Gyn Pre-planning: Intracavitary Insertion

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Sydney Lewis
5 years ago
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1 Gyn Pre-planning: Intracavitary Insertion Risk factors: Age > 60 years Distorted cervical canal Retroverted uterus Necrosis Myoma Perforation Incidence: 3% 10%! Intraoperative: Ultrasound guidance Granai CO, et al. Gyn Oncol 1984 Segedin B, et al. Radiol Oncol 2013 Lanciano et al, IJROBP 1994 Pre-BT: MRI Navigation Mayr NA, et al. Brachytherapy 2005 Sharma DN, et al. Gynecol Oncol 2010 Davidson MTM, et al. Brachytherapy 2008 Sahinler I, et al. IJROBP 2004 Irwin W, et al. Gynecol Oncol 2003 MIlman RM, et al. Clin Imaging 1991 Van Dyk S, et al. IJROBP 2009 Davidson MT, et al. Brachytherapy 2008 Jhingran A, Eifel PJ. IJROBP 2000 Barnes EA, et al. Int J Gyn Cancer 2007

2 MRI guided Navigation of Intracavitary insertion Pre-EBRT MRI VMAT & Daily CBCT Week 5: Uterus in RVF RT Pre-BT MRI Pre-BT Clinical? NCCCR, Doha HIGH PERFORATION RISK

3 Uterus Perforation risk Perforation risk Cervix Vaginal wall Cervicouterine canal MRI guided Navigation Cervical os (mm): 18 from right fornix 18 from anterior fornix NCCCR, Doha, Unpublished material Tandem Path (mm): U: 5, UA: 5, UAL: 25, UPL: 25; T: 60

5 Initial MRI & Clinical findings EBRT + ChT Pre BT Clinical findings Insertion

6 Schmid MP, et al. Acta Oncol 2013;52: Based on initial MRI: Parametrial spread and regression patterns PARAMETRIAL REMNANTS [%] 19 % 68 % 88 % 90 % 85 % Predominantly expansive Expansive + Infiltrative inner infiltrating parts 1/3 Infiltrative middle 1/3 Infiltrative outer 1/3 INITIAL PATTERN OF TUMOR GROWTH

7 Based on initial MRI: Parametrial spread and regression patterns Clock-wise coordinates Clinical finidngs Insertion depths 15 mm 30 mm 25 mm 20 mm 30 mm 15 mm

8 Based on initial MRI: Parametrial spread and regression patterns 15 mm 30 mm 25 mm 20 mm 30 mm 15 mm

9 Based Based on pre-brachytherapy on initial MRI MRI Initial MRI & Clinical findings EBRT + ChT Pre BT Pre BT MRI Clinical findings Insertion

10 Based on pre-brachytherapy MRI: Without applicator in place 4th week MRI Clock-wise coordinates Add clinical examination picture Insertion depths same concept as the pre-ebrt approach

11 Based on pre-brachytherapy MRI: Without applicator in place

12 Based on pre-brachytherapy MRI: Without applicator in in place

13 Based on pre-brachytherapy MRI: With applicator in place BT 1: Intracavitary BT 2: IC + needles Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):

14 Based on pre-brachytherapy MRI: With applicator in place BT 0: BT 1: IC IC+ needles BT 2: IC + needles Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):

15 Based on pre-brachytherapy MRI: With applicator in place Primary vaginal cancer Recurrent endometrial cancer Recurrent cervical cancer BT 0 : MRI with MUPIT template in place BT: IC + needles (LPSC) Fokdal L, et al. Radiother Oncol 2011;100:

Based on pre-brachytherapy MRI: With applicator in place 1 9 10 8 11 7 12 16% 12% 8% 4% 0% Virtual 6 Actual 1 5 2 4 3 Number Depth Preplanned 5.3 (2.7) 3.3 (1.

16 Based on pre-brachytherapy MRI: With applicator in place % 12% 8% 4% 0% Virtual 6 Actual Number Depth Preplanned 5.3 (2.7) 3.3 (1.5) Implanted BT1 5.3 (2.9) 3.0. (1.0) Implanted BT2 5.4 (3.0) 2.9 (1.1) Fokdal L, et al. Radiother Oncol 2013;107: Courtesy: Lindegaard J. Aarhus University Hospital

Week5: BT 0 (paracervical block) B R 0 T C α β R

CTV Pre-planned needles HR CTV A week later C BT

17 Based on pre-brachytherapy MRI: With applicator in place Cervix cancer N = 18 pts IC/IS: 14 pts Week5: BT 0 (paracervical block) B R 0 T C α β R T C d A Prescribed dose T Prescribed dose T HR CTV Pre-planned needles HR CTV A week later C BT 1&2: IC/IS implant HR CTV D R T T d Prescribed dose T α β R Petric P, et al. Radiol Oncol 2014 Actual needles Pre-planned needles Actual needles

18 Based on pre-brachytherapy MRI: With applicator in place D90 [Gy α/β=10 ] Median : 1 (0 3.6) Gy V100 [%] Petric P, et al. Radiol. Oncol Median : 1.4 ( ) %

19 Based on pre-brachytherapy MRI: With applicator in place EQD2: Bladder D2cc [Gy] EQD2: Rectum D2cc [Gy] Petric P, et al. Radiol. Oncol 2014 EQD2: Sigmoid D2cc [Gy]

Intracavitary + Interstitial Techniques Rationale

Vienna, 14. 15. May, 2018 Intracavitary + Interstitial Techniques Rationale Primoz Petric NCCCR, HMC, Doha Dimensions of prescribed dose: different levels Prescribed dose Standard loading Modified loading