Exclusive radiotherapy for primary squamous cell carcinoma of the vagina

TRImodal DEfinitive invasive vagiNal carcinoma Treatment (TRIDENT protocol): how a standardized approach may change prognostic outcomes

OBJECTIVE

Vaginal carcinoma is a rare malignancy accounting for 1-2% of all gynecological cancers. Surgery has a limited role, while definitive radiotherapy-chemotherapy followed by interventional radiotherapy is considered a valid alternative. The aim of the TRIDENT (TRImodal DEfinitive invasive vagiNal carcinoma Treatment) pilot study was to report the results of a modern standardized trimodal protocol treatment consisting of image guided definitive radiotherapy-chemotherapy followed by image guided interventional radiotherapy in terms of safety and efficacy.

METHODS

Between January 2019 and December 2021, we analyzed 21 consecutive patients with primary vaginal cancer who had received radiotherapy-chemotherapy followed by interventional radiotherapy. The primary study endpoint was local control, and secondary endpoints were metastasis free survival, overall survival, and rate and severity of acute and late toxicities.

RESULTS

14 patients had FIGO (International Federation of Gynecology and Obstetrics) stage II, five patients had stage III, and two had stage IVB disease. Median total external beam radiotherapy dose for the tumor was 45 Gy. Median total dose on positive nodes was 60 Gy. Median total dose for interventional radiotherapy was 28 Gy over four high dose rate fractions to achieve between 85 and 95 Gy equivalent dose, in 2 Gy fractions (EQD2)α/β10, to the high risk clinical target volume, and 60 Gy EQD2α/β10 to the intermediate risk clinical target volume. All patients received weekly platinum based chemotherapy. Median follow-up was 20 months (range 10-56 months). Two year actuarial local control, metastasis free survival, and overall survival rate were 79.4%, 90.5%, and 79.4%, respectively. In terms of acute toxicity, there were no grade 4 events and only one acute grade (G) 3 toxicity (skin). Only vaginal stenosis (G3) was documented 12 months after therapy due to late toxicity.

CONCLUSIONS

In this study, definitive radiotherapy-chemotherapy followed by interventional radiotherapy was a safe and effective treatment modality for primary vaginal cancer.

Advanced primary vaginal squamous cell carcinoma: A case report and literature review

Background

Vaginal carcinoma is a gynecological malignancy with low incidence, and there are few relevant and specific guidelines for vaginal cancer in our country and abroad. Here, we report the case who was diagnosed with advanced, primary vaginal squamous cell carcinoma and underwent integrated treatment successfully.

Case introduction

A 64-year-old Chinese woman underwent subtotal hysterectomy for uterine fibroids in 1998 and laparoscopic extensive residual cervical resection, bilateral ovarian salpingectomy, and pelvic lymph node dissection for residual cervical adenocarcinoma (stage IB1) in the First Affiliated Hospital of China Medical University in 2018. There was no postoperative review. The patient experienced vaginal discharge in March 2020, and vaginal bleeding occurred in July 2020. Our patient was diagnosed with stage IVA vaginal squamous cell carcinoma, based on a gynecological examination, colposcopy biopsy with histopathological examination, computed tomography scan, and tumor marker levels by two professors. After three phases of treatment (sequential treatment with chemotherapy plus radiotherapy, chemotherapy combined with immune checkpoint inhibitors, and immune checkpoint inhibitors combined with tyrosine kinase inhibitors therapy), her condition improved. Her current state is generally good, and she has achieved complete remission.

Conclusion

We report a rare case of a patient with primary advanced vaginal carcinoma combined with cervical adenocarcinoma. The patient was treated for approximately 2 years, and her personalized treatment showed promising results. We will continue to follow up with the patient and monitor her response to the current treatment process.

Updates in the treatment of vaginal cancer

Vaginal cancer is a rare cancer. A lot of the data used in the treatment of this cancer are extrapolated from cervical cancer data. Radiation therapy plays a significant role in the treatment of vaginal cancer. The advances in radiation therapy in both external beam and brachytherapy have improved local control, survival, and toxicity. Brachytherapy plays an important role in treating vaginal cancer, but treatment should be individualized to each tumor. Imaging, particularly magnetic resonance imaging, plays an essential role in the management of patients with vaginal cancer, from diagnosis to staging to treatment management to surveillance.

Role of radiotherapy in the treatment of primary vaginal cancer: Recommendations of the French society for radiation oncology

Primary vaginal cancers are rare tumours, for which external beam radiotherapy and brachytherapy are major treatment tools. Given the complexity of brachytherapy techniques, the treatment should be performed in specialised centres. We present the recommendations of the French society for radiation oncology on the indications and techniques for external beam radiotherapy and brachytherapy for primary vaginal cancer.

Twenty years' experience of primary vaginal cancer treatment at one cancer centre: does residence status matter?

Objectives

To study the long-term results of the treatment of patients with vaginal cancer and to examine whether there are any differences in diagnostic and survival rates between urban and rural patients.

