the standard of care for locally advanced cervical cancer consists of external beam radiation therapy ( ebrt ) with concurrent cisplatin chemotherapy followed by brachytherapy ( bt ) boost [ 1 , 2 ] . until recently ,
the standard approach for cervical bt consisted of 2d planning with orthogonal x - ray films , prescribing dose to point a. however , with the advent and accessibility of sophisticated imaging systems , cervical bt is now routinely performed with mri ( magnetic resonance imaging ) or ct ( computed tomography ) based planning , prescribing the treatment dose to a clinical target volume ( ctv ) [ 3 , 4 ] . either planning method requires an experienced radiation oncologist to ensure proper applicator placement and replicable setup geometry . as a result ,
the american brachytherapy society ( abs ) and the groupe europen de curiethrapie/ european society for therapeutic radiology and oncology ( gec - estro ) working group have released specific guidelines to aid radiation oncologists in performing effective and safe cervical bt [ 3 , 4 ] .
while anomalies of the uterus and cervix are a relatively rare phenomenon , they can significantly impact the ability to perform technically safe and efficacious cervical bt .
additionally , the guidelines set forth by abs and gec - estro do not take into account uterine and cervical anatomic anomalies .
given the rarity of female genital tract anomalies , there are only 2 published cases of cervical bt in patients with anatomic uterine abnormalities [ 6 , 7 ] .
herein , we report the unusual case of a patient with a congenital septate uterus , who was subsequently diagnosed with locally advanced adenocarcinoma of the cervix and treated with ebrt , concurrent cisplatin , and ct - guided cervical bt .
the patient is a 34-year - old g4p3 premenopausal female who presented with pain and discomfort during a post - partum pelvic exam in march 2011 , 8 weeks after c - section delivery of her third child .
she has necessitated a c - section delivery for all of her children due to a congenital septate uterus .
two months post - partum , the patient developed new , progressive dyspareunia with vaginal spotting and clot passage , prompting medical evaluation .
examination by gynecology in december 2011 revealed a large cervical mass which was biopsied , demonstrating poorly differentiated adenocarcinoma consistent with endocervical origin .
an endocervical curettage demonstrated poorly differentiated adenocarcinoma and squamous carcinoma in situ , cin 3 , with foci of squamous differentiation within the invasive component of the tumor .
1a ) demonstrated a 3.1  2.6  3.0 cm enhancing mass within the endocervix .
protrusion of the mass was noted into the anterior and posterior vaginal fornices with minimal invasion into uppermost vaginal tissues and bilateral parametrial invasion .
. also noted was an enlarged node in the right proximal external iliac chain measuring 2.3  1.4 cm .
her septate uterus was radiographically confirmed , with a septate approaching , but not involving , the internal os , making this a class v uterine anomaly ( table 1 ) . 
 
pretreatment ( a ) and pre - brachytherapy ( b ) mri images in the axial and sagittal planes demonstrating a septate uterus with a large tumor involving the cervix and parametria .
the pre - brachytherapy mri images were obtained at fraction 18 of whole pelvic radiation with concurrent cisplatin chemotherapy , and demonstrate a partial response to therapy american fertility society classification of uterine anomalies des 
diethylstilbestrol a positron emission tomography ( pet ) scan was also obtained and confirmed the presence of a hypermetabolic cervical mass with an suv max of 15.6 .
in addition , the enlarged right external iliac lymph node was hypermetabolic with an suv max of 9.3 .
no findings of metastatic disease were identified . in january 2012 , the patient was referred to our institution ( a tertiary academic center ) for further evaluation . on physical examination ,
she was noted to have a 4 to 4.5 cm exophytic , friable mass , completely replacing the cervix .
although the tumor was replacing the entire cervix , bimanual exam revealed that the bulk of the tumor was located on the left lateral aspect of the cervix , with palpable disease extension into the posterior and left vaginal fornices .
