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Abstract: Purpose: To evaluate local control, survival and toxicity in patients with early-stage endometrioid adenocarcinoma of the uterus treated with adjuvant high-dose-rate (HDR) vaginal brachytherapy (VB) alone using a novel low dose regimen. Methods: We reviewed records of 414 patients with stage IA to stage II endometrial adenocarcinoma treated with VB alone from 2005 to 2011. Of these, 157 patients with endometrioid histology received 24Gy in 6 fractions of HDR vaginal cylinder brachytherapy and constitute the study population. Dose was prescribed at the cylinder surface and delivered twice weekly in the post-operative setting. Local control and survival rates were calculated by the Kaplan–Meier method. Results: All 157 patients completed the prescribed course of VB. Median follow-up time was 22.8months (range, 1.5–76.5). Two patients developed vaginal recurrence, one in the periurethral region below the field and one in the fornix after treatment with a 2.5-cm cylinder. Three patients developed regional recurrence in the para-aortic region. Two patients developed distant metastasis (lung and carcinomatosis). The 2-year rate of vaginal control was 98.6%, locoregional control was 97.9% and disease-free survival was 96.8%. The 2-year overall survival rate was 98.7%. No Grade 2 or higher vaginal, gastrointestinal, genitourinary or skin long-term toxicity was reported for any patient. Conclusion: Vaginal brachytherapy alone in early-stage endometrial cancer provides excellent results in terms of locoregional control and disease-free survival. The fractionation scheme of 24Gy in 6 fractions prescribed to the cylinder surface was well-tolerated with minimal late toxicity. [Copyright &y& Elsevier]

The Sedlis criteria define risk factors for recurrence warranting post-hysterectomy radiation for early-stage cervical cancer; however, these factors were defined for squamous cell carcinoma (SCC) at an estimated recurrence risk of ≥30%. Our study evaluates and compares risk factors for recurrence for cervical SCC compared with adenocarcinoma (AC) and develops histology-specific nomograms to estimate risk of recurrence and guide adjuvant treatment. We performed an ancillary analysis of GOG 49, 92, and 141, and included stage I patients who were surgically managed and received no neoadjuvant/adjuvant therapy. Multivariable Cox proportional hazards models were used to evaluate independent risk factors for recurrence by histology and to generate prognostic histology-specific nomograms for 3-year recurrence risk. We identified 715 patients with SCC and 105 with AC; 20% with SCC and 17% with AC recurred. For SCC, lymphvascular space invasion (LVSI: HR 1.58, CI 1.12–2.22), tumor size (TS ≥4 cm: HR 2.67, CI 1.67–4.29), and depth of invasion (DOI; middle 1/3, HR 4.31, CI 1.81–10.26; deep 1/3, HR 7.05, CI 2.99–16.64) were associated with recurrence. For AC, only TS ≥4 cm, was associated with recurrence (HR 4.69, CI 1.25–17.63). For both histologies, there was an interaction effect between TS and LVSI. For those with SCC, DOI was most associated with recurrence (16% risk); for AC, TS conferred a 15% risk with negative LVSI versus a 25% risk with positive LVSI. Current treatment standards are based on the Sedlis criteria, specifically derived from data on SCC. However, risk factors for recurrence differ for squamous cell and adenocarcinoma of the cervix. Histology-specific nomograms accurately and linearly represent risk of recurrence for both SCC and AC tumors and may provide a more contemporary and tailored tool for clinicians to base adjuvant treatment recommendations to their patients with cervical cancer. • Adenocarcinoma is a distinct cervical cancer subtype and treatment should be based on data specific to this subtype. • Risk factors for recurrence differ for squamous cell carcinoma and adenocarcinoma of the cervix. • For adenocarcinoma of the cervix, tumor size is the risk factor associated with the highest risk of recurrence. • For squamous cell carcinoma, depth of invasion is the risk factor associated with the highest risk of recurrence. • Histology-specific nomograms accurately and linearly represent risk of recurrence for squamous cell and adenocarcinoma. [ABSTRACT FROM AUTHOR]

