Use of Smit Sleeve in cervix HDR brachytherapy

Discussion in 'Radiation Oncology' started by CanRadOnc, Apr 1, 2009.

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  1. CanRadOnc

    CanRadOnc Canadian member

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    Apr 27, 2008
    Hello,

    I am currently looking into the use of the Smit sleeve for the insertion of intrauterine applicators in HDR brachytherapy to see if they would be something that our centre would use. We have no practical experience regarding its use.

    I have not found much literature discussing its use but I am still continuing with my research. Does anyone have any experience and opinion regarding its use?

    So far, I have come up with a list of pros and cons:

    Pros:
    1. Eliminate multiple dilations of the cervix and hence less need for anaesthesia (1-2 vs 3-4)
    2. Decreased risk of perforation (with closed end sleeve)
    3. Shorter treatment time due to faster insertion
    4. Less traumatic insertions (no seed markers needed, no need to grasp cervix)
    5. Easier insertions for the brachytherapist


    Cons:
    1. Potential? patient discomfort/pain for 4 weeks (in addition to side effects from chemoRT)
    2. Sleeve has to be sutured on cervix which can slough off and sleeve will not stay in place
    3. Difficult/Not possible for advanced cases
    4. Potentially more trauma/anxiety/anaesthesia esp. if sleeve does not stay in place

    Thanks in advance. I look forward to the replies and discussions.
     
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  3. Palex80

    Palex80 RAD ON 7+ Year Member

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    1. Why 4 weeks? We usually insert the Smit sleeve after completion of EBRT and then complete brachytherapy within 2 weeks. We don't use a central block and do HDR-boost after EBRT with 4x7 Gy for HR-PTV and 5x7 Gy for IR-PTV 2times/week.
    2. This does happen sometimes, but usually only when you insert the sleeve during EBRT and while tumour is still collapsing. If you insert the sleeve just before you start HDR-boost (we generally apply the first fraction on the same day we insert the sleeve), you don't have that much of a tumour falling apart before you can take the sleeve off again.
    3. That's true, but in these cases HDR-brachytherapy is not always the best option. A patient with extensive lymph node metastasis or cT3 may not profit that much from HDR-boost.
    4. That rarely happens. Especially in patients with anteflected uterus (did I spell that right?), the sleeve tends to stay in place on its own.
     
  4. Spiced Meats

    Spiced Meats

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    Necro bump but what do you mean in this situation?
     
  5. Palex80

    Palex80 RAD ON 7+ Year Member

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    Don't get me wrong, I am all for HDR-boost when feasible and useful. However there are patients, where you shouldn't stop EBRT after 45-50 Gy, but you should try to go higher with EBRT and then deliver HDR.
    Patients with extensive pelvic wall involvement by the primary, will receive very little dose to large parts of the tumor if you stick to HDR-boost with an intracervical/intrauterine applicator alone.
    These are the patients, where the surface of the applicator is something like 4-5 cm away from the lateral extension of the tumor on the pelvic wall.
    If you don't use interstitial HDR-boost with needles you are simply not going to get enough dose with your intracervical applicator to the lateral parts of the tumor. Now, we don't do needles, so that's a problem for us.

    I've seen colleagues arguing:
    "Oh we should stop EBRT at 45 Gy, cause we want to give 4 x HDR boost to the primary. We can't go higher than 45 Gy, cause we need to reserve some dose for the rectum during HDR brachy"
    Net effect:
    45 Gy EBRT delivered to the tumor, then 4x HDR boost. Dose per fraction to lateral parts of the tumor was lower than 2 Gy/fraction during HDR-brachy, cause otherwise rectum contraints would not be met. Small bowel constraints come into play as well sometimes.
    So parts of the tumor only got <54 Gy.
    In patients like these I tend to push for maximal dose EBRT (>60 Gy), then replan (maybe even push a break of 1-2 weeks in between to allow for shrinking of tumor) and then do HDR brachy.
    It's also why we generally perform an MRI at around 40 Gy during EBRT and decide then how far to push the dose of EBRT before going to HDR brachy. Most patients show good remission at that point.
     
  6. RadOncDoc21

    RadOncDoc21 5+ Year Member

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    Anybody know a good way to plan using both eclipse and oncentra... I usually have both up to get a relative dose comparison but with anatomy changes and different software, it's hard to calculate dose in certain areas.

    I actually don't mind the smit sleeve and it does save a lot of time, just make sure the gyn onc putting them in is good.
     
