Uterine perforation during intracavitary application. Prognostic significance in carcinoma of the cervix

Integration of Ultrasound in Image-Guided Adaptive Brachytherapy in Cancer of the Uterine Cervix

Cervical cancer continues to be a public health concern, as it remains the second most common cancer despite screening programs. It is the third most common cause of cancer-related death for women, and the majority of cases happen in developing nations. The standard treatment for locally advanced cervical cancer involves the use of external beam radiation therapy, along with concurrent chemotherapy, followed by an image-guided adaptive brachytherapy (IGABT) boost. The five-year relative survival rate for European women diagnosed with cervical cancer was 62% between 2000 and 2007. Updated cervical cancer treatment guidelines based on IGABT have been developed by the Gynecological working group, which is composed of the Group Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology. The therapeutic strategy makes use of three-dimensional imaging, which can be tailored to the target volume and at-risk organs through the use of computed tomography or magnetic resonance imaging. Under anaesthesia, the brachytherapy implantation is carried out. Ultrasonography is utilised to assess the depth of the uterine cavity and to facilitate the dilation of the uterine canal during the application insertion. In this study, we examine data from the international literature regarding the application of ultrasound in cervical cancer brachytherapy.

Uterine perforation during brachytherapy for cervical cancer: Complications, outcomes, and best practices for forward treatment planning and management

PURPOSE

The purpose of the study was to determine the incidence of uterine perforations, review the associated complications, and propose guidelines for management of perforations after brachytherapy.

METHODS AND MATERIALS

A retrospective chart review was conducted for all patients with cervical cancer who received single or multiple high-dose-rate brachytherapy implants between April 2006 and May 2017 at a single academic institution. CT and MRI images were retrospectively evaluated to record incidences of uterine perforation of tandem during brachytherapy. Acute and long-term complications during and after treatment were scored using the Common Terminology Criteria for Adverse Events, Version 4.0, of the National Cancer Institute.

RESULTS

A total of 123 patients were included in the study. Perforations were observed in 22 patients (17.9%) with 31 (6.4%) of the 482 total implants. Of the different categories of adverse events, only the rate of acute infectious complications among those with perforations (n = 3, 13.6%) versus those without perforations (n = 3, 3.0%) was significant (p = 0.040). Two of the three perforated patients with acute infections had mild urinary tract infections, and all resolved without complications or treatment delays. The remaining one patient had a frank perforation of the anterior uterine wall with a subsequent Grade 3 pyometra infection despite administration of prophylactic antibiotics and 1-week treatment delay. This case was eventually resolved with cervical dilation and evacuation of fluid. Long-term complications were not different between the two arms.

CONCLUSIONS

Patients with cervical cancer with uterine perforations may be able to safely proceed with brachytherapy treatment without delay or need for prophylactic antibiotics in the acute setting. Further validating data would be able to assist in establishing a new standard of care and help prevent unnecessary and harmful breaks during treatment.

Complications of intracavitary brachytherapy for gynecologic cancers and their management: A comprehensive review

Intracavitary gynecologic brachytherapy in the form of tandem-based brachytherapy and vaginal cylinder-based brachytherapy represents a fundamental component of the treatment of women with cervical or uterine cancer due to the ability to deliver a therapeutic dose of radiation with sharp dose falloff. This results in highly effective treatment in terms of oncologic outcomes with an overall favorable toxicity profile. Still, complications and side effects of brachytherapy do exist. While advances in brachytherapy techniques have led to a significant decrease in the rates of toxicity, a thorough understanding of the potential complications is crucial to ensuring optimal outcomes for women with gynecologic cancer undergoing brachytherapy. Use of equivalent dose at 2 Gy per fraction (EQD2) models has allowed incorporation of external beam radiotherapy dose to the brachytherapy dose leading to development of consolidated dose constraints for organs-at-risk in the modern era. This manuscript offers a comprehensive review of potential complications associated with intracavitary brachytherapy for gynecologic cancer including predictive factors, mitigation tactics, and management strategies.

A phase III randomised trial of trans-abdominal ultrasound in improving application quality and dosimetry of intra-cavitary brachytherapy in locally advanced cervical cancer

INTRODUCTION

Intra-cavitary brachytherapy (ICB) remains an integral part of radiotherapy treatment in cervical cancer. Two-dimensional X ray point-based planning remains common and blind insertion leads to uterine perforations and higher toxicity. We conducted a randomised controlled trial of using trans-abdominal ultrasound in performing ICB to reduce perforation and organ at risk doses.