The optimal overall treatment time (OTT) from radical surgery to the end of adjuvant radiation therapy for some squamous cell carcinomas has been found to impact treatment outcomes. This study aims to identify the impact of OTT on overall survival (OS) for women with completely resected, node-positive squamous cell carcinomas of the vulva. The National Cancer Data Base was queried for women with surgically resected, node-positive vulvar squamous cell carcinomas between 2004 and 2016 who were treated with adjuvant radiation therapy. Kaplan-Meier analysis with log-rank test and Cox proportional hazards tests were utilized for OS calculations. A total of 1500 women met inclusion criteria. The median OTT was 104 days. Shorter OTT was associated with age, facility volume, private insurance, and duration of post-operative hospitalization. Median OS with OTT ≤ 104 days was 56.1 months vs 45.4 months if ≥105 days (p = 0.015). On multivariable Cox analysis, OTT was independently associated with an increased risk of death of 0.4% per additional day (95%CI 1.001–1.007, p = 0.003), as were age at diagnosis (HR 1.031 [95%CI 1.024–1.037], p < 0.001), number of nodes positive (HR 1.031 [95%CI 1.024–1.037], p = 0.006), the use of concurrent chemotherapy (HR 0.815 [95%CI 0.693–0.960], p = 0.014) and increasing pT/pN stage. After propensity adjustment for factors predicting a shorter OTT, OTT continued to be associated with an increased risk of death per additional day (HR 1.004 [95%CI 1.001–1.007], p = 0.007). Overall treatment time is an independent risk factor for death in women being treated with adjuvant radiation therapy following complete resection of node-positive squamous cell carcinoma of the vulva. • OTT of adjuvant radiation therapy is an independent risk factor for death in women with resected, node-positive vulvar cancer • Each additional day between surgery and completion of adjuvant radiation contributes to higher risk of death • This is the first study to evaluate the impact of OTT on overall survival in this population of patients [ABSTRACT FROM AUTHOR]

To report procedure time for novel MRI catheter tracking technology in patients undergoing template-based interstitial gynecologic brachytherapy implants. From 2018 to 2022, gynecologic patients undergoing template-based (Syed/Neblett) interstitial brachytherapy were included in this analysis. There are two cohorts: those treated with MRI-tracking technology and a comparison cohort. All patients underwent a standard template-based interstitial procedure, which included clinical examination, procedure preparation, obturator and needle insertion, mid-procedure MR images (if any), and final MRI acquisitions used in contouring and treatment planning. Additionally, for patients consenting to the MR-guided treatment investigation, custom-built MRI-tracking stylets were inserted in the implantable catheters to visualize positioning on the mid-procedure MR images as they were implanted. The procedural workflow is illustrated in Figure 1. For the investigational patient group, data logs recorded the procedure time dedicated to needle insertion. The comparison cohort of patients treated without MRI-tracking technology was used to determine the impact to procedure time when adding novel, developmental MRI-tracking technology. Extracted from the electronic medical record, the procedure start time was indicated by anesthesia handover to the attending radiation oncologist and procedure completion was indicated by the acquisition time of the post-implant MR imaging sequence. The procedure times and needle insertion times were reported as the median and interquartile range, which were compared using a student's t-test with alpha of 0.05 indicating significance. For both cohorts, patient and treatment characteristics are reported including primary disease site and average needles inserted. Between 2018 to 2022, 18 patients consented to interstitial procedures guided by MRI-tracking technology. For the same period, the comparison cohort without MRI-tracking technology included 62 patients. The disease sites for the MRI-tracking patients are eight cervix, seven vaginal, and three endometrial recurrences. The average needles inserted (± standard deviation) were 13 (± 4) and 14 (± 4) for the MRI-tracking and comparison cohorts (p = 0.49), respectively. Additionally, the median (interquartile range) procedure time was 95 (70 to 119) minutes and 99 (83 to 110) minutes for the MRI-tracking and non-MRI tracking patients, respectively. No statistical difference in procedure time is observed (p = 0.55). For patients with MRI-tracking, data logs times showed a median of 28 (23 to 43) minutes, which indicates the needle insertion is approximately one third of the total procedure time and approximately 2.2 minutes per needle. In the developmental stage of MRI-tracking technology, procedural times are not observed to be different from the standard procedures. Clinical implementation of developmental MRI-tracking stylets resulted in procedure time that did not show a difference when compared to standard procedures. This result suggests the additional overhead of incorporating developmental MRI-tracking technology in the procedure is offset by the physician's capability to more quickly complete the implant based on mid-procedure visualization of catheter implants. [ABSTRACT FROM AUTHOR]

