Problems in reporting doses and volumes during multiple high-dose-rate intracavitary brachytherapy for carcinoma cervix as per ICRU Report 38: a comparative study using flexible and rigid applicators

OBJECTIVE: The objective was to evaluate the extent of geometric and positional variations of two different applicators during multiple high-dose-rate (HDR) intracavitary brachytherapy (ICBT) in carcinoma cervix and its implication on reporting as per International Commission on Radiation Units and Measurement (ICRU) Report 38. METHODS: Fifty patients, following teletherapy, were randomly allocated to two groups of 25 each. They received a dose of 6 Gy to point A during each of the three HDR ICBT applications by either a flexible Ralstron or a rigid geometry Rotterdam applicator. The various applicator components related to its geometry and their Cartesian coordinates were evaluated from orthogonal films. The doses to ICRU bladder, rectal, pelvic, lymphatic trapezoid points, and dimensions of 6-Gy ICRU height, width, thickness, and volume were estimated for each application. RESULTS: Significant variation was observed with the three HDR ICBT applications for each group, for all components and for both applicators, although it was relatively more with the flexible Ralstron applicator. The average shift in each of the coordinates of os, uterine tip, and ovoids was around 10 mm for both groups. These resulted in significant variations in all the ICRU Report 38 reporting parameters for three insertions in any given patient and across 25 patients of both groups. CONCLUSIONS: Multiple HDR ICBT applications led to significant variation in the applicator geometry and its positions in pelvis, irrespective of the applicator rigidity. This results in uncertainties in reporting as per ICRU Report 38 guidelines, and thus calls for its revision.