MANCHESTER SYSTEM FOR
MANCHESTER SYSTEM FOR
GYNECOLOGICAL APPLICATIONS
GYNECOLOGICAL APPLICATIONS
Anil Sharma, PhD
Anil Sharma, PhD
‘
‘
Radium treatment
Radium treatment
’
’
of
of
uterine cervix
uterine cervix
The use of Radium sources
The use of Radium sources
for treatment of uterine
for treatment of uterine
cervix started in 1903. The
cervix started in 1903. The
dose prescription was
dose prescription was
entirely empirical due the
entirely empirical due the
lack of:
lack of:
–
–
knowledge about the

a designated region


Within any system, specification of
Within any system, specification of
treatment in terms of dose, timing, and
treatment in terms of dose, timing, and
administration is necessary so as to
administration is necessary so as to
implement prescription in a reproducible
implement prescription in a reproducible
manner.
manner.
Dosimetric Systems
Stockholm system Paris System
Stockholm system
Stockholm system
¾
¾
Fractionated (2
Fractionated (2
-
-
3 applications) delivered
3 applications) delivered
within about a month
within about a month
¾
¾
Each application 20

¾
Total mg
Total mg
-
-
hrs were usually 6500 to 7100 out
hrs were usually 6500 to 7100 out
of which 4500 mg
of which 4500 mg
-
-
hrs were in vagina.
hrs were in vagina.
Paris System
Paris System
¾
¾
Single application
Single application
¾
¾
5 days to deliver 7200
5 days to deliver 7200
-
-
8000 mg
8000 mg
-
-
hrs.

intrauterine source.
Stockholm and Paris
Stockholm and Paris
Systems
Systems


Uterine sources in both systems
Uterine sources in both systems
were arranged in a line
were arranged in a line
extending from the external
extending from the external
os
os
to nearly the top of the uterine
to nearly the top of the uterine
cavity
cavity


Both systems preferred the
Both systems preferred the
longest possible intrauterine tube
longest possible intrauterine tube
to increase the dose to
to increase the dose to
paracervical
paracervical
region and pelvic

mg
-
-
hrs
hrs
, is used in conjunction with
, is used in conjunction with
external beam therapy,
external beam therapy,
specified in terms
specified in terms
of absorbed dose
of absorbed dose
, overall radiation
, overall radiation
treatment cannot be adequately defined
treatment cannot be adequately defined
2.
2.
Dose prescription in terms of mg
Dose prescription in terms of mg
-
-
hrs
hrs
ignored anatomical targets and tolerance
ignored anatomical targets and tolerance
organs.
organs.
Manchester Approach

delivered in
“
“
fixed mg
fixed mg
-
-
hr
hr
systems
systems
”
”
in a more
in a more
meaningful way,
meaningful way,
Tod
Tod
and
and
Meredith began to calculate
Meredith began to calculate
the dose (in roentgens) to
the dose (in roentgens) to
various sites in the pelvis by
various sites in the pelvis by
defining a series of points
defining a series of points
anatomically comparable

to the area in the medial edge of the broad ligament
where uterine vessels cross the
where uterine vessels cross the
ureter
ureter


To this pyramid shaped area, the base of which rests
To this pyramid shaped area, the base of which rests
on the lateral vaginal
on the lateral vaginal
fornices
fornices
and apex curves
and apex curves
around the
around the
anteverted
anteverted
uterus, the name
uterus, the name
“
“
Paracervical
Paracervical
Triangle
Triangle
”
”
was given.