  7. Palex80

    Palex80 RAD ON 7+ Year Member

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    I am not sure if I got this right. Do you mean if there's a way to get a cumulative dose preview with both systems? Like a cumulative dose calculation of both the EBRT and brachy?
    We cannot do that with Oncentra and Monaco.
    I presume that MIM Maestro should be able to do that. You would probably need deformable registration, since the applicators is going to change a lot in terms of anatomy in the pelvis.
     
  8. seper

    seper 5+ Year Member

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    Yes, need deformable image registration (MIM or Velocity). Results are underwhelming, though (implant screws it up). I don't routinely do dose summation because I don't want my physicist to hate me.
     
    medgator likes this.
  9. seper

    seper 5+ Year Member

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    As far as cons of using a Smit sleve, I'm surprised that no one mentioned increased risk of infection. Some older attendings have very strong opinion about this. Myself, I've had a couple of patients who needed combo antibiotics for PID-type clinical picture towards the end of HDR course.... I still much prefer to use a sleeve.


     
  10. RadOncDoc21

    RadOncDoc21 5+ Year Member

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    We have MIMs and its been a miss so far on this but I admit, we haven't really pursued as we should but it sounds like it's still not a home run either.

    I don't know... I guess I can just throw dose around and hope for the best (somewhat joking). It gets really tricky when we start adding in the EBRT LN boost etc.
     
    seper likes this.
  11. Reaganite

    Reaganite Member 10+ Year Member

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    The issue I've had with sleeves is they delay treatment too much. My Gyn Oncs won't put them in until after EBRT and often this introduces a 1-2 week delay in treatment. Honestly, I rarely see cases where I need a sleeve anyway, so I stopped doing them.
     
  12. seper

    seper 5+ Year Member

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    Yeah, one has to resign to be always calling GynOncs multiple times and begging them to put sleeves in... However, once Smit sleeve in - the patient is mine. I schedule HDR whenever I want, don't need anesthetist, OR time, nothing.

     
    RadOncDoc21 likes this.
  13. evilbooyaa

    evilbooyaa 5+ Year Member

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    We usually don't, but we did one recently with Smit sleeve insertion by Gyn-onc immediately prior to placement of T&O. We cut off the end as it was too short for the patient's uterus.

    Smit sleeve fell out by the beginning of treatment 3. Proceeded with remainder of treatments without smit sleeve, without issue.
     
  14. BobbyHeenan

    BobbyHeenan 2+ Year Member

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    I used to place my own Smitt sleeve at time of first insertion in the OR. It was very helpful for future insertions that could be done with ativan and morphine in the office.

    However, my current set up is prohibitive of in-office insertions (can't give light sedation due to administration blue tape, so I do them at day surgery with sedation). So I haven't found Smitt sleeve to be that helpful.

    Are you all doing your insertions under general anesthesia or in the office under light sedation?
     
  15. medgator

    medgator Senior Member 10+ Year Member

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    I do everything with the sleeve under general or spinal. I find I can't do a good job packing the implant away from the bladder and rectum otherwise.

    Fortunately our office with HDR is in a freestanding building connected to the hospital with ORs.
     
  16. seper

    seper 5+ Year Member

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    I've found that once a close-ended Smit sleeve is in place, no sedation is ever needed to place T&R . I use some PO Ativan and opioids for an occasional anxious patient.
     
  17. BobbyHeenan

    BobbyHeenan 2+ Year Member

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    I work in a hospital, so I've been doing general or spinal but have done it like seper is describing in the office. However, right now that's not a good option for me.

    As mentioned, my experience with in-office procedures has been hit or miss. With a good tolerant patient it can go very well with a Smitt sleeve. With an anxious patient (and especially patients with pre-existing opiate issues - I practice in an opiate endemic area, so a percocet before an implant is a drop in the bucket for some of my patients), I get sub optimal packing.

    As an aside, I really like the rectal retractor you can get on some of the HDR tandem/ovoid kits. It's more reproduceable than packing and seems to work really well. I didn't use these in training but have found them to be very helpful.
     
    seper likes this.
  18. seper

    seper 5+ Year Member

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    yep, retractor is now standard with both commercially available T&R sets (Varian and Nucletron/Electa)
     
  19. BobbyHeenan

    BobbyHeenan 2+ Year Member

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    I had no idea about this. I had TONS of cervix brachy cases at a high volume center as a resident. Our professors were fantastic, but we never used these. I don't know if it was just to teach us the importance/technique of packing or whatever, but man when my partners in practice showed me this thing it blew my mind.

    That's probably over stating it, but it's so simple and helps.
     
