Management Of Early Stage Ca Cervix [Autosaved]


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  • Management Of Early Stage Ca Cervix [Autosaved]

    1. 1. Dr. Manoj Kumar B. Moderator : Prof. F D Patel PGIMER 29 th Jan 2009
    2. 2. <ul><li>India </li></ul><ul><li>Commonest carcinoma in females, Incidence 1.3 lakh/year </li></ul><ul><li>24% of all female malignancies </li></ul><ul><li>At PGI: 25.4% of all female malignancies & 70.7% of gynaecological malignancies </li></ul><ul><li>Worldwide </li></ul><ul><li>2 nd commonest female malignancy </li></ul><ul><li>12% of all female malignancies </li></ul><ul><li>Highest incidence in Zimbabwe </li></ul>
    3. 3. <ul><li>Abnormal bleeding PV </li></ul><ul><ul><li>PCB </li></ul></ul><ul><ul><li>PMB </li></ul></ul><ul><li>Discharge PV </li></ul><ul><li>Advanced stage </li></ul><ul><ul><li>pelvic pain, backache </li></ul></ul><ul><ul><li>pressure symptoms pertaining to bowel and bladder/ fistulas </li></ul></ul>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
    4. 5. <ul><li>Direct Invasion </li></ul><ul><li>Lymphatic spread </li></ul><ul><li>Blood-borne metastasis </li></ul>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
    5. 6. <ul><li>Tumor-volume, stage, LN status, histology ,vascularity , oncogenes , receptors </li></ul><ul><li>Patient - Age, S/E condition ,immune status </li></ul><ul><li>Medical condition- anemia, hypertension and the t/t factors </li></ul><ul><li>Treatment related factors-dose, no. of intracavitary </li></ul>
    6. 8. <ul><li>Both the primary lesion and the potential sites of spread should be evaluated and treated </li></ul><ul><li>Optimal therapy consists of radiation or surgery ALONE - Morbidity is higher when both are combined </li></ul>
    7. 9. <ul><li>Management would depend on </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Patient desire </li></ul></ul><ul><ul><li>Expertise available </li></ul></ul><ul><ul><li>Medical comorbidity </li></ul></ul><ul><li>Role of conservative procedures (LEEP, crotherapy,conization) </li></ul><ul><ul><li>Young patient who desire pregnancy, ready for a close follow up, good gynecological expertise are available. </li></ul></ul>
    8. 10. <ul><li>If patient has completed family, does not desire a reproductive function then-type 1 hysterectomy (simple Extrafascial hysterectomy) </li></ul><ul><li>Role of radiation – </li></ul><ul><ul><li>strong medical CI </li></ul></ul><ul><ul><li>multifocal CIS in cervix and vagina </li></ul></ul><ul><li>Can be treated with brachytherapy-(5000mg.h) with 4500cgy to point A </li></ul>
    9. 11. <ul><li>The risk of lymph node spread is <1%. </li></ul><ul><li>The majority diagnosed on cone biopsy of the cervix or, more commonly, following LLETZ </li></ul><ul><li>Management depends on </li></ul><ul><ul><li>Patient desire </li></ul></ul><ul><ul><li>Finding on cone biopsy and endocervical curettage </li></ul></ul><ul><li><3mm invasion & no LVSI – lymph node dissection not needed </li></ul><ul><li>Choices – No LVSI </li></ul><ul><ul><li>Fertility desired - conization </li></ul></ul><ul><ul><li>Fertility not desired – extrafascial hysterectomy </li></ul></ul>
    10. 12. <ul><li>Close follow up if </li></ul><ul><ul><li>margin of cone biopsy negative </li></ul></ul><ul><ul><li>ECC is negative </li></ul></ul><ul><ul><li>No LVSI </li></ul></ul><ul><li>If family completed- Simple hysterectomy </li></ul><ul><li>Simple hysterectomy -If either one is positive, after doing a repeat conization to make sure that the stage is stage IA I </li></ul>
    11. 13. <ul><li>The risk of lymph node metastases ~5% </li></ul><ul><li>The recommended treatment for stage Ia2 cervical disease is </li></ul><ul><ul><li>modified radical hysterectomy and pelvic lymphadenectomy, or </li></ul></ul><ul><ul><li>cervical cone biopsy with extraperitoneal or laparoscopic pelvic lymphadenectomy (if fertility desired) </li></ul></ul><ul><li>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. </li></ul><ul><li>Medically unfit - ICBT plus external beam radiotherapy </li></ul>
    12. 14. <ul><li>Radical hysterectomy (TypeIII) plus pelvic/paraaortic lymphadenectomy </li></ul><ul><li>OR </li></ul><ul><li>Definitive RT </li></ul><ul><ul><li>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 </li></ul></ul>
    13. 15. <ul><li>Young women </li></ul><ul><ul><li>Advantages of possible ovarian conservation and preservation of sexual function </li></ul></ul><ul><ul><li>Shortening and fibrosis of the vagina can be limited if the woman is sexually active </li></ul></ul><ul><ul><li>Pelvic relapses can be successfully cured by radiotherapy </li></ul></ul><ul><ul><li>Surgery allows the status of the lymph nodes, the most dependent variable associated with survival, to be assessed accurately </li></ul></ul><ul><li>The optimal choice depends upon </li></ul><ul><ul><li>Patient's age Childbearing plans </li></ul></ul><ul><ul><li>Disease stage </li></ul></ul><ul><ul><li>Comorbidities </li></ul></ul><ul><ul><li>Histopathological review </li></ul></ul><ul><ul><li>Physician and patient preference </li></ul></ul>