PATIENT AND METHODS

The present study is a phase III open label randomised controlled trial of ultrasound guided ICB conducted on invasive cervical cancer patients. Patients were randomised by a simple computer-generated randomization chart into Arm A (No Ultrasound guidance) and Arm B (ICB with ultrasound guidance). The uterine perforation rates, tandem length change rates, bladder doses, rectal dose and procedure times were compared. Fischer exact test was used to compare the arms and p value <0.05 considered significant.

RESULTS

A total of 160 patients were randomised. With US assistance, the uterine perforation rate was 1.25% (n = 1). In the non-US assistance arm the perforation rate was 12.5% (n = 10) (p = 0.005). Mean time to complete the entire procedure was significantly shortened from 26 min to 19 min favouring the US arm (p = 0.001). Dosimetric assessment between the two groups showed significant decrease in dose received by the various organs at risk with US assistance.

CONCLUSION

The present study confirms significant improvement in application quality as well as dosimetry with reduction in procedure time. Trans-Abdominal US should be routinely used for ICB procedures, particularly in resource limited settings.

Decrease in uterine perforations with ultrasound image-guided applicator insertion in intracavitary brachytherapy for cervical cancer: A systematic review and meta-analysis

PURPOSE

To estimate uterine perforations rates during intracavitary brachytherapy for cervical cancer with and without ultrasound (US) image guidance.

MATERIALS AND METHODS

A systematic search of databases (PubMed and EMBASE) was performed. The pooled summary uterine perforation rate (detected by postinsertion CT or MRI) for the un-guided insertion group and the guided insertion group was calculated by using the random-effects model weighted by the inverse variance.

RESULTS

A total of 690 articles were initially found, resulting in 12 studies that met the inclusion criteria. A total of 1757 insertions and 766 patients were included in the meta-analysis. The overall uterine perforation rate per insertion was 4.56% (95%CI: 2.35-8.67) and per patient was 7.39% (95%CI: 3.92-13.50). The pooled perforation rate per insertion without image guidance was 10.54% (95%CI: 6.12-17.57) versus 1.06% (95%CI: 0.41-2.67) with image guidance (p < 0.01). The pooled perforation rate per patient without guidance was 16.67% (95%CI: 10.01-26.45) versus 2.54% (95%CI: 1.21-5.24) with image guidance (p < 0.01). The ratio of perforations in the un-guided/guided groups was 9.94 and 6.56, per insertion and per patient, respectively. The most common sites of perforation were the posterior wall (>47 events) and the uterine fundus (24 events). None of the studies reported significant acute clinical consequences. Prophylactic antibiotic after perforation was used in 3 of the 4 studies that described the management.

CONCLUSION

Using postinsertion CT or MRI to detect the perforation, the rate of uterine perforation per insertion in patients who received US-guided intracavitary brachytherapy insertion is 90% lower than with un-guided insertion.

Clinical and dosimetric consequences of imperfect applicator insertion in cervical cancer brachytherapy

PURPOSE

This study analyzes clinical consequences and dosimetric variations after imperfect brachytherapy insertions. It examines treatment decisions after such insertions in patients having difficult anatomy, which leads to good subsequent insertions with acceptable dose volume parameters.

MATERIAL AND METHODS

We reviewed images of all insertions performed during last one year and sorted faulty ones out. Clinical outcome was assessed, analyzing original treatment records. Repeat three-dimensional planning using identical dose-optimization-technique compared their dosimetry. Statistical analysis using SPSS^®-Statistics-software included Fisher's-exact-test to analyze predisposing factors for faulty insertions and predictive factors for subsequent satisfactory insertion. Friedman test was used to compare dose-volume-effects of normalization.

RESULTS

Eighteen of 292 brachytherapy plans revealed imperfect insertions, including thirteen perforations (4.5%). Lack of pre-planning, obstructing mass, narrow vagina, acute anteversion of uterus, and multi-parity were significant (p ≤ 0.05) predisposing factors for atypical insertions. Satisfactory optimization was possible after correcting acute anteflexion or positioning tandem in retroverted direction in uncorrectable retroverted uterus. Dose normalization at point A shifted optimized dose from contoured volume to point of normalization, often undesirably. This difference, however, was statistically not significant (p = 0.121). In patients having obstructing mass, subsequent insertions were perfect, and dose volume parameters were acceptable only when full prescribed dose was delivered to at least 60% volume of the mass after a faulty insertion (p < 0.001).

