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Noorian F, Abellana R, Zhang Y, Herreros A, Lancellotta V, Tagliaferri L, Sabater S, Torne A, Agusti-Camprubi E, Rovirosa A. Impact of Vaginal Dilator Use and 68 Gy EQD2 (α/β=3) Dose Constraint on Vaginal Complications in External Beam Irradiation Followed by Brachytherapy in Post-Operative Endometrial Cancer. J Pers Med 2024; 14:838. [PMID: 39202029 PMCID: PMC11355937 DOI: 10.3390/jpm14080838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/08/2024] [Accepted: 08/07/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND This study evaluated the clinical outcomes of applying a 68 Gy EQD2(α/β=3) dose constraint to the most exposed 2 cm3 area of the vagina in post-operative endometrial cancer patients treated with vaginal-cuff brachytherapy after external beam irradiation and the impact of vaginal dilator use on late vaginal complications. MATERIAL AND METHODS We analyzed 131 patients treated with vaginal-cuff brachytherapy after external beam irradiation. Group-1 (65 patients) received one fraction of 7 Gy, and Group-2 (66 patients) received one fraction of between 5.5 and 7.0 Gy after applying a 68 Gy EQD2(α/β=3) dose constraint. Vaginal-cuff relapse, late toxicity, clinical target volume, vaginal dilator use, D90, and EQD2(α/β=3) at 2 cm3 of the most exposed part of the clinical target volume were evaluated. Descriptive analysis, the chi-squared test, Student's t-test, and the Cox proportional and Kaplan-Meier models were used for the statistical analysis. RESULTS With a median follow-up of 60 months, the vaginal-cuff relapse rate was 1/131 (0.8%). Late vaginal complications appeared in 36/65 (55.4%) Group-1 patients and 17/66 (25.8%) Group-2 patients (p = 0.003). Multivariate analysis showed that belonging to Group-1 and vaginal dilator use of <9 months were independent prognostic factors of late vaginal complications with hazard ratios of 1.99 (p = 0.021) and 3.07 (p = 0.010), respectively. CONCLUSIONS A 68 Gy EQD2(α/β=3) constraint at 2 cm3 of clinical target volume and vaginal dilator use of ≥9 months were independent prognostic factors, having protective effects on late vaginal complications.
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Affiliation(s)
- Faegheh Noorian
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Rosa Abellana
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
| | - Yaowen Zhang
- Cancer Center, Henan Provincial People’s Hospital, No.7 Weiwu Road, Zhengzhou 450003, China;
| | - Antonio Herreros
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
| | - Valentina Lancellotta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Policlinic Universitario Gemelli, 00168 Rome, Italy; (V.L.); (L.T.)
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Policlinic Universitario Gemelli, 00168 Rome, Italy; (V.L.); (L.T.)
| | - Sebastià Sabater
- Radiation Oncology Department, Hospital General Universitario de Albacete, 02006 Albacete, Spain;
| | - Aureli Torne
- Gynaecological Cancer Unit, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
| | - Eduard Agusti-Camprubi
- Radiological Protection Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
| | - Angeles Rovirosa
- Fonaments Clínics Department, Universitat de Barcelona, 08036 Barcelona, Spain; (F.N.); (R.A.); (A.H.)
- Radiation Oncology Department, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain
- Gynaecological Cancer Unit, Hospital Clinic, Universitat de Barcelona, 08036 Barcelona, Spain;
- Institut d’Investigació Biomèdica Agustí Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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Noorian F, Abellana R, Zhang Y, Herreros A, Baltrons C, Lancellota V, Tagliaferri L, Sabater S, Torne A, Rovirosa A. Are 7.5 Gy×2 fractions more efficient than 6 Gy×3 in exclusive postoperative endometrial cancer brachytherapy? A clinical and dosimetrical analysis. Radiother Oncol 2023; 189:109909. [PMID: 37699447 DOI: 10.1016/j.radonc.2023.109909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE To compare two vaginal brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) patients considering vaginal-cuff relapses (VCR), late toxicities, dosimetry analysis and vaginal dilator use. MATERIAL AND METHODS 110 PEC patients were treated with exclusive high-dose-rate VBT using two schedules. Group-1:44-patients received 6 Gy×3fractions (September-2011-April-2014); Group-2:66-patients were treated with 7.5 Gy×2fractions with a dose limit of equivalent total doses in 2-Gy fr (EQD2(α/β=3)) of 68 Gy in the most exposed 2 cm3 of clinical target volume (CTV) (July-2015-November-2021). The dose was prescribed at 5 mm from the applicator surface. Were evaluated the overall radiation dose delivered to 90% of the CTV (D90), the CTV receiving 100% of the prescription dose (V100) and the EQD2(α/β=3) received in the most exposed 2 cm3 to dose in CTV. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum and objective LENT-SOMA criteria for late vaginal toxicity (LVT). STATISTICS Descriptive analysis, Chi-square, Student's t-tests and Kaplan and Meier method. RESULTS The median follow-up was 60 months (15.9-60). There were no VCR or late toxicities in bladder or rectum. LVT ≥ G1 appeared in 26/44 (59.1%) in Group-1 and 25/66 (37.9%) in Group-2. The mean EQD2(α/β=3) received by the most exposed 2 cm3 of CTV was 63.7 Gy ± 10.0 in Group-1 and 60.5 Gy ± 3.8 in Group-2 (p = 0.063). There were no differences in adherence to vaginal dilator use ≥9 months, overall D90 and V100. CONCLUSION Considering the lack of vaginal relapses and similar LVT over time, 7.5 Gy×2fractions seem more efficient in terms of patient comfort, workload, and cost. This is the first study using dosimetry parameters to compare effectivity of schedules. Larger series are needed to confirm the present results.
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Affiliation(s)
- Faegheh Noorian
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Rosa Abellana
- Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Yaowen Zhang
- Cancer Center, Henan Provincial People's Hospital, No.7 Weiwu Road, Zhengzhou 450003, China.
| | - Antonio Herreros
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
| | - Clara Baltrons
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Vallentina Lancellota
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | - Luca Tagliaferri
- U.O.C. Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy.
| | | | - Aureli Torne
- Gynecological Cancer Unit, Hospital Clinic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain.
| | - Angeles Rovirosa
- Radiation Oncology Dpt. Hospital Clínic Barcelona, C/ Villarroel, 170, 08036 Barcelona, Spain; Fonaments Clínics Dpt. Faculty of Medicine, Universitat de Barcelona, C/ Casanovas 153, 08036 Barcelona, Spain.
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Kunz JN, Huang YJ, Casper AC, Suneja G, Burt LM, Jhingran A, Joyner MM, Harkenrider MM, Small W, Grant JD, Kidd EA, Boucher K, Gaffney DK. Dosimetric Evaluation of Organs at Risk From SAVE Protocol. Int J Radiat Oncol Biol Phys 2023; 117:274-280. [PMID: 37023988 DOI: 10.1016/j.ijrobp.2023.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/26/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
PURPOSE The objective of this work was to evaluate dosimetric characteristics to organs at risk (OARs) from short-course adjuvant vaginal cuff brachytherapy (VCB) in early endometrial cancer compared with standard of care (SOC) in a multi-institutional prospective randomized trial. METHODS AND MATERIALS SAVE (Short Course Adjuvant Vaginal Brachytherapy in Early Endometrial Cancer Compared to Standard of Care) is a prospective, phase 3, multisite randomized trial in which 108 patients requiring VCB were randomized to an experimental short-course arm (11 Gy × 2 fractions [fx] to surface) and SOC arm. Those randomized to the SOC arm were subdivided into treatment groups based on treating physician discretion as follows: 7 Gy × 3 fx to 5 mm, 5 to 5.5 Gy × 4 fx to 5 mm, and 6 Gy × 5 fx to surface. To evaluate doses to OARs of each SAVE cohort, the rectum, bladder, sigmoid, small bowel, and urethra were contoured on planning computed tomography, and doses to OARs were compared by treatment arm. Absolute doses for each OAR and from each fractionation scheme were converted to 2 Gy equivalent dose (EQD23). Each SOC arm was compared with the experimental arm separately using 1-way analysis of variance, followed by pairwise comparisons using Tukey's honestly significant difference test. RESULTS The experimental arm had significantly lower doses for rectum, bladder, sigmoid, and urethra compared with the 7 Gy × 3 and 5 to 5.5 Gy × 4 fractionation schemes; however, the experimental arm did not differ from the 6 Gy × 5 fractionation scheme. For small bowel doses, none of the SOC fractionation schemes were statistically different than the experimental. The highest EQD23 doses to the examined OARs were observed to come from the most common dose fractionation scheme of 7 Gy × 3 fx. With a short median follow-up of 1 year, there have been no isolated vaginal recurrences. CONCLUSIONS Experimental short-course VCB of 11 Gy × 2 fx to the surface provides a comparable biologically effective dose to SOC courses. Experimental short-course VCB was found to reduce or be comparable to D2cc and D0.1cc EQD23 doses to rectum, bladder, sigmoid, small bowel, and urethra critical structures. This may translate into a comparable or lower rate of acute and late adverse effects.
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Affiliation(s)
- Jeremy N Kunz
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah.