Purpose: Accurate target definition is critical for the appropriate application of radiation therapy. In 2008, the Radiation Therapy Oncology Group (RTOG) published an international collaborative atlas to define the clinical target volume (CTV) for intensity modulated pelvic radiation therapy in the postoperative treatment of endometrial and cervical cancer. The current project is an updated consensus of CTV definitions, with removal of all references to bony landmarks and inclusion of the para-aortic and inferior obturator nodal regions.Methods and Materials: An international consensus guideline working group discussed modifications of the current atlas and areas of controversy. A document was prepared to assist in contouring definitions. A sample case abdominopelvic computed tomographic image was made available, on which experts contoured targets. Targets were analyzed for consistency of delineation using an expectation-maximization algorithm for simultaneous truth and performance level estimation with kappa statistics as a measure of agreement between observers.Results: Sixteen participants provided 13 sets of contours. Participants were asked to provide separate contours of the following areas: vaginal cuff, obturator, internal iliac, external iliac, presacral, common iliac, and para-aortic regions. There was substantial agreement for the common iliac region (sensitivity 0.71, specificity 0.981, kappa 0.64), moderate agreement in the external iliac, para-aortic, internal iliac and vaginal cuff regions (sensitivity 0.66, 0.74, 0.62, 0.59; specificity 0.989, 0.966, 0.986, 0.976; kappa 0.60, 0.58, 0.52, 0.47, respectively), and fair agreement in the presacral and obturator regions (sensitivity 0.55, 0.35; specificity 0.986, 0.988; kappa 0.36, 0.21, respectively). A 95% agreement contour was smoothed and a final contour atlas was produced according to consensus.Conclusions: Agreement among the participants was most consistent in the common iliac region and least in the presacral and obturator nodal regions. The consensus volumes formed the basis of the updated NRG/RTOG Oncology postoperative atlas. Continued patterns of recurrence research are encouraged to refine these volumes. [ABSTRACT FROM AUTHOR]

The American Brachytherapy Society brachytherapy schools have been pivotal in teaching and evolving the art of brachytherapy over the past decades. Founded in 1995, the schools have consistently provided content for the major disease sites including gynecologic, prostate, and breast with ocular, vascular, head and neck, pediatric, intraluminal, systemic, and intraoperative approaches more selectively addressed. In addition, Physics schools, either coupled with clinical schools or as stand-alone venues, have provided an essential educational component for practicing physicists, a pivotal part of the brachytherapy team. Celebrating 25 years in existence, this historical overview of the American Brachytherapy Society brachytherapy schools is a tribute to the many teachers who have shared their expertise, to the many students who have been enthusiastic and interactive participants, and the staff who have made it all possible, with the reward of perpetuating the important and timely art of brachytherapy. [ABSTRACT FROM AUTHOR]

Background: In India, where the annual incidence of cancer is projected to reach 1.7 million by 2020, the need for clinical research to establish the most effective, resource-guided, and evidence-based care is paramount. In this study, we sought to better understand the research training needs of radiation oncologists in India.Methods: A 12 item questionnaire was developed to assess research training needs and was distributed at the research methods course jointly organized by Indian College of Radiation Oncology, the American Brachytherapy Society, and Education Committee of the American Society of Therapeutic Radiation Oncology during the Indian Cancer Congress, 2017.Results: Of 100 participants who received the questionnaire, 63% responded. Ninety percent (56/63) were Radiation Oncologists. Forty-two percent (26/63) of respondents had previously conducted research. A longer length of practice (>10 years) was significantly associated with conducting research (odds ratio (OR) 6.99, P = 0.031) and having formal research training trended toward significance (OR 3.03, P = 0.058). The most common reason for not conducting research was "lack of training" (41%, 14/34). The most common types of research conducted were Audits and Retrospective studies (62%, 16/26), followed by a Phase I/II/III Trial (46%, 10/26). Having formal research training was a significant factor associated with writing a protocol (OR 5.53, P = 0.016). Limited training in research methods (54%, 13/24) and lack of mentorship (42%, 10/24) were cited as reasons for not developing a protocol. Ninety-seven percent (57/59) of respondents were interested in a didactic session on research, specifically focusing on biostatistics.Conclusions: With research training and mentorship, there is a greater likelihood that concepts and written protocols will translate into successfully completed studies in radiation therapy. [ABSTRACT FROM AUTHOR]

