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Carcinoma cervix brachytherapy- dr upasna

complete presentation of all aspects of brachytherapy in carcinoma cervix

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Carcinoma cervix brachytherapy- dr upasna

  1. 1. PRESENTER – DR UPASNA SAXENA MODERATOR – DR SHEH RAWAT
  2. 2.  EVOLUTION  ADVANTAGES  TYPES  ICRT  PRESCRIPTION POINTS  APPLICATORS  PROCEDURE  2D PLANNING  3D PLANNING •VAGINAL CUFF BRACHYTHERAPY •VAGINAL MOULD •INTERSTITIAL BRACHYTHERAPY •INDICATIONS •ADVANTAGES •APPLICATORS •PROCEDURE •PLANNING •ABS GUIDELINES OF DOSES AND SCHEDULING
  3. 3.  ‘Brachy’ Greek word for ‘short distance‘  The term brachytherapy proposed first time by Forsell in 1931  Form of radiation treatment in which radiation is delivered by small sealed radioactive sources arranged in a geometric fashion in & around tumor.
  4. 4.  Radioactivity was described by Becquerel in 1896  Marie curie extracted radium from pitchblende ore in 1898  Danlos and Bloc performed first radium implant (1901)  First “schools” of brachytherapy were at Stockholm , Memorial Salon Kettering and the Holt Radium Institute (Paris).  Ra & Rn –two radioactive sources used extensively in the early years
  5. 5.  From 1940 – 1970s , Co⁶⁰, Cs¹³⁷, Ir¹⁹² first used in brachytherapy  Cs¹³⁷ began to replace Ra²²⁶  Wickham-The father of radium treatment of uterine cancer treated 1000 cases from 1906-1910  1953-Afterloading technique- Henschke. He was also first to use Ir192  LDR brachytherapy became the gold standard.
  6. 6.  Rules for implantation were made  1970 -Emergence of remote after loading system ( selectron machine – LDR machine)  HDR became widely accepted after a long struggle particularly for Ca Cervix  PDR has now been developed  Now with more sophisticated imaging, hardware and software : image assisted and image guided brachytherapy coming up Intracavitary Brachytherapy: Stockholm system (1914) Paris System (1926) Manchester System (1938) Interstitial Brachytherapy: Manchester system Quimby System Paris system
  7. 7. 7 Advantages of brachytherapy • A high localized radiation dose to a small volume --higher local control •Spares surrounding normal organs and tissues •Ultimate form of conformal radiotherapy •Shorter treatment time- convenient, prevents tumour proliferation •Non-homogenour dose distribution to tumour targeting the hypoxic central core
  8. 8.  Invasive  Needs expertise and experience and equipment  Time consuming  Difficult to maintain uniformity across various centres
  9. 9.  According to method of source loading :  Preloading  Afterloading  Manual afterloading  Remote afterloading  According to type of application :  Intracavitary  Interstitial  Intraluminal – cylinders/ moulds
  10. 10. 10 •According to dose rate •Ultra-low dose rate (ULDR): 0.01-0.3 Gy/hour •LDR- 0.4-2 Gy/hr  Cs-137 •MDR- 2-12 Gy/hr •HDR- > 12Gy/hr  Ir-192 •PDR- dose rate as HDR, But delivered in pulses , say for 10-15 minutes every hour
  11. 11. 11 Microselectron HDR Selectron LDR Microselectron PDR
  12. 12. Between the period 1910-1950 three preloading systems were devloped for CA cervix  Paris System  Stockholm System  Manchester System Subsequently remote after loading technique was developed which overcame the hazards of preloaded sources.