, the patient was staged as international federation of gynecology and obstetrics ( figo ) stage iib .
the patient was initiated on whole pelvic rt to a dose of 45 gy in 25 daily fractions of 1.8 gy each using a 4-field technique with 18 mv photons .
the bilateral parametria were boosted with an additional dose of 5.4 gy in 3 fractions .
the pet avid right external iliac node received an additional dose of 9 gy in 5 fractions , bringing the total dose to the lymph node to 59.4 gy . throughout treatment ,
the patient received concurrent weekly cisplatin chemotherapy at a dose of 40 mg / m for 6 cycles .
the patient was evaluated on fraction 18 of ebrt with physical exam and a pre - brachytherapy planning mri ( fig .
on physical examination , the mass had decreased in size and measured approximately 3 cm , but remained exophytic in nature . left parametrial involvement was still noted , but improved from initial examination .
magnetic resonance imaging exam demonstrated a 2.3  1.6  1.9 cm endocervical mass , with partial response to therapy .
additionally , the right external iliac node was decreased in size , now measuring 2.0  1.1 cm , with a central necrotic component .
the patient 's septate uterus presented several challenges for bt setup geometry and treatment planning requiring multiple adaptations of customary bt techniques .
a standard uterine tandem could not be employed in this setting given the prominent low septate nearly abutting the internal cervical os . to accommodate her septate uterus , a rotte - y applicator ( nucletron , an elekta company , elekta ab , stockholm , sweden )
the rotte - y applicator consists of 2 individual uterine tandems that lock together once the applicator is in place .
for insertion of the applicator , each uterine septate was first sounded under ultrasound ( us ) guidance prior to placement of the tandems .
the right tandem was then placed into the right septate with the aid of us .
once the right tandem was in correct position with the tip of the tandem abutting the right fundus , the left tandem was placed in a similar manner .
once the two tandems were in place , they were secured together with the locking mechanism on the external portion of the rotte - y apparatus .
photograph of the assembled rotte - y applicator prior to placement after the tandems were successfully placed , two ct - compatible ovoids were assembled onto colpostats ( nucletron , an elekta company ) and placed in the right and left vaginal fornices , respectively , with the pair of tandems bi - secting the ovoids at midplane .
a simple bridge was used to connect the rotte - y tandem to the colpostats .
once the apparatus was secured in place within the uterus and vagina , and the appropriate geometry obtained , extensive vaginal packing was placed into the vagina with 4  4 gauze to create bladder and rectal separation , as well as stabilize the applicator in a fixed position .
photograph of the completely assembled treatment apparatus including the rotte - y applicator attached to a pair of colpostats with large ovoids via a simple bridge the patient was then transferred to the ct simulator to obtain the planning ct images in 2.5 mm slices .
the ct images were uploaded to the treatment planning system , oncentra masterplan ( nucletron , an elekta company ) .
the 4 applicator channels ( 2 channels of the rotte - y applicator and 2 colpostat channels ) were identified and reconstructed on the planning ct .
dwell positions were identified and activated ( represented as red dots on the 3d graphical reconstruction found in figs . 4 and 5 ) . a basic plan
was then created as a starting point for further graphical optimization , prescribing a dose of 5.5 gy to point a , and a 125% of the prescription dose ( 6.875 gy ) to the surface of the ovoids / vaginal mucosa . for purposes of this plan ,
point a was defined as 2 cm superior to the line connecting the superior aspect of the ovoids and 2 cm lateral to the line running between and parallel to the two channels of the rotte - y applicator .
three - dimensional graphical rendering of the assembled treatment apparatus in the coronal ( a ) and right anterior - lateral ( b ) views , diagraming the anatomic relationship of the apparatus to the hr - ctv ( red ) and normal structures including the bladder ( yellow ) , rectum ( blue ) , and the sigmoid colon ( green ) .
the red dots within the tandems and colpostats represent the planned dwell positions of the hdr ir source representative coronal image from the final brachytherapy plan .
isodose distribution is demonstrates adequate coverage of the hr - ctv with a conformal brachytherapy plan .
