TREATMENT OF CARCINOMA CERVIX USING TANDEM AND CYLINDER AS BRACHYTHERAPY DEVICE

Abstract

Background :- Cervical cancer is one of the most common gynecologic cancer worldwide. There were an estimated 530 000 cases of cervical cancer and 275 000 deaths from the disease in 2008. It is the third most common female cancer ranking after breast (1.38 million cases) and colorectal cancer (0.57 million cases). The incidence of cervical cancer varies widely among countries. India also has the highest age standarised incidence of cervical cancer in South Asia at 22, compared to 19.2 in Bangladesh, 13 in Srilanka, and 2.8 in Iran. Cervical cancer as per HBCR data Skims is not common cancer in Kashmir the incidence varies from 18 to 30 cases per year. There are various methods of treatment for carcinoma cervix depending on the stage of disease e;g Surgery , EBRT , Brachytherapy  and chemotherapy.EBRT followed by brachytherapy as a boost gives excellent local control. There are various applicators available for brachytherapy ,in this study we have used tandem and cylinder as brachytherapy device .local control and toxicities were studied of patients who were receiving boost by brachytherapy using tandem and cylinder as applicator.

Objectives:-to study local control and toxicities(acute and chronic).

Study Design:- This study was conducted in the Department of Radiation Oncology Sheri Kashmir Institute of Medical Sciences, Srinagar. It was an observational study conducted betweenJanuary2014 to December 2018. This study was approved by the ethical committee of Sheri Kashmir Institute of Medical Sciences, Srinagar.A total no of 144 carcinoma cervix patients were registered at REGIONAL CANCER CENTRE of Sheri Kashmir Institute of Medical Sciences during the study period, Of which 31patients who fulfilled the following criteria were enrolled in the study. Inclusion criteria was Clinical stage IA –IVA carcinoma cervix, Performance status ECOG (0-3), Written consent for treatment. Exclusion criteria was Patients undergone surgery, Prior pelvic radiotherapy  for some other disease, Performance status ECOG>3,Stage IVB(distant metastasis). Methods and Materials:-  After complete evaluation of diagnosis and staging workup, all patients were treated initially with external beam radiotherapy.A dose of 45Gy was delievered by AP/PA portals to pelvis@ 1.8 Gy per fraction 5 days a week for a period of 5 weeks concurrent with weekly cisplatin 40mg/m^{2 .}  Patients were assessed for intracavitory brachytherapy in the last week of EBRT. . Intracavitary brachytherapy involves a procedure in which applicators are placed in uterus and vagina through the vaginal cavity to treat the cervical cancer. There are varieties of applicators used for intracavitary brachytherapy . In our study, all the selected cases were treated by using Tandem and cylinder applicator. All of the cases received three ICBT treatments with one week interval between each session. After intracavitary applicator placement, all patients were subjected to pelvic CT scan. . If everything in place then imaging data was exported for the treatment planning system in DICOM format via institution network. Brachyvision (version 11.0) treatment planning system was used for treatment planning of all patients. Patients were then shifted to the treatment room. Then the next step was to contour the target volumes and organs at risk. The intent is to deliver a radiation dose appropriate to cure gross and subclinical disease. Bladder and rectum, sigmoid were contoured as OARS. .After the applicator tracing, the reference points were defined(Reference point A Lt &Rt) and a dose of 6-7 Gy was prescribed at point A. Dose optimization was done so that the OARs received the doses within the tolerance limit and the target receives the prescribed dose as per the standard agencies. Patients were followed weekly, during treatment with CBC and KFT and after completion of treatment, patients were followed for one year. Clinical evaluation, gynaecological checkup and imaging was done at 3 months, 6 months and one year. The patients were. monitored using CTCAE (Common Terminology Criteria for Adverse Events) for toxicities(acute and late toxicities)and by imaging for local control.

Statistical Methods:-The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. Graphically the data was presented by bar and pie diagrams.

Results:-31 patients met the study criterion. Median age at presentation was 50-59years (range30-70 years). 3(6.7%) patients were having adenocarcinoma and 28(90.3%)   squamous cell carcinoma as histology. Patients were treated by external beam radiation therapy in the dose of 45Gy/25 # concurrent with cisplatin 40 mg/m² followed by brachytherapy in a dose of 6-7 Gy per fraction for 3 sessions. The patients received a mean 2cc dose to bladder 10.15± 3.86 SD and to rectum 9.94±3.17 SD. At 3 months of follow up 1(3.2%), patient had radiation-induced proctitis of grade 2 and 3 (9.7%) had radiation-induced cystitis of grade 1 and 1 (3.2%) had grade 2 cystitis and at 6 months of follow up 1 (3.2%) had grade 1, 1 (3.2%) had grade 2, and 1(3.2%) had grade 3 radiation-induced proctitis.After a median follow up of one year 26(83.9%) patients were disease-free,1 (3.2%) had local recurrence, 2(6.5%) had distant metastatis and 2 (6.5%) died.

Conclusion:- We observed that:

1. Carcinoma cervix is not common in our region (0.64%).
2. Most of the patients were in the age group of 50-59 (38.7%).
3. Most of the patients were in postmenopausal status at presentation (67.6%).
4. Squamous cell carcinoma was the most common histology (90.3%).
5. Bleeding per vagina was the most common symptom  (77.4%).
6. Acute and late toxicities were comparable with the traditional Brachytherapy applicators used for managing carcinoma cervix.
7. Local control was achieved in 83.87% of cases.
8. Two-year survival was 93.5%.

We observed that Tandem and Cylinder applicator is an excellent device to be used for intracavitory brachytherapyin carcinoma cervix, it is simple and safe to use. It does not need anaesthesia, besides this the toxicities and local control are similar with the other standard applicators used in brachytherapy in carcinoma cervix. The drawback in this study was that the sample size was small and it was not a comparative study. We recommend that a comparative study on larger sample size need to be conducted for establishing the use of Tandem and Cylinder as brachytherapy applicator in the management of carcinoma cervix.