18. Primary vaginal cancer and vaginal recurrences - The GEC-ESTRO Handbook of Brachytherapy

Primary vaginal cancer and vaginal recurrences

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THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 01/09/2023

18 Primary vaginal cancer and vaginal recurrences Henrike Westerveld, Nicole Eder-Nesvacil, Maximilian Schmid

1. Summary 2. Introduction 3. Anatomy 4. Pathology

3 3 3 4 4 6 7 8

9. Treatment planning

10 11 12 12 13 14 15

10. Dose, dose rate and fractionation

11. Monitoring

12. Results

5. Work up

13. Adverse Events 14. Key messages 15. References

6. Indications and contra-indications

7. Clinical Target Volume

8. Technique

1. SUMMARY

Definitive radiotherapy including brachytherapy plays a central role in the management of primary vaginal cancer and previously non-irradiated vaginal recurrences from cervical or endometrial cancer. Non-mutilating surgery is typically restricted to small tumours in the upper part of the vagina or close to the vulva. In the majority of patients, a combination of external beam radiotherapy (EBRT) with or without concomitant chemotherapy and brachytherapy is recommended, whereas selected small superficial tumours (T0/T1) may be treated with brachytherapy alone. MRI together with gynaecological examination are the preferred modalities for target volume definition and image-guidance. The brachytherapy application depends on the local tumour spread and the response to external beam radiotherapy +/- chemotherapy. Superficial tumours at brachytherapy can be treated with intra-vaginal applicators alone, whereas in larger tumours with residual paravaginal disease combined intracavitary and interstitial applicators should be used. Local tumour control rates >80% at 5 years can be reached with radiochemotherapy and image-guided brachytherapy in locally advanced disease. Although prospective data are limited, major treatment related toxicity seems to occur more frequently than when treating primary cervical cancer, mainly due to the higher frequency of painful vaginal ulcerations, complete vaginal stenosis, and fistulae.

2. INTRODUCTION

3. ANATOMY

This chapter describes the management of vaginal malignancies in adults referring to the treatment of primary vaginal cancer and vaginal recurrences from cervical or endometrial cancer. Due to the rarity of vaginal malignancies (primary vaginal cancer accounts for only 2% of all gynaecological malignancies) there is only limited literature and specific evidence available, especially in light of the nowadays standard of image-guided brachytherapy. Therefore, many treatment recommendations are derived from cervical cancer, with which they share anatomical and some aetiological and pathological similarities. Also, symptoms are comparable to those from cervical cancers including vaginal discharge, bleeding and pain during sexual intercourse. Radiotherapy including brachytherapy plays a central role in the management of vaginal malignancies as non-mutilating surgery is typically restricted to small superficial tumours in the upper part of the vagina or close to the vulva. Recent evidence from a SEER analysis in 2,517 patients with vaginal cancer suggests improved survival when brachytherapy is part of the treatment [1].

The vagina is a fibromuscular, tubular and expandable cavity, between the bladder, urethra and rectum. It is limited by the cervix superiorly and by the urethral meatus externus and the vulva/ introitus inferiorly. The vagina extends laterally to the paravaginal and parametrial tissues including the Bartholin glands, anteriorly to the bladder, urethra and crux of the clitoris, and posteriorly to the rectum and anorectal sphincter complex (Figure 1)[2]. The vaginal wall consists of different layers, namely the vaginal mucosa, the lamina propria including blood vessels and lymphatic tissue, a smooth muscle layer, and the adventitia, consisting of a dense layer of connective tissue with blood vessels, lymphatic tissue, and nerves [3]. Dependent on the location and expansion of the vagina, the vaginal wall has a thickness of approximately 3-5 mm. The vagina is anatomically divided in three parts: the lower, middle and upper third. The introitus is located approximately at PIBS-2cm level. The transitional zone from lower to middle part of the vagina is indicated by the PIBS. The transitional zone from middle to upper part of the vagina is in general located at the level of the caudal border of the bladder neck [4].