Radiation Oncology

Technical Article Journal of Medical Imaging and Radiation Oncology (2008) 52, 77–84

Ultrasound-based conformal planning for

gynaecological brachytherapy
S van Dyk1 and D Bernshaw2
1
Radiation Therapy Services and 2Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

SUMMARY
This report describes the evolving use of transabdominal ultrasound (TAUS) as an imaging tool to verify tandem
placement, localize the treatment volume and aid conformal brachytherapy planning for both cervical and uterine
corpus cancers. Two patients, one with cancer of the cervix and one with cancer of the endometrium, are used as
examples to illustrate the advantages of using TAUS. TAUS is used to guide applicator insertion and check the
applicator in the treatment position. The dimensions of the uterus are recorded. Brachytherapy isodose plans are
generated based on these measurements. Confirmation of uterine dimensions and isodose coverage is obtained
using MRI taken after the initial fraction of treatment has been delivered. We illustrate how TAUS is successfully
used to correct and verify tandem placement after the patient has been moved from insertion to treatment posi-
tion. We also show how to use TAUS for conformal planning, based on individually derived target dimensions.
TAUS has successfully been used to conformally plan treatment to the uterus and cervix, minimizing brachytherapy-
related toxicity to surrounding structures. Ultrasound is portable, inexpensive and simple to use and allows for
accurate, conformal, reproducible and adaptive treatments.

Key words: bracytherapy; cervical cancer; conformal planning; ultrasound.

INTRODUCTION formation, pain and pelvic discomfort. Detection of perforations

Intracavitary brachytherapy (BT) is an integral part of treatment for
cancer of the cervix.1 Its efficacy and success are attributable to its
ability to deliver high doses of radiation to a localized area, with
relative sparing of adjacent normal tissues. Success of the treat-
ments rests on the accurate placement of the applicators in relation
to the surrounding anatomy and to each other.2,3 Historically, appli-
cations have largely relied on standard insertion techniques, but
less than ideal placements and difficult insertions have led many
practitioners to use various imaging methods for confirmation of
tandem placement. These include transabdominal ultrasound
(TAUS), transvaginal ultrasound (US), transrectal US, CT, MRI
and surgical interventions such as laparotomy and laparoscopy.
The emphasis has largely been on detecting uterine perforations
and myometrial penetrations to avoid unnecessary acute physical
side-effects of treatment such as bleeding, infection or abscess
also minimizes the chances of radiation-induced complications
to surrounding tissues such as enteritis, fistulas and necrosis.4
The use of intraoperative TAUS has been described by a num-
ber of authors, giving detailed explanations of the technique used
and emphasizing the ability to view the uterus and tandem ade-
quately.5 The main purpose of use has been to evaluate the
position of the tandem within the uterus and to use US to guide
the repositioning of a suboptimal implant. At the Peter MacCallum
Cancer Centre, TAUS has been used for 20 years for similar
reasons. Past practice has been to sound the uterus, dilate the
cervix and insert the tandem under US guidance. The position of
the tandem within the pelvis was then assessed with fluoroscopy
before orthogonal X-rays were taken for planning purposes.
More recently, our protocol makes use of a number of differ-
ent imaging methods, such as MRI and TAUS. These imaging

S van Dyk Dip App Sci MIR; D Bernshaw MRACP, FRANZCR.

Correspondence: Ms. Sylvia van Dyk, St Andrews Place, East Melbourne, Vic. 3002, Australia. Email: sylvia.vandyk@petermac.org
Conflict of interest: None.
Submitted 21 April 2007; accepted 6 May 2007.
doi: 10.1111/j.1440-1673.2007.01917.x

