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CT appearance of the Syed-Neblett device for interstitial brachytherapy of gynecologic malignancies
Computerized Medical Imaging and Graph&, Vol. 20, No. 5, pp. 403-406, 1996 Copyright 6 1996Eltier ScienceLtd. All rights rcsmved printed in Great Britain 0895-611l/96 $15.00 + .OO
Pergamon
PII: f3o@M-6111(
CT APPEABANCE OF THE SYFD-NEBLETT DEVICL FOR INTERSTITIAL BRACWYTHEBAPY OF GYNECOLOGIC MALIGNANCIES
Norman Yeung*, Robert S. Shapiro*‘, Neville Glajchen* and Richard Stock? *Department of Radiology, Mount Sinai Medical Center of the City University of New York, New York, NY 10029-6574, USA TDepartment of Radiation Oncology, Mount Sinai Medical Center of the City University of New York, New York, NY 10029-6574, USA (Received 2 April 1996; revtied 15 July 1996)
surroundingnormaltissue.Copyright 0 1996ElsevierScienceLtd. Key Wor& Syed-Neblett, Brachytherapy, Computed tomography (CT), Gynecological, Neoplasms
salpingo-oopherectomy 4.5 yr ago. The patient currently presented after a single episode of profuse vaginal bleeding. The patient underwent CT and MRI evaluation which showed a mass at the left vaginal apex, but no evidence of lymphadenopathy. A vaginal biopsy showed adenocarcinoma. The patient underwent external beam radiation therapy to the whole pelvis, followed by interstitial implants using a Syed-Neblett device. A CT scan performed to evaluate the position of the device showed at various levels the multiple metallic guides imaged in cross-section, the template within the pelvis, and area of tumor recurrence (Fig. 1). The scout image from the CT scan showed the metallic guides as well as the perineal template (Fig. 2).
INTRODUCTION
The purpose of this article is to describe the CT appearance and use of the Syed-Neblett intracavitary implant. The Syed-Neblett template is a relatively new device used by radiation oncologists for high dose interstitial brachytherapy of gynecologic malignancies. The template acts as a guide for which hollow metallic rods are inserted into the perineum. Through these metallic rods, ribbons of radiation implants are inserted near the tumor for maximum effectiveness. With this device, the radiation oncologist can increase the maximum radiation dosage to the tumor, while limiting the dosage to the surrounding normal tissue. In our medical center, after intra-operative placement of the Syed-Neblett device, the patient is evaluated by CT to confirm placement of the template and rods prior to insertion of radioactive seeds. The CT findings of this perineal device have not been described previously, and this article serves to familiarize radiologists with its appearance, indications, and complications.
DISCUSSION
The Syed-Neblett device (Alpha-Omega Services, Bellflower, CA) is an interstitial transperineal implant that is inserted for high dose brachytherapy of gynecological malignancies. The purpose is to deliver inaximal radiation dose to the tumor and minimal radiation to the surrounding tissue. The Syed-Neblett device consists of a perineal template, vaginal obturator, and 20 cm 17-gauge hollow guides which holds the radiation implants. The device is implanted through the perineum by the radiation oncologist with the assistance of the gynecology surgeons in the operating room under direct vision and palpation. Intraoperatively, adjacent bowel loops may be displaced away from the catheter tips
CASE REPORT
The patient is a 64-yr-old women with a prior history of stage 13 endometrial carcinoma, treated with total abdominal hysterectomy and bilateral ‘Correspondence should be addressed to Robert S. Shapiro at Departmmt of Radiology--Box 1234, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574, USA. Tel: 212-241-5755; Fax: 212-427-8137. 403
Computerized Medical Imaging and Graphics
September-&tober/l996,
Volume 20, Number 5
Fig. 1. (a) CT sectionat the level of the vaginal cuff showsmultiple metallic guidesof the Syed-Neblett de1 tice, imagedin cross-section(black arrows).The surroundingsoft tissuedensitiesrepresenttumor recurrence.(b) CT sectionat the level of the vagina showsthe vaginal obturator (openarrow) and metallicguides(smallarrow:3)of the Syed-Neblett device. (c) CT sectionbelow the perineumshow the perineal template of the Syed-Nelblett device.
CT appearanceof the Syed-Neblett device N. YEUNG ef al. l
405
Fig. 2. Scout imagefrom the CT scanshowsthe Syed-Neblett device.
by the use of an omental sling (2). Possible complications from the Syed-Neblett would include problems during implantation of the template and hollow rods such as bowel or bladder perforation. Other problems would be changes directly related to the local effects of the radiation such as tissue fibrosis. After surgery, patients may undergo imaging by plain film or computed tomography for evaluation of implant device position which was the case for our patient. The patients are transferred to the radiation therapy suites where the radiation implants are introduced into the hollow guides. After the patient had completed the desired course of therapy, the Syed-Neblett is then removed prior to hospital discharge. In the United States, surgery remains the treatment of choice for primary malignancies of the uterus and cervix with radiotherapy playing an important role in adjuvant therapy for recurrent disease (2). However, external beam radiation dose is limited by the comorbidity associated with radiation damage to adjacent normal tissue within the radiation field. Brachytherapy has become an alternative form of treatment for those patients with recurrent
gynecological malignancies who have had previous surgery and maximum external beam radiation. Brachytherapy allows for maximum calculated dosage of radiation to tumor tissue while limiting the dosage to surrounding normal tissues (1).
