Vaginal stenosis following irradiation therapy for carcinoma of the cervix uteri

Definitive radiation for advanced cervix cancer is not associated with vaginal shortening-a prospective vaginal length and dose correlation

PURPOSE

Prospectively measure change in vaginal length after definitive chemoradiation (C-EBRT) with Intracavitary Brachytherapy (ICBT) for locally advanced cervix cancer (LACC) and correlate with vaginal dose (VD).

MATERIALS AND METHODS

Twenty one female patients with LACC receiving C-EBRT and ICBT underwent serial vaginal length (VL) measurements. An initial measurement was made at the time of the first ICBT procedure and subsequently at 3 month intervals up to 1 year post radiation. The vagina was contoured as a 3-dimensional structure for each brachytherapy plan. The difference in VL before and at least 6 months after the last fraction of brachytherapy was considered as an indicator of toxicity.

RESULTS

The mean initial VL was 8.7 cm (6.5-12) with median value of 8.5 cm. The mean VL after 6 months was 8.6 cm (6.5-12) and VL change was not found to be statistically significant. The median values (interquartile ranges) for vaginal D0.1cc, D1cc, and D2cc were 129.2 Gy (99.6-252.2), 96.9 Gy (84.2-114.9), and 89.6 Gy (82.4-102.2), respectively. No significant correlation was found between vaginal length change and the dosimetric parameters calculated for all patients.

CONCLUSION

Definitive C-EBRT and ICBT did not significantly impact VL in this prospective cohort probably related to acceptable doses per ICRU constraints. Estimate of vaginal stenosis and sexual function was not performed in this cohort which is a limitation of this study and which we hope to study prospectively going forward.

Change in vaginal length and sexual function in women who undergo surgery ± radiation therapy for endometrial cancer

PURPOSE

Endometrial Cancer (EC) is the most common gynecologic malignancy in the United States. Standard treatment is TAH/BSO with radiation therapy (RT) and chemotherapy given based on risk. Treatment can cause significant vaginal changes, including shortening, narrowing, loss of elasticity, atrophy, and dryness. These are not life threatening, but affect a woman's physical, psychological, and social functioning. Adjuvant vaginal dilator use is often advised, but there are inconsistent recommendations on use. This prospective study compared vaginal length changes and sexual function in women compliant with dilation versus not after surgery and RT.

METHODS AND MATERIALS

Enrolled patients underwent surgery for Stage I-IIIC EC ±RT. Vaginal dilator use was recommended for women receiving RT (external beam or brachytherapy). Vaginal length was measured with a vaginal sound and the Female Sexual Function Index (FSFI) was used to assess sexual function.

RESULTS

Forty-one enrolled patients had sufficient data for analysis. Dilation significantly increased FSFI scores (p = 0.02) while RT without dilation showed a significant decrease (p = 0.04). Dilation helped maintain vaginal length for all patients (0 cm vs. 1.8 cm loss (p = 0.03)). Individual arms did not show statistically significant changes in length with dilation, though the trend showed RT without dilation had an average loss of 2.3 cm as compared to only 0.2 cm for regular dilation. Notably, there was no difference in length change with dilation for surgery alone versus surgery and RT (p = 0.14).

CONCLUSION

This data provides novel, prospective evidence of the benefit of vaginal dilation for maintaining vaginal length and improving sexual health after any pelvic treatment for EC. This evidence also supports that the addition of RT after surgery does not appear to significantly worsen vaginal shortening. This study has important implications for providing a strong foundation for future studies and helping to establish solid clinical management criteria for the prevention of vaginal stenosis and promotion of female sexual health.

Vaginal dilator use more than 9 months is a main prognostic factor for reducing G2‑late vaginal complications in 3D‑vaginal‑cuff brachytherapy (interventional radiotherapy)?

PURPOSE

Analyse the impact of different prognostic factors on G2-late vaginal complications after vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) in postoperative endometrial cancer (PEC).

METHODS

One hundred and twenty-six PEC patients treated with VBT ± EBRT were retrospectively analysed considering age, body mass index, applicator diameter, clinical target volume (CTV), use of dilators, chemotherapy and EQD2_(α/β=3) at the most exposed 2 cm³ of the CTV as prognostic factors for vaginal complications. Late vaginal complications were evaluated using objective LENT-SOMA criteria.

STATISTICS

descriptive analysis, Chi-square, Fisher and Student tests were applied. Univariate and multivariate analyses were performed with the Baptista-Pike exact method and multiple logistic regression.

RESULTS

Mean age was 65 years (SD ± 10), and median follow-up was 66 months (8-104). 19/126 patients (15%) showed G2-late vaginal complications, and 107/126 (85%) G0-G1. Univariate analysis showed: CTV ≤ 9 cm³ (p = 0.036), use of dilators < 9 months (p = 0.015), and total ≥ 68 Gy EQD2 received by 2 cm³ of CTV (p = 0.039) were associated with G2-late vaginal toxicity. Multivariate analysis showed the use of dilators < 9 months as an independent prognostic factor for G2-late vaginal toxicity (p = 0.043, OR 8.59, CI 1.59-159.9).

CONCLUSION

The use of dilators < 9 months in VBT ± EBRT for PEC was an independent prognostic factor for G2-late vaginal toxicity. The use of vaginal dilators ≥ 9 months requires further analysis in studies evaluating late vaginal toxicity.

"Labia majora fasciocutaneous flap reconstruction in complex urogynecological fistulas with vaginal deficit - A versatile approach"

OBJECTIVES

To appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of seven cases.

METHODS

Seven patients with complex urogynecological fistulas with vaginal deficit were treated over last three years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all.

RESULTS

All radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of six-month follow-up.

CONCLUSION

Transvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

Vaginal dilator use to promote sexual wellbeing after radiotherapy in gynecological cancer survivors

This study investigated the efficacy of a vaginal dilator (VD) for the treatment of radiation-induced vaginal stenosis (VS) and the effect of a VD on sexual quality of life.Fifty three patients with endometrial or cervical cancers participated in this prospective observational study. All participants were treated with radical or adjuvant external beam radiotherapy and/or brachytherapy. They were routinely examined 4 times after radiotherapy (RT) and were also asked to complete a validated sexual function-vaginal changes questionnaire. SPSS version 20 and Minitab version 16 were used for the statistical analysis. The statistical significance was set at P < .05.The VS grading score decreased and the comfortably insertable VD size gradually increased throughout a year of VD use; all patients with initial grade 3 showed a VS of grade 2 after 12 months of VD use and 65.8% of the patients with initial grade 2 demonstrated a final VS of grade 1, while 77.8% of the participants who started with the first size of VD reached the third size after 12 months. Starting VD therapy ≤3 months after the end of RT was associated with a significant decrease in VS. A total of 60.9% of participants reported that they did not feel their vaginas were too small during intercourse after 12 months of dilation, whereas only 11.5% gave the same answer before starting dilation. Furthermore, 47.17% rated their satisfaction with their sexual life 5 out of 7 and only 3.77% gave a score of 3 after 12 months of dilation.Endometrial and cervical cancer survivors are encouraged to use VD to treat VS and for sexual rehabilitation after RT. This study recommends starting vaginal dilation no more than 3 months after treatment at least 2 to 3 times a week for 10 to 15 minutes over 12 months. However, larger, well-designed randomized clinical trials should be conducted to develop specific guidelines for VD use and efficacy in VS and sexual sexual quality of life after RT.

Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial

BACKGROUND

We aimed to evaluate the effects of different therapeutic options to prevent the evolution of vaginal stenosis after pelvic radiotherapy in women with cervical cancer.

METHODS

open-label randomized clinical trial of 195 women, stage I-IIIB, aged 18-75 years, using topical estrogen (66), topical testosterone (34), water-based intimate lubricant gel (66), and vaginal dilators (29) to assess the incidence and severity of vaginal stenosis after radiotherapy at UNICAMP-Brazil, from January/2013 to May/2018. The main outcome measure was vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE) scale and percental changes in vaginal volume. The women were evaluated at four different times: shortly after the end of radiotherapy, and four, eight, and 12 months after the beginning of the intervention. Statistical analysis was carried out using Symmetry test, Kruskal-Wallis test and multiple regression.

RESULTS

the mean age of women was 46.78 (±13.01) years, 61,03% were premenopausal and 73,84% had stage IIB-IIIB tumors. The mean reduction in vaginal volume in the total group was 25.47%, with similar worsening in the four treatment groups with no statistical difference throughout the intervention period. There was worsening of vaginal stenosis evaluated by CTCAE scale after 1 year in all groups (p < 0.01), except for the users of vaginal dilator (p = 0.37).

CONCLUSIONS

there was a reduction in vaginal volume in all treatment groups analyzed, with no significant difference between them. However, women who used vaginal dilators had a lower frequency and severity of vaginal stenosis assessed by the CTCAE scale after one year of treatment.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials, RBR-23w5fv . Registered 10 January 2017 - Retrospectively registered.

Utilizing Colpocleisis to Repair a Vesicovaginal Fistula in a Cervical Cancer Patient with History of Pelvic Radiation: A Case Report and Literature Review

Background

Vesicovaginal fistula is a rare and distressing urological condition. It is especially prevalent in developing countries with the predominant etiology secondary to obstructed labor. Radiation therapy in female patients with cervical cancer is a risk factor for vesicovaginal fistula formation in the United States. Case Presentation. A 53-year-old woman with a history of cervical cancer and radiation presented with continuous urinary incontinence. Following diagnostic vaginoscopy, a 1 cm vesicovaginal fistula was diagnosed at the vaginal apex. The patient elected for surgical repair. She subsequently underwent successful transvaginal fistula closure using colpocleisis to optimally address the systemic factors of poor wound healing associated with irradiated tissue. Because of the adjacent tissue having been compromised by pelvic radiation, we opted to use a biologic graft made of human cadaveric pericardial tissue (CPT) instead of a native tissue flap to provide additional support for the fistula repair.

Conclusion

A transvaginal approach for surgical repair of vesicovaginal fistula can be successful in patients with a prior history of pelvic radiation. Transvaginal colpocleisis is a viable option to augment vesicovaginal fistula repair for patients with significant comorbidities when sexual intercourse is no longer desired.

Results of a Phase I-II Study on Laser Therapy for Vaginal Side Effects after Radiotherapy for Cancer of Uterine Cervix or Endometrium

Women who have previously received radiotherapy (RT) for gynecologic cancer often suffer from vaginal fibrosis and stenosis. The success of “non-ablative” laser therapy for postmenopausal vaginal atrophy has led to the idea of testing the laser in patients submitted to RT. In this prospective observational study, we selected patients who underwent pelvic RT followed by vaginal laser treatment. We scheduled three treatment sessions (at T0–T1–T2) and three controls (at T1–T2–T3) one month apart. The follow-up (at T4) was carried out six months after the last treatment. Vaginal Health Index (VHI) and vaginal length were evaluated. Sexual function was assessed through Female Sexual Function Index (FSFI). Overall, 43 patients with severe vaginal shortening, atrophy and stenosis was enrolled and treated with intravaginal non-ablative CO₂ laser. We observed a progressive increase in vaginal length of 9% (p = 0.03) at T2 and 28% (p < 0.0001) at T3; effects were maintained at T4 (p < 0.0001). After the first application VHI showed a significant improvement of 57% at T3 (p < 0.0001). The results were maintained at T4 (p < 0.0001). No changes were found in FSFI. All procedures were well tolerated. In conclusion, laser therapy improved vaginal length and VHI in women undergoing pelvic RT; prospective studies are needed.

Intrafractional vaginal dilation in anal cancer patients undergoing pelvic radiotherapy (DILANA) - a prospective, randomized, 2-armed phase-II-trial

BACKGROUND

The incidence of anal cancer is rising in the last decades and more women are affected than men. The prognosis after chemoradiation is very good with complete remission rates of 80-90%. Thus, reducing therapy-related toxicities and improving quality of life are of high importance. With the development of new radiotherapy techniques like IMRT (Intensity-modulated radiotherapy), the incidence of acute and chronic gastrointestinal toxicities has already been reduced. However, especially in female anal cancer patients genital toxicities like vaginal fibrosis and stenosis are of great relevance, too. Up to now, there are no prospective data reporting incidence rates, techniques of prevention or impact on quality of life. The aim of the DILANA trial is to evaluate the incidence and grade of vaginal fibrosis, to optimize radiotherapy by reducing dose to the vaginal wall to minimize genital toxicities and improve quality of life of anal cancer patients.

METHODS

The study is designed as a prospective, randomized, two-armed, open, single-center phase-II-trial. Sixty patients will be randomized into one of two arms, which differ only in the diameter of a tampon used during treatment. All patients will receive standard (chemo) radiation with a total dose of 45-50.4 Gy to the pelvic and inguinal nodes with a boost to the anal canal up to 54-60 Gy. The primary objective is the assessment of the incidence and grade of vaginal fibrosis 12 months after (chemo) radiation depending on the extent of vaginal dilation. Secondary endpoints are toxicities according to the CTC AE version 5.0 criteria, assessment of clinical feasibility of daily use of a tampon, assessment of compliance for the use of a vaginal dilator and quality of life.

DISCUSSION

Prospective studies are needed evaluating the incidence and grade of vaginal fibrosis after (chemo) radiation in female anal cancer patients. Furthermore, the assessment of techniques to reduce the incidence of vaginal fibrosis like intrafractional vaginal dilation as well as other radiotherapy-independent methods like using a vaginal dilator are essential. Additionally, implementation of a systematic assessment of vaginal stenosis is necessary to grant reproducibility and comparability of future data.

TRIAL REGISTRATION

The trial is registered with clinicaltrials.gov (NCT04094454, 19.09.2019).

DW-MRI predictive factors for radiation-induced vaginal stenosis in patients with cervical cancer

AIM

To find diffusion-weighted (DW) magnetic resonance imaging (MRI) parameters predictive for radiation-induced vaginal stenosis (VS) in locally advanced cervical cancer (LACC) treated with neoadjuvant chemoradiation therapy (CRT).

MATERIALS AND METHODS

Retrospective analysis of 43 patients with LACC who underwent 1.5 T DW-MRI before (baseline), after 2 weeks (early), and at the end of CRT (final). At MRI, vaginal length, thickness, width, and cervical tumour volume (TV) were measured. Vaginal signal intensity at DW-MRI was analysed at final MRI. CRT-induced VS was graded using Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Correlations between DW-MRI and clinical data were made using Wilcoxon's test, Mann-Whitney test, Fisher's exact test, or chi-squared test as appropriate. Receiver operating characteristic (ROC) curves were generated for variables to evaluate diagnostic ability to predict CRT-induced VS using a logistic regression model.