ª 2008 The Authors

Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
78
methods assist with applicator positioning, target localization and
definition and conformal treatment planning, and the protocol is
constantly evolving to make better use of these methods. The
ability to establish, in real time, the correlation of the tandem
within the target organ and to successfully determine the size
and shape of the uterus, in conjunction with the use of a high
dose rate (HDR) stepping source treatment system, has influ-
enced significantly our practice of BT. The HDR treatment sys-
tem was introduced into our department in 1998. The advantages
of HDR stepping source delivery,6 coupled with advances in
imaging and target definition and the potential for decreased
7
toxicity, led us to change the method of cervix treatment ex-
clusively to HDR in 2002. This report provides an overview of
US-assisted insertion, conformal planning and verification for
patients undergoing HDR intracavitary BT.
MATERIALS AND METHODS
The BT protocol consists of five fractions of HDR BT following
the completion of external beam radiotherapy (EBRT) with con-
8
current chemotherapy. This is to take advantage of the effects
of chemoradiotherapy on the tumour volume, in particular
tumour shrinkage, enabling consistent and reproducible inser-
tion of the applicator.9 When HDR treatment was introduced,
10
cervix BT was based on ‘standard’ Manchester-type planning.
A library set of plans simulating Manchester loadings was
developed for each tandem and ovoid combination and stored
in the PLATO planning system (Nucletron, Veenendal, the
Netherlands). The dose was prescribed to point A and doses
to bladder and rectum were assessed according to International
Commission of Radiological Units and Measurements (ICRU)
report 38 recommendations.11 TAUS has been used since 1986
to assist with viewing of the uterine canal, cervical dilatation and
to avoid uterine and myometrial perforations. Since the acqui-
sition of MRI-compatible applicators in 2000, MRI images have
been taken immediately after delivery of the first fraction of
treatment. The images obtained were used to optimize the BT
plan for the subsequent four fractions. In 2003, based on our
observation that uterine body measurements in relation to the
tandem could be obtained using TAUS, we commenced the
assessment of the use of TAUS-based measurements as part
of an US image-based conformal planning protocol. Although
US cannot image the gastrointestinal structures adjacent to the
uterus, it provides excellent view of the size and shape of the
uterus and the filled bladder. We have found this information to
be extremely useful in assessing the suitability of the initial plan
for a given individual and believe this information can potentially
contribute to a reduction in treatment toxicity. We continue to
obtain MRI scans following the first insertion for absolute con-
firmation of tumour location and also to confirm the correlation
of the applicators to cervical, uterine, vesical and gastrointesti-
nal structures. No replanning is carried out at the subsequent
applications unless a change in the correlation between the
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
S VAN DYK AND D BERNSHAW
patient’s anatomy and the applicator system has been detected
clinically or on US imaging.
Brachytherapy application procedure
It is our preference that patients are anaesthetized using spinal
anaesthesia during the first BT insertion because of the time
needed to obtain the MRI images. The patient’s legs are sup-
ported in lithotomy position for applicator insertion. An examin-
ation under anaesthesia is carried out to assess response,
remaining tumour anatomy as well as upper vaginal size to deter-
mine the choice of vaginal ovoid size. A urinary catheter is
inserted, the balloon filled with 7 ml diluted contrast and posi-
tioned against the bladder neck and the bladder filled with up
to 300 ml of sterile saline. The uterus is sounded under TAUS
control (Falcon, BK-medical, Hervel, Denmark, 2.7–5.0 MHz
transabdominal transducer; BK-medical Falcon, Denmark) to
ascertain the required length of the tandem and the cervical canal
is dilated. Magnetic resonance imaging-compatible tandems
(Nucletron) are available in 40, 50 and 60 mm lengths and ovoids
in 2.0, 2.5 and 3.0 cm diameters. The selected tandem is inserted
under TAUS guidance and the ovoids and vaginal spatula are
inserted. Vaginal packing using radiopaque gauze moistened with
1% chlorhexidine obstetric examination cream is inserted to dis-
place the rectum and bladder away from the applicator system.
Imaging X-ray, US and MRI
Following applicator placement and packing, the patient’s legs are
lowered and the patient is rescanned. If the tandem is not found to
be centred in the uterus on sagittal and axial US imaging, it is man-
ually manipulated until the best position possible is obtained.
Orthogonal radiographs, taken in the treatment position, define
the tandem position within the pelvis but do not define the tandem
position within the uterus. This can only be achieved using US, CT
or MRI sectional imaging.12–16 Dimensions of the uterus and cervix
are recorded to generate an US-based conformal plan. After US
imaging, the bladder is drained and the implant is screened using
fluoroscopy to record the tandem position within the bony pelvis.
Isocentric radiographs are taken at 0
and 90
. These images are
required to assess the radiological quality of the implant,17 that is, the
geometry of the applicators in relation to each other and bony anat-
omy and for digitizing the implant geometry into the PLATO planning
system. Before the introduction of the image-based BT, a radiolog-
ically ‘ideal’ implant4 was considered to be where the tandem was
positioned half-way between the symphysis pubis and the sacrum
and well oriented in the sagittal midline with no lateral deviation. With
the introduction of MRI and now TAUS, it has become clear that this
