Chapter 41

Brachytherapy for Gynecological Malignancies

John L. Horton, Ph.D. University of Texas M. D. Anderson Cancer Center Department of Radiation Physics Houston, Texas

Introduction
Brachytherapy for gynecological cancer has a long and successful history. Wickham treated cervical cancer with radium as early as 1906 and reported results for 1000 patients by 1913 (Janeway 1919). Today, intracavitary brachytherapy combined with megavoltage external beam therapy is the standard treatment for cervical cancer. Five-year disease free survival for patients with cervical cancer treated with radiation therapy ranges from 70% to 90% for FIGO stages I & II, 25% to 48% for stage III, and 5% to 34% for stage IV (Perez, Brady, and Halperin 2004). Eifel and colleagues reported in a retrospective study of 3489 patients with cervical cancer treated with radiation therapy, a 3.3% incidence of major late bladder complications, 3.2%, for rectum and 4.2%, for small bowel (Eifel et al. 2002). In this section we will review the anatomy of the female pelvis, various gynecological cancerous diseases, and the staging of these diseases. We will reexamine the past, discuss the present, and provide our predictions of the future of brachytherapy for gynecological cancers. The early treatment for gynecological malignancies was with radium. In the 1970s 137Cs was widely adopted as a radium substitute. Applicators evolved and manual afterloading of implants became the standard replacing preloaded applicators. Applicators now include templates for interstitial implants for vaginal, vulvar, and more advanced cervical disease. The initial radium treatments were low dose rate (LDR) treatments with the patient confined to the hospital. Today, the majority of patients continue to receive LDR treatments with 137Cs; however, there is a continuing increase in the percentage of outpatients receiving high dose rate (HDR) treatments with remote afterloader units. With recent changes in the U.S. Nuclear Regulatory Commission requirements for pulsed dose rate (PDR) remote afterloading units, more attention and consideration is being directed at PDR as a replacement for LDR 137Cs. Early treatments were performed following semi-empirically derived guidelines and standardized implant rules based on dosimetry calculations for idealized implants with doses determined at geometrically identified points on plane radiographs serving as surrogates for tumor and critical structure doses. The International Commission of Radiation Units and Measurements (ICRU) developed recommendations in an attempt to standardize the dose reporting for brachytherapy implants. Today, a remote afterloading unit with a stepping source provides the ability to achieve a higher degree of dose conformation to the target volume with computerized optimization of the treatment plan. Imaging is an essential component for any meaningful computerized optimization. Three-dimensional imaging with CT and/or MR is becoming evermore important in the evaluation and planning of implants. These topics are discussed in the following chapters.

References
Eifel, P., A. Jhingran, D. Bodurka, C. Levenback, and H. Thames. (2002). Correlation of smoking history and other patient characteristics with major complications of pelvic radiation therapy for cervical cancer. J Clin Oncol 20:36513657. Janeway, H. (1919). The treatment of uterine cancer by radium. Surg Gynecol Obstet 29:242265. Perez, C., L. Brady, and E. Halperin (eds.). Principles and Practice of Radiation Oncology. Philadelphia: Lippincott Williams and Wilkins, 2004.

783