Dr. Manoj Kumar B.Moderator : Prof. F D Patel

PGIMER29th Jan 2009

India Commonest carcinoma in females, Incidence 1.3 lakh/year 24% of all female malignancies At PGI: 25.4% of all female malignancies & 70.7% of

gynaecological malignanciesWorldwide 2nd commonest female malignancy 12% of all female malignancies Highest incidence in Zimbabwe

• Abnormal bleeding PV • PCB• PMB

• Discharge PV• Advanced stage

• pelvic pain, backache• pressure symptoms pertaining to bowel and bladder/ fistulas

To confirm- Punch biopsy /conization/D&C /colposcopy

To stage- CXR,IVP, Cystoscopy (Rectosigmoidscopy, barium enema, CT, MRI, PET)

Base line-Hgm ,KFT, RBS,ALP

Direct Invasion Lymphatic spread Blood-borne metastasis

Corpus 10-30% Urinary Bladder Cervical Epithelium Cervical Stroma Parametrium

Vagina Rectum

LN Involvement (%) Pelvic Stage Para-Aortic 0.5 Ia1 0 4.8 Ia2 2.0 15.9 Ib 2.2 30.0 II 15 50 .0 III 25

1. Tumor-volume, stage, LN status, histology ,vascularity , oncogenes , receptors

2. Patient - Age, S/E condition ,immune status 3. Medical condition- anemia, hypertension and the t/t factors4. Treatment related factors-dose, no. of intracavitary

Both the primary lesion and the potential sites of spread should be evaluated and treated

Optimal therapy consists of radiation or surgery ALONE - Morbidity is higher when both are combined

Management would depend on Age Patient desire Expertise available Medical comorbidity

Role of conservative procedures (LEEP, crotherapy,conization) Young patient who desire pregnancy, ready for a close

follow up, good gynecological expertise are available.

If patient has completed family, does not desire a reproductive function then-type 1 hysterectomy (simple Extrafascial hysterectomy)

Role of radiation – strong medical CI multifocal CIS in cervix and vagina

Can be treated with brachytherapy-(5000mg.h) with 4500cgy to point A

The risk of lymph node spread is <1%. The majority diagnosed on cone biopsy of the cervix or,

more commonly, following LLETZ Management depends on

Patient desire Finding on cone biopsy and endocervical curettage

<3mm invasion & no LVSI – lymph node dissection not needed

Choices – No LVSI Fertility desired - conization Fertility not desired – extrafascial hysterectomy

Close follow up ifmargin of cone biopsy negative ECC is negative No LVSI

If family completed- Simple hysterectomy Simple hysterectomy -If either one is positive, after

doing a repeat conization to make sure that the stage is stage IAI

The risk of lymph node metastases ~5% The recommended treatment for stage Ia2 cervical disease is

modified radical hysterectomy and pelvic lymphadenectomy, or

cervical cone biopsy with extraperitoneal or laparoscopic pelvic lymphadenectomy (if fertility desired)

Selected women with early-stage, low-volume disease who require fertility preservation- Radical trachelectomy with reanastomosis of the vaginal and uterine isthmus and extraperitoneal or laparoscopic pelvic lymphadenectomy.

Medically unfit - ICBT plus external beam radiotherapy

Radical hysterectomy (TypeIII) plus pelvic/paraaortic lymphadenectomy

OR Definitive RT

Stage Ib1 cervical disease is the ideal stage for radical hysterectomy and pelvic lymphadenectomy, although a similar cure rate can be achieved using primary radiotherapy

Young women Advantages of possible ovarian conservation and preservation

of sexual function Shortening and fibrosis of the vagina can be limited if the

woman is sexually active Pelvic relapses can be successfully cured by radiotherapy Surgery allows the status of the lymph nodes, the most

dependent variable associated with survival, to be assessed accurately

The optimal choice depends upon Patient's age Childbearing plans Disease stage Comorbidities Histopathological review Physician and patient preference

Radiotherapy is associated with Radiotherapy-induced menopause Vaginal stenosis Late complication of radiation-induced carcinogenesis Other - cystitis and proctitis

