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Uterine perforation during brachytherapy for cervical cancer: Complications, outcomes, and best practices for forward treatment planning and management

  • William Small Jr.
    Correspondence
    Corresponding author. Department of Radiation Oncology, Director, Cardinal Bernardin Cancer Center, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Avenue, Maywood, IL 60153. Tel.: 708-216-2559; fax: 708-216-6076.
    Affiliations
    Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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  • Yo Sup Kim
    Affiliations
    Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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  • Cara Joyce
    Affiliations
    Department of Health Informatics and Data Science, Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL
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  • Murat Surucu
    Affiliations
    Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA
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  • Mark Leshyk
    Affiliations
    Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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  • Matthew M. Harkenrider
    Affiliations
    Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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  • Ronald K. Potkul
    Affiliations
    Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
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  • Margaret Liotta
    Affiliations
    Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
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  • Abigail Winder
    Affiliations
    Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL
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  • Basel Altoos
    Affiliations
    Department of Radiation Oncology, Loyola University Chicago, Loyola University Medical Center, Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL
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      Abstract

      Purpose

      The purpose of the study was to determine the incidence of uterine perforations, review the associated complications, and propose guidelines for management of perforations after brachytherapy.

      Methods and Materials

      A retrospective chart review was conducted for all patients with cervical cancer who received single or multiple high-dose-rate brachytherapy implants between April 2006 and May 2017 at a single academic institution. CT and MRI images were retrospectively evaluated to record incidences of uterine perforation of tandem during brachytherapy. Acute and long-term complications during and after treatment were scored using the Common Terminology Criteria for Adverse Events, Version 4.0, of the National Cancer Institute.

      Results

      A total of 123 patients were included in the study. Perforations were observed in 22 patients (17.9%) with 31 (6.4%) of the 482 total implants. Of the different categories of adverse events, only the rate of acute infectious complications among those with perforations (n = 3, 13.6%) versus those without perforations (n = 3, 3.0%) was significant (p = 0.040). Two of the three perforated patients with acute infections had mild urinary tract infections, and all resolved without complications or treatment delays. The remaining one patient had a frank perforation of the anterior uterine wall with a subsequent Grade 3 pyometra infection despite administration of prophylactic antibiotics and 1-week treatment delay. This case was eventually resolved with cervical dilation and evacuation of fluid. Long-term complications were not different between the two arms.

      Conclusions

      Patients with cervical cancer with uterine perforations may be able to safely proceed with brachytherapy treatment without delay or need for prophylactic antibiotics in the acute setting. Further validating data would be able to assist in establishing a new standard of care and help prevent unnecessary and harmful breaks during treatment.

      Keywords

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