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anthony C Casper
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Lindsay M Burt
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Melissa M Joyner
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Center, Intermountain Health Care, Murray, Utah
| | - Elizabeth A Kidd
- Department of Radiation Oncology, Stanford Cancer Institute, Stanford University, Stanford, California
| | - Ken Boucher
- Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Wernicke AG, Parashar B, Samuel E, Sabbas A, Gupta D, Caputo T. Partial-Length Treatment With Brachytherapy in Patients With Endometrial Cancer With High-Risk Features Is as Effective as Full-Length Vaginal Brachytherapy but With Reduced Toxicity. Pract Radiat Oncol 2023; 13:e416-e422. [PMID: 37295725 DOI: 10.1016/j.prro.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Full-length vaginal (FLV) brachytherapy for patients with endometrial cancer and high-risk features should be considered as per the American Brachytherapy Society to reduce distal vaginal recurrence in patients with endometrial cancers with papillary serous/clear cell histologies, grade 3 status, or extensive lymphovascular invasion. We sought to investigate this patient population and report outcomes of treatment with high-dose-rate (HDR) brachytherapy in women treated with FLV brachytherapy versus partial-length vaginal (PLV) brachytherapy. METHODS AND MATERIALS With institutional review board approval, we identified patients with endometrial cancer meeting American Brachytherapy Society criteria of high-risk features treated with adjuvant HDR between 2004 and 2010. HDR doses were 21Gy in 3 fractions delivered to either the full-length or partial-length vagina. Acute and late toxicities were evaluated using the Radiation Therapy Oncology Group scale and Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer grading, respectfully. Vaginal recurrences were assessed by physical examination and pap smears. Statistical analyses were performed using SPSS version 23 software. RESULTS Of 240 patients treated with HDR brachytherapy, 121 were treated with FLV brachytherapy, and 119, with PLV brachytherapy. The median follow-up was 9.5 years (range, 8-11 years) for FLV patients and 8.5 years (range, 7-10 years) for PLV patients; 0% of patients had vaginal recurrences, and 1.4% and 0.9% had proximal vaginal recurrences, respectively (P = .54). All patients treated with FLV brachytherapy developed grade 3 mucositis of the lower vagina/introitus (P < .0001) and had increased analgesics use compared with those treated with PLV brachytherapy (P < .0001). In total, 23% of patients treated with FLV brachytherapy developed grade 3 stenosis of the lower vagina/introitus, in contrast to 0% of patients treated with PLV brachytherapy (P < .0001). CONCLUSIONS PLV brachytherapy is as effective as FLV brachytherapy in reducing local recurrence and causes a significantly lower incidence of acute and late toxicities. The results of this study caution radiation oncologists regarding the careful use of FLV brachytherapy in patients with endometrial cancer and high-risk features.
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Affiliation(s)
- A Gabriella Wernicke
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York; Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York.
| | - Bhupesh Parashar
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Eileen Samuel
- Department of Radiation Medicine, Zucker School of Medicine at Hofstra/Northwell Health, New York, New York
| | - Albert Sabbas
- Department of Radiation Oncology, Weill Medical College of Cornell University, New York, New York
| | - Divya Gupta
- Senior Group Medical Directory, GlaxoSmithKline, Waltham, Massachusetts
| | - Thomas Caputo
- Department of Obstetrics and Gynecology, Division of Gynecological Oncology, Weill Medical College of Cornell University, New York, New York
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Vaginal dilator use more than 9 months is a main prognostic factor for reducing G2‑late vaginal complications in 3D‑vaginal‑cuff brachytherapy (interventional radiotherapy)? Clin Transl Oncol 2023; 25:1748-1755. [PMID: 36752959 DOI: 10.1007/s12094-023-03099-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/31/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Analyse the impact of different prognostic factors on G2-late vaginal complications after vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) in postoperative endometrial cancer (PEC). METHODS One hundred and twenty-six PEC patients treated with VBT ± EBRT were retrospectively analysed considering age, body mass index, applicator diameter, clinical target volume (CTV), use of dilators, chemotherapy and EQD2(α/β=3) at the most exposed 2 cm3 of the CTV as prognostic factors for vaginal complications. Late vaginal complications were evaluated using objective LENT-SOMA criteria. STATISTICS descriptive analysis, Chi-square, Fisher and Student tests were applied. Univariate and multivariate analyses were performed with the Baptista-Pike exact method and multiple logistic regression. RESULTS Mean age was 65 years (SD ± 10), and median follow-up was 66 months (8-104). 19/126 patients (15%) showed G2-late vaginal complications, and 107/126 (85%) G0-G1. Univariate analysis showed: CTV ≤ 9 cm3 (p = 0.036), use of dilators < 9 months (p = 0.015), and total ≥ 68 Gy EQD2 received by 2 cm3 of CTV (p = 0.039) were associated with G2-late vaginal toxicity. Multivariate analysis showed the use of dilators < 9 months as an independent prognostic factor for G2-late vaginal toxicity (p = 0.043, OR 8.59, CI 1.59-159.9). CONCLUSION The use of dilators < 9 months in VBT ± EBRT for PEC was an independent prognostic factor for G2-late vaginal toxicity. The use of vaginal dilators ≥ 9 months requires further analysis in studies evaluating late vaginal toxicity.
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Parsons MW, Huang YJ, Burt L, Suneja G, Gaffney D. Vaginal cuff brachytherapy for endometrial cancer: a review of major clinical trials with a focus on fractionation. Int J Gynecol Cancer 2022; 32:311-315. [DOI: 10.1136/ijgc-2021-002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/03/2022] Open
Abstract
The use of vaginal cuff brachytherapy in the adjuvant management of endometrial cancer has increased over time. Recommendations from the American Brachytherapy Society, American Society of Radiation Oncology, and European Society for Medical Oncology help to guide the application of vaginal cuff brachytherapy. However, wide variation in practice remains regarding treatment techniques. This article reviews the use of vaginal cuff brachytherapy in the post-operative management of endometrial cancer. It covers risk stratification, treatment rationale, outcomes, and treatment planning recommendations with a specific focus on dose-fractionation regimens. The authors performed a thorough literature review of articles pertinent to the goals of this review. Also presented are early results of the Short Course Adjuvant Vaginal Cuff Brachytherapy in Early Endometrial Cancer Compared with Standard of Care (SAVE) trial of a two-fraction vaginal cuff brachytherapy regimen.Adjuvant vaginal cuff brachytherapy for early-stage endometrial cancer results in excellent disease control with minimal toxicity. The PORTEC-2 trial showed that vaginal cuff brachytherapy is non-inferior to external beam radiation for vaginal recurrence in patients at high-intermediate risk. Vaginal cuff brachytherapy may also be used as a boost following external beam radiation in combination with chemotherapy for high-risk histologies. Numerous techniques can be used for vaginal cuff brachytherapy, including various medical devices, dose-fractionation schedules, and treatment planning approaches. The early control results of the SAVE trial are promising and we are hopeful that this trial establishes two fraction regimens as a viable option for vaginal cuff brachytherapy.
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Arden JD, Dokter J, Almahariq MF, Marvin K, Nandalur SR, Al-Wahab Z, Gadzinski J, Rosen B, Jawad MS. Toxicity and Efficacy After Adjuvant Vaginal Brachytherapy Using 30 Gy in 6 Fractions for Stages I and II Endometrial Cancer. Adv Radiat Oncol 2021; 6:100773. [PMID: 34934859 PMCID: PMC8655421 DOI: 10.1016/j.adro.2021.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/02/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose This study aimed to evaluate outcomes and toxicity in patients with endometrial cancer per our institutional adjuvant vaginal cuff brachytherapy (VBT) fractionation scheme. Methods and Materials We identified women with International Federation of Gynecology and Oncology stages I and II endometrial cancer who underwent surgical staging and adjuvant high-dose-rate VBT without external beam radiation. All patients received 30 Gy in 6 fractions to the upper one-third of the vagina, prescribed to a depth of 5 mm and delivered twice weekly. Toxicities were prospectively elicited at each follow up, and rates of recurrence and survival were retrospectively assessed. Results We identified 247 eligible patients treated between 1992 and 2018 with a median follow up of 5.8 years (range, 0.1-24.7 years). Most patients had stage I disease (52% stage IA; 37% stage IB), and 11% of patients were stage II. Deep myometrial invasion was predictive of local recurrence (P = .002). The 5-year rates of local recurrence, regional recurrence, and distant metastases were 5%, 5%, and 7%, respectively. Five-year overall and disease-free survival were 91% and 83%, respectively. The most common grade 1 toxicities were acute fatigue (11% crude rate), urinary frequency (11%), chronic (>6 months) urinary frequency (13%), urinary incontinence (13%), and vaginal stenosis (21%). There were few grade 2 toxicities (all <5%) and no grade 3 to 5 toxicities. Conclusions The adjuvant VBT fractionation scheme of 30 Gy in 6 fractions results in low rates of toxicity, with no grade ≥3 adverse events, and local control rates comparable with those from other published series using different fractionation schemes.