  13. 13. INTRACAVITARY BRACHYTHERAPY
  14. 14.  ICRU specified dose specification system that relates dose distribution to target volume, instead of dose to specific point.  Also includes information on various treatment parameters. DOSIMETRIC INFORMATION FOR REPORTING  Complete description  Technique  Time-dose pattern  Treatment prescription  Total Reference Air Kerma  Dose description  Prescription points/surface  Reference dose in central plane  Mean central /peripheral dose  Volumes: Treated/ point A/ reference volume  Dose to Organs at Risk : bladder, rectum
  15. 15.  the dose should be prescribed & assessed at a representative point.  Point A, lies in the paracervical triangle.  Chosen initially because  Believed to be a good index of normal tissue tolerance which is the dose limiting factor “High dose in the paracervical tissues, where the uterine vessels are crossed by the ureter, produces dangerous extrinsic reactions”  And comparable from case to case, not too variable with application (textbook by Paterson)  ABS recommends this point as it falls within the portion of the isodose distribution with little cephalocaudal gradient.
  16. 16.  Definition  Original – 2cm lateral to the central canal of the uterus, and 2cm up from the mucous membrane of the lateral fornix in the axis of the uterus.
  17. 17.  Although point A was defined in terms of important anatomical structures, these can not be revealed on a radiograph.  So point A definition was modified in 1953.  “2 cm superior from lower end of central radium tube and 2 cm lateral from uterine canal in radiograph of radium insertion.  Variant – beginning at the flange abutting the cervical os. Manchester cont
  18. 18.  Tandem and ovoid - Draw a line connecting middle of sources in vaginal ovoids on A-P radiograph and move 2 cm plus the radius of ovoid superiorly along the tandem from intersection of this line with intrauterine source line and then 2 cm lateral on either side of the tandem.
  19. 19.  Vaginal ring applicator – use line connecting lateral most source dwell points on the ring and then extend 2 cm superiorly (along the tandem from where the line intersects the tandem) and then 2 cm laterally on either side  Tandem and cylinders – extend 2 cm along tandem from the flange, and then 2 cm laterally from it on each side
  20. 20.  Is at same level as point A, but 5 cm from the midline.  Depicts dose delivered to obturator nodes.  Indicates rate of fall-off of dosage laterally.  Dose to point B is ~ 20-25% of dose at point A.  Depends upon total amount of radium used
  21. 21.  is used by Mallinckrodt Institute of Radiology System to specify minimum dose to pelvic lymph nodes.  It is 6 cm to Rt and Lt of patient midline in same plane as of classical point A.
  22. 22.  Description of reference volume i.e the tissue volume encompassed by a reference isodose surface is proposed for specification in reporting  An absorbed dose level of 60 Gy was widely accepted as reference level  Reference volume described is pear shaped co-incident with intra-uterine sources
  23. 23.  This Reference volume is defined by 3 dimension: 1) Height(dh): Maximum dimension along the intrauterine source, measured in oblique frontal plane. 2) Width (dw): Maximum dimension perpendicular to the intra-uterine source, measured in oblique frontal plane. 3) Thickness (dt): Maximum dimension perpendicular to the intrauterine source and is measured in saggital plane.
  24. 24. ICRU 38 Cont
  25. 25. 47 BLADDER REFERENCE POINT: Foley balloon with 7 cc contrast pulled down . •On lateral x-ray- •Anteroposterior line drawn through the centre of balloon .A point on this line on the posterior surface of the balloon •AP x-ray •at the centre of the balloon •There are some articles that suggest that dose at bladder base and bladder neck should be recorded
