Interstitial High-Dose-Rate Gynecologic

Brachytherapy: Clinical Workflow Experience

From Three Academic Institutions
Joann I. Prisciandaro, PhD,* Xiao Zhao, MD,† Sonja Dieterich, PhD,† Yasmin Hasan, MD,z
Shruti Jolly, MD,* and Hania A. Al-Hallaq, PhDz

An interstitial brachytherapy approach for gynecologic cancers is typically considered

for patients with lesions exceeding 5 mm within tissue or that are not easily accessible
for intracavitary applications. Recommendations for treating gynecologic malignan-
cies with this approach are available through the American Brachytherapy Society, but
vary based on available resources, staffing, and logistics. The intent of this manuscript
is to share the collective experience of 3 academic centers that routinely perform
interstitial gynecologic brachytherapy. Discussion points include indications for inter-
stitial implants, procedural preparations, applicator selection, anesthetic options,
imaging, treatment planning objectives, clinical workflows, timelines, safety, and poten-
tial challenges.
Interstitial brachytherapy is a complex, high-skill procedure requiring routine practice to
optimize patient safety and treatment efficacy. Clinics planning to implement this approach
into their brachytherapy practice may benefit from considering the discussion points
shared in this manuscript.
Semin Radiat Oncol 30:29−38 Ó 2019 Elsevier Inc. All rights reserved.

Introduction the placement of an intracavitary applicator, interstitial needles,

or a hybrid approach depending on the “extent, thickness, loca-

B rachytherapy has been an integral component of care for

patients with gynecologic malignancies since the early
part of the 20th century. When utilized as part of a patient’s
treatment course, brachytherapy has been found to improve
the survival of patients presenting with cervical,1-5 endome-
trial,6-10 and vaginal11 cancers. Treatment is delivered following
*
Department of Radiation Oncology, University of Michigan/Michigan Med-
icine, Ann Arbor, MI
y
Department of Radiation Oncology, University of California Davis Medical
Center, Sacramento, CA
z
Department of Radiation and Cellular Oncology, The University of Chi-
cago, Chicago, IL
Grant Support: None.
Disclosures: H. Al-Hallaq receives royalties and licensing fees for computer-
aided diagnosis technology through the University of Chicago and
receives research funds from Varian Medical Systems not related to the
current work.S. Dieterich receives research funds from Varian Medical
Systems not related to the current work and receives textbook royalties
from Elsevier.S. Jolly is a consultant for Varian Medical Systems.
Address reprint requests to Joann I. Prisciandaro, PhD, Department of Radi-
ation Oncology, University of Michigan/Michigan Medicine, UH B2
C432, SPC 5010, 1500 East Medical Center Dr., Ann Arbor, MI 48109.
E-mail: joannp@med.umich.edu
tion, and morphology of the disease.”12 For lesions that extend
beyond 5 mm within tissue and/or are not accessible or condu-
cive to an intracavitary applicator, an interstitial approach is
used to improve the dosimetric coverage of the target volume
while minimizing dose to the neighboring, normal critical
structures.12,13
The American Brachytherapy Society (ABS) has published
guidelines for treating gynecologic malignancies.12-16 These
documents include a description of the variation in implant
procedures and fractionation schemes given different treatment
sites, clinical scenarios, and available resources. Viswanathan
et al13,14 have stated that “variations in approaches to interstitial
brachytherapy, as with most medical procedures, are common-
place and may readily fall within accepted and appropriate
management of these patients.” However, given the varied
approaches, it can be challenging for practitioners to select the
appropriate approach for their patients given the available
resources and workflow within their clinics. The goal of this
manuscript is to provide an overview of gynecologic interstitial
procedures as practiced at 3 academic centers, based in part
upon a 2017 American Association of Physicists in Medicine
(AAPM) presentation.17

