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Computed tomography-based analysis of dose distribution to pelvic lymph nodal stations by intracavitary brachytherapy in radical treatment of cervical carcinoma - an institutional prospective observational study
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Received: ,
Accepted: ,
How to cite this article: Vempati V, Keesara SR, Muddana SST, Palkonda VAR, Ganesan P, Upadhyay P. Computed tomography-based analysis of dose distribution to pelvic lymph nodal stations by intracavitary brachytherapy in radical treatment of cervical carcinoma - an institutional prospective observational study. South Asian J Cancer. 2026;15:106-13. doi: 10.25259/SAJC_55_2025
Abstract
Objectives:
Carcinoma of the cervix is the fourth most frequent cancer in women globally. The uterine cervix has a rich lymphatic supply. Lymph node involvement is one of the negative prognostic factors. Treatment for carcinoma cervix involves a combination of external beam radiation therapy with concurrent chemotherapy, followed by brachytherapy with intracavitary or interstitial technique. While prophylactic nodal irradiation to pelvic nodes is routinely done, a simultaneous integrated boost is given to gross lymph nodes. This study aims to evaluate the dose contribution to the pelvic lymph node regions during brachytherapy.
Material and Methods
A prospective observational study was conducted at an oncological centre in Hyderabad between March 2024 and April 2025. The study included 23 patients diagnosed with cervical cancer. Eligibility criteria required patients to have an Eastern Cooperative Oncology Group (ECOG) performance status score ranging from 0 to 2 at the time of enrolment. Eligible patients received radical radiation therapy with concurrent chemotherapy followed by three fractions of high dose rate (HDR) intracavitary brachytherapy (7 Gy each to Point A). CT-based planning with modified Fletcher applicators was performed, with pelvic lymph node groups and organs at risk contoured per RTOG/ABS (Radiation Therapy Oncology Group/American Brachytherapy Society) guidelines. Dose–volume histogram (DVH) parameters (D100, D98, D90) for nodal stations were analysed and normalised to the Point A dose. Treatment planning was executed on Oncentra v4.3 and delivered using an Ir-192 source. The study aimed to estimate nodal dose contributions relative to Point A and assess organ-at-risk constraints during brachytherapy.
Results:
23 cervical cancer patients (median age 54 years) were enrolled, most presenting in FIGO stage IIIC; 78% had adenocarcinoma. Dose–volume histogram analysis of pelvic nodal groups during HDR intracavitary brachytherapy (7 Gy to Point A) showed wide variation in nodal dose contributions. Against a dose of 7Gy to Point A, the obturator nodes received the highest mean D90 (≈1.5 Gy; ~21.6% of the Point A dose), while the common iliac nodes received the lowest (≈0.17 Gy; ~2.5%). External iliac nodes averaged ~0.55 Gy (≈7.9%), internal iliac ~0.89 Gy (≈12.6%), and presacral nodes ~1 Gy (≈14.3%). Bilateral averages confirmed this gradient, with obturator nodes consistently highest and common iliac lowest.
Conclusion:
This study demonstrates that pelvic lymph nodes receive measurable dose contributions from standard Fletcher applicator–based HDR brachytherapy in radical cervical cancer treatment. The obturator nodes consistently received the highest relative dose, while the common iliac nodes received the lowest.
Keywords
Brachytherapy
Carcinoma
Cervix
Image-guided
Lymph nodes
INTRODUCTION
Carcinoma of the cervix is the fourth most frequent cancer in women globally.[1] The uterine cervix has a rich lymphatic supply. Lymph node involvement is one of the negative prognostic factors, and usually it is considered in the general treatment strategy along with other factors.[2,3]
A combination of external beam radiation therapy with concurrent chemotherapy followed by brachytherapy is the standard of care in the treatment of locally advanced cervical cancer.[4-8] The first component aims to cover the low-risk clinical target volume (CTV), including lymph node areas. The second aims to escalate the dose to the cervical tumour itself. The recommended dose in external beam radiation therapy (EBRT) to cover the low-risk CTV varies from 45 Gy to 50 Gy. This dose range is considered effective to treat microscopic disease, but is too low a dose to treat macroscopic lymph nodes. It is therefore recommended to boost pathological nodes, although the optimal dose to reach remains debated.[9]
Pathologically enlarged lymph nodes can be treated by EBRT boost using simultaneous integrated boost or sequential boost after completion of elective whole pelvic irradiation. Although the EBRT dose to lymph nodes is usually planned, the dose contribution from brachytherapy is most often not reported, and hence its impact on lymph node control has not been assessed.