  26. 26.  RECTAL REFERENCE POINT: • Lateral x-ray-an anteroposterior line drawn from the lower end of intra uterine source (or middle of intra vaginal sources). Point located on this line 5 mm behind the post vaginal wall • AP x-ray-this at the lower end of intrauterine source or at the middle of intravaginal sources • Some articles show that rectal dose along several points over the length of the implant
  27. 27. On lateral radiograph  A line is drawn from junction of S1-S2 to the top of symphysis pubis  Then a line is drawn from the middle of that line to the middle of anterior aspect of L4
  28. 28.  A point 6 cm lateral to the midline at the inferior end is used to estimate dose rate to mid-external illiac nodes  At the top of trapezoid points 2 cm lateral to midline at L4 level gives an estimate to dose of Para-aortic nodes  Midpoint of line connecting to these to points is used to estimate the dose to common illiac node
  29. 29. 51 LYMPHATIC TRAPEZOID
  30. 30.  This point represent the absorbed dose to distal part of parametrium and obturator nodes  On frontal radiograph, the pelvic wall reference point is intersected by 2 line, a horizontal line tangential to the highest point of acetabulum and a vertical line to the inner aspect of acetabulum  On lateral radiograph highest point of Rt & Lt acetabulum is joined and pelvic reference point is at the mid-distance of these 2 points
  31. 31. 53 PELVIC WALL POINTS
  32. 32. DRAWBACK OF ICRU 38
  33. 33.  Lack of information about correlation between  Applicator and tumour  Applicator and OAR  Tumour and OAR  OAR anatomic boundaries not very clear, estimated based on contrast  Dose to target and OARs is not reliable  All doses reported are a point dose which do not depict the actual dose delivered to entire structure  Points do not correlate with local control or toxicity
  34. 34.  It relates to position of sources and not to specific anatomic structure.  It is very sensitive to position of ovoid sources relative to tandem sources which should not be determining factor in deciding on implant duration.  Depending on size of cervix point A may be inside or outside of tumor. Manchester cont
  35. 35.  A & B are not anatomic sites  A &B varies with applicator type  A is not in paracervical triangle  A is not a reliable indicator of minimum tumor dose  B does not always represent obturator node
  36. 36. 59 Loose Tandem & Ovoids Stockholm Paris or London colpostat Manchester system Fixed applicators Fletcher-suit-Delclos Manchester Vienna ring INTRACAVITARY APPLICATORS
  37. 37.  Loose system.  Intrauterine applicator  Rubber tubing, with flange at end.  Varying length, can take – 1,2,3 radium tubes in line.  Ovoids  Rubber or nylon  Shape follows the distribution in 3-D space of the isodose curves around the contained radium tube, ensuring homogenous dose on its surface.
  38. 38. LOOSE APPLICATORS
  39. 39. 62 STOCKHOLM SYSTEM PARIS SYSTEM
  40. 40. STOCKHOLM APPLICATOR
  41. 41. 64 MANCHESTER SYSTEM Point A : 2 cm lateral to the central canal of the uterus and 2 cm up from the mucous membrane of the lateral fornix in the axis of the uterus.( In practice,2 cm up from the flange and 2cm lateral from the central axis) Point B : Being in the transverse axis through points A , 5 cm from midline
  42. 42. RIGID APPLICATORS
  43. 43.  Tandems of angles 0, 15, 30 and 45 degress  Length is adjustable with a flange placed according to length of the uterus to prevent perforation and mark the external os on radiograph
  44. 44.  Ovoids  3 sizes  Small –shortest dia – 2cm  Medium – dia – 2.5cm  Large – dia – 3cm.  Pairs of ovoids held apart by a “SPACER” .  Fixes at a distance of 1 cm.  “WASHER” – holds the ovoids in position in narrow vagina.  Range of ovoid pair – 4-7cm.