CONCLUSIONS

Pre-planning by imaging is suggested in all cases of brachytherapy. Insertion of adequate length of tandem aligned to uterine axis is warranted for adequate tumor coverage. Whenever detected, acute anteflexion and mobile retroversion should be corrected. Tandem inserted in retroverted direction in uncorrectable retroverted uterus generates acceptable dose volume parameters. In cases with obstructive cervical mass, good subsequent insertion is possible with acceptable dose volume parameters, if planned dose can be delivered to its 60% volume.

Intraoperative sonographic guidance for intracavitary brachytherapy of cervical cancer

BACKGROUND

To describe the role and benefits of intraoperative sonographic (US) guidance in intracavitary brachytherapy of cervical cancer.

METHODS

The data of 142 patients who received tandem-based intracavitary brachytherapy for cervical cancer between January 2010 and June 2015 were retrospectively reviewed. US guidance was carried out for tandem selection and appropriate application. The complications and applicator conformity were assessed with planning CT.

RESULTS

Intracavitary brachytherapy was performed under US guidance for 412 insertions in 113 consecutive patients with cervical cancer. Before we started to use US guidance, applications were done in 29 patients: uterine perforation occurred in two patients (6.9%), the tandem length was short in two patients (6.9%), the tandem length was long in four patients (13.8%), and tandem was in myometrium in three patients (10.3%). We then decided to use US guidance routinely. With US guidance, only 1 of 113 patients had uterine perforation (0.9%), tandem length was short in only one patient (0.9%), and tandem was in myometrium in one patient (0.9%).

CONCLUSIONS

Real-time US provided safe and effective guidance for intracavitary brachytherapy of cervical cancer resulting in decreased rates of perforations and misplacement of applicators. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:8-13, 2018.

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

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.

Uterine perforation and its dosimetric implications in cervical cancer high-dose-rate brachytherapy

Purpose

To retrospectively assess the incidence of sub-serosal and uterine perforation of intra-uterine tandem in intracavitary high-dose-rate (HDR) brachytherapy for cervical cancer, and to evaluate its dosimetric implications on computed tomography (CT)-based treatment planning.

Material and methods

Computed tomography images and brachytherapy plans of cervical cancer patients treated from February 2006 to December 2012 were reviewed for sub-optimal implants (sub-serosal and uterine perforation), and their correlation with cancer FIGO stage and patients’ age. For each patient, the plans showing sub-optimal insertion of intra-uterine tandem were analyzed and compared to plans with adequate insertion. The difference in dose coverage of clinical-target-volume (CTV) and variation of the dose delivered to organs-at-risk (OARs) rectum and bladder were evaluated.

Results

A total of 231 brachytherapy plans for 82 patients were reviewed. We identified 12 (14.6%) patients and 14 (6%) applications with uterine perforation, and 12 (14.6%) patients and 20 (8.6%) applications with sub-serosal insertion of tandem. Data analysis showed that advanced stage correlates with higher incidence of sub-optimal implants (p = 0.005) but not the age (p = 0.18). Dose-volume-histograms (DVHs) analysis showed large variations for CTV dose coverage: D₉₀ significantly decreased with average of –115.7% ± 134.9% for uterine perforation and –65.2% ± 82.8% for sub-serosal insertion (p = 0.025). The rectum and bladder dose assessed by D_2cc increased up to 70.3% and 43.8%, respectively, when sub-optimal insertion of uterine tandem occurred.

Conclusions

We report a low incidence of uterine perforation and sub-serosal insertion of uterine tandem in intracavitary HDR brachytherapy for cervical cancer. However, the effects on treatment plan dosimetry can be considerably detrimental. Therefore, we recommend image-guided insertion, at least for the challenging cases.

