Brachytherapy (BT) is an essential component in the curative treatment of cervical cancer. With commercial BT implant devices, called applicators, the radioactive sources can only be positioned in fixed intracavitary channels or in a fixed array of interstitial needles. Patient-tailored BT applicators containing individualised needle channels have the potential to enhance the delivered dose to the tumour while minimising tissue damage of the organs-at-risk (OARs). During the optimisation process of the needle channels, several constraints must be considered. The needle paths in the applicator are curvature-constrained, and the needles should not collide with each other or potentially perforate OARs. Furthermore, clinicians can impose additional constraints based on their preferences.

Existing approaches in literature for optimising needle placement in patient-tailored BT applicators for cervical cancer treatment have employed various algorithms. However, these approaches often rely on significant approximations. For instance, some assume that all needles are inserted in parallel or focus solely on optimising geometric coverage as opposed to optimising the dose distribution. Moreover, the few methods in literature incorporating needle path planning in the optimisation process require manually pre-specified dwell positions. To improve dose conformity and minimise the dependence on the clinician’s expertise and time, there is a need for the development of software that optimises the needle placement and paths without resorting to these severe assumptions.
This work proposes and validates a novel three-stage approach to generate a patient-tailored applicator configuration without resorting to fully geometric optimisation. First, a high-potential set of dwell positions is obtained by running a modified version of the dwell time optimisation software BiCycle (Erasmus Medical Centre, Rotterdam, the Netherlands) on a grid of possible dwell positions. This results in a resolution optimal treatment plan when not considering geometry and applicator constraints. The positions with the highest dwell times according to the resolution optimal treatment plan are selected in the high-potential set. Next, a weighted set cover problem is used iteratively to find a combination of feasible needle segments to cover all dwell points in the high-potential set at a minimum distance. Lastly, needle channels to steer the needle to these segments are simultaneously optimised to be of minimum curvature and mutually collision-free.

To evaluate our approach, a virtual configuration and planning study was performed in a cohort of 22 locally advanced cervical cancer patients previously treated with the Venezia (Elekta AB, Stockholm, Sweden). The resulting treatment plans of the clinically used configuration were compared with the resulting treatment plans of the proposed patient-tailored and grid configurations on clinically relevant dose-volume histogram parameters, dwell times, conformity index and number of interstitial needles. Statistical significance is assessed with Wilcoxon signed-rank tests.

The proposed workflow was demonstrated to be feasible, and for every patient, a configuration could be generated in clinically acceptable time. All treatment plans generated for the grid configuration, the patient-tailored configuration and the clinical configuration were acceptable following the EMBRACE ll aims. Planning aims, however, were met more frequently with both the grid configurations (145/151 instances) and the patient-tailored configurations (137/151 instances) in comparison with the clinically used configurations (119/151 instances). The treatment plans generated with the grid configurations obtained significantly better (p < 0.01) median normalised CTVIR D98 dose with respect to the clinical configurations. Moreover, with the grid configurations, there was a significant improvement in median normalised D2cm3 dose for the bladder (p < 0.001), rectum (p < 0.001), sigmoid (p < 0.01) and bowel (p < 0.001) compared to treatment plans obtained with the clinical configurations. The treatment plans generated with the patient-tailored configurations obtained comparable target doses, but median normalised D2cm3 doses for the bladder (p < 0.001), rectum (p < 0.01) and bowel (p < 0.01) were significantly better for the patient-tailored configurations compared to the clinical configurations.

The proposed automated patient-tailored BT source channel configuration planning method was demonstrated to be clinically feasible. The resulting treatment plans have dosimetric advantages over the treatment plans generated with the clinical applicator configuration. Improvements to the intracavitary dwell position placement are expected to further increase dose conformity.