In response to Swamidas and Kirisits

Abstract

We were dismayed to read the short and unsatisfactory paragraph discussing the use of transabdominal ultrasound to guide brachytherapy for cervix cancer in an editorial from a country burdened with one‐fifth of all new cases of cervix cancer. We expected a more pragmatic approach from this region given the recognition of the disparity in resource and technology utilization between external beam treatment and brachytherapy in your environment. To say that ultrasound “will certainly play an important role in the future” implies ultrasound has no role in the present, this is both erroneous and mendacious reporting. Two clinical outcome studies using transabdominal ultrasound have been reported in the literature, neither of which were discussed in the editorial.[1,2] These reports have both shown how the use of low cost accessible transabdominal ultrasound can incorporate soft tissue imaging into a brachytherapy program and achieve similar survival rates and late effects as magnetic resonance imaging‐based three‐dimensional planning. It is possible to see the width, height, and thickness of the cervix using transabdominal ultrasound. One just has to turn the transducer through 90°. To caution against the use of ultrasound because technology is not as advanced as desired is extremely self‐limiting. It is not necessary to track the applicator in relation to the ultrasound scan set as the applicator itself acts as a fiducial and calibration device within the image. Transrectal ultrasound (TRUS) is limited by the short focal length (60 mm) and small field of view and while it may be a useful tool to assess cervix tumor width, there are no reports of its use in measuring cervix tumor height in locally advanced cancers. Tumor width, height, and thickness have not been measured with the applicator in situ with TRUS, nor has brachytherapy been planned using these images. At present, two‐dimensional transabdominal ultrasound images, which depict the applicator and anatomy, are used to verify applicator position by many departments around the world and used to guide planning in the two departments mentioned. These two departments have shown that use of transabdominal ultrasound significantly improved the dose distribution for target and OAR in comparison with conventional point X‐ray based planning. In a region where X‐ray based planning is the norm, resources are limited and patients are poor, it behooves us to explore accessible time and cost‐effective solutions and make image‐guided conformal brachytherapy possible for all.