Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.154
Andre Karius, Claudia Schweizer, Vratislav Strnad, Michael Lotter, Stephan Kreppner, Rainer Fietkau, Christoph Bert
Purpose Permanent prostate brachytherapy with seeds represent a standard of care procedure for low to intermediate risk prostate cancer. It is known to provide high cure rates and disease-free survival with tolerable toxicity. One disadvantage is that the implant arrangement cannot be altered after implantation. However, it is known that seed-displacements against their implant location may occur during the treatment course. The scope of this work was to perform a comparative analysis of seed-displacements within the prostate until day 1 and day 30 after implantation. This aimed to assess geometric and dosimetric implant variations and to identify possibilities for corresponding stability enhancements. Materials and Methods Seed-displacements between intraoperative transrectal ultrasound (TRUS) (day 0 of brachytherapy), quality assurance computed tomography (CT) (day 1), and post-plan CT (day 30) were analyzed for 21 consecutive patients. The implant arrangement observed at day 1 and 30 was registered to the day 0 and day 1 implant, and a corresponding 1:1 seed assignment was performed using the Hungarian method. These procedures were done on a pure seed-only level, i.e. without resorting to patient anatomy. Seed-displacements were evaluated depending on strand-length and implant location within the prostate. Corresponding dosimetric effects were assessed. Correlations of implant variations with patient-specific factors as prostate volume (change), dosimetric effects, as well as number of used needles and seeds were evaluated. Results Seed-displacements in the immediate post-implant phase until day 1 of brachytherapy (median displacements: 3.9±3.4 mm) were stronger than in the time to post-plan CT (2.3±2.6 mm). Implant variations occurred enhanced along the cranial-caudal direction, i.e. along the implantation direction. Seeds in base and apex tended to move towards the prostate midzone in both examined time periods. No dependency of seed-displacements on seed strand-length was observed until day 30, but strands containing one (7.0±4.5 mm) or two (8.0±5.7 mm) seeds showed larger positional deviations than strands of higher lengths (up to 4.2±7.0 mm) from day 0 to day 1. D90 (dose that 90% of prostate receives) was with variations of 2±17 Gy more stable from day 1 to 30 than in the immediate post-implant phase (-18±10 Gy). Seed-displacements were correlated with both dosimetric variations as well as prostate volume changes and the number of implanted seeds and needles. Conclusions Seed-displacements were stronger in the immediate post-implant phase than from day 1 to 30. Based on our observations, this may result from uncertainties in the gold-standard TRUS-guided implantation process. Our findings suggest a high importance of achieving a dose coverage close to 100% during intra-operative treatment planning, to ensure sufficient prostate dose coverage even after corresponding coverage declines originating from edema or systematic uncertainties. Im
{"title":"PO53","authors":"Andre Karius, Claudia Schweizer, Vratislav Strnad, Michael Lotter, Stephan Kreppner, Rainer Fietkau, Christoph Bert","doi":"10.1016/j.brachy.2023.06.154","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.154","url":null,"abstract":"Purpose Permanent prostate brachytherapy with seeds represent a standard of care procedure for low to intermediate risk prostate cancer. It is known to provide high cure rates and disease-free survival with tolerable toxicity. One disadvantage is that the implant arrangement cannot be altered after implantation. However, it is known that seed-displacements against their implant location may occur during the treatment course. The scope of this work was to perform a comparative analysis of seed-displacements within the prostate until day 1 and day 30 after implantation. This aimed to assess geometric and dosimetric implant variations and to identify possibilities for corresponding stability enhancements. Materials and Methods Seed-displacements between intraoperative transrectal ultrasound (TRUS) (day 0 of brachytherapy), quality assurance computed tomography (CT) (day 1), and post-plan CT (day 30) were analyzed for 21 consecutive patients. The implant arrangement observed at day 1 and 30 was registered to the day 0 and day 1 implant, and a corresponding 1:1 seed assignment was performed using the Hungarian method. These procedures were done on a pure seed-only level, i.e. without resorting to patient anatomy. Seed-displacements were evaluated depending on strand-length and implant location within the prostate. Corresponding dosimetric effects were assessed. Correlations of implant variations with patient-specific factors as prostate volume (change), dosimetric effects, as well as number of used needles and seeds were evaluated. Results Seed-displacements in the immediate post-implant phase until day 1 of brachytherapy (median displacements: 3.9±3.4 mm) were stronger than in the time to post-plan CT (2.3±2.6 mm). Implant variations occurred enhanced along the cranial-caudal