THIEME 1 Letter to the Editor From Point A to MRI-Guided Brachytherapy in Cancer Cervix: Rationalizing Brachytherapy Practice in India Sajal Goel 1 Munish Gairola 2 Anil K. Dhull 3 Vikas Roshan 4 Meenakshi Mittal 5 1 Department of Radiation Oncology, Patel Hospital, Jalandhar, Punjab, India 2 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, Rohini, Delhi, India 3 Department of Radiation Oncology, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India 4 Department of Radiation Oncology, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu and Kashmir, India 5 Department of Radiation Oncology, Ivy Hospital, Chandigarh, India Address for correspondence Sajal Goel, DNB, Department of Radiation Oncology, Patel Hospital, Civil Lines, Jalandhar 144001, Punjab, India (e-mail: drsajal.goel@gmail.com). DOI https://doi.org/ 10.1055/s-0039-3401473 ISSN 2454-6798. ©2019 Spring Hope Cancer Foundation & Young Oncologist Group of Asia Asian J Oncol Cervical brachytherapy practice in India is diverse. The choice of appropriate technique depends on residual tumor topography at brachytherapy, availability of applicators, and expertise. Image-based interstitial brachytherapy adequately cov- ers parametrial and posterior disease, prevents overdosage to critical organs in small cervix, and spares sigmoid colon better. 1 The residual tumor in pelvis should be thoroughly assessed using clinical examination, X-ray, computed tomog- raphy (CT) scan, magnetic resonance imaging (MRI), or ultrasound. Most radiation oncologists are comfortably per- forming CT-based brachytherapy. MRI-based brachytherapy is less commonly used. CT overestimates the disease but MRI is more conformal, although the latter requires more time and expertise. Ultrasound is an effective alternative to clin- ical examination and MRI of pelvis for delineating residual disease. 2 Intraoperative ultrasound helps in guiding place- ment of uterine tandem and prevents uterine perforation. 3 The structures chiefly contoured are gross tumor volume (GTV), high risk clinical target volume (HRCTV), intermediate risk clinical target volume (IRCTV), bladder, rectum, and sig- moid. 4 The prescription points are Point A and HRCTV. 4 The applicators used routinely are Fletcher Suit Delclos, Manchester Tandem and Ovoid, Ring and Tandem (including MRI compatible), Vienna, Martinez Universal Perineal Inter- stitial Template (MUPIT), and Syed Neblett template. 5 MRI-based brachytherapy as routine seems difficult due to the uncommon practice of delineating IRCTV, high patient load, and cost. However, existing literature substantiates that MRI-based brachytherapy offers better local control, progres- sion-free survival, overall survival, and less grade 3–4 com- plications of organs at risk. 6,7 These advantages translate into less overall treatment cost. 8 It seems a good alternative for future brachytherapists. Funding None. Note Presentation at a meeting: Proceedings from a multi-insti- tutional panel discussion in North Zone AROICON 2019 Organization: Sri Guru Ram Das University of Medical Sciences Place: Amritsar, Punjab Date: 21 September 2019 Confict of Interest None declared. Acknowledgments The authors want to acknowledge useful inputs from Dr. Anchal Aggarwal and Dr. Shikha Chawla, who are both serving as consultants, and Christy Alekchander and Anjali Sharma, who are both serving as medical physicists in the Department of Radiation Oncology at the Patel Hospital in Jalandhar, Punjab, India. References 1 Vargo JA, Beriwal S. Image-based brachytherapy for cervical cancer. World J Clin Oncol 2014;5(5):921–930 2 Mahantshetty U, Khanna N, Swamidas J, et al. Trans-abdominal ultrasound (US) and magnetic resonance imaging (MRI) correla- tion for conformal intracavitary brachytherapy in carcinoma of the uterine cervix. Radiother Oncol 2012;102(1):130–134 3 Spartacus RK, Dana R, Gaur P, Nandwana U, Rastogi K, Agarwal N. The role of ultrasound-guided applicator placement in Published online: 04.12.2019