Rectum separation in patients with cervical cancer for treatment planning in primary chemo-radiation

Simone Marnitz,Filiberto Guiseppe Vercellino,Bernhard Gebauer,Elena Burova,Volker Budach,Christhardt Köhler,Friederike Weißer

doi:10.1186/1748-717x-7-109

Simone Marnitz, Filiberto Guiseppe Vercellino + Show 5 more

Open Access

https://doi.org/10.1186/1748-717x-7-109

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Abstract

PurposeTo proof feasibility of hydrogel application in patients with advanced cervical cancer undergoing chemo-radiation in order to reduce rectal toxicity from external beam radiation as well as brachytherapy.Material and methodsUnder transrectal sonographic guidance five patients with proven cervical cancer underwent hydro gel (20 cc) instillation into the tip of rectovaginal septum adherent to posterior part of the visible cervical tumor. Five days after this procedure all patients underwent T2 weighted transversal and sagittal MRI for brachytherapy planning. MRI protocol included T2 weighted fast spin echo (FSE) imaging in sagittal, coronal and para-axial orientation using an 1.5 Tesla MRI. Separation of anterior rectal wall and cervix was documented.ResultsHydrogel application was uneventful in all patients and no toxicity was reported. Separation ranged from 7 to 26 mm in width (median 10 mm). The length of the separation varied between 18 and 38 mm (median 32 mm). In all patients displacement was seen in the posterior vaginal fornix, and/or at the deepest part of uterine cervix depending on the extension of the cul-de-sac in correlation to the posterior wall of the uterus. In patients with bulky tumor and/or deep (vaginal) extend of peritoneal cavity tumour was seen mainly cranial from the rectovaginal space and therefore above the hydrogeI application. Only in the extra-peritoneal (lower) part of the cervix a good separation could be achieved between the rectum and cervix.ConclusionHydrgel instillation in patients with cervial cancer undergoing chemoradiation is safe and feasible. Because of the loose tissue of the cul-de-sac and its intra- and extraperitoneal part, hydrogel instillation of 20 cc did not result in a sufficient separation of the cervix from anterior wall.

Highlights

Primary chemoradiation (RCTX) is the treatment of choice in patients with locally advanced and/or lymph node positive cervical carcinoma [1]
Some proposals for dose sparing to the small bowel like treatment in prone position or use of bowel displacement systems did not gain acceptance in clinical routine [16,17]
Most data concerning rectal separation using hydrogel were published on prostate cancer patients

Summary

Introduction

Primary chemoradiation (RCTX) is the treatment of choice in patients with locally advanced and/or lymph node positive cervical carcinoma [1]. Paradigm shift from radiation to RCTX lead to an improvement with regard to local control as well as progression free and overall survival [2]. RCTX can be associated with considerable acute and late gastrointestinal (GI) toxicity [1,4]. Reported grade 3 and 4 late GI toxicity is in the range of 4%–40% depending on target volumes and radiation. Efforts have been made to better target definition for external beam radiation and dose escalation [13,14,15], dose prescription and application of brachytherapy, as well as simultaneous consideration of therapy related toxicity. Some proposals for dose sparing to the small bowel like treatment in prone position or use of bowel displacement systems did not gain acceptance in clinical routine [16,17]

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