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Purpose Brachytherapy (BT) forms major treatment modality in squamous cell carcinoma of head and neck cancers (HNC). However, there is a dearth of literature and guidelines for the use in various indications. High-dose-rate brachytherapy (HDR-BT) in Indian scenario is an important treatment modality, and the recommendations in this guidelines aim to provide the necessary recommendations for the use of HDR-BT for uniform application across the country in patients with HNC. Material and methods A panel consisting of members of the Indian Brachytherapy Society (IBS), based on their clinical experience was invited. The process involved defining important steps, precautions, target volumes and indications, thorough literature review, and discussion with fellow members. The guidelines were established and formulated the recommendations for HDR-BT based on available evidences and individual experience for sites, relevant to Indian settings. Results The IBS recommends the use of HDR brachytherapy as a part of treatment of head and neck tumors. The scope of these guidelines and recommendations included practical suggestions, ensuring efficient use of brachytherapy treatment as radical with external beam radiotherapy (EBRT) boost, palliative and adjuvant as definitive, or re-radiation as salvage for HNC in India. The IBS has made specific site-wise recommendations for previously untreated and recurrent HNC patients on their selection criteria, implant techniques, target volume definition, and HDR treatment parameters, such as time, dose rate, total dose, and fractionation schedules. Limited experience exists with HDR-BT in patients with head and neck cancers in India and across the globe. Conclusions IBS provided a consensus statement and guidelines for the head and neck brachytherapy and believed that these recommendations will overcome the fear of practicing radiation oncologists. This should generate interest amongst students and will help radiation oncologists all across the country to use the art of brachytherapy carefully in HNC patients, with better curative and salvage options.

Purpose High-dose-rate (HDR) interstitial brachytherapy has an established role in head and neck malignancies and offers good survival rates; however, there is scant data on improved local control (LC) and treatment-related complications in recurrent cases. We present our results in patients with recurrent head and neck cancers treated with HDR interstitial brachytherapy. Material and methods Twenty-five patients with recurrent head and neck cancers were treated with HDR interstitial brachytherapy using Iridium 192 between 2009 and 2016. Of these, 75% received radical brachytherapy, and 25% received external beam radiation therapy (EBRT) followed by brachytherapy boost. Treatment sites included oral cavity (15/25) and oropharynx (10/25). Median dose of 4.5 Gy was administered twice per day, with median total brachytherapy dose of 40.5 Gy in radical and 27 Gy for EBRT cases. Results With median follow-up of 25 months, 4 local recurrences were observed within first year of follow-up. Two-year local control and overall survival outcomes for the entire group were 75% and 68%, respectively. Local control rate with radical BRT vs. BRT as a boost following EBRT was found to be significant (2-year LCR 62% vs. 85%; p < 0.02). Dosimetric assessment revealed D90 – 4.08 Gy, V100 – 94.1%, V150 – 24.7%, and V200 – 10.1%. Xerostomia, altered taste, and dysphagia were the major complications commonly grade 1 and 2. Grade 3 toxicity was only 2%. Pre-treatment volume > 85 cc had a negative impact on overall survival (26 months vs. 12 months; p = 0.02), and interval time between primary and recurrence more than 15 months had an impact on the local control rate (p < 0.01). Conclusions Results of HDR interstitial brachytherapy have shown acceptable local control and overall survival rates along with tolerable toxicities and morbidity in recurrent head and neck cancers.

Cervical cancer requires multimodality therapy, resulting in acute toxicities. Intensity-modulated radiation therapy (IMRT) is postulated to spare bone marrow (BM) and bowel to reduce acute hematological and gastrointestinal (GI) toxicities of chemoradiotherapy.This is a prospective randomized phase III study enrolling patients with Stage IB to IVA cervical carcinoma in two arms receiving either three-dimensional conformal radiotherapy (3DCRT) or IMRT from December 2017 to December 2019. The primary objective was to compare the hematologic toxicities (Grade 2 or more neutropenia as the primary factor) and the secondary objectives were to compare GI toxicities, and dosimetric analysis for volumes of BM, and bowel irradiated. SPSS version 20 was used for all statistical calculations.Eighty patients with histopathologically confirmed cervical cancer were randomized to receive IMRT or 3DCRT (40 in each arm). The median age of the patients was 56.5 (36-67) and 59.5 (37-68) years, respectively, in IMRT and 3DCRT arms. The median dose of external radiation was 50 Gy in 25 fractions, and of brachytherapy was 24 Gy in 3 fractions in both the arms. The incidence of grade ≥2 neutropenia was 42.5% and 15% in the 3DCRT and IMRT arms, respectively (P0.001). All patients received concurrent chemotherapy with cisplatin, with the median number of cycles being 5 (range 3-5) in both the arms. All five cycles of concurrent chemotherapy could be completed in 25 (62.5%) patients in the IMRT arm and 24 (60%) patients in the 3DCRT arm.IMRT significantly reduces acute hematologic and GI toxicities compared with 3DCRT with a better dosimetry profile.

Purpose : To evaluate the treatment outcomes with high-dose-rate (HDR) interstitial brachytherapy (HDR-BRT) in head and neck cancers (HNC). Material and methods : Fifty-eight patients with HNC as per American Joint Committee on Cancer (AJCC) TNM staging criteria were analyzed retrospectively between 2008 and 2015. Forty-two patients received external beam radiotherapy (EBRT) with HDR-BRT and 16 patients received BRT alone. The survival was calculated with respect to median biological equivalent doses (BED) and median 2 Gy equivalent dose (EQD 2 ), keeping / = 10 for tumor. Loco-regional control and disease free survival was assessed. Results : The median follow-up period was 25 months (2-84 months). The disease-free survival (DFS) probability at year 1 was 82.7%, and 68% at year 7. The overall survival probability was 91.3% at year 1 and 85.8% at year 7. The local control rate was 70%. The rate of recurrence was 30%. Distant metastasis rate was 17.2%. The median BED and EQD 2 , respectively, were 86.78 Gy and 71.6 Gy. The DFS was 74.1% and 75.9% in patients receiving a dose more than median BED and EQD 2 , respectively, and was 64.8% and 61.5% for less than the median dose. Conclusions : The overall outcome was good with implementation of HDR-BRT used alone or as boost, and shows DFS as better when the dose received is more than the median BED and median EQD 2 . The role of HDR-BRT in HNC is a proven, effective, and safe treatment method with excellent long term outcome as seen in this study, which reflects the need for reviving the forgotten art and science of interstitial brachytherapy in HNC.