Methods

The data of 70 patients with primary vaginal cancer treated at NN Alexandrov National Cancer Centre of Belarus from 2000 to 2019 were included. The median age was 64 years (range = 56–75). Morphology in 91.4% (64/70) of the cases was squamous cell cancer, in 7.1% (5/70) it was adenocarcinoma and in 1.4% (1/70) it was adenosquamous carcinoma. In total, there were 31 patients from urban and 39 from rural areas. The groups were comparable in age (61 versus 67, p = 0.104), morphology (p = 0.188) and distribution of stages: stage I in 7 and 10 patients (22.6% and 25.6%, respectively; p = 0.999), stage II in 14 and 16 patients (45.1% and 41.0%, respectively; p = 0.810), stage III in 6 and 6 patients (19.4% and 15.4%, respectively; p = 0.754) and stage IV in 4 and 7 patients (12.9% and 18.0%, respectively; p = 0.744).

Results

The median follow-up time was 33 months (range = 1–220). A total of 42 women died: 28 from progression of vaginal cancer and 14 from other diseases. Overall survival (OS) was 31.9 ± 6.8%, median survival was 41 months (95% CI = 0.0–105.3). Disease-specific survival (DSS) for the entire group was 54.5 ± 6.8%; median was not reached. The overall survival rate of urban women was 44.8 ± 10.6% and for rural it was 22.5 ± 8.2% (p = 0.142); DSS was 57.6 ± 10.5% and 53.0 ± 8.4% (p = 0.448), respectively.

Conclusion

DSS rate was 54.0 ± 6.8% and the OS rate did not exceed 31.9 ± 6.8%. Rural residence was not associated with late stage at diagnosis or receipt of treatment.

Image-Guided Adaptive Brachytherapy (IGABT) for Primary Vaginal Cancer: Results of the International Multicenter RetroEMBRAVE Cohort Study

PURPOSE

This study assessed outcomes following the nowadays standing treatment for primary vaginal cancer with radio(chemo)therapy and image-guided adaptive brachytherapy (IGABT) in a multicenter patient cohort.

METHODS

Patients treated with computer tomography (CT)-MRI-assisted-based IGABT were included. Retrospective data collection included patient, tumor and treatment characteristics. Late morbidity was assessed by using the CTCAE 3.0 scale.

RESULTS

Five European centers included 148 consecutive patients, with a median age of 63 years. At a median follow-up of 29 months (IQR 25-57), two- and five-year local control were 86% and 83%; disease-free survival (DFS) was 73% and 66%, and overall survival (OS) was 79% and 68%, respectively. Crude incidences of ≥ grade-three urogenital, gastro-intestinal and vaginal morbidity was 8%, 3% and 8%, respectively. Lymph node metastasis was an independent prognostic factor for disease-free survival (DFS). Univariate analysis showed improved local control in patients with T2-T4 tumors if >80 Gy EQD2α/β10 was delivered to the clinical target volume (CTV) at the time of brachytherapy.

CONCLUSIONS

In this large retrospective multicenter study, IGABT for primary vaginal cancer resulted in a high local control with acceptable morbidity. These results compared favorably with two-dimensional (2D) radiograph-based brachytherapy and illustrate that IGABT plays an important role in the treatment of vaginal cancer.

Survival and prognostic factors in primary vaginal cancer: an analysis of 2004-2014 SEER data

Background

Primary vaginal cancer (PVC) is a rare gynecological malignant tumor and we know little about its survival and prognostic factors. The purpose of this study is to evaluate the potential survival and prognostic factors in women with PVC.

Methods

We used data from the Surveillance, Epidemiology, and End Results (SEER) program to identify 1,781 women who had been diagnosed with PVC between 2004 and 2014. Univariate and multivariable analyses were used to evaluate cases survival and prognostic factors. A stratified analysis was further performed to analyze the prognostic factors in each stage.

Results

There were 20.0% of patients aged ≥80 years and most women were married, 42.1%, and then widowed, 25.2%. The histology types include squamous (74.5%), adenocarcinoma (16.7%), melanoma (3.3%) and sarcoma (1.5%). Five-year cause-specific survival (CSS) rates were overall: 57.8%, Stage I: 76.4%, Stage II: 61.9%, Stage III: 53.3% and Stage IV: 22.5%. Univariate analysis showed that age, marital status, race, pathological grading, histology, TNM stage, tumor size, surgery and radiation were related to prognosis. The 5-year CSS of married women is 64.4%, while those of divorced/separated and widowed are 56.6% and 44.1%, respectively. Multivariate analysis indicated that age, histology, TNM stage, tumor size, surgery and radiation were independent prognostic factors. The elderly (≥80) cases and those with melanoma were correlated to worse prognosis at any stage of PVC. As tumor stage progressed, both of the ≥80 years old patients and the melanoma cases showed a decline tendency of mortality risk.

Conclusions

PVC is a rare gynecological malignant tumor and more likely to occur among older women. Squamous cell carcinoma is the most frequently observed histological type, while melanoma is extremely rare. Age, histology, TNM stage, tumor size, surgery and radiation are independent prognostic factors. Although marital status does not affect survival rates, married women are likely to live longer than widowed and divorced/separated cases. Age ≥80 years seems to be an important cut point in the survival of vaginal cancer. Older age (≥80 years) and melanoma have greater influences on mortality risk in early-stage disease.