RESULTS

Asymptomatic vaginal toxicity (CTCAE Grade 1) was observed in 14 patients and symptomatic CRT-induced VS (CTCAE Grade ≥2) was detected in 29 patients. Baseline TV was higher in Grade 1 than in Grade ≥2 (p=0.013). Median vaginal length, thickness, and width decreased between baseline and final MRI in all patients (p<0.0001) without significant variances between CTCAE grades. Significant differences were observed in DW-MRI patterns (p<0.0001). In Grade ≥2, DWI showed signal loss of vaginal mucosa in 17 patients (63%) and diffuse restricted diffusion of vaginal wall in eight patients (30%). AUC was 0.938 (coefficient=4.72; p<0.001) for DWI and 0.712 (coefficient=-2.623×10 ^-5; p=0.004) for TV.

CONCLUSIONS

This is the first study using DW-MRI for predicting CRT-induced VS. DWI is useful tool in patients with LACC after CRT for early prevention and management strategies for VS.

[Acquired vaginal stenosis: about a case and literature review]

Vaginal stenosis or gynatresia is a congenital disease and it is part of Mayer-Rokitansky-Kustner-Hauser syndrome. Acquired vaginal stenosis is a rare complication of vaginal delivery and may be caused by an infection, charlatans, birth injury or postpartum hypoestrogeny. We report a case of postpartum complete vaginal stenosis secondary to vaginal injuries as a result of medical negligence. The study involved a 19 year old patient, who had had dead child born vaginally at home, presenting with a two-year history of secondary amenorrhea associated with chronic pelvic pain. The patient reported the occurrence of multiple not sutured vaginal tears. Pelvic MRI showed complete extended vaginal stenosis of about 25mm with upstream haematological retention and bilateral hematosalpinx. The patient underwent release of vaginal adhesions followed by regular vaginal dilation. Only two cases have been reported in the literature. Pain and dyspareunia were the most common symptoms. All cases were treated by a release of the synechias and vaginal dilation.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PURPOSE

Guidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.

METHODS AND MATERIALS

A comprehensive literature review (1972-2017) was conducted using search terms "vaginal stenosis," "radiation," and "vaginal dilator." Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.

RESULTS

VS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.

CONCLUSIONS

This review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.

The impact of vaginal dilator use on vaginal stenosis and sexual quality of life in women treated with adjuvant radiotherapy for endometrial cancer

BACKGROUND

Despite a lack of evidence and low compliance, current guidelines recommend the use of a vaginal dilator (VD) after pelvic radiotherapy (RT). We analyzed the effect of VD on vaginal stenosis (VS) and its influence on sexual quality of life (QoL) in women treated with adjuvant RT for endometrial cancer (EC).

METHODS

Between 2014 and 2015, 56 consecutive patients were instructed to use a VD after completion of treatment. The maximum diameter of the comfortably introducible VD was measured before and at 1 year after treatment. The degree of VS was evaluated clinically, and sexual QoL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) sexual functioning items before RT, during RT, at 6 weeks, and at 1 year after RT.

RESULTS

One year after RT, mean VD diameter had decreased by 2.7 ± 3.2 mm (p < 0.001) and 36 patients (64.3%) had clinical VS (grade I-III). A larger decrease in VD diameter correlated with a higher degree of clinical VS (p < 0.001). VD use (p = 0.81), RT modality (p = 0.68), and adjuvant ChT (p = 0.87) had no influence on VD diameter. Sexual activity decreased during RT and increased beyond pre-RT values 1 year after RT (p < 0.001). Sexual enjoyment decreased continuously during and after completion of RT (p = 0.013) and was influenced negatively by a higher degree of clinical VS (p = 0.01).

CONCLUSION

Almost two thirds of patients developed clinical VS 1 year after adjuvant RT for EC, and sexual enjoyment was substantially reduced by VS. The use of a VD after RT may not serve to prevent sexual impairments and VS.

AVALIAÇÃO E CLASSIFICAÇÃO DA ESTENOSE VAGINAL NA BRAQUITERAPIA: VALIDAÇÃO DE CONTEÚDO DE INSTRUMENTO PARA ENFERMEIROS

RESUMO Objetivo: validar os conteúdos de um instrumento elaborado para avaliação e classificação da estenose vaginal pós-braquiterapia para aplicação por enfermeiros. Método: estudo metodológico que incluiu dez enfermeiros experts em braquiterapia. A coleta de dados foi realizada entre dezembro de 2015 a abril de 2016 e ocorreu com a aplicação de formulário disponibilizado aos experts via ferramenta do Google Drive/Microsoft® em três rodadas de validação, conduzida pela Técnica Delphi; 12 conteúdos foram avaliados. A análise dos dados ocorreu pelo cálculo do Índice de Validade de Conteúdo - IVC. Resultados: na primeira rodada, o uso de absorventes íntimos (tampões) foi excluído (IVC=0,4), outros conteúdos foram ajustados, bem como a aparência do instrumento, de acordo com as recomendações dos experts. Os conteúdos na terceira rodada de avaliação atingiram o IVC=1. Conclusão: a validação de conteúdo de instrumento padroniza a técnica, consequentemente, incrementa e qualifica a prática clínica e o desenvolvimento de pesquisas.

Factors associated with changes in vaginal length and diameter during pelvic radiotherapy for cervical cancer

OBJECTIVES

This study reports the incidence and factors associated with vaginal stenosis and changes in vaginal dimensions after pelvic radiotherapy for cervical cancer.

METHODS

A descriptive longitudinal study with 139 women with cervical cancer was conducted from January 2013 to November 2015. The outcome variables were vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE v3.0) and changes in vaginal diameter and length after the end of radiotherapy. Independent variables were the characteristics of the neoplasm, clinical and sociodemographic data. Bivariate analysis was carried out using χ ², Kruskal-Wallis and Mann-Whitney's test. Multiple analysis was carried out using Poisson regression and a generalized linear model.

RESULTS

Most women (50.4%) had stage IIIB tumors. According to CTCAE v3.0 scale, 30.2% had no stenosis, 69.1% had grade 1 and 0.7% had grade 2 stenosis after radiotherapy. Regarding changes in vaginal measures, the mean variation in diameter was - 0.6 (± 1.7) mm and the mean variation in length was - 0.6 (± 1.3) cm. In the final statistical model, having tumoral invasion of the vaginal walls (coefficient + 0.73, p < 0.01) and diabetes (coefficient + 1.16; p < 0.01) were associated with lower vaginal stenosis and lower reduction of vaginal dimensions. Advanced clinical stage (coefficient + 1.44; p = 0.02) and receiving brachytherapy/teletherapy (coefficient - 1.17, p < 0.01) were associated with higher reduction of vaginal dimensions.

CONCLUSIONS

Most women had mild vaginal stenosis with slight reductions in both diameter and length of the vaginal canal. Women with tumoral invasion of the vagina have an increase in vaginal length soon after radiotherapy due to a reduction in tumoral volume.