  45. 45.  Select the longest possible intra-uterine applicator and the largest possible size of ovoids, which can be placed snugly.  Carries the ovoid closer to point B  Gives better proportional depth dose.  Pushes the isodose of lethal damage as laterally as possible.  Longer tandem – more contribution to pt B  Bigger ovoid – vaginal surface dose falls by 35%
  46. 46.  Intact uterus should always have a tandem placed  Supracervical hysterectomy- short tandem  Intact uterus with extensive disease – tandem with interstitial needles
  47. 47.  INTERSTITIAL – large lesions, lower vaginal disease, applicators not fitting  TANDEM + CYLINDER – upper vaginal stenosis/narrowing, superficial disease (5mm thick) in lower vagina  TANDEM + RING – shallow fornices
  48. 48.  TANDEM + OVOIDS – barrel shaped cervix, using largest ovoid. To cover cervix, uterus, medial parametrium and upper 1-2 cm of vagina  TANDEM + RING/OVOIDS + INTERSTITIAL NEEDLES – large bulky tumours (for tumour coverage and OAR sparing), vaginal extension of disease, fistulae, pelvic side wall invasion  OVOIDS OR CYLINDERS ALONE – for post op cases
  49. 49. 78 ICRT STEPS  Anesthesia / sedation Positioning - Lithotomy  Cleaning & draping  Bladder catheterization—7 cc radio opaque contrast in balloon. If US guided procedure planned, 100-120 cc saline infused into the bladder  EUA  Dilatation of os Uterine sounding to assess length Insertion of tandem and ovoids  Posterior and anterior vaginal packing
  50. 50. 79
  51. 51. 80 A COMPLETED HDR ICRT APPLICATION
  52. 52. 81 AN HDR OVOID APPLICATION
  53. 53.  After the application – patient is shifted for imaging  AP and orthogonal x-rays for 2-D planning.  Planning CT scan for 3-D planning  MRI based planning – 1.5-T MR sequence maybe used that allows the needle tip to appear as a balloon on saggital image and cross on axial image
  54. 54. 84 SIMULATION Markers Markers Orthogonal radiographs
  55. 55.  Potish et al used linear least-square regression to show that although there was good correlation between the milligram-hours and colpostats and the dose to point A, it was markedly affected by the position of the tandem and colpostats  MD Anderson quatified the acceptable implant geometry
  56. 56.  Tandem should be  4 cm from sacrum  1/3 distance between pubis and sacrum  Midway betweem sacrum and bladder  Tandem should bisect the ovoids in AP & lat films  Distance between vaginal ovoids and cervical marker seeds was 7mm
  57. 57.  Superior tip should be below promontry (in the pelvis)  The bladder and rectum should be packed away from the implant with no packing above the ovoids  Packing was within a line 5mm behind the line along posterior surface of ovoids, running parallel to the tandem
  58. 58.  Ovoids should fill the vaginal fornices – largest ovoid size to be used. - should be separated by 0.5 –1.0 cm, admitting the flange on the tandem with no inferior displacement -should be against the cervix (marker seeds)  The axis of the tandem should be central between the ovoids  Should be bisected by the tandem
  59. 59.  RTOG 0116 and 0128 studied 103 patients (both LDR and HDR).  They concluded that unacceptable geometry had higher LR (HR=2.67, 95%CI=1.11 to 6.45; p=0.03)  Displacement of ovoids in relation to the cervix and inappropriate packing also resulted in a lower DFS
  60. 60.  Check proper application  Proper delineation of OARs  More reliable dose distribution  Kim et al found that dose to point A is significantly lower than D90 of HRCTV. Though dose to point A should be reported  Himmelman et al described individualized computer treatment optimization of source position and dwell time
  61. 61. Modern Intracavitary Techniques Covering the target volume with prescribed dose ( ) Standard loading Mid-coronal view target V A
  62. 62. Modern Intracavitary Techniques Covering the target volume with prescribed dose ( ) Modified loading Mid-coronal view target V A
  63. 63.  Advantages  Acceptability due to wide use  Checks applicator geometry or perforation  Easy delineation of applicator  OARs position  Disadvantage  Artifacts due to metal applicator  Overestimate the tumour contours as compared to MRI  Can not distinguish sigmoid well as there is no contrast  Can not distinguh cervix from uterus – hence both are contoured in CT based guidelines
