Ina. 1. Rodiarion Oncology Biol. Phys., Vol. 10, pp. 297-305 0360s3016/84 53.00 + .

M)
Printed in the U.S.A. All righls reserved. Copyright C 1984 Pergamoo Press Ltd.

??Technical Innovations and Notes

A MULTIPLESITE PERINEAL APPLICATOR (MUPIT)

FOR TREATMENT OF PROSTATIC, ANORECTAL,
AND GYNECOLOGIC MALIGNANCIES

ALVARO MARTINEZ, M.D.,‘T~ RICHARD S. Cox, PH.D.2

AND GREGORY K. EDMUNDSON’
‘Presently from the Department of Oncology, Division of Therapeutic Radiology, Mayo Clinic, Rochester, MN
55905; 2 Department of Radiology, Division of Therapeutic Radiology, Stanford University School of Medicine,
Stanford, CA 94305

Recently, transperiwal interstiti&intracevitary applicators have been used to treat IoeaIly limited and advanced
perineal and gyneeologic malignancies. We have developed a single afterloading applicator, referred to as the
“MUPIT” (Martinez Universal Perineal Interstitial Template), whlcb with its prototypes has been utilized to treat
78 patients with malignancies of the cervix, vagina, female uretbra, perineum, prostate, and anorectal region. The
device baslcally consists of two acrylic cylinders, an acrylic template with a predrilled array of holes that serve as
guides for trocars, and a cover plate. Some of the guide holes on the template are angled outward to permit a wide
lateral coverage without danger of striking the ischlmn. The cylinders have an axial hole large enough to pass a
central tandem or a suction tube for the drainage of secretions. Thus, the device allows for the interstitial placement
of ‘uIr ribbolrs as well as the intracavitary placement of either ‘uCs tubes or % ribbons. In use, the cylinders are
placed in the vagina and rectum and then fastened to the template, so that a fixed geometric relationship among
the tumor volume, normal structures, and source placement ls preserved throughout the course of the implantation.
Hollow, closed+uul, stainless steel trocars are then inserted through the guide holes that produce optimal coverage
of the treatment volume. Appropriate computer programs also have heen developed on a minicomputert for the
corresponding dose-rate computations. These programs run with suillcient speed that they may be used for both the
planning of the source placement beforehand and the computation of the actual dose-rate distribution obtained. The
advantages of tbe system are (1) greater control of the placement of sources relative to the tumor volume and critical
structures owing to the fixed geometry provided by the template and cylinders, and (2) improved dose-rate
distributions obtained by means of computer-assisted optimization of the source placement and strength during the
planning phase.

Perineal interstitial applicator, Prostate, Anorectal, Gynecologic tumors.

INTRODUCTION produce a more homogeneous distribution of radiation

Locally advanced perineal and gynecologic malignancies
are often difficult to manage by either radical surgery or
conventional radiotherapy and present a therapeutic
challenge. Presently available intracavitary applicators,
such as the Fletcher-Suit,13 the Henschke,’ the Bleo-
dorm3 the Delclos,4 the Chassagne,’ and others, have
been effective in controlling early gynecologic cancers,
but the local control rates for advanced disease remain
~ow.‘*~~‘~~-~*
The most likely explanations are inadequate
tumor coverage and tumor-dose inhomogeneity within
the implanted volume.
The transperineal interstitial-intracavitary applicators
are intended to improve target-volume coverage and to
dose. The Syed-Neblett parametrial butterAyS and the
Syed-Neblett rectal templateI were developed to treat
single-site tumors. At the same time, but independently,
we were working with a multiple-site single-template
interstitial-intracavitary applicator, the MUPIT (Mar-
tinez Universal Perineal Interstitial Template), which
provides for the use of both 13’Cs tubes and i9*Ir
ribbons. In conjunction with external-beam irradiation,
the MUPIT (and its prototypes) has been employed in
the treatment of 78 patients with primary or recurrent
cervical, vaginal, female urethral, perineal, prostatic, and
anorectal carcinomas. This report focuses on the
description and use of the MUPIT, which provides

Reprint requests to: Alvaro Martinez, M.D., Division of
Therapeutic Radiology, Mayo Clinic, Rochester, MN 55905.
Acknowledgements-We thank Mr. Peter Hausman, ma-
chine shop of the Stanford Radiotherapy Division, and Mr.
Warren N. Lenz, Section of Engineering, from the Mayo
Clinic, for their contributions to the construction of this
applicator. Our gratitude to Ms. June M. Henn for her
secretarial assistance in the preparation of this manuscript.
tPDP 11/SO.
Accepted for publication 23 September 1983.