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Affiliation(s)
- Jessica D Arden
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jonathan Dokter
- Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Muayad F Almahariq
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kimberly Marvin
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Sirisha R Nandalur
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Zaid Al-Wahab
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Jill Gadzinski
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Barry Rosen
- Department of Gynecologic Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Maha Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
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Martins J, Vaz AF, Grion RC, Costa-Paiva L, Baccaro LF. Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial. BMC Cancer 2021; 21:682. [PMID: 34112100 PMCID: PMC8191143 DOI: 10.1186/s12885-021-08274-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/29/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND We aimed to evaluate the effects of different therapeutic options to prevent the evolution of vaginal stenosis after pelvic radiotherapy in women with cervical cancer. METHODS open-label randomized clinical trial of 195 women, stage I-IIIB, aged 18-75 years, using topical estrogen (66), topical testosterone (34), water-based intimate lubricant gel (66), and vaginal dilators (29) to assess the incidence and severity of vaginal stenosis after radiotherapy at UNICAMP-Brazil, from January/2013 to May/2018. The main outcome measure was vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE) scale and percental changes in vaginal volume. The women were evaluated at four different times: shortly after the end of radiotherapy, and four, eight, and 12 months after the beginning of the intervention. Statistical analysis was carried out using Symmetry test, Kruskal-Wallis test and multiple regression. RESULTS the mean age of women was 46.78 (±13.01) years, 61,03% were premenopausal and 73,84% had stage IIB-IIIB tumors. The mean reduction in vaginal volume in the total group was 25.47%, with similar worsening in the four treatment groups with no statistical difference throughout the intervention period. There was worsening of vaginal stenosis evaluated by CTCAE scale after 1 year in all groups (p < 0.01), except for the users of vaginal dilator (p = 0.37). CONCLUSIONS there was a reduction in vaginal volume in all treatment groups analyzed, with no significant difference between them. However, women who used vaginal dilators had a lower frequency and severity of vaginal stenosis assessed by the CTCAE scale after one year of treatment. TRIAL REGISTRATION Brazilian Registry of Clinical Trials, RBR-23w5fv . Registered 10 January 2017 - Retrospectively registered.
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Affiliation(s)
- Jumara Martins
- Radiotherapy Section, Woman's Hospital - Caism/Unicamp, Campinas, SP, Brazil
| | - Ana Francisca Vaz
- Radiotherapy Section, Woman's Hospital - Caism/Unicamp, Campinas, SP, Brazil
| | - Regina Celia Grion
- Radiotherapy Section, Woman's Hospital - Caism/Unicamp, Campinas, SP, Brazil
| | - Lúcia Costa-Paiva
- Department of Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP, Rua Alexander Fleming, 101, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-881, Brazil
| | - Luiz Francisco Baccaro
- Department of Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP, Rua Alexander Fleming, 101, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-881, Brazil.
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Jensen GL, Barry PN, Eldredge-Hindy H, Silva SR, Todd SL, Hammonds KP, Zimmerman WR, Metzinger DS, El-Ghamry MN. Vaginal cuff brachytherapy: do we need to treat to more than a two-centimeter active length? J Contemp Brachytherapy 2021; 13:294-301. [PMID: 34122569 PMCID: PMC8170526 DOI: 10.5114/jcb.2021.105971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/09/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE American Brachytherapy Society (ABS) guidelines recommend using a 3-5 cm active length (AL) when treating vaginal cuff (VC) in adjuvant setting of endometrial cancer (EC). The purpose of this study was to evaluate local control and toxicity, using an AL of 1 or 2 cm and immobilization with a traditional table-mounted (stand) or patient-mounted (suspenders) device. MATERIAL AND METHODS Between 2005 and 2019, 247 patients with EC were treated with adjuvant high-dose-rate vaginal cuff (HDR-VC) brachytherapy with or without external beam radiation (EBRT). Treatment was prescribed to a 0.5 cm depth, with an AL of 1 or 2 cm, using stand or suspenders. VC boost after EBRT was typically administered with 2 fractions of 5.5 Gy, while VC brachytherapy alone was typically applied with 3 fractions of 7 Gy or 5 fractions of 5.5 Gy. RESULTS The combination of suspender immobilization and an AL of 2 cm (n = 126, 51%) resulted in 5-year local control of 100%. An AL of 2 cm compared to 1 cm correlated with better local control (99.1% vs. 88.5%, p = 0.0479). Regarding immobilization, suspenders correlated with improved local control compared to stand (100% vs. 86.7%, p = 0.0038). Immobilization technique was significantly correlated with AL (p < 0.0001). Only 5 (2.0%) patients experienced grade ≥ 3 toxicity, all of whom received EBRT. CONCLUSIONS In the present series, an AL of 2 cm provided excellent local control, while 1 cm was inadequate. Suspender immobilization was a practical alternative to stand immobilization in HDR brachytherapy of the vaginal cuff.
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Affiliation(s)
- Garrett L. Jensen
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Parul N. Barry
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Magee Women’s Hospital, Pittsburgh, USA
| | - Harriet Eldredge-Hindy
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Scott R. Silva
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Sarah L. Todd
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | | | - Walker R. Zimmerman
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
| | - Daniel S. Metzinger
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
| | - Moataz N. El-Ghamry
- Department of Radiation Oncology, Baylor Scott and White Health, Temple, USA
- Department of Radiation Oncology, Division of Gynecologic Oncology, University of Louisville School of Medicine, James Graham Brown Cancer Center, Louisville, USA
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10
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de Morais Siqueira T, Derchain S, Juliato CRT, Pinto E Silva MP, Machado HC, Brito LGO. Vaginal stenosis in women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study of vaginal measurements, risk for sexual dysfunction and quality of life. Int Urogynecol J 2021; 33:637-649. [PMID: 33891152 DOI: 10.1007/s00192-021-04798-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/09/2021] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Radiotherapy (RT) for cervical (CC) and endometrial cancer (EC) is known to lead to vaginal stenosis (VS), but the comparison between vaginal anatomical measurements and the risk of sexual dysfunction presents a wide variety of results among the literature. Thus, we sought to assess the prevalence of VS, vaginal measurements, sexual dysfunction and QOL in women with CC and EC submitted to pelvic RT with or without previous surgery. METHODS Cross-sectional study that included 61 women with CC and 69 with EC. VS was classified by the Common Terminology Criteria for Adverse Effects version 5.0 (CTCAE v5.0), sexual function by the validated Female Sexual Function Index (FSFI) and QOL by the validated World Health Organization questionnaire (WHOQOL-BREF). Acrylic cylinders were used for vaginal measurements. Uni-/multivariate analyses to address factors associated with VC in both groups were performed. RESULTS The prevalence of VS was 79% and 67% within patients with CC and EC, respectively. Vagina length was decreased in both groups without statistical difference (7.2 ± 1.7 vs. 6.6 ± 1.8;p = 0.072). Vaginal diameter was significantly higher (p = 0.047) in women with EC (25.4 ± 6.3) than in those with CC (23.1 ± 5.7). Sexual dysfunction was highly prevalent for both CC and EC (88% vs. 91%; p = 0.598). There was no difference in all WHOQOL-BREF domains between women with CC and EC. CONCLUSIONS VS is highly prevalent in CC and EC patients, with vaginal length decreased in both groups but with a higher vaginal diameter in those with EC. Nevertheless, sexual dysfunction is highly prevalent in both groups.
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Affiliation(s)
- Thaís de Morais Siqueira
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil
| | - Sophie Derchain
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil
| | - Cassia Raquel Teatin Juliato
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil
| | - Marcela Ponzio Pinto E Silva
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil
| | - Helymar Costa Machado
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil
| | - Luiz Gustavo Oliveira Brito
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Rua Alexander Fleming 101, Cidade Universitária, Campinas, SP, 13083-881, Brazil.
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Prospective randomized trial of email and/or telephone reminders to enhance vaginal dilator compliance in patients undergoing brachytherapy for gynecologic malignancies. Brachytherapy 2021; 20:788-795. [PMID: 33867298 DOI: 10.1016/j.brachy.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/01/2021] [Accepted: 03/13/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate whether email survey +/- telephone reminder versus no intervention would facilitate compliance with vaginal dilator use in women undergoing brachytherapy for gynecologic malignancies and to assess changes in vaginal canal (VC) length between the groups. METHODS AND MATERIALS A 72 patients were enrolled onto a three-arm single-institution randomized prospective clinical trial and stratified by whether they received external beam radiation treatment in addition to brachytherapy and by total radiation dose to the VC. Patients were subsequently randomized to one of three groups: email survey alone, email survey + telephone reminder, or no intervention. Change in VC length over time was measured for each patient. RESULTS The median follow-up time was 17.3 months. There were no differences in patient-reported compliance between the 3 groups. Vaginal dilator compliance fell over the course of the study period and was 33% at 24 months. Baseline VC length and radiation dose were found to be the most important predictors of VC shortening over time. When accounting for baseline length, radiation dose, and follow-up time, type of intervention did not impact changes in VC length from baseline (p = 0.20). CONCLUSIONS Our study is the first to show the importance of baseline VC length as it relates to VC shortening following brachytherapy for gynecologic cancers and highlights the difficulties in improving VC compliance among this patient population. Further study is required to improve the incidence of late effects in this group.
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12
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Vaginal cuff brachytherapy practice in endometrial cancer patients: a report from the Turkish Oncology Group. J Contemp Brachytherapy 2021; 13:152-157. [PMID: 33897788 PMCID: PMC8060958 DOI: 10.5114/jcb.2021.105282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 01/22/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The American Brachytherapy Association is attempting to develop standards for delivering brachytherapy, although differences in practice have been reported in the literature. This study evaluated vaginal cuff brachytherapy (VBT) practice and quality of life-related recommendations among Turkish radiation oncologists. Material and methods A nationwide web-based 17-item survey was distributed to the members of the Turkish Society for Radiation Oncology. These members received e-mail notifications, and a link was posted on the Turkish Society for Radiation Oncology internet site to solicit voluntary responses The survey addressed the simulation processes, target volume, prescribed dose, delivery schedules, and recommendations related to vaginal side effects. Results Fifty-seven radiation oncologists responded to the survey. The most used dose fraction schemes for adjuvant VBT were 7 Gy × 3 fractions (30%), 5.5 Gy × 5 fractions (26%), and 6 Gy × 5 fractions (28%). The preferred VBT scheme was 5 Gy × 3 fractions (50%) when the external beam radiotherapy (EBRT) dose was 45 Gy external radiotherapy, while the preferred schemes were 6 Gy × 3 fractions (30%) or 5 Gy × 3 fractions (32%) when the external radiotherapy dose was increased to 50.4 Gy. One-half of the respondents delivered VBT twice a week, and the dose was prescribed to 0.5 cm from vaginal mucosa by 86% of the respondents. There was no common definition for the dose prescription length, which was defined as 3 cm from the vaginal cuff in 33% of responses and as 4 cm in 35% of responses. For serous and clear cell histological types, 38% of the respondents targeted "full cylinder length". To prevent vaginal side effects, 78% of the respondents recommended using a vaginal dilator and/or sexual intercourse after VBT. Conclusions This survey revealed variations in the clinical practice of VBT among Turkish radiation oncologists, which suggests that standardization is necessary.
