The use of laminarias for osmotic dilation of the cervix in gynecological brachytherapy applications

Laminaria tent insertion in preplanning MRI for CT-based cervical cancer brachytherapy

PURPOSE

Preplanning magnetic resonance imaging (MRI) is routinely used in image-guided adaptive brachytherapy (IGABT) for cervical cancer. However, a preplanning MRI performed without an applicator does not have good accuracy of image fusion with a planning computed tomography (CT) performed with an applicator. This study aimed to evaluate the efficacy of laminaria tent insertion during pre-planning MRI for cervical cancer brachytherapy (BT).

METHODS AND MATERIALS

Sixteen patients with cervical cancer were enrolled in the study. Images obtained from a single preplanning MRI performed with a laminaria tent inserted into the cervix were fused with images from the planning CT performed with an applicator during each BT session. The alignment between the high-risk clinical target volume on MRI (HR-CTVMRI) and planning CT (HR-CTVCT) was assessed. Image fusion accuracy was classified as follows: maximum misalignment between HR-CTVMRI and HR-CTVCT <5 mm was excellent, 5-10 mm as available, and >10 mm as not available. Image fusion accuracy was reviewed by two radiation oncologists.

RESULTS

Fifty-nine BT sessions were analyzed. Fusion images for 39 (66%) sessions were categorized as excellent, and those for the remaining 12 (20%) sessions were available, and 8 (14%) were not available. Complications reported after laminaria tent insertion were grade-1 fever for 5 (8%) BT sessions in 5 patients and grade-1 pain for 8 (13%) sessions in 5 patients.

CONCLUSION

Laminaria tent insertion during pre-planning MRI may improve the accuracy of image fusion with planning CT and may help delineate the HR-CTV in CT-based IGABT for cervical cancer.

Hypnosedation for endocavitary uterovaginal applications: A pilot study

PURPOSE

Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment.

METHODS AND MATERIALS

Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical" anesthesia technique.

RESULTS

A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred.

CONCLUSION

With a 70% success rate (correct implant with mean pain and anxiety scores < 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea.

Pain relief procedures before high-dose-rate brachytherapy for non-surgical treatment of cervix cancer

Cervical cancer (CC) is a neoplasm with great potential for prevention, but it is still an important public health problem in most developing countries. No significant difference is found in the literature between intracavitary high-dose-rate (HDR) and low-dose-rate (LDR) brachytherapy, when considering overall, disease specific, and recurrence-free survivals. Cervical dilatation is mandatory for the insertion of intra-uterine tandems for CC intracavitary brachytherapy. Pain and discomfort may eventually be the limiting factors of the procedure, sometimes leading to unsatisfactory results in terms of adequate position of the applicator set. In this paper, we critically reviewed the current sedation and anesthetic options for comfort and safety procedures when performing intracavitary brachytherapy.

Pain and symptom assessment during multiple fractions of gynecologic high-dose-rate brachytherapy

PURPOSE

A prospective assessment of tolerability of gynecologic brachytherapy was completed to determine adequacy of analgesia and symptom control for patients undergoing CT-guided brachytherapy, with multiple fractions delivered during a single applicator insertion.

METHODS AND MATERIALS

Seventeen patients receiving high-dose-rate brachytherapy for gynecologic cancer (other than vaginal vault) completed ratings of pain intensity, anxiety, and nausea at five key time points before, during, and after brachytherapy. Symptoms were assessed with patient-reported scores using an 11-point numeric rating scale. The patient population included cervical (n=12), endometrial (n=3), and vulvar-vaginal (n=2) malignancies. Patients underwent general anesthesia for applicator placement. Analgesia consisted of subcutaneous route opioid, and oral opioid and/or nonopioid as needed for the duration of the treatment planning and delivery.

RESULTS

The mean scores for pain were highest after patients were transferred to the CT scanner, 3.3±2.6, compared with baseline scores of 0.9±1.7. Pain scores were 2.3±2.3 during the remainder of the procedure, and 2.7±2.1 after the removal of the applicator. The highest mean anxiety scores occurred before the brachytherapy procedure, 4.3±3.4, with resolution of anxiety during the procedure to 1.3±1.6. The mode of nausea scoring during the procedure was 0.

CONCLUSION

For most of the patients, the delivery of multiple fractions of image-guided high-dose-rate brachytherapy is well tolerated with maximum scores of mild-moderate pain and distress, and no significant nausea. This can be accomplished with applicator placement under general anesthesia and standard medical management.

Results of radiation therapy for uterine cervical cancer using high dose rate remote after loading system

In Japan, radiotherapy with high dose rate remote after loading system (HDR-RALS) for intracavitary brachytherapy is the standard treatment for more than 30 years. This report showed the usefulness of HDR-RALS for uterine cervical cancer. From 1980 through 1999, 442 patients with uterine cervical cancers (stage I: 66, stage II: 161, stage III: 165, stage IV: 50) were treated. Radiotherapy was performed both external teletherapy and HDR-RALS. Overall survival rate at 5 years was 60.2%. The 5-year actuarial incidence of all complications was 16.4%. The 5-year actuarial incidence of all complications in cases treated with the sum doses of whole pelvic irradiation (without central shield) and RALS up to 49 Gy, 50 to 59 Gy or larger doses were 7.5%, 11.0% and 25.2%, respectively. Radiation therapy using HDR-RALS was very effective. While the dose of whole pelvic irradiation was increased, the actuarial incidence of all complications was increased.

Analgesia for pelvic brachytherapy

Pelvic brachytherapy presents the anaesthetist with numerous challenges. Patients vary from highly distressed young adults, to the elderly with coincidental disease severe enough to preclude surgery. The painful radioactive implants remain in place for a number of days. Treatment in isolated rooms reduces radiation exposure to staff, but makes close postoperative monitoring difficult, so the analgesic technique should involve minimum risk to the patient. Although there is very little published evidence of specific analgesic techniques in this area, knowledge of these problems allows the anaesthetist to select appropriate systemic analgesics and regional blocks to provide safe and effective pain relief.