Tough Gyn Case

[ramsesthenice]

I have a case that has become tough for good reasons. A lady in her late 50s who was treated for a SCC of her cervix with primary chemorads (including LDR implant) in 1996. She showed up around Christmas time with a 3 cm clear cell tumor in her right vaginal fornix extending just to the ectocervix (or where it should be...its pretty well obliterated). She also had a few good sized (3+ cm) inguinal nodes which were positive. I had them give her 6 rounds of carbo/tax + avastin (they held the avastin for the last 2 cycles since we were going to radiate). Did it all upfront to buy me as much time as possible. She had an outstanding response to chemo. Her nodes went from 3 cm to 1.5 cm and her primary was down to maybe a cm. Was planning on treating the pelvis, vagina, uterus/parametria, and inguinals with EBRT (36 to the uninvolved pelvis in light of prior RT, 54 to the inguinals, 45 to the vagina/cervix) and T&O vs hybrid implants. I'll finish EBRT this week and on MRI this week there is no residual disease in the groins or vagina. On exam the vagina really does look clear.

So here is my dilemma: She has had a great response but she has no salvage options short of an exenteration. So on the one hand I don't want to underdo it. On the other hand, she has already had a lot of RT (but no baseline functional issues or bladder/rectal involvement) so I don't really want to overdo it either. What would you do now? And I am only asking dose. Under no circumstance will I consider a point A style plan. It will be more limited to the right fornix/low cervix regardless of dose. Also thinking T&O/hybrid instead of cylinder to cover the low cervix without nuking the surface dose.

1) Omit brachy
2) 5 Gy x 3
3) 6 Gy x 3
4) 6 Gy x 5

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[seper]

I would implant.
Do you actually see the cervical os? I doubt you can sound uterus here.
So it leaves a vaginal based type of hybrid apparatus.
Prescribed dose would entirely depend on how far away from sources you would draw the target.

 

[ramsesthenice]

Do you actually see the cervical os? I doubt you can sound uterus here.

Good question. I clearly see where the OS was but it is inverted and retracted. Whether what I see is obliterated cervical tissue or retracted vaginal mucosa I am honestly not sure but I suspect that you are right and nothing much is going to fit into what is left of the cervical channel either way. This is precisely why I mentioned hybrid above. Otherwise it could be neatly covered with a conventional T&O applicator.

 

[thecarbonionangle]

6x5. Patients only salvage option is horrific and data on pelvic exents on women and suicide rates is out there. No more conformal treatment than brachy.

 

[Palex80]

So, let me get this right... This patient has had something like 50 Gy (?) to the pelvis 25 years ago delivered to large parts of her small bowel, bladder and rectum (I assume some 2D-technique was utilized, perhaps a 4 field box?) and has now received another 54 Gy to parts of these OARs?
I would have grave concerns mainly because of small bowel, Avastin is an additional risk factor here.
I wouldn't worry too much about the rectum or the bladder, but small bowel toxicity would scare me.
I woudn't ommit brachytherapy, but I would probably try to fractionate as much as possible.

 

[ramsesthenice]

So, let me get this right... This patient has had something like 50 Gy (?) to the pelvis 25 years ago delivered to large parts of her small bowel, bladder and rectum (I assume some 2D-technique was utilized, perhaps a 4 field box?) and has now received another 54 Gy to parts of these OARs?
I would have grave concerns mainly because of small bowel, Avastin is an additional risk factor here.
I wouldn't worry too much about the rectum or the bladder, but small bowel toxicity would scare me.
I woudn't ommit brachytherapy, but I would probably try to fractionate as much as possible.

Fortunately, no you don't have it straight. The only thing that got 54 is the involved inguinal nodes which are well outside of her prior treated field. I limited the uninvolved pelvic nodes and the uterus/parametrial tissues to 36 Gy to try to limit dose to previously radiated small bowel. There is no small bowel anywhere near the proximal vagina or cervix. I am honestly not too worried about the small bowel.

The avastin does factor in a bit though because her risk of fistulization is probably pretty high (higher than someone who has already had a definitive course once before). Thank god it is not right on rectum or bladder. I should be able to keep them quite low (on paper at least).

