Int. J. Radiation Oncology Biol. Phys., Vol. 36, No. 3, pp.

699-709, 1996
Copyright 6 1996 Elsevier Science Inc.
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ELSEVIER PII: SO360-3016(96)00373-2

l Technical Innovations and Notes

CT-GUIDED INTERSTITIAL IMPLANTATION OF

GYNECOLOGIC MALIGNANCIES

BETH ERICKSON, M.D., KATHERINE ALBANO, M.S. AND MIKE GILLIN, PH.D.
Department of Radiation Oncology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226

Purpose:To establishthe efficacy of computedtomography (CT)-basedplanning and analysisof transperlneal

implants.
Methods and Materials: For patients with bulky diseaseor geometrically unfavorable anatomy, transperineal
interstitial implantation of gynecologlctumors offers an alternative to standardintracavitary techniques.Control
of doserate and total dosedistributionsto producea homogenous, low doserate implant presentsa challengeto
the radiation oncologistin thesecompleximplants,asdoesthe relationshipof thesedistributionsto the patients’s
anatomy. We have usedCT imaging following needleimplantation, prior to sourceloading, in 25 patients (28
implants),asan aid in both the planning of the implant and the analysisof the dosimetry.
Results:The spatialrelationshipbetweenthe needlesand the normal anatomy can be clearly defined,despitethe
presenceof someartifacts. Tumor volumeis lessclearly vlsuallled but the adequacyof needleplacementcan be
assessed and adjustedif necessary.Modifications of the planned sourceplacement,basedupon the location of
specificneedlesand critical structures, can be madeprior to loading the patient. Doserate and total dosedistrl-
hutions are displayedwith the appropriate anatomy on axial imagesand on reconstructedsagittal and coronal
planes.Multiple points of dosespecificationfor the rectum and the bladder are easilydellned.Doserate adjust-
ment can be made by selectivelychangingthe activity associatedwith a particular needleor needles.Multiple
implantsaswell as external beamirradiation can alsobe integrated.
Conclusions:CT-baseddosimetry haspermitted intelligent planning decisionsto be madeprior to and during
theseimplants. It hasfurther allowed more accurateanatomically baseddosimetricanalysis,with visualization
and control of doserate and total dosedistributions displayedtogether with the patient’s anatomy. This more
elaborateanalysisshouldultimately lead to a better understandingof the reasonsfor local control and compll-
cationsand their relationshipsto doserate, total dose,and volume. Copyright 0 1996 Elsevier Science Inc.

Interstitial, Syed-Neblett,Template, Gynecologic,Transperineal.

INTRODUCTION tional low dose rate systems, with a resultant increase in

Template-guided gynecologic tumors offers an alternative
to intracavitary techniques in the setting of bulky disease
or anatomic distortion (l-6,8-10, 15, 18,23-26,29,30,
36, 38-41,43,44,48-51,54, 56,57, 59,60, 62,63,65-
69, 71, 80-83, 85). The theoretical benefits of interstitial
implantation include treating the disease precisely in its
anatomical location, independent of volume and anatom-
ical distortion, and providing a wider more uniform dis-
tribution of radiation in the pelvis (1).
It has been a challenge to evaluate and describe the
dosimetry assoicated with transperineal implants that are
characterized by multiple source lengths and activities,
as well as to understand the dose distribution to structures
of interest. Additionally, these large volume implants
have been criticized for dose distribution inhomogeneity
and dose rates higher than those recommended in tradi-
complications (1, 30).
To address these criticisms, we have pursued the use
of computed tomography (CT)-guided dosimetry in the
planning and analysis of interstitial implants of gyne-
cologic malignancies. Traditionally, computerized do-
simetry has been generated from orthogonal films,
rendering limited information about the spatial relation-
ships between the bladder, rectum, and implanted
sources and no information about the relationship of the
needles to the tumor volume. The point doses generated
for normal organs and tumor appear inadequate in this
setting, as do the two-dimensional isodose distributions.
Alternatively, we propose CT imaging following needle
implantation to identify tumor volume and critical nor-
mal structures, to confirm the adequacy of needle place-
ment in relation to these structures and the need for
adjustment, to analyze and manipulate the dose distri-

Reprint requests to: Beth Erickson, M.D., Medical College of thusiastic preparation of this manuscript.
Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226. Accepted for publication 15 July 1996.
AcknowEedgements-Special thanks to Lori Kapellen for her en-

