When an unexpected diagnosis occurs: a vaginal premenopausal sarcoma / Quando um diagnóstico inesperado ocorre: um sarcoma vaginal na pré-menopausa

Abstract Vaginal cancer is a rare entity. The evidence on its management resides mostly in clinical cases or small case series. Of the histological types, the most frequent is the squamous cell carcinoma, followed by adenocarcinoma. But what to do when identifying an even more infrequent sarcoma in a premenopausal woman? In this study, we describe the case of a 53-year-old woman presenting with metrorrhagia for two months, who was evaluated after an intense episode. A necrotic and ulcerative vaginal swelling was documented and then submitted to biopsy, which revealed a vaginal sarcoma. The patient was referred to radiation therapy with 50 Gy (aiming to control the symptoms and to cause tumor reduction for posterior pelvic exenteration with intraoperative radiotherapy) and developed an extra-pelvic metastization at the end of the treatment, which caused a fast negative outcome. Despite the initial poor prognosis, a chemo-irradiation or primary surgery regimen might have achieved (although with greater side effects) a better survival. This case-report entails a discussion about the strategies to manage vaginal sarcoma in advanced stage and in premenopausal women.

Resumo O cancro vaginal é uma doença rara. A evidência para a sua abordagem reside fundamentalmente em casos clínicos ou pequenas séries de casos. Dentre os tipos de cancro histológicos, o mais frequente é o carcinoma espinocelular, seguido do adenocarcinoma. Mas o que fazer em presença de um sarcoma ainda mais raro numa mulher pré-menopáusica? No presente estudo, descrevemos o caso de uma mulher de 53 anos apresentando metrorragia por dois meses, avaliada após um episódio intenso. Foi então documentada uma tumefacção vaginal necrótica e ulcerativa, submetida a biópsia, que revelou um sarcoma vaginal. A paciente foi encaminhada para radioterapia com50 Gy (comos objetivos de controlo da sintomatologia e de redução tumoral para posterior exenteração pélvica com radioterapia intraoperatória) e desenvolveu, ao final do tratamento, umquadro demestastização extra pélvica, que ocasionou um desfecho negativo rápido. Apesar do mau prognóstico inicial, um esquema de quimiorradiação ou cirurgia primária poderiam ter alcançado (ainda que com maiores efeitos laterais) uma maior sobrevivência. Este estudo de caso aborda uma discussão sobre as estratégias de abordagem do sarcoma vaginal em estádios avançados e na mulher pré-menopáusica.

Septic Arthritis of the Hip Joint after Pelvic Radiotherapy in Patients with Cancer: Case Report

Septic arthritis of the hip joint after radiotherapy is a rare complication with distinctive features. It is difficult to recognize this complication because of its late onset and lack of significant fever. We describe three cases of patients with septic arthritis in the hip joint who had a history of radiotherapy in the pelvic region. Our patients developed septic arthritis 1, 2, and 3 years after radiotherapy and these occurrence intervals were relatively shorter when compared to previous literature. Hip joint destruction was noted in all cases. Resection of the femoral head was required to control the infection in two cases. Careful attention is requested to detect septic arthritis when patient experiences pain in joint where underwent radiotherapy. For this case, prompt laboratory study, radiological evaluation, and joint fluid aspiration and culture are required. If there is evidence of infection in these results, a proper and immediate treatment must be started.

Nutritional Status and Quality of Life of Oncology Patients Prior to Pelvic Radiotherapy

Introduction: Malnutrition among cancer patients is associated with a higher risk of gastrointestinal toxicity which develops during treatment and may affect quality of life (QOL). Thus, this cross-sectional study aimed to determine the nutritional status and QOL of 30 oncology patients (mean age 50.0+10.7 years) prior to pelvic radiotherapy at Hospital Sultan Ismail, Johor Bahru. Methods: Patients were assessed for anthropometry measurements, 24-h diet recall and nutritional status using Scored Patient-Generated Subjective Global Assessment (PG-SGA) questionnaire while the European Organization for Research and Treatment of Cancer Care Quality of Life Questionnaire (EORTC QLQ-C30) was used to assess QOL two weeks prior to the initiation of pelvic radiotherapy. Results: Mean Body Mass Index (BMI) of patients was 23.3+3.3kg/m2 and 33% of patients experienced weight loss prior to pelvic radiotherapy. The PG-SGA rating indicated that 63% of patients were at Stage A (well-nourished) and 37% were in Stage B (moderate malnutrition). The PG-SGA numerical score was a significant predictor of QOL, after adjusting for socio-demographic factors (R2=0.861, p<0.05). Conclusion: In general, the low nutritional status of the patients indicates the need for early nutritional assessment, education and intervention in ensuring optimal nutritional status throughout the pelvic radiotherapy treatment.

