However, considering the clinical stage III a wide range of results has been found in the literature [31–36]. Vahrson and Romer [14] reported a significantly greater survival rate for stage-III patients using HDR brachytherapy. In the series of Ferrigno et al [37] stage-III patients treated with HDR brachytherapy had a poorer outcome when compared with those treated with LDR brachytherapy. Overall survival and disease-free survival at a 5-year period was statistically superior in the

LDR group. These results probably are caused by the different tumor-related prognostic factors in stage-III patients, including tumor volume, extension of parametrial invasion (unilateral or bilateral), presence of hydronephrosis, lymph node metastasis, and extension of this website vaginal involvement. Consequently, when these patients do not receive radiotherapy combined to chemotherapy, they may still have a large volume of disease at the time of brachytherapy, even if one waits until the end of 5 weeks of daily treatment. With a large tumor volume at brachytherapy, point-A prescription SAHA HDAC price simply does not cover the tumor volume. The current treatment plan and technique for gynecological brachytherapy is still based on the conventional, orthogonal film-based approach developed 40 years ago. The source loading and dose prescription of a conventional point-A plan in cervical cancer is not consistent

with the individual tumor extent, resulting in either undercoverage of the tumor extent or unnecessary BI 10773 solubility dmso dosage of the surrounding normal tissue. So, in order to safely treat large volume disease (i.e. stage-IIIB patients), three dimensional

(3D) image-based treatment planning is necessary to ensure proper tumor coverage. Several investigators have studied three dimensional (3D) image-based brachytherapy planning using ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and positron-emission tomography (PET) in cervical cancer [38–46]. Although the studies had some different findings, the conventional point-A plan, compared with the 3D image-guided plan, generally overestimated the minimal dose delivered to the target volume and underestimated the maximal doses Phosphatidylethanolamine N-methyltransferase to the rectum and bladder [40, 42–46]. In addition to that, 3D image-guided planning allows the evaluation of individual dose distributions applied to a certain volume, such as the gross tumor volume (GTV), clinical target volume (CTV), and organs at risk. Recently, the GEC-ESTRO working group for gynecologic brachytherapy introduced guidelines for contouring the target volumes and organs at risk (OARs) for 3D image-based treatment planning in cervical cancer [41]. It is therefore imperative with HDR for large volume disease that the practitioners contour the normal tissues and look at the dose volume values to try to minimize normal tissue dose. Despite these limitations for large tumors (i.e.