Gyn Pre-planning: Intracavitary Insertion Risk factors: Age > - PowerPoint PPT Presentation

Gyn Pre-planning: Intracavitary Insertion Risk factors: • Age > 60 years • Distorted cervical canal • Retroverted uterus Perforation Incidence: • Necrosis ≈ 3% – 10% ! • Myoma Pre-BT: Intraoperative: MRI Navigation Ultrasound guidance Van Dyk S, et al. IJROBP 2009 Granai CO, et al. Gyn Oncol 1984 Sahinler I, et al. IJROBP 2004 Davidson MT, et al. Brachytherapy 2008 Mayr NA, et al. Brachytherapy 2005 Segedin B, et al. Radiol Oncol 2013 Irwin W, et al. Gynecol Oncol 2003 Jhingran A, Eifel PJ. IJROBP 2000 Sharma DN, et al. Gynecol Oncol 2010 Lanciano et al, IJROBP 1994 MIlman RM, et al. Clin Imaging 1991 Barnes EA, et al. Int J Gyn Cancer 2007 Davidson MTM, et al. Brachytherapy 2008

MRI guided Navigation of Intracavitary insertion Pre-EBRT MRI VMAT & Daily CBCT Week 5: Uterus in RVF RT Pre-BT MRI Pre-BT Clinical ? HIGH PERFORATION RISK NCCCR, Doha

Uterus Perforation risk Perforation risk Cervix Vaginal Cervico- wall uterine canal MRI guided Navigation Cervical os (mm): • 18 from right fornix • 18 from anterior fornix Tandem Path (mm): U: 5, UA: 5, UAL: 25, UPL: 25; T: 60 NCCCR, Doha, Unpublished material

Gyn Pre-planning: Intracavitary / Interstitial Insertion

Gyn Pre-planning: Intracavitary / Interstitial Insertion Initial MRI Pre BT EBRT + & Clinical findings ChT Clinical findings Insertion

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on initial MRI: Parametrial spread and regression patterns PARAMETRIAL REMNANTS [%] 90 % 88 % 85 % 68 % 19 % Predominantly Expansive + Infiltrative inner Infiltrative Infiltrative outer expansive infiltrating parts 1/3 middle 1/3 1/3 INITIAL PATTERN OF TUMOR GROWTH Schmid MP, et al. Acta Oncol 2013;52:1384-1390

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on initial MRI: Parametrial spread and regression patterns Clinical finidngs Clock-wise coordinates Insertion depths 20 mm 15 mm 30 mm 30 mm 15 mm 25 mm

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on initial MRI: Parametrial spread and regression patterns 20 mm 15 mm 30 mm 30 mm 15 mm 25 mm

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI Based on initial MRI Initial MRI Pre BT EBRT + Pre BT & Clinical findings ChT Clinical findings MRI Insertion

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: Without applicator in place 4th week MRI Add clinical examination Clock-wise coordinates picture Insertion depths …same concept as the pre-EBRT approach…

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: Without applicator in place

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: Without applicator in place With applicator in place

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place BT 1: BT 2: Intracavitary IC + needles Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):1424-1430

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place BT 0: BT 1: BT 2: IC IC + needles IC + needles Nomden CN, et al. Int J Radiat Oncol Biol Phys 2012;82(4):1424-1430

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place • Primary vaginal cancer “BT 0”: MRI with MUPIT • Recurrent endometrial cancer template in place • Recurrent cervical cancer BT: IC + needles (LPSC) Fokdal L, et al. Radiother Oncol 2011;100:473-479

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place 1 12 16% 11 1 Number Depth 12% 10 2 8% Preplanned 5.3 (2.7) 3.3 (1.5) 4% 9 3 0% Implanted BT1 5.3 (2.9) 3.0. (1.0) 8 4 Implanted BT2 5.4 (3.0) 2.9 (1.1) 7 5 6 Virtual Actual Courtesy: Lindegaard J. Aarhus University Hospital Fokdal L, et al. Radiother Oncol 2013;107:63-68.

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place Week5: BT 0 Cervix cancer (paracervical block) N = 18 pts IC/IS: 14 pts 0 ° 0 ° 0 ° B B A A T T T T T R R R T C C C T T C C C d d d d α α α β β β R R R R R Prescribed dose Prescribed dose T T T T Prescribed dose Prescribed dose HR CTV HR CTV HR CTV HR CTV Pre-planned needles Pre-planned needles C C D D BT 1&2: IC/IS implant T T T R R ∆ d ∆ d ∆ d A week later HR CTV HR CTV T T ∆α ∆α Prescribed dose Prescribed dose T T ∆β ∆β R R R Pre-planned needles Pre-planned needles Actual needles Actual needles Actual needles Actual needles Petric P, et al. Radiol Oncol 2014

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place 35 30 D90 [Gy α / β =10 ] 25 20 15 Median ∆ : 1 (0 – 3.6) Gy 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 100 90 80 70 V100 [%] 60 Median ∆ : 1.4 (0.1 – 9.2) % 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Petric P, et al. Radiol. Oncol 2014

Gyn Pre-planning: Intracavitary / Interstitial Insertion Based on pre-brachytherapy MRI: With applicator in place 20 EQD2: Bladder D2cc [Gy] 18 16 14 12 10 16 8 EQD2: Sigmoid D2cc [Gy] 14 6 12 4 2 10 0 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 6 4 18 EQD2: Rectum D2cc [Gy] 2 16 0 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Petric P, et al. Radiol. Oncol 2014