Vienna-II ring applicator for distal parametrial/pelvic wall disease in cervical cancer brachytherapy: An experience from two institutions: Clinical feasibility and outcome

Mahantshetty, Umesh; Sturdza, Alina; Naga, Pushpa; Berger, Daniel; Fortin, I.; Motisi, Laura; Schmid, Maximilian; Aravindakshan, Dheera; Ghadi, Yogesh; Swamidas, Jamema; Chopra, Supriya; Gurram, Lavanya; Nesvacil, N.; Kirisits, Christian; Pötter, Richard

doi:10.1016/j.radonc.2019.08.004

Cited by 45 publications

(38 citation statements)

References 28 publications

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“…Local control rates reported in a recent study from Tata Memorial Hospital and the Medical University of Vienna with the Vienna-II applicator, which consists of a modified Vienna applicator with an additional cap fixed to the vaginal ring to allow for oblique needle placement, were comparable with the rates of local control within our study, with 23% of patients within their study developing local failure compared to 21% cumulative incidence within our study [18]. There were moderate rates of acute and late Grade 3þ toxicities in their series, with active bleeding observed in 27.5% of patients following applicator removal, arterial bleeding observed in 9% of patients, and one patient requiring surgical intervention for myoma rupture.…”

Section: Discussionsupporting

confidence: 86%

Early outcomes after definitive chemoradiation therapy with Vienna/Venezia hybrid high-dose rate brachytherapy applicators for cervical cancer: A single-institution experience

et al. 2021

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The Vienna and Venezia (Elekta) are hybrid intracavitary/interstitial brachytherapy (BT) applicators for cervical cancers unsuitable for intracavitary BT alone to improve target coverage or reduce critical organ dose. There is limited outcome data with the use of these applicators outside published experience of the EMBRACE group. We report feasibility and early outcomes with the use of these hybrid applicators at our institution. METHODS AND MATERIALS: Hybrid applicators were used to treat 61 patients with cervical cancer from November 2011 to December 2019. Indications for hybrid applicator use were involvement of the vagina in 10 patients (16%), residual central or parametrial disease in 46 patients (75%), and a narrow introitus in 5 patients (9%). Toxicities were graded using the CTCAE v4.0. Outcomes were assessed with the KaplaneMeier method. RESULTS: Median follow-up was 16 months (IQR 9e32 mos). Median HRCTV volume was 31.6 cm 3 (IQR 25e48 cm 3 ). Median HRCTV D90 was 86.1 Gy (IQR 84.3e88.0 Gy). In 54 patients with follow-up PET/CT at 3 months, complete initial imaging response locally was seen in 46 patients.Estimated 12-month KaplaneMeier overall survival, locoregional control, distant control, and recurrence-free survival estimates were 86.9%, 80.6%, 73.8%, and 65.9%, respectively. The 12month incidence of Grade 3þ GI/GU chronic toxicities was 5.7%, consisting of vesicovaginal fistula, rectovaginal fistula, and ureterovesical fistula. CONCLUSIONS: Our single-institution data support the use of the hybrid applicators, as an alternative to traditional BT applicators when clinically warranted. Use of hybrid applicators is feasible with adequate coverage of disease in the vagina and parametrium.

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Section: Discussionsupporting

confidence: 86%

Early outcomes after definitive chemoradiation therapy with Vienna/Venezia hybrid high-dose rate brachytherapy applicators for cervical cancer: A single-institution experience

et al. 2021

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“…MRI-based BT is a complex, time-constrained, and resourceintensive procedure, which can be challenging. Generally, the BT procedure comprises anesthesia, applicator insertion, image acquisition, patient transport, waiting for treatment, dose delivery, applicator removal and removed processes, whereas the acute side effects include anesthesia-related side effects and operative injury, pain, bleeding as well as infection (10)(11)(12). To the best of our knowledge, the present study is the first report describing acute side effects in BT procedure for cervical cancer.…”

