Two German clinics belong to the world’s first to begin clinical use of Elekta’s new advanced gynecological applicator
First use of Venezia on European continent – Venezia avoids undesired EBRT boost to bladder and pelvic bones, enables straightforward use of interstitial needles to treat parametrial disease extension – “Clickable” design facilitates applicator insertion
Ludwig-Maximillians University of Munich (LMU Munich) and Sana Klinikum Offenbach (Offenbach, Germany) ushered in a new era of precision brachytherapy for cervical cancer by treating their first patients using the Venezia™ Advanced Gynecological Applicator. Recently, doctors at LMU Munich performed a Venezia-assisted interstitial brachytherapy procedure for a 51-year-old patient with advanced cervical cancer and 24 hours later, Sana Klinikum Offenbach clinicians treated a 54-year-old woman with stage IIB cervical cancer with infiltration of the parametrium.
Venezia is designed to treat not only the cervix using an intracavitary technique, but also disease extensions in the parametrium and vagina employing an interstitial approach. The applicator enables doctors to treat advanced stages of cervical cancer, such as stages IIIA and IIIB with vaginal and parametrial extensions, which previously required freehand placement of interstitial needles, a procedure requiring a great deal of experience and skill.
Boosting dose to cervical/parametrium targets, while minimizing exposure to normal tissues
“We acquired Venezia to provide a cutting-edge comprehensive brachytherapy solution for our patients with more complex, higher stage gynecologic cancers,” says Stefanie Corradini, MD, radiation oncologist at LMU Munich, who subspecialized in women’s cancers. “Without Venezia, these patients would otherwise be sub-optimally treated with standard tandem & ring/ovoid applicators, or require more risky perineal template or freehand needle implants.”
“Before we had Venezia, patients with advanced cervical cancer who were not candidates for surgery would receive radiation therapy including intracavitary brachytherapy boosts for their central cervical tumor plus an external beam boost if they had parametrial extension,” Dr. Corradini says. “However, an external beam boost gives additional undesired dose to the bladder and pelvic bones. This in turn can limit the deliverable dose to parametrial tumor regions and result in cancer recurrence. With Venezia, parametrial disease can instead be treated effectively with interstitial needles while minimizing dose to nearby normal tissues.”
The Venezia applicator adds both parallel and oblique interstitial needles that can reach areas of cancer not accessible by traditional intracavitary tandem & ring/ovoid applicators. This allows specialists such as Dr. Corradini to treat advanced GYN cancers with very conformal radiation dosing while minimizing radiation exposure to normal organs such as rectum, bladder and bowel.
“The parallel and oblique needles used with Venezia significantly improve upon the classical pear-shaped radiation dose distribution of standard tandem & ring/ovoid applicators, allowing us to treat local disease beyond the cervix,” she adds. “With the ability to load interstitial needles directly through the ring, the Venezia eliminates the need for potentially imprecise freehand needle placement. This in turn improves the safety, reproducibility and reliability of gynecologic brachytherapy implants, which are often repeated multiple times for a patient.”
“In the six cases that we’ve treated with Venezia so far, using the applicator has been extremely intuitive. Within just a few trial runs of applicator assembly, the team became proficient in handling Venezia.”
For planning cases with Venezia, LMU Munich uses Oncentra Brachy.
“The Applicator Modeling feature decreases the amount of time we have to spend on applicator reconstruction, and the same applies to implants with the Implant Modeling tool,” Dr. Corradini observes. “With Oncentra Brachy it’s also easy to define patient anatomy through contouring in arbitrary planes.”
Simpler interstitial brachytherapy for cervical cancer patients
Among the largest brachytherapy centers in Germany, and with three decades of experience in the discipline, Sana Klinikum Offenbach physicians perform approximately 300 brachytherapy procedures per year for a range of indications, including GYN malignancies.
“Brachytherapy for cervical cancer is done for about one patient per week, due to the rareness of the disease in Germany and the country’s strong tradition of surgery as the frontline treatment,” says Professor Peter Niehoff, MD, Head of the Department of Radiation Oncology. “But the guidelines are changing. Normally, if it’s a small cancer the patient will have surgery, but now the new guidelines indicate that if the patient has positive lymph nodes or if its IIB, the recommendation is chemoradiation plus brachy boost.”
Sana Klinikum Offenbach physicians have been performing freehand interstitial brachytherapy for cervical cancer years, Prof. Niehoff notes.
“We try to use interstitial needles for every patient,” he says. “There are only a few patients who get intracavitary brachy only, because if it’s a stage IIB, the tumor is usually too big, so we try to treat it with interstitial brachytherapy. Our hospital’s tumor board generally specifies this treatment.”
Even with a center that is experienced in interstitial brachytherapy, however, the prospect of moving away from freehand needle placement to ring-guided needle insertion with Venezia was attractive to Prof. Niehoff.
“If you place interstitial needles freehand, you can’t have precisely parallel needle placements,” he explains. “With Venezia it is significantly easier. We acquire an MRI before treatment that we can use to create a virtual plan, which shows us which holes to use and precisely how far to advance the needles. Then we implant the patient using rectal ultrasound to visualize the advancement of the needles. After that, they go to MRI and that’s the pre-implant and the post-implant plan, and then we can adapt it to our dose distribution. It’s very easy. We essentially changed our whole procedure.”
“I am impressed by the “clickable” design of the applicator, making the device easy to use in comparison to other applicators. Venezia is much better than any other applicator I’ve seen before.”
“I worked with another vendor’s cervical cancer applicator last year that had a much bigger ring that made inserting the applicator difficult,” Prof. Niehoff notes. “The two halves of Venezia are much easier to handle. You can insert the cervical probe first and then put in one-half of the ring into the patient and click it the cervical probe, or you can do it the other way around. It makes it much simpler when you’re dealing with a patient with a narrower vagina.
“The design of Venezia was clearly conceived of by people who know how to implant a patient with cervical cancer,” he adds. “It is meant for practical use – we learned within one implantation how to use this applicator. Venezia is much better than any other applicator I’ve seen before.”
Prof. Niehoff hopes to extend the benefits of interstitial brachytherapy with Venezia to patient groups who would normally have surgery.
“As I mentioned, for small, non-infiltrating cervical cancers the tradition has been very high for surgery, but if the patients are older and have comorbidities, or even have positive lymph nodes, they were not allowed to have surgery,” he says. “So, we’re beginning to see non-advanced cases for primary brachytherapy, and this reflects the newer guidelines.”
The two lunar-shaped ovoids of Venezia form a ring that when clicked together provide the ease of insertion of a tandem and ovoid applicator in combination with the dose distribution afforded by a ring applicator. The ring creates a pear-shaped dose distribution, a proven dosimetry shape that matches the cervix and endometrium.
Cervical cancer in Germany*
- Nearly 5,000 cervical cancer cases are diagnosed annually in Germany (estimate for 2012)
- It is the 12th leading cause of female cancer in Germany
- Cervical cancer is the 3rd most common female cancer in German women aged 15 to 44 years
- About 1,566 cervical cancer deaths occur each year in Germany (estimate for 2012)
- In Germany, the disease ranks as the 16th leading cause of female cancer deaths
- Cervical cancer is the 4th leading cause of cancer deaths in women aged 15to 44 years in Germany