To evaluate the efficacy and safety of CT-guided iodine-125 (¹²⁵I) radioactive seed implantation in non-small cell lung cancer (NSCLC) patients with severe pulmonary dysfunction. METHODS:A retrospective analysis was performed on 56 NSCLC patients with severe pulmonary dysfunction who underwent ¹²⁵I seed implantation at Nanchong Central Hospital from January 2020 to December 2024. Short-term efficacy, survival outcomes, pulmonary function, Karnofsky Performance Status (KPS), and adverse events were observed. Prognostic factors were analyzed by Cox regression. RESULTS:The 1-year objective response rate (ORR) was 60.7% and disease control rate (DCR) was 67.9%. The median overall survival (OS) was 18.0 months, and median progression-free survival (PFS) was 13.0 months. Multivariate analysis showed that tumor maximum diameter, D90 ≥120 Gy, and postoperative systemic therapy were independent prognostic factors for OS and PFS. The most common adverse event was pneumothorax requiring drainage (25.0%), with no grade ≥3 radiation pneumonitis or treatment-related deaths. Pulmonary function and KPS scores showed no significant deterioration within 12 months postoperatively. CONCLUSION:CT-guided ¹²⁵I seed implantation is effective and safe for NSCLC patients with severe pulmonary dysfunction, with favorable tumor control and survival while preserving pulmonary function without significant decline within 12 months.
PURPOSE:Simulation is commonly used for applicator placement verification during vaginal brachytherapy (VBT) for high-intermediate risk (HIR) endometrial cancer (EC). We evaluated vaginal recurrence (VR) outcomes in a single-institution cohort treated with VBT without simulation and compared results with those of PORTEC-4a, which mandated simulation. METHODS AND MATERIALS:We conducted a retrospective cohort study of women with HIR EC treated with VBT without simulation. VR was analyzed in a competing risks framework. Outcomes were compared with the PORTEC-4a standard brachytherapy arm. RESULTS:A total of 255 patients were included, with a median follow-up of 60.1 months. Eleven VR events were observed. The 5-year cumulative incidence of VR was 3.6% (95% CI = 1.2-6.5%). This was compared with a 5-year VR incidence of 1.6% (95% CI = 0.00-3.32%) in the PORTEC-4a standard brachytherapy arm. No significant differences in VR were observed across clinical subgroups or by applicator type. CONCLUSIONS:In this retrospective cohort meeting PORTEC-4a eligibility criteria, VBT without simulation was associated with low VR rates, comparable to those reported with simulation-verified VBT. These findings suggest that omission of simulation may not compromise vaginal control in appropriately selected patients and support further prospective evaluation of verification strategies.
PURPOSE:To evaluate the long-term follow-up quality of life (QOL) outcomes in patients who underwent low-dose-rate brachytherapy (LDR-BT) for prostate cancer. METHODS AND MATERIALS:Between May 2010 and January 2018, 853 patients who completed Expanded Prostate Cancer Index Composite (EPIC) questionnaires before treatment were enrolled in the present study. QOL was evaluated before treatments, at 1, 3, 6, 12, 24, 36, 48, 60, and 120 months after LDR-BT. Factors related to satisfaction with LDR-BT were evaluated using binary logistic regression analysis. RESULTS:At 1, 3, 6, 12, 24, 36, 48, 60 and 120 months after LDR-BT, 553/852 (65%), 570/840 (68%), 609/847 (72%), 677/837 (81%), 645/814 (79%), 636/789 (81%), 656/767 (86%), 626/730 (86%), and 282/330 (85%) patients were satisfied with the treatment. At 24, 60, and 120 months after LDR-BT, maintained QOL in the urinary (Odds ratio (OR): 0.43, 95% confidence interval (CI): 0.29-0.61) and bowel (OR: 0.61, 95% CI 0.43-0.87) domains, maintained QOL in the urinary (OR: 0.30, 95% CI 0.20-0.47), bowel (OR: 0.53, 95% CI 0.35-0.82), and hormonal domains (OR: 0.44, 95% CI 0.28-0.70), and biochemical recurrence-free within 5 years after LDR-BT (OR: 0.16, 95% CI 0.07-0.39), and maintained QOL in the bowel (OR: 0.43, 95% CI 0.23-0.81) domain were significantly related to satisfaction with LDR-BT for prostate cancer, respectively. CONCLUSIONS:Maintained urinary, bowel, and hormonal QOL and biochemical control were related to satisfaction with LDR-BT for prostate cancer.