Section: Discussionmentioning

confidence: 77%

Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy

et al. 2021

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PurposeTo report applicator insertion-related acute side effects during brachytherapy (BT) procedure for cervical cancer patients.Materials and MethodsBetween November 2017 and December 2019, 407 BT fractions were performed in 125 patients with locally advanced cervical cancer. Acute side effects recorded comprised anesthesia-related side effects, mechanical-related side effects and infection, whose frequency and degree were recorded. Pain was assessed using numeric rating scale; vaginal bleeding volume was counted by weighing gauze pieces used in packing. The BT procedure comprised eight stages: anesthesia, applicator insertion, image acquisition, transport, waiting for treatment, dose delivery, applicator removal, and removed which denoted 0.5–12.0 h period after removal, with time of each stage recorded. Factors influencing acute side effects were assessed by Spearman correlation and Mann–Whitney U test.ResultsThe most common acute side effect was pain, followed by vaginal bleeding. The mean scores for pain were highest during removal time, 4.9 ± 1.6 points. The mean vaginal bleeding volume was 44.4 ml during removal time. Mean total procedure time was 218.8 (175–336) min, having positive relationship with frequency of acute side effects. The total procedure time with acute side effects was longer than that without acute side effects. The longest procedure time was waiting time, 113.0 (91.0–132.0) min. More needles generated higher pain scores and larger volume of vaginal bleeding.ConclusionPain and vaginal bleeding were the most common acute side effects, especially during removal time, which physicians should focus on. Shortening patients’ waiting time helps to reduce the total procedure time, thus, reduce acute side effects. While meeting dose requirement, less needles are helpful to reduce acute side effects.

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“…In another publication, in 23 patients with a mean HR-CTV volume of 48 cc, a mean D 90 HR-CTV of 89 ±3.4 Gy was reported [ 6 ]. The largest experience ever reported was with the Vienna II applicator, which is a Vienna TM applicator with an add-on cap allowing for additional oblique needles into the distal parametrium [ 31 ]. Mean distance between tandem and outer contour of HR-CTV was 38 mm, and mean HR-CTV (±SD) volume was 69 ±32 cm 3 , which is comparable to the patients in our cohort.…”

Section: Discussionmentioning

confidence: 99%

Venezia applicator with oblique needles improves clinical target volume coverage in distal parametrial tumor residue compared to parallel needles only

Kissel¹,

Fournier-Bidoz²,

Henry³

et al. 2021

jcb

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Purpose: Residual distal parametrial involvement after radiochemotherapy is a true challenge for brachytherapists since the width and asymmetry of high-risk clinical target volume (HR-CTV) are difficult to cover properly with a standard implant.Material and methods: Dosimetric plans of five patients treated with Venezia advanced gynecological applicator at our institution were reviewed. For each patient, we compared the original plan with a new plan where oblique needles were removed and re-optimized manually. Optimization process was halted when EQD2 10 D 90 HR-CTV reached 90 Gy, when one hard constraint to organs at risk (OARs) was reached according to the EMBRACE II protocol, or when dose-rate of one of OARs exceeded 0.6 Gy/h.Results: Tumors were large; median HR-CTV volume was 64 cc and median distance between tandem and outer contour of HR-CTV was 40 mm. For the five patients, HR-CTV EQD2 10 D 90 was superior in the plan using oblique needles, with a median difference of 6.5 Gy (range, 1.7-8.5 Gy). Median D 90 HR-CTV and intermediate-risk CTV (IR-CTV) were significantly increased with oblique needles: 85.9 Gy (range, 83.2-90.3 Gy) vs. 81.5 Gy (range, 77.4-84 Gy), and 68.7 Gy (range, 66.3-72.3 Gy) vs. 67 Gy (range, 64.3-69.1 Gy), p = 0.006 for both. There were no significant differences in the dose to OARs. Plans with only parallel needles had less favorable dose distribution, with cold spots on the outer parametria and higher vaginal activation to compensate parametrial coverage in its inferior part.Conclusions: Venezia TM applicator permits reproducible application to increase CTV coverage in patients with distal parametrial tumor residue during brachytherapy, while maintaining acceptable dose to OARs.

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Vienna-II ring applicator for distal parametrial/pelvic wall disease in cervical cancer brachytherapy: An experience from two institutions: Clinical feasibility and outcome

Cited by 45 publications

References 28 publications

Early outcomes after definitive chemoradiation therapy with Vienna/Venezia hybrid high-dose rate brachytherapy applicators for cervical cancer: A single-institution experience

Early outcomes after definitive chemoradiation therapy with Vienna/Venezia hybrid high-dose rate brachytherapy applicators for cervical cancer: A single-institution experience

Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy

Venezia applicator with oblique needles improves clinical target volume coverage in distal parametrial tumor residue compared to parallel needles only

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