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Development and validation of a normal tissue complication probability model for acquired nasal cavity stenosis and atresia after radical radiotherapy for nasopharyngeal carcinoma. Radiother Oncol 2021; 160:9-17. [PMID: 33839205 DOI: 10.1016/j.radonc.2021.03.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/18/2021] [Accepted: 03/28/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE Curative radiotherapy for nasopharyngeal carcinoma (NPC) can lead to acquired nasal cavity stenosis and atresia (ANCSA). As the first study to investigate risk factors of ANCSA in a large cohort of NPC patients, this article aims to develop and validate a multivariate normal tissue complication probability (NTCP) model to predict the development of ANCSA and to establish a nomogram for clinical use. METHODS AND MATERIALS The retrospective cohort was comprised of 548 NPC patients treated with radical radiotherapy. The cohort was randomly divided into training and validation groups. Least absolute shrinkage and selection operator regression was performed for variable selection from the clinical and dosimetric characteristics in the training group. A multivariate NTCP model and a nomogram were established for the prediction of ANCSA development. Discrimination and calibration were tested using receiver operating characteristic (ROC) curves and calibration tests, respectively, for both groups. RESULTS ANCSA was observed in 132 (24.1%) of 548 patients with NPC who underwent radical radiotherapy. The median time to ANCSA detection after treatment was 2.8 months (range, 0.0-57.7 months). Five potential predictors, including choanal invasion, low white blood cell count, high C-reactive protein level, high serum amyloid A level, and high V70Gy of the nasal cavity, were selected to develop the NTCP model based on 365 patients in the training group. The model had a fairly good discriminative power according to the ROC analysis in both the training (area under ROC curve = 0.79, 95%CI: 0.73-0.84) and validation (0.73, 0.64-0.82) groups. The calibration power was tested using the calibration test in the training (E-max = 0.069, E-avg = 0.015, p = 0.977) and validation (E-max = 0.057, E-avg = 0.032, p = 0.747) groups. CONCLUSIONS We developed and successfully validated an NTCP model for early prediction of ANCSA in patients with NPC after radical radiotherapy. This could help clinicians assess the risk of ANCSA before the initiation of follow-ups and ensure appropriate and timely management of this complication.
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Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances. ACTA ACUST UNITED AC 2021; 57:medicina57040336. [PMID: 33915994 PMCID: PMC8066324 DOI: 10.3390/medicina57040336] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/03/2022]
Abstract
Radiation-induced vaginal stenosis (VS) is a common side effect of pelvic radiotherapy (RT). RT-induced VS may have various negative effects on women’s quality of life, in particular dyspareunia, decreased vaginal lubrication and difficulties in sexual intercourse. This narrative review provides the aspects of RT-induced VS pathogenesis, incidence, evaluation and associated risk factors. Available treatment modalities are discussed in the article, putting the focus on preliminary, although promising, experience in the use of hyaluronic acid and laser therapy in cancer survivors after pelvic RT.
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15
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Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review. J Sex Med 2021; 18:493-514. [PMID: 33526400 DOI: 10.1016/j.jsxm.2020.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 12/10/2020] [Accepted: 12/25/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Vaginal stenosis (VS) is a common side effect of pelvic radiotherapy for gynecological cancer in women. It has a high incidence variability, likely due to unstandardized and subjective assessment methods. Furthermore, even though the worldwide standard treatment for VS is vaginal dilation, low compliance rates have been noted. AIM To evaluate the parameters used to diagnose VS and to assess whether the lack of an objective measure of VS hampers vaginal dilator use. METHODS A systematic review in accordance with the PRISMA reporting guidelines was conducted. PubMed, EMBASE, and Web of Science databases were searched. Randomized trials and prospective, retrospective, and cross-sectional studies published from January 2011 to February 2020 were included. OUTCOMES The main outcome of this study was a review of the published literature on assessment methods for VS and compliance to vaginal dilator use. RESULTS Of the 28 articles obtained, only 7 used objective methods to measure the vaginal volume. 3 studies have demonstrated patient's concern with VS development and showed a high compliance to dilator use, whereas others reported several barriers to dilator use. CLINICAL IMPLICATIONS Lack of an objective assessment method can be a predisposing factor for uncertain VS incidence rates and impair compliance to vaginal dilator therapy, leading to long-term VS and sexual dysfunction. STRENGTHS & LIMITATIONS This is the first systematic review on the heterogeneity of VS evaluation methods and compliance to vaginal dilator use. All studies were comprehensively evaluated by 2 reviewers. The limitations included the heterogeneity of the study designs and the unstandardized criteria used to classify stenosis or to evaluate compliance to dilator use. Although 3 well-known databases were used, the inclusion of more data sources could have increased the number of publications included in this review. CONCLUSION VS is frequently diagnosed using subjective parameters. Few unstandardized objective methods are used to evaluate this condition. Regarding compliance to vaginal dilator use, there was a high dropout rate during follow-up and no consensus on starting time or ideal usage. Haddad NC, Soares Brollo LC, Pinho Oliveira MA, et al. Diagnostic Methods for Vaginal Stenosis and Compliance to Vaginal Dilator Use: A Systematic Review. J Sex Med 2021;18:493-514.
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16
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Zhang Y, Fornes B, Gómez G, Bentoldrà I, Carmona C, Herreros A, Sabater S, Nicolás I, Li Y, Sánchez J, Biete A, Torné A, Ascaso C, Rovirosa Á. EQD2 Analyses of Vaginal Complications in Exclusive Brachytherapy for Postoperative Endometrial Carcinoma. Cancers (Basel) 2020; 12:E3059. [PMID: 33092163 PMCID: PMC7589275 DOI: 10.3390/cancers12103059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/08/2020] [Accepted: 10/16/2020] [Indexed: 11/28/2022] Open
Abstract
Background: To evaluate whether EQD2(α/β = 3Gy) at 2 cm3 of the most exposed area of the vagina is related to late vaginal toxicity in postoperative endometrial cancer (PEC) patients (p) treated with exclusive brachytherapy (BT). Methods: From 2014 to 2017, 43p were included in this study. BT was administered: 3-fractions of 6Gy in 37p and 2-fractions of 7.5Gy in 6p. The dose was prescribed at a depth of 5 mm from the applicator surface with dose-point optimization based on distance. The active treatment length was 2.5 cm. CTV-D90 and the dose to the most exposed 2 cm3 of the vagina was calculated for each patient. Late toxicity of the bladder and rectum was assessed using Radiation Therapy Oncology Group (RTOG) criteria, and vaginal toxicity by objective Late Effects Normal Tissue Task Force (LENT)-Subjective, Objective, Management, Analytic (SOMA) (LENT-SOMA) criteria. Statistics: frequency tables, mean, median, range, standard deviation, and box plot. Results: The median follow-up was 51 months (12-68). 20 p (46.5%) and 2 p (4.7%) developed G1 and G2 vaginal complications, respectively. Only 1/2 p-G2 receiving EQD2(α/β = 3Gy) at 2 cm3 >68Gy presented vaginal shortening and 18/20 p-G1 received doses < 68Gy. Conclusions: PECp receiving exclusive brachytherapy with doses < 68Gy EQD2(α/β = 3Gy) at 2 cm2 of the vagina presented only G0-G1 vaginal toxicity, except for one with bleeding telangiectasias. Larger prospective studies are necessary to confirm the present results.
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Affiliation(s)
- Yaowen Zhang
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
- Radiation Oncology Department, Hospital Clínic Universitari, 08036 Barcelona, Spain
| | - Balbino Fornes
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
| | - Gabriela Gómez
- Radiation Oncology Department, Hospital Ángeles Chihuahua, 31217 Chihuahua, Mexico;
| | - Irene Bentoldrà
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
| | - Clara Carmona
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
| | - Antonio Herreros
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
- Radiation Oncology Department, Hospital Clínic Universitari, 08036 Barcelona, Spain
| | - Sebastià Sabater
- Radiation Oncology Department, Hospital General Universitario de Albacete, 02006 Albacete, Spain;
| | - Inmaculada Nicolás
- Gynecologic Cancer Unit, Hospital Clínic Unversitari, 08036 Barcelona, Spain; (I.N.); (A.T.)
| | - Yan Li
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
| | - Joan Sánchez
- Economics Department, Hospital Clínic Universitari, 08036 Barcelona, Spain;
| | - Albert Biete
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
- Radiation Oncology Department, Hospital Clínic Universitari, 08036 Barcelona, Spain
- Gynecologic Cancer Unit, Hospital Clínic Unversitari, 08036 Barcelona, Spain; (I.N.); (A.T.)
| | - Aureli Torné
- Gynecologic Cancer Unit, Hospital Clínic Unversitari, 08036 Barcelona, Spain; (I.N.); (A.T.)
| | - Carlos Ascaso
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
| | - Ángeles Rovirosa
- Fonaments Clinics Department, University of Barcelona, 08036 Barcelona, Spain; (Y.Z.); (B.F.); (I.B.); (C.C.); (A.H.); (Y.L.); (A.B.); (C.A.)
