About Bioline  All Journals  Testimonials  Membership  News

Journal of Cancer Research and Therapeutics
Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI)
ISSN: 0973-1482 EISSN: 1998-4138
Vol. 7, Num. 4, 2011, pp. 391-392

Journal of Cancer Research and Therapeutics, Vol. 7, No. 4, October-December, 2011, pp. 391-392


Resurecting brachytherapy from brink of oblivion

Department of Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India
Correspondence Address: Anusheel Munshi, 120, Radiation Oncology, Tata Memorial Hospital, Parel, Mumbai, India,

Code Number: cr11108

DOI: 10.4103/0973-1482.9199

From too much zeal for the new and contempt for what is old

Good Lord, deliver us. -

Sir Robert Hutchison

Brachytherapy is a unique form of radiotherapy involving science, skill, and judgment. This technique is useful in approximately 5-10% of all cancer patients. [1] Sometimes it needs to be reiterated that brachytherapy was the first radiotherapy modality to be used for treatment on cancer patients, much before the first teletherapy machine was invented. [2] In early 20th century this fine art evolved under the astute guardianship of stalwarts like Madam Curie, Paterson, Parker, Fletcher, Deutrix, to name a few. With painstaking effort, Paterson and Parker established norms for uniform dose rate at a point, designated point A in carcinoma cervix patients. [3] This constant dose rate held true for various combinations of tandem and ovoid loading patterns and was thus a remarkable feat indeed in that era. Calculations and rules for other systems followed, including the famous rules of the Paris system. [4]

The concept of brachytherapy was appealing. One put the radioactive source close to the patient, often in the tumor itself, took advantage of inverse square law in getting a low dose to the normal structures, and kept the treatment "inside out" (as opposed to outside in treatment for teletherapy). [5] The decades of 30's to 70's in the 20th century could be easily regarded as the golden period of brachytherapy. During this period, radiation oncologist and physicists developed newer treatment techniques and patterns for brachytherapy care. It became the dominant mode of treatment in superficial and accessible tumors. Low-dose rate techniques were established, with the evolution of the iridium wire, cesium needle, various seeds, and pellets. [6] This was also the time when the teletherapy machines had just been conceived. Consequently, teletherapy treatment was simple, often consisting of square or rectangular portals. Naturally, brachytherapy provided the only means for a "conformal treatment or conformal boost." Clinicians and physicist therefore spent considerable time and attention to fine tuning this technique and took justifiable pride in the outcomes of this technique.

But a series of events in the past decades have lead to a severe decline in interest in the art of brachytherapy. Its first cousin, teletherapy has made phenomenal strides which have seemingly buoyed radiation oncology to a superfast and supersonic era. Orthovoltage and telecesium machines have become curiosities for present day residents and trainees. Contouring-based treatment, akin to surgical resection of the tumor and lymph nodes with sparing of the normal structures has become the norm in most centers. Intensity-modulated radiotherapy has allowed radiation oncologists to give integrated and highly conformal treatments or avoidance, as the case may be, a capability hitherto confined to brachytherapy treatment. [7] Teletherapy has attempted to make inroads even the brachytherapy stronghold of carcinoma cervix. Advancements such as proton therapy have shown the ability to give near zero dose distal to the desired area. [8] Feasibility studies have been done to see the role of superfine rotational therapy and arc therapy techniques as a substitute for brachytherapy in cervical cancers. [9],[10] Features such as image guidance, gating, and 4D techniques lead to a natural decline in doing brachytherapy procedures because in hand was a noninvasive technique which fulfilled the dosimetric wish list of the radiation oncologist. These were welcome advancements for many oncologists wary over the issue of summation of doses to a given region by teletherapy and brachytherapy. This had always been a vexed issue, with its complexities of matching doses and dose rates by converting them to a "teletherapy equivalent." [11]

