Vaginal Recurrence Research Articles

Clinical results of image-guided interstitial brachytherapy with or without external beam radiotherapy for postsurgical vaginal recurrence of cervical and endometrial cancers

PurposeThis study aimed to evaluate the clinical outcome and efficacy of image-guided interstitial brachytherapy (ISBT) for postsurgical vaginal recurrence of cervical and endometrial cancers.Materials and methodsThe study included 11 patients who received CT-based image-guided high-dose-rate ISBT with or without external beam radiotherapy (EBRT). Local control, progression-free survival, and treatment-related toxicities were evaluated retrospectively.ResultsOf the 11 patients, 4 underwent ISBT with EBRT and the other 7 ISBT alone; two of the latter patients received previous pelvic radiotherapy. After a median follow-up of 43.9 months (range 3.9–92.7 months), the 2-year local control rate was 100%. The median equivalent doses in 2 Gy fractions received by at least 90% of the clinical target volume for ISBT with versus without EBRT were 82.2 Gy (range 60.4–84.2 Gy) versus 69.0 Gy (range 50.8–98.2 Gy). The 2-year progression-free survival rates after ISBT with versus without EBRT were 75% versus 80%, and the difference was not significant (p = 0.74). Grade 3 late toxicities occurred in two patients.ConclusionOur radiotherapy strategy using image-guided ISBT, either with or without EBRT, for postsurgical vaginal recurrence showed effective treatment outcomes.

Biological Planning of Radiation Dose Based on In Vivo Dosimetry for Postoperative Vaginal-Cuff HDR Interventional Radiotherapy (Brachytherapy)

(1) Background: Postoperative vaginal-cuff HDR interventional radiotherapy (brachytherapy) is a standard treatment in early-stage endometrial cancer. This study reports the effect of in vivo dosimetry-based biological planning for two different fractionation schedules on the treatment-related toxicities. (2) Methods: 121 patients were treated. Group A (82) received 21 Gy in three fractions. Group B (39) received 20 Gy in four fractions. The dose was prescribed at a 5 mm depth or to the applicator surface according to the distance between the applicator and the rectum. In vivo dosimetry measured the dose of the rectum and/or urinary bladder. With a high measured dose, the dose prescription was changed from a 5 mm depth to the applicator surface. (3) Results: The median age was 66 years with 58.8 months mean follow-up. The dose prescription was changed in 20.7% of group A and in 41% of group B. Most toxicities were grade 1–2. Acute urinary toxicities were significantly higher in group A. The rates of acute and late urinary toxicities were significantly higher with a mean bladder dose/fraction of >2.5 Gy and a total bladder dose of >7.5 Gy. One patient had a vaginal recurrence. (4) Conclusions: Both schedules have excellent local control and acceptable rates of toxicities. Using in vivo dosimetry-based biological planning yielded an acceptable dose to the bladder and rectum.

Ultrastaging of ‘negative’ pelvic lymph nodes in patients with low- and intermediate-risk endometrioid endometrial cancer who developed non-vaginal recurrences

ObjectiveEvidence on micrometastases and isolated tumor cells as factors associated with non-vaginal recurrence in low- and intermediate-risk endometrial cancer is limited. The goal of our study was to investigate risk...

Computed Tomography-Based Interstitial Brachytherapy for Recurrent Cervical Carcinoma in the Vaginal Apex