Radiation-induced vaginal stenosis: current perspectives

Treatment of gynecological cancer commonly involves pelvic radiation therapy (RT) and/or brachytherapy. A commonly observed side effect of such treatment is radiation-induced vaginal stenosis (VS). This review analyzed the incidence, pathogenesis, clinical manifestation(s) and assessment and grading of radiation-induced VS. In addition, risk factors, prevention and treatment options and follow-up schedules are also discussed. The limited available literature on many of these aspects suggests that additional studies are required to more precisely determine the best management strategy of this prevalent group after RT.

[Comparison of survival and chronic gastrointestinal toxicities in patients with locally advanced cervical cancer, treated by conventional or intensity-modulated radiation technique]

PURPOSE

To evaluate prospectively chronic gastrointestinal toxicity in patients with cervical cancer treated with conventional irradiation or with intensity-modulated irradiation (IMRT).

PATIENTS AND METHODS

Between June 2005 and September 2013, 109 patients underwent external radiotherapy followed by brachytherapy for cervical cancer at the "Institut de Cancérologie de Lorraine". Each patient receiving IMRT was paired with a patient receiving conventional radiotherapy on the following criteria: concomitant chemotherapy, additional nodal dose, treatment of para-aortic lymph node area, age. The toxicity collection was prospective using the RTOG scale. The main objective was to compare the incidence of gastrointestinal toxicity chronic between the two groups. In a second time, the influence of dosimetric parameters on chronic GI toxicity was investigated. Comparisons of acute toxicity, chronic genitourinary toxicities, overall survival, disease-free survival were secondary objectives.

RESULTS

Sixty-six patients were able to be matched. Overall survival at 36 months was 71% in the conventional radiotherapy group against 73% in the IMRT group (P=0.54). There was no significant difference between the two groups in terms of digestive chronic toxicity (P=0.17), nor in terms acute gastrointestinal toxicities (P=0.6445) and genitourinary (P=0.5724). IMRT spared significantly small bowel (P=0.0006) and rectum (P=0.0046) from 30Gy dose, and bladder from 45Gy (P<0.001). The incidence of genitourinary toxicity was significantly different between the two groups (P=0.03) in favor of conventional radiotherapy.

CONCLUSION

Our study does not seem to show significant difference in the occurrence of chronic gastrointestinal toxicities between the two groups. Clinical efficacy seems comparable. Larger studies with longer follow-up period should be conducted.

Pelvic-Floor Properties in Women Reporting Urinary Incontinence After Surgery and Radiotherapy for Endometrial Cancer

BACKGROUND

Endometrial cancer is the fourth most prevalent cancer in Canadian women. Radiotherapy (RT) is frequently recommended as an adjuvant treatment. There is a high prevalence (>80%) of urinary incontinence (UI) after RT. It is plausible that UI is associated, at least in part, with alterations of the pelvic-floor muscles (PFM).

OBJECTIVE

The aim of this exploratory study was to compare the PFM functional properties of women reporting UI after hysterectomy and RT for endometrial cancer with those of women with a history of hysterectomy but without UI.

DESIGN

A descriptive cross-sectional study was conducted. Eleven women were recruited for the affected group, and 18 were recruited for the comparison group.

METHODS

Urogenital and bowel functions were assessed using International Consultation on Incontinence Questionnaires, and PFM properties were evaluated using a Montreal dynamometer. Nonparametric tests were used for comparison of personal characteristics, functional status, and muscle properties. A correspondence analysis detailed the association between UI severity and PFM properties.

RESULTS

Maximal opening of dynamometer branches, maximal vaginal length, PFM maximum force and rate of force development in a strength test, and number of rapid contractions during a speed test were reduced in the affected group. No significant difference was found for the endurance test. The severity of UI was found to correspond to the rate of force development and the number of rapid contractions in a speed test, endurance, age, and vaginal length.

LIMITATIONS

The results are limited to the population studied. The small sample size limited the strength of the conclusions.

CONCLUSIONS

Some evidence of alterations in PFM properties were found in women with UI after hysterectomy and RT for endometrial cancer. These alterations appeared to be associated with UI, suggesting a possible role for rehabilitation.

The effect of pelvic radiotherapy on vaginal brachytherapy cylinder diameter: Implications for optimal treatment order

PURPOSE

To determine the factors that correlate with cylinder size in vaginal brachytherapy (VB) after hysterectomy for endometrial carcinoma.

METHODS AND MATERIALS

Patients treated for endometrial cancer from January 1, 2003 to December 31, 2013 were reviewed from a single institution. Patients included underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy followed by high-dose-rate VB with or without external beam pelvic radiotherapy (EBRT). According to institutional guidelines, the vaginal cylinder size selected was the largest diameter cylinder the patient could comfortably accommodate. Patient, tumor, and treatment factors were recorded and compared with cylinder size.

RESULTS

Three hundred eighty-one eligible patients were identified, including 121 patients treated with pelvic radiotherapy (RT) before VB and 260 treated with VB alone. On univariate analysis, weight (p = 0.0004), body mass index (BMI) (p = 0.001), and receipt of pelvic RT (p ≤ 0.0001) were the only statistically significant factors correlated with vaginal cylinder size. On multivariate analysis, receipt of EBRT retained significance after adjusting for weight or BMI. In patients receiving VB alone, median cylinder size was 3 cm; after pelvic RT, it was 2.5 cm.

CONCLUSIONS

Higher weight and BMI correlated with accommodation of larger cylinder size. Accounting for this, the receipt of EBRT before VB was associated with smaller cylinder size. Dosimetric data show that larger cylinder size provides superior dose distribution. Although historically the VB boost follows EBRT, reversal of this order may be preferred.

EVALUATION AND CLASSIFICATION OF VAGINAL STENOSIS AFTER BRACHYTHERAPY

ABSTRACT This narrative review identified, in the scientific production, the methods used for evaluating and classifying vaginal stenosis in women who have undergone brachytherapy. Data collection was undertaken in July 2013 in the publications of SciELO, MEDLINE and PubMed, without time limits, and in studies cited by two scientific reviews which addressed the issue investigated here. The search protocol included the description of the method for evaluating and classifying vaginal stenosis. Comparative analysis between the findings showed there to be diversity among the methods used by different researchers. In the light of this finding, this study proposes elements for making an evaluative instrument to be applied by nurses. The standardization of the technique will help in the early detection of vaginal stenosis and in the care for women subsequent to vaginal brachytherapy.

Prospective study of vaginal dilator use adherence and efficacy following radiotherapy

BACKGROUND AND PURPOSE

Vaginal stenosis (VS) after pelvic radiotherapy (RT) can impair long-term quality of life. We prospectively assessed adherence and efficacy of vaginal dilator (VD) use in women after pelvic RT.

MATERIAL AND METHODS

Women with gastrointestinal (n=63) and gynecologic (n=46) cancers self-reported use and VD size in monthly diaries for 12months after radiotherapy. Adherence was measured as actual VD use out of recommended times over 12months (3×/week×52weeks=156).

RESULTS

Among 109 participants, aged 28-81years (median, 58years), mean percent adherence over 12months was 42% (95% confidence interval [CI], 36-48%). Adherence was highest in the first quarter (56%), but fell to 25% by the fourth. Disease type, treatment sequence, and chemotherapy were predictors of adherence (all P<.05). Eighty-two percent maintained pre-RT VD size at 12months; of 49% with a decrease in VD size at 1month post-RT, 71% returned to pre-RT VD size at 12months. Disease type, younger age, and increased adherence at 6months were associated with maintaining or returning to pre-RT size at 12months (all P⩽.05).