the red dots within the tandems and colpostats represent the planned dwell positions of the hdr ir source then , using pelvic exam findings and the pre - brachytherapy mri as a guide , the high risk ctv ( hr - ctv ) was then contoured per gec - estro guidelines .
the gtv could not be contoured on the ct images given the difficulty with tissue delineation between normal cervix and tumor on the ct .
optimization points were then placed laterally along the length of the rotte - y applicator , to deliver the prescription dose superior to point a and sufficiently cover the hr - ctv .
normal structures including the rectum , sigmoid colon , and bladder were identified and contoured .
figure 4 demonstrates a 3d graphical representation of the applicator and its anatomic relationship to the hr - ctv and normal structures .
once a computer generated plan was in place , manual optimization of the isodose distribution was then performed on the graphically optimized plan to further enhance hr - ctv coverage and decrease dose to normal structures .
real - time plan analysis was performed taking dose - volume histogram ( dvh ) data into account to meet normal structure tolerances .
organ at risk constraints were calculated based on the patient 's ebrt dose of 45 gy with subsequent parametrial boost ( 5.4 gy in 3 fractions ) , as well as 5 total bt fractions at 5.5 gy per fraction , per gec - estro recommendations .
coverage for the hr - ctv was analyzed using the recommend dvh parameter of d90 , which was greater than 5.6 gy for each fraction of bt .
total d90 ( ebrt + bt ) to the hr - ctv was 86.3 gyeqd2 .
dose limits to normal structures were within acceptable limits for the entire course of radiation : bladder d2cc = 86.6 gyeqd2 , rectum d2cc = 73.7 gyeqd2 , and sigmoid d2cc = 72.1 gyeqd2 .
we were comfortable with the slightly high dose to the rectum and sigmoid , given the final 3 fractions of ebrt were to parametria and lymph node only ( above d2cc calculations assumes whole pelvis for all treatments ) .
treatment was then delivered with high - dose rate ( hdr ) ir using an hdr after - loading system ( nucletron , an elekta company ) .
the patient tolerated her bt extremely well , with no significant complications or side effects during treatment .
the same radiation oncologist performed all 5 brachytherapy fractions . the total treatment time ( ebrt plus bt ) was 48 days .
the patient is a 34-year - old g4p3 premenopausal female who presented with pain and discomfort during a post - partum pelvic exam in march 2011 , 8 weeks after c - section delivery of her third child .
she has necessitated a c - section delivery for all of her children due to a congenital septate uterus .
two months post - partum , the patient developed new , progressive dyspareunia with vaginal spotting and clot passage , prompting medical evaluation .
examination by gynecology in december 2011 revealed a large cervical mass which was biopsied , demonstrating poorly differentiated adenocarcinoma consistent with endocervical origin .
an endocervical curettage demonstrated poorly differentiated adenocarcinoma and squamous carcinoma in situ , cin 3 , with foci of squamous differentiation within the invasive component of the tumor .
1a ) demonstrated a 3.1  2.6  3.0 cm enhancing mass within the endocervix .
protrusion of the mass was noted into the anterior and posterior vaginal fornices with minimal invasion into uppermost vaginal tissues and bilateral parametrial invasion .
. also noted was an enlarged node in the right proximal external iliac chain measuring 2.3  1.4 cm .
her septate uterus was radiographically confirmed , with a septate approaching , but not involving , the internal os , making this a class v uterine anomaly ( table 1 ) . 