MRI findings at image guided adaptive cervix cancer brachytherapy: radiation oncologist's perspective

Magnetic resonance imaging (MRI) represents the reference imaging modality for image guided adaptive brachytherapy (IGABT) of cervix cancer. Accurate interpretation of pre-treatment MRI is required for proper understanding of the tumor extent and topography at IGABT. Planning and optimal timing of the application begins already before treatment, and may need to be adapted during external beam irradiation (EBRT) according to additional clinical and/or radiological findings. The level of MRI utilization in IGABT depends on the infrastructural capabilities of individual centers, ranging from no use at all to repetitive imaging during EBRT and each IGABT fraction. In this article, we summarize the role of different imaging modalities and practical aspects of MRI interpretation in cervix cancer IGABT, concentrating on the systematic evaluation of post-insertion images. MRI with the applicator in place from the radiation oncologist’s perspective should begin with immediate identification of eventual complications of the application procedure and assessment of the implant adequacy, followed by appropriate corrective measures in case of adverse findings. Finally, the tumor extent, topography, and treatment response should be evaluated in the context of initial clinical and radiological findings to allow for an appropriate selection and delineation of the target volumes.

Uterine perforation - 5-year experience in 3-D image guided gynaecological brachytherapy at Institute of Oncology Ljubljana

BACKGROUND

Accurate applicator placement is a precondition for the success of gynaecological brachytherapy (BT). Unrecognized uterine perforation can lead to bleeding, infection, high doses to pelvic organs and underdosage of the target volume, resulting in acute morbidity, long-term complications and reduced chance of cure. We aimed to assess the incidence and clinical characteristics of our cases with uterine perforation, review their management and impact on the treatment course.

PATINETS AND METHODS

In all patients, treated with utero-vaginal image guided BT for gynaecological cancer between January 2006 and December 2011, the CT/MR images with the applicator in place were reviewed. The incidence of uterine perforations was recorded. Clinical factors that may have predisposed to increased risk of perforation were recorded. Management of perforations and their impact on treatment course was assessed.

RESULTS

219 patients (428 applications) were suitable for analysis. Uterine perforation was found in 13 (3.0%) applications in 10 (4.6%) patients. The most frequent perforation site was posterior uterine wall (n = 9), followed by anterior wall (n = 2) and fundus (n = 2). All cases were managed conservatively, without complications. Prophylactic antibiotics were administered in 8 cases. In 4 patients, abdominal and/or transrectal ultrasound (US) guidance was used on subsequent applications for applicator insertion; adequate applicator placement was achieved and treatment completed as planned in all cases.

CONCLUSIONS

3D imaging for BT planning enables accurate identification of uterine perforations. The incidence of perforations at our department is one of the lowest reported in the literature. US guidance of applicator insertion is useful and feasible, allowing to complete the planned treatment even in challenging cases.

Intraoperative Ultrasound Guidance During Intracavitary Brachytherapy Applicator Placement in Cervical Cancer: The University of Alabama at Birmingham Experience

Objective

The objective of this study was to evaluate the University of Alabama at Birmingham experience with routine intraoperative ultrasound (IUS)–guided tandem placement for cervical cancer.

Methods

Between 1999 and 2008, 243 cervical cancer patients underwent IUS-guided tandem placement. One hundred thirty-nine patients received low-dose-rate brachytherapy, and 104 received high-dose-rate brachytherapy. Three hundred fifty-six IUS-guided procedures were performed. Clinical and imaging data were retrospectively analyzed to evaluate complications requiring reinsertion of tandem placement in the context of IUS.

Results

All 243 cervical cancer patients completed intracavitary brachytherapy. Five (1.4%) of 356 IUS-guided applicator placements resulted in uterine perforation. All of these patients underwent successful tandem insertion on the second attempt, and no significant clinical sequelae occurred. Intraoperative ultrasound enabled direct uterine visualization and facilitated real-time feedback for selection of a suitable tandem length and curvature; no suboptimal placements requiring return to the operating room occurred (excluding perforation).

Conclusions

In this large series, IUS guidance substantially increased the rate of successful applicator placement and diminished the rate of uterine perforation relative to historical controls. We strongly recommend the use of IUS guidance during operative intrauterine tandem placement for cervical cancer.

Should uterine tandem applicators ever be placed without ultrasound guidance? No: a brief report and review of the literature

BACKGROUND

Brachytherapy is an integral component of the curative treatment of locally advanced cervical cancer. Optimal applicator placement is associated with improvements in local control and treatment-related toxicity. Uterine perforation by the tandem is common and often undetected by orthogonal radiographs. The role of ultrasound in guiding tandem placement remains controversial.

METHODS

A 55-year-old woman with International Federation of Gynecology and Obstetrics stage IIB cervix cancer underwent placement of a Fletcher-Suit-Delcos tandem and ovoids applicator. Postoperative computed tomography was used for treatment planning.

