In brachytherapy of uterine cervical cancer using a high dose rate remote afterloading system, it is of prime importance to deliver a accurate dose in each fractionated treatment by minimizing the difference between the pre-treatment planned and post-treatment calculated doses. The post-treatment calculated point A dose was not much different from the pretreatment planned dose (500 cGy). The average+/-standard deviation was 500+/-18 cGy and 84 percent of 82 intracavitary radiotherapy was within the range of 500+/-25 cGy.
Brachytherapy ; Cervix Uteri* ; Female ; Radiotherapy* ; Uterine Cervical Neoplasms

No abstract available.
Cervix Neoplasms/*radiotherapy ; Female ; Human ; Neoplasm Metastasis ; Pregnancy

It is well known that intracavitary radiotherapy (ICR), either alone or in combination with external-beam radiotherapy (EBRT) is an essential component of the radiation treatment of uterine cervical cancer. Although low-dose-rate (LDR) brachytherapy has been successfully applied to the management of such patients, several radiation oncologists have experience of using high-dose-rate (HDR) brachytherapy with promising clinical results over the past 4 decades. However, there has been a considerable reluctance by radiation oncologists and gynecologists in North America to employ the HDR remote afterloading technique instead of the more firmly established LDR treatment modality. In contrast, the HDR-ICR system is rapidly gaining acceptance in Korea since the introduction of the Ralstron, remotely controlled afterloading system using HDR Co-60 sources, at the Yonsei Cancer Center in 1979. According to brachytherapy statistics reported by the Korean Society of Therapeutic Radiology and Oncology, in 1997, brachytherapy was performed upon 1,758 Korean patients with uterine cervical cancer, of whom approximately 83% received HDR brachytherapy. In this review, we present our experiences of HDR-ICR for the treatment of uterine cervical cancer. In addition, we discuss the controversial points, which are raised by those considering the use of HDR-ICR for uterine cervical cancer; these issues include physical and radiobiological considerations, and the prospect of future technical improvements.
Brachytherapy/*methods ; Cervix Neoplasms/*radiotherapy ; Dose Fractionation ; Female ; Human ; Radiotherapy Planning, Computer-Assisted

Commercially available rectal retractors can be used in high dose rate intracavitary brachytherapy (HDR ICR) as one of the methods for reducing the rectal dose in radiotherapy for a uterine cervical cancer. However, the extent of the rectal protection achieved using these rectal retractors has not been reported. The aim of the study was to examine the effect of a rectal retractor on reducing the rectal dose in HDR ICR. Thirty patients were treated with HDR ICR using rectal retractors. Tandem and ovoids were applied in 15 patients and ovoids only were used in the other 15 patients. During the simulation, the rectum was filled with barium, and anteroposterior and lateral radiographs were then taken with and without the rectal retractor. Along the anterior rectal wall outlined, 4 to 8 points (median 6) were chosen to calculate the dose for each patient including the rectal point (RP), which is an author-defined rectal point modified from the definition of the rectal reference point in the ICRU report 38. The length of the measured rectum was 3-7 cm (median 5 cm). The bladder point (BP) dose was measured as recommended by the ICRU. The prescription doses to point A varied from 3.5 to 5 Gy (median 4 Gy). Paired comparisons were made on the individual patients by calculating the normalized mean doses of the RP, the maximal point (MP), and the longitudinal average (LA) with and without the rectal retractor. The doses to the bladder points (BP) were also calculated in parallel to the rectal points. The anterior rectal walls were displaced posteriorly after inserting the rectal retractor. In the tandem and ovoids group, the number of patients with a reduced dose in the RP, MP and LA were 14 (93.3%), 12 (80.0%) and 13 (86.7%), respectively. In the ovoids only group, the corresponding figures were 14 (93.3%), 14 (93.3%) and 14 (93.3%). In the tandem and ovoids group, the reduced dose in the RP, MP, and LA dose were 0.52 Gy (13.0%), 0.50 Gy (12.5%), and 0.39 Gy (9.8%), respectively (p < 0.05). In the ovoids only group, the RP, MP, and LA dose were reduced by 0.62 Gy (15.5%), 0.92 Gy (23.0%), and 0.54 Gy (13.5%), respectively (p < 0.05). There was no significant change in the bladder point doses when the rectal retractor was applied, although the mean BP dose were 0.27 Gy and 0.09 Gy lower for the tandem and ovoids group and for ovoids only group, respectively (p > 0.05). The mean RP, MP, and LA dose reduction rates of the patient subgroup where the RP dose was < 70% of the prescription dose were compared with the subgroup where the RP dose was > 70%. The effect of the rectal dose reduction was significant only in the subgroup of patients who received > 70% of the prescription dose (p < 0.05). The use of the rectal retractor was a simple and an effective method for reducing the rectal dose. It was also considered to be a highly reproducible method, which can replace the time-consuming vaginal gauze packing in HDR-ICR.
Brachytherapy/*instrumentation/methods ; Cervix Neoplasms/*radiotherapy ; Female ; Human ; Radiotherapy Dosage ; *Rectum ; Surgical Instruments ; Vagina