Purpose To report the incidence, severity, and time of onset of late toxicities in patients of endometrial adenocarcinoma (EA) treated with external beam radiotherapy (EBRT) + brachytherapy (BT), or vaginal brachytherapy (VBT) alone. Material and methods Archives of a single institution from 2008-2015 were studied. The indications for EBRT and VBT were based on standard recommendations. EBRT was planned to 50 Gy/25 fractions/5 weeks/3DCRT with 4-field ‘box’ technique on a dual energy linear accelerator. VBT was planned using appropriate vaginal cylinder treating upper half of vaginal cuff, prescribed 5 mm from vaginal surface using Ir-192 micro-Selectron to doses of 4 Gy x 4 fractions/4 days or 6 Gy x 5 fractions/ 7 days with or without EBRT, respectively. Intra-cavitary BT (ICBT) was prescribed to point A to 7 Gy x 3 fractions once weekly. Survival was calculated from Kaplan-Meier curves, and toxicity was recorded using CTCAE V3. Results Of 120 patients registered, 19 were excluded due to inadequate follow-up. Among the 63 patients who received RT, 18 received VBT alone and 40 received adjuvant EBRT + VBT. Five patients received definitive EBRT + ICBT, all of whom are disease free with median follow-up of 36.5 (range: 18-76) months. With median follow-up of 30 (range: 0.8-81) months, median DFS and OS were 79.2% and 75.7%, respectively in the adjuvant RT setting. Cystitis, proctitis, and enteritis was reported in 7% (all grade I/II), 17% (9% grade I/II and 8% grade III), and 5% (all grade I/II), respectively. All toxicities were seen in the EBRT arm. EBRT resulted in significantly higher proctitis than VBT alone (p = 0.02). The median time to cystitis, proctitis, and enteritis were 27, 17, and 28 months, respectively. Conclusion With the use of 3D-CRT in endometrial adenocarcinoma, late toxicity rates appear low and mild, however EBRT leads to significantly higher proctitis than VBT alone., Purpose T2 weighted MRI is recommended for IGABT in cervical cancer. HRCTV (volume for optimization) contains suspicious grey zones that are contoured subjectively on case to case basis. Whether these zones contain macroscopic residual, the disease is unknown. DWI and the derived ADC are functional imaging that may add additional biological information on these grey zones. The objectives were: 1. To investigate the presence or absence of abnormal ADC outside the HRCTV contours as defined by GEC ESTRO; 2. To objectively define the extent of HRCTV contours in the suspicious grey zones with the help of ADC derived from diffusion weighted imaging (DWI). Material and methods 30 patients with biopsy proven squamous cell carcinoma of cervix were included. These 30 patients were divided into 3 groups of 10 selectively chosen patients, based on commonly experienced clinical scenario: 1st group: large parametrial disease and near complete response post EBRT; 2nd group: large parametria poor response; 3rd group: no parametria and near complete response. All patients underwent a diagnostic MRI of abdomen and pelvis along with DWI. ADC maps were derived using three levels of b values 0, 600, 1000 s/mm2 from DWI ADC for the following regions were calculated. Tumor, tumor edge, 1 cm lateral to tumor edge and 5 mm medial to obturator internus in the parametrial region. Post EBRT MRI was taken after the 1st application of brachytherapy along with DWI and ADC was derived; HRCTV was contoured using GEC ESTRO guidelines on T2W para axial images, and fused with DWI and ADC images. ADC was again calculated for the same areas (as mentioned earlier) on the brachytherapy MRI with respect to the HRCTV contours, and it was investigated whether the abnormal ADC lies inside or outside the contours. Results and conclusion Discussed during the Conference., Purpose To evaluate the treatment outcomes with HDR interstitial brachytherapy in head and neck cancers at our Institute with use of angio-catheters as carrier source of Iridium-192 wire implants, a retrospective analysis was carried out. Material and methods 58 patients with head and neck malignancies of varying TNM staging as per AJCC staging criteria were analyzed retrospectively between 2008 and 2015. 42 patients (72.41%) received EBRT with HDR-BT and 26 patients (27.59%) received BT alone. 23 patients (39.65%) received concurrent chemotherapy. The age group ranged from 27 to 81 years (median age: 56 years) with 41 patients (70.69%) males and 17 patients (29.31%) females. HDR-BT was delivered with Iridium- 192 wire implants using plastic bead techniques with varying dose rates. The biological equivalent doses (BED) were calculated for both BT and EBRT keeping α/β = 10 for tumor and α/β = 3 for normal tissue and subsequently median BED doses were calculated; similarly, 2 Gy equivalent dose (EQD2) were calculated and loco-regional control and disease free survival was assessed. Results After completion of HDR-BT, patients were followed-up one month later and subsequently every 3 months for first 2 years and thereafter every 6 months with median follow-up period of 25 months (range: 2-84 months). The DFS probability at year 1 was 82.76% and 68.05% at year 7. The overall survival probability was 91.37% at year 1 and 85.89% at year 5. The local control rate was 67.27% and control rates according to the stage of disease and T size classification are mentioned in Table 1. The rate of local recurrence was 8.62%, regional recurrence was 1.72%, loco-regional failure was 3.44%, and distant metastases following local or regional failure was 17.23%. The Median BED for α/β = 10 was 86.775 Gy, and DFS was 74.07% in patients receiving more than 86.775 Gy; DFS was 64.82% in patients receiving less than 86.775 Gy and median BED for α/β = 3 was 128.76 Gy; DFS was 74.07 in patients receiving more than 128.76 Gy as compared to 64.82% in patients receiving less than 128.76 Gy. The median EQD2 for α/β = 10 was 71.6 Gy, and for α/β = 3 was 75.85 Gy. The DFS was 75.86% in patients receiving more than median dose of 71.6 Gy compared to 61.53% in those receiving less than the median dose. The DFS was 78.57% in patients receiving median dose of 75.85 Gy as compared to 59.26% in those receiving less than the median dose. Conclusion The overall outcome in patients with oral cavity and oropharyngeal malignancies was good with implementing of HDR – interstitial brachytherapy and use of angio-catheters as carriers of Iridium-192 wire. The BED10 value of 86.775 Gy and BED3 of 128.76 Gy showed that the dose received more than the median reported better outcomes in the form of DFS. The EQD2 calculated values suggested the dose received more than 71.6 Gy (α/β = 10) and 75.85 Gy (α/β = 3) showed better outcomes. The role of HDR interstitial brachytherapy in head and neck cancers is a proven, effective, and safe treatment method with excellent long term outcome., Purpose Accelerated partial breast irradiation (APBI) is a rapidly evolving technique in the management of early breast carcinoma with favorable prognostic factors. With an aim to assess the local control and overall survival in early breast carcinoma treated with APBI. Material and methods 41 patients from 2007-2015 with early breast carcinoma treated in our tertiary cancer care center were included in this study. All patients underwent breast conservation surgery with axillary dissection followed by APBI using interstitial brachytherapy technique. Catheters were implanted in 2 planes superficial and deep with each catheter placed 1 cm apart. CT scan was done and CTV was contoured to include tumor cavity with 2 cm margins. CTV was edited 5 mm below the skin. Brachytherapy plans were approved as per ABS recommendations with > 90% of the target receiving 90% of the prescribed dose. V150 < 70 cc, V200 < 20 cc, and skin dose < 100%. Radiation was delivered with 34 Gy in 10 fractions with an interfractional interval of 6 hours, 2 fractions per day for 5 consecutive days. Results The median age of patients was 60 yrs., with T1 – 61% (25), T2 – 39% (16), luminal type A – 71% and type B – 29%. All patients had margin and node negative. The median follow-up period was 27 months (range: 12-90). 30 patients were disease free, 2 patients had local recurrence, and 9 patients were to lost follow-up. Kaplan-Meier test was used for survival analysis. The median overall survival was 31 months. None of the patient had acute skin toxicity and had good cosmesis results on long term follow-up. Conclusion APBI is a promising option for early breast carcinoma with favorable prognostic factor. In future, APBI shall be the gold standard for early breast carcinoma, since local recurrences occur more in and around the tumor cavity., Purpose Brachytherapy is essential component in management of cervix carcinoma. Volumetric MR image based brachytherapy is the current standard of care. However, many centers do not have MRI or MR compatible applicators in our country. The aim of present study is to analyze the outcome of patients treated with computed tomography based brachytherapy planning. The objective of the present study is to assess local control, acute and chronic complications in patients treated with this technique. Material and methods All cases of cervix carcinoma treated with definitive radiotherapy from April 2013 till December 2015 were analyzed. Definitive radiotherapy included external beam radiotherapy (with concurrent platinum based chemotherapy) followed by brachytherapy. Brachytherapy technique: All patients underwent HDR brachytherapy on Cobalt-60 remote afterloading machine. Intracavitary or interstitial application was decided based on parametrial involvement and favorable anatomy. Two applications were done one week apart, 2 fractions of 7 Gy (HDR) were delivered to target volume in each application 4-6 hours apart. All patients underwent CT simulation for planning, the bladder, rectum, sigmoid, small bowel, and PTV (gross residual disease at the time of application) were contoured (Figure 1). 