PMC6159297_01
Top: Positron emission tomography/CT scan prior to the start of treatment, demonstrating a recurrent periclitoral mass. Bottom: complete resolution of the focal uptake at 15 months post treatment with radiation and ipilimumab.
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Positron emission tomography/CT scan at that time demonstrated focal uptake in this area but no regional/distant metastases (Figure 1). Most recently, at her 15-month follow-up, she remains disease- and symptom-free (Figure 1).
Intensity-modulated radiotherapy treatment plan showing dose distribution and treatment fields.
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Radiation was planned with intensity-modulated radiation therapy (IMRT) to the vulva and vagina (no elective nodal radiation to the groin) to an initial dose of 45 Gy (1.8 Gy/fraction over 25 fractions), and was to be followed by an electron boost to a total dose of 63 Gy (1.8 Gy/fraction over 10 fractions) at the site of the positive margin (Figure 2).
Grade 3 desquamating skin toxicity from concurrent ipilimumab and radiation, shown in the radiation field. (a,b) Initial demonstration of the reaction. (c,d) 1 day after the initial appearance.
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By 48.6 Gy dose (10 days post ipilimumab cycle 2), the patient developed a grade 3 skin reaction (Figure 3c,d) that was characterized as a moist desquamation with significant oedema, erythema and pain in the vaginal/vulvar/perianal region and was restricted to the radiation field (Figure 4a).
Photographs demonstrating temporal resolution of the reaction. (a) 10 days after the initial appearance. (b) 6 months post radiation completion. (c) 8 months post radiation completion. Treatment was with a combination of 0.1% topical triamcinolone, 60 mg oral prednisone and diphenhydramine for pruritus.
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By 48.6 Gy dose (10 days post ipilimumab cycle 2), the patient developed a grade 3 skin reaction (Figure 3c,d) that was characterized as a moist desquamation with significant oedema, erythema and pain in the vaginal/vulvar/perianal region and was restricted to the radiation field (Figure 4a). At follow-up 8 months post completion of radiotherapy, she had complete resolution of the in-field toxicity and improvement of her ipilimumab-associated cutaneous eruption (Figure 4b,c).
Timeline of events starting with the initial radiation treatment. Note that the skin reaction occurs 10 days after the second cycle of ipilimumab and 4 weeks after the first cycle. Treatment with oral and topical steroids led to resolution within 3 weeks.
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A timeline of these events is illustrated in Figure 5.