Inr. J Radiorion Oncology Biol. Phys.. Vol. 9. pp. 1897-1903 036&3016/83/$3.M) + 00 Printed in the U.S A All rights reserved. Copyright 0 1983 Pergamon Press Ltd. ?? Brief Communication THE SYED-NEBLETT INTERSTITIAL TEMPLATE IN LOCALLY ADVANCED GYNECOLOGICAL MALIGNANCIES FRANCISCO AMPUERO, M.D.,* LARRY L. Doss, M.D.,? MIRKUTUB KHAN, M.D.,? BETTY SKIPPER, PH.D.,$ AND ROBERT D. HILGERS, M.D.* Divisions of *Gynecologic Oncology, ?Radiation Oncology and $Family, Community and Emergency Medicine, Cancer Research and Treatment Center, University of New Mexico Medical Center, Albuquerque, NM Twenty-eight patients with locally advanced malignancies of the cervix and vagina were treated with a combination of external radiation therapy and afterloading Syed-Neblett iridium template. There were 22 patients with squamous cell cancer and two patients with adenocarcinomas of the cervix. Four patients with squamous cell cancer of the vagina were treated with this method. Only patients with locally advanced disease (cervical lesion r4 cm in diameter) and poor vaginal anatomy were selected for this modality of therapy. In our series the incidence of distant failures of 39 % seems to confirm the significance of local volume of disease as a prognostic indicator; despite a local control rate of 59 %, only 33 % of our patients are alive from 25-51 months. Complications occurred in 12 patients (42 %). Six patients (22 %) developed severe rectal stricture or rectovaginal fistula necessitating diverting sigmoid colostomy; five patients (18 % ) developed hemorrhagic proctitis with diarrhea and tenesmus; one patient developed vaginal vault necrosis. Complications occurred 7 to 24 months following therapy. Six of the 12 patients developing complications are dead of disease. On the basis of this study and be-causeof the low cure rate and high incidence of complications, the value of the Syed-Neblett template in locally advanced gynecologic malignancies should be reconsidered. Syed Neblett, Transperineal gynecological implant, Transperineal volume implant, Carcinoma of the cervix, Ckcinoma of the vagina. INTRODUCTION During the past 12 years, afterloading techniques for the delivery of radiation to the vagina, cervix, uterus, and parametria have changed rapidly. Delcos et al.* in 1970, introduced afterloading vaginal cylinders of variable diameters for the irradiation of primary vaginal tumors. The Delcos applicator can be combined with a central, Fletcher tandem to simultaneously irradiate the cervix and uterine cavity. The Fletcher tandem can be used with colpostats to distribute the dose into the proximal para- metria. These systems are adequate for early vaginal and cervical disease; however, bulky disease in the perivaginal and distal parametrial regions will not be uniformly treated by such brachytherapy devices. To facilitate the application of the uniform radiation field to the entire paracolpium and parametrium, interstitial implants to deliver radiation therapy to these anatomical areas have been used in the past. Since the original description by Pitts and Watterman in 19309 the use of interstitial volume implants for treatment of gynecological malig- nancies has been reintroduced several times, only to be abandoned despite the quoted good results obtained with this therapeutic modality. The theoretical benefits of this treatment modality are to treat the disease precisely in its anatomical location and to provide a wider and more uniform distribution of radiation in the pelvis. In 1974, Feder et al. reintroduced the use of interstitial implants in pelvic tumors and in 1978 reported their own experience using the afterloading technique with iridium- 1 92.4 This technique was particu- larly recommended for patients with distorted vaginal anatomy where central tandem and colpostats could not be adequately applied. The Syed-Neblett afterloading template consists of the vaginal obturator and an acrylic perineal plate. The template allows the insertion of 44 trochars in five concentric rings around the lateral plane of the vagina. The trochars are afterloaded with the iridium- 192 in nylon ribbons and a tandem is provided for the placement of intrauterine cesium or radium sources. The technique for the use of Syed-Neblett template has been described by Fleming et al.’ Since the reintroduction of the interstitial perineal implants by Syed and Neblett, occasional reports have Reprint requests to: Francisco Ampuero, M.D., Cancer Research and Treatment Center, 900 Camino de Salud N.E., Albuquerque, NM 87 131. Accepted for publication 21 July 1983. 1897