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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5186_Библиотеки_им_академика_М_И_Перельмана.pdf
brachytherapyplanningbasedonCTorMRIofthepelviswiththeapplicatorsinplace.
Tumorvolumesandcriticalstructuresarecontouredasisdone withmodernexternalbeam
radiation therapy planning. The application of these methods in brachytherapy is complex
because of the heterogeneous distribution of radiation doses around the brachytherapy
sources.Althoughthetransitiontoimage-guidedbrachytherapyshouldbeimplemented
withcaution,recentstudieshaveindicatedthatthesemethodscanbeusedtoimprove
localcontrolratesanddecreasetheriskoflatecomplications(94,95).
InterstitialImplants
Interstitial brachytherapy refers to the placement of radioactive sources within tissues.
Various sources of radiation—such as
192
Ir,
198
Au,
103
Pd, and
125
I—may be obtained as
radioactive wires or seeds.
192
Ir may be obtained as separate sources that are usually
distributed at regular intervals (usually 1 cm) in Teflon tubes or as wires with activity
specifiedin terms of the mCipercentimeter.Today,most gynecologicinterstitialimplants
areperformedusing asteppingsource of
192
Irandare deliveredeitherusing afractionated
high–dose-ratescheduleorapulseddoserate.
Figure 5.12 Interstitial implant for a stage II adenocarcinoma of the vagina. The initial
tumor(left)involved the anterior andlateralwallsofthedistalvagina,displacingthe urethra.
The patient was initially treated with IMRT, delivering 50 Gy to gross disease and 45 Gy to
areas at risk for microscopic disease. She then had one pulsed–dose-rate brachytherapy
treatment. Ten needles were inserted transperineally, parallel to the vaginal wall (center).
Needleswereinsertedfreehandunderdigitalguidancetoassureaccurateplacement;a3-cm
diametercylinderwithcentral andperipheralchannelswasalsoplaced in thevaginaandthe
implantwassecuredtomaintainitspositionduringtreatment.Thepatientreceivedatotaldose
of20 to 24 Gy over 66 hoursat a dose rateof approximately 45 cGyper hour (right). At 6
years, she has no evidence of disease and is without GU or GI complaints. (Modified with
permission from figure CS11.3 in Eifel P, Klopp AH. Gynecologic Radiation Oncology. A
PracticalGuide,1sted.Philadelphia,PA:WoltersKluwer;2017:113–131.)
Sourcesmaybepositionedinthetumorortumorbedinavarietyofways:
1. Permanentseedimplants(usually
125
I,
103
Pd,or
198
Au).Thesecanbeinsertedusinga
specializedseedinserter.Theseimplantsaremostcommonlyusedtotreatprostatecancer
butaresometimesusedtotreatpelvicoraorticlymphnodes,particularlyinthecaseof
nodalrecurrenceafterirradiation.
2. Temporary Teflon catheter implants. These can be placed intraoperatively and
subsequently loaded with radioactive sources (usually
192
Ir). Catheters may be sutured
directly against the operative bed or placed in a silicone rubber template that can be
placedontheoperativebed.
3. Compositetemporaryimplants.Theseallow placementof interstitialneedlesthrough
vaginalintracavitaryapplicators.Variousformsincludevaginalovoids,ringapplicators,
and vaginal cylinders that permit insertion of catheters trans-vaginally through the
vaginalapplicatorsintoparacervicaltissues.
4. Temporary transperineal implants. These can be placed freehand, an approach that
may allow better control of needle placement in selected cases. Freehand implants are
particularlyusefulfortreatingurethralandvaginaltumors(Fig.5.12).
5. Temporary transperineal template-guided interstitial needle implants (Fig. 5.13).
Thesecanbe placed using a Lucite templatewithregularly spaced holes and a central
obturatorthatcanholdatandemoradditionalneedles.Needlesareafter-loaded,usually
with
192
Ir. These implantsareused to treat vaginal andsomecervical tumors. In some
cases, particularly for treatment of apical vaginal lesions, guidance by laparoscopy or
laparotomyorreal-timeMRImaybeusedtoguideneedleplacement(96,97).
Likeintracavitarytherapy,interstitialtherapydeliversarelativelyhighdoseofradiationtoa
smallvolume,sparingthesurroundingnormaltissues.However,therisktonormaltissues
adjacenttothe tumor orinthe tumor bed maystillbesignificant,particularly if the
needle placement is inaccurate. Also, although interstitial implants often permit
deliveryofahighertumordosethanexternalbeamtherapy,thisisonlyadvantageousif
theentiretarget volumecanbetreatedtoatumoricidaldose(usually atleast65 to70
Gy).Ifanatomicfactorspreventplacementofanimplantthatwillcovertheentiretarget,itis
sometimesbettertotreatusingexternalbeamtherapyalone.
Some investigators have advocated the use of perineal template-guided interstitial
brachytherapytotreatdifficult cases of locally advanced cervical cancer (98,99). The
abilitytoplacesourcesinthelateralparametriumwiththistechniquesuggestsatheoretical
advantage over intracavitary treatment for patients with pelvic sidewall involvement.