position does not necessarily ensure the optimum correlation
between the uterus and tandem. It is necessary to confirm and
optimize this correlation as it defines the success and quality of
the implant in terms of local control and morbidity.18
During the first implant only, the applicator is sutured to the
patient’s perineum to minimize movement of the system during
ª 2008 The Authors
ULTRASOUND BASED BRACHYTHERAPY
transfer to the MRI scanner (SignaLX 1.5, General Electric Med-
ical Systems, Milwaukee, WI, USA). The first fraction is planned
based on the US-derived dimensions of the uterus and cervix.
After the first treatment, the patient is transferred from the
operating theatre to the MRI scanner for imaging with the appli-
cator in situ. Axial, sagittal and coronal image sets are taken per-
pendicular to the body axis with a slice thickness of 5 mm and no
interslice gap using a torso coil, fast spin echo and T2-weighted
images. The axial images are sent to the planning computer by
DICOM transfer. These images form the basis of a 3-D MRI-based
treatment-planning protocol currently under development.
First BT insertion
TAUS is used to ensure that the tandem is centred within the
uterus and to obtain tandem to uterine surface measurements
in the sagittal and transverse planes. These measurements are
used to design the plan for the first fraction of treatment and
define the target volume. The BT target volume is determined
by assessing the initial tumour volume and extension, as seen
on pretreatment MRI and positron emission tomography scans,
in conjunction with the clinical examination and US dimensions
of the uterus and cervix at the time of insertion. A library plan
using the nominated tandem length and ovoid diameter is
retrieved from the planning computer and renamed for the
patient. The plan is modified by adjusting dwell positions, dwell
times and prescription points, to conform the isodose lines to
the size and shape of the target area as seen on US. The iso-
dose plot is printed to scale and, at present, manually overlaid
on the sagittal US image to check organ coverage. The plot is
also overlaid on the lateral X-ray film to calculate bladder and
rectal doses using ICRU-38-recommended dose points. If
these doses are assessed to be within tolerance of these
organs, prescribed treatment proceeds.
After the first treatment, MRI images are taken as described
above. Single coronal and sagittal images that best display the
tandem are printed with one magnified image per sheet of film.
With the current TAUS protocol, we have observed excellent
correlation of uterine size and shape between US and MRI.
A retrospective review of US-based and MRI-based planning
confirming the correlation has been completed and is being
prepared for publication.
Subsequent fractions
The applicator geometry is digitized from the orthogonal X-ray
films into the planning system. Points of interest are also digit-
ized from the films including ICRU-38 bladder and rectal points,
point A, point B, surface of ovoids and any pelvic nodal boost
points requested by the clinician. The dose, activity, dwell
weights, dwell positions and treatment time are entered as trea-
ted. The coronal and lateral isodose plots are printed at the
same magnification as the MRI images and manually overlaid
onto these images for evaluation.
ª 2008 The Authors
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
79
Detailed tumour response and size and location of any
residual tumour are assessed on the MRI scans, and the uter-
ine dimensions from US and MRI are compared. We have
been able to observe consistently good correlation between
these two imaging methods in terms of size and shape of
the uterus and cervix. Residual tumour and target volume
coverage are assessed on the MRI scans, as are doses to
the bladder, rectum, sigmoid colon and small bowel loops.
Adjustments to the plan in the form of dose sculpting may be
made to further reduce toxicity to surrounding structures if
target coverage permits. Dose normalization is made to the
100% isodose line describing the size and shape of the target
structure, rather than to standard points.19–23 Bladder and rec-
tal dose points are calculated and recorded according to
ICRU-38 recommendations. Total BT doses are summed
and extrapolated from the treatment plans used and the
implant position is reproduced for subsequent fractions with
TAUS. At our centre, logistics of cost, accessibility and time
limit the use of MRI to one or two fractions per patient. TAUS,
in contrast to MRI, is readily available and is used for each
implant.
External beam radiotherapy combined with BT
Brachytherapy, consisting of five fractions, with intent to
deliver 6 Gy per fraction to the BT target volume, com-
mences at the completion of EBRT. Total treatment time is
46–56 days. BT doses are reported as the physical dose
delivered.
It is assumed that the entire BT clinical volume receives 40–
45 Gy from the external beam component of treatment. Critical
structures are also presumed to have received 100% of the
external beam dose.
Total doses are based on the addition of EBRT and
BT doses using the linear quadratic formula to calculate the
biologically equivalent doses (BED). BED are then reconverted
to equivalent doses as if given as fractionated irradiation at
2 Gy per fraction.24 Total doses to target volume and point
A are recorded in terms assuming a/b10 early response and
a/b3 late response, whereas critical structures are recorded
as a/b3 alone.
The desired target volume dose is 80 Gya/b10 to 94 Gya/b3.
Critical structure dose tolerance is 70–75% of target dose.
RESULTS
Routine use of TAUS permits safe and accurate placement of the
treatment catheters, as illustrated in the following case studies.
The distinctive dimensions and shape of each patient’s cervix
and uterus were noted and individualized plans were designed
based on these measurements. TAUS was used to reproduce
tandem placement in subsequent insertions using the initial
study as a reference.
80 S VAN DYK AND D BERNSHAW

