Single- versus Multi-computed Tomography Simulation for High-dose-rate Postoperative Gynecological Intracavitary Brachytherapy.

Introduction: This study aimed to investigate whether there is a dosimetric difference of implementing single instead of multi-computed tomography (CT) simulation treatment planning for high-dose-rate postoperative gynecological intracavitary brachytherapy (BT). Materials and Methods: Eighty patients were registered in the study. They received three BT fractions of 7 Gy/week (three CTs, three original plans). The organs at risk (OAR), the rectal wall, and the clinical target volume (CTV) were delineated. The delivered doses for the 2cc of OARs (D2cc), 1cc of rectal wall (D1cc), as well as for the 90% and 100% of CTV volume (DCTV90%, DCTV100%) were evaluated. To evaluate the values of the above parameters if the single-CT-simulation method has been chosen, the time of the first treatment plan was corrected for the decay and applied as the second and third CT, retrospectively, creating the next fractions (two revised plans). Results: No statistically significant (P > 0.05) differences were found between the original and revised plans for the OARs and CTV. However, for the single-CT-simulation method, it was noted that the dose constraints for the total rectal dose were exceeded in some cases (36.3%). Conclusion: The fact that rectal dose constraints were exceeded in 1/3 of patients with the single-CT-simulation method is dosimetrically significant.

Predictive model for totally implanted venous access ports­related long­term complications in patients with lung cancer.

Totally implanted venous access ports (TIVAPs), which are typically used in oncological chemotherapy and parenteral nutritional support, are convenient and safe, and thus offer patients a higher quality of life. However, insertion or removal of the device requires a minor surgical operation. Long-term complications (>30 days post insertion), such as catheter migration, catheter-related thrombosis and infection, are major reasons for TIVAP removal and are associated with a number of factors such as body mass index and hemoglobin count. Since management of complications is typically time-consuming and costly, a predictive model of such events may be of great value. Therefore, in the present study, a predictive model for long-term complications following TIVAP implantation in patients with lung cancer was developed. After excluding patients with a large amount of missing data, 902 patients admitted to The First Affiliated Hospital with Nanjing Medical University (Nanjing, China) were ultimately included in the present study. Of the included patients, 28 had complications, indicating an incidence rate of 3.1%. Patients were randomly divided into training and test cohorts (7:3), and three machine learning-based anomaly detection algorithms, namely, the Isolation Forest, one-class Support Vector Machines (one-class SVM) and Local Outlier Factor, were used to construct a model. The performance of the model was initially evaluated by the Matthew's correlation coefficient (MCC), area under curve (AUC) and accuracy. The one-class SVM model demonstrated the highest performance in classifying the risk of complications associated with the use of the intracavitary electrocardiogram method for TIVAP implantation in patients with lung cancer (MCC, 0.078; AUC, 0.62; accuracy, 66.0%). In conclusion, the predictive model developed in the present study may be used to improve the early detection of TIVAP-related complications in patients with lung cancer, which could lead to the conservation of medical resources and the promotion of medical advances.

Delineation of intracavitary electrograms for the automatic quantification of decrement-evoked potentials in the coronary sinus with deep-learning techniques.

Cardiac arrhythmias cause depolarization waves to conduct unevenly on the myocardial surface, potentially delaying local components with respect to a previous beat when stimulated at faster frequencies. Despite the diagnostic value of localizing the distinct local electrocardiogram (EGM) components for identifying regions with decrement-evoked potentials (DEEPs), current software solutions do not perform automatic signal quantification. Electrophysiologists must manually measure distances on the EGM signals to assess the existence of DEEPs during pacing or extra-stimuli protocols. In this work, we present a deep learning (DL)-based algorithm to identify decrement in atrial components (measured in the coronary sinus) with respect to their ventricular counterparts from EGM signals, for disambiguating between accessory pathways (APs) and atrioventricular re-entrant tachycardias (AVRTs). Several U-Net and W-Net neural networks with different configurations were trained on a private dataset of signals from the coronary sinus (312 EGM recordings from 77 patients who underwent AP or AVRT ablation). A second, separate dataset was annotated for clinical validation, with clinical labels associated to EGM fragments in which decremental conduction was elucidated. To alleviate data scarcity, a synthetic data augmentation method was developed for generating EGM recordings. Moreover, two novel loss functions were developed to minimize false negatives and delineation errors. Finally, the addition of self-attention mechanisms and their effect on model performance was explored. The best performing model was a W-Net model with 6 levels, optimized solely with the Dice loss. The model obtained precisions of 91.28%, 77.78% and of 100.0%, and recalls of 94.86%, 95.25% and 100.0% for localizing local field, far field activations, and extra-stimuli, respectively. The clinical validation model demonstrated good overall agreement with respect to the evaluation of decremental properties. When compared to the criteria of electrophysiologists, the automatic exclusion step reached a sensitivity of 87.06% and a specificity of 97.03%. Out of the non-excluded signals, a sensitivity of 96.77% and a specificity of 95.24% was obtained for classifying them into decremental and non-decremental potentials. Current results show great promise while being, to the best of our knowledge, the first tool in the literature allowing the delineation of all local components present in an EGM recording. This is of capital importance at advancing processing for cardiac electrophysiological procedures and reducing intervention times, as many diagnosis procedures are performed by comparing segments or late potentials in subsequent cardiac cycles.