    RadOncDoc21 likes this.
  20. RadOncDoc21

    RadOncDoc21 5+ Year Member

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    Same here, I never knew about them until after I started practicing and it saves so much time. I do mine under general anesthesia.
     
  21. Aphtalyfe

    Aphtalyfe 7+ Year Member

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    We place our own smit sleeves in OR (never heard of a smit sleeve falling out here) 1-2 weeks prior to the completion of EBRT with treatments done outpatient with some ativan/percocet. If semi-advanced disease (~2B) we use Utrecht hybrid applicator and treat outpatient without EBRT parametrial boost. If disease is very locally advanced we do interstitial implant in OR and admit for treatment.
     
    seper likes this.
  22. seper

    seper 5+ Year Member

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    That's a good idea... I guess I've always been too timid to try to dilate os and suture Smit sleeve by myself... Question, what kind of pre-meds do give for Utrecht implant (when you're advancing those interstitial needles that thread through ovoids)?

     
  23. evilbooyaa

    evilbooyaa 5+ Year Member

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    Haven't seen a rectal retractor, anyone have a link for website/video? We use a vaginal packing system like most. General anesthesia for all insertions. Patient population here has, in general, extremely low pain tolerance and has strong propensity for high opioid requirements at baseline, so feasibility of doing procedure in clinic (besides administrative red tape on running sedation in the department) is limited.

    Maybe the Gyn-Onc used the wrong suture to secure the Smit sleeve I mentioned? Given concerns about ability to cut and remove the suture after treatment completed, she used something absorbable (which she told us would last about 5 to 6 weeks for our 2.5 week treatment course).
     
  24. BobbyHeenan

    BobbyHeenan 2+ Year Member

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    The product pdf for the Oncentra gyn brachy brochure has some pictures. Note that on some of the tandem and ovoid pics there is a little paddle that sits posterior to the ovoids. That's what they call a rectal retractor. Like Walter Sobchak says, "the beauty of this is in its simplicity." It's easy to miss in the pics but it's an awesome little tool.

    Regarding suturing the Smitt sleeve....when I was doing them myself I tried to take a bit of upper vaginal mucosa and not cervix tumor when throwing the stitch. If you suture through tumor when it shrinks away it will come out. I always then cut that suture as I was inserting the final tandem implant on the last day of treatment and held the sleeve in place while removing the suture thread. Then when you pull out the tandem the sleeve and tandem come out together. It helps to have those really long surgical forceps and scissors, obviously.
     
  25. Aphtalyfe

    Aphtalyfe 7+ Year Member

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    We usually give the standard percocet/ativan and then also add on a fentanyl lollipop if needed.
     
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  26. Aphtalyfe

    Aphtalyfe 7+ Year Member

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    We use Vaginal Balloon Packing System as a rectal retractor.
     
  27. Palex80

    Palex80 RAD ON 7+ Year Member

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    Does this system only work with ovoids or would it work if you use a ring applicator (like the Vienna ring)?
     
    Last edited: Mar 25, 2017
  28. Aphtalyfe

    Aphtalyfe 7+ Year Member

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    Not sure to be honest... Never used a ring applicator before.
     
  29. evilbooyaa

    evilbooyaa 5+ Year Member

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    That's we use as well, and it pulls the parts of the rectum that are able (basically anything distal to the beginning of the vagina (proximal to the cervical os), and in patients with continued bulky tumors, anything distal to the tumor) quite well for dosimetry.

    I thought this rectal retractor thing was something in addition to that.

    We use T & O as well so I'm not sure about utility with a ring applicator.
     
  30. Spiced Meats

    Spiced Meats

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    I've used the balloon packing with both ring and ovoids.

    Thanks for your thoughtful response to my earlier question. What criteria do you use for doing an external only boost for women with cervical disease? There are several situations I've seen to date where the tumor has a broad rectosigmoid interface or frank invasion through the rectum that hasn't receded during treatment that I believe fit that. In that situation I attempt to push the dose to 70 Gy.
     
    Last edited: Mar 27, 2017
  31. seper

    seper 5+ Year Member

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    "Broad interface" is not an indication for omitting brachytherapy. I've never personally seen your other situation, frank invasion through rectum at 45 Gy, but my feeling is to get the patient evaluated for exenteration instead of pushing more XRT.

     
  32. Spiced Meats

    Spiced Meats

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    Disease was hitting the lateral sidewall in the rectal invasion case so the gyn onc did not want to exenerate. She had multiple large high PA nodes so this might have been for the best.