Patient studies
Patient 1
This case shows problems associated with treatment of car-
cinoma of the endometrium and eccentric placement of the
tandem in the pelvis.
A 70-year-old patient was diagnosed with International Fed-
eration of Gynaecology and Obstetrics stage 1, poorly differ-
entiated carcinoma of the endometrium. Hysterectomy was
recommended but was declined by the patient on religious
grounds. The patient was treated with 40 Gy EBRT to the
whole pelvis over 4 weeks, with concurrent chemotherapy
(carboplatinum) given weekly. Following completion of EBRT,
she commenced BT, five fractions treated twice weekly. The
tandem was inserted under US guidance (Fig. 1a). The uterine
dimensions were measured in the axial and sagittal planes and
used to derive the treatment plan. The patient’s legs were low-
ered for treatment and orthogonal X-rays were taken. These
showed ideal placement of the tandem within the bony pelvis
(Fig. 1b). During this period, TAUS was not used to assess the
intrauterine position of the tandem after the patient’s legs were
lowered for treatment. Post-treatment MRI imaging confirmed
the size and shape of the uterus as measured on US but
showed malplacement of the tandem in the uterus (Fig. 1c).
At the following insertion, TAUS was used both at the time of
insertion and after the patient’s legs had been lowered to the
treatment position. The tandem was manipulated under US
guidance, until it was seen to be well centred in the uterus in
both the axial and sagittal planes (Fig. 1d). The tandem is seen
to be quite posterior on X-ray as it has been ‘relaxed’ into the
centre of the uterus under US guidance rather than being
forced into the ideal radiological position (Fig. 1e). The X-ray
image shows a tandem positioned somewhat posterior to the
original insertion and, if viewed in isolation and according to
ideal placement criteria, could cause concern regarding possi-
ble overdose of the sigmoid colon. When viewed in conjunction
with the US and MRI images, we observed that the tandem was

