Z-Guggulsterone br A total of applicator insertions were per
A total of 73 applicator insertions were performed: 23 patients received one implant, whereas 25 had two. Most patients receiving a single implant had a recurrent uterine cancer with good response to EBRT or were elderly and fragile patients with a vaginal cancer primary. These pa-tients were treated with three brachytherapy fractions. Except for one, all patients with cervical primaries were treated with four fractions in two insertions a week apart. The median clinical target volume (CTV) was 52 cm3 (range 4e205 cm3). A median of 17 (10e25) and 19 (8e 26) needles were used in the first and second insertions,
Clinical and treatment characteristics
Cervix (recurrent) 2
Uterus (recurrent) 13
Total number of BT insertions 73
Patients with second insertion 25
Twenty-eight patients had radiological evidence of nee-dle intrusion(s) to at least one pelvic organ. After planning imaging, no needle was repositioned due to organ intrusion. The dwell positions within the intruded organ at risk were not loaded. From the 73 insertions, the most commonly intruded organs were bowel and bladder, both with 18 intru-sions, followed by rectum with 12 intrusions (Table 2). Figure 1 shows examples of needle intrusions to organs at risk.
A total of 14 acute complications were potentially related to the P-ISBT procedure (Table 3). Nine were possibly attributed to interstitial needles: four patients developed hematuria, with three of them requiring manual bladder irrigation before Foley removal (Grade 2). The other patient was completely asymptomatic (Grade 1); three patients developed perineal infections days after the procedure (Grade 2) and required oral antibiotics; 1 patient developed a pelvic abscess 2 months after brachytherapy, requiring percutaneous drainage and intravenous Z-Guggulsterone (Grade 3); one patient had vaginal bleeding during appli-cator removal and required transfusion (Grade 3). The pa-tient that developed the pelvic abscess had an IB2 cervical cancer treated with salvage radiotherapy (EBRT þ ISBT) after an initial trachelectomy. This patient received intraoperative antibiotic prophylaxis but
Radiological organ intrusion
Procedure with Procedure Number of intruded Organ no intrusion with intrusion needles, median (range)
Fig. 1. Pelvic organs intruded by interstitial catheters. Planning computed tomography axial planes showing bowel (a), bladder (b), and rectum (c) intruded by interstitial catheters after interstitial brachytherapy implant.
developed an abscess in the left pelvis 2 months after the last ISBT, requiring percutaneous abscess drainage and intravenous antibiotic. The two bacteria species cultured in this collection were Peptostreptococcus anaerobius and Finegoldia magna. No bowel or bladder needle intrusion was seen. The closest needle was 3 cm away from the loca-tion of the eventual collection. This patient also had radio-logical left hydroureter on CT simulation with evidence of a radiological needle intrusion at the ureter. There was no clinical sequelae related to this radiological finding and kidney function was stable throughout treatment. The hy-droureter resolved on followup ultrasound postapplicator removal. No patient developed acute gastrointestinal com-plications and five had general clinical events: hyperkale-mia during hospital stay, sensitivity reaction to hydromorphone, ventricular tachycardia, pulmonary throm-boembolism and moderate emesis.
No difference in infection rates was seen between pa-tients receiving one or two ISBT insertions ( p 5 1.0) and the number of catheters inserted did not correlate with the infection rate ( p 5 0.83). Four patients developed Grade 1 or 2 hematuria. One patient had G1 hematuria with no needle seen intruding the bladder in the planning CT. Table 4 depicts the number of patients with Grade 2 hema-turia in comparison with the presence of bladder intrusions and number of intruding needles.