Endoscopic findings of rectal mucosal damage after pelvic radiotherapy for cervical carcinoma: correlation of rectal mucosal damage with radiation dose and clinical symptoms

PURPOSE: To describe chronic rectal mucosal damage after pelvic radiotherapy (RT) for cervical cancer and correlate these findings with clinical symptoms and radiation dose. MATERIALS AND METHODS: Thirty-two patients who underwent pelvic RT were diagnosed with radiation-induced proctitis based on endoscopy findings. The median follow-up period was 35 months after external beam radiotherapy (EBRT) and intracavitary radiotherapy (ICR). The Vienna Rectoscopy Score (VRS) was used to describe the endoscopic findings and compared to the European Organization for Research and Treatment of Cancer (EORTC)/Radiation Therapy Oncology Group (RTOG) morbidity score and the dosimetric parameters of RT (the ratio of rectal dose calculated at the rectal point [RP] to the prescribed dose, biologically effective dose [BED] at the RP in the ICR and EBRT plans, alpha/beta = 3). RESULTS: Rectal symptoms were noted in 28 patients (rectal bleeding in 21 patients, bowel habit changes in 6, mucosal stools in 1), and 4 patients had no symptoms. Endoscopic findings included telangiectasia in 18 patients, congested mucosa in 20, ulceration in 5, and stricture in 1. The RP ratio, BEDICR, BEDICR+EBRT was significantly associated with the VRS (RP ratio, median 76.5%; BEDICR, median 37.1 Gy3; BEDICR+EBRT, median 102.5 Gy3; p < 0.001). The VRS was significantly associated with the EORTC/RTOG score (p = 0.038). CONCLUSION: The most prevalent endoscopic findings of RT-induced proctitis were telangiectasia and congested mucosa. The VRS was significantly associated with the EORTC/RTOG score and RP radiation dose.

Result of 3-dimensional conformal radiotherapy combined with concurrent chemotherapy for postoperatively Ioco-regionally recurrent or mastastatic rectal cancer / 中华放射肿瘤学杂志

Objective To evaluate the efficacy of three-dimensional conformal radiotherapy (3DCRT) combined with concurrent chemotherapy for loco-regionally recurrent or mastastatie rectal cancer. Methods Between June 2004 and January 2007,47 patients with loco-regionally recurrent or nmatastatic rectal cancer were treated by 3DCRT of 55-65 Gy in 1.8-2.0 Gy fractions. Chemotherapy was given concurrenfly using oxaliplatin(100 mg/m2 ,iv drop,d1 ) and capecitabine(1500 mg/m2,orally,dl-14,21 days per cycle). Results After the follow-up of 12-35 months, the total response rate, complete response rate and partial response rate were 79% (37/47) ,19% (9/47) and 60% (28/47) ,respectively. The pain-alleviation rate and the mean pain-alleviation time were 85% and 6 months. The 1- and 2-year survival rates were 83% and 51%. Quality of life was improved without any treatment related death. Conclusions 3DCRT combined with concurrent chemotherapy is effective and well-tolerated in patients with post-operatively locoregionally recurrent or mastastatic rectal cancer.

Analysis of the Inter- and Intra-treatment Isocenter Deviations in Pelvic Radiotherapy With Small Bowel Displacement System / 대한방사선종양학회지

PURPOSE: To evaluate the extent and frequency of the inter- and intra-treatment isocenter deviations of the whole pelvis radiation field in using small bowel displacement system (SBDS). METHODS AND MATERIALS: Using electronic portal imaging device (EPID), 302 postero-anterior (PA) and 232 lateral portal images were prospectively collected from 11 patients who received pelvic radiation therapy (7 with cervix cancer and 4 with rectal cancer). All patients were treated in prone position with SBDS under the lower abdomen. Five metallic fiducial markers were placed on the image detection unit for the recognition of the isocenter and magnification. After aligning the bony landmarks of the EPID images on those of the reference image, the deviations of the isocenter were measured in right-left (RL), cranio-caudal (CC), and PA directions. RESULTS: The mean inter-treatment deviation of the isocenter in each RL, CC, and PA direction was 1.2 mm (+/-1.6 mm), 1.0 mm (+/-3.0 mm), and 0.9 mm (+/-4.4 mm), respectively. Inter-treatment isocenter deviations over 5 mm and 10 mm in RL, CC, and PA direction were 2, 12, 24%, and 0, 0, 5%, respectively. Maximal deviation was detected in PA direction, and was 11.5 mm. The mean intra- treatment deviation of the isocenter in RL, CC, and PA direction was 0 mm (+/-0.9 mm), 0.1 mm (+/-1.9 mm), and 0 mm (+/-1.6 mm), respectively. All intra-treatment isocenter deviations over 5 mm in each direction were 0, 1, 1%, respectively. CONCLUSION: As the greatest and the most frequent inter-treatment deviation of the isocenter was along the PA direction, it is recommended to put more generous safety margin toward the PA direction on the lateral fields if clinically acceptable in pelvic radiotherapy with SBDD.

Minimization of Small Bowel Volume within Treatment Fields Using Customized Small Bowel Displacement System (SBDS) / 대한치료방사선과학회지

PURPOSE: Authors designed a customized Small Bowel Displacement System (SBDS) to displace the small bowel from the pelvic radiation fields and minimize treatment-related bowel morbidities. METHODS AND MATERIALS: From August 1995 to May 1996, 55 consecutive patients who received pelvic radiation therapy with the SBDS were included in this study. The SBDS consists of a customized styrofoam compression device which can displace the small bowel from the radiation fields and an individualized immobilization abdominal board for easy daily setup in prone position. After opacifying the small bowel with Barium , the patients were laid prone and posterior-anterior (PA) and lateral (LAT) simulation films were taken with and without the SBDS. The areas of the small bowel included in the radiation fields with and without the SBDS were compared. RESULTS: Using the SBDS, the mean small bowel area was reduced by 59% on PA and 51% on LAT films (P=0.0001). In six patients (6/55, 11%), it was possible that no small bowel was included within the treatment fields. The mean upward displacement of the most caudal small bowel was 4.8 cm using the SBDS. Only 15% (8/55) of patients treated with the SBDS manifested diarrhea requiring medication. CONCLUSION: The SBDS is a novel method that can be used to displace the small bowel away from the treatment portal effectively and reduce the radiation therapy morbidities. Compliance with setup is excellent when the SBDS is used.