https://doi.org/10.1016/j.semradonc.2019.08.001 29
1053-4296/© 2019 Elsevier Inc. All rights reserved.
30
Sites and Indications for
Interstitial Brachytherapy
Interstitial brachytherapy is indicated for patients with a vari-
ety of gynecologic cancers, as shown in Table 1, when the
tumor volume cannot be adequately treated by the standard
intracavitary applicators.18 Examples include patients with
vaginal lesions greater than 0.5 cm depth, bulky cervical
lesions (>4-5 cm after external beam radiotherapy [EBRT]),
tumors extending into the lateral parametria or pelvic side-
wall, tumors extending into the lower vaginal canal,19-24 and
suboptimal anatomy (ie, narrow vaginal apex or inaccessibil-
ity to the cervical os).
In the case of cervical cancer, the standard intracavitary
applicators, tandem and ovoids or tandem and ring, provide a
concentric dose distribution that may not sufficiently cover
tumors with an eccentric shape. As a result, more than 20%-
50% of cervical cancer patients may benefit from interstitial
versus intracavitary brachytherapy.25,26 In the case of postoper-
ative endometrial or vaginal cancer, the most commonly used
applicator is the vaginal cylinder. Shielded or multichannel cyl-
inder applicators allow for a reduction in the dose to organs at
risk (OARs) but are still limited in treatment depth.27,28
Patients with recurrent tumors may also benefit from intersti-
tial brachytherapy as the rapid dose fall-off could allow for an
increase in therapeutic dose while protecting nearby OARs.29
These indications for interstitial brachytherapy cannot
always be determined upfront and may require reassessment
of tumor response near completion of EBRT. Contraindications
for interstitial brachytherapy are mainly associated with patient
comorbidities that preclude the patient from tolerating pro-
longed immobilization, surgery (eg, in the event a minilaparot-
omy is necessary), or anesthetics.12 In patients with metastatic
disease, poor performance status, or limited life expectancy,
the risk of interstitial brachytherapy may outweigh the poten-
tial benefit. Interstitial brachytherapy is a high-skill procedure
that requires routine practice to optimize patient safety and
treatment efficacy. Without the required expertise, it may not
provide the anticipated benefits or be difficult to perform
safely. Thus, patients should be referred to a tertiary center
that treats a high volume of interstitial cases.12
Applicator Selection
For patients requiring an interstitial implant, several applica-
tor options can be considered. Traditionally, interstitial
implants have been performed using a template-based
Table 1 Snap Shot of the Distribution of Cancers Treated With Interstitial Brachytherapy at Each Institution Between January
2015 and April 2018
Cancer Type Institution 1
Cervical 78.3%
Endometrial 4.3%
Urethral 4.3%
Vaginal 8.7%
Vulvar − 3%
Ovarian 4.3%
J.I. Prisciandaro et al.
approach. The template is used to help guide the placement
of metallic or plastic needles. Templates typically consist of a
perineal template, and a multichannel cylinder that allows
for the placement of needles at the apex of the vaginal vault,
and when present, into the cervix. For patients with an intact
uterus, a tandem may be placed in the center of the cylinder
to improve dosimetry and improve stability of the applicator.
Templates are commercially available, such as the Martinez
Universal Perineal Interstitial Template (MUPIT),30 the
Kelowna template, and the Syed-Neblett template,23 and
have also been designed and fabricated in-house.31-34 One of
the treating institutions uses a commercial template, while a
second utilizes a custom template that is designed and fabri-
cated in-house, and allows for diverging needles that are
intended to overcome implant issues due to pubic arch inter-
ference. The third institution uses a mixture of commercially
available templates along with flexible or free-hand needles
to account for anatomic challenges.
More recently, hybrid intracavitary-interstitial applicators,
such as the Vienna,35 Utrecht,36 and Venezia37 applicators
have been made commercially available (Fig. 1). The Vienna
and Utrecht applicators are modified tandem and ring and
tandem and ovoid style applicators, respectively, in which
holes are spaced along the perimeter of the ring or length of
ovoids to accommodate the placement of needles. This
allows for the source to be positioned at desired locations
along the length of the tandem and ring or ovoids. These
applicators can be used to deliver more conformal dose dis-
tributions than the standard tandem and ring or ovoids for
patients with limited lateral parametrial invasion or residual
bulky posterior disease. The more recently introduced Vene-
zia applicator has 2 lunar-shaped ovoids that fit together to
form a ring for ease of insertion, and needles can be placed
through the ring at different angles. For more advanced
tumors, interstitial needles can be placed through an addi-
tional perineal template.37 As compared to the Vienna or
Utrecht applicators, the Venezia applicator allows for the
treatment of patients with more extensive vaginal, parame-
trial or pelvic side wall invasion.
In addition to these commercially available solutions, it is
possible to insert needles along with an intracavitary implant
using a free hand approach; however, the lack of a template
can make accurate placement, as well as immobilization of
the needles, somewhat challenging. A free hand technique
especially requires the use of intraprocedure imaging (eg,
ultrasound [US] or computed tomography [CT]) to verify
proper and safe positioning of interstitial needles.
Institution 2 Institution 3
41% 67.3%
28% 21.2%
− −
28% 11.5%
−
− −
Interstitial High-Dose-Rate Gynecologic Brachytherapy 31

Figure 1 Examples of commercially available hybrid intracavitary-interstitial applicators, the (a) Vienna,35 (b) Utrecht,36
and Venezia37 applicators. (Color version of figure is available online.)