Dosimetric comparison of intra-cavitary brachytherapy technique with free-hand (intra-cavitary + interstitial) technique in cervical cancer.

Purpose: The aim of the study was to dosimetrically compare intra-cavitary brachytherapy technique (ICBT) with free-hand (intra-cavitary + interstitial, IC + IS) technique. Material and methods: Twenty seven locally advanced carcinoma cervix patients were included in the study. Patients with more than medial 1/3rd parametrial residual disease without extending upto lateral pelvic wall were included, following external beam radiotherapy (EBRT), in which cobalt-60 high-dose-rate (60Co HDR) brachytherapy source was used. Dose for both plans were 6.5 Gy × 4 fractions, 2 fractions per day, 6 hours apart, over 2 days. Free-hand brachytherapy technique, consisted of placement of central tandem and 2 ovoids along with needles without using template, was applied. Two plans were generated by activating and deactivating the needles, and compared by normalizing to V100. Results: A total of 79 needles were applied. Using paired-t test, dosimetric comparison of both the plans was done. Free-hand plan had a significant higher mean V90 (volume receiving 90% of the dose) of 94.2% compared with 87.22% in ICBT plan (p ≤ 0.0001). Free-hand and ICBT plans presented a mean V100 values of 89.06% and 81.51% (p ≤ 0.0001), respectively, favoring free-hand plan. The mean D90 (dose to 90% volume), D98, and D100 of free-hand plan were 6.28 Gray (Gy), 4.91 Gy, and 3.62 Gy, respectively, but equivalent parameters in ICBT plan were 5.26 Gy, 3.72 Gy, and 2.61 Gy, with p value ≤ 0.0001. In both the plans, D2cc of the bladder, rectum, and sigmoid were 4.59 Gy, 3.98 Gy, 2.77 Gy, and 4.46 Gy, 3.90 Gy, 2.67 Gy, respectively, with no statistical significance. Conclusions: Free-hand brachytherapy (IC + IS) achieves a statistically significant better dose distribution to high-risk clinical target volume (HR-CTV) comparing with ICBT technique with similar dose to organs at risk.

First Local Experience of Intra-Cavitary Yttrium-90 Citrate Colloid Irradiation via Ommaya Reservoir for Refractory Cystic Craniopharyngioma: a Case Report.

Craniopharyngioma is uncommon benign intracranial tumour that can be cured by surgical resection followed by conventional radiotherapy. However, its anatomical localisation makes the treatment hazardous or impossible. This case report aims to discuss the first local experience of using beta-emitting Yttrium-90 radioisotope in treating a patient with refractory cystic craniopharyngioma. A 43-year-old male who has underlying refractory cystic craniopharyngioma complicated with visual impairment and panhypopituitarism was referred to our nuclear medicine department for intra-cavitary irradiation therapy. Initially, he was presented with blurring of vision and headache which he had two previous resection surgeries of cystic craniopharyngioma. However, due to persistent symptoms, he had Ommaya reservoir shunt inserted for regular aspiration. Despite regular aspiration, his symptoms worsen. He was unsuitable for radiotherapy thus was considered for intra-cystic irradiation with radioisotope. Prior to the therapy, he had pre-therapy assessment with Tc-99 m MAA. He subsequently received Ytrrium-90 citrate colloid of 300 Gy radiation dose to the inner surface of the tumour which complicated with post therapy inflammatory reaction. This first local experience highlights the role of radioisotope as the valuable minimally invasive adjuvant therapy in treating a patient with refractory cystic craniopharyngioma. Further follow-up is necessary to assess the outcome and possible late complications.