Without this option, many women would require radical pelvic surgery. Some patients may receive this therapy even if they have had the maximum external beam radiation dose. Monk et al. reported a series of 28 patients with recurrent uterine or cervical cancer who received interstitial brachytherapy with the Syed-Neblett device. Monk reported an overall cure rate of 36% as compared to 15-50% of similar patients treated with other methods of salvage radiotherapy (2). SUMMARY In summary, this report describes the CT appearance and use of the Syed-Neblett intracavitary device. As this form of brachytherapy gains wider acceptance by radiation therapists, radiologists may expect to encounter CT scans of patients with this implanted device. Knowledge of this device should aid in the proper interpretation of CT scans, and radiation treatment planning in patients undergoing this form of brachytherapy.
REFERENCES 1. Syed, A.M.; Putbawala,A.A.; Neblett, D.; Disaia,P.J.; Berman,M.L.; Rettenmaier, M.; Nabck,R.; McNamara,C. Transperineal interstitial-intraeavitary “Syed-Neblett”applicator in the treatmentof carcinomaof the uterinecervix. Endoeurie Hypertberm.Oncol. 2:1-13;1986.
406
Computerized Medical Imaging and Graphics
2. Monk, B.J.; Walker, J.L.; Tewari, K.; Ramsinghani, N.; Syed, A.M.; DiSaia, P.J. Gpen interstitial brachytherapy for the treatment of local-regional recurrences of uterine corpus and cervix cancer after primary surgery. Gynecol. Gncol. 52:222228; 1994.
September-Gctober/l996,
Volume 20, Number 5
About tbe Author-ROBBRT S. SHAPIRO is an Associate Professor of Radiology and director of the Division of Ultrasound at Mount Sinai Medical Center. His areas of interest include CT, Ultrasound, and MRI. About the Aath~r-NEVILLE GLAJCHEN is an Assistant Professor of Radiology at Mount Sinai Medical Center. His area of interest is Cross-Sectional Imaging with an emphasis on MRI.
About tha AIIUKII-NORMAN %KrNG is currently a resident in Diagnostic Radiology at Mount Sinai Hospital in New York. His primary interest is Cross&ctional Imaging and Interventional Radiology.
About the A&IO~-RICHARD STOCK is an Associate Professor of Radiation Oncology at Mount Sinai Medical Center. His area of interest is Brachytherapy.
Pergamon
PII: f3o@M-6111(
CT APPEABANCE OF THE SYFD-NEBLETT DEVICL FOR INTERSTITIAL BRACWYTHEBAPY OF GYNECOLOGIC MALIGNANCIES
Norman Yeung*, Robert S. Shapiro*‘, Neville Glajchen* and Richard Stock? *Department of Radiology, Mount Sinai Medical Center of the City University of New York, New York, NY 10029-6574, USA TDepartment of Radiation Oncology, Mount Sinai Medical Center of the City University of New York, New York, NY 10029-6574, USA (Received 2 April 1996; revtied 15 July 1996)
surroundingnormaltissue.Copyright 0 1996ElsevierScienceLtd. Key Wor& Syed-Neblett, Brachytherapy, Computed tomography (CT), Gynecological, Neoplasms
salpingo-oopherectomy 4.5 yr ago. The patient currently presented after a single episode of profuse vaginal bleeding. The patient underwent CT and MRI evaluation which showed a mass at the left vaginal apex, but no evidence of lymphadenopathy. A vaginal biopsy showed adenocarcinoma. The patient underwent external beam radiation therapy to the whole pelvis, followed by interstitial implants using a Syed-Neblett device. A CT scan performed to evaluate the position of the device showed at various levels the multiple metallic guides imaged in cross-section, the template within the pelvis, and area of tumor recurrence (Fig. 1). The scout image from the CT scan showed the metallic guides as well as the perineal template (Fig. 2).
INTRODUCTION
The purpose of this article is to describe the CT appearance and use of the Syed-Neblett intracavitary implant. The Syed-Neblett template is a relatively new device used by radiation oncologists for high dose interstitial brachytherapy of gynecologic malignancies. The template acts as a guide for which hollow metallic rods are inserted into the perineum. Through these metallic rods, ribbons of radiation implants are inserted near the tumor for maximum effectiveness. With this device, the radiation oncologist can increase the maximum radiation dosage to the tumor, while limiting the dosage to the surrounding normal tissue. In our medical center, after intra-operative placement of the Syed-Neblett device, the patient is evaluated by CT to confirm placement of the template and rods prior to insertion of radioactive seeds. The CT findings of this perineal device have not been described previously, and this article serves to familiarize radiologists with its appearance, indications, and complications.
