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About the effectiveness of brachytherapy for vaginal cancer

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  1. 1. Cornelia G. Verhoef and Elzbieta van der Steen -Banasik Tumor control and toxicity after radiotherapy and MUPIT implants for primary vaginal carcinoma Lia Verhoef and Elzbieta van der Steen-Banasik
  2. 2. Background <ul><li>Primary vaginal carcinoma is a rare tumor entity </li></ul><ul><li>2 % of all gynaecological tumors </li></ul><ul><li>0.15 % of all cancers </li></ul><ul><li>No prospective randomized trials available </li></ul>
  3. 3. Background <ul><li>Treatment traditionally consists of external beam radiotherapy, followed by brachytherapy </li></ul><ul><li>Recently, concurrent cisplatin and deep hyperthermia are used in locally advanced disease </li></ul>
  4. 4. Patients & methods: Treatment scheme <ul><li>External beam radiotherapy to the pelvis: 23 x 2 Gy, 5x /wk </li></ul><ul><li>FIGO III/IV: External beam boost to all macroscopic tumor with a margin, dose 2 x 2 Gy </li></ul><ul><li>Groins were included if the tumor invades the lower half of the vagina </li></ul><ul><li>Brachytherapy dose: 20-24 Gy in 50 cGy hourly pulses (TD 70 Gy) </li></ul><ul><li>Recently: addition of 40 mg/m2 cisplatin weekly ( 5 gifts) or weekly deep hyperthermia in FIGO-II /III/IV tumors </li></ul><ul><li>Treatment was to be completed within 7 weeks (including brachytherapy) </li></ul>
  5. 5. Patients & methods: Brachytherapy <ul><li>Tumors < 0.5 cm thick: cylinder </li></ul><ul><li>Tumor 0.5-1 cm thick: asymmetrical cylinder (Miami type) with asymmetric loading </li></ul><ul><li>Tumor > 1 cm thick: MUPIT implantation </li></ul><ul><li>Dose: 20-24 Gy in 50 cGy hourly pulses (TD 70-73 Gy) </li></ul>
  6. 6. Study question <ul><li>In 1999 a PDR machine was installed </li></ul><ul><li>MUPITs are a rare and invasive procedure </li></ul><ul><li>We wished to evaluate the oncologic results and toxicity of MUPIT implants </li></ul>
  7. 7. MUPIT: Martinez Universal Perineal Template
  8. 8. Methods : MUPIT procedure <ul><li>Preplanning based on pre-radiotherapy tumor assessment </li></ul><ul><li>Epidural anaesthesia, usually with sedation </li></ul><ul><li>Urinary catheter </li></ul><ul><li>Placement of cylinder and needles (prepuncture with a sharp needle followed by placement of a rounded needle) </li></ul><ul><li>Sometimes laparoscopic guidance in proximal tumors </li></ul><ul><li>After recovery, planning CT and final planning </li></ul>
  9. 9. Methods: Planning <ul><li>Contouring of tumor, rectum and bladder </li></ul><ul><li>Planning according to the Paris system </li></ul><ul><li>50-60 cGy hourly pulses </li></ul><ul><li>Total dose 10 Gy to the whole vagina </li></ul><ul><li>10-14 Gy to the GTV </li></ul><ul><li>Dose limits for rectum and bladder as in cervical carcinoma: Max 75 Gy in 2 cm 3 in the rectum, max 90 Gy in 2 cm 3 in the bladder </li></ul>
  10. 10. Example: 68-year old lady, FIGO II proximal SCC <ul><li>External beam radiotherapy to the pelvis 25 x 2 Gy </li></ul><ul><li>Weekly cisplatin 40 mg/m 2 </li></ul><ul><li>MUPIT procedure with 12 needles </li></ul><ul><li>20 50 cGy pulses to the whole vagina and GTV </li></ul><ul><li>23 60 cGy pulses to the GTV and 1 cm margin </li></ul>
  11. 11. Example: MUPIT, whole vagina 20*50 cGy
  12. 12. Example : DVH rectum: 7 Gy in 2 cm 2
  13. 13. Example: DVH target (GTV)
  14. 14. Example: MUPIT, boost 23*60 cGy
  15. 15. Example: DVH rectum boost
  16. 16. Example: DVH GTV boost
  17. 17. Example: Planning results Prescribed BT dose =2360 cGy GTV volume = 18.5 cc <ul><li>D100 (GTV) =1981 cGy </li></ul><ul><li>D90 (GTV) = 2566 cGy </li></ul><ul><li>V100 (GTV) =17.8 and 17.7 cc </li></ul><ul><li>V90 (GTV)=18.4 and 18.2 cc </li></ul><ul><li>Rectal dose (2 cc)= 65 Gy </li></ul><ul><li>Bladder dose (2 cc) = 68.5 Gy </li></ul>
  18. 18. Results: Patient characteristics <ul><li>10 patients with primary vaginal carcinoma </li></ul><ul><li>8 patients SCC, 2 clearcell carcinomas </li></ul><ul><li>Stage I: 1, Stage II: 5, Stage III: 4 </li></ul><ul><li>2 patients received concurrent cisplatin </li></ul><ul><li>1 patient received neo-adjuvant taxol/cisplatin </li></ul><ul><li>1 patient was also treated by hyperthermia (5x) </li></ul><ul><li>Mean age 67,5 yrs (57-87 yrs) </li></ul>
  19. 19. Results : treatment <ul><li>All patients completed treatment </li></ul><ul><li>No peri- or postoperative complications </li></ul><ul><li>Median treatment time 37 days (34-45 days) </li></ul><ul><li>Total doses ranged from 70-73,5 Gy </li></ul><ul><li>Median follow-up 55 months ( 12-101) </li></ul>
  20. 20. Results: Outcome <ul><li>All patients reached a clinical complete response </li></ul><ul><li>No local or regional recurrences observed </li></ul><ul><li>1 patient developed liver metastases and died 4 yrs thereafter </li></ul><ul><li>1 patient died from intercurrent disease 4 yrs after treatment </li></ul><ul><li>All other patients are diseasefree </li></ul><ul><li>There was 1 gr 3 (ulcer) ,1 gr 4 and 1 gr 2 (proctitis) complication </li></ul>
  21. 21. Conclusions <ul><li>The MUPIT procedure appears to be successfull approach for treating vaginal tumors </li></ul><ul><li>Careful preparation and planning are necessary to obtain good clinical results </li></ul><ul><li>Care should be taken to avoid longer dwelltimes in the mucosa/skin in distal tumors </li></ul>