297
 298 Radiation Oncology ??Biology ??Physics February 1984. Volume IO. Number 2

(1) greater control over the placement of sources

relative to the tumor volume and critical anatomic
structures than is possible with other applicators and
(2) improved dose-rate distributions by utilizing
computerized optimization of source placement and
source strength during both the planning and the loading
phase.

DESCRIPTION OF THE APPLICATOR

The MUPIT consists of a flat acrylic template and a
flat acrylic cover plate, two sets of acrylic cylinders,
obturators, screws, and stainless-steel needles of
different lengths (Fig. 1). The template and the cover
plate each measure 11 cm vertically, 8 cm horizontally, Fig. 1. MUPIT contains acrylic predrilled template and cover
and 1 cm in thickness. In use, the vertical axis of the plate, acrylic cylinders, obturators, screws, and stainless steel
needles.
template lies roughly along the anteroposterior direction
in the patient and the horizontal axis along the lateral
direction. To avoid confusion, the terms “inferior” and
“superior” will be used, with their customary meanings,
when referring to the patient, and the terms “upper” and
“lower” will be used when referring to the vertical
directions of the template.
The template has an array of holes that, for the most
part, determine the geometry of source placement with
respect to anatomic structures (see Figs. 7 and 12). Three
large holes are located along the vertical centerline: the
top slotted hole allows the passage of a Foley catheter
from the urethra and the center and bottom holes
accommodate the vaginal and rectal cylinders, re-
spectively (Fig. 1). To allow for differences in anatomy,
the cylinders of each set have two diameters; however,
they all have flanges that are well matched to their
corresponding holes in the template. Once the Fig. 2. Acrylic predrilled template attached to both the rectal
and vaginal cylinders. Obturator of one of the two cylinders is
appropriate-sized cylinders have been inserted into the not used.
patient, the template can be bolted firmly to the cylinders
(Fig. 2), thereby fixing the geometric relationship of the
template and the anatomic structures. To further fix the erally outward (Figs. 3 and 13). The use of the type II
geometry, two small holes (located in each corner of the rows allows a wider volume of parametrial or pararectal
template) are used to suture the assembly to the patient’s tissues to be covered at depth without danger of striking
perineum. the ischium. The holes in each row are spaced 12.5 mm
Around the three large holes in the template is a apart. Thus, a volume extending 4cm to either side of
bilaterally symmetric array of small holes that serve as midplane can be covered by the use of only type I rows.
guides for trocars (Fig. 1). The interstitial capability of When type II rows are added, volumes extending lat-
the MUPIT is utilized by transperineally inserting the erally outward to 7 cm can be covered at a depth of
trocars through the guide holes and afterloading them 14cm.
with ‘921rseeds. The layout of the guide holes is such that The vaginal and rectal cylinders provide the intra-
the inserted trocars lie in parallel horizontal planes, cavitary capability of the MUPIT (Fig. 2). A center tube
perpendicular to the plane of the template (Fig. 3). These runs the length of each cylinder and is designed to accept
planes are spaced vertically at about 1 cm intervals; the either the tandem for 13’Cstubes or a drainage tube. In
actual spacings were determined so as to provide a addition to having a center tube, each cylinder has a
regular distribution about the large holes. To achieve flange that carries an array of eight guide holes for the
this geometry, the array is made up of horizontal rows placement of trocars. The guide holes are located on a
of holes that are of two types: type I rows, wherein the circle that is slightly smaller than the diameter of the
holes are perpendicular to the template (Figs. 3 and 8) cylinder. and they continue as grooves along the length
interspersed with type II rows, wherein the holes are of the cylinder. This design facilitates the placement of
oblique to the template, angled approximately 13” lat- trocars near the vaginal or rectal wall.