 
pretreatment ( a ) and pre - brachytherapy ( b ) mri images in the axial and sagittal planes demonstrating a septate uterus with a large tumor involving the cervix and parametria .
the pre - brachytherapy mri images were obtained at fraction 18 of whole pelvic radiation with concurrent cisplatin chemotherapy , and demonstrate a partial response to therapy american fertility society classification of uterine anomalies des 
diethylstilbestrol a positron emission tomography ( pet ) scan was also obtained and confirmed the presence of a hypermetabolic cervical mass with an suv max of 15.6 .
in addition , the enlarged right external iliac lymph node was hypermetabolic with an suv max of 9.3 .
no findings of metastatic disease were identified . in january 2012 , the patient was referred to our institution ( a tertiary academic center ) for further evaluation . on physical examination ,
she was noted to have a 4 to 4.5 cm exophytic , friable mass , completely replacing the cervix .
although the tumor was replacing the entire cervix , bimanual exam revealed that the bulk of the tumor was located on the left lateral aspect of the cervix , with palpable disease extension into the posterior and left vaginal fornices .
, the patient was staged as international federation of gynecology and obstetrics ( figo ) stage iib .
the patient was initiated on whole pelvic rt to a dose of 45 gy in 25 daily fractions of 1.8 gy each using a 4-field technique with 18 mv photons .
the bilateral parametria were boosted with an additional dose of 5.4 gy in 3 fractions .
the pet avid right external iliac node received an additional dose of 9 gy in 5 fractions , bringing the total dose to the lymph node to 59.4 gy . throughout treatment ,
the patient received concurrent weekly cisplatin chemotherapy at a dose of 40 mg / m for 6 cycles .
the patient was evaluated on fraction 18 of ebrt with physical exam and a pre - brachytherapy planning mri ( fig .
on physical examination , the mass had decreased in size and measured approximately 3 cm , but remained exophytic in nature . left parametrial involvement was still noted , but improved from initial examination .
magnetic resonance imaging exam demonstrated a 2.3  1.6  1.9 cm endocervical mass , with partial response to therapy .
additionally , the right external iliac node was decreased in size , now measuring 2.0  1.1 cm , with a central necrotic component .
the patient 's septate uterus presented several challenges for bt setup geometry and treatment planning requiring multiple adaptations of customary bt techniques . a standard uterine tandem could not be employed in this setting given the prominent low septate nearly abutting the internal cervical os .
to accommodate her septate uterus , a rotte - y applicator ( nucletron , an elekta company , elekta ab , stockholm , sweden ) was used ( fig .
the rotte - y applicator consists of 2 individual uterine tandems that lock together once the applicator is in place . for insertion of the applicator ,
each uterine septate was first sounded under ultrasound ( us ) guidance prior to placement of the tandems .
the right tandem was then placed into the right septate with the aid of us .
once the right tandem was in correct position with the tip of the tandem abutting the right fundus , the left tandem was placed in a similar manner .
once the two tandems were in place , they were secured together with the locking mechanism on the external portion of the rotte - y apparatus .
photograph of the assembled rotte - y applicator prior to placement after the tandems were successfully placed , two ct - compatible ovoids were assembled onto colpostats ( nucletron , an elekta company ) and placed in the right and left vaginal fornices , respectively , with the pair of tandems bi - secting the ovoids at midplane .
a simple bridge was used to connect the rotte - y tandem to the colpostats .
once the apparatus was secured in place within the uterus and vagina , and the appropriate geometry obtained , extensive vaginal packing was placed into the vagina with 4  4 gauze to create bladder and rectal separation , as well as stabilize the applicator in a fixed position .
photograph of the completely assembled treatment apparatus including the rotte - y applicator attached to a pair of colpostats with large ovoids via a simple bridge the patient was then transferred to the ct simulator to obtain the planning ct images in 2.5 mm slices .
the ct images were uploaded to the treatment planning system , oncentra masterplan ( nucletron , an elekta company ) .
the 4 applicator channels ( 2 channels of the rotte - y applicator and 2 colpostat channels ) were identified and reconstructed on the planning ct .
dwell positions were identified and activated ( represented as red dots on the 3d graphical reconstruction found in figs . 4 and 5 ) .
