CAPRI

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Heard something about the balloons malfunctioning resulting in retained material at time of removal.

We transitioned to an interstitial obturator with needles down the middle and at 6 obturator holes. Then the whole thing was placed into a plastic shield and inserted
 
firewicket said:
Anyone have any idea why the CAPRI for intravaginal brachytherapy stopped being manufactured?
What are people using for this type of treatment now?
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Depends on where in the vagina we are talking about and how big it is. I usually end up using a hybrid applicator with a 0 tandem (so a flat top) with vaginal caps and a few free-hand needles loaded through a perineal template. If it is really distal I do it all free hand.
 
I do not have any on-hands experience with it, but if you are not trying to cover the entire vagina, it may be feasible to use a modified version of the new Venezia applicator from Elekta.

1618310337011.png


If one removes the tip of the intrauterine catheter, you would be able to cover the proximal vaginal cuff using the rest of the configuration.
1618310586355.png

One possible problem is the fact that the peripheral channels are probably quite close to the surface of the applicator, thus the plan may produce high surface doses. The other problem are the different available diameters with this device. And it's probably quite pricey too... I can envision this as a possible option for a well lateralized tumor in the proximal vagina but certainly not as your "standard" applicator.
 
Palex80 said:
I do not have any on-hands experience with it, but if you are not trying to cover the entire vagina, it may be feasible to use a modified version of the new Venezia applicator from Elekta.

View attachment 334733

If one removes the tip of the intrauterine catheter, you would be able to cover the proximal vaginal cuff using the rest of the configuration.
View attachment 334736
One possible problem is the fact that the peripheral channels are probably quite close to the surface of the applicator, thus the plan may produce high surface doses. The other problem are the different available diameters with this device. And it's probably quite pricey too... I can envision this as a possible option for a well lateralized tumor in the proximal vagina but certainly not as your "standard" applicator.
Click to expand...

Palex, you are pretty spot on as usual. The Venezia applicator is my standard applicator for most situations but it is a little more versatile than pictured above. It is a pretty slick system for most cervical cancers and vaginal cuff recurrences. As shown in the pictures above you basically have a T&O that lets you supplement with needles in a superior or lateral direction. The key word here is supplement. It is very rare to have a primary cervical tumor that wouldn't benefit from having an extra source or 2 to strike a better balance between tumor coverage and normal tissue dosing but does that normally warrant the added effort and patient discomfort of going full interstitial? Of course not. This is an easy way of popping in a needle or 2 with relatively minimal effort (once you are comfortable with US guidance etc).

What about truly massive tumors? It is possible to essentially recreate a Sayed with this thing but it is honestly easier to just use a Sayed for those cases. I am far faster inserting a Sayed than this thing with 12 needles. The dose distribution will be similar so why not use the one that is technically easier for me?

Now lets talk vaginal tumors (the topic at hand). You are absolutely right about the limitations. There is a zero tandem (with no intrauterine catheter) and when you use the zero tandem with the vaginal caps you essentially have a multichannel cylinder which will suffer from high surface dose for all but the most superficial tumors. But your pictures are missing a key part of the system

1618317363910.png


There is also a perineal template which allows you to supplement with free hand needles in the paravaginal space. For lateralized tumors this can be a pretty slick system that gives you great plans that is technically pretty straight forward to use for someone with reasonable interstitial experience. As one example, I had a case last week of someone with a distal vaginal SCC that was unfortunately smack in the left periurethral tissue extending to a depth of about 1 cm. I popped in the 0 degree with no vaginal caps and 3 perineal needles in the periurethral space by free hand (sounds frightening, but you can see the foley and you know where the urethra is while you are inserting the needles). Insertion took all of 10 minutes. 70% of the dose came from the interstitial needles and I supplemented with the left ovoid channel to cool off the uninvolved urethra as much as possible. Again, for really huge vaginal tumors you could use this, but it would probably require more effort than most conventional systems. Fortunately, I have not met one of those tumors in recent memory.

Bottom line, there are no universal applicators. If you are going to do a lot of anything the best thing you can do for yourself is familiarize yourself with the strengths and weaknesses of the available options to best utilize them for each situation.
 
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