Role of vaginal pallor reaction in predicting late vaginal stenosis after high-dose-rate brachytherapy in treatment-naive patients with cervical cancer

Abstract

ObjectiveTo assess actual rates of late vaginal stenosis and identify predisposing factors for complications among patients with previously untreated cervical cancer following high-dose-rate brachytherapy.MethodsWe performed longitudinal analyses of 57 patients using the modified Dische score at 6, 12, 18, 24, 36, and 60 months after treatment, which consisted of 15 interstitial brachytherapys and 42 conventional intracavitary brachytherapys, with a median follow-up time of 36 months (range, 6 to 144 months).ResultsMore than half of the patients developed grade 1 (mild) vaginal stenosis within the first year of follow-up, and grade 2 (97.5%, moderate) to grade 3 (severe) stenosis gradually increased with time. Actual stenosis rates for grade 1, 2, and 3 were 97.5% (95% confidence interval [CI], 92.7 to 97.5), 60.7% (95% CI, 42.2 to 79.3), and 7.4% (95% CI, 0 to 18.4) at 3 years after treatment. Pallor reaction grade 2-3 at 6 months was only a statistically significant predisposing factor for grade 2-3 late vaginal stenosis 3 years or later with a hazard ratio of 3.48 (95% CI, 1.32 to 9.19; p=0.018) by a multivariate Cox proportional hazard model. Patients with grade 0-1 pallor reaction at 6 months showed a grade ≥2 vaginal stenosis rate of 53%, whereas the grade 2-3 pallor reaction group achieved a grade ≥2 vaginal stenosis rate at 3 years at 100% (p=0.001).ConclusionHigh-dose-rate brachytherapy was associated with high incidence of late vaginal stenosis. Pallor reaction grade 2-3 at 6 months was predictive of late grade 2-3 vaginal stenosis at 3 years after treatment. These findings should prove helpful for patient counseling and preventive intervention.

Radiation-induced vaginal stenosis: current perspectives

“…Pallor reaction of vaginal tissues has also been proposed as a predisposing factor for late VS as both have a pathophysiological basis related to mucosal thinning and dryness, atrophy, inflammation and fibrosis 8,29. An assessment of grade 2 vaginal pallor reaction at 6 months was reported as predictive of late VS of grades 2 and 3 at 3 years after treatment with high-dose rate brachytherapy for cervical cancer 8. Cigarette smoking has also been proposed as a possible patient-related factor predisposing to VS 6.…”

“… 7 Another prospective study of 54 patients also reports that VS gradually increases with time, with grade 1 stenosis occurring within the first year of follow-up and the time to occurrence of moderate-to-severe stenosis gradually increasing up to 3 years following treatment. 8 …”

“… 7 Pallor reaction of vaginal tissues has also been proposed as a predisposing factor for late VS as both have a pathophysiological basis related to mucosal thinning and dryness, atrophy, inflammation and fibrosis. 8 , 29 An assessment of grade 2 vaginal pallor reaction at 6 months was reported as predictive of late VS of grades 2 and 3 at 3 years after treatment with high-dose rate brachytherapy for cervical cancer. 8 Cigarette smoking has also been proposed as a possible patient-related factor predisposing to VS. 6 This is certainly plausible given the widely recognized synergistic effect of cigarette smoking and late radiation effects on normal mucosal tissues of the aerodigestive tract observed in a number of tumor sites including cervical, lung and head and neck cancer.…”

Pelvic Radiation Therapy Induced Vaginal Stenosis: A Review of Current Modalities and Recent Treatment Advances

“…The study reported that mostly VS results in the first year after treatment [ 10 ]. According to other studies, VS continuously develops with time, meaning that mild VS occurs in the first year, and moderate or severe VS—three years after the treatment is finished [ 11 ]. RT-induced VS in cancer survivors for rectal and anal cancer is less described in the scientific literature.…”

“…This is seemingly possible given the widely known co-active effect of cigarette smoking and radiation reactions on normal tissues of the aero-digestive tract seen in numerous tumors, including cervical tumors [ 22 ]. A vaginal pallor reaction is also considered to be a risk factor, knowing that the pathophysiology is associated with atrophy, inflammation, lack of moisture and fibrosis [ 11 ].…”