I had no intention of skipping brachy altogether since we really don't have salvage options. But I was thinking of splitting the difference and doing 3 implants of 5-6 Gy as opposed to the more standard 6 x 5. Just wanted to see what other people thought.

 

[Palex80]

Fortunately, no you don't have it straight. The only thing that got 54 is the involved inguinal nodes which are well outside of her prior treated field. I limited the uninvolved pelvic nodes and the uterus/parametrial tissues to 36 Gy to try to limit dose to previously radiated small bowel. There is no small bowel anywhere near the proximal vagina or cervix. I am honestly not too worried about the small bowel.

The avastin does factor in a bit though because her risk of fistulization is probably pretty high (higher than someone who has already had a definitive course once before). Thank god it is not right on rectum or bladder. I should be able to keep them quite low (on paper at least).

I had no intention of skipping brachy altogether since we really don't have salvage options. But I was thinking of splitting the difference and doing 3 implants of 5-6 Gy as opposed to the more standard 6 x 5. Just wanted to see what other people thought.

Ok, thank you! Sorry, I misread it.

I'd still fractionate more.
It will help to keep the surface dose low. Do you really need to "nuke the surface", like you very eloequently said, if it looks clear?
For instance 5 x 4 instead of 3 x 6 Gy?

 

[ramsesthenice]

Ok, thank you! Sorry, I misread it.

I'd still fractionate more.
It will help to keep the surface dose low. Do you really need to "nuke the surface", like you very eloequently said, if it looks clear?
For instance 5 x 4 instead of 3 x 6 Gy?

Im planning on using a couple needles. Surface dose should be pretty good. But your point is taken.

 

[Palex80]

Im planning on using a couple needles. Surface dose should be pretty good. But your point is taken.

Oh, if you are going to impant needles, then I fully understand that a lower number of insertions make totally sense.

I only have limited experience with needles, but one of my mentor attendings enjoyed giving BID fractionation to avoid high single doses in vulvar/vagina cases, similar to yours.
She inserted the needles in the morning, did all the planning and delivered the first fraction before noon. Then she sent the patient back to the ward (with the needles in place) and had them bring her down to the vault for a second fraction late in the afternoon / early evening.

It's a bit like pulsed dose rate brachytherapy (for the poor / unfortunate ones who do not have access to one).

 

[thecarbonionangle]

Would do 7gyx3 if you want to do three fractions

i agree that a syed or hybrid approach with 4-5 fractions and a BID day is also a great option.

 

[ramsesthenice]

Oh, if you are going to impant needles, then I fully understand that a lower number of insertions make totally sense.

I only have limited experience with needles, but one of my mentor attendings enjoyed giving BID fractionation to avoid high single doses in vulvar/vagina cases, similar to yours.
She inserted the needles in the morning, did all the planning and delivered the first fraction before noon. Then she sent the patient back to the ward (with the needles in place) and had them bring her down to the vault for a second fraction late in the afternoon / early evening.

It's a bit like pulsed dose rate brachytherapy (for the poor / unfortunate ones who do not have access to one).

Please don't get me started on BID. We should be doing but every time I bring it up admin has a million BS logistical reasons we can't do it (all of which ultimately boil down to them not wanting to float a nurse or hire another 0.5 nursing FTE). For perineal or complicated insertions I put everything in for an afternoon treatment, leave everything in, admit O/N to gyn (like we use to do for LDR cases) and then deliver a second fraction the following morning. Its the only realistic way for me to get 2 fractions in per insertion. And also a great example of everything that is wrong with big health care systems. The cost of doing it this way is far higher than doing a BID treatment. But hey, on the books it looks better.

 

[FrostyHammer]

Please don't get me started on BID. We should be doing but every time I bring it up admin has a million BS logistical reasons we can't do it (all of which ultimately boil down to them not wanting to float a nurse or hire another 0.5 nursing FTE). For perineal or complicated insertions I put everything in for an afternoon treatment, leave everything in, admit O/N to gyn (like we use to do for LDR cases) and then deliver a second fraction the following morning. Its the only realistic way for me to get 2 fractions in per insertion. And also a great example of everything that is wrong with big health care systems. The cost of doing it this way is far higher than doing a BID treatment. But hey, on the books it looks better.