2 cc dose of bladder, rectum, and sigmoid was severely restricted to 85%, 65%, and 65% of the prescription dose. Acute complications, local control, and chronic toxicities were recorded and analyzed. Results 71 patients who fitted the inclusion criteria were included. The analysis involved 139 sessions of brachytherapy (59 intracavitary and 80 interstitial sessions). The mean 2 cc dose for bladder, rectum, and sigmoid were 76.1% (± 5.3), 58.4% (± 7.7), and 45.7% (± 13.7), respectively. The mean D90 of PTV was 84% (± 10.2). The local control at the end of 6 months was 93% and at 2 years was 86.4%. Five (6.9%) patients developed hemorrhagic radiation proctitis; one patient developed hemorrhagic cystitis. Conclusion CT based volumetric brachytherapy planning yields comparable outcomes with that of the MRI based volumetric planning techniques in Indian setup., Purpose Intraluminal brachytherapy (ILBT) is recommended in the treatment of esophagus carcinoma in definitive and palliative setting. ILBT offers an elegant path to deliver high doses to the primary tumor while mitigating the problem of high doses to surrounding organs at risk, especially the spinal cord, encountered with external beam radiotherapy (EBRT). With an aim to study the profile of patients of esophagus carcinoma treated with ILBT, the outcome of the treatment in terms of response assessment, toxicity, and survival were analyzed. Material and methods The study period was between January 2014 and June 2015, with 25 patients of esophagus carcinoma middle third, treated with ILBT either as part of definitive radiotherapy or as part of palliative radiotherapy. The patients with unifocal disease ≤ 10 cm in length and with no recorded intra-abdominal or distant metastases received definitive radiotherapy with 44 Gy/22 fractions through EBRT with concurrent cisplatin followed by, 10 Gy/2 fractions of ILBT boost once weekly. The patients with local advanced disease for palliation received 36 Gy/12 fractions through EBRT, followed by 10 Gy/2 fractions of ILBT once weekly. The outcome of the treatment was assessed in terms of dysphagia score, dysphagia free survival, toxicities, and overall survival. Results Median age of patients was 55 years. Histopathologically, 96% of patients had squamous cell carcinoma. 16 (64%) were treated with definitive radiotherapy while the rest, 9 (36%) with palliative intent. At a median follow-up of 9 months, 13 patients were dysphagia free and 5 deaths occurred. One month after completion of the treatment, 18 patients were dysphagia free, while two patients had partial relief, and 5 patients did not notice any relief in dysphagia. Two patients died within 6 months of completion, while 2 patients developed trachea-esophageal fistula during follow-up. Conclusion ILBT is a safe modality for boost in treatment of esophagus carcinoma, if the patients are selected with caution., Purpose The grade of post-implant skin marks after B-MIB is an important factor in determining cosmesis. This study intends to establish the correlation between catheter entry-exit dosimetry and the grade of skin marks at entry-exit sites. Methods Visibility and quality of entry and exit marks were noted plane-wise for 10 patients with minimum 18 months’ follow-up post implant and graded as ‘not visible], ‘faint’, ‘clear’, and ‘prominent’. Catheters with entry-exit points closest to first/last dwell positions were selected from each plane of implant. Distance from first/last dwell position, dose, closest distances from CTV, and reference isodose (85%) were obtained for the selected catheters and correlated with implant mark grades given to corresponding plane using Spearman’s co-efficient. Results With a mean age of 57.2 years (45-68) and mean follow-up of 31.9 months (18-49), intra-op implant was done in 5 out of 10 patients. Number of planes were 3 in 50%, 4 in 50%, and median number of needles implanted were 19 (16-22). Cosmesis was good or excellent in 7 out of 10 patients. Breast fibrosis was seen in 1 patient, tumor bed fibrosis in 3 patients, telangiectasia in 1 patient, and fat necrosis in 1 patient. Total 67 planes of implant analyzed as a comment on exit marks was missing in one patient. Dose at selected catheter was also the corresponding plane Dmax. Spearman’s co-efficient for correlation with quality of implant marks: dose at entry-exit: 0.214 (p = 0.004), distance from first/last dwell position: –0.027 (p = 0.410), distance from CTV: –0.165 (p = 0.083), distance from isodose: –0.081 (p = 0.248). Conclusion There is a statistically significant positive correlation between maximum dose received in a plane of implant and grade of marks. This study needs to be completed on a larger sample size, so that the dose constraints for entry-exit points can be determined., Purpose The aim of this retrospective study was to assess the treatment outcomes in patients with locally advanced gynecological malignancies treated with interstitial brachytherapy using Syed Neblett template to study local control, overall survival, and acute and late sequelae of the treatment. Material and methods 71 patients with histopathological confirmation of squamous cell carcinoma of cervix (56), vault (9), vagina (6) were treated by EBRT to the pelvis using 15 MV X-rays to a total dose of 5000 cGy, followed by interstitial brachytherapy using Syed Neblett applicator by transperineal approach between July 2010 to May 2016. Median age was 51 yrs. Only those patients who were unsuitable for intracavitary application or found to have probable improper dose distribution were treated by template. The dose delivered was 1500 to 2100 cGy treated in 3 fractions with a minimum gap of 6 hrs. between fractions on Varisource iX HDR. Results Among 71 patients, five patients were lost to follow-up and excluded from the study. The range of follow- up duration was 2 to 71 months. Median follow-up period was 20 months. Parameters studied were local control, acute and late sequelae, and distant metastasis. Local control was achieved in 54/66 (81.81%), local recurrence was seen in 12/66 (18.18%) patients. Out of 10 patients who developed distant metastasis, eight patients were locally controlled and two had local recurrence. Late sequelae, mainly vaginal stenosis was observed in 61/66 (92%). Local control was better with non-bulky tumors and in patients with good regression of the disease after EBRT. Conclusion Interstitial template brachytherapy using Syed Neblett applicator is a good alternative to deliver high dose radiation to patients with locally advanced gynecological malignancies, in whom it is unlikely to acquire a proper dose distribution with intracavitary radiation. Loco-regional control was significantly better than EBRT alone with acceptable complications., Purpose The aim of the study is to evaluate the differences in dosimetry between tandem-ovoid and tandem- ring gynecologic brachytherapy applicators in image based brachytherapy. Material and methods 100 CT datasets of cervical cancer patients (stage IB2-IIIB) receiving HDR application (50 tandem-ovoid and 50 tandem-ring) were studied. The external beam radiotherapy dose was 50 Gy. Brachytherapy was delivered using a CT-MRI compatible tandem-ovoid (50 patients) and a tandem-ring applicator (50 patients) to a dose of 8 Gy in 2 fractions. Bladder and rectum was contoured using Oncentra planning system. DVHs were calculated and D2cc was recorded for bladder and rectum, and compared with the corresponding ICRU point doses. The point B dose, the treated volume, high dose volume, and the treatment time was recorded and compared for the two applicators. Results Table 1. Conclusion The results indicate that the OAR doses assessed by DVH criteria were higher than ICRU point doses for bladder with both tandem-ovoid and tandem- ring applicators, whereas DVH based dose was lower than ICRU dose for rectum. The point B dose, the treated volume, and high dose volume was found to be slightly higher with tandem-ovoid applicator. The mean D2cc dose for bladder and rectum was lower with tandem-ring applicators. The clinical implication of the above dosimetric differences needs to be further evaluated., Purpose To evaluate the treatment outcomes of HDR interstitial brachytherapy in patients with squamous cell carcinoma of the oral tongue. Material and methods Retrospective analysis of patients with oral tongue cancers who were treated with HDR interstitial brachytherapy using 192Ir, between August 2010 and October 2015 were included in the study. Patients who have received brachytherapy as a salvage treatment for recurrences were excluded from the study. Endpoints were local control, disease-free survival (DFS), overall survival (OS), and late toxicity. Plastic tube technique was used as illustrated below. Results 14 patients treated at our institute were identified. Patient characteristics include: Male/Female = 9/5, median age 53.5 years, 71% grade II, median depth of invasion 8 mm, stage I and II – 10 patients, and stage IVA – 4 patients. In stage I and II, seven patients received brachytherapy after initial surgery: median dose 36 Gy/10 fractions, BED10 Gy (range: 