Definitive radiotherapy with image-guided adaptive brachytherapy for primary vaginal cancer

Primary vaginal cancer is a rare cancer and clinical evidence to support recommendations on its optimal management is insufficient. Because primary vaginal cancer resembles cervical cancer in many aspects, treatment strategies are mainly adopted from evidence in locally advanced cervical cancer. To date, the organ-sparing treatment of choice is definitive radiotherapy, consisting of external beam radiotherapy and brachytherapy, combined with concurrent chemotherapy. Brachytherapy is an important component of the treatment and its steep dose gradient enables the delivery of high doses of radiation to the primary tumour, while simultaneously sparing the surrounding organs at risk. The introduction of volumetric CT or MRI image-guided adaptive brachytherapy in cervical cancer has led to better pelvic control and survival, with decreased morbidity, than brachytherapy based on x-ray radiographs. MRI-based image-guided adaptive brachytherapy with superior soft-tissue contrast has also been adopted sporadically for primary vaginal cancer. This therapy has had promising results and is considered to be the state-of-the-art treatment for primary vaginal cancer in standard practice.

Surgical outcomes of early-stage primary vaginal nonsquamous cell carcinoma

OBJECTIVE

Definitive radiation therapy (RT), using external beam RT and/or brachytherapy, is a standard treatment option for primary vaginal carcinoma. However, this treatment has poor prognosis when applied to vaginal nonsquamous cell carcinoma (non-SCC). We aimed to clarify treatment outcome and surgical safety in early-stage primary vaginal non-SCC.

METHODS

After receiving approval from the institutional review board, we retrospectively reviewed the clinical records and pathological samples of patients treated at our hospital between 1991 and 2018. Among 49 patients with primary vaginal carcinoma, 12 with histologically confirmed early-stage primary vaginal non-SCC were included in this study.

RESULTS

In total, 40% of patients with primary vaginal carcinoma treated at our hospital had primary vaginal non-SCC. The average observation time was 34 months (median 53.3 months). Three patients had local recurrence: 2 in pelvic lymph nodes and 1 in the vagina. Furthermore, 2 patients died of their disease. Five-year local control rate of stage I and stage II non-SCC was 75% and 100%, respectively. Disease-specific survival rate of stage I and stage II non-SCC was 81.8% and 100%, respectively. No major morbidity was observed. Three patients required allogeneic blood transfusion, whereas 1 underwent autotransfusion. None of the 12 patients were discharged with self-catheterization.

CONCLUSION

Five-year local control and disease-specific survival rates of patients surgically treated for vaginal non-SCC were favorable. Therefore, surgery could be a safe and reasonable option for early-stage primary vaginal non-SCC.

Recommendations from gynaecological (GYN) GEC-ESTRO working group - ACROP: Target concept for image guided adaptive brachytherapy in primary vaginal cancer

BACKGROUND AND AIM

External beam radiotherapy (EBRT) combined with brachytherapy has an essential role in the curative treatment of primary vaginal cancer. EBRT is associated with significant tumour shrinkage, making primary vaginal cancer suitable for image guided adaptive brachytherapy (IGABT). The aim of these recommendations is to introduce an adaptive target volume concept for IGABT of primary vaginal cancer.

METHODS

In December 2013, a task group was initiated within GYN GEC-ESTRO with the purpose to introduce an IGABT target concept for primary vaginal cancer. All participants have broad experience in IGABT and vaginal cancer brachytherapy. The target concept was elaborated as consensus agreement based on an iterative process including target delineation and dose planning comparison, retrospective analysis of clinical data and expert opinions.

RESULTS

Gynaecological examination and MR imaging are the modalities of choice for local tumour assessment. A specific template for standardised documentation with clinical drawings for vaginal cancer was developed. The adaptive target volume concept comprises different response-related target volumes. For EBRT these are related to the primary tumour and the lymph nodes, while for IGABT these are related to the primary tumour and are consisting of the residual gross tumour volume (GTV-T_res) and the high-, and intermediate risk clinical target volumes (CTV-T_HR, CTV-T_IR).

CONCLUSION

This target concept for IGABT of primary vaginal cancer defines adaptive target volumes for volumetric dose prescription and should improve comparability of different radiotherapy schedules of this rare disease. A prospective evaluation of the target volume concept within a multicentre study is planned.

Outcomes of vaginal squamous cell carcinoma of patients treated with radiation therapy: a series of 37 patients from a single expert center

INTRODUCTION

The aim is to assess the outcome of patients treated for vaginal carcinoma with radiation therapy in terms of long-term tolerance and survival.

MATERIALS AND METHODS

This single-center retrospective study included patients with squamous cell carcinoma of the vagina treated with pelvic external beam radiation therapy (EBRT) with or without vaginal brachytherapy (VB) between 1990 and 2013.