  64. 64.  Advantages  Better for tumour and parametrial visualization  Can distinguish sigmoid colon and also cervix from uterus  Disadvantage  Needs specific titanium & zirconium applicators  Poor bony anatomy distinction  Necessary to fuse CT scan with MRI for planning  Inconvenient & Expensive
  65. 65. 3D imaging Contouring Reconstruction of applicator 3D dose planning Dose delivery Applicator insertion
  66. 66.  Cervix and GTV can not be differentiated, so uterus along whole tandem should be included in CTV  The top dwell position is optimized off the sigmoid  Uterosacral ligaments, if detected, should be included in the CTV contours
  67. 67.  First guidelines published in 2004 by ABS (Nag et al)  Guidelines of GEC-ESTRO (Groupe European Curietherapy-European Society for Therapeutic Radiation Oncology) issued guidelines for MRI based brachytherapy in 2005 (Haier-meder et al, Poetter et al)  In july 2005, ABS and GEC-ESTRO agreed to follow GEC-ESTRO guidelines
  68. 68.  GEC-ESTRO guidelines are followed-  GTV – include all T2 bright area of enhancement  HRCTV(high risk CTV) – entire cervix, any regions of high to intermediate signal intensity in the parametria, uterus and vagina and any residual disease clinically  IRCTV (intermediate risk CTV) – subtracts the OAR from the GTV at the time of diagnosis and a 1cm margin to the HRCTV
  69. 69. 102 cervix cervix HR-CTV Initial tumour extension (at diagnosis) IR-CTV Complete remission Partial remission Stable disease Residual disease 10 mm cervix cervix 10 mm Legend 10 mm CTV BT
  70. 70. 103
  71. 71. 104
  72. 72. 105
  73. 73. Either based on  Point A as per ICRU and ABS guidelines  Volume based prescription
  74. 74. 107 PLANNING ICRT isodose curves
  75. 75. 108 OVOID ISODOSE CURVES
  76. 76. It is early to draw definitive conclusions BUT First results show that systematic MRI based treatment planning enables prospective control and maybe reduction of morbidity DIRECT COMPARISON G3-G4 gastrointestinal and urinary late morbidity (Pötter et al R&O 2007) 10% in 1998–2000 and 2% in 2001–2003 G3 gastrointestinal and urinary late morbidity (Haie-Meder et al R&O 2009,2010, Chargari et al Int J Radiat Oncol Biol Phys 2009 ) 5% in 2000–2004 and 2% in 2004–2006 Outcome of 3D-Image Based Gynaecological Brachytherapy Morbidity: Rectum, Sigmoid, Bladder, Vagina
  77. 77. 112 Eliminates RT exposure hazard for caregivers, visitors; eliminates source prepration and transportation Allows shorter treatment time Less patient discomfort Possible to trt patients who can’t tolerate long periods of isolation Less risk of applicator movement during therapy Due to OPD procedure results in cost shifting Allows greater displacement of nearby normal tissues by packing Possible to treat large number of patients Allows use of smaller diameter sources than are used in LDR Reduces the need of dilatation Reduces the need of GA High risk who don’t tolerate GA Physically easier to insert applicator into the cervix Makes dose distribution optimization possible Allows integration of EBRT & HDR, which can lead to a shorter overall Rx duration & better tumor control HDR vs. LDR IN CA CERVIX -ADVANTAGES
  78. 78.  Limited experience  Requires infrastructure  Maintenance is costly  Potential for more late effects in non- fractionated HDR
  79. 79.  Similar outcomes in LDR vs HDR  Recommended to use 3D imaging for HDR  For larger tumours (>4cm)using HDR early on during treatment, results in poor outcome  Displacing the bladder and rectum away while short HDR treatment may overcome the disadvantage of toxicity associated with fewer no of HDR fractions  Newman et all treated 115 patients , 87 LDR, 30 HDr. No significant differences were found in the local control and toxicity
  80. 80. 115 HDR (%) LDR (%) 5 yr Dis Sp. Sur ST II 69 87 ST III 55 60 5 yr Pelvic RFS ST II 89 100 ST III 69 70 Distant Metastases 25 24 Pelvic R/E 18 13 Para aortic Recurrence 10 11 Overall 5yr compli 10 13 ST II 5 12 ST III 7 13 Rectum 3.5 8.7 Small Bowel 2.4 1.6 Bladder 4 7.5 P= ns P= ns Hareyama et al. Cancer 2002.
