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Routine use of ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer - a South Indian institutional experience.

Rao PB, Ghosh S - J Contemp Brachytherapy (2015)

Bottom Line: Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised.It is an accurate, fast, easily available, and cost-effective method.Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiotherapy, GSL Cancer Hospital, GSL Medical College, Rajahmundry, Andhra Pradesh, India.

ABSTRACT

Purpose: Intracavitary brachytherapy necessitates the insertion of a tandem applicator through the cervical os into the uterine cavity. Blind insertion of the tandem may result in suboptimal tandem placement. This decreases the control of the tumor locally and may result in uterine perforation. Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised. The aim of this work is to evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer.

Material and methods: This is a prospective single institutional study conducted from April 2013 to May 2015. A total of 96 patients of locally advanced cervical cancer were treated with routine ultrasound guided brachytherapy amounting to a total of 282 intracavitary applications.

Results: In 78 of the study patients, the cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. In another 12 patients, though the os could be identified visually, uterine sounding was only possible under ultrasound guidance. In another 4 patients, the cervical os could not be identified visually as the cervix was flushed with vagina and ultrasound guidance was necessary for accurate os identification. In 2 of the study patients, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than intracavitary brachytherapy. Out of the 96 study patients, the length of the uterine canal changed in 15 patients during the subsequent brachytherapy application.

Conclusions: This procedure is strongly advocated for proper placement of the tandem applicator and to avoid perforations. It is an accurate, fast, easily available, and cost-effective method. Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

No MeSH data available.


Related in: MedlinePlus

Tandem insertion and the role of ultrasound guidance in the study patients
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Figure 0002: Tandem insertion and the role of ultrasound guidance in the study patients

Mentions: Figure 2 depicts the role of ultrasound guided tandem insertion in the study patients. Ninety-six patients underwent routine ultrasound guided tandem placement in the present study. The cervical os was accurately identified in 91 patients visually, which was then confirmed with ultrasound guidance. In 78 of these patients, the uterine sound was inserted without any ultrasound guidance into the uterine canal accurately. The position of the uterine sound in the uterine canal was confirmed with ultrasound. In these patients, the benefit of USG guidance was to know the angulation of the tandem required, the length of the tandem to be inserted, and the position of the uterus (acutely anteverted or retroverted). In another 12 patients, though the os could be identified visually, insertion of the uterine sound in the cervical canal was only possible with ultrasound guidance. This was because of the cervical canal stenosis due to radiation or disease induced fibrosis and greater extent of the residual disease. However, proper placement of the tandem applicator could only be performed with ultrasound guidance in these patients. In one of these 91 patients, although the cervical os was identifiable correctly with naked eye (which was again confirmed with USG), the uterine sound could not be passed even with ultrasound guidance, as the os was completely stenosed due to fibrosis. This patient was treated with interstitial brachytherapy. In another 4 patients, the cervix was completely flushed with vagina and the os was unidentifiable visually alone. In these patients, the cervical os was accurately identified and tandem was placed successfully by intraoperative ultrasound scanning. In another study patient, the cervical anatomy was completely destroyed by the tumor and the patient was treated with interstitial brachytherapy. Hence, a tedious insertion of the tandem with naked eye, a risk of uterine perforation, and inappropriate placement of the uterine tandem was avoided in 18 of the study patients (12 patients with stenosed os, where tandem insertion required USG guidance; 4 patients with cervix flushed with vagina, where USG guidance was necessary for os identification, and 2 patients, where intraoperative ultrasound was essential to understand the necessity for interstitial brachytherapy). Ultrasound guidance failed to identify the os in only one patient where the cervical anatomy was completely destroyed by the tumor.


Routine use of ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer - a South Indian institutional experience.

Rao PB, Ghosh S - J Contemp Brachytherapy (2015)

Tandem insertion and the role of ultrasound guidance in the study patients
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4663212&req=5

Figure 0002: Tandem insertion and the role of ultrasound guidance in the study patients
Mentions: Figure 2 depicts the role of ultrasound guided tandem insertion in the study patients. Ninety-six patients underwent routine ultrasound guided tandem placement in the present study. The cervical os was accurately identified in 91 patients visually, which was then confirmed with ultrasound guidance. In 78 of these patients, the uterine sound was inserted without any ultrasound guidance into the uterine canal accurately. The position of the uterine sound in the uterine canal was confirmed with ultrasound. In these patients, the benefit of USG guidance was to know the angulation of the tandem required, the length of the tandem to be inserted, and the position of the uterus (acutely anteverted or retroverted). In another 12 patients, though the os could be identified visually, insertion of the uterine sound in the cervical canal was only possible with ultrasound guidance. This was because of the cervical canal stenosis due to radiation or disease induced fibrosis and greater extent of the residual disease. However, proper placement of the tandem applicator could only be performed with ultrasound guidance in these patients. In one of these 91 patients, although the cervical os was identifiable correctly with naked eye (which was again confirmed with USG), the uterine sound could not be passed even with ultrasound guidance, as the os was completely stenosed due to fibrosis. This patient was treated with interstitial brachytherapy. In another 4 patients, the cervix was completely flushed with vagina and the os was unidentifiable visually alone. In these patients, the cervical os was accurately identified and tandem was placed successfully by intraoperative ultrasound scanning. In another study patient, the cervical anatomy was completely destroyed by the tumor and the patient was treated with interstitial brachytherapy. Hence, a tedious insertion of the tandem with naked eye, a risk of uterine perforation, and inappropriate placement of the uterine tandem was avoided in 18 of the study patients (12 patients with stenosed os, where tandem insertion required USG guidance; 4 patients with cervix flushed with vagina, where USG guidance was necessary for os identification, and 2 patients, where intraoperative ultrasound was essential to understand the necessity for interstitial brachytherapy). Ultrasound guidance failed to identify the os in only one patient where the cervical anatomy was completely destroyed by the tumor.

Bottom Line: Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised.It is an accurate, fast, easily available, and cost-effective method.Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiotherapy, GSL Cancer Hospital, GSL Medical College, Rajahmundry, Andhra Pradesh, India.

ABSTRACT

Purpose: Intracavitary brachytherapy necessitates the insertion of a tandem applicator through the cervical os into the uterine cavity. Blind insertion of the tandem may result in suboptimal tandem placement. This decreases the control of the tumor locally and may result in uterine perforation. Although routine real time ultrasound guided tandem placement has shown better results, it is seldom practised. The aim of this work is to evaluate the role of routine real-time intraoperative trans-abdominal ultrasound guided tandem placement in intracavitary brachytherapy for the treatment of cervical cancer.

Material and methods: This is a prospective single institutional study conducted from April 2013 to May 2015. A total of 96 patients of locally advanced cervical cancer were treated with routine ultrasound guided brachytherapy amounting to a total of 282 intracavitary applications.

Results: In 78 of the study patients, the cervical os could be easily identified visually, which was then confirmed with ultrasound guidance. In another 12 patients, though the os could be identified visually, uterine sounding was only possible under ultrasound guidance. In another 4 patients, the cervical os could not be identified visually as the cervix was flushed with vagina and ultrasound guidance was necessary for accurate os identification. In 2 of the study patients, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than intracavitary brachytherapy. Out of the 96 study patients, the length of the uterine canal changed in 15 patients during the subsequent brachytherapy application.

Conclusions: This procedure is strongly advocated for proper placement of the tandem applicator and to avoid perforations. It is an accurate, fast, easily available, and cost-effective method. Hence, it can be incorporated in intracavitary applications for cervical cancers even in the developing countries where cost, accessibility, and time are important issues.

No MeSH data available.


Related in: MedlinePlus