48-56), 2 patients after EBRT 50 Gy/ 25 fractions (dose 17.5 Gy/5 fractions, combined BED10Gy 84 Gy), and one patient received brachytherapy alone (45 Gy/9 fractions, BED10Gy 67.5 Gy). All stage IVA patients who declined surgery, received post-EBRT brachytherapy at 50.4 Gy/28 fractions (median dose 6 Gy/4 fractions, combined BED10Gy 82 Gy). Three of these stage IVA patients received neoadjuvant chemotherapy. Median follow- up period was 25.7 months (range:11.6-59.3) for stage I & II, and 25.5 months (range: 12-61.1) for stage IVA. Local control rates at 2 years were 90% for stage I & II, and 50% for stage IVA. Median DFS and OS were 20.7 and 25.7 months, respectively, for stage I and II, and 14.5 and 25.5 months, respectively, for stage IVA. Three patients who developed local recurrences were salvaged surgically, except one patient who declined surgery. One patient developed soft tissue necrosis and none developed osteoradionecrosis. Conclusion HDR interstitial brachytherapy provides good local control for early oral tongue cancers. In patients with locally advanced tongue cancers who decline surgery, brachytherapy can be considered as a treatment option in combination with external beam radiotherapy. However, due to paucity of data, a prospective multicenter trial with large number of patients is needed., Purpose Newer axial imaging has facilitated from point based to widely practiced manual forward intra- cavitary brachytherapy (ICBT) planning in the management of cervical cancer. However, the manual forward planning is an operator dependent and time consuming. Magnetic resonance imaging (MRI) based ICBT have improved visualization and better delineation of the target volume and organs at risk (OAR). The availability of software optimizing tools such as inverse planning simulation annealing (IPSA) and hybrid inverse planning and optimization (HIPO) allows its utility with MRI volume based ICBT planning. Aim To compare dosimetrically various parameters of target volume and OAR in the MRI volume based ICBT planning of cervical cancer using dose volume histogram (DVH) for point based, manual forward, IPSA, and HIPO methods. Material and methods A prospective study of 15 consecutive patients treated with definitive radiochemotherapy for biopsy proven cervical cancer in May-June 2016 was conducted at Vydehi Institute of Medical Sciences, Bengaluru. All patients underwent external beam radiotherapy with dose of 45-50 Gy in conventional fractionation with concurrent weekly chemotherapy, followed by 3-4 fraction of MRI volume based ICBT for a total treatment duration of ≤ 8 weeks. GEC-ESTRO and ICRU-38 recommendations were used to define dosimetric parameters for MRI volume based and point based ICBT planning, respectively. The DVH of each patient was evaluated and compared for point based, manual forward, IPSA, and HIPO optimization for 1st fraction ICBT planning on MR images. Results The results of dosimetric parameters such as GTV D100, GTV D98, HRCTV D100, HRCTV D98, HRCTV D90, HRCTV D50, D2cc, and D0.1cc for bladder, rectum, sigmoid, vagina, V150, V200, point A, point B, bladder point, rectal point, vaginal point, homogeneity index (HI), and conformity index (CI) will be presented in the conference, Purpose To compare the bladder, sigmoid colon, and rectum doses in supine versus lithotomy positions during intracavitary brachytherapy (ICBT) in cervix carcinoma patients. Material and methods 30 patients with FIGO stage IIB-IIIB received concurrent chemoradiation to 50 Gy/ 25 fractions/5 weeks with weekly cisplatin followed by 3 fractions of ICBT, 7 Gy each, 1 week apart. Following ICBT application, each patient underwent pelvic CT scan twice, first in supine and then in lithotomy position during first two applications, providing 60 data sets in each arm. Target – HRCTV and IRCTV and organs at risk (OAR) – bladder, rectum, sigmoid colon were contoured. Dose was prescribed to point A, and ICRU bladder and rectal reference points were identified. The DVH parameters for target (D90, D100, and V100 for HRCTV and IRCTV) and OAR (ICRU points for bladder and rectum, and D0.1cc, D1cc, D2cc for bladder, rectum, and sigmoid colon) in both supine and lithotomy positions were evaluated. Results Median age was 52 years; 80% of patients had squamous cell carcinoma; 77% and 23% of patients were FIGO stage IIB and IIIB, respectively; 73% had residual disease at the time of first ICBT. Mean dosimetric parameters for OAR in supine and lithotomy positions are shown in Table 1. HRCTV D90 was 9.96 Gy and 10.41 Gy in supine and lithotomy positions, respectively (p > 0.05). Patients felt more comfortable in supine position when compared to lithotomy position. Conclusion There were no statistical significant differences in target coverage and doses to OAR between supine and lithotomy position during ICBT in cervix carcinoma. Considering patient comfort, we recommend the standard supine position for treatment., Purpose In sync with the theme of IBS CON 2016 – BRACHYTHERAPY – AN IMMORTAL ART, we present this data from a single Indian institution, reconfirming the importance of perioperative brachytherapy in soft tissue sarcomas (STS) of the extremities and superficial trunk, and emphasizing the fact that treatment results are never the same without brachytherapy. This retrospective study from our institution aims to highlight the indispensable role of brachytherapy in achieving excellent local control rates and permitting function preservation of extremities. Material and methods From August 2007 to April 2015, thirty-one cases were retrieved and 20 cases were analyzed (14 primary and 6 recurrent). The follow-up period was between 13 and 93 months. The inclusion criteria for HDR and brachytherapy were as follows: 1. high grade tumor; 2. low grade tumor > 10 cm; 3. recurrent tumor; 4. positive/close margins. After reviewing either the pre-op biopsy report or frozen section reports and preoperative MRI of the site, catheters were placed equidistant to each other with 1-1.5 cm spacing with a margin of 1-2 cm from the tumor bed. Catheters were held by sutures to maintain the equidistance. On the 6th post-operative day, the patient underwent image guided (CT-based) planning, and 3-3.5 Gy/ fraction *6/7, twice daily were delivered. Three weeks later, the patient received EBRT (45-54 Gy). Median follow-up was 48 months. Results There were two cases of local failure within the radiation field and both patients expired due to distant metastasis. The local control rate was 90%. Among the late complications, 10% (2/20 patients) developed RTOG grade II restricted joint movements. One patient developed grade IV radiation dermatitis (non-healed ulcer till date). Fifty percentage of patients developed grade I myalgia, and 15% (3/20) had grade II myalgia (NCI-CTCAE v4.0). Conclusion Immediate postoperative HDR brachytherapy with/without EBRT provides better local control rates than EBRT alone with acceptable complications., Purpose To evaluate the role of HDR SBT approach in vulvar cancer and to report its clinical outcome data and toxicity results. Material and methods From January 2001 to January 2016, we performed a retrospective analysis of all case records of vulvar cancer patients treated with HDR-ISBT. Statistical analyses of overall survival (OS), disease-free survival (DFS) and local control (LC) rates were determined using Kaplan-Meier method. Results A total of 38 vulvar cancer patients with median age of 60 years had undergone ISBT. Among them, 29 patients were treated with definitive RT (6 with concurrent chemotherapy), 6 patients with adjuvant RT, and 3 patients for salvage RT. All of them received 192Ir HDR ISBT with (n = 29) or without (n = 9) prior EBRT. Majority of implants were freehand plastic tube technique (n = 23) in single (n = 5) or multiple plane (n = 18); 13 patients had template based and two had a combination of freehand and template based volume implant. Patients who received BT as sole treatment received median EQD2 of 38.4 Gy10, and those patients who received ISBT as a boost received 23.3 Gy10. At the end of 3 months of BT, 94.7% and 5.3% achieved complete response and partial response, respectively. Nine out of 36 patients with CR developed recurrent disease later: local in 4 (11.1%), regional in 3 (8.4%), and distant in 2 (5.5%) of cases. Of the 38 patients, 6 patients developed acute grade 3 skin reactions, and 7 patients had delayed complications. Median follow- up was 20 months. The 3-year actuarial OS, DFS, and LC rate was 64%, 64%, and 69%, respectively. Conclusion Improved local control with acceptable toxicity can be achieved with ISBT with or without EBRT. In this regard, HDR ISBT either as radical or as boost is an effective alternative option, and comparable clinical outcome with other treatment modality along with benefits of organ and function preservation., Purpose Definitive chemoradiotherapy is standard of care in management of anal carcinoma. Interstitial brachytherapy increases the dose to tumor volume and, at the same time, limits the volume of irradiated normal tissue, thereby decreasing long term side effects. Despite wide availability of HDR brachytherapy, there is limited data on brachytherapy for anal carcinoma. With an aim to assess the dosimetric and clinical outcome and long term side effects in patients of anal cancer treated with image based high dose rate interstitial brachytherapy following chemoradiation or as radical treatment. Material and methods Seven patients of anal canal cancer were treated from