- Radiation Oncology Department, Hospital Clínic Universitari, 08036 Barcelona, Spain
- Gynecologic Cancer Unit, Hospital Clínic Unversitari, 08036 Barcelona, Spain; (I.N.); (A.T.)
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Carter J, Goldfarb S, Baser RE, Goldfrank DJ, Seidel B, Milli L, Saban S, Stabile C, Canty J, Gardner GJ, Jewell EL, Sonoda Y, Kollmeier MA, Alektiar KM. A single-arm clinical trial investigating the effectiveness of a non-hormonal, hyaluronic acid-based vaginal moisturizer in endometrial cancer survivors. Gynecol Oncol 2020; 158:366-374. [PMID: 32522420 PMCID: PMC7423634 DOI: 10.1016/j.ygyno.2020.05.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess the efficacy of non-hormonal, hyaluronic acid (HLA)-based vaginal gel in improving vulvovaginal estrogen-deprivation symptoms in women with a history of endometrial cancer. METHODS For this single-arm, prospective, longitudinal trial, we enrolled disease-free women with a history of endometrial cancer who underwent surgery (total hysterectomy) and postoperative radiation. Participants used HLA daily for the first 2 weeks, and then 3×/week until weeks 12-14; dosage was then increased to 5×/week for non-responders. Vulvovaginal symptoms and pH were assessed at 4 time points (baseline [T1]; 4-6 weeks [T2]; 12-14 weeks [T3]; 22-24 weeks [T4]) with clinical evaluation, the Vaginal Assessment Scale (VAS), Vulvar Assessment Scale (VuAS), Female Sexual Function Index (FSFI), and Menopausal Symptom Checklist (MSCL). RESULTS Of 43 patients, mean age was 59 years (range, 38-78); 54% (23/43) were partnered; and 49% (21/43) were sexually active. VAS, VuAS, MSCL, and SAQ (Sexual Activity Questionnaire) scores significantly improved from baseline to each assessment point (all p < .002). FSFI total mean scores significantly increased from T1 to T2 (p < .05) and from T1 to T4 (p < .03). At T1, 41% (16/39) felt confident about future sexual activity compared to 68% (17/25) at T4 (p = .096). Severely elevated vaginal pH (>6.5) decreased from 30% (13/43) at T1 to 19% (5/26) at T4 (p = .41). CONCLUSION The HLA-based gel improved vulvovaginal health and sexual function of endometrial cancer survivors in perceived symptoms and clinical exam outcomes. HLA administration 1-2×/week is recommended for women in natural menopause; a 3-5×/week schedule appears more effective for symptom relief in cancer survivors.
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Affiliation(s)
- Jeanne Carter
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Psychology, Weill Cornell Medical College, New York, NY, United States of America.
| | - Shari Goldfarb
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - Raymond E Baser
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Deborah J Goldfrank
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Barbara Seidel
- Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Lisania Milli
- Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Sally Saban
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Cara Stabile
- Plastic and Reconstructive Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Jocelyn Canty
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Elizabeth L Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Marisa A Kollmeier
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
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One-week vaginal brachytherapy schedule as exclusive adjuvant post-operative treatment in intermediate- and high-intermediate-risk endometrial cancer patients. J Contemp Brachytherapy 2020; 12:124-130. [PMID: 32395136 PMCID: PMC7207237 DOI: 10.5114/jcb.2020.94581] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/14/2019] [Indexed: 01/20/2023] Open
Abstract
Purpose The aim of the study was to report survival outcomes and toxicities incidence by using one-week vaginal brachytherapy (VBT) schedule in intermediate- and high-intermediate-risk endometrial cancer patients. Material and methods One hundred and eight patients were treated with exclusive high-dose-rate (HDR) brachytherapy short schedule (7 Gy/fraction/every other day/1 week). Acute and late rectal, urinary, and vaginal toxicities were recorded according to radiation therapy oncology group (RTOG) scores and late effects normal tissue task force – subjective, objective, management, analytic (LENT-SOMA) scores, respectively. Overall survival (OS), cause specific survival (CSS), and disease-free survival (DFS) were evaluated. Results Median follow-up was 44 months (range, 6-117 months). The 5-year OS, CSS, and DFS rates were 92.7%, 96.4%, and 89.5%, respectively. Seven of 108 (6.5%) patients relapsed after a median time of 31 months (range, 5-56 months). Death occurred in 6 patients. Four patients died for intercurrent causes without an evidence of disease. Acute bladder toxicity G1-G2 was reported in 11 of 108 (10%) patients, vaginal toxicity G1-G2 in 6 of 108 (5.5%), and gastrointestinal toxicity was observed in 3 of 108 (3%) patients. Late bladder and gastrointestinal G1 toxicities were reported in 4 of 108 (4%) and 1 of 108 (1%) patients, respectively. Late vaginal toxicity (G1-G2) was recorded in 3 of 108 (3%) cases. No grade 3-4 bladder, vaginal, and gastrointestinal toxicities were noted. Conclusions Exclusive short course adjuvant VBT is an effective treatment in patients with early-stage endometrial cancer and provides good outcomes in terms of disease local control and DFS, with low rates of toxicity profile.
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Liu M, Juravic M, Mazza G, Krychman ML. Vaginal Dilators: Issues and Answers. Sex Med Rev 2020; 9:212-220. [PMID: 32014450 DOI: 10.1016/j.sxmr.2019.11.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Vaginal dilators are often prescribed to facilitate an adaptive brain-body connection to decrease anxiety and pain that can be experienced in anticipation of sexual intercourse among populations of women with sexual pain syndromes. Postmenopausal women, cancer survivors, and women with a wide variety of pelvic floor disorders who experience genito-pelvic pain/penetration disorder (GPPPD) are often advised to incorporate vaginal dilators into their pelvic floor rehabilitation program and treatment regimens to enable penetrative intercourse with less pain. However, little is known about the behaviors of dilator users, what treatment protocols are most effective, how patients are currently using their dilators, and how effective are clinicians in helping their patients achieve success with their dilation therapy. METHODS A recent PubMed literature search was performed using the key words vaginal dilator, vaginal dilator therapy, sexual quality of life, vaginal stenosis, vaginal dilation, vaginismus. A total of 29 English articles were reviewed and summarized. Articles were excluded for the following reasons: not in English and unrelated to dilator therapy. MAIN OUTCOME MEASURE This article will summarize the current research on vaginal dilators and discuss needs for future research to maximize patients' compliance and success with this treatment. Much of the summary data regarding user behavior will come from the early survey data with Milli, a novel, patient-controlled electronic dilator that slowly expands 1 mm at a time from its smallest diameter, 15 mm to a maximum diameter of 40 mm. Milli is currently being used by more than 1,000 women, and 3-month follow-up data were recorded on 335 of those patients. RESULTS Dilators exist in multiple forms (plastic, latex, and medical grade material), may come individually or in sets, and many have special features such as vibration or the ability to be heated or cooled before use. Little is known about patients' use of dilators and the Milli's 3-month survey serves as an insight to patient dilator behavior. The most common medical goals for patients undergoing dilation treatment were return to penetrative intercourse and pain reduction during coitus. Patients were dilated on average 2.72 days/week; 56.8% of patients had suffered from sexual pain for 2 or more years and 36.3% had previously used static dilators. More than 70% of Milli users purchased Milli and are using Milli without the direct guidance of a clinician. The most common emotions patients used to describe their treatment were not only "anxious," "frustrated," but also "empowered" and "optimistic." The most common dilatory session duration was 6-10 minutes, mostly in the evening/bedtime (68.3%), located in the bedroom (96.8%). Adjunctive treatment included the following: vaginal moisturizers, local estrogen products, coital lubricants, and genital pelvic floor physical therapy. During the dilation sessions, women most often watched TV/videos, practiced mindfulness, or listened to soothing music. Factors that showed trends toward improved patient outcomes were length of dilation treatment (greater than 3 months) and use of meditation and soothing music. Factors not associated with improvement trends were as follows: when/where patients dilated and patient demographics including age, race, or religious preferences. CONCLUSION Patients who purchase dilators have often suffered with their condition for a long time and had difficulty finding a competent health-care clinician well versed in sexual pain syndromes that can help them. When patients did find a clinician, there were no clinically proven standardized protocols or formalized guidelines to give to patients about how to best use their dilators. Larger long-term interventions investigating a standardized dilation protocol are planned in future studies to better elucidate the effective and optimal dilation treatment plans. Liu M, Juravic M, Mazza G, et al. Vaginal Dilators: Issues and Answers. Sex Med Rev 2021;9:212-220.
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Affiliation(s)
- Marisa Liu
- University of California Irvine, Department of OBGYN, Irvine, CA, USA
| | | | - Genevieve Mazza
- University of California Irvine, Department of OBGYN, Irvine, CA, USA
| | - Michael L Krychman
- University of California Irvine, Department of OBGYN, Irvine, CA, USA; Southern California Center for Sexual Health and Survivorship Medicine Inc, Newport Beach, CA, USA.
