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Abstract
There are two primary types of cervical carcinomas, one being adenocarcinoma, and the most
prevalent being squamous cell carcinoma (Wesola & Jelen, 2015). Pap smears are the
recommended screening device (Castillo et al., 2016) which can detect cervical cancer. In later
stages, cervical cancer can metastasize to organs and lymph nodes. The tolerance doses of
critical structures must be identified and considered during treatment planning to provide the
patient with the best quality of life (Rideaux, 2016). Treatment options include but are not
limited to surgery (Rideaux, 2016), IMRT (Marnitz et al., 2015), chemotherapy (Rose et al.,
2011), and brachytherapy (Viswanathan et al., 2012). During brachytherapy, the radioactive
tandem and ovoid implants are inserted through the intrauterine canal. The most common subsets
of brachytherapy treatment are high-dose rate (HDR), and low-dose rate (LDR) (Wang et al.,
2010). Within brachytherapy, different isotopes are used. Studies show several isotopes having
both positive and negative effects on different patient factors such as, radioresistance, and
Common isotopes that are used are Iridium-192, Californium-252, Cobalt-60, and Radium-226
(Viswanathan et al., 2017). This review will focus on brachytherapy and analyzing the different
a type of cancer that occurs in the lining tissue of the cervix. When cells on the surface level of
the cervix continuously divide, cervical lesions appear, and if the lesions are left untreated, those
cells can turn into cancer. There is no known cause of cervical cancer but there are different
factors that have been associated with it. This cancer affects women in the United States but is
more prevalent in third world countries. With cervical cancer being so prevalent, it is imperative
different from external radiation because the source is placed close to or directly into the tumor
which decreases exposure to surrounding organs. Brachytherapy can be broken down into high-
dose rate (HDR) and low-dose rate (LDR). Different isotopes or sources can be used to treat
cervical cancer. The most common sources used for cervical cancer include, but are not limited
to, Iridium 192, Californium-252, Cobalt-60, and Radium-226. Scientific studies have found
advantages and disadvantages to these different isotopes that can provide better or worse
Literature Review
The cervix is part of the female genitalia and is located inside the superior portion of the
vaginal canal where it connects with the uterus. The cervix is commonly broken up into two
anatomical locations: the endocervix, where the cervix meets the uterus; and the exocervix,
where the cervix meets the vagina. The cervix also has an opening called the cervical os that is
made up of squamous cell epithelium. The most common site for cervical cancer is at the
BRACHYTHERAPY: ISOTOPES 4
squamocolumnar junction where the squamous cells of the cervical os meet the columnar cells of
Cervical cancer is one of the most common cancers in women, and also has some of the
highest mortality rates (Castillo et al., 2016). Although advanced screenings are reducing
mortality, approximately 500,000 new cases are diagnosed each year with most occurring in less
developed countries, where access to healthcare services is scarce (Wesola & Jele, 2015). The
mean age for cervical cancer patients is vast, covering ages as young as 15 to geriatric patients
over 50 years old (Castillo et al., 2016). There are two classifications of cervical cancer:
squamous cell carcinoma, which constitutes over 85% of cases; and adenocarcinoma which is
The causes for the development of cervical cancer are widely unknown, although more
and more studies are linking increased amounts of unprotected sexual activity with multiple
partners to the development of cervical cancer. Cheah, Koh, Nazarina, Teoh, & Looi (2016)
found that human papillomavirus (HPV) is a significant precursor to the development of cervical
cancer, and Rideaux (2016) has stated that in addition to multiple sexual partners at an early age,
HPV is responsible for nearly 99% of cervical cancers (p. 740). Identification and management
of HPV can aid in the prevention or diagnosis of early-stage cervical cancer, thus reducing the
number of patients given a grave prognosis. On a molecular level, the gene marker p16 has been
proposed as the HPV marker for the high-risk strands 16 & 18 that transform into cervical cancer
(Cheah, Koh, Nazarina, Teoh, & Looi; 2016). P16 prevents the phosphorylation of kinase
inhibitors CDK4 and CDK6 in addition to the retinoblastoma gene product pRb (2016). It has
been proven that the upregulation of p16 causes the transformation of the host cells in
conjunction with hrHPV, the genetic marker for HPV (2016). In genetic screening of patients
BRACHYTHERAPY: ISOTOPES 5
with cervical cancer, squamous cell carcinoma and high-grade squamous intraepithelial lesions
showed positive p16 gene expressions in over 70% of cases where hr HPV was also present
(2016). This finding can aid in the early categorization and treatment of cervical cancer for those
with HPV.
