Advanced Vaginal Cancer Research Articles

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

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

Characteristics and outcomes for patients with advanced vaginal or vulvar cancer referred to a phase I clinical trials program: the MD Anderson cancer center experience

BackgroundEarly-stage vaginal and vulvar cancer can be cured. But outcomes of patients with metastatic disease are poor. Thus, new therapeutic strategies are urgently required.MethodsIn this retrospective study, we analyzed the clinical outcomes of consecutive patients with metastatic vaginal or vulvar cancer who were referred to a phase I trial clinic between January 2006 and December 2013. Demographic and clinical data were obtained from patients’ electronic medical records.ResultsPatients with metastatic vaginal (n = 16) and vulvar (n = 20) cancer who were referred for phase I trial therapy had median overall survival durations of 6.2 and 4.6 months, respectively. Among those who underwent therapy (n = 27), one experienced a partial response and three experienced stable disease for at least 6 months. Patients with a body mass index ≥30 had a significantly longer median overall survival duration than did those with a body mass index <30 (13.2 months versus 4.4 months, p = 0.04). Preliminary data revealed differences in molecular profiling between patients with advanced vaginal cancer and those with advanced vaginal cancer.ConclusionsMetastatic vaginal and vulvar cancers remain to be difficult-to-treat diseases with poor clinical outcomes. The currently available phase I trial agents provided little meaningful clinical benefits. Understanding these tumors’ molecular mechanisms may allow us to develop more effective therapeutic strategies than are currently available regimens.

A Custom-made Urethral Applicator for High-Dose-Rate Brachytherapy in Advanced Vaginal Cancer

Urethral extension in vaginal cancer presents a difficult area to treat effectively and without complication. After pelvic irradiation, gross disease in this region may be boosted externally or preferably with HDR brachytherapy. However, depending on the depth and positioning of the lesion, a single or multi-channel vaginal cylinder may not effectively target the area. An interstitial template can be considered, but carries additional procedural risk. In this study, we present the case of a patient with locally advanced vaginal cancer with significant periurethral extension, effectively treated with a custom urethral brachytherapy applicator built from common components.

SU-E-T-148: An Optimizing Study of a New Multi Channel Virginal Cylinder Applicator in Brachytherapy.

A new CT/MRI vaginal multichannel applicator was introduced by Elekta/Nucletron® recently. The multi-lumen cylindrical device intends to improve and optimize treatment of local advanced vaginal cancer. The design of this applicator includes several inner peripheral channels in equal spacing isotropically 5 mm from the surface of cylinder. The central tube provides the unique function as it was in traditional single channel treatment. Ninteen CT image sets of six patients were taken with multichannel applicator inserted. The single channel plan was planned before multichannel plan to justify the dose coverage to the prescribed volume and the doses received by bladder and rectum. The Oncentra® Brachytherapy planning system was employed to generate forward plan in single channel and inverse plan in multichannel where doses to bladder and rectum were evaluated and weighted by using Inverse Planning Simulated Annealing (IPSA) algorithm. Figure.1 shows plan Result from single channel and Figure.2 shows multichannel Result with IPSA. The comparison confirms multichannel provides better coverage of V90, V95 and V100 to the prescribed 5 mm vaginal cuff rind. The maximal doses delivered to bladder and rectum were reduced and the mean dose was lowered in average by 5-9% and 7-11% respectively. The nature of Brachytherapy is to take advantages of short fall off of radiation dose outside the intended treated tumor and minimize dose to surrounding tissues and critical organs. However treatment technique and plan optimization could be improved and be enhanced to benefit cancer treatment from advanced design of the applicators. This study demonstrates a new multichannel applicator affords promising conformal treatment to the tumor and liberates the doses to the critical structures by using optimization to meet our objectives.

Treatment of Locally Advanced Vaginal Cancer With Radiochemotherapy and Magnetic Resonance Image-Guided Adaptive Brachytherapy: Dose–Volume Parameters and First Clinical Results

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. 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. 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. 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.