March 2010 to March 2016 and included in this analysis. Five patients were treated with external radiation therapy with or without chemotherapy followed by interstitial brachytherapy boost, and two patients were treated with radical interstitial brachytherapy. CT based planning was done after placement of needles using template (MUPIT). Target volume was contoured on CT scans and dosimetric parameters were evaluated after plan optimization. The patients were followed-up for local control and toxicity grading as per the RTOG scales. Local control, sphincter preservation rates, and disease free survival were evaluated. Results The mean clinical target volume was 25 ± 4 cm3, and D90 and D100 were calculated. The mean values of coverage index (CI), dose homogeneity index (DHI), overdose volume index (ODI), dose non-uniformity ratio (DNR), and conformal index (COIN) were 0.95, 0.58, 0.13, 0.40, and 0.57, respectively. The median follow-up, acute and late toxicities, local control, disease free survival, and rate of sphincter preservation were assessed. Conclusion The image based treatment planning provides better dose conformality with reduced toxicities and good sphincter preservation rates. The dose conformality can be assessed with volumetric quality indices and dose parameters., Purpose This study reports the retrospective results of a single-institution experience with HDR intraluminal brachytherapy (HDR-ILRT) used as a boost in the treatment of esophageal cancer with external beam radiation therapy (EBRT) with or without chemotherapy. Material and methods Patients without evidence of metastatic disease were identified. Fifty-two untreated cases of squamous cell carcinoma arising from the middle or lower one-third of the esophagus, with no apparent extra- esophageal spread on a computed tomography (CT) scan and with a Karnofsky performance status of over 70 were chosen. Majority of them had been treated with EBRT to a dose of 50 Gy/25 fractions/5 weeks (30 Gy/15 fractions followed by 20 Gy/10 fractions to reduced volume on re-plan CT). They were further divided into two groups: those that received further boost with EBRT of about 10-20 Gy (group I) and those that received further boost with ILRT to a dose of 12 Gy in two sessions of 6 Gy each a week apart (group II). All patients were assessed symptomatically, endoscopically, and radiologically on follow-up. Results There was significant difference in relief of dysphagia, local control, disease free, and overall survival (better in the combined arm), although, the results were not always statistically significant. Incidence of strictures, other complications, and survival probabilities were also studied. Thus, EBRT and ILRT can give a better local response than EBRT alone for the same biological dose in the treatment of esophageal carcinoma. Conclusion HDR-ILRT is safe and beneficial for local control when added as boost in the radical treatment of patients with esophageal cancer., Purpose To report the technical aspects of customized high dose rate brachytherapy for recurrent vaginal rhabdomyosarcoma in pediatric age groups. Material and methods The pediatric patients are presented with a proliferative growth of the vaginal apex, which was reported as embryonal rhabdomyosarcoma (botryoid variant). In view of the large volume disease, a multidisciplinary approach of anterior chemotherapy followed by surgery was adopted. However, patients are recurred despite negative margin and was planned for re-excision, adjuvant radiotherapy, and further chemotherapy. The children were examined under anesthesia to determine anatomical dimensions of vagina. The vagina cylinder made with diameter of 1 cm and length of 5 cm. We created a wax cylinder to incorporate a single channel MR compatible tube. The root of the cylinder was expanded and customized to allow stability. Patients received an equivalent dose of 41.4 Gy (4 Gy, 7 fractions) by high dose rate brachytherapy (single fraction per day). The patients underwent a pre-plan prior to application. Taking into the consideration, the primary presentation of the disease, a treatment length of 4 cm was decided upon and 95% coverage was achieved with total rectal dose of 16 Gy and bladder dose of 15 Gy. The cumulative equivalent dose to the ovary was restricted to less than 4 Gy. The treatment was executed smoothly without any acute side effects or significant symptoms/side effects on follow-up. Results Pediatric vaginal rhabdomyosarcoma postoperative radiotherapy has been shown to improve local control and survival. Radiation to the pelvis in the pediatric age group for girls is associated with serious late effects like infertility, premature ovarian ablation, vaginal stenosis, and damage to reproductive structures that may result in miscarriages. Brachytherapy as a local modality can restrict some of these side effects. However, there is no standard applicator that can be applied for pediatric vagina of children in this age category. There is the need to create a customized applicator to suit the precise anatomy of the patient under consideration. At our Institute, we have successfully created a simple single channel MR compatible vaginal applicator and could successfully execute the desired treatment regimen. Conclusion A customized applicator provides the advantages of effective brachytherapy treatment that can restrict dose to normal tissues and is easily reproducible., Purpose Cholangiocarcinoma is a dismal disease, presenting in advanced stage, which is not amenable for curative resection and not much has developed in this area. Liver transplantation has been proposed to be a curative treatment modality for locally advanced hilar tumors with no evidence of extrahepatic tumors. External radiotherapy can achieve satisfactory local tumor control but ILBT imposes a high radiation dose to the tumor volume, bypasses the radiosensitive structures, and therefore, spares the surrounding normal structures from radiation toxicity. Objectives To assess the survival outcomes in advanced, unresectable cholagiocarcinoma patients with intrabiliary intraluminal brachytherapy intervention. Material and methods A total of six unresectable cholangiocarcinoma males’ patients in the age group of 38-80 years were studied. All patients had a percutaneous biliary drain inserted (PTBD) (9-12 French catheters) prior to ILBT. One patient received EBRT along with ILBT, the rest received only ILBT. The number of brachytherapy sessions ranged between 1 to 5. Treatment volume encompassed the stricture site with an additional margin proximally and distally. Treatment was delivered with a HDR 192Ir afterloader. Results No serious toxicities were reported immediately after, or during the treatment. Overall survival was in the range of 6 to 16 months. Conclusion ILBT in cholangicarcinomas is not very commonly practiced. It is worthwhile to reconsider its evaded potential on local tumor control and symptom free survival by proper randomized controlled trials., Purpose Soft tissue tumors(STS) of extremities are rare tumors. Radiotherapy is an integral component in the treatment of soft tissue sarcomas; interstitial brachytherapy has added advantage in delivering boost or radical dose, sparing the critical organs. Objectives We examined the treatment outcomes of soft tissue sarcomas (STS) in patients who underwent surgery followed by interstitial brachytherapy with or without chemotherapy. Material and methods We studied interstitial brachytherapy (ISBT) of extremity sarcomas in 10 patients (8 lower extremity and 2 upper extremity) aged between 12-60 yrs., comprising of 7 males and 3 females. 80% of patients underwent per-op brachytherapy implant, remaining 20% underwent post-operative implant. Brachytherapy consisted of high dose rate, iridium-192 implant. 40% had combined EBRT and ISBT, ranging between 4 to 10 sessions of ISBT. Patients were followed-up for a period of 12 to 76 months. Results Complete local response was achieved in 80% of patients, one patient had partial response, one patient expired due to chemotherapy related neutropenic sepsis. Overall survival rate was 90%. Conclusions ISBT (interstitial brachytherapy) is a safe procedure producing excellent results in terms of local control. Reconstructed flaps were well taken., Purpose Brachytherapy plays an essential role as a part of the cervical cancer management for its ability to deliver high dose to the tumor while reducing the dose to the surrounding critical organs. Over the last few years, the use of 3D image based brachytherapy has been revolutionized. In 2005, recommendations for 3D image based brachytherapy were developed by Groupe Europeen de Curietherapie of the European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) has now become standard. Vienna group and EMBRACE study group have reported a promising clinical outcome of patients treated with MR image-guided adaptive brachytherapy with excellent local control rates. However, there is paucity of Indian data on MRI volume based brachytherapy in management of cervical cancer, thereof, the study was undertaken to know the utility of GEC-ESTRO recommendations in our settings. With an aim to assess the tumor response, local control and toxicities and/or depending on the response after radiochemotherapy treated with MR based brachytherapy in cervical cancer. Material and methods A study of 50 biopsy proven cervical cancer patients with stage IB2-IVA was recruited at Vydehi Hospital, Bangalore. All the patients have undergone EBRT to a dose of 