direction, i.e. along the implantation direction. Seeds in base and apex tended to move towards the prostate midzone in both examined time periods. No dependency of seed-displacements on seed strand-length was observed until day 30, but strands containing one (7.0±4.5 mm) or two (8.0±5.7 mm) seeds showed larger positional deviations than strands of higher lengths (up to 4.2±7.0 mm) from day 0 to day 1. D90 (dose that 90% of prostate receives) was with variations of 2±17 Gy more stable from day 1 to 30 than in the immediate post-implant phase (-18±10 Gy). Seed-displacements were correlated with both dosimetric variations as well as prostate volume changes and the number of implanted seeds and needles. Conclusions Seed-displacements were stronger in the immediate post-implant phase than from day 1 to 30. Based on our observations, this may result from uncertainties in the gold-standard TRUS-guided implantation process. Our findings suggest a high importance of achieving a dose coverage close to 100% during intra-operative treatment planning, to ensure sufficient prostate dose coverage even after corresponding coverage declines originating from edema or systematic uncertainties. Im","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434445","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.141
Diana Lucia Guevara-Barrera, Silvia Rodriguez Villalba, Luis Suso-Martí, Enrique Sanchis-Sánchez, Francisco Blazquez Molina, Maria José Pérez-Calatayud, José Pérez-Calatayud, Manuel Santos Ortega
Purpose Tumor coverage with conventional MRI compatible combined intracavitary/interstitial (IC/IS) applicators is scarce in some patients with locally advanced gynecological malignancies. In these cases, it is recommended to add a larger interstitial component using transperineal templates (P-ISBT). Our department has been performing this type of implant since 2005 using MUPIT applicator and CT-based planning. In 2013 we switched to MRI-based planning and a compatible applicator had to be developed. It combines an IC component (intrauterine tandem) with a perineal template and Titanium needles. It is an attempt to combine the technical advantages of the MUPIT and of the MRI, while preserving the stability, geometry, and robustness of the implant. In contrast with the CT, MRI provides an excellent visibility of soft tissue, allowing a better delineation of residual tumor at the time of BT, resulting in more accurate and generally smaller treatment volumes. The aim of this work is to present the impact and benefice of MRI implementation in P-ISBT. For this purpose, the two groups of patients (pre- and post-2013) were compared in terms of CTV volume and late toxicity. Materials and Methods From 2005 to 2022, 169 patients diagnosed with primary/recurrent gynecological tumors were treated with P-ISBT. 80 patients, without dosimetric data (planned in a retired TPS) were excluded, leaving 89 patients for analysis. Patients were treated with either MUPIT or MRI-based applicator. Implants were performed by the same team of radiation oncologists, and following the same delineation and prescription protocols. Dose prescription was 24 Gy in 6 fractions for CT-based plans, and 25.5 Gy in 6 fractions for MRI-based plans. Fractions were administered twice daily. Dosimetric planning is also homogeneous within the two patient groups plan optimization was performed through the help of geometrical optimization, followed by a fine-tuning manual optimization, in order to avoid inner over-dose volumes.The CTV volumes of both groups of patients have been compared. Similarly, to demonstrate homogeneity in dosimetric planning, CTV overdose volumes V120%, V150% and V200% were compared. Finally, toxicity outcomes were analyzed using CTCAE v5.0. SPSS Statistics was used for analysis. Results 24 patients treated with MUPIT were compared to 65 patients treated with MRI- applicator. Mean CTV volumes were compared in Table 1 for patients with primary cervical cancer and in other cases (vaginal primary or recurrent), showing a halved volume in favor of MRI.Overdose volumes were compared for different CTV volume categories (image 1). The results for the 3 indices are fully equivalent for the different volume ranges As for late toxicities: G1-2 rectal toxicity was 37.5% in MUPIT vs. 7.7% in MRI-based applicator (P=0.0006); G3 rectal toxicity was 12.5% vs. 6.2% respectively (ns). G1-2 urinary toxicity was 8.3% in MUPIT vs. 6.2% in MRI-based applicator (ns); G3 urinary toxicity was