AimsTo determine the factors influencing the outcomes of patients with recurrences post-hysterectomy for cervical cancers treated with external beam radiotherapy (EBRT) and interstitial brachytherapy. Materials and methodsThis prospective study accrued 90 patients between October 2008 and May 2014. All patients had had a prior hysterectomy and were diagnosed with recurrent vaginal apex cancers with squamous cell carcinomas. All underwent EBRT of 50 Gy (2 Gy/fraction) using tomotherapy-based image-guided intensity-modulated radiotherapy with concurrent chemotherapy of weekly cisplatin (40 mg/m2) followed by high dose rate interstitial brachytherapy boost of 20 Gy (4 Gy/fraction twice a day). Local relapse, disease-free and overall survival were determined. ResultsAt a median follow-up of 74 months (4–123 months), 10/90 (11%) patients had local failure as the first site of relapse and 12/90 (13.3%) had first distant relapse. Only one patient had synchronous local and distant relapse. The 7-year local relapse-free, disease-free and overall survival were 87.6, 68.3 and 68.3%, respectively. Grade 2 and 3 rectal toxicity were seen in 5.6 and 3.1% of patients, respectively. Among these, two (2.2%) patients underwent temporary diversion colostomy due to vaginal sigmoid and rectovaginal fistula. Grade 2 and 3 bladder toxicity were seen in 5.6 and 1.1% of patients, respectively. In summary, the lateral disease extent (P = 0.048) and the presence of nodal disease at diagnosis (P = 0.08) had a statistically significant or borderline impact on local relapse without any impact on disease-free survival. Tumour size in itself did not affect overall survival. ConclusionWith the integration of EBRT and interstitial brachytherapy, most vaginal apex recurrences can be salvaged. An excellent local control and survival is achievable using intensity-modulated radiotherapy with image guidance and concurrent chemotherapy followed by high dose rate interstitial brachytherapy.

Comparison of treatment outcomes of pelvis external radiotherapy with and without vaginal brachytherapy for cervical cancer patients with positive or close vaginal resected margins.

We evaluated whether there is a difference in the local recurrence and survival after pelvic external radiotherapy (ERT) with and without boost vaginal brachytherapy (VB) in cervical cancer patients with positive or close vaginal resected margins (RM). We retrospectively reviewed FIGO stage IA-IIB cervical cancer patients treated with postoperative ERT between 1997 and 2018. The sixty patients showing close (safety margin < 5mm) or positive vaginal RM were included. ERT was delivered with median 50.4Gy in 28 fractions to the pelvis and VB with median 30Gy in 6 fractions. The median follow-up duration was 46months. Five out of 30 patients treated with ERT alone experienced vaginal recurrence within 2years after surgery. The 5-year local control (LC) was 100% in patients receiving ERT + VB compared with 81.3% in patients receiving ERT alone (log rank p = 0.022). The 5-year pelvic control (PC) was 95.8% for patients receiving ERT + VB and 76.8% for ERT alone (p = 0.041). The 5-year overall survival and recurrence-free survival (RFS) were not significantly different between treatment groups. In multivariate analysis, perineural invasion was a significant risk factor for PC (p = 0.024). Parametrial involvement (p = 0.044) and vascular invasion (p = 0.032) were unfavorable prognostic factors for RFS. Late toxicity occurrences were not significant in both groups. VB after ERT improved LC and PC in cervical cancer patients with close or positive RM after hysterectomy. The toxicities were not increased after VB was added to ERT.

Surgery followed by concurrent radiochemotherapy as treatment for patients with locally recurrent cervical cancer.

BackgroundNo standard treatment exists for patients with recurrent cervical cancer. This study aimed to determine the role of surgery, followed by concurrent radiochemotherapy, as a treatment for recurrent pelvic cervical cancer without previous radiotherapy.MethodsThe current study identified patients diagnosed with vaginal and/or pelvic sidewall recurrent cervical cancer after primary surgery without radiotherapy in Zhejiang Cancer Hospital from May 2012 to November 2016. These enrolled patients underwent surgery, followed by concurrent radiochemotherapy and data were analyzed.ResultsThis study enrolled 27 patients, including 11 with central (vaginal) and 16 with noncentral (pelvic sidewall with or without vaginal) recurrences. The median follow-up time after recurrence was 64 months (range, 5–110 months). All patients underwent surgery to resect the tumor as completely as possible and pelvic external beam radiotherapy (EBRT) with a median equivalent dose in 2 Gy fractions (EQD2) of 45.1 Gy (range, 44.3–47.8 Gy) with concurrent weekly cisplatin chemotherapy. The median EQD2 dose for the tumor bed/residual tumor was 51 Gy (range, 44.3–73.4 Gy), including 18 patients with a boost dose by EBRT or vaginal brachytherapy (VBT). The 5-year overall survival (OS) rates were 77.1% (central) and 65.7% (noncentral) without a statistically significant difference (P=0.246). Progression-free survival (PFS) rates were 81.8% (central) and 34.4% (noncentral), respectively, with a statistically significant difference (P=0.047). Three patients with noncentral recurrence experienced grade ≥3 complications associated with surgery.ConclusionsSurgery followed by concurrent radiochemotherapy was a feasible and effective treatment with acceptable complications for locally recurrent cervical cancer, which markedly improved the survival of pelvic sidewall recurrence.

