1. Patient and Tumour Characteristics Median age 60 years (26-92) Karnofsky Status:median 90 (50-100) Histology:SCC: n=120 (83%) Tumor size: ≥ 5 cm: n=78 (52%) ≤Ib1,IIA=18(12%) Lymph node involvement: n=57 (39%) - EBT: 45 Gy/1,8 Gy per fraction - HDR–BT: 4 x 7 Gy (40 Gy (EQD2)) pt A/HR CTV - Since 2001 (D90): total dose 85+ Gy (EQD2) - Intracavitary + interstitial, if insufficient response - Cis-Platinum 5x40mg/m2 (57%), since 4/99 Treatment schedule (Overall treatment time 6-7 weeks)

2. HR CTV concept GTV, HR CTV+OAR contouring Biological modelling (linear-quadratic) Dose Volume constraints: OAR (2 cm 3 ): 75/90 Gy (EQD2, α/ β3) Prescription: HR CTV - (D90): 80-85+ Gy(EQD2, α/ β10) Prospective 3D image based optimisation MRI based Treatment Planning Major Learning Period: 98-2000 (n=73) Systematic prospective protocol since 2001 (n=72) no systematic prospective protocol (point A/OAR)

3. Outcome after complete remission non central true pelvic and distant recurrence non central true pelvic central true pelvic recurrence pelvic lymph node and distant pelvic lymph node distant recurrence disease free (64%) n=138 Treatment time: 98-2003 Median follow up: 39 months

4. Stage IIB, Large Tumour, ≥ 5 cm (treated 12/2002) Before EBRT: 5 cm wide, 5 cm thick, 7 cm high: 85 cm 3 At 1. Brachytherapy after EBRT:2 cm x 3 cm x 3 cm, 9 cm 3, 6 months after treatment: Radioth&Oncol 2005 Continuous Complete Remission good remission, sufficient for intracavitary BT Initial tumor extension

5. Stage IIIB- (treated 11/1998) Insufficient response-no adaptation of application technique At Brachytherapy after EBRT 9 months after treatment Dose distribution at brachytherapy At time of diagnosis Residual tumorInsufficient adaptationRecurrence Initial tumor extension

6. Tumor size ------- < 5cm ------- ≥5cm CCR at 3 years: Vienna 93-2003 (335 patients) 100% 91% Total:Events: < 5cm n=34n=0 ≥5 cm n=38n=4 (28) (12) (4) (30) (17) (9) 96% 72% Total:Events: < 5cm n=33n=1 (at 36m) ≥5 cm n=40n=10 (30) (26) (22) (23) (15) (10) CCR true pelvis (98-00) CCR true pelvis (01-03)

7. Late side effects at 3 years LENT/SOMA: absolute numbers G 0G 1G 2G 3G 4 Bladder12471112 Rectum135262- Intestines13651-3 Total141835 PeriodPts.G3-4 98-00736 01-03722

8. Conclusion MRI assisted treatment planning in intracavitary cervical cancer brachytherapy plus risk adapted interstitial brachytherapy + cis-Platinum (145 consecutive patients) High local control tumors < 5 cm: up to 100% tumors ≥ 5 cm: ~ 90% Low rate of side effects G3/4: < 5% (crude)