a basic plan was then created as a starting point for further graphical optimization , prescribing a dose of 5.5 gy to point a , and a 125% of the prescription dose ( 6.875 gy ) to the surface of the ovoids / vaginal mucosa . for purposes of this plan ,
point a was defined as 2 cm superior to the line connecting the superior aspect of the ovoids and 2 cm lateral to the line running between and parallel to the two channels of the rotte - y applicator .
three - dimensional graphical rendering of the assembled treatment apparatus in the coronal ( a ) and right anterior - lateral ( b ) views , diagraming the anatomic relationship of the apparatus to the hr - ctv ( red ) and normal structures including the bladder ( yellow ) , rectum ( blue ) , and the sigmoid colon ( green ) .
the red dots within the tandems and colpostats represent the planned dwell positions of the hdr ir source representative coronal image from the final brachytherapy plan .
isodose distribution is demonstrates adequate coverage of the hr - ctv with a conformal brachytherapy plan .
the red dots within the tandems and colpostats represent the planned dwell positions of the hdr ir source then , using pelvic exam findings and the pre - brachytherapy mri as a guide , the high risk ctv ( hr - ctv ) was then contoured per gec - estro guidelines
. the gtv could not be contoured on the ct images given the difficulty with tissue delineation between normal cervix and tumor on the ct .
optimization points were then placed laterally along the length of the rotte - y applicator , to deliver the prescription dose superior to point a and sufficiently cover the hr - ctv .
normal structures including the rectum , sigmoid colon , and bladder were identified and contoured .
figure 4 demonstrates a 3d graphical representation of the applicator and its anatomic relationship to the hr - ctv and normal structures .
once a computer generated plan was in place , manual optimization of the isodose distribution was then performed on the graphically optimized plan to further enhance hr - ctv coverage and decrease dose to normal structures .
real - time plan analysis was performed taking dose - volume histogram ( dvh ) data into account to meet normal structure tolerances .
organ at risk constraints were calculated based on the patient 's ebrt dose of 45 gy with subsequent parametrial boost ( 5.4 gy in 3 fractions ) , as well as 5 total bt fractions at 5.5 gy per fraction , per gec - estro recommendations .
coverage for the hr - ctv was analyzed using the recommend dvh parameter of d90 , which was greater than 5.6 gy for each fraction of bt .
total d90 ( ebrt + bt ) to the hr - ctv was 86.3 gyeqd2 .
dose limits to normal structures were within acceptable limits for the entire course of radiation : bladder d2cc = 86.6 gyeqd2 , rectum d2cc = 73.7 gyeqd2 , and sigmoid d2cc = 72.1 gyeqd2 .
we were comfortable with the slightly high dose to the rectum and sigmoid , given the final 3 fractions of ebrt were to parametria and lymph node only ( above d2cc calculations assumes whole pelvis for all treatments ) .
treatment was then delivered with high - dose rate ( hdr ) ir using an hdr after - loading system ( nucletron , an elekta company ) .
the patient tolerated her bt extremely well , with no significant complications or side effects during treatment .
the patient remains without evidence of local or systemic recurrence with a follow up duration of 20 months .
a ct scan of the chest , abdomen , and pelvis with contrast at 13 months post treatment was negative .
a mri of the pelvis with and without contrast at 20 months post treatment was also negative for any evidence of recurrence .
the patient has received a physical exam with pap testing at regular 3 months intervals since completing treatment .
all exams have been negative for disease recurrence , but have noted mild proximal vaginal narrowing , consistent with a late grade 1 radiation toxicity .
the patient did report 3 episodes of mild gross hematuria at 19 months post treatment without associated urgency , frequency , or dysuria .
the patient remains without evidence of local or systemic recurrence with a follow up duration of 20 months .
a ct scan of the chest , abdomen , and pelvis with contrast at 13 months post treatment was negative .
a mri of the pelvis with and without contrast at 20 months post treatment was also negative for any evidence of recurrence .
the patient has received a physical exam with pap testing at regular 3 months intervals since completing treatment .
all exams have been negative for disease recurrence , but have noted mild proximal vaginal narrowing , consistent with a late grade 1 radiation toxicity .