 Multiple site perineal applicator ??A. MARTINEZ
Fig. 3. MUPIT with two rows of straight needles on the right
and three rows of straight needles and one row of angled
needles on the left. Different lengths on each side.
The trocars are modified 17-gauge needles that have
a bore large enough to accept the ig21rribbons (Fig. 3).
The pointed end is sealed with a small fillet of solder and
reground to resemble the point of a nail. The opposite
end is flared to facilitate loading (Fig. 3). To cover
treatment volumes that may vary widely in depth from
patient to patient, several sets of trocars of different
lengths are available.
PREIMPLANT PLANNING
The patient is seen conjointly at the subspecialty clinic
corresponding to the site of origin of the tumor. When
the patient becomes a candidate for primary radio-
therapy, a complete workup is obtained and the need for
external-beam therapy, in addition to the implant, is
assessed. Most patients are treated with a combination
of external-beam megavoltage irradiation and the MU-
PIT implant. A discussion of the integration of these two
modalities is a subject of another publication. The type
of anesthesia is selected, and the factors involved in
treatment planning are determined. Vaginal and rectal
et d. 299
cylinders of the appropriate diameter and length are
chosen. The lateral, anterior, and posterior extents of the
treatment volume are determined, and the correspond-
ing lateral, upper, and lower guide holes in the template
are selected. The superior extension of the tumor deter-
mines the depth to which the trocars must be placed, and
the inferior extent determines the number of sources per
ribbon required for adequate coverage of the treatment
volume. These data (the identification of cylinders and
guide holes utilized, the depth of insertion of the trocars
and tandem, and the number of sources per ribbon)
serve as input for the treatment-planning computer
program.
Since the geometric relationship of the cylinders and
trocars is fixed, the three-dimensional positions of all the
individual seeds and tubes can be calculated. Dose rates
at any point can then be determined by furnishing the
activity of the sources chosen from the current inven-
tory. Distributions of dose rate are computed in cross-
sectional planes (parallel to the template) at depths
specified by the user, usually every few centimeters
throughout the treatment volume. If the dose-rate distri-
bution is judged to be inadequate, modifications are
made in the plan and the distribution is recalculated.
Once a plan is accepted, the physician knows exactly
what protocol to follow in the operating room and what
the resulting dose-rate distribution will be, since the
geometry is completely fixed by the applicator. If the
chosen plan cannot be executed in the operating room,
further planning is required between the time of place-
ment and that of afterloading.
IMPLANTATION PROCEDURE
Patient preparation
After the planning session has been completed, the
implant procedure is scheduled. For bowel preparation,
the patient is advised to take clear liquids the day before
admission and is hospitalized 24 hr before the im-
plantation. Preoperative laboratory studies include
complete blood count with differential platelet count,
coagulation studies, electrolytes, urinalysis, chest roent-
genogram, and electrocardiogram. If the patient is well
hydrated and in good general condition, one bottle of
magnesium citrate is given the morning of admission.
One gram of neomycin every 4 hr and 1 g of erythro-
mycin every 6 hr are administered orally. Tap water
enemas are given until the return is clear; these are
followed by a retention enema consisting of 0.1% neo-
mycin in 500 ml of normal saline, followed again by tap
water enemas until the return is clear. The enemas are
usually completed by 4: 00 p.m. on the evening before
implantation. The perineum is shaved. Female patients
also receive two vaginal douches with povidone-iodine.
On the morning of implantation, thigh hoses are fitted
and fluids are started intravenously. Potassium replace-
ment is added, if indicated. In the operating room, a
 300 Radiation Oncology ??Biology ??Physics February 1984. Volume 10, Number 2