To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic. An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel. Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended. The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19. • An international panel of gynecologic radiation oncologists offer recommendations for RT during the COVID-19 pandemic. • Recommendations for cervical cancer, uterine cancer, vulvar cancer, vaginal cancer and ovarian cancer have been provided. • Recommendations for RT timing, fractionation, and dose have been provided for external beam radiation and brachytherapy. • The panel emphasizes strategies to reduce risk of transmission of the novel SARS-CoV-2 to patients and healthcare workers. • These recommendations may be used any time an event occurs which limits healthcare resources, including natural disasters. [ABSTRACT FROM AUTHOR]

To understand the reasons behind current low utilization of brachytherapy for locally advanced cervical cancer in the United States. A 17-item survey was e-mailed to the American Brachytherapy Society (ABS) listserv of active members in 2018. Responses of attending physicians in the United States were included in the analysis. Among a total of 135 respondents, 81 completed the survey. Eighty-four percent agree/strongly agree that cervical brachytherapy is underutilized, and 46.9% disagree/strongly disagree that residents are receiving adequate training for brachytherapy; 75.3% agree/strongly agree that inadequate maintenance of brachytherapy skills is a major obstacle to brachytherapy use; and 71.6% agree/strongly agree that increased time requirement constitutes a major obstacle. Over 97% will recommend brachytherapy for most patients with cervical cancer if given access/time; 72.8% always perform their own brachytherapy, whereas 29.6% reported some type of barrier exists in performing brachytherapy themselves, with time required to perform brachytherapy (9.9%) being a leading factor. A quarter (24.7%) routinely refer to other radiation oncologists for brachytherapy. Even among ABS members, 37.0% reported that they would perform an intensity-modulated radiation therapy or stereotactic body radiation therapy boost in specific scenarios in potentially curable patients. The most common scenario is inability to place a uterine tandem (56.7%). The underutilization of brachytherapy in cervical cancer is widely recognized by ABS members with inadequate training during residency and inadequate maintenance of skills being possible major contributing factors. Even among ABS members, there are identifiable barriers. Continued advocacy and future initiatives in enhancing access to brachytherapy training and efficiency are needed. [ABSTRACT FROM AUTHOR]

