Radiation-induced rectovaginal fistulas in locally advanced gynaecological malignancies-new patients, old problem?

PURPOSE: Radiation-induced rectovaginal fistula (RI-RVF) is a chronic and serious condition with a significant influence on quality of life. The aim of this study is to evaluate the results of surgical treatment of rectovaginal fistulas of patients previously undergoing radiotherapy. METHODS: Fifty patients treated in the Gynaecological Radiotherapy Unit for gynaecologic malignancy and in the Department of General and Colorectal Surgery for RI-RVF between 2003 and 2013 were enrolled into a prospectively maintained database and underwent regular follow-up examinations in an outpatient clinic, during which surgical outcomes were assessed. RESULTS: Median age was 60 years (range 40-84 years). Cervical cancer was the most common cause of radiotherapy. Median time of fistula development after radiotherapy was 20 months (range 5-240 months). In 48 (96%) patients, only faecal diversion could be performed, while two patients underwent rectal resection. The fistula healed in six patients. Factors that correlated with fistula healing were a distance from the anal verge above 7 cm (p = 0.007 OR 18 95%CI 2.2609-14.3062) and creation of loop ileostomy (p = 0.08 OR 17 95%CI 1.2818-23.9701), whereas a prolonged course of radiotherapy of more than 6 weeks (p = 0.047) correlated negatively. In multivariate analysis, only distance from the anal verge remained significant (p = 0.031 OR 2.35 95%CI 1.0422-5.2924). CONCLUSIONS: The treatment of radiation-induced rectovaginal fistulas needs to be tailored individually to each patient. Faecal diversion remains the simplest and safest method of treating RI-RVF, especially in the group of patients who cannot undergo complicated surgical procedures, and offers acceptable quality of life.

Interdisciplinary treatment of the patient with adenoid cystic carcinoma of the Bartholin's gland resulting in 15 years' survival: a case report and review of literature.

Carcinoma of the Bartholin's gland is very rare, comprises below 2% of Bartholin's gland lesions and adenoid cystic carcinoma (ADC) is one of the most uncommon variants and accounts for 10-15% of Bartholin's gland malignancies. There is no consensus on treatment of ADC of the Bartholin's gland: reported cases were treated with local excision or vulvectomy with or without lymphadenectomy followed or not by radiotherapy. The survival of patients varies significantly, so we present a case of interdisciplinary treatment of ADC resulting in 15 years' survival. The patient was initially treated with local excision, but the margins were not clear. Then vulvectomy, inguinal lymphadenectomy and adjuvant brachytherapy were performed resulting in 7 years free of the disease. Relapses were excised by abdominoperineal amputation of the rectum and distal part of the vagina with sigmoideostomy, excisions of local recurrences in vagina and metastasectomy of isolated lung metastases. The patient died manifesting multiple lung metastases 15 years after the initial diagnosis. Based on our experience and world literature, in cases of adenoid cystic carcinoma of the Bartholin's gland, vulvectomy with or without lymphadenectomy should be considered as a treatment of choice and in patients with positive margin, surgery should be extended by adjuvant radiotherapy.

Comparison of prognosis in patients with endometrioid endometrial cancer staged IB in FIGO 1988 and 2009 classifications.

PURPOSE: Since 2009 the new FIGO Staging System of endometrial cancer, which changed the previous FIGO 1988 Staging System, has been in use. The aim of the study was to compare prognosis in patients with endometrioid endometrial cancer at stage IB of the 2009 FIGO Staging System and of the 1988 FIGO Staging System. METHODS: We analyzed 173 patients: 108 patients (group A) at stage IB in FIGO 1988 Staging System, and 68 patients (group B) at stage IB in FIGO 2009 Staging System from 262 consecutive endometrioid endometrial cancer patients. The disease-free survival (DFS) and overall survival (OS) were compared between these groups. RESULTS: The DFS rate was 96.3 % in group A and it was 87.7 % in group B (p = 0.029). Relapses were observed in 12 patients (6.4 %) from 6 to 57 months (mean 28.1; SD = 14.6) after initial surgery, and occurred in four patients from group A (3.7 %) and eight patients from group B (12.3 %) (p = 0.032). The OS rate was 94.4 % in group A and it was 83.1 % in group B (p = 0.018). During follow-up, 17 patients (9.8 %) died: six patients from group A (5.6 %), and 11 patients from group B (16.9 %). CONCLUSIONS: Stage IB in FIGO 2009 Staging System is associated with worse prognosis compared to stage IB according to FIGO 1988 classification. There seems to be a need to use exclusively the new FIGO 2009 classification worldwide to avoid therapeutic mistakes, which can be caused by diverse nomenclature.

Clinical significance of serum CA-125 and soluble tumor necrosis factor receptor type I in cervical adenocarcinoma patients.