CONCLUSION

VD use is effective in minimizing VS, but adherence at 12months was poor. Studies evaluating methods of improving adherence and determining the optimal frequency and duration of use are needed.

Predictors of vaginal stenosis after intravaginal high-dose-rate brachytherapy for endometrial carcinoma

PURPOSE

Intravaginal high-dose-rate brachytherapy is an effective adjuvant treatment for localized endometrial carcinoma. However, relatively little is known about risk factors of post-treatment vaginal stenosis (VS).

METHODS AND MATERIALS

We included patients treated with brachytherapy for endometrial carcinoma from September 2011 to January 2014 with at least 3 months of followup. Patients who received external beam radiation therapy were excluded. VS was prospectively graded at each followup visit per Common Terminology Criteria for Adverse Events, version 4.03. χ(2) and t test analyses were used to assess the association of VS with various patient, tumor, treatment, and post-treatment factors. Multivariable logistic regression analysis was used to identify independent predictors of VS Grade ≥1 and ≥2.

RESULTS

All 101 patients were disease free at last followup. Mean followup was 12.9 months (range, 3-34). Highest VS grades were zero in 67%, one in 26%, two in 6%, and three in 1%. Borderline significant variables associated with Grade ≥1 VS included vagina length, proportion of vagina treated, and total dose. Dilator use was significantly associated with Grade ≥2. Multivariable analysis revealed that proportion of vagina treated >60% (odds ratio [OR], 3.48; p = 0.009) and total dose >14 Gy (OR, 4.27; p = 0.015) were independent predictors of Grade ≥1 VS, and lack of consistent dilator use was an independent predictor of Grade ≥2 VS (OR, 5.60; p = 0.047).

CONCLUSIONS

Patients treated with a higher total dose to a larger proportion of the vagina were more likely to develop Grade ≥1 VS. Consistent dilator use may also be protective against Grade ≥2 VS.

Vaginal dilator therapy for women receiving pelvic radiotherapy

BACKGROUND

Vaginal dilation therapy is advocated after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina), but can be uncomfortable and psychologically distressing.

OBJECTIVES

To assess the benefits and harms of different types of vaginal dilation methods offered to women treated by pelvic radiotherapy for cancer.

SEARCH METHODS

Searches included the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 5), MEDLINE (1950 to June week 2, 2013), EMBASE (1980 to 2013 week 24) and CINAHL (1982 to 2013).

SELECTION CRITERIA

Comparative data of any type, which evaluated dilation or penetration of the vagina after pelvic radiotherapy treatment for cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. We found no trials and therefore analysed no data.

MAIN RESULTS

We identified no studies for inclusion in the original review or for this update. However, we felt that some studies that were excluded warranted discussion. These included one randomised trial (RCT), which showed no improvement in sexual scores associated with encouraging women to practise dilation therapy; a recent small RCT that did not show any advantage to dilation over vibration therapy during radiotherapy; two non-randomised comparative studies; and five correlation studies. One of these showed that objective measurements of vaginal elasticity and length were not linked to dilation during radiotherapy, but the study lacked power. One study showed that women who dilated tolerated a larger dilator, but the risk of objectivity and bias with historical controls was high. Another study showed that the vaginal measurements increased in length by a mean of 3 cm after dilation was introduced 6 to 10 weeks after radiotherapy, but there was no control group; another case series showed the opposite. Three recent studies showed less stenosis associated with prophylactic dilation after radiotherapy. One small case series suggested that dilation years after radiotherapy might restore the vagina to a functional length.

AUTHORS' CONCLUSIONS

There is no reliable evidence to show that routine, regular vaginal dilation during radiotherapy treatment prevents stenosis or improves quality of life. Several observational studies have examined the effect of dilation therapy after radiotherapy. They suggest that frequent dilation practice is associated with lower rates of self reported stenosis. This could be because dilation is effective or because women with a healthy vagina are more likely to comply with dilation therapy instructions compared to women with strictures. We would normally suggest that a RCT is needed to distinguish between a casual and causative link, but pilot studies highlight many reasons why RCT methodology is challenging in this area.

Vaginal dose point reporting in cervical cancer patients treated with combined 2D/3D external beam radiotherapy and 2D/3D brachytherapy

BACKGROUND AND PURPOSE

Traditionally, vaginal dose points have been defined at the vaginal source level, thus not providing dose information for the entire vagina. Since reliable vaginal dose volume/surface histograms are unavailable, a strategy for comprehensive vaginal dose reporting for combined EBRT and BT was established and investigated.

MATERIAL AND METHODS

An anatomical vaginal reference point was defined at the level of the Posterior-Inferior Border of Symphysis (PIBS), plus two points ±2 cm (mid/introitus vagina). For BT extra points were selected for the upper vagina at 12/3/6/9 o'clock, at the vaginal surface and 5 mm depth. A vaginal reference length (VRL) was defined from ring centre to PIBS. Fifty-nine patients treated for cervical cancer were included in this retrospective feasibility study.

RESULTS

The method was applicable to all patients. Total EQD2 doses at PIBS and ±2 cm were 36.7 Gy (3.1-68.2), 49.6 Gy (32.1-89.6) and 4.3 Gy (1.0-46.6). At the vaginal surface at ring level doses were respectively 266.1 Gy (67.6-814.5)/225.9 Gy (61.5-610.5) at 3/9 o'clock, and 85.1 Gy (55.4-140.3)/72.0 Gy (49.1-108.9) at 12/6 o'clock. Mean VRL on MRI was 5.6 cm (2.0-9.4).

CONCLUSIONS

With this novel system, a comprehensive reporting of vaginal doses is feasible. The present study has demonstrated large dose variations between patients observed in all parts of the vagina, resulting from different contributions from EBRT and BT.

Can an educational intervention improve compliance with vaginal dilator use in patients treated with radiation for a gynecological malignancy?

OBJECTIVE

To investigate whether an educational intervention would facilitate compliance with vaginal dilators and potentially reduce stenosis in women receiving radiotherapy as treatment for a gynecological malignancy.

METHODS

From 2002 to 2009, all patients undergoing pelvic radiotherapy (either external beam radiotherapy or brachytherapy) at our center for treatment of gynecological malignancies were educated about the use of vaginal dilators. Sixty patients agreed to participate in a prospective 12-month study to evaluate use. The patients had a structured educational intervention regarding dilator use. Assessment was prospectively performed via questionnaires at baseline, 3, 6, 9, and 12 months after completion of radiotherapy. Data collected included patients' demographics, treatment, incidence of stenosis, and usage of and attitudes toward dilator use.

RESULTS

The median age of the patients was 60 years. Primary disease site was the uterus (56.6%) and cervix (40.0%). At 12 months, 52% of patients were still using the dilators, and 35% were using the dilators at least 2 to 3 times per week. Frequency of dilator use was greater in those patients older than 50 years (P = 0.005), even after adjusting for sexual frequency, and in those experiencing pain on vaginal examination (P < 0.001). It was less frequent in those patients who were sexually active (P = 0.035). At 12 months, 11% of the patients had flimsy adhesions and 6.5% had partial stenosis. No patients had complete stenosis. The only independent predictor of stenosis was the treatment group with a hazard ratio of 0.200 (95% confidence interval, 0.059-0.685), favoring surgery and any radiotherapy reducing the risk of stenosis compared to definitive radiation therapy alone.