    14. 16. <ul><li>Radiotherapy is associated with </li></ul><ul><ul><li>Radiotherapy-induced menopause </li></ul></ul><ul><ul><li>Vaginal stenosis </li></ul></ul><ul><ul><li>Late complication of radiation-induced carcinogenesis </li></ul></ul><ul><ul><li>Other - cystitis and proctitis </li></ul></ul><ul><li>Radiotherapy is </li></ul><ul><ul><li>Easier to deliver for patients who are obese/elderly/severe illness—major C/I to the surgical approach </li></ul></ul><ul><ul><li>Avoids the risks of anaesthesia and the laparotomy scar </li></ul></ul><ul><ul><li>Iatrogenic mortality is rare </li></ul></ul><ul><ul><li>Complications after radiotherapy arise later than after surgery, although radiotherapy-related complications are often permanent </li></ul></ul>
    15. 17. <ul><li>Options </li></ul><ul><ul><li>Primary chemoradiotherapy </li></ul></ul><ul><ul><ul><li>Post RT hysterectomy </li></ul></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>Primary radical hysterectomy & lymphadenectomy followed by RT </li></ul></ul><ul><ul><ul><li>Undiagnosed, coexisting pelvic mass </li></ul></ul></ul><ul><ul><ul><li>Anatomic alterations making optimal RT difficult </li></ul></ul></ul>
    16. 18. <ul><li>Landoni’s trial 5-year actuarial survival was the same in the surgery and radiation groups (83%), </li></ul><ul><li>469 patients (343 evaluable); IB-IIA at m ed. FU 87 months </li></ul><ul><li>Radical RT Radical Sx+/- RT </li></ul><ul><li>5-Yr OS & DFS 74% 83% (p=NS) </li></ul><ul><li>Severe Morbidity 12% 28% (p=0.0004) </li></ul><ul><li>Worst morbidity in patients receiving both modalities </li></ul>
    17. 19. <ul><li>FIVE YEAR SURVIAL DATA FOLLOWING RADICAL RADIATION IN CARCINOMA CERVIX </li></ul><ul><li>Stage Incidence 5 Year Survival (%) </li></ul><ul><li> IA 95-100 </li></ul><ul><li> IB 5.0 85 </li></ul><ul><li> IIA 75 </li></ul><ul><li> IIB 25.0 65 </li></ul><ul><li> IIIA 48 </li></ul><ul><li>IIIB 68.0 27 </li></ul><ul><li> IVA 2.0 0 </li></ul><ul><li>Coia et al Cancer 1990;17:973-98 </li></ul>
    18. 20. <ul><li>STAGE </li></ul><ul><li>IA 4.6% </li></ul><ul><li>IB 11.2% </li></ul><ul><li>IIA 8.4% </li></ul><ul><li>IIB 30.1% </li></ul><ul><li>III 52.3% </li></ul><ul><li>IVA 69.2% </li></ul><ul><ul><ul><li>Implies 70% cases fail first within Pelvis </li></ul></ul></ul><ul><ul><ul><li>Distant Metastasis nearly equal in all stages (7-10%) </li></ul></ul></ul><ul><li>Coia et al Cancer 1990;17:973-98 </li></ul>
    19. 21. <ul><li>Newton - 5-year survival rate for 119 patients with stage-I over 10 yrs- 81% for radical surgery and 74% for radiotherapy(non significant) </li></ul><ul><li>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) </li></ul><ul><li>So in stage IB-IIA , if the patient is likely to require adjuvant treatment than it is better to treat with radiation. </li></ul><ul><li>So the treatment in these should be unimodal as far as possible </li></ul>
    20. 22. <ul><ul><li>Ca cervix stages IA2, IB, and IIA initially treated with radical hysterectomy and pelvic lymphadenectomy- </li></ul></ul><ul><ul><ul><li>High risk disease </li></ul></ul></ul><ul><ul><li>Positive pelvic lymph nodes and/or </li></ul></ul><ul><ul><li>Positive / close margins and/or </li></ul></ul><ul><ul><li>Microscopic parametrial involvement </li></ul></ul><ul><li>High risk group-Concurrent chemotherapy and Pelvic RT </li></ul><ul><li>Intermediate risk group-Stage IB cervical cancer with negative lymph nodes but with ≥2 following features: </li></ul><ul><ul><li>>1/3 (deep) stromal invasion </li></ul></ul><ul><ul><li>LVSI </li></ul></ul><ul><ul><li>Tumor ≥ 4 cm </li></ul></ul><ul><li>These patients are given 46-50 GY by external radiation after 4-6 weeks of surgery </li></ul><ul><li>Low risk - If none of the above mention factors are present </li></ul>
    21. 24. <ul><li>Fertility sparing surgeries </li></ul><ul><ul><li>Conization </li></ul></ul><ul><ul><li>Trachelectomy </li></ul></ul><ul><li>Radical hysterectomy </li></ul><ul><li>Laparoscopic assisted radical vaginal hysterectomy </li></ul><ul><li>Lymphadenectomy </li></ul><ul><li>Exentration </li></ul><ul><li>Oophoropexy </li></ul>
    22. 25. <ul><li>Removes the cervical lesion, the transformation zone & the endocervical canal in the shape of a cone along with endocervical curettage </li></ul><ul><li>Indications: both diagnostic & therapeutic </li></ul><ul><ul><li>To assess correctly the depth and the linear extent when microinvasion suspected </li></ul></ul><ul><ul><li>Inconclusive colposcopy </li></ul></ul><ul><ul><ul><li>TZ not fully visualized </li></ul></ul></ul><ul><ul><ul><li>A visible lesion extending to endocx canal </li></ul></ul></ul><ul><ul><ul><li>Dysplastic fragments in ECC </li></ul></ul></ul><ul><ul><ul><li>Discordance of >1 grade among the diagnostic evaluation </li></ul></ul></ul><ul><ul><li>Treatment of Stage Ia1 </li></ul></ul><ul><li>Loop diathermy excision </li></ul><ul><li>Cold knife conization </li></ul><ul><li>Laser conization </li></ul>
    23. 26. <ul><li>Presence of dysplasia either at the endocervical conization margi n or in the endocervical curettings is a strong predictor of residual invasive disease </li></ul><ul><li>Residual invasive disease </li></ul><ul><ul><li>4 % when both are negative </li></ul></ul><ul><ul><li>33% when both are positive </li></ul></ul><ul><ul><li>22 % with positive endocervical conization margin </li></ul></ul><ul><li>Repeat conization should be performed to exclude more deeply invasive residual disease. </li></ul>
