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Wallner K, Sherertz T, Anderson A, Blau M, Panjwani N. (Potential) mishaps of high dose rate vaginal cuff brachytherapy. Pract Radiat Oncol 2023:S1879-8500(23)00050-4. [PMID: 36889643 DOI: 10.1016/j.prro.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Considering how commonly vaginal cuff brachytherapy is used, there is relatively little literature regarding the potential, albeit low, risk for complications. We present here three potentially serious mishaps, involving cylinder misplacement, dehiscence, and excessive normal tissue irradiation due to unique anatomy. METHODS Three patients with potentially serious treatment errors were encountered in the authors' usual clinical practice. Each patient's records were reviewed for this report. RESULTS For patient #1, CT simulation revealed grossly inadequate cylinder insertion, most obvious on the sagittal view. For patient #2, CT simulation revealed that the cylinder extended beyond the perforated vaginal cuff and was surrounded by bowel. For patient #3, CT images were used only to verify cylinder depth. A standard library plan, based on cylinder diameter and active length was used. In retrospect, the images revealed an unusually thin rectovaginal septum, with the lateral and posterior vaginal wall thickness estimated to be less than 2 mm. Her fractional normal tissue doses were calculated for this report, revealing a rectal Dmax (per fraction) of 10.8 Gy, D2.0 of 7.4 Gy, and a V100 of 2.8 cc. All doses were far in excess of those anticipated for a minimal 0.5 cm vaginal wall depth. CONCLUSION Vaginal cuff HDR brachytherapy is a high volume, routine procedure. Even in experienced hands, however, it carries a risk of improper cylinder placement, cuff dehiscence, and excessive normal tissue dose, all of which could seriously impact outcomes. These potential mishaps would be better appreciated and avoided with more extensive use of CT-based quality assurance measures.
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Affiliation(s)
- Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Tracy Sherertz
- Department of Radiation Oncology, Kaiser Permanente, Seattle, WA
| | - August Anderson
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Molly Blau
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Neil Panjwani
- Department of Radiation Oncology, University of Washington, Seattle, WA
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Venner EK, Ward KA, Wages NA, Walker B, Libby BP, Showalter TN, Romano KD. Evaluating the relationship between vaginal apex "dog ears" and patterns of recurrence in endometrial cancer following adjuvant image guided vaginal cuff brachytherapy. Brachytherapy 2023; 22:139-145. [PMID: 36414525 DOI: 10.1016/j.brachy.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE The aim of this investigation is to characterize vaginal apex "dog ears" and their association with patterns of treatment failure in patients with endometrial cancer treated with adjuvant high-dose-rate (HDR) single-channel vaginal cuff brachytherapy (VCB). METHODS A retrospective review of patients treated with HDR VCB from 2012 to 2021 for medically operable endometrial cancer at a single institution was conducted. Dog ears, defined as tissue at the apex extending at least 10 mm from the brachytherapy applicator were identified on CT simulation images. Fisher exact test and a multivariate logistic regression model evaluated the association between factors of interest with treatment failure. Vaginal cuff failure free survival (VCFFS) was calculated from first brachytherapy to vaginal cuff recurrence (VCR). RESULTS A total of 219 patients were reviewed. In this sample, 57.5% of patients met criteria for having dog ears. In total, 13 patients (5.9%) developed a VCR. There was no statistically significant difference in the rate of VCR between patients with and without dog ears (7.1% vs. 4.3%, p = 0.56). There was a trend toward increased risk of recurrence with higher grade histology identified in the multivariate logistic regression model (p = 0.085). The estimated 3-year probability of VCFFS was 86%. CONCLUSIONS Vaginal apex dog ears are prevalent but are not found to statistically increase the risk of VCR after VCB in our single institution experience. However, while local failure remains low in this population, we report an absolute value of over twice as many VCRs in patients with dog ears, indicating that with improved dog ear characterization this may remain a relevant parameter for consideration in treatment planning.
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Affiliation(s)
- Emily K Venner
- University of Virginia School of Medicine, Charlottesville, VA
| | - Kristin A Ward
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Nolan A Wages
- University of Virginia, Department of Public Health Sciences, Charlottesville, VA
| | - Bryant Walker
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Bruce P Libby
- Moffitt Cancer Center, Department of Radiation Oncology, Tampa, FL
| | - Timothy N Showalter
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA
| | - Kara D Romano
- University of Virginia, Department of Radiation Oncology, Charlottesville, VA.