{"title":"PO40","authors":"Diana Lucia Guevara-Barrera, Silvia Rodriguez Villalba, Luis Suso-Martí, Enrique Sanchis-Sánchez, Francisco Blazquez Molina, Maria José Pérez-Calatayud, José Pérez-Calatayud, Manuel Santos Ortega","doi":"10.1016/j.brachy.2023.06.141","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.141","url":null,"abstract":"Purpose Tumor coverage with conventional MRI compatible combined intracavitary/interstitial (IC/IS) applicators is scarce in some patients with locally advanced gynecological malignancies. In these cases, it is recommended to add a larger interstitial component using transperineal templates (P-ISBT). Our department has been performing this type of implant since 2005 using MUPIT applicator and CT-based planning. In 2013 we switched to MRI-based planning and a compatible applicator had to be developed. It combines an IC component (intrauterine tandem) with a perineal template and Titanium needles. It is an attempt to combine the technical advantages of the MUPIT and of the MRI, while preserving the stability, geometry, and robustness of the implant. In contrast with the CT, MRI provides an excellent visibility of soft tissue, allowing a better delineation of residual tumor at the time of BT, resulting in more accurate and generally smaller treatment volumes. The aim of this work is to present the impact and benefice of MRI implementation in P-ISBT. For this purpose, the two groups of patients (pre- and post-2013) were compared in terms of CTV volume and late toxicity. Materials and Methods From 2005 to 2022, 169 patients diagnosed with primary/recurrent gynecological tumors were treated with P-ISBT. 80 patients, without dosimetric data (planned in a retired TPS) were excluded, leaving 89 patients for analysis. Patients were treated with either MUPIT or MRI-based applicator. Implants were performed by the same team of radiation oncologists, and following the same delineation and prescription protocols. Dose prescription was 24 Gy in 6 fractions for CT-based plans, and 25.5 Gy in 6 fractions for MRI-based plans. Fractions were administered twice daily. Dosimetric planning is also homogeneous within the two patient groups plan optimization was performed through the help of geometrical optimization, followed by a fine-tuning manual optimization, in order to avoid inner over-dose volumes.The CTV volumes of both groups of patients have been compared. Similarly, to demonstrate homogeneity in dosimetric planning, CTV overdose volumes V120%, V150% and V200% were compared. Finally, toxicity outcomes were analyzed using CTCAE v5.0. SPSS Statistics was used for analysis. Results 24 patients treated with MUPIT were compared to 65 patients treated with MRI- applicator. Mean CTV volumes were compared in Table 1 for patients with primary cervical cancer and in other cases (vaginal primary or recurrent), showing a halved volume in favor of MRI.Overdose volumes were compared for different CTV volume categories (image 1). The results for the 3 indices are fully equivalent for the different volume ranges As for late toxicities: G1-2 rectal toxicity was 37.5% in MUPIT vs. 7.7% in MRI-based applicator (P=0.0006); G3 rectal toxicity was 12.5% vs. 6.2% respectively (ns). G1-2 urinary toxicity was 8.3% in MUPIT vs. 6.2% in MRI-based applicator (ns); G3 urinary toxicity was","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"46 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434509","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.190
Ming Xu
The objective was to evaluate radioactive angles and dose distribution of partially shielded GYN cylinders during HDR Brachytherapy in a commercial treatment planning system (TPS). Patient treatment plans with partial shielded cylinders were generated in Brachytherapy planning using Eclipse TPS. The AAPM TG-43 dose calculation formalism was commonly used to provide rapid patient treatment. The Acuros algorithm in AAPM TG-186 MBCDAs with the same source position and planned dwell time was used to compare shielding effects and unblocked dose distributions. Acuros calculations employed solid applicators with shielded angles of 90°, 180°, and 270° from the TPS library, with tungsten alloy shielded segments. All calculations were performed in the water phantom. The differences between the AAPM TG-43 and TG-186 algorithms in these applicators were evaluated in terms of shielded angle, radioactive range, low dose bath background, and dose distribution. Patient planning using various shielded angle cylinders anteriorly or posteriorly to minimize local bladder or rectal dose on patient CT images for vaginal cuff treatment. The dwell time at the source position was calculated according to the 3D TG-43 algorithm, ignoring the shielding effect of the applicator to result in a cylindrically symmetrical dose distribution along the cylinder axis. Acuros dose calculation implemented Monte-Carlo (MC) algorithm approach. The 3D asymmetric dose distribution was shown in the sagittal view as expected. Low dose bath in the shielded areas was observed at approximately 10-15% of the prescribed dose. The low dose bath level changed slowly with shielding angle. The physical shielding angle was effectively shielded within the dose distribution range. The radioactive angle can be defined as the angle of the radioactive coverage portion from the source, or the angle between the designed isodose points to the center of cylindrical section. As showed in the figure below, a 180° shielded cylinder can shield a maximum range of about 210° in the posterior portion. When the sum of the shieling angle and radioactive angle was 360°, the radioactive angle was equal to 150°. This behavior was confirmed for shielding angles of 90°, 180°, and 270°, respectively in Acuros calculations. The radioactive angle was found to be smaller than the physical shielding angle. The presence of the metal block appeared to prevent deposition of scattered doses to unshielded tissue. This reduced scatter made the blocking angle projection wider than its physical angle. A slightly longer Acuros dwell time at a few percent was required to achieve the same dose level calculated for TG-43. Acuros calculations for shielded cylinder suggest that the shielded region in dose distribution is wider than the physically shielded part of segment. The radioactive angle is smaller than the physical shielded angle. Shielded areas are kept in low dose baths of prescribed doses. A slightly longer dwell time is required t