699
 I. J. Radiation Oncology 0 Biology l Physics
Fig. 1. AP radiograph of Syed-Neblett template, needles, and
tandem. Note: Cervical markers above bladder catheter bulb.
“Dummy” sources are in several central and peripheral nee-
dles.
bution as it relates to these structures, and to assist with
dose specification and the integration of external beam
irradiation.
METHODS AND MATERIALS
We have used CT imaging following needle implan-
tation, prior to source loading, in 25 patients undergoing
28 implants for advanced gynecologic malignancies, as
an aid in both the planning of the implant and the anal-
ysis of the dosimetry. On the day of implantation, all
patients have an epidural catheter placed, both for in-
traoperative analgesia as well as for postoperative pain
management (7,77). Sounding and dilatation of the cer-
vix are accomplished, and radiopaque cervical markers
are sewn on the anterior and posterior lips of the cervix
or upper and lower boundaries of the vaginal lesion of
interest. For patients with uterine (cervical) carcinoma,
‘Syed 1 (36 needles), 2 (44 needles), 3 (54 needles) GYN
templates Best Industries 7643-B Fullerton Road, Springfield,
Volume 36, Number 3, 1996
a Fletcher-Suit stainless steel tandem without a sail is
inserted. If a tandem cannot negotiate the endocervical
canal, a 25 cm guide needle is inserted instead (40) and
held in place with a custom-built obturator insert. The
Syed-Neblett obturator is then threaded over the tan-
dem. A “sleeve” fabricated at our institution is placed
over the obturator when needles are to be inserted into
the obturator surface grooves, to prevent their direct
contact with the vaginal mucosa (20). The Syed-Neblett
template ’ is then threaded over the obturator and posi-
tioned. Insertion of the 17 gauge needles that measure
20-25 cm in length follows. Not all of the template
holes are necessarily used but the choice is based on the
location of the tumor volume. The depth of needle in-
sertion is determined through a combination of pretreat-
ment MRI review and intraoperative ultrasound (22).
Alternatively, needle depth can be determined with the
aid of laparoscopy or laparotomy (2, 3, 6, 8, 9, 15, 18,
23, 25, 30, 43, 52, 56, 66, 67, 71). The patient is trans-
ferred to the recovery room and epidural anesthesia
optimized.
Later that day or early the next day, the patient un-
dergoes a pelvic CT scan with intravenous contrast to
delineate the bladder and rectal contrast. A dilute con-
trast is used in the rectum so that needles near or poten-
tially in the rectal wall are not obscured by the contrast.
Air in the rectum can also serve as a contrast agent.
Thirty to 40 axial images are obtained with a slice thick-
ness of 5 mm. The axial images are then formatted and
reviewed by the diagnostic radiologist, radiation oncol-
ogist, and physicist. This will readily identify problems
such as a pelvic hematoma, perforated tandem, or the
need for adjustment of the depth of needle insertion
early in the time course of events. Reconstructed sagittal
and coronal views are available that give further insight
into the appropriateness of needle depth insertion.
Orthogonal films are taken to identify needles following
the CT scan. Dummy sources are placed in four to six
needles at a time and orthogonal films successively re-
peated. At our institution, these films are used to help iden-
tify the needles on the CT images but the sources can also
be directly digitized into the planning computer from
them. These films are also used to determine the active
length of the sources which average 7.3 cm with 15 seeds
separated by 5 mm from center to center (range 4- 12 cm).
The length of the sources is determined by the relationship
of needle tips to the location of the radioopaque cervical
markers (Fig. 1). A minimum extension 2 cm beyond the
cervical or vaginal markers is established.
The CT study is read into the computer’ and source
locations entered onto the CT images. There are several
methods of source entering, all of which make use of the
orthogonal films (65). One method is to digitize the source
VA 22153.
‘Theraplan VS.
 CT-guided interstitial implantation of gynecologic malignancies
Fig. 2. Axial CT with contours around contrast-filled bladder
and rectosigmoid, as well as the needles and central obturator
within the needle volume (reference dose).
locations directly from the films. This is time consuming
for large implants containing hundreds of seeds. Addi-
tionally, if the patient moves during the simulation be-
tween films, then the relative position of the patient moves
and the relative positions of the sources will be changed,
A second method decreases the digitization time by ap-
proximating the seed strands as continuous line sources
and digitizing the two endpoints only. A third method,
most typically used at our institution, finds the CT coor-
dinates for the needles on each CT slice. Individual seeds
are then entered at these coordinates. The simulator films
are necessary to identify the needles on the CT images,
particularly those that are deviated from the horizontal
plane, to predict where they would lie on the CT images
at different levels. Often at the cephalic end of the implant
needles converge in groups and must be individually iden-
tified to assign their correct activity.
The software is limited to 500 seeds or 30 line sources
per plan and if this number is exceeded, two plans must
be calculated and summed. This information can then be
reviewed as a composite plan on the computer screen and
on printed isodose distributions.
Contours of the rectosigmoid, bladder, and needle vol-
ume are delineated and entered on each appropriate axial
image through use of a track ball (Fig. 2). The tumor vol-
ume is assumed to be within the needle contour, although
this may not always be true. Comparison of the location
of the needles and the preimplant MRI or CT is sometimes
helpful in making a more accurate determination of tumor
volume location. Isodose distributions can then be
generated.
RESULTS
The spatial relationship between the needles and normal
anatomy can be clearly defined despite the presence of
some artifact from the metal needles and cervical markers.
0 B. ERICKSON er al. 701
The CT confirms the adequacy of needle and tandem
placement through its display of the needles in the pa-
tient’s anatomy. Because of the epidural analgesia, the
needles and tandem can be manipulated after the patient
leaves the operating room if necessary. It is possible to
delineate the portion of the uterus cephalad to the needles
but difficult to distinguish the cervix traversed by the nee-
dles. If perforation of the uterus has occurred (5 pts), the
tandem (1 pt) or needles (4 pts) can be retracted to an
intrauterine position (Fig. 3a). Likewise, if the needles
have advanced into small bowel, the needles can be re-
tracted appropriately (3 pts) (Fig. 3b). It is easy to see the
proximity of the needles to the bladder and rectum and if
there is inadvertent penetration of the rectosigmoid (6 pts)
or bladder (4 pts), these needles may be removed or left
unloaded (Fig. 3c and d). Contrast in the rectosigmoid
along it circuitous course makes it distinguishable on each
slice (Fig. 4a). Though contrast is routinely placed in the
Foley catheter bulb, it is also possible to see the entire
bladder and the outline of the posterior wall due to the
excreted IV contrast (Fig. 4b). The bladder and rectum are
often ‘ ‘draped’ ’ across the nearby needles exposing a
larger surface area to nearby sources than revealed on
plane films (Fig. 4b). Modification of the planned source
placement based upon the location of specific needles and
critical structures revealed on CT can, therefore, be made
before or after source loading (Fig. 4a and b). In 22 of the
28 (79%) implants, needles near the rectum, bladder, or
bowel as identified on CT were either not loaded, selec-
tively unloaded, or loaded with sources of lower activity
to decrease doses near these structures. Additionally, sim-
ilar changes in source loading due to needle convergence
as identified on CT were made in 7 of the 28 (25%) im-
plants. Needle convergence is poorly identified on the 2D
isodose distributions when CT is not used. In 7 of 28 im-
plants (25%) the needles were advanced or retracted in a
cephalo-caudad direction to a more optimum position as
identified on CT.
Dose rate and total dose distributions are displayed with
the appropriate anatomy on axial CT images, and on re-
constructed sagittal and coronal images, enabling direct
visualization of the dose distribution throughout the nee-
dle volume, as well as the rectum and bladder (Fig. 5a-
c, Fig. 6a-c). There is a clearer understanding of the dose
distribution as it relates to both the needle volume and the
critical organs with this CT-guided approach. Multiple
points of dose specification for the rectum and bladder are
easily defined on the CT. The isodose curve that intersects
just beyond the walls of the rectum and bladder is chosen
as the normal tissue dose rate. The dose and dose rates to
the tumor volume (reference isodose), “point A” region
(Fig. 5a-c), the vaginal mucosa (obturator surface) (Fig.
6a-c) and pelvic sidewall (Fig. 5c) are also assessed from
the dosimetry display. The “point A” slice is defined as
2 cm up from the stainless steel cervical marker balls and
represents a region rather than a point. By assessing the
dose distribution in the “point A” region, one can per-
702 I. .I. Radiation Oncology 0 Biology l Physics Volume 36, Number 3, 1996