Radiotherapy for Vaginal Recurrences of Cervical Cancer in Patients After Prior Surgery: Analysis of Effect and Prognostic Factors.

ObjectiveThe role of salvage radiotherapy (RT) in the treatment for vaginal recurrence of cervical cancer in patients after prior surgery remains controversial. The aim of this study was to evaluate the efficacy and toxicity of salvage RT and explore prognostic factors associated with the survival after recurrence.MethodsPatients with cervical cancer, treated for vaginal recurrences at Peking Union Medical College Hospital between July 2011 and November 2019, were identified. All the patients underwent prior surgery for primary tumor and received salvage RT including external beam radiotherapy (EBRT), brachytherapy (BT), or both. The irradiation field and dose depended on the conditions of patients. Recurrence patterns were classified into four categories according to the site of recurrence. Prognostic factors on the overall survival (OS), progression-free survival (PFS), and local control (LC) were analyzed, and late toxicity was evaluated.ResultsA total of 141 patients were included in the analysis, with a median follow-up time of 40.8 months. The estimated 5-year OS, PFS, and LC rates were 81%, 75%, and 87%, respectively. In multivariate analysis, endovaginal recurrence and no irradiation history were favorable prognostic factors associated with OS (all p < 0.05), PFS (all p < 0.05), and LC (all p < 0.05). The area under the receiver operating characteristic (ROC) curve (AUC) of the recurrence pattern is larger than the stage of primary tumor (0.734 vs. 0.670).ConclusionsRT was an effective treatment with tolerable toxicity for vaginal recurrences of cervical cancer in patients with prior surgery. Recurrence pattern and irradiation history were important prognostic factors.

Effect of surgical approach on risk of recurrence after vaginal brachytherapy in early-stage high-intermediate risk endometrial cancer

Objectives: The objective was to determine if surgical approach affects time to recurrence in early-stage high-intermediate risk endometrial cancer (HIR-EC) treated with adjuvant vaginal brachytherapy (VBT). Methods: In this retrospective cohort study, HIR-EC patients treated with VBT between 2005-2017 were identified and those who received open or minimally invasive hysterectomies (MIS) were included. Clinical and surgical variables were analyzed and time to recurrence was compared between surgical groups. Results: We identified 494 patients, of which 363 had MIS hysterectomies, 92.5% had endometrioid histology, 45.7% were stage IA and 48.0% stage IB. Open hysterectomy patients had higher BMIs (p=0.007), lower rates of lymph node sampling (p<0.001) and lymphovascular space invasion (LVSI) (p=0.036), however in patients who recurred, no differences were noted between groups. Overall, 65 patients (13.2%) recurred, 14 in the open group (10.7%) and 51 in the MIS group (14.0%) (p=0.58), while vaginal recurrences were noted in 4.6% and 6.1% respectively. When compared to the open group, the MIS group had a significantly shorter time to any recurrence (p=0.022), to pelvic (p=0.05) and locoregional recurrence (p=0.021) and to death from any cause (p=0.039). After adjusting for age, BMI, grade, LVSI and surgery date, the MIS group had a higher risk of any recurrence (HR 2.29 (1.07-4.92), p=0.034) and locoregional recurrence (HR 4.18 (1.44-12.1), p=0.008). Conclusions: Patients with HIR-EC treated with VBT after MIS hysterectomy have a shorter time to recurrence and higher risk of recurrence when compared to open hysterectomy patients. Further studies into the safety of MIS in high-intermediate risk patients are required. The objective was to determine if surgical approach affects time to recurrence in early-stage high-intermediate risk endometrial cancer (HIR-EC) treated with adjuvant vaginal brachytherapy (VBT). In this retrospective cohort study, HIR-EC patients treated with VBT between 2005-2017 were identified and those who received open or minimally invasive hysterectomies (MIS) were included. Clinical and surgical variables were analyzed and time to recurrence was compared between surgical groups. We identified 494 patients, of which 363 had MIS hysterectomies, 92.5% had endometrioid histology, 45.7% were stage IA and 48.0% stage IB. Open hysterectomy patients had higher BMIs (p=0.007), lower rates of lymph node sampling (p<0.001) and lymphovascular space invasion (LVSI) (p=0.036), however in patients who recurred, no differences were noted between groups. Overall, 65 patients (13.2%) recurred, 14 in the open group (10.7%) and 51 in the MIS group (14.0%) (p=0.58), while vaginal recurrences were noted in 4.6% and 6.1% respectively. When compared to the open group, the MIS group had a significantly shorter time to any recurrence (p=0.022), to pelvic (p=0.05) and locoregional recurrence (p=0.021) and to death from any cause (p=0.039). After adjusting for age, BMI, grade, LVSI and surgery date, the MIS group had a higher risk of any recurrence (HR 2.29 (1.07-4.92), p=0.034) and locoregional recurrence (HR 4.18 (1.44-12.1), p=0.008). Patients with HIR-EC treated with VBT after MIS hysterectomy have a shorter time to recurrence and higher risk of recurrence when compared to open hysterectomy patients. Further studies into the safety of MIS in high-intermediate risk patients are required.