  81. 81.  HIGHER TOXICITY grade>2 seen for higher values of D2cc (Koom et al) For interstitial, EQD2 of <62 Gy is recommended and it is further reduced as the length of vagina treated increases
  82. 82.  EVOLUTION  ADVANTAGES  TYPES  ICRT  PRESCRIPTION POINTS  APPLICATORS  PROCEDURE  2D PLANNING  3D PLANNING •VAGINAL CUFF BRACHYTHERAPY •VAGINAL MOULD •INTERSTITIAL BRACHYTHERAPY •INDICATIONS •ADVANTAGES •APPLICATORS •PROCEDURE •PLANNING •ABS GUIDELINES OF DOSES AND SCHEDULING
  83. 83.  Used in post op cases of carcinoma cervix (>=4weeks postop)  Less than radical hysterectomy  Close/positive margins  Large or deeply invasive tumours  Parametrial/vaginal involvement  Extensive LVI  Intact uterus with narrow vagina, in combination with a tandem Ovoids alone can also be used, but cylinders are more effective to treat the ‘dog ears’ of the vault and whole length of vagina
  84. 84. Dog ears of vaginal vault
  85. 85.  3-5 cm proximal vagina is treated  Whole length treated only if -  Papillary serous/clear cell  Grade 3 disease  Extensive LVI  Prescription at 0.5 cm from vaginal surface as 95% lymphatics are located within 3mm of the mucosa (Choo J et al)
  86. 86.  ABS suggests  If only upper length of vagina is to be treated, cylinder should not extend to introitus  If whole vagina is to be treated, cylinder should extend beyond introitus  Condoms should be placed on the cylinders to facilitate cleaning and for applicator longevity  Single channel or multiple channel applicators are used  Single channel – low dose to mucosa with larger size cylinders  Multiple channel – risk of higher dose to the mucosa has to be guarded
  87. 87. 123 HDR SORBO APPLICATOR SET
  88. 88. 124 ASSEMBLED HDR SORBO
  89. 89. 125 SORBO-PROCEDURE
  90. 90. The vaginal cylinder is 30 mm in diameter with cylinder sleeves of 35 and 40 mm.
  91. 91.  IMAGING  X-ray  CT scan  MRI  If imaging shows significant soft tissue above apex of vagina, EBRT maybe preferable
  92. 92. 130 SORBO ISODOSE CURVES
  93. 93.  Form of brachytherapy where sealed radioactive sources are directly implanted into the tumour in a geometric fashion  First suggested in USA by Alexander Graham Bell (1903)  At same time independently being used in France & Germany  First case treated for an inoperable Parotid Sarcoma
  94. 94. 140 Indications of interstitial implantation in ca cervix • Extensive residual disease(not likely to be taken care of by intracavitary application) • Os not negotiable • Fistulae • Adjacent organ invasion • Extensive parametrial +/- sidewall invasion • Vaginal extension • Recurrent disease (post RT/post surgery) • Narrow vagina • Prior supracervical hysterectomy
  95. 95. 141 Intracavitary brachytherapy Interstitial brachytherapy More accumulated experience Relatively new technique Easy to perform Requires expertise Less invasive More invasive Dose to cervix and adjacent paracervical areas Dose to cervix, paracervical and parametrial tissues Lesser possibilities of optimisation of dose Owing to many number of needles, more possibilities of dose optimisation Used in most cases Used with special indications
  96. 96. SYSTEMS •Manchester system •Quimby system •Paris system •Stepping source dosimetry
  97. 97.  The Paris System lead to a Stepping Source Dosimetry System (SSDS) for HDR  Dose points are placed midway between the catheters, not only in the central plane but along all catheters  Dwell times are optimized such that the same dose is delivered to all dose points; dwell times in the outer ends of the catheters are increased substantially