Squamous cell cervical cancer is an asymptomatic, slow growing tumor that takes years
to develop and causes clinical problems. Symptoms for cervical cancer include: abnormal
vaginal discharge, pelvic or back pain, painful urination, and hematuria or hematochezia with
bowel symptoms present in more advanced stages. The most common form of clinical
presentation for squamous cell is abnormal vaginal bleeding (Castillo et al., 2016). Lymphatic
obstruction or nerve involvement may be indicated by edema in lower extremities or pelvic pain.
The general diagnostic work up for cervical cancer starts with a physical exam and an
interview on the patients medical/family history. Diagnostic procedures that can be done include
a primary screening Papanicolaou smear (Pap smear), colposcopy, conization, punch biopsies,
dilatation and curettage, cystoscopy, and a rectosigmoidoscopy for advanced stage cervical
cancer. The cells of the cervix are examined under a microscope from a pap smear for any visible
abnormalities (Rideaux, 2016). It is suggested that a biopsy should be done even if testing shows
a slight abnormality or lesion. After a diagnosis is made, a complete blood count should be
produced to check hepatic function, renal function, and possible metastasis. Rideaux (2016) also
states that the use of PET/CT scans are becoming extremely beneficial to detect not only the
lymph node involvement, but also the possibility of distant metastasis such as to the bones and
lungs.
BRACHYTHERAPY: ISOTOPES 6
The most common staging system used for all types of cervical cancer is the International
Federation of Gynecological and Obstetrics, also known as FIGO. With this system, squamous
cell carcinoma of the cervix is categorized into 5 stages between 0 and 4. According the Rideaux
epithelial cells, then it is considered stage 0, which indicates an absence of cancer. The following
stages, according to FIGO, are as follows: Stage I, the cancer cells are in the epithelium
connective tissue, Stage II, the cancer has spread to the upper portion of the vagina, Stage III,
shows signs of spread in the lower portions of the vagina and to the wall of the pelvis, and Stage
IV, shows spread to the mucosa of either the rectum or the bladder, or spreads beyond the true
pelvis. Another staging system that can be used is the TNM (Tumor Node Metastasis) system,
however, it is very similar to the FIGO system but does not include the 0 stage.
Carcinoma of the cervix can metastasize in three ways: through hematogenous spread,
direct invasion, and the lymphatics. All research completed proves that direct invasion often
occurs to the uterus, vagina, parametrium, pelvis, rectum, and bladder. In a study that was
published in 2016, the 3-5 year survival rate for patients with stage IV is 21-48%. 1 in 4 patients
showed rectal invasion with no survival rate above 4 years, and the other 75% showed invasion
to the bladder (Wakatsuki et al., 2016). Even though direct invasion to the vagina and pelvic wall
is the most common form of metastasis, squamous cell carcinomas can also spread to the lungs,
liver, and bone through hematogenous spread, or through lymph to the parametrial nodes and
Brachytherapy
BRACHYTHERAPY: ISOTOPES 7
Washington and Leaver define brachytherapy as therapy at short distances. (2015) This
form of therapy utilizes radioactive isotopes coming from an external source or implanted seeds
that deliver the radiation dose. These sources are encased and sealed within a small metal
structure. Seeds were the primary source of brachytherapy treatment in the early 1900s when
radiation was first being discovered as an imaging source and as a form of cancer treatment.
