Novel anesthetic technique for combined intracavitary and interstitial brachytherapy for cervix cancer in an outpatient setting

Abstract

PurposeTo determine the feasibility and safety of outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia.Material and methodsWe included patients diagnosed with non-metastatic cervix cancer and have completed brachytherapy between December 2015 and December 2016. Moderate to deep sedation was achieved using intravenous midazolam, propofol, fentanyl, and oxycodone. Local anesthesia was achieved with 2% lignocaine gel and a paracervical block containing a mixture of 1% ropivacaine, 2% lignocaine, and 1 : 1,000 adrenaline. Ceftriaxone and ondansetron were given prophylactically. Physiologic monitoring was performed throughout and pain scores were recorded using the Numeric Rating Scale. Follow-up was conducted at 8 weeks from the last fraction of brachytherapy. The feasibility and safety endpoints were a post-anesthesia discharge score (PADS) of 9 or above, and no grade 3 or above adverse events, respectively.ResultsA total of thirty-five brachytherapy insertions were carried out on nine patients. The median age of the patients was 56 years (range, 40-65). Eight patients had American Society of Anesthesiologists’ physical status of I or II, and one had a status of III. The mean duration of the insertion was 39 minutes (standard deviation [SD] = 14), during which no adverse events occurred. There was no significant nausea or vomiting post-sedation. The median pain scores post-insertion and during recovery were 0 (range, 0-6) and 0 (range, 0-7), respectively. At discharge, all patients had pain scores of 0 and maximum PADS of 10. The mean time to discharge was 4.1 hours (SD = 0.95). There were no brachytherapy-related admissions or complications.ConclusionsOutpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia is feasible and safe. This could potentially lead to significant cost savings.

Non-anesthetist-administered moderate sedation with midazolam and fentanyl for outpatient MRI-aided hybrid intracavitary and interstitial brachytherapy in cervix cancer: a single-institution experience

“…In this study, we found that the mean applicator insertion time and total procedural time was 32.4 ±14.9 minutes and 4.5 ±1.2 hours, respectively, which are comparable to results from other groups. Similar study by Leong and colleagues reported mean insertion time of 39 minutes and mean time to discharge of 4.1 hours [25]. Liu et al evaluated a technique of interstitial brachytherapy in 28 patients using applicator combining uterine tandem and metal needles, where the needles were inserted free-hand under real-time CT guidance [27].…”

“…So far, in existing publications on interstitial brachytherapy with modern hybrid applicators involving deep sedation, general, or spinal anesthesia, the procedures required the presence of anesthetist. Leong et al reported their experience of 35 insertions using Utrecht applicators performed under moderate to deep sedation administered by anesthetist, combining with paracervical block and local anesthesia [25]. A recent study by Walter et al presented their initial results of Venezia applicator in 10 patients, where insertions were performed under general or spinal anesthesia [18].…”

Comparative study to evaluate dosimetric differences in patients of locally advanced carcinoma cervix undergoing intracavitary brachytherapy under two different anaesthesia techniques: an audit from a tertiary cancer centre in India

“…Chen et al in their study showed that local vaginal anaesthesia with 10% lidocaine solution can significantly decrease the degree of painful sensation during HDR-ICBT and is safe to administer for the procedure for cervical cancer [12]. Study done by Leong et al concluded that outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anaesthesia is feasible and safe and could potentially lead to significant cost savings [13].…”

Paracervical blocks facilitate timely brachytherapy amidst COVID-19

“…A randomized trial applicable to BT found a significant pain reduction (13 mm vs 54 mm on pain visual analog scale) in patients undergoing laminaria placement, a procedure similar to dilation for BT, in which only mild uterine manipulation is anticipated ( 14 ). Despite the successful implementation of PCBs in several BT clinics internationally, adoption of brachytherapist-directed local anesthesia in the US has been limited ( [15] , [16] , [17] ).…”