title: Customized gynecologic interstitial implants: CT-based planning, dose evaluation, and optimization aided by laparotomy.
abstract: OBJECTIVE
  Interstitial perineal implants may be utilized to deliver a high local radiation dose in the treatment of advanced gynecologic malignancies. Lack of knowledge of the precise anatomic relationships between the implant and the target and critical organs may limit efficacy and increase complication risks. Computed tomography (CT)-based planning, dose evaluation, and optimization of customized interstitial implants, aided by laparotomy, have been developed to overcome these limitations.
  
  
  METHODS
  Twenty patients with locally advanced gynecologic malignancies treated between May 1990 to October 1996 with external irradiation and one or two implants. Interstitial implants were performed when intracavitary brachytherapy was judged to be inadequate or when the response to external radiation and an intracavitary implant was not satisfactory. Customized interstitial implants were planned using preimplantation CT to determine catheter angles and paths that best implanted the target while avoiding pelvic bones and organs. Laparotomy aimed at lysing bowel adhesions, placement of omental carpet, and refining needle placement. Postimplantation CT was used for loading optimization and dose evaluation.
  
  
  RESULTS
  Catheter angles 15-25 degrees were found to adequately implant anteriorly laying targets while avoiding pubic bones and bladder. Adhesiolysis of bowel loops from the vaginal apex was required in patients with prior hysterectomy. Small modifications in catheter placements were made during laparotomy in all implants. Postimplantation CTs showed deviations of the catheter positions compared with the planning CTs and were essential in determining target and organ doses and loading optimization. At a median follow-up of 42 months (range: 9-80 months), local control rate is 55% and disease-free survival 40%. Late complications occurred in 2 of 11 of patients without local recurrence.
  
  
  CONCLUSIONS
  CT-based planning, loading optimization, and dose evaluation of customized implants improve radiation dose delivery. Laparotomy enhances implant accuracy and safety. Local tumor control rate is still unsatisfactory. It reflects the shortcomings of technical advances alone in poor prognosis tumors like those selected for this series.
authors.affiliation: Department of Radiation Oncology, University of Michigan, Ann Arbor 48109, USA.
authors.forename: A
authors.initials: A
authors.lastname: Eisbruch
authors.forename: C M
authors.initials: CM
authors.lastname: Johnston
authors.forename: M K
authors.initials: MK
authors.lastname: Martel
authors.forename: J M
authors.initials: JM
authors.lastname: Robertson
authors.forename: K R
authors.initials: KR
authors.lastname: Reynolds
authors.forename: L H
authors.initials: LH
authors.lastname: Marsh
authors.forename: J A
authors.initials: JA
authors.lastname: Roberts
mesh_terms: D000230:Adenocarcinoma / Q000532:radiotherapy; D000328:Adult; D000368:Aged; D001918:Brachytherapy; D016889:Endometrial Neoplasms / Q000532:radiotherapy; D005260:Female; D005833:Genital Neoplasms, Female / Q000473:pathology / Q000532:radiotherapy*; D006801:Humans; D008875:Middle Aged; D009367:Neoplasm Staging; D011879:Radiotherapy Dosage; D002583:Uterine Cervical Neoplasms / Q000532:radiotherapy