PURPOSE:To introduce STAMP (structure- and template-assisted multi-dose-level planning), a standardized semi-automatic inverse planning workflow for multi-dose-level interstitial gynecologic (GYN) HDR brachytherapy using the VEGO (Varian, v16.1) optimization algorithm. The workflow aims to enhance planning consistency and reduce reliance on planner expertise. MATERIALS AND METHODS:STAMP uses predefined optimization structures and standardized objective templates to guide inverse planning. This approach was retrospectively applied to 30 GYN interstitial HDR brachytherapy patients at a single institution. Plan quality was evaluated using total OAR D2cc, CTV coverage, and total dwell times, and compared against clinical plans using two-sided Wilcoxon rank-sum tests (p = 0.05). RESULTS:STAMP plans required a median of 4 optimization iterations (range: 1-8). Clinical and STAMP plans achieved comparable CTV coverages, and both met EMBRACE I OAR constraints, with STAMP showing slightly improved OAR sparing. No statistically significant differences were found in dosimetric metrics or total dwell times. CONCLUSIONS:We developed a semi-automatic clinical workflow for multi-dose-level inverse planning for interstitial GYN HDR brachytherapy, utilizing optimization structures and objective templates. Our study demonstrated the ability to efficiently generate noninferior inverse plans using this standardized workflow with reduced variability.
Equivalent dose in 2 Gy fractions remains the operational reporting standard for cervical cancer HDR brachytherapy outcomes. Coverage goals, dose constraints, and the evidence linking volumetric dose parameters to local control and late morbidity were all derived within this framework. At the same time, EQD2 in cervix HDR brachytherapy is influenced by four recurring operational domains of uncertainty. First, steep near-source dose gradients amplify the biological consequence of geometric and contouring uncertainty through the nonlinear EQD2 transform, so small spatial errors can produce disproportionately large biological differences. Second, source decay prolongs delivery across the exchange cycle by up to 2.3-fold, while repair kinetics for late-responding pelvic organs at risk remain incompletely defined, making time-corrected biological dose inherently model-dependent. Third, large per-fraction doses place biological conversion in a regime where standard linear-quadratic assumptions are less secure: the most probable cervical tumor α/β derived from in vitro data is below the conventional assumption, and reported deviations in converted prescription dose can reach 10 Gy for common HDR schedules. Fourth, inter-fraction applicator reinsertion, organ filling, tissue deformation, and packing shift pelvic OARs relative to the high-dose region, so cumulative D2cc represents repeated sampling of near-maximum sub-volumes rather than a voxelwise dose history. Across these domains, the dose calculation algorithm adds a further layer of complexity, because published clinical thresholds were calibrated in the TG-43 framework. The literature does not support abandoning current EQD2-based constraints. Instead, current coverage goals and OAR constraints should remain the primary clinical reference while the delivery and accumulation factors that affect their interpretation are reported more explicitly.
PURPOSE:To report long-term oncologic outcomes and toxicity of real-time transrectal ultrasound (TRUS)-guided high-dose-rate (HDR) brachytherapy monotherapy for low-risk and favorable intermediate-risk prostate cancer treated with 13.5 Gy × 2 fractions. METHODS AND MATERIALS:We performed a single-institution retrospective cohort study of consecutive patients treated with TRUS-guided, real-time planned HDR brachytherapy monotherapy (two fractions of 13.5 Gy separated by approximately two weeks). Biochemical failure was defined by the Phoenix definition. Kaplan-Meier methods estimated biochemical progression-free survival (bPFS) with 95% confidence intervals (CIs). Univariate Cox models explored associations between candidate predictors and bPFS. Toxicity was graded using CTCAE v4. RESULTS:300 patients were included with a median follow-up of 86.1 months [IQR 59.2 - 101.2]; the 5- and 10-year biochemical progression-free survival rates were 93.7% (95% CI: 91.0-96.6%) and 81.8% (95% CI: 76.0-87.9%), respectively. Late grade 2-3 genitourinary (GU) toxicity occurred in 20 patients (6.7%); no grade 4 events were observed. No grade ≥2 gastrointestinal (GI) toxicity was recorded. CONCLUSIONS:Real-time TRUS-guided HDR brachytherapy monotherapy using 13.5 Gy × 2 provides durable long-term biochemical control with a favorable toxicity profile. Achieving a PSA nadir <0.2 ng/mL appears to be a strong predictor of biochemical control and merits incorporation into risk stratification and follow-up.