{"title":"PO89","authors":"Ming Xu","doi":"10.1016/j.brachy.2023.06.190","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.190","url":null,"abstract":"The objective was to evaluate radioactive angles and dose distribution of partially shielded GYN cylinders during HDR Brachytherapy in a commercial treatment planning system (TPS). Patient treatment plans with partial shielded cylinders were generated in Brachytherapy planning using Eclipse TPS. The AAPM TG-43 dose calculation formalism was commonly used to provide rapid patient treatment. The Acuros algorithm in AAPM TG-186 MBCDAs with the same source position and planned dwell time was used to compare shielding effects and unblocked dose distributions. Acuros calculations employed solid applicators with shielded angles of 90°, 180°, and 270° from the TPS library, with tungsten alloy shielded segments. All calculations were performed in the water phantom. The differences between the AAPM TG-43 and TG-186 algorithms in these applicators were evaluated in terms of shielded angle, radioactive range, low dose bath background, and dose distribution. Patient planning using various shielded angle cylinders anteriorly or posteriorly to minimize local bladder or rectal dose on patient CT images for vaginal cuff treatment. The dwell time at the source position was calculated according to the 3D TG-43 algorithm, ignoring the shielding effect of the applicator to result in a cylindrically symmetrical dose distribution along the cylinder axis. Acuros dose calculation implemented Monte-Carlo (MC) algorithm approach. The 3D asymmetric dose distribution was shown in the sagittal view as expected. Low dose bath in the shielded areas was observed at approximately 10-15% of the prescribed dose. The low dose bath level changed slowly with shielding angle. The physical shielding angle was effectively shielded within the dose distribution range. The radioactive angle can be defined as the angle of the radioactive coverage portion from the source, or the angle between the designed isodose points to the center of cylindrical section. As showed in the figure below, a 180° shielded cylinder can shield a maximum range of about 210° in the posterior portion. When the sum of the shieling angle and radioactive angle was 360°, the radioactive angle was equal to 150°. This behavior was confirmed for shielding angles of 90°, 180°, and 270°, respectively in Acuros calculations. The radioactive angle was found to be smaller than the physical shielding angle. The presence of the metal block appeared to prevent deposition of scattered doses to unshielded tissue. This reduced scatter made the blocking angle projection wider than its physical angle. A slightly longer Acuros dwell time at a few percent was required to achieve the same dose level calculated for TG-43. Acuros calculations for shielded cylinder suggest that the shielded region in dose distribution is wider than the physically shielded part of segment. The radioactive angle is smaller than the physical shielded angle. Shielded areas are kept in low dose baths of prescribed doses. A slightly longer dwell time is required t","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434518","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.105
Yixiang Liao, Ken Tatebe, Julius Turian
Purpose The conventional vaginal cylinder design consists of cylindrical segments and a hemi-spherical top, with a diameter matched to the cylinder portion. This design is driven primarily by geometric simplicity, without much consideration for the dose distribution around the brachytherapy source, nor the anatomy of patients. Careful plan optimization is required to make the prescription isodose line conform to the surface of the cylinder. However, the conformity is not optimal due to the discrepancy between the cylinder shape and the intrinsic dose anisotropy of the source perpendicular to the azimuthal plane. We propose an alternative design for an ergonomic vaginal applicator (EVA), which requires minimal optimization, provides a more natural dose conformity, and is more ergonomic for the patient. Materials and Methods In treating with brachytherapy alone for postoperative endometrial cancer, our typical prescription is 6 Gy x 5 fractions to the surface, covering the top 4 cm of the vaginal cuff. To create the proposed applicator, the existing cylinder channel, using the first 10 dwell positions (5mm-interval), are uniformly loaded for 17.33 seconds with nominal 10 Ci Ir-192 HDR source (GammaMedPlusiX and Eclipse). The prescription isodose line then takes the shape of an ovoid, with 3 cm diameter at middle length, paralleling a typical size used for