51 oral: MRI-Guided BT With Ebrt Plus Chemotherapy for the Treatment of Locally Advanced Vaginal Cancer

51 oral: MRI-Guided BT With Ebrt Plus Chemotherapy for the Treatment of Locally Advanced Vaginal Cancer

54 oral: Frequency-Distribution Mapping of HR-CTV in Locally Advanced Cervix Cancer: A New Tool for Development of Novel Brachytherapy Techniques

Purpose: Reported local failure rates for FIGO stage II-IVA vaginal cancer usually range between 20% and 60%, even in recent series. In this study we investigate the clinical feasibility and report about the first treatment outcomes of MRI image guided brachytherapy (IGBT) in these pts using the same strategy as recently developed for cervix cancer. Materials: Forty pts with vaginal cancer were treated at our institution from 1999-2006. Thirteen pts met the inclusion criteria for this study and received IGBT based on a prospective protocol. FIGO stage distribution was: stage II=4, stage III=5, stage IV=4. Five pts had positive pelvic lymph nodes and in 7 pts tumour size was >5cm. All pts received EBRT (40-50Gy) and 11 pts concurrent chemotherapy (9 cisplatin and 2 MMC+5-FU). IGBT dose prescription was either 4x7 Gy (HDR) or 35-40 Gy (0.5-0.8Gy; PDR) to the HR CTV. In 10 cases a combined intravaginal/interstitial application technique was used. Based on the recent developments in the treatment of cervical cancer pts with IGBT (Gyn GEC ESTRO Recommendations), systematic concepts for HR CTV, OAR, biological modelling, DVH-analysis, dosevolumeadaptation (D90, D2cc), and dose escalation were integrated into the treatment (planning) of all pts. Reported doses were converted to the equivalent dose in 2Gy (EQD2) applying the LQ-model (α/β of 10 for tumour and 3 for OAR). Clinical results were calculated using the KaplanMeier method. Results: Spatial relations between vaginal cylinder +/needle applicators, HR CTV, and OAR were clearly visible on MRI in all cases. Mean total prescribed dose was 80Gy EQD2 (1SD±8Gy).Mean D90 for HR CTV was 86Gy EQD2 (1SD±13Gy). For OAR the following mean D2cc were documented: 80Gy (1SD±20Gy) for bladder, 76Gy (1SD ±16Gy) for urethra, 70Gy (1SD ±9Gy) for rectum and 60Gy (1SD±9Gy) for sigmoid colon. All pts achieved complete remission at 3 months. Median follow up was 43 months (range: 1987 months). Two pts developed fistula (1 vesico-vaginal, 1 recto-vaginal) due to tumour-necrosis and 1 with distal vaginal involvement complete vaginal obliteration. Three recurrences were documented: 1 local in a patient with FIGO stage III and 2 distant. All these pts had positive pelvic lymph nodes. Actuarial local control, OS and CSS rates at three years were 92%, 85% and 85%. For FIGO stages II, III, and IV they were 100%, 80% and 75%, respectively. Conclusions: IGBT for vaginal cancer seems to be feasible similar to the concepts as introduced for cervix cancer. Clinical and dosimetric results of this first experience with IGBT for locally advanced vaginal cancer are promising. Local control and survival in this small series seems to be significantly higher than in previous reports about conventional X-ray based brachytherapy, associated at the same time with acceptable morbidity. However, further prospective studies with more pts are needed to confirm these results.

Vesicovaginal fistula caused by a vaginal foreign body in a 72-year-old woman: case report and literature review

We report a case of vesicovaginal fistula associated to a vaginal foreign body. A 72-year-old woman consulted our clinic complaining of severe urinary incontinence. The leakage was continuous and significant and she was feeling a "vaginal mass". Pelvic examination was suspicious for an advanced vaginal cancer, but further investigations showed the presence of a retained vaginal foreign body complicated by perforation of the bladder.

Treatment of locally advanced vaginal cancer with radio-chemotherapy and MRI-guided brachytherapy: Clinical feasibility and first results

Purpose: One of the most important therapeutic goals for locally advanced vaginal cancer is local control. The local failure rates reported in the literature for FIGO stage II-IVA usually range between 20% and 60%, even in recent series. The aims of this study were to investigate the clinical feasibility and to report about the first treatment outcomes of MRI-guided brachytherapy (IGBT) in these patients following the same strategy as recently developed for cervix cancer.

