It Doesn’t Feel Pity, Or Remorse, Or Fear, And It Absolutely Will Not Stop, Ever, Until The Radiation Plan is Done!

[MegaVoltagePhoton]

I wish I could say it doesn’t but again, do more brachy (especially with distal vaginal involvement). It is real. But generally manageable.

Causing a fistula is one of the worst feelings the world when treating cervical cancer patients. Luckily though cure rates are high and patients are usually grateful they are alive.

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[ramsesthenice]

Causing a fistula is one of the worst feelings the world when treating cervical cancer patients. Luckily though cure rates are high and patients are usually grateful they are alive.

It helps that it’s typically not a surprise. Most of the time they had bulky posterior disease or long segment bladder/rectal involvement and you are able to prepare people for the possibility. I consent everyone for the possibility but make very sure to let people at elevated risk know I think that is the case. But I also make it clear that if I under dose and they need salvage surgery they will lose everything in the pelvis. Even though this is a fairly morbid complication, virtually everyone is pretty understanding and I think the key is making sure they are mentally prepared.

 

[ramsesthenice]

That just means you’re not seeing your complications. Radiation cystitis is extremely common and urethral stricture and fistulae are less common but seen as well (especially with brachy)

I take back my prior statement. I have not seen a fistula in one of my personal patients but I did have a recital cancer patient this year who had LDR brachy about 15 years ago who had repair of a rectal fistula and the op/path report both mention a seed being in the rectal wall . This brings me to secondary cancers which do also happen (just a long time later). It’s hard to know how many would have happened without RT but the best estimates are at least 20-30% of in field cancers post-RT probably would not have happened otherwise (though by letter of the law if it is in field and > 5-10 years later it’s considered a secondary cancer). Like asbestos and smoking and lung cancer, I see a fairly clear link between pelvic RT and smoking and bladder cancers. I always make sure to give special attention to smoking cessation for patients getting pelvic RT.

 

[thecarbonionangle]

I wish I could say it doesn’t but again, do more brachy (especially with distal vaginal involvement). It is real. But generally manageable.

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[thecarbonionangle]

If you are running needles to treat posterior bladder wall and rectal incolvement is it a surprise that when this tumor dies a hole is left behind and a fistula is likely? Did radiation “cause” the fistula or is there more to this story that some surgeons/specialists fail to understand because they cannot move past the caveman “radiation bad”

 

[ramsesthenice]

If you are running needles to treat posterior bladder wall and rectal incolvement is it a surprise that when this tumor dies a hole is left behind and a fistula is likely? Did radiation “cause” the fistula or is there more to this story that some surgeons/specialists fail to understand because they cannot move past the caveman “radiation bad”

At some point this is all semantics and while I think that in some instances you may be right, its a bad complication and when a patient develops a complication they didn't have before you treated I find it best to just accept you might have caused it. The bottom line is that cloacas are for reptiles, not people.

 

[Mandelin Rain]

Sometimes the only thing separating the urine from the stool/vagina is tumor.

Obviously not what anyone wants but sometimes causing a fistula is just, doing your job.

 

[ramsesthenice]

Sometimes the only thing separating the urine from the stool/vagina is tumor.

Obviously not what anyone wants but sometimes causing a fistula is just, doing your job.

True but thank god for fibrosis. Loss of a clear plane between the tumor and rectum/bladder is far from a guarantee for getting a fistula. I am definitely seeing less of these since I started using a hybrid system. But even with optimal dose shaping if the anatomy is bad its just going to happen sometimes. Can't beat yourself up about it. Just have to do your best to minimize the risk.

 

[salubalu]

I wish I could say it doesn’t but again, do more brachy (especially with distal vaginal involvement). It is real. But generally manageable.

I was trolling a little...

 

[ramsesthenice]

I was trolling a little...

well played