Intensity modulated radiotherapy (IMRT) technique allows the use of simultaneous integrated boost (SIB) in the pathologic nodes, requiring integration of the initial EBRT treatment plan and the dose contribution to pelvic nodes by brachytherapy. Presently, limited data have been reported on dose contribution from image-guided adaptive brachytherapy to the pelvic nodes.[10,11] The aim of this study is to refine these findings by investigating the contribution of Brachytherapy to the pelvic lymph nodal stations and to propose SIB dose per fractionation.
MATERIAL AND METHODS
This is a prospective observational study conducted on 23 patients from March 2024 to April 2025 at an Oncological institute in Hyderabad. Patients who were older than 18 years of age, with PS ECOG 0-2 with pathologically proven cervical cancer receiving radical radiation therapy with concurrent chemotherapy, followed by intracavitary brachytherapy, who were willing to give consent to participate in the study were included.
Patients with a history of prior irradiation to the cervix, distant metastases, post-surgery patients receiving adjuvant radiation therapy, histologies like sarcoma, and neuroendocrine tumours were excluded.
Patients eligible for the study were counselled in detail and, after taking informed consent, were started on protocol-based treatment. Baseline performance score, general and tumour-specific clinical examination, and lab data were recorded. Interim clinical examination of the tumour by per vaginal, per speculum, and per rectal examination at 3 weeks of EBRT, at the end of EBRT, and prior to each brachytherapy application.
Procedure for brachytherapy
One day prior to the application, all patients were prescribed laxatives to achieve proper rectal emptying. All patients underwent 3 intracavitary brachytherapy insertions. Pain control was achieved with conscious sedation. Each patient was positioned in the lithotomy position and catheterised prior to the procedure. Examination of the tumour by pelvic examination was carried out. Modified Fletcher tandem and ovoid applicators were used for insertion, and the applicators were secured in place with vaginal packing. The patient was made to lie in the treatment position with arms by the side. A contrast-enhanced CT scan of the pelvis with a slice thickness of 2mm was taken as part of the simulation.
Brachytherapy contouring and constraints
Various pelvic lymph nodal stations were contoured.[12-16] Organs at risk, i.e., rectum, bladder, sigmoid colon, head of femur, were contoured as per RTOG contouring guidelines. Dose volume histograms corresponding to the brachytherapy plan were generated, and constraints for OAR were applied according to ABS guidelines.[17]
Definitions of pelvic lymph node boundaries were created using the RTOG guidelines for delineating clinical target volume for IMRT for postoperative endometrial and cervical cancers.[18,19]
The common iliac, presacral, external iliac, internal iliac, and obturator lymph node groups were contoured. All nodal groups, except for presacral, were contoured as separate left-and right-sided structures with the generation of a combined bilateral structure. Contours were created by adding a uniform 7-mm margin around the vessels with exclusion of muscle, bone, and bowel. The presacral contour was created by adding a 1.5 cm margin extending from the anterior aspect of the vertebral body.
During treatment planning, Point A was defined as 2 cm superior to the superior aspect of the ovoids along the length of the intrauterine tandem and 2 cm lateral and perpendicular to the tandem.[20] Left, right, and bilateral averages of the Point A prescription dose were collected for each fraction.
To analyse each treatment session, various DVH parameters were collected for the 5 lymph node groups of interest. These values included the D100, D98, and D90 (dose to maximally irradiated 100%, 98%, and 90% of the volume, respectively). D90 was of particular interest because it is the standard parameter for reporting dosage to target volumes.[21] Left-sided (L), right-sided (R), and bilateral (Bil) values were collected for each parameter. The DVH values for each fraction were normalised as a percentage of the corresponding Point A dose from the same fraction [e.g., (B/L Obturator D90/B/L Point A) 100x]. An average and standard deviation of the normalised values were calculated to establish an estimate of nodal dose in relation to the Point A prescription dose.
The prescribed brachytherapy doses were an HDR dose of 7 Gy per fraction. All doses were prescribed to Point A as per ICRU 38. Treatment planning was done in the Oncentra treatment planning system version 4.3. Treatment was delivered on Nucletron MicroSelectron HDR brachytherapy with Iridium 192 source. At each application of brachytherapy, the dose contribution to various pelvic nodal stations and the dose contribution to organs at risk were assessed.