Neoplastic plexopathy is usually associated with advanced systemic cancer, regional progression of the primary tumor and complication of cancer treatment including radiotherapy. Lumbosacral plexopathy is most commonly found in colorectal cancer and its symptom begins with leg pain, and thereafter numbness and weakness develops. Radiotherapy is generally considered as the 1st line therapy for metastatic plexopathy and it is also a way to relieve pain. We experienced one case of recurrent cervix cancer with lumbosacral nerve root metastasis after radical abdominal hysterectomy without additional radiation therapy and then we report it together with a brief review of literatures.
Cervix Uteri* ; Colorectal Neoplasms ; Female ; Hypesthesia ; Hysterectomy ; Leg ; Neoplasm Metastasis* ; Radiotherapy ; Uterine Cervical Neoplasms*

Five hundred and fifty patients treated for carcinoma of the uterine cervix at the Department of Therapeutic Radiology, Seoul National University Hospital from 1979 to 1986, were analyzed retroepectively for late rectal complications. Of them, 468 patients received primary radiotherapy for the cervix cancer in intact uterus, and the other eighty two patients were treated postoperatively. The cumulative incidence of radiation induced rectal complication of grade 2 or 3 was 6.7% at five years. The mean rectal dose for the group of patients with complication was higher than the group without complication, and the difference was statistically significant (p< 0.01). But relationship between mean rectal dose and severity of complication was not found. The frequency of complication (grade 1, 2, 3) increased as a function of radiation dose to rectum; from 16.1% for patients with rectal dose less than 6,000 cGy to 71.2% for patients with rectal dose higher than 8,000 cGy. Among various factors analyzed, history of diabetes mellitus, number of intracavitary irradiation, size of ovoid, retroflexion of uterus and the total dose delivered to rectum turned out to have significant effect on the complication.
Cervix Uteri* ; Diabetes Mellitus ; Female ; Humans ; Incidence ; Radiation Oncology ; Radiotherapy ; Rectum ; Seoul ; Uterine Cervical Neoplasms ; Uterus

