Personalized brachytherapy in gynecological cancers: procedural narrative in patients with a poor response or challenging anatomy after chemoradiation.

Purpose: Brachytherapy plays a critical role in managing gynecological cancers. However, for patients who have a poor response to chemoradiation or present with complex anatomy, delivering tumoricidal doses may be challenging. In this case series, we present a descriptive narrative of techniques adopted for brachytherapy, dosimetric and early clinical outcomes for such clinical challenging cases. Material and methods: Patients who had a poor response to chemoradiation or with challenging anatomy received individualized brachytherapy between 2021 and 2023. All underwent pre-brachytherapy clinical assessment and MRI. These patients were treated with personalized brachytherapy techniques based on tumor extent and anatomy. Manual dose optimization and adjustments to dose fractionation were tailored on a case-by-case basis maximizing tumor control and limiting organ-at-risk doses. Results: In the six patients included in this report, the median high-risk clinical target volume (HR-CTV) volume was 51.1 cc. For each patient, the implant was individualized using a combination of applicators, 3D-printed applicators or freehand needles. At a median follow-up of 31 months, three out of six patients were locally controlled. Out of the three patients with locally controlled disease, one patient developed grade 2 posterior fourchette necrosis. Conclusions: Though the results provide a descriptive narrative, they also highlight a clinical care gap that brachytherapy alone cannot yet address for patients. Advancing individualized brachytherapy by incorporating novel agents and techniques may help improve treatment outcomes.