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Following a seemingly straightforward procedure to place the necessary applicators (comprising the central tandem into the uterine cavity, and the right and the left ovoids into the lateral vaginal fornices), this patient of cervical-carcinoma, who was scheduled to receive intracavitary brachytherapy (ICBT) was taken up for CT scanning intended for dose-optimised three-dimensional conformal brachytherapy.
Surprisingly, it was noted that the central tandem had pierced through the posterior wall of the uterus to enter the abdominal cavity (figures 1⇓–3). The uterine body was visualised as anteflexed, even though a preprocedure clinical examination was not suggestive of the same. The applicators were removed, and the procedure was …