FIGO stage IB1 cervical carcinoma: Place and principles of brachytherapy

The treatment of cervical cancers according to FIGO staging is well defined. For FIGO stage IB2 or more, chemoradiotherapy followed by uterovaginal brachytherapy boost is the standard treatment. Surgery is the preferred choice for less advanced tumors. However, most French institutions propose preoperative brachytherapy followed by hysterectomy with pelvic lymphadenectomy for FIGO stage IB1 tumors over 2 cm. Brachytherapy is also used for the boost after adjuvant pelvic external beam radiotherapy. Tridimensional dosimetry with optimization allows better treatment planning, delivering high doses to target volumes with limited irradiation to the organs at risk. We will discuss the indications of brachytherapy for FIGO stage IB1 tumors and the principles of pulsed-dose rate and high-dose rate techniques.     

Combination external beam radiotherapy and high-dose-rate intracavitary brachytherapy for uterine cervical cancer: analysis of dose and fractionation schedule

PURPOSE: To determine an appropriate dose and fractionation schedule for a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT) for uterine cervical cancer. METHODS: Eighty-eight patients with uterine cervical squamous cell carcinoma treated with EBRT and HDR-ICBT were analyzed. Twenty-five patients were classified as early disease (nonbulky Stage I/II, less than 4-cm diameter) and 63 patients as advanced disease (greater than 4 cm diameter or Stage IIIB) according to the American Brachytherapy Society definition. Tumor diameter was measured by MRI. Pelvic EBRT was delivered before applications of ICBT. HDR-ICBT was performed once a week, with a fraction point A dose of 6 Gy. Source loadings corresponded to the Manchester System for uterine cervical cancer. No planned optimization was done. A Henschke-type applicator was mostly used (86%). Median cumulative biologic effective dose (BED) at point A (EBRT + ICBT) was 64.8 Gy(10) (range: 48-76.8 Gy(10)) for early disease, and 76.8 Gy(10) (range: 38.4-86.4 Gy(10)) for advanced disease. Median cumulative BED at ICRU 38 reference points (EBRT + ICBT) was 97.7 Gy(3) (range: 59.1-134.4 Gy(3)) at the rectum, 97.8 Gy(3) (range: 54.6-130.4 Gy(3)) at the bladder, and 324 Gy(3) (range: 185.5-618 Gy(3)) at the vagina. Actuarial pelvic control rate and late complication rate were analyzed according to cumulative dose and calculated BED. RESULTS: The 3-year actuarial pelvic control rate was 82% for all 88 patients: 96% for those with early disease, and 76% for advanced disease. For pelvic control, no significant dose-response relationship was observed by treatment schedules and cumulative BED at point A for both early and advanced disease. The 3-year actuarial late complication rates (Grade > or =1) were 12% for proctitis, 11% for cystitis, and 14% for enterocolitis. There were significant differences on the incidence of proctitis (p < 0.0001) and enterocolitis (p < 0.0001), but not for cystitis by the treatment schedules and cumulative point A BED. All 4 patients treated with 86.4 Gy(10) at point A suffered both proctitis and enterocolitis. Patients with cumulative BED at rectal point of > or =100 Gy(3) had significantly higher incidence of proctitis (31% vs. 4%, p = 0.013). CONCLUSIONS: In view of the therapeutic ratio, cumulative BED 70-80 Gy(10) at point A is appropriate for uterine cervical cancer patients treated with a combination of EBRT and HDR-ICBT. Present results and data from other literatures suggested that cumulative BED at the rectal point should be kept below 100-120 Gy(3) to prevent late rectal complication.     

局部晚期宫颈癌CT引导组织间插植BT与腔内BT剂量学与近期疗效比较

目的 探讨CT引导下组织间插植BT技术较传统腔内BT技术在局部晚期宫颈癌治疗中的剂量学优势,提供一种更加有利的临床治疗方法。方法 28例经过体外放疗后仍残留巨大肿块(肿瘤> 5 cm)的局部晚期宫颈癌患者接受CT引导下的组织间插植BT。将该研究的剂量学结果,包括总剂量(体外放疗和BT)的HR-CTV D90和膀胱、直肠及乙状结肠的D2cc,与之前一组接受传统腔内BT (宫腔管+卵圆体对)的30例患者进行比较分析。结果 HR-CTV D90的平均值在腔内BT组、组织间插植BT组分别为(76.9±5.7)、(88.1±3.3) Gy。膀胱、直肠、乙状结肠D2cc在腔内BT组和组织间插植BT组中分别为(84.7±6.8)、(69.2±4.2)、(67.8±4.5) Gy 和(81.8±6.5)、(66.8±4.0)、(64.8±4.1) Gy。1年LC率在腔内BT组和组织间插植BT组分别为59.3%和85.2%。结论 与传统腔内BT相比较,CT引导下组织间插植BT技术具有剂量学优势或许是临床可行的,但长期疗效和不良反应还需进一步评估。     