pelvic examination with an anosigmoidoscope or a intermittent suction, is inserted through the center hole
cystoscope is performed when required with the patient of the cylinder. Generous gauze padding is utilized to
under general anesthesia. The extent of the tumor is cover the template.
carefully reassessed, and radiopaque markers delineating
the tumor margins are placed. Prostate implantation
Cervix and vaginal implantation. The patient is placed After the staging pelvic lymphadenectomy is com-
in the lithotomy position and several 1-O silk sutures are pleted, the endopelvic fascia is opened and the prostate
stitched through the normal tissues (whenever possible) gland, seminal vesicles, and posterolateral pelvic wall are
or tumor (or both). By applying gentle traction on these exposed. Metal markers are placed to delineate the
sutures, the tumor can be immobilized during insertion boundary of the tumor. With *the patient in the lithot-
of the trocar. A Foley catheter with diatrizoate in the omy position and the surgeon’s one hand in the peri-
balloon is left in the bladder. If necessary, the cervix is toneal cavity, the guide needle is positioned trans-
dilated, the uterine canal is sounded, and a tandem is perineally just below the pubic bone and pushed into the
inserted. The sutures are pulled through the central peritoneal cavity, until a satisfactory superior margin is
orifice of the vaginal cylinder, and the cylinder is slipped obtained. This needle is then removed, and the depth of
over the tandem into the vagina and fixed to each other the insertion is measured so the correct needle length can
with a set screw. The template is then attached to the be determined. The template, “upside down,” is applied
cylinder and sutured to the patient’s perineum; special against the perineum. Utilizing the previous skin punc-
care is taken to avoid tilting the template. The physician, ture and needle tract, the most superior needle is inserted
utilizing a double glove, places a finger in the rectum. to the preset depth. The remainder of the needles are
While the assistant pulls gently on the sutures, he pushes -
the first needle transperineally through the tissues to the
appropriate depth. Next, the needles nearest the rectum
are then inserted while gentle tension is maintained on
the sutures. Care is taken to avoid either perforating the
rectal mucosa or leaving the free-floating needles in the
rectal lumen. After the surgeon’s finger is removed from
the rectum, the cylinder is placed in the rectum and
attached to the template. This assures that a fixed
distance between the vaginal and the rectal canal is
maintained and that the posterior rectal wall is held
away from the radioactive sources. A rectal tube is
inserted for removal of flatus and drainage of secretions.
The remaining needles are placed around the vaginal
cylinder to the preset depth. The sutures are removed.
The template is sutured to the perineum with 1-O silk
sutures, and the cover plate is placed over the sutured
template and screwed to it to prevent displacement of the
needles (Fig. 4). Sterile gauze is placed between the skin
and the template (Fig. 5). The Foley catheter is attached
to the draining bag. Care must be taken to keep the
bladder distended so as to decrease the radiation to this
organ and to displace the small bowel away from the
sources of radiation. The rectal tube is connected to
intermittent suction.