RESULTS

The applicator appeared to be appropriately placed on clinical exam and orthogonal radiographs. Postoperative computed tomography revealed the tandem had perforated the anterior uterine wall. In a second procedure, the tandem was placed correctly under intraoperative ultrasonography.

CONCLUSIONS

A review of the literature finds a relatively high rate of uterine perforation of the uterus that is undetected by orthogonal radiographs or clinical examination. Multiple reports support the use of real-time ultrasound for patients with especially challenging anatomy. As this report illustrates, uterine perforation is possible in any patient. Therefore, routine real-time ultrasonography should be considered for all uterine tandem insertions.

Ultrasound-guided tandem placement for low-dose-rate brachytherapy in advanced cervical cancer minimizes risk of intraoperative uterine perforation

OBJECTIVES

Tandem placement as part of low-dose-rate (LDR) brachytherapy boost for cervical cancer may be complicated by uterine perforation. The objective of this study was to describe a 10-year experience of using intraoperative ultrasound guidance in an attempt to minimize the risk of uterine perforation.

METHODS

Operative and inpatient records were reviewed to identify cases in which intraoperative ultrasound guidance was employed in order to assist tandem placement, and to determine whether clinical or radiographic findings subsequently suggested uterine perforation. Demographic factors were collected in order to determine the baseline risk of perforation within this population.

RESULTS

Between 1998 and 2008, 71 patients underwent 110 ultrasound-guided placements of tandem applicators. The median age was 48 (range, 26-88) years, and 20% were older than 60 years. Disease stage was FIGO IB1 (n = 10), IB2 (n = 13), IIA (n = 4), IIB (n = 19), IIIA (n = 2), IIIB (n = 16), IVA (n = 5) and IVB (n = 2). The median gravidity was 3 (range 1-10) and median parity was 3 (range 0-10). Seven patients had a preimplant history of pelvic infection, four had a history of intrauterine contraceptive device use, and 10 had a prior history of Cesarean section delivery. Only one patient experienced infection that may have been attributable to tandem placement-associated uterine perforation. At median survivor follow-up of 34 months, 19 patients had died. The estimated 3-year disease-free and overall survival rates for the entire population were 60% and 66%, respectively.

CONCLUSIONS

Within the present population, intraoperative ultrasound guidance of tandem placement was associated with no confirmed cases of uterine perforation.

Prospective comparison of clinical and computed tomography assessment in detecting uterine perforation with intracavitary brachytherapy for carcinoma of the cervix

Brachytherapy (BT) is an essential component of radical treatment for cervix cancer. Uterine perforation is a potential complication of intrauterine applicator (tandem) insertion. Postprocedure pelvic computed tomography (CT) scans are routinely performed at this center. The objective of this study was to prospectively compare radiation oncologists' (RO) clinical impression of satisfactory tandem placement with actual tandem placement as determined from pelvic CT. Patients with cervix cancer undergoing low-dose rate BT from April 2003 to December 2005 were prospectively identified. After tandem placement, patients were brought to the radiotherapy department for pelvic imaging (plain films and CT). Prior to viewing imaging, the RO specified whether they were concerned vs not concerned about uterine perforation. The CT was then reviewed to determine actual tandem placement (perforation vs no perforation). One hundred twenty-four sequential tandem insertions were performed in 114 patients and eligible for analysis. The incidence of CT detected uterine perforation was 13.7% (17/124). Physician concern, age greater than or equal to 60, and tumor size were significant predictors of uterine perforation (P < 0.0001, P= 0.0019, and P= 0.0016, respectively). The overall sensitivity and specificity for physician concern was 52.9% and 84.1%, respectively. CT detected perforation in 8.2% (8/98) of insertions where the RO was clinically confident of correct tandem placement. Pelvic CT was a useful modality to accompany clinical assessment in identifying uterine perforation in cervix BT. As a low but potentially clinical significant number of perforations identified on CT were not suspected clinically, we recommend acquiring pelvic imaging in all patients following tandem insertion to ensure intrauterine tandem positioning.

Computer tomography-assisted three-dimensional technique to assess rectal and bladder wall dose in intracavitary brachytherapy for uterine cervical cancer

We used a computer tomography (CT)-assisted three-dimensional (3D) technique to assess dose to the rectum and bladder in intracavitary brachytherapy (ICBT) for patients with cervical cancer, and compared this technique with the conventional method. The results revealed that the difference in dose to the rectal and bladder wall between these two methods were significant. The CT-assisted technique is a feasible method, and it gives different results than the conventional method.