04

63
Fig. 3. (a) Axial CT demonstratingperforateduterinetandem(arrow). (b) Axial CT demonstratingneedlesin small
bowel near the cephaladend of the implant (arrows). (c) Axial CT demonstratingneedlesin wall of contrasted-
filled rectum (arrows).(d) Axial CT demonstratingintendedinsertionof needlesinto posteriorbladderwall in a
patient with bladderinvasionby tumor.

haps, in some manner, relate a traditional intracavitary
prescription point to the interstitial plan.
The homogeneity of the dose rate distribution can be
assessed,as well as the location and dimensions of “hot
spots” within the distribution. Selection of the “reference
isodose” is possible when viewing the distribution and
displaying various dose rate surfaces. The reference iso-
doseis defined asthe isodosesurface, which, in the central
plane, surrounds all of the needleswith somerestrictions.
Various criteria have been developed to select an appro-
priate reference isodose. A dose rate gradient across the
implant greater than 20% to significant volumes is
avoided. In the central plane of the implant, the isodose
surface whose value is <125% of the reference isodose
should not be contiguous and should have dimensionsless
than 2 X 2 cm. A maximum of two times the reference
isodose (hyperdose sleeve) is acceptable in direct prox-
imity to the needles, but its diameter should be less than
1 cm. Such criteria can be applied by viewing the dose
distributions superimposedupon the anatomy on multiple
axial CT slices, as well as the 2D isodose distributions
(Fig. 5b and Fig. 6b). With these principles guiding the
initial loading, the isodosedistribution is superimposedon
the CT and loading changes made as needed to achieve
these ideals.
Traditional low dose rates are the goal, including “ref-
erence” dose rates of 0.6-0.8 Gy/h, “point A” dose rates
of OS-O.8 Gy/h; obturator surface dose rates of 0.8- 1.O
Gy/h and bladder and rectal dose rates ~80% of the ref-
erence dose rate. Differential source activity is used to
achieve these dose rates and improve homogeneity within
the implant, with the core sourcestypically l/2 to l/3 the
activity of the peripheral sources(0.13 mCi/seed vs. 0.37
mCi/seed) (1, 6, 23, 26, 39, 48-51, 70, 71, 82-84). The
dose distribution can be manipulated, altering the dose
rates, homogeneity and shapeof the distribution by selec-
tively changing the activity associated with a particular
needle or needles, by selectively unloading, either im-
 CT-guided interstitial implantation of gynecologic malignancies
(4
lb)
Fig. 4. (a) Axial CT demonstrating circuitous rectosigmoid dis-
tinguished with contrast. Note: needle (arrow) in close proximity
to rectum which was not loaded. Note: Large uterine myoma
which is not traversed by needles (M). (b) Axial CT demon-
strating the contrast filled bladder, which is draped laterally near
the peripheral needles (arrow). These needles were loaded with
sources of lower activity because of this proximity. Contrast is
also present in the rectosigmoid.
mediately, or during the implant, strategic needles, or by
changing the number of seeds in each needle.
Through a combination of differential source loading
and identification and manipulation of needle and source
positions on CT, maximum reference dose rates between
60 to 80 cGy/h were achieved in 27 of the 28 implants
(96%). Vaginal obturator surface dose rates of 80 to 100
cGy/h were achieved in 18 of the 28 implants (64%); rec-
tal and bladder dose rates less than or equal to 80% of the
reference dose rate were achieved in 22 of the 28 implants
(79%); dose rate gradients greater than 20% across the
central plane of the implant were avoided in 20 of 28
implants (71%); in the central plane of the implant the
isodose surface whose value was less than or equal to
125% of the reference isodose was not contiguous and had
dimensions less than 2 cm x 2 cm in 12 of the 28 implants
(46%) and a value of less than 150% in 24 of the 28
l B. ERICKSON et al. 703
implants (86%); a maximum of two times the reference
isodose (hyperdose sleeve), less than 1 cm in diameter,
was achieved in 26 of the 28 implants (93%) and a central
cold spot was avoided in 27 of the 28 implants (96%). In
three of the implants with high rectal dose rates, the target
volume was adjacent to the rectum. Needle convergence
was implicated for uncorrectable dose rate gradients in
five patients.
Total doses to the tumor volume or reference isodose
from the implant range from 25-40 Gy over 2-4 days
depending upon the bulk of tumor remaining after external
beam and the site of presentation (cervix vs. vagina). Total
doses to the isodose line 20% higher than the reference
isodose are also tabulated as are total doses to the recto-
sigmoid, bladder, obturator surface, and pelvic sidewall.
Whole pelvis external beam doses of 45 Gy generally pre-
cede implantation bringing the total dose to the reference
isodose and/or “point A” to 70-90 Gy.
The CT-based dosimetry system also enables entry of
the external beam fields and doses, so that cumulative im-
plant and external dose distributions can be realized. This
can be helpful in the design of midline blocks, which cor-
respond to the lateral and cephalad boundaries of the nee-
dles, or for the reduced pelvic sidewall boosts, by viewing
color wash displays. Multiple implants can also be sum-
mated in this way.
DISCUSSION
Traditionally, interstitial implantation has been guided
by published systems, referring to a set of rules taking into
account the source strengths, geometry, and method of
application to obtain suitable dose distributions over the
volumes to be treated. Prior to computerized dosimetry,
early interstitial techniques relied on Paterson-Parker and
Quimby tables as well as film dosimetry for analysis of
the dose distribution. Though guidelines for volume im-
plants were laid down in the Quimby and Paterson-Parker
systems, these rules were designed for radium sources,
and certainly do not apply to the rigid source distribution
defined by the template. The Paris system, though often
applied to planar, template-defined implants, does not ad-
dress volume implants greater than two planes (17). The
large volume implants of the pelvis described are not ap-
propriately guided by the traditional rules, with needle and
source placement rigidly determined by the template
holes, without the ability to cross sources, and dose dis-
tributions determined through use of computerized dosim-
etry instead. Interpretation of this dosimetry has been a
challenge.
Both the MUPIT (Martinez Universal Perineal Intersti-
tial Template) and the Syed-Neblett applicators were in-
troduced in 1974 in concert with computerized dosimetry
(48-52, 24, 80). Initially preplanned dose rate plots were
used for Syed-Neblett dosimetry, based on achievement
of ideal positioning of the system (58). Subsequently,
computer-generated orthogonal film-based dosimetry, as
 I. J. Radiation Oncology 0 Biology 0 Physics Volume 36, Number 3, 1996

