Enhancing brachytherapy in cervical cancer: Initial dosimetric experience and assessment of Tulip hybrid applicator – the Add-On advantage

Ayesha Maniyar; Ram Charith Alva; Kirthi Koushik; Sagarika Nithyanand; Janaki G.; Revathy P.; Arul R.; Mohan Kumar; Lithika Lavanya

doi:10.5114/jcb.2026.161423

eISSN: 2081-2841
ISSN: 1689-832X

Journal of Contemporary Brachytherapy

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abstract:

Original paper

Enhancing brachytherapy in cervical cancer: Initial dosimetric experience and assessment of Tulip hybrid applicator – the Add-On advantage

Ayesha Iqbal Maniyar

^{1, 2}

,

Ram Charith Alva

^{1, 2}

,

Kirthi Koushik

^{2, 3}

,

Sagarika Nithyanand

^{1, 2}

,

Janaki M. G.

⁴

,

Revathy P.

⁴

,

Arul Ponni T. R.

⁴

,

Mohan Kumar

⁴

,

Lithika Lavanya

⁴

Aster International Institute of Oncology (AIIO), Bengaluru, India
M. S. Ramaiah Medical College and Hospital, Bengaluru, India
HCG Cancer Hospital, Bengaluru, India
Department of Radiation Oncology, M. S. Ramaiah Medical College and Hospital, Bengaluru, India

J Contemp Brachytherapy 2026

DOI: https://doi.org/10.5114/jcb.2026.161423

Online publish date: 2026/04/30

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Purpose
To report initial clinical experience of the Tulip Add-On hybrid intracavitary/interstitial (IC/IS) brachytherapy applicator in locally advanced carcinoma cervix, and to compare its dosimetric performance with conventional IC brachytherapy.

Material and methods
Eight patients with FIGO stage IIB-IIICr1 cervical cancer were treated between January 2021 and January 2022. All received external beam radiotherapy with concurrent chemotherapy, followed by CT-guided IC/IS brachytherapy using Henschke applicator with Tulip Add-On interstitial needles. Paired dosimetric plans (IC/IS vs. IC-only) were generated for each patient. Target coverage (D90, D98, D100, V90, and V100) and implant quality indices, including conformity index (CI), dose homogeneity index (DHI), dose non-uniformity ratio (DNR), and overdose volume index (ODI), were analyzed, along with organ at risk (OAR) doses.

Results
Median age was 58 years; median high-risk clinical target volume (HR-CTV) was 55.6 cc (range, 25.6-81 cc). Six patients required bilateral and two unilateral interstitial insertions. Compared with IC-only, IC/IS plans significantly improved HR-CTV coverage: D90 was 77.2 Gy vs. 69.5 Gy, and D100 was 63.8 Gy vs. 56.9 Gy. OAR doses were similar (rectum D2cc: 65.9 Gy vs. 65.5 Gy; bladder D2cc: 71.6 Gy vs. 74.0 Gy). Quality indices favored the hybrid approach, with higher CI (0.615 vs. 0.556) and DHI (0.45 vs. 0.40), and lower DNR and ODI values.

Conclusions
The Tulip Add-On applicator offers superior HR-CTV coverage without compromising OARs sparing. It is a practical, resource-adaptive technique that combines simplicity of intracavitary brachytherapy with dosimetric advantages of interstitial approaches, particularly valuable for patients with residual parametrial disease post-EBRT.

keywords:

Enhancing brachytherapy in cervical cancer: Initial dosimetric experience and assessment of Tulip hybrid applicator – the Add-On advantage

Ayesha Iqbal Maniyar 1, 2 , Ram Charith Alva 1, 2 , Kirthi Koushik 2, 3 , Sagarika Nithyanand 1, 2 , Janaki M. G. 4 , Revathy P. 4 , Arul Ponni T. R. 4 , Mohan Kumar 4 , Lithika Lavanya 4

hybrid brachytherapy, cervical cancer, ICRU 38, image-guided brachytherapy, ICRU 89, ICRU 58, IGABT

Ayesha Iqbal Maniyar

^{1, 2}

,

Ram Charith Alva

^{1, 2}

,

Kirthi Koushik

^{2, 3}

,

Sagarika Nithyanand

^{1, 2}

,

Janaki M. G.

⁴

,

Revathy P.

⁴

,

Arul Ponni T. R.

⁴

,

Mohan Kumar

⁴

,

Lithika Lavanya

⁴