RU2798944C1 - Method of intraoperative installation of tantalum brackets for modeling radiation therapy fields in malignant neoplasms of the endometrium. - Google Patents

Abstract

FIELD: medicine; oncology; gynecology.

SUBSTANCE: after extirpation of the uterus with appendages, tantalum brackets are installed along the anterior and posterior surfaces of the vaginal stump, at the level of the upper and lower boundaries of lymph node dissection, on the peritoneum of the bladder and the peritoneum in the region of the rectum. The vaginal stump is marked over the entire surface with three brackets along the suturing line, the area of lymphadenectomy is marked and the brackets are placed from the area of the removed Pirogov Cloquet's lymph node, fixing them along the lower third of the psoas major muscle to the level of the inferior mesenteric artery, fixing the brackets to the fiber of this area. Next, the area of the bladder is marked in the area of its separation, fixing the bracket to the peritoneum of the bladder, as well as to the anterior wall of the vaginal stump at the level of the separated bladder, fixing the bracket to the peritoneum covering the wall of the rectum in the area of the Douglas space, suturing this marked peritoneum to the back wall of the vaginal stump.

EFFECT: method makes it possible to improve marking accuracy before further radiation therapy, provides good visualization of borders and topography of marked organs, improves treatment results and minimizes complications.

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Description

This method relates to medicine, namely to surgical treatment in oncology (oncogynecology), in particular to the specialty of Oncology.

The proposed method is effective and can be used in the work of an oncologist intraoperatively during the surgical stage of treatment of malignant neoplasms of the endometrium. This method involves intraoperative marking with tantalum brackets of the vaginal stump, the upper and lower boundaries of the pelvic lymphadenectomy, the wall of the rectum, and the bladder. This method makes it possible to increase the accuracy of marking before further radiation therapy, provides good visualization of the boundaries and topography of the marked organs, improves treatment results and minimizes complications.

External beam radiation therapy and brachytherapy can be used for cancer of the uterine body at any stage of the disease [Russian Association of Oncologists. Clinical guidelines "Cancer of the uterine body and uterine sarcomas", 2021, access mode (07/01/2022): https://oncology-association.ru/klinicheskie-rekomendaczii#nav-main]. The potential of malignant tumors to lymphogenous metastasis requires the use of not only extended operations, but also radiation methods of exposure in the postoperative period to areas of regional metastasis. The combination of various methods of influencing the tumor and the area of regional metastasis increases the effectiveness of treatment and significantly improves long-term results of treatment, preventing tumor recurrence [Application No. 2163100 RU. IPC A61B 17/00, A61M 36/00, A61N 5/00. Grobel O.V. The method of combined treatment of oncological diseases of the pelvic organs. Published: 20.02.2001]. The effectiveness and safety of treatment depends on the quality of pre-beam topometry. A known method of marking radiation fields (pelvic formations) in external beam radiation therapy. The pelvic organs are marked with radiopaque markers of different penetrating power for X-rays. In this case, the cervix is marked with a metal radiopaque label, the rectum is marked with a barium suspension, and air is introduced into the bladder in a volume equal to the amount of residual urine previously removed from it. This method is used in medicine, but is of limited use, due to the need for contrast immediately before marking, and also with this method, the upper and lower borders of lymphadenectomy are not visualized. This method is taken as a prototype.

The proposed method is based on the task of improving the accuracy and simplicity of marking when planning remote radiation therapy in the pelvic area.

This problem is solved by the fact that in the proposed method of intraoperative installation of tantalum brackets for modeling radiation therapy fields for malignant neoplasms of the endometrium after extirpation of the uterus with appendages (Fig. 1, Fig. 3), the next step is to intraoperatively install tantalum brackets along the anterior and posterior surfaces of the vaginal stump , at the level of the upper and lower borders of lymph node dissection, on the peritoneum of the bladder and the peritoneum in the region of the adjacent rectum (Fig. 2, Fig. 4). Tantalum staples are non-absorbable, biologically inert, radiopaque suture material. These properties of brackets allow them to be used as labels. The vaginal stump is marked over the entire surface with 3 brackets along the suturing line. The area of lymphadenectomy is marked - the brackets are installed from the area of the remote lymph node Pirogov Cloquet (fixed along the lower third of the psoas major muscle to the level of the inferior mesenteric artery (fixed to the tissue of this area). Next, the area of the bladder is marked (in the area of its separation). The bracket is fixed to the peritoneum of the bladder to the anterior wall of the vaginal stump at the level of the separated bladder.To the peritoneum of the rectal wall (in the area of its separation along the peritoneum of the posterior Douglas space) a bracket is fixed and this marked peritoneum is sutured to the posterior wall of the vaginal stump.These marks are set intraoperatively.Due to In the future, when marking on the simulator, the borders of lymphadenectomy, critical organs are visualized.In the future, radiotherapists, when marking in the course of computed tomography (CT), identify brackets, compare with CT navigation and conduct radiation planning with greater accuracy.This method leads to the fact that that the target is irradiated more efficiently.