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Guy CL, Fields EC, Quinn BA, Fisher CM, Ladbury CJ, Romano KD, Todor D. The vaginal cylinder: Misunderstood, misused, or trivial? An in-depth dosimetric and multiinstitutional outcome investigation. Brachytherapy 2019; 18:763-770. [PMID: 31558353 DOI: 10.1016/j.brachy.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/06/2019] [Accepted: 08/13/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The purpose of the study was to investigate the impact on dose distribution and radiobiological metrics of common high-dose-rate vaginal brachytherapy treatment parameters and to analyze multiinstitutional data for clinically significant impact on outcomes in early-stage endometrial cancer. METHODS AND MATERIALS Treatment plans were created for all combinations of prescription parameters and used to quantify the dosimetric impact of each parameter and to estimate the dose delivered using common voxel-integrated radiobiological metrics. A rating system, based on risk grouping from GOG and PORTEC trials, was used to consolidate staging information into a cancer "aggressiveness" measure. Correlations between the rating, toxicity, disease recurrence, and plan parameters were investigated. RESULTS When prescribing to 5 mm depth, the variation caused by the diameter was very large across all dose metrics, ranging from 51% to 175% increase with the most divergence in BEDmax. For surface prescription, changing the cylinder diameter from 4 cm to 2 cm caused the dose metrics of BEDmin, Dmin, and gBEUD (a = -3) to increase by 117%, 67%, and 52%, respectively. Prescription to 5-mm depth caused changes across all dose metrics of 260% compared with surface prescription for a 2-cm cylinder. Deeper prescription point (p = 0.005) and longer treatment length (p = 0.01) were correlated with increased stenosis rates. No correlation between recurrence and any plan parameter was found. CONCLUSIONS Dramatic differences in dose distributions arise by small variations of plan parameters, with large impact on rates of vaginal stenosis, but no clear relation with local recurrence. To help radiation oncologists interpret the magnitude of these effects for their patients, we created a tool that allows comparison between dose and fractionation parameters.
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Affiliation(s)
- Christopher L Guy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Bridget A Quinn
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | - Colton J Ladbury
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Cerentini TM, Schlöttgen J, Viana da Rosa P, La Rosa VL, Vitale SG, Giampaolino P, Valenti G, Cianci S, Macagnan FE. Clinical and Psychological Outcomes of the Use of Vaginal Dilators After Gynaecological Brachytherapy: a Randomized Clinical Trial. Adv Ther 2019; 36:1936-1949. [PMID: 31209699 PMCID: PMC6822871 DOI: 10.1007/s12325-019-01006-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the dimensions of the vaginal canal in patients undergoing gynaecological brachytherapy and the effect of the use of vaginal dilators (VD) used in the follow-up of pelvic physiotherapy. METHODS A total of 88 patients were randomly allocated to the control group (CG) and intervention group (IG). Three evaluations were performed: pre-brachytherapy, post-brachytherapy and follow-up of 3 months. The CG received standard guidance from the health team while the IG was instructed to use VD for 3 months. The dimensions of the vaginal canal (main outcome) were defined by the length of the vagina (centimetres), width (number of full clockwise turns of the opening thread of a gynaecological speculum) and area (defined by the size of the VD). Quality of life and pelvic floor (PF) functionality were also evaluated. RESULTS There was no effect of the VD on vaginal length, width and area among the intention-to-treat (ITT) population. However, in the analysis stratified by adhesion, the CG had a significant decrease in the vaginal area. PF was predominantly hypoactive throughout the follow-up. Quality of life improved in both groups, but the reduction of constipation, vaginal dryness and stress urinary incontinence manifested only in the IG. CONCLUSION The use of VD did not alter the dimensions of the vaginal canal within the first 3 months after the end of radiotherapy treatment. However, there was a large sample loss during follow-up so studies with a larger sample number and longer follow-up time need to be conducted. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT03090217.
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Affiliation(s)
| | - Júlia Schlöttgen
- Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil
| | | | | | - Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gaetano Valenti
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Stefano Cianci
- Unità Operativa Ginecologia Oncologica, Dipartimento Scienze della Salute della Donna e del Bambino, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Damast S, Jeffery DD, Son CH, Hasan Y, Carter J, Lindau ST, Jhingran A. Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology. Pract Radiat Oncol 2019. [PMID: 31302301 DOI: 10.1016/j.prro.2019.07.001.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
PURPOSE Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology. METHODS AND MATERIALS A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions. RESULTS VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown. CONCLUSIONS This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
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Affiliation(s)
- Shari Damast
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut.
| | - Diana D Jeffery
- Department of Defense, Defense Health Agency, Falls Church, Virginia
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Jeanne Carter
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Medicine-Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Damast S, Jeffery DD, Son CH, Hasan Y, Carter J, Lindau ST, Jhingran A. Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology. Pract Radiat Oncol 2019; 9:479-491. [PMID: 31302301 DOI: 10.1016/j.prro.2019.07.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 05/03/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology. METHODS AND MATERIALS A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions. RESULTS VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown. CONCLUSIONS This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.
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Affiliation(s)
- Shari Damast
- Department of Therapeutic Radiology, Yale University, New Haven, Connecticut.
| | - Diana D Jeffery
- Department of Defense, Defense Health Agency, Falls Church, Virginia
| | - Christina H Son
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Yasmin Hasan
- Department of Radiation and Cellular Oncology, University of Chicago, Chicago, Illinois
| | - Jeanne Carter
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stacy Tessler Lindau
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois; Department of Medicine-Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois; Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Ager BJ, Francis SR, Do OA, Huang YJ, Soisson AP, Dodson MK, Werner TL, Sause WT, Grant JD, Gaffney DK. Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer? Brachytherapy 2019; 18:453-461. [PMID: 31005603 DOI: 10.1016/j.brachy.2019.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/22/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer. METHODS Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival. RESULTS Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts. CONCLUSIONS VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.
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Affiliation(s)
- Bryan J Ager
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Samual R Francis
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Olivia A Do
- Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Y Jessica Huang
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Andrew P Soisson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Mark K Dodson
- Department of Obstetrics and Gynecology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Theresa L Werner
- Department of Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - William T Sause
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - Jonathan D Grant
- Department of Radiation Oncology, Intermountain Medical Group, Intermountain Healthcare, Salt Lake City, UT
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT.
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Akbaba S, Oelmann-Avendano JT, Krug D, Arians N, Bostel T, Hoerner-Rieber J, Nicolay NH, Debus J, Lindel K, Foerster R. The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer. Strahlenther Onkol 2019; 195:902-912. [PMID: 30997541 DOI: 10.1007/s00066-019-01466-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 03/29/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Despite a lack of evidence and low compliance, current guidelines recommend the use of a vaginal dilator (VD) after pelvic radiotherapy (RT). We analyzed the effect of VD on vaginal stenosis (VS) and its influence on sexual quality of life (QoL) in women treated with adjuvant RT for endometrial cancer (EC). METHODS Between 2014 and 2015, 56 consecutive patients were instructed to use a VD after completion of treatment. The maximum diameter of the comfortably introducible VD was measured before and at 1 year after treatment. The degree of VS was evaluated clinically, and sexual QoL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) sexual functioning items before RT, during RT, at 6 weeks, and at 1 year after RT. RESULTS One year after RT, mean VD diameter had decreased by 2.7 ± 3.2 mm (p < 0.001) and 36 patients (64.3%) had clinical VS (grade I-III). A larger decrease in VD diameter correlated with a higher degree of clinical VS (p < 0.001). VD use (p = 0.81), RT modality (p = 0.68), and adjuvant ChT (p = 0.87) had no influence on VD diameter. Sexual activity decreased during RT and increased beyond pre-RT values 1 year after RT (p < 0.001). Sexual enjoyment decreased continuously during and after completion of RT (p = 0.013) and was influenced negatively by a higher degree of clinical VS (p = 0.01). CONCLUSION Almost two thirds of patients developed clinical VS 1 year after adjuvant RT for EC, and sexual enjoyment was substantially reduced by VS. The use of a VD after RT may not serve to prevent sexual impairments and VS.
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Affiliation(s)
- Sati Akbaba
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Jan T Oelmann-Avendano
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Strasse 3, 24105, Kiel, Germany
| | - Nathalie Arians
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Tilman Bostel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, University Hospital Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Juliane Hoerner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Radiation Oncology, Freiburg University Medical Center, Robert-Koch-Strasse 3, 79106, Freiburg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Katja Lindel
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany.,Department of Radiation Oncology, Staedtisches Klinikum Karlsruhe, Moltkestrasse 90, 76133, Karlsruhe, Germany
| | - Robert Foerster
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany. .,Heidelberg Institute for Radiation Oncology (HIRO), National Center for Radiation Research in Oncology (NCRO), Heidelberg, Germany. .,Department of Radiation Oncology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Vaginal toxicity after high-dose-rate endovaginal brachytherapy: 20 years of results. J Contemp Brachytherapy 2018; 10:559-566. [PMID: 30662479 PMCID: PMC6335557 DOI: 10.5114/jcb.2018.79713] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate vaginal toxicity (primary endpoint) and local control (secondary endpoint) in patients with endometrial cancer who underwent primary surgery and adjuvant high-dose-rate (HDR) endovaginal brachytherapy (BT). Material and methods In September 2017, the authors conducted a comprehensive literature search of the following electronic databases: PubMed, Web of Science, Scopus, and Cochrane library. In this systematic review, the authors included randomized trials, non-randomized trials, prospective studies, retrospective studies, and cases. The time period of the research included articles published from September 1997 to September 2017. Results Acute endovaginal toxicity occurred in less than 20.6% and all acute toxicities were G1-G2. The most common early side effects due to HDR-BT treatment were vaginal inflammation, vaginal irritation, dryness, discharge, soreness, swelling, and fungal infection. G1-G2 late toxicity occurred in less than 27.7%. Finally, G3-G4 late vaginal occurred in less than 2%. The most common late side effects consisted of vaginal discharge, dryness, itching, bleeding, fibrosis, telangiectasias, stenosis, short or narrow vagina, and dyspareunia. Conclusions The data suggest that HDR endovaginal brachytherapy, with or without chemotherapy, is very well tolerated with low rates of acute and late vaginal toxicities. Further prospective studies with higher numbers of patients and longer follow-up are necessary to evaluate acute and late toxicities after HDR endovaginal brachytherapy.
