Appropriate Methodology for EBRT and HDR Intracavitary/Interstitial Brachytherapy Dose Composite and Clinical Plan Evaluation for Patients With Cervical Cancer

Purpose: This study assessed the appropriateness of full parameter addition (FPA) methods with respect to the 3-dimensional deformable dose composite method for evaluating combined external beam radiation therapy (EBRT) and intracavitary brachytherapy (ICBT). Methods and Materials: A total of 22 patients who received EBRT and high-dose-rate ICBT were retrospectively evaluated. Split-ring and tandem applicators were used for all patients. Additional interstitial needles were used for 5 patients to supplement the implant. Deformable image registrations were performed to deform the secondary EBRT and ICBT planning computed tomography (CT) images onto the reference CT from the third fraction of ICBT. The Dice similarity coefficient was used to evaluate the quality of deformable registration. Doses were transferred to the reference CT, scaled to the equivalent dose in 2-Gy fractions and combined to create the dose composite. Eight dose-accumulation methods were evaluated and compared. D_2cc and D_0.1cc for organs at risk were investigated. Results: The differences in D_2cc for rectum, bladder, sigmoid, and bowel between the FPA method for whole-pelvis EBRT and ICBT, calculated using an old American Brachytherapy Society worksheet (FPA_E_h + I_old) and deformable composite for EBRT with boosts and ICBT (Def_E + B + I) were –2.19 ± 1.37 Gy_{α/β = 3}, –0.64 ± 1.13 Gy_{α/β = 3}, –2.06 ± 2.71 Gy_{α/β = 3}, and –1.59 ± 0.89 Gy_{α/β = 3}, respectively. The differences in D_2cc for rectum, bladder, sigmoid, and bowel between the new ABS worksheet (FPA_E_h + B + I_abs) and the Def_E + B + I method were 1.21 ± 1.22 Gy _{α/β = 3}, 1.93 ± 1.38 Gy_{α/β = 3}, 0.72 ± 1.12 Gy_{α/β = 3}, and 1.19 ± 1.46 Gy_{α/β = 3}, respectively. Differences in dose-volume histogram parameter values among Def_E + B + I and other FPA methods were not statistically significant (P > .05). Conclusions: Compared with the FPA-based method, deformable registration–based dose composites demonstrated lower OAR D_2cc and D_0.1cc values; however, the differences were not statistically significant. The current ABS-recommended FPA-based sheet can serve as an acceptable plan evaluation tool for clinical purposes.