3T multiparametric MRI-guided high-dose-rate combined intracavitary and interstitial adaptive brachytherapy for the treatment of cervical cancer with a novel split-ring applicator.

PURPOSE: To evaluate the role of 3T-MRI-guided adaptive high-dose-rate (HDR) combined intracavitary and interstitial brachytherapy for cervical cancer using a novel intracavitary split-ring (ICSR) applicator adapter. METHODS AND MATERIALS: We retrospectively reviewed all HDR brachytherapy cases from 2013 to 2015 using an ICSR applicator. Initial optimization was performed using 3T multiparametric MRI (mpMRI) series with an applicator in place. The mpMRI series were discretionarily acquired before subsequent fractions for possible target adaptation. When necessary, interstitial needles (ISNs) were inserted through a novel ICSR adapter or freehand. Dosimetric parameters, clinical outcomes, and toxicities were compared between groups. RESULTS: Seventeen patients were included, with a mean followup of 32 months. An mpMRI series preceded each initial fraction and 52.9% of patients underwent ≥1 additional pretreatment mpMRI. Among these subsequent fractions, the high-risk clinical target volume was reduced in 80% vs. 41% without pretreatment mpMRI. Five patients had ISN placement (seven insertions) to improve extracervical target coverage. Mean D90 (Gy) per fraction to the high-risk clinical target volume and intermediate-risk clinical target volume with and without an ISN were 7.51 ± 1.07 vs. 6.14 ± 0.52 (p = 0.028) and 6.35 ± 0.75 vs. 5.21 ± 0.49 (p = 0.007), respectively. Mean fractional D2cc (Gy) for organs at risk was comparable. No Grades 3-4 toxicity was reported. Disease-free survival and local control for the ICSR-ISN and ICSR-alone groups were 29.8 months/80.0% and 31.2 months/83.3%, respectively. CONCLUSIONS: The mpMRI acquisition with ICSR applicator in place immediately before HDR brachytherapy for cervical cancer guided successful adaptive treatment optimization and delivery. Our initial experience with a novel interstitial adapter for the split-ring applicator demonstrated excellent target coverage without compromising organs at risk, resulting in good local control and disease-free survival.

Standardization of laparoscopic pelvic examination: a proposal of a novel system.

Objective. Laparoscopic pelvic assessment is often performed in a nonstandardized fashion depending on the surgeon's discretion. Reporting anatomic findings is inconsistent and lesions in atypical locations may be missed. We propose a method for systematic pelvic assessment based on anatomical landmarks. Design. Retrospective analysis. Setting. Tertiary care academic medical center. Intervention. We applied this system to operative reports of 540 patients who underwent diagnostic or operative laparoscopy for unexplained infertility between 2006 and 2012. The pelvis was divided into 2 midline zones (zone I and II) and right and left lateral zones (zone III and IV). All reports were evaluated for the comprehensiveness of description with respect to normal findings or pathology for each zone. Results. Of 540 surgeries, all reports commented on the uterus, tubes, and ovaries (100%), but only 17% (n = 93, 95% CI: 13.8-20.2) commented on the dome of the bladder and the anterior cul-de-sac. 24% (n = 130, 95% CI: 20.4-27.6) commented on the posterior cul-de-sac, and 5% (n = 29, 95% CI: 3.2-6.8) commented on the pelvic sidewall. Overall, 6% (n = 34, 95% CI: 4-8) reported near complete documentation of the pelvic zones. Conclusion. Implementation of a systematic approach for laparoscopic pelvic examination will enhance the diagnostic accuracy and provide better communication between care providers. In the absence of pelvic pathology, we recommend a minimum of 6 photographs of the 6 pelvic zones.