RESULTS
A total of 23 patients aged 75 or younger were enrolled in the study. The mean age was 53.11 years, and the median age was 54 years. Most of the patients presented in FIGO Stage IIIC. 18(78.26%) patients have adenocarcinoma.
Mean absolute value of D90 of right common iliac lymph nodes is 0.16 Gy against a dose of 7 Gy to Point A. The right common iliac lymph nodal region received the lowest dose with each fraction of intracavitary brachytherapy. Mean absolute value of D90 of left common iliac lymph nodes is 0.18 Gy against a dose of 7 Gy to Point A. The left common iliac lymph nodal region received a relatively low dose with each fraction of intracavitary brachytherapy [Figures 1a and b]. Mean absolute value of D90 of right external iliac lymph nodes is 0.54 Gy against a dose of 7 Gy to Point A. Mean absolute value of D90 of left external iliac lymph nodes is 0.57 Gy against a dose of 7 Gy to Point A. Mean absolute value of D90 of right internal iliac lymph nodes is 0.88 Gy against a dose of 7 Gy to Point A. Mean absolute value D90 of left internal iliac lymph nodes is 0.9 Gy against a dose of 7 Gy to Point A. Mean absolute value D90 of right obturator lymph nodes is 1.51 Gy against a dose of 7 Gy to Point A. Obturator group of lymph nodes received highest dose among the pelvic lymph nodal stations during each fraction of intracavitary brachytherapy. Mean absolute value of D90 of left obturator lymph nodes is 1.52 Gy against a dose of 7 Gy to Point A. Obturator group of lymph nodes received the highest dose among the pelvic lymph nodal stations during each fraction of intracavitary brachytherapy [Table 1].
| Dosimetric parameters | Right Common Iliac Lymph nodes | Left Common Iliac Lymph nodes | Right External Iliac Lymph nodes | Left External Iliac Lymph nodes | Right Internal Iliac Lymph nodes | Left Internal Iliac Lymph nodes | Right Obturator Lymph nodes | Left Obturator Lymph nodes | Presacral Lymph nodes |
|---|---|---|---|---|---|---|---|---|---|
| D 100 (Gy) | 0.13 | 0.16 | 0.22 | 0.27 | 0.45 | 0.44 | 0.96 | 0.93 | 0.56 |
| D 98 (Gy) | 0.13 | 0.14 | 0.49 | 0.44 | 0.70 | 0.64 | 1.25 | 1.31 | 0.79 |
| D 90 (Gy) | 0.16 | 0.18 | 0.54 | 0.57 | 0.88 | 0.90 | 1.51 | 1.52 | 1.0 |
Gy: Gray (unit of absorbed radiation dose).
Mean values of D90 of right and left common iliac lymph nodes, normalised as a percentage of the corresponding Point A dose, are 2.3 % and 2.6 %, respectively, against a dose of 7 Gy to Point A. Mean values of D90 of Right and Left External Iliac Lymph Nodes normalized as a percentage of corresponding Point A dose are 7.7 % and 8.1 % respectively against a dose of 7 Gy to Point A. Mean values of D90 of Right and Left Internal Iliac Lymph Nodes normalized as a percentage of corresponding Point A dose are 12.5 % and 12.8 % respectively against a dose of 7 Gy to Point A. Mean values of D90 of Right and Left Obturator Lymph Nodes normalized as a percentage of corresponding Point A dose are 21.5 % and 21.7 % respectively against a dose of 7 Gy to Point A. Mean value of D90 of Presacral Lymph Nodes normalized as a percentage of corresponding Point A dose is 14.3 % against a dose of 7 Gy to Point A [Table 2].
| Nodal group | Mean of D90 expressed as a % of Point A |
|---|---|
| Right common iliac nodes | 2.3% |
| Left common iliac nodes | 2.6% |
| Right external iliac nodes | 7.7% |
| Left external iliac nodes | 8.1% |
| Right internal iliac nodes | 12.5% |
| Left internal iliac nodes | 12.8% |
| Right obturator nodes | 21.5% |
| Left obturator nodes | 21.7% |
| Presacral nodes | 14.3% |
Mean absolute values of D90 of bilateral common iliac, bilateral external iliac, bilateral internal iliac, bilateral obturator, and presacral lymph nodes are 0.25 Gy, 0.82 Gy, 1.33 Gy, 2.27 Gy, 1 Gy, respectively, against a dose of 7 Gy to Point A with corresponding percentages as mentioned in the above table. The obturator nodal region received the highest dose, and the common iliac the lowest [Table 3, Graph 1].