(2015) The first primary isotopes used for brachytherapy were Cesium-137, Radium-226,
Iridium-192, and Cobalt-60. Some were better than others based on their half-life, toxicity, and
specific activity. (2015) The purpose of brachytherapy, like external beam therapy, is to
significantly reduce the tumor volume and cancer cells. The way this is done is by placing the
sources on or near the tumor bed and allowing the sources to expel radiation. Some of the areas
commonly treated with brachytherapy are the prostate, breast, cervix, uterus, and lung. For
beam radiotherapy (EBRT) to act as a treatment boost and help improve control, survival, and
recurrence rates. (Banerjee, 2014) The source, normally Iridium-192, is inserted into the vagina
to the cervix and stays there for an allotted dwell time (Washington, 2015). Brachytherapy is
the only method of radiation treatment seen to deliver a high enough dose to safely control
cervical cancer. (Banerjee, 2014) The intracavitary treatment applicator for cervical cancer is
either a Tandem and Ovoid or Capri depending on the area needing to be treated, the size of the
tumor, and the persons anatomy. (2014) For interstitial treatment, different templates of tubes
are used in order to treat larger tumors that are lower in the vagina and that impede an applicator
to be inserted. (2014)
There are also two branches of brachytherapy treatments: low-dose rate (LDR) and high-
dose rate (HDR). (Washington, 2015) Historically LDR was the brachytherapy treatment of
BRACHYTHERAPY: ISOTOPES 8
choice, but more recently HDR has come to the forefront due to its unique remote after-loading
technique. (Banerjee, 2014) For this process, the radioactive isotope is driven through different
channels inside the applicator and has periods of dwell time inside each channel before it is
retracted. HDR allows for dose sculpting and shorter treatment times, so it is ideal for
outpatients, however LDR is still regularly used for inpatients. The fractionation for cervical
HDR can vary, but most often the patient receives 4 or 5 fractions with 5-7 Gy per fraction.
(2014)
Cervical carcinoma has traditionally been treated with low-dose rate (LDR)
(Gaur et al., 2012). LDR gives a range of 0.4-2Gy per hour, in comparison with HDR which
ranges around 12 Gy per hour. LDR is considered radiobiologically more accurate because it
gives a continuous exposure of the cancer cells non cell cycle specific killing and also decreases
risk of late normal toxicity and increased the repair capacity to normal tissues. LDR can usually
give a dose range of 0.4-2 Gy per hour, most though are given with doses of 2 Gy per hour with
Radium has a half-life of 1622 years. During treatment, the patient is under anesthesia
and in an operating room for the applicator placement. For the duration of the LDR treatment,
the patient is considered radioactive, and has to be placed into isolation, where the hospital
staff is exposed more often. Radium, in most hospital settings, have been replaced with Cesium-
137 because the half-life is shorter, and because it has a low specific activity.
Cesium-137 is suitable for low dose rate implants because of its low specific activity rate.
It has a half-life of 30.7 years and can be used for a long period of time in the department. The
BRACHYTHERAPY: ISOTOPES 9
photon emission of a Cesium 137 source is 0.662 MeV. The emitted beta particles have the
brachytherapy treatments. Cf-252 was discovered in 1956 as a high linear energy transfer (LET).
It is a neutron/gamma radioactive source and was found to be used to overcome tumor resistance
to gamma radiation. The first trials with Cf-252 were not convincing, in the 70s, however,
depending on the method of administration it has shown promising results in the recent studies,
Brachytherapy treatment today still utilize both Radium-226 and Cesium-137. Studies
have shown that both isotopes have very similar characteristics for treatment, however, small
differences still exist. The major disadvantage of the use of Radium-226 is the treatment time per
two insertions at a dose rate of 53 cGy per hour (Wang et al., 2014). This gives each treatment
insertion time to around 70 hours. Each insertion is also separated by 7-10 days. With the use of
Cesium-137, Wang (2014) also describes that the dose is reduced to 65 Gy to point A. This
isotope-source also required two insertions, however, gives a higher dose rate per hour at 140-
180 cGy per hour. With that being said, the total treatment time per insertion decreases from 70
hours each to only 20 hours per insertion. A common component of each isotope-source the dose
to the rectum is kept low due to careful vaginal packing during the applicator insertion in the
operating room.
With the highlight of Californium-252 being studied, many factors are coming to light
with the combination of use with Cf-252 with either LDR sources, and the use of external-beam
BRACHYTHERAPY: ISOTOPES 10
radiation therapy. In a long-term randomized study with 227 patients, Cf-252 was given to 117
patients in the 1st week of treatment followed by EBRT and then in the 5th week given either Ra-
226 or Cs-137 (Tacev et al., 2003). The results of the study compared those given Cf-252 with
those 110 patients who did not get the neutron treatment and only received conventional gamma
radiation. The 5- year overall survival rate was 18.9% better in the patients who received Cf-252
treatment, and specifically in patients with Stage IIIB had a 22.8% better 5-year OS rate than the
patients with conventional treatment. The study also focused on tumor recurrence in patients
with advanced stage cervical cancer. The most common site for tumor recurrence was in the
small pelvis, and the patients who received the Cf-252 had a 19% lower recurrence rate of all the
patients (Tacev et al., 2003). What is known about Californium-252 is because it is a neutron
source, it has the ability to attack those cancer cells that are becoming radioresistant and directly
invades the neutrons of the tumor population. Attacking just the neutrons of the tumor cell
population allows for the minimization of post-radiation damage to the healthy tissues
surrounding.