Radiotherapy is Easier to deliver for patients who are obese/elderly/severe

illness—major C/I to the surgical approach Avoids the risks of anaesthesia and the laparotomy scar Iatrogenic mortality is rare Complications after radiotherapy arise later than after

surgery, although radiotherapy-related complications are often permanent

Options Primary chemoradiotherapy

Post RT hysterectomy

OR Primary radical hysterectomy & lymphadenectomy

followed by RT Undiagnosed, coexisting pelvic mass Anatomic alterations making optimal RT difficult

Landoni’s trial 5-year actuarial survival was the same in the surgery and radiation groups (83%),

469 patients (343 evaluable); IB-IIA at med. FU 87 months

Radical RT Radical Sx+/- RT5-Yr OS & DFS 74% 83% (p=NS)

Severe Morbidity 12% 28% (p=0.0004)

Worst morbidity in patients receiving both modalities

FIVE YEAR SURVIAL DATA FOLLOWING RADICAL RADIATION IN CARCINOMA CERVIXStage Incidence 5 Year Survival (%) IA 95-100 IB 5.0 85 IIA 75 IIB 25.0 65 IIIA 48

IIIB 68.0 27 IVA 2.0 0

Coia et al Cancer 1990;17:973-98

STAGE IA 4.6%

IB 11.2%

IIA 8.4%

IIB 30.1%

III 52.3%

IVA 69.2%

Implies 70% cases fail first within Pelvis Distant Metastasis nearly equal in all stages (7-10%)

Coia et al Cancer 1990;17:973-98

Newton - 5-year survival rate for 119 patients with stage-I over 10 yrs- 81% for radical surgery and 74% for radiotherapy(non significant)

Morley and Seski's study, of 446 patients with stage-Ib treated with radical hysterectomy and bilateral pelvic lymphadenectomy or external irradiation and brachytherapy, reported crude 5-year survival of 87% and 83%, respectively. These rates suggest that both treatments are equally effective for early-stage cancers (Ib and IIa)

So in stage IB-IIA , if the patient is likely to require adjuvant treatment than it is better to treat with radiation.

So the treatment in these should be unimodal as far as possible

Ca cervix stages IA2, IB, and IIA initially treated with radical hysterectomy and pelvic lymphadenectomy- High risk disease

Positive pelvic lymph nodes and/or Positive / close margins and/or Microscopic parametrial involvement High risk group-Concurrent chemotherapy and Pelvic RT Intermediate risk group-Stage IB cervical cancer with

negative lymph nodes but with ≥2 following features: >1/3 (deep) stromal invasion LVSI Tumor ≥ 4 cm These patients are given 46-50 GY by external radiation after

4-6 weeks of surgery Low risk- If none of the above mention factors are present

Fertility sparing surgeries Conization Trachelectomy

Radical hysterectomy Laparoscopic assisted radical vaginal hysterectomy Lymphadenectomy Exentration Oophoropexy

Removes the cervical lesion, the transformation zone & the endocervical canal in the shape of a cone along with endocervical curettage

Indications: both diagnostic & therapeutic To assess correctly the depth and the linear extent when

microinvasion suspected Inconclusive colposcopy

TZ not fully visualized A visible lesion extending to endocx canal Dysplastic fragments in ECC Discordance of >1 grade among the diagnostic evaluation

Treatment of Stage Ia1 Loop diathermy excision Cold knife conization Laser conization

Presence of dysplasia either at the endocervical conization margin or in the endocervical curettings is a strong predictor of residual invasive disease

Residual invasive disease 4 % when both are negative 33% when both are positive 22 % with positive endocervical conization margin

Repeat conization should be performed to exclude more deeply invasive residual disease.

This fertility-sparing surgery was pioneered in France by Dr. Daniel Dargent (1995)

Preoperative MRI - to determine the tumor volume and diameter and the degree of endocervical extension

Tricky and difficult to master: the surgeon removes the cervix, parametrium, surrounding lymph nodes, and upper 2 cm of the vagina. The uterus is then attached to the remaining vagina. A cerclage is placed where the Neocervix used to be to allow the patient to carry a pregnancy

Transvaginally /transabdominally/laparoscopic with lymphadenectomy

Selection criteria Lesion size < 2 cm Absence of overt LN metastases Absence of LVSI