the patient did report 3 episodes of mild gross hematuria at 19 months post treatment without associated urgency , frequency , or dysuria .
the standard of care for locally advanced cervical carcinoma consists of ebrt with concurrent cisplatin chemotherapy followed by bt boost [ 1 , 2 ] .
multiple studies demonstrate the importance of cervical bt as a component of cervical cancer treatment [ 911 ] .
furthermore , successful treatment relies heavily on the quality of the implant and implant geometry .
although rare , abnormal uterine anatomy can severely compromise bt geometry if not appropriately recognized prior to the implant . herein , we report the unusual case of locally advanced adenocarcinoma of the cervix in a patient with a septate uterus , which presented significant challenges in delivering safe and effective cervical bt .
anatomical anomalies of the female reproductive tract are a rare phenomenon , likely occurring in less than 1% of females , although the true incidence is a subject to debate with incidence estimates anywhere from 0.16 - 10% [ 6 , 12 , 13 ] .
development of the female urogenital tract begins in utero , at approximately week 6 of embryologic life with the mllerian ( paramesonephric ) ducts , wolffian ( mesonephric ) ducts , and genital ridge all playing critical roles in urogenital tract development .
these anomalies are most commonly classified according to the american fertility society ( currently known as the american society for reproductive medicine ) classification scheme   which breaks down female genital tract anomalies into 7 distinct classes , as outlined in table 1 .
this patient has a class v anomaly : septate uterus resulting from failure of resorption of the septum between two mllerian ducts . with the rarity of anatomical uterine anomalies in the general population ,
however , it has been estimated that as many as 5% of cervical cancer patients may have undetected malformations .
with many cases of cervical cancer diagnosed and treated in economically disadvantaged areas where ct and mri imaging are not readily available ( and as such are not required by figo for staging ) , the true incidence of those with a coexisting uterine anomaly and cervical cancer may be underreported .
most are treated with surgical approaches when feasible , due to anatomic difficulties in managing these patients from a radiotherapeutic perspective .
our review of the literature revealed only 2 cases of cervical cancer in women with congenital anomalies of the female reproductive tract treated with definitive radiotherapy with cervical bt as a component of treatment [ 6 , 7 ] . in 2000 , lee et al .   reported a rare case of squamous cell carcinoma of the cervix in a patient with didelphus uterus , a class iii mllerian duct anomaly resulting in two uterine cavities and two cervices .
this patient presented with a figo stage iia1 tumor arising from the left cervix , with a minor degree of proximal vaginal involvement .
she was treated with whole pelvic ebrt to a dose of 45 gy in 25 fractions .
this was followed by bilateral cervical bt , placing a tandem into each cervix and respective uterine cavity using a symmetrical dual channel applicator .
orthogonal radiography was used for planning , with the dose prescribed to a modified prescription point ( 2 cm superior to the mean midline position of the two flanges ) rather than 2 distinct a points .
the use of 2 a points was not used , as prescribing dose to 2 cm lateral and 2 cm superior to each cervical os would have resulted in a much wider prescription isodose surface with the potential for significant overdosing of critical midline structures ( bladder , bowel , rectum ) . the patient was treated with two fractions of hdr , the first prescribed to 6 gy , the second fraction prescribed to 6.5 gy . in 2010 , loo et al .  
reported a case of stage iia2 squamous cell carcinoma of the cervix with bicornuate bicollis uterus ( class iv mllerian duct anomaly ) , treated with whole pelvic ebrt and bilateral intracavitary bt .
this patient received ebrt to a dose of 50 gy in 25 fractions with weekly cisplatin chemotherapy at a dose of 40 mg / m .
intracavitary bt was performed using low dose rate ( ldr ) techniques with cs using a perspex vaginal cylinder applicator with a tungsten rectal shield .
the patient was treated to a dose of 18 gy over 2 fractions prescribed to manchester point a. on the first fraction of bt , the right side was treated with a calculation also being preformed to the left point a with the aid of a wire marker in the left uterine cavity .
