Dosimetric impact of applicator displacement on three-dimensional image-guided high-dose-rate brachytherapy treatments for cervical cancer

Purpose: To determine the dosimetric impact of brachytherapy applicator displacement during intracavitary (IC) and combined intracavitary/interstitial (IC/IS) high-dose-rate brachytherapy in the treatment of cervical cancer. Material and methods: Data from 27 consecutively treated patients undergoing IC or IC/IS high-dose-rate brachytherapy with tandem and ovoid-based applicators at a single academic medical center were analyzed. Virtual applicator displacements (a single shift of whole applicator with tandem/ovoid/associated needles) of 0 (clinical position), 2, 5, 7, and 10 mm in the inferior direction were modeled on treatment planning CT or MRI scans, with maintaining the same dwell times. Radiation dose to target volumes (D₉₀ of high-risk clinical target volume) and organs at risk (OARs) (D_0.1cc, D_1cc, and D_2cc of bladder, rectum, and sigmoid) were calculated for each virtual applicator shift, and significance of displacements was assessed using general linear model and Kruskal-Wallis test. Results: Mean dose to high-risk clinical target volume (HR-CTV) D₉₀ was 95.7%, 88.9%, 84.6%, and 77.1% of the prescribed dose in clinical position with displacements of 2, 5, 7, and 10 mm, respectively. Rectal D_2cc significantly increased by 28% and 44% at displacement of 7 mm and 10 mm, respectively. IC/IS cases showed relatively greater dosimetric differences than IC cases, with HR-CTV D₉₀ doses of 94.4%, 85.8%, 80.4%, and 72.4% at virtual displacements of 2, 5, 7, and 10 mm, respectively. Conclusions: Applicator displacements of 5 mm or greater result in statistically significant and clinically meaningful decreases in radiation dose to HR-CTV during 3-dimensional high-dose-rate brachytherapy treatment planning, with corresponding increase in radiation dose to the rectum. IC/IS applicator displacements lead to relatively greater differences than those of IC applicators.