Fig. 1. (a) Ultrasound image taken at the time of first insertion, used to determine size and shape of uterus to assist with planning. (b) Lateral X-ray
film showing ideal position of tandem in pelvis at first insertion. (c) Sagittal MRI image following first treatment. Note, anterior wall under considerable
traction. Iso-shape based on US measurements replicates target shape but is misplaced because of the position of the tandem within the uterus.
(d) US image taken with legs down in treatment position. Tandem well centred in the uterus. (e) Lateral film taken before second fraction. Position of
tandem is relaxed into uterus, based on US images. US, ultrasound. (f) Sagittal MRI image of second insertion. Well-centred tandem, sculpted isolines
shown are based on dimensions of the uterus acquired with US.

ª 2008 The Authors

Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
ULTRASOUND BASED BRACHYTHERAPY
well placed within the uterus and were reassured that the resul-
tant isodose coverage was well directed at the uterus and cer-
vix. Subsequent MRI imaging confirmed central tandem
placement and appropriateness of the conformal isodose cov-
erage as determined by US planning (Fig. 1f).
Patient 2
This case shows problems associated with the presence of
a small uterus and the use of dose sculpting to minimize toxicity
to surrounding structures.
The 70-year-old patient presented with postmenopausal
bleeding 3 months after a right hemicolectomy for poorly differ-
entiated caecal adenocarcinoma with negative nodes. The
diagnosis of FIGO stage 2A squamous cell cancer of the cervix
was made. The patient was treated with pelvic EBRT of 40 Gy
in 20 fractions over 4 weeks, with concurrent weekly cisplati-
num. BT followed EBRT. Because of concerns relating to her
previous surgery for caecal cancer and obstructive bowel
problems, the planned BT dose was reduced. The patient
received a total dose, (EBRT 1 BT), of 73 Gy10 to 82.8 Gy3
(2 Gy equivalent doses) to the BT target volume. Bladder and
rectal ICRU 38 points received 51 and 48 Gy3, respectively.
The tandem was inserted under US guidance, with the
patient in lithotomy position. After the patient’s legs were low-
ered to treatment position, she was rescanned with TAUS. The
uterus was found to be quite small, and uterine dimensions
were measured and recorded on film. The tandem was well
centred according to US (Fig. 2a). A treatment plan was
devised based on the US measurements. The X-ray shows
the tandem to be quite posterior and certainly not bisect-
ing the midplane of the pelvis (Fig. 2b). The MRI scan illustrates
the conformal nature of the iso-plan that was generated based
Fig. 2. (a) Ultrasound taken with the patient in treatment position (legs lowered flat on bed). Dimensions of uterus are taken in the sagittal and axial
planes and used to derive a treatment plan. (b) X-ray taken after US positioning of tandem. (c) Excellent correlation of uterine size and shape is seen
between the US-based plan and the MRI images. US, ultrasound.
ª 2008 The Authors
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
81
on US measurements (Fig. 2c). The excellent correlation
between the US and MRI uterine size and shape can also be
seen. Certainly, this patient’s bowel would have been in the
high-dose zone in the earlier era of standard Point A prescrip-
tion and dosimetry. In this case, use of US alerted us to the
small dimensions of her uterus and averted a possible overdose
to surrounding bowel.
DISCUSSION
US-based planning for intracavitary BT has been systematically
introduced into daily practice over a period of 3–5 years.
Improvements in US imaging have enabled us to include it as
part of our image-based BT protocol. Magnetic resonance
imaging images taken before treatment and at the first BT inser-
tion have been routinely used to assess tumour response to
chemoradiation since 2000. The use of MRI has also gradually
evolved to incorporate treatment planning and evaluation of BT
isodose coverage. When a number of MRI images showed less
than ideal placements of the tandem, a solution that gave real-
time images at the time of insertion and treatment was sought.
US, which was being used to avoid perforation at the time of
tandem insertion, was further used to check tandem placement
once the patient was placed in the treatment position. This use
of US has been demonstrably successful in ensuring accurate
placement of the tandem within the uterus in the sagittal and
axial planes. Excellent image quality has ensured that the uter-
ine size and shape is clearly seen and enables the isodose plan
to be based on the dimensions of the uterus and cervix. The
US-based plans, later evaluated in comparison with the MRI
images, show excellent correlation between target volume
coverage and surrounding tissue sparing. Replanning based
on MRI imaging is minimal and rarely necessary.
82
Ultrasound is also used to reproduce the target applicator
correlation for subsequent insertions. At present, US is largely
used in an ‘image-guided’ fashion. The images are used to im-
plement the original treatment plan. As the use, understanding
and technology evolves, US is anticipated to play a significant
role in the evolution of adaptive BT treatments.
The use of US to assist radiotherapy treatment planning has
25
been reported as early as 1973 by Brascho. Whereas most of
