16 Cervix Carcinoma

314 Cervix Cancer

The modern Manchester applicators physically mimic the classical technique. The intrauterine tubes have the same fixed lengths and fixed cervical flange and are angled at 40 degrees to the line on the vaginal component of the tube. The vaginal ovoids have kept their ellipsoid shape (large, medium, small, half) with the small ovoids extended posteriorly by 5 mm to build packing into them. These three afterloading tubes are held together and their relative positions fixed by a clamp ensuring an ideal physical arrangement. The whole system is held in place in the individual patient by vaginal gauze packing. When the vagina is too narrow for this arrangement a vaginal cylinder is fitted to the vaginal part of the uterine tube (61). Nowadays uterine tubes with different lengths graduated in centimetres are commercially available allowing for adaptation according to the individual anatomy (with a fixed uterine flange) and angled at varying degrees to the line of the vaginal component (0°,15°,30°,45°) (Fig 14.6). 7.3 ”Fletcher” based techniques (22,35,54). Fig 14.7: Fletcher based Technique

Fig 14.7A-C: Classical Fletcher applicator set (A) which is available for a Cesium source and – with a smaller tube diameter - for an Iridium source. The different angles and the different lengths of the intrauterine tubes are demonstrated as well as the shape and size of the different colpostats (diameter 20,25,30 mm) (B, C). Shielding is integrated into the anterior and posterior part of each colpostat. There is a clamp to fix the position of the ovoids and the intrauterine tube to each other (Nucletron ®). D: CT/MRI compatible Fletcher-like applicator set for Iridium, which is also available for Cesium. The colpostat dimensions are identical to the metallic version. The outer diameters are slightly larger. No shielding is integrated. The whole system is fixed with a screw (Nucletron ®).