However,the placement of straight needles into an irregular target volume surrounded by
rectum, small bowel and bladder poses some particularly difficult challenges. Some
investigators have claimed high local control rates with this approach (98,99). However,
survivalrateshavenotbeenclearlysuperiortothoseachievedwithcombinedexternal
beamandintracavitarytherapy, and the risk of major complications may be greater
(31,100).Compositeapplicatorsthatuseinterstitialneedlesonlytosupplementintracavitary
treatments hold promise, particularly for patients who have eccentric disease involving
parametrium (101). Because the risk of major complications is high if sources are placed
close to a hollow viscus, interstitial implants should only be performed by experienced
brachytherapistsusinghigh-qualityimageguidance,preferablyMRI.
Figure 5.13 A perineal template with a central vaginal cylinder (left) used to treat a
patient with an apical recurrence of endometrial cancer. This was used to guide 10
needles through the cylinder and paravaginal tissues and into an apical vaginal tumor;
laparoscopicguidancewasused to retractbowelandbladderduringthe insertion. Thegross
tumor had initially received 50 Gy of external beam irradiation. The dose distribution
achievedfrominterstitialbrachytherapy(right).Theredfillrepresents the target high-risk
tumorvolume (HRCTV). The dose deliveredwith pulsed–dose-rate brachytherapy was 30to
32Gy,bringingthetotaltumordoseto80 to 82 Gy.(Reprinted with permissionfromEifel P,
Klopp AH. Gynecologic Radiation Oncology. A Practical Guide, 1st ed. Philadelphia, PA:
WoltersKluwer;2017.)
The radiation oncology community remains polarized as to the appropriateness of
interstitial therapy for patients with intact cervical carcinomas and as yet no
randomized trials have been conducted to compare the therapeutic ratio of
conventional intracavitary irradiation with that of interstitial treatment. However
interstitial implants play a critical role in the treatment of most vaginal cancers, vaginal
recurrencesofcervicalorendometrialcancer,andsomeurethralcancers.
Palliation
Radiationtherapyplaysanimportantroleinthepalliationofadvancedandmetastatic
gynecologiccancers.Patientswhosediseaseisconfinedtothepelvisandregionalnodesare
usually treated with curative intent. However, for patients who have incurable metastatic
disease,ashortcourseofradiationtherapycanproviderapidimprovementinsymptomsfor
many patients. In particular, radiation therapy is usually very effective for controlling
pain or bleeding from central pelvic cancers. The tumor is typically treated using
hypofractionated external beam therapy; some of the fractionation schedules that are
commonlyusedinclude30Gyin10fractions,20Gyin4fractions,or9to10Gyinasingle
fraction.Althoughthesetreatmentscangivepromptandoftenprolongedreliefofsymptoms,
theywillnotsterilizethetumorinthetreatedregion.
Hypofractionatedexternalbeamtreatmentshouldneverbeusedtotreatbleedingpelvic
tumors if there is a chance of cure because the exposure of normal tissues to high
fractional doses of radiation compromises the ability to deliver a definitive
comprehensivetreatmentplan.
Radiationisgenerally very effective in relievinglocalized pain from bonemetastases.
Mediastinal irradiation can be effective in relieving vascular or tracheobronchial
obstruction.Spinalcordcompressionisanindicationforemergencyradiationtherapy
ifsurgicalinterventioniscontraindicatedandtypicallyprovidesatleasttemporaryreliefof
symptomsfrom brain metastases.Patients who receiveradiationtherapy forspinalcord or
brainmetastasesshould alwaysreceivedexamethasonebeforeradiation tocontrolpotential
swelling during the initial phase of treatment. The steroids can usually be tapered rapidly
afterthepatienthasstabilized.
Beforeadecisionismadetotreatwithpalliativeintent,acarefulevaluationshouldbe
madetoconfirmthatthereisnochanceofcure.Evensomepatientswitholigometastatic
diseasehave been cured with definitivecourses of radiation. Survival ratesas high as 30–
40% have been reported for patients with stage IVB cervical cancer based on positive
supraclavicular nodes (87). There have also been reports of cures in patients with limited
brain,bone,mediastinal,orlungmetastases(102).
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6
Pathology
ChristinaS.Kong
TeriA.Longacre
Theindividualorganswithinthegenitaltractmakeupanextendedmülleriansystemthatcan
give rise to a wide variety of histologically similar tumors and be problematic for tumor
classificationandassignmentofprimarysite.Thischapterprovidesanoverviewofthemain
tumors that are encountered in the female genital tract, emphasizing key histopathologic
featuresandpertinentancillarydiagnosticstudies.
To maximize the information provided by pathologic examination, it is important that the
treating clinician understand basic concepts of gynecologic oncologic pathology. It is
similarlyimportantforthepathologisttounderstandbasicclinical,radiologic,andserologic
data. The integration of clinical, radiologic, and pathologic information is central to
intraoperative evaluation, and ultimately to treatment planning, and it occurs best
within the framework of the multidisciplinary tumor board conducted in most major
cancercenters.