| Nodal group | Mean absolute D90 (Gy) | Mean + SD absolute D90 (Gy) | Mean absolute D 90 normalised as a % corresponding Point A dose | Mean + SD D90 (% of Point A) |
|---|---|---|---|---|
| Bilateral common iliac nodes | 0.25 | 0.25 ± 0.09 | 3.6% | 3.6 % ± 1.2 |
| Bilateral external iliac nodes | 0.82 | 0.82 ± 0.16 | 11.8% | 11.8 % ± 2.3 |
| Bilateral internal iliac nodes | 1.33 | 1.33 ± 0.31 | 19% | 19 % ± 4.5 |
| Bilateral obturator nodes | 2.27 | 2.27 ± 0.49 | 32.4% | 32.4 % ± 7 |
| Presacral nodes | 1 | 1 ± 0.32 | 14.3% | 14.3 % ± 4.6 |
G : Gra t of absorbed radiation dos D: Standard deviation.
Mean values of D2cc of organs at risk, i.e., rectum, urinary bladder, right head of femur, left head of femur, sigmoid colon, are 4.7 Gy, 6.55 Gy, 0.96 Gy, 1 Gy, 3.48 Gy, respectively, against a dose of 7 Gy to Point A. Dose constraints were achieved well for all the organs at risk [Table 4].
| OAR | Mean + Standard deviation of |
|---|---|
| D2cc (Gy) | |
| Rectum | 4.79 ± 1.2 |
| Bladder | 6.55 ± 1.4 |
| Right head of the femur | 0.96 ± 0.1 |
| Left head of femur | 1.02 ± 0.1 |
| Sigmoid colon | 3.48 ± 1.5 |
D2cc: Dose received by 2 cc of a specific organ at risk in a single patient. It represents the maximum dose received by that specific organ. OAR: Organs at risk, Gy: (Gray unit of absorbed radiation dose).
DISCUSSION
In this study, we aimed to define a relationship between the prescription dose to Point A and the dose delivered to various pelvic lymph node groups during CT-based HDR Brachytherapy for the treatment of cervical cancer. The results of our study show relationships between Point A and nodal doses to be fairly consistent.
Grossly involved pathological pelvic lymphadenopathy has been consistently correlated with inferior outcomes in locally advanced cervical carcinoma.[22] Adequate coverage of regional pelvic lymphatics to eradicate microscopic disease and treat grossly involved lymphadenopathy with tumoricidal boost doses is a critical determinant of clinical outcomes.[23] More accurate estimation of nodal dose during brachytherapy is required for appropriate doses to the regions of involved pelvic lymph nodes, particularly in patients receiving an External Beam nodal boost.
Previous published studies have shown the advantage of radiation dose escalation to 55.8 - 65 Gy to obtain adequate local control in grossly involved pelvic and periaortic lymphadenopathy.[24-27] In addition, nodal disease control has been shown to correlate with nodal bulk and size.
The American College of Radiology appropriateness criteria recommend a total dose of 60 Gy to grossly involved lymphadenopathy that is not surgically resected, with strict respect to dose tolerances of organs at risk (OARs).[28] Specifically, relevant to this study, the American Brachytherapy Society consensus treatment guidelines for low- and middle-income countries recommend a nodal boost of 60 - 70 Gy when 3D conformal external beam treatment planning is available.[29]
Early reports evaluating nodal dose based on the Manchester system criticised Point B as a poor surrogate for obturator nodal dose, as it does not always represent the absorbed dose, depending on the variability of patient anatomy.[30] Two studies examining the correlation between Point B and pelvic lymph node coverage using 3D CT-based planning similarly found poor correlation of Point B with regional nodal absorbed dose.[21,31] Instead, it was concluded that 3D-based contouring and volume-based dose reporting remain the best way to determine cumulative nodal dose in patients receiving an EBRT boost to the nodal regions.[21] The significant correlation of nodal D90 with Point A defined by our study helps to overcome these limitations and guide physicians to calculate nodal dose during brachytherapy.