Isolated vaginal recurrences in women with stage I endometrial cancer

<h3>Objectives:</h3> To compare clinical and pathologic characteristics of women with surgical stage I endometrial cancer by location of first recurrence; to describe characteristics of isolated vaginal recurrence. <h3>Methods:</h3> All women with surgical stage I endometrial carcinoma treated at two major cancer centers from 2009-2017 were identified. Surveillance was done at standard intervals and consisted of symptom assessment and pelvic exam. Imaging was ordered as clinically indicated. Appropriate statistical analyses were used to compare isolated with extra-vaginal recurrences. Vaginal recurrence in the presence of other sites of disease were included in the extra-vaginal recurrence group. <h3>Results:</h3> 2817 women were analyzed. Median age at diagnosis was 61 years (range 26-92 yrs). At a median follow-up of 36 months (range, 0-139 mos). 280 (10%) recurred: 61 (2%) isolated vaginal, 219 (8%) extra-vaginal (which included 18 cases with a vaginal component). Of the 61 isolated vaginal recurrences, 42 (69%) were located at the cuff, 19 (31%) along the vaginal canal (Figure 1). All isolated recurrences were clinically detected on exam, except for 1 (2%) detected by imaging; endometrioid histology and Grade II were the most common findings (85% and 44%, respectively).Median time to recurrence after initial diagnosis for isolated vaginal recurrence was 11 months (range, 1-68 mos); for extra-vaginal recurrence, 20 months (range, 1-98 mos) (p<0.01). From initial diagnosis to first recurrence, 3-year PFS was 89.8% (SE±0.7) for minimally invasive surgery (MIS), 88.3% (SE±2.0) open approach (p=0.7). 3-year PFS for isolated vaginal recurrence was 97.8% (SE±0.3) MIS, 97.1% (SE±1.0) open (p=0.8). 3-year PFS for extra-vaginal recurrence was 91.9% (SE±0.6) MIS, 90.9% (SE±1.8) open (p=0.8).280 (10%) of the 2817 patients recurred. Those with extra-vaginal recurrences were more likely than those with isolated vaginal recurrences to receive IVRT (64% vs 33%, p<0.01). 153 (5%) patients received non-IVRT-based treatment, of whom 5 (3%) had isolated vaginal recurrences. 1698 (60%) received no adjuvant treatment; 36 (2%) of these had isolated vaginal recurrences.Of the 557 (20%) treated with IVRT alone postoperatively, 73 (13%) recurred with 13 (2%) having isolated vaginal recurrence. The majority recurred at the vaginal apex (77%). Compared with extra-vaginal recurrences, isolated recurrences were more likely to be endometrioid (85% vs 54%, p<0.01), to have <50% myoinvasion (62% vs 48%, p=0.04), to have no LVSI (72% vs 55%, p<0.05), and were less likely to have Grade 3 histology (16% v 62%, p<0.01). <h3>Conclusions:</h3> Isolated vaginal recurrences in stage I endometrial cancer are detected earlier than non-vaginal recurrences, likely due to frequency of clinical exams after initial staging surgery. Surgical approach does not seem to impact overall or isolated recurrence. Adjuvant IVRT alone after primary surgery carries a 2% risk of isolated cuff recurrence.