Tandem application with transvaginal ultrasound guidance

PURPOSE

Intrauterine tandem placement can be difficult in brachytherapy for cervical cancer. A prospective study was planned to investigate transvaginal ultrasound (TVU) guidance for intrauterine tandem insertions in the treatment of cervix cancer.

METHODS AND MATERIALS

Between January 1997 and January 2002, TVU was used after pelvic external beam radiotherapy in 48 cervical cancer patients with a high complication risk because the cervical canal orifice could not be identified and/or the patients could not undergo hysterometry. The TVU findings were graded as 1-4, with a higher number indicating greater difficulty in implantation. The tandem was inserted using the guidance of the TVU findings. Tandem application difficulties were graded in accordance with the number of implantation trials. The relations between tandem applicability and possible factors were analyzed.

RESULTS

By TVU, the difficulties in tandem insertion were graded as Grade 1 in 5 cases, Grade 2 in 23 cases, Grade 3 in 17 cases, and Grade 4 in 3 cases. The tandem was inserted in 19 patients on the first try, 12 patients on the second try, 12 patients on the third try, and 2 patients on the fourth try. However, the cervical canal could not be opened in 3 patients. Factors such as median age, stage, chemotherapy, diameter of the tandem applicators, time between external beam radiotherapy and brachytherapy, and the rate of tumor regression were not statistically significant. The ultrasound grade (p = 0.02) and diameter of the tandem applicator (p = 0.007) were statistically significant. Perforation and sepsis were not observed.

CONCLUSION

TVU guidance before brachytherapy has a positive contributory effect in reducing the morbidity rate of patients considered high risk.

Uterine perforation at the time of brachytherapy for carcinoma of the cervix

OBJECTIVE

The reported incidence of uterine perforation by tandems at the time of vaginal brachytherapy for management of cervical cancer ranges from 1.75% to 10% per application. The potential ramifications of afterloading a tandem that is outside the uterine cavity within the pelvis are sufficiently severe, in terms of bowel injury, that a reliable means of determining tandem positioning at the time of placement is essential.

METHODS

We examined a representative patient that underwent tandem placement for Federation Internationale of Gynecologic Oncologist (FIGO) stage Ib1 cervical Squamous Cell Carcinoma (SCCA). The information provided by conventional radiographic assessment and clinical impression was not helpful in ultimately determining tandem placement.

RESULTS

Direct endoscopic visualization provided accurate and irrefutable evidence of tandem location and positioning prior to leaving the operating room.

CONCLUSION

A variety of techniques have been described to assist in accurate placement of the uterine tandem prior to afterloading, when utilizing definitive chemoradiation in the management of cervical carcinoma. These include postoperative plain films or computerized tomography, versus intraoperative transabdominal or transrectal ultrasound guidance at the time of placement. Postoperative techniques that confirm perforation necessitate a second visit to the operating room, a second general anesthetic, as well as a treatment delay that may impact negatively upon central control rates in the long term. Intraoperative techniques have their limitations as well, particularly in the obese patient. With difficult or questionable insertions, direct endoscopic evaluation at the time of tandem insertion is the only means of knowing definitively the location of the tandem prior to leaving the operating room.

Perioperative and postoperative complications of intracavitary radiation for FIGO stage I-III carcinoma of the cervix

PURPOSE

To evaluate perioperative and postoperative complications of low-dose-rate (LDR) intracavitary radiation therapy in patients with FIGO Stage I-III carcinoma of the uterine cervix.

METHODS AND MATERIALS

We retrospectively reviewed the medical and radiotherapy records of all patients treated with radiation between 1960 and 1992 at The University of Texas M. D. Anderson Cancer Center for FIGO I-III carcinomas of the cervix. Patients who had had initial hysterectomy or whose treatment did not include intracavitary irradiation were excluded. The final study included 4043 patients who had undergone 7662 intracavitary procedures.