Manchester Approach
–
–
second step
second step


Design
Design
applicators
applicators
and their loading to
and their loading to
enable the same dose
enable the same dose
-
-
rate to this
rate to this
point
point
‘
‘
A
A
’
’
regardless of which
regardless of which
combination of applicators is used.

lengths, meant for
one, two or three
one, two or three
radium tubes.
radium tubes.
Vaginal
Vaginal
Ovoids
Ovoids


The vaginal applicators
The vaginal applicators
(
(
ovoids
ovoids
) were made of hard
) were made of hard
rubber or plastic with
rubber or plastic with
diameters of 20, 25 or 30
diameters of 20, 25 or 30
mm, mimicking the shape of
mm, mimicking the shape of
isodose
isodose
surface around a
surface around a
radium tube of 15 mm length

different sizes of the vagina,
but also to take advantage of
but also to take advantage of
vaginal capacity to carry the
vaginal capacity to carry the
radium laterally
radium laterally
Manchester Approach
Manchester Approach
–
–
third step
third step


Define
Define
a set of rules
a set of rules
dictating the
dictating the
relationship, position, and activity of
relationship, position, and activity of
radium sources in the uterine and
radium sources in the uterine and
vaginal applicators to achieve the
vaginal applicators to achieve the
consistent dose rates
consistent dose rates
Radium Sources and Their

contained 4, 4, 6 units, medium intrauterine
tube with 4, 6 and short with 8 units. Large,
tube with 4, 6 and short with 8 units. Large,
medium and small
medium and small
oviods
oviods
were assigned 9,
were assigned 9,
8, and 7 units in each ovoid.
8, and 7 units in each ovoid.
Dose Specification
Dose Specification


Optimal total dose to point
Optimal total dose to point
‘
‘
A
A
’
’
: 8000 R
: 8000 R


Number of sessions: 2
Number of sessions: 2


dose at point
‘
‘
A
A
’
’
was delivered from radium
was delivered from radium
in the vaginal
in the vaginal
ovoids
ovoids
.
.
Manchester System
Manchester System
Modification of Paris and Stockholm
Modification of Paris and Stockholm
systems
systems
–
–
source loading technique of Paris system
source loading technique of Paris system
–
–
fractionated delivery of dose from the
fractionated delivery of dose from the
Stockholm system.

‘
A
A
’
’
Although point ‘A’
was defined in
relation to important
anatomical
structures, these
cannot be revealed
on a radiograph.
So point ‘A’ definition
was modified in 1953
and is sometimes
denoted as Ao (o stands
for external os).
Point
Point
‘
‘
B
B
’
’


While the dose to point
While the dose to point
‘

.


This point was chosen since it gives
This point was chosen since it gives
not only the dose in the vicinity of
not only the dose in the vicinity of
the pelvic wall near the
the pelvic wall near the
obturator
obturator
nodes, but also a good measure of
nodes, but also a good measure of
the lateral spread of the effective
the lateral spread of the effective
dose.
dose.


The dose at point B depends very
The dose at point B depends very
little on the actual geometrical
little on the actual geometrical
distribution of radium, such as the
distribution of radium, such as the
size of the
size of the
ovoids
ovoids
and intrauterine

’
lies is considered to be carried
lies is considered to be carried
with the uterus, but point B,
with the uterus, but point B,
which does not directly depend
which does not directly depend
on the uterus, remains as a fixed
on the uterus, remains as a fixed
point, 5 cm laterally from a point
point, 5 cm laterally from a point
2 cm up the midline from the end
2 cm up the midline from the end
of the radium tube.
of the radium tube.


In the loading rules of the
In the loading rules of the
Manchester system, it was
Manchester system, it was
recommended that, if possible,
recommended that, if possible,
largest
largest
ovoids
ovoids
be used to carry
be used to carry
the radium close to point

Vaginal Mucosa


Rectovaginal
Rectovaginal
Septum
Septum
Vaginal Mucosa
Vaginal Mucosa
“
“
The tolerance of vaginal mucosa is
The tolerance of vaginal mucosa is
such that not more than about 40% of
such that not more than about 40% of
the total dose to point
the total dose to point
‘
‘
A
A
’
’
can safely be
can safely be
delivered through the vaginal
delivered through the vaginal
ovoids
ovoids
and this should be taken into account