Dr. Pedro Ramirez

By the Numbers

11,000Incidence of invasive cervical cancer diagnosed

annually in the US

3,500U.S. women who will die of the disease this year

43%Diagnoses in women aged 45 years or younger

550 Approximate number of patients worldwide who

have chosen radical trachelectomy in 13 yrs

204Reported number of babies born to women who

have undergone radical trachelectomy

5% recurrence and 3% death after recurrence

OncoLog, June 2008, Vol. 53, No. 6

RVT is a safe and feasible procedure to perform in women with small cervical carcinomas who wish to preserve fertility

Complications : cervical stenosis, vaginal discharge, or dysmenorrhea and reduced fertility , 2nd trimester miscarriage or premature delivery, deep dyspareunia and recurrent candidiasis

The tumor recurrence rate is 5% and the mortality rate from disease recurrence is about 3%; these results are comparable to those observed with radical hysterectomy

Lesion size >2 cm is probably the most important risk factor in terms of tumor recurrence

Pregnancy rates following RVT range between 41% -79%, and term delivery ( 37 weeks) is reached in 38% of the pregnancies

To treat cervical cancer while maintaining a woman’s fertility is a significant breakthrough

OncoLog, June 2008, Vol. 53, No. 6

Excision of the uterus en bloc with the parametrium (i.e., round, broad, cardinal, and uterosacral ligaments) and the upper one-third to one-half of the vagina

Inspection of abdomen and pelvis Inspection and palpation of pelvic & PA LN Any suspicion of disease-frozen section to be done No gross e/o metastatic disease-surgery begun Metastatic disease identified- abandon surgery Premenopausal women- ovarian preservation

Extrafascial hysterectomy-The fascia of the cervix and lower uterine segment, which is rich in lymphatic, is removed with the uterus

Stage Ia1 without LVSI No pelvic LND

The uterine artery is ligated where it crosses over the ureter and the uterosacral and cardinal ligaments are divided midway towards their attachment to the sacrum and pelvic sidewall, respectively. The upper one-third of the vagina is resected.

Less extensive Selective removal of enlarged LNs

The uterine artery is ligated at its origin from the superior vesical or internal iliac artery. Uterosacral and cardinal ligaments are resected at their attachments to the sacrum and pelvic sidewall. The upper one-half of the vagina is resected.

Pelvic LND

TYPE IV - The ureter is completely dissected from the vesicouterine ligament, the superior vesical artery is sacrificed, and three-fourths of the vagina is resected

TYPE V - There is additional resection of a portion of the bladder or distal ureter with ureteral reimplantation into the bladder.

Rarely used

Procedure : laparoscopic visualization of the abdominal cavity to exclude

macroscopic disease Laparoscopic lymphadenectomy Radical vaginal hysterectomy (type II or III)

Advantages : Less blood loss Better cosmetic results Faster recovery, shorter hospitalization

Complications Similar to those seen with abdominal surgery

First station-Parametrial, internal iliac, external iliac, presacral,common iliac

Second station- Para-aortic nodes

Aim- To discovers positive lymph nodes as clinical staging is imprecise

Clinical stage fails to identify para-aortic involvement Stage 1b - 7 % Stage IIb -18%

Treatment plan changes in 40% Pelvic LN dissection PA LN dissection-

Bulky cx ca Grossly positive LNs For whom frozen section evaluation will be performed

Arguments in favor Surgical staging is the most accurate method of

determining lymph node involvement. Therapeutic survival benefit of resecting bulky lymph

nodes prior to chemo radiation Arguments against

Delay in the institution of primary CRT Increased risk of morbidity (especially late bowel

obstructions) with the combined modality approach. Methods

Transperitoneal approach-radiotherapy induced bowel complications – 30%

Extraperitoneal dissection-postradiotherapy bowel complications-<5%

Laparoscopic lymphadenectomy

An ultraradical surgical procedure consisting of an en bloc resection of the female reproductive organs, lower urinary tract, and a portion of the rectosigmoid.

