second pelvic primary 2 months after the end of adjuvant chemo-radiation for SCC of the vulva

[Kroll2013]

Dear colleagues,
I need your opinion concerning my 60yo patient, no comorbidities.
she received in June 2017 adjuvant chemo radiation to the pelvis and vulvar tumor bed for a SCC.
she received between 45-54 Gy SIB.
2 months later she presented with an important pain to the left iliac fossa.
pelvic MRI showed a left parametrial mass of 3cm. biopsy revealed SCC.
the review of CBCTs done during radiation showed no mass at this level.
so it is a rapidly growing synchronous tumour.
the surgeon proposed pelvic exenteration with double stomas. this was refused by the patient.
what about the possibility of re-irradiation ?
one problem: this tumor is at the level of the obturators with 2 intestinal loops very proximal to the tumor that received 45Gy.
her pain is increasing day after day. the most recent MRI showed increase in size and starting to take in the muscles
what do you suggest:
1- palliative RT : 15*2.5GY to the tumor
2- reRT wit SBRT? at what dose ?
3- chemotherapy
4- reconsider pelvic exenteration

ty

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[Palex80]

I do not think that this is a "second pelvic primary".
This is most probably a lymph node relapse in the pelvis (obturator nodes). If it's growing as fast as you describe and causing symptoms the tumor mass has already crossed the borders of the lymph node and is growing (as you correctly pointed out) into adjacent tissue.
I am sorry to say, but this is likely palliative now.
It grew shortly after radiochemotherapy, meaning platin-refractory disease. Was part of the mass in the original volumes you used to electively treat the pelvis?

You could consider to give her a palliative dose of RT and go for second line chemo or perhaps some immunotherapy if you can get her on a trial. Chances for response to RT are slim. A full bladder may help with the bowel?

 

[seper]

Agree with re-irradiation to moderate dose. Also, are you sure obturator nodes/paracolpal tissues were included in prior PTV?

 

[nkmiami]

For re-irradiation treatments, I have used pulsed dose external beam where 20 cGy is given every 3 minutes and taken the patient around 40-50 Gy with xeloda. I know this sounds wierd but there is actually a lot of history and some biology behind this. If you want further details, you could PM me or call Steven Howard at Wisconsin or Jim Welsh at Loyola. I know Fox Chase still continues to utilize it. Anecdotally, sometimes a tumor that hasnt responded to conventional xrt will respond to this.

(you could also discuss with surgeon stereo 8gy x4/5- and be ready to just sacrifice that nearby bowel- may be surgeon could put mesh spacer or move it away, resect it laparacopically right after radiation etc)
lastly, may want to get next generation sequencing/pdl1 expression on primary to see if she candidate for immunotherapy (with or after stereo). even if insurance wont pay, we have had no problem getting compassionate release from the drug companies in these situations. Anecdotally, p16+ squamous cell may be amenable to these drugs.

 

[evilbooyaa]

Look back at your CT Sim. Sure there was nothing there? Where was the original primary? Clitoral or midline vulva disease can drain directly into obturator nodal areas. If this region was in your PTV then this is a bad player for disease.