Treatment planning methodology for the Miami Multichannel Applicator following the American Brachytherapy Society recently published guidelines: the Lahey Clinic experience

The objective of this study was to develop a standardized procedure from simulation to treatment delivery for the multichannel Miami applicator, in order to increase planning consistency and reduce errors. A plan is generated prior to the 1st treatment using the CT images acquired with the applicator in place, and used for all 3 fractions. To confirm the application placement before each treatment fraction, an AP image is acquired and compared with the AP baseline image taken at simulation. A preplanning table is generated using the EBRT doses and is used to compute the maximum allowable D2cc for bladder, rectum, and sigmoid, and the mean allowable dose for the upper vaginal wall per HDR brachytherapy fraction. These data are used to establish the criteria for treatment planning dose optimization. A step-by-step treatment planning approach was developed to ensure appropriate coverage for the tumor (D90 > 100% prescribed dose of 700 cGy/fraction) and the uninvolved vaginal surface (dose for the entire treatment length > 600 cGy/fraction), while keeping the organs at risk below the tolerance doses. The equivalent dose 2 Gy (EQD2) tolerances for the critical structures are based on the American Brachytherapy Society (ABS) recently published guidelines. An independent second check is performed before the 1st treatment using an in-house Excel spreadsheet. This methodology was successfully applied for our first few cases. For these patients: the cumulative tumor dose was 74-79 EQD2 Gy10 (ABS recommended range 70-85); tumor D90 was >100% of prescribed dose (range 101%-105%); cumulative D2cc for bladder, rectum, and sigmoid were lower than the tolerances of 90, 75, and 75 EQD2 Gy3, respectively; cumulative upper vaginal wall mean dose was below the tolerance of 120 EQD2 Gy3; the second check agreement was within 5%. By using a standardized procedure the planning consistency was increased and all dosimetric criteria were met.