PURPOSE: In radiotherapy for cervix cancer, both 3-dimensioal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) could reduce the dose to the small bowel (SB), while the small bowel displacement system (SBDS) could reduce the SB volume in the pelvic cavity. To evaluate the effect of the SBDS on the dose to the SB in 3D-CRT and IMRT plans, 3D-CRT and IMRT plans, with or without SBDS, were compared. MATERIALS AND MEHTODS: Ten consecutive uterine cervix cancer patients, receiving curative radiotherapy, were accrued. Ten pairs of computerized tomography (CT) scans were obtained in the prone position, with or without SBDS, which consisted of a Styrofoam compression device and an individualized custom-made abdominal immobilization device. Both 3D-CRT, using the 4-field box technique, and IMRT plans, with 7 portals of 15 MV X-ray, were generated for each CT image, and prescribed 50 Gy (25 fractions) to the isocenter. For the SB, the volume change due to the SBDS and the DVHs of the four different plans were analyzed using paired t-tests. RESULTS: The SBDS significantly reduced the mean SB volume from 522 to 262 cm3 (49.8% reduction). The SB volumes that received a dose of 10~50 Gy were significantly reduced in 3D-CRT (65~80% reduction) and IMRT plans (54~67% reduction) using the SBDS. When the SB volumes that received 20~50 Gy were compared between the 3D-CRT and IMRT plans, those of the IMRT without the SBDS were significantly less, by 6~7%, than those for the 3D-CRT without the SBDS, but the volume difference was less than 1% when using the SBDS. CONCLUSION: The SBDS reduced the radiation dose to the SB in both the 3D-CRT and IMRT plans, so could reduce the radiation injury of the SB.
Cervix Uteri* ; Female ; Humans ; Immobilization ; Prone Position ; Radiation Injuries ; Radiotherapy ; Uterine Cervical Neoplasms*

PURPOSE: This study evaluated early bowel complications in cervix cancer patients, following external radiotherapy (ERT) and high dose rate intracavitary radiation (HDR ICR). Factors affecting the risk of developing early bowel complications and its incidence are analyzed and discussed. MATERIALS AND METHODS: The study is the retrospective review of 66 patients who received radiotherapy at Chungbuk National University Hospital from April 1994 to December 1998. The patients underwent 41.4 or 50.4 Gy ERT according to FIGO stage and tumor size, then A point dose was boosted to 71.4 or 74.4 Gy using a remotely controlled afterloading Buchler HDR ICR. The EORTC/RTOG morbidity criteria were used to grade early bowel complications, which are valid from day 1, the commencement of therapy, through day 90. The actuarial incidence, severity of complications were investigated and clinical pretreatment factors relevant to complications were found through univariate (Wilcoxon) and multivariate (Cox proportional hazard model) analysis. RESULTS: Of the 66 patients, 30 patients (46%) developed early bowel complications; 25 patients (38%) with grade 1 or 2, 4 patients (6%) with grade 3 and 1 patient (2%) with grade 4. The complications usually began to occur 3 weeks after the commencement of radiotherapy. The actuarial incidence of early bowel complications was 41% at 10 weeks. The early bowel complications were associated significantly with an old age and a history of previous abdomino-pelvic surgery. All three patients who had a protracted overall treatment time (about 2 weeks) due to severe bowel complication, suffered from pelvic recurrences. CONCLUSION: Forty six percent of patients experienced early bowel complications, most of which were grade 1 or 2 and relieved spontaneously or by medication. The patients with an old age or a previous surgery have a high probability of early complications and they may be less compliant with planned radiotherapy. So more careful precaution is necessary for these patients.
Cervix Uteri* ; Chungcheongbuk-do ; Female ; Humans ; Incidence ; Radiotherapy* ; Recurrence ; Retrospective Studies ; Uterine Cervical Neoplasms

