PURPOSE To present issues to be considered in, and make proposals for, image-based brachytherapy for cervical cancer. METHODS AND MATERIALS The Image-Guided Brachytherapy Working Group, consisting of representatives from the Gynecology Oncology Group (GOG), Radiologic Physics Center (RPC), American Brachytherapy Society (ABS), American College of Radiology (ACR), American College of Radiology Imaging Network (ACRIN), American Association of Physicists in Medicine (AAPM), Radiation Therapy Oncology Group (RTOG), and American Society for Therapeutic Radiology and Oncology (ASTRO), proposed guidelines for image-based brachytherapy for cervical cancer. This report was based on their aggregate clinical experience and a review of the literature. It reflects only the personal opinions of the authors and is not meant to be an endorsement from any of the above organizations. RESULTS The Group recommended T(2)-weighted MRI using a pelvic surface coil with MRI-compatible brachytherapy applicators in place for image-based intracavitary brachytherapy for cervical cancer. Imaging must be performed with the patient in the treatment position, with all other treatment conditions duplicated as closely as possible. Future use of positron emission tomography or positron emission tomography/CT may obviate the need for special applicators. The group proposed the following terminology for image-based brachytherapy. The GTV((I)) is defined as the gross tumor volume as defined through imaging, GTV is defined as the GTV((I)) plus any clinically visualized or palpable tumor extensions, and GTV + cx is defined as the GTV plus the entire cervix. The dose-volume histograms (DVH) of the GTV, GTV((I)), GTV + cx should be performed, and the dose to 100%, 95%, or 90% of the GTV (D(100), D(95), and D(90), respectively) and the percentage of the GTV covered by Point A dose (V(100)) should be reported. Similarly, the DVH of the bladder and rectum wall should be performed, and the maximal dose at any point within the bladder and rectal wall should be reported, along with the maximal dose to a contiguous 1, 2, and 5 cm(3) volume of the bladder and rectum, respectively. In addition, the dose at the International Commission on Radiation Units and Measurements reference point for the bladder and rectum should be reported. The Group thought that the current dose prescription method in use for cervical cancer brachytherapy (i.e., to prescribe to Point A in most institutions) should not be changed as yet, because image-based dosimetry is not ready for routine practice. The Group proposes that for research purposes, individual centers and cooperative groups (e.g., GOG, RTOG, ACRIN) collect image-based dosimetry information and perform DVHs and correlate these data with the clinical outcome to determine which of the above parameters are relevant. The Group encourages external funding for image-based dosimetry and recommends that brachytherapy manufacturers develop image-compatible applicators. CONCLUSION Although current institutional brachytherapy prescription for cervical cancer should continue, image-based data collection and analysis are needed to optimize cervical cancer brachytherapy. Proposals are made for research in image-based brachytherapy for cervical cancer.
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