How do you approach boosting a vaginal cuff recurrence of cervical cancer with brachytherapy that is tethered to small bowel?

Tough case.

Controlling cancer is important.

MRI guided brachy and making sure GTV is adequately covered even if bowel wall gets that dose.

Warn the patient about bowel obstruction and the need to bypass in future.

An incredibly challenging case!

I would consider using TRUS to guide needles in addition to laparoscopic guidance and would advance the needles into the bowel if necessary to cover the GTV.

I would accept some under coverage of GTV along the bowel/GTV interface as long it's dosed to the tolerance o...

If a poor candidate for brachytherapy, can also consider upper vaginectomy with small bowel anastomosis following initial EBRT.

Otherwise, advance needles slowly with interval imaging to get optimal positioning without perforation. Can also consider transrectal US for needle advancement.

The risk of fistula will be higher and should also be explained to the patient.

Depending upon the patient's risk tolerance, age, and performance status, the bowel may need to be underdosed.

I don't do gynecologic brachy anymore, but there once was an expandable applicator that looked something like a squid (can't remember the name of it) due to the multiple catheters extending down from the expandable fluid-filled head, but it allowed more customizable dose to the vaginal mucosa as you...

We would do a laparoscopic attempt to create a plane between the bowel and tumor, then mobilize and suture mesenteric fat into the area to maintain separation. The needle position and depth can also be evaluated/confirmed laparoscopically.
If that separation attempt fails, I would consider placing t...