CONCLUSIONS

Our educational intervention facilitates compliance with vaginal dilators. Surgery and adjuvant radiation therapy (with or without cisplatin as a radiation sensitizer) may predict a lower risk of vaginal stenosis compared to definitive radiation therapy alone.

Chore or priority? Barriers and facilitators affecting dilator use after pelvic radiotherapy for gynaecological cancer

PURPOSE

Pelvic radiotherapy for gynaecological cancer often leads to damage of the vaginal mucosa, resulting in stenosis (obstruction by scar tissue). Stenosis has been associated with sexual dysfunction and can hinder medical examinations to detect recurrence. The use of vaginal dilators is frequently recommended to prevent or minimise stenosis, but women are reluctant to use these devices. The aim of this study was to explore the patient experience of dilator use and identify the barriers and facilitators affecting compliance with clinician recommendations.

METHODS

Women were eligible for the study if they had undergone pelvic radiotherapy for gynaecological cancer up to 2 years ago and received a vaginal dilator as part of their post-treatment rehabilitation. Fifteen participants completed a semi-structured interview.

RESULTS

Barriers to dilator use included: uncertainty about how/when to use dilators, viewing it as a negative experience, lack of time or forgetting and the need for discretion due to an association with sex aids. Facilitators included: concern about stenosis, belief that dilators work, reminders of stenosis, acceptance of dilator use as part of their normal routine or an extension of medical treatment and focusing on positive aspects. These factors were incorporated into a model of dilator use based on the Health Belief Model.

CONCLUSIONS

This is the first qualitative study to specifically investigate the patient experience of dilator use. The barriers and facilitators identified in this study and the proposed theory-based model provide new insights to inform future research and clinical management of dilator use.

Patient compliance with the use of vaginal dilators following pelvic radiotherapy for a gynaecological cancer

Background: In July 2005 the national forum of gynaecological oncology nurses published the first UK best practice guidelines for the use of vaginal dilators after pelvic radiotherapy. It was written following a Cochrane review by Denton and Maher suggesting that vaginal dilators minimised vaginal stenosis and improved sexual function. Women within the author’s large cancer centre are advised to use vaginal dilators in accordance with the national recommendations.

Primary outcome measure: To evaluate compliance with the use of vaginal dilators in women who have received radiotherapy for either cervix or endometrial cancer. Compliance was defined as the use of vaginal dilators two or more times a week, at 6 months.

Design: One hundred and sixty-four women were posted questionnaires. Potential participants had received pelvic radiotherapy for cancer of the cervix or endometrium, were 6 months to 5 years post-treatment and disease free. The 18-point questionnaire consisted of 11 points assessing demographics and dilator use, while points 12–18 related to vaginal symptoms. Simple descriptive statistics were used to describe demographics. Mann–Whitney U and Fisher’s exact tests were used for one-at-a-time analysis of compliance against age, vaginal symptoms, treatment modality and cancer type.

Results: Seventy-five completed questionnaires were returned (response rate 45.7%). Seventy-four out of the 75 respondents had been offered vaginal dilators during treatment. 89.2% (66/74) were compliant with vaginal dilation (95% confidence interval 80.1% to 94.4%).

Conclusion: The compliance rate in this study was greater than seen in previously published studies. This could be due to the intervention by practitioners within the author’s cancer centre. Further prospective evaluation studies are required to explore the potential benefits of intervention at 6 months post-treatment to improve long-term compliance.

Topic update: effects of colorectal cancer treatments on female fertility and potential methods for fertility preservation

PURPOSE

Preservation of fertility in young females with a diagnosis of colorectal cancer is gaining increasing importance as survival rates of cancer increase. This review examines the effects of pelvic surgery, chemotherapy, and radiotherapy on fecundity. It also discusses the options available to patients including ovarian transposition, gonadotropin-releasing hormone analogs, embryo and ovarian cryopreservation, and ovarian tissue transplantation.

METHODS

A search of MEDLINE, EMBASE, and the Cochrane library was performed using keywords and exploded Mesh search headings and the subsequent articles were reviewed. Relevant studies were included.

RESULTS

There are no studies that examine the effect of surgery for colorectal cancer on female fertility, in particular, surgery below the peritoneal reflection for rectal cancer. However, patients with familial adenomatous polyposis have a similar fecundity before and after proctocolectomy with ileal pouch-anal anastomosis. These patients did significantly better than patients with ulcerative colitis who underwent the same procedure. There is conflicting evidence regarding the effects of open vs laparoscopic surgery on fertility. Oxaliplatin, an adjuvant therapy, has moderate gonadotoxic effects. Fluorouracil is considered to have almost no effect on human reproductive function. Gonadotropin-releasing hormone agonists are currently used to preserve female fecundity during chemotherapy. A recent update of patients treated for Hodgkin lymphoma showed that significantly fewer women treated with a gonadotropin-releasing hormone agonist during chemotherapy exhibited premature ovarian failure. Ovarian transposition reduces the radiation dose to approximately 5% to 10% of the dose to the ovaries in their normal position. Other options are available to women with cancer who wish to preserve their germ line, including embryo and oocyte cryopreservation and ovarian tissue cryopreservation.

CONCLUSION

Significant advances are now allowing females to preserve their fertility after cancer treatment. It is essential that patients receive adequate fertility counseling before any intervention to give them an opportunity to consider fertility alternatives.

Vaginal dilator therapy for women receiving pelvic radiotherapy

BACKGROUND

Many vaginal dilator therapy guidelines advocate routine vaginal dilation during and after pelvic radiotherapy to prevent stenosis (abnormal narrowing of the vagina). The UK Gynaecological Oncology Nurse Forum recommend dilation "three times weekly for an indefinite time period". The UK patient charity Cancer Backup advises using vaginal dilators from two to eight weeks after the end of radiotherapy treatment. Australian guidelines recommend dilation after brachytherapy "as soon as is comfortably possible" and "certainly within four weeks and to continue for three years or indefinitely if possible". However, dilation is intrusive, uses health resources and can be psychologically distressing. It has also caused rare but very serious damage to the rectum.

OBJECTIVES

To review the benefits and harms of vaginal dilation therapy associated with pelvic radiotherapy for cancer.

SEARCH STRATEGY

Searches included the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4), MEDLINE (1950 to 2008), EMBASE (1980 to 2008) and CINAHL (1982 to 2008).

SELECTION CRITERIA

Any comparative randomised controlled trials (RCT) or data of any type which compared dilation or penetration of the vagina after pelvic radiotherapy treatment for cancer.

DATA COLLECTION AND ANALYSIS

The review authors independently abstracted data and assessed risk of bias. We analysed the mean difference in sexual function scores and the risk ratio for non-compliance at six weeks and three months in single trial analyses. No trials met the inclusion criteria.

MAIN RESULTS

Dilation during or immediately after radiotherapy can, in rare cases, cause damage and there is no persuasive evidence from any study to demonstrate that it prevents stenosis. Data from one RCT showed no improvement in sexual scores in women who were encouraged to practice dilation. Two case series and one comparative study using historical controls suggest that dilation might be associated with a longer vaginal length but these data cannot reasonably be interpreted to show that dilation caused the change in the vagina.

