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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 1  |  Page : 7-11

The role of ultrasound-guided applicator placement in intracavitary brachytherapy for cervical cancer


1 Department of Radiotherapy, SMS Medical College, Jaipur, Rajasthan, India
2 Department of Radiotherapy, Dr S.N. Medical College, Jaipur, Rajasthan, India
3 Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India

Date of Web Publication18-Jun-2018

Correspondence Address:
Dr. R K Spartacus
Department of Radiotherapy, SMS Medical College, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_21_17

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  Abstract 

Context: Intracavitary brachytherapy (ICBT) involves insertion of a tandem applicator through the cervical os into the uterine cavity. Proper placement is critical to the success of ICBT: inadequate applicator geometry is associated with significantly impaired local control and operative complications (uterine perforation). One technique for real-time verification of tandem position is intraoperative ultrasonography (USG).
Aims: The aim of this study is to evaluate the role of intraoperative transabdominal ultrasound-guided tandem placement in brachytherapy for cervical cancer.
Settings and Design: This was a retrospective interventional study.
Subjects and Methods: This was a single institutional study conducted from October 2013 to September 2014. Seventy-seven patients (219 intracavitary applications) of locally advanced cervical cancer were treated with routine ultrasound-guided brachytherapy after pelvic external beam radiotherapy (EBRT).
Results: In 62 of the study patients, the cervical os could be identified visually. In 13 patients, ultrasound guidance was necessary for accurate os identification and proper tandem placement due to cervical canal stenosis. In another 2, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than ICBT (as a result of cervical anatomy distortion). At 24 months, disease-free status was achieved by 68.85% of patients. Seven patients developed Grade 1 bladder Radiation Therapy Oncology Group toxicity, and one had Grade 2 toxicity. Ten patients had Grade 1, and three had Grade 2 Rectal toxicities.
Conclusions: We encountered no case of tandem malplacement or uterine perforation in our study. The disease control and treatment toxicity were within acceptable limits. USG image-based tandem application provides an accurate, fast, easily available, and cost-effective method for proper brachytherapy applicator placement.

Keywords: Applicator, brachytherapy, cervical cancer, ultrasound


How to cite this article:
Spartacus R K, Dana R, Gaur P, Nandwana U, Rastogi K, Agarwal N. The role of ultrasound-guided applicator placement in intracavitary brachytherapy for cervical cancer. J Med Soc 2018;32:7-11

How to cite this URL:
Spartacus R K, Dana R, Gaur P, Nandwana U, Rastogi K, Agarwal N. The role of ultrasound-guided applicator placement in intracavitary brachytherapy for cervical cancer. J Med Soc [serial online] 2018 [cited 2018 Jul 16];32:7-11. Available from: http://www.jmedsoc.org/text.asp?2018/32/1/7/214734


  Introduction Top


Cervical cancer is the second most common female malignancy in India with an incidence of 122,844 patients in 2012.[1] Locally advanced cervical cancers which constitute the majority of our patients are treated with external beam radiation therapy (EBRT) along with cisplatin-based concurrent chemotherapy and brachytherapy.[2],[3] Brachytherapy (Brachy is Greek for short distance) involves placing a radioactive source inside or near the tumor which helps achieve high radiation doses to the tumor and sparing the nearby normal tissue. Brachytherapy forms an integral part in the treatment of cervical cancers.[4] Intracavitary brachytherapy (ICBT) requires the placement of a tandem applicator into the uterine cavity through the cervical os. This is often done “blindly,” by advancing the tandem until one encounters slight resistance to indicate that the tandem tip has reached the uterine fundus.[5] The risk of uterine perforation with this technique is 2%–14%.[5],[6],[7],[8],[9],[10] This can result in inappropriately high radiation doses to organs at risk.[11] Proper placement is critical to the success of ICBT: inadequate geometry has been correlated with significantly impaired local control.[12],[13] One technique for “real-time” verification of tandem position is intraoperative ultrasonography (USG).[9],[14] This study evaluates our departmental experience with USG-guided brachytherapy application using a high-dose rate (HDR) brachytherapy (multisource HDR remote afterloading unit with a 60 cobalt radionuclide source) machine.


  Subjects and Methods Top


Seventy-seven patients with locally advanced, histopathologically proved squamous cell carcinomas of the cervix, (FIGO 2009 Stage IB2-IIIB) attending our Department (October 2013 to September 2014) for ICBT were studied after clearance from the institutional ethical committee. This was a retrospective interventional study. All patients had received definitive 50 Gy/25# EBRT (± concurrent chemotherapy) to the pelvis.

