PMC5611395_01
(A) Pretreatment image of Patient A's posterior lesion adjacent to the anus (white arrow). (B) Preplanning computed tomography (CT) scan for patient A with mock-up of needle placement. (C) Treatment setup for patient A showing placement of guide needles (prior to flexible breast catheter placement). (D) Brachytherapy treatment plan for patient A (red = gross tumor, brown = rectum).
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F1
Not surprisingly, only 4 months after this surgery, she developed a perianal recurrence in the posterior aspect of the previous surgical site (Figure 1A). A preplan was created with the dose prescribed to the periphery of the GTV (contoured generously around the wire marker) (Figure 1B). Four needle-guided flexible catheters were placed in a single plane through the 3 cm x 3 cm lesion (Figure 1C). The patient received an interstitial dose of 25 Gy in 5 fractions over a 3-day period (Figure 1D).
PMC5611395_02
(A) Pretreatment image of tumor in right vulva. (B) Preplanning computed tomography (CT) scan for patient B with mock-up of needle placement. (C) Treatment setup for patient B with interstitial needles and modified Syed template to allow transrectal ultrasound. (D) Interstitial needle insertion under fluoroscopic guidance.
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F2
Following treatment, she represented with progressive perineal pain and was found to have a large tumor recurrence/persistence on the right vulva with complete obliteration of the vaginal canal (Figure 2A). The preplan created from the scan used 17 needles (Figure 2B). We used a modified Syed template with a custom cutout to allow for the transrectal probe for ultrasound image-guidance (Figure 2C). 17 stainless steel needles were inserted to a predetermined depth based on dosimetric planning using both ultrasound and real time fluoroscopy (Figure 2D).
(A,B) Brachytherapy treatment plan for patient B (red = gross tumor, yellow = bladder, brown = rectum). (C) Dose volume histogram for patient B.
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F3
The treatment plan and dose volume histogram from postimplatn CT images are displayed in Figures 3A-C.