Ah yes, admin. Anti-patients, anti-doctors, anti-logic. They say one shouldn't wish ill on others, but for them one can't help but make an exception...

 

[thecarbonionangle]

Ah yes, admin. Anti-patients, anti-doctors, anti-logic. They say one shouldn't wish ill on others, but for them one can't help but make an exception...

Theres always a Mark Twain quote: “I've never wished a man dead, but I have read some obituaries with great pleasure.”

 

[BobbyHeenan]

Can I tag on another case in this thread, please? Mods please move if we need a new thread.

In 2007 my patient had EBRT plus brachy with tandem/ovoid for definitive treatment of a well differentiated endometrial carcinoma. Issues with a recent MI and stent and couldn't have TAH/BSO then. I don't have any dicom files but I do have some older gyn onc notes. Apparently where she had radiation that practice was bought out and no electronic records of her tratement exist.

In 2017 had vaginal bleeding. Uterus biopsy (done via CT guidance) then showed carcinosarcoma. Has a TAH/BSO then, robotic assisted, with a T2N0M0 carcinosarcoma replacing the cervix. + parametrial margins. Adjuvant carbo/taxol. Then NED.

Fast forward to 2020, she's 62 years old. Obesity and C.AD. her major comorbidities. Moved to my area. Was found on just routine pelvic to have an erythematous , slightly raised lesion in the upper vagina. Biopsy is ER + adenocarinoma. Nothing can be seen on scans including pelvic MRI and PET scan. When I examined her I could barely even see what was biopsied. She was put on Tamoxifen and this thing went away for about 6 months.

However, now the lesion is a little larger. Kind of just a raised red area right around the right side of cuff. Maybe 2 cm in length but not thick. Can't really be palpated. Not terribly thick. Certainly no big masses or parametrial involvement.

We are taking her to the OR for thorough exam under anesthesia. I plan to place little fiducial markers where I see it, as in office exam suggested it was mostly toward one side.

I'm open to treatment options. I do a fair amount of gyn brachy and have a multi channel cylinder. I typically refer out for interstitial but when I talked to academic Gyn rad onc they said unless thick or seen on imaging, they wouldn't do interstitial.

Any suggestions on dosing here?

I was thinking like 6 fractions, maybe 4 Gy to vaginal surface, 6-7 Gy to 5mm depth up at apex and make sure the area is well covered. I'm going to re-image her again with an MRI.

 

[ramsesthenice]

Can I tag on another case in this thread, please? Mods please move if we need a new thread.

In 2007 my patient had EBRT plus brachy with tandem/ovoid for definitive treatment of a well differentiated endometrial carcinoma. Issues with a recent MI and stent and couldn't have TAH/BSO then. I don't have any dicom files but I do have some older gyn onc notes. Apparently where she had radiation that practice was bought out and no electronic records of her tratement exist.

In 2017 had vaginal bleeding. Endomtrial biopsy then showed carcinosarcoma. Has a TAH/BSO then, robotic assisted, with a T2N0M0 carcinosarcoma replacing the cervix. + parametrial margins. Adjuvant carbo/taxol. Then NED.

Fast forward to 2020, she's 62 years old. Obesity and C.AD. her major comorbidities. Moved to my area. Was found on just routine pelvic to have an erythematous , slightly raised lesion in the upper vagina. Biopsy is ER + adenocarinoma. Nothing can be seen on scans including pelvic MRI and PET scan. When I examined her I could barely even see what was biopsied. She was put on Tamoxifen and this thing went away for about 6 months.

However, now the lesion is a little larger. Kind of just a raised red area right around the right side of cuff. Maybe 2 cm in length but not thick. Can't really be palpated. Not terribly thick. Certainly no big masses or parametrial involvement.

We are taking her to the OR for thorough exam under anesthesia. I plan to place little fiducial markers where I see it, as in office exam suggested it was mostly toward one side.

I'm open to treatment options. I do a fair amount of gyn brachy and have a multi channel cylinder. I typically refer out for interstitial but when I talked to academic Gyn rad onc they said unless thick or seen on imaging, they wouldn't do interstitial.

Any suggestions on dosing here?