    24. 27. <ul><li>This fertility-sparing surgery was pioneered in France by Dr. Daniel Dargent (1995) </li></ul><ul><li>Preoperative MRI - to determine the tumor volume and diameter and the degree of endocervical extension </li></ul><ul><li>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 </li></ul><ul><li>Transvaginally /transabdominally/laparoscopic with lymphadenectomy </li></ul><ul><li>Selection criteria </li></ul><ul><ul><li>Lesion size < 2 cm </li></ul></ul><ul><ul><li>Absence of overt LN metastases </li></ul></ul><ul><ul><li>Absence of LVSI </li></ul></ul>Dr. Pedro Ramirez
    25. 28. By the Numbers 11,000 Incidence of invasive cervical cancer diagnosed annually in the US 3,500 U.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 204 Reported 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
    26. 29. <ul><li>RVT is a safe and feasible procedure to perform in women with small cervical carcinomas who wish to preserve fertility </li></ul><ul><li>Complications : cervical stenosis, vaginal discharge, or dysmenorrhea and reduced fertility , 2 nd trimester miscarriage or premature delivery, deep dyspareunia and recurrent candidiasis </li></ul><ul><li>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 </li></ul><ul><li>Lesion size >2 cm is probably the most important risk factor in terms of tumor recurrence </li></ul><ul><li>Pregnancy rates following RVT range between 41% -79%, and term delivery ( 37 weeks) is reached in 38% of the pregnancies </li></ul><ul><li>To treat cervical cancer while maintaining a woman’s fertility is a significant breakthrough </li></ul><ul><li>OncoLog, June 2008, Vol. 53, No. 6 </li></ul>
    27. 30. <ul><li>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 </li></ul><ul><li>Inspection of abdomen and pelvis </li></ul><ul><li>Inspection and palpation of pelvic & PA LN </li></ul><ul><li>Any suspicion of disease-frozen section to be done </li></ul><ul><li>No gross e/o metastatic disease-surgery begun </li></ul><ul><li>Metastatic disease identified- abandon surgery </li></ul><ul><li>Premenopausal women- ovarian preservation </li></ul>
    28. 32. <ul><li>Extrafascial hysterectomy-The fascia of the cervix and lower uterine segment, which is rich in lymphatic, is removed with the uterus </li></ul><ul><li>Stage Ia1 without LVSI </li></ul><ul><li>No pelvic LND </li></ul>
    29. 33. <ul><li>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. </li></ul><ul><li>Less extensive </li></ul><ul><li>Selective removal of enlarged LNs </li></ul>
    30. 34. <ul><li>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. </li></ul><ul><li>Pelvic LND </li></ul>
    31. 35. <ul><li>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 </li></ul><ul><li>TYPE V - There is additional resection of a portion of the bladder or distal ureter with ureteral reimplantation into the bladder. </li></ul><ul><li>Rarely used </li></ul>
    32. 36. <ul><li>Procedure : </li></ul><ul><ul><li>laparoscopic visualization of the abdominal cavity to exclude macroscopic disease </li></ul></ul><ul><ul><li>Laparoscopic lymphadenectomy </li></ul></ul><ul><ul><li>Radical vaginal hysterectomy (type II or III) </li></ul></ul><ul><li>Advantages : </li></ul><ul><ul><li>Less blood loss </li></ul></ul><ul><ul><li>Better cosmetic results </li></ul></ul><ul><ul><li>Faster recovery, shorter hospitalization </li></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Similar to those seen with abdominal surgery </li></ul></ul>
    33. 37. <ul><li>First station-Parametrial, internal iliac, external iliac, presacral,common iliac </li></ul><ul><li>Second station- Para-aortic nodes </li></ul>
    34. 38. <ul><li>Aim- To discovers positive lymph nodes as clinical staging is imprecise </li></ul><ul><li>Clinical stage fails to identify para-aortic involvement </li></ul><ul><ul><li>Stage 1b - 7 % </li></ul></ul><ul><ul><li>Stage IIb -18% </li></ul></ul><ul><li>Treatment plan changes in 40% </li></ul><ul><li>Pelvic LN dissection </li></ul><ul><li>PA LN dissection- </li></ul><ul><ul><li>Bulky cx ca </li></ul></ul><ul><ul><li>Grossly positive LNs </li></ul></ul><ul><ul><li>For whom frozen section evaluation will be performed </li></ul></ul>
    35. 39. <ul><li>Arguments in favor </li></ul><ul><ul><li>Surgical staging is the most accurate method of determining lymph node involvement. </li></ul></ul><ul><ul><li>Therapeutic survival benefit of resecting bulky lymph nodes prior to chemo radiation </li></ul></ul><ul><li>Arguments against </li></ul><ul><ul><li>Delay in the institution of primary CRT </li></ul></ul><ul><ul><li>Increased risk of morbidity (especially late bowel obstructions) with the combined modality approach. </li></ul></ul><ul><li>Methods </li></ul><ul><ul><li>Transperitoneal approach-radiotherapy induced bowel complications – 30% </li></ul></ul><ul><ul><li>Extraperitoneal dissection-postradiotherapy bowel complications-<5% </li></ul></ul><ul><ul><li>Laparoscopic lymphadenectomy </li></ul></ul>