the discussion was concerned with the use of US to acquire
anatomical information for developing optimized EBRT plans,
Brascho also commented on the usefulness of US in planning
BT for uterine or cervical tumours. Brascho’s prediction that
diagnostic US examinations would become a standard method
of obtaining anatomical information for radiation therapy plan-
ning has not quite eventuated. However, some of his other
predictions, although not in widespread use, deserve some
acknowledgement and encouragement, particularly those in
gynaecological BT. Brascho postulated that the use of serial
US scans throughout treatment may allow adjustment of radi-
ation fields as tumour-size changes. This vision was a precursor
to the image-guided adaptive treatments that we are pursuing
with our own use of US-guided planning and treatment.
Overall, the use of US published studies has largely been
5,26,27
concerned with accurate tandem placement. Ultrasound
has been described for use in planning but mainly in reference
to BT for endometrial cancer. In 1975, Wenzel reported improved
radiotherapy dose calculations using US uterine localization.
Wenzel described using US to reliably measure the dimensions
of the uterus, which were then transposed to the radiographs,
enabling accurate dosimetry to be calculated on the serosal sur-
face.28 In 1978, Brascho et al. reported use of TAUS in planning
intracavitary radiotherapy for endometrial carcinoma. The bene-
fits and recommendations in that paper well describe the current
rationale for using US in cervix BT. TAUS gives information about
the uterine and cervical size and shape and the implied correla-
tion to other pelvic organs. Routine US examination after appli-
cator insertion can detect poorly positioned applicators and allow
corrective action to be taken. Brascho et al. concluded that TAUS
is a simple and reliable method of obtaining precise anatomical
information regarding uterine size, shape and relative position to
the bladder and rectum. This information is the key to individual-
ized treatment planning for intracavitary radiation and should be
reflected in better clinical results.29 The use of US for planning BT
endometrial treatment has been reported periodically by a number
of authors; all report the value of using US in determining the
dimensions of the target area and limiting dose to this area, thus
sparing surrounding tissues and reducing the risk of radiation
side-effects.30,31,32,33
The use of US for specifically planning intracavitary cervix
treatment is less reported. Barillot et al. describe using US to
assess bladder doses for comparison with ICRU 38 reference
calculations in cervix patients since 1990. Use of US was con-
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
S VAN DYK AND D BERNSHAW
fined to assessing the doses observed at the bladder wall.34 Mayr
et al. report using US to guide implant placements in 17 patients
with a retroverted uterus. Ultrasound was not used to plan treat-
ment but rather to aid and ensure safe tandem placement.35
There do not appear to be any other reports referring to the
use of US as a planning and treatment aid for intracavitary
cervical BT.
We have found TAUS to be extremely useful in dealing with
situations that can compromise tandem insertion. Such situa-
tions include a retroverted uterus, stenosed, fibrosed or dis-
torted cervix, scar tissue after EBRT and a necrotic friable
cervix and uterus following EBRT. TAUS has also been bene-
ficial in detecting poor tandem placement as a result of uneven
tumour shrinkage, the presence of fibroids or an off-centred
uterus. All these situations can result in less than ideal placement
of the tandem and undesirable dose deposition in surrounding
critical structures. The unpredictability of small bowel and colon
late sequelae in historical series may well be attributable to the
effects of these situations on the overall dosimetry.36
Historically, the limitations of TAUS were often stated as
poor image quality in certain settings. These settings include
gas in the bowel, obesity and inadequate view of the fundus of
the uterus. Gas in the bowel can be overcome by better bowel
preparation, and fundal imaging can be improved with adequate
bladder filling and experienced sonographer technique. Current
generation US scanners are far superior to previous genera-
tions in both image quality and image handling and are routinely
used in the gynaecological diagnostic setting.37 The obese
patient is better managed and imaged with the newer and more
sophisticated equipment. In our experience, US BT planning
and treatment has never been compromised by a large body
habitus.
Irvin et al. in an excellent discussion on uterine perforations
state that ‘.although ultrasound provides excellent visualisa-
tion of the tandem, uterus and urinary bladder.it is unable to
demonstrate the anatomical relationship of the tandem to adja-
cent structures such as colon and small intestines’.4 Although it
is true that the sigmoid colon cannot be seen, an excellent view
of the tandem within the uterus allows dose shaping and sculpt-
ing to be carried out by conforming the isolines to the uterine
surface, thereby limiting dose to any surrounding structures to
acceptable tolerances. In fact, the information derived from all
imaging methods, TAUS, CT and MRI, regarding small bowel