I was thinking like 6 fractions, maybe 4 Gy to vaginal surface, 6-7 Gy to 5mm depth up at apex and make sure the area is well covered. I'm going to re-image her again with an MRI.

If you have a multichannel cylinder you should be fine without needles based on how thin it sounds. You just don't want to use a single channel cylinder for cases like these. No reason to give uniformly high doses to the entire proximal vagina if it is well lateralized. Just get that MRI first to make sure it is not thicker than expected

Now to your question of dose. What are you trying to accomplish here? Durable palliation or cure? Is 6-7x5 enough for a recurrent tumor that has presumably survived prior treatment? I suspect this is not from her prior endometrial cancer but part of a mixed component from her more recent carcinosarcoma. I think doing brachy only is the better part of valor, but you could probably get a way with a little EBRT as well (using very conformal IMRT) to the upper parametrial/paravaginal tissues. This think looks small but it has a proven history of being pretty sneaky. If you are going for cure you may want to think about being a little more aggressive. Obviously, it would carry more risk and depending on her overall health (which doesn't sound great) and expectations it may not be the right move, but I would just be clear with her what you are trying to achieve. Tam is obviously not going to buy you much mileage if the radiation doesn't work. I hate these cases.

My bias (not having seen the person) would probably be to just do brachy like you proposed and hope for the best. Sounds like she has a lot of other issues and doesn't need a whole lot more. The only reservation I have is that it pretty quickly shrugged off the tam. There is potential for disaster no matter which way you go.

 

[Palex80]

It sounds like a reasonable approach, the dose varies according to what you think you can spare and how much of that area and the OARs have already received dose from the past treatment. Multi-catheter appicator and/or shielded applicators are great for these cases. If the lesion is superficial, I wouldn't go for an implant either.

 

[bachiraki]

Can I tag on another case in this thread, please? Mods please move if we need a new thread.

In 2007 my patient had EBRT plus brachy with tandem/ovoid for definitive treatment of a well differentiated endometrial carcinoma. Issues with a recent MI and stent and couldn't have TAH/BSO then. I don't have any dicom files but I do have some older gyn onc notes. Apparently where she had radiation that practice was bought out and no electronic records of her tratement exist.

In 2017 had vaginal bleeding. Uterus biopsy (done via CT guidance) then showed carcinosarcoma. Has a TAH/BSO then, robotic assisted, with a T2N0M0 carcinosarcoma replacing the cervix. + parametrial margins. Adjuvant carbo/taxol. Then NED.

Fast forward to 2020, she's 62 years old. Obesity and C.AD. her major comorbidities. Moved to my area. Was found on just routine pelvic to have an erythematous , slightly raised lesion in the upper vagina. Biopsy is ER + adenocarinoma. Nothing can be seen on scans including pelvic MRI and PET scan. When I examined her I could barely even see what was biopsied. She was put on Tamoxifen and this thing went away for about 6 months.

However, now the lesion is a little larger. Kind of just a raised red area right around the right side of cuff. Maybe 2 cm in length but not thick. Can't really be palpated. Not terribly thick. Certainly no big masses or parametrial involvement.

We are taking her to the OR for thorough exam under anesthesia. I plan to place little fiducial markers where I see it, as in office exam suggested it was mostly toward one side.

I'm open to treatment options. I do a fair amount of gyn brachy and have a multi channel cylinder. I typically refer out for interstitial but when I talked to academic Gyn rad onc they said unless thick or seen on imaging, they wouldn't do interstitial.

Any suggestions on dosing here?

I was thinking like 6 fractions, maybe 4 Gy to vaginal surface, 6-7 Gy to 5mm depth up at apex and make sure the area is well covered. I'm going to re-image her again with an MRI.

I had a similar case Last year. Pt is a 84-year old female with cervical cancer diagnosed in 1990 treated with Pelvic RT and LDR Intracavitary Brachytherapy. In 1996 she had hysterectomy for persistently positive PAP smears. No issues till Jan 2020 when she presented with vaginal bleeding and diagnosed with Squamous cell carcinoma.

Workup showed disease confined to upper vagina as shown above. Pt was treated with Cs-131 interstitial, single plane free seed implant in Jan, 2020 To a dose of 50Gy prescribed to 5mm depth.