HDR gets its name because the treatments give off a high-dose of radiation per fraction
in a short amount of time. HDR was developed to overcome the disadvantages of LDR. Those
disadvantages being: radiation exposure to medical staff, prolonged treatment times, mandatory
hospitalization of patients, and applicator movement during treatment waiting period. HDR
brachytherapy machines initially used a cobalt-60 source. More recently, Ir-192 sources have
brachytherapy, (Gaur, 2012). The source design for iridium-192 technology has revolutionized
the design of remote afterloading equipment. With HDR, facilities are able to treat more patients,
BRACHYTHERAPY: ISOTOPES 11
however HDR can be very costly due to the afterloader. The higher cost makes HDR a more
difficult treatment method for developing countries, (Mobit, 2015). Also, the high dose per
fraction of HDR can cause late toxicity, (Gaur, 2012). The advantages of HDR include,
computerized optimization of dosimetry, less risk of radiation exposure for medical personnel,
and less chances of organ motion during radiation delivery (Gaur, et al. 2012).
Co-60 has a half-life of 5.27 years, but also has a high specific activity. The average
energy of Co-60 is 1.25 MeV, (Ghorban, 2016). Cobalt is unpopular because of the source sizes
are larger than Ir-192. Co-60 does have a longer half-life than Ir-192, so it only gets changed
every 6-8 years. Co-60 is more economical and attractive for low resource settings. One
disadvantage of Co-60 is the high energy that increases the possibility of toxicity, (Ntekim,
2010).
In comparison, Ir-192 has a half-life of 73.81 days and a high specific activity. The
average energy of Ir-192 is 0.380 MeV. These factors make it very suitable for interstitial
brachytherapy, (Ghorban, 2016). Because of its half-life, Ir-192 has to be changed 3-4 times a
year. Ir-192 is mostly used worldwide. One reason is the smaller size of the source makes it more
cost effective. Though there are many differences between Co-60 and Ir-192, their characteristics
treatment due to the ability to treat more patients in a day in an outpatient setting. Traditional
HDR used Cobalt-60, which is still widely used in developing countries, but also comes with the
risk of higher toxicities due to its high gamma energy. Recently, the switch to Iridium-192 has
been made, however, is not as economical for some due to the half-life difference, and the
BRACHYTHERAPY: ISOTOPES 12
amount of times a year the source needs to be changed out. In a prospective study with 70
patients from July 2008-March 2009, the toxicity rates with the use of Co-60 are described. HDR
with a dose of 19.5 Gy in 3 weekly fractions was given to patients no earlier than the 3rd week of
their EBRT treatment. The traditional tandem and ring applicator was used with each fraction
having a dose of 6.5 Gy. The results described that 50 % of all patients experienced grade 1
proctitis (Inflammation of the lining of the rectum), and 46% experienced grade 1 diarrhea, and
40% experienced grade 1 cystitis and frequent urination (Ntekim, Adenipekun, Akinlade &
Campbell, 2010). With most side effects being a grade 1 and only 2 patients who experienced
grade 3 diarrhea, the use of Co-60 appears to have the same beneficial factors as Ir-192. Previous
studies mentioned by Ntekim et al., stated that 8% of patients show gastrointestinal toxicity using
Ir-192 (2010).