for the second fraction of treatment , the geometry was reversed so that the left side was treated and the dose to the right point a was calculated using the wire marked in the right uterine cavity .
our review of the literature did not find any previous report of a patient with a septate uterus treated with cervical bt . here , we report the first published case of cervical carcinoma in a patient with a septate uterus managed with concurrent chemo and radiation therapy .
additionally , this is the first paper in the literature to describe the process of cervical bt in a patient with a congenital uterine anomaly using ct - based planning with adaptation of the gec - estro and abs guidelines .
like lee et al . , we used a symmetric dual channel applicator , with separate tandems placed into the right and left uterine septate , respectively . unlike the patient described by lee et al .
our patient also had large vaginal fornices , allowing the placement of ct - compatible ovoids in the vaginal apex , aiding in our treatment planning , geometry , and target volume coverage , allowing for increased dose conformity to the hr - ctv .
, who used orthogonal imaging for planning , we utilized ct based planning for each fraction .
ideally , mri based planning would be used in such a delicate case . however , this was not possible as the rotte - y applicator was not mri compatible .
three - dimensional planning techniques were undoubtedly useful in accurately delineating the target volume ( hr - ctv ) , and reducing dose to normal structures via manual optimization of isodose distribution on the treatment planning system in this patient . critical analysis of hr - ctv coverage and dose to critical organs could be analyzed and adjusted based on readily available dvh data , which is not possible using 2d planning techniques . with the adaptation of sophisticated imaging systems such as ct and mri , the ability to perform cervical bt with greater accuracy continues to improve . in the setting of uterine anomalies , ct or mri guided planning
can greatly improve the ability to deliver safe and effective bt with improved target delineation and coverage , while minimizing dose to adjacent normal tissues .
the application of abs and gec - estro guidelines are helpful in patients with uterine anomalies treated with 3d - based cervical bt as a guide for delineating and monitoring coverage of , and doses to , the target volume are nearby normal structures .
vinai gondi has served on the medical advisory board for novocure and has received an honorarium from the american board of medical specialties ( abms ) .
the remaining authors have no conflicts of interest to report with regard to publication of this manuscript .
 purposeto describe an approach to cervical brachytherapy in a patient with congenital septate uterus and locally advanced cervical carcinoma.material and methodsthe patient is a 34-year - old female with septate uterus presenting with pelvic pain . 
 workup demonstrated a stage iib cervical adenocarcinoma with imaging evidence of an involved right external iliac lymph node . 
 the patient received whole pelvic radiation , with concurrent weekly cisplatin ( 40 mg / m2 ) , to a dose of 45 gy in 25 fractions followed by a parametrial boost of 5.4 gy and an additional nodal boost of 9 gy.resultsthe patient was initiated on cervical brachytherapy following fraction 23 of pelvic radiation . to conform to her septated uterus , 
 a rotte - y tandem was used . 
 additionally , 2 ct - compatible ovoids were placed in the vaginal apex to enhance dose distribution and coverage of the target volume . 
 each fraction of brachytherapy was performed with ct - based planning . a high - risk clinical target volume ( hr - ctv ) and 
 normal structures were defined and constrained per american brachytherapy society ( abs ) and groupe europen de curiethrapie / european society for therapeutic radiology and oncology ( gec - estro ) guidelines . 
 the brachytherapy dose was 27.5 gy in 5 fractions of 5.5 gy each , prescribed to the hr-ctv.conclusionsherein , we report the first documented case of cervical brachytherapy in a patient with septate uterus and locally advanced cervical carcinoma . using ct - guided planning , in conjunction with the abs and gec - estro guidelines , 
 the patient was effectively treated with adapted cervical brachytherapy , meeting criteria for hr - ctv coverage and normal tissue tolerances . 
Purpose
Material and methods
Case report: patient history
Brachytherapy technique
Results
Patient follow up
Discussion
Disclosure
Disclosure