can be used in a similar way. If the uterus is clearly seen (as is
possible on all three methods), then dose sculpting to the size
and shape of the uterus can prevent excessive toxicity to all
surrounding structures.
The benefit of using TAUS is that imaging and planning can
take place at the time of the insertion whether it is in the theatre
or the BT suite. TAUS can also be used to confirm the tandem
position within the uterus by scanning just before the com-
mencement of treatment. The accessibility of TAUS, along
ª 2008 The Authors
ULTRASOUND BASED BRACHYTHERAPY
with ease of use, makes incorporating it into a gynaecological
BT programme feasible. TAUS enables conformal planning and
its greatest contribution to gynaecological BT may well be the
reduction in toxicity so long associated with intracavitary BT.
The benefits for departments and countries that bear a large
burden of patients diagnosed with cervix cancer, such as those
in the developing world, are immense. Use of TAUS is simple,
cost-effective and efficient. The BT procedure is not unduly
lengthened while planning with TAUS. The greatest potential
of TAUS is its ability to enable the physician to ‘see’ while plac-
ing the applicator and to assess the dosimetric coverage to the
target area and the surrounding structures, both at the time of
insertion and treatment.
CONCLUSION
TAUS has been successfully incorporated into our planning and
treatment protocol for intracavitary BT. We are routinely using
US imaging to conformally plan the first BT insertion. TAUS is
also used as a daily verification tool to confirm tandem place-
ment within the uterus, to confirm the position of the tandem in
relation to the bladder neck and to verify the size and shape of
the uterus at each treatment.
The use of standard planning to point A and standard critical
structure doses based on ICRU 38 have been widely com-
mented on in published studies. Certainly, the prevailing trend
is to recognize the limitations of these systems in the era of 3-D
planning and imaging and to suggest ways to implement more
individually based planning.13,21,22,28,38 The gold standard in
tumour delineation and applicator positioning is MRI, but the
reality for the majority of treatment centres around the world
20,39,40
is that access to MRI is limited and expensive. Ultrasound
is proving to be a viable asset in conjunction with MRI and may
yet prove to be a limited but satisfactory alternative imaging tool
in the absence of MRI. It is portable, inexpensive and simple to
use. The applicator position can be checked both at the time of
insertion and treatment. TAUS enables conformal BT that is
shaped to the individual cervical and uterine dimensions and
spares surrounding structures. Ultrasound in combination with
an HDR treatment system can form the basis of an accurate,
reproducible, adaptive treatment protocol that is accessible and
economically viable for most radiotherapy departments.
REFERENCES
1. Lanciano RM, Won M, Coia LR, Hanks GE. Pretreatment and
treatment factors associated with improved outcome in squamous
cell carcinoma of the uterine cervix: a final report of the 1973 and
1978 patterns of care studies. Int J Radiat Oncol Biol Phys 1991;
20: 667–76.
2. Fletcher GH. Text Book of Radiotherapy, 3rd edn. Lea and
Febiger, Philadelphia, PA, 1980.
3. Corn BW, Galvin JM, Soffen EM, Henze G, Schwaibold F. Positional
stability of sources during low-dose-rate brachytherapy for cervical
carcinoma. Int J Radiat Oncol Biol Phys 1993; 26: 513–8.
ª 2008 The Authors
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
83
4. Irvin W, Rice L, Taylor P, Andersen W, Schneider B. Uterine per-
foration at the time of brachytherapy for carcinoma of the cervix.
Gynecol Oncol 2003; 90: 113–22.
5. McGinn CJ, Stitt JA, Buchler DA, Kinsella TJ. Intraoperative ultra-
sound guidance during high dose rate intracavitary brachytherapy
of the uterine cervix and corpus. Endocurietherapy Hyperthermia
Oncol 1992; 8: 101–4.
6. Houdek PV, Schwade JG, Abitbol AA et al. Optimization of high
dose-rate cervix brachytherapy. Part I: dose distribution. Int J
Radiat Oncol Biol Phys 1991; 21: 1621–5.
7. Orton CG, Seyedsadr M, Somnay A. Comparison of high and low
dose rate remote afterloading for cervix cancer and the importance
of fractionation. Int J Radiat Oncol Biol Phys 1991; 21: 1425–34.
8. Allen D, Narayan K. Managing advanced-stage cervical cancer.
Best Pract Res Clin Obstet Gynaecol 2005; 19: 591–609.
9. Lee CM, Shrieve DC, Gaffney DK. Rapid involution and mobility of
carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2004; 58:
625–30.
10. Tod M, Meredith W. Treatment of cancer of the cervix uteri –
a revised ‘‘Manchester method’’. Br J Radiol 1953; XXVI: 252–7.
11. International commission on radiation units and measurements.
ICRU Report 38 Dose and volume specification for reporting intra-
cavitary therapy in gynecology. 1985.
12. Fellner C, Potter R, Knocke TH, Wambersie A. Comparison of
radiography- and computed tomography-based treatment plan-
ning in cervix cancer in brachytherapy with specific attention to
some quality assurance aspects. Radiother Oncol 2001; 58: 53–62.
13. Schoeppel SL, Ellis JH, LaVigne ML, Schea RA, Roberts JA.
Magnetic resonance imaging during intracavitary gynecologic
brachytherapy. Int J Radiat Oncol Biol Phys 1992; 23: 169–74.
14. Tardivon AA, Kinkel K, Lartigau E, Masselot J, Gerbaulet AP,