PURPOSE: This paper reports a dosimetric study of 88 patients treated with a combination of external radiotherapy and high dose rate ICR for FIGO stage IIB carcinoma of the cervix. The purpose is to investigate the correlation between the radiation doses to the rectum. external radiation dose to the whole pelvis. ICR reference volume. TDF, BED and the incidence of late rectal complications, retrospectively METHODS AND MATERIALS: From November 1989 through December 1992, 88 patients with stage IIB cervical carcinoma received radical radiotherapy at Department or Radiation Oncology in Yonsei University Hospital. Radiotherapy consisted of 44-54 Gy(median 49 Gy) external beam irradiation plus high dose rate intracavitary brachy therapy with 5 Gy per fraction twice a week to a total dose of 30 Gy on point A. The maximum dose to the rectum by contrast(r,R) and reference rectal dose by ICRU 38(dr, DR) were calculated. The ICR reference volume was calculated by Gamma Dot 3.11 HDR planning system, retrospectively. The time-dose factor(TDF) and the biologically effective dose (BED) were calculated. RESULTS: Twenty seven(30.7%) of the 88 patients developed late rectal complications : 12 patients(13.6%) for grade 1, 12 patients(13.6%) for grade 2 and 3 patients(3.4%) for grade 3. We found a significant correlation between the external whole pelvis irradiation dose and grade 2, 3 rectal complicaition. The mean dose to the whole pelvis for the group of patients with grade 2, 3 complication was higher, 4093.3+/-453.1 cGy, than that for the patients without complication 3873.8+/-415.6 (0.05p<0.1). The gradual increase in the frequency of grade 2, 3 rectal compication increased as a function of the dose of external beam therapyto the whole pelvis(midline shielding start dose) and total rectal dose. The mean total rectal dose by rectal barium(R) for the group of patients with grade 2, 3 rectal complication was higher, 7163.0+/-838.5 cGy, than that for the patients without rectal complication, 6772.7+/-884.0(p<0.05). There was no correlation of the rate of grade 2, 3 rectal complication with the ICR rectal doses(r,dr), ICR reference volume, TDF and BED. CONCLUSION: This investigation has revealed a significant correlation between the dose calculated at the rectal dose by ICRU 38(DR) or the most anterior rectal dose by contrast(R), dose to the whole pelvis and the incidence of grade 2,3 late rectal complications in patients with stage IIB cervical cancer undergoing external beam radiotherapy and HDR ICR. Thus there rectal reference points doses and whole pelvis dose appear to be useful prognostic indicators of late rectal complication in high dose rate ICR treatment in cervical carcinoma.
Brachytherapy* ; Cervix Uteri* ; Female ; Humans ; Incidence ; Pelvis ; Radiation Oncology ; Radiotherapy ; Rectum ; Retrospective Studies ; Uterine Cervical Neoplasms

PURPOSE: The purpose of this study was to investigate the positional change of the uterus during radiotherapy MATERIALS AND METHODS: Between 1997 and 2001, 47 patients received definitive radiotherapy for cervical cancer at the Samsung Medical Center. For each patient, two MRI scans were taken; one before and the other 3~4 weeks after the radiotherapy treatment. In T2 weighted MRI images, the positional change of the uterine was quantified by measuring six quantities; the distance from the cervix os to the isthmus of the uterus (Dcx), the maximum length from the isthmus of the uterus to the uterine fundus (Dco), the maximum vertical distance of the uterine body (Dco-per), the angle between the vertical line and the cervical canal in the sagittal images (Acx), the angle of the uterine corpus from the vertical line in the sagittal plan (Aco-ap), and the relative angle of the uterine corpus from a fixed anatomical landmark in the axial images (Aco-axi). RESULTS: The mean Dcx values, before and during the treatment, were 36.7 and 27.8 mm, respectively. The Dco deviated by more than 10 mm in 14 cases (29.8%). The change in the Acx ranged from 0.1 to 67.8degrees (mean 13.2degrees). The Aco-ap changed by a maximum of 84.8degrees (mean 16.9degrees). The differences in the Dcx plus the Dco in the smaller (<4 cm) and larger (>or= 4 cm) tumors were 5.3 and 19.4 mm, respectively. With patients less than 60 years old, or with a tumor size larger than 4 cm, the difference in the Acx was statistically significant. CONCLUSION: The positional changes of the uterus, during radiation treatment, should be considered in the 3DCRT or IMRT treatment planning, particularly in patients under 60 years of age or in those with a tumor size greater than 4 cm in maximum diameter.
Cervix Uteri* ; Female ; Humans ; Magnetic Resonance Imaging ; Middle Aged ; Radiotherapy* ; Uterine Cervical Neoplasms* ; Uterus*