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Glatzer M, Tanderup K, Rovirosa A, Fokdal L, Ordeanu C, Tagliaferri L, Chargari C, Strnad V, Dimopoulos JA, Šegedin B, Cooper R, Nakken ES, Petric P, van der Steen-Banasik E, Lössl K, Jürgenliemk-Schulz IM, Niehoff P, Hermansson RS, Nout RA, Putora PM, Plasswilm L, Tselis N. Role of Brachytherapy in the Postoperative Management of Endometrial Cancer: Decision-Making Analysis among Experienced European Radiation Oncologists. Cancers (Basel) 2022; 14:cancers14040906. [PMID: 35205653 PMCID: PMC8869913 DOI: 10.3390/cancers14040906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/01/2022] [Accepted: 02/05/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary There are various society-specific guidelines addressing adjuvant brachytherapy (BT) after surgery for endometrial cancer (EC). However, these recommendations are not uniform. Against this background, clinicians need to make decisions despite gaps between best scientific evidence and clinical practice. We analysed decision criteria influencing the selection for adjuvant radiotherapy among European radiation oncology experts. For this, GEC-ESTRO provided 19 European radiation oncology experts on gynaecological brachytherapy for decision-making analyses. The manuscript presents patterns in decision-making among these experts and demonstrates areas of consensus/discrepancies. We also analysed dose prescription and techniques of brachytherapy. This analysis is of special value as the objective approach enabled us to obtain an unbiased description of decision-making among the specialists (the study was not aimed to create or enforce a consensus). The manuscript provides valuable insight into clinical decision-making with a high impact on treatment selection, as expected differences between experts were observed. With this manuscript we are able to visualize and quantify these. This information is relevant for interdisciplinary discussions. Abstract Background: There are various society-specific guidelines addressing adjuvant brachytherapy (BT) after surgery for endometrial cancer (EC). However, these recommendations are not uniform. Against this background, clinicians need to make decisions despite gaps between best scientific evidence and clinical practice. We explored factors influencing decision-making for adjuvant BT in clinical routine among experienced European radiation oncologists in the field of gynaecological radiotherapy (RT). We also investigated the dose and technique of BT. Methods: Nineteen European experts for gynaecological BT selected by the Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology provided their decision criteria and technique for postoperative RT in EC. The decision criteria were captured and converted into decision trees, and consensus and dissent were evaluated based on the objective consensus methodology. Results: The decision criteria used by the experts were tumour extension, grading, nodal status, lymphovascular invasion, and cervical stroma/vaginal invasion (yes/no). No expert recommended adjuvant BT for pT1a G1-2 EC without substantial LVSI. Eighty-four percent of experts recommended BT for pT1a G3 EC without substantial LVSI. Up to 74% of experts used adjuvant BT for pT1b LVSI-negative and pT2 G1–2 LVSI-negative disease. For 74–84% of experts, EBRT + BT was the treatment of choice for nodal-positive pT2 disease and for pT3 EC with cervical/vaginal invasion. For all other tumour stages, there was no clear consensus for adjuvant treatment. Four experts already used molecular markers for decision-making. Sixty-five percent of experts recommended fractionation regimens of 3 × 7 Gy or 4 × 5 Gy for BT as monotherapy and 2 × 5 Gy for combination with EBRT. The most commonly used applicator for BT was a vaginal cylinder; 82% recommended image-guided BT. Conclusions: There was a clear trend towards adjuvant BT for stage IA G3, stage IB, and stage II G1–2 LVSI-negative EC. Likewise, there was a non-uniform pattern for BT dose prescription but a clear trend towards 3D image-based BT. Finally, molecular characteristics were already used in daily decision-making by some experts under the pretext that upcoming trials will bring more clarity to this topic.
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Affiliation(s)
- Markus Glatzer
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Correspondence:
| | - Kari Tanderup
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (K.T.); (L.F.)
| | - Angeles Rovirosa
- Department of Radiation Oncology, Hospital Clinic Barcelona, 08036 Barcelona, Spain;
- Fonaments Clinics Department, Faculty of Medicine, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Lars Fokdal
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark; (K.T.); (L.F.)
| | - Claudia Ordeanu
- Department of Radiotherapy, Institute of Oncology “Prof. Dr. Ion Chiricuta”, 400015 Cluj-Napoca, Romania;
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Roma, Italy;
| | - Cyrus Chargari
- Department of Radiation Oncology, Gustave Roussy Comprehensive Cancer Center, 94805 Paris, France;
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, 91054 Erlangen, Germany;
| | - Johannes Athanasios Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Barbara Šegedin
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Rachel Cooper
- Radiotherapy Research Group, Leeds Cancer Centre, St. Jame’s University Hospital, Leeds LS9 7TF, UK;
| | | | - Primoz Petric
- Department of Radiation Oncology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | | | - Kristina Lössl
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Ina M. Jürgenliemk-Schulz
- Department of Radiation Oncology, Cancer Center, University Medical Center Utrecht, 3584 AB Utrecht, The Netherlands;
| | - Peter Niehoff
- Department of Radiation Oncology, Sana Klinikum Offenbach GmbH, 63069 Offenbach, Germany;
| | - Ruth S. Hermansson
- Department of Oncology, Faculty of Medicine and Health, Örebro University, 70 185 Örebro, Sweden;
| | - Remi A. Nout
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3000 CA Rotterdam, The Netherlands;
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Ludwig Plasswilm
- Department of Radiation Oncology, Kantonsspital St. Gallen, 9007 St. Gallen, Switzerland; (P.M.P.); (L.P.)
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, 3041 Bern, Switzerland;
| | - Nikolaos Tselis
- Klinik für Strahlentherapie und Onkologie, Universitätsklinikum Frankfurt, Goethe Universität, 60590 Frankfurt, Germany;
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