With both isotopes highly used in different parts of the world, many studies are being
done to examine any other possible comparisons between Co-60 and Ir-192 besides the cost
barrier. Palmer, Hayman & Muscat did a study in 2012 involving only 8 patients, however, were
evaluating the differences of Co-60 and Ir-192. In these 8 patients, identical positions and
applicator loadings were performed, as well as all patients received the identical prescribed dose
to Point A. The results showed that the differences between the 2 isotopes if very minimal. Co-
60 showed a slight 3.3% increase dose to the rectum, which also increased to dose along the
extension of the source axis (Palmer et al., 2012). These results show the slight incidences of Co-
60, however, Wang describes that because Co-60 has a higher gamma energy, it increases the
radiation dose to critical structures such as the rectum and bladder (2014). Also described is that
Ir-192 has a lower gamma energy and limits the dose to those structures, and reduces effects on
normal tissue compared to Co-60. Despite the fact that the use of HDR isotopes in general will
BRACHYTHERAPY: ISOTOPES 13
generate higher complications to structures such as the rectum and small bowel, neither source
Californium-252 recently has been discussed with the use of LDR brachytherapy, but it
also shows promising effects with the use of HDR as well. Cf-252 not only is a neutron/gamma
source, but it also has a high linear energy transfer or LET. This allows for the inhibition of cell
damage repair of the cancer cells. Using Cf-252 for advanced cervical cancer with high
proportions of cells that are radioresistant shows the greatest results (Janulionis et al., 2015). The
study done with 232 Stage IIB patients from 1989-1999 with HDR Cf-252 was done to find
results compared to patients receiving Co-60 ICBT and EBRT. A total of 121 patients received
Cf-252 and 111 received Co-60 HDR. Both groups started ICBT in the 3rd week of the external
beam therapy, with a total dose of 40 Gy with one fraction a week for a total of 5 fractions. The
OS rate of 5, 10, and 15 for patients in both groups were very similar with Cf-252 having a 5-
year rate of 63.6% and Co-60 with a 62.2%. The major difference lies in tumor recurrence and
distant metastasis between the groups (Janulionis et al., 2015). In the group given Cf-252, 92.6%
of patients presented no tumor recurrence and 91.7% presented no distant metastasis. The group
given Co-60, 82.9% showed no tumor recurrence and 87.4% presented no distant metastasis.
That gives a total of a 9.7% difference of the group in tumor recurrence and a 4.3% difference in
distant metastasis. Another major component difference in the isotopes used was the percentage
of patients who experienced adverse effects such as proctitis, cystitis, and hydronephrosis. Only
10.7% experienced effects with Cf-252, however, 13.5% experienced them with Co-60. When
Conclusion
BRACHYTHERAPY: ISOTOPES 14
There are a variety of different treatment methods, variations of treatment types, and
combinations of treatment methods for cervical cancer. These being: surgery, chemotherapy, and
radioactive sources- are placed inside of patients for a particular length of time. Brachytherapy
can further be divided into LDR and HDR treatments. For LDR, Ra-226 and Cs-137 are two
isotopes that have similar characteristics for treatment. However, Ra-226 has a treatment
insertion time of 70 hours, while Cs-137 has a treatment insertion time of only 20 hours. Cf-252
has shown positive results in the treatment of patients with LDR in combination with EBRT. For
HDR, Co-60 and Ir-192 are two isotopes used. These two have similar characteristics when it
comes to treatment, but Ir-192 is cheaper than Co-60 due to its smaller size. When Cf-252 was
used in a study compared to Co-60, about 3% less of the patients treated with Cf-252
experienced adverse side effects. As discussed, there are many advantages and disadvantages
that have been studied between isotopes. Science has truly advanced over time, specifically in
Annotated Bibliography
Banerjee, R., Kamrava, M. (2014). Brachytherapy in the treatment of cervical cancer: a review.
In this review, gynecologic brachytherapy peer-reviewed studies and experiments are focused
on, especially on recent advances in brachytherapy technology and treatment techniques. Patient
evaluation, staging, applicator selection, treatment planning, clinical outcomes, and toxicity are
also reviewed.
BRACHYTHERAPY: ISOTOPES 15
Castillo, M., Astudillo, A., Clavero, O., Velasco, J., Ibez, R., & Sanjos, S. D. (2016). Poor cervical
cancer screening attendance and false negatives. A call for organized screening. Plos One, 11(8).
doi:10.1371/journal.pone.0161403
In this study, data was collected from the records of 374 women diagnosed with cervical
cancer from hospitals in Asturias, Spain. They gathered clinical information, staging, and
all previous cytological data to estimate ratios and confidence intervals to evaluate the
difference in women diagnosed with or without prior screenings. The overall goal was to
evaluate the data to suggest that more screening facilities are needed in rural areas.