Workflow response to treatment, serial pelvic examinations are typically

Applicator Placement
Table 2 summarizes the main workflow steps at the 3 institu-
tions. Depending on the available resources and patient’s
comorbidities, the interstitial applicator(s)/needles may be
placed in an operating room (OR) or in a radiation oncology
procedure room by radiation oncologists and/or gynecologic
oncologists with the patient in the dorsal lithotomy position.
Two of the treating institutions perform all interstitial
implants in an OR under general anesthesia while the other
institution uses a dedicated brachytherapy suite within the
department with the patient under spinal or epidural anes-
thesia. To assess tumor dimensions and invasion as well as
performed throughout external beam treatment. Prior to
brachytherapy, imaging of the pelvis is obtained, specifically
T2-weighted (T2W) magnetic resonance imaging (MRI)
using vaginal contrast. The imaging is reviewed prior to and/
or during the implant to assist with needle placement, or
during treatment planning to assist with target delineation.
In advance of the implant procedure, patients undergo
preoperative anesthesia clearance and laboratory evaluations.
Closer to the procedure date, patients are provided with pre-
operative instructions for bowel preparation to decrease the
risk of surgical complications. Bowel preparation is often ini-
tiated 1-2 days prior to the planned implant, with the admin-
istration of enemas or ingestion of an oral laxative such as

Table 2 Summary of Interstitial Brachytherapy Workflow Elements Among 3 Academic Institutions

