1. PO31: Definitive Treatment of Locally Advanced Vulvar Squamous Cell Carcinoma in an Elderly with External Beam Radiotherapy, Chemotherapy, and Cesium-131 Interstitial and Iridium-192 Intracavitary Brachytherapy: A Case Report.
- Author
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Johnson, Jeremiah, Chow, Zeta, Soleimani-Meigooni, Ali, and Fabian, Denise
- Subjects
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VULVAR cancer , *EXTERNAL beam radiotherapy , *SQUAMOUS cell carcinoma , *LOW dose rate brachytherapy , *RADIOISOTOPE brachytherapy , *INTERSTITIAL brachytherapy - Abstract
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]
- Published
- 2023
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