She remains no evidence currently with obliteration and narrowing of upper vagina as shown in the following pic.

Your patient looks like she would be a good candidate for Cs-131 interstitial seed single plane implant to a dose of 50-55Gy. Cs-131 interstitial implant in previously radiated patients is safe as it limits volume of re-irradiation to just upper vagina which has high tolerance with radiation.

Following publication sheds more light on Cs-131 outcomes in Gyn cancers.

Implementation and early clinical results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies

Permanent interstitial brachytherapy is an ideal yet underutilized treatment modality for accessible, small volume gynecological malignancies. We pres…

www.sciencedirect.com

 

[thecarbonionangle]

I had a similar case Last year. Pt is a 84-year old female with cervical cancer diagnosed in 1990 treated with Pelvic RT and LDR Intracavitary Brachytherapy. In 1996 she had hysterectomy for persistently positive PAP smears. No issues till Jan 2020 when she presented with vaginal bleeding and diagnosed with Squamous cell carcinoma. View attachment 337804
Workup showed disease confined to upper vagina as shown above. Pt was treated with Cs-131 interstitial, single plane free seed implant in Jan, 2020 To a dose of 50Gy prescribed to 5mm depth. View attachment 337807
She remains no evidence currently with obliteration and narrowing of upper vagina as shown in the following pic.
View attachment 337803
Your patient looks like she would be a good candidate for Cs-131 interstitial seed single plane implant to a dose of 50-55Gy. Cs-131 interstitial implant in previously radiated patients is safe as it limits volume of re-irradiation to just upper vagina which has high tolerance with radiation.

Following publication sheds more light on Cs-131 outcomes in Gyn cancers.

Implementation and early clinical results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies

Permanent interstitial brachytherapy is an ideal yet underutilized treatment modality for accessible, small volume gynecological malignancies. We pres…

www.sciencedirect.com

Cool case. Thanks for sharing. Do you guys not do HDR interstitial?

 

[ramsesthenice]

I had a similar case Last year. Pt is a 84-year old female with cervical cancer diagnosed in 1990 treated with Pelvic RT and LDR Intracavitary Brachytherapy. In 1996 she had hysterectomy for persistently positive PAP smears. No issues till Jan 2020 when she presented with vaginal bleeding and diagnosed with Squamous cell carcinoma. View attachment 337804
Workup showed disease confined to upper vagina as shown above. Pt was treated with Cs-131 interstitial, single plane free seed implant in Jan, 2020 To a dose of 50Gy prescribed to 5mm depth. View attachment 337807
She remains no evidence currently with obliteration and narrowing of upper vagina as shown in the following pic.
View attachment 337803
Your patient looks like she would be a good candidate for Cs-131 interstitial seed single plane implant to a dose of 50-55Gy. Cs-131 interstitial implant in previously radiated patients is safe as it limits volume of re-irradiation to just upper vagina which has high tolerance with radiation.

Following publication sheds more light on Cs-131 outcomes in Gyn cancers.

Implementation and early clinical results utilizing Cs-131 permanent interstitial implants for gynecologic malignancies

Permanent interstitial brachytherapy is an ideal yet underutilized treatment modality for accessible, small volume gynecological malignancies. We pres…

www.sciencedirect.com

Saw a case not to different in follow up today. She got definitive radiation for MIBC (66.6) in 2015 the developed a carcinosarcoma of the uterus in 2017. They respected it and gave her chemo. She recurred in the cuff last summer and I offered her a cylinder for a flattish recurrence. She opted for chemo instead and grew through 2 lines. They sent her back to me for palliation when it had completely replaced the vault and was thought 5x5x3 cm in size. No distant disease. I dropped 6 needles in it and gave 6x5 with no EBRT just hoping it would be a conformal form of palliation. Now, it was almost spherical and as a result the plans were very hot and conformal. I think my D90s were closer to 8 each day. Saw her for her 6 month scan today and she is still disease free on exam and MRI. I am honestly shocked. I wouldn’t have bet someone else’s money on getting that kind of response. She has not had any tox yet but in fairness, it’s still early. Badness could still happen. But the point remains, in my experience the pelvis can be more forgiving for retreatment than people give it credit. Especially with a conformal therapy like Brachy.