Workflow Overview
Location of implant
3D imaging modality for
simulation
Number of applicators/nee-
dles implanted
Number of active needles (ie,
has dwell time)
Number of fractions/implants
Location of HDR afterloader
Planning strategy
Do you parallelize any tasks?
Staff allotment
EQD2 worksheet use during
planning?
Use of virtual plans or
“preplans”?
Replanning/reimaging?
Abbreviations: AMP, authorized medical physicist, AU, authorized user (physician); CMD, certified medical dosimetrist; EQD2, biological dose
equivalent to 2Gy fractions; FTE, full-time equivalent.
Institution 1 Institution 2 Institution 3
Operating room Operating room Dedicated brachytherapy
suite
CT scan (preimplant MRI) CT & MR scans CT scan (preimplant MRI)
>20 titanium needles & cen- »13 plastic needles (range 10-20 titanium, stainless steel
tral obturator/tandem 6-24) or plastic needles; central
obturator/tandem in select
cases
»16 »11 »12
5 fractions in 1 implant (89%) 3-4 fractions in 1 implant 2-3 fractions per implant, total
6 fractions in 2 implants of 5-6 fractions in 2 implants
(11%)
LINAC vault Dedicated brachytherapy Dedicated brachytherapy
suite suite
3D with volume optimization 3D with volume 3D with volume optimization
optimization
Yes (contouring, needle digiti- No, with exception of Yes (contouring, image
zation & check, EQD2 work- EQD2 worksheet fusion)
sheet, MRI import)
2 FTE on initial day (2 AMP); 1 2 FTE on initial & subse- 2 FTE on initial day (1 AMP, 1
FTE on subsequent days quent days (1 AMP, 1 CMD); 1 FTE on subsequent
(1AMP) CMD) days (1AMP)
Yes Yes Yes
Yes CT-based to plan needle No No
loading & retraction
No, needles adjusted to Yes, imaging before every Yes, imaging before every
match plan prior to fraction, replan if needles fraction, replan if needles
treatment deviate by >3 mm cannot be adjusted to previ-
ous position
32
magnesium citrate or polyethylene glycol. This is followed by a
clear liquid diet until the night before the procedure when the
patient is instructed to have nothing by mouth. For patients
who are hospitalized for a prolonged period of time with the
applicator and implant in place, a more complete bowel prepa-
ration can be of benefit. An antidiarrheal medicine such as
Imodium can be given while the applicator is in place to pre-
vent the patient from having bowel movements. For patients
under regional anesthesia, this can be of additional benefit
given mobility issues and to reduce the risk of infection.
Immediately preceding the implant procedure, patients are
anesthetized through the administration of a general, intrave-
nous monitored, or regional (eg, spinal block, epidural) anes-
thetic. Two of the treating institutions administer anesthesia
via an epidural (with or without general anesthetic or moder-
ate sedation), while the third delivers a general anesthetic dur-
ing the implant, followed by a pain control infusion pump for
the duration of the treatment. A combined spinal-epidural
approach can provide better pain control during the implant
portion of the procedure. For patients where the applicator is
kept in place overnight, the epidural remains in place for con-
tinuous infusion of anesthetic until completion of treatment.
Real-time imaging, for example, fluoroscopy, CT or US,
may be utilized to guide the implant. Occasionally, a minila-
parotomy is performed by the gynecologist if the lesion is in
close proximity or adheres to bowel, if the patient is unable
to undergo preimplant MR imaging and the patient’s
response to external beam is unclear, or in the case of an
intact uterus, when the uterus is extremely retro- or ante-
verted. In these situations, a minilaparotomy may prove ben-
eficial in gaining better access to the target, and increasing the
distance between the implant and the normal structures (eg,
moving normal structures and/or using an omental flap).
Given that patients will have the interstitial applicator(s)/nee-
dles in place for several days, a Foley catheter is introduced
into the patient’s bladder. The bladder may be filled with ster-
ile water or saline to assist with transabdominal US imaging,
uterus displacement, needle placement and/or to ensure the
bladder is not perforated during the implant procedure.
Once the implant is complete, the applicator(s)/needles
should be immobilized. This may be accomplished, in the
case of the perineal template, by ensuring the appropriate
suturing of the template to the patient. The needles may be
marked at a reference location relative to the template or cyl-
inder, in the case of a template-based approach, to provide a
quick visual confirmation of the needle insertion depth, and
secured using a collet lock, friction collar, or glue. Two of
the treating institutions routinely postpone marking and
immobilizing the needles until the completion of the plan-
ning simulation so that the needles may be verified and/or
advanced under image guidance. Additionally, to prevent
biological fluid from entering the needles, obturators/stylets
may be reintroduced into the needles or plugs/caps may be
added to the connector ends.
Care is taken when lowering the patient from the dorsal
lithotomy position and transferring the patient to a stretcher
for recovery. At one institution, an abductor pillow or wedge is
used between the patient’s legs to minimize the likelihood of
J.I. Prisciandaro et al.
dislodging the applicator(s)/needles. Soft padding such as
Mepilex can be placed on the patient’s thighs to prevent fric-
tion and irritation of the skin from the template. Additionally,
for ease of transfer, an air transfer system, such as a Hovermatt,
can be used beneath the patient. Specific instructions are pro-
vided to the entire care team (eg, nurses, therapists, inpatient
staff) regarding the maximum angle in which the stretcher may
be elevated to prevent the patient from being adjusted to a
higher Fowler (seated) position, to minimize the risk that the
interstitial needles may perforate the patient’s bowel.
Simulation
Before simulation images are acquired, the needles are
inspected to ensure they have not been dislodged or compro-
mised. This is of particular importance for plastic needles
that are not as robust as their metal counterparts. To verify
the integrity of the needles, the metal obturator/stylet for
each needle is individually removed and inspected for bio-
logical fluid using a wipe test. Compromised needles are
removed, replaced (typically under image guidance), or
marked so they are not inadvertently used for treatment. For
planning and to ensure consistency and reproducibility of
needle connections, the needles or grid are numerically
labeled and/or a schematic of the template and needles is
drawn. Additionally, the needle lengths are recorded. Some
clinics may choose to insert x-ray markers into plastic nee-
dles just prior to image acquisition to assist with needle
reconstruction at time of planning. Bladder and rectal con-
trast can be given at this time with optimal bladder fill and
clamping of the Foley afterward. If fluid is introduced into
the bladder, the quantity is noted, and reproduced prior to
each treatment. At completion of treatment, the Foley is
unclamped and the bladder emptied.
Once the patient is ready for their CT simulation, they are
aligned on the couch with a scout image. If the needles
require adjustment under CT guidance, a short length scan,
approximately from the pelvic crest to 2-3 cm inferior of the
needle tips, is acquired with slice thickness of ≤3 mm in the
absence of the metal obturators/stylets and reviewed. The
metal obturators/stylets are reintroduced into the needles
before needles are advanced. Otherwise, a scan ranging from
the pelvic crest to 1-2 cm inferior of the template surface is
acquired, ideally with a slice thickness of ≤1 mm, but not
larger than 2 mm. Once approved by the attending physician
and/or physicist, the patient may be moved to a holding area/
hospital bed while a treatment plan is developed.
At institutions where MRI simulation is employed in addi-
tion to CT, in order to improve the visualization of the high-
risk clinical target volume (CTV), care is taken to ensure that
all equipment used for the procedure (ie, brachytherapy,
anesthesia, and transfer equipment) is MR-compatible. If the
needles or needle connectors are made of a paramagnetic
metal such as titanium, one may wrap the ends of the needles
in a towel or sheet to prevent them from coming into direct
contact with the patient’s skin. A scout is acquired to set the
borders of the acquisition field, and the scan angled so that
the needles, needle tips, and relevant anatomy is captured,
Interstitial High-Dose-Rate Gynecologic Brachytherapy 33

