Outpatient hybrid intracavitary-interstitial brachytherapy for cervical cancer with minimal sedation in a freestanding setting.

Background: Radiation therapy for locally-advanced cervical cancer consists of external beam radiation therapy and brachytherapy. Image-guided brachytherapy and hybrid intracavitary and interstitial brachytherapy treatments (HBT) can potentially improve outcomes; however, current literature describes the procedure requiring significant resources, limiting widespread use. Here is described a single institutional experience with CT-guided interstitial needle placement in a typical freestanding outpatient setting. Methods: All patients that were treated with HBT from June 2018 to May 2020 were included in this series. All tandem, ovoid and needle insertions and high dose rate (HDR) treatments were performed in a freestanding clinic. The patients were treated using minimal sedation (oral lorazepam and oxycodone/acetaminophen). If any vaginal bleeding occurred, vaginal packing was inserted with pressure held. Time stamps and clinical data was collected during each procedure. Results: Sixty-three (63) patients underwent placement of a total of 244 interstitial implants. Two of sixty-three (2/63, 3.2%) patients were unable to tolerate the procedure under minimal sedation and converted to epidural anesthesia. The median time for the entire procedure, from the time of patient entry into the CT room to exit of the HDR treatment room, was 70.0 min (mean 70.3 mins, range 54-100 mins). The median time after tandem and ovoid insertion to complete interstitial needle insertion was 9.0 mins (mean 9.8 mins, range 4-24 mins). Bleeding occurred in 22.1 % (54/244) of implants, which resolved after median 3 (mean 3.33, range 1-8) minutes of vaginal packing with pressure. Conclusion: High-dose-rate, image-guided adaptive hybrid brachytherapy boost with minimal sedation is feasible in the freestanding clinic setting, with a high percentage of patients completing treatment (96.8 %). Twenty-two percent (22.1 %) of patients had vaginal bleeding, all resolved with vaginal packing and pressure. Combining intracavitary and interstitial implants using a hybrid applicator appears to be feasible, efficient and safe in an outpatient freestanding clinic. Further studies are warranted.