3487 Rectal eus guided hdr- brachytherapy in patients with anal and perianal malignancies.

Purpose: Nowadays radiotherapy of anal or perianal malignancies is the treatment method of choice to avoid lost of continence due to rectum exstirpation. Material and methods: In 1992 a new endosonography related interventional tissue ablation was inaugurated using interstitial HDR- 192Iridium radiation for anal and perianal malignancies; based on ERS a threedimensional reconstruction of the tumor and the surrounding tissue was calculated. This reconstruction was used to perform a computed radiation simulation. The patients underwent percutaneus radiation (45Gy). Six weeks after percutaneus radiation the interstitial afterloading therapy was done. For HDR- Implantation we inserted needles transperineally under ERS guidance corresponding to the computed simulation into the tumor. The afterloading procedure was repeated one after one week (2x6 Gy, reduced to 2x4 Gy since 1993). Results: From 1992 to 1997 we had treated 36 patients in 71 afterloading procedures. Diagnosis was anal cancer (n=29), anal cancer recurrence (n=1), perianal sarcoma (n=3) and advanced vaginal cancer with infiltration of the rectum (n=3). Complete tumor regression could be achieved by ERS guided interstitial HDR afterloading therapy in all cases. Five recurrent tumors (13,9%) were detected in follow up (mean = 44 month; 3-66 month); 2 in anal carcinoma patients (local recurrence rate for anal cancer 6,7%), two in patients with advanced vaginal cancer and one in sarcoma patient. Every recurrence was treated by abdominoperinal exstirpation of the rectum, all patients are aliving to today. Complication ratio was low, we found two radiogenic anal ulcer, of which one could be healed by conservative management. After reduction of brachytherapy dose to 2x4 Gy we did not any severe side effects furthermore. Conclusion: ERS- based 3D- reconstruction and ERS- guided interstitial HDR- brachytherapy allows treatment in curative intention of anal or perianal malignancies with a high rate of curation. Due to optimized target field reduction and online ultrasound control of the afterloading needle position a low complication rate could be achieved.

Immunohistochemical study of HLA antigens and lymphocytic infiltrations in advanced vaginal cancer regressed by adjuvant therapy with intratumoral sizofiran

Marked tumor regression in advanced vaginal cancer was induced by adjuvant therapy with the biological response modifier sizofiran (SPG) in a 94-year-old woman. SPG was repeatedly injected into the tumor. To examine the relationship between tumor cell expression of human leukocyte antigens (HLA) and lymphocytic infiltrates in tumor tissues, we performed immunohistochemical examinations using monoclonal antibodies to HLA-ABC, HLADR, Leu2a, Leu3a, and Leu4. HLA-DR expression, which was not seen before the administration of SPG, was positive with the repeated SPG injections. The subsets of Leu4(CD3) -positive cells and. cells increased markedly as the infiltration advanced. These findings suggest that repeated intratumoral injection of SPG may enhance cell-mediated immune response via an increase in the expression of HLA-DR antigens.

Effect of recombinant human interleukin-3 (rhIL-3) on persisting chemotherapy-induced thrombocytopenia

A 57 year old woman with heavily pretreated advanced vaginal cancer (FIGO III) developed severe thrombocytopenia (7000/microliter) with bleedings after chemotherapy. This patient was treated with recombinant human interleukin-3 (rhIL-3) after 26 platelet transfusions (25 pooled transfusions and one HLA-matched platelet transfusion) had not been effective. Increase of thrombocyte counts began 2 days after rhIL-3 therapy. Side-effects due to rhIL-3 administration (flu-like symptoms) were mild and could be treated effectively with paracetamol and clemastin. These data support first evidence for efficacy of rhIL-3 in chemotherapy-induced thrombocytopenia and may open new perspectives for its clinical application.

Advanced vaginal cancer responding to preoperative intra-arterial chemotherapy

Advanced vaginal cancer responding to preoperative intra-arterial chemotherapy

Histologic disappearance of locally advanced vaginal cancer after combination chemotherapy

Clinically and histologically complete disappearance of local tumor and pelvic sidewall involvement was achieved in a patient with primary advanced squamous cell carcinoma of the vagina administered combination chemotherapy prior to operation. Radical hysterectomy, total vaginectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and paraaortic lymph node biopsy were performed after seven courses of combination chemotherapy with vinblastine, bleomycin, and cis-platinum. This encouraging result warrants further investigation of combination chemotherapy in other patients.