PO36

Abstract

Purpose Cancer of the cervix is the most common malignancy treated at Gaborone Private Hospital, the only facility with radiotherapy in Botswana. Patients are treated with both curative and palliative intent. Curative patients are offered concurrent chemoradiotherapy followed by high dose rate brachytherapy. Palliative patients receive external beam radiation, commonly using AP-PA fields. Doses range from 8Gy Single fraction to 30Gy in ten fractions over two weeks. We report a patient receiving hemostatic high dose rate brachytherapy using intrauterine tandem insertion only. Materials and Methods In April 2022, a 43-year-old patient, HIV positive and virally suppressed, was referred to us with a four day history of severe vaginal bleeding. She had had a biopsy two months prior to presentation proving invasive squamous cell carcinoma of the cervix. She was staged as 4A with frozen pelvis and was on the waiting list for palliative radiation. However, the linear accelerator was down, and we were awaiting the engineer from neighboring South Africa. The patient had already been transfused a total of ten units of packed cells, three having been transfused the day prior to presentation. Her renal function was normal, and hemoglobin was 9g/dl. The patient presented in a stable condition with ECOG PS of two. After a quick history and physical examination, the patient gave signed consent for haemostatic brachytherapy. Vital signs were normal with blood pressure 100/60 mmHg, pulse 88 beats per minute and no fever. She was pre medicated with Cyclokapron 1 gram IV, Oxynorm 10 mg po, Paracetamol 1g IV and sedated with bromazepam 3mg po stat. A large bore cannula was inserted and a drip with IV Ringers lactate was inserted for slow infusion. Under sterile conditions, speculum showed a bulky cervical mass more than 8cm. Gentle probing with uterine sound identified the os. An 8cm tandem was inserted into the uterus (blind insertion no ultrasound guidance) and packing was done to stabilize the tandem. A CT scan was performed, and the images were transferred to the Nucleotron High Dose Rate Unit. A target volume was outlined on CT images. Since there was extensive rectal/ sigmoid and bladder invasion no OARs were contoured. (Fig 1). A plan was generated delivering 5.7 Gy to most of the GTV (EQD2 8Gy). The instruments were removed, and vaginal packing was done to stay overnight. Results The treatment was well tolerated and on completion of the treatment vaginal bleeding had stopped. Time from consultation to completion of treatment (i.e. haemostasis) was less than 90 minutes. Removal of vaginal pack the next morning showed no fresh bleeding. The patient reported vaginal spotting on day 3 when passing stool. Telephonic consultation after two weeks and one month confirmed no vaginal bleeding. The patient was referred back for consideration of colostomy so she could be assessed for further treatment. Conclusion In this patient we demonstrated that brachytherapy is an effective tool to achieve acute haemostasias. Especially in settings with limited resources, it could be used instead of external beam radiation. Minimal time was spent in patient preparation, treatment planning, and haemostasis was immediate. This can buy time for other palliative measures to be implemented. We continue to use this method for palliative radiation and plan to report on a series in the future. Also further follow up of patients will be done to assess survival and quality of life. Cancer of the cervix is the most common malignancy treated at Gaborone Private Hospital, the only facility with radiotherapy in Botswana. Patients are treated with both curative and palliative intent. Curative patients are offered concurrent chemoradiotherapy followed by high dose rate brachytherapy. Palliative patients receive external beam radiation, commonly using AP-PA fields. Doses range from 8Gy Single fraction to 30Gy in ten fractions over two weeks. We report a patient receiving hemostatic high dose rate brachytherapy using intrauterine tandem insertion only. In April 2022, a 43-year-old patient, HIV positive and virally suppressed, was referred to us with a four day history of severe vaginal bleeding. She had had a biopsy two months prior to presentation proving invasive squamous cell carcinoma of the cervix. She was staged as 4A with frozen pelvis and was on the waiting list for palliative radiation. However, the linear accelerator was down, and we were awaiting the engineer from neighboring South Africa. The patient had already been transfused a total of ten units of packed cells, three having been transfused the day prior to presentation. Her renal function was normal, and hemoglobin was 9g/dl. The patient presented in a stable condition with ECOG PS of two. After a quick history and physical examination, the patient gave signed consent for haemostatic brachytherapy. Vital signs were normal with blood pressure 100/60 mmHg, pulse 88 beats per minute and no fever. She was pre medicated with Cyclokapron 1 gram IV, Oxynorm 10 mg po, Paracetamol 1g IV and sedated with bromazepam 3mg po stat. A large bore cannula was inserted and a drip with IV Ringers lactate was inserted for slow infusion. Under sterile conditions, speculum showed a bulky cervical mass more than 8cm. Gentle probing with uterine sound identified the os. An 8cm tandem was inserted into the uterus (blind insertion no ultrasound guidance) and packing was done to stabilize the tandem. A CT scan was performed, and the images were transferred to the Nucleotron High Dose Rate Unit. A target volume was outlined on CT images. Since there was extensive rectal/ sigmoid and bladder invasion no OARs were contoured. (Fig 1). A plan was generated delivering 5.7 Gy to most of the GTV (EQD2 8Gy). The instruments were removed, and vaginal packing was done to stay overnight. The treatment was well tolerated and on completion of the treatment vaginal bleeding had stopped. Time from consultation to completion of treatment (i.e. haemostasis) was less than 90 minutes. Removal of vaginal pack the next morning showed no fresh bleeding. The patient reported vaginal spotting on day 3 when passing stool. Telephonic consultation after two weeks and one month confirmed no vaginal bleeding. The patient was referred back for consideration of colostomy so she could be assessed for further treatment. In this patient we demonstrated that brachytherapy is an effective tool to achieve acute haemostasias. Especially in settings with limited resources, it could be used instead of external beam radiation. Minimal time was spent in patient preparation, treatment planning, and haemostasis was immediate. This can buy time for other palliative measures to be implemented. We continue to use this method for palliative radiation and plan to report on a series in the future. Also further follow up of patients will be done to assess survival and quality of life.