1. Incorporating Cesium-131 Interstitial Implants into Daily Clinical Practice: How to Make Radiation appear exactly where you want.
Jonathan Feddock, MD
Department of Radiation Medicine
University of Kentucky

2. Vaginal cuff recurrence of cervix cancer s/p rad
hysterectomy and adjuvant RT

3. Okazawa et al. J Rad Res, Open Access, October 15, 2012.

4. Basic Facts
Radiation Therapy has a well-established role in the curative management of many gynecologic cancers.
Local recurrences following initial treatment including RT are problematic. Options are felt to include radical surgery in very selected patients or palliative care.
Exenterative surgery will be aborted in 25-35% of patients in whom it is attempted. When performed serious acute morbidity, some mortality, and uniform loss of structure and function result.

5. Basic Facts
Re-irradiation is often not considered, in spite of data suggesting its curative potential in well-selected patients. Reasons for not considering re-irradiation include:
Concerns about radiation injury.
Patient eligibility for phase I-II trials.
Familiarity of the treating physician
If pelvic exenteration is an option (small, central pelvic recurrence), wouldn’t it still be an option if small-volume re-irradiation was either unsuccessful or caused a local complication?

6. Vaginal cuff recurrence of cervix cancer s/p rad
hysterectomy and adjuvant RT

7. Orthogonal Radiographs of an Interstitial Au-198 Implant of a Vaginal Cuff Recurrence

8. Reconstructed Dose Cloud of 50 Gy

9. 4 days after Au-198 permanent seed implant

10. 8 weeks after Au-198 permanent seed implant (still NED after 10 years)

11. Interstitial Re-irradiation (IRI)
13 pts with recurrent or new primary gyn cancers underwent IRI between
Mean and median age: 63, 70 yrs, respectively
Diagnosis at time of IRI
Recurrent endometrial ca, n = 6
Recurrent cervical ca, n = 4
New primary vaginal ca, n = 3
All biopsy-confirmed recurrence
Metastatic work-up negative
Randall ME, Evans L, Greven KM, et al. Interstitial Reirradiation for Recurrent Gynecologic Malignancies: Results and Analysis of Prognostic Factors. Gyn Oncol (1993) 48:

12. Interstitial Re-irradiation (IRI)
7 permanent seed implants (5 Au-198, 2 Pd-103)
6 temporary implants (LDR Ir-192, SNIT)
Mean and median implanted volumes: 14.3, 12 cc
9/13 (69%) had CR
6/14 (46%) NED months later
Median f/u = 58 months
Only 1 possible complication: R-V fistula 22 months following SNIT, in presence of recurrent dz
Randall ME, Evans L, Greven KM, et al. Interstitial Reirradiation for Recurrent Gynecologic Malignancies: Results and Analysis of Prognostic Factors. . Gyn Oncol (1993) 48:

13. IRI Prognostic Factors
Cervical and vaginal > endometrial
Squamous > adenocarcinoma
Smaller tumor volumes
Higher RT doses (> 50 Gy)
Permanent implants > temporary (SNIT)
Vaginal wall/suburethra > vaginal cuff
Longer disease-free intervals
Randall ME, Evans L, Greven KM, et al. Interstitial Reirradiation for Recurrent Gynecologic Malignancies: Results and Analysis of Prognostic Factors. Gyn Oncol (1993) 48:

14. RECURRENT DISEASE Advantages for using Surgery
Ability to assess extent of disease and act accordingly
Applicable to larger volume recurrences
Avoids risk of late radiation injury

15. RECURRENT DISEASE Advantages for Re-Irradiation
Little peri-operative morbidity or mortality
Little or no hospitalization required, especially for permanent implants
Preserves structure and function in most patients
More applicable to patients with medical co- morbidities
More acceptable to patients
Relatively inexpensive compared to surgery