The National Institute for Health and Care Excellence (NICE) has recommended the use of contact X-ray brachytherapy (CXB) for rectal cancer patients who are not suitable for surgery. At present, patients with early rectal cancer who wish to avoid major surgery and a stoma are not usually offered CXB as an alternative treatment option to surgery. The main reason for this has been a lack of large, randomised trial evidence, hence NICE encouraged provision of this evidence in their recommendation. In 2015, the OPERA (Organ Preservation in Early rectal Adenocarcinoma) trial was set up and the 3-year organ-preservation results were presented at the American Society of Clinical Oncology (ASCO) meeting in Chicago on 4 June 2022. We are now awaiting full publication of the OPERA results. Most rectal cancer patients who are not suitable for surgery are currently offered external beam radiotherapy (EBRT) with or without chemotherapy after the multidisciplinary discussions. Clinical complete response (cCR) rates vary between 20 and 50% after EBRT. Those who achieve cCR usually adopt a 'watch and wait' policy, but patients who have residual disease are often not offered any additional treatment. We hypothesised that dose escalation with a CXB boost could achieve a higher cCR and therefore lead to improved organ-preservation rates. This was the rationale behind the OPERA trial, which randomised patients between standard of care [EBRT with chemotherapy (EBCRT)] followed by an EBRT boost against EBCRT with a CXB boost to evaluate the role of CXB in dose escalation. In 1993, the first CXB centre was established in the UK at Clatterbridge Cancer Centre. There are now four centres offering CXB in the UK and 10 centres in Europe. Patients should be provided with full information during the consent discussion and offered all the treatment options that are available, so that they can share in decision making and be empowered to make treatment decisions of their choice after proper fully informed consent. Randomised trial evidence of the role of dose escalation with CXB from the OPERA trial, when published, will help in consenting patients who are keen to avoid surgery. We hope this review will help to provide some information about who should be offered CXB, when this modality should be offered and how this is delivered. (c) 2022 Published by Elsevier Ltd on behalf of The Royal College of Radiologists.

Madam — This letter is a response to the recent overview on high dose rate (HDR) brachytherapy in high-risk localised disease in the prostate cancer special issue by Morton and Alrashidi [ [1] Morton G.C. Alrashidi S.M. High dose rate brachytherapy in high-risk localised disease — why do anything else?. Clin Oncol. 2020; 32: 163-169 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar ].

S3, ASCRS 2017; Annual Meeting 7 Radiotherapy dose and fractionation RCR (2016); 2nd edition. www.rcr.ac.uk 8 Sun Myint A, Smith F, Wong H et al. Salvage surgery for local regrowth following external beam radiotherapy followed by contact X-ray brachytherapy and ‘Watch & wait’ for rectal cancer. Do we compromise the chance of cure? https://doi.org/10.1016/j.ejso.2017.10.145 9 Sun Myint A. Contact radiotherapy for elderly patients with early low rectal cancers. Br J Hosp Med 2013; 74: 696–

Background: Intensity-modulated radiotherapy (IMRT) allows a highly conformal dose to be delivered to the planning target volume (PTV) with reduced normal tissue toxicity. Daily soft tissue matching (STM) with conebeam CT (CBCT) ensures the target remains within the PTV and is particularly important in cervical IMRT as the clinical target volume (CTV) is very mobile. Bladder and rectal protocols can help, but may fail due to patient compliance, reduced bladder capacity, dehydration or delays.

Background to the audit: Locally advanced cervical cancer is treated with chemoradiotherapy and brachytherapy.[1],[2] Guidelines support the implementation of image-guided brachytherapy (IGBT).[3],[4] [5] IGBT allows dose escalation whilst minimising dose to organs at risk, improving local control and survival.[6] Interstitial needles improve coverage of the high risk clinical target volume (HR-CTV) particularly when the tumour is large (>5 cm).

ESTRO 36 _______________________________________________________________________________________________ validation) were 0.63, 0.68 and 0.66 respectively.Based on this model, 2 groups risk were identified.The 3-year OS, DFS and LRC were 88% (95CI: 67.4 -100%), 78.7 % (63.6 -97.3%) and 83.6% (95CI: 70.1 -99.7%) for low-risk group vs 45.5% (95CI: 23.8 -86.8%), 33.3% (95CI: 15 -74.2%) and 38.1% (95CI: 17.9 -81.1%) for high-risk group (p<0.01)(Figure 1 and2).Conclusion TLG of the primary tumor and the distance between lymph node and the primary tumor, weighted by the MTV of lymph nodes, were correlated with LRC, DFS and OS.These parameters seem to have a higher predictive value than classical prognostics parameters, and may be useful to tailoring the therapeutic approach in this type of cancer.