PurposeThis study is intended to compare dose-volume parameters evaluated using different forward planning- optimization techniques, involving two applicator systems in intracavitary brachytherapy for cervical cancer. It looks for the best applicator-optimization combination to fulfill recommended dose-volume objectives in different high-dose-rate (HDR) fractionation schedules.Material and methodsWe used tandem-ring and Fletcher-style tandem-ovoid applicator in same patients in two fractions of brachytherapy. Six plans were generated for each patient utilizing 3 forward optimization techniques for each applicator used: equal dwell weight/times (‘no optimization’), ‘manual dwell weight/times’, and ‘graphical’. Plans were normalized to left point A and dose of 8 Gy was prescribed. Dose volume and dose point parameters were compared.ResultsWithout graphical optimization, maximum width and thickness of volume enclosed by 100% isodose line, dose to 90%, and 100% of clinical target volume (CTV); minimum, maximum, median, and average dose to both rectum and bladder are significantly higher with Fletcher applicator. Even if it is done, dose to both points B, minimum dose to CTV, and treatment time; dose to 2 cc (D2cc) rectum and rectal point etc.; D2cc, minimum, maximum, median, and average dose to sigmoid colon; D2cc of bladder remain significantly higher with this applicator. Dose to bladder point is similar (p > 0.05) between two applicators, after all optimization techniques.ConclusionsFletcher applicator generates higher dose to both CTV and organs at risk (2 cc volumes) after all optimization techniques. Dose restriction to rectum is possible using graphical optimization only during selected HDR fractionation schedules. Bladder always receives dose higher than recommended, and 2 cc sigmoid colon always gets permissible dose. Contrarily, graphical optimization with ring applicators fulfills all dose volume objectives in all HDR fractionations practiced.

No abstract

PurposeThis study analyzes clinical consequences and dosimetric variations after imperfect brachytherapy insertions. It examines treatment decisions after such insertions in patients having difficult anatomy, which leads to good subsequent insertions with acceptable dose volume parameters.Material and methodsWe reviewed images of all insertions performed during last one year and sorted faulty ones out. Clinical outcome was assessed, analyzing original treatment records. Repeat three-dimensional planning using identical dose-optimization-technique compared their dosimetry. Statistical analysis using SPSS®-Statistics-software included Fisher’s-exact-test to analyze predisposing factors for faulty insertions and predictive factors for subsequent satisfactory insertion. Friedman test was used to compare dose-volume-effects of normalization.ResultsEighteen of 292 brachytherapy plans revealed imperfect insertions, including thirteen perforations (4.5%). Lack of pre-planning, obstructing mass, narrow vagina, acute anteversion of uterus, and multi-parity were significant (p ≤ 0.05) predisposing factors for atypical insertions. Satisfactory optimization was possible after correcting acute anteflexion or positioning tandem in retroverted direction in uncorrectable retroverted uterus. Dose normalization at point A shifted optimized dose from contoured volume to point of normalization, often undesirably. This difference, however, was statistically not significant (p = 0.121). In patients having obstructing mass, subsequent insertions were perfect, and dose volume parameters were acceptable only when full prescribed dose was delivered to at least 60% volume of the mass after a faulty insertion (p < 0.001).ConclusionsPre-planning by imaging is suggested in all cases of brachytherapy. Insertion of adequate length of tandem aligned to uterine axis is warranted for adequate tumor coverage. Whenever detected, acute anteflexion and mobile retroversion should be corrected. Tandem inserted in retroverted direction in uncorrectable retroverted uterus generates acceptable dose volume parameters. In cases with obstructive cervical mass, good subsequent insertion is possible with acceptable dose volume parameters, if planned dose can be delivered to its 60% volume.

We report a unique case of successfully performed intraluminal brachytherapy for low volume urethral mucosal recurrence of transitional cell carcinoma urinary bladder, initially treated by transurethral resection of bladder tumor, followed by radical cystectomy. Since the patient was unwilling to undergo any other operational interventions, intraluminal brachytherapy of urethra was attempted. Fluroscopy guided intraluminal HDR brachytherapy using Lumencath® catheter under local anesthesia, and remote afterloading system (Nucletron, an Elekta company, Elekta AB, Stockholm, Sweden) was performed. A fraction dose of 7 Gy in seven weekly fractions was prescribed at 0.5 cm from the single applicator. The result was promising in terms of local control and symptomatic relief. Therefore, intraluminal brachytherapy in low volume superficial local disease in urethra may play a potential role, and should be applied when repeated surgery is not feasible due to technical or medical reasons.

Paraneoplastic syndrome frequently presents before cancer is diagnosed and can be associated with neoplastic disease that is not yet radiographically detectable. We report on the case of a 35-year-old woman who presented at the neurology department with complaints of insidious onset and gradually progressive weakness in all four limbs, which had lasted for the past six months. The weakness originally commenced in both lower limbs and was progressive, ascending in nature from distal to proximal. Both upper limbs were affected seven days later. Magnetic resonance imaging of the dorsal spine revealed long-segment T2 and short T1 inversion recovery (STIR) hyperintensity, suggestive of myelitis. Nerve conduction studies and an electromyogram suggested sensory motor polyneuropathy which affected all four limbs. On gynaecological check-up, a diagnosis of International Federation of Gynaecology and Obstetrics (FIGO) stage IIB carcinoma cervix was made. Histology diagnosed it as a case of small cell neuroendocrine carcinoma. Thus, a diagnosis of chronic inflammatory demyelinating polyneuropathy, arising as a paraneoplastic syndrome in the carcinoma cervix, was made. The patient was treated with chemotherapy, steroids and radical radiotherapy. She recovered partially from her motor deficiencies and completely from her sensory derangement, and was devoid of gynaecological complaints. The cancer growth regressed completely.Peer reviewed.