Combined intensity-modulated radiation therapy and brachytherapy in the treatment of cervical cancer

PURPOSE: This treatment planning study compared pseudo-step-wedge intensity modulation (PSWIM), intensity-modulated radiation therapy (IMRT), and conventional external irradiation, all combined with brachytherapy, for treatment of patients with cervical cancer. METHODS AND MATERIALS: This was a prospective study of 10 patients treated with PSWIM delivering 50.4 Gy to the pelvic lymph nodes and 20 Gy to the cervical tumor. This treatment was compared with a conventional treatment plan with a four-field box to 45 Gy and to an IMRT plan delivering 45 Gy. In each case, brachytherapy was prescribed to a total Point A low-dose-rate equivalent dose of 85 Gy. Total doses to Points A, Point P, the bladder point, and the rectal point were calculated. Acute toxicity and treatment response were prospectively recorded. RESULTS: The mean PSWIM total low-dose-rate equivalent dose to Points A and P (97.3 Gy and 65.1 Gy, respectively) was significantly higher, the mean rectal dose was the same, and the mean bladder dose was higher than with IMRT or four-field box. No acute toxicity of greater Grade 2, as defined by the than Radiation Therapy Oncology Group, was experienced. The positron emission tomography-based treatment response compared favorably with our institutional experience. CONCLUSIONS: Use of PSWIM and brachytherapy delivers significantly more dose to the tumor and lymph nodes than do competing techniques. Rectal doses are comparable. Maximum bladder point doses are higher. Toxicity and tumor response are acceptable.     

Late rectal complications evaluated by computed tomography-based dose calculations in patients with cervical carcinoma undergoing high-dose-rate brachytherapy

PURPOSE: To investigate the efficacy of dose calculations at the computed tomography (CT)-based rectal point (CTRP) as a predictive factor for late rectal complications in patients with cervical carcinoma who were treated with a combination of high-dose-rate intracavitary brachytherapy and external beam radiotherapy. METHODS AND MATERIALS: Ninety-two patients with uterine cervical carcinoma undergoing definitive radiotherapy alone were retrospectively analyzed. The median follow-up time for all patients was 32 months (range, 13-60 months). The cumulative biologically effective dose (BED) was calculated at the rectal reference point as defined by the International Commission on Radiation Units and Measurements Report 38 (BED(RP)) and at the CTRP (BED(CTRP)). Late rectal complications were recorded according to the Radiation Therapy Oncology Group grading system. RESULTS: The late rectal complications were distributed as follows: Grade 0, 68 patients (74%); Grade 1, 20 patients (22%); Grade 2, 4 patients (4%). Univariate analysis showed that BED(RP), BED(CTRP), RP dose/point A dose ratio, and CTRP dose/point A dose ratio were significantly correlated with late rectal complications (p < 0.05). On multivariate analysis, patients with a rectal BED(CTRP) >/=140 Gy(3) presented with significantly greater frequency of rectal complications (p = 0.031). CONCLUSIONS: The present results suggest that BED(CTRP) is a useful predictive factor for late rectal complications.     

192 Ir腔内加体外放射治疗宫颈癌118例分析

目的：研究^192Ir高剂量率腔内加体外放射治疗宫颈癌的疗效和放射反应。方法：118例宫颈癌患者采用^192Ir高剂量率腔内加体外放射治疗，开始体外全盆腔照射，5次／周，2Gy/次，盆腔平面中心剂量26－40Gy,2.5-4.0周完成；然后中间挡铅，4个野照射，4次／周，2Gy/次，宫旁剂量20－25Gy；同时腔内治疗，1次／周，6Gy/次，剂量为36－42Gy。结果：全组3、5年生存率分别为83．1％和72．0％，Ⅱ，Ⅲ期5年生存率分别为80．6％和58．7％（P＞0．05）。早期放射性直肠反应发生率为13．6％，膀胱反应发生率为5．9％；晚期放射性直肠炎发生率为15．3％，膀胱炎为4．2％，直肠阴道瘘为0．9％。结论：^192Ir高剂量率腔内加体外照射治疗宫颈癌疗效肯定，应用方便，副作用少。     