Purpose: Chartrounds (www.chartrounds.com) was established in the United States in 2010 as a web-based platform for radiation oncologists to review cases with leading disease-site experts. However, the need for access to experts for peer review and education is not unique to the United States, and the Chartrounds platform was therefore adapted for improved global reach. Chartrounds was first expanded to India, and herein we report our initial experience with this initiative.Methods and Materials: The US Chartrounds platform was adapted to create Chartrounds India (ind.chartrounds.com). Through collaboration with the Association of Radiation Oncologists of India, India-based specialists were recruited, and the association's membership list was used to announce sessions to potential participants.Results: Between June 2017 and January 2018, 27 Chartrounds India sessions were completed, led by 21 different specialists (representing 10 centers in India) and covering 11 different disease sites/topics. A total of 240 members from 126 centers (private: 56%; teaching: 36%; public: 8%) across 24 states/territories participated in ≥1 session. Of the 240 members who participated in ≥1 session, 159 (66%) participated in ≥2 sessions and 60 (25%) participated in ≥5 sessions. The average number of participants per session was 34 (range, 13-72). On average, 80% of respondents rated the sessions as high or very high quality; 87% and 95% agreed or strongly agreed that the time was used effectively and that the sessions were relevant to daily practice, respectively. Seventy-six percent agreed or strongly agreed that the sessions will result in a change in their practice. The average feedback survey response rate was 32% (range, 17%-49%).Conclusions: Chartrounds has proven to be an effective resource for US-based radiation oncologists, and our initial experience with Chartrounds India suggests that an online platform for radiation oncology case review and education can be successfully implemented globally with use of local disease site experts. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the survival endpoints in women with International Federation of Gynecology and Obstetrics (FIGO) stage II endometrial cancer who received adjuvant vaginal brachytherapy (VBT) alone using multi-institutional pooled data.Methods and Materials: We performed a multi-institutional analysis of surgically staged patients with FIGO stage II endometrioid-type endometrial cancer treated with VBT alone. Patient, tumor, and treatment characteristics were collected and analyzed. Univariable and multivariable frailty survival models were performed to assess clinicopathologic risk factors for recurrence and death.Results: One hundred six patients were included (92 VBT alone and 14 VBT with chemotherapy) with median follow-up of 39.0 months. Pelvic node dissection was performed in 89.6% of patients. One hundred four patients (98.1%) and 2 patients (1.9%) had microscopic and macroscopic cervical stromal invasion, respectively. Grade 1 or 2 disease occurred in 88.6% of patients. For patients treated with VBT without chemotherapy, the 5-year estimates of vaginal failure, pelvic nodal failure, and distant metastases were 2.6%, 4.2%, and 7.2%, respectively. Five-year progression-free survival and overall survival were 74.0% and 76.2%, respectively. On univariable and multivariable models for progression-free survival, increasing age and lack of pelvic node resection were hazardous (P < .05).Conclusions: Vaginal and pelvic failure rates were low in this selected population of stage II patients receiving adjuvant VBT without external beam radiation therapy. It is reasonable to consider adjuvant VBT alone in selected patients with grade 1 or 2 disease and microscopic cervical stromal invasion who underwent pelvic lymphadenectomy. [ABSTRACT FROM AUTHOR]

Purpose: To prospectively compare survival between human immunodeficiency virus (HIV)-infected versus HIV-uninfected cervical cancer patients who initiated curative chemoradiation therapy (CRT) in a limited-resource setting.Methods and Materials: Women with locally advanced cervical cancer with or without HIV infection initiating radical CRT in Botswana were enrolled in a prospective, observational, cohort study from July 2013 through January 2015.Results: Of 182 women treated for cervical cancer during the study period, 143 women initiating curative CRT were included in the study. Eighty-five percent of the participants (122 of 143) had stage II/III cervical cancer, and 67% (96 of 143) were HIV-infected. All HIV-infected patients were receiving antiretroviral therapy (ART) at the time of curative cervical cancer treatment initiation. We found no difference in toxicities between HIV-infected and HIV-uninfected women. The 2-year overall survival (OS) rates were 65% for HIV-infected women (95% confidence interval [CI] 54%-74%) and 66% for HIV-uninfected women (95% CI 49%-79%) (P = .70). Factors associated with better 2-year OS on multivariate analyses included baseline hemoglobin >10 g/dL (hazard ratio [HR] 0.37, 95% CI 0.19-0.72, P = .003), total radiation dose ≥75 Gy (HR 0.52, 95% CI 0.27-0.97, P = .04), and age <40 years versus 40-59 years (HR 2.17, 95% CI 1.05-4.47, P = .03).Conclusions: Human immunodeficiency virus status had no effect on 2-year OS or on acute toxicities in women with well-managed HIV infection who initiated curative CRT in Botswana. In our cohort, we found that baseline hemoglobin levels, total radiation dose, and age were associated with survival, regardless of HIV status. [ABSTRACT FROM AUTHOR]

