The standard of care for locally advanced cervical cancer is external beam radiotherapy (EBRT) with simultaneous chemotherapy followed by an internal radiation boost. New imaging methods such as positron-emission tomography and magnetic resonance imaging have been implemented into daily practice for better tumor delineation in radiotherapy planning. The method of delivering radiation has changed with technical advances in qualitative imaging and treatment delivery. Image-guided radiotherapy (IGRT) plays an important role in minimizing treatment toxicity of pelvic radiation and provides a superior conformality for sparing the organs at risk (OARs) such as bone marrow, bowel, rectum, and bladder. Similarly, three-dimensional image-guided adaptive brachytherapy (3D-IGABT) with computed tomography (CT) or magnetic resonance imaging (MRI) has been reported to improve target coverage and reduce the dose to normal tissues. Brachytherapy is a complementary part of radiotherapy treatment for cervical cancer and, over the past 20 years, 3D-image-based brachytherapy has rapidly evolved and established itself as the gold standard. With new techniques and adaptive treatment in cervical cancer, the concept of personalized medicine is introduced with an enhanced comprehension of the therapeutic index not only in terms of volume (three-dimensional) but during treatment too (four-dimensional). Current data show promising results with integrated IGRT and IGABT in clinical practice and, therefore, better local control and overall survival while reducing treatment-related morbidity. This review gives an overview of the substantial impact that occurred in the progress of image-guided adaptive external beam radiotherapy and brachytherapy.

Background: Palliative radiotherapy plays a crucial role in managing symptomatic gynecological cancers (GCs). This article aims to systematically review literature studies on palliative pelvic radiotherapy in cervical, endometrial, ovarian, vaginal, and vulvar cancers. The primary focus is centered around evaluating symptom relief, quality of life (QOL), and toxicity in order to ascertain optimal radiotherapy regimens. Methodology: For this thorough review, we mainly relied on Medline to gather papers published until November 2023. Selected studies specifically detailed symptomatology and QOL responses in palliative pelvic radiotherapy used for GCs. Results: Thirty-one studies, mostly retrospective studies and those lacking standardized outcome measures, showed varied responses. Encouraging outcomes were noted in managing hemorrhage (55%) and pain control (70%). However, comprehensively assessing overall symptom response rates and toxicity remained challenging. Investigations into 10 Gy fractionation revealed benefits in addressing tumor-related bleeding and pain in female genital tract cancers. Conclusions: Palliative pelvic radiotherapy effectively manages symptomatic GCs. Nonetheless, unresolved dosing and fractionation considerations warrant further investigation. Embracing modern therapies alongside radiotherapy offers improved symptom control, emphasizing the importance of selecting suitable patients for successful GC palliation interventions.

Background: Cervical cancer treatment with advanced radiotherapy techniques benefits from image guidance, particularly when anatomical changes occur during therapy. This case emphasizes the need for adaptive radiotherapy when target volume shifts significantly. Methods: A 70-year-old woman with International Federation of Gynecology and Obstetrics (FIGO) IIIC2 9th edition cervical squamous cell carcinoma presented with a distended uterine cavity due to fluid accumulation. She underwent definitive chemoradiotherapy using Volumetric Modulated Arc Therapy (VMAT) and weekly cisplatin. Results: Daily Cone Beam Computed Tomography (CBCT) imaging revealed progressive uterine shrinkage as intrauterine fluid drained, significantly altering target volume and organ-at-risk (OAR) positioning. These changes necessitated two re-planning CT scans during external beam radiotherapy to maintain accurate dosing and avoid OAR toxicity. The patient completed treatment, including image-guided brachytherapy, without complications. Adaptive planning ensured adequate tumor coverage and minimized normal tissue exposure. Conclusions: This case highlights the critical role of daily CBCT in detecting anatomical changes during radiotherapy. Adaptive re-planning, though rarely required more than once, was essential here to preserve treatment accuracy. CBCT should be considered a standard verification tool in cervical cancer radiotherapy, particularly in cases involving intrauterine fluid.