|Year : 1997 | Volume
| Issue : 7 | Page : 231-235
Evaluation of transperineal template implant technique in Indian cervical carcinoma patients
Subhash Chander, Aarti K Patel, Ritu Grover, GK Rath
Department of Radiotherapy. Institute Rotary Cancer Hospital, All India Institute of Medical sciences, New Delhi-110 029., India
Department of Radiotherapy. Institute Rotary Cancer Hospital, All India Institute of Medical sciences, New Delhi-110 029.
|How to cite this article:|
Chander S, Patel AK, Grover R, Rath G K. Evaluation of transperineal template implant technique in Indian cervical carcinoma patients. Indian J Med Sci 1997;51:231-5
|How to cite this URL:|
Chander S, Patel AK, Grover R, Rath G K. Evaluation of transperineal template implant technique in Indian cervical carcinoma patients. Indian J Med Sci [serial online] 1997 [cited 2013 May 20];51:231-5. Available from: http://www.indianjmedsci.org/text.asp?1997/51/7/231/11512
| ¤ Introduction|| |
In India, as in other developing countries, carcinoma of uterine cervix poses a major health problem. The situation is rendered more complex by the fact that bulk of these patients have advanced disease at presentation io oncology clinics.
Extensive involvement of the cervix, vagina and lateral pelvic tissues as well as high frequency of regional nodal metastases are conducive to poor prognosis. Radiotherapy is the mainstay of treatment commprising of teletherapy and intracavitary radio therapy (ICRT). Despise this radical approach more than 50% of the patients fail locally.  This can be ascribed to unsatisfactory radiation dose distribution with ICRT in certain cases. Inaccurate placement of ICRT applicator in presence of poor local geommetry and inefficiency in delivering boost doses to gross residual disease in parametrium contribute to high failure rate.
In such situation interstitial implant using Syed-Neblett Template may provide better option.  We are in advanced cases of carcinoma cervix at AIIMS. The data so accumulated forms the subject matter for the present communication.
| ¤ Material and Methods|| |
A total of 19 patients have been taken up in this study. All of them had biopsy proven squamous cell carcinoma of the uterine cervix within the age range of 32-61 (median = 49). Staging was done as per FIGO 1992, fifteen patients belonged to stage III B while 2 each were in stage II B and IV A. None had any evidence of distant metastases.
The indications for transperineal template implant in them were poor local geometry (10 patients), gross residuall disease hindering the feasibility of ideal ICRA, application (4 patients), recurrent cases requiring reirradiation were three. In 2 patients, ICRT was attempted but could not be completed due to technical reasons. All were treated with external radiotherapy (Ext RT) prior to being considered for template implant. In most instances Ext RT dose was 50 Gy in 27 fractions delivered over five and a half weeks. Last 10 Gy were given with midline shielding to protect bladder and rectum. In two cases 30 Gy in 10 fractions over 2 weeks were given with the palliative intent. However upon reassessment very good response was observed. Subsequently they were considered for further Ext RT, dose equivalent to 50 Gy in conventional fractionation [Table 1].
Procedure : The transperioneal interstitial implant was carried out using Syed-Neblett applicator which consists of template, vaginal obturator and 17 G hollow steel guides.  The patients were given general/spinal anaesthesia and put in lithotomy position. Detailed examination under anaesthesia was performed. After inserting the first guide needle in the anterior cervical lip, the template and vaginal obturator were placed in position. More guide needles were inserted through the fenestration in the template. Template was secured in correct location with two silk sutures. Localisation films were taken. Dose computation was done on the computer. Iridium 92 sources were loaded in to the hollow guide needles. Once the desired dose had been delivered, sources were removed followed by template and needles in single stroke. The details of the treatment are provided in [Table 2]. Fourteen patients were delivered 30 Gy. Seleced dose rate ranged from 40-60 cGy/hour. Total treatment time was 31-75 hours with the median of 48 hours.