Cervical cancer radiotherapy side effects. (n.d.). Retrieved November 28, 2016, from
http://www.cancerresearchuk.org/about-cancer/type/cervical-
cancer/treatment/radiotherapy/cervical-cancer-radiotherapy-side-effects
The Cancer Research UK is a registered charity in England, Wales, Scotland, and the Ilse
of Man. Their website strives to provide information about cancer to the public. This web
page addresses the side effects during and after treatment, the long term side effects,
changes to the womb, ovaries and vagina, the bladder and bowel effects, bleeding and
swelling that is all in relation to cervical cancer.
Cheah, P., Koh, C., Nazarina, A., Teoh, K., & Looi, L. (2016). Correlation of p16INK4a
papillomavirus.pdf
This study was done to detect the relationship between the human papillomavirus and
cervical cancer. The researchers assessed this using p16 immunosuppression within
cancerous cervical lesions, specifically low grade squamous intraepithelial lesions, high
grade squamous intraepithelial lesions, and squamous carcinoma.
Gaur, R., Singh, O., Kumar, M., Patel, A.K., Sharma, D., & Rath, G. (2012). Comparison of low- and
high-dose rate brachytherapy in carcinoma cervix: results from a randomized study. Indian
http://medind.nic.in/iaa/t12/i9/iaat12i9p203.pdf
BRACHYTHERAPY: ISOTOPES 16
This randomized study was done to compare low dose rate (LDR) and high dose rate (HDR)
brachytherapy. 60 patients were randomized into either LDR or HDR groups after completing
external beam therapy. The researchers then assessed and compared the regional control,
toxicity, and side-effects of the two groups.
Gerbaulet, A., Potter, R., Haie-Meder, C., (2002). Cervix carcinoma. In Gerbaulet, A. The GEC ESTRO
This is a chapter from a book that introduces brachytherapy and treatment techniques used for cervical
cancer. It goes into detail about the different applicator settings for both high dose rate and low
dose rate. The various sources used for each treatment were also discussed with the parameters
of the applicators and toxicities that could occur.
Ghorbani, M., Hashempour, M., Azizi, M., & Meigooni, A.S. (2016). Evaluating the effect of various
Australasian College of Physical Scientists and Engineers in Medicine, 39. doi: 10.1007/s13246-
016-0441-2
This study was done to research various applicators and dosimetry parameters for cervical
carcinoma. The various isodoses studied were Iridium-192, Cesium-137, and Cobalt-60 along
with their dose rate constant, radial dose function and isodose curves. Different applicator types
tested included plastic, titanium, and stainless steel.
Janulionis, E., Valuckas, K.P., Liukpetryte, S., Samerdokiene, V., & Atkocius, V. (2015). Californium
versus cobalt brachytherapy combined with external-beam radiotherapy for IIB stage cervical
doi: 10.5114/jcb.2015.55117
This retrospective study compared long-term survival rates, curative effects, and recurrence rates
for stage IIB cervical cancer patients. The two groups studied were either treated with
Californium-252 or Cobalt-60. Survival rates were similar, however tumor recurrence was lower
for the Californium group.
Mobit, P.N., Packianathan, S., He, R., & Yang, C.C. (2015). Comparison of Axxent-xoft, Ir-192, and
This retrospective study compared treatment plans for tandem and ovoid insertion with either
Iridium-192 or Cobalt-60. 10 patients who had received treatment with Ir-192 had their plans re-
run with Axxent-xoft software to have them treated with Co-60 instead. These plans were then
compared for organ-at-risk dose differences and treatment volume percentages.
Marnitz, S., Wlodarczyk, W., Neumann, O., Koehler, C., Weihrauch, M., Budach, V., & Cozzi, L.
(2015). Which technique for radiation is most beneficial for patients with locally advanced
cervical cancer? Intensity modulated proton therapy versus intensity modulated photon
treatment, helical tomotherapy and volumetric arc therapy for primary radiation an
This study was conducted with 20 cervical cancer patients were treated with intensity
modulated radiotherapy delivered by helical tomotherapy, RapidArc therapy, or IMRT
with protons. The planning volume A was the cervix, uterus, pelvic, and, in some cases,
the para-aortic lymph nodes. The planning volume B was the parametrium.
Ntekim, A., Adenipekun, A., Akinlade, B., & Campbell, O. (2010). High dose rate brachytherapy in the
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2934612/
This prospective study is comparing the toxicity of Co-60 to Ir-192 in hopes of switching to Co-
60 for cervical brachytherapy in order to be more economically friendly. 70 patients were
selected who had already received external beam treatment and then were given 3 fractions of
HDR with Co-60. Tumor grades were reviewed after treatment and compared to those with Ir-
192 treatment.
