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Morbidity / Complications

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Presentation on theme: "Morbidity / Complications"— Presentation transcript:

1 Morbidity / Complications
Patients experienced only expected post-implant reactions Two patients with self-limited superficial necrosis of vaginal mucosa No hospitalizations, fistulas or other severe side effects Wooten CE, Randall ME, … Feddock J. Implementation and Early Clinical Results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies. Gyn Oncol 2014.


3 Use of Cesium-131 in Definitive Therapy for Gynecologic Malignancies
Primarily used as a boost: Adjuvantly for a positive margin (vaginal cuff post hysterectomy) Definitively to treat gross disease Unresectable disease Small volume residual following standard therapy Ideally reserved for patients considered unsuitable for treatment using Syed-Neblett either for medical or logistical reasons

4 UK Experience using Cs-131 as a component of primary therapy
Median age: 66 (37-87) Type of Cancer N= Recurrent Endometrioid AdenoCa 5 Post-operative Endometrioid AdenoCa 4 Post-operative Cervical SCCa 2 Primary Vaginal AdenoCa 3 Vaginal Melanoma Vulvar SCCa

5 Characteristics of Cs-131 Implants used for Primary Therapy
Total implants performed: 18 Median dose = 22 Gy (15-50 Gy) Median seed count = 13 (9-30) Median source strength = 0.76 u/seed ( ) Median area treated = 6 cm2 ( cm2) Indication for Cesium-131 Boost N= Microscopic positive margin 4 Gross disease post-operatively 2 Gross disease at end of primary radiation 10 Gross disease before primary radiation (melanoma)

6 Results incorporating Cesium-131 into Initial Therapy
Median Follow-up 6.7 months ( months) Disease control: There have been no local failures – LC = 100% Only one patient has developed regional and/or metastatic disease Patient with vaginal melanoma developed a confirmed inguinal lymph node recurrence at 8.2 months post treatment Toxicity: Very low – nearly all develop acute grade 1-2 mucosal reactions that quickly resolve Two patients have developed grade 3 mucosal reactions One with persistent changes beyond 6 months One patient has identified persistent grade 2 GU toxicity beyond 6 months

7 A Case of Vulvovaginal Melanoma
40 Gy to 5mm using Cs-131 2 weeks later Additional 30 Gy using EBRT

8 What can be gained by adding Interstitial Brachytherapy?
45 Gy PRT followed by ICB 7 Gy to 5mm depth x3 45 Gy PRT followed by ICB 7 Gy to surface x2 then 20 Gy Cs-131 Dose to 5mm Depth BED = 88.8 Gy EQD23 = 74.0 Gy Dose to Vaginal Surface BED = Gy EQD23 = 87.0 Gy Dose to the Rectum (approx 5mm deep) EQD210 = 85.2 Gy 7 Gy per implant delivered to the entire active length treated Dose to 5mm Depth BED = 88.8 Gy EQD23 = 73.0 Gy Dose to Vaginal Surface BED = 97.4 Gy EQD23 = 81.1 Gy Dose to the Rectum (approx 5mm deep) EQD210 = 70.2 Gy Gy per implant times active length Receives prescription dose of Cs-131 implant, but to length of 1-1.5cm All calculations performed using GEC-ESTRO LQ Worksheet.

9 Patient Selection How do we decide which type of implant to use?
Depth of the tumor < 5mm: vaginal cylinder will do fine 5mm – 1cm: permanent implant using Cesium-131 or Gold-198 ≥ 1cm: Syed-Neblett or other catheter based treatment Vaginal Cylinder Permanent Seeds Syed-Neblett

10 Conclusions UK first to utilize/investigate Cs131 permanent interstitial implants for recurrent or new primary gynecologic malignancies. Actuarial local control rate at time of analysis was 84.4%, exceeding other published rates with minimal toxicity. Interstitial implants with Cs-131 should be more frequently and widely incorporated into management of gynecologic malignancies, including accessible recurrences following previous RT.

11 So How Do I Perform One? 42 year old female diagnosed with Stage II clear cell uterine cancer after TAH/BSO/LNS Receives adjuvant therapy: 45 Gy to the Pelvis followed by 6 cycles of Carbo/Taxol Within first month off therapy develops vaginal bleeding Biopsy proven recurrence at vaginal apex Treated with Vaginal brachytherapy 30Gy/10 fractions BID to the surface 3 weeks post brachytherapy, exam demonstrates progressive tumor at the vaginal apex MRI confirms this is only site of disease Scheduled for Exenteration with Gyn Oncologist Treated instead with Interstitial Re-irradiation using Cesium-131

12 2.5cm 4cm

13 Description of Procedure
Gross tumor volume to be implanted determined based on three-dimensional tumor measurements based on pelvic exam and imaging Total activity, seed strength, and geometry calculated using Paterson-Parker rules Outpatient procedure in the Radiation Oncology Department Premedication: 5-10 mg po Diazepam Local anesthesia: 2% lidocaine ± epinephrine Individual seed applicators to insert each seed

14 Plan to deliver 55 Gy to 3 x 4.5cm ellipse 3cm
B 4.5cm 1. Determine the Area: π * A * B = π * 1.5 * 2.25 = 10.6 cm 2. Determine the necessary activity to deliver 10 Gy in Radium equivalent

15 3. Convert the activity in Radium equivalent to activity in Au-198:
8.25 R-cm2/mg-hr * 250 mg-hrs * 55 Gy = mCi of Au-198 2.38 R-cm2/mg-hr mg-hrs Gy 4. Convert the activity in Au-198 into activity in Cs-131 using conversion factor of 1.1: 51.09 mCi of Au-198 * 1.1 = mCi of Cs-131 5. Determine the number of seeds necessary to perform the implant: Using Paterson-Parker Rules Area <25 cm2 2/3 in the peripheral, 1/3 central Circumference = cm Spacing seeds evenly at 1cm increments – 12 seeds will be needed If 2/3 = 12, then 1/3 will equal 6 So total number of seeds = 18

16 6. Determine the activity needed per seed:
Total activity = mCi of Cs-131 = 3.12 mCi/seed Seed count 18 seeds Convert to Air-Kerma Strength using factor of 0.638: Air-Kerma Strength = 3.12 mCi/seed * u/mCi = 1.99 u/seed So, we need to order 18 seeds at 1.99 u/seed to deliver 55 Gy to 5mm depth I usually order 10% extra in order to account for tumor growth between calculation and implant date So we ordered #21 seeds

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