S2999
Invited Speaker
ESTRO 2026
emphasis on robustness and explicit uncertainty management in modern clinical practice.
Recent advances in brachytherapy physics are enabling more automated, personalized, and independently verified treatments, with several developments from the past few years already influencing clinical practice. Progress has been notable in workflow automation, patient-specific applicator design, commissioning and verification methodologies, and the increasing integration of uncertainty awareness into clinical decision-making. Automation is increasingly explored as a means to support key steps of the brachytherapy workflow. Recent studies have investigated approaches to automation of segmentation of anatomical structures, catheter reconstruction, and aspects of treatment planning. While many of these methods remain under evaluation, they show promise for reducing manual workload, improving consistency, and supporting more standardized clinical workflows. In parallel, advances in 3D printing technologies are enabling increased personalization of brachytherapy treatments. Patient-specific applicators are being applied in multiple clinical scenarios, including contact brachytherapy for skin lesions and individualized gynecological applicators adapted to patient anatomy. In head-and-neck brachytherapy, recent work has demonstrated the feasibility of reducing the number of implanted catheters while maintaining adequate target coverage through optimized, patient-specific applicator concepts. These developments illustrate how individualized applicator design can improve both procedural feasibility and dosimetric outcomes. Despite increasing automation and personalization, rigorous commissioning and independent verification remain fundamental for safe clinical implementation. The recent GEC-ESTRO recommendations on TG-43 treatment planning system commissioning and quality assurance provide structured guidance and practical verification tools that support consistent implementation across centres and enhance understanding of treatment planning system behaviour. In addition, recent methodological work has proposed practical approaches for independent verification of manufacturer-provided dose data for beta-emitting 106-Ru applicators, addressing a long- standing need for verification methods for these systems. There is also growing emphasis on uncertainty-aware approaches, where sources of uncertainty are increasingly considered explicitly in planning, evaluation, and outcome modelling. Such developments support more informed clinical decision-making and improved interpretation of treatment results. Together, these developments highlight how brachytherapy physics continues to evolve toward more automated, individualized, and rigorously verified treatment workflows, with increasing
5313 Prostate precision: Next-gen brachytherapy
breakthroughs Iosif Strouthos
Department of Radiation Oncology, German Oncology Center, Limassol, Cyprus. University Clinic, European University Cyprus, Nicosia, Cyprus Prostate cancer remains the most frequently diagnosed malignancy in men across Europe and North America, and brachytherapy (BT) continues to represent one of the most biologically potent and anatomically precise treatment modalities. However, the field is undergoing a major transformation. Advances in molecular imaging, artificial intelligence (AI), robotics, and biological dose escalation are driving prostate BT into the era of precision medicine. A key development is the emergence of focal and ultra-focal BT. Based on evidence that recurrences often arise from the dominant intraprostatic lesion (DIL), these approaches enable targeted dose escalation while minimizing toxicity to surrounding organs. A 2025 meta-analysis of 26 studies (1,492 patients) demonstrated that focal BT achieves comparable biochemical control with significantly reduced genitourinary and gastrointestinal toxicity compared to whole-gland treatment. In parallel, prospective data from MR-guided focal salvage HDR BT delivering 27 Gy in 2 fractions reported 84% complete radiological response and grade ≥ 3 toxicity rates below 2%, highlighting a paradigm shift in managing radiorecurrent disease. The integration of PSMA PET/CT and multiparametric MRI into BT workflows represents another major advance. PSMA PET improves detection of intraprostatic recurrence and supports precise target delineation. Expert consensus now recommends both PSMA PET/CT and mpMRI as essential for restaging prior to salvage BT, marking a transition toward biologically guided treatment. Emerging evidence consistently shows that ablative dosing of the DIL while respecting organs at risk improves disease control without compromising safety. AI-driven planning and MRI-compatible robotics are further reshaping the field. Platforms such as BRIGHT enable automated, multi-criteria optimisation, generating high-quality treatment plans with reduced operator dependence. Deep learning tools for catheter reconstruction have achieved submillimetric accuracy, improving procedural efficiency. Meanwhile, MRI- compatible robotic systems such as CoBra are enabling real-time adaptive interventions, supported
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