(4

Fig. 5. (a) Axial CT at level of “point A” with superimposeddoserate distribution.Note: Contrast-defined

bladder
andrectumintersectedby the isodosedistribution.(b) 2D isodosedistributioncorrespondingto this sameaxial CT
slice.Note: Contourof rectumandbladder(R, B). (c) Axial CT at level of “point A” with total dosesuperimposed.
Note: pelvic sidewalldistribution, aswell as,distributionthrough the rectum and bladder.

usedin most seriesreporting interstitial implantation tech-
niques, was recommended following implantation (11,
27). A true understanding of the dose distribution as it
relates to tumor volume and critical normal structures has,
however, remained somewhat elusive utilizing orthogonal
film-based dosimetry. The relationship of the needlesand
dosedistribution to the implanted cervical marker, bladder
catheter bulb, rectal contrast, and pelvic sidewall struc-
tures can be established. However, with such techniques,
soft tissue structures such as the uterus and cervix cannot
be fully imaged. Though contrast can be instilled in the
rectum and bladder, it is difficult to accurately determine
which portions of these organs are actually closest to the
needles from the plane films (Fig. 7). One must rely on
potentially inaccurate point dosesto make treatment de-
cisions along with superimposition of the isodosecurves
on the implant film. Such 2D orthogonal film-based do-
simetry appearsinadequate in the setting of large volume
interstitial implants.
Despite years of clinical use, few rules other than dif-
ferential source loading perhaps, have been establishedto
guide the insertion and interpret the dosimetry associated
with transperineal interstitial implantation of pelvic ma-
lignancies. When using the Syed-Neblett applicator, the
choice of source strength, number, and location as well as
interpretation of the resultant dosimetry has been left to
the discretion of the brachytherapist, with little guidance
as to selection of the appropriate dose rates, prescription
isodose, and uncertainly as to the significance of the vol-
ume of tissue treated to selected doses.The use of points
 CT-guided interstitial implantation of gynecologic malignancies 0 B. ERICKSON et al.

(4

03

Fig. 6. (a) Axial CT at level of posterior cervical marker ball with superimposed dose rate distribution. Note:
Contrast-defined bladder and rectum intersected by the isodose distribution and vaginal obturator (arrowhead). (b)
2D isodose distribution corresponding to the axial CT slice. Note: Contour of bladder, rectum, and vaginal obturator
(R, B, arrowhead). (c) Axial CT at same level with total dose superimposed. Note: Vaginal obturator (arrowhead)
distribution, as well as, distribution through the rectum and bladder.