  98. 98. 147 • History • Clinical examination • CT / MRI • PAC clearance of the patient • Admit the patient 48 hours prior to the implant PATIENT EVALUATION
  99. 99. 148 One day prior to the implant Clear liquid diet from 24 hours prior to the implant Shave and clean perineum Start antibiotic Peglec 1 sachet diluted in I litre of water to drink till evening Proctoclysis enema / soap water enema at 10 PM Carry out anesthetic pre op orders Nil orally after 10 PM On day of implant Proctoclysis enema/ soap water enema early morning Slow iv fluids started in the morning PRE OP PREPARATION
  100. 100. 149 Martinez Universal Perineal Interstitial Template
  101. 101. 152 TRUS GUIDANCE
  102. 102.  Implant Orientation and Needle identification is very important
  103. 103. 155 IMAGING
  104. 104. •Visible target and OAR •Easy reconstruction of the needles •Optimization program
  105. 105.  D90, D100, V100 for HRCTV  V150, V200 may be reported  OAR reporting – same as in image based ICRT
  106. 106. 159 POST OP •Carefully observe for any bleeding per rectum/hematuria •Maintain frog leg position •Maintain continuous infusion of epidural anaesthesia IMPLANT REMOVAL •Each needle to be removed separately •Apply tincture benzoin at the bleeding points •Advise perineal sitz baths and vaginal douches 2-3 times 3 hours apart after implant removal
  107. 107. 161 TEMPLATE RESULTS Syed , Puthawala et al- IJROBP Sep 2002 • N=185 • EBRT-5040 cGy-----Template LDR 40-50 Gy in 2 applications • 5YDFS- IB-65%, II-67%, III-49%, IV-17 % • Grade 3,4 late complications- 10% Demanes et al- IJROBP Aug 1999, CEC ,1991-96 • N=62 ,locally advanced , early with abn anatomy • EBRT-50Gy ----Template 5.5 - 6 Gy X 6 # • 5YDFS - I-81%, II-47% III-39%, IV-0% • LC rate- I-100% (12/12), II- 93% (25/27) III- 95% (18/19) IV- 75% (3/4) • Grade 3-4 late complications -6.5 %
  108. 108.  Image guided insertion resulted in lesser risk of inadvertent insertion into surrounding organs and accurate placement of catheters  In face of inadvertent insertion into a normal organ, need not remove it, just do not load the needle  Optimization by PDR or HDR improves target coverage and OAR avoidance  Mikami et al reported displacement of 1-2mm cranio- caudal, replanning for >3mm displacemnt (daily CT scans)
  109. 109.  Damatao et al reported <1cm displacement occurred over the course of treatment  Shukla et al reported these shifts for alternate fraction CT imaging  Cranial – 2.5mm  Caudal – 17.4mm  Anterior- 1.7mm  Posterior – 2.1mm  Right – 1.7 mm  Left - 0.6mm
  110. 110.  Essential part of treatment (along with EBRT) of carcinoma cervix stage IB2-IV A  Maybe used alone for stage IA-IB1
  111. 111.  Staging evaluation before starting EBRT and before commencing brachytherapy  Imaging – CT scan +/- MRI  Whole treatment (EBRT + brachy) within 8 weeks.  Delay decreases LC and survival 1% per day  Patients at risk of DVT should receive heparin +/- compression stockings or calf compression devices
  112. 112.  Trimethoprim-sulphamethoxazole should be used for coverage  Fiducial seeds to mark cervical os and extent of disease, possible  Smitt sleeve may be used  Rectal separator reduced the rectal dose substantially. Acc to Lee et al, it applied only when target received >70% of prescribed dose
  113. 113.  Van Dyk et al and Mahantshetty et al compared US and MRI guided target and OAR delineation and found them comparable  A study showed that local recurrence when dose to HRCTV of >87 Gy vs <87Gy was 4% vs 20%  LC of >95% for HRCTV D90 >87Gy (Dimopoulous JC et al)