    36. 40. <ul><li>An ultraradical surgical procedure consisting of an en bloc resection of the female reproductive organs, lower urinary tract, and a portion of the rectosigmoid. </li></ul><ul><li>Indications </li></ul><ul><ul><li>Recurrent or advanced gynecologic cancer </li></ul></ul><ul><ul><li>Extensive central pelvic disease that cannot be resected with a lesser procedure </li></ul></ul><ul><ul><li>Has received Radiation before </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Presence of distant metastasis - 50% </li></ul></ul><ul><ul><li>Unresectable or extrapelvic disease - 30-50% </li></ul></ul><ul><ul><li>Disease extending to pelvic side walls </li></ul></ul>
    37. 41. <ul><li>Laterally extended endopelvic resection </li></ul><ul><li>For recurrent disease involving pelvic side walls </li></ul><ul><li>Extended lateral resection plane </li></ul><ul><li>Internal iliac vessels, endopelvic part of obturaror internus, coccygeus, iliococcygeus, pubococcygeus are removed </li></ul><ul><li>Limited experience </li></ul>
    38. 42. <ul><li>Aim: To shield the normal premenopausal ovary from the damaging effects of radiation </li></ul><ul><li>Procedure: The ovaries and their vascular supply are brought out of the pelvis and sutured lateral and above the psoas muscle </li></ul><ul><li>Ovarian failure can result despite oophoropexy because of scatter radiation and surgically induced changes in ovarian blood supply& innervation </li></ul>
    39. 43. <ul><li>Acute </li></ul><ul><ul><li>Hemorrhage~0.8 lt </li></ul></ul><ul><ul><li>UV fistula ~ 1-2% </li></ul></ul><ul><ul><li>VVF~1% </li></ul></ul><ul><ul><li>Pulmonary embolism~1-2% </li></ul></ul><ul><ul><li>SI obstruction~1% </li></ul></ul><ul><ul><li>Infections~25-50% </li></ul></ul><ul><li>Subacute </li></ul><ul><ul><li>Post op UB dysfunction </li></ul></ul><ul><ul><li>Lymphocyst formation </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>UB hypotonia or atony (MC) </li></ul></ul><ul><ul><li>Ureteral stricture </li></ul></ul>
    40. 45. <ul><li>The ca cervix has two component </li></ul><ul><ul><li>Central tumor - growth in the cervix: best treated by brachytherapy </li></ul></ul><ul><ul><li>Peripheral - growth in the parametrium: controlled by EBRT </li></ul></ul><ul><li>Early stage cancer - ICBT+EBRT either simultaneously or sandwich </li></ul><ul><li>Advanced stage -XRT f/b ICBT </li></ul>
    41. 46. <ul><li>Also in tumors which are </li></ul><ul><ul><li>Bulky cervical lesions or in tumor beyond stage IIa to improve the geometry of intracavitary application </li></ul></ul><ul><ul><li>Exophytic, easily bleeding tumors </li></ul></ul><ul><ul><li>Tumor with necrosis or infection </li></ul></ul><ul><ul><li>Parametrial involment </li></ul></ul><ul><ul><li>External irradiation should be given prior to brachytherapy as it reduces the tumor volume, restores normal anatomy and improve the geometry of brachytherapy . </li></ul></ul>
    42. 47. <ul><li>The relative proportion of XRT increases with increasing tumor bulk and stage </li></ul><ul><li>Except for small tumors XRT precedes ICBT </li></ul><ul><li>At least two ICBT are more effective than one </li></ul><ul><li>The Para central dose should be 70-85 Gy , depending on tumor bulk and stage </li></ul><ul><li>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 </li></ul>
    43. 48. <ul><li>Target </li></ul><ul><ul><li>Primary tumor with the first echelon group of lymph nodes </li></ul></ul><ul><ul><li>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) </li></ul></ul><ul><li>With adequate margin for microscopic spread and daily set up variability </li></ul><ul><li>Radiation therapy technique </li></ul>
    44. 50. <ul><li>2 field </li></ul><ul><ul><li>Less time required </li></ul></ul><ul><ul><li>More skin reaction </li></ul></ul><ul><ul><li>Can treat lower presacral lymph nodes </li></ul></ul><ul><ul><li>Useful when lower part of vagina involved </li></ul></ul><ul><li>4 field </li></ul><ul><ul><li>Less skin reaction </li></ul></ul><ul><ul><li>More homogenous dose distribution (especially in large separation) </li></ul></ul><ul><ul><li>Lateral most part of parametrium also gets effective dose </li></ul></ul><ul><ul><li>If beam weightage is adjusted the dose to bladder and rectum can be decreased </li></ul></ul>
    45. 51. <ul><li>SSD treatments: </li></ul><ul><ul><li>Relatively more homogenous dose distribution </li></ul></ul><ul><ul><li>Setup possible without requiring expensive aids e.g. Laser </li></ul></ul><ul><ul><li>PDD charts can be used for simple dose calculations </li></ul></ul><ul><ul><li>Lesser skin reactions </li></ul></ul><ul><li>SAD treatments: </li></ul><ul><ul><li>Less number of MUs rqd </li></ul></ul><ul><ul><li>Time taken is less </li></ul></ul><ul><ul><li>Impact of setup inaccuracies is minimized in 2 field techniques </li></ul></ul><ul><ul><li>Ease of setup reproducibility in multi field treatments </li></ul></ul>
    46. 52. <ul><li>Anterior field </li></ul><ul><ul><li>Center 3 cm above the pubic tubercle , a square 15 x 15 </li></ul></ul><ul><li>Posterior field , </li></ul><ul><ul><li>Center 5 cm above tip of coccyx , a square 15 x 15 </li></ul></ul><ul><li>lateral field , </li></ul><ul><ul><li>8 cm above table top 15 x 10 field </li></ul></ul><ul><li>All treated by SSD technique </li></ul><ul><li>Verification with x-rays </li></ul>
