Challenges in intracavitary brachytherapy application in anatomically variable uterus
Abstract
Introduction: Cancer cervix is the 2nd most common malignancy among Indian females with 1,23,907 new cases every year. Treatment options include radical radiotherapy wherein internal radiation plays an imperative role. Intracavitary applications in anatomically distorted uteri present a challenge and often result in sub-optimal applications. The purpose of this study is to determine the incidence of anatomically variable uterus in cancer cervix patients and the rate of intra-operative complications with Intracavitary brachytherapy (ICBT). Materials and methods: An audit of 276 biopsy-proven cancer cervix patients treated with ICBT between Jan 2019 to June 2022 was undertaken. FIGO stage I-IVA were included while metastatic and post-operative cases were excluded. All applications were done using the Modified Fletcher-Suit applicator, and planned on CT using Brachy vision 13.6.5, based on Point A. Results: 41/276 (14.9%) patients presented with anatomically variable uteri. 20/41 (48.78%) were retroverted uteri, 11/41 (26.82%) were anteflexed and 5 each (12.19%) had cervical stenosis and atrophied uteri respectively. The total number of applications performed was 120, and complications were recorded in 42 applications. There was a statistically significant correlation between the patient’s age and the incidence of procedural complications, with an increased incidence of complications in the advanced age group (p-value — 0.001). Similarly, a significant correlation was found between distorted anatomy and the incidence of complications (p-value — 0.045). The higher rectal dose was observed in anteflexed uteri (p-value — 0.001) while retroverted uteri was associated with a higher bladder dose (p-value — 0.001). Conclusions: In anatomically difficult uteri, brachytherapy application is a challenge with significantly high rates of complications including perforation. Careful selection of tandem length and orientation of the uterine anatomy after the first fraction may enable better application in subsequent fractions.
Keywords: Intracavitary brachytherapycancer cervixperforation
References
- Cancer Today. Global Cancer Observatory. accessed online at. https://gco.iarc.fr/today/fact-sheets-populations.
- Otter S, Franklin A, Ajaz M, et al. Improving the efficiency of image guided brachytherapy in cervical cancer. J Contemp Brachytherapy. 2016; 8(6): 557–565.
- Corn BW, Hanlon AL, Pajak TF, et al. Technically accurate intracavitary insertions improve pelvic control and survival among patients with locally advanced carcinoma of the uterine cervix. Gynecol Oncol. 1994; 53(3): 294–300.
- Irvin W, Rice L, Taylor P, et al. Uterine perforation at the time of brachytherapy for carcinoma of the cervix. Gynecol Oncol. 2003; 90(1): 113–122.
- Bahadur YA, Eltaher MM, Hassouna AH, et al. Uterine perforation and its dosimetric implications in cervical cancer high-dose-rate brachytherapy. J Contemp Brachytherapy. 2015; 7(1): 41–47.
- Powell-Smith C. Factors influencing the incidence of radiation injury in cancer of the cervix. J Can Assoc Radiol. 1965; 16: 132–137.
- Mayr NA, Montebello JF, Sorosky JI, et al. Brachytherapy management of the retroverted uterus using ultrasound-guided implant applicator placement. Brachytherapy. 2005; 4(1): 24–29.
- Prabhakar GS, Revannasiddaiah S, Susheela SP, et al. Uterine perforation during intracavitary brachytherapy for carcinoma of the cervix. BMJ Case Rep. 2012; 2012.
- Chakrabarti B, Pal SK, Sepai HM, et al. Clinical and dosimetric consequences of imperfect applicator insertion in cervical cancer brachytherapy. J Contemp Brachytherapy. 2018; 10(4): 321–336.
- Segedin B, Gugic J, Petric P. Uterine perforation - 5-year experience in 3-D image guided gynaecological brachytherapy at Institute of Oncology Ljubljana. Radiol Oncol. 2013; 47(2): 154–160.
- Granai CO, Allee P, Doherty F, et al. Intraoperative real-time ultrasonography during intrauterine tandem placement. Obstet Gynecol. 1986; 67(1): 112–114.
- Gupta P, Aich RK, Deb AR. Acute complications following intracavitary high-dose-rate brachytherapy in uterine cancer. J Contemp Brachytherapy. 2014; 6(3): 276–281.