A and B may be problematic as prescription points when
assessing dose rate distributions in volume implants, al-
though Syed’s original work and that of others does refer
to such points (2-5, 24, 26, 40, 41, 65, 80, 82, 83, 85).
Correlation of interstitial doses with these traditional point
doses may be important if viewed as normal tissue toler-
ance points. Often times the isodose that encompasses the
needles, unrelated to internal anatomy, is chosen as the
reference isodose. The resultant dose rate gradient across
the treatment volume, with central hot spots, accounts in
part for the high complication rates observed in some of
the initial series. Gaddis et al. recommend consideration
be given instead to the homogeneous maximum, mini-
mum, and average tumor dose within a given tumor vol-
ume. However, no published guidelines exist for dose lim-
itations for the bladder, rectum, or medial parametria, nor
is there a recorded maximum or average homogeneous
tumor dose per unit volume beyond which an intolerable
complication rate exists (30). Further guidelines are
greatly needed to guide the process of interstitial implan-
tation. The CT-based planning and analysis will make an
important contribution in formalizing these guidelines.
Initial work following intracavitary insertions has set
the stage for CT-based analysis of interstitial implants
(12-14, 16, 28, 31, 33, 35, 37,40,42,45-47, 53,55, 61,
64,72-75,78,79,86, 87). These CT-based methods have
accurately localized intracavitary applicators and demon-
strated the three-dimensional anatomic relationship of the
706 I. J. RadiationOncology 0 Biology 0 Physics
Fig. 7. Lateral radiograph with Syed-Neblett template, needles,
and tandem with the rectum defined by air. Note needles seem-
ingly within the rectal lumen that were determined on CT to be
lateral to the rectal lumen.
applicators, uterus, and neighboring structures. The dose
delivered to the tumor volume and neighboring organs has
been calculated by superimposing isodose curves on the
CT scans. Additionally, the combination of external beam
and intracavitary doses has been superimposed on the
scans if the patient’s contour is entered into the computer
and the location of the applicator is known with a common
reference point on both the CT and orthogonal films cho-
sen (28, 31, 42, 55).
As CT-based dosimetry has enhanced the understand-
ing of intracavitary dose distributions, it offers further
promise in the comprehension of complex interstitial im-
plant distributions. The ability to relate the dose distri-
REFERENCES
1. Ampuero, F.; Doss, L. L.; Khan, M.; Skipper, B.; Hilgers,
R. D. The Syed-Neblett interstitial template in locally ad-
vanced gynecological malignancies. Int. J. Radiat. Oncol.
Biol. Phys. 9:1897-1903; 1983.
Volume 36, Number 3, 1996
bution to soft tissue structures is invaluable in this setting
despite some artifact from the stainless steel needles and
limitation in assessing tumor volume. Superimposition of
isodose distributions onto CT scans was suggested by Her-
skovic, Lee, and Padikal as a means to relate the dose
distribution to the anatomy, although CT scans were not
obtained with applicators in place (32). Mention of CT
scanning following needle placement for pelvic malignan-
cies has been reported in several series, although few de-
tails were offered regarding its implementation (6, 19,34,
40,62,76). Montemaggi et al, used CT after Syed-Neblett
interstitial applications to assess needle position and the
incidence of significant side effects was reduced to 7%
from a previously reported 17% when CT was used to
optimize the dose distribution (57).
Despite reports of CT scanning following needle place-
ment in several series, a comprehensive approach to its
use has not been previously published. The purpose of our
work has been to describe an in-depth CT-based approach
to the planning and analysis of these complex, large vol-
ume implants in combination with differential source
loading to achieve homogeneous low dose rate implants.
The CT imaging following needle implantation has ena-
bled us to identify needles, tumor volume, and critical
normal structures; to confirm the adequacy of needle
placement in relation to these structures and identify the
need for adjustment; to analyze and manipulate the dose
distribution as it relates to these structures; and to assist
with dose specification and the integration of external
beam irradiation. It has offered us an invaluable tool with
which to better understand and manipulate these complex
dose distributions.
CONCLUSION
CT-based dosimetry has permitted intelligent planning
decisions to be made prior to and during these implants.
It has further allowed more accurate anatomically based
dosimetric planning and analysis. It has also enabled in-
tegration of external beam irradiation and summation of
multiple implants. In the future, better tumor volume de-
lineation may be made possible through the use of MRI
rather than CT (15, 21). Given the dosimettic complexity
of transperineal interstitial implants various tools includ-
ing dose-volume histograms should be developed and
tested in attempts to further evaluate and summarize this
procedure. This may ultimately provide further insight
into the relationship of dose, dose rate, and volume to local
control and complications.
2. Aristizabal, S. A.; Snrwit, E. A.; Hevezi, J. M.; Heusinkveld,
R. S. Treatment of advanced cancer of the cervix with trans-
perineal interstitial irradiation. Int. J. Radiat. Oncol. Biol.
Phys. 9:1013-1017; 1983.
 CT-guided interstitial implantationof gynecologic malignancies0
3. Aristizabal, S. A.; Surwit, E. A.; Valencia, A.; Hevezi, .I.
Treatment of locally advanced cancer of the cervix with
transperineal interstitial irradiation. Am. J. Clin. Oncol.
6645-650; 1983.
4. Aristizabal, S. A.; Valencia, A.; Ocampo, G.; Surwit, E. Inter-
stitial parametrial irradiation in cancer of the cervix stage IIB-
BIB. Endocuriether./Hyperthermia Oncol. 1:4148; 1985.
5. Aristizabal, S. A.; Woolfitt, B.; Valencia, A.; Ocampo, G.;