Indications Recurrent or advanced gynecologic cancer Extensive central pelvic disease that cannot be resected with a lesser

procedure Has received Radiation before

Contraindications Presence of distant metastasis - 50% Unresectable or extrapelvic disease - 30-50% Disease extending to pelvic side walls

Laterally extended endopelvic resection For recurrent disease involving pelvic side walls Extended lateral resection plane Internal iliac vessels, endopelvic part of obturaror

internus, coccygeus, iliococcygeus, pubococcygeus are removed

Limited experience

Aim: To shield the normal premenopausal ovary from the damaging effects of radiation

Procedure: The ovaries and their vascular supply are brought out of the pelvis and sutured lateral and above the psoas muscle

Ovarian failure can result despite oophoropexy because of scatter radiation and surgically induced changes in ovarian blood supply& innervation

Acute Hemorrhage~0.8 lt UV fistula ~ 1-2% VVF~1% Pulmonary embolism~1-2% SI obstruction~1% Infections~25-50%

Subacute Post op UB dysfunction Lymphocyst formation

Chronic UB hypotonia or atony (MC) Ureteral stricture

The ca cervix has two component Central tumor - growth in the cervix: best treated by

brachytherapy Peripheral - growth in the parametrium: controlled by EBRT

Early stage cancer - ICBT+EBRT either simultaneously or sandwich

Advanced stage -XRT f/b ICBT

Also in tumors which are Bulky cervical lesions or in tumor beyond stage IIa to

improve the geometry of intracavitary application Exophytic, easily bleeding tumors Tumor with necrosis or infection Parametrial involmentExternal irradiation should be given prior to

brachytherapy as it reduces the tumor volume, restores normal anatomy and improve the geometry of brachytherapy.

The relative proportion of XRT increases with increasing tumor bulk and stage

Except for small tumors XRT precedes ICBT At least two ICBT are more effective than one The Para central dose should be 70-85 Gy , depending

on tumor bulk and stage The pelvic side wall should be treated to 45-50 Gy for

suspected microscopic nodal disease, and up to 60 Gy for clinically involved nodes

Target Primary tumor with the first echelon group of lymph nodes The primary tumor, with pelvic lymph nodes up to common

iliac lymph node( paracervical, parametrial, internal iliac, external iliac, presacral, sacral and the obturator LNs)

With adequate margin for microscopic spread and daily set up variability

Radiation therapy technique

2 fieldLess time required

More skin reaction Can treat lower presacral

lymph nodes Useful when lower part

of vagina involved

4 field Less skin reaction More homogenous dose

distribution (especially in large separation)

Lateral most part of parametrium also gets effective dose

If beam weightage is adjusted the dose to bladder and rectum can be decreased

SSD treatments: Relatively more

homogenous dose distribution

Setup possible without requiring expensive aids e.g. Laser

PDD charts can be used for simple dose calculations

Lesser skin reactions

SAD treatments: Less number of MUs rqd Time taken is less Impact of setup inaccuracies

is minimized in 2 field techniques

Ease of setup reproducibility in multi field treatments

Anterior field Center 3 cm above the pubic tubercle , a square 15 x 15

Posterior field , Center 5 cm above tip of coccyx , a square 15 x 15

lateral field , 8 cm above table top 15 x 10 field

All treated by SSD technique Verification with x-rays

Superior border- L4-L5 junction (to encompass the common iliac node)

Lateral border- 1.5 cm from the widest pelvic part of the pelvic brim

Inferior-no vaginal wall involved- lower border of the obturator foramen.

If they are then – 2cm below the lower most point of involment .In case lower vaginal wall involment-portals may be modified to cover the inguinal LN

Superior and inferior would be corresponding to the AP-PA fields

Anterior –vertical line to the anterior edge of pubic symphysis

Posterior-to encompass the sacral hallow ( junction S2-S3)

Dose 45-50 Gy over 41/2 - 5 wks @1.8 to 2 Gy/# Target Para central dose ie dose to point A is 75-80 Gy

of combined XRT & ICBT dose. So the rest of the dose has to be given by brachytherapy.

The WPRT followed by split fields that protect midline organs at risk (bladder and rectum) while treating the parametrium.

Three approaches :Simple rectangular block, a block customized to a single

brachytherapy isodose line.Step wedge filter constructed to conform to multiple

brachytherapy isodose lines.A customized step wedge filter has the potential to

produce a more homogeneous dose distribution but has not achieved widespread use due to labor intensive construction.

Rectangular block shield preferred Superior border-at inferior or middle

of SI joint Inferior would be at caudal aspect of

pelvic field Lateral would be such that what is

covered by a 4cm , width block at isocenter.

Pelvic geometry changes considerably when the brachytherapy applicator is removed and the packing is removed.

