Practical Considerations During Brachytherapy Applicator Placement for Locally Advanced Cervical Cancer.

Brachytherapy is an integral part of the definitive treatment for locally advanced cervical cancer (LACC) following external beam radiation therapy (EBRT). Placement of brachytherapy applicators is an important skill for radiation oncologists and care must be taken to place applicators appropriately to limit complications associated with the procedure and ensure that the radiation dose sufficiently covers the target while sparing the surrounding organs at risk (OARs). Using example cases, we discuss strategies for the placement of brachytherapy applicators in patients with anatomical considerations such as large obstructing uterine fibroids and the retroverted uterus. We also discuss the management of uterine perforation during applicator placement and approaches to patients with a poor response to EBRT prior to brachytherapy delivery. We draw upon the available literature and our clinical experience to suggest approaches to these challenging scenarios.