Surwit, E. A.; Sim, D. Interstitial parametrial implants in
carcinoma of the cervix stage IIB. Int. J. Radiat. Oncol. Biol.
Phys. Biol. 13445450; 1987.
6. Bentel, G. C.; Oleson, J. R.; Clarke-Pearson, D.; Soper,
J. T.; Montana, G. S. Transperineal templates for brachy-
therapy treatment of pelvic malignancies-A comparison of
standard and customized templates. Int. J. Radiat. Oncol.
Biol. Phys. 19:751-758; 1990.
7. Blythe, J. G.; Hodel, K. A.; Wahl, T. M.; Miller, R. N.;
Mayfield, W. R.; Schneider, S. L. Continuous postoperative
epidural analgesia for gynecologic oncology patients. Gy-
necol. Oncol. 37:307-3 10; 1990.
8. Branson, A. N.; Dunn, P.; Kam, K. C.; Lambert, H. E. A
device for interstitial therapy of low pelvic tumors the Ham-
mersmith perineal hedgehog. Br. J. Radiol. 58:537-542;
1985.
9. Childers, J. M.; Brainard, P.; Rogoff, E. E.; Surwit, E. A.
Laparoscopically assisted transperineal interstitial irradiation
and surgical staging for advanced cervical carcinoma. En-
docuriether./I-Iyperthermia Oncol. 10:83-86; 1994.
10. Choy, D.; Wong, R. L. C.; Sham, J.; Wu, P. M.; Foo, D. L.;
Ngan, H. Y. S.; Ma, H. K. Vaginal template implant for
cervical carcinoma with vaginal stenosis or inadvertent di-
agnosis after hysterectomy. Int. J. Radiat. Oncol. Biol. Phys.
28:457-462; 1993.
11. Chu, J.; Fong, K. Endocurietherapy dosimetry for a cylin-
drical template applicator. Endocuriether./HyperthermiaOn-
col. 1:83-89; 1985.
12. Cionini, L.; Andreucci, L.; Pacini, P.; Bucciolini, M. In:
Mould, R. F., ed. Brachytherapy 1984 Proceedings 3rd In-
ternational Selectron Users Meeting. The Netherlands: Nu-
cletron Trading BV; 1985:8&90.
13. Cionini, L.; Santoni, R. Treatment planning by computed
tomography in the curietherapy of invasive cervical cancer.
Cervix 8:277-289; 1990.
14. Coltart, R. S.; Nethersell, A. B. W.; Tomas, S.; Dixon,
A. K. A CT based dosimetry system for intracavitary therapy
in carcinoma of the cervix. Radiother. Oncol. 10:295-305;
1987.
15. Corn, B. W.; Lanciano, R. M.; Rosenblum, N.; Schnall, M.;
King, S.; Epperson, R. Improved treatment planning for the
Syed-Neblett template using endorectal-coil magnetic reso-
nance and intraoperative (laparotomy/laparoscopy) guid-
ance: A new integrated technique for hysterectomized
women with vaginal tumors. Gynecol. Oncol. 56255-261;
1995.
16. Datta, N. R.; Maria Das, K. J.; Ayyagari, S. Three-dimen-
sional dose representation of dose distribution for intracav-
itary brachytherapy in carcinoma of the cervix. Endocurie-
therapy/ Hyperthermia Oncol. 9:133-137; 1993.
17. Deore, S. M. Different perspectives in dosimetry of Iridium-
192 implants. Endocuriether./Hyperthermia Oncol. 4:49-50;
1988.
18. Disaia, P. J.; ‘Syed, A. M. N.; Puthawala, A. A. Malignant
neoplasia of the upper vagina. Endocuriether.lHyperthermia
Oncol. 6:251-256; 1990.
19. Donath, D.; Clark, B.; Kaufmann, C.; Evans, M. D. C.; Stan-
imir, G. HDR interstitial brachytherapy of lower gynecolog-
ical tract cancer. In: Mould, R. F., ed. International brachy-
therapy programme & abstracts 7th international brachy-
B. ERICKSON et al. 707
therapy working conference. The Netherlands: Nucletron In-
ternational BV; 1992:219-225.
20. Erickson, B.; Albano, K.; Withnell, J.; Gillin, M. Modifica-
tion of the Syed-Neblett template system to enable loading
of the vaginal obturator. Endocuriether./Hyperthermia On-
col. 12:7-16; 1995.
21. Erickson, B. A.; Erickson, S. J.; Prost, R. W.; Albano, K.;
Gillin, M. T. Magnetic resonance imaging following inter-
stitial implantation of pelvic malignancies. Radiat. Oncol.
Invest. 2:295-300; 1995.
22. Erickson, B.; Foley, W. D.; Gillin, M.; Albano, K.; Wilson,
J. F. Ultrasound-guided transperineal interstitial implanta-
tion of pelvic malignancies: Description of the technique.
Endocuriether./Hyperthermia Oncol. 11: 107-l 13; 1995.
23. Erickson, K. R.; Truitt, J. S.; Bush, S. E.; Ritcher, N.; Pathak,
D.; Khan, K. M. Interstitial implantation of gynecologic ma-
lignancies using Syed-Neblett template: Update of results,
technique, and complications. Endocuriether./Hyperthermia
Oncol. 5:99-105; 1989.
24. Feder, B. H.; Syed, A. M. N.; Neblett, D. Treatment of ex-
tensive carcinoma of the cervix with the ‘ ‘transperineal para-
metrial butterfly”. Int. J. Radiat. Oncol. Biol. Phys. 4:735-
742; 1978.
25. Fleming, P.; Syed, A. M. N.; Neblett, D.; Puthawala, A.;
George, F. W.; Townsend, D. Description of an afterloading
19’Ir interstitial-intracavitary technique in the treatment of
carcinoma of the vagina. Obstet. Gynecol. 55:525-530;
1980.
26. Fontanesi, J.; Dylewski, G.; Photopulos, G.; Tai, D. L.;
Eddy, T.; Kun, L. E. Impact of dose on local control and
development of complications in patients with advanced gy-
necological malignancies treated by interstitial template
boost technique. Enocuriether./Hyperthermia Oncol. 9:115-
119; 1993.
27. Forell, B. W. Ideal vs. actual dosimetry for iridium- 192 tem-
plate procedures. Phys. Med. Biol. 28:417-l20; 1983.
28. Frommhold, H.; Url, M.; Hetzel, H. Conventional and CT
assisted treatment planning for cervical cancer treated with
the selectron. In: Mould, R. F., ed. Brachytherapy 1984 pro-
ceedings 3rd international selectron users meeting. The
Netherlands: Nucletron Trading BV; 1985:128-132.
29. Fu, K. K.; Sneed, P. K.; Leibel, S. A.; Nori, D.; Peschel,
R. E. Carcinoma of the cervix. In: Interstitial Collaborative
Working Group, eds. Interstitial brachytherapy. New York:
Raven Presss, Ltd.; 1990:179-188.
30. Gaddis, 0.; Morrow, C. P.; Klement, V.; Schlaerth, J. B.;
Nalick, R. H. Treatment of cervical carcinoma employing a
template for transperineal interstitial Ir19’ brachytherapy. Int.
J. Radiat. Oncol. Biol. Phys. 9:819-827; 1983.
31. Gardani, G.; Tana, S.; Zonca, G.; Valentini, V.; Mantello,
G.; Piermattei, A. Computerized planning of combined bra-
thy and teletherapy: A comparison of experiences. RAYS
15:525-538; 1990.
32. Herskovic, A.; Lee, S.; Padikal, T. Utilization of the com-
puted tomography scanner in interstitial dosimetry. Radiol-
ogy 135:781-782; 1980.
33. Himmelmann, A.; Bjurstam, N.; Ragnhult, I. Computer to-