 

[bachiraki]

Cool case. Thanks for sharing. Do you guys not do HDR interstitial?

For low volume disease like my above case I do single session CS-131 free seed implant.

for high volume disease like the one described by Ramsesthenice above, I do HDR.

 

[bachiraki]

Saw a case not to different in follow up today. She got definitive radiation for MIBC (66.6) in 2015 the developed a carcinosarcoma of the uterus in 2017. They respected it and gave her chemo. She recurred in the cuff last summer and I offered her a cylinder for a flattish recurrence. She opted for chemo instead and grew through 2 lines. They sent her back to me for palliation when it had completely replaced the vault and was thought 5x5x3 cm in size. No distant disease. I dropped 6 needles in it and gave 6x5 with no EBRT just hoping it would be a conformal form of palliation. Now, it was almost spherical and as a result the plans were very hot and conformal. I think my D90s were closer to 8 each day. Saw her for her 6 month scan today and she is still disease free on exam and MRI. I am honestly shocked. I wouldn’t have bet someone else’s money on getting that kind of response. She has not had any tox yet but in fairness, it’s still early. Badness could still happen. But the point remains, in my experience the pelvis can be more forgiving for retreatment than people give it credit. Especially with a conformal therapy like Brachy.

Great outcome.. did you do 6Gy x 5 twice a week? Thanks

 

[ramsesthenice]

Great outcome.. did you do 6Gy x 5 twice a week? Thanks

That would have been my normal schedule but they live a couple hours away so for their convenience we did weekly. The nice thing about stretching it out was I got to see this thing implode. The GTV volume was almost 40 ccs on fraction 1 and only 15 ccs for fraction 5. I never had issues with rectal or bladder dosing (on paper at least) but following ALARA the smaller sizes with subsequent fractions had to help. I want to be clear that I am not trying to sell the magic of interstitial. This response was exceptional (far beyond typical) and her local recurrence risk is still high. But considering my goal was to help with discharge and bleeding, I can safely say we far exceeded that initial goal regardless of what ultimately happens.

 

[seper]

Can I tag on another case in this thread, please? Mods please move if we need a new thread.

In 2007 my patient had EBRT plus brachy with tandem/ovoid for definitive treatment of a well differentiated endometrial carcinoma. Issues with a recent MI and stent and couldn't have TAH/BSO then. I don't have any dicom files but I do have some older gyn onc notes. Apparently where she had radiation that practice was bought out and no electronic records of her tratement exist.

In 2017 had vaginal bleeding. Uterus biopsy (done via CT guidance) then showed carcinosarcoma. Has a TAH/BSO then, robotic assisted, with a T2N0M0 carcinosarcoma replacing the cervix. + parametrial margins. Adjuvant carbo/taxol. Then NED.

Fast forward to 2020, she's 62 years old. Obesity and C.AD. her major comorbidities. Moved to my area. Was found on just routine pelvic to have an erythematous , slightly raised lesion in the upper vagina. Biopsy is ER + adenocarinoma. Nothing can be seen on scans including pelvic MRI and PET scan. When I examined her I could barely even see what was biopsied. She was put on Tamoxifen and this thing went away for about 6 months.

However, now the lesion is a little larger. Kind of just a raised red area right around the right side of cuff. Maybe 2 cm in length but not thick. Can't really be palpated. Not terribly thick. Certainly no big masses or parametrial involvement.

We are taking her to the OR for thorough exam under anesthesia. I plan to place little fiducial markers where I see it, as in office exam suggested it was mostly toward one side.

I'm open to treatment options. I do a fair amount of gyn brachy and have a multi channel cylinder. I typically refer out for interstitial but when I talked to academic Gyn rad onc they said unless thick or seen on imaging, they wouldn't do interstitial.

Any suggestions on dosing here?

I was thinking like 6 fractions, maybe 4 Gy to vaginal surface, 6-7 Gy to 5mm depth up at apex and make sure the area is well covered. I'm going to re-image her again with an MRI.

Prior to brachy, I would give about 30 Gy of EBRT.