Brachytherapy approaches integrate a diverse skillset in the management of a wide range of diseases. These approaches include key clinical decision-making skills as well as a unique set of procedural skills. Consensus statement training objectives for brachytherapy were previously assembled and published by the American Brachytherapy Society. As a continuation of this effort, the development of focused competencies in line with the US Accreditation Council for Graduate Medical Education Milestones was recommended. This work is designed to create a resource to support individual programs and licensing jurisdictions to assess and monitor trainee education and skill development for endoluminal brachytherapy for esophageal and endobronchial applications.
PURPOSE:The reaction of lung tissue to extreme single brachytherapy doses have not been analyzed in the past. METHODS:Overall, 46 lung tumors were treated in 32 patients with HDR (high dose rate) brachytherapy (median dose 20Gy). Treatment planning (n = 46) and follow up CT images (n = 154) performed up to 60 months after brachytherapy were evaluated. RESULTS:The long-term local tumor control was 81%. Pneumonitis was classified as grade 1, 2 and 3 in 26 (57%), 4 (9%) and 3 (7%). Early changes include spotted consolidation in the majority and ground glass opacity in about 40% of patients within the first six months. Partial atelectasis or pleural effusion were observed in 10-20%, respectively. In the period after 6 months, streaky or dense consolidation were noted in the majority of follow-up images. The lung tissue consolidation progresses into retraction. Lung atelectasis occurred in about 10% of patients. Pleural effusion was noted more rarely. CONCLUSION:As a result of high focal doses in one fraction, tissue consolidation must be expected in all patients, with progressive retraction predominantly in the second year after brachytherapy. There is a smaller risk of partial atelectasis and pleural effusion.
BACKGROUND:Completion of curative intent radiation for locally advanced cervical cancer (LACC) within 56 days is independently associated with improved outcomes. This study characterizes barriers to care among patients with LACC completing timely definitive treatment with external beam radiotherapy (EBRT) and brachytherapy (BT) boost. METHODS:Patients treated with curative intent radiation therapy from 2005-2021 at a tertiary care center were retrospectively reviewed, with patient and treatment characteristics being recorded. Multivariate risk analysis of clinical, sociodemographic, and geographic factors yielded a prognostic point-based "LACC-PRO" scoring system. RESULTS:325 patients with LACC treated with EBRT and BT were analyzed. Prolonged treatment time was associated with non-Hispanic ethnicity (p = 0.002), ECOG ≥ 1 (p < 0.001), current smoking (p = 0.002), lack of insurance coverage (p = 0.025), para-aortic nodal coverage (p = 0.015), lack of pre-BT imaging (p = 0.034), and non-primary site EBRT location (p = 0.005). Total scores on the predictive nomogram ranged from 0-18 (median 7). Among 140 patients with scores >7, 53.6% experienced prolonged treatment compared to 17.8% of the 185 patients with scores ≤7. CONCLUSIONS:Clinical and sociodemographic factors detrimentally impact timely completion of definitive radiation for LACC patients. A predictive nomogram may help identify patients at risk for prolonged treatment time. These results require validation in a larger cohort.
PURPOSE:We describe a novel system which enhances and clarifies the live transrectal US information during gynecological brachytherapy implants for improved needle guidance during insertion. It combines a freehand, stepper-less transrectal ultrasound (US) probe with an electro-magnetic tracking system to continuously fuse a preexisting MR and visualize the inserted needle. METHODS:A BK Spekto with a biplanar 9048 US probe, was instrumented with a Northern Digital Inc. Electro-magnetic tracker, part of the 3D Guidance Trakstar system. Software was developed using the 3D Slicer toolkit to enable live and continuous fusion of a preacquired MR. Contours generated on the MR can displayed on the live US image. A custom tracked stylet be placed inside a needle to visualize its location on the live US image using an overlay. RESULTS:The system was assessed on a CIRS 054 phantom before being deployed in clinical implants. Registration accuracy between the live US image and the MR/contours was assessed by comparing the phantom or patient anatomy on the live US with the overlaid contours. A similar method was use for the needle localization tool. An accuracy < 4 mm was measured for the US/MR fusion, and < 5 mm for the needle localization overlay. CONCLUSIONS:A novel system has been developed and clinically tested to enhance the capabilities of US imaging for gynecological brachytherapy procedures by incorporating MR information and needle recognition. These features can help guide the practitioner to a geometrically more robust implant with actionable feedback.
