The variation of inguinal lymph node depth in adult women and its importance in planning elective irradiation for vulvar cancer

Definitive chemoradiation or radiation therapy alone for the management of vulvar cancer

Vulvar cancer is rare, and unresectable disease provides a therapeutic conundrum. Although definitive surgery remains the mainstay for curative treatment of vulvar cancer, a minority of patients present with advanced disease for which surgical resection would be extraordinarily morbid. Pre-operative and definitive radiation with radiosensitizing systemic therapy allows such patients an opportunity for cure. In this review, we explore the origins of pre-operative radiation, current treatment standards for pre-operative and definitive chemoradiation, and future directions.

Primary groin irradiation versus primary groin surgery for early vulvar cancer

BACKGROUND

Despite changes in technique, morbidity after surgery for vulvar cancer is high and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy to the groin in terms of groin recurrences and survival show conflicting results.

OBJECTIVES

To determine whether the effectiveness and safety of primary radiotherapy to the inguinofemoral lymph nodes in early vulvar cancer is comparable with surgery.

SEARCH STRATEGY

We searched The Cochrane Gynaecological Cancer Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE from 1966 to July 2010.

SELECTION CRITERIA

We selected randomised clinical trials (RCTs) comparing inguinofemoral lymph node dissection and primary radiotherapy of the inguinofemoral lymph nodes for patients with early squamous cell cancer of the vulva.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted results. Primary outcome measures were the incidence of groin recurrences, patient survival and morbidity.

MAIN RESULTS

No new RCTs were identified by the updated search. Out of twelve identified papers only one met the selection criteria. From this one small RCT of 52 women, there was a trend towards increased groin recurrence rates (relative risk (RR) 10.21, 95% confidence interval (CI) 0.59 to 175.78), lower disease-specific survival rates (RR 3.70, 95% CI 0.87 to 15.80), less lymphoedema (RR 0.06, 95% CI 0.00 to 1.03) and fewer life-threatening cardiovascular complications (RR 0.08, 95% CI 0.00 to 1.45) in the radiotherapy group. Primary surgery was associated with a longer hospital stay than primary groin irradiation (RR 0.28, 95% CI 0.13 to 0.58).

AUTHORS' CONCLUSIONS

Primary radiotherapy to the groin results in less morbidity but may be associated with a higher risk of groin recurrence and decreased survival when compared with surgery. Due to the small numbers in this trial and criticisms regarding the depth of radiotherapy applied, corroboration of these findings by larger RCTs using a standardised radiotherapy method, is desirable. However, until better evidence is available, surgery should be considered the first choice treatment for the groin nodes in women with vulvar cancer. Individual patients not physically able to withstand surgery may be treated with primary radiotherapy.

Current controversies in the management of patients with early-stage vulvar cancer

PURPOSE OF REVIEW

The purpose of this review is to outline current controversies in management of early-stage vulvar cancer. The main focus will be on the procedures for assessing the sentinel node and the treatment of those with evidence of metastatic involvement.

RECENT FINDINGS

Assessment of the sentinel node has recently been introduced into the standard treatment of early-stage squamous cell vulvar cancer. The combination of a radioactive tracer and blue dye is the most accurate technique for sentinel node detection. Preoperative imaging is recommended to rule out gross nodal involvement and ultrasound with fine needle aspiration cytology by an experienced radiologist appears to have the highest sensitivity/specificity for detecting metastases, although large comparative studies are not available. All patients with sentinel node metastases require additional treatment to the groin, independent of the size of metastasis in the sentinel node and currently this involves inguinofemoral lymphadenectomy. Further research is ongoing to investigate the role of radiotherapy instead of lymphadenectomy. The little experience there is of sentinel node biopsy in vulvar melanoma suggests that the procedure is feasible and inclusion criteria should follow those of cutaneous melanoma.

SUMMARY

Sentinel node biopsy is safe in treatment of early-stage vulvar cancer. Ongoing studies are investigating the optimal additional treatment for patients with a positive sentinel node in terms of efficacy and morbidity.

Magnetic Resonance Imaging in Gynecological Oncology

Magnetic resonance imaging (MRI) has become an indispensable tool in the assessment of malignant disease. With increasingly sophisticated systems and technical advancements, MRI has continued to expand its role in providing crucial information regarding cancer diagnosis and management. In gynecological malignancies, this modality has assumed greater responsibility, particularly in the evaluation of cervical and endometrial cancers. In addition to conventional imaging, innovative techniques such as dynamic contrast-enhanced MRI and diffusion-weighted MRI show promise in offering early assessment of tumor response. This paper reviews the current role of MRI in gynecological cancers and highlights the potential of novel techniques in improving patient care.

Treatments for gynaecological cancers

Gynaecological cancers account for a significant amount of morbidity and mortality in the world, with varying incidences and outcomes depending on the country. These malignancies consist of vulval, vaginal, cervical, endometrial, fallopian and ovarian cancers, and account for between 10 and 15% of women's cancers. Although mainly a disease of post-menopausal women, when affecting younger women, fertility-related consequences exist. Therapeutic interventions for gynaecological cancers include surgery, chemotherapy and radiotherapy, with combination modalities often required. The basis for certain therapies are derived from appropriately conducted randomized clinical trial, whereas in some settings, therapy is based on clinical experience and intuition. This review will endeavour to focus on the evidence base, though inevitably, non-evidence based practice is unavoidable.

Management of vulvar cancers

AIM

The radical surgical approach in the treatment of vulvar cancer patients has led to a favorable prognosis for the majority of the patients with early stage squamous cell cancer. However, the morbidity is impressive, leading to more individualized treatment. The aim of this review is to give an overview of the management of vulvar cancer.