Palmer, A., Hayman, O., & Muscat, S. (2012). Treatment planning study of the 3D dosimetric
differences between Co-60 and Ir-192 sources in high dose rate (HDR) brachytherapy for cervix
This study compared Co-60 and Ir-192 sources when using 3D treatment plans. 8 patients were
separated into the two groups and identical dwell positions and loading was used. Although Co-
60 gave a higher rectal dose, the two isotopes gave near-identical treatments.
BRACHYTHERAPY: ISOTOPES 18
Rideaux, K. (2016). Gynecologic cancers. In Washington, C.M. & Leaver, D (Eds.), Principles and
practice of radiation therapy. (4 ed.) (pp. 740-741). St. Louis, MO: Elsevier.
th
(2012). A phase I study of concurrent weekly topotecan and cisplatin chemotherapy with whole
pelvic radiation therapy in locally advanced cervical cancer: A gynecologic oncology group
This literature review showed phase I of a study using the chemotherapy drug cisplatin
with topotecan in combination with radiation therapy and brachytherapy for the treatment
of patients with cervical cancer. This study was done to evaluate the effectiveness of said
treatment method.
Taev, T., Ptkov, B., & Vratislav, S. (2003). Californium-252 versus conventional gamma radiation
in the brachytherapy of advanced cervical carcinoma. Strahlentherapie und Onkologie, 179. doi:
10.1007/s00066-003-1005-4
This randomized study used 227 women with stage IIB cervical carcinoma and separated them
into one of two treatment groups. One group received Californium-252 neutron treatment
whereas the other group received a combination of Radium or Cesium gamma treatment.
Survival rates and recurrence rates were then compared.
Viswanathan, A. N., Moughan, J., Small, W., Levenback, C., Iyer, R., Hymes, S., . . . & Gaffney, D. K.
(2012). The quality of cervical cancer brachytherapy implantation and the impact on local
recurrence and disease-free survival in radiation therapy oncology group prospective trials 0116
doi:10.1097/igc.0b013e31823ae3c9
grade of cervical cancer. The purpose of this study was to help the quality of life of the
patients to be cancer free with no reoccurrence.
Wakatsuki, M., Kato, S., Kiyohara, H., Ohno, T., Karasawa, K., Tamaki, T., . . . & Nakano, T. (2016).
The prognostic value of rectal invasion for stage IVA uterine cervical cancer treated with
This literature review was based off a study done with 67 patients with stage IVA
cervical cancer were treated with photon radiation therapy. 53 patients had bladder
invasion. 7 patients had rectal mucosal invasion. The other 7 patients had both bladder
and rectal mucosal invasion. Their outcome and prognostic factors were evaluated
following treatment.
Wang, J., Andrae, B., Sundstrm, K., Strm, P., Ploner, A., Elfstrm, K. M., . . . & Sparn, P. (2016).
Risk of invasive cervical cancer after atypical glandular cells in cervical screening: nationwide
In Sweden, records were evaluated from 3,054, 328 women's files who received cervical
cytological testing. 14, 625 of the women had glandular cells appear on their tests, 65,
633 women had high grade squamous intraepithelial lesions, and 244, 168 had low grade
squamous intraepithelial lesions. This study was done to examine the correlation between
atypical glandular cells and cervical cancer.
Wang, X., Tian, J.H., Yang, K., Wang, J., Jiang, L., & Hao, X.Y. (2014). High dose rate versus low dose
rate intracavity brachytherapy for locally advanced uterine cervix cancer. Cochrane Database of
This meta-analysis review evaluated the safety and efficacy of HDR and LDR brachytherapy
with external beam therapy to treat cervical carcinoma. Four studies with 1265 women were used
in the comparison of 5-10 year survival rates, local recurrence, distant metastasis, and organ-at
risk complications.
Wesoa, M., & Jele, M. (2015). Morphometric differentiation of squamous cell carcinoma and
doi:10.5114/pjp.2015.57255
BRACHYTHERAPY: ISOTOPES 20
This study evaluated the differences between two types of cervical cancers in women:
squamous cell carcinoma and adenocarcinoma. The morphometric characteristics of each
type were assessed and compared.