mography measurements of the cervix and distances to the
bladder and rectum in intracavitary radiation treatment of
gynecological cancer. Strahlentherapie 159:198-202; 1983.
34. Hockel, M.; Knapstein, P. G.; Kutzner, J. A novel combined
operative and radiotherapeutic treatment approach for recur-
rent gynecologic malignant lesions infiltrating the pelvic
wall. Surg. Gynecol. Obstet. 173:297-302; 1991.
35. Hunter, R. D.; Wong, F.; Moore, C.; Notley, H. M.; Wilkin-
son, J. Bladder base dosage in patients undergoing intracav-
itary therapy. Radiother. Oncol. 7:189-197; 1986.
36. John, B.; Scarbrough, E. C.; Nguyen, P. D.; Antich, P. P. A
diverging gynecological template for radioactive interstitial/
708 I. J. Radiation Oncology 0 Biology l Physics
intracavitary implants of the cervix. Int. J. Radiat. Oncol.
Biol. Phys. 15:461465; 1988.
37. Kapp, K. S.; Stuecklschweiger, G. F.; Kapp, D. S.; Ha&l,
A. G. Dosimetry of intracavitary placements for uterine and
cervical carcinoma: Results of orthogonal film, TLD, and
CT-assisted techniques. Radiother. Oncol. 24: 137-146;
1992.
38. Kavanagh, B. D.; Bentel, G. C.; Montana, G. S. Soft tissue
complication rates after low dose rate brachytherapy using
customized perineal templates. Int. J. Radiat. Oncol. Biol.
Phys. 30:508; 1994.
39. Konski, A.; Mueller, W.; Mama, G.; Zeidner, S.; Mah, J.;
Neisler, J.; Phibbs, G.; Eggleston, W. Interstitial volume im-
plantation of gynecologic tumors: Indications and efficacy.
Endocuriether./Hyperthermia Oncol. 11:25-30; 1995.
40. Kumar, P. P.; Good, R. R.; Jones, E. 0. Dosimetry compar-
ison between interstitial and intracavitary irradiation in the
treatment of uterine cervix cancer. Radiat. Med. 4:89-96;
1986.
41. Kumar, P. P.; Taylor, J.; Scott, J. C.; Jacobs, A. J.; Rojas, J.
Indication for interstitial brachytherapy in carcinoma of the
uterine cervix. J. Natl. Med. Assoc. 76:721-725; 1984.
42. Lee, K. R.; Mansfield, C. M.; Dwyer, S. J., III; Cox, H. L.;
Levine, E.; Templeton, A. W. CT for intracavitary radio-
therapy planning. AJR 135:809-813; 1980.
43. Leung, S. Perineal template techniques for interstitial im-
plantation of gynecological cancers using the paris system
of dosimetry. Int. J. Radiat. Oncol. Biol. Phys. 19:769-774;
1990.
44. Leung, S.; Sexton, M. Radical radiation therapy for car-
cinoma of the vagina-impact of treatment modalities on
outcome: Peter MacCallum cancer institute experience
1970-1990. Int. J. Radiat. Oncol. Biol. Phys. 25:413-
418; 1993.
45. Ling, C. C.; Schell, M. C.; Working, K. R.; Jentzsch, K.;
Harisiadis, L.; Carabell, S.; Rogers, C. C. CT-assisted as-
sessment of bladder and rectum dose in gynecological im-
plants. Int. J. Radiat. Oncol. Biol. Phys. 13:1577-1582;
1987.
46. Lukka, H. R.; Moore, C. J.; Hunter, R. D. The relationship
between the bladder and the cervix in patients undergoing
intracavitary therapy. Br. J. Radiol. 60:355-359; 1987.
47. Makin, W. P.; Hunter, R. D. CT scanning in intracavitary
therapy: Unexpected findings in “straightforward” inser-
tions. Radiother. Oncol. 13:253-255; 1988.
48. Martinez, A.; Cox, R. S.; Edmundson, G. K. A multiple-site
perineal applicator (MUPIT) for treatment of prostatic, ano-
rectal, and gynecologic malignancies. Int. J. Radiat. Oncol.
Biol. Phys. 10:297-305; 1984.
49. Martinez, A.; Edmundson, G. K.; Clarke, D. The role of
transperineal template implants in gynecological malignan-
cies. Brachyther. J. 5:107-113; 1991.
50. Martinez, A.; Edmundson, G. K.; Cox, R. S.; Gunderson,
L. L.; Howes, A. E. Combination of external beam irradia-
tion and multiple-site perineal applicator (MUPIT) for treat-
ment of locally advanced or recurrent prostatic, anorectal,
and gynecologic malignancies. Int. J. Radiat. Oncol. Biol.
Phys. 11:391-398; 1985.
5 1. Martinez, A.; Herstein, P.; Pormuff, J. Interstitial therapy of
perineal and gynecological malignancies. Int. J. Radiat. On-
col. Biol. Phys. 9:409-416; 1983.
52. Martinez, A.; S&ray, M. F. Template and other extended
techniques for pelvic and perineal implants. ASTRO Re-
fresher Course, October 2, 1985.
53. Mazeron, J. J.; Chassagne, D.; Masselot, J. Experience of
CT scanning in gynecological brachytherapy: Corpus and
cervix. In: Computerized tomographic scanners in radio-
therapy in Europe. Br. J. Radiol. 15:59-61; 1981.
Volume 36, Number 3, 1996
54. Meerwaldt, J. H.; Koper, P. C. M.; Visser, A. G.; Subandono,
A. J. Interstitial radiotherapy for advanced stage cervical
cancer. In: Mould, R. F., ed. Brachytherapy 2. The Nether-
lands: Nucletron International BV; 1989:317-323.
55. Mishra, S.; Chadha, M.; Panigrahi, N.; Vikram, B. Com-
puted tomography-assisted three-dimensional dosimetry in
high dose rate brachytherapy. Endocuriether.lHyperthermia
Oncol. 10:71-77; 1994.
56. Monk, B. J.; Walker, J. L.; Tewari, K.; Ramsinghani, N. S.;
Syed, A. M. N.; Disaia, P. J. Gpen interstitial brachytherapy
for the treatment of local-regional recurrences of uterine cor-
pus and cervix cancer after primary surgery. Gynecol. Oncol.
52:222-228; 1994.
57. Montemaggi, P.; Smaniotto, D.; Valentini, V.; Luzi, S.; Cas-
piani, 0.; Balducci, M. Decreased side effects for locally
advanced cervical carcinoma using CT & optimization. In:
Mould, R. F., ed. International brachytherapy programme &
abstracts 7th international brachytherapy working confer-
ence. The Netherlands: Nucletron International BV;
1992:38:173-175.
58. Neblett, D. L.; Harrop, R.; Haymond, H. R.; Koval, J. M.;
Syed, A. M. N. Interstitial intracavitary (Syed-Neblett Ap-
plicator) dose rate distribution plots. Laclusc Med. Center
USC School Med. Publicat. l:l-24; 1978.
59. Nori, D. Principles of radiation therapy in the treatment of
vaginal tumors. In: Nori, D.; Hilaris, B. S., eds. Radiation
therapy of gynecological cancer. New York: Alan R. Liss,
Inc.; 1987:173-190.
60. Nori, D.; Hilaris, B. S.; Stanimir, G.; Lewis, J. L., Jr. Radi-
ation therapy of primary vaginal carcinoma. Int. J. Radiat.
Oncol. Biol. Phys. 9(10):1471-1475; 1983.
61. Notley, H. M.; Wilkinson, J.; Hunter, R. D. Dose distribution
studies of selectron treatments. In: Mould, RF, ed. Brachy-