Method to assess the need for re-planning HDR brachytherapy tandem and ring treatments.

High dose rate (HDR) brachytherapy procedures for cervical cancer require multiple applicator insertions for multiple (typically 5) fractions of a single plan, which carries a risk for variability in applicator position between fractions. Due to applicator displacement relative to patient anatomy, the dose to nearby organs-at-risk (OARs) may vary significantly from one fraction to the next. The purpose of this study was to evaluate the effect of changes in HDR tandem and ring (T&R) applicator position on doses to nearby OARs and to present a quick and simple method to estimate doses to OARs inter-fractionally without having to perform a re-plan. Ninety CT image sets for 20 patients, ages 44 to 86, undergoing T&R-based HDR for cervical cancer were used retrospectively for this study. Measures of applicator positional and angular changes relative to the bony anatomy were obtained using image fusion in MIM software, between the planning CT (plan CT) and the CT on the treatment day (CT-TX). Dosimetric data were determined, also using MIM software, using the original (first fraction) dose distribution applied to organs at risk (rectum and bladder), transferred via rigid registration from the plan CT to each CT-TX. Bladder and rectum contours were also transferred from each plan CT to each CT-TX and were tweaked manually to match anatomy on each CT-TX and examined visually for appropriateness. Differences in translation and rotation of the T&R applicator between the planning CT and subsequent individual fractions were recorded and plotted against dose differences between each fraction of treatment and the original (first) fraction. Absolute dose (D2cc) and volume (V50) differences vs positional shifts were calculated and plotted, and the Pearson Product-Moment correlation coefficient between dose parameters and measured positional shifts was determined. Average dosimetric differences between planned dose and subsequent fractional doses obtained through rigid registration were 1.48 ± 1.92 Gy, 14.91 ± 11.92 cm3, 0.56 ± 0.93 Gy, and 1.77 ± 2.18 cm3 for Bladder D2cc, Bladder V50, Rectum D2cc, and Rectum V50, respectively. Correlation between Bladder V50 and sagittal plane rotation gave an r2 of 0.4, showing the most correlation of all parameters studied. Bladder dose and volume increased by a maximum of about 2.7 Gy and 50 cm3 overall for Bladder D2cc and Bladder V50, respectively. Bladder V50 was most sensitive to T&R applicator displacements. We have quantified the effects of applicator positional changes on dose changes for the bladder and rectum. Even large changes in applicator position between fractions did not result in significant changes in dose to these normal tissues, indicating that adaptive re-planning is not necessary.

Are prophylactic antibiotics required for combined intracavitary and interstitial brachytherapy of gynecologic cancers?

The purpose of this study is to evaluate the need for prophylactic antibiotic treatment prior to combined intracavitary and interstitial (hybrid) brachytherapy for gynecologic cancer. A total of 105 gynecologic cancer patients received 405 brachytherapy sessions, including 302 sessions of intracavitary brachytherapy and 103 sessions of hybrid brachytherapy. Prophylactic antibiotics were administered before 35% of the hybrid brachytherapy sessions. The incidence of postbrachytherapy fever and the frequency of subsequent antibiotic use for infection were compared between treatment groups. Among patients treated with hybrid brachytherapy, fever ≥37.5°C occurred in 16.4% of those not receiving prophylactic antibiotics and 16.7% of those receiving prophylactic antibiotics (P > 0.05). Similarly, fever ≥38.0°C occurred in 4.9% of patients not receiving prophylactic antibiotics and 2.4% of those receiving prophylactic antibiotics (P > 0.05). Additional antibiotics were used to treat postbrachytherapy infections in 4.8% of the group receiving prophylactic antibiotics and 0% of those not receiving prophylactic antibiotics, again without statistically significant difference. There were also no significant differences in posttreatment fever incidence and antibiotics use for infection between intracavitary brachytherapy and hybrid brachytherapy sessions. In conclusion, the incidences of infection and fever are low following hybrid brachytherapy, so prophylactic antibiotics are generally unnecessary.

Effects of pain management using nonsteroidal anti-inflammatory drug suppositories during brachytherapy for cervical cancer: A single-center prospective observational study.