RESULTS

Thirty-seven patients were included with stage I (24%), II (60%), III (8%), or IV (8%) vaginal tumors. Median age was 66 years (range 27-86 years). Median tumor size was 4 cm (range 0.7-12 cm). Seven patients underwent first intention surgery. The 37 patients received pelvic EBRT (45 Gy) with inguinal irradiation in 57% of cases. Fifteen (41%) received concurrent chemotherapy. Low-dose supplemental VB was performed in 31 patients (84%) (median dose: 20 Gy). Median follow-up was 59 months (range 7-322 months). Four patients (11%) had late grade 3-4 complications. Relapse occurred in 11 patients (30%), five of them locally. The 5-year relapse-free and cancer-specific survival rates were 68% and 76%, respectively. Surgery and concurrent chemotherapy did not seem to have an impact on the course of the disease.

CONCLUSION

In our experience, pelvic EBRT leads to prolonged survival with acceptable long-term toxicity in patients with squamous cell carcinoma of the vagina.

Diagnosis, Therapy and Follow-up of Vaginal Cancer and Its Precursors. Guideline of the DGGG and the DKG (S2k-Level, AWMF Registry No. 032/042, October 2018)

Purpose This is an official guideline, published and coordinated by the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Society for Gynecology and Obstetrics (DGGG). Vaginal cancers are rare tumors, which is why there is very little evidence on these tumors. Knowledge about the optimal clinical management is limited. This first German S2k guideline on vaginal cancer has aimed to compile the most current expert knowledge and offer new recommendations on the appropriate treatment as well as providing pointers about individually adapted therapies with lower morbidity rates than were previously generally available. The purpose of this guideline is also to set up a register to record data on treatment data and the course of disease as a means of obtaining evidence in future. Methods The present S2k guideline was developed by members of the Vulvar und Vaginal Tumors Commission of the AGO in an independently moderated, structured, formal consensus process and the contents were agreed with the mandate holders of the participating scientific societies and organizations. Recommendations To optimize the daily care of patients with vaginal cancer: 1. Monitor the spread pattern; 2. Follow the step-by-step diagnostic workup based on initial stage at detection; 3. As part of individualized clinical therapeutic management of vaginal cancer, follow the sentinel lymph node protocol described here, where possible; 4. Participate in the register study on vaginal cancer.

Total Reference Air Kerma is Associated with Late Bowel Morbidity in Locally Advanced Cervical Cancer Patients Treated with Image-Guided Adaptive Brachytherapy

No dose volume parameter has been identified to predict late bowel toxicities in locally advanced cervical cancer (LACC) patients treated with image-guided adaptive brachytherapy. We examined the incidence of bowel toxicities according to the total reference air kerma (TRAK) in 260 LACC patients. In both univariate and multivariate analysis, late morbidity positively correlated with a TRAK ≥2 cGy (centigray) at 1 meter, emphasizing the importance of this parameter in term of late bowel morbidity. Objective: There is no validated dose volume parameter to predict late bowel toxicities in cervical cancer patients treated with image-guided adaptive brachytherapy (IGABT). We examined the incidence of bowel toxicities according to the TRAK, which is proportional to the integral dose to the patients. Material/Methods: Clinical data of 260 LACC patients treated with curative intent from 2004 to 2016 were examined. Patients received chemoradiation plus a pulse-dose rate IGABT boost. The relationship between TRAK and morbidity was assessed by Kaplan-Meier method, log-rank tests, and Cox proportional-hazards model on event-free periods. Results: Median follow-up was 5.2 years (SE (Standard Error): 0.21). Probability of survival without late bowel toxicity Grade ≥ 2 rate for patients without recurrence (n = 227) at 5 years was 66.4% (SE 3.7). In univariate analysis, bowel and/or sigmoid dose/volume parameters were not significant. Late morbidity positively correlated with active smoking, CTVHR volume >25 cm³, and a TRAK ≥2 cGy at 1 meter. In multivariate analysis, the following factors were significant: Active smoking (p < 0.001; HR: 2.6; 95%CI: 1.4–5.0), and the TRAK (p = 0.02; HR: 2.4; 95%CI: 1.2–5.0). Conclusion: TRAK was associated with late bowel toxicities probability, suggesting that the integral dose should be considered, even in the era of IGABT.

Definitive Radiotherapy in Invasive Vaginal Carcinoma: A Systematic Review

AIM

This study systematically reviews the recent literature on the role of definitive radiotherapy (RT) in the management of vaginal cancer (VC) and presents comprehensive data on clinical outcomes and toxicity.

METHODS

The authors performed a literature search using PubMed (2007-2016) to identify all prospective and retrospective studies that have been published on RT in invasive VC.

RESULTS

Of the 199 identified studies, 13 met the inclusion criteria. All studies had a retrospective design. Overall, 793 patients (median, 45; range, 26-138) were included. A high heterogeneity was found across studies in terms of RT techniques, assessment criteria, and reported outcomes. The majority of the patients were treated with a combination of external beam RT and brachytherapy (74.2%). Acute and late grade ≥3 toxicity rates ranged from 0.0% to 24.4% (median, 8.7%) and from 0.0% to 22.5% (median, 12.8%), respectively. The 5-year local control rates ranged between 39% and 79%. The 5-year overall survival ranged between 34% and 71.0% (median, 63.5%). Early stage of the disease (International Federation of Gynecology and Obstetrics stages I-II vs. III-IV), small tumor size (<4 cm), previous hysterectomy, high pretreatment/treatment hemoglobin levels (≥12/12.5 mg/dL), and patients' age <70 or <64 years were correlated with better clinical outcomes.