AUTHORS' CONCLUSIONS

Routine dilation during or soon after cancer treatment may be harmful. There is no reliable evidence to show that routine regular vaginal dilation during or after radiotherapy prevents the late effects of radiotherapy or improves quality of life. Gentle vaginal exploration might separate the vaginal walls before they can stick together and some women may benefit from dilation therapy once inflammation has settled but there are no good comparative supporting data.

Management of vulvovaginal strictures/shortened vagina

Vaginal strictures are generally difficult to manage and tend to reccur despite appropriate initial therapy. Vaginal dilation with or without surgery is the main stay of treatment. Causes, diagnosis and management of the vulvovaginal strictures are presented.

Dilating the vagina to prevent damage from radiotherapy: systematic review of the literature

BACKGROUND

UK guidelines recommend routine vaginal dilation during and after pelvic radiotherapy to prevent stenosis.

OBJECTIVE

To examine critically the evidence behind this guideline.

SEARCH STRATEGY

Cochrane-style systematic review of the data and literature relevant to vaginal dilation and stenosis attributable to radiotherapy.

SELECTION CRITERIA

Any and every measure of vaginal or sexual function after radiotherapy.

DATA COLLECTION AND ANALYSIS

Numerous papers gave recommendations on dilation during or immediately after radiotherapy, but only seven contained relevant data. Case reports describe vaginal fistulas or psychological morbidity. Two trials showed that encouraging dilation increased compliance, but the first trial found no difference in sexual function scores. One comparative unmatched trial showed no advantage from inserting mitomycin C. A report of five women implied that stenosis can be treated by dilation many years after radiotherapy. One uncontrolled observational report involving 89 women showed that the median vaginal length 6-10 weeks after therapy was measured at 6 cm, but women tolerated a 9-cm measurer after 4 months of dilation experience. One retrospective report implied that dilation lowered stenosis rates, but the control group is not comparable.

MAIN RESULTS

Dilation during or immediately after radiotherapy can cause damage, and there is no evidence that it prevents stenosis. Dilation might stretch the vagina if commenced after the inflammatory phase.

AUTHOR'S CONCLUSIONS

Dilation might help treat the late effects of radiotherapy, but it must not be assumed that this applies to the acute toxicity phase. Routine dilation during treatment is not supported by good evidence.

Frequency of esophageal stenosis after simultaneous modulated accelerated radiation therapy and chemotherapy for head and neck cancer

BACKGROUND

Chronic esophageal toxicity after radiotherapy alone for cancer of the head and neck (HNCa) is rare: 2.6% for strictures and 0.8% for stenosis after a 60-Gy dose. With combined modality therapy, stricture rates of 22% to 37% have been reported. We report the frequency of esophageal toxicity after simultaneous modulated accelerated radiation therapy (SMART) with chemotherapy for HNCa.

METHODS

The records of the otolaryngology/head and neck surgery department of Emory University, Atlanta, GA, were screened for patients undergoing combined modality therapy using SMART for HNCa. Radiation Oncology records were reviewed for target and critical normal structure dosimetry, with detailed analysis of esophageal and supraglottic laryngeal dosimetry. Hospital and clinic records were reviewed for evidence of esophageal toxicity.

RESULTS

From January 2003 to August 2005, 99 patients underwent definitive therapy for squamous cell HNCa using SMART and chemotherapy. Follow-up was documented in all cases. Median dose to sites of gross primary or nodal disease was 70.29 Gy, at 2.13 Gy per fraction. Median dose to the ipsilateral neck was 63.03 Gy at 1.91 Gy per fraction. Median dose to the contralateral neck in 97 patients treated was 57.75 Gy at 1.75 Gy per fraction. Thirteen (13%) patients developed esophageal strictures. Five (5%) patients had complete esophageal stenosis. Four (14%) of the 29 patients with either a hypopharyngeal primary or a N2c nodal disease developed complete stenosis. A statistically larger esophageal volume of esophagus reactivity > or = 60 Gy (V(60)) was found in patients who developed stenosis/stricture when compared with a randomly selected population of N2a/b patients who did not develop those toxicities. Esophageal stenosis/stricture was also numerically more common in patients receiving taxane-based chemotherapy, developing in 23%, as opposed to 9% in patients treated with platinum-based chemotherapy.

CONCLUSION

The risk of esophageal stenosis may increase with SMART and chemotherapy for HNCa. Potential mechanisms to reduce this include (a) contouring the esophagus as a dose-limiting structure; (b) early flexible examination posttreatment, with early intervention with dilation; (c) improved therapy for mucositis.

Measurement of vaginal length: Reliability of the vaginal sound--a Gynecologic Oncology Group study

A decrease in vaginal length associated with treatments for gynecological malignancies, particularly pelvic radiotherapy, negatively impacts sexuality. Research into this important problem has been hampered by a lack of instrumentation to measure vaginal length. The Gynecologic Oncology Group recently evaluated the reliability of an instrument, the "vaginal sound," designed to measure vaginal length. Eighty-eight physicians and nurses attended a training session in the use of the vaginal sound that included a clinical practicum with live models. Reliability was assessed at the time of the practicum. The instrument performed well, with vaginal lengths in models without cancer in the upper range of normal as documented by Masters and Johnson. The vaginal sound also appeared to be sensitive to hypothesized changes in vaginal length. Interrater reliability was high with intraclass correlation coefficients of 0.88 among instructors and 0.76 among trainees. In conclusion, the vaginal sound is a simple, yet reproducible measure and adds methodologic rigor to studies of vaginal length.

Vaginal stenosis in patients treated with radiotherapy for carcinoma of the cervix

The aim of our study was to determine the incidence, timing, and severity of vaginal stenosis in patients with carcinoma of the cervix who had received pelvic and/or vaginal radiotherapy as part of their treatment. We also sought to determine if there were any predisposing factors for the development of stenosis. A retrospective chart review was undertaken for all the patients diagnosed with carcinoma of the cervix between January 1, 1990, and December 31, 2000 and treated with pelvic and/or vaginal radiation at Westmead Hospital. Since January 1, 1990, data regarding vaginal stenosis has been prospectively recorded on all the patients. Data collected included patient demographics, stage of disease, treatments administered, and incidence, timing, and severity of vaginal stenosis. One hundred and eighty-eight patients were treated. Mean age was 58.6 years. Thirteen percent of patients had stage IB disease, 45% had stage II disease, 39.5% had stage III disease, and 1.5% had stage IV disease. One hundred and seventy-nine patients returned for follow-up, and data regarding vaginal toxicity were available in 98%. Twenty-seven percent had grade 1 toxicity (partial stenosis or shortening but not complete occlusion), and 11% had grade 2 (complete occlusion). Stenosis of any grade was noted at a mean of 9.6 months and median of 7.5 months (range, 26 days-5.6 years) from completion of treatment. The only prognostic factor associated with increased risk of stenosis was age greater than 50 years (odds ratio 2.26). Vaginal stenosis is a common complication of pelvic and vaginal radiotherapy, occurring in 38% of patients. Stenosis occurs most often in the first year after treatment. Patients over the age of 50 are most at risk.