INTRODUCTION: No standardized pain management protocol exists for intracavitary brachytherapy, and various methods of analgesia have been used in different countries and institutions. This study aimed to investigate the effects of pain management during intracavitary brachytherapy using nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen suppositories. METHODS: In this single-center, prospective, observational study, patients undergoing intracavitary brachytherapy for cervical cancer completed a questionnaire survey after each brachytherapy session, which comprised questions regarding pain intensity, satisfaction with analgesia, and desire for effective anesthesia. RESULTS: Data analysis was performed using data from 100 brachytherapy sessions of 27 patients. The median numerical rating scale (NRS; 0-10) score for each intracavitary brachytherapy session was 3-4. The median satisfaction scale score for analgesia (5-point scale, 1-5) for each session was approximately 4. Eight patients (29.6%) answered that they desired anesthesia more effective than suppositories at any session of brachytherapy. A comparison of the high (NRS ≥4) and low (NRS ≤3) NRS groups during the first session revealed that the high NRS group tended to have higher NRS scores and lower satisfaction with analgesia during all sessions. A positive correlation was observed between tumor size and the NRS score during the first brachytherapy session. CONCLUSIONS: The NRS score was approximately 3-4, and satisfaction with analgesia was approximately 4 out of 5 when NSAIDs or acetaminophen suppositories were used as analgesics during intracavitary brachytherapy for cervical cancer. Although the current pain management protocol is clinically acceptable, inadequate analgesia is indicated in approximately 30% of patients.

Systematic application of SICA-PED protocol for central venous catheterization in neonates: A prospective clinical study on 104 cases.

BACKGROUND: Catheterization of central vessels can be associated with early and late, potentially fatal complications. A proactive approach is imperative to reduce the frequency and magnitude of adverse events. Recently, the GAVeCeLT has proposed a protocol called SICA-PED (i.e. Safe Insertion of Central Access in Pediatric patients) and includes seven evidence-based strategies. METHODS: Through a single-center prospective observational study, the authors wanted to consolidate the efficacy and safety of these protocol in newborns. In a series of 104 newborns, the seven steps of the protocol were applied (1) pre-procedural ultrasound study of the RaCeVA veins, (2) correct aseptic technique, (3) ultrasound-guided venipuncture, (4) intraprocedural localization of the tip of the catheter with TTE (ECHO TIP) and (iECG) intracavitary electrocardiogram, (5) reasoned choice of the implant exit site with the RAVESTO Tunneling technique, (6) anchoring without stitches, and (7) exit point protection with the use of glue and transparent semipermeable membrane. The authors have included a further precaution in point (6) the subcutaneous anchoring system has added the counter-fixation of the catheter wings that we will call 6Plus Point. RESULTS: All infants requiring implantation of elective us-guided central venous access were enrolled in the study. None of the 104 implanted central venous catheters experienced early complications (accidental arterial puncture, PNX, primary malposition); rare late complications such as ecchymosis, CRBSI, exit site infection or dislodgement were observed, No catheter-related thrombotic phenomena were observed. The CRBSI catheter-related infection rate was 2.47 × 1000 days catheter cases. CONCLUSION: The results of this prospective study strengthen the feasibility and efficacy of the SICA-Ped Protocol. Demonstrating that the systematic application of the evidence-based seven-step implantation strategy increases the success rate, minimizes early and late complications, which result in increased patient safety.

Immuno-Molecular Targeted Therapy Use and Survival Benefit in Patients with Stage IVB Cervical Carcinoma in Commission on Cancer®-Accredited Facilities in the United States.

PURPOSE: To investigate IMT use and survival in real-world stage IVB cervical cancer patients outside randomized clinical trials. METHODS: Patients diagnosed with stage IVB cervical cancer during 2013-2019 in the National Cancer Database and treated with chemotherapy (CT) ± external beam radiation (EBRT) ± intracavitary brachytherapy (ICBT) ± IMT were studied. The adjusted hazard ratio (AHR) and 95% confidence interval (CI) for risk of death were estimated in patients treated with vs. without IMT after applying propensity score analysis to balance the clinical covariates. RESULTS: There were 3164 evaluable patients, including 969 (31%) who were treated with IMT. The use of IMT increased from 11% in 2013 to 46% in 2019. Age, insurance, facility type, sites of distant metastasis, and type of first-line treatment were independently associated with using IMT. In propensity-score-balanced patients, the median survival was 18.6 vs. 13.1 months for with vs. without IMT (p < 0.001). The AHR was 0.72 (95% CI = 0.64-0.80) for adding IMT overall, 0.72 for IMT + CT, 0.66 for IMT + CT + EBRT, and 0.69 for IMT + CT + EBRT + ICBT. IMT-associated survival improvements were suggested in all subgroups by age, race/ethnicity, comorbidity score, facility type, tumor grade, tumor size, and site of metastasis. CONCLUSIONS: IMT was associated with a consistent survival benefit in real-world patients with stage IVB cervical cancer.