CONCLUSION

Only retrospective studies, in a limited number, have been published on RT in VC in the past decade, with significant heterogeneity in terms of treatment characteristic and evaluation criteria. Clinical results were strongly influenced by tumor stage. Prospective randomized studies are needed to improve patients' outcomes, especially in advanced-stage disease.

IMPLICATIONS FOR PRACTICE

This study systematically reviews the recent literature on the role of definitive radiotherapy in the management of vaginal cancer and presents comprehensive data on clinical outcome and toxicity. The prognosis of patients is dismal, with a 5-year overall survival of approximately 50%. Early stage of the disease, small tumor size, previous hysterectomy, high pretreatment/treatment hemoglobin levels, and patients' age were correlated with a better clinical outcome. A brachytherapy boost should be delivered, especially in patients with higher-stage disease. The addition of concurrent weekly cisplatin should be considered in most patients, and transfusion should be used to maintain high hemoglobin levels.

Japan Society of Gynecologic Oncology guidelines 2015 for the treatment of vulvar cancer and vaginal cancer

BACKGROUND

Vulvar cancer and vaginal cancer are relatively rare tumors, and there had been no established treatment principles or guidelines to treat these rare tumors in Japan. The first version of the Japan Society of Gynecologic Oncology (JSGO) guidelines for the treatment of vulvar cancer and vaginal cancer was published in 2015 in Japanese.

OBJECTIVE

The JSGO committee decided to publish the English version of the JSGO guidelines worldwide, and hope it will be a useful guide to physicians in a similar situation as in Japan.

METHODS

The guideline was created according to the basic principles in creating the guidelines of JSGO.

RESULTS

The guidelines consist of five chapters and five algorithms. Prior to the first chapter, basic items are described including staging classification and history, classification of histology, and definition of the methods of surgery, radiation, and chemotherapy to give the reader a better understanding of the contents of the guidelines for these rare tumors. The first chapter gives an overview of the guidelines, including the basic policy of the guidelines. The second chapter discusses vulvar cancer, the third chapter discusses vaginal cancer, and the fourth chapter discusses vulvar Paget's disease and malignant melanoma. Each chapter includes clinical questions, recommendations, backgrounds, objectives, explanations, and references. The fifth chapter provides supplemental data for the drugs that are mentioned in the explanation of clinical questions.

CONCLUSION

Overall, the objective of these guidelines is to clearly delineate the standard of care for vulvar and vaginal cancer with the goal of ensuring a high standard of care for all women diagnosed with these rare diseases.

Descriptive epidemiological study of vaginal cancer using data from the Osaka Japan population-based cancer registry: Long-term analysis from a clinical viewpoint

Vaginal cancer is such a rare tumor that epidemiological and clinical information for it is based mainly on studies of small numbers of cases. The aim of the present study was to perform a descriptive epidemiological analysis of vaginal cancer using a significantly larger population-based dataset from the Japanese Osaka Cancer Registry.The age-standardized incidence of vaginal cancer per 1,000,000 persons, from 1976 to 2010, was calculated and examined for trends. Relative-survival analysis was applied to estimate a more up-to-date 10-year period calculation, using data from recently followed-up patients. The conditional 5-year survival of patients who survived for 0 to 5 years after diagnosis was calculated.A total of 481 cases of vaginal cancer were registered in Osaka during the 35-year period from 1976 to 2010. The age-adjusted incidence rate has significantly and consistently decreased over this time [annual percent change (APC) = -1.29, 95% confidence interval (95% CI): -0.3 ∼ -2.2]; however, due to significant population aging, the raw incidence of vaginal cancer appeared to have been increasing. The 10-year relative survival of patients with surgery-based treatments was comparable to that of radiation-based treatments, implying that surgery and radiotherapy provide similar therapeutic benefits (P = .98). The 10-year relative survival was not significantly different during the period of 1976 to 2000 compared with the period of 2001 to 2008, although there has been, in the latter period, a tendency for improvement of long-term survival, especially for survival longer than 5 years. The longer the time after diagnosis, the higher the conditional 5-year relative-survival at 0 to 4 years after diagnosis.The age-adjusted incidence of vaginal cancer has decreased since 1976. Regrettably, the 10-year survival rate did not similarly improve, and it remained stable during the period from 2001 to 2008, compared with the period from 1976 to 2000, indicating that significant work remains to be done to develop more effective vaginal cancer treatments.

Definitive treatment of primary vaginal cancer with radiotherapy: multi-institutional retrospective study of the Korean Radiation Oncology Group (KROG 12-09)

OBJECTIVE

To assess the outcome of the treatment of primary vaginal cancer using definitive radiotherapy (RT) and to evaluate the prognostic factors of survival.

METHODS

The medical records of nine institutions were retrospectively reviewed to find the patients with vaginal cancer treated with definitive RT with or without chemotherapy. A total of 138 patients met the inclusion criteria. None had undergone curative excision.