Ostensibly, the High Dose Rate (HDR) treatment system brought in various welcome changes in the form of exposure protection, shortened treatment time, and patient convenience. It seemed a clean and effective way of delivering Brachytherapy. The advantages and uniqueness of HDR planning systems for brachytherapy include possibilities for the differential loading of applicators in an attempt to produce an ideal dose distribution. [12] Practically however, radiation biologists, physicists, and radiation oncologists could never decide, besides other issues, on a specific model for Low Dose Rate (LDR) to HDR conversion. These conversion factors varied for various sites and various dose fractionations. Even after application of some models, radiation oncologists were uncertain about the late sequelae from use of this much higher dose rate. [13],[14]

To add to the list, further challenges to brachytherapy were posed by poor reimbursement patterns for this treatment. Typically, Brachytherapy in HDR is delivered in dose per fractions varying from 3-9 gray (compared to 1.8 to 2 Gy per fraction for the external radiotherapy) depending on site and surrounding organs at risk. Fewer fractions translated into lesser reimbursements (owing to a commonly followed per fraction reimbursement pattern). This trend of poorer reimbursements was visible in the western nations and the sentiment has been duly echoed in private Indian hospitals as well. [15]

Taking the argument further, even academic organizations such as ESTRO, ASTRO, and AROI have kept brachytherapy out of the focus area. As an example, of the 35 courses listed in the ESTRO calendar for 2012, only 3 directly address the topic of brachytherapy. [16] Further, and of note, brachytherapy is a technique involving hand skills. Hands on workshops for young impressionable minds are the need of the hour. Contemporary brachytherapy experts have played their bit in not having disseminated this art to their pupils and perhaps failed to make this field exciting and continuously evolving. As a result, for the present, IMRT, IGRT, 4D treatment, and proton beams are ruling the roost.

Among this picture of gloom, some silver linings do flash. Mammosite/Mammasphere/SAVI for breast cancers, Magnetic resonance imaging (MRI)-based cervical/parametrial implants, and gliasite for brain tumors are modern innovations of brachytherapy. [17],[18],[19],[20] Intravascular and intraluminal therapies too have been innovatively used.

Where does brachytherapy go from here? Rekindling the flame of brachytherapy may well require a Herculean effort. We need to use this fine art wherever possible, remembering that as of now, this technique still remains unmatched in its sharp fall off and precision in its treatment delivery. For brachytherapy and its future, the call could be close. Is Sir Robert Hutchison (and Madam Curie) hearing?