Enhancing tube feeding method for neurosurgery: the application of improved PICC technique.

BACKGROUND AND PURPOSE: Peripherally inserted central catheter (PICC) used in neurosurgical patients requires changes in patients' head positions. However, such changes can worsen pressure on the brain tissue, lead to sudden acute brain herniation and respiratory arrest, resulting in a higher chance of patient death. This paper addresses the aforementioned problems by introducing a new PICC catheterization method. METHOD: In a retrospective study, the records of patients with PICC from April 2020 to April 2023 were reviewed, and they were divided into three groups based on the methods employed. The first group as the conventional group, involved changing patients' body positions during catheterization. The second group, as the intracavitary electrocardiographic (IECG) group, utilized intracavitary electrocardiographic monitoring and involved changing patients' body positions during catheterization. The third group as the intracavitary electrocardiographic with improved body positioning (IECG-IBP) group, catheterization was performed with guidance from intracavitary electrocardiographs and without changing the patients' body positions. The ECG changes among patients undergoing different catheter delivery methods were then compared, as well as the rate of catheter tip misplacement. RESULT: The study encompassed a total of 354 cases. Our findings reveal distinct P wave amplitude percentages among the groups: 0% in the conventional group, 88.46% in the IECG group, and 91.78% in the IECG-IBP group. Furthermore, the following catheter tip misplacement rates were recorded: 11.54% for the conventional group, 5.39% for the IECG group, and 5.47% for the IECG-IBP group. Significantly notable differences were observed in these two key indicators between the conventional group and the IECG-IBP group. Notably, the IECG-IBP group demonstrated a more favorable outcome compared to the IECG group. CONCLUSION: In patients with neurosurgical diseases, especially those with tracheostomy and nuchal stiffness, the IECG-IBP PICC catheter insertion method can effectively reduce the patient's neck resistance, does not increase the patient's headache and dizziness symptoms, and does not reduce the success of one-time catheterization. Rate and does not increase the incidence of jugular venous ectopia.

Intracavitary electrocardiogram guidance for peripherally inserted central catheter placement in a patient with persistent left superior vena cava: A case report.

Intracavitary electrocardiogram (IC-ECG) guidance is widely used for peripherally inserted central catheter (PICC) placement. The P wave variation has rarely been reported in persistent left superior vena cava (PLSVC). Here, we report a PLSVC case of P wave variation in PICC placement guided by IC-ECG. In this case, the P wave variation of the PLSVC was quite different from that of the right superior vena cava (RSVC). The tip of the catheter was located at the lower segment of the left superior vena cava according to postoperative radiography examination. PICC functioned normally, and no complications occurred.

Effect of intracavitary electrocardiographic localization on the success rate and complications of PICC in infants.

BACKGROUND: Peripherally inserted central catheter (PICC) is widely used in chemotherapy of children with malignant tumors because of its safe operation and long indwelling time. OBJECTIVE: To investigate the effect of intracavitary electroencephalogram (CEEG) localization technique on the success rate and complications of PICC in infants. METHODS: A total of 180 children with PICC catheterization and maintenance at Shijiazhuang People's Hospital First Hospital from January 2017 to January 2020 were selected and divided into control group (n= 90 cases) and observation group (n= 90 cases). The control group observed the tip position of the fixed catheter through X-ray film and adjusted the catheter until its tip was located in the superior vena cava. The observation group used intracavitary electrocardiogram positioning technology. Comparison of the effects of two groups on the success rate and complications of PICC puncture in infants and young children. RESULTS: The success rate of one puncture in the observation group was significantly higher than that in the control group (P< 0.05). Within one month of catheterization, 13 cases had complications, with an incidence rate of 16.00% lower than the control group's 34.00% (27/80) (P< 0.05). The screening test results showed that the specificity, sensitivity, Youden index, accuracy, kappa coefficient, positive and negative predictive value were 88.89%, 97.56%, 0.86, 96.00%, 0.86, 0.86, respectively. The measured values were 97.56% and 88.89% respectively, and the cost and time of localization were lower than those of X-ray. CONCLUSION: The technique of intracavitary electrogram can be more accurate for infants to place the tip of central venous catheter through peripheral vein, which can effectively improve the success rate of one puncture with low cost, and has high reliability, accuracy and practicability, which is safe and effective.

