Perioperative morbidity and mortality of high-dose-rate gynecologic brachytherapy

Purpose: To determine the 30-day morbidity and mortality rates for patients with an intact uterus undergoing high-dose-rate (HDR) brachytherapy, and t o assess risk factors which may predict for these potentially life-threaten ing complications. Methods and Materials: From August 1989 to December 1994, 128 cervical and 41 medically inoperable endometrial cancer patients were treated with 5 out patient weekly HDR brachytherapy insertions. Patients with cervical cancer also were treated with external beam radiotherapy. Acute events that result ed in either hospitalization (morbidity) or death (mortality) within 30 day s of the implant were analyzed. Univariate and multivariate analyses were p erformed to identify risk factors. Results: Overall there were 16 acute events in 169 patients (9.5%). The ove rall morbidity and mortality rates for the cervical and endometrial patient s were 5.5%, 1.6%, 7.3%, and 9.8%, respectively. The following factors were significant by univariate analysis: age per decade, American Society of An esthesiologists (ASA) score, Karnofsky Performance Status (KPS), significan t medical history, diagnosis of cervical vs. endometrial cancer, and mean t ime exceeding 160 minutes for the procedure. Since age was the most signifi cant predictive factor (p = 0.0003), bivariate analyses were performed by a djusting for age. In these analyses only ASA and KPS maintained significanc e, while a positive medical history was of borderline significance (p = 0.0 7). Conclusion: The morbidity and mortality rates observed in gynecologic patie nts selected for HDR brachytherapy were similar to low-dose-rate, but highe r than other HDR reports. Reasons for this include a higher risk population , especially those with medically inoperable endometrial cancer. In the cer vical cancer patients, some of the complications may have also been a resul t of the external beam portion of the radiation. In order to minimize the a cute complications observed in the present HDR brachytherapy system, the fo llowing changes have been implemented: appropriate patient selection, anest hesiology involvement to monitor conscious sedation for high-risk patients, external beam radiotherapy alone in patients at extremely high risk, deep vein thrombosis (DVT) prophylaxis, use of intraoperative ultrasound, shorte r duration in the brachytherapy suite, and preradiation treatment plans (pl ans executed prior to the insertion) if applicable. Finally, this analysis suggests that these procedures should be performed in a hospital-based sett ing where appropriate support is available. (C) 1998 Elsevier Science Inc.