Brachytherapy procedure was done in mini operation theater under intravenous conscious sedation. Patient was positioned in lithotomy position for applicator insertion. Pelvic examination was done to assess disease status, size of cervix, and fornices and to determine the size of vaginal ovoid. An enema was done prior for an empty rectum.

Placement of a Foley catheter and drainage of urine was then performed, followed by retrograde instillation of 250–300 mL of normal saline by gravity into the bladder. The catheter was then clamped, and with the patient's bladder full, real-time transabdominal pelvic ultrasound scanning was performed. A Sonnet Type B portable ultrasound machine with a curved 6.5-MHz ultrasound transducer (Larsen and Toubro Limited) was used. The uterus was dilated under ultrasound guidance. The tandem curvature and depth of placement were selected based on the uterine flexion and height from the external cervical os to the fundus, after which the tandem was carefully placed under real-time ultrasound guidance [Figure 1]a and [Figure 1]b. The bladder was then drained, and the balloon was filled with 7 ml diluted contrast and positioned against the bladder neck. Placement of vaginal ovoids was then performed. Vaginal packing was done using gauze soaked with radiopaque solution diluted with normal saline. Orthogonal radiographs (anteroposterior and right lateral) were taken (by a C-arm X-ray machine) in the supine position and transferred to treatment planning system (HDR Plus Version 2.5.3.) for reconstructing the applicator position and geometry. Each patient received 3 fractions of HDR ICBT of 7.5 Gy/fraction. Postoperative USG and clinical examination were performed in all patients to rule out uterine perforation.
Figure 1: Tandem placed inside uterine cavity in (a) sagittal and (b) axial views

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Treatment response was assessed using the WHO Criteria.[15] Lower gastrointestinal and genitourinary reactions grading was done as per the Radiation Therapy Oncology Group (RTOG) toxicity criteria.[16]


  Results Top


Patient characteristics are mentioned in [Table 1]. In 62 of the study patients, the cervical os could be identified visually. In 13 patients, ultrasound guidance was necessary for accurate os identification and proper tandem placement due to cervical canal stenosis which could be due to EBRT, disease induced, or because of residual disease. In another 2, intraoperative ultrasound helped in identifying the patients suitable for interstitial brachytherapy rather than ICBT (as a result of cervical anatomy distortion). These two patients were referred to another center for interstitial brachytherapy. However, both refused citing economic and logistic reasons even after counseling. They were treated with further EBRT. In all the patients, USG guidance helped in assessing the required angulation of the tandem, length to be inserted inside the uterine canal and uterine position (anteverted or retroverted). No case of applicator malplacement or uterine perforation was observed. At the end of treatment (EBRT + ICBT) [Table 2], complete response rate was 75.33% and 19 patients (24.67%) had a partial response (PR). At 24 months, disease-free status was achieved by 68.85% (42/61) of patients. Seven patients developed Grade 1 bladder RTOG toxicity, and one had Grade 2 toxicity. Ten patients had Grade 1, and three had Grade 2 rectal toxicities.
Table 1: Patient characteristics (n=77)

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Table 2: Disease response and toxicity

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  Discussion Top


The two major objectives of a USG-guided tandem application are to achieve an optimal applicator position and to prevent inadvertent uterine perforation and its complications.

The dose distribution around a tandem-based brachytherapy implant is determined by the applicator position, source location, and source strength. The tandem should be positioned midline in the pelvis, the ovoids should be symmetric, and the packing should not cross over the top of the ovoids, pushing the cervix away from dose. Proper placement of the applicator homogeneously distributes dose throughout the pelvis, ensuring adequate tumor and nodal coverage.[13]

Viswanathan et al. studied (103 patients) that individual brachytherapy parameters, including the symmetry of ovoids in relation to the tandem, displacement of ovoids in relation to the cervical os, tandem bisecting the ovoids, tandem in the midpelvis, and appropriateness of packing, were scored for each implant. Patients with unacceptable symmetry of ovoids to the tandem had a significantly higher risk of local recurrence (LR) than patients in the acceptable group (hazard ratio [HR] = 2.67, 95% confidence interval [CI] = 1.11, 6.45, P = 0.03). Patients with displacement of ovoids in relation to the cervical os had a significantly increased risk of LR (HR = 2.50, 95% CI = 1.05, 5.93, P = 0.04) and a lower disease-free survival rate (HR = 2.28, 95% CI = 1.18, 4.41, P = 0.01).[17]

