Concomitant External-beam Irradiation and Chemotherapy Followed by High-dose Rate Brachytherapy Boost in the Treatment of Squamous Cell Carcinoma of the Vagina: A Single-Center Retrospective Study.

AIM: To assess the outcome of 35 patients with vaginal carcinoma treated with different radiotherapy modalities. MATERIALS AND METHODS: Thirty-one patients received external-beam irradiation (EBRT) to the entire vagina, para-vaginal area and pelvic nodes (total dose=45-50.4 Gy). Concomitant chemotherapy was used in 22 patients. Nineteen patients received additional 15-25 Gy high-dose-rate brachytherapy (BT) boost and eight received additional EBRT boost to the primary tumor site. Four women received exclusive 30-40 Gy high-dose-rate BT. RESULTS: Median progression-free survival and median overall survival were 22 months and 89 months, respectively. Age <70 years, use of EBRT plus BT, and concomitant chemotherapy were associated with better progression-free (p=0.002, p=0.007, and p=0.02) and overall (p=0.01, p=0.009, p=0.009) survival. CONCLUSION: Concomitant EBRT and chemotherapy followed by BT is the best treatment for vaginal carcinoma.

[Chemoradioresistance of the female reproductive system cancer--can local laser hyperthermia contribute to its overcoming?].

There is presented the method of local laser hyperthermia on the domestic nanotechnological optic-fiber device LAZON-FT integrated into the program of brachytherapy for tumors of the female reproductive system. This is a universal radiosensibilizator that demonstrates the acceleration of tumor regression also during local and systemic chemotherapy--tumor regression at 50-705 in such conditions permits recommend it in locally advanced cervical and endometrial cancer as well as cancer of the vulva and vagina in the frames of combined use with brachytherapy and chemotherapy.

Is there a place for sentinel technique in treatment of vaginal cancer?: feasibility, clinical experience, and results.

OBJECTIVE: To evaluate the clinical feasibility of sentinel lymph node (SLN) technique and the role of single-photon emission computed tomography with CT (SPECT/CT) compared to lymphoscintigraphy for detection of SLN in vaginal cancer. METHODS: The study was performed in a prospective, unicentric setting. Patients with vaginal carcinoma were scheduled for surgery and SLN labeling by peritumoral injection of 10-MBq technetium Tc 99m nanocolloid and patent blue. After 30 minutes, lymphoscintigraphy and SPECT/CT were carried out. We evaluated the number of SLNs in lymphoscintigraphy, SPECT/CT, and intraoperative histology of SLN and non-SLN as well as the impact of these results to therapeutic approach. RESULTS: Between January 2009 and December 2012, the SLN technique was used for 7 of 11 patients treated due to vaginal cancer. Detection rate was 100% (7/7). Lymphoscintigraphy and SPECT/CT showed at least one SLN in each patient. Lymphoscintigraphy detected 2.6 SLNs (range, 2-4 SLNs) per patient compared to 4.3 SLNs (range, 2-8 SLNs) in SPECT/CT (P = 0.053). Sentinel lymph nodes were detected in all patients during surgery with a mean number of 4.3 (range, 1-5). Pelvic SLNs were detected in all 6 patients with infiltration of middle or proximal vaginal third (100%). If the distal vaginal third was additional (3/7 patients) or exclusively (1/7 patients) infiltrated, the inguinal SLN detection rate was 33% and 100%, respectively. All patients with nodal metastases had at least one SLN positive for tumor. There were no false negatives. In 2 (29%) of 7 patients, treatment approach was modified owing to affected SLN. CONCLUSION: The SLN technique was favorably used in vaginal cancer in this series. It assists in identifying an inguinal and/or pelvic lymphatic drainage. When performed accurately (technetium Tc 99m nanocolloid, lymphoscintigraphy and/or SPECT/CT, blue dye), this technique predicts regional nodal status. This allows tumor stage-adjusted therapy. Single photon emission computed tomography/CT improves preoperative planning and facilitates detection, thus enhancing the clinical value of the SLN technique and improving the oncologic safety of surgery.