High-dose-rate afterloading brachytherapy in carcinoma of the uterine cervix

The Brachytron has been used in the University of California at San Diego Medical Center since 1970 as one method of treating gynecological malignancies. This machine contains a high intensity cobalt 60 remote afterloading cycling source used for intracavitary brachytherapy. One hundred twenty-seven patients with epithelial carcinoma of the cervix are available for analysis of 5-year survival, and 176 are analyzed for treatment complications two years following therapy. Five year survival figures for FIGO-staged patients treated with external beam pelvic irradiation and intracavitary Brachytron treatments are as follows: Stage I, 89%; Stage II, 58%; Stage III, 33%, and two of five patients Stage IVa. Rectal complications graded moderate or severe (M, S) were dose-related and gradually decreased over the years as techniques improved. Complications from early results in 1970-1972 (24% M, 10% S) were reduced to lower levels in 1976-1979 (14% M, 4% S). The Brachytron offers the advantage of rapid dose delivery. Thus, patients can be treated in an outpatient setting, avoiding the cost of hospitalization and the risks of anesthesia. The Brachytron also offers virtually complete radiation safety to all attending medical personnel. With survival and complication figures similar to those reported for patients treated with conventional low-dose-rate brachytherapy, the Brachytron represents an effective alternate mode of therapy for uterine carcinoma.     

Time course and incidence of late complications in patients treated with radiation therapy for FIGO Stage IB carcinoma of the uterine cervix

: To determine the time course and incidence of late complications from radiation therapy in patients treated with radiation for FIGO Stage IB carcinoma of the uterine cervix, and to evaluate patient and tumor factors associated with an increased probability of treatment complications. : The medical records of 1784 patients with FIGO Stage IB cervical carcinoma who were treated with initial radiation therapy between 1960 and 1989 were retrospectively reviewed. Follow-up was obtained from clinic visits and correspondence with patients and their physicians. Treatment complications were graded retrospectively. Complication rates were calculated actuarially; patients who died of disease or intercurrent illness without experiencing a major complication were censored at the time of death. There were 1241, 924, 548, and 274 patients followed fro more than 5, 10, 15, and 20 years, respectively. : Of patients treated for Stage IB cervical carcinoma, 7.7% and 9.3% had experienced major (≥Grade 3) complications at 3 and 5 years, respectively. After 5 years, there was a small but continuous risk of approximately 0.34% per year, resulting in an overall actualrial risk of having had major complications of 14.4% at 20 years. The risk of developing major urninary tract complications was approximately 0.7% per year for the first 3 years of follow-up, decreasing to about 0.25% per year for at least 25 years. In contrast, the risk of developing rectal complications was about 1% per year during the first 2 years, with a subsequent sharp decline to about 0.06% per year between Years 2 and 25. The risk of fistula formation was approximately doubled in the 234 patients who underwent adjuvant extrafascial hystectomy (5.3 vs. 2.6% at 20 years; p = 0.04) and in the 111 patients who had pretreatment laparotomy (5.2 vs. 2.9%; p = 0.007). The risk of developing small bowel obstruction was increased in patients who underwent pretreatment laparotomy (14.5 vs. 3.7% at 10 years; p < 0.0001) and in patients who weighed <120 pounds (8.2 vs. 3.6%; p = 0.004), but was not increased in patients who underwent adjuvant hysterectomy. A signicantly greater risk of gastrointestinal complications was observed in black and non-Hispanic white patients than in Hispanic women (p = 0.01), even though there was no difference in the rate of developing urinary tract complications (p = 1.0). There was no correlation between the actuarial risk of developing major complications and the patients' age at the time of treatment, but not the cumulative risk was greater for patients who were treated at a young age because these patients were more likely to survive to be exposed to a very long period of risk. : Using techniques described by Fletcher and Delclos, the risk of major complications from aggressive irradiation for Stage IB carcinoma of the cervix is low and does not warrant compromises in the intensity of treatment that might decrease the high cure rates achieved in such patients. The long time course of some late complications also suggests that continued surveillance of survivors, by physicians experienced in the diagnosis and management of the sequelae of the curative radiation treatment of cervical center, is important.     