Corn et al. analyzed whether the technical qualities of a BT application have an impact on the outcome of patients with locally advanced cervix cancer treated by definitive irradiation. Plain radiographs of 66 patients were reviewed by a radiation physicist and a radiation oncologist with expertise in gynecologic radiotherapy. On the basis of assessment of four parameters, the applications were scored as ideal, unacceptable, or adequate. Significantly improved 5-year local control was seen when comparing ideal and adequate placement to unacceptable placement (68% vs.34%, P = 0.02). A strong trend toward improved 5-year survival was also noted among the groups with ideal and adequate placement as opposed to unacceptable placement (61% vs.42%, P = 0.13). This study demonstrates direct influence of competent technical implant performance on local tumor control and even on survival.[12]

The reported risk of uterine perforation without ultrasound guidance ranges from 2% to 14% in various studies.[5],[6],[7],[8],[9],[10] Uterine perforation, apart from causing discomfort and abdominal pain, can lead to inappropriately high radiation doses to organs at risk.[11] It may also result in reapplication of the tandem applicator and cause treatment delay. Extended overall treatment time increases the chances of local failure.[18] Risk factors for improper tandem placement include patients aged 60 and above, history of prior cervical surgery, cervical os stenosis, cervical anatomical distortion, uterine retroversion, and disease extent.[6],[7],[8],[9],[14]

Multiple studies have described the use of intraoperative USG to optimize tandem placement. Real-time USG affords the brachytherapist the opportunity to correct inadequate tandem length or myometrial penetration. Intraoperative ultrasound is also helpful in the context of difficult tandem placement, as it allows for cervical manipulation to facilitate insertion. This modality also facilitates optimal placement within the uterus through direct visualization.[10],[14],[19],[20],[21],[22]

Without ultrasound-guided tandem placement, Granai et al.[10] reported 10% of patients with uterine perforations. Kim et al.[8] reported uterine perforations in 2.3% of the 622 study patients. Even by placing metal clips on the uterine serosa to assess tandem placement, Matsuyama et al.[23] reported a 9.8% rate of uterine perforation without ultrasound guidance. While with the routine use of ultrasound-guided tandem placement, Watkins et al.[24] and Schaner et al.,[25] both reported only 1.4% rate of uterine perforation. Davidson et al., alike the current study, did not experience any uterine perforation at all in 21 patients (35 intracavitary insertions) with the use of ultrasound during tandem placement.[19] The routine use of real-time ultrasound-guided ICBT was also found to shorten the time to complete the procedure. Corn et al.[9] have demonstrated the use of ultrasound-guided tandem placement in cases of cervical stenosis, undetermined orientation of the uterine canal, and in cases of the previous perforation. Mayr et al.[26] demonstrated that ultrasound guidance facilitated accurate tandem placement in patients with retroverted uterus.

Van Dyk et al. opined that the use of routine USG for tandem applicator placement is an accurate, cost-effective, easily accessible, and faster method of ICBT application [27] with lesser incidence of uterine perforations.[28] Thus, its use is even more applicable in low-resource settings. The limitation of our study is that it did not compare USG-guided tandem insertions directly with blind tandem insertions.


  Conclusions Top


We encountered no case of applicator tandem malplacement or uterine perforation in our study. The disease control and treatment toxicity were within acceptable limits. USG image-based tandem application provides an accurate, fast, easily available, and cost-effective method for proper brachytherapy applicator placement. The above advantages also make it a promising modality in high burden but low-resource settings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Rose PG, Ali S, Watkins E, Thigpen JT, Deppe G, Clarke-Pearson DL, et al. Long-term follow-up of a randomized trial comparing concurrent single agent cisplatin, cisplatin-based combination chemotherapy, or hydroxyurea during pelvic irradiation for locally advanced cervical cancer: A Gynecologic Oncology Group Study. J Clin Oncol 2007;25:2804-10.  Back to cited text no. 5
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Katz A, Eifel PJ. Quantification of intracavitary brachytherapy parameters and correlation with outcome in patients with carcinoma of the cervix. Int J Radiat Oncol Biol Phys 2000;48:1417-25.  Back to cited text no. 13
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