Simple straight 4 cm shield is better.

Brachytherapy plays an essential role in the treatment of all invasive cancer of the cervix.

Brachytherapy is used in form of intracavitary application where radioactive sources are placed in uterine cavity and vagina, usually inside a predefined applicator with special geometry and in selected cases complemented by interstitial implants

In radical treatment, brachytherapy is usually combined with EBRT, but it can also be combined with surgery pre- and/or postoperatively

Brachytherapy plays a crucial role in invasive cervical cancer treatment (stage I-IVA) as It permits the delivery of a very high radiation dose to the

central pelvis, while sparing bladder, rectum and small bowel. Uterovaginal brachytherapy should therefore always be considered as a major curative treatment

Short overall treatment time Counter tumor repopulation

Preservation of normal anatomy Preservation of sexual function Survival increases when Brachytherapy is used

Depending upon loading technology Preloaded – radium tubes Afterloaded

Manual – Cs 137

Remote – Cs 137, Co 60, Ir192

Based on dose rates used LDR

0.4-2 Gy/ hr Ra 226, Cs 137

MDR 2-12 Gy/hr Cs 137

In PGI we consider, any dose rate > 0.9 Gy/hr which require dose rate correction as MDR

HDR > 12 Gy/hr Co 60, Ir192

The whole uterus including the cervix and the vaginal wall are densely vascularized and their tolerance to radiation is very high

In contrast, critical organs which are directly adjacent to the cervix like the rectum and bladder are more radiosensitive

In some cases, the very radiosensitive small or large bowel (sigmoid) may be in direct contact to the uterine wall as well.

The vagina also considered as an organ at risk Therefore , we need a peer shaped dose distribution in coronal section

(A P view) and a banana in saggital section (lateral view) Relationship of uterus & vagina

Uterus is usually anteverted & anteflexed and it lies at right angles to the vagina. Construction of applicator.

Relationship of rectum & bladder Important consideration regarding the dose received by brachytherapy –

complications Spread of disease

Predominant line of spread – laterally thru paracervical tissues into parametrium Into uterus & vagina Only in very advanced – into bladder & rectum Brachytherapy doses should reach more laterally than anteroposteriorly

This method was introduced by Forsell and Heyman’ at the Radium hemmet in Stockholm.

Fractionated course of radiation delivered over a period of one month.

Three insertions each of 22 hours separated by 1-3 weeks. Intra-vaginal boxes Silver or gold Intrauterine tube -flexible rubber Unequal loading

30 - 90 mg of radium in uterus 60 - 80 mg in vagina

Total prescribed dose -6500-7100 mg Ra 4500 mg Ra contributed by the vaginal box Dose rate-110R/hr or 2500mg/hr/#

Kottmeier and Forssner have further developed and modified

A single application of radium for 120 hrs.(45R/hr)

Two cork colpostats (cylinder) with 13.3 mg radium in each and an intrauterine silk rubber tube with 33.3 mg radium

Delivers a dose of 7000- 8000 mg-hrs of radium.

The intrauterine sources contained three radioactive sources, with source strengths in the ratio of 1:1:0.5. the colpostats harbored sources with the same strength as the topmost uterine source

Drawbacks of Paris and Stockholm systems Long treatment time-Long hospital stay in the bed

with its associated complications of confinement Discomfort to the patient No dose prescription More hospital visits

The rigid uterine tandem with a ring applicator was developed during 1960 as an afterloading device

The length and the curvature of the intrauterine tandem is chosen dependent on the size and the bending of the uterine cavity

The diameter of the ring which is perpendicular to the axis of the intrauterine tube is also chosen according to the individual anatomical situation

The ring is covered by a cap for reduction of the dose to the vaginal mucosa. The ring is fixed to the intrauterine tandem. The angle between the ring and the tandem is always 90 degrees.

The angle between the ring and the axis of the vagina is selected according to the angle between the axis of the vagina and the uterus

The applicator is fixed against the cervix by an individual packing device

The best known development in brachytherapy technology in cervical cancer has been the Manchester Technique, originated by Tod and Meredith in 1938

Hard rubber ovoids replaced the colpostats held apart by a washer or spacer. The ovoids were shaped to produce a radiation dose uniform within 10% over the surface of the ovoids

Associated with this was an intrauterine tandem with designated loading in both the ovoids and the tandem to maximize the appropriateness of the radiation dose delivery within the volume encompassed by the device

Generally, the treatment was separated into two fractions over a period of 10 days

The significant principle of the Manchester system was to prescribe treatment in terms of radiation dose to define points of interest within the paracervical tissues and the pelvic wall, which were identified by Tod and Meredith as point A and point B.