Transvaginal approach combined intracavitary and interstitial brachytherapy assisted by transrectal ultrasound: results from 30 patients with locally advanced cervical cancer.

PURPOSE: This study evaluated the efficacy and safety of transvaginal approach combined intracavitary and interstitial brachytherapy (IC/IS BT) assisted by transrectal ultrasound (TRUS) for treatment of locally advanced cervical cancer (LACC). MATERIALS AND METHODS: A total of 30 patients of LACC treated with external beam radiotherapy and IC/IS BT via transvaginal approach assisted by transrectal ultrasound were observed retrospectively. The 2-year local control (LC), progression-free survival (PFS), and overall survival (OS) were analyzed using the Kaplan-Meier method. Late adverse events were also evaluated to assess the safety of IC/IS BT. RESULTS: The median follow-up period was 22 months. The 2-year LC, PFS, and OS were 90%, 61%, and 82%, respectively. We observed no critical complications related to the IC/IS BT technique. Late adverse events of grade 3 or more included one case of grade 4 colon perforation. CONCLUSION: Our patient series demonstrated that radiotherapy combined with transvaginal approach, TRUS-assisted IC/IS BT achieves favorable local control and safety for LACC.

Dose and fractionation regimen for brachytherapy boost in cervical cancer in the US.

PURPOSE: Curative-intent radiotherapy for locally advanced and select early stage cervical cancer in the US includes external beam radiotherapy (EBRT) with brachytherapy. Although there are guidelines for brachytherapy dose and fractionation regimens, there are limited data on practice patterns. This study aims to evaluate the contemporary utilization of cervical cancer brachytherapy in the US and its association with patient demographics and facility characteristics. METHODS: We retrospectively analyzed clinical covariates of cervical cancer patients diagnosed and treated in 2018-2020 with curative-intent radiotherapy from the 2020 National Cancer Database. Associations between patient and institutional factors with the number of brachytherapy fractions were identified with logistic regression. Factors with association (p < 0.10) were then included in a multivariable logistic regression model. All tests were two-sided with significance <0.05 unless specified otherwise. RESULTS: Among the eligible 2517 patients, 97.3% received HDR or LDR and is further analyzed. More patients received HDR than LDR brachytherapy (98.9% vs 1.1%) and intracavitary than interstitial brachytherapy (86.4% vs 13.6%). The most common number of HDR fractions prescribed were 5 (51.0%), 4 (32.9%), and 3 (8.6%). After adjusting for the other variables in the model, ethnicity, private insurance status, overall insurance status, and facility type were the only factors that were significantly associated with the number of brachytherapy factions (p < 0.0001, p = 0.028, p = 0.001, and p < 0.0001, respectively, n = 2184). CONCLUSIONS: In the US, various HDR brachytherapy regimens are utilized depending on patient and institutional factors. Future research may optimize cervical cancer brachytherapy by correlating specific dose and fractionation regimens with patient outcomes.

Isthmocele, not cesarean section per se, reduces in vitro fertilization success: a systematic review and meta-analysis of over 10,000 embryo transfer cycles.

