Ultrasound for diagnosing and preventing malplacement of intrauterine tandems.

Postoperative B-mode ultrasound was used to evaluate final tandem position in 50 consecutive placements (28 patients). In 34% (17 of 50), the tandem was found to be suboptimally positioned; in 24% (12 of 50), it penetrated the myometrium; and in 10% (five of 50), it frankly perforated the uterus. The uterine fundus was the region most commonly perforated, and the anterior myometrium was the site most frequently penetrated. In all cases in which postoperative ultrasound showed malpositioning, the clinical and radiographic assessment indicated proper intracavitary placement. Ultrasound affected clinical management in 42% (21 of 50) of the placements involving 61% (17 of 28) of the patients. To improve tandem placement, we used intraoperative real-time ultrasound to guide 73 consecutive surgical insertions. Ultrasound clearly visualized the procedure, allowing tandems to be positioned with confidence even in the most difficult cases. The immediate feedback from intraoperative ultrasound eliminated malplacements and thus the need for a second anesthesia to reposition the tandem.

Postoperative radiation therapy for incompletely resected colorectal carcinoma.

The efficacy of high-dose post-operative radiation therapy was evaluated in 56 patients with pathologically proven or suspected residual disease after surgical resection of colon or rectal carcinoma. Patients had either microscopic or gross residual. They were treated with pelvic or abdominal irradiation to a dose of 4500 cGy followed by boost therapy to as much as 6000 to 7000 cGy if small bowel could be moved from the radiation field. Patients with microscopic residual had a local failure rate of 30% compared to 57% in those with gross residual disease. Five-year disease-free survival was 45% in patients with microscopic versus 10.6% for those with gross residual tumor. There was a trend toward a dose response curve for those with microscopic disease, but none was noted with gross residual. In view of the limited results obtained with current external beam techniques, it is recommended that newer avenues, such as high-dose preoperative therapy combined with intraoperative radiation, be investigated in this poor prognosis group.

Intraoperative real-time ultrasonography during intrauterine tandem placement.

Real-time ultrasound is used in the operating room as an aid in the placement of the intrauterine tandem. This method provides excellent imaging of the ongoing procedure, facilitating final tandem placement in the endometrial cavity even in the most difficult case.

Ultrasound used for assessing the in situ position of intrauterine tandems.

Intracavitary radiation is an integral part of the treatment in many gynecologic cancers. The intrauterine tandem has a well-established role in treating both cervical and endometrial malignancies. The effectiveness of this therapy and its complications are directly related to the proper intracavitary position of the tandem. To date, there has been no objective technique appropriate for routine use in assessing the precise in situ location of these devices, apart from plain abdominal films. As such, little is known about the incidence or types of procedural complications and the sequelae associated with improper tandem placement. Here it is reported that ultrasound is an effective tool for evaluating the in situ position of the intrauterine tandem. Two cases are presented demonstrating important applications of this method.