The proposed method was developed and tested in the gynecological oncology department (Chelyabinsk Regional Clinical Center of Oncology and Nuclear Medicine) from March 2020 to March 2022. Clinical testing of this method was carried out in 15 patients with cancer of the uterus IB stage of the disease. All patients, according to clinical recommendations, taking into account the stage of the disease, underwent extirpation of the uterus with appendages, with pelvic lumbar lymphadenectomy. In all patients, the diagnosis was histologically verified at the prehospital stage. The tumor histotype was high grade endometrioid adenocarcinoma (G3). The first group of the study included 5 patients (33.4%). All patients underwent hysterectomy with appendages, pelvic and lumbar lymphadenectomy. After the stage of surgical treatment, this group of patients was intraoperatively marked with tantalum brackets for the following structures: the vaginal stump, the area of lymphadenectomy - the bed of the removed: internal, external and general lymph nodes, sacral lymph nodes to the level of the inferior mesenteric lymph nodes. Next, the bladder wall and the rectal wall were marked by fixing the brackets to the peritoneum in the region of the organs listed above, with fixation to the anterior and posterior walls of the vagina, respectively. The control group (the second group of the study) included an identical group of patients - 10 people (66.6%) who underwent a standard operation - extirpation of the uterus with appendages, pelvic and lumbar lymphadenectomy, without marking the area of lymphadenectomy and risk organs with tantalum brackets. The average volume of blood loss in both groups did not differ and averaged 200±100.0 ml. The number of removed lymph nodes in the first group was 25±5, in the second group 23±5. On the 12th-15th day of the postoperative period, all patients were discharged. The postoperative period proceeded without complications. All patients after surgical treatment were planned postoperative external beam radiation therapy (RT) with preliminary CT - topometry on the pelvic area and the area of regional metastasis. and brachytherapy with irradiation of the vaginal stump. The planned volume of postoperative RT included the small pelvis, the area of lymph node dissection, parametric fat. Risk organs (bladder, bowel loops), depending on their filling, may change in volume in preparation for the study. For the safest possible RT, it is recommended to use conformal RT with the IMRT (intensity-modulated radiation therapy) technique, radiation therapy with intensity modulation). With it, the lowest toxicity rates are noted with maximum local control, however, this technique is not always available in the regions, which does not allow for the most accurate and safe radiation therapy for organs.

Thus, in the first and second groups of the study, postoperative RT was performed: remote RT (EBRT) on the small pelvis with a total dose of 46 Gy in the fractionation mode 2 Gy 5 times a week and brachytherapy on the vaginal stump to a depth of 0.5 cm of the mucous membrane, 3 fractions of 4 Gy. In the first study group, LT was calculated according to the standard CT-navigation technique, but taking into account the established intraoperative tantalum marks, which clearly visualized the target organs (bladder and rectum), the vaginal wall and the area of lymphadenectomy (upper and lower borders). In the second group of the study, marking was carried out according to the standard method without tantalum marks (brackets).

Radiation therapy was carried out in both groups at the scheduled time without interruptions in treatment. In the first group of the study, 1 patient (6.6%) had grade 2 radiation epithelitis on the 14th day after the end of radiation therapy, and 1 patient (6.6%) had radiation rectitis on the 30-40th day after the start of EBRT. In the second group of the study, 3 (20%) had grade 2 radiation cystitis on the 21st day of EBRT, 5 (33.3%) had stage 1 radiation cystitis from 14-25 days of EBRT, 5 (33.3%) in the period from 10-14 days after the end of RT, radiation epithelitis of 2-3 degrees was recorded. In 2 (12.3%) patients, radiation rectitis of the 2nd degree was recorded in the period from 25-35 days after the start of EBRT. Based on the foregoing, it can be concluded that the proposed method of intraoperative installation of tantalum brackets for modeling radiation therapy fields in malignant neoplasms of the endometrium is an effective method that improves the quality of treatment due to more accurate and efficient planning of radiation therapy, and reduces the percentage of post-radiation complications.

The method is illustrated:

Fig. 1. Schematic representation of the small pelvis of a woman (front view, frontal section), the area of lymph node dissection during surgical treatment after extirpation of the uterus with appendages is highlighted in green.

Fig. Fig. 2. Schematic representation of the small pelvis of a woman (front view, frontal section), with the designation of the settings of the marks with tantalum brackets in the projection of the edges of the right and left psoas major muscles, the zone of suturing the dome of the vaginal stump, and the tissue of the upper border of lymph node dissection.

Fig. Fig. 3. Schematic representation of the small pelvis of a woman (side view, sagittal section) after extirpation of the uterus with appendages.

Fig. Fig. 4. Schematic representation of the small pelvis of a woman (side view, sagittal section) after extirpation of the uterus with appendages, with the designation of the installation of marks with tantalum brackets in the projection of the sutured dome of the vaginal stump, the wall of the rectum, and the bladder.

Claims (1)

A method for intraoperative installation of tantalum brackets for modeling radiation therapy fields for malignant neoplasms of the endometrium, characterized in that after extirpation of the uterus with appendages, tantalum brackets are installed along the anterior and posterior surfaces of the vaginal stump, at the level of the upper and lower borders of lymph node dissection, on the peritoneum of the bladder and peritoneum in the area of rectal adjacency, for this, the vaginal stump is marked over the entire surface with three brackets along the suturing line, the area of lymphadenectomy is marked and brackets are placed from the area of the remote lymph node of Pirogov Cloquet, fixing them along the lower third of the psoas major muscle to the level of the inferior mesenteric artery, fixing brackets to the fiber of this area; further mark the area of the bladder in the area of its separation, fixing the bracket to the peritoneum of the bladder, as well as to the anterior wall of the vaginal stump at the level of the separated bladder, fixing the bracket to the peritoneum covering the wall of the rectum in the Douglas space area, suturing this marked peritoneum to the back wall of the vaginal stump.

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