Vaginal vault brachytherapy in endometrial cancer: verifying target coverage with image-guided applicator placement

Humphrey, Pauline; Cornes, Paul; Al-Booz, Hoda

doi:10.1259/bjr.20120428

Cited by 23 publications

(15 citation statements)

References 4 publications

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“…In this present study, we found that 75 patients (43%) had $1 air gap with a mean volume of 0.31 cm 3 (range, 0.04-2.93 cm 3 ) and an average distance of mucosa displacement of 3.6 mm (range, 1.8-8.8 mm) with 38.9% of the vaginal mucosa displaced away from the surface of the cylinder by $2 mm. The incidence of air gaps was lower and similar between our study and that of Humphrey et al, 7 because in these studies, the vaginal cylinder with the largest diameter ($3.0 cm) was used more frequently than in other studies (Table 3). Another important finding was that the incidence of vaginal mucosa displaced away from the surface of the cylinder by $2 mm was the highest in patients for whom a smaller diameter cylinder was used compared with other studies.…”

Section: Discussionsupporting

confidence: 89%

“…The average total pocket volume was 0.34 cm 3 (range, 0.01-1.32 cm 3 ), and the average distance that the mucosa was displaced was 3.7 mm (range, 1.3-8.0 mm) with 88.8% of the vaginal mucosa displaced away from the cylinder surface by $2 mm. Humphrey et al 7 found that 38 out of 103 patients (37%) had $1 air gap within the target volume, while air gaps $2 mm were seen in only 11 out of 103 patients. In this present study, we found that 75 patients (43%) had $1 air gap with a mean volume of 0.31 cm 3 (range, 0.04-2.93 cm 3 ) and an average distance of mucosa displacement of 3.6 mm (range, 1.8-8.8 mm) with 38.9% of the vaginal mucosa displaced away from the surface of the cylinder by $2 mm.…”

Section: Discussionmentioning

confidence: 99%

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The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Onal

Güler²,

Dolek³

2015

BJR

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Objective: To evaluate the incidence, size and predisposing factors for air pockets around the vaginal cylinder and their dosimetric effect on the vaginal mucosa. Methods: We investigated 174 patients with endometrial carcinoma treated with external radiotherapy (RT) and brachytherapy (BRT) (101 patients, 58%) or BRT alone (73 patients, 42%). The quantity, volume and dosimetric impact of the air pockets surrounding the vaginal cylinder were quantified. The proportions of patients with or without air pockets during application were stratified according to menopausal status, treatment modality and interval between surgery and RT. Results: Air pockets around the vaginal cylinder were seen in 75 patients (43%), while 99 patients (57%) had no air pockets. Only 11 patients (6.3%) received less than the prescribed dose (average 93.9% of prescribed dose; range, 79.0-99.2%). Air pockets were significantly fewer in pre-menopausal patients or in patients treated with the combination of external RT and BRT than in postmenopausal patients or patients treated with BRT alone. A significant correlation existed between the mucosal displacement of the air gap and the ratio of the measured dose at the surface of the air gap and prescribed dose (Pearson r 5 20.775; p , 0.001). Conclusion: Air pockets were still a frequent problem during vaginal vault BRT, especially in post-menopausal patients or in patients treated with BRT alone, which may potentially cause dose reductions at the vaginal mucosa. Advances in knowledge: Air pockets around the vaginal cylinder remain a significant problem, which may potentially cause dose reduction in the target volume.The primary treatment of choice in localized endometrial cancer is surgery. Adjuvant radiotherapy (RT) is recommended in intermediate-and high-risk patients in order to diminish disease recurrence. RT can be in the form of external RT (ERT) with vaginal vault brachytherapy (BRT) or BRT only, depending on the risk factors and stage of disease.The purpose of vaginal vault BRT is to eradicate a microscopic tumour at the lymphatics located in the vaginal vault. It was demonstrated that .90% of lymphatics lie within 2-3 mm from the surface of stretched mucosa.1 For this reason, in order to deliver adequate doses to the submucosal lymphatics, the vaginal cylinder must be in direct contact with the vaginal surface, as recommended by the American Brachytherapy Society (ABS).2 The Group Europeén de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) guidance 3 is to prescribe vaginal BRT to 5 mm from the applicator surface with a 2-mm tolerance. The most commonly used applicator for vaginal vault high-dose-rate BRT is a segmented cylinder. 4 However, during application, air gaps may be observed, which may potentially cause underdosage of the vaginal mucosa.Cameron et al 5 found that 18 of 25 patients (72%) had air gaps .2 mm in the cranial part of the vagina, with the median number of air pockets per patient being 1 (range, 0-5). Richardson et al 6 reported that 20 o...