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Stahl JM, Qian JM, Tien CJ, Carlson DJ, Chen Z, Ratner ES, Park HS, Damast S. Extended duration of dilator use beyond 1 year may reduce vaginal stenosis after intravaginal high-dose-rate brachytherapy. Support Care Cancer 2018; 27:1425-1433. [PMID: 30187220 DOI: 10.1007/s00520-018-4441-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 08/23/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Vaginal dilators (VD) are recommended following vaginal or pelvic radiotherapy for patients with endometrial carcinoma (EC) to prevent vaginal stenosis (VS). The time course of VS is not fully understood and the optimal duration of VD use is unknown. METHODS We reviewed 243 stage IA-II EC patients who received adjuvant brachytherapy (BT) at an academic tertiary referral center. Patients were instructed to use their VD three times per week for at least 1-year duration. The primary outcome was development of grade ≥ 1 VS using CTCAEv4 criteria during the follow-up period. The log-rank test and multivariable Cox proportional hazards modeling were used to evaluate the effect of VD use (noncompliance vs. standard compliance [up to 1 year] vs. extended compliance [over 1 year]) on VS. RESULTS The median follow-up was 15.2 months over the 5-year study period. At 15 months, the incidence of VS was 38.8% for noncompliant patients, 33.5% for those with standard compliance, and 21.4% for those with extended compliance (median time to grade ≥ 1 VS was 17.5 months, 26.7 months, and not yet reached for these groups, respectively). On multivariable Cox regression analysis, extended compliance remained a significant predictor of reduced VS risk when compared to both noncompliance (HR 0.38, 95% CI 0.18-0.80, p = 0.012) and standard compliance (HR 0.43, 95% CI 0.20-0.89, p = 0.023). CONCLUSIONS The risk of VS persists beyond 1 year after BT. Extended VD compliance beyond 1 year may mitigate this risk.
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Affiliation(s)
- John M Stahl
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA.
| | - Jack M Qian
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Christopher J Tien
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - David J Carlson
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Zhe Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Elena S Ratner
- Department of Gynecology and Reproductive Sciences, Section of Gynecologic Oncology, Yale University School of Medicine, New Haven, CT, USA
| | - Henry S Park
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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Qian JM, Stahl JM, Young MR, Ratner E, Damast S. Impact of vaginal cylinder diameter on outcomes following brachytherapy for early stage endometrial cancer. J Gynecol Oncol 2018; 28:e84. [PMID: 29027402 PMCID: PMC5641534 DOI: 10.3802/jgo.2017.28.e84] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/16/2017] [Accepted: 08/10/2017] [Indexed: 01/23/2023] Open
Abstract
Objective To examine the outcomes (tolerability, toxicity, and recurrence) of vaginal brachytherapy (VBT) among endometrial cancer (EC) patients treated with small cylinder size. Methods Patients with EC who received adjuvant VBT between September 2011 and December 2015 were reviewed. Patients were fitted with the largest vaginal cylinder they could comfortably accommodate, from 2.0–3.0 cm diameter. Small cylinders were defined as size 2.3 cm or less. Patient, tumor, or treatment characteristics were correlated with need for small cylinders. Treatment tolerability, measures of gastrointestinal (GI), genitourinary (GU), and vaginal toxicity, and rates of recurrence were analyzed. Results Three hundred four patients were included. Small cylinders were used in 51 patients (17%). Normal body mass index (BMI; p<0.001), nulligravidity (p<0.001), and shorter vaginal length (p<0.001) were associated with small cylinder size. There was no acute or late grade 3 toxicity. Rates of acute (grade 1–2) GI, GU, or vaginal symptoms were low (10%, 11%, and 19%, respectively). Small cylinder size was associated with increased likelihood of reporting acute GI (p<0.05) but not GU or vaginal symptoms. Small cylinder size was associated with higher risk of grade 1–2 vaginal stenosis (odds ratio [OR]=4.7; 95% confidence interval [CI]=1.5–14.7; p=0.007). There was no association between cylinder size and recurrence rate (p=0.55). Conclusion VBT is generally very well tolerated, however, patients fitted with smaller cylinders (commonly nulligravid and low BMI) may have increased side effects. Further study to improve the dosimetry of VBT for patients requiring small cylinders may be worthwhile.
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Affiliation(s)
- Jack M Qian
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - John M Stahl
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Melissa R Young
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA
| | - Elena Ratner
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT, USA.
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Factors associated with changes in vaginal length and diameter during pelvic radiotherapy for cervical cancer. Arch Gynecol Obstet 2017; 296:1125-1133. [PMID: 28975498 DOI: 10.1007/s00404-017-4553-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 09/22/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study reports the incidence and factors associated with vaginal stenosis and changes in vaginal dimensions after pelvic radiotherapy for cervical cancer. METHODS A descriptive longitudinal study with 139 women with cervical cancer was conducted from January 2013 to November 2015. The outcome variables were vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE v3.0) and changes in vaginal diameter and length after the end of radiotherapy. Independent variables were the characteristics of the neoplasm, clinical and sociodemographic data. Bivariate analysis was carried out using χ 2, Kruskal-Wallis and Mann-Whitney's test. Multiple analysis was carried out using Poisson regression and a generalized linear model. RESULTS Most women (50.4%) had stage IIIB tumors. According to CTCAE v3.0 scale, 30.2% had no stenosis, 69.1% had grade 1 and 0.7% had grade 2 stenosis after radiotherapy. Regarding changes in vaginal measures, the mean variation in diameter was - 0.6 (± 1.7) mm and the mean variation in length was - 0.6 (± 1.3) cm. In the final statistical model, having tumoral invasion of the vaginal walls (coefficient + 0.73, p < 0.01) and diabetes (coefficient + 1.16; p < 0.01) were associated with lower vaginal stenosis and lower reduction of vaginal dimensions. Advanced clinical stage (coefficient + 1.44; p = 0.02) and receiving brachytherapy/teletherapy (coefficient - 1.17, p < 0.01) were associated with higher reduction of vaginal dimensions. CONCLUSIONS Most women had mild vaginal stenosis with slight reductions in both diameter and length of the vaginal canal. Women with tumoral invasion of the vagina have an increase in vaginal length soon after radiotherapy due to a reduction in tumoral volume.
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Morris L, Do V, Chard J, Brand AH. Radiation-induced vaginal stenosis: current perspectives. Int J Womens Health 2017; 9:273-279. [PMID: 28496367 PMCID: PMC5422455 DOI: 10.2147/ijwh.s106796] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Treatment of gynecological cancer commonly involves pelvic radiation therapy (RT) and/or brachytherapy. A commonly observed side effect of such treatment is radiation-induced vaginal stenosis (VS). This review analyzed the incidence, pathogenesis, clinical manifestation(s) and assessment and grading of radiation-induced VS. In addition, risk factors, prevention and treatment options and follow-up schedules are also discussed. The limited available literature on many of these aspects suggests that additional studies are required to more precisely determine the best management strategy of this prevalent group after RT.
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Affiliation(s)
- Lucinda Morris
- Crown Princess Mary Cancer Centre Westmead, Radiation Oncology Network, Westmead
| | - Viet Do
- Crown Princess Mary Cancer Centre Westmead, Radiation Oncology Network, Westmead
| | - Jennifer Chard
- Crown Princess Mary Cancer Centre Westmead, Radiation Oncology Network, Westmead
| | - Alison H Brand
- Discipline of Obstetrics, Gynaecology and Neonatology, Westmead Clinical School, University of Sydney, Camperdown
- Department of Gynaecological Oncology, Westmead Hospital, Westmead, NSW, Australia
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Kachnic LA, Bruner DW, Qureshi MM, Russo GA. Perceptions and practices regarding women's vaginal health following radiation therapy: A survey of radiation oncologists practicing in the United States. Pract Radiat Oncol 2017; 7:356-363. [PMID: 28377136 DOI: 10.1016/j.prro.2017.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 01/31/2017] [Accepted: 02/10/2017] [Indexed: 12/14/2022]
Abstract
PURPOSE Vaginal stenosis (VS) is a recognized complication of pelvic and vaginal radiation therapy (RT). METHODS AND MATERIALS A 26-item survey assessing the signs/symptoms, risk factors, diagnosis, prevention, treatment, and impact of VS on women's sexual health was distributed to radiation oncologists. Descriptive statistics were calculated. Chi-square tests examined differences in categorical responses. RESULTS A total of 233 (10.5%) participants completed the entire survey. Twelve percent, 21%, and 68% report treating gynecologic (GYN) tumors only, non-GYN pelvic tumors only, or both, respectively. Regarding risk factors, 78% believed that VS can be caused by pelvic RT alone, 91% by vaginal brachytherapy alone, and 98% by combined pelvic RT and vaginal brachytherapy. Approximately one-half of respondents felt that being postmenopausal and having a hysterectomy before radiation therapy were risk factors for VS, whereas the other half felt that these were not risk factors. All respondents agreed that VS is a clinical diagnosis. Respondents indicated that VS symptoms include dyspareunia, vaginal pain, dryness, and/or bleeding (100%, 90%, 85%, and 72%, respectively); 65% indicated all 4. The most commonly recommended treatment for VS is vaginal dilator use. Radiation oncologists who treat GYN-only versus non-GYN cancers were more likely to perform a vaginal examination, to distribute written instructions regarding vaginal dilator use (P = .002), to have vaginal bleeding reported after RT (P = .001), and to refer patients to a sexual counselor (P = .007). Most providers (73%) expressed willingness to participate in prospective research on the diagnosis and treatment of VS. CONCLUSIONS This is the first large-scale survey of radiation oncologists' perceptions and practices regarding VS. There is agreement among providers regarding the signs/symptoms of VS and strategies for its prevention/treatment using vaginal dilators. Further prospective and observational research is needed. This survey shows a willingness on the part of providers to take part in prospective research regarding the diagnosis, impact, and treatment of VS on women's sexual health.