Analysis of dosimetry and clinical efficacy of intracavitary/interstitial brachytherapy in locally advanced cervical cancer

Objective To study the dosimetric differences and short-term efficacy between intracavitary/interstitial brachytherapy (IC/ISBT) and conventional intracavitary brachytherapy (ICBT). Methods Forty-five patients with locally advanced cervical cancer were treated with IC/ISBT and ICBT. Points A (A1,A2), D90%, D100%, organs at risk, and the doses of bladder, colon, rectum and small intestine were calculated and the short-term efficacy was observed between two groups. Results Point A dose was significantly improved in IC/ISBT compared with ICBT (P<0.05). The D90% and D100% in IC/ISBT were significantly higher than those in ICBT (both P<0.05). After brachytherapy, IC/ISBT could obtain a significantly larger increase in target dose when residual tumor diameter was ≥3 cm compared with ICBT (P<0.05). The D2cm³ and D0.1cm³ of bladder, rectum, colon and small intestine did not significantly differ between IC/ISBT and ICBT (all P>0.05). The 1-,3-and 6-month clinical efficacy did not significantly differ between two technologies (all P>0.05). Conclusion During brachytherapy for locally advanced cervical cancer (residual tumor diameter ≥3 cm), IC/ISBT significantly increases the doses of target area and point A without increasing the dose of organs at risk or lowering the short-term clinical efficacy, which has significant dosimetric advantages.     

局部晚期宫颈癌后装腔内联合组织间插植剂量学及临床疗效分析

目的 研究后装腔内/组织间插植近距离治疗(IC/ISBT)与传统后装腔内近距离治疗(ICBT)相比较的剂量学差异及其近期疗效。方法 45例局部晚期宫颈癌患者采用IC/ISBT及ICBT方法进行后装近距离治疗,分别对两种治疗方法的A点(A1、A2)、D90%、D100%以及膀胱、结肠、直肠、小肠受量进行计算,同时观察近期疗效。结果 IC/ISBT比ICBT放疗A点剂量显著提升(P<0.05);并且IC/ISBT的D90%、D100%也均明显高于ICBT (P<0.05)。外照射后残存肿瘤直径≥3cm时,IC/ISBT比ICBT可获得较高的靶区剂量提升(P<0.05)。IC/ISBT与ICBT的膀胱、直肠、结肠、小肠D2cm³、D0.1cm³相近(P>0.05)。疗后1、3、6个月的近期疗效IC/ISBT与ICBT相近(P>0.05)。结论 局部晚期宫颈癌(残存肿瘤直径≥3cm)后装近距离治疗中IC/ISBT在不增加危及器官受量及降低近期疗效前提下显著地提高了靶区、A点剂量,具有明显剂量学优势。     

宫颈癌腔内联合组织间插植近距离放疗应用进展

对50余篇有关宫颈癌近距离放疗相关文献进行阅读,简述腔内近距离放疗及组织间插植近距离放疗的发展、适用范围及其局限性,重点探讨腔内联合组织间插植近距离放疗的相关研究应用进展,主要包括施源器种类、适应证、插植针应用规律及剂量学优势、早晚期不良反应、远期随访结果等方面。     

High-dose-rate intracavitary brachytherapy boost for early T stage nasopharyngeal carcinoma{private}

PURPOSE: To investigate any possible therapeutic gain from dose escalation with brachytherapy for early T stage nasopharyngeal carcinoma (NPC). METHODS AND MATERIALS: One hundred forty-five patients with T1-2b N0-3 NPC were boosted with high-dose-rate intracavitary brachytherapy after completion of two-dimensional external radiotherapy (ERT) during the period from 1999 to 2003. To compare the efficacy of brachytherapy boost, another 142 patients with T1-2b N0-3 disease who were treated with ERT alone during 1994 to 1999 were evaluated. All patients were treated with ERT to a total dose of 66 Gy in 6.5 weeks. The brachytherapy boost group was given 10-12 Gy in 2 weekly fractions. RESULTS: Dose escalation beyond 66 Gy with brachytherapy boost was shown to improve local control and survival. The 5-year actuarial local failure-free survival, regional failure-free survival, distant metastasis-free survival, progression-free survival, cancer-specific survival, and overall survival rates for the brachytherapy group and the control group were 95.8% and 88.3% (p = 0.020), 96% and 94.6% (p = 0.40), 95% and 83.2% (p = 0.0045), 89.2% and 74.8% (p = 0.0021), 94.5% and 83.4% (p = 0.0058), and 91.1% and 79.6% (p = 0.0062), respectively. The 5-year major-complication-free survival rate was 89.5% for the brachytherapy group and 85.6% for the control group (p = 0.23). CONCLUSIONS: For patients who are treated with two-dimensional treatment techniques, dose escalation with brachytherapy boost improves local control and overall survival of patients with T1-T2a and possibly non-bulky T2b disease.     

