Prospective comparison of clinical and computed tomography assessment in detecting uterine perforation with intracavitary brachytherapy for carcinoma of the cervix

Abstract

Brachytherapy (BT) is an essential component of radical treatment for cervix cancer. Uterine perforation is a potential complication of intrauterine applicator (tandem) insertion. Postprocedure pelvic computed tomography (CT) scans are routinely performed at this center. The objective of this study was to prospectively compare radiation oncologists' (RO) clinical impression of satisfactory tandem placement with actual tandem placement as determined from pelvic CT. Patients with cervix cancer undergoing low-dose rate BT from April 2003 to December 2005 were prospectively identified. After tandem placement, patients were brought to the radiotherapy department for pelvic imaging (plain films and CT). Prior to viewing imaging, the RO specified whether they were concerned vs not concerned about uterine perforation. The CT was then reviewed to determine actual tandem placement (perforation vs no perforation). One hundred twenty-four sequential tandem insertions were performed in 114 patients and eligible for analysis. The incidence of CT detected uterine perforation was 13.7% (17/124). Physician concern, age greater than or equal to 60, and tumor size were significant predictors of uterine perforation (P < 0.0001, P= 0.0019, and P= 0.0016, respectively). The overall sensitivity and specificity for physician concern was 52.9% and 84.1%, respectively. CT detected perforation in 8.2% (8/98) of insertions where the RO was clinically confident of correct tandem placement. Pelvic CT was a useful modality to accompany clinical assessment in identifying uterine perforation in cervix BT. As a low but potentially clinical significant number of perforations identified on CT were not suspected clinically, we recommend acquiring pelvic imaging in all patients following tandem insertion to ensure intrauterine tandem positioning.

Optimization of high-dose-rate cervix brachytherapy applicator placement: The benefits of intraoperative ultrasound guidance

“…Consistent with the findings of Barnes et al [11], after implementing 3D imaging, we observed occult perforations in 10% of insertions using postoperative CT, many of which were not suspected clinically. CT imaging following intracavitary implants also revealed a number of cases in which the placement of the tandem was suboptimal in relation to the uterine cavity.…”

Consensus statement for brachytherapy for the treatment of medically inoperable endometrial cancer

“…In a prospective study from the University of Toronto in cervix cancer patients, the CT-detected rate of uterine perforation was 13.7% (42). Radiation oncologists were asked to rate their confidence in whether the uterus was perforated.…”

Uterine perforation during intracavitary brachytherapy for carcinoma of the cervix

“…Though the x-ray simulation is simple and less-expensive, CT-simulation is clinically advantageous as it provides an opportunity for volumetric dose-optimisation. The current case demonstrates another advantage, that is, the possible detection of unexpected uterine perforations 2 3Learning points

Given that the tissues could be friable and prone to perforations owing to the cancer itself and the usual use of prior external beam radiotherapy, the potential risk of uterine perforation should not be underestimated.

The use of ultrasound-guidance during applicator placement may reduce the risk of uterine perforations 1

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