    47. 53. <ul><li>Superior border- L4-L5 junction (to encompass the common iliac node) </li></ul><ul><li>Lateral border- 1.5 cm from the widest pelvic part of the pelvic brim </li></ul><ul><li>Inferior-no vaginal wall involved- lower border of the obturator foramen. </li></ul><ul><li>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 </li></ul>
    48. 54. <ul><li>Superior and inferior would be corresponding to the AP-PA fields </li></ul><ul><li>Anterior –vertical line to the anterior edge of pubic symphysis </li></ul><ul><li>Posterior-to encompass the sacral hallow ( junction S2-S3) </li></ul>
    49. 55. <ul><li>Dose 45-50 Gy over 4 1 / 2 - 5 wks @1.8 to 2 Gy/# </li></ul><ul><li>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. </li></ul>
    50. 56. <ul><li>The WPRT followed by split fields that protect midline organs at risk (bladder and rectum) while treating the parametrium. </li></ul><ul><li>Three approaches : </li></ul><ul><ul><li>Simple rectangular block, a block customized to a single brachytherapy isodose line. </li></ul></ul><ul><ul><li>Step wedge filter constructed to conform to multiple brachytherapy isodose lines. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
    51. 57. <ul><li>Rectangular block shield preferred </li></ul><ul><li>Superior border-at inferior or middle of SI joint </li></ul><ul><li>Inferior would be at caudal aspect of pelvic field </li></ul><ul><li>Lateral would be such that what is covered by a 4cm , width block at isocenter. </li></ul><ul><li>Pelvic geometry changes considerably when the brachytherapy applicator is removed and the packing is removed. </li></ul><ul><li>Simple straight 4 cm shield is better. </li></ul>
    52. 58. <ul><li>Brachytherapy plays an essential role in the treatment of all invasive cancer of the cervix. </li></ul><ul><li>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 </li></ul><ul><li>In radical treatment, brachytherapy is usually combined with EBRT, but it can also be combined with surgery pre- and/or postoperatively </li></ul>
    53. 59. <ul><li>Brachytherapy plays a crucial role in invasive cervical cancer treatment (stage I-IVA) as </li></ul><ul><ul><li>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 </li></ul></ul><ul><ul><li>Short overall treatment time </li></ul></ul><ul><ul><ul><li>Counter tumor repopulation </li></ul></ul></ul><ul><ul><li>Preservation of normal anatomy </li></ul></ul><ul><ul><li>Preservation of sexual function </li></ul></ul><ul><ul><li>Survival increases when Brachytherapy is used </li></ul></ul>
    54. 60. <ul><li>Depending upon loading technology </li></ul><ul><ul><li>Preloaded – radium tubes </li></ul></ul><ul><ul><li>Afterloaded </li></ul></ul><ul><ul><ul><li>Manual – Cs 137 </li></ul></ul></ul><ul><ul><ul><li>Remote – Cs 137 , Co 60 , Ir 192 </li></ul></ul></ul><ul><li>Based on dose rates used </li></ul><ul><ul><li>LDR </li></ul></ul><ul><ul><ul><li>0.4-2 Gy/ hr </li></ul></ul></ul><ul><ul><ul><li>Ra 226 , Cs 137 </li></ul></ul></ul><ul><ul><li>MDR </li></ul></ul><ul><ul><ul><li>2-12 Gy/hr </li></ul></ul></ul><ul><ul><ul><li>Cs 137 </li></ul></ul></ul><ul><ul><ul><ul><li>In PGI we consider, any dose rate > 0.9 Gy/hr which require dose rate correction as MDR </li></ul></ul></ul></ul><ul><ul><li>HDR </li></ul></ul><ul><ul><ul><li>> 12 Gy/hr </li></ul></ul></ul><ul><ul><ul><li>Co 60 , Ir 192 </li></ul></ul></ul>
    55. 61. <ul><li>The whole uterus including the cervix and the vaginal wall are densely vascularized and their tolerance to radiation is very high </li></ul><ul><li>In contrast, critical organs which are directly adjacent to the cervix like the rectum and bladder are more radiosensitive </li></ul><ul><li>In some cases, the very radiosensitive small or large bowel (sigmoid) may be in direct contact to the uterine wall as well. </li></ul><ul><li>The vagina also considered as an organ at risk </li></ul><ul><li>Therefore , we need a peer shaped dose distribution in coronal section (A P view) and a banana in saggital section (lateral view) </li></ul><ul><li>Relationship of uterus & vagina </li></ul><ul><ul><li>Uterus is usually anteverted & anteflexed and it lies at right angles to the vagina. </li></ul></ul><ul><ul><ul><li>Construction of applicator. </li></ul></ul></ul><ul><li>Relationship of rectum & bladder </li></ul><ul><ul><li>Important consideration regarding the dose received by brachytherapy – complications </li></ul></ul><ul><li>Spread of disease </li></ul><ul><ul><li>Predominant line of spread – laterally thru paracervical tissues into parametrium </li></ul></ul><ul><ul><li>Into uterus & vagina </li></ul></ul><ul><ul><li>Only in very advanced – into bladder & rectum </li></ul></ul><ul><ul><li>Brachytherapy doses should reach more laterally than anteroposteriorly </li></ul></ul>