Follow up.: After completion of interstitial brachytherapy these patients were followed up regularly every month for a period of 6 months. At this time Pap smear More Details test, ultra sound examination of the abdomen and pelvis, haematological, and biochemical profiles as well as skiagram of the chest were conducted. Henceforth they were seen every 2 months. The follow up period in this group is 2-14 months, the median being 6 months.
| ¤ Results|| |
Response : There was complete disappearance of disease at local and regional sites in 14 cases, although residual disease was noted in 4 patients. One patient failed at local and also manifested pulmonary metastases.
Cmplications : The treatment consisting of Ext RT and interstitial brachytherapy was well tolerated by most patients. Eleven patients showed features of mild transient enteritis, proctosigmoiditis and cystitis. Three patients had severe episodic protosigmoiditis, cystitis and haematuria. None had local necrosis or fistulization. All complications could be managed conservatively.
| ¤ Discussion|| |
Patients having stage III cervical carcinoma, treated with Ext RT and conventional ICRT eventually fail at local site in more than 50% instances. In majority this is the only manifestation of recurrent disease. 
In presence of persistent post Ext RT bulky disease, extensive parametrial component or narrow vagina, suboptimal coverage of the target volume results owing to inaccurate positioning of ICRA applicators. Interstitial template implant - provides uniform radiation dose to a well defined volume. Lateral pelvic wall and parametrium may be given additional dose.
Prempreel  reported a 96% local controlW rate and 61 five year disease free survival rate in 23 patients treated with a combination of Ext RT, ICRT and interstitial implant to parametrium. Aristizabal et al  reported 60% disease free survival rate in a group of 43 women treated with Ext RT and ICRT. The acturial 5 year survival was 75%. While among 45 patients given Ext RT and implant, these results were 62% and 77% respectively. The pelvic failure rate with the former was 16% and in the interestitial technique group it was 17%.
A high incidence of local failure is observed in patients revealing bilateral hydronephrosis, barrel shaped tumours and frozen pelvis after treatment using template implant.  Syed et a1  treated 60 patients employing Ext RT and template implant with/without ICRT; 47 (78) achieved loco-regional control for a minimum follow up period of 36 months. Overall disease free acturial, survival of 58% was observed.
In our series, the follow up period is small and preliminary results are available. Complete response was observed in 14 patients while 5 patients had local/distant failure. The patients taken up were those found to be unsuitable for conventional ICRT application due to advanced cancer distorted anatomy, extensive growth or recurrence. The prognosis in such patients is not generally good with standard ICRT techniques. Transient cystitis, enteritis and proctosigmoiditis were seen in 11 patients and 3 had somewhat more severe complications as detailed above.
Syed et al  noted transient proctitis and cystitis in 10% (6/66) and rectovaginal fistula in 2/60 cases. Hughes-Davies et al.  reported 14 instances of acute coinplications including 6 cases of bladder perforation. In this group of 139 patients of pelvic malignancy receiving parametrial in erstitial brachytherapy, late complications requiring surgical intervention were fistula (18 patients), bladder and bowel complications in 17 and 28 patients respectively. The authors observed that parametrical implant is of modest efficacy with significant morbidity. However it may well be remembered that most of there patients had otherwise poor prognosis. Gaddis et al  found non-tumour associated fistula rate to be 13.3%. Although in literature the fistulla rates are generally reported to be 1.4-5.3%. As regards higher complication rate in some series, in an analysis it was shown that the patients developing sequelae of therapy had a slightly better survival than those who did not reveal any complication. This was related to improved tumour control with higher doses of radiation. 
| ¤ Summary|| |
The prognosis in advanced cervical cancer patients is poor specially in presence of distorted anatomy, gross residual growth etc. In these cases template implant offers good option for treatment. We have carried out the procedure in 19 patients with acceptable level of complication. Preliminary results have been described.
| ¤ References|| |
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[Table 1], [Table 2]