cylinder applicator treatments. Similarly, uniform loading times of 10, 13.6, 21.8, and 26.5 seconds correspond to maximal diameters of 2, 2.5, 3.5, and 4 cm, respectively. The prescription isodose line is converted to a contour that can be exported and used to construct an applicator. The surface of this applicator naturally conforms to the prescription isodose line, which removes the need for any further plan optimization. Dose along the surface and at 5mm distance from the applicator equator to the tip of the dome are reported. Results Using the 3 cm diameter case as an example, the average surface dose (± Std. Dev) is 100% ± 3.2% with the EVA, compared to 100% ± 5.5% with the conventional cylinder, showing improved surface dose homogeneity with EVA, even after extensive optimization of the cylinder plan. The doses at 5mm depth are comparable: 57.3 ± 6.8% and 57.9 ± 6.2%, respectively. In addition, the tapered tip of EVA is likely easier to implant and would cause less discomfort for patients. Another potential benefit of the EVA is that its tapered tip may be less likely to trap air bubbles between the applicator and the vaginal cuff. Conclusions A novel design for a vaginal applicator is achieved that requires minimal planning optimization, with improved surface dose homogeneity, and better ergonomics. These are expected to provide both superior dosimetry and better overall clinical experience. The conventional vaginal cylinder design consists of cylindrical segments and a hemi-spherical top, with a diameter matched to the cylinder portion. This design is driven primarily by geometric simplic
传统的阴道筒设计由圆柱形部分和半球形顶部组成，直径与筒体部分相匹配。这种设计主要是由几何的简单性驱动的，没有太多考虑近距离治疗源周围的剂量分布，也没有考虑患者的解剖结构。为了使处方等剂量线符合圆筒表面，需要仔细的计划优化。然而，由于圆柱体形状与垂直于方位面的源的本征剂量各向异性之间存在差异，一致性不是最优的。我们提出了一种人体工程学阴道涂抹器(EVA)的替代设计，它需要最小的优化，提供更自然的剂量一致性，并且对患者更符合人体工程学。材料与方法在子宫内膜癌术后单独近距离放疗时，我们的典型处方为6 Gy x 5次照射至表面，覆盖阴道袖带顶部4cm。为了创建建议的涂抹器，使用前10个停留位置(5mm间隔)的现有圆柱体通道，使用标称10 Ci Ir-192 HDR源(GammaMedPlusiX和Eclipse)均匀加载17.33秒。处方等剂量线呈卵形，中间长度直径为3厘米，与圆柱体涂抹器治疗的典型尺寸平行。同样，均匀加载时间分别为10、13.6、21.8和26.5秒时，最大直径分别为2、2.5、3.5和4 cm。将处方等剂量线转换为可导出并用于构建涂抹器的轮廓。这种涂抹器的表面自然符合处方等剂量线，这消除了任何进一步的计划优化的需要。剂量沿表面和在5mm距离从涂抹赤道到顶端的圆顶报告。结果以直径为3 cm的病例为例，EVA的平均表面剂量(±Std. Dev)为100%±3.2%，而常规圆柱体为100%±5.5%，即使对圆柱体方案进行了广泛优化，EVA的表面剂量均匀性也有所改善。5mm深度的剂量具有可比性:分别为57.3%±6.8%和57.9±6.2%。此外，EVA的锥形尖端可能更容易植入，并减少患者的不适。EVA的另一个潜在好处是，它的锥形尖端可能不太可能在涂抹器和阴道袖带之间捕获气泡。结论:一种新颖的阴道涂抹器设计，只需最小的规划优化，改善表面剂量均匀性，更好的人体工程学。这些有望提供更好的剂量学和更好的整体临床经验。传统的阴道筒设计由圆柱形部分和半球形顶部组成，直径与筒体部分相匹配。这种设计主要是由几何的简单性驱动的，没有太多考虑近距离治疗源周围的剂量分布，也没有考虑患者的解剖结构。为了使处方等剂量线符合圆筒表面，需要仔细的计划优化。然而，由于圆柱体形状与垂直于方位面的源的本征剂量各向异性之间存在差异，一致性不是最优的。我们提出了一种人体工程学阴道涂抹器(EVA)的替代设计，它需要最小的优化，提供更自然的剂量一致性，并且对患者更符合人体工程学。在术后子宫内膜癌的单独近距离放疗中，我们的典型处方是6 Gy x 5个分量到表面，覆盖阴道袖带顶部4cm。为了创建建议的涂抹器，使用前10个停留位置(5mm间隔)的现有圆柱体通道，使用标称10 Ci Ir-192 HDR源(GammaMedPlusiX和Eclipse)均匀加载17.33秒。处方等剂量线呈卵形，中间长度直径为3厘米，与圆柱体涂抹器治疗的典型尺寸平行。同样，均匀加载时间分别为10、13.6、21.8和26.5秒时，最大直径分别为2、2.5、3.5和4 cm。将处方等剂量线转换为可导出并用于构建涂抹器的轮廓。这种涂抹器的表面自然符合处方等剂量线，这消除了任何进一步的计划优化的需要。剂量沿表面和在5mm距离从涂抹赤道到顶端的圆顶报告。以直径为3 cm的病例为例，EVA的平均表面剂量(±Std. Dev)为100%±3.2%，而传统圆柱体为100%±5.5%，即使在对圆柱体方案进行了广泛优化后，EVA的表面剂量均匀性也得到了改善。5mm深度的剂量是相当的:57。 传统的阴道筒设计由圆柱形部分和半球形顶部组成，直径与筒体部分相匹配。这种设计主要是由几何的简单性驱动的，没有太多考虑近距离治疗源周围的剂量分布，也没有考虑患者的解剖结构。为了使处方等剂量线符合圆筒表面，需要仔细的计划优化。然而，由于圆柱体形状与垂直于方位面的源的本征剂量各向异性之间存在差异，一致性不是最优的。我们提出了一种人体工程学阴道涂抹器(EVA)的替代设计，它需要最小的优化，提供更自然的剂量一致性，并且对患者更符合人体工程学。材料与方法在子宫内膜癌术后单独近距离放疗时，我们的典型处方为6 Gy x 5次照射至表面，覆盖阴道袖带顶部4cm。为了创建建议的涂抹器，使用前10个停留位置(5mm间隔)的现有圆柱体通道，使用标称10 Ci Ir-192 HDR源(GammaMedPlusiX和Eclipse)均匀加载17.33秒。处方等剂量线呈卵形，中间长度直径为3厘米，与圆柱体涂抹器治疗的典型尺寸平行。同样，均匀加载时间分别为10、13.6、21.8和26.5秒时，最大直径分别为2、2.5、3.5和4 cm。将处方等剂量线转换为可导出并用于构建涂抹器的轮廓。这种涂抹器的表面自然符合处方等剂量线，这消除了任何进一步的计划优化的需要。剂量沿表面和在5mm距离从涂抹赤道到顶端的圆顶报告。结果以直径为3 cm的病例为例，EVA的平均表面剂量(±Std. Dev)为100%±3.2%，而常规圆柱体为100%±5.5%，即使对圆柱体方案进行了广泛优化，EVA的表面剂量均匀性也有所改善。5mm深度的剂量具有可比性:分别为57.3%±6.8%和57.9±6.2%。此外，EVA的锥形尖端可能更容易植入，并减少患者的不适。EVA的另一个潜在好处是，它的锥形尖端可能不太可能在涂抹器和阴道袖带之间捕获气泡。结论:一种新颖的阴道涂抹器设计，只需最小的规划优化，改善表面剂量均匀性，更好的人体工程学。这些有望提供更好的剂量学和更好的整体临床经验。传统的阴道筒设计由圆柱形部分和半球形顶部组成，直径与筒体部分相匹配。这种设计主要是由几何的简单性驱动的，没有太多考虑近距离治疗源周围的剂量分布，也没有考虑患者的解剖结构。为了使处方等剂量线符合圆筒表面，需要仔细的计划优化。然而，由于圆柱体形状与垂直于方位面的源的本征剂量各向异性之间存在差异，一致性不是最优的。我们提出了一种人体工程学阴道涂抹器(EVA)的替代设计，它需要最小的优化，提供更自然的剂量一致性，并且对患者更符合人体工程学。在术后子宫内膜癌的单独近距离放疗中，我们的典型处方是6 Gy x 5个分量到表面，覆盖阴道袖带顶部4cm。为了创建建议的涂抹器，使用前10个停留位置(5mm间隔)的现有圆柱体通道，使用标称10 Ci Ir-192 HDR源(GammaMedPlusiX和Eclipse)均匀加载17.33秒。处方等剂量线呈卵形，中间长度直径为3厘米，与圆柱体涂抹器治疗的典型尺寸平行。同样，均匀加载时间分别为10、13.6、21.8和26.5秒时，最大直径分别为2、2.5、3.5和4 cm。将处方等剂量线转换为可导出并用于构建涂抹器的轮廓。这种涂抹器的表面自然符合处方等剂量线，这消除了任何进一步的计划优化的需要。剂量沿表面和在5mm距离从涂抹赤道到顶端的圆顶报告。以直径为3 cm的病例为例，EVA的平均表面剂量(±Std. Dev)为100%±3.2%，而传统圆柱体为100%±5.5%，即使在对圆柱体方案进行了广泛优化后，EVA的表面剂量均匀性也得到了改善。5mm深度的剂量是相当的:57。 (3±6.8%)和(57.9±6.2%)。此外，EVA的锥形尖端可能更容易植
