Cervical Cancer With Vaginal Recurrence and Prior Pelvic Radiation

A 71-year-old woman with significant medical history of uncontrolled diabetes and multiple myocardial infarctions presented with postmenopausal bleeding and was diagnosed with Federation of Gynecology and Obstetrics stage IIB mesonephric adenocarcinoma of the cervix. The patient proceeded with definitive chemoradiation, 45 Gy in 25 fractions daily external beam radiation to the whole pelvis with concurrent weekly cisplatin, followed by iridium 192 high-dose-rate tandem and ovoid intracavitary brachytherapy boosts, 5.5 Gy for 5 fractions twice weekly to high-risk clinical target volume. The patient tolerated the procedures well with minimal acute toxicity. She returned for surveillance follow-up and did not have evidence of disease on pelvic examination 3 months after treatment. The patient then underwent positron emission tomography/computed tomography 6 months after treatment, which did not reveal evidence of a hypermetabolic lesion. However, she was found to have 2 separate, small 1- to 2-cm nodules in the anterior and right lateral side of the vaginal vault on surveillance pelvic examination 18 months after treatment. Restaging positron emission tomography/computed tomography scan did not reveal any regional or distant metastases. A biopsy was performed and confirmed recurrent mesonephric adenocarcinoma. Figure 1 demonstrates the relationship of disease recurrence in the vaginal vault within the previous radiation field. 1.What would be your treatment recommendation with respect to surgery, systemic therapy, and radiation therapy?2.For radiation therapy, what would be your technique, dose, fractionation, and volumes for treatment, and how would you handle overlap with organs at risk?3.How would you counsel the patient on longer-term risks of reirradiation?