Radiation therapy for vaginal and perirectal lesions in recurrent ovarian cancer

<h3>Objectives:</h3> The role for radiation therapy (RT) to treat ovarian cancer (OC) patients with locally recurrent vaginal/perirectal lesions remains unclear, though we hypothesize that these patients may be salvaged locally and gain long-term survival benefit. We aimed to describe our institutional outcomes using vaginal brachytherapy±intensity modulated radiation therapy (IMRT) to treat this population and report our in-field control rate, RT-related toxicities, post-RT chemotherapy-free interval (CFI), RT-related toxicities, progression-free survival (PFS), and overall survival (OS). We also studied the prognostic impact of platinum status immediately prior to RT. <h3>Methods:</h3> This is a single institution retrospective case series of 17 recurrent OC patients treated with brachytherapy±IMRT for vaginal and/or perirectal recurrences between January 2006 and November 2019. Intent of RT (palliative or definitive) was determined collaboratively by the treating gynecologic and radiation oncologists. PFS and OS were defined from date of RT completion to either progression or death/last follow-up, respectively. <h3>Results:</h3> This was a heavily pre-treated cohort (median 3 prior lines of chemotherapy, range 1-9), with a median follow-up of 28.4 months (range 4.5-166.4) after RT completion (Figure 1). Most patients had high-grade serous histology (9 of 17) with the remainder of patients even distributed between low-grade serous, clear cell, mixed, and carcinosarcoma. Eleven patients were treated with definitive intent, including 4 with isolated vaginal/perirectal disease. Three patients received concurrent chemotherapy or immunotherapy and RT. Four (23.5%) patients had in-field failures at 2.3, 10.9, 23.2, and 25.7 months post-RT, all of whom had been treated with definitive intent. The 9 patients who were platinum-sensitive prior to RT had similar median PFS (8.1 vs. 10.4 months, log-rank p=0.91), but longer OS (53.9 vs 16.5 months, log-rank p=0.03) compared to their platinum-resistant counterparts. Excluding patients with low-grade histology or who were treated with palliative RT, the median CFI was 12.6 months (range 1.3-31.7). When including all patients, the two patients with the longest CFI post-RT included a <i>BRCA2</i> mutation carrier with an isolated vaginal recurrence and a patient with a <i>MLH1</i> somatic mutation treated with concurrent RT and pembrolizumab. RT was well tolerated with 2 (12%) experiencing grade 3/4 gastrointestinal/genitourinary toxicities. <h3>Conclusions:</h3> RT to treat locally recurrent vaginal and perirectal lesions in heavily pre-treated OC patients is safe and may effectively provide locoregional control.

18F-FDG PET/CT in Relapsed Endometrial Cancer Treated with Preoperative PD-1 Inhibitor Dostarlimab.

Dostarlimab is an immune checkpoint inhibitor (ICI) targeting the Programmed-Death-1 (PD-1) co-receptor, recently approved by the European Medicines Agency (EMA) and the Food and Drug Administration (FDA) as a novel therapy for recurrent or advanced endometrial cancer. We report the case of a 64-year-old woman, experiencing vaginal recurrence with microsatellite instability high/hypermutated of a FIGO stage IA grade 2 endometrial endometrioid adenocarcinoma. She received preoperative chemotherapy with four cycles of carboplatin plus paclitaxel, with stable disease on pelvic magnetic resonance imaging (MRI) and fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT). Dostarlimab (500 mg intravenously every 3 weeks) was then introduced. The subsequent evaluation after three perfusions demonstrated a complete metabolic response on 18F-FDG PET/CT according to immunotherapy-modified PET response criteria in solid tumors (imPERCIST) criteria, then confirmed by MRI according to immune response evaluation criteria in solid tumors (iRECIST). This clinical description suggests that 18F-FDG PET/CT might take place among available tools for guiding the preoperative management for recurrent endometrial cancer patients receiving dostarlimab immunotherapy that should be further explored through clinical trials.