Rectal implantation
In the operating room, the patient is placed in the
knee-chest position and a Foley catheter is inserted. The
preselected rectal cylinder is inserted and fixed to the
template. The template is sutured to the skin with silk
sutures. The needles are then inserted transperineally to
the preset depth. When the lesion is in the anterior
anorectal wall, in males, care must be taken to avoid Fig. 4. MUPIT sutured to patient’s perineum. Foley catheter,
cylinders, and needles in place. The funnel-like configuration
perforating the prostatic urethra. In females, the vaginal on the end of each needle facilitates afterloading. The cover
cylinder is utilized to keep a fixed distance between the plate is screwed to the template to keep the needles and
rectal and vaginal walls. A rectal tube, applied to radioactive material in place.
 Multiple site perineal applicator ??A. MARTINEZer al.
Fig. 5. Complated MUPIT implant in a patient with Stage
IIIB cancer of the cervix.
then positioned transperineally; however, the spacing of
the tips is checked intraperitoneally. Rectal examination
is performed to be sure that no needles have penetrated
the rectal mucosa. The rectal cylinder is inserted, and a
rectal tube is secured to the skin and connected to
intermittent suction. The template is sutured to the skin
with 1-O silk sutures and the cover plate is screwed to the
template. The abdominal skin is closed (Fig. 6). A Foley
catheter with bladder distention is maintained until the
MUPIT is removed.
Female urethral implantation
Although the patient is hospitalized the afternoon
before the procedure, a less extensive bowel preparation
is ordered. In the operating room, with the patient in the
lithotomy position, several silk sutures are stitched
through the tumor in order to immobilize the tumor
during insertion of the needles. A three-way Foley
catheter, 14-F to 16-F, is selected. Methylene blue is
injected into the third lumen, and a small hole is made
in the catheter. A trocar with a blind end is introduced
through this hole into the Foley catheter and is advanced
301
Fig. 6. MUPIT implant with the template “upside down” in
a patient with Stage C cancer of the prostate. Note the
funnel-like configuration of needles. Cover plate not yet
placed.
to the base of the balloon. This will allow afterloading
of “*Ir inside the urethra. The tip of the catheter is
passed through the plate hole and inserted into the
urethra. The balloon is filled with 5 ml of diatrizoate,
and the bladder is drained. The template is sutured to the
perineum, and the periurethral needles are inserted to the
preset depth. The vaginal cylinder is introduced to
increase the stability of the applicator, to allow im-
plantation of the anterior vaginal wall, and to displace
the posterior vaginal wall away from the sources. Gauze
padding is utilized around the template, and the entire
applicator is covered.
Postoperative procedure
Once the placement is completed, and with the patient
in the supine position (prone for anorectal implants),
orthogonal films with dummy sources are taken in the
 302 Radiation Oncology ??Biology ??Physics February 1984, Volume 10. Number 2

operating room for verification of the treatment. Load-

0 Straight needles
ing of the needles with 19*Ir ribbons (the tandem is
seldom utilized with 13’Cs)is done in the patient’s room. * Angled needles
An 8 mg dose of morphine is given intravenously every % @I 0.6 mg Ra EQ
3-5 hr to control the pain associated with the cervical,
0 @ 0.3 mg Ra Eq
vaginal, rectal, or prostate implants. The urethral im-
plants require fewer needles of shorter length, so the
amount of discomfort is less than that of other perineal
Z 0 Anterior
plants. Wide-spectrum antibiotic coverage is recommen- ,p-; p--7
Holes for suture \
ded. Diphenoxylate, 3-4 times a day, is given and the
patient receives only intravenous replacement during the
Opening for E&c; _ E
implantation period. Patients must remain on their
backs (with the exception of anorectal implants, usually
they lie on their abdomens); however, the head of the
bed can be elevated to 20”. Since these patients generally
have about 100 mg Ra eq of iridium, the nursing person-
nel should be carefully instructed on patient care so as i . . . *
to minimize their exposure. Large bed shields are very Rectal
useful for decreasing the exposure and allowing more cyflnder~~~ : ’ 1
time for nursing care. Once the urine output has sta-
bilized, the Foley catheter is clamped for 4 hr, 200 ml are
drained, and the catheter is clamped again. This maneu-
ver maintains bladder distention, decreasing the radi-
ation to both bladder and small intestine.
Base of template
The implant is removed at the patient’s bedside.
Premeditation with diazepam, 10 mg orally 0.5 hr before Fig. 7. Illustration of the layout for symmetric loading in the
removal, and morphine, up to 10 mg intravenously, treatment of a central bulky tumor. Only straight needles with
differential loading (two different activities) are used. No
given in increments of 2-3 mg, is usually required. The central tandem is utilized.
patient is hospitalized for 24 hr after the implant has
been removed and is observed for bleeding, fever, or
local infection. Perineal sitz baths and vaginal douches --- Needle with lr-192 rtbbon

are given every 3 hr during this period, and the patient

is dismissed with pain medication and indications for Cephelad
perineal hygiene.

