title: Should uterine tandem applicators ever be placed without ultrasound guidance? No: a brief report and review of the literature.
abstract: BACKGROUND
  Brachytherapy is an integral component of the curative treatment of locally advanced cervical cancer. Optimal applicator placement is associated with improvements in local control and treatment-related toxicity. Uterine perforation by the tandem is common and often undetected by orthogonal radiographs. The role of ultrasound in guiding tandem placement remains controversial.
  
  
  METHODS
  A 55-year-old woman with International Federation of Gynecology and Obstetrics stage IIB cervix cancer underwent placement of a Fletcher-Suit-Delcos tandem and ovoids applicator. Postoperative computed tomography was used for treatment planning.
  
  
  RESULTS
  The applicator appeared to be appropriately placed on clinical exam and orthogonal radiographs. Postoperative computed tomography revealed the tandem had perforated the anterior uterine wall. In a second procedure, the tandem was placed correctly under intraoperative ultrasonography.
  
  
  CONCLUSIONS
  A review of the literature finds a relatively high rate of uterine perforation of the uterus that is undetected by orthogonal radiographs or clinical examination. Multiple reports support the use of real-time ultrasound for patients with especially challenging anatomy. As this report illustrates, uterine perforation is possible in any patient. Therefore, routine real-time ultrasonography should be considered for all uterine tandem insertions.
authors.affiliation: Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA. wsmall@nmff.org
authors.forename: William
authors.initials: W
authors.lastname: Small
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: Strauss
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Hwang
authors.forename: Leeber
authors.initials: L
authors.lastname: Cohen
authors.forename: John
authors.initials: J
authors.lastname: Lurain
mesh_terms: D001918:Brachytherapy / Q000009:adverse effects* / Q000295:instrumentation* / Q000379:methods; D002294:Carcinoma, Squamous Cell / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D005260:Female; D005548:Foreign-Body Migration / Q000209:etiology / Q000517:prevention & control; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D008875:Middle Aged; D061089:Radiotherapy, Image-Guided / Q000295:instrumentation / Q000379:methods*; D014463:Ultrasonography; D002583:Uterine Cervical Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy*; D014595:Uterine Perforation / Q000209:etiology / Q000517:prevention & control; D014599:Uterus / Q000000981:diagnostic imaging*