Ultrasound-Guided Brachytherapy for Cervical Cancer - A Tool for Quality Improvement in Brachytherapy?

Nowadays, brachytherapy is one of the major components to treat inoperable cervical cancer. Brachytherapy yields a higher dose to the target (cervix) while sparing normal tissues. Developments of brachytherapy stepped forward in the previous decade by image-guided brachytherapy (IGBT) turning brachytherapy from point-based planning to volume-based planning and IGBT improves the treatment quality for cervical cancer. Magnetic resonance imaging (MRI) or computed tomography (CT) is utilized in brachytherapy and showed promising results internationally. However, in a limited-resource area, the implementation of IGABT is difficult due to many causes (manpower, equipment, or budgets). To improve the quality in limited resources, ultrasound is introduced. The utilization of ultrasound in brachytherapy practice is to prevent uterine perforation during application. With present data, measurement by ultrasound showed the correlation to MRI measurement in uterine dimensions. With these aspects, there are many researches using ultrasound to improve the quality of treatment in brachytherapy, for example, to guide contouring on CT or to support brachytherapy planning. The use of ultrasound improves the quality of brachytherapy in comparison to conventional planning and supports the improvement in brachytherapy for cervical cancer.

Comparative dosimetry of brachytherapy treatment planning between a volume-based plan by CT and a point-based plan by TAUS in CT datasets for brachytherapy

Aim: To evaluate comparative dosimetry of brachytherapy treatment planning between a volume-based plan by computed tomography (CT) and a point-based plan by transabdominal ultrasound (TAUS) in CT datasets for brachytherapy. Materials and methods: From 2019 to 2021, 59 different datasets of CT images were collected from 38 patients treated by intracavitary brachytherapy with tandem ovoid or tandem ring applicators. At that time, TAUS was performed to prevent uterine perforation and to evaluate topography of the cervix during application. In volume-based planning by CT, the target dose was used to keep the dose at 90% of high-risk clinical target volume (HR-CTV), to give a dose of at least 7Gy, while in the point-based plan by TAUS, the target dose was used to keep the minimum dose to eight cervix reference points (measured by TAUS), to give a dose of at least 7Gy. The doses to targets and organs at risk were evaluated and compared between volume-based planning by CT and the point-based plan by TAUS. Results: Of 59 fractions, a tandem ovoid applicator was used in 48 fractions (81·3%). In the volume-based plan by CT, the mean doses to HR-CTV(D90), intermediate-risk clinical target volume (IR-CTV)(D90), bladder(D2cc), rectum(D2cc) and sigmoid colon(D2cc) were 7·0, 3·9, 4·9, 2·9 and 3·3 Gy, respectively, while in the point-based plan by TAUS, the mean doses to HR-CTV(D90), IR-CTV(D90), bladder(D2cc), rectum(D2cc) and sigmoid colon(D2cc) were 8·2, 4·6, 5·9, 3·4 and 3·9 Gy, respectively. The percentages of mean dose differences between TAUS and CT of HR-CTV(D90), IR-CTV(D90), bladder(D2cc), rectum(D2cc) and sigmoid colon(D2cc) were 17·7, 19·5, 20·5, 19·5, 21·3 and 19·8%, respectively. With the target dose to the point-based plan by TAUS (7 Gy to the cervix reference points), this was close to D98 of HR-CTV with a mean percentage of difference of 0·6%. Findings: The point-based plan by TAUS showed higher values to targets and organs at risk than the volume-based plan by CT. With the point-based plan by TAUS, it was close to D98 of HR-CTV.