Purpose Interstitial high-dose rate ( HDR) brachytherapy is an important therapeutic strategy for the treatment of locally advanced gynecologic ( GYN) cancers. The outcome of this therapy is determined by the quality of dose distribution achieved. This paper focuses on a novel yet simple heuristic for catheter selection for GYN HDR brachytherapy and their comparison against state of the art optimization strategies. The proposed technique is intended to act as a decision-supporting tool to select a favorable needle configuration. Materials The presented heuristic for catheter optimization is based on a shrinkage-type algorithm ( SACO). It is compared against state of the art planning in a retrospective study of 20 patients who previously received image-guided interstitial HDR brachytherapy using a Syed Neblett template. From those plans, template orientation and position are estimated via a rigid registration of the template with the actual catheter trajectories. All potential straight trajectories intersecting the contoured clinical target volume ( CTV) are considered for catheter optimization. Retrospectively generated plans and clinical plans are compared with respect to dosimetric performance and optimization time. Results All plans were generated with one single run of the optimizer lasting 0.6-97.4 s. Compared to manual optimization, SACO yields a statistically significant ( P ≤ 0.05) improved target coverage while at the same time fulfilling all dosimetric constraints for organs at risk ( OARs). Comparing inverse planning strategies, dosimetric evaluation for SACO and 'hybrid inverse planning and optimization' ( HIPO), as gold standard, shows no statistically significant difference ( P > 0.05). However, SACO provides the potential to reduce the number of used catheters without compromising plan quality. Conclusion The proposed heuristic for needle selection provides fast catheter selection with optimization times suited for intraoperative treatment planning. Compared to manual optimization, the proposed methodology results in fewer catheters without a clinically significant loss in plan quality. The proposed approach can be used as a decision support tool that guides the user to find the ideal number and configuration of catheters. [ABSTRACT FROM AUTHOR]

There is a growing need for a more diverse physician workforce to address gender, racial, and ethnic disparities in medicine. Investigations into vulnerable populations, including African, Native, Hispanic, and rural Americans all have overwhelmingly shown that these groups have diminished access and increased barriers to receiving radiation treatment. Increasing diversity among physicians can help address health care disparities in underserved populations. Accessible and inclusive residency training programs are needed to promote recruitment and retention of underrepresented physician groups. However, limited attention has been given to the potential benefits of training physicians with differences other than gender, race, or ethnicity. Americans with a disability represent about 27% of the population, whereas 1%-3% of physician trainees report having a disability. In 2017, our program matched a Deaf resident who preferentially utilized American Sign Language (ASL) to communicate. However, to date, there had been no published strategies on how to create an ASL inclusive residency training program for Deaf trainees. Herein, we report the development of a Deaf and ASL-inclusive residency program to serve as a model, which can be tailored to meet the needs of other underrepresented physician trainees in radiation oncology. In preparation, department leadership engaged key stakeholders and leaders within the university's health system and among the department faculty, residents, and staff as well as the incoming resident, which led to the development and implementation of an inclusive ASL training model for the program. In this process, 5 important principles and steps were identified. First, the trainee should be directly engaged and involved as a primary and key collaborator as to any cultural, linguistic, or physical needs and preferences. Second, key stakeholders within the institution, including hospital and department leadership, should be engaged early, and involved in implementing and creating strategies. Third, with the trainee's input, efforts should be initiated to utilize resources internal and external to the institution, including institutional ADA officers, disability services, and training consultants. Fourth, cultural and communication expectations should be discussed with faculty and staff with the goal of creating an inclusive training culture for all participants. Finally, workspace accommodations that remove any physical barriers should be addressed based on the trainee's input. Through collaborative efforts, a Deaf and ASL-signing resident was successfully integrated into the residency program. The 5 principles of our model allow for efficient implementation of a similar framework at other institutions seeking to employ similar inclusivity initiatives. [ABSTRACT FROM AUTHOR]

