Introduction/Background The standard treatment for locally advanced vulvar cancer is neodjuvant chemoradiation followed by evaluation for surgery. However a vast majority of patients are yet unable to undergo surgery due to proximity of the tumour to eloquent structures as urethra, post forchette, distal vagina or anal sphincter muscles

Methodology In our institution, patients with locally advanced vulva cancer are evaluated by examination under anaesthesia for disease mapping prior to initiating chemoradiation. PETCT and/or MRI is performed for staging and colposcopy is performed to exclude simultaneous malignancy in cervix. After chemoradiation a joint examination under anaesthesia is performed by the surgical and radiation oncology team and when patients are deemed surgically resectable interstitial brachytherapy is performed. In each patient the brachytherapy procedure is individualised to ensure target coverage and sparing of adjacent normal structures. This video demonstrates the free hand interstitial technique of a women with locally advanced vulvar cancer with distal vaginal, periurethral involvement. Also disease was close to posterior forchette and clitoris.

Results Free hand multilane interstitial implant was performed. After external radiation of 45/Gy/25 fractions/5 weeks additional HDR brachytherapy boost of 3.5 Gy x 4 fractions were delivered twice daily. Video demonstrates the complex implant procedure. Additionally aspects of treatment planning and implant removal will be discussed. A summary of techniques of interstitial brachytherapy will be presented. Apart from the case brachytherapy in setting of field cancerisation will also be discussed.

Conclusion Interstitial brachytherapy is a highly conformal and effective way of radiation dose escalation in patients with medically inoperable Ca Vulva. Further training of gynecology radiation oncology community is needed to improve outcomes in these cohorts of patients.