The point should have met the following criteria to be acceptable: It should have been anatomically comparable from patient to

patient. Should have been in a region where the dosage is not highly

sensitive to small alteration in applicator position Should have been in position, so that it allowed correlation of

the dose levels with the clinical effects To design a set of applicators and their loading (with a given

amount of radium), which would give the same dose rate irrespective of the combination of applicators used

To formulate a set of rules regarding the activity, relationship and positioning of the radium sources in the uterine tumors and the vaginal ovoids, which will give rise to the desired dose rate

It was the work of T F Todd who described a paracervical triangle where initial lesion of radiation necrosis occurs.

Area in the medial edge of broad ligament where the uterine vessel cross over the ureter.

Point A -Since for assessment of dosage a definite point had to be fixed .

Anatomical (original) -The point A was described fixed point 2cm lateral to the center of uterine canal and 2 cm from the mucosa of the lateral fornix

Modified (Physical)- the point A is situated 2 cm from the lower end of lower most intra uterine source along the uterine axis and 2 cm lateral to it

Variant-beginning at the flange abutting the cervical os

ABS point H- From the point of intersection of the line connecting middle of both the ovoids with the central tandem, move superiorly along the tandem, 2cm + radius of the colpostats & then 2cm perpendicular to the tandem in the lateral direction

Point B To know the rate of fall of dose external to point A, as an index

to the volume of tissue treated Quantifies the dose delivered to the obturator lymph nodes Def: 5cm from the patient’s midline, at the same level as point A Dose to Pt B, depends little on the geometric distribution of

radium, but on the total amount of radium used Dose ~15-20 % of the dose at point A

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.

3 sizes Small– 2cm Medium –2.5cm Large –3cm

Pairs of ovoids held apart by a “SPACER” – rubber Fixes at a distance of 1 cm

“WASHER” – holds the ovoids in position in narrow vagina

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 lateral throw off/ more contribution to pt

B Bigger ovoid – to reduce mucosal dose/vaginal surface dose falls

by 35% If smallest ovoids – not insertable – ovoids in tandem

Reduce the dose to Pt A – by 7.5% But increase the Tx time

In order that point A receives same dosage rate no matter which ovoid combination is used ,it is necessary to have different radium loading for each applicator size.

Dose rate 57.5 R/hr to point A (variability of 0.8 R/hr) that is about 8000R in 140 hr at point A.

Not more than 1/3 dose to point A must be delivered from vaginal radium

Tube TypeLength

Tubes used

Mg Ra loaded

Units loaded from fundus

to cervix

Tubes (mg) used for loading

Large 6 3 35 6-4-4 15-10-10

Medium 4 2 25 6-4 15-10

Small 2 1 20 8(10) 20

Ovoid Tubes usedMg Ra loaded

Units loaded

Tubes (mg) used for loading

Large 3 22.5 9 10-10-5 or 20/25*

Medium 2 20 8 20

Small 1 17.5 7 10-5-5 or 20/15**

Always use the largest ovoid that fits in possible Use as long a tandem possible ,not more than 6 cm Dose to point A- 8000 R Dose to uterus wall -30,000 R Dose to cervix- 20-25000 R Dose to vaginal mucosa-20,000 R Dose to recto-vaginal septum- 6750 R Dose limitation-UB < 80 Gy and rectum < 75 Gy

Modern Manchester applicators physically mimic the classical technique. The intrauterine tubes have the same fixed lengths and fixed

cervical flange and are angled at 40 degrees to the line on the vaginal component of the tube.

The vaginal ovoids have kept their ellipsoid shape (large, medium, small, half) with the small ovoids extended posteriorly by 5 mm to build packing into them.