DOSIMETRY OF THE MUPIT

Two typical loadings and the corresponding dose rate III1 I I I I-- Y : 120
distributions for the treatment of cancer of the vagina I 14 I I I,“,1 I
and cervix are shown in Figs. 7-16. In Fig. 7, a sym- [ [r 1 [ 1 I I-- y:‘oo
metric loading for treating large centerline tumors is
presented. The 19*Irribbons contain eight seeds each and
extend from a depth of 65-135 mm into the tissues (Fig.
8). A total activity of 96mg Ra eq is divided among 14
full-strength ribbons (0.6mg Ra eq/seed) and 12 half-
strength ribbons (0.3 mg Ra eq/seed) (Fig. 7). The
resulting dose-rate distributions for transverse planes at
depths of 100 (middle of implant), 120, and 140 mm
(5 mm beyond end of implant) may be seen in Figs. 9,
10, and Il. The tumor volume, which extends 8 cm Base Of t*mpfat*
laterally, 7 cm caudocephalad, and 4 cm anteroposterior, _____._. ~. .~__._~
is best covered by the 75 rad/hr line. Note that the 65.3210123.55

dose-rate decreases to 40 rad/hr 5 to 10 mm outside of

these lines and beyond the ends of the implant (Figs.
9-11). This rapid falloff allows sparing of normal tissues
and critical structures (bladder and rectum) to a degree
not possible with external-beam X-ray treatment. And
Fig. 8. Illustration of the geogtric arrangement of the MU-
PIT, needles, and 19*Irribbons corresponding to layout in Fig.
7. The needles are closed in the distal end (nail configuration)
and opened (funnel-shape) in the proximal end. Dosimetric
calculation planes in the y-axis are shown.
 Multiple site perineal applicator ??A. MARTINEZ
et al. 303

the maximal dose-rate within the treatment volume is

just over 100 rad/hr, occurring in small, isolated volumes
MUPIT/
at the midplane and around individual seeds. This degree
of uniformity cannot be achieved with any standard
intracavitary applicator. It is due in part to the judicious
choice of full- and half-strength ribbons.
When treating patients with tumors that extend lat-
20 r/h
erally on one side of the midplane only, an asymmetric
loading is used (Fig. 12). The treatment volume extends
25 mm laterally on one side and from 50 to 65 mm on
the other (Fig. 13). In this situation, angled trocars are
used in order to cover tissues at distances this far from
midline. A total activity of 102.6 mg Ra eq is divided
among 18 full- and 10 half-strength ribbons, 15 of which cm, 6 5 4 3 2 10 1 * 3 4 5 6 1
I

contain eight seeds each (Fig. 12). To avoid hot spots

where the application of the three inner angled trocars Fig. 9. Isodose distribution for symmetric loading in layout of
cross that of the straight trocars, three short ribbons Fig. 7. calculation plane y = 100 mm, or 2cm above the
cylinder tip. The 75 rad/hr isodose line covers from the center
(two with three seeds and one with two seeds) are used 4.5 cm laterally on each side. Within 1 cm, the dose rate
(Fig. 13). The corresponding dose-rate distributions are decreases to 40 radlhr.
presented in Figs. 14-16. The 75 rad/h line covers the
treatment volume in all three transverse views, for Calculation Plane.
depths of 70, 100, and 130 mm. The dose-rate again MUPIT y: 120mm

decreases to 40 rad/h within 10 mm of the 75 rad/h line

(Figs. 14-16). Also, small isolated regions occur near
midplane and around individual seeds, where the dose-
rate exceeds 100 rad/h.
Note that for either symmetric or asymmetric tumors, 20 r/h

the dose-rate distribution has been shaped. Near the

longitudinal midplane of the patient, the treatment
volume is narrowed so as to avoid overdosing the rectum
and bladder. For asymmetric tumors, the distribution is
again narrowed in the extreme lateral region. This is
achieved by the choice of locations in which trocars are
inserted. The same shaping can be done in the infero-
superior planes by varying the depth of insertion and the Fig. 10. Isodose distribution for symmetric loading in layout
number of seeds per ribbon. This degree of control over of Fig. 7. Calculation plane y = 120 mm, or 4 cm above the
the shape of the volume treated cannot be obtained with cylinder. Rectum and bladder covered by 40 rad/hr isodose
line, while the tumor is covered by 75 rad/hr isodose line.
either external-beam or conventional intracavitary appli-
cators.