therapy 1984 proceedings 3rd international selectron users
meeting. The Netherlands: Nucletron Trading BV; 1985:93-
94.
62. Osian, A. D.; Anderson, L. L.; Linares, L. A.; Nori, D.; Hi-
laris, B. S. Treatment planning for permanent and temporary
percutaneous implants with custom made templates. Int. J.
Radiat. Oncol. Biol. Phys. 16:219-223; 1989.
63. Phillips, T. L.; Nori, D.; Peschel, R. E. Carcinoma of the
vagina and vulva. In: Interstitial Collaborative Working
Group, eds. Interstitial brachytherapy. New York: Raven
Press, Ltd; 1990:189-197.
64. Pilepich, M. V.; Prasad, S.; Madoc-Jones, H.; Bedwinek,
J. M. Effect of bladder distension on dosimetry in gyneco-
logical implants. Radiology 140:5 165 18; 198 1.
65. Potish, R. A.; Williamson, J. F. Clinical and physical aspects
of interstitial template therapy in gynecologic malignancy.
In: Levitt, S. H.; Khan, F. M.; Potish, R. A., eds. Techno-
logical basis of radiation therapy. Philadelphia, PA: Lea &
Febiger; 1992:155-170.
66. Puthawala, A. A.; Syed, A. M. N.; Fleming, P. A.; Disaia,
P. J. Reirradiation with interstitial implant for recurrent pel-
vic malignancies. Cancer 50:2810-2814; 1982.
67. Puthawala, A.; Syed, A. M. N.; Nalick, R.; McNamara, C.;
Disaia, P. J. Integrated external and interstitial radiation ther-
apy for primary carcinoma of the vagina. Obstet. Gynecol.
62:367-372; 1983.
68. Randall, M. E.; Barrett, R. J. Interstitial irradiation in the
management of recurrent carcinoma of the cervix. Natl. Can-
cer Med. J. 49:306-308; 1988.
69. Randall, M. E.; Evans, L.; Greven, K. M.; McCunniff, A. J.;
Doline, R. M. Interstitial reirradiation for recurrent gyneco-
logic malignancies: Results and analysis of prognostic fac-
tors. Gynecol. Oncol. 48:23-31; 1993.
70. Richards, M. J. S.; Lewis, H. L.; Bruckman, J. E.; Klein,
K. A.; Fidler, A. B.; Allen, J. J.; Glover, J. R.; Ciriacks, C.
 CT-guided interstitial implantation of gynecologic malignancies 0 B. ERICKSONet al.
The use of differential loading with Iridium-192 intersti-
tial brachytherapy. EndocurietherapyiHyperthermia On-
col. 4:245-252; 1988.
71. Rush, S.; Lovecchio, J.; Gal, D.; DeMarco, L.; Potters, L.;
DeBlasio, D. Comprehensive management including inter-
stitial brachytherapy for locally advanced or recurrent gy-
necologic malignancies. Gynecol. Oncol. 46:322-325; 1992.
72. Schoeppel, S. L.; Fraass, B. A.; Hopkins, M. P.; LaVigne,
M. L.; Lichter, A. S.; McShan, D. L.; Noffsinger, S.; Perez-
Tamayo, C.; Roberts, J. A. A CT-compatible version of the
fletcher system intracavitary applicator: Clinical application
and 3-dimensional treatment planning. Int. J. Radiat. Oncol.
Biol. Phys. 17:1103-l 109; 1989.
13. Schoeppel, S. L.; LaVigne, M. L.; Martel, M. K.; McShan,
D. L.; Fraass, B. A. Computed tomography-based dosimetry
of gynecological intracavitary brachytherapy: A new method
for source localization. Endocuriether./I-Iyperthermia Oncol.
8:137-143; 1992.
74. Schoeppel, S. L.; LaVigne, M. L.; Martel, M. K.; McShan,
D. L.; Fraass, B. A.; Roberts, J. A. Three-dimensional treat-
ment planning of intracavitary gynecologic implants: Anal-
ysis of ten cases and implications for dose specification. Int.
J. Radiat. Oncol. Biol. Phys. 28:277-283; 1994.
75. Sewchand, W.; Prempree, T.; Patanaphan, V.; Whitley,
N. 0.; Heidtman, B.; Scott, R. M. Value of multi-planar CT
images in interactive dosimetry planning of intracavitary
therapy. Int. J. Radiat. Oncol. Biol. Phys. 8:295-301; 1982.
76. Shahabi, S.; Mehta, M.; Wiley, A. L.; Gehring, M. A.; Olsen,
K. J.; Vainio, P. A. Computed tomographic dosimetric plan-
ning for optimization of pelvic interstitial implants. Endo-
curiether./Hyperthermia Oncol. 6:47-52; 1990.
77. Shaves, M.; Barnhill, D.; Bosscher, J.; Remmenga, S.; Hahn, M.;
Park, R. Indwelling epidural catheters for pain control in gyne-
cologic cancer patients. Obstet. Gynecol. 77642644; 199 1.
78. Silto, Y.; Sekiguchi, K. Intracavitary radiation treatment
with ovoids spec. Jpn. J. Clin. Radiol. 27:485488; 1982.
79. Stuecklschweiger, G. F.; Arian-Schad, K. S.; Poier, E.; Pos-
chauko, J.; Hackl, A. Bladder and rectal dose of gynecologic
709
high-dose-rate implants: Comparison of orthogonal radio-
graphic measurements with in vivo and ct-assisted measure-
ments. Radiology 181:889-894; 1991.
80. Syed, A. N. M.; Feder, B. H. Technique of after-loading
interstitial implants. Radiol. Clin. 46:458475; 1977.
8 1. Syed, A. N. M.; Feder, B. H.; George, F. W.; Neblett, D.;
Schaeflein, J. W. Management of extensive residual cancer
with interstitial iridium implant: A preliminary report. In:
Hilaris, B., ed. Afterloading 20 years of experience 1955-
1975. New York: Memorial Sloan Kettering Center;
1975:119-124.
82. Syed, A. M. N.; Puthawala, A. A. Interstitial-intracavitary
“Syed-Neblett” applicator in the treatment of carcinoma of
the cervix. In: Nori, D.; Hilaris, B. S., eds. Radiation therapy
of gynecological cancer. New York: Alan R. Liss, Inc.;
1987:297-307.
83. Syed, A. M. N.; Puthawala, A. A.; Neblett, D.; Disaia,
P. J.; Berman, M. L.; Rettenmaier, M.; Nalick, R.; Mc-
Namara, C. Transperineal interstitial-intracavitary
“Syed-Neblett” applicator in the treatment of carcinoma
of the uterine cervix. Endocuriether./Hyperthermia On-
col. 2: l-13; 1986.
84. Thomadsen, B.; Shahabi, S.; Mehta, M.; Buchler, D.; Giese,
W. Differential loadings of brachytherapy templates. Endo-
curiether./Hyperthermia Oncol. 6: 197-202; 1990.
85. Vermund, H.; Alqaisi, M.; Chenier, T.; Christie, K.; Semer,
D.; Wiley, A. Interstitial and intracavitary brachytherapy in
carcinoma of the uterine cervix. Endocuriether./Hyperther-
mia Oncol. 11:43-55; 1995.
86. Wilkinson, J. M.; Moore, C. J.; Notley, H. M.; Hunter,
R. D. The use of Selectron afterloading equipment to sim-
ulate and extend the Manchester System for intracavitary
therapy of the cervix uteri. Br. J. Radiol. 56:409-414;
1983.
87. Yu, W. S.; Sagerman, R. H.; Chung, C. T.; King, G. A.;
Dalal, P. S.; Bassano, D. A.; Ames, T. E. Anatomical rela-
tionships in intracavitary irradiation demonstrated by com-
puted tomography. Radiology 143:537-541; 1982.