1.Wilson JF, Chassagne D, Joslin C. International clinical trials in radiation oncology. Brachytherapy trials. Int J Radiat Oncol Biol Phys 1988;14:S57-63.   Back to cited text no. 1    
2.Paine CH, Ash DV. Interstitial brachytheraphy: Past-present-future. Int J Radiat Oncol Biol Phys 1991;21:1479-83.  Back to cited text no. 2    
3.Bloedorn FG. Application of the Paterson-Parker system in interstitial radium therapy. Am J Roentgenol Radium Ther Nucl Med 1956;75:457-75.  Back to cited text no. 3    
4.Pierquin B, Dutreix A, Paine CH Chassagne D, Marinello G, Ash D. The Paris system in interstitial radiation therapy. Acta Radiol Oncol 1978;17:33-48.  Back to cited text no. 4    
5.Toita T. Current status and perspectives of brachytherapy for cervical cancer. Int J Clin Oncol 2009;14:25-30.   Back to cited text no. 5    
6.Vicini FA, Kini VR, Edmundson G, Gustafson GS, Stromberg J, Martinez A. A comprehensive review of prostate cancer brachytherapy: Defining an optimal technique. Int J Radiat Oncol Biol Phys 1999;44:483-91.  Back to cited text no. 6    
7.Munshi A, Agarwal JP. Evolution of radiation oncology: Sharp gun, but a blurred target. J Cancer Res Ther 2010;6:3-4.   Back to cited text no. 7    
8.Arimoto T, Kitagawa T, Tsujii H, Ohhara K. High-energy proton beam radiation therapy for gynecologic malignancies. Potential of proton beam as an alternative to brachytherapy. Cancer 1991;68:79-83.  Back to cited text no. 8    
9.Hsieh CH, Wei MC, Hsu YP, Chong NS, Chen YJ, Hsiao SM, et al. Should helical tomotherapy replace brachytherapy for cervical cancer? Case report. BMC Cancer 2010;10:637.   Back to cited text no. 9    
10.Gielda BT, Shah AP, Marsh JC, Smart JP, Bernard D, Rotmensch J, et al. Helical tomotherapy delivery of an IMRT boost in lieu of interstitial brachytherapy in the setting of gynecologic malignancy: Feasibility and dosimetric comparison. Med Dosim 2011;36:206-12.  Back to cited text no. 10    
11.López Carrizosa MC, Samper Ots PM, Rodríguez Pérez A, Sotoca A, Sáez Garrido J, de Miguel MM. High dose rate brachytherapy (HDR-BT) in locally advanced oesophageal cancer. Clinic response and survival related to biological equivalent dose (BED). Clin Transl Oncol 2007;9:385-91.  Back to cited text no. 11    
12.Hoskin PJ, Rembowska A. Dosimetry rules for brachytherapy using high dose rate remote afterloading implants. Clin Oncol (R Coll Radiol) 1998;10:226-30.   Back to cited text no. 12    
13.Hareyama M, Sakata K, Oouchi A, Nagakura H, Shido M, Someya M, et al. High-dose-rate versus low-dose-rate intracavitary therapy for carcinoma of the uterine cervix: A randomized trial. Cancer 2002;94:117-24.  Back to cited text no. 13    
14.Orton CG, Seyedsadr M, Somnay A. Comparison of high and low dose rate remote afterloading for cervix cancer and the importance of fractionation. Int J Radiat Oncol Biol Phys 1991;21:1425-34.  Back to cited text no. 14    
15.Smith-Fuss W. Significant payment decreases to freestanding cancer centers that provide high-dose-rate brachytherapy. J Am Coll Radiol 2009;6:372-3.  Back to cited text no. 15    
16.Available from: [Last Accessed on 2011 Dec 24].  Back to cited text no. 16    
17.Beriwal S, Kannan N, Kim H, Houser C, Mogus R, Sukumvanich P, et al. Three-dimensional high dose rate intracavitary image-guided brachytherapy for the treatment of cervical cancer using a hybrid magnetic resonance imaging/computed tomography approach: Feasibility and early results. Clin Oncol (R Coll Radiol) 2011;23:685-90.  Back to cited text no. 17    
18.Waksman R. Vascular brachytherapy: A landmark chapter in the field of interventional cardiology. EuroIntervention 2011;6:669-71.  Back to cited text no. 18    
19.Shin HS, Seong J, Kim WC, Lee HS, Moon SR, Lee IJ, et al. Combination of external beam irradiation and high-dose-rate intraluminal brachytherapy for inoperable carcinoma of the extrahepatic bile ducts. Int J Radiat Oncol Biol Phys 2003;57:105-12.  Back to cited text no. 19    
20.Kelly JF, Delclos ME, Morice RC, Huaringa A, Allen PK, Komaki R. High-dose-rate endobronchial brachytherapy effectively palliates symptoms due to airway tumors: The 10-year M. D. Anderson cancer center experience. Int J Radiat Oncol Biol Phys 2000;48:697-702.  Back to cited text no. 20    

Copyright 2011 - Journal of Cancer Research and Therapeutics

Home Faq Resources Email Bioline
© Bioline International, 1989 - 2024, Site last up-dated on 01-Sep-2022.
Site created and maintained by the Reference Center on Environmental Information, CRIA, Brazil
System hosted by the Google Cloud Platform, GCP, Brazil