PERITONEAL Calculation Plane.

OUR SERIES
Between June 1976 and December 1982, 78 patients
with cervical, vaginal, female urethral, anorectal, and
prostatic carcinomas were seen and treated with the
MUPIT and its prototypes at the Divisions of Radiation 20 r/h
Therapy, Stanford University Medical Center and Mayo
Clinic. These patients were referred to us by members of
the Divisions of Gynecologic Oncology, General
Surgery, and Urology. Most of these patients presented
with locally advanced tumors and were treated with a
combination of external-beam and implant irradiation.
L 11 11 10 ’ 8 1 ’ 1 1
Two patients with early disease who were considered cm, e 5 4 3 2 10 12 3 4 5 8 7

poor surgical risks were treated with the perineal appli-

Fig. 11. Isodose distribution for symmetric loading in layout
cator alone. The follow-up for all patients ranged from of Fig. 7. Calculation plane y = 140 mm, or 0.5 cm above the
3 months to 6.7 years; to date, eight patients have local tip of the needles. This represents the dose delivered to the
recurrences. Three patients have major complications. In peritoneal cavity.
 304 Radiation Oncology ??Biology ??Physics February 1984, Volume IO. Number 2

Straight needles Calculatton Plane

MUPIT y=70mm
* Angled needles
m 0.6 mg Ra Eq
4 $z 0.3 mg Ra Eq

Z 0 Anterior
Holes for suture /-,

Opening for

1
Foley cathet er

Vaginal
cylinder Fig. 14. Isodose distribution for asymmetric loading in layout
of Fig. 12. Calculation plane J = 70mm above the first 19*Ir
seed at the intersection of the straight and angled needles (see
Rectal
Fig. 13). The 75 rad/hr isodose line covers laterally 2.8 cm on
cylinder the patient’s left and almost 6 cm on the patient’s right. There
. . .\ j . . is a very small spot of 100 rad/hr.
.--’ ”
. . . .
2 _ ” D

/
Base of template

Fig. 12. Illustration of the layout for asymmetric loading when

treating a tumor that extends laterally on one side of the
midplane only. Both straight and angled needles are utilized on
one side (right). Differential loading (two different activities).
No central tandem is utilized.

--- Needle ~4th lr- 192 rbbon

Cephalad

OV
11.5 nml

c p T_ Fig. 15. Isodose distribution for asymmetric loading in layout

1
( Top of needle )
II 1 1 1, I -
of Fig. 12. Calculation plane y = 100 mm, or 2 cm above the
\ \ ’ cylinder. The 75 rad/hr isodose line covers laterally 3 cm on the
\ \ I I,I I I I-- Y:‘30
patient’s left and 6.3 cm on the patient’s right. There is a larger
\ \I 131 I I I area of 100 rad/hr.
\ I 14 I I I,“,1
I [,I I I I-- Y:‘OO
I

Base of template

i I 1 , 1 / 1 ,

cm7 6 5 4 3 2 10 12 3 4

Fig. 13. Illustration of the geometric arrangement of the Fig. 16. Isodose distribution for asymmetric loading in layout
MUPIT, needles, and 19’Ir ribbon corresponding to layout of of Fig. 12. Calculation plane y = 130 mm, or 5 cm above the
Fig. 12. The needles are closed in the distal end (nail cylinder. The 75 rad/hr isodose line covers laterally 2.8 cm on
configuration) and opened (funnel-shaped) in the proximal the patient’s left and 6.6 cm on the patient’s right. There is a
end. Dosimetric calculation planes in the y-axis are shown. very small area of lOOrad/hr.