Figure 2 Target visualization differences on (a) MRI and (b) CT with the applicator in situ. The high-risk CTV as visual-
ized on the T2-weighted MRI is contoured in magenta. The orange contour is the modified high-risk CTV on CT
accounting for uncertainties in the MR/CT registration, as well as a region of concern/uncertainty identified on CT.
(Color version of figure is available online.)

and that the slices are oriented perpendicular (ie, para-axial)
or parallel (eg, para-sagittal, para-coronal) to the long axis of
the cervical canal or vaginal vault.38
To best visualize the high-risk CTV, T2W fast spin echo
scans are acquired as recommended by Dimopoulous et al.38
Although MR imaging improves the visualization of the
high-risk CTV (Fig. 2), applicator reconstruction is challeng-
ing (Fig. 3), especially in the presence of air pockets and
when needles cross. As such, at institutions acquiring both
imaging datasets, the CT and MR images are registered, and
applicator reconstruction is typically performed on the CT
dataset. One of the 3 treating institutions acquires both plan-
ning CT and MRI datasets following the interstitial GYN
implant unless the patient has an MRI contraindication.
Treatment Goals and Planning
Patients with extensive gynecologic disease requiring intersti-
tial brachytherapy typically receive standard external beam
therapy followed by interstitial brachytherapy delivered in 1
implant treated twice daily over a number of days.12,14 The
recommended dose to tumor and OARs has been defined in
literature per treatment site and guidelines have been estab-
lished by professionals societies/organizations such as the
ABS,12,14 the European Society for Radiotherapy and Oncol-
ogy (ESTRO),25,39,40 and the International Commission on
Radiation Units and measurements (ICRU).41 For patients
with bulky disease, interstitial brachytherapy may be delivered
using 2 separate implants separated by at least 1-2 weeks.