RESULTS

Eleven (0. 3%) patients had documented or suspected cases of thromboembolism resulting in 4 deaths. Of these 11 patients, 8 had clinical or radiographic evidence of tumor involving pelvic nodes or fixed pelvic wall. The risk of postoperative thromboembolism did not decrease significantly with the routine use of mini-dose heparin prophylaxis (p = 0.3). Other life-threatening perioperative complications included myocardial infarction (1 death in 5 patients), cerebrovascular accident (2 patients), congestive heart failure or atrial fibrillation (3 patients), and halothane liver toxicity (2 deaths in 2 patients). Intraoperative complications included uterine perforation (2.8%) and vaginal laceration (0.3%), which occurred more frequently in patients >/= 60 years old (p < 0.01). Fourteen percent of patients had a temperature >/= 101 degrees F during at least one hospital stay. The only correlation between minor intraoperative complications and disease-specific survival was found in patients who had Stage III disease and uterine perforation; survival was significantly (p = 0.01) decreased in these patients.

CONCLUSIONS

Fatal or life-threatening complications of intracavitary treatment were very rare. Deep venous thrombosis (DVT) and pulmonary embolism (PE) did not occur in otherwise healthy patients with early disease and were rare even when disease was more advanced. Minor perioperative complications were not correlated with serious late complications or with death from disease.

Uterine perforation by an intracavitary tandem: CT demonstration

Perforation of the uterus by a tandem device is an important complication of intracavitary radiotherapy for cervical carcinoma. Although the sonographic appearance of this complication is well recognized, its demonstration by computed tomography (CT) has been reported in only a single case. We report a second case and discuss the CT findings.

The usefulness of ultrasonography in intracavitary radiotherapy using selectron applicators

Uterine perforation can occur during the procedure of intracavitary insertions for the treatment of carcinoma of the cervix. If radiation treatment proceeds in the situation of inadvertent perforation, severe complication may result. The ultrasonographic studies of five patients with metal intrauterine applicators in situ are described. The applicator appeared as a linear echogenic density within the uterine cavity. The thickness of the uterine wall and the fundus could be clearly identified in a normal insertion. In the presence of uterine perforation, the applicator was seen traversing the myometrium necessitating alteration of the treatment plan.

Complications of uterine cervix carcinoma treatments: the problem of a uniform classification

Ninety-six articles published in English, French and Italian between 1938 and 1986 have been examined in order to analyze the classifications and reporting methods used by different researchers. Specialty and nationality of authors, classifications used, organs, systems and anatomic sites considered, weight given to the most frequently encountered complications are studied. Fifty-nine papers make no use of classification of complications of any kind, neither by onset time, nor by severity, but simply describe the observed events. The remaining 37 papers use a classification based on varying criteria. Thirty-four authors use a classification by severity according to different criteria; four authors classify complications according to the treatment required. In the remaining 30 papers a true scale is used. A total of 22 classifications emerges from these papers; in eight cases a previously published classification is used. The weight assigned by different authors to specific complications has been compared. The following main points emerge from the analysis: about two authors out of three simply describe the observed complications; 30 rely on a true scale of severity, but 22 different grading systems are used. Most classifications do not cover all possible complications, both surgical and radiotherapeutic, but concentrate on those complications which are typically generated by author's therapeutic approach. Only three take into account complications related to different treatment modalities. The observation period is not standardized: published data derive from follow-up times spanning from some months to many years. Authors mainly focus their interest on gastrointestinal and/or urinary complications; other organs and systems are rarely considered.(ABSTRACT TRUNCATED AT 250 WORDS)

CT scanning in intracavitary therapy: unexpected findings in "straightforward" insertions

Since 1980, pelvic CT scanning has been performed in 40% of patients who underwent afterloading intracavitary treatment for carcinoma of the cervix. The unexpected findings of uterine perforation are reported in 3% of these patients and the consequences are discussed.

A CT based dosimetry system for intracavitary therapy in carcinoma of the cervix

The physical dose distribution from intracavitary sources used in the treatment of carcinoma of the cervix can be accurately calculated in three dimensions. However, it is no simple matter to relate dose to critical tissues within the pelvis. We have studied 10 patients and have used CT scanning with dummy sources to determine the dose to lymph nodes, bladder and rectum. This technique may be superior to the use of orthogonal radiographs and highlights the limitations of the use of the flexible rectal dose meter. Further work will required to determine whether or not the morbidity of radical radiotherapy can be reduced using such detailed dosimetry to adjust therapy and eliminate small areas of high dose to critical normal tissues. In one case, CT showed a spontaneous and unexplained uterine perforation by the intrauterine tube one day after check films had shown a satisfactory position.