Local control of locally advanced uterine sarcoma achieved by cervical brachytherapy with gel spacer following cyclic hypofractionated radiation therapy (QUAD shot) in a patient who refused surgery

Radiation therapy is not mentioned in various guidelines for primary treatment of uterine sarcoma. Radiation therapy is considered useful for palliative purposes, but an optimal radiation schedule has not been established. An 85-year-old woman was recommended to undergo surgery for locally advanced uterine sarcoma of unknown histological subtype, but she refused because of her poor physical and social circumstances. She instead received chemotherapy; however, the lesion progressed, and the patient opted for best supportive care. Palliative radiation therapy was indicated for genital bleeding. She thereafter received the QUAD shot regimen, in which 3.7 Gy was administered twice a day for 2 consecutive days and repeated every 4 weeks for a total dose of 44.4 Gy in 3 cycles. The lesion significantly decreased in size, and no new regional or distant metastases were identified. Although only palliative radiation therapy was initially intended, the favourable response with no new lesion development prompted us to offer additional brachytherapy for curative intent, and the patient accepted. She underwent 2 sessions of uterine cervical intracavitary and interstitial brachytherapy using a gel spacer, and local control of the lesion was achieved at 1-year and 3 months follow-up of treatment without major adverse events. In select patients for whom a favourable response is achieved after the QUAD shot, the addition of intracavitary and interstitial brachytherapy with a gel spacer may result in curative treatment. This therapy could be a very promising and attractive option for patients with uterine sarcoma who have complications or special social circumstances.