Intraoperative Sonographic Guidance for Intracavitary Brachytherapy of Cervical Cancer Tugana Akbas, MD , 1 Gamze Ugurluer, MD , 2 Meltem Acil, MD, 3 Taner Arpaci, MD, 1 Meltem Serin, MD 2 1 Acibadem University, Vocational School of Health Services, Acibadem Adana Hospital, Adana, Turkey 2 Department of Radiation Oncology, Acibadem University, School of Medicine, Acibadem Adana Hospital, Adana, Turkey 3 Department of Anesthesiology, Acibadem University, School of Medicine, Acibadem Adana Hospital, Adana, Turkey Received 16 November 2016; accepted 21 May 2017 ABSTRACT: Background. To describe the role and benefits of intraoperative sonographic (US) guidance in intracavitary brachytherapy of cervical cancer. Methods. The data of 142 patients who received tandem-based intracavitary brachytherapy for cervi- cal cancer between January 2010 and June 2015 were retrospectively reviewed. US guidance was carried out for tandem selection and appropriate application. The complications and applicator conformity were assessed with planning CT. Results. Intracavitary brachytherapy was performed under US guidance for 412 insertions in 113 consecu- tive patients with cervical cancer. Before we started to use US guidance, applications were done in 29 patients: uterine perforation occurred in two patients (6.9%), the tandem length was short in two patients (6.9%), the tandem length was long in four patients (13.8%), and tandem was in myometrium in three patients (10.3%). We then decided to use US guidance routinely. With US guidance, only 1 of 113 patients had uterine perforation (0.9%), tandem length was short in only one patient (0.9%), and tandem was in myometrium in one patient (0.9%). Conclusions. Real-time US provided safe and effec- tive guidance for intracavitary brachytherapy of cervi- cal cancer resulting in decreased rates of perforations and misplacement of applicators. V C 2017 Wiley Peri- odicals, Inc. J Clin Ultrasound 00:000–000, 2017; Published online in Wiley Online Library (wileyonline- library.com). DOI: 10.1002/jcu.22510 Keywords: cervical cancer; intracavitary brachyther- apy; uterus; uterine perforation; ultrasound INTRODUCTION C ervical cancer is a major health problem, and it is the fourth most common cancer in women worldwide, with 85% of cases occurring in developing countries, where cervical cancer is a leading cause of cancer death in women. 1–3 The standard treatment for locally advanced cervical cancer (stages IB2 to IVA) is external beam radiation therapy with concurrent chemo- therapy followed by brachytherapy. 3 Intracavi- tary brachytherapy facilitates delivery of a high radiation dose to the tumor with relative spar- ing of normal tissues and is an integral compo- nent of curative radiation therapy for this disease. 4 For intracavitary brachytherapy, an applica- tor (a uterine tandem and vaginal ovoids or a ring) is placed in the uterine cavity and vaginal fornices under sedation or anesthesia through the cervical os; this is often done “blindly” by advancing the tandem until sensing the uterine fundus. Intraoperative complications of brachytherapy include vaginal lacerations, pen- etration of the tandem into the uterine wall, The results of this study have been presented as an electronic poster and as an oral communication at the European Con- gress of Radiology (ECR), March 2–6, 2016, Vienna, Austria. Correspondence to: T. Akbas V C 2017 Wiley Periodicals, Inc. VOL. 00, NO. 00, MONTH 2017 1