32 Paediatric Malignancies

Paedriatric Malignacies 621

This perioperative brachytherapy is a complex procedure and necessitates excellent collaboration not only between experienced surgeon and radiation oncologist, but also with the pathologist and radiologist. Nowadays a perineal rectal ultrasound guided approach may be considered as used for brachytherapy of prostate cancer in the adult patient with plastic or steel needles. (13,21) Brachytherapy of the bladder requires a perioperative approach, comparable to that in the adult patient (Fig 31.4 A,B). In both situations, the use of a personalized moulded applicator is recommended as used for adult patients with gynaecological cancer (Fig 31.5A). Nevertheless, in children the cervico-vaginal impression is made under general anaesthesia often using a condom introduced into the vaginal cavity for easy removal of the impression from the vagina which is too small to receive liquid paste and strips. It is also more often necessary to push the impression out of the vagina with an intrarectal finger. The following steps are identical to making a mould in adult patients: impression into plaster, rough mould, positioning of the catheters according to the anatomy and the CTV, making appropriate perforations including four small holes to suture the applicator with silk thread to the inferior lateral parts of the vagina (Fig 31.5B and C). 7.5 Vagina/Cervix (rhabdomyosarcoma), Vagina/Cervix (clear-cell adenocarcinoma)

A: Determination of the GTV on the vaginal impression; first step in making the applicator.

B: Personalised vaginal applicator containing four plastic tubes.

C: Check radiograph, lateral view, with 5 iridium wires: 1 in the uterine catheters, 4 in the vaginal applicator.

Fig 5: Vaginal RMS, residual tumour after chemotherapy: Intravaginal and intrauterine brachytherapy with a personalised mould applicator