Figure 3 Parasagittal view of pelvic anatomy on CT and MR for a patient stage IVA cervical cancer patient with bladder
invasion following the implantation of 13 interstitial needles. (a) Three needles can be easily visualized in this plane on
CT, as shown with the red arrows. (b) However, the needles are challenging to discern on a 2D TSE T2-weighted or
(c) a 3D VIBE T1-weighted MRI. (Color version of figure is available online.)
34
For high dose rate (HDR) treatment planning, optimization-
based strategies typically require the definition of volumes, for
example, the high-risk CTV and OARs which typically include
the bladder, rectum, sigmoid, and, in some cases, small bowel,
and urethra. The target volume can be defined on CT using
implanted fiducials, preimplant imaging (eg, diagnostic MRI),
and clinical findings, or defined directly on MRI. A common
dosimetric goal is to achieve at least 90% target volume cover-
age by the prescription dose, that is, D90 ≥100% of the
prescribed dose, while minimizing dose to the OARs. Dose-
volume parameters tracked for the OARs can include the dose
to different volumes, for example, 0.1 cc, 1 cc, and 2 cc. There
are no dose-volume goals specific to gynecologic interstitial
therapy for OARs; however, the EQD2 limits for intracavitary
cervix cancer brachytherapy summarized by the Groupe
Europeen de Curietherapie and the European Society for
Radiotherapy & Oncology (GEC-ESTRO) and the EMBRACE
studies have been applied to interstitial cases.25,26,42 In some
cases, the target volume dose may be decreased to maintain
the dose to the OARs within desired limits.12,25,26,40,42
To achieve the dose-volume goals, a number of different
optimization techniques are available within the HDR brachy-
therapy treatment planning system (TPS) to differentially
weight the dwell positions and achieve the desired dose distri-
bution. Manual optimization, in which the user manually
enters dwell times may be utilized, although with large inter-
stitial implants, this technique is not the most efficient means
of treatment planning. Point-based optimization techniques,
including geometric optimization (GO) where the source
dwell positions are used for optimization of dwell weights,
and dose point optimization (DPO) where dose points are
placed at a given distance along the needles may be utilized.
Alternatively, there are volume-based optimization techni-
ques, for example, inverse-planning simulated annealing
(IPSA) or volume optimization (VO), depending on the TPS,
where structures of interest are contoured and dose-volume
constraints and priorities are entered into an optimizer.43 One
can also employ a hybrid approach in which a plan generated
through a computer-aided optimization technique (eg, GO,
DPO, IPSA, or VO) can be fine-tuned manually or vice versa,
to achieve the desire dose objectives.
Regardless of the optimization strategies or goals employed,
a review of the dwell times is performed to avoid exceedingly
high dwell times, and evaluate hot spots (eg, 150% and 200%)
to ensure that they are concentrated closely around the needle
and noncontiguous when possible.12 All 3 institutions cur-
rently use TG-4344,45 based dose calculation algorithms for
treatment planning. Model-based dose calculation algorithms46
can be used to account for dose changes due to tissue inhomo-
geneities.
Pretreatment Verification and Treatment
Delivery
Prior to treatment, the treatment plan is reviewed and
approved by the Authorized User physician, and a written
directive completed in accordance with Title 10 of the Code
of Federal Regulations Part 35. If the treatment plan was
J.I. Prisciandaro et al.
generated by a medical physicist, ideally, an independent
qualified medical physicist not involved in the planning pro-
cess reviews the plan and written directive.
Next, procedure-specific quality assurance is conducted.
Checks include, but are not limited to, a verification of the
applicator/needle positions and integrity, the successful com-
pletion of daily quality assurance, the successful transfer of the
treatment plan to the treatment control system, patient time-
out, and performance of a pretreatment radiation survey.
Although elements of the checks will need to be customized
to an institution’s workflow and equipment, many of these
checks may be amassed from published recommendations
(eg, AAPM task group reports,47,48 the American Society
for Radiation Oncology [ASTRO] HDR brachytherapy white
paper,49 and ABS guidelines12,14). The applicator/needle posi-
tions may be verified radiographically, if an in-room imager is
available within the HDR suite, or visually by referring to a
schematic or documentation of the number of implanted nee-
dles, arrangement, and recorded needle lengths.
Last, prior to initiating treatment, the applicator(s)/needles
need to be connected to the HDR afterloader unit via transfer
tubes. Given the complexity of the implant, typically 2 indi-
viduals, one connecting and the second double checking the
connections, are involved in this process to ensure the individ-
ual applicator(s)/needles are connected to the appropriate
channels. Prior to initiating treatment, the treatment team
must verify that any physiological monitors, if present in the
treatment room, are visible from the console area.
At completion of treatment, a post-treatment radiation
survey is conducted, and the treatment record verified. To
ensure the integrity of the implant, the metal obturator/
stylets or caps/plugs are reintroduced into/onto each needle,
and if an abductor/wedge pillow is used, it is replaced.
Instructions are given to the care team, and posted on the
stretcher, regarding the maximum angle in which the
stretcher may be elevated.
Timeline (Implant to Treatment)
Interstitial treatments are composed of multiple sequential
steps that culminate in treatment. The steps can be catego-
rized as: (1) patient preparation and applicator insertion, (2)
image acquisition (eg, CT and/or MR), (3) needle localization
and digitization, (4) target and OAR delineation, (5) dose cal-
culation/optimization, (6) pretreatment quality control, and