High-dose irradiation for prostate cancer via a high-dose-rate brachytherapy boost: results of a phase I to II study

OBJECTIVE: To evaluate outcomes of intermediate- and high-risk prostate cancer patients on a prospective dose-escalation study of pelvic external-beam radiation therapy (EBRT) combined with high-dose-rate (HDR) brachytherapy boost. METHODS: From November 1991 to April 2003, 197 patients were treated for intermediate- and high-risk disease features. All patients had prostate-specific antigen>10 ng/ml, Gleason score>or=7, or clinical stage>or=T2b, and all received pelvic EBRT (46 Gy) while receiving either two or three HDR boost treatments. HDR dose fractionation increased progressively and was divided into two dose levels. The mean prostate biologic equivalency dose was 88.2 Gy for the low-dose group and 116.8 Gy for the high-dose group (alpha/beta=1.2). Clinical failure was either local failure or distant metastasis; clinical event-free survival (cEFS) was defined as patients who lived free of clinical failure. RESULTS: Median follow-up was 4.9 years. The 5-year rates were as follows: biologic failure (BF), 18.6%, clinical failure (CF), 9.8%, cEFS 84.8%, cause-specific survival (CSS), 98.3%, and overall survival (OS), 92.9%. Five-year biochemical failure (68.7% vs. 86%, p<0.001), CF (6.1% vs. 15.6%, p=0.04), cEFS (75.5% vs. 91.7%, p=0.003), CSS (95.4% vs. 100%, p=0.02), and OS (86.2% vs. 97.8%, p=0.002) were significantly better for the high-dose group. Multivariate analysis showed that high-dose group (p=0.01, HR 0.35) and Gleason score (p=0.01, HR 1.84) were significant variables for cEFS. Multivariate analysis showed that high-dose group (p=0.01, HR 0.14) and age (p=0.03, HR 1.09 per year) were significant variables for overall survival. CONCLUSION: There is a strong dose-response relationship for intermediate- to high-risk prostate cancer patients. Improved locoregional control with higher radiation doses alone can significantly decrease biochemical and clinical failures.     

Perioperative and postoperative complications of intracavitary radiation for FIGO stage I-III carcinoma of the cervix

Purpose: To evaluate perioperative and postoperative complications of low-dose-rate (LDR) intracavitary radiation therapy in patients with FIGO Stage I–III carcinoma of the uterine cervix.

Methods and Materials: We retrospectively reviewed the medical and radiotherapy records of all patients treated with radiation between 1960 and 1992 at The University of Texas M. D. Anderson Cancer Center for FIGO I–III carcinomas of the cervix. Patients who had had initial hysterectomy or whose treatment did not include intracavitary irradiation were excluded. The final study included 4043 patients who had undergone 7662 intracavitary procedures.

Results: Eleven (0.3%) patients had documented or suspected cases of thromboembolism resulting in 4 deaths. Of these 11 patients, 8 had clinical or radiographic evidence of tumor involving pelvic nodes or fixed pelvic wall. The risk of postoperative thromboembolism did not decrease significantly with the routine use of mini-dose heparin prophylaxis (p = 0.3). Other life-threatening perioperative complications included myocardial infarction (1 death in 5 patients), cerebrovascular accident (2 patients), congestive heart failure or atrial fibrillation (3 patients), and halothane liver toxicity (2 deaths in 2 patients). Intraoperative complications included uterine perforation (2.8%) and vaginal laceration (0.3%), which occurred more frequently in patients ≥ 60 years old (p < 0.01). Fourteen percent of patients had a temperature ≥ 101°F during at least one hospital stay. The only correlation between minor intraoperative complications and disease-specific survival was found in patients who had Stage III disease and uterine perforation; survival was significantly (p = 0.01) decreased in these patients.

Conclusions: Fatal or life-threatening complications of intracavitary treatment were very rare. Deep venous thrombosis (DVT) and pulmonary embolism (PE) did not occur in otherwise healthy patients with early disease and were rare even when disease was more advanced. Minor perioperative complications were not correlated with serious late complications or with death from disease.     