Anal canal mucinous adenocarcinoma with invasion of gluteus and perineum treated with surgery and hyperbaric oxygen therapy.

The case of a 66-year-old female patient with late diagnosis of giant anal canal mucinous adenocarcinoma invading the gluteal and vulvar regions is reported. Because of the patient's severe clinical status and disease morbidity, surgical resection of the lesion was accomplished, with no adjuvant chemo- or radiotherapy. In the postoperative period, the patient received hyperbaric oxygen therapy, which facilitated and even accelerated local healing. Total closure of the raw flesh area was achieved, with no recurrence signals of cancer being detected after one-year follow-up. We are convinced that, in this difficult case, hyperbaric oxygen therapy played a crucial role in patient recovery and wound healing, allowing for early closure with good progression.

Use of combined radiation and hyperthermia for gynecological cancer.

PURPOSE OF REVIEW: We reviewed all literature on the clinical use of combined radiation and hyperthermia for gynecologic malignancies. RECENT FINDINGS: Combined radiation and hyperthermia should be considered an alternative to chemoradiation for patients with locally advanced cervix cancer and be the first treatment of choice for these patients when radiation cannot be combined with chemotherapy. Several randomized trials have shown an improvement by adding hyperthermia to radiation that is comparable to the improvement found with the addition of chemotherapy to radiation. Hyperthermia does not seem to add to treatment-induced toxicity and the results of hyperthermia are consistent even at 12 years follow-up and could be reproduced in a large, unselected group of cervix cancer patients. A novel indication for combined radiotherapy and hyperthermia is vaginal cancer. Recently, a cohort study showed that the addition of hyperthermia to radiation seems to improve overall survival for patients with vaginal cancer International Federation of Gynecology and Obstetrics stage III. SUMMARY: Combined radiation and hyperthermia should be considered for patients with locally advanced cervix cancer (International Federation of Gynecology and Obstetrics stage IIb and upwards) as an alternative to chemoradiation for patients with a contraindication for chemotherapy. For other patients, the optimal treatment combination is the subject of randomized trials. For vaginal cancer, a prospective registration study is currently ongoing.

Concomitant radiotherapy and hyperthermia for primary carcinoma of the vagina: a cohort study.

OBJECTIVE: To evaluate the supplementary value of adding hyperthermia to radiotherapy in patients with primary vaginal cancer. STUDY DESIGN: Cohort of 44 patients diagnosed with primary vaginal cancer between 1990 and 2002 was assessed. Survival rates and median survival of patients with primary vaginal cancer undergoing radiotherapy with and without hyperthermia were compared. Hyperthermia was solely added to radiotherapy in case of a tumor size >4 cm in diameter for FIGO stage III disease. RESULTS: The calculated overall 5-year survival of primary vaginal cancer was 63%. In comparison to histologic high grade tumors, higher survival rates for histologic low grade tumors were calculated. For FIGO stage III of disease, the addition of hyperthermia to radiotherapy for tumors >4 cm in diameter resulted similar survival rates and median survival when compared to those achieved by radiotherapy as monotherapy in tumors of <4 cm in diameter. CONCLUSIONS: The addition of hyperthermia to radiotherapy might result in better survival rates in primary vaginal cancer for tumors >4 cm in diameter. The supplementary effect of hyperthermia to radiotherapy may be a feasible and beneficial approach in the treatment of vaginal cancer.

The first report of extraosseous Ewing's sarcoma in the rectovaginal septum.