Abdominal and vaginal pelvic support with concomitant hysterectomy for uterovaginal pelvic prolapse: a comparative systematic review and meta-analysis

While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse. A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2. Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P= 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P= 0.58 and P= 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P= 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P= 0.01]. ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.

Race-related disparities in patterns of uterine cancer recurrence.

5571 Background: Racial disparities in uterine cancer outcomes are present, as Black patients with uterine cancer have markedly higher mortality when compared with White patients. Potential etiologies of this discrepancy have been investigated, including implicit bias, histopathologic factors and stage at presentation, molecular and genetic factors, and socioeconomic factors. The purpose of this study is to explore if non-White patients with uterine cancer are more likely to experience distant cancer recurrence compared to White patients. Methods: A single-institution retrospective cohort study was performed examining all patients diagnosed with uterine cancer from 2006-2016. Data regarding patient demographics, medical co-morbidities, histology, stage, treatment course, and disease recurrence were abstracted from the medical record. Race was categorized based on how a patient was registered in the medical record. The primary outcome was location of recurrence, with local recurrence defined as vaginal/cuff recurrence and distant recurrence representing nodal, intraperitoneal, or distant recurrence. A multivariable regression model was built in a backwards stepwise fashion to examine the association of individual covariates with distant recurrence as opposed to vaginal recurrence. Results: A total of 1205 patients with uterine cancer were included for analysis. Three hundred eighteen (26.5%) patients were White, 472 (39.2%) Black, 319 (26.5%) Hispanic, 91 (7.6%) Asian, and 4 (0.3%) other. A total of 223 (18.5%) patients experienced disease recurrence. Black women experienced a statistically significant increased risk of recurrence compared with non-Black women [OR 1.99 (95% CI 1.37-2.88), p &lt; 0.01]. Additionally, Black patients were significantly more likely to experience nodal, intra-peritoneal and distant recurrences relative to White patients (p &lt; 0.01). When adjusting for covariates including race, histology, grade, stage and adjuvant treatment, non-White race [OR 3.87 (95% CI (1.42-10.54), p &lt; 0.01] was associated with significant increase in risk of distal recurrence. Conclusions: The findings of this study suggest that non-White race is potentially contributory to distant recurrence of uterine cancer, even when accounting for histopathologic differences, stage at presentation, and other traditional covariates. These findings suggest that the disparate outcomes experienced by non-White patients are likely multi-factorial in nature and highlight the need for efforts focused on optimizing treatment and improving outcomes of non-White women with uterine cancer.[Table: see text]

Adjuvant Radiation Field Extent and Sites of Failure in Node Positive Endometrioid Endometrial Cancer