The highest dose contribution from brachy therapy is to the obturator and internal iliac nodes. There are multiple retrospective studies done evaluating the dose contributed by intracavitary brachytherapy to Point A.[32-35] Our study results were consistent with the existing studies. [Table 5]
| Nodal group | Our study | Bacorro et al. (2017) | Weaver et al. (2017) |
|---|---|---|---|
| Brachytherapy dose | 7Gy/fr | PDR BT | 5-7Gy/fr |
| Mean -5.9Gy/fr | |||
| Bilateral common iliac nodes | 0.25 | 2.6 | 0.52 |
| Bilateral external iliac nodes | 0.82 | 4.6 | 0.57 |
| Bilateral internal iliac nodes | 1.33 | 6.4 | 0.73 |
| Bilateral obturator nodes | 2.27 | 4.8 | 1.18 |
| Presacral nodes | 1 | 2.0 | 0.25 |
Gy: Gray unit of absorbed radiation dose, PDR BT: Pulsed Dose Rate Brachytherapy.
Considering that brachytherapy dose contributions to Pelvic Lymph Nodes are usually thought to be negligible and not considered during radiotherapy planning, on the contrary, our results show that these doses are substantial and should not be ignored. Clinicians may take this data as a reference, for example, in planning boost doses to grossly involved pelvic lymph nodes. However, there is an important caveat to the application of our results: nodal regions are anatomically complex and can include nodes that are at substantially different distances from brachytherapy sources. Due to the rapid fall-off of radiation dose with distance from the source, nodes that are closer may receive substantially higher doses than nodes that are further away, even though they are located within the same nodal region. As the mean doses we have calculated are single average values across each nodal region, the radiation oncologist must exercise clinical judgment in applying our results, always considering the location of the involved node in relation to the brachytherapy source.
Several observations have also been made on further analysis of our results. First, we noted that the Common Iliac nodal group received the lowest doses, followed by the external iliac group, the presacral group, the internal iliac group, and the obturator group. Relatively high Obturator nodal doses have also been observed in a previously published study.[32-35] This is likely due to the fact that the Obturator lymph node region is situated most inferiorly and medially, and thus closest to the applicators.
Table 6 shows a sample calculation of the boost required to reach a total D90 of 60 Gy in the right obturator node following 50 Gy of whole-pelvis EBRT and a cumulative brachytherapy Point A prescription dose of 21 Gy in three fractions.
| Whole-pelvis EBRT dose | Calculated brachytherapy contribution | Total nodal dose without boost | Boost dose required to reach 60 Gy | Boost dose to be delivered |
|---|---|---|---|---|
| 50 Gy | 21 Gy x 0.215 = 4.51 Gy | 54.5 Gy | 5.5 Gy | 2 Gy x 3 frs =6 Gy |
EBRT: External beam radiation therapy, Gy: Gray unit of absorbed radiation dose.
Table 7 shows a sample calculation of the boost required to reach a total D90 of 60 Gy in the right obturator node following 45 Gy of whole-pelvis EBRT and a cumulative brachytherapy Point A prescription dose of 28 Gy in four fractions.
| Whole-pelvis EBRT dose | Calculated brachytherapy contribution | Total nodal dose without boost | Boost dose required to reach 60 Gy | Boost dose to be delivered |
|---|---|---|---|---|
| 45 Gy | 28 Gy x 0.215 = 6.02 Gy | 51 Gy | 9 Gy | 1.8Gy x 5frs =9Gy |
EBRT: External beam radiation therapy, Gy: Gray unit of absorbed radiation dose.
The advent of IMRT with simultaneous integrated nodal boost technique has shown clinical promise and increased utilisation in the management of locally advanced cervical carcinoma, making the customisation of nodal boost dose with planned brachytherapy imperative.[36-38]
Our results and those available in the literature give indications to anticipate the contribution of brachytherapy to the treatment of pelvic nodes. This is particularly important as the use of SIB is increasing. The mean doses delivered to the obturator, presacral, and internal iliac nodes range from 3 – 5 Gy for three fractions of intracavitary brachytherapy with 7 Gy prescribed to Point A per fraction. For external iliac and common iliac nodes, which are more distant, the EQD2 contribution is significantly less, about 1 - 2.5 Gy.