  114. 114.  STAGE IA  LDR - 60Gy in one # or 75-80 Gy in 2#  HDR – 5GY X 10#  STAGE IB to IVA (35-45Gy following 45Gy EBRT)  Small tumour (non bulky stage I/II ,< 4 cm diameter) – 80-85Gy to point A Pelvic side wall dose-50-55 Gy  Large tumour ( > 4 cm diameter or stage IIIB) good response, point A – 85-90Gy poor response, point A - >90Gy Pelvic side wall dose-55-60 Gy
  115. 115. 172 • ABS recommends that OAR dose should be <80% of prescription dose •Keep the bladder dose below the LDR equivalent of 80 Gy •Keep the rectal dose below the LDR equivalent of 75 Gy (use LQ model with late tissue effect parameters-a/b -3)
  116. 116.  2 sessions  First within 4-6 weeks of starting EBRT  Second 1-2 weeks after 1st application (to allow tumour volume reduction) PDR •Same dose in pulses •No established guidelines about dose per pulse and pulse intervals SCHEDULING
  117. 117. HDR dose LDR equivalent 6 Gy X 4 32 Gy 6Gy X 5 40Gy
  118. 118.  Optimal time-dose-fractionation scheme for HDR brachytherapy of cervix is yet to be established  LDR to HDR reduction factor (Orton et al)  0.54-0.6 for 3-5 #  0.75 for 6-8 #  EQD2 (equivalent dose in 2Gy) obtained by  ABS worksheet  Isoeffect tables by Liu et al (Concluded that 2-4 # LDR is equivalent to 4-7 # of HDR)  Viswanathan et al found significant variations internationally
  119. 119.  Complete/partial response with tumour <4cm - EQD2 >= 80Gy  Non responders/residual tumour >4cm – EQD2 85- 90Gy
  120. 120.  Different schedules  Deliver max EBRT to reduce tumour volume and treat nodes 5days/wk  brachy  Starting 2nd week, weekly #. No EBRT or chemo on brachy day. Boost to nodes on non brachy day  EBRT  5# given twice/week
  121. 121. BRACHY ALONE  LDR dose equivalent of 60Gy  HDR –  PORTEC 2 – 7Gy X 3  MD Anderson – 6Gy X 5  Dana Farber/Bringham – 4Gy X 6
  122. 122. BRACHY AS A BOOST TO EBRT  No disease  LDR equivalent of 70Gy  HDR  RTOG 0921 – 6Gy X 3  RTOG 0418 – 6Gy X 2  Margin positive/ recurrence  70-80Gy LDR equivalent
  123. 123. Treated with interstitial +/- EBRT  PREVIOUSLY IRRADIATED - 40-45Gy by interstitial alone/EBRT boost alone  PREVIOUSLY SURGERY ALONE – EBRT 45-50Gy  20-35Gy interstitial for total dose of 80Gy
  124. 124. 185 • TOLERANCE DOSES  Cervix & uterus – 200 -300 Gy  Vaginal mucosa – 160 -200 Gy  Recto sigmoid & large bowel – 50 -60 Gy  Small bowel – 45 -50Gy  Urinary bladder – 55 -60Gy
  125. 125.  Retrospective. 7662 intracavitary procedures in 4043 patients for FIGO I-III cervical CA (Jhingran A et al)  Complications  2.8% uterine perforation rate  14% have fever >101 C during at least 1 admission  0.1% fatal thromboembolism rate Perforation did not affect DSS in stage I, II, but did lead to worse prognosis in stage III. Vaginal lacerations – mild – no intervention - Large – bleeding may require postponing session and control of bleeding by pressure or suturing of mucosa
  126. 126.  Eifel PJ et al.  Retrospective. 1784 pts, FIGO stage IB.  Grade 3 or higher complications occurred in 7.7% at 3 yrs and 9.3% at 10 yrs. After 10 yrs, 0.34% per year, so at 20 yrs, 14.4% risk.  Risk of rectal complications was the greatest, more than urinary complications.
  127. 127.  Age did not affect the usefulness of brachytherapy  Always recommended whenever possible even in elderly
  128. 128.  EBRT reports significantly inferior results than brachytherapy  60Gy volume is much larger and high central tumour dose is much less in EBRT than in brachytherapy  Recommended only for  Medical reasons  Unusual anatomic configurations of the pelvis or tumour
  129. 129. 190
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complete presentation of all aspects of brachytherapy in carcinoma cervix

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