oving the localThe effect of addition of interstitial brachytherapy control rate in advanced carcinoma of cervix

The study was undertaken with an aim to determine the role of interstitial brachytherapy in the management of advanced malignancy of uterine cervix. Thirty six histologically proven patienls of certical cancer of stage III and IV, previously treated with either external beam radiotherapy or combined chemo and radiotherapy were takenfor the study between December 1995 and June 1999. All of the patients were not otherwise suitable for routine intracavitary brachytherapy. The clinical indications were poor pelvic geomelry (1 4), residualdisease(10), recurrentdisease(7)andfailedintracavitaryradiotherapy(5).Thetotaldoseofradiationgivenwas2S-32Gy. llith a median follow up of 15.5 months (range 4-40 months), 21 (58.8%ù patients were having no evidence of disease locally, 14 (38.8%0) had residual disease and I patients was having progressive disease. In the residual disease group a better palliation ffict was seen in l0 patients. The local control was betterfor the tumors < 4 cm in largest diameter compared to more bullry tumors. In 8 patients there was grade I, three patients had developed grade II complications and grade III complication was seen in no patienls. Both grade I and II symptoms were managed conservatively. There were no acute treatment related dealhs. The 2 and 5 years survival rate was 34.70À and 10.6% with a median of 21.8 months. Transperineal lemplate can safely be practiced for lhe managemenl of lhe patients of certical cancer, not suitable for intracavitary brachytherapy or the dose distribution is sub-optimal by intracavitary procedure to improve local control rate. Kqtwords: Transperineal template, interstitial brachytherapy, cervical cancer, radiotherapy The cancer of uterine cervix is the second most common malignancy of the female genital tract worldwide. In Indian women it is the commonest form of cancer mortality and morbidity, accounting for 24Yo of all female malignancies. In all the cancer Department of Radiation Oncologt, All India Institute of Medical Sciences, New Delhi-I 10029 registries of India it tops the list of female malignancy except Mumbai and Delhi where breast cancer is the commonest. It is the only malignancy of female reproductive tract which can be prevented for its long pre-invasive clinical course by practice of an effective, inexpensive screening technique that allows the detection of pre-malignant conditions which can be treated effectively and not allowing them to develop into an invasive cancer. The possibility of clinical down staging as a result of screening and VoI9, No 3, July September 2000 early detection should be considered. According to WHO report 1997 the most potential risk factors were identified and it was suggested that a decrease in the incidence of sexually transmitted disease in female population'lower the chance of initiation of carcinoma cervix by 5OVo.If the population between the age 3564 years are screened at an interval of 3 and l0 years, the incidence is decreased by 80 and 55Vo respectively. The incidence also falls by 30Vo , when parity is less.r There is an alarming incidence of about 524,000 new cases per year worldwide, out of which 80Vo occur in the developing countries.r Unfortunately a great majority of the cases in India present at an advanced condition, when radiotherapy remains the mainstay of management. The usual institutional protocol of treating cancer cervix is to administer external beam radiotherapy (EBRT) from a tele-cobalt or linear accelerator by four field box technique followed by intracavitary radiotherapy (ICRT). But in certain challenging situations like patients having poor and inadequate pelvic geometry, recurrent or residual disease requiring re-irradiation and failed ICRT can be taken care by interstitial transperineal brachytherapy. In ideal situations a vaginal vault and cervical stump recurrence can be managed with interstitial brachytherapy. At our institution 40 patients with advanced carcinoma of cervix were managed with this technique. MATERIAL AND METHODS The facility of transperineal brachytherapy was started in December 1995 and thirty six patients of histopathologically proven patients of cancer cervix were taken for the procedure till January 1999. All the patients were assessed in the combined gynecological malignancy clinic before the procedure and properly explained regarding it with their consent. Routine haemogram, liver and renal function tests, X-ray of the chest was performed. Ultrasonogram (US) of the abdomen and pelvis alongwith transrectal US was done in order to asses the tumor extent and volume. CT scan of pelvis is done to see tumor infiltration. Pre-anesthesia checkup is rrnndatory before the procedure. The clinical indications were poor geometry (14), residual disease (10), recurrent disease (7) and failed ICRT (5). The patient is properly evaluated under anesthesia, r"rterine sounding was done to asses the length of the uterine cavity in order to finalize the length of the needle to be pushed in. The length of the vaginal canal is also measured and the first guide needle is put at l2 o' clock position on Intestitial brachitherapy in carcinoma of cervix 205 the anterior lip of the cervix. The needles are of l8G size and having one end blind. The obturator is put in the vagina over the first guide needle and template positioning is done. The needles were put in a sequential manner starting from the inner circle. The template is secured by silk suture. In all the cases the procedure was performed using Syed-Neblett transperineal template. After the procedure is over, orthogonal X-ray pictures are taken in order to confirm the needles are in proper position, followed by treatment planning to get a homogeneous dose distribution inside the tumor volume and the Iridium192 sources were loaded. During the procedure care was taken not to perforate the rectal mucosa. The patients were followed up at an interval of six weeks for the first year, two monthly for the next year and three monthly for the third year. PAP smear and US is done every six months, CT scan of the abdomen and pelvis is done every year.