RESULTS

The median follow-up time of the survivors was 77.6 months and the median survival time was 46.9 months. The 5-year overall survival, cancer-specific survival (CSS), and progression-free survival (PFS) rates were 68%, 80%, and 68.7%, respectively. In the survival analysis, the multivariate analysis showed that a lower the International Federation of Gynecology and Obstetrics (FIGO) stage and prior hysterectomy were favorable prognostic factors of CSS, and a lower FIGO stage and diagnosed prior to year 2000 were favorable prognostic factors of PFS. In the subgroup analysis of the patients with available human papillomavirus (HPV) results (n=27), no statistically significant relationship between the HPV status and recurrence or survival was found. Grade 3 or 4 acute and late toxicity were present in 16 and 9 patients, respectively. The FIGO stage and the tumor size were predictors of severe late toxicity.

CONCLUSION

The data clearly showed that a higher FIGO stage was correlated with a worse survival outcome and higher severe late toxicity. Therefore, precise RT and careful observation are crucial in advanced vaginal cancer. In this study, the HPV status was not related to the survival outcome, but its further investigation is needed.

Role of Radical Surgery in Early Stages of Vaginal Cancer—Our Experience

Objectives

The objective of our present study was to evaluate the efficacy of radical vaginectomy with or without radical hysterectomy in patients with International Federation of Gynecology and Obstetrics stage I and II vaginal cancers.

Materials and Methods

A retrospective study was carried out on 11 patients aged 35 to 78 years. All the patients underwent radical surgery for vaginal cancer from April 2010 till June 2015. Kaplan-Meier analyses were used to calculate the disease-free survival and overall survival at 12 months.

Results

The mean age of patients was 53.2 years. Ten patients were with International Federation of Gynecology and Obstetrics stage I, whereas one had stage II vaginal cancer. The histology was squamous cell cancer in 9 patients and small cell neuroendocrine cancer in 2 patients. The lesion was confined to the upper two third of the vagina in 8 cases, and the lower one third was involved in 3 cases. All the patients underwent radical surgery. Lymph node dissection was done in 9 patients out of whom lymph nodes were positive in 3 patients. Two patients had positive margins. Adjuvant treatment was given to patients with positive margins or positive nodes. Five patients did not require any adjuvant treatment, and 1 patient defaulted adjuvant treatment. One patient developed vesicovaginal fistula. Over a follow-up period ranging from 5 to 67 months, local recurrence developed in 1 patient, whereas no patient died of disease. One patient was lost to follow-up at 15 months. The 12-month disease-free survival was 88.9%, and 12-month overall survival was 100%.

Conclusions

Stage I and selected stage II vaginal cancer patients have good outcomes in terms of survival and local tumor control if managed judiciously by initial surgery followed by selective adjuvant therapy.

Primary vaginal cancer: role of MRI in diagnosis, staging and treatment

Primary carcinoma of the vagina is rare, accounting for 1-3% of all gynaecological malignancies. MRI has an increasing role in diagnosis, staging, treatment and assessment of complications in gynaecologic malignancy. In this review, we illustrate the utility of MRI in patients with primary vaginal cancer and highlight key aspects of staging, treatment, recurrence and complications.

Ureteral stent insertion for gynecologic interstitial high-dose-rate brachytherapy

PURPOSE

To determine the utility of ureteral stents in interstitial gynecological brachytherapy.

METHODS AND MATERIALS

We reviewed 289 patients with cervix cancer treated with high-dose-rate interstitial brachytherapy who did not have pretreatment hydronephrosis to determine the relative incidence of benign ureteral strictures after treatment. We also did comparative dosimetry analysis in five cases of high-dose-rate brachytherapy. Bilateral ureteral stents were placed during the procedure. Three dosimetry plans were created to determine the impact of modifying clinical target volume (CTV) and applying ureteral dose constraints. In Plan 1, the ureters were contoured and excluded from the CTV and 120% dose constraints were applied. In Plan 2, the ureters were contoured and excluded, but no dose constraints were applied to the ureter. In Plan 3, the CTV was created as if the location of the ureters was unknown and then ureteral dose was determined.

RESULTS

There were 11 ureteral strictures observed in 255 nonstented cases and 0 ureteral strictures in 34 stented cases. Plan 1 reduced the ureter dose (D(0.1cc)) by a median 22% (7.0-53.8%) compared with Plan 2 and by a median of 30.9% (12.3-65%). compared with Plan 3.

CONCLUSIONS

Placement of stents and ureteral dose constraints facilitates dosimetry and reduces the dose to ureters. Temporary ureteral stents prevent obstruction during interstitial gynecologic brachytherapy and allows the ureters to be addressed as an organ at risk.

[Management of vaginal carcinoma in patients over 70 years old: advantage of a radiotherapy-brachytherapy association]

OBJECTIVE

Report and discuss the management of the primitive vaginal cancer in elderly adults at a single institute.

PATIENTS AND METHODS

Data from patients more than 70 year-old treated for a primitive vaginal cancer at the Institut de Cancérologie de la Loire Lucien-Neuwirth was retrospectively collected.