AIMS AND BACKGROUND: To report an extremely rare case of Ewing's sarcoma located in the rectovaginal septum. Ewing's sarcoma is a highly malignant neoplasm of bone, which usually occurs during childhood. Common extraosseous localizations of Ewing's sarcoma include the trunk, extremities, uterus, cervix and vagina. METHODS: A 45-year-old woman presented to us with a six-month history of pain in the lower abdomen during intercourse. Pelvic examination was performed and a palpable mass was found. The mass had a size of 9 x 6 cm, a soft tissue consistency, was partially movable and the patient felt the pain during palpation. Examination of the inguinal lymph nodes revealed no signs of inguinal adenopathy. The results of laboratory tests, rectoscopy, chest X-rays, barium enema and bone scan were normal. Computed tomography (CT) showed an inhomogeneous expansive mass in the rectovaginal septum measuring 8.7 x 6.1 cm, without any signs of rectum or bladder invasion. The vascular structures of the pelvis were normal. At laparotomy the process was judged inoperable and only biopsy of the tumor mass was carried out. Histology showed a neoplasm with small, round to oval cells with scarce cytoplasm. Immunohistology with the monoclonal antibody CD99 (MIC-2 gene product, Ewing's sarcoma marker, clone 12E7, DAKO A/S, Glostrup, Denmark) revealed an extraosseous Ewing's sarcoma. The patient was treated with chemotherapy followed by whole-pelvis external beam radiation and intracavitary brachytherapy. RESULTS: A residual mass measuring 3.5 x 2.5 cm was visible on a control CT scan 18 months after treatment; however, the patient was feeling well and refused surgery to remove the residual mass. CONCLUSIONS: To our knowledge this is the first reported case of extraosseous Ewing's sarcoma in the rectovaginal septum.

A new microwave applicator with integrated cooling system for intracavitary hyperthermia of vaginal carcinoma.

An improved design of a previously described intracavitary microwave hyperthermia applicator is presented. The applicator consists of a coaxial choke antenna designed to be positioned into a perspex obturator. The antenna can be fitted in the obturator in three defined positions depending on the specific clinical situation: the selected median, paramedian or lateral position can each provide differently directed heating patterns. This feature combined with the additional axial variability of the antenna position within the obturator can lead to a highly targeted heating of tumours and a reduced risk of unwanted heating of normal tissues. Various phantom studies were conducted using both liquid and solid phantoms. The saline phantom was used to check the typical action of the choke of the antenna where it was found that the antenna choke is efficiently working resulting in a heating pattern which is dependent of the insertion depth of the antenna. The solid phantom was used to measure the typical specific absorption rate (SAR) distribution of each antenna/obturator configuration.

The use of microwave-induced hyperthermia in conjunction with afterloading irradiation of vaginal carcinoma. A preliminary report.

Technically improved microwave antennas for clinical hyperthermia induction have made it possible to combine this treatment modality with external and intracavitary irradiation of vaginal and cervical carcinomas. A microwave applicator with a frequency of 915 MHz was used in tissue phantom measurements and inserted into perspex vaginal obturators for measurement of the specific absorption rate in different planes. A Lund Science Hyperthermia System 4010 with a 200 W generator and a separate thermometry system (ATS 100) was used in the patient treatments. Nine patients with vaginal squamous cell carcinomas have been treated with this applicator and obturator setup as an adjunct to intracavitary irradiation with high dose-rate afterloading technique. The treatments of two patients are described in this preliminary report.

Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations.

We have introduced a therapeutic alternative to exenteration for locally advanced vulvovaginal cancer using surgery for the vulvar (external genital) phase of this disease presentation, combined with radiotherapy for the internal genital phase (with adequate overlap of fields to protect surgical margins). The rationale is that this approach treats the cancer and its dual regional spread patterns, while at the same time preserving the bladder and/or rectum, and should be associated with less morbidity and mortality than exenterative surgery. This report updates our experience with a total of 48 treated cases (37 primary cases and 11 cases of recurrent disease). Of the 37 primary cases, 20 were FIGO stage III, 4 were FIGO stage IV, and 3 other cases represented "field" cancers involving vulva and/or cervix and/or vagina. Utilizing a Life Table analysis, the 5-year survival for the primary cases was 75.6%. Published FIGO survival for stage III is 32% and for stage IV 10.5%. Life Table analysis projects a 62.6% survival for recurrent cases and an overall 72% 5-year survival for all 48 cases treated. With 48 patients treated, 48 bladders and 48 rectums were at risk for surgical removal had exenteration been employed. One patient had a total pelvic exenteration for local failure, and one had a posterior exenteration for local failure. One bladder and one rectum were lost to permanent diversion because of radiation injury. Thus, 5 of these major viscera were lost of the 96 total, and 91 (94.8%) were retained. Radiation therapy and surgical details have been reviewed relevant to local control and local failure and complications. The continuing evolution of treatment modifications of all modalities will be discussed. The apparent advantages of this combined therapeutic approach over exenterative surgery include high probability of bladder and/or rectal preservation, low primary mortality, low treatment morbidity, and very good results in cancer control.

