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Effective treatment for locally-advanced vulvar cancer remains a challenge and often requires multi-modality care. Unresectable disease may be managed with a combination of chemotherapy, external beam radiation (EBRT), and brachytherapy. Cesium-131 Low Dose Rate (LDR) interstitial brachytherapy is an effective modality to deliver high-quality localized radiation. This case report highlights the technique and efficacy of Cesium-131 LDR interstitial brachytherapy as a part of multimodal therapy in treating a medically inoperable patient with advanced age and multiple medical comorbidities. Patient is a 79-year-old female who presented with medically inoperable FIGO Stage IVA squamous cell carcinoma of the vulva with extensive left labial disease and circumferential extension into the upper vagina. In addition, patient had hypermetabolic left inguinal lymph node metastasis on PET/CT imaging. Patient was subsequently treated with EBRT (4930 cGy over 29 fractions was delivered to the vulva, vagina, and regional lymphatics, followed by a sequential boost of 1620 cGy over 9 fractions to the involved left inguinal lymph node) with concurrent weekly cisplatin. Following EBRT, the patient had residual disease burden. She was noted to have cobblestoning of the anterior vaginal wall extending laterally on both sides, with palpably bulky disease in roughly the 10 o'clock position along her right lateral vaginal wall. She was offered High Dose Rate (HDR) interstitial brachytherapy boost, but declined this treatment due to her age and multiple medical comorbidities. She was subsequently treated with Cesium-131 LDR interstitial brachytherapy. Cesium-131 interstitial free seeds were placed with the seed inserters starting proximally and extending distally along the anterior vaginal wall in a planer fashion. 3000 cGy was prescribed to the tumor using 28 sources, each with a strength 0.72 U per seed. Dose distribution is represented in Figure 1 (Coronal CT scan demonstrating the radiation dose distribution of Cesium-131 permanent LDR implant to gross residual vaginal disease following EBRT). This was followed by vaginal cylinder HDR intracavitary brachytherapy utilizing Iridium-192 (800 cGy was prescribed at 5 mm depth from the vaginal cylinder surface delivered over 2 fractions). PET/CT done at 3 months showed complete metabolic resolution of all disease without evidence of recurrent or metastatic disease. At the patient's 21-month follow up, she had no evidence of disease on clinical exam or PET/CT imaging at that time. Acute toxicities included CTCAE grade 2-3 vulvar and inguinal skin erythema and mild diarrhea. Late toxicities include vaginal wall fibrosis at the site of Cesium-131 implant. Cesium-131 LDR interstitial brachytherapy implementation in a multimodal therapy setting is proved to be a feasible and promising treatment option to achieve long-term local control in a medically inoperable patient with an extensive vulvovaginal neoplasm. This study demonstrates a proof of concept of the safety and viability of Cesium-131 LDR interstitial brachytherapy for definitive management in selective patient populations. Future research is warranted. [ABSTRACT FROM AUTHOR]

Radiation management literature focused on optimizing care for patients with intellectual disability is sparse. We add our experience to the literature with the goal to improve care to this vulnerable patient population. To this end, we report three cases of prostate cancer in patients with limited cognition who were treated with low dose rate (LDR) prostate brachytherapy to highlight an effective strategy to deliver optimal care to this group of patients. This is a case series of three adult male patients with limited cognition each of whom developed prostate cancer which was managed primarily with LDR brachytherapy. Patient #1: A 53-year-old male with favorable intermediate-risk prostate cancer (PSA 8.8 ng/ml, Grade Group 2), Patient #2: a 68-year-old male with unfavorable intermediate risk prostate cancer (PSA 12.6 ng/ml, Grade Group 3), and Patient #3: a 52-year-old male with high-risk prostate cancer (PSA 24 ng/ml, Grade Group 1), all of whom had intellectual disability, were evaluated for radiation therapy. A thorough discussion occurred with each patient and their legal guardian about prostate cancer therapy options including surgery versus radiation treatment with or without androgen deprivation therapy. Radiation therapy treatment strategies presented included low dose rate brachytherapy versus external beam radiation treatment including SBRT to a total dose of 3625 cGy in 5 fractions every other day or a moderately hypofractionated regimen to a total dose of 7000 cGy in 28 daily fractions Monday to Friday. In each case, a shared decision was made for each patient to undergo interstitial prostate seed implant. Of note, two out of the three patients lived more than an hour away from the radiation treatment center and relied on family support for transportation needs. Each patient initially underwent a prostate volume study with a transrectal ultrasound to 1) determine the dimensions of the prostate and 2) develop a plan for radiation dose coverage of the prostate with interstitial Cs-131 brachytherapy seeds. Each patient then underwent seed implantation under anesthesia followed by fluoroscopy and post-implant CT, to assess for appropriate seed placement as well as the post-implant dosimetry. Patient #1 received a total prescription dose of 110 Gy to the prostate D90 using 61 sources each with a strength of 1.6 U per seed for a total strength of 97.6 U and at 14 months follow up, his PSA had decreased to 1.7 ng/ml from 8.8 ng/ml. Patient #2 received a total prescription dose of 100 Gy to the prostate D90 using 59 sources each with a strength of 1.43 U per seed for a total strength of 84.37 U, and at 38 months follow up, his PSA had decreased to 0.018 ng/ml from 12.6 ng/ml. Patient #3 received 115 Gy to the prostate D90 using 90 sources each with a strength of 1.8 U per seed for a total of 162 U, and at 34 months follow up, his PSA had decreased to 0.8 ng/mL from 24 ng/ml. In all three cases, treatment was completed without complications and there was no CTCAE grade 3 or higher toxicity noted. In patients with limited cognition with select non-metastatic prostate cancer, low dose rate brachytherapy is an excellent treatment modality. It provides adequate tumor control with acceptable radiation induced toxicities. It reduces the transportation burden associated with multiple treatment sessions by requiring only two visits to a radiation treatment center. The use of sedation reduces the challenge associated with patient immobilization encountered with external beam radiation treatments. And, it is less invasive than surgery. These advantages for LDR brachytherapy are extremely useful for patients with limited cognition. Thus, LDR brachytherapy should be strongly considered for this patient population when applicable. [ABSTRACT FROM AUTHOR]