CT引导下三管式腔内后装与腔内结合插植后装用于宫颈癌治疗的对比研究

目的:比较局部晚期宫颈癌采用标准三管施源器的腔内后装(tandem and ovoid)与腔内结合组织间插植后装的剂量学差异。方法:CT引导下的三维适形近距离治疗局部晚期宫颈癌患者20 例,间隔采用三管式腔内后装与腔内结合组织间插植共 72次。 按照施源器的不同分成 ２个组,每组 36 次,对靶区剂量、危及器官等进行比较。结果:在给予A点相同处方剂量的情况下,HR-CTV D90、D100在三管式腔内后装组与腔内结合组织间插植后装组中分别为（590.0±46.4）cGy、（471.2±66.2）cGy,（502.8±67.7）cGy、（335.9±46.0）cGy,P＜0．05),膀胱、直肠、乙状结肠D2cc均相近（P=0.85、0.28、0.53）。结论:采用腔内结合插植后装治疗局部晚期宫颈癌比三管式腔内后装可获得更高的靶区剂量,但长期疗效及晚期反应仍需进一步研究。     

Analysis of prognostic factors in stage IIB–IVA cervical carcinoma treated with radiation therapy: Value of computed tomography

: Androgen ablation is often combined with radiation in the treatment of patients with prostate cancer, yet, the optimal sequencing and the mechanisms governing the interaction are not understood. The objectives were to determine if cell killing via apoptosis is enhanced when the combined treatment is administered and to defined the relationship of changes in this form of cell killing to tumor volume growth delay.

: Dunning R3327-G rat prostate tumors, grown inthe flanks of Copenhagen rats, were used at a volume of approximately 1 cc. Androgen ablation was initiated by castration, and androgen restoration was achived with 0.5 cm silastic tube implants containing testosterone. ⁶⁰Co was used for irradiation. The terminal deoxynucleotidyl transferase (TUNEL) histochemical assay was used to quantify apoptosis.

: Tumors from intact and castrate unirradiated control rats had average apoptotic indices (percent of apoptotic cells) of 0.4 and 1.0%, respectively. The apoptotic index varied only slightly over time (3 h to 28 days) after castration (range 0.75-1.43%). Irradiation of intact rats to 7 Gy resulted in a peak apoptotic response at 6 h of 2.3%. A supradditive apoptotic response was seen when castration was initiated 3 days prior to 7 Gy radiation, with peak levels of about 10.1%. When the radiation was administered at increasing times beyond 3 dats after castration, the apoptotic response gradually diminished and was back to levels seenin intact rats by 28 days after castration. Tumor volume growth delay studies were consistent with, but not conclusive proof of, a supraadditive effect when the combination was used.

: A supraaddtive apoptotic response was seen when androgen ablation and radiation were used to treat androgen sensitive R3327-G rat prostate tumors. This supraadditive effect was dependent on the timing of the two treatments. Further studies are required to more fully define the optimal timing and administration of androgen ablation and radiation.     

Effect of bladder distension on dose distribution of intracavitary brachytherapy for cervical cancer: three-dimensional computed tomography plan evaluation

PURPOSE: To quantify the effect of bladder volume on the dose distribution during intracavitary brachytherapy for cervical cancer. METHODS AND PATIENTS: The study was performed on 10 women with cervical cancer who underwent brachytherapy treatment. After insertion of the brachytherapy applicator, the patients were transferred to the computed tomography unit. Two sets of computed tomography slices were taken, including the pelvis, one with an empty bladder and one after the bladder was filled with saline. The target and critical organs were delineated by the radiation oncologist and checked by the expert radiologist. The radiotherapy plan was run on the Plato planning system, version 14.1, to determine the dose distributions, dose-volume histograms, and maximal dose points. The doses and organ volumes were compared with the Wilcoxon signed ranks test on a personal computer using the Statistical Package for Social Sciences, version 11.0, statistical program. RESULTS: No significant difference regarding the dose distribution and target volumes between an empty or full bladder was observed. Bladder fullness significantly affected the dose to the small intestine, rectum, and bladder. The median of maximal doses to the small intestine was significantly greater with an empty bladder (493 vs. 284 cGy). Although dosimetry revealed lower doses for larger volumes of bladder, the median maximal dose to the bladder was significantly greater with a full bladder (993 vs. 925 cGy). The rectal doses were also affected by bladder distension. The median maximal dose was significantly lower in the distended bladder (481vs. 628 cGy). CONCLUSIONS: Bladder fullness changed the dose distributions to the bladder, rectum, and small intestine. The clinical importance of these changes is not known and an increase in the use of three-dimensional brachytherapy planning will highlight the answer to this question.