Objectives: Current guidelines recommend risk-reducing bilateral salpingo-oophorectomy (RRSO) for women diagnosed with BRCA1 mutations by ages 35-40 and BRCA2 mutations by ages 40-45. Our study aimed to examine guideline concordance for RRSO in a cohort of women with BRCA1 and BRCA2 mutations. Methods: We performed a retrospective cohort study of women aged 18-45 diagnosed with pathogenic BRCA1 or BRCA2 mutations seen by gynecologic oncologists at a single academic center between 2015 and 2019 and were eligible for RRSO per national guidelines. Our primary outcome was guideline concordance, defined as 1) electing RRSO by age 35 for women with BRCA1 and by age 40 for women with BRCA2, or 2) if the patient was diagnosed after age 35 with BRCA1 or after age 40 with BRCA2, electing RRSO within one year of diagnosis. Patients were monitored for electing RRSO by July 1st, 2021. We excluded those previously diagnosed with gynecologic malignancies and those whose current age was less than 35 for BRCA1 and less than 40 for BRCA2. We examined patient differences in guideline concordance using Fisher's exact and Pearson's Chisquare tests. We then identified relevant patient factors associated with guideline concordance using univariate log-binomial regression. Results: Of 62 total patients, 41 had a diagnosis of a suspected pathogenic or pathogenic BRCA1 mutation (median age at diagnosis 34 y), and 21 had a diagnosis of suspected pathogenic or pathogenic BRCA2 mutation (median age at diagnosis 41 y). Overall, 23% of patients (n =14/62) were guideline-concordant, or 27% of BRCA1 patients (n =11/41) and 14% of BRCA2 patients (n =3/21). In the descriptive analysis, guideline concordance was more common in non-White women compared to White women (n =7/18 vs n =7/44, p=0.09) and single women compared to partnered women (n =4/8 vs n =10/54, p=0.07). More women with a family history of both breast and ovarian cancer were guideline-concordant than women with a family history of breast cancer only (n =9/27 vs n =5/30, p=0.14). However, women with a personal history of breast cancer were less commonly guideline-concordant than women without a personal history (n =3/19 vs n =11/43, p=0.5). In univariate analysis, factors significantly associated with guideline concordance were non-White compared to White race (RR: 2.4, 95% CI: 1.00-5.97) and being single compared to being partnered (RR: 2.7, 95% CI: 1.11-6.58). There were no significant associations with guideline concordance by patient BMI, having children, having private insurance, income, type of BRCA diagnosis, past diagnosis of breast cancer, or family history of breast or ovarian cancer. [Display omitted] Conclusions: A minority of reproductive-age BRCA1/2 patients met guideline concordance for electing RRSO. Being guideline-concordant was associated with non-White and single status. Further studies are needed to verify and identify disparities in meeting guideline- recommended timing of RRSO for the BRCA1/BRCA2 population. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this American Brachytherapy Society task force is to present a literature review and patterns of care by a panel of experts for the management of vaginal recurrence of endometrial cancer. Methods and materials In 2016, the American Brachytherapy Society Board selected a panel of experts in gynecologic brachytherapy to update our current state of knowledge for managing vaginal recurrence of endometrial cancer. Practice patterns were evaluated via an online survey and clinical updates occurred through a combination of literature review and clinical experience and/or expertise. Results There are various retrospective series of patients treated with radiation for vaginal recurrence of endometrial cancer, which include a varied group of patients, multiple treatment techniques, and a range of total doses and demonstrate a wide scope of local control and overall survival outcomes. In the era of image-guided brachytherapy, high local control rates with low significant late-term morbidities can be achieved. Lower rates of local control and higher late-term toxicity are reported in the retreatment setting. In patients with no previous history of radiation treatment, external beam radiation therapy followed by brachytherapy boost should be used. There are varying practices with regard to the definition and appropriate doses of both the high-risk clinical target volume and the intermediate-risk clinical target volume in the setting of vaginal recurrence of endometrial cancer. There are limited data to provide appropriate dose constraints for some organs at risk with the majority of guidance taken from the definitive cervical cancer literature. Conclusions A summary of literature and expert practice patterns for patient selection, dose recommendations, and constraints are provided as guidance for practitioners. [ABSTRACT FROM AUTHOR]