    56. 62. <ul><li>This method was introduced by Forsell and Heyman’ at the Radium hemmet in Stockholm. </li></ul><ul><li>Fractionated course of radiation delivered over a period of one month. </li></ul><ul><li>Three insertions each of 22 hours separated by 1-3 weeks. </li></ul><ul><li>Intra-vaginal boxes Silver or gold </li></ul><ul><li>Intrauterine tube -flexible rubber </li></ul><ul><li>Unequal loading </li></ul><ul><ul><li>30 - 90 mg of radium in uterus </li></ul></ul><ul><ul><li>60 - 80 mg in vagina </li></ul></ul><ul><li>Total prescribed dose -6500-7100 mg Ra </li></ul><ul><ul><li>4500 mg Ra contributed by the vaginal box </li></ul></ul><ul><ul><li>Dose rate-110R/hr or 2500mg/hr/# </li></ul></ul><ul><li>Kottmeier and Forssner have further developed and modified </li></ul>
    57. 63. <ul><li>A single application of radium for 120 hrs. (45R/hr) </li></ul><ul><li>Two cork colpostats (cylinder) with 13.3 mg radium in each and an intrauterine silk rubber tube with 33.3 mg radium </li></ul><ul><li>Delivers a dose of 7000- 8000 mg-hrs of radium. </li></ul><ul><li>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 </li></ul><ul><li>Drawbacks of Paris and Stockholm systems </li></ul><ul><li>Long treatment time-Long hospital stay in the bed with its associated complications of confinement </li></ul><ul><li>Discomfort to the patient </li></ul><ul><li>No dose prescription </li></ul><ul><li>More hospital visits </li></ul>
    58. 64. <ul><li>The rigid uterine tandem with a ring applicator was developed during 1960 as an afterloading device </li></ul><ul><li>The length and the curvature of the intrauterine tandem is chosen dependent on the size and the bending of the uterine cavity </li></ul><ul><li>The diameter of the ring which is perpendicular to the axis of the intrauterine tube is also chosen according to the individual anatomical situation </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>The applicator is fixed against the cervix by an individual packing device </li></ul>
    59. 65. <ul><li>The best known development in brachytherapy technology in cervical cancer has been the Manchester Technique, originated by Tod and Meredith in 1938 </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Generally, the treatment was separated into two fractions over a period of 10 days </li></ul><ul><li>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. </li></ul>
    60. 66. <ul><li>The point should have met the following criteria to be acceptable: </li></ul><ul><ul><li>It should have been anatomically comparable from patient to patient. </li></ul></ul><ul><ul><li>Should have been in a region where the dosage is not highly sensitive to small alteration in applicator position </li></ul></ul><ul><ul><li>Should have been in position, so that it allowed correlation of the dose levels with the clinical effects </li></ul></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>It was the work of T F Todd who described a paracervical triangle where initial lesion of radiation necrosis occurs. </li></ul><ul><li>Area in the medial edge of broad ligament where the uterine vessel cross over the ureter. </li></ul>
    61. 67. <ul><li>Point A -Since for assessment of dosage a definite point had to be fixed . </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Variant -beginning at the flange abutting the cervical os </li></ul><ul><ul><li>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 </li></ul></ul>
    62. 68. <ul><li>Point B </li></ul><ul><ul><li>To know the rate of fall of dose external to point A, as an index to the volume of tissue treated </li></ul></ul><ul><ul><li>Quantifies the dose delivered to the obturator lymph nodes </li></ul></ul><ul><ul><li>Def: 5cm from the patient’s midline, at the same level as point A </li></ul></ul><ul><ul><li>Dose to Pt B, depends little on the geometric distribution of radium, but on the total amount of radium used </li></ul></ul><ul><ul><li>Dose ~15-20 % of the dose at point A </li></ul></ul>
    63. 69. <ul><li>Loose system </li></ul><ul><li>Intrauterine applicator </li></ul><ul><ul><li>Rubber tubing, with flange at end. </li></ul></ul><ul><ul><li>Varying length, can take – 1,2,3 radium tubes in line. </li></ul></ul><ul><li>Ovoids </li></ul><ul><ul><li>Rubber or nylon </li></ul></ul><ul><ul><li>Shape follows the distribution in 3-D space of the isodose curves around the contained radium tube, ensuring homogenous dose on its surface. </li></ul></ul><ul><ul><li>3 sizes </li></ul></ul><ul><ul><ul><li>Small– 2cm </li></ul></ul></ul><ul><ul><ul><li>Medium –2.5cm </li></ul></ul></ul><ul><ul><ul><li>Large –3cm </li></ul></ul></ul><ul><ul><li>Pairs of ovoids held apart by a “ SPACER” – rubber </li></ul></ul><ul><ul><ul><li>Fixes at a distance of 1 cm </li></ul></ul></ul><ul><ul><li>“ WASHER” – holds the ovoids in position in narrow vagina </li></ul></ul>
    64. 70. <ul><li>Select the longest possible intra-uterine applicator and the largest possible size of ovoids, which can be placed snugly </li></ul><ul><ul><li>Carries the ovoid closer to point B </li></ul></ul><ul><ul><li>Gives better proportional depth dose </li></ul></ul><ul><ul><li>Pushes the isodose of lethal damage as laterally as possible </li></ul></ul><ul><ul><li>Longer tandem – more lateral throw off/ more contribution to pt B </li></ul></ul><ul><ul><li>Bigger ovoid – to reduce mucosal dose/vaginal surface dose falls by 35% </li></ul></ul><ul><li>If smallest ovoids – not insertable – ovoids in tandem </li></ul><ul><ul><li>Reduce the dose to Pt A – by 7.5% </li></ul></ul><ul><ul><li>But increase the Tx time </li></ul></ul>
