The value of hybrid interstitial tandem and ring applicators for organ at risk dose reduction in small volume cervical cancer

Magnetic resonance imaging (MRI)-guided adaptive brachytherapy is the standard of care for cervical cancer. Hybrid intracavitary/interstitial applicators for bulky tumor (high-risk clinical target volume [HR-CTV] > 30 cc) dose escalation is recommended in the EMBRACE II trial. The value of hybrid applicators for smaller HR-CTV (< 30 cc) in organ at risk (OAR) sparing is less certain. Twenty-seven patients with FIGO stage I-IVA cervical cancer treated with definitive chemoradiation and MRI-based brachytherapy using conventional tandem and ring (TR) applicators were re-planned using virtual needles. They were then summed with the external beam dose to evaluate target coverage and OAR dose using EQD summation. Target and OAR dose with/without hybrid applicator use were compared. Eighty-one percent had HR-CTV volumes < 30 cc, for which, hybrid TR applicators had significantly lower mean D to all OARs without differences in target coverage. For HR-CTV < 30 cc, the bladder and rectal OAR goals per EMBRACE II were exceeded in significantly fewer patients with the hybrid TR applicators. No significant difference was found in the sigmoid D dose goal. In small volume tumors (< 30 cc), hybrid applicators may offer improved OAR sparing compared with conventional tandem and ring applicators, and may increase the proportion of patients meeting EMBRACE II OAR goals.