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Bijoy Anand
Case Study
Spring 2017

LDR Brachytherapy for Squamous Cell Cancer of the Cervix

History of Present Illness: Patient ST is a 51 year-old female who had symptoms of pelvic pain
and leaking urine since July 2016. She first sought medical attention at an outside emergency
clinic and was told that she had an ovarian mass and possibly a cervical mass as well. She was
admitted through University of Florida (UF) Health Emergency Department on September 13,
2016. There it was found that she had a large pedunculated mass in the cervical region. The
biopsy was non-diagnostic and she was scheduled to be seen in the gynecology department.
She returned to the emergency department on September 30, 2016 complaining of sharp
chest pain. Following the pulmonary embolism protocol, a chest CT angiogram was performed
which revealed no evidence of an embolus. A 2-cm hepatic cyst was noted. That same day, a CT
with contrast was performed scanning the abdomen and pelvis. It revealed a heterogeneous
growing mass in the lower uterine segment and cervical region with associated dilation of the
vagina with proteinaceous material and gas. This was followed with a PET CT scan on October
14, 2016, which showed intense abnormal tracer accumulation in the lower uterine segment with
a standard uptake value (SUV) of 7.5. Upon review of the scan the radiation oncologist (RO)
also found an increased uptake in a left pelvic lymph node and a faint increased uptake in a right
obturator node findings indicative of cancer with nodal involvement.
On October 18, 2016, ST was examined under anesthesia. The examination revealed that
there was a 7-cm cervical mass with intraluminal vaginal extension into the level of lower
vagina. A minimal extension onto the left vaginal fornix was noted as well as evidence of very
early parametrial involvement. Cystoscopy and proctoscopy were negative. The radiation
oncologists diagnosis was: clinical Stage IIB Squamous Cell Cancer of the Cervix with PET
evidence of bilateral pelvic lymphadenopathy.
ST presented with the persisting condition of leaking urine, and pain in the suprapubic
region and pelvis which radiated to her back. She also complained of loss of appetite and
mentioned that she had lost 20 lbs. in the past 3 months. Aside from these, she appeared as a
well-developed, well-nourished person in no acute distress. She had no fever, chills, headaches,
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seizures, vision or hearing loss.

Past Medical History: Patient ST has a history of hypertension. In the past, she has had
arthroscopic surgery on her right knee. She reported no known allergies.
Social and Family History: There is significant history of cancer in patients immediate family.
She has a sister with breast cancer and a brother with throat cancer. ST stated that she is a non-
smoker and has no history of tobacco or alcohol use.
Medications: At the time of her examination, ST was taking Hydrocodone/Acetaminophen
5/325 and Naproxen - twice daily - for controlling pain. She was on Hydrochlorothiazide, a
diuretic, for controlling her high blood pressure. She was also on Atrovent for a respiratory
condition and she was taking a cough expectorant, Mucinex.
Diagnostic Imaging: A CT with contrast was performed scanning patients abdomen and pelvis
region on September 30, 2016. This was followed by a PET CT scan two weeks later. The
findings from these studies have been presented in the first section.
Radiation Oncologist Recommendations: The RO found ST a candidate for definitive
treatment. He recommended 3 courses of external beam radiotherapy (EBRT) combined with 2
courses of low dose rate (LDR) intracavitary brachytherapy using tandem-and-ovoid (T&O)
applications, and concurrent cisplatin chemotherapy. The RO discussed with the patient his
recommended therapy regimen and the rationale for irradiation, as well as the possible side
effects, risks, and complications.
Brachytherapy is the use of sealed radioactive sources placed in close proximity to the
treatment target volume.1 In intracavitary brachytherapy treatments, sources are loaded into
applicators, which are positioned into cavities within the human anatomy adjacent to the target
tissue. The applicators remain in the patient for the duration of the treatment and are removed at
the completion. There are site specific applicators designed to fit into cavities which place the
radioactive sources near target tissues. For cervical cancer, it is called tandem-and-ovoid
applicator.
The Plan (prescription): The main course of RT was to be a 4-field box treating the whole
pelvis with 45 Gy in 25 fractions. The other two courses of RT were for treating the parametria
and the pelvic nodes, and the PET positive nodes. Finally, two fractions of Intra-uterine LDR
Brachytherapy T&O treatment were prescribed to provide dose to the cervix and the
parametrium.
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The details of ROs prescription are as follows:

4500 cGy in 25 Fractions (Fx) 3-D conformal x-ray 4-field whole pelvis treatment (180
cGy/Fx)
540 cGy/3 Fx (180 cGy/Fx) AP:PA right and left parametrial and pelvic nodal boosts
900 cGy/5 Fx (180 cGy/Fx) IMRT boost to right and left PET positive pelvic nodes
Tandem & Ovoid x 2.
[Note: For purpose of this case study, only the T&O planning will be discussed. But, for
completeness sake, it should be mentioned that ST was CT-simmed on 11/14/16 and then she
underwent the 3 phases of her RT prior to receiving Brachytherapy]
Patient Setup/Immobilization (LDR): On January 3rd, 2017, patient ST was taken to OR and
placed under general anesthesia in supine position. A Foley catheter was inserted to empty the
bladder. And it also served the added purpose of helping us visualize the organ on the set-up
films. Then the oncologist placed the tandem applicator in her uterine cavity and secured with 3
rolls of gauze and Sulfanilamide cream. Patients labia were sutured around tandem applicator to
keep it secured in place. Next, a set of rectal marker balls were placed in her rectum to visualize
that organ. Finally, a stainless steel ring of known diameter (3.9 cm) was taped to the inner thigh
of the patient. This was for the purpose of determining the magnification on the two films. With
the patient in the set-up position, anterior and lateral images were taken using a mobile x-ray
machine (Figures 1 and 2).
In 1985, the International Commission on Radiation Units and Measurements (ICRU)
made several recommendations on the reporting of cervix cancer brachytherapy treatment
dosimetry.2 Our institution follows the traditional Manchester system protocol of prescribing the
dose to points A and B as described in ICRU report 38. The left and right lateral paracervical
points 2 cm superior to the vaginal fornix, and 2 cm lateral from the uterine canal are defined as
Points AL and AR. Manchester system also specifies point B, which are located at the same
superior-inferior level, but at 5 cm lateral from patients midline. Points BL and BR represent the
dose to parametria. For delivery of prescription to cervix, the dose prescribed to point A - whilst
sparing bladder and rectum. Points A and B are illustrated in the diagram below.
A relative to tandem
B relative to midline

Points A in purple, point B in red. For distance, long arrows = 5 cm, shorter arrow = 2 cm