IMPORTANCE: Previous reviews have shown that a history of cesarean section (CS) is associated with a worse in vitro fertilization (IVF) prognosis. To date, whether the decline in the IVF chances of success should be attributed to the CS procedure itself or to the presence of isthmocele remains to be clarified. OBJECTIVE: To summarize the available evidence regarding the impact of isthmocele on IVF outcomes. DATA SOURCES: Electronic databases and clinical registers were searched until May 30, 2023. STUDY SELECTION AND SYNTHESIS: Observational studies were included if they assessed the effect of isthmocele on IVF outcomes. Comparators were women with isthmocele and women without isthmocele with a previous CS or vaginal delivery. Study quality was assessed using the modified Newcastle-Ottawa Scale. MAIN OUTCOMES: The primary outcome was the live birth rate (LBR). The effect measures were expressed as adjusted odds ratios (aORs) and unadjusted odds ratios (uORs) with 95% confidence intervals (95% CIs). The body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation working group methodology. RESULTS: Eight studies (n = 10,873 patients) were included in the analysis. Women with isthmocele showed a lower LBR than both women with a previous CS without isthmocele (aOR, 0.62; 95% CI, 0.53-0.72) and those with a history of vaginal delivery (aOR, 0.55; 95% CI, 0.42-0.71). The LBRs in women with a previous CS without isthmocele and those with a history of vaginal delivery were similar (aOR, 0.74; 95% CI, 0.47-1.15). Subgroup analysis suggested a negative effect of the intracavitary fluid (ICF) in women with isthmocele on the LBR (uOR, 0.36; 95% CI, 0.18-0.75), whereas the LBRs in women without ICF and those without isthmocele were similar (uOR, 0.94; 95% CI, 0.61-1.45). CONCLUSION AND RELEVANCE: We found moderate quality of evidence (Grading of Recommendations Assessment, Development and Evaluation grade 3/4) supporting a negative impact of isthmocele, but not of CS per se, on the LBR in women undergoing IVF. The adverse effect of isthmocele on IVF outcomes appears to be worsened by ICF accumulation before embryo transfer. CLINICAL TRIAL REGISTRATION NUMBER: CRD42023418266.

Clinical outcome after high dose rate intracavitary brachytherapy with traditional point 'A' dose prescription in locally advanced carcinoma of uterine cervix: dosimetric analysis from the perspective of computed tomography imaging-based 3-dimensional treatment planning.

OBJECTIVE: To analyze tumour response and toxicity with respect to cumulative radiotherapy dose to target and organs at risk (OARs) with computed tomography (CT)-based image guided adaptive brachytherapy planning for locally advanced carcinoma cervix. METHODS: Patients were treated with two-dimensional concurrent chemoradiotherapy to whole pelvis followed by intracavitary brachytherapy (ICBT) with dose prescription to point 'A'. CT image-based delineation of high-risk clinical target volume (HR-CTV), urinary bladder, rectum and sigmoid colon was done with generation of dose-volume histogram (DVH) data and optimization of doses to target and OARs. Follow up assessments were done for response of disease and toxicity with generation of data for statistical analysis. RESULTS: One hundred thirty-six patients were enrolled in the study. Delineated volume of HR-CTV ranged from 20.9 to 37.1 mL, with median value of 30.2 mL. The equivalent dose in 2 Gy per fraction (EQD2) for point 'A' ranged from 71.31 to 79.75 Gy with median value of 75.1 Gy and EQD2 HR-CTV D90 ranged from 71.9 to 89.7 Gy with median value of 85.1 Gy. 69.2% of patients showed complete response and after median follow-up of 25 months, 50 patients remained disease free, of whom, 74.0% had received ≥85 Gy to HR-CTV D90 versus 26.0% receiving <85 Gy to HR-CTV D90. CONCLUSION: s Amidst the unavailability of magnetic resonance imaging facilities in low middle income countries, incorporation of CT-image based treatment planning into routine practice for ICBT provides the scope to delineate volumes of target and OARs and to generate DVH data, which can prove to be a better surrogate for disease response and toxicity.

Outcomes and comparison of dosimetric parameters between intracavitary (Fletcher) and combined intracavitary/interstitial (Utrecht) brachytherapy in locally advanced cervical cancer.

