Gynecologic oncology 2019-03
Outcomes after definitive re-irradiation with 3D brachytherapy with or without external beam radiation therapy for vaginal recurrence of endometrial cancer.
Abstract
Background
Limited outcome data exists on salvage re-irradiation for vaginal relapse of previously-irradiated endometrial cancer. We report our 10-year experience with management of vaginal recurrence using definitive intent re-irradiation brachytherapy with or without EBRT.
Methods
A retrospective review was performed on 22 patients treated with definitive-intent re-irradiation brachytherapy ± EBRT for vaginal recurrence of endometrial cancer. The cumulative rectosigmoid and bladder D2cc (EQD2) were limited to <75 Gy and <90 Gy, respectively. Kaplan-Meier and Cox proportional hazards modeling were used to estimate survival. Severe (grade 3 or higher) radiation-related toxicities, defined according to CTCAE v4, were recorded.
Results
Prior radiation therapy consisted of vaginal brachytherapy (54.5%), pelvic EBRT (22.7%), or combination pelvic EBRT and brachytherapy (22.7%). Median re-irradiation interval was 26.6 months. Salvage re-irradiation consisted of EBRT with brachytherapy in 50.0% and brachytherapy alone in 50.0%. Median HR-CTV D90 (EQD2) was 64.5 Gy (IQR: 49.6-75.8). Median cumulative D2cc for bladder, rectum, and sigmoid were 72.1 Gy (range: 30.3-81.8), 70.6 Gy (range: 32.0-80.5), and 52.7 Gy (range: 29.6-75.3), respectively. At a median follow-up of 27.6 months, 3-year local control, regional control, disease-free survival, and overall survival rates were 65.8%, 76.6%, 40.8%, and 68.1%, respectively. There were no grade ≥ 3 acute or late rectosigmoid or bladder toxicities.
Conclusion
Re-irradiation with 3D conformal brachytherapy for vaginal recurrence is feasible and safe as long as cumulative dose to surrounding normal organs is limited, and offers a chance to potentially salvage 40% of patients presenting with vaginal recurrence in the setting of prior pelvic radiation.
Related Questions
How would you manage a recurrent cervical cancer previously treated with vaginal cuff brachytherapy and has had a complete response to chemo-immunotherapy?
Ling et al., PMID 30600093 -The paper gives our philosophy in this scenario. The total dose is the function of dose to target and cumulative dose to rectum and bladder. To be able to give a higher dose with brachy, generally would favor around 30.6 Gy with EBRT and then limit the last 14.4 Gy to the...
How do you manage a distal vaginal recurrence of endometrial adenocarcinoma in a patient who had adjuvant external beam and cylinder brachytherapy boost to the top 4 cm of the vaginal cuff?
I would treat with EBRT to primary plus both inguinal regions followed by image based brachytherapy. Would add concurrent chemo if bulky disease. Dose of EBRT adjusted based on overlapLing et al., PMID 30600093
How would you approach second isolated vaginal cuff recurrence in a young patient with FIGO IA Grade 2 endometrioid endometrial adenocarcinoma who received EBRT+ interstitial brachy for her initial recurrence?
The dose delivered initially was on the lower side which may be a reason for recurrence. Normally we aim for 75 Gy EQ2 dose. This is our series for reradiation if exenteration is not an option Ling et al., PMID 30600093.