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Introduction/Background Despite modern techniques in external beam radiotherapy (EBRT), intensity modulated radiation therapy (IMRT) and stereotactic radiotherapy (SRT), brachytherapy (BT) remains one of the most important modalities for the treatment of advanced gynaecological cancer. In some special cases commercially available applicators for MRI-guided intracavitary/interstitial (IC/IS) BT do not offer proper target coverage. With the help of additive technologies, 3D-printed applicators can be tailored to the patient‘s tumour and anatomy. Methodology In this report two cases of gynaecological cancer, one vaginal and one recurrent endometrial cancer are presented. The design of the applicator was based on MRI images of the patient with the standard Varian vaginal cylinder inserted. Parallel and oblique needles were virtually added to the planning system to get the best possible coverage of the tumour while respecting the dose constraints to the organs at risk (OARs). Individual applicators were made from biocompatible polyamide PA 12 with selective laser sintering (SLS) technology (figure 1). The next BT was performed with an individual applicator in situ. Rectal ultrasound was used for needle guidance. The dose-volume histogram (DVH) parameters for each patient were compared according to the planning aims. The planning aim for D90 high-risk clinical target volume (CTV-THR) was to reach physical dose > 20.5 Gy per one BT fraction delivered in 24 pulses of pulsed dose rate (PDR) BT. Results The DVH parameters for both cases per one BT fraction are presented in table 1. The procedure and the implantation of the needles was performed without complications in regional anaesthesia. The applicator was well tolerated, no adverse effect was reported during the treatment or removal of the applicator. Conclusion The advantages of using an individually-designed multi-channel vaginal applicator are: better target coverage in advanced tumours extended in the vagina can be used in a narrow vagina implantation guidance of several oblique and parallel needles can be performed with minimized trauma to the surrounding tissue allows for the treatment of several tumour locations in the same BT fraction Disclosures Helena Barbara Zobec Logar, Robert Hudej and Manja Kobav have nothing to disclose.

Purpose To evaluate the clinical use of 3D printing technology for the modelling of individual applicators for advanced gynecological tumors in magnetic resonance imaging (MRI)-based brachytherapy (BT). Material and methods We tested individually designed 3D-printed applicators in nine patients with advanced gynecological cancer. Before BT was performed, all patients were treated with external beam radiotherapy (EBRT). The most common indication for individualized BT was advanced gynecological tumors where the use of standard BT applicators was not feasible. Other indications were suboptimal dose-volume histogram (DVH) parameters for high-risk clinical target volume (CTV-THR) at the first BT (V100 ≤ 90% of CTV-THR volume and D98 ≤ 80%, D90 ≤ 100%, and D100 ≤ 60% of dose aim). The EQD2 dose aim to the target volume D90 CTV-THR per one BT fraction was 20 Gy for cervical or recurrent endometrial cancer and 16 Gy for vaginal cancer patient. The first BT with the standard applicator in situ was used as the virtual plan for designing a 3D-printed applicator. The next BT was performed with a 3D-printed applicator in situ. The primary endpoint was to improve CTV-THR DVH parameters without exceeding the dose to the organs at risk (OARs). Results All DVH parameters for CTV-THR were significantly higher with the use of an individually designed applicator. Mean D90 CTV-THR improved from 14.1 ±5.4 Gy to 22.0 ±2.5 Gy and from 7.1 Gy to 16.2 Gy for cervical/recurrent endometrial and vaginal cancer, respectively (p < 0.001). The mean D2cm3 bladder, rectum, sigmoid, and bowel dose was within institutional dose constraints, and increased from 13.0 ±1.5 Gy to 13.6 ±1.5 Gy (p = 0.045), 10.8 ±1.2 Gy to 11.7 ±1.3 Gy (p = 0.004), 8.9 ±3.2 Gy to 10.3 ±3.3 Gy (p = 0.008), and 8.7 ±3.8 Gy to 9.2 ±3.1 Gy (p = 0.2). Conclusions With the use of individual 3D-printed applicators, all DVH parameters for CTV-THR significantly improved without compromising the dose constraints for the OARs.

Background The aim of this retrospective single institution study was to analyse long term results of vulvar cancer treatment with conventional 2D radiotherapy in Slovenia between years 1997–2004. Patients and methods Fifty-six patients, median age 74.4 years +/- 9.7 years, mainly stage T2 or T3, were included in the study. All patients were treated with radiotherapy, which was combined with surgery (group A), used as the primary treatment (group B) or at the time of relapse (group C). Chemotherapy was added in some patients. Histology, grade, lymph node status, details of surgery, radiation dose to the primary tumour, inguinofemoral and pelvic area as well as local control (LC) and survival were evaluated. Results Overall survival (OS), disease specific survival (DSS) and LC rates at 10-years for all patients were as follows: 22.7%, 34.5% and 41.1%, respectively. The best 10-years results of the treatment were achieved in the primary operated patients treated with adjuvant radiotherapy +/-chemotherapy (OS 31.9%, DSS 40.6% and LC 47.6%). Positive lymph nodes had a strong influence on LC. In case of positive nodes LC decreased by 60% (p = 0.03) and survival decreased by 50% (p = 0.2). There was a trend to a better LC with higher doses ≥ 54.0 Gy (p = 0.05). Conclusions The best treatment option for patients with advanced vulvar cancer is combined treatment with surgery and radiotherapy +/- chemotherapy, if feasible. Radiotherapy with the dose of ≥ 54.0 Gy should be considered to achieve better LC if positive adverse factors are present.

