CORRESPONDENCE AND BRIEF REPORTS

High dose rate (HDR) cervical ring applicator tocontrol bleeding from cervical carcinoma

To the Editor:We read with great interest the article High dose

rate (HDR) cervical ring applicator to control bleedingfrom cervical carcinoma by Grisgby et al.(1) Theauthors have addressed the use of HDR brachyther-apy, in probably the first report in the literature, tocontrol the bleeding from cervical cancer. The prob-lem of vaginal bleeding requiring hemostatic radio-therapy is more frequently encountered in developingcountries where the majority of cervical cancerpatients present with bulky advanced diseases. Theoncologists who face this problem more often willfind this article very useful since low dose rate(LDR) brachytherapy machines are increasinglybeing replaced by HDR machines in such countries.However we argue certain points in this study.

The authors have used 2 HDR fractions of 5 Gyeach by intravaginal brachytherapy at a one-weekinterval. They have reported the control of vaginalbleeding in 93% of patients. Though they have notmentioned whether it was at the end of the first frac-tion or the second, it seems the assessment for arrestof bleeding was done at the completion of two frac-tions. We are of the opinion that the assessment couldhave been done after the first fraction and if thebleeding stops, a likely possibility in several patients,the second fraction of HDR brachytherapy could havebeen avoided. Instead, the patients showing hemosta-sis after the first fraction should have been treatedsubsequently by external beam radiation therapy(EBRT) in the same manner as after the second frac-tion of HDR brachytherapy. EBRT is also a provenmodality for effective control of hemorrhagic cervicalcancer(2—4). Though earlier reports(2,3) have usedhigher dose per fraction (up to 10 Gy per fraction),currently conventional fractionation(4) is preferreddue to equal efficacy and lesser radiation morbidityassociated with it.

The authors have not described the dose fractionschedule of EBRT they used. It is important since theradiation-related morbidity is a sequelae of the entireregime of radiation therapy and not just HDRbrachytherapy.

As has been traditionally done in the past, theauthors also have not considered the dose of hemo-static brachytherapy into the composite total dose topoint A. The initial practice of hemostatic radiationtherapy was with deep X-ray therapy with the help oftransvaginal cone in which the dose fall off is mainlyin the forward direction, ie, within the tumor tissue,and the bladder and rectum do not receive any sig-nificant dose. In case of hemostatic brachytherapyeither by LDR ovoids or HDR ring applicator, thedose fall off is in all directions and bladder, rectum,and other tissues might receive a significant propor-tion of the prescribed dose. In this study by Grisgsbyet al. the average dose received by the rectum is 1.75Gy as compared to 5 Gy to the tumor. If we calculatethe BED2Gy (biological equivalent dose) for laterectal morbidity for 10 Gy delivered in two HDRfractions of 5 Gy each, it will be approximately3.5 Gy. This dose obviously cannot be ignoredkeeping in mind the limited rectal tolerance. Sincethis was the average dose received by the rectum, insome cases this dose might have been higher also. Atleast in such patients, the dose of hemostatic brachy-therapy may not be totally ignored and should beaccordingly accounted for in the composite total doseprescription.

G.K. Rath, D.N. Sharma*,D.K. Parida & M. GairolaDepartment of Radiation Oncology, All India Institute of

Medical Sciences and *Department of Radiation Oncology,Maulana Azad Medical College and LN Hospital,

New Delhi, India

References

1 Grigsby PW, Portelance L, Williamson JF. High doserate (HDR) cervical ring applicator to control bleedingfrom cervical carcinoma. Int J Gynecol Cancer 2002;12:18—21.

2 Boulware RJ, Caderao JB, Delclos L, Wharton JT, Peters LJ.Whole pelvis megavoltage Irradiation with single dosesof 1000 rad to palliate advanced gynecologic cancers. IntJ Radiat Oncol Biol Phys 1979;5:333—8.

3 Moez RT, SpanosWJ, Doss L, Johanson R, Wasserman TH.Misonidazole combined with large fraction pelvic

Int J Gynecol Cancer 2003, 13, 389—390

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irradiation in the treatment of patients with advancedpelvic malignancies. Am J Clin Oncol 1983;6:417—22.

4 Kagan RA. Palliation of visceral recurrences and metas-tases. In: Perez, CA, Brady, LW, eds. Principles and

Practice of Radiation Oncology. Philadelphia: Lippincott-Raven, 1998: 2219—26.

Accepted for publication March 10, 2003.

390 G. K. Rath et al.

# 2003 IGCS, International Journal of Gynecological Cancer 13, 389—390