RESULTS

From August 1999 to January 2009, 9/24 patients treated for a primitive vaginal cancer had more than 70 year-old. The median age was 81 years (7-94 years). Most patients had a performance status less or equal to 1 (n=6), a squamous cell carcinoma (n=7) and a FIGO stage less or equal to II (n=6). All patients were treated with 3D external beam radiation, 3 received concurrent chemotherapy, 3 had a supplementary brachytherapy, and 6 had a colpohysterectomy. Among 7 evaluable patients, there were 4 complete responses, 2 partial responses and one progression. Main acute toxicities were gastrointestinal (n=5), urinary (n=3), general (n=3) and cutaneous (n=2). Three patients experienced late toxicities. Four patients had a local recurrence after a mean delay of 10.8 months. At last news, 4 patients were still alive and 4/5 deaths were related to the cancer. All (n=3) patients who received the combination of radiotherapy - brachytherapy were alive and disease-free. Median overall survival was 18 months.

DISCUSSION AND CONCLUSIONS

Primitive vaginal cancers are rare and aggressive tumours. Our results suggested the feasibility of the combination of radiotherapy and brachytherapy for elderly patients. Prospective trials remain needed to better define and validate the optimal strategy, especially in elderly adults.

Adjuvant and definitive radiation therapy for primary carcinoma of the vagina using brachytherapy and external beam radiation therapy

PURPOSE

To report the outcomes of patients receiving vaginal brachytherapy and/or external beam radiation therapy (EBRT) for primary vaginal cancer.

MATERIAL AND METHODS

Between 1983 and 2009, 63 patients received brachytherapy and/or EBRT for primary tumors of the vagina at a single tertiary center. Patient data was collected via chart review. The Kaplan-Meier method was used to calculate actuarial pelvic local control (LC), disease-free survival (DFS), overall survival (OS), and severe late toxicity rates. Acute and late toxicities were scored according to the Common Terminology Criteria for Adverse Events version 3 (CTCAE v3.0).

RESULTS

Median follow up was 44.2 months. Patients with early stage disease (stages I and II) had significantly improved 5-year OS when compared to patients with locally advanced disease (stages III and IVA) (73.3 vs. 34.4%, p = 0.032). Patients with greater than 1/3 vaginal involvement had significantly worse prognosis than patients with tumors involving 1/3 or less of the vagina, with the later having superior DFS (84.0 vs. 52.4%, p = 0.007) and LC (86.9 vs. 60.4%, p = 0.018) at 5-years. Age, histology, and brachytherapy technique did not impact treatment outcomes. The 5-year actuarial grade 3 or higher toxicity rate was 23.1% (95% CI: 10.6-35.6%). Concurrent chemotherapy had no impact on outcomes or toxicity in this analysis.

CONCLUSIONS

Success of treatment for vaginal cancer depends primarily on disease stage, but other contributing factors such as extent of vaginal involvement and tumor location significantly impact outcomes. Treatment of vaginal cancer with primary radiotherapy yields acceptable results with reasonable toxicity rates. Management of this rare malignancy requires a multidisciplinary approach to appropriately optimize therapy.

Radiotherapy for carcinoma of the vagina. Immunocytochemical and cytofluorometric analysis of prognostic factors

BACKGROUND AND PURPOSE

The aim of this study was to assess the potential prognostic factors in patients with primary invasive vaginal carcinoma (PIVC) treated with radical irradiation.

PATIENTS AND METHODS

The analysis was performed on 77 patients with PIVC treated between 1985 and 2005 in the Maria Skłodowska-Curie Memorial Institute of Oncology, Cancer Center in Krakow. A total of 36 patients (46.8 %) survived 5 years with no evidence of disease (NED). The following groups of factors were assessed for potential prognostic value: population-based (age), clinical (Karnofsky Performance Score [KPS], hemoglobin level, primary location of the vaginal lesion, macroscopic type, length of the involved vaginal wall, FIGO stage), microscopic (microscopic type, grade, mitotic index, presence of atypical mitoses, lymphatic vessels invasion, lymphocytes/plasmocytes infiltration, focal necrosis, VAIN-3), immunohistochemical (protein p53 expression, MIB-1 index), cytofluorometric (ploidity, index DI, S-phase fraction, proliferation index SG2M) factors.

RESULTS

Significantly better 5-year NED was observed in patients: < 60 years, KPS ≥ 80, FIGO stage I and II, grade G1-2, MIB-1 index  < 70, S-phase fraction < 10, and proliferation index < 25. Independent factors for better prognosis in the multivariate Cox analysis were age < 60 years, FIGO stage I or II, and MIB-1 index < 70.

CONCLUSION

Independent prognostic factors in the radically irradiated PIVC patients were as follows: age, FIGO stage, MIB-1 index.

Treatment of locally advanced vaginal cancer with radiochemotherapy and magnetic resonance image-guided adaptive brachytherapy: dose-volume parameters and first clinical results

PURPOSE

To investigate the clinical feasibility of magnetic resonance image-guided adaptive brachytherapy (IGABT) for patients with locally advanced vaginal cancer and to report treatment outcomes.