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

Onal

Güler²,

Dolek³

2015

BJR

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“…They show that 3D planning for each fraction does not decrease dose to the normal tissues but incurs greater expense than performing 3D planning for the first fraction only [102–104]. CT-based treatment planning effectively allows assessment of air gaps between the applicator and the vaginal cuff prior to treatment delivery [105]. For treatment planning, optimization points should be placed around both the apex and the lateral aspects of the applicator [90].…”

Section: Vaginal Brachytherapy Treatment Deliverymentioning

confidence: 99%

American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review

et al. 2017

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This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the post-operative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early stage endometrial cancer patients results in very low rates of vaginal recurrence (0–3.1%) with low rates of late toxicity which are primarily vaginal in nature. PORTEC-2 supports that VBT results in non-inferior rates of vaginal recurrence compared to external beam radiotherapy (EBRT) for the treatment of high-intermediate risk patients. VBT as a boost following EBRT, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians both prefer joint decision-making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multi-disciplinary setting and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.

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“…They reported that this ratio was lowered to 11 patients by placing larger cylinders in spaces larger than 2 mm and required repositioning, and that there is a significant air gap exceeding 2 mm in only 7% of patients. [51] In two other studies, air gaps exceeding 2 mm were reported with a rate of 32% and 72%. [52,53] However, most of them have little clinical significance, and were reported to include only 0.86% of the vaginal surface.…”

Section: Treatment Preparation and Applicator Selectionmentioning

confidence: 87%

Vaginal Cuff Brachytherapy in Endometrial Cancer

Gürsel¹

2019

TJ Oncol

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Endometrial cancer is the most common gynecological cancer in developed countries, and its etiopathogenesis includes obesity, metabolic syndrome and unopposed estrogen effect. Therefore, the incidence is increasing and it is estimated to double in 2030. The main treatment modality is surgery, radiotherapy has role for inoperable patients and adjuvant period. Although adjuvant radiotherapy (external and/or brachytherapy) is possible, there are different literature information about indications and methods of administration. Stage and risk factors are important criteria for adjuvant treatment decision in today's routine clinical practice, grade of tumor, myometrial invasion, lymphatic vascular invasion (LVI (+)), tumor size, lymph node status, extension of tumor to cervix or vagina, age, type of surgery, and other comorbid conditions are all factors under consideration to determine the type and decision of adjuvant therapy. It has been shown that, of molecular markers which are effective on survival, POLE mutation leads to good prognosis and L1CAM and TP53 lead to poor prognosis and increased metastasis rate, and these molecular differences can also be utilized in designing adjuvant therapy in the future. When compared to the risk groups, radiotherapy reduces the risk of recurrence in the low-risk group from 5-6% to 2% and in the moderate-risk group from 12-15% to 3-6%. In the high-moderate risk group, it reduces from 18-26% to 5-6%. Vaginal brachytherapy is a preferred method to prevent the recurrence of vaginal cuff with far fewer side effects than external radiotherapy. The literature review showed that there are 24 different types of single application protocol and 22 different application protocols after external radiotherapy. In the treatment of endometrium cancer, vaginal cuff radiotherapy provides excellent results in disease control with a very low side effect rate, if applied properly and for the correct indication.

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Vaginal vault brachytherapy in endometrial cancer: verifying target coverage with image-guided applicator placement

Cited by 23 publications

References 4 publications

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

The impact of air pockets around the vaginal cylinder on vaginal vault brachytherapy

American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review

Vaginal Cuff Brachytherapy in Endometrial Cancer

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