{"title":"PO04","authors":"Yixiang Liao, Ken Tatebe, Julius Turian","doi":"10.1016/j.brachy.2023.06.105","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.105","url":null,"abstract":"Purpose The conventional vaginal cylinder design consists of cylindrical segments and a hemi-spherical top, with a diameter matched to the cylinder portion. This design is driven primarily by geometric simplicity, without much consideration for the dose distribution around the brachytherapy source, nor the anatomy of patients. Careful plan optimization is required to make the prescription isodose line conform to the surface of the cylinder. However, the conformity is not optimal due to the discrepancy between the cylinder shape and the intrinsic dose anisotropy of the source perpendicular to the azimuthal plane. We propose an alternative design for an ergonomic vaginal applicator (EVA), which requires minimal optimization, provides a more natural dose conformity, and is more ergonomic for the patient. Materials and Methods In treating with brachytherapy alone for postoperative endometrial cancer, our typical prescription is 6 Gy x 5 fractions to the surface, covering the top 4 cm of the vaginal cuff. To create the proposed applicator, the existing cylinder channel, using the first 10 dwell positions (5mm-interval), are uniformly loaded for 17.33 seconds with nominal 10 Ci Ir-192 HDR source (GammaMedPlusiX and Eclipse). The prescription isodose line then takes the shape of an ovoid, with 3 cm diameter at middle length, paralleling a typical size used for cylinder applicator treatments. Similarly, uniform loading times of 10, 13.6, 21.8, and 26.5 seconds correspond to maximal diameters of 2, 2.5, 3.5, and 4 cm, respectively. The prescription isodose line is converted to a contour that can be exported and used to construct an applicator. The surface of this applicator naturally conforms to the prescription isodose line, which removes the need for any further plan optimization. Dose along the surface and at 5mm distance from the applicator equator to the tip of the dome are reported. Results Using the 3 cm diameter case as an example, the average surface dose (± Std. Dev) is 100% ± 3.2% with the EVA, compared to 100% ± 5.5% with the conventional cylinder, showing improved surface dose homogeneity with EVA, even after extensive optimization of the cylinder plan. The doses at 5mm depth are comparable: 57.3 ± 6.8% and 57.9 ± 6.2%, respectively. In addition, the tapered tip of EVA is likely easier to implant and would cause less discomfort for patients. Another potential benefit of the EVA is that its tapered tip may be less likely to trap air bubbles between the applicator and the vaginal cuff. Conclusions A novel design for a vaginal applicator is achieved that requires minimal planning optimization, with improved surface dose homogeneity, and better ergonomics. These are expected to provide both superior dosimetry and better overall clinical experience. The conventional vaginal cylinder design consists of cylindrical segments and a hemi-spherical top, with a diameter matched to the cylinder portion. This design is driven primarily by geometric simplic","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.224
Javier Rodriguez Corredor
Worldwide, non-melanoma skin cancer (NMSC) has a high incidence. In 2020, Colombia, a Latin American country, had a NMSC incidence of 7.9 per 100.000 inhabitants. High Dose Rate (HDR) skin brachytherapy is a validated treatment option, with optimal and promising local control rates and cosmetic results, equivalent to surgical management and external radiation therapy. Nevertheless, this treatment technique may be scarce in Low Middle-Income Countries (LMICs), due to personnel training and technology requirements. We present the largest cohort of patients treated with HDR skin brachytherapy in Colombia, treated at the Colombian National Cancer Institute and a proposal for a low-priced, widely available, marker technique for Computed Tomography (CT) Simulation. This was a retrospective review of all patients with skin tumors treated with Ir-192 high dose rate (HDR) surface cast brachytherapy from January 1, 2019, to January 28, 2023 at the National Institute of Medicine. cancerology, Bogota - Colombia. 44 lesions (36 patients) were identified. The median age at diagnosis was 76 years (range = 50-98). The majority were basal cell carcinomas (82%, n = 36), squamous cell carcinomas (15%, n =7 ), and one cutaneous lymphoma (3%, n = 1). Most of the lesions were located in the head region. and neck. The most used RT dose was 40 Gy/8 interday fractions; all patients had individualized CT-based planning with alternative donut-type fiducial markers. Six months survival (OS) was 94% and 6-month progression-free survival (PFS) was 92%. Most of the deaths were from unrelated causes. Response was assessed in the clinic at 1 week and 2, 4, and 6 months after treatment. Our complete response (CR) rate was 97%, with partial response in one patient, we reported a local control (CL) rate at 6 months of 86%, and local recurrence in one patient. The procedure was well tolerated, with no grade 3-5 acute or late toxicities assessed on the RTOG and LENT/SOME scales. The median depth of the isodose line at 100% was 0.5 cm and the median surface dose = 120%. The median V 90 = 93%. Surface brachytherapy is an excellent alternative for the treatment of non-melanoma cancer, with response rates and effective local cancer control. In low-resource countries, treatments such as brachytherapy improve patient adherence, becoming future perspectives to be implemented. challenges in techniques, dosimetry, and casts provide challenges that evoke recursive solutions like our donut radiopaque fiduciary, thus demonstrating the skills of the radiation oncologist in the face of variability.