METHODS AND MATERIALS

Thirteen patients with vaginal cancer were treated with external beam radiotherapy (45-50.4 Gy) plus IGABT with or without chemotherapy. Distribution of International Federation of Gynecology and Obstetrics stages among patients were as follows: 4 patients had Stage II cancer, 5 patients had Stage III cancer, and 4 patients had Stage IV cancer. The concept of IGABT as developed for cervix cancer was transferred and adapted for vaginal cancer, with corresponding treatment planning and reporting. Doses were converted to the equivalent dose in 2 Gy, applying the linear quadratic model (α/β = 10 Gy for tumor; α/β = 3 for organs at risk). Endpoints studied were gross tumor volume (GTV), dose-volume parameters for high-risk clinical target volume (HRCTV), and organs at risk, local control (LC), adverse side effects, and survival.

RESULTS

The mean GTV (± 1 standard deviation) at diagnosis was 45.3 (±30) cm(3), and the mean GTV at brachytherapy was 10 (±14) cm(3). The mean D90 for the HRCTV was 86 (±13) Gy. The mean D2cc for bladder, urethra, rectum, and sigmoid colon were 80 (±20) Gy, 76 (±16) Gy, 70 (±9) Gy, and 60 (±9) Gy, respectively. After a median follow-up of 43 months (range, 19-87 months), one local recurrence and two distant metastases cases were observed. Actuarial LC and overall survival rates at 3 years were 92% and 85%. One patient with Stage IVA and 1 patient with Stage III disease experienced fistulas (one vesicovaginal, one rectovaginal), and 1 patient developed periurethral necrosis.

CONCLUSIONS

The concept of IGABT, originally developed for treating cervix cancer, appears to be applicable to vaginal cancer treatment with only minor adaptations. Dose-volume parameters for HRCTV and organs at risk are in a comparable range. First clinical results indicate excellent LC. Further prospective multicenter studies are needed to establish this method and to confirm these results.

Primary Vaginal Cancer and Chemoradiotherapy: A Patterns-of-Care Analysis

Introduction:

No prospective randomized trials exist to delineate the role of combined chemoradiotherapy (CRT) in the treatment of vaginal cancer (VC). We sought to describe the utilization rate of CRT and evaluate the potential survival benefit of CRT over radiotherapy alone in VC.

Methods:

A retrospective analysis of the SEER-Medicare-linked database was performed analyzing women with VC treated with external beam radiation and/or brachytherapy and diagnosed between 1991 and 2005.

Results:

Of the 1709 primary VC patients in the SEER-Medicare database, 326 met inclusion criteria. Most were white (80.1%) and in the 70- to 74-year age group (42.1%). Squamous cell carcinoma was the most predominant histologic diagnosis (80.4%). Brachytherapy was used in 34% of patients, whereas cisplatin was the chemotherapy of choice in 59% of CRT patients. Median follow-up was 21.5 months. Kaplan-Meier estimated that 5-year cause-specific survival (CSS) and overall survival (OS) was 67.6% and 27.1%, respectively. Before 1999, CRT was used in 7.5% of patients compared with 36.1% of patients thereafter (P< 0.001). Chemoradiotherapy was less likely to be used in patients older than 80 years (P< 0.001) but was otherwise balanced in race, stage, grade, histologic diagnosis, comorbidities, and brachytherapy use. Chemoradiotherapy did not correlate with CSS (hazard ratio [HR], 0.91;P= 0.84) or OS (HR, 1.34;P= 0.21) by multivariate analysis. Factors associated with worse CSS include stage IVA disease (HR, 4.2;P= 0.003) and 2 or more comorbidities (HR, 2.89;P= 0.03). Factors associated with worse OS include age older than 80 years (HR, 1.78;P= 0.04), stage IVA disease (HR, 3.35;P< 0.0001), and 2 or more comorbidities (HR, 2.58;P= 0.001).

Conclusions:

Chemoradiotherapy utilization for VC has increased since 1999. We failed to delineate a CSS or OS benefit for CRT in this cohort.

Use of combined radiation and hyperthermia for gynecological cancer

PURPOSE OF REVIEW

We reviewed all literature on the clinical use of combined radiation and hyperthermia for gynecologic malignancies.

RECENT FINDINGS

Combined radiation and hyperthermia should be considered an alternative to chemoradiation for patients with locally advanced cervix cancer and be the first treatment of choice for these patients when radiation cannot be combined with chemotherapy. Several randomized trials have shown an improvement by adding hyperthermia to radiation that is comparable to the improvement found with the addition of chemotherapy to radiation. Hyperthermia does not seem to add to treatment-induced toxicity and the results of hyperthermia are consistent even at 12 years follow-up and could be reproduced in a large, unselected group of cervix cancer patients. A novel indication for combined radiotherapy and hyperthermia is vaginal cancer. Recently, a cohort study showed that the addition of hyperthermia to radiation seems to improve overall survival for patients with vaginal cancer International Federation of Gynecology and Obstetrics stage III.

SUMMARY

Combined radiation and hyperthermia should be considered for patients with locally advanced cervix cancer (International Federation of Gynecology and Obstetrics stage IIb and upwards) as an alternative to chemoradiation for patients with a contraindication for chemotherapy. For other patients, the optimal treatment combination is the subject of randomized trials. For vaginal cancer, a prospective registration study is currently ongoing.