DISCUSSION
The Syed-Neblett device (Alpha-Omega Services, Bellflower, CA) is an interstitial transperineal implant that is inserted for high dose brachytherapy of gynecological malignancies. The purpose is to deliver inaximal radiation dose to the tumor and minimal radiation to the surrounding tissue. The Syed-Neblett device consists of a perineal template, vaginal obturator, and 20 cm 17-gauge hollow guides which holds the radiation implants. The device is implanted through the perineum by the radiation oncologist with the assistance of the gynecology surgeons in the operating room under direct vision and palpation. Intraoperatively, adjacent bowel loops may be displaced away from the catheter tips
CASE REPORT
The patient is a 64-yr-old women with a prior history of stage 13 endometrial carcinoma, treated with total abdominal hysterectomy and bilateral ‘Correspondence should be addressed to Robert S. Shapiro at Departmmt of Radiology--Box 1234, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029-6574, USA. Tel: 212-241-5755; Fax: 212-427-8137. 403
Computerized Medical Imaging and Graphics
September-&tober/l996,
Volume 20, Number 5
Fig. 1. (a) CT sectionat the level of the vaginal cuff showsmultiple metallic guidesof the Syed-Neblett de1 tice, imagedin cross-section(black arrows).The surroundingsoft tissuedensitiesrepresenttumor recurrence.(b) CT sectionat the level of the vagina showsthe vaginal obturator (openarrow) and metallicguides(smallarrow:3)of the Syed-Neblett device. (c) CT sectionbelow the perineumshow the perineal template of the Syed-Nelblett device.
CT appearanceof the Syed-Neblett device N. YEUNG ef al. l
405
Fig. 2. Scout imagefrom the CT scanshowsthe Syed-Neblett device.
by the use of an omental sling (2). Possible complications from the Syed-Neblett would include problems during implantation of the template and hollow rods such as bowel or bladder perforation. Other problems would be changes directly related to the local effects of the radiation such as tissue fibrosis. After surgery, patients may undergo imaging by plain film or computed tomography for evaluation of implant device position which was the case for our patient. The patients are transferred to the radiation therapy suites where the radiation implants are introduced into the hollow guides. After the patient had completed the desired course of therapy, the Syed-Neblett is then removed prior to hospital discharge. In the United States, surgery remains the treatment of choice for primary malignancies of the uterus and cervix with radiotherapy playing an important role in adjuvant therapy for recurrent disease (2). However, external beam radiation dose is limited by the comorbidity associated with radiation damage to adjacent normal tissue within the radiation field. Brachytherapy has become an alternative form of treatment for those patients with recurrent
gynecological malignancies who have had previous surgery and maximum external beam radiation. Brachytherapy allows for maximum calculated dosage of radiation to tumor tissue while limiting the dosage to surrounding normal tissues (1).
Without this option, many women would require radical pelvic surgery. Some patients may receive this therapy even if they have had the maximum external beam radiation dose. Monk et al. reported a series of 28 patients with recurrent uterine or cervical cancer who received interstitial brachytherapy with the Syed-Neblett device. Monk reported an overall cure rate of 36% as compared to 15-50% of similar patients treated with other methods of salvage radiotherapy (2). SUMMARY In summary, this report describes the CT appearance and use of the Syed-Neblett intracavitary device. As this form of brachytherapy gains wider acceptance by radiation therapists, radiologists may expect to encounter CT scans of patients with this implanted device. Knowledge of this device should aid in the proper interpretation of CT scans, and radiation treatment planning in patients undergoing this form of brachytherapy.
REFERENCES 1. Syed, A.M.; Putbawala,A.A.; Neblett, D.; Disaia,P.J.; Berman,M.L.; Rettenmaier, M.; Nabck,R.; McNamara,C. Transperineal interstitial-intraeavitary “Syed-Neblett”applicator in the treatmentof carcinomaof the uterinecervix. Endoeurie Hypertberm.Oncol. 2:1-13;1986.
406
Computerized Medical Imaging and Graphics
2. Monk, B.J.; Walker, J.L.; Tewari, K.; Ramsinghani, N.; Syed, A.M.; DiSaia, P.J. Gpen interstitial brachytherapy for the treatment of local-regional recurrences of uterine corpus and cervix cancer after primary surgery. Gynecol. Gncol. 52:222228; 1994.
September-Gctober/l996,
Volume 20, Number 5
About tbe Author-ROBBRT S. SHAPIRO is an Associate Professor of Radiology and director of the Division of Ultrasound at Mount Sinai Medical Center. His areas of interest include CT, Ultrasound, and MRI. About the Aath~r-NEVILLE GLAJCHEN is an Assistant Professor of Radiology at Mount Sinai Medical Center. His area of interest is Cross-Sectional Imaging with an emphasis on MRI.
About tha AIIUKII-NORMAN %KrNG is currently a resident in Diagnostic Radiology at Mount Sinai Hospital in New York. His primary interest is Cross&ctional Imaging and Interventional Radiology.
About the A&IO~-RICHARD STOCK is an Associate Professor of Radiation Oncology at Mount Sinai Medical Center. His area of interest is Brachytherapy.