45-50 Gy in conventional fractionation with concurrent weekly chemotherapy, followed by 3-5 fractions of brachytherapy with 5-7 Gy/ fraction, and treatment duration ≤ 8 weeks. A pre-EBRT MRI was taken, along with a CT simulation. On the first fraction of BT, a MRI scan was taken along with the BT applicator (MRI-BT) and on subsequent sittings; CT simulation was done, which was fused with MRI-BT. The GTV, HR-CTV and OAR were delineated and planned according to GEC-ESTRO recommendations. Patients were followed-up 6 weeks after completion of treatment, then every 3 month for assessment local control and toxicity. Results and conclusions Were discussed during the conference., Purpose To evaluate acute toxicity in patients of carcinoma cervix who were treated with three different schedules of HDR intracavitary brachytherapy. Material and methods Locally advanced and medically inoperable contraindicated early stage carcinoma cervix patients were treated with either neoadjuvant chemotherapy followed by radiotherapy or concurrent chemoradiotherapy, or only radiotherapy followed by any of the three schedules of intracavitary brachytherapy consisting of 7 Gy in 3 sessions, 4 Gy in 6 sessions, or 6 Gy in 3 sessions. Patients were evaluated for acute toxicity as per RTOG criteria. Results 130 histopathologically proven squamous cell carcinoma cervix patients were analyzed from 2008 to August 2014. Total number of patients in three various schedules of brachytherapy group (7 Gy x 3 sessions, 6 Gy x 3 sessions, 4 Gy x 6 sessions) were 43, 38, and 49, respectively. Acute toxicities such as diarrhea was 18.60%, 13.15%, and 22.45%, urinary tract toxicities were 13.95%, 13.15%, and 8.16%, nausea and vomiting were 23.25%, 23.68%, and 26.53% in three schedules of ICBT respectively. Grade I skin reactions were in the range of 65.1%, 76.31%, 67.35%, grade II were 27.90%, 15.79%, 24.49%, and grade III were 6.98%, 7.89%, 8.16% for three schedules of ICBT. Grade I mucosal reactions were in the range of 69.77%, 73.68%, 69.39%; grade II were 23.26%, 18.42%, 21.49%; grade III were 6.98%, 7.89% and 6.12%. Conclusion Our analyzed results of the study showed mixed results with diarrhea, nausea, and vomiting. Grade III skin reactions were seen in 4 Gy x 6 sessions group. Grade II skin reactions and grade II mucositis were more common in 7 Gy x 3 sessions group. Grade I and grade III skin reactions were more common. Further studies should be conducted with various schedules of brachytherapy to assess acute toxicities and optimal brachytherapy schedule., Purpose Investigated CT-scan based high dose rate interstitial brachytherapy (HDR-ISBT) planning for uterine cervical cancer based on GEC-ESTRO guidelines. The objective of the study was dosimetric evaluation, critical organ toxicity pattern, and local control. Material and methods 20 cervical cancer patients were enrolled. ISBT was performed using Syed Neblett template. Total treatment doses were 6 Gy in 3 fractions (brachytherapy) combined with external beam radiotherapy 45 Gy in 25 fractions, at 1.8 Gy per fraction. Treatment plans were created based on planning computed tomography. DVHs of the high-risk clinical target volume (HR CTV), intermediate-risk CTV (IR CTV), and the bladder and rectum were calculated. Indices were calculated on brachytherapy plans. Dose values were biologically normalized to equivalent doses in 2 Gy fractions (EQD2). Results The median D90 (HR CTV) and D90 (IR CTV) per fraction were 6.09 Gy (range: 3.57-6.81), and 4.35 Gy (range: 1.92-5.29), respectively. The median V100 (HR CTV) and V100 (IR CTV) were 90.82% (range: 67-97), and 54% (range: 40-73.9), respectively. When the dose of EBRT was added, the median EQD2 D90 and D100 of HR CTV were 66.65 Gy and 53.45 Gy. The D2cc of the bladder was 66.5 Gy (range: 56.8-78.4) and of the rectum was 67.9 Gy (range: 61.7-73.9). The mean CI and HI were 0.728 and 3.18, respectively. Conclusion Our method of image-based ISBT using CT-scan was feasible. The CT-based BT tissue delineation seems adequate and appears to be valid for evaluation of OAR. At present, MRI remains the reference standard for contouring tumor volumes. 30% patients achieved complete response and are disease-free; 50% patients achieved partial response., Purpose The optimal integration of intracavitary brachytherapy (ICBT) and external beam radiotherapy is important in the treatment of cervix carcinoma. While high dose rate ICBT has become popular due to its logistical advantages over low dose rate ICBT, it necessitates dose fractionation to reduce normal tissue complications [1]. There are inadvertent changes in the position/geometry of the applicator and interfraction deformations in organs at risk (OAR) due to movement, shape changes, and variable filling of these hollow organs. This results in considerable variation of dose to surrounding normal tissues due to steep dose gradient in regions close to the brachytherapy source. Material and methods This study was designed to answer the following two specific questions. What was the magnitude of interfraction dose variation to OAR? And: Can re-planning with each fraction be avoided in a subset of patient population with minimal variation in applicator geometry? For this study, orthogonal films of 100 patients, treated from March 2014 to June 2016, were evaluated. Treatment planning and the dose distribution were evaluated using Nucletron Plato Treatment Planning System. Results The results will be presented at the conference., Purpose Brachytherapy remains an integral part in the management of cervical cancer. During the process of brachytherapy, the volume of surrounding distensible structures such as urinary bladder, rectum, and bowel may have its impact on dosimetric coverage of target volume and exposure of high dose rate radiation to organs at risk (OAR). Various degrees of bladder distension can be used to alter the position of uterine cervix tumor target and shift OAR away to achieve better tumor control. Objectives To dosimetrically compare the effect of bladder filling on various parameters of tumor target and OAR in CT volume based ICBT planning for treatment of cervical cancer. Material and methods A prospective study of 10 consecutive patients treated with definitive radio-chemotherapy for biopsy proven cervical cancer from May to June 2016 was conducted at Vydehi Institute of Medical Sciences, Bengaluru. All the patients underwent external beam radiotherapy to a dose of 45-50 Gy in conventional fractionation with concurrent weekly chemotherapy, followed by 3-4 fraction of ICBT for a total treatment duration of ≤ 8weeks. The bladder filling with 1 : 10 iohexol diluted normal saline was done with brachytherapy applicators before simulation and treatment. GEC-ESTRO recommendations were used to define dosimetric parameters for CT volume based ICBT planning. The DVH of each patient was evaluated and compared for no filling, 50 ml, 100 ml, and 200 ml bladder filling for each fraction ICBT planning on CT images. Results The results of dosimetric parameter for no filling, 50 ml, 100 ml, and 200 ml bladder filling for ICBT planning for each patient such as GTV D100, GTV D98, HRCTV D100, HRCTV D98, HRCTV D90, HRCTV D50, D2cc and D0.1cc of bladder, rectum, sigmoid, vagina, V150, V200, point A, point B, homogeneity index (HI), and conformity index (CI) will be presented in the conference. Conclusion Will be presented in the conference., Purpose Dosimetric evaluation of bladder and rectal radiation dose in cervix carcinoma patients using CT simulation and Cobalt-60 as source in HDR brachytherapy. Material and methods From January 2016 to June 2016, 30 eligible patients of age 30-60 years with squamous cell cervix carcinoma of all stages up to III B, completed EBRT and were scheduled for brachytherapy. All patients were treated with conventional EBRT 50 Gy in 2 Gy/fractions for 5 days a week/25 fractions, followed by 2 fractions ICA application consisted of placement of intra-uterine tandem 4 to 6 cm into uterine cavity after dilatation, and ovoids in vagina at the level of fornices. This was followed by gauze packing in anterior and posterior vaginal space to displace the bladder and the rectum away from and to fix the applicators in position. Results CT simulation of 2 mm thickness was obtained, 2 cm above the tandem superiorly and to the level of pubic symphysis inferiorly (from Barnard Institute of Radiology). Planning target volume, rectum, and bladder were contoured. Treatment planning were carried out using HDR plus treatment planning system based on ICRU 38 recommendations. Point A and point B, bladder and rectal doses were studied after the treatment was carried out using Cobalt-60 HDR remote after loading machine. Conclusion Out of the 30 patients, the average dose received by point A, point B, bladder, and rectal points were within tolerable limits, which is shown in the tabular column., Purpose Conventional intracavitary brachytherapy would result in sub-optimal dose coverage in locally advanced cervix carcinoma, for which interstitial brachytherapy is the preferred option. Here, we investigate the feasibility of brachytherapy with combined intracavitary- interstitial (IC-IS) approach for patients with extensive parametrial involvement. Material and methods Two patients with cervix carcinoma FIGO stage IIIB with bilateral parametrial involvement up to lateral pelvic wall were treated with IC-IS applicator. Patient no 1 was treated with 3DCRT 45 Gy/25 fractions (treated elsewhere), and patient no 2 with IMRT 50 Gy in 