Onkologija, leto XXII, št. 1, junij 2018, Onkologija, Volume XXII, No. 1, June 2018

The aims of this study were to determine the characteristics of the apex beat in the full left lateral position in healthy adults, and to assess its value in the diagnosis of left ventricular dilatation.77 healthy adults and 27 patients with left ventricular dilatation were evaluated by history, physical examination, electrocardiography, apexcardiography and complete transthoracic echocardiographic examination. The location, size and quality of the apex beat were determined in the 90-degree left lateral position. A palpable apex beat, located in the 5th or 6th intercostal space, was recorded in 87% of the healthy adults. The lateral margin was palpated in a 3-cm-wide area from the left anterior axillary line (LAAL) towards the mid-clavicular line (MCL). The mean diameter and area were 2.5 +/- 0.5 cm and 5.0 +/- 2.5 cm2, respectively. In 51% the apex impulse intensity was of medium degree, in 25% weak and in 24% strong. It was palpable in all patients with left ventricular enlargement in the 5th, 6th or 7th intercostal space. The lateral margin was located in a 4.5-cm-wide area, 3.5 cm left from the LAAL to 1 cm right from it. The mean diameter and area were 5.0 +/- 1.0 cm and 20.0 +/- 7.0 cm2, repectively. The intensity was weak in 56% and medium degree in the rest. The diameteror = 4.0 cm was sensitive (96%) and specific (96%) for the enlarged left ventricle. The location of the apex beat with the cut-off point in the LAAL was equally sensitive but less specific (63%) for left ventricular dilatation.Palpation of the apex beat in the full left lateral position is very suitable for detecting the left ventricular dilatation at bedside. The size of the apex beat appears to be a more reliable diagnostic sign of left ventricular dilatation than its location.

Background. The aim of this retrospective study was to analyse results of the two-dimensional (2D) uterine cervix cancer treatment at the Institute of Oncology Ljubljana from 1998 till 2002, before the three-dimensional (3D) approach was introduced in our clinical practice. Methods. Ninety-eight patients with the following FIGO stage distribution were analysed: 10% IB, 7% IIA, 37% IIB, 4% IIIA and 42% IIIB. The influence of age, haemoglobin level, histology, grade, stage, lymph node status, cumulative point A dose, and an overall treatment time on the survival and local control (LC) were evaluated. Acute and late side effects were assessed. Results. Five and 8-year overall survival (OS), disease specific survival (DSS) and LC rate were as follows: 47.2% and 43.0%, 54.7% and 53.4%, 74.9% and 72.5%, respectively. Point A dose and histology of the tumour influenced OS, positive lymph nodes DSS and point A dose LC rate. Probability of grade three and four late complications in the first five years was 7.1% for gastrointestinal tract and 3.3% for genitourinary system and vagina. Conclusions. Point A dose was independent predictor of OS and LC rate, lymph node status predicted DSS, while histology of the tumour influenced OS.

Introduction: MRI sequences with short scanning times may improve accessibility of image guided adaptive brachytherapy (IGABT) of cervix cancer. We assessed the value of 3D MRI for contouring by comparing it to 2D multi-planar MRI. Material and methods: In 14 patients, 2D and 3D pelvic MRI were obtained at IGABT. High risk clinical target volume (HR CTV) was delineated by 2 experienced radiation oncologists, using the conventional (2D MRI-based) and test (3D MRI-based) approach. The value of 3D MRI for contouring was evaluated by using the inter-approach and interobserver analysis of volumetric and topographic contouring uncertainties. To assess the magnitude of deviation from the conventional approach when using the test approach, the inter-approach analysis of contouring uncertainties was carried out for both observers. In addition, to assess reliability of 3D MRI for contouring, the impact of contouring approach on the magnitude of inter-observer delineation uncertainties was analysed. Results: No approach- or observer - specific differences in HR CTV sizes, volume overlap, or distances between contours were identified. When averaged over all delineated slices, the distances between contours in the interapproach analysis were 2.6 (Standard deviation (SD) 0.4) mm and 2.8 (0.7) mm for observers 1 and 2, respectively. The magnitude of topographic and volumetric inter-observer contouring uncertainties, as obtained on the conventional approach, was maintained on the test approach. This variation was comparable to the inter-approach uncertainties with distances between contours of 3.1 (SD 0.8) and 3.0 (SD 0.7) mm on conventional and test approach, respectively. Variation was most pronounced at caudal HR CTV levels in both approaches and observers. Conclusion: 3D MRI could potentially replace multiplanar 2D MRI in cervix cancer IGABT, shortening the overall MRI scanning time and facilitating the contouring process, thus making this treatment method more widely employed.