HYPOTHESIS: The purpose of this study was to answer the question whether the measurement of the pretreatment tumor markers and cytokine levels would be of clinical use in patients with cervical adenocarcinoma. METHODS: CA-125, carcinoembryonic antigen (CEA), and squamous cell carcinoma (SCC), as well as interleukin 6 (IL-6), IL-8, vascular endothelial growth factor, IL-1 receptor antagonist, soluble tumor necrosis factor receptor type I (sTNF RI), and sTNF RII, were assessed in the sera of 120 cervical adenocarcinoma patients. RESULTS: CA-125 presented a better diagnostic sensitivity than did CEA and SCC, whereas the concentration of most cytokines, except for sTNF RII, revealed higher sensitivity, than did the standard tumor markers. The highest sensitivity was found for sTNF RI. The concentrations of the examined parameters were found to be significantly higher in patients with advanced stage (IIB-IV) as compared with patients with I-IIA stage. [Float1]Serum concentration of IL-6 was the only one that differs significantly, depending on the histological grade. During the 3-year follow-up, 25 patients relapsed, and 73 patients were disease-free. Significantly higher pretreatment serum concentrations of the examined parameters (except for SCC and IL-1 receptor antagonist) were found in patients who developed recurrences. Soluble tumor necrosis factor receptor type I and CA-125 were found to present the highest sensitivity, with areas under the receiver operating characteristic curve of 0.833 and 0.809, respectively. As the result of univariate analysis, CA-125, CEA, sTNF RII, IL-6, sTNF RI, and clinical stage were considered factors of poor prognosis. Multivariate analysis has proven that CA-125 and clinical stage were the only significant independent prognostic factors of the disease-free survival. CONCLUSION: CA-125 is an independent prognostic factor for disease-free survival. Our results have also demonstrated that sTNF RI is probably the most useful marker in cervical adenocarcinoma patients, especially in the early stages of disease.

Highly conformal CT based surface mould brachytherapy for non-melanoma skin cancers of earlobe and nose.

PURPOSE: Brachytherapy (BT), due to rapid dose fall off and minor set-up errors, should be superior to external beam radiotherapy (EBRT) for treatment of lesions in difficult locations like nose and earlobe. Evidences in this field are scarce. We describe computed tomography (CT) based surface mould BT for non-melanoma skin cancers (NMSC), and compare its conformity, dose coverage, and tissue sparing ability to EBRT. MATERIAL AND METHODS: We describe procedure of preparation of surface mould applicator and dosimetry parameters of BT plans, which were implemented in 10 individuals with NMSC of nose and earlobe. We evaluated dose coverage by minimal dose to 90% of planning target volume (PTV) (D90), volumes of PTV receiving 90-150% of prescribed dose (PD) (VPTV90-150), conformal index for 90 and 100% of PD (COIN90, COIN100), dose homogeneity index (DHI), dose nonuniformity ratio (DNR), exposure of organs. Prospectively, we created CT-based photons and electrons plans. We compared conformity (COIN90, COIN100), dose coverage of PTV (D90, VPTV90, VPTV100), volumes of body receiving 10-90% of PD (V10-V90) of EBRT and BT plans. RESULTS: We obtained mean BT-DHI = 0.76, BT-DNR = 0.23, EBRT-DHI = 1.26. We observed no significant differences in VPTV90 and D90 between BT and EBRT. Mean BT-VPTV100 (89.4%) was higher than EBRT-VPTV100 (71.2%). Both COIN90 (BT-COIN90 = 0.46 vs. EBRT-COIN90 = 0.21) and COIN100 (BT-COIN100 = 0.52 vs. EBRT-COIN100 = 0.26) were superior for BT plans. We observed more exposure of normal tissues for small doses in BT plans (V10, V20), for high doses in EBRT plans (V70, V90). CONCLUSIONS: Computed tmography-based surface mould brachytherapy for superficial lesions on irregular surfaces is a highly conformal method with good homogeneity. Brachytherapy is superior to EBRT in those locations in terms of conformity and normal tissue sparing ability in high doses.

[Preoperative high-dose brachytherapy in cases of endometrial carcinoma--preliminary assessment of outcomes and safety]. / Przedoperacyjna brachyterapia HDR (high dose rate) w raku trzonu macicy--wstepna ocena wyników i bezpieczenstwa stosowania metody.

INTRODUCTION: Rising incidence of endometrial carcinoma provokes searching for the best and the safest treatment method. MATERIALS AND METHODS: We included in our observation 35 patients suffering from gynaecologic malignancies. They had been treated in H. Jordan s Memorial Hospital. Institute of obstetrics and Gynaecology of the Medical Academy in Lódz and in the Polish Mother's Memorial Hospital-Research Institute, co-operating with the Gynaecologic Radiotherapy Department. The intracavitary method of treatment is described, emphasising the need of precise patients' qualification for this procedure. The importance of MRI as a diagnostic procedure is stressed. All patients were referred for surgical procedures including regional lymph nodes removal 6 weeks after completion of the brash therapy treatment. Pan hysterectomy was performed in 30 cases. 5 patients refused surgical treatment. RESULTS: In the majority of patients (18) the histological examination of specimen (uterus. ovaries, and lymph nodes) was free from cancer cells. These patients did not require further whole pelvis irradiation. CONCLUSIONS: In our material preoperative brachytherapy procedure allowed to avoid whole pelvis irradiation in more than half of the patients. This procedure is also cost effective as patients avoid long-time hospitalisation combined with teleradiotherapy. It is also worth to stress that patients avoid complications related to teleradiotherapy of the pelvis as well as long term treatment and rehabilitation.