25 fractions with concurrent cisplatin. After EBRT, the first patient had residual disease in the bilateral parametrium up to pelvic wall, cervix, and fornices. Patient no 2 had residual disease in the cervix and medial 2/ 3rd of right parametrium. Brachytherapy was performed under general anesthesia with IC-IS applicator, which consists of tandem, ovoids, and template for needles. After planning CT scan, HR CTV and organs at risk (OAR) were contoured according to American Brachytherapy Society guidelines. For the study purpose, three different plans were generated with different combinations of applicator and needles (i.e., conventional tandem and ovoids (ICBT), tandem and interstitial needles (ISBTWT), tandem-ovoids and interstitial needles (ISBTWTO)). Dose and volume parameters were evaluated and compared for both HR CTV and OAR. Results With ISBTWTO there was an average improvement of HR CTV D90 by 10% as compared with ISBTWT and 57% with ICBT. The average ratio of D90 HRCTV/D2cc bladder ((gain factor (GF)) were 0.95, 0.86, 0.68 in the ISBTWTO, ISBTWT, and ICBT, respectively, while GF for rectum were 1.2, 1.06, and 0.52, respectively, and 1.64, 1.63, and 0.63, respectively for sigmoid. ISBTWO plan has better coverage (17.9% increase) at cost of increased V200 (10.5%) and V150 (14.9%) compared with ISBTWT plan. Conclusion ISBTWTO could be a comparable alternative to ISBTWT with improved coverage., Purpose To evaluate the late toxicity in locally advanced and medically inoperable early cervix carcinoma patients treated with various schedules of EBRT, chemotherapy, and HDR-ICBT. Material and methods Between 2008 and 2014, 130 patients were treated in our Institute with either neoadjuvant chemotherapy followed by radiotherapy or concurrent chemoradiotherapy, or only radiotherapy or concurrent chemoradiation therapy with platin analogs followed by any of the three schedules of intracavitary brachytherapy, consisting of 7 Gy in 3 sessions, 6 Gy in 3 sessions, or 4 Gy in 6 sessions. Cervix carcinoma patient with history of hysterectomy and carcinoma endometrium were excluded. Results Chronic toxicities such cystitis were 4.65%, 2.63%, and 8.16%; vaginal stenosis were seen in 13.95%, 7.89%, and 12.25%; proctitis were seen in 18.60%, 10.52%, and 16.33%, and dry vagina appeared in 11.63%, 15.79%, and 16.33% of patients in three schedules of HDR-ICBT of 7 Gy in 3 sessions, 6 Gy in 3 sessions and 4 Gy in 6 sessions, respectively. Conclusion Incidence of fibrosis, cystitis, and dry vagina are more common in receiving 4 Gy in 6 sessions of brachytherapy. Incidence of vaginal stenosis and proctitis were more common in case of 7 Gy in 3 sessions of brachytherapy schedules. This study emphasizes the importance of further randomized studies to assess late toxicities and optimal brachytherapy schedules., Purpose Brachytherapy is the most essential component of treatment of ca cervix patients. The era of LDR brachytherapy is fading and today, majority of the patients are treated by HDR brachytherapy. Though there was uniformity in dose prescription in LDR brachytherapy, there is a wide range of discrepancy in dose scheduling of HDR brachytherapy because of resources and logistic issues. Since the local control and toxicities depend on the total dose and dose per fraction, it is important to be aware of the biologic effective dose (BED) and 2 Gy equivalent dose (EQD2) of different radiotherapy schedules. Material and methods It is a retrospective dosimetric study on 20 ca cervix patients post-external radiotherapy of 45 Gy in 25 fractions with weekly cisplatin who underwent intra cavitary brachytherapy (ICBT). CT scan simulation was done after insertion of ICBT applicators. Target and organ at risk were contoured according to GEC-ESTRO guidelines. Four different treatment plans were generated for each patient with dose prescriptions of 5.5 Gy x 4, 6.5 Gy x 4, 7.5 Gy x 3, and 9 Gy x 2 fractions to high risk CTV (HRCTV) by using HDR plus treatment planning system. D90, V150, V200, BED, and EQD2 for 2 cc bladder, 2 cc rectum, and point A were calculated. The results were analyzed by One Way ANNOVA test, using SPSS 15.0 statistical software. Results There was no significant difference in the values of D90, V150, V200, BED, and EQD2 for 2 cc of bladder and rectum (p = 0.10). BED and EQD2 of point A were higher for prescription 6.5 Gy x 4 and 7.5 Gy x 3 fractions (p = 0.0001) (Figure 1). Conclusion Prescription of 6.5 Gy x 4 and 7.5 Gy x 3 fractions deliver higher BED and EQD2 dose to point A compared to 5.5 Gy x 4, or 9 Gy x 2 fractions with acceptable doses to bladder and rectum in HDR intra cavitary brachytherapy for ca cervix patients., Purpose Pediatric vaginal yolk sac tumor is an extremely rare clinical entity. Chemotherapy and surgery remains the mainstay of treatment, while radiotherapy has a definite role in select patients. Material and methods A one year and 3 months old girl was brought with a history of bleeding and spontaneous expulsion of a mass from vagina. Histopathological evaluation of the expelled mass revealed pure yolk sac tumor. Her AFP values were found to be elevated with normal BHCG. She received 5 cycles of JEB (bleomycin, etoposide, carboplatin) chemotherapy, followed by wide excision of residual with Martius labial fat pad graft. Results Her postoperative histopathology was reported as no evidence of malignant tumor. But after 2 months of follow-up, her AFP was found to be rising and vaginoscopy showed recurrence. She received next line of chemotherapy with 6 cycles of VeIP (vinblastine, ifosfamide, cisplatin). The post-chemotherapy vaginoscopy revealed residual lesion. In view of the possibility of significant morbidity with repeat surgery and for organ preservation, brachytherapy was considered. She was treated with vaginal mould brachytherapy. Since the CTV included almost entire vagina, partial vaginal treatment was not considered. She received 3 Gy per fraction x 14 fractions, 2 fractions per day. She is doing well with normal AFP levels and excision of probable residual on vaginoscopy being negative for malignancy at 3-month follow-up. Conclusions The obvious advantage of brachytherapy over external beam radiotherapy can be exploited in pediatric patients. The irradiated volume with brachytherapy can be kept significantly lower compared to EBRT. Thus, the late complications, which have a strong relation to a dose volume effect such as growth retardation, prevention of sterility, or chances of second primary tumors can be kept to a minimum with brachytherapy., Purpose To evaluate the clinical outcomes and dose optimization using CT based planning in gynecological malignancy (cervical and endometrial cancer) undergoing interstitial (MUPIT) brachytherapy. Material and methods 30 patients with histologically diagnosed endometrial or cervical malignancy who underwent hysterectomy and received external beam radiation followed by HDR interstitial brachytherapy with MUPIT. The clinical target volume and organs at risk were delineated and optimization was done for optimum CTV coverage and sparing of organs at risk. The coverage index (CI), dose homogeneity index (DHI), overdose index (OI), dose non-uniformity ratio (DNR), external volume index (EI), conformity index (COIN), and dose volume parameters recommended by GEC-ESTRO were evaluated. The patients were followed-up and toxicities were graded as per RTOG scales, and local control rates and disease free survival were evaluated. Results The mean CTV volume, D90, and D100 were calculated. The OAR, which included bladder and rectum were assessed for the volume along with D2cc, D1cc, and D0.1cc were assessed for bladder and rectum/rectosigmoid. Mean CI, DHI, OI, DNR, EI, COIN were evaluated. The median follow-up was assessed and as per the RTOG toxicity scale, it was used to evaluate the toxicities on follow-up for the patients. The local control rate and disease free survival were assessed at the same. Conclusion CT based planning using MUPIT for gynecological brachytherapy implants has good outcomes as assessed in our study. Plan evaluation and documentation using various indices and parameters recommended by GEC-ESTRO assist in objective evaluation and reproducibility, and correlate with clinical outcomes of the disease., Purpose To assess the role of brachytherapy in the form of central vaginal source (CVS) in early endometrial cancer and its relation with the functional quality of patients following treatment. Material and methods Between November 2015 and April 2016, 20 patients with early stage of endometrial cancer, treated in our department with external beam irradiation followed by brachytherapy (CVS) were included in this study. The patients were treated with 50 Gy in 25 fractions with external beam irradiation followed by brachytherapy with central vaginal source with varying diameter (2-3.5 cm) and applying 12-14 Gy in two fractions one week apart. The patient’s quality of life was assessed, using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (QLQ C30) and Endometrial Cancer Module QLQ EN24. The questionnaire was taken at starting of the treatment, before starting brachytherapy, and at the end of brachytherapy, and the results were analyzed using appropriate statistical tests. Results The patients showed better physical functioning after the use of brachytherapy as compared to that after external beam irradiation alone. The symptom score, lymphedema, pain, and diarrhea were also better after completion of brachytherapy. Among the sexually active