(7) treatment delivery. Although steps 1-6 are performed in
a single calendar day, some clinics initiate treatment on the
day of implantation while others do so on the subsequent
calendar day.
When comparing the workflow to the timeline among
institutions, a few qualitative patterns emerge, although no
side-by-side comparisons have been performed. Institutions
that utilize multiple scanning modalities (eg, CT and MRI)
generally require a longer time (45-90 minutes) to finalize
the treatment plan. The timeline is somewhat correlated to
the number of needles implanted, delineation of 3D vol-
umes, and the use of 3D dose optimization for planning.
This can be explained by the fact that manual or iterative
Interstitial High-Dose-Rate Gynecologic Brachytherapy
processes such as these add time to the overall process. On
the other hand, use of metallic needles whose digitization
can be automated to a certain degree, in many planning sys-
tems, appears to reduce the timeline compared to plastic nee-
dles with markers. Of course, reductions in digitization time
may be offset by the use of an increased number of needles
and may not necessarily result in an overall time-to-treat-
ment reduction. While not evidenced by the timeline, per-
sonal experience suggests that an increased frequency of
performing these procedures tends to decrease the timeline
(eg, <12-hour initial timelines were reduced to <9 hours
from implant to treatment). With the use of an image-guided
brachytherapy suite, this time can be further reduced (eg, 4-
6 hours) as a patient does not have to be transferred out of
the room and can remain in the same position from implant
to treatment.
When subsequent treatments are delivered on the follow-
ing calendar days, verification of the implant geometry prior
to treatment may prolong the time dedicated to these proce-
dures, depending on the technique used for implant verifica-
tion. For instance, if a repeat CT scan is performed, needle
position can initially be verified using a side-by-side visual
comparison. However, additional time is necessary to regis-
ter the scan to the planning CT which can provide an
updated dose distribution. The timeline can be extended fur-
ther if the treatment team deems it necessary to reoptimize
the plan. However, if a visual inspection of the needles is per-
formed (eg, verifying needles lengths and/or comparing the
position of the template and/or cylinder to marks on the
implanted needles), the length of the verification process can
be significantly reduced, leaving the repeat CT to be used on
an as-needed basis, such as patients at risk of OAR overdos-
ing due to intrafractional organ motion.50
Safety
Staffing, Roles of Team Members, Training
Irrespective of whether a new GYN interstitial brachytherapy
program is being developed, new members are added to the
team, or if the team maintains status quo, it is important to
ensure that all team members receive the appropriate educa-
tion and training.48,51-54 Training should be performed when a
member is added to the team, new equipment is used, and at a
minimum, on an annual basis to ensure competency. Training
should include a review of the procedural workflow, radiation
safety, proper handling and operation of equipment (eg, appli-
cator(s)/needles, imaging systems, treatment planning system,
afterloader), detection of errors, and emergency procedures.
All procedural workflows should be documented in a policy
and procedures manual which is easily accessible to all team
members. In addition to review, scenario-based training such
as working through a mock implant using an end-to-end test
for an interstitial procedure or a mock safety emergency event
is highly recommended. Scenario-based trainings are most
effective if all care team members involved in a procedure (eg.,
physician, resident, physicist, nurse, radiation therapist) are
35
available to participate. For new programs, Thomadsen et al55
recommend training include a hands-on component, and team
members involved in radiotherapy decisions participate in a
minimum of 5 proctored cases before performing procedures
independently.
As AAPM TG-100 on failure modes and effects analysis
emphasizes, developing a prospective safety analysis of pro-
cedures is essential to develop a comprehensive QA program
beyond the technical safety checks. Mayadev et al56 have
published on the design, analysis, and implementation of
FMEA-based quality control procedures in brachytherapy.
MR Safety
Caution must be exercised when a patient with a brachyther-
apy implant undergoes an MRI due to the potential risk the
applicator may introduce to the neighboring tissues. Risks
include applicator movement or torque induced by the main
magnetic field, vibrations of the device due to the gradient
fields, and applicator heating that may be produced by the
gradient and radiofrequency fields.57 Additionally, image
artifacts and distortions may be produced in the vicinity of
the device. Commercial applicators are labeled by vendors in
1 of 3 classifications, MR unsafe, MR safe, and MR condi-
tional.58 As the name implies, MR unsafe devices pose a known
hazard in all MRI environments. These devices are typically
made of a ferromagnetic material. On the other hand, MR safe
devices present no known hazards in all MRI environments
(eg, nonconducting, nonmagnetic items). However, particular
caution should be applied to applicators labeled as MR-condi-
tional, as the device has demonstrated no known hazards but
under specific MR conditions. The conditional classification
can change if the MR environment is altered such as changing
the field strength, spatial gradient, radiofrequency fields, time
rate of change of the magnetic field, and/or the specific absorp-
tion rate.58
Challenges That Require Future
Development
Integration of MRI
As compared to CT, MRI has superior soft tissue contrast
that has resulted in its increased usage for the evaluation of
treatment response and contour delineation for treatment
planning. According to the ABS practice pattern survey, MRI
utilization with brachytherapy has increased from 2% in
2007 to 34% in 2014.59 Although MRIs have become more