    The "broad interface" case was similar to something like this picture - [​IMG]
     
  33. evilbooyaa

    evilbooyaa 5+ Year Member

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    ^^ That's post external beam radiation? You can't treat that at all effectively because of dosimetric issues with intracavitary. For people with experience with Vienna or Utrecht applicators, would that be at all feasible? We don't use either of those at my institution.

    Having minimal experience in interstitial, would that even be accessible for interstitial?
     
  34. thecarbonionangle

    thecarbonionangle 2+ Year Member

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    In the case of someone with multiple high PA nodes, is there any other distant disease on PET? I would boost these nodes to mid 60's with EBRT if possible. is the above MRI taken at the end of EBRT or pre-EBRT?

    Assuming this is a post-EBRT MRI, definitely intra-cavitary brachy is out of the question. What is the exam of the patient after EBRT? You need to get a BED of 85-90Gy to the tumour and you can't do that with intra-cavitary when the disease is that extensive. If there is rectal invasion and the Gyn onc said is not willing to do an exenteration: do you have the option to ask the second opinion of another surgeon? can you re-discuss with the surgeon if they particularly concerned about a certain margin? if so, you could potentially clear this margin with a pre-op interstitial boost, followed by completion radical surgery (likely exenteration). If surgery is absolutely out of the question, You could consider a heroic interstitial implant. I can't say if it is possible because I haven't seen all the slices of the MRI. It does look like there is anterior disease abutting the bladder but this disease does not extend cranially toward the fundus which is a good thing ( you wouldn't have to go through the bladder). It also looks like the anterior vaginal wall is likely involved (maybe even posterior). Getting the rest of the posterior pelvic disease looks potentially possible, but difficult. How long are the interstitial needles you have and how much is the dead space? based on what I see you'd be looking at advancing the needles 16-17 cm from the cervical os toward the recto-sigmoid and you will most certainly have to advance the needles into the sigmoid to account for dead space (1-2cm dead space let's assume). If you're pushing for potential cure or give aggressive local control, you'd push the dose to a BED past the rectal tolerance. The patient is likely to require a palliative diversion at some point anyways.

    Another option would be EBRT standard fraction boost vs. consider SBRT boost. I'd definitely give the patient extra dose before proceeding with more palliative chemo and I wouldn't just do an intra-cavitary implant.
     
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  35. Spiced Meats

    Spiced Meats

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    Thanks for your thorough response. The first patient had no distant disease on PET - I boosted those nodes to 60. Very worried about her meting out in the long term and have been pushing for adjuvant chemo.

    The other patient MRI was pre EBRT, the post MRI had a nice but not nice enough response. Surgeon was concerned about the margin. We are in a resource poor, LDR only setting so interstitial was not an option. Even if it was not sure I'd consider it without a planned resection, the dose at the needle would be untenable. I went with external to 70 Gy. Hopefully at the least I've cleared it to allow exenteration.
     
  36. thecarbonionangle

    thecarbonionangle 2+ Year Member

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    Are the vaginal walls involved on exam? They look pretty thick, especially the anterior wall looks thickened to at least mid lower vagina. What dose did you get to point A? If you didn't do an intracavitary implant, you can get further dose to the lower vagina with an LDR Tandem and ovoid with a cylinder in the tandem below the ovoids, using a "hanging source" (load the source below the flange). The plan would be hot at the vaginal mucosa but you'd get further dose to the lower vaginal wall. The surgeon may have trouble clearing such a low margin if that is involved.

    I have no experience with LDR needle implants but you can do these with iridium wire. In HDR interstitial implant, you're always going to have high dose points near the needles, like in LDR prostate seed implants. We tend not to look at those individual tiny dose points.
     
  37. Palex80

    Palex80 RAD ON 7+ Year Member

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    Exactly. Major invasion into structures around the cervix, like the mesorectum or pelvic wall fixation generally mean you will probably not gonna get enough response after 45-50 Gy to go for a good brachy plan (especially without interstitial treatment).
    In cases like this we generally go up to 60 Gy then wait for a couple of weeks and reevaluate brachytherapy or resection.
    I am also quite reluctant to push for brachytherapy in patients with clear invasion of the bladder. I've seen a few fistulas after brachytherapy and think that these patients may probably be better served with preop RT followed by surgery (even if that means sacrificing the bladder).
     
  38. seper

    seper 5+ Year Member

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    The picture above is a monster. Is it even a Gyne malignancy?
    To answer the question of omitting brachy for large cervical cancers, of course people do it. You can get close to 70 Gy sometimes using "shrinking fields". As you'd expect, local control is lousy. 1/3 for me thus far :(.
     
    Last edited: Mar 29, 2017

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