patients, the sexual function was not worsened after brachytherapy. The functional scores were better in patients with normal body mass index as compared to those with obesity, especially lymphedema was affected in such cases. Conclusion The role of brachytherapy is an important part of treatment of early endometrial cancers and does not affect quality of life, especially the functional and sexual aspects as compared to outcomes after external beam irradiation. The BMI also affects the outcome in quality of life., Purpose Soft tissue sarcomas are rare group of solid tumors comprising of 1% of all solid tumors. The management of soft tissue sarcomas have evolved due to advancements in imaging, histopathology, cytogenetics, and the use of multimodality treatment. The treatment strategies emphasize on the control of disease locally, sparing of limb function, and improvement in the quality of life. High dose rate brachytherapy has formed a part of the management, and has the advantage of providing concentrated dose to tumors and sparing of surrounding normal tissues. In this study, we examined the clinical outcome of high dose brachytherapy for STS at our Hospital through retrospective analysis of the prospective database maintained. Objectives To review the clinical outcome and quality of life in patients with soft tissue sarcoma treated at our Center through high dose rate interstitial brachytherapy. Material and methods Eleven patients with different sites and grades of soft tissue sarcoma underwent surgery and intraoperative catheter implantations in a single plane in biopsy proven soft tissue sarcoma cases. Then, the patients underwent high dose rate brachytherapy with Iridium 192. The patients received an average dose of 3.5 Gy per fraction (two fractions per day, 6 hours apart) with total dose of 35 Gy/10 fractions/5 days, and after completion of treatment were followed-up at 1 month and later every 3 months for 2 years, followed by 6 months’ interval. Results The patients were followed-up for range of 1-42 months (median: 12 months) and the overall control rate was 72.72%. The local recurrence was noted in only one patient (9.09%) and two patients developed distant metastases (18.18%). Conclusion The results in our study suggested the importance of HDR brachytherapy in management of soft tissue sarcoma. The local control rate was 72.72%. The dose of 35 Gy over 10 fractions in 5 days was found to be effective in local control and limb salvage in case of soft tissue sarcoma as practiced at our Centre., Purpose Breast conserving surgery has formed a major treatment aspect in early breast cancer where the radiation therapy has formed an integral part in treatment of that disease. 3D-CRT is the technique of choice in the treatment and interstitial brachytherapy has been employed in select cases. We report a single-institutional dosimetric comparison of patients treated with two forms of accelerated partial breast irradiation: interstitial HDR brachytherapy and 3D conformal external beam quadrant irradiation (3D-CRT). Material and methods A retrospective dosimetric comparison of interstitial HDR brachytherapy and 3D-CRT was performed. Five patients were included for a dosimetric comparison of the dose received by the ipsilateral breast, PTV, heart, and ipsilateral lung. Interstitial patients were treated with 3.5 Gy in 10 fractions to 35 Gy. 3D-CRT patients were treated with 3.85 Gy in 10 fractions to 38.5 Gy using multiple iso-centric beams. The CT images from simulation or implant evaluation were transferred into our 3D treatment planning software. The lumpectomy cavities were outlined for every patient. The PTV was constructed as a uniform expansion of 1.5 cm for all interstitial HDR patients, and a 1.0 cm expansion in addition to the CTV expansion of 1.0 cm and 1.5 cm for the 3D-CRT patients. The CTV expansion for 3D-CRT and the PTV expansion for the brachytherapy patients were limited to the chest wall and skin. Normal structures including both ipsilateral lung and breast and heart for left-sided lesions were outlined. The lumpectomy cavity was subtracted from the PTV and normal breast tissue for evaluation. To evaluate dose to the ipsilateral breast and lung, PTV, and heart, a dose-volume histogram (DVH) analysis was performed. All histograms were normalized to the volume of the structure (i.e., expressed as percent volume). Results The average percentage of the breast receiving 100% and 50% of the prescribed dose (PD) was higher in the 3D-CRT group (24% and 48%, respectively) compared with interstitial patients (10% and 26%, respectively). Improved coverage of the PTV was noted in the 3D-CRT plans compared with interstitial HDR plans. With the interstitial HDR technique, 58% of the PTV received 100% of the PD compared with 100% with 3D-CRT techniques. The percentage of the PTV receiving 90% of the PD was 68% and 100% for the interstitial HDR and 3D-CRT patients, respectively. The ipsilateral lung V20 was slightly higher for 3D-CRT at 5% compared with 0% for brachytherapy technique. The heart doses were found to be least with interstitial brachytherapy compared to 3D-CRT. Conclusion In those treated with 3D-CRT, the coverage of the PTV was better with 3D-CRT but varied with the definition used. The coverage at 90% of the PD, statistical difference was observed between 3D-CRT and interstitial brachytherapy (3D-CRT better than interstitial). 3D-CRT resulted in better coverage of the PTV compared with interstitial brachytherapy technique. Better PTV coverage with 3D-CRT came at the cost of a higher integral dose to the remaining normal breast. The lung dose, cardiac dose, and contralateral breast dose were minimal with interstitial brachytherapy compared to 3D-CRT. Dosimetrically, the best partial breast irradiation technique appears to depend on the clinical situation., Purpose Radiotherapy (RT) for ca cervix patients is incomplete without brachytherapy. High dose rate (HDR) brachytherapy has shown an advantage over low dose rate (LDR) brachytherapy in terms of better nursing care and radiation safety. Unlike in LDR, various dose regimens are followed in HDR brachytherapy. Some institutes follow brachytherapy sequentially after external RT and some along with external RT during weekends. There are no comparative studies on sequential and weekend brachytherapy and hence in our study, we have focused on the radio biology of these two regimens. Material and methods We have conducted a dosimetric comparative study on 40 plans of 20 ca cervix patients post external RT of 45 Gy in 25 fractions with weekly cisplatin who underwent intra cavitary brachytherapy (ICBT). CT scan simulation was done after insertion of ICBT applicators. Target and organs at risk were contoured according to GEC-ESTRO guidelines. Two different treatment plans were generated for each patient with dose prescriptions to high risk CTV (HRCTV) by using HDR plus treatment planning system. Plan A: 5.5 Gy once a week x 5 fractions, and Plan B: 5.5 Gy once every 6 hours x 5 fractions. Biologic effective dose (BED) and 2 Gy equivalent dose (EQD2) for 2 cc bladder, 2 cc rectum, and HRCTV were calculated for both plans and compared by using Student t-test. Results Plan B showed higher BED and EQD2 for HRCTV, 2 cc of bladder and rectum (p = 0.0001). Conclusion Sequential HDR ICBT for ca cervix patients of 5.5 Gy x 5 fractions with 6 hours interval between the fractions given after completion of external RT, delivers higher BED and EQD2 to HRCTV compared to 5.5 Gy once a week for 5 weeks during external beam RT with acceptable doses to bladder and rectum., Purpose In patients with early breast cancer, an adjuvant radiotherapy is part of a standard of care for BCT. APBI is a hypofractionation irradiation approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than conventional whole breast irradiation (WBI). Despite the lack of level I evidence, preliminary results from several large national trials suggest that APBI is safe and effective option. Thus, several consensus groups including GEC-ESTRO, ASTRO, and ABS endorse the use of guidelines in selecting patients for APBI. The purpose of this study is to analysis clinical outcomes of patients treated in our Institution with MIB-APBI regimen in comparison to GEC-ESTRO consensus for patient selection. Material and methods Between 2012 and 2014, patients who underwent MIB-APBI with a minimum of 24 months of follow-up were retrospectively analyzed. Statistical analyses of overall survival (OS) and local control (LC) rates were determined. Results A total of 37 patients had undergone MIB-APBI with median age of 57 years. Freehand multiplanar intra-op implant was done in 20 patients, and post-op implant in 17 patients with median 20 catheters. As per analyses with GEC ESTRO consensus for patients’ selection, our cohort consisted 10 (27%), 25 (67.6%), and 2 (5.4%) patients belonging to low, intermediate, and high risk group, respectively. With median follow-up of 36 months, 33 of 37 patients were alive, out of which two are alive with metastatic disease. Remaining 4 had died (2 had died of metastatic disease). None of the patients had a local or regional recurrence. Good to excellent cosmesis was achieved in 86% of entire cohort. 2 yr. OS and LC is 89.2% and 97.3%, respectively. Conclusions APBI brachytherapy needs to be customized individually and based on tumor-specific characteristics; it can be considered even in intermediate and highly selected cases of high risk group of GEC ESTRO consensus with enough risk for local failure.