Anatomical Contouring (LDR): The two x-ray films presented an accurate depiction of the
Pt. A relative to tandem on tandem axis
A&B POSITIONS
set-up. They were next affixed atop a digitizer and the magnification of each was calculated by
B points on axis parallel to x axis where tandem axis intersects midline
measuring the size of the ring on the two images.
5cm
Next, the patients midline was determined on
5cm
the film using the sacro-iliac joints and the spine. A film origin was defined at a point clearly
visible on both films. In this case, the tip of the first source was chosen to be this point.
After appropriately magnifying and demagnifying the projections, the ovoid sources,
reference, and anatomical points (AL, AR, BL BR, bladder, and rectum) were marked on the two
films. Using a china pencil, a contour was drawn on the lateral film with the help from the image
of the gauze outlining the rectal wall. This helped us locate the rectum point on the film.
Similarly, the image of Foley catheter helped us localize the bladder point (which is the posterior
most side of the catheter). Finally, the tandem sources were marked on both films.
Beam Isocenter/Arrangement (LDR): The planning points are all located relative to the
cervical os. This is where the flange is located. Our choice of origin was influenced by this. The
length of tandem is 6.5 cm from the tip to the flange. For this treatment, ovoids with large caps
were found appropriate. This choice is dictated by vaginal space caps should be large enough
to fill the space, but not too large so that packing gauze can still be filled in.
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Treatment Planning: Using a digitizer, these image points were transferred to the Pinnacle
v8.0m TPS. Next, the source strength values were put into the TPS for dose modeling. Cesium-
137 was the radioisotope chosen because of its long half-life of 30 years so that the dose rate
does not vary significantly over the duration of treatment. Also, it has no gaseous decay products,
so it is much safer than radium (which generates the hazardous radioactive radon gas).3 It emits a
gamma ray of 0.66 MeV which is less penetrating than Cobalt-60 (1.25 MeV).
For this treatment, a configuration of 3 sources in the tandem with no spacers, and 1
source in each ovoids was chosen. There were sources available in 6 different strengths. The TPS
was able to generate a dose distribution for any desired combination.
A choice of 4 different source combinations was prepared and presented to the RO
(Figure 3). The doctor chose the 4th combination. His choice was based on the ratio of the
average dose of point A to bladder, and point A to rectum. This was to enable the maximum
sparing of the two critical organs here bladder and rectum. The physicians choice of source
strengths was also affected by the consideration of total treatment duration he did not want the
patient to be in this uncomfortable situation any longer than necessary. For fraction 1, a treatment
time of 40 hours was chosen based on the dose rate and the prescribed dose.
Figure 4 is a printout from the treatment plan generated by Pinnacle showing the dose to
points A, B, bladder, and rectum as calculated by the TPS. Figure 5 shows the dose calculated for
the total duration of the treatment.
Quality Assurance/Physics Check: Physics staff checked magnification and correct placement
of reference points. An independent calculation of dose to reference points was also performed
using an Excel spreadsheet. Figure 6 shows the summary sheet of this check. Also, figure 7
shows the summary of the total dose to the cervix from all 4 phases of the treatment.
Sources were inventoried before the implant and after their retrieval. The patient and the
hospital room where she stayed for two days were surveyed for radiation. The adjacent rooms,
hallway and stairwell were surveyed too. This was done using a Ludlum 14C Geiger survey
meter, which was calibrated less than a year ago.
Conclusion: This was the first brachytherapy plan I ever saw outside of the textbook. It was very
interesting to learn all the details. This plan presented unique difficulties because of use of 2D
planning system. Especially complicated was the trick of connecting the same points in AP and
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lateral views using the process of magnifying, demagnifying and projecting. Also, I learned how
to use a digitizer another first!
This plan involved more fundamental dose calculations performed by dosimetrist that in
3D conformal radiation therapy. I could see how this calculation is done by following it in the
Excel spreadsheet. Finally, the challenge in this plan was to achieve the best coverage of cervix
while sparing rectum and bladder. I saw how that was done by varying the source strengths of the
tandem sources versus the ovoid sources.
I am very intrigued by the new technology where one can do CT-guided brachytherapy.
Obviously, this is only possible when using applicators made of materials that will not create CT
artifacts.
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References

1 Khan FM. The Physics of Radiation Therapy. 4th ed. Philadelphia, PA: Lippincott Williams
& Wilkins; 2010:315
2 ICRU 38
3 Bentel G. Radiation Therapy Planning. 2nd ed. New York, NY: McGraw-Hill; 1996:536
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Figures

Figure 1. AP x-ray film of the patients pelvis showing the tandem, the two ovoids, gauze, Foley
catheter, and rectal marker. The anatomical and the reference points are marked.
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Figure 2. Lateral x-ray film of the patients pelvis showing the tandem, the two ovoids, gauze,
Foley catheter, and rectal marker. The anatomical and the reference points are marked.
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Figure 3. Worksheet presenting 4 different choices - prepared for the RO to choose the
appropriate source combinations based on the needs of patient plan
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Figure 4. A printout from the treatment plan generated by Pinnacle showing the dose to points
A, B, bladder, and rectum as calculated by the TPS.
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Figure 5. Details pertaining to the dose calculated for the total duration of the treatment.
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Figure 6. Excel spreadsheet showing the independent calculation of dose to reference points as a
check
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Figure 7. This presents the summary of the total dose to the cervix from all 4 phases of the
treatment