Three after loading tubes are held together and their relative positions fixed by a clamp ensuring an ideal physical arrangement. The whole system is held in place in the individual patient by vaginal gauze packing

Advantages:1. Loose system and therefore,

can suit to any anatomical situation

2. Well studied method and hence control rate and morbidity is well defined

3. It is cost effective

Disadvantages:1. Loose system and therefore,

chances of slipping of ovoids and hence disturbed geometry and creation of cold and hot spots leading to high failure or increased morbidity

2. Radiation hazard : being a preloaded system

This led to development of fixed preloaded and afterloading applicators.

Nowadays uterine tubes with different lengths graduated in cm are commercially available allowing for adaptation according to the individual anatomy (with a fixed uterine flange) and angled at varying degrees to the line of the vaginal component (0°,15°,30°,45°)

Fletcher developed a system for radium that combined a rigid metallic intrauterine tandem with cylindrical colpostats; the latter are positioned against the cervix, perpendicular to the axis of the vagina

System was modified by Delclos and Suit for manual after loading and then for remote after loading (Fletcher-Suit-Delclos applicator)

The intrauterine tandem is available in a variety of curvatures. The length can be adjusted by positioning an adjustable flange. The cylindrical colpostats are 2 cm in diameter but can be enlarged by the addition of caps to 2.5 or 3.0 cm diameter (Fig 14.7). Tungsten shielding is integrated into anterior and posterior part of the standard colpostats to reduce the dose to bladder and rectum

The tandem and colpostats are selected to conform to the tumor volume and topography and the individual patient’s anatomy

Afterloading systems Developed in 1968 by Joslin Initially Cobalt 60, now iridium 192

For equivalence to LDR the dose/# needs to be ~3 Gy However, this based on the t1/2 of late reacting tissues – 1.5

hrs. If assumed to be 4-6 hrs, then dose/# be 6-12 Gy and HDR

may be radiobiologically better. Also better geometrical sparing due to better packing away

of critical organs. Dose rate correction

0.54-0.6 (Orton et al) 0.58 (Patel et al) – for 3-5 HDR applications 0.75 – for 6-8 applications

Advantages Shorter treatment times, resulting in:

Outpatient treatment Less patient discomfort since prolonged bed rest is eliminated Treating patients intolerant of isolation or at risk for acute

cardiopulmonary toxicity due to prolonged bed rest Reduced applicator movement during therapy Greater displacement of nearby normal tissues Possibility of treating larger number of patients

Allows use of smaller diameter sources than are used in HDR: Resulting in less patient discomfort, thereby; Reducing the need for dilatation of the cervix and therefore reducing the

need for heavy sedation or general anesthesia (allowing treatment for high-risk patients who are unable to tolerate general anesthesia).

Making insertion of the tandem into the cervix easier Tailor dose distribution to target through optimization Elimination of exposure to personnel

PatientPreparation

ApplicatorCheck

Applicatorimplantationand fixation

ImagingTreatmentPlanning

Treatment excution

GA Lithotomy position Perineal area is

disinfected Draping Catheterization

•Applicator set is check for integrity and completeness•Uterine sounding•Correct size of ovoid is selected and mounted onto the ovoidtubes•Dilatation of the cervix•Length of uterus is measured

Correct length of IU-tube is selected and inserted

•Select proper size ovoids•Fixate these to the ovoid tubes•Insert one by one and attach to the fixing mechanism

Insert gauze packing to push rectum and bladder away reducing the dose to these organs

Radio opaque rectal marker inserted

X-ray catheters

Tandem -1/3 of the way between S1 –S2 and the symphysis pubis

The tandem -midway between the bladder and S1 -S2

Marker seeds should be placed in the cervix

Ovoids should be against the cervix (marker seeds)

Tandem should bisect the ovoids The bladder and rectum should

be packed away from the implant

The ovoids should fill the vaginal fornices – largest ovoid size to be used.

The ovoids should be separated by 0.5 –1.0 cm, admitting the flange on the tandem.