    65. 72. <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Not more than 1/3 dose to point A must be delivered from vaginal radium </li></ul>
    66. 73. Tube Type Length 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 used Mg 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**
    67. 74. <ul><li>Always use the largest ovoid that fits in possible </li></ul><ul><li>Use as long a tandem possible ,not more than 6 cm </li></ul><ul><li>Dose to point A- 8000 R </li></ul><ul><li>Dose to uterus wall -30,000 R </li></ul><ul><li>Dose to cervix- 20-25000 R </li></ul><ul><li>Dose to vaginal mucosa-20,000 R </li></ul><ul><li>Dose to recto-vaginal septum- 6750 R </li></ul><ul><li>Dose limitation-UB < 80 Gy and rectum < 75 Gy </li></ul>
    68. 75. <ul><li>Modern Manchester applicators physically mimic the classical technique. </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><li>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 </li></ul>
    69. 76. <ul><li>Advantages: </li></ul><ul><li>Loose system and therefore, can suit to any anatomical situation </li></ul><ul><li>Well studied method and hence control rate and morbidity is well defined </li></ul><ul><li>It is cost effective </li></ul><ul><li>Disadvantages: </li></ul><ul><li>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 </li></ul><ul><li>Radiation hazard : being a preloaded system </li></ul><ul><li>This led to development of fixed preloaded and afterloading applicators. </li></ul>
    70. 77. <ul><li>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°) </li></ul>
    71. 78. <ul><li>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 </li></ul><ul><li>System was modified by Delclos and Suit for manual after loading and then for remote after loading (Fletcher-Suit-Delclos applicator) </li></ul><ul><li>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 </li></ul><ul><li>The tandem and colpostats are selected to conform to the tumor volume and topography and the individual patient’s anatomy </li></ul>
    72. 79. <ul><li>Afterloading systems </li></ul><ul><ul><li>Developed in 1968 by Joslin </li></ul></ul><ul><ul><li>Initially Cobalt 60, now iridium 192 </li></ul></ul><ul><li>For equivalence to LDR the dose/# needs to be ~3 Gy </li></ul><ul><li>However, this based on the t1/2 of late reacting tissues – 1.5 hrs. </li></ul><ul><li>If assumed to be 4-6 hrs, then dose/# be 6-12 Gy and HDR may be radiobiologically better. </li></ul><ul><li>Also better geometrical sparing due to better packing away of critical organs. </li></ul><ul><li>Dose rate correction </li></ul><ul><ul><li>0.54-0.6 (Orton et al) </li></ul></ul><ul><ul><li>0.58 (Patel et al) – for 3-5 HDR applications </li></ul></ul><ul><ul><li>0.75 – for 6-8 applications </li></ul></ul>
    73. 80. <ul><li>Advantages </li></ul><ul><ul><li>Shorter treatment times, resulting in: </li></ul></ul><ul><ul><ul><li>Outpatient treatment </li></ul></ul></ul><ul><ul><ul><li>Less patient discomfort since prolonged bed rest is eliminated </li></ul></ul></ul><ul><ul><ul><li>Treating patients intolerant of isolation or at risk for acute cardiopulmonary toxicity due to prolonged bed rest </li></ul></ul></ul><ul><ul><ul><li>Reduced applicator movement during therapy </li></ul></ul></ul><ul><ul><ul><li>Greater displacement of nearby normal tissues </li></ul></ul></ul><ul><ul><ul><li>Possibility of treating larger number of patients </li></ul></ul></ul><ul><ul><li>Allows use of smaller diameter sources than are used in HDR: </li></ul></ul><ul><ul><ul><li>Resulting in less patient discomfort, thereby; </li></ul></ul></ul><ul><ul><ul><li>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). </li></ul></ul></ul><ul><ul><ul><li>Making insertion of the tandem into the cervix easier </li></ul></ul></ul><ul><ul><li>Tailor dose distribution to target through optimization </li></ul></ul><ul><ul><li>Elimination of exposure to personnel </li></ul></ul>
    74. 81. Patient Preparation Applicator Check Applicator implantation and fixation Imaging Treatment Planning Treatment excution
    75. 82. <ul><li>GA </li></ul><ul><li>Lithotomy position </li></ul><ul><li>Perineal area is disinfected </li></ul><ul><li>Draping </li></ul><ul><li>Catheterization </li></ul>
    76. 83. <ul><li>Applicator set is check for integrity and completeness </li></ul><ul><li>Uterine sounding </li></ul><ul><li>Correct size of ovoid is selected and mounted onto the ovoidtubes </li></ul><ul><li>Dilatation of the cervix </li></ul><ul><li>Length of uterus is measured </li></ul>
    77. 84. <ul><li>Correct length of IU-tube is selected and inserted </li></ul><ul><li>Select proper size ovoids </li></ul><ul><li>Fixate these to the ovoid tubes </li></ul><ul><li>Insert one by one and attach to the fixing mechanism </li></ul>
    78. 85. <ul><li>Insert gauze packing to push rectum and bladder away reducing the dose to these organs </li></ul><ul><li>Radio opaque rectal marker inserted </li></ul>
    79. 86. X-ray catheters
