Gyn Pre-planning: Intracavitary Insertion Risk factors: Age > - - PowerPoint PPT Presentation

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Aug 21, 2023 137 likes •343 views

Gyn Pre-planning: Intracavitary Insertion Risk factors: Age > 60 years Distorted cervical canal Retroverted uterus Perforation Incidence: Necrosis 3% 10% ! Myoma Pre-BT: Intraoperative: MRI Navigation

SLIDE 1

Gyn Pre-planning: Intracavitary Insertion

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

Perforation Incidence: ≈ 3% – 10% !

Granai CO, et al. Gyn Oncol 1984 Segedin B, et al. Radiol Oncol 2013 Lanciano et al, IJROBP 1994 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

Intraoperative: Ultrasound guidance Pre-BT: MRI Navigation

Risk factors:

Age > 60 years
Distorted cervical canal
Retroverted uterus
Necrosis
Myoma

SLIDE 2

MRI guided Navigation of Intracavitary insertion

NCCCR, Doha

Pre-EBRT MRI

RT

VMAT & Daily CBCT Week 5: Uterus in RVF Pre-BT MRI

?

Pre-BT Clinical HIGH PERFORATION RISK

SLIDE 3

Cervical os (mm):

18 from right fornix
18 from anterior fornix

Perforation risk

Tandem Path (mm): U: 5, UA: 5, UAL: 25, UPL: 25; T: 60

MRI guided Navigation

Uterus Cervix Vaginal wall Perforation risk Cervico- uterine canal

NCCCR, Doha, Unpublished material

SLIDE 4

Gyn Pre-planning: Intracavitary / Interstitial Insertion

SLIDE 5

Initial MRI & Clinical findings EBRT + ChT

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Pre BT Clinical findings Insertion

SLIDE 6

19 % 68 % 88 % 90 % 85 %

Predominantly expansive Expansive + infiltrating parts Infiltrative inner 1/3 Infiltrative middle 1/3 Infiltrative outer 1/3 PARAMETRIAL REMNANTS [%] INITIAL PATTERN OF TUMOR GROWTH

Schmid MP, et al. Acta Oncol 2013;52:1384-1390

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on initial MRI: Parametrial spread and regression patterns

SLIDE 7

Clinical finidngs Clock-wise coordinates Insertion depths

15 mm 30 mm 25 mm 20 mm 30 mm 15 mm

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on initial MRI: Parametrial spread and regression patterns

SLIDE 8

15 mm 30 mm 25 mm 20 mm 30 mm 15 mm

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on initial MRI: Parametrial spread and regression patterns

SLIDE 9

Based on pre-brachytherapy MRI

Initial MRI & Clinical findings EBRT + ChT Insertion

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Pre BT Clinical findings Pre BT MRI

Based on initial MRI

SLIDE 10

Add clinical examination picture

Clock-wise coordinates Insertion depths

Gyn Pre-planning: Intracavitary / Interstitial Insertion

4th week MRI …same concept as the pre-EBRT approach…

Based on pre-brachytherapy MRI: Without applicator in place

SLIDE 11

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on pre-brachytherapy MRI: Without applicator in place

SLIDE 12

Gyn Pre-planning: Intracavitary / Interstitial Insertion

With applicator in place

Based on pre-brachytherapy MRI: Without applicator in place

SLIDE 13

Gyn Pre-planning: Intracavitary / Interstitial Insertion

With applicator in place

Based on pre-brachytherapy MRI:

Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):1424-1430

BT 1:

Intracavitary

BT 2:

IC + needles

SLIDE 14

Gyn Pre-planning: Intracavitary / Interstitial Insertion

With applicator in place BT 2:

IC + needles

BT 1: IC + needles

Based on pre-brachytherapy MRI:

Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):1424-1430

BT 0: IC

SLIDE 15

Gyn Pre-planning: Intracavitary / Interstitial Insertion

With applicator in place

Based on pre-brachytherapy MRI:

Fokdal L, et al. Radiother Oncol 2011;100:473-479

Primary vaginal cancer
Recurrent endometrial cancer
Recurrent cervical cancer

“BT 0”: MRI with MUPIT template in place

BT: IC + needles (LPSC)

SLIDE 16

0% 4% 8% 12% 16%

12 1 2 3 4 5 6 7 8 9 10 11

Virtual Actual

1

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on pre-brachytherapy MRI: With applicator in place

Fokdal L, et al. Radiother Oncol 2013;107:63-68.

Courtesy: Lindegaard J. Aarhus University Hospital

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)

SLIDE 17

Petric P, et al. Radiol Oncol 2014

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on pre-brachytherapy MRI: With applicator in place

Week5: BT 0 (paracervical block)

Pre-planned needles Prescribed dose HR CTV T

B C

α β 0°

T R

Pre-planned needles Prescribed dose HR CTV T

B C

α β 0°

T C R

α β 0°

T R

d C

T R

T R T R

HR CTV Prescribed dose T

A R ∆α

Pre-planned needles Actual needles

T R ∆d

Prescribed dose HR CTV Actual needles T

D ∆β T C R ∆α

Pre-planned needles Actual needles

T R ∆d T R ∆d

Prescribed dose HR CTV Actual needles T

D ∆β T C

BT 1&2: IC/IS implant

A week later

Cervix cancer N = 18 pts IC/IS: 14 pts

SLIDE 18

5 10 15 20 25 30 35 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

D90 [Gyα/β=10]

10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

V100 [%]

Median ∆: 1 (0 – 3.6) Gy Median ∆: 1.4 (0.1 – 9.2) %

Petric P, et al. Radiol. Oncol 2014

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Based on pre-brachytherapy MRI: With applicator in place

SLIDE 19

2 4 6 8 10 12 14 16 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 2 4 6 8 10 12 14 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

EQD2: Rectum D2cc [Gy] EQD2: Sigmoid D2cc [Gy]

2 4 6 8 10 12 14 16 18 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

EQD2: Bladder D2cc [Gy]