PurposeIn patients with node-positive endometrial cancer, adjuvant radiation therapy with chemotherapy decreases local-regional recurrence compared with chemotherapy alone. However, the optimal radiation field borders and extent of nodal coverage have not been well studied. In a multi-institutional cohort, survival outcomes and sites of failure were analyzed for patients with International Federation of Gynaecology and Obstetrics (FIGO) stage IIIC endometrioid endometrial cancer treated with pelvic radiation therapy (PRT) versus extended-field radiation therapy (EFRT), which encompassed high para-aortic lymph nodes. Methods and MaterialsIn a multi-institutional retrospective study, 143 patients with FIGO stage IIIC1 or IIIC2 endometrioid endometrial cancer treated with adjuvant radiation therapy from 2000 to 2016 were identified. Patient subgroups were classified by substage and radiation field extent: stage IIIC1 received EFRT, stage IIIC1 received PRT, and stage IIIC2 received EFRT. Recurrence-free survival (RFS), overall survival (OS), and out-of-field recurrence were calculated by the Kaplan-Meier method. Multivariate analysis was performed using the Cox proportional hazards model. Sites of failure were categorized as within or outside the radiation field. ResultsThe median follow-up was 59 months; 87% of patients received chemotherapy. The 5-year RFS and OS rates were 73% and 87%, respectively. By subgroup, 5-year RFS rates were 79% for stage IIIC1 EFRT, 73% for stage IIIC1 PRT, and 69% for stage IIIC2 EFRT (P = .4). On multivariate analysis, the recurrence risk was highest for stage IIIC2 EFRT, although this result was not statistically significant (adjusted hazard ratio, 2.0; P = .4). In-field vaginal and nodal recurrences were observed in 2 patients (1%) and 4 patients (3%), respectively. Of 78 patients with stage IIIC1 cancer treated with PRT, 5 (6%) had isolated para-aortic nodal relapse outside the radiation field; 3 were long-term survivors (more than 6 years after salvage therapy). For patients with para-aortic recurrence, 86% had lymphovascular invasion, 71% had myometrial invasion of ≥50%, and 57% had grade 3 disease. ConclusionsAdjuvant chemoradiation therapy resulted in excellent survival outcomes for patients with FIGO stage IIIC endometrioid endometrial cancer. For patients with positive pelvic nodes, isolated para-aortic relapse outside the PRT field was uncommon and amenable to salvage therapy.

SP-0098 GEC-ESTRO/ABS/CBG recommendations on target definition in vaginal recurrence

SP-0098 GEC-ESTRO/ABS/CBG recommendations on target definition in vaginal recurrence

Abdominal radical trachelectomy as fertility-sparing management for early stages of cervical cancer: Our experience in 18 cases.

The aim of this study was to present our experience of 18 cases of abdominal radical trachelectomy (ART), including 5 performed during pregnancy, analyzing patient selection, surgical complications, and oncological and obstetrical outcomes. This reproductive study included all early stage cervical cancer patients referred for ART at the 1st Obstetrics and Gynecology Clinic of the Emergency Clinical County Hospital Targu Mures, between 2010 and 2020. A total of 19 women were considered for ART, and only 1 case required conversion to radical hysterectomy. The patient mean age was 31 years (range 24-38 years), and 66.67% of the patients were nulliparous. Six women (33.33%) had stage IA2, 4 (22.22%) had stage IB1, 5 (27.78%) had stage IB2, and 4 (22.22%) had stage IB3 disease. One intraoperative complication occurred in this series, which consisted in both right ureteral and bladder injuries. Early postoperative complications were represented by urinary bladder dysfunction (33.33%), symptomatic pelvic lymphocele (11.1%), peritonitis (5.5%), and wound infection (5.5%). Late postoperative complications included cervical stenosis (5.5%), amenorrhea (11.1%), and pelvic abscess (5.5%). Four out of the 18 patients were operated on during pregnancy between 14 and 20 weeks; 2 of them gave birth at term, 2 of them aborted shortly after the surgery. Two vaginal recurrences were recorded; both were managed by hysterectomy, partial colpectomy and adjuvant chemoradiotherapy. At this moment, all patients are alive with no evidence of disease and 3 of them managed to conceive. In conclusion, ART should be recommended as a fertility-preserving procedure for women in their reproductive age. In selected cases, ART can be performed during pregnancy with encouraging results.

Definitive radiotherapy for vaginal recurrence of early-stage endometrial cancer: survival outcomes and effect of mismatch repair status

ObjectiveTo evaluate clinical outcomes, prognostic factors, and toxicity in patients with vaginal recurrence of early-stage endometrial cancer treated with definitive radiotherapy.MethodsRetrospective review identified 62 patients with stage I–II endometrial cancer...