OBJECTIVE: To report outcomes of combined intracavitary/interstitial (IC/IS) image-guided brachytherapy (IGBT) in locally advanced cervical cancer, and to compare its dosimetric parameters with intracavitary-only (IC) brachytherapy in a first-in-country experience. METHODS AND MATERIALS: Between January 2021 and September 2022, a total of 160 insertions were done in 40 patients with FIGO IB3-IVA cervical cancer undergoing IGBT using a hybrid (Utrecht) applicator. Corresponding treatment plans for IC brachytherapy were generated during treatment, and optimized. A preplanned comparison of dosimetric parameters, defined in GEC-ESTRO was conducted. RESULTS: The clinical use of a hybrid IC/IS applicator was feasible in all insertions. An average of 14 needles were inserted in each patient over four fractions. Mean HR-CTV D90 and D98 was 86 (SD 1.9) Gy and 75.7 (SD 2.3) Gy using hybrid applicator, and 80 (SD 5.4) Gy and 69.8 (SD 5.2) Gy using IC applicator, with a mean dose gain of 6.0 (SD 5.0) Gy and 5.9 (SD 4.7) Gy (p <0.001), respectively. Likewise, mean D2cc for bladder and sigmoid were significantly lower in the hybrid technique. Mean contribution of brachytherapy to total HR-CTV D90 (in absolute EQD2 Gy) was 41.7 Gy using IC/IS applicator while 35.7 Gy for IC-only applicator (p = 0.027). Clinical response at 12 weeks showed an overall response rate (ORR) and complete response (CR) rates of 92.5% and 77.5%, respectively. CONCLUSIONS: IGBT using a hybrid IC/IS applicator showed excellent tolerability and yielded favorable results, resulting in significant dosimetric improvement in terms of primary target dose, and sparing OARs.

Vaginal Dose Reduction by Changing the Ovoid Loading Pattern in Image Guided Intracavitary Brachytherapy of Cervix.

Aim: Locally advanced cervical cancer is frequently treated using a combination of external beam radiotherapy and brachytherapy. Radiotherapy often leads to vaginal morbidity, which poses a significant problem. This study aims to analyze the impact of reducing ovoid loading on dosimetry. Materials and methods: We analyzed forty-five CT-based intracavitary brachytherapy plans from fifteen patients. Three plan sets were created for the 45 applications: a standard loading plan (A), a plan with reduced ovoid loading (B), and a tandem-only loading plan (C). We generated Dose-Volume Histograms and recorded dose volume parameters for the three plan sets. Results: The D90 for the Clinical Target Volume (CTV) did not show significant differences among the three plan sets (p = 0.20). The average D90 values for plans A, B, and C were 8.15 Gy, 8.16 Gy, and 7.4 Gy, respectively. No statistically significant differences were observed in D2cc bladder (p = 0.09) (average values: 6.8 Gy, 6.5 Gy, and 5.9 Gy for plans A, B, and C, respectively) and D2cc sigmoid (p = 0.43) (average values: 2.8 Gy, 2.6 Gy, and 2.4 Gy, respectively) among the three plan sets. However, there was a statistically significant difference in D2cc rectum (p < 0.001) (average values: 4 Gy, 3.3 Gy, and 1.8 Gy, respectively), as well as in vaginal dose points (p < 0.001). Conclusion: Reducing ovoid loading significantly decreased the doses to vaginal dose points and the rectum without compromising the dose to the Clinical Target Volume (CTV). Therefore, in carefully selected cases, the adoption of tandem-only loading or reduced ovoid loading could be considered to minimize vaginal morbidity following high dose rate intracavitary brachytherapy.

Combined intra-cavitary course of left anterior descending artery and myocardial bridge of right coronary artery in right ventricle hypertrophy: a case report.

Background: Intra-cavitary (IC) coronary course is a rare anatomical variant that has become more commonly reported in the last decade. While the condition is generally benign and often discovered incidentally during coronary computed tomography angiography (CCTA), these arteries are vulnerable to injury during cardiac interventions. It is unclear whether right ventricle (RV) pathology, such as dilatation or hypertrophy, plays a role in this condition. Case summary: A patient in their fifties with a medical history of rheumatic heart disease and atrial fibrillation presented with dyspnoea and orthopnea but denied any previous chest pain. Upon examination, the patient exhibited slow atrial fibrillation and generalized anasarca. Echocardiography revealed severe mitral stenosis, tricuspid regurgitation, pulmonary hypertension, and a significantly dilated and impaired RV. Before surgery, a CCTA was performed and revealed an abnormal mid-left anterior descending (LAD) course through the RV cavity with complete systolic attenuation. This finding was later confirmed through invasive angiography. Additionally, the right coronary artery (RCA) showed a mid-segment myocardial bridge (MB). The patient was scheduled for mitral and tricuspid valves' surgery with no planned intervention to the LAD or RCA. Discussion: Coronary IC course is a rare finding that poses a risk of arterial injury during invasive cardiac procedures. It is important for all cardiac interventionists to be familiar with this diagnosis and the potential hazards during cardiac interventions. Further research is needed to determine whether RV dilatation or hypertrophy can exacerbate coronary IC course or MB.