{"title":"PO124","authors":"Javier Rodriguez Corredor","doi":"10.1016/j.brachy.2023.06.224","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.224","url":null,"abstract":"Worldwide, non-melanoma skin cancer (NMSC) has a high incidence. In 2020, Colombia, a Latin American country, had a NMSC incidence of 7.9 per 100.000 inhabitants. High Dose Rate (HDR) skin brachytherapy is a validated treatment option, with optimal and promising local control rates and cosmetic results, equivalent to surgical management and external radiation therapy. Nevertheless, this treatment technique may be scarce in Low Middle-Income Countries (LMICs), due to personnel training and technology requirements. We present the largest cohort of patients treated with HDR skin brachytherapy in Colombia, treated at the Colombian National Cancer Institute and a proposal for a low-priced, widely available, marker technique for Computed Tomography (CT) Simulation. This was a retrospective review of all patients with skin tumors treated with Ir-192 high dose rate (HDR) surface cast brachytherapy from January 1, 2019, to January 28, 2023 at the National Institute of Medicine. cancerology, Bogota - Colombia. 44 lesions (36 patients) were identified. The median age at diagnosis was 76 years (range = 50-98). The majority were basal cell carcinomas (82%, n = 36), squamous cell carcinomas (15%, n =7 ), and one cutaneous lymphoma (3%, n = 1). Most of the lesions were located in the head region. and neck. The most used RT dose was 40 Gy/8 interday fractions; all patients had individualized CT-based planning with alternative donut-type fiducial markers. Six months survival (OS) was 94% and 6-month progression-free survival (PFS) was 92%. Most of the deaths were from unrelated causes. Response was assessed in the clinic at 1 week and 2, 4, and 6 months after treatment. Our complete response (CR) rate was 97%, with partial response in one patient, we reported a local control (CL) rate at 6 months of 86%, and local recurrence in one patient. The procedure was well tolerated, with no grade 3-5 acute or late toxicities assessed on the RTOG and LENT/SOME scales. The median depth of the isodose line at 100% was 0.5 cm and the median surface dose = 120%. The median V 90 = 93%. Surface brachytherapy is an excellent alternative for the treatment of non-melanoma cancer, with response rates and effective local cancer control. In low-resource countries, treatments such as brachytherapy improve patient adherence, becoming future perspectives to be implemented. challenges in techniques, dosimetry, and casts provide challenges that evoke recursive solutions like our donut radiopaque fiduciary, thus demonstrating the skills of the radiation oncologist in the face of variability.","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"6 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434532","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.173
Evans Amoah, Jeremiah Johnson, Stephen Strup, Ali Soleimani-Meigooni, William St. Clair
Purpose Radiation management literature focused on optimizing care for patients with intellectual disability is sparse. We add our experience to the literature with the goal to improve care to this vulnerable patient population. To this end, we report three cases of prostate cancer in patients with limited cognition who were treated with low dose rate (LDR) prostate brachytherapy to highlight an effective strategy to deliver optimal care to this group of patients. Materials and Methods This is a case series of three adult male patients with limited cognition each of whom developed prostate cancer which was managed primarily with LDR brachytherapy. Results Patient #1: A 53-year-old male with favorable intermediate-risk prostate cancer (PSA 8.8 ng/ml, Grade Group 2), Patient #2: a 68-year-old male with unfavorable intermediate risk prostate cancer (PSA 12.6 ng/ml, Grade Group 3), and Patient #3: a 52-year-old male with high-risk prostate cancer (PSA 24 ng/ml, Grade Group 1), all of whom had intellectual disability, were evaluated for radiation therapy. A thorough discussion occurred with each patient and their legal guardian about prostate cancer therapy options including surgery versus radiation treatment with or without androgen deprivation therapy. Radiation therapy treatment strategies presented included low dose rate brachytherapy versus external beam radiation treatment including SBRT to a total dose of 3625 cGy in 5 fractions every other day or a moderately hypofractionated regimen to a total dose of 7000 cGy in 28 daily fractions Monday to Friday. In each case, a shared decision was made for each patient to undergo interstitial prostate seed implant. Of note, two out of the three patients lived more than an hour away from the radiation treatment center and relied on family support for transportation needs. Each patient initially underwent a prostate volume study with a transrectal ultrasound to 1) determine the dimensions of the prostate and 2) develop a plan for radiation dose coverage of the prostate with interstitial Cs-131 brachytherapy seeds. Each patient then underwent seed