Vanel D. MR imaging during intracavitary brachytherapy of vaginal
and cervical cancer: preliminary results. Radiographics 1996; 16:
1363–70.
15. Wachter-Gerstner N, Wachter S, Reinstadler E, Fellner C,
Knocke TH, Potter R. The impact of sectional imaging on dose
escalation in endocavitary HDR-brachytherapy of cervical
cancer: results of a prospective comparative trial. Radiother
Oncol 2003; 68: 51–9.
16. Krempien RC, Daeuber S, Hensley FW, Wannenmacher M,
Harms W. Image fusion of CT and MRI data enables improved
target volume definition in 3D-brachytherapy treatment planning.
Brachytherapy 2003; 2: 164–71.
17. Unal A, Hamberger AD, Seski JC, Fletcher GH. An analysis of the
severe complications of irradiation of carcinoma of the uterine
cervix: treatment with intracavitary radium and parametrial irradi-
ation. Int J Radiat Oncol Biol Phys 1981; 7: 999–1004.
18. Corn BW, Hanlon AL, Pajak TF, Owen J, Hanks GE. Technically
accurate intracavitary insertions improve pelvic control and sur-
vival among patients with locally advanced carcinoma of the uter-
ine cervix. Gynecol Oncol 1994; 53: 294–300.
19. Petereit DG, Fowler JF. High-dose-rate brachytherapy. High-
dose, high-tech, and high results. Int J Radiat Oncol Biol Phys
2003; 55: 1159–61.
20. Nag S, Cardenes H, Chang S et al. Proposed guidelines for image-
based intracavitary brachytherapy for cervical carcinoma: report
from Image-Guided Brachytherapy Working Group. Int J Radiat
Oncol Biol Phys 2004; 60: 1160–72.
21. Kim RY, Caranto JF, Pareek PN, Virostek LJ. Dynamics of pear-
shaped dimensions and volume of intracavitary brachytherapy
in cancer of the cervix: a desirable pear shape in the era of
84
three-dimensional treatment planning. Int J Radiat Oncol Biol Phys
1997; 37: 1193–9.
22. Decker WE, Erickson B, Albano K, Gillin M. Comparison of tradi-
tional low-dose-rate to optimized and nonoptimized high-dose-rate
tandem and ovoid dosimetry. Int J Radiat Oncol Biol Phys 2001;
50: 561–7.
23. Potter R, Van Limbergen E, Gerstner N, Wambersie A. Survey of
the use of the ICRU 38 in recording and reporting cervical cancer
brachytherapy. Radiother Oncol 2001; 58: 11–8.
24. Nag S, Gupta N. A simple method of obtaining equivalent doses
for use in HDR brachytherapy. Int J Radiat Oncol Biol Phys 2000;
46: 507–13.
25. Brascho DJ. Diagnostic ultrasound in radiation treatment planning.
J Clin Ultrasound 1973; 1: 320–29.
26. Granai CO, Doherty F, Allee P, Ball HG, Madoc-Jones H, Curry
SL. Ultrasound for diagnosing and preventing malplacement of
intrauterine tandems. Obstet Gynecol 1990; 75: 110–13.
27. Kim RY, Levy DS, Brascho DJ, Hatch KD. Uterine perforation
during intracavitary application. Prognostic significance in carcin-
oma of the cervix. Radiology 1983; 147: 249–51.
28. Wenzel WW. Improved radiotherapy dose calculations using ultra-
sound uterine localization. J Clin Ultrasound 1975; 3: 311–12.
29. Brascho DJ, Kim RY, Wilson EE. Use of ultrasonography in
planning intracavitary radiotherapy of endometrial carcinoma.
Radiology 1978; 129: 163–7.
30. Englemeier KH, Hecker R, Hotzinger H, Thiel H. Automatic con-
tour search and segmentation of sonographic transverse sectional
pictures of the uterus with regard to optimisation of individual isodose
planning in uterine cancer. Strahlentherapie 1985; 161: 275–80.
31. Gunter HH, Degenhardt F. Ultrasound studies in afterloading ther-
apy of uterine malignancy. Ultraschall Med 1995; 16: 162–6.
Journal compilation ª 2008 The Royal Australian and New Zealand College of Radiologists
S VAN DYK AND D BERNSHAW
32. Chun M, Ball HG, Doherty F, Tercilla OF, Madoc-Jones H, Curry
SL. Uterine thickness determination using real-time ultrasonogra-
phy: a guide for intracavitary brachytherapy in the treatment of
endometrial carcinoma. Gynecol Oncol 1990; 36: 176–80.
33. Nguyen TV, Petereit DG. High-dose-rate brachytherapy for med-
ically inoperable stage I endometrial cancer. Gynecol Oncol 1998;
71: 196–203.
34. Barillot I, Horiot JC, Maingon P, Bone-Lepinoy MC, Vaillant D,
Feutray S. Maximum and mean bladder dose defined from ultra-
sonography. Comparison with the ICRU reference in gynaecolog-
ical brachytherapy. Radiother Oncol 1994; 30: 231–8.
35. Mayr NA, Montebello JF, Sorosky JI et al. Brachytherapy manage-
ment of the retroverted uterus using ultrasound-guided implant
applicator placement. Brachytherapy 2005; 4: 24–9.
36. Barillot I, Horiot JC, Maingon P et al. Impact on treatment outcome
and late effects of customized treatment planning in cervix
carcinomas: baseline results to compare new strategies. Int J
Radiat Oncol Biol Phys 2000; 48: 189–200.
37. Fleischer AC. Gynecologic sonography: past, present, and future.
J Ultrasound Med 2003; 22: 759–63.
38. Kim R, Pareek P. Radiography-based treatment planning com-
pared with computed tomography (CT)-based treatment planning
for intracavitary brachytherapy in cancer of the cervix: analysis of
dose-volume histograms. Brachytherapy 2003; 2: 200–206.
39. Erickson BA. The sculpted pear: an unfinished brachytherapy tale.
Brachytherapy 2003; 2: 189–99.
40. Haie-Meder C, Potter R, Van Limbergen E et al. Recommenda-
tions from Gynaecological (GYN) GEC-ESTRO Working Group (I):
concepts and terms in 3D image based 3D treatment planning in
cervix cancer brachytherapy with emphasis on MRI assessment of
GTV and CTV. Radiother Oncol 2005; 74: 235–45.
ª 2008 The Authors