The document discusses a study evaluating the oncologic results and toxicity of MUPIT (Martinez Universal Perineal Template) implants for primary vaginal carcinoma. Ten patients with primary vaginal carcinoma underwent external beam radiotherapy followed by MUPIT brachytherapy. All patients completed treatment without complications and achieved a clinical complete response with no local or regional recurrences observed after a median follow-up of 55 months. However, there were some grade 2-4 toxicities observed, suggesting careful planning is needed to minimize toxicity when using the MUPIT procedure.

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. Background Primary vaginal carcinoma is a rare tumor entity 2 % of all gynaecological tumors 0.15 % of all cancers No prospective randomized trials available

3. Background Treatment traditionally consists of external beam radiotherapy, followed by brachytherapy Recently, concurrent cisplatin and deep hyperthermia are used in locally advanced disease

4. Patients & methods: Treatment scheme External beam radiotherapy to the pelvis: 23 x 2 Gy, 5x /wk FIGO III/IV: External beam boost to all macroscopic tumor with a margin, dose 2 x 2 Gy Groins were included if the tumor invades the lower half of the vagina Brachytherapy dose: 20-24 Gy in 50 cGy hourly pulses (TD 70 Gy) Recently: addition of 40 mg/m2 cisplatin weekly ( 5 gifts) or weekly deep hyperthermia in FIGO-II /III/IV tumors Treatment was to be completed within 7 weeks (including brachytherapy)

5. Patients & methods: Brachytherapy Tumors < 0.5 cm thick: cylinder Tumor 0.5-1 cm thick: asymmetrical cylinder (Miami type) with asymmetric loading Tumor > 1 cm thick: MUPIT implantation Dose: 20-24 Gy in 50 cGy hourly pulses (TD 70-73 Gy)

6. Study question In 1999 a PDR machine was installed MUPITs are a rare and invasive procedure We wished to evaluate the oncologic results and toxicity of MUPIT implants

7. MUPIT: Martinez Universal Perineal Template

8. Methods : MUPIT procedure Preplanning based on pre-radiotherapy tumor assessment Epidural anaesthesia, usually with sedation Urinary catheter Placement of cylinder and needles (prepuncture with a sharp needle followed by placement of a rounded needle) Sometimes laparoscopic guidance in proximal tumors After recovery, planning CT and final planning

9. Methods: Planning Contouring of tumor, rectum and bladder Planning according to the Paris system 50-60 cGy hourly pulses Total dose 10 Gy to the whole vagina 10-14 Gy to the GTV 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

10. Example: 68-year old lady, FIGO II proximal SCC External beam radiotherapy to the pelvis 25 x 2 Gy Weekly cisplatin 40 mg/m 2 MUPIT procedure with 12 needles 20 50 cGy pulses to the whole vagina and GTV 23 60 cGy pulses to the GTV and 1 cm margin

11. Example: MUPIT, whole vagina 20*50 cGy

12. Example : DVH rectum: 7 Gy in 2 cm 2

13. Example: DVH target (GTV)

14. Example: MUPIT, boost 23*60 cGy

15. Example: DVH rectum boost

16. Example: DVH GTV boost

17. Example: Planning results Prescribed BT dose =2360 cGy GTV volume = 18.5 cc D100 (GTV) =1981 cGy D90 (GTV) = 2566 cGy V100 (GTV) =17.8 and 17.7 cc V90 (GTV)=18.4 and 18.2 cc Rectal dose (2 cc)= 65 Gy Bladder dose (2 cc) = 68.5 Gy

18. Results: Patient characteristics 10 patients with primary vaginal carcinoma 8 patients SCC, 2 clearcell carcinomas Stage I: 1, Stage II: 5, Stage III: 4 2 patients received concurrent cisplatin 1 patient received neo-adjuvant taxol/cisplatin 1 patient was also treated by hyperthermia (5x) Mean age 67,5 yrs (57-87 yrs)

19. Results : treatment All patients completed treatment No peri- or postoperative complications Median treatment time 37 days (34-45 days) Total doses ranged from 70-73,5 Gy Median follow-up 55 months ( 12-101)

20. Results: Outcome All patients reached a clinical complete response No local or regional recurrences observed 1 patient developed liver metastases and died 4 yrs thereafter 1 patient died from intercurrent disease 4 yrs after treatment All other patients are diseasefree There was 1 gr 3 (ulcer) ,1 gr 4 and 1 gr 2 (proctitis) complication

21. Conclusions The MUPIT procedure appears to be successfull approach for treating vaginal tumors Careful preparation and planning are necessary to obtain good clinical results Care should be taken to avoid longer dwelltimes in the mucosa/skin in distal tumors