Table 5.

Consensus panel recommendation for patients with vaginal cancer.

Priority A	Technique and Dose	Priority B	Technique and Dose
Bleeding or severely painful lesions in patients with metastatic disease	10 Gy × 1 f. (can be repeated monthly up to 2 more times) [[45], [46], [47], [48]] “Quad Shot” of 3.7 Gy BID x 4 f. (can be repeated monthly up to 2 more times) [49,50] 4 Gy × 5 f. [51,52]	Post-operative patients with close/positive margins or pathologically involved nodes with no gross residual disease.	Close/positive marginsa, b: IC/IS BT +/− EBRT [67,89] or CRT [90] Pathologically involved nodes: CRT to 45–50.4 Gy with consideration of SIB boost to 55–60 Gy to any areas of gross disease [91]
Medically or surgically inoperable patients with stage I disease	Definitive RT If lesion is ≤0.5 cm depth, use IC BT alone with EQD2 of 60–75 Gy to the tumor with 2 cm margin (7 Gy × 5 fx) using a shielded or multichannel vaginal cylinder [42,67] If lesion is >0.5 cm in depth, treat WP with EBRT to 45 Gy followed by IS BT boost to EQD2 of 70 Gy (7 Gy × 3 fx) [42,67]
Intact stage II-IVA disease	Definitive CRT with EBRT to 45–50.4 Gy to the WP (and bilateral inguinal nodes if the tumor is in the lower third of the vagina). Boost any clinically positive nodes with an additional 20–25 Gyc Boost: If lesion is ≤0.5 cm in depth, boost with IC BT 7 Gy × 3 f. [42,67] If lesion is >0.5 cm in depth, boost with IS BT (7 Gy × 3) [42,67]

ABS: American Brachytherapy Society; BID: twice per day, BT: brachytherapy; CRT: chemoradiotherapy; EBRT: external beam radiation therapy; EQD2: Equivalent dose in 2 Gray fractions; fx: fraction; Gy: Gray; IC: intracavitary; IS: interstitial; RT: radiation therapy; SIB: simultaneous integrated boost; WP: whole pelvis

^aThe decision to delay therapy and the interval of delay should be determined based on (1) individual risk of the patient to have an adverse outcome due to COVID-19 based on age and medical comorbidity, (2) individual risk of disease progression given treatment delay, and (3) epidemiologic data based on the project peak of the pandemic in a specific geographic area.

^bEBRT can be delayed up to 6 weeks for patients with positive margins and up to 8 weeks for patients with close margins.

^cAny EBRT boosts should be delivered with SIB technique, if possible, to reduce the total number of fractions.