Relying on a pelvic EBRT dose of 50 Gy delivered with a fractionation of 2 Gy x 25 and an aim of reaching 60 Gy to pathological lymph nodes, we can define two SIB's from our study results:
2.2 Gy x 25 (55 Gy, 55.9 in EQD2) in the obturator, internal iliac, and presacral nodes
2.3 Gy x 25 (57.5 Gy, 58.9 in EQD2) in the external iliac and common iliac nodes
The dose levels of 2.2 Gy and 2.3 Gy per fraction in nodes of the true pelvis and outside the true pelvis, respectively, are currently used in the EMBRACE II study.[39]
Since external beam IMRT planning and often delivery are completed before brachytherapy, estimating brachytherapy dose contribution from Point A to the Lymph node stations can be utilised in designing a simultaneous integrated boost dose to the Lymph node areas.
Our study is limited by minimal diversity, a small number of patients assessed, and being treated at a single institute, which may be biased toward regional demographics and patient characteristics. This may reduce the applicability of this data when applied to different patient populations. Institutional variance in treatment planning and differences in uterine and vaginal loading patterns may also affect nodal doses. In addition, only patients treated with tandem and ovoid applicators were included in this study, and hence, the results of this study may not be applicable to other types of applicators.
We recognise that there is potential for pelvic lymph node movement, both during EBRT and brachytherapy, which is not specifically quantified in the contouring guidelines. However, as we are considering the nodal regions as a group, the impact on dosimetry is likely to be relatively smaller than if we were considering the pathologically involved nodes themselves.
There are other factors that may have an impact on tumour control, such as initial nodal PET-avidity and the number of chemotherapy cycles received. Hence, our dosimetric results should be placed in context. Attention should be paid to giving: 1) an adequate dose of chemotherapy and 2) close follow-up of patients with highly PET-avid nodes (if initial PET scans are available) for monitoring of potential nodal recurrences, along with giving adequate radiation dose to the lymph node.
While our study has considered cases treated under the point-based treatment planning system, we recognise that centres are increasingly moving towards volume-based treatment planning, as well as combined intracavitary and interstitial brachytherapy systems. Under the GEC-ESTRO working group recommendations, high-risk (HR) CTV and intermediate- risk (IR) CTV areas should be delineated. The high-risk area receiving a total dose of greater than 80 Gy from EBRT and brachytherapy combined, and the intermediate risk area receiving a total dose of at least 60 Gy, should be delineated. Ideally, an MRI should be obtained with each brachytherapy fraction, and the target should be modified with each fraction. With volume-based planning, we would expect the doses received by the PLNs to be influenced by the volumes of the HR and IR CTVs, potentially resulting in more inter-patient variation depending on anatomical differences as well as the extent of disease.
This study determines cumulative doses to at-risk and involved Nodal regions. Although defining a relationship between Point A and nodal doses during CT-based treatment planning is important, further investigation assessing if a similar relationship is found in MRI-based planning or with hybrid intracavitary/interstitial applicators is warranted to validate our findings and may be more applicable to centres with higher resource utilisation and modern image-guided adaptive MRI-based brachytherapy delivery.
TAKE HOME MESSAGE
Our study demonstrates that Pelvic Lymph Nodes receive a significant dose contribution from standard Fletcher suit applicator-based HDR brachytherapy in the radical treatment of cervical cancer, with relatively high dose received by the Obturator group of Lymph nodes and the lowest by the common iliac group of lymph nodes, which is consistent with results of existing data. Relying on a pelvic EBRT dose of 50 Gy delivered with a fractionation of 2 Gy x 25 and an aim of reaching 60 Gy to pathological lymph nodes, we can define two SIB's from our study results:
2.2 Gy x 25 (55 Gy, 55.9 in EQD2) in the obturator, internal iliac, and presacral nodes
2.3 Gy x 25 (57.5 Gy, 58.9 in EQD2) in the external iliac and common iliac nodes
The dosimetric results of this study serve as a guide for the radiation oncologist to estimate doses received by involved lymph nodes from brachytherapy and to take them into account during the prior external beam radiation planning phase.
Ethical approval:
The study approved by the Institutional Ethics committee at Apollo Hospitals, Hyderabad, number EC/NEW/INST/2020/519, dated 18th September 2020.
Declaration of patient consent:
Patient's consent not required as patients identity is not disclosed or compromised.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
Use of artificial intelligence (AI)-assisted technology for manuscript preparation: The authors confirm that they have used artificial intelligence (AI)-assisted technology solely for language refinement and to improve the clarity of writing. No AI assistance was employed in the generation of scientific content, data analysis or interpretation.
Financial support and sponsorship: Nil.
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