Purpose To compare clinical outcomes of MR-based versus CT-based high-dose-rate interstitial brachytherapy (ISBT) for vaginal recurrence of endometrioid endometrial cancer (EC). Methods and Materials We reviewed 66 patients with vaginal recurrent EC; 18 had MR-based ISBT on a prospective clinical trial and 48 had CT-based treatment. Kaplan–Meier survival modeling was used to generate estimates for local control (LC), disease-free interval (DFI), and overall survival (OS), and multivariate Cox modeling was used to assess prognostic factors. Toxicities were evaluated and compared. Results Median followup was 33 months (CT 30 months, MR 35 months). Median cumulative equivalent dose in 2-Gy fractions was 75.5 Gy for MR-ISBT and 73.8 Gy for CT-ISBT ( p = 0.58). MR patients were older ( p = 0.03) and had larger tumor size (>4 cm vs. ≤ 4 cm) compared to CT patients ( p = 0.04). For MR-based versus CT-based ISBT, 3-year KM rate for local control was 100% versus 78% ( p = 0.04), DFI was 69% versus 55% ( p = 0.1), and OS was 63% versus 75% ( p = 0.81), respectively. On multivariate analysis, tumor Grade 3 was associated with worse OS (HR 3.57, 95% CI 1.25, 11.36) in a model with MR-ISBT (HR 0.56, 95% CI 0.16, 1.89). Toxicities were not significantly different between the two modalities. Conclusion Despite worse patient prognostic features, MR-ISBT was associated with a significantly better (100%) 3-year local control, comparable survival, and improved DFI rates compared to CT. Toxicities did not differ compared to CT-ISBT patients. Tumor grade contributed as the most significant predictor for survival. Larger prospective studies are needed to assess the impact of MR-ISBT on survival outcomes. [ABSTRACT FROM AUTHOR]

Purpose: We designed and built dedicated active magnetic resonance (MR)-tracked (MRTR) stylets. We explored the role of MRTR in a prospective clinical trial.Methods and Materials: Eleven gynecologic cancer patients underwent MRTR to rapidly optimize interstitial catheter placement. MRTR catheter tip location and orientation were computed and overlaid on images displayed on in-room monitors at rates of 6 to 16 frames per second. Three modes of actively tracked navigation were analyzed: coarse navigation to the approximate region around the tumor; fine-tuning, bringing the stylets to the desired location; and pullback, with MRTR stylets rapidly withdrawn from within the catheters, providing catheter trajectories for radiation treatment planning (RTP). Catheters with conventional stylets were inserted, forming baseline locations. MRTR stylets were substituted, and catheter navigation was performed by a clinician working inside the MRI bore, using monitor feedback.Results: Coarse navigation allowed repositioning of the MRTR catheters tips by 16 mm (mean), relative to baseline, in 14 ± 5 s/catheter (mean ± standard deviation [SD]). The fine-tuning mode repositioned the catheter tips by a further 12 mm, in 24 ± 17 s/catheter. Pullback mode provided catheter trajectories with RTP point resolution of ∼1.5 mm, in 1 to 9 s/catheter.Conclusions: MRTR-based navigation resulted in rapid and optimal placement of interstitial brachytherapy catheters. Catheters were repositioned compared with the initial insertion without tracking. In pullback mode, catheter trajectories matched computed tomographic precision, enabling their use for RTP. [ABSTRACT FROM AUTHOR]

Background and Objectives. Attention to ovary dose is important for premenopausal women undergoing radiation therapy (RT) and must not be overlooked when treating extremity sarcoma. We assessed whether ovary-sparing RT plans could decrease ovary dose without compromising target coverage. Methods. Standard sarcoma target volumes and organs at risk (OAR) were contoured by a sarcoma dedicated radiation oncologist on CT planning scans for 23 women with thigh or buttock sarcoma. IMRT plans (50 Gy) with and without attempted ovary-sparing were created by an expert sarcoma dosimetrist. Results. All plans met target coverage goals. Compared to standard plans, ovary-sparing plans had lower mean bilateral ovary doses (MBOD) (652 versus 483 cGy, p=0.007) but higher bone doses (mean V50: 8.5% versus 6.9%, p=0.049) and lower conformity indexes (1.12 versus 1.19, p=0.009). Tumors < 8 cm from the pubic symphysis had significant MBOD reduction with ovary-sparing plans (376 cGy versus 619 cGy, p=0.0184). On multivariate analysis, distance to pubic symphysis and proximal medial thigh site were associated with MBOD reduction with ovary-sparing plan. Conclusions. For preoperative IMRT, ovary-sparing planning significantly reduces ovarian dose in women with sarcoma of the proximal thigh and near the pubic symphysis. [ABSTRACT FROM AUTHOR]