Problematic issues of diagnosis and treatment of vulvovaginitis of mixed bacterial-candidiasis etiology

The aim of the study is to evaluate the effectiveness of modern antiseptic agent Gynodek in the treatment of mixed bacterial-candidiasis vulvovaginitis.Materials and methods. There were 67 patients with bacterial-candidiasis vulvovaginitis under observation. The diagnosis of candidiasis infection was verified according to the data of clinical and laboratory research methods. Patients received vaginal gel Gynodek 5 ml once a day for 7 days. The effectiveness of treatment was assessed according to the data of the clinical examination before treatment and on the 7th day of observation, and according to the laboratory (bacterioscopic, bacteriological) data before and after treatment. Complete clinical and bacterial debridement was criteria of the treatment effectiveness.Results and discussion. The clinical picture of bacterial-fungal vulvovaginitis was characterized by a decrease in the number and severity of symptoms such as hyperemia and edema of the mucous membrane, discharge from the genital tract was not typical.There were no complaints in 95.5% of the examined women after end of therapy, there were no objective symptoms in all women on the 7th day of treatment. Bacteriological examination after 2 weeks confirmed the therapy effectiveness in 86.6% of women. Peptostreptococcus spp. after treatment sowed at significant concentrations 106–107 CFU/ml only in 1.5% of patients, Streptococcus spp. in 8.9% of women, Candida albicans in 13.4%. Lactobacilli in the amount of 107 CFU/ml were in 86.6% of patients, which indicates a rapid restoration of normal vaginal microflora.Conclusions. Bacterial-fungal associations of microorganisms in the vaginal biotope lead to a complex clinical symptoms, which makes it difficult to make a timely diagnosis. Gynodek vaginal gel is highly effective against gram-positive, gram-negative and fungal microflora, which makes it the drug of choice in the treatment of bacterial-candidiasis vulvovaginitis. Gynodek creates a comfortable pH, promotes the rapid restoration of own lactoflora, and increases the functional activity of the vaginal mucosa epithelium, which ensures the prevention of vaginal infection recurrence.

Sequencing chemotherapy before radiotherapy for women with stage IIIC endometrial cancer

ObjectiveIt is unclear how to best sequence adjuvant chemotherapy and radiotherapy for advanced endometrial cancer. We studied the outcomes for women treated with chemotherapy before radiotherapy in a chemotherapy-first (chemotherapy...

The impact of modern preoperative high-dose-rate brachytherapy in early-stage cervical cancer

PurposeTo analyze the clinical outcomes and the safety of preoperative high-dose-rate (HDR) image-guided adaptive brachytherapy (IGABT) followed by minimally invasive surgery (MIS) in the multidisciplinary management of early-stage cervical cancer. Methods and materialsMedical records of all consecutive patients with early-stage cervical cancer treated at our institution between 2012 and 2018 with preoperative IGABT in a multidisciplinary approach were reviewed. Treatment schedule was pelvic node dissection, preoperative IGABT followed 6–8 week later by MIS hysterectomy. ResultsSeventy patients with cervical cancer FIGO stages (IB1 18.6%, IB2 75.7% and IIA1 5.7%) were treated by preoperative HDR brachytherapy. With a median follow-up of 37.4 months [95% confidence interval, 32.1-39.7 months] isolated vaginal vault recurrence was not observed, 3 pelvic relapses were reported (4.3%). None of patients received postoperative radiotherapy (EBRT) or radiochemotherapy. The estimated 3-year local and pelvis relapse free survival for the entire population were respectively 98% [95% confidence interval, 89%–100%] and 90% [80%–96%]. The estimated 3-year disease-free survival (DFS) for the entire population was 88% [77–94%]. The 3-year overall survival (OS) rate was 97% [88%–99%]. Microscopic vaginal resection margin (R1) was observed in one patient ([1].4%). Lymph-vascular space invasion (LVSI) was found found in 6 (8.6%) patients. Forty-eight late complications in 36 patients (51.4%) were observed. Five (7.1%) grade 3 vaginal wound dehiscence toxicities were observed. Urinary and gastrointestinal toxicities were grade 1–2. No grade 4–5 complications were observed. ConclusionsPreoperative image-guided adaptive brachytherapy followed by minimally invasive surgery allows high local control, reduces positive surgical margins and rates of lymph-vascular space invasion avoiding adjuvants treatments. Surgical approaches must be discussed with patients including preoperative brachytherapy as a down-staging treatment.