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Affiliation(s)
- Lisa A Kachnic
- Vanderbilt Ingram Cancer Center, Vanderbilt University, Nashville, Tennessee
| | | | | | - Gregory A Russo
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review. Brachytherapy 2017; 16:95-108. [PMID: 27260082 PMCID: PMC5612425 DOI: 10.1016/j.brachy.2016.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/30/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the postoperative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early-stage endometrial cancer patients results in very low rates of vaginal recurrence (0-3.1%) with low rates of late toxicity which are primarily vaginal in nature. Post-Operative Radiation Therapy in Endometrial Cancer 2 (PORTEC-2) supports that VBT results in noninferior rates of vaginal recurrence compared to external beam radiotherapy for the treatment of high-intermediate risk patients. VBT as a boost after external beam radiotherapy, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians prefer joint decision making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multidisciplinary setting, and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.
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MESH Headings
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/radiotherapy
- Advisory Committees
- Brachytherapy/methods
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/radiotherapy
- Carcinosarcoma/pathology
- Carcinosarcoma/radiotherapy
- Combined Modality Therapy
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/radiotherapy
- Female
- Humans
- Hysterectomy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/radiotherapy
- Radiotherapy, Adjuvant/methods
- Societies, Medical
- United States
- Vagina
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Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ellen Jones
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
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A new short daily brachytherapy schedule in postoperative endometrial carcinoma. Preliminary results. Brachytherapy 2016; 16:147-152. [PMID: 28029590 DOI: 10.1016/j.brachy.2016.10.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the preliminary results of vaginal-cuff relapses (VCR) and complications of a short brachytherapy (BT) schedule in postoperative endometrial carcinoma. METHODS AND MATERIALS From September 2011 to December 2014, 102 patients were treated with postoperative BT for endometrial carcinoma. Seventy-four patients received a single 7 Gy dose after external beam irradiation (Group 1), and 28 intermediate-risk patients received three daily fractions of 6 Gy (Group 2). The dose was prescribed at 5 mm from the applicator surface. Toxicity was prospectively evaluated after the objective late effects of normal tissues-subjective, objective, management, analytic scores for vagina and RTOG scores for rectum and bladder. STATISTICS χ2 and Student's t tests. RESULTS The mean followup was 28.85 months (9.6-58.5) in Group 1 and 31.19 months (7.7-62.3) in Group 2. No VCR was found during followup. Late toxicity: vagina toxicity was developed in 24.32% of the patients in Group 1 (G1-G2) and in 21.4% in Group 2 (G1-G2 but 1 G3). Rectal toxicity appeared in only 2.7% of patients in Group 1 (G1). Neither Group 1 nor Group 2 presented late bladder toxicity. No differences were found in late toxicity between Groups 1 and 2. CONCLUSIONS The present short BT schedule was safe in relation to VCR and late toxicity for the followup period studied. These results are similar to those of two larger previous schedules performed in our center in relation to the same point of followup.
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Zhang H, Gopalakrishnan M, Lee P, Kang Z, Sathiaseelan V. Dosimetric impact of cylinder size in high-dose rate vaginal cuff brachytherapy (VCBT) for primary endometrial cancer. J Appl Clin Med Phys 2016; 17:262-272. [PMID: 27685113 PMCID: PMC5874121 DOI: 10.1120/jacmp.v17i5.6182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 04/15/2016] [Accepted: 05/16/2016] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the dosimetric impact of cylinder size in high‐dose‐rate (HDR) vaginal cuff brachytherapy (VCBT). Sample plans of HDR VCBT in a list of cylinders ranging from 2.5 to 4 cm in diameter at 0.5 cm increment were created and analyzed. The doses were prescribed either at the 0.5 cm depth with 5.5 Gy for 4 fractions or at the cylinder surface with 8.8 Gy for 4 fractions, in various treatment lengths. A 0.5 cm shell volume called PTV_Eval was contoured for each plan and served as the target volume for dosimetric evaluation. The cumulative and differential dose volume histograms (c‐DVH and d‐DVH), mean doses (D‐mean) and the doses covering 90% (D90), 10% (D10), and 5% (D5) of PTV_Eval were calculated. In the 0.5 cm depth regimen, the DVH curves were found to have shifted toward the lower dose zone when a larger cylinder was used, but in the surface regimen the DVH curves shifted toward the higher dose zone as the cylinder size increased. The D‐means of the both regimens were between 6.9 and 7.8 Gy and dependent on the cylinder size but independent of the treatment length. A 0.5 cm variation of diameter could result in a 4% change of D‐mean. Average D90s were 5.7 (ranging from 5.6 to 5.8 Gy) and 6.1 Gy (from 5.7 to 6.4 Gy), respectively, for the 0.5 cm and surface regimens. Average D10 and D5 were 9.2 and 11 Gy, respectively, for the 0.5 cm depth regimen, and 8.9 and 9.7 Gy, respectively, for the surface regimen. D‐mean, D90, D10, and D5 for other prescription doses could be calculated from the lookup tables of this study. Results indicated that the cylinder size has moderate dosimetric impact, and that both regimens are comparable in dosimetric quality. PACS number(s): 87.61.‐c, 87.53.Jw, 87.19.xj
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Affiliation(s)
- Hualin Zhang
- Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital.
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Foerster R, Schnetzke L, Bruckner T, Arians N, Rief H, Debus J, Lindel K. Prognostic factors for long-term quality of life after adjuvant radiotherapy in women with endometrial cancer. Strahlenther Onkol 2016; 192:895-904. [DOI: 10.1007/s00066-016-1037-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
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Zhang H, Donnelly ED, Strauss JB, Qi Y. Therapeutic analysis of high-dose-rate (192)Ir vaginal cuff brachytherapy for endometrial cancer using a cylindrical target volume model and varied cancer cell distributions. Med Phys 2016; 43:483. [PMID: 26745941 DOI: 10.1118/1.4939064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To evaluate high-dose-rate (HDR) vaginal cuff brachytherapy (VCBT) in the treatment of endometrial cancer in a cylindrical target volume with either a varied or a constant cancer cell distributions using the linear quadratic (LQ) model. METHODS A Monte Carlo (MC) technique was used to calculate the 3D dose distribution of HDR VCBT over a variety of cylinder diameters and treatment lengths. A treatment planning system (TPS) was used to make plans for the various cylinder diameters, treatment lengths, and prescriptions using the clinical protocol. The dwell times obtained from the TPS were fed into MC. The LQ model was used to evaluate the therapeutic outcome of two brachytherapy regimens prescribed either at 0.5 cm depth (5.5 Gy × 4 fractions) or at the vaginal mucosal surface (8.8 Gy × 4 fractions) for the treatment of endometrial cancer. An experimentally determined endometrial cancer cell distribution, which showed a varied and resembled a half-Gaussian distribution, was used in radiobiology modeling. The equivalent uniform dose (EUD) to cancer cells was calculated for each treatment scenario. The therapeutic ratio (TR) was defined by comparing VCBT with a uniform dose radiotherapy plan in term of normal cell survival at the same level of cancer cell killing. Calculations of clinical impact were run twice assuming two different types of cancer cell density distributions in the cylindrical target volume: (1) a half-Gaussian or (2) a uniform distribution. RESULTS EUDs were weakly dependent on cylinder size, treatment length, and the prescription depth, but strongly dependent on the cancer cell distribution. TRs were strongly dependent on the cylinder size, treatment length, types of the cancer cell distributions, and the sensitivity of normal tissue. With a half-Gaussian distribution of cancer cells which populated at the vaginal mucosa the most, the EUDs were between 6.9 Gy × 4 and 7.8 Gy × 4, the TRs were in the range from (5.0)(4) to (13.4)(4) for the radiosensitive normal tissue depending on the cylinder size, treatment lengths, prescription depth, and dose as well. However, for a uniform cancer cell distribution, the EUDs were between 6.3 Gy × 4 and 7.1 Gy × 4, and the TRs were found to be between (1.4)(4) and (1.7)(4). For the uniformly interspersed cancer and radio-resistant normal cells, the TRs were less than 1. The two VCBT prescription regimens were found to be equivalent in terms of EUDs and TRs. CONCLUSIONS HDR VCBT strongly favors cylindrical target volume with the cancer cell distribution following its dosimetric trend. Assuming a half-Gaussian distribution of cancer cells, the HDR VCBT provides a considerable radiobiological advantage over the external beam radiotherapy (EBRT) in terms of sparing more normal tissues while maintaining the same level of cancer cell killing. But for the uniform cancer cell distribution and radio-resistant normal tissue, the radiobiology outcome of the HDR VCBT does not show an advantage over the EBRT. This study strongly suggests that radiation therapy design should consider the cancer cell distribution inside the target volume in addition to the shape of target.
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Affiliation(s)
- Hualin Zhang
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Eric D Donnelly
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Jonathan B Strauss
- Department of Radiation Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Northwestern Memorial Hospital, Chicago, Illinois 60611
| | - Yujin Qi
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, NSW 2522, Australia
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