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Treatment of late recurrent vaginal malignancy after initial radiotherapy for carcinoma of the cervix: an analysis of 73 cases.

PURPOSE
To evaluate the reirradiation therapy in late recurrent vaginal malignancy after initial radiotherapy for carcinoma of the cervix.


METHODS
From July 1972 to July 1992, 73 cases of late recurrent (over 5 years) vaginal malignancy after initial radiotherapy for cervical cancer were treated in our hospital. Both the original and recurrent cancers were biopsy-proven squamous cell carcinoma. All of these patients received reirradiation therapy; chemotherapy or operation was combined when necessary. The reirradiation was planned according to the site and volume of the recurrent tumor, previous radiation dose, and radiation side effects. Brachytherapy was mainly used. Before 1981, radium therapy was delivered at 30-40 Gy in 3-5 fractions to tumor base within 3-4 weeks. High-dose-rate (100 cGy/min) cobalt-60 afterloading therapy (Ralstron therapy) has been used instead of radium since 1981; the dose to the tumor base was 20-35 Gy/3-5 fractions/3-4 weeks. Then, vaginal mold was supplemented with a dose to a point 0.5 cm below the surface of the vaginal mucosa at 20-30 Gy/4-6 fractions/2-3 weeks. When the vulva or groin was involved, cobalt-60 or high-energy electron beam radiation was added with a dose at 30-40 Gy. Among these, 61 patients received irradiation therapy alone. Eleven patients received irradiation combined with chemotherapy. One patient received hysterectomy after reirradiation.


RESULTS
The 2-, 3-, and 5-year survival rates in this series were 54.7% (40/73), 46. 6% (28/60), and 40.3% (21/52), respectively. The 5-year survival rates for upper, upper-middle, and upper-lower vaginal tumor were 81. 8% (9/11), 33.3% (5/15), and 25.0% (3/12), respectively. The effect for upper vaginal recurrent malignancy was remarkably better than that for the upper-lower rate (P < 0.05). The local control rates for tumor >4 and <4 cm were 26.6% (4/15) and 86.5% (32/37), respectively (P < 0.01). The side effects of reirradiation in this series were serious: both moderate and severe radiation reactions were rectum 13.6% (10/73), hematuria 12.3% (9/73), vesicovaginal fistula 1.4% (1/73), and rectum-vaginal fistula 11.0% (8/73).


CONCLUSIONS
We conclude that reirradiation for late recurrence in the vagina after previous radiotherapy for cervical cancer is valuable. Early detection and treatment could achieve better results. The smaller the recurrent tumor volume, the better the treatment effects. Reirradiation therapy should be carefully managed in order to reduce the complications as much as possible.