The axis of the tandem should be central between the ovoids

For treatment planning purposes CT or MR images are taken

PLATO Brachytherapy and PLATO INSIGHT are used for catheter reconstruction

Description as complete as possible of the clinical conditions Complete description of the technique

Complete description of the time-dose pattern Treatment prescription Total Reference Air Kerma (TRAK) Dose at reference points : Point A and reference

points related to bony structures Volumes for reporting and their dimensions :

Treated Volume, point A volume, reference volume

Dose to Organs at Risk : bladder, rectum

Reference volume: Dimensions of the volume included in the corresponding isodose - 60 Gy

Treated Volume: pear and banana shape volume that received (at least) the dose selected and specified by the radiation oncologist as being appropriate to achieve the purpose of the treatment, e.g., tumor eradication or palliation, within the limits of acceptable complications

Irradiated volumes: volumes, surrounding the Treated Volume, encompassed by a lower isodose to be specified, e.g., 90 – 50% of the dose defining the Treated Volume. Reporting irradiated volumes may be useful for interpretation of side effects outside

Point A, as defined in this report, is specified relative to the applicator as visualised on orthogonal planar films

It is located in the oblique frontal plane (ICRU Report 38) containing the intrauterine source(s) and bisecting the vaginal sources

In that plane and from its intersection with the plane containing the vaginal sources, a point is taken, on the midline, cranially at a distance equal to the source-to vaginal mucosal distance (cranial contour of the vaginal sources) + 2 cm left and right A points are located in the oblique frontal plane, perpendicularly to the intrauterine source(s), at 2 cm laterally from the midline

Bladder reference point It is related to a Foley balloon in the trigone of the bladder.

The balloon is filled with 7 cc of radio opaque fluid The catheter is pulled downwards to bring the balloon

against the urethra On the lateral radiograph, the bladder reference point is

obtained on an AP line drawn through the centre of the balloon. The reference point is taken on this line at the posterior surface of the balloon

On the AP radiograph, the reference point is taken at the centre of the balloon.

The reference point for the rectal dose is related to the applicator and located 5 mm behind the posterior vagina wall on an AP line drawn from the middle of the vaginal sources

On the lateral radiograph, an anterior-posterior line is drawn from the lower end of the intrauterine source (or from the middle of the intravaginal sources)

The point is located on this line, 5 mm behind the posterior vaginal wall (not in the contrast filling tube).

The posterior vaginal wall is visualized, depending upon the technique, by means of an intravaginal mould or by opacification of the vaginal cavity with radio-opaque gauze used for packing

On the frontal radiograph, this reference point is taken at the intersection of (the lower end of) the intrauterine source through the plane of the vaginal sources

The pelvic wall reference point, as proposed by Chassagne and Horiot, is intended to be representative of the absorbed dose at the distal part of the parametrium and at the obturator lymphnodes

LDR (<200cgy/hr)- 35-40 Gy at point A MDR (200-1200cgy/hr) - 35 Gy LDR equivalent at point A HDR(>1200cgy/hr)-9 Gy in 2 #/ or 6.8Gy in 3# at point A

Brachytherapy can follow external irradiation SIMULTANEOUS: in stage I , stage II with very minimal

parametriun involvement- 5 sessions of ICT(9gy /#/ 5 ,1week apart) with 40 Gy by XRT given simultaneously

SANDWICH : in the same stages with MDR done with 40 Gy LDR equivalent – XRT 40 Gy – MDR with 35 Gy LDR equivalent

In both above cases a midline shield is used

Large local growth > 4 cm Vaginal wall involvement ( middle- lower 1/3) Heavy parametrium infiltration VVF or VRF In adequate space Medical contraindication Metastatic disease

In such cases ,supplementary radiation 2000cgy /10# /2 weeks

Completion of treatment First follow up-6 weeks, asses the response2 monthly follow up for 1 year, 4 monthly for 2nd

year, 6 monthly then till the 5th year , annually there after

Acute complication (cell loss in rapidly dividing tissue) Acute radiation enteritis(75%, 3 week) Skin reaction( 2 field) Nausea Anorexia Fatigue,Weakness Dysuria, frequency

Chronic complication (endothelial damage) Cervix and vagina-obliteration of os, shortening of vagina ,fistula Ovary-early menopause GI-ulceration ,hemorrhage ,stricture ,small bowel

obstruction,malabsorbtion. Mucosal thinning, telangiectasia and fibrotic contracture in

bladder. Skin- thining ,loss of appendage, telangiectasia,subcut fibrosis.

Two forms of radical treatment are surgery and radiation

External radiation is needed for all but the earliest of tumors, for treatment of the regional lymphatics

Intracavitary Brachytherapy plays an important and predominant role in the cure of cancer of cervix