implantation under anesthesia followed by fluoroscopy and post-implant CT, to assess for appropriate seed placement as well as the post-implant dosimetry. Patient #1 received a total prescription dose of 110 Gy to the prostate D90 using 61 sources each with a strength of 1.6 U per seed for a total strength of 97.6 U and at 14 months follow up, his PSA had decreased to 1.7 ng/ml from 8.8 ng/ml. Patient #2 received a total prescription dose of 100 Gy to the prostate D90 using 59 sources each with a strength of 1.43 U per seed for a total strength of 84.37 U, and at 38 months follow up, his PSA had decreased to 0.018 ng/ml from 12.6 ng/ml. Patient #3 received 115 Gy to the prostate D90 using 90 sources each with a strength of 1.8 U per seed for a total of 162 U, and at 34 months follow up, his PSA had decreased to 0.8 ng/mL from 24 ng/ml. In all three cases, treatment
{"title":"PO72","authors":"Evans Amoah, Jeremiah Johnson, Stephen Strup, Ali Soleimani-Meigooni, William St. Clair","doi":"10.1016/j.brachy.2023.06.173","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.173","url":null,"abstract":"Purpose Radiation management literature focused on optimizing care for patients with intellectual disability is sparse. We add our experience to the literature with the goal to improve care to this vulnerable patient population. To this end, we report three cases of prostate cancer in patients with limited cognition who were treated with low dose rate (LDR) prostate brachytherapy to highlight an effective strategy to deliver optimal care to this group of patients. Materials and Methods This is a case series of three adult male patients with limited cognition each of whom developed prostate cancer which was managed primarily with LDR brachytherapy. Results Patient #1: A 53-year-old male with favorable intermediate-risk prostate cancer (PSA 8.8 ng/ml, Grade Group 2), Patient #2: a 68-year-old male with unfavorable intermediate risk prostate cancer (PSA 12.6 ng/ml, Grade Group 3), and Patient #3: a 52-year-old male with high-risk prostate cancer (PSA 24 ng/ml, Grade Group 1), all of whom had intellectual disability, were evaluated for radiation therapy. A thorough discussion occurred with each patient and their legal guardian about prostate cancer therapy options including surgery versus radiation treatment with or without androgen deprivation therapy. Radiation therapy treatment strategies presented included low dose rate brachytherapy versus external beam radiation treatment including SBRT to a total dose of 3625 cGy in 5 fractions every other day or a moderately hypofractionated regimen to a total dose of 7000 cGy in 28 daily fractions Monday to Friday. In each case, a shared decision was made for each patient to undergo interstitial prostate seed implant. Of note, two out of the three patients lived more than an hour away from the radiation treatment center and relied on family support for transportation needs. Each patient initially underwent a prostate volume study with a transrectal ultrasound to 1) determine the dimensions of the prostate and 2) develop a plan for radiation dose coverage of the prostate with interstitial Cs-131 brachytherapy seeds. Each patient then underwent seed implantation under anesthesia followed by fluoroscopy and post-implant CT, to assess for appropriate seed placement as well as the post-implant dosimetry. Patient #1 received a total prescription dose of 110 Gy to the prostate D90 using 61 sources each with a strength of 1.6 U per seed for a total strength of 97.6 U and at 14 months follow up, his PSA had decreased to 1.7 ng/ml from 8.8 ng/ml. Patient #2 received a total prescription dose of 100 Gy to the prostate D90 using 59 sources each with a strength of 1.43 U per seed for a total strength of 84.37 U, and at 38 months follow up, his PSA had decreased to 0.018 ng/ml from 12.6 ng/ml. Patient #3 received 115 Gy to the prostate D90 using 90 sources each with a strength of 1.8 U per seed for a total of 162 U, and at 34 months follow up, his PSA had decreased to 0.8 ng/mL from 24 ng/ml. In all three cases, treatment","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434361","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-01DOI: 10.1016/j.brachy.2023.06.114
Saryleine Ortiz de Choudens, Christina Small-Tom, Lindsey McAlarnen, Susan Duyar, Rebekah Summey, Erin Bishop, Elizabeth Hopp, William Bradley, Denise Uyar, Janet S. Rader, Meena Bedi, Beth Erickson
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 sh
{"title":"PO13","authors":"Saryleine Ortiz de Choudens, Christina Small-Tom, Lindsey McAlarnen, Susan Duyar, Rebekah Summey, Erin Bishop, Elizabeth Hopp, William Bradley, Denise Uyar, Janet S. Rader, Meena Bedi, Beth Erickson","doi":"10.1016/j.brachy.2023.06.114","DOIUrl":"https://doi.org/10.1016/j.brachy.2023.06.114","url":null,"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 sh","PeriodicalId":93914,"journal":{"name":"Brachytherapy","volume":"74 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135434508","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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