PO13

Abstract

Purpose Dose intensive image-based brachytherapy has become the gold standard treatment for cervical cancer, with an improvement in disease control and radiation-induced morbidity. A significant contribution to dose escalation has been the addition of needles to intracavitary applicators, with both hybrid and template-based insertions. These applications afford brachytherapists more flexibility of dose shaping and tumor coverage, while sparing organs at risk. Many of these procedures can now be performed in departmental brachytherapy suites within radiation oncology departments, where support from other hospital teams is not always readily available. One of the most feared complications during removal of interstitial brachytherapy applicators is a bleeding event, which can range from minor blood loss to life threatening bleeding. In particular, the use of needles that are inserted into the highly vascular vaginal, cervical and parametrial tissues can increase the risk of these events, including injury of venous and arterial structures. Being prepared for potential bleeding events is of the utmost importance in order to ensure a rapid and effective response. Materials and Methods Our goal is to establish a set of guidelines which can be used to prepare for and treat bleeding events during gynecologic brachytherapy. The proposed methods have been used at our institution and were developed in collaboration with the gynecology oncology team. Results First, we recommend pre-operative evaluation of blood counts following chemoradiation, pre-existing bleeding disorders, anticoagulant use, non-steroidal anti-inflammatory drug use, and disease location. A full pre-operative evaluation by a trained anesthesiologist can expedite this evaluation. Blood counts and electrolytes should be obtained on procedure day and prior to needle insertion, and if necessary, significant pre-procedure abnormalities addressed with transfusions or other supplements. Assessment of the location of residual disease and proximity to nearby vessels, as well as the projected location and number of needles is strategic. Considerations for removal of inpatient applications where multiple fractions have been delivered over several days should include timing of prophylactic anticoagulation discontinuation, pre-pull hemoglobin/hematocrit/platelet levels, and if needed, transfusion prior to applicator removal. For all patients, continuous monitoring of vitals before and during applicator removal, as well as dual IV access and blood type and crossing should be considered. IV fluids should be readily available should bleeding cause a drop in blood pressure. Preparation of a fully equipped vaginal packing kit complete with speculums, ring forceps, packing gauze, saline, lubricant and Monsel's solution is essential. For severe bleeding events, with rapid emergence of symptomatic anemia including tachycardia, hypotension, pallor, dizziness or other subjective symptoms, a rapid response team should be activated while vaginal packing takes place. In addition, having members of the Gynecologic Oncology team alerted before pull or present at the time of pull can expedite intervention in high risk cases. For persistent bleeding and suspicion of vascular injury, emergent percutaneous embolization of pelvic vessels by interventional radiologists can be an effective strategy. Post procedure monitoring of blood counts and vitals, as well as consideration for admission are important interventions. Conclusions Organizing the brachytherapy team to respond to bleeding events at the time of applicator removal is an integral responsibility when implementing interstitial techniques. Having an organized approach to respond to these acute events is essential in preventing unwanted outcomes and sustaining the vital benefits that these applications afford. Dose intensive image-based brachytherapy has become the gold standard treatment for cervical cancer, with an improvement in disease control and radiation-induced morbidity. A significant contribution to dose escalation has been the addition of needles to intracavitary applicators, with both hybrid and template-based insertions. These applications afford brachytherapists more flexibility of dose shaping and tumor coverage, while sparing organs at risk. Many of these procedures can now be performed in departmental brachytherapy suites within radiation oncology departments, where support from other hospital teams is not always readily available. One of the most feared complications during removal of interstitial brachytherapy applicators is a bleeding event, which can range from minor blood loss to life threatening bleeding. In particular, the use of needles that are inserted into the highly vascular vaginal, cervical and parametrial tissues can increase the risk of these events, including injury of venous and arterial structures. Being prepared for potential bleeding events is of the utmost importance in order to ensure a rapid and effective response. Our goal is to establish a set of guidelines which can be used to prepare for and treat bleeding events during gynecologic brachytherapy. The proposed methods have been used at our institution and were developed in collaboration with the gynecology oncology team. First, we recommend pre-operative evaluation of blood counts following chemoradiation, pre-existing bleeding disorders, anticoagulant use, non-steroidal anti-inflammatory drug use, and disease location. A full pre-operative evaluation by a trained anesthesiologist can expedite this evaluation. Blood counts and electrolytes should be obtained on procedure day and prior to needle insertion, and if necessary, significant pre-procedure abnormalities addressed with transfusions or other supplements. Assessment of the location of residual disease and proximity to nearby vessels, as well as the projected location and number of needles is strategic. Considerations for removal of inpatient applications where multiple fractions have been delivered over several days should include timing of prophylactic anticoagulation discontinuation, pre-pull hemoglobin/hematocrit/platelet levels, and if needed, transfusion prior to applicator removal. For all patients, continuous monitoring of vitals before and during applicator removal, as well as dual IV access and blood type and crossing should be considered. IV fluids should be readily available should bleeding cause a drop in blood pressure. Preparation of a fully equipped vaginal packing kit complete with speculums, ring forceps, packing gauze, saline, lubricant and Monsel's solution is essential. For severe bleeding events, with rapid emergence of symptomatic anemia including tachycardia, hypotension, pallor, dizziness or other subjective symptoms, a rapid response team should be activated while vaginal packing takes place. In addition, having members of the Gynecologic Oncology team alerted before pull or present at the time of pull can expedite intervention in high risk cases. For persistent bleeding and suspicion of vascular injury, emergent percutaneous embolization of pelvic vessels by interventional radiologists can be an effective strategy. Post procedure monitoring of blood counts and vitals, as well as consideration for admission are important interventions. Organizing the brachytherapy team to respond to bleeding events at the time of applicator removal is an integral responsibility when implementing interstitial techniques. Having an organized approach to respond to these acute events is essential in preventing unwanted outcomes and sustaining the vital benefits that these applications afford.