POSITIVE ADAPTIVE RESPONSE OF WOMEN IN LOW SOCIO-ECONOMIC CLASS FOR CHANGE OF CONTRACEPTIVE METHOD FROM COMBINED CONTRACEPTIVE PILLS TO COPPER INTRAUTERINE DEVICE

Objective: To ensure family spacing in our low socio-economic class. Study Design: Quasi-experimental study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2018 to Dec 2019. Methodology: Two hundred females using oral contraceptive pills for spacing of children coming to Pak Emirates Military Hospital were selected. The problems of using contraceptive pills were identified. Out of these 87 women agreed to choose an intrauterine copper device (IUCD). Results: Out of 200 women 87 converted from oral contraceptive pills to intrauterine copper device use. Most of them faced daily dosage problems 168 (84%). Nausea was encountered by 123 (61.5%) women and later settled in 89 (44.5%) women. About 31 (15.5%) were worried about the chances of uterine perforation and 56 (28%) were worried about lost intrauterine copper device resulting in laparotomy. About 65 (32.5%) were afraid of infection, backache and vaginal discharge. About 91 (45.5%) women thought to have gastric problems with the intrauterine copper device. About 71 (81%) agreed to have a spacing of children for about five years and removal whenever desired. Conclusion: Intrauterine contraception is a very safe and efficient method for contraception as compared to oral pills. If expertise is, available it should be used and couples should be fully educated for its safety.

Medical Management of Pyometra in the Delayed Postoperative Period

Pyometra is a rare condition in which purulent material becomes entrapped within the uterine cavity. If unrecognized in a timely fashion, life-threatening complications can arise. The following is a case report of a 50-year-old female who presented to the emergency department with abdominal pain and heavy vaginal bleeding. She was diagnosed with a pyometra based on imaging and treated conservatively with antibiotics. The patient ultimately had an uncomplicated hysterectomy with resolution of normal female pelvic anatomy prior to surgery. Pyometra should be considered when women present with diffuse abdominal pain or peritonitis. As demonstrated in this report, early detection and conservative management may help prevent serious complications such as uterine perforation, lead to shorter hospital stays, and result in safer operative management.

AN UNUSUAL CASE OF POSTPARTUM CHORIOCARCINOMA WITH VAGINAL METASTASIS AND UTERINE PERFORATION

Gestational trophoblastic disease is a heterogenous group of interrelated lesions that arise from abnormal proliferation of placental 1 trophoblasts . Choriocarcinoma differs from any type of villous trophoblast and is the most aggressive GTN and is highly chemosensitive. When a patient reports with irregular bleeding during her postpartum or postabortion, pregnancy related causes should be ruled out. We describe a patient who presented to us after a term pregnancy and was diagnosed to have stage III choriocarcinoma.

586 Peri-Pancreatic Migration of Lost Intra Uterine Device: Case Report and Review of Literature

Intra uterine devices (IUDs) is one of the most effective form of contraception available today. Uterine perforation and IUD migration is a rare but serious complication and is reported to occur in 0.05 to 13 cases out of 1000 IUCD placements. Migration of IUD to pelvis and lower abdominal organs following uterine perforation has been reported widely in literature. However far migration into the upper abdomen in very rare. Here we report a case asymptomatic peri-pancreatic migration of IUD. A 65-year-old lady being investigated for pneumonia was picked up to have an asymptomatic IUD lying in front of the pancreas. The patient recalled having a hormonal Mirena coil placed 12 years previously for menopausal symptoms. Routine 3-year general practitioner follow-up failed to detect the IUD on vaginal examination. The patient denied spontaneous IUD discharge. However, three subsequent pelvic ultrasound scans did not detect any retained IUD and she was discharged as unrecognized IUD expulsion. She remained asymptomatic for the next 12 years with no abdominal symptoms though she did report to the General Practitioner, multiple episodes of new onset hot flushes when opening bowels - which was managed conservatively with reassurance. It was decided to surgically remove the IUD. Intraoperatively, the IUD was found densely adherent to the lesser omentum close to the pancreas and stomach and was removed safely laparoscopically. The patient made a good postoperative overnight recovery and was discharged. Intra-abdominal migration of IUDs is a very rare complication of IUD insertion and when detected should be promptly treated with Laparoscopic removal.