accessible, few radiation oncology clinics have access to a
dedicated MR simulator. Location of the MRI relative to radi-
ation oncology and scheduling constraints, as well as reim-
bursements can hinder the full integration of MRI into the
brachytherapy workflow. With time, MRI may become as
ubiquitous as CT in radiation oncology clinics. However,
until that time, early scheduling and continued communica-
tion with outside departments overseeing the use MRIs is
essential.
36
Coordination and Communication Among
the Care Team
Interstitial GYN brachytherapy often requires the coordina-
tion of care between multiple divisions/departments. When
developing or modifying the planned clinical workflow, it is
imperative to invite representatives from all members of the
care team to provide input, as well as feedback on sugges-
tions. Additionally, continued communication among the
care team is important. This can be challenging during the
procedure, so establishing contacts in advance is important.
Additionally, identifying a point person within the brachy-
therapy team in advance to work with the contacts in other
divisions/departments may assist in reducing delays on the
date of the procedure.
Strategies to Reduce Planning Timeframe
Due to the time-intensive nature of interstitial brachytherapy,
tools to reduce the planning timeframe could improve the
overall treatment efficiency and quality. These interventions
could occur at any of the planning steps and include: autoseg-
mentation, more robust applicator(s)/needle identification
tools, autoplanning or knowledge-based planning, paralleliza-
tion of workflows, and plan verification.
Automation of planning could improve the quality and effi-
ciency of interstitial brachytherapy in addition to providing an
assessment of individual plan quality as compared to past
cases. While most examples of automated planning have been
for external beam therapy, there is the potential to apply
many elements of these techniques to brachytherapy planning
as has recently been done for prostate interstitial planning.60,61
Deep-learning methods have shown promise in segmenting
the bladder and rectum62 but more development is needed
before these can be extended to organs with variable anatomi-
cal presentation such as the bowel. At present, deep-learning
or artificial intelligence (AI) is still in research development.
Before AI-based technology is implemented in the clinic, it
must be carefully validated across multiple institutions and
patient cohorts to avoid the introduction of bias in decision-
making.63 While current planning systems are capable of nee-
dle digitization, these tools often fail when needles intersect or
when the contrast between the needles and surrounding tissue
decreases (ie, in MRI or for plastic catheters). Improving the
robustness of these algorithms,64 in addition to enabling auto-
mated catheter/needle selection65 for dose optimization could
greatly enhance efficiency. Tools that automatically select cath-
eters/needles for loading and estimate the dwell times would
be especially useful if they could generate plans that were
robust to intra- or interfraction motion on the order of that
typically encountered during the course of treatment.50
Although knowledge-based planning has yet to be applied to
brachytherapy, it has the potential to benefit interstitial HDR
planning. For example, high-dose volumes are a function of
implant geometry and comparison to the best achievable plan
in past cases with similar geometry could provide added
assurance regarding this metric.
The ability to parallelize the various elements of the treat-
ment planning workflow (ie, contouring and applicator
J.I. Prisciandaro et al.
reconstruction) would improve efficiency. For example, Dam-
ato et al demonstrated that parallelizing target/OAR delinea-
tion with needle digitization could significantly reduce the
overall procedure time.66 Finally, automation of planning veri-
fication and quality assurance processes could also help to
standardize planning while improving efficiency.67
Conclusions
Interstitial GYN brachytherapy is a complex, time and resource
intensive process. To establish a successful program, the team
members require procedure-specific training, technical exper-
tise, and a sufficient caseload to maintain competency. This
manuscript reflects a summary of clinical practice from 3 aca-
demic institutions, which on average perform 1-2 interstitial
brachytherapy case per month. The intent of interstitial GYN
brachytherapy across all 3 sites is the delivery of volume-based
treatment plans that achieve at least 90% target volume cover-
age by the prescription dose while maintaining OAR constraints
per GEC-ESTRO and EMBRACE protocol recommendations.
To safely achieve this goal, communication is imperative. All
key members of the care team need to be consulted to discuss
their role, develop policies and procedures, establish a clinical
workflow, and for periodic program updates. The 3 treating
sites have found value in performing dry runs before introduc-
ing a change in their workflow. Additionally, routine check-ins
with team members (eg, a brachytherapy huddle) may prove
valuable in identifying and discussing program needs and
resolving potential issues.
For clinics considering the addition of interstitial GYN
brachytherapy, the treating sites recommend reaching out to
an experienced team. If a clinic is unable to dedicate the time
and resources needed to establish a safe interstitial GYN
practice, the center should refer patients to a tertiary institu-
tion that is equipped to treat complex brachytherapy cases.
Implementation of interstitial GYN brachytherapy varies
among institutions depending on the available equipment
and resources. Clinics planning to initiate an interstitial GYN
brachytherapy program should tailor the implementation to
match their equipment and departmental workflows.
Acknowledgment
The authors would like to thank Dr Jacqueline Zoberi for her
contributions, discussions, and feedback on the initial draft
of this manuscript.
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