Purpose: The optimal adjuvant radiotherapy for uterine cancer remains controversial. For intermediate-risk or high-risk uterine cancer, generally accepted adjuvant radiation is either vaginal brachytherapy (VBT) or external beam radiotherapy (EBRT) or combination of EBRT followed by VBT boost to vaginal cuff. Because many VA medical centers are not equipped with brachytherapy service to accomplish this task, the patients are referred for non-VA care to other institutions for VBT. At Kansas City VA Medical Center (KCVAMC), we looked at the feasibility of simultaneous integrated boost (SIB) to vaginal cuff with intensity-modulated radiation therapy (IMRT) in lieu of VBT.
Methods: Two patients with uterine malignancies were seen at KCVAMC after total abdominal hysterectomy and bilateral salpingo oophorectomy, referred for adjuvant radiotherapy: Patient 1 is a 69-year-old woman with grade 2 adenocarcinoma with > 50% myometrial invasion; Patient 2 is a 63-year-old woman with undifferentiated uterine sarcoma with microscopic involvement of lymph nodes with non-Hodgkin lymphoma, completed 3 cycles of R-CHOP chemotherapy and referred for adjuvant radiotherapy. Both patients were planned for whole pelvic radiation with planning CT simulation with vaginal cylinder for delineating the target boost volume, which is about upper half of the vagina with 1.0 to 1.5 cm superior and lateral margins. An IMRT plan was generated to cover the whole pelvis and boost volume to deliver 51 to 54 Gy to whole pelvis with 60 Gy to boost volume in 30 fractions. A dose constraint to bladder and rectum was observed.
Results: In this case report a technique of SIB to vaginal cuff in lieu of VBT is described. This technique is feasible, convenient, and less expensive for patients who are recommended for VBT boost. Both patients developed grade 2 gastrointestinal toxicity with diarrhea, which was well controlled with symptomatic medication. Both patients are about 1 year from completion of treatment and doing well.