An effective group psychoeducational intervention for improving compliance with vaginal dilation: a randomized controlled trial

PURPOSE

Although vaginal dilation is often recommended to minimize or prevent vaginal scarring after pelvic radiotherapy, compliance with this recommendation has historically been very low. Therefore, effective intervention strategies are needed to enhance compliance with vaginal dilation after radiotherapy for gynecologic cancer.

METHODS AND MATERIALS

This study was a randomized controlled clinical trial of a psychoeducational intervention specifically designed to increase compliance with vaginal dilation. The information-motivation-behavioral skills model of enhancing compliance with behavioral change was the basis for the intervention design. Forty-two sexually active women, 21 to 65 years of age, diagnosed with Stages Ic-III cervical or endometrial cancer, who received pelvic radiotherapy, were randomized to either the experimental psychoeducational group or the information-only control group. Assessment via questionnaire occurred before treatment and at 6-week, 6-month, 12-month, 18-month, and 24-month follow-up. Assessment via interview also occurred at 6-month, 12-month, 18-month, and 24-month follow-up.

RESULTS

The psychoeducational intervention was successful in increasing compliance with vaginal dilation.

CONCLUSIONS

This study is the first randomized controlled study to demonstrate the effectiveness of an intervention in increasing compliance with the use of vaginal dilators.

Preventing vaginal stenosis after brachytherapy for gynaecological cancer: an overview of Australian practices

Despite advances in brachytherapy techniques in recent years, patients still experience a variety of treatment-related complications. Vaginal stenosis is a recognised toxicity of brachytherapy for the treatment of gynaecological cancer. It can result in long-term sexual dysfunction and painful vaginal examinations; however, it is generally accepted that it may be prevented by regular sexual intercourse or the use of vaginal dilators. The incidence of vaginal stenosis is variably reported in the literature, while preventative strategies and compliance are infrequently described and rarely evaluated. A telephone survey of radiation oncology centres in Australia was undertaken as a quality improvement activity to determine best practice for the use of vaginal dilators for the prevention of vaginal stenosis, by way of identifying similarities of practice. The results revealed a lack of consistency for all variables, including which patients are advised to use vaginal dilators, the time to initiate use, frequency of use, insertion time and duration of use. These findings suggest that current methods for preventing radiation-induced vaginal stenosis warrant formal evaluation in order to establish an evidence base for practice.

Early development of vaginal shortening during radiation therapy for endometrial or cervical cancer

Vaginal necrosis can occur following radiation therapy for gynecological malignancies. The distal vaginal mucosa has a poorer radiation tolerance than the mucosa in the upper region. We examined the extent of vaginal shortening in patients treated by intravaginal brachytherapy with or without pelvic irradiation. Maximal extension of the vaginal cylinder above the pubis was measured for each insertion. We found that the difference in mean values between insertions (2.3 vs. 1.7 cm) was highly statistically significant (P < 0.0001). Our study shows that vaginal shortening can occur during the course of intracavity and external irradiation. These alterations in vaginal anatomy can have important consequences on doses received by the distal vaginal mucosa.

Psychoeducational group increases vaginal dilation for younger women and reduces sexual fears for women of all ages with gynecological carcinoma treated with radiotherapy

PURPOSE

The association between radiotherapy for gynecological carcinoma and sexual dysfunction is well established. Regular vaginal dilation is widely recommended to these women as a way for them to maintain vaginal health and good sexual functioning. However, the compliance rate with this recommendation is low. The purpose of this study was to test the effectiveness of a group psychoeducational program based on the "information-motivation-behavioral skills" model of behavior change in increasing the rate of compliance.

METHODS AND MATERIALS

Thirty-two women with Stage I or II cervical or endometrial carcinoma who were being treated with radiotherapy were randomized and received either the experimental group program or the control intervention that consisted of written information and brief counseling. Outcome measures included global sexual health, knowledge about sexuality and cancer, fears about sexuality after cancer, and vaginal dilation compliance.

RESULTS

Younger women attending the experimental program (44.4%) were significantly more likely to follow recommendations for vaginal dilation than those who received the control intervention (5.6%). Women, regardless of age, who received the experimental intervention reported less fear about sex after cancer treatment. The older women who received the experimental intervention gained more sexual knowledge. There was no evidence that the experimental intervention improved global sexual health.

CONCLUSIONS

This is the first controlled study to provide evidence of an intervention's effectiveness 1. in increasing women's vaginal dilation following radiotherapy for gynecological carcinoma and 2. in reducing their fears about sex after cancer. Most women, particularly younger women, are unlikely to follow the recommendation to dilate unless they are given assistance in overcoming their fears and taught behavioral skills.

Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma

PURPOSE

This study was designed to document the incidence and degree of vaginal stenosis, sexual activity, and satisfaction in women treated with intracavitary radiation therapy for cervical or endometrial carcinoma.

METHODS AND MATERIALS

The incidence of vaginal stenosis in 90 patients treated for either cervical carcinoma (n = 42) or endometrial carcinoma (n = 48) with standard doses of intracavitary radiation from 1989 to 1992 with at least 6 months follow-up was recorded. Vaginal length was measured using a modified vaginal dilator calibrated in centimeters. Semistructured patient interviews documented pretreatment and posttreatment sexual activity and sexual satisfaction.

RESULTS

Vaginal length was found to be dependent on diagnosis (cervical vs. endometrial), stage (I vs. II/III), and follow-up interval (6-12 months, 12-24 months, and > 24 months). Slightly more women reported sexual activity post vs. pretreatment (31% active pretreatment vs. 43% active posttreatment). However, 22% of women reported a decrease in sexual frequency and 37% reported a decrease in sexual satisfaction. Reports for all parameters were worse for women treated for cervical carcinoma vs. women treated for endometrial carcinoma with the exception of dyspareunia.

CONCLUSION

High-dose radiation for either cervical or endometrial carcinoma at standard doses with or without hysterectomy can cause a decrease in vaginal length as compared to the normal vaginal length of 8 to 9 cm documented by Masters and Johnson. Women treated with intracavitary implants remained as sexually active postimplant as preimplant, however, coital frequency and sexual satisfaction decreased while dyspareunia increased. The decrease in vaginal length may explain in part the decrease in sexual satisfaction but cause and effect have not been established.

Changes in sexual behavior following radiation therapy for cervical cancer

Twenty-one women with cervical cancer Types I and II, treated by radiation were evaluated by comparing periods before cancer and after therapy in order to identify changes in sexual behavior; if so, whether they attributed the changes to therapy, or whether other factors were associated with being sexually dysfunctional or non-dysfunctional. Data were obtained through administration of a sexual behavior questionnaire, personal interviews and review of medical records. Statistically significant changes were found: decreased frequency of masturbation and intercourse, decreased frequency of orgasm through non-coital sexual activities, less satisfaction with sex, and less enjoyment of intercourse. The majority believed that changes were due to radiation therapy and reflected decreased feelings of self-esteem, sex desirability and attractiveness. Most of the women believed that cancer could be transmitted through intercourse. Women who did not follow advice regarding use of vaginal dilators and did not resume their pre-illness level of sex were more likely to develop physical and sexual changes. The subjects' need for sexual counselling concerning the effect of the illness and treatment on relationships with partners was strongly evident. Suggestions for preventing undesirable physical and psychological changes, and guidelines for counselling are provided.