METHODS

We have reviewed the literature on the modifications in treatment of vulvar cancer with the emphasis on surgery and radiotherapy for primary disease.

RESULTS

While surgery is the cornerstone of treatment for early stage squamous cell vulvar cancer (with wide local excision and uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as standard treatment), until now there has been a limited role for primary radiotherapy although this may be an attractive alternative for the inguinofemoral lymphadenectomy in the future. The sentinel lymph node procedure with the combined technique (preoperative lymphoscintigraphy with (99m)technetium-labeled nanocolloid and Patente Blue) is a promising staging technique for patients with vulvar cancer. The clinical implementation of the sentinel lymph node procedure and the role of additional histopathological techniques of the sentinel lymph nodes have to be investigated. In advanced vulvar cancer, chemoradiation followed by surgery should be regarded as the treatment of first choice for these patients.

CONCLUSIONS

Due to the rarity of vulvar cancer it is quite clear that further studies will have to be performed by international collaborative groups. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce morbidity of treatment, but their safety needs to be studied in clinical trials.

Prediction of lymph node metastases in vulvar cancer: a review

The aim of this study was to review the literature on currently available non- and minimally-invasive diagnostic methods and analysis of primary tumor characteristics for prediction of inguinofemoral lymph node metastases in patients with primary squamous cell carcinoma of the vulva. We used the English language literature in PubMed and reference lists from selected articles. Search terms included vulvar carcinoma, prognosis, lymph node metastases, ultrasound, computer tomography, magnetic resonance imaging, positron emission tomography, and sentinel lymph node. No study type restrictions were imposed. Currently no noninvasive imaging techniques exist that are able to predict lymph node metastases with a high enough negative predictive value. A depth of invasion < or =1 mm is the only histopathologic parameter that can exclude patients for complete inguinofemoral lymphadenectomy. No other clinicopathologic parameter allows exclusion of lymph node metastases with a high enough negative predictive value. The minimally invasive sentinel node procedure is a promising technique for selecting patients for complete lymphadenectomy, but its safety has not been proven yet.

Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva

We set out to study whether computerized tomography (CT) scanning of the vulva and the groin and groin ultrasound scanning (USS) alone or with fine needle aspiration cytology (FNAC) (USS/FNAC) influenced or could influence the surgical management of primary squamous cell carcinoma of the vulva (SCCaV). Forty-four patients underwent surgery for primary SCCaV following radiologic imaging by one or more modalities. Patient details included the clinical assessment of the carcinoma, radiologic findings, the operation performed, and whether the decision regarding the type and extent of surgery for the vulval carcinoma and, in particular, for the groin node dissection was or could be influenced by the radiologic findings. The age range was 38-87 years, with a median of 74 years. A total of 75 groin dissections were performed. Twenty-five of the 44 patients (56.8%) did not have groin node metastasis, 14 had unilateral metastasis (31.8%), and 5 (11.4%) had bilateral metastasis. All cases with histologically proven nodal status were analyzed to compare the preoperative imaging status with the histology. The calculated sensitivity, specificity, negative predictive value, and positive predictive value for CT were 58%, 75%, 75%, and 58%, for USS alone-87%, 69%, 94%, and 48%, and for USS-guided FNAC-80%, 100%, 93%, and 100%, respectively. There was no patient in whom surgical planning for the vulval carcinoma or the groin nodes was or could be altered by the CT findings. The data do not support the routine use of CT scanning in patients with primary SCCaV, either in assessment of the primary vulval carcinoma or in detecting groin nodal metastases. For the groin nodes, USS/FNAC is superior to CT in assessing disease status. In contrast to CT, USS/FNAC may have a useful clinical role in the management of the groin nodes in vulval carcinoma.

Irradiating the groin nodes without breaking a leg: A comparison of techniques for groin node irradiation

The purpose of this study was to determine the optimal technique for delivering postoperative radiotherapy for vulvar cancer and other tumors requiring treatment of the inguinal nodes. This project compared tumor coverage and normal tissue sparing for the 5 main radiotherapy techniques that are used to treat vulvar cancer. The intensity-modulated radiation therapy (IMRT) plan was undesirable because it resulted in an excessive dose to portions of the central pelvic structures. The photon thunderbird with skin match was unacceptable because it underdosed a portion of the groin region. The electron thunderbird was ideal for thin patients but was not applicable for most patients because of excessive dose to the skin and subcutaneous tissues. The photon through-and-through and the photon thunderbird with deep match were acceptable in most situations. In thin patients, where the depth of the inguinal vessels is less than 3 cm, the electron thunderbird is the technique of choice. In the average-sized patient, both the photon through-and-through and the photon thunderbird with deep match are reasonable options. The available literature suggests that the risk of femoral neck fracture or necrosis of the femoral head is approximately 11% at 5 years using the photon through-and-through technique. In our opinion, this is an acceptable price to pay for reliable node coverage, setup simplicity, and zero risk of overdose at field junctions.

Irradiation of the inguinal lymph nodes in patients of differing body habitus: A comparison of techniques and resulting normal tissue complication probabilities

The treatment of the inguinal lymph nodes with radiotherapy is strongly influenced by the body habitus of the patient. The effect of 7 radiotherapy techniques on femoral head doses was studied. Three female patients of differing body habitus (ectomorph, mesomorph, endomorph) were selected. Radiation fields included the pelvis and contiguous inguinal regions and were representative of fields used in the treatment of cancers of the lower pelvis. Seven treatment techniques were compared. In the ectomorph and mesomorph, normal tissue complication probability (NTCP) for the femoral heads was lowest with use of anteroposterior (AP) and modified posteroanterior (PA) field with inguinal electron field supplements