Therapeutic effect of hyperthermia combined with chemotherapy on vulvar and vaginal carcinoma.

A clinical trial was performed to investigate the efficacy of hyperthermia in combination with chemotherapy for gynecological malignancies. Sixty-nine patients with vaginal or vulvar malignancies (9 primary vulvar, 3 recurrent vulvar, 11 primary vaginal, 4 primary cervical, 40 recurrent cervical, and 2 recurrent ovarian carcinomas) were treated by thermochemotherapy (42 cases) or chemotherapy alone (27 cases). After treatment, 7 patients underwent surgery and 46 patients irradiation. The chemotherapeutic schedule was mainly a combination therapy with bleomycin and mitomycin C (B-M). Microwaves of 2.45 GHz were applied to induce local hyperthermia. The side effects of chemotherapy were not increased by hyperthermia. The rate of partial response plus complete response increased to 84% (16/19) in primary cancers and 45% in recurrent cancers by hyperthermia, compared to the respective values of 40% (2/5) and 17% (3/17) for chemotherapy alone. However, a satisfactory prognosis cannot be expected with thermochemotherapy, unless additional treatments are performed. Subsequent surgery or radiation treatment improved the progression-free interval.

Management of condyloma acuminatum.

This article describes an approach to the evaluation and treatment of condyloma acuminatum (anogenital warts) that is based on the results of new clinical research on the biology of the human papillomavirus. A more extensive diagnostic protocol, including routine cervicovaginal examination and Papanicolaou smear, is proposed for female patients because of the close association of genital human papillomavirus infections with cervical carcinoma. Two highly effective therapies, cryosurgery and carbon dioxide laser photocoagulation, are described and compared with older regimens. Recent developments in immunotherapy for resistant condyloma acuminatum are also discussed.

Design and thermometry of an intracavitary microwave applicator suitable for treatment of some vaginal and rectal cancers.

The construction of a modified coaxial cable as an intracavitary microwave applicator suitable for use in some vaginal and rectal cancers is presented. Thermometry was performed for microwave frequencies of 300, 400, 650, and 915 MHz. Temperature profiles in tissue phantoms were obtained with non-perturbing temperature probes and thermography, and the data were compared with those obtained in dogs. The temperature profiles were dependent on the frequency of the microwaves and the insertion depth of the applicator. In addition, an acrylic cylindrical spacer external to the applicator also altered the heating pattern. Therefore, with proper combinations of frequency, insertion depth and spacer, the applicator can be used for heating tumors in some clinical situations.

[Treatment of tumors by local hyperthermia in urology and gynecology (author's transl)]. / Hyperthermie localisée dans le traitement des tumeurs en urologie et en gynécologie. Phase expérimentale chez l'animal et phase clinique chez l'homme.

An experimental study by the authors, on the effects of local-regional hyperthermia on bladder B.N.A. induced carcinoma of the dog has been going on since 1966. The authors have observed complete disappearance in the animals of the mucosa and sub-mucosa neoplasia, even after 6 years from the date of treatment. The sterilization of the neoplastic surface was checked by several histological sections observations on two excised bladders. As the results showed no negative secondary effects, the authors have started, since 1973, a clinical study of hyperthermia treatment of the bladder, vagina, female urethra and rectum stump carcinoma. Heat was obtained and introduced into the bladder by leans of an apparatus specifically designed for this purpose; the double-circuit terminal probe supplies a thermocouple controlled constant temperature. We are submitting the cases treated together with a discussion on results obtained and problems faced.