Clinical Investigations
High-dose-rate Intracavitary Brachytherapy in the Management of Cervical and Vaginal Intraepithelial Neoplasia

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Abstract

Purpose: To assess the effectiveness of high-dose rate intracavitary brachytherapy (HDR-ICR) in patients with grade 3 cervical intraepithelial neoplasia (CIN-3) and grade 3 vaginal intraepithelial neoplasia (VAIN-3).

Methods and Materials: This was a retrospective analysis in 20 patients with CIN-3 (n = 14) or VAIN-3 (n = 6), average age 61.9 years, managed with HDR-ICR at Kanagawa Cancer Center. Two patients with CIN-3 with microinvasive foci and 11 other patients with CIN-3 were treated with HDR-ICR for cervical lesions. Six patients with CIN-3 after hysterectomy received HDR-ICR for recurrent or residual VAIN-3 lesions. One patient received radiation therapy for both CIN-3 and VAIN-3 lesions. All these patients but one were postmenopausal.

Results: Seventeen patients were treated with HDR-ICR alone, and three with combined external radiation therapy. The dose was calculated at Point A located 2 cm superior to the external os and 2 cm lateral to the axis of the intrauterine tube for intact uterus. For lesions of the vaginal stump, the dose was calculated at a point 1 cm superior to the vaginal apex or 1 cm beyond vaginal mucosa. In the 14 patients treated for CIN-3 lesions, the mean total dose of HDR-ICR was 26.1 Gy (range 20–30). Six patients received HDR-ICR for VAIN-3 lesions with mean dose of 23.3 Gy (range 15–30). At follow-up (mean 90.5 months; range 13–153), 14 patients were alive and 6 had died owing to nonmalignant intercurrent disease. No patient developed recurrent disease. Rectal bleeding occurred in three patients, but this symptom subsided spontaneously. Moderate and severe vaginal reactions were noted in two patients, in whom the treatment had included the entire vagina.

Conclusions: HDR-ICR can be employed as the primary management strategy for postmenopausal women with CIN-3. In intraepithelial neoplasia involving the vaginal wall after hysterectomy, HDR-ICR should be considered as an alternative to total vaginectomy.

Introduction

The death rate from cervical cancer is widely recognized to have decreased following the introduction of mass screening of the population at risk with cytologic smears and the resulting prompt treatment of cervical cancer and cervical intraepithelial neoplasia (CIN). Barron et al. [1]reported that the natural history of mild and moderate dysplasia is significantly different from that of severe dysplasia and carcinoma in situ (CIS) of the cervix, but that the latter share the same natural history and potential to become invasive. Therefore, the authors suggested that CIN grade 3 (CIN-3) includes both severe dysplasia and CIS.

The standard treatment for CIN-3 is cervical conization. The disease in selected patients can be managed by outpatient therapy using either cryotherapy or laser ablation. Hysterectomy has been considered the treatment of choice in the past, but it now appears that this is not always justified. Intracavitary treatment has also been employed in the past for CIS, but it appears no longer to be necessary in primary management, as other techniques have now become available. Irradiation may be used for CIN-3 in patients with medical contraindications to surgery.

Vaginal intraepithelial neoplasia (VAIN) sometimes occurs during the course of follow-up for CIN in patients with posthysterectomy status. The incidence of VAIN after hysterectomy is low; however, these lesions have the potential to progress to invasive cancer. Although the most effective treatment for VAIN is uncertain, irradiation is used for a VAIN lesion involving the vaginal wall after hysterectomy.

The purpose of this study was to assess the effectiveness of high-dose-rate intracavitary brachytherapy (HDR-ICR) in the management of patients with CIN-3 and VAIN-3.

Section snippets

Methods and Materials

This was a retrospective analysis conducted in 20 patients with CIN-3 (n = 14) or with VAIN-3 after CIN-3 (n = 6), managed with HDR-ICR at Kanagawa Cancer Center between April 1983 and July 1993. The patients ranged in age from 40 to 77 years, with mean age of 61.9 years. HDR-ICR were used to treat cervical lesions alone in 13 patients. One patient received HDR-ICR for both CIN-3 and VAIN-3 lesions in the cervix and vagina. Six patients with CIN-3 after hysterectomy received HDR-ICR for

Results

The mean duration of follow-up was 90.5 months (range 13–153). Fourteen women (70%) were alive at the last follow-up with no sign of recurrence.

Discussion

In earlier years of the period in question, a large number of patients with CIN-3 were treated with intracavitary brachytherapy or other radical procedures such as hysterectomy 3, 4, 5, 6, 7. Creasman and Rutledge [4]and Kolstad and Klem [7]compared the recurrence rate of CIS in groups of patients treated with different modalities as the initial treatment. The recurrence rates following radiation therapy that they reported were similar to those obtained following either conization and simple

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