_I - ._,_
-.-^ ,_
 Multiple site perineal applicator 0 A. Mmnmz
one patient with a large Stage IIB cancer of the cervical
stump, a contracted painful bladder developed 18
months after treatment, necessitating urinary diversion.
The second patient had a massive cloacogenic carcinoma
involving the rectum, the ischiorectal fossa, and the
vagina. This patient developed a necrotic rectal ulcer
that failed to heal and required a diverting colostomy 15
months after implantation. The third patient, with Stage
IIIB cancer of the cervix and massive involvement of the
posterior vaginal wall, developed an ulcer of the anterior
rectal mucosa; the ulcer healed with conservative treat-
ment. These three patients are presently free of disease.
Minor complications included diarrhea with rectal
tenesmus in most patients treated for rectal lesions and
temporary dysuria with increase in urinary frequency in
patients treated for urethral and prostatic malignancies.
Vaginal and rectal mucositis occurred in almost all
patients, and in several, perineal wet reactions also
developed. Two patients had local infections, and both
were treated with antibiotics.
For this group of 78 patients, most of whom had
locally advanced perineal gynecologic malignancies, our
REFERENCES
1. Chassagne, D., Attaia, A.B., Pierquin, B.: Rtsultats de
l’endocuriethkrapie par fiis d’iridium 192en gynkologie. J.
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2. Chassagne, D., Pierquin, B.: La pl&iocuriethCrapie des
cancers du vagin par moulage plastique avec iridium 192
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Radiol. Electr. 47: 89-93, 1965.
3. Chau, P.M.: Radiotherapeuticmanagement of malignant
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Henschke, U.K.: “Afterloading” applicator for radiation
et al. 305
preliminary results demonstrate a high local control rate
(70/78 or 90%) and a low incidence of major compli-
cations (3/78 or 3.8%). A complete analysis of the
clinical results is the subject of a later paper.”
The MUPIT allows wide lateral coverage of the
parametrial and pararectal tissues, particularly when the
angled holes are utilized, and thus is able to reach tissues
that are normally underdosed by other applicators.
Moreover, the multiple site capability and large number
of trocar guide holes, which permit symmetric and
asymmetric placements, provide a flexibility in matching
the dose distribution to the tumor volume which had not
been attainable before. The fixed and stable geometry of
the template and cylinders, maintaining a constant
relationship among the sources, tumor, and normal
tissues, enable the therapist to more surely maximize
tumor dose and minimize normal tissue reactions. For
these reasons, we believe that the MUPIT represents
an improvement over other single-site intracavitary
or interstitial applicators for the treatment of patients
with locally advanced perineal and gynecologic malig-
nancies.
therapy of carcinoma of the uterus. Radiology 74: 834,
1960.
9. Henschke, U.K., Hilaris, B.S., Mahan, G.D.: After-
loading in interstitial and intracavitary radiation therapy.
Am. J. Roentgenol. 90: 386395, 1963.
10. Martinez, A., Herstein, P., Portnuff, J.: Interstitial therapy
of perineal and gynecological malignancies. Int. J. Radiat.
Oncol. Biol. Phys. 9: 409-416, 1983.
11. Martinez, A., Howes, A., Edmundson, G.K., Cox, R.S.:
Combination of external beam irradiation and the
multiple-site perineal applicator (MUPIT) for the treat-
ment of locally advanced or recurrent anorectal, prostatic
and gynecologic malignancies. Submitted for public-
ation to Int. J. Radiat. Oncoi. Biol. Phys.
12. Perez, C.A., Korba, A., Sharma, S.: Dosimetric consid-
erations in irradiation of carcinoma of the vagina. Int. J.
Radiat. Oncol. Biol. Phys. 2: 639-649, 1977.
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Modification of Fletcher ovoid system for afterloading,
using standard-sized radium tubes (milligram and micro-
gram). Radiology 81: 126-131, 1963.
14. Syed, A.M.N., Puthawala, A., Neblett, D., George, F.W.,
III, Myint, U.S., Lipsett, J.A., Jackson, B.R., Flemming,
P.A.: Primary treatment of carcinoma of the lower rectum
and anal canal by a combination of external irradiation
and interstitial implant. Radiology 128: 199-203, 1978.