PURPOSE:In-room cone-beam CT (CBCT) is an emerging imaging solution for brachytherapy. This study evaluates organ-at-risk (OAR) contour and dosimetric differences between CT- and CBCT-based treatment plans for cylinder-based brachytherapy. MATERIALS AND METHODS:Ten patients who received high-dose-rate (HDR) cylinder-based brachytherapy were retrospectively analyzed. Standard pelvic CT images were used for treatment planning, and in-room CBCT images were acquired prior to the treatment to verify cylinder placement. The CT-based plans were replanned on their corresponding CBCT images. OARs were independently contoured on both CT and CBCT and compared using Dice similarity coefficient (DSC), and Hausdorff distance (HD). Dosimetrically, D₂cc were compared between CT and CBCT. RESULTS:Among the ten patients, CBCT provided reliable images for HDR cylinder treatment planning in terms of applicator digitalization and OAR delineation. Considerable variabilities between CT and CBCT for OARs were observed. Median DSC values were 0.73, 0.78, 0.74, and 0.48 and median HD values were 15.5 mm, 12.2 mm, 16.0 mm, and 22.5 mm for the bladder, rectum, small bowel, and sigmoid, respectively. Median values of D₂cc differences between the CT-based plans and the CBCT-based plans were 3.4 cGy, 25.1 cGy, 26.2 cGy, and 58.3 cGy for the bladder, rectum, small bowel, and sigmoid, respectively. CONCLUSION:In-room mobile CBCT provides a practical and efficient solution for vaginal cylinder HDR brachytherapy. The image quality was sufficient for accurate delineation of the applicator and OARs, helping streamline the workflow. Although inter-fractional variations in OAR position and volume were observed, these changes remained within clinically acceptable limits.
High-dose-rate (HDR) brachytherapy for rectal cancer is an evolving modality that integrates advanced imaging, personalized applicator design, and multidisciplinary coordination to support organ preservation and improve patient outcomes. As interest in rectal brachytherapy grows-driven by technological innovation and emerging clinical evidence-there is a critical need to define the competencies required for safe and effective practice. This Clinical Competency Review outlines contemporary approaches to HDR rectal brachytherapy, including patient selection, treatment planning, applicator technologies, and quality assurance. It complements existing training frameworks by proposing structured milestones adapted from the Accreditation Council for Graduate Medical Education and informed by international consensus. By delineating procedural expectations and knowledge domains, this document aims to support the development of standardized training pathways and promote high-quality implementation of rectal brachytherapy across diverse clinical settings.
PURPOSE:Endoscopy is critical in the identification of rectal tumors, but is prone to observer errors. The aim of this study was to assess the inter- and intra-observer variability in delineating rectal lesions in endoscopic images taken during high-dose-rate (HDR) brachytherapy and develop a deep learning-based automatic tumor segmentation model. MATERIALS AND METHODS:Three expert annotators identified tumors, scaring, ulcers and radiation proctitis in 801 endoscopic images from 24 patients. Inter-observer variability was evaluated at both whole-image and contour levels. Intra-observer variability was assessed by re-annotating 15 images from 14 patients after six months. Four DeepLabV3 models with a ResNet50 backbone were trained using a nested cross-validation approach: one per annotator and a fourth trained on majority-vote contours. Model performance was evaluated on 60 unseen images, which the annotators rated using a five-point Likert scale. RESULTS:Manual annotations showed significant variability for ulcers and radiation proctitis (average Dice: 0.36 and 0.57) versus tumors (0.83). Intra-observer Dice scores were 0.72, 0.68, and 0.87 across annotators. The majority-vote model outperformed individual annotator models (average Dice: 0.77) but generated many false positives, misclassifying ulcers and proctitis as tumors. Annotators generally rated the model trained on their own contours higher on the unseen test set. CONCLUSIONS:This work highlights the variability in expert annotations used as ground-truth for deep learning-based segmentation of rectal tumors in endoscopic images acquired during HDR brachytherapy. Automated contouring may provide a foundation for adaptive, AI-assisted brachytherapy workflows.
PURPOSE:This study describes the development, implementation, and evaluation of an online educational program on CT-based image-guided adaptive brachytherapy for locally advanced cervical cancer (LACC) by BrachyAcademy, in collaboration with the lead author of the IBS-GEC ESTRO-ABS CT-based contouring recommendations. MATERIALS AND METHODS:In 2023-24, the program comprised three components: a procedural video, a webinar, and an interactive online contouring workshop. The workshop included two homeworks on LACC cases using ProKnow software. Participants delineated high-risk clinical target volume (CTVHR) and intermediate-risk clinical target volume (CTVIR) and organs at risks. Postworkshop contouring efficiency was assessed by comparing participants' contours to master contours. Feedback was collected through postcourse evaluation forms. RESULTS:The procedural video reached 487 individuals from 70 countries; the webinar engaged 148 participants from 39 countries, with an additional 115 on-demand viewers. Thirty-five radiation oncologists from 20 countries participated in the workshop, and 27 (77%) completed both homeworks for both cases. Comparison between homeworks demonstrated significant improvements in CTVHR and CTVIR contouring. Postcourse evaluation forms (n = 25) showed that 92% of respondents' expectations were fully met, with an average satisfaction score of 9.3/10. CONCLUSION:Participation highlighted a broad, global interest in CT-based brachytherapy education. Strategies are being explored to scale up the online program and integrate it with in-person workshops.
PURPOSE:Brachytherapy (BT) is an increasingly used modality for delivering highly conformal, surface-weighted radiation to cancers involving the skin with excellent cosmetic outcomes. Its applications span nonmelanoma skin cancers and cutaneous manifestations of hematologic and other malignancies, and are useful in the definitive or palliative settings. Currently, there is no standardized framework for training radiation oncologists in delivering cutaneous BT. This review outlines current evidence and principles to guide patient selection, proper setup, planning, and treatment delivery in accordance with the recent ABS/GEC-ESTRO Consensus Statement on Objectives for BT training. METHODS AND MATERIALS:A narrative review was conducted, synthesizing consensus guidelines, key clinical series, historical planning systems, and contemporary recommendations from experts and professional societies. RESULTS:Both electronic and radionuclide-based high-dose-rate BT offer flexible, conformal treatment options for diverse anatomical sites with respective advantages and limitations. Optimal application depends on risk stratification, evaluating locoregional involvement and pathologic features. High-quality delivery requires precise imaging and target delineation, matching anatomic complexity with the appropriate applicator selection and placement, appropriate planning, and rigorous quality assurance. Fractionation schedules range from conventional to ultra-hypofractionated, with prescription depth and applicator type guiding dose. CONCLUSIONS:The clinical and technical evidence summarized within establishes a practical framework for the core competencies necessary to perform high-quality skin brachytherapy.
Vaginal brachytherapy is a critical component in the treatment of gynecologic malignancies. Training in brachytherapy indications, procedural techniques, prescription dose/fractionation, treatment planning, and safety is essential to the safe and effective delivery of vaginal brachytherapy. This manuscript outlines the necessary knowledge and procedural skills for successful vaginal cylinder brachytherapy practice.
BACKGROUND:Urinary toxicity is a common side effect of prostate brachytherapy. This study evaluated the relationship between urethral dosimetry and urinary symptoms following low-dose prostate brachytherapy. METHODS:We retrospectively analyzed 175 patients who underwent I-125 prostate brachytherapy. Urethral contours were generated using MRI-TRUS fusion and transferred to day-30 CT scans. Dosimetric parameters were calculated for both rigid and deformed urethral models. Urinary symptoms were assessed using the International Prostate Symptom Score (IPSS) at baseline and 1 month after treatment. Correlations between dosimetric parameters and IPSS were analyzed. RESULTS:Median IPSS increased from 4 at baseline to 9 at 1 month. Weak correlations were observed between 1-month IPSS and urethral volume, length, and V150 (volume receiving ≥150% of the prescribed dose). Patients with urethral V150 ≥0.61cc had significantly higher 1-month IPSS (mean difference 2.8 points, p = 0.001). In multivariate analysis, only baseline IPSS (p < 0.001) and prostate volume (p = 0.021) independently predicted 1-month IPSS. No dosimetric parameters predicted acute urinary retention. CONCLUSIONS:Early urinary toxicity after prostate brachytherapy is multifactorial. Baseline urinary function and prostate volume were the strongest predictors, but maintaining low urethral V150 remains important to limit morbidity.