    80. 87. <ul><li>Tandem -1/3 of the way between S1 –S2 and the symphysis pubis </li></ul><ul><li>The tandem -midway between the bladder and S1 -S2 </li></ul><ul><li>Marker seeds should be placed in the cervix </li></ul><ul><li>Ovoids should be against the cervix (marker seeds) </li></ul><ul><li>Tandem should bisect the ovoids </li></ul><ul><li>The bladder and rectum should be packed away from the implant </li></ul>
    81. 88. <ul><li>The ovoids should fill the vaginal fornices – largest ovoid size to be used. </li></ul><ul><li>The ovoids should be separated by 0.5 –1.0 cm, admitting the flange on the tandem. </li></ul><ul><li>The axis of the tandem should be central between the ovoids </li></ul>
    82. 89. <ul><li>For treatment planning purposes CT or MR images are taken </li></ul><ul><li>PLATO Brachytherapy and PLATO INSIGHT are used for catheter reconstruction </li></ul>
    83. 93. <ul><li>Description as complete as possible of the clinical conditions Complete description of the technique </li></ul><ul><li>Complete description of the time-dose pattern </li></ul><ul><li>Treatment prescription </li></ul><ul><li>Total Reference Air Kerma (TRAK) </li></ul><ul><li>Dose at reference points : Point A and reference points related to bony structures </li></ul><ul><li>Volumes for reporting and their dimensions : Treated Volume, point A volume, reference volume </li></ul><ul><li>Dose to Organs at Risk : bladder, rectum </li></ul>
    84. 94. <ul><li>Reference volume: Dimensions of the volume included in the corresponding isodose - 60 Gy </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
    85. 95. <ul><li>Point A, as defined in this report, is specified relative to the applicator as visualised on orthogonal planar films </li></ul><ul><li>It is located in the oblique frontal plane (ICRU Report 38) containing the intrauterine source(s) and bisecting the vaginal sources </li></ul><ul><li>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 </li></ul>
    86. 96. <ul><li>Bladder reference point </li></ul><ul><li>It is related to a Foley balloon in the trigone of the bladder. The balloon is filled with 7 cc of radio opaque fluid </li></ul><ul><li>The catheter is pulled downwards to bring the balloon against the urethra </li></ul><ul><li>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 </li></ul><ul><li>On the AP radiograph, the reference point is taken at the centre of the balloon. </li></ul>
    87. 97. <ul><li>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 </li></ul><ul><li>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) </li></ul><ul><li>The point is located on this line, 5 mm behind the posterior vaginal wall (not in the contrast filling tube). </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul>
    88. 100. <ul><li>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 </li></ul>
    89. 102. <ul><li>LDR (<200cgy/hr)- 35-40 Gy at point A </li></ul><ul><li>MDR (200-1200cgy/hr) - 35 Gy LDR equivalent at point A </li></ul><ul><li>HDR(>1200cgy/hr)-9 Gy in 2 #/ or 6.8Gy in 3# at point A </li></ul>
    90. 103. <ul><li>Brachytherapy can follow external irradiation </li></ul><ul><li>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 </li></ul><ul><li>SANDWICH : in the same stages with MDR done with 40 Gy LDR equivalent – XRT 40 Gy – MDR with 35 Gy LDR equivalent </li></ul><ul><li>In both above cases a midline shield is used </li></ul>
    91. 104. <ul><li>Large local growth > 4 cm </li></ul><ul><li>Vaginal wall involvement ( middle- lower 1/3) </li></ul><ul><li>Heavy parametrium infiltration </li></ul><ul><li>VVF or VRF </li></ul><ul><li>In adequate space </li></ul><ul><li>Medical contraindication </li></ul><ul><li>Metastatic disease </li></ul><ul><li>In such cases ,supplementary radiation 2000cgy /10# /2 weeks </li></ul>
    92. 105. <ul><li>Completion of treatment </li></ul><ul><ul><li>First follow up-6 weeks, asses the response </li></ul></ul><ul><ul><li>2 monthly follow up for 1 year, 4 monthly for 2 nd year, 6 monthly then till the 5 th year , annually there after </li></ul></ul>
    93. 106. <ul><li>Acute complication (cell loss in rapidly dividing tissue) </li></ul><ul><ul><li>Acute radiation enteritis(75%, 3 week) </li></ul></ul><ul><ul><li>Skin reaction( 2 field) </li></ul></ul><ul><ul><li>Nausea </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Fatigue,Weakness </li></ul></ul><ul><ul><li>Dysuria, frequency </li></ul></ul><ul><li>Chronic complication (endothelial damage) </li></ul><ul><ul><li>Cervix and vagina-obliteration of os, shortening of vagina ,fistula </li></ul></ul><ul><ul><li>Ovary-early menopause </li></ul></ul><ul><ul><li>GI-ulceration ,hemorrhage ,stricture ,small bowel obstruction,malabsorbtion. </li></ul></ul><ul><ul><li>Mucosal thinning, telangiectasia and fibrotic contracture in bladder. </li></ul></ul><ul><ul><li>Skin- thining ,loss of appendage, telangiectasia,subcut fibrosis. </li></ul></ul>
    94. 107. <ul><li>Two forms of radical treatment are surgery and radiation </li></ul><ul><li>External radiation is needed for all but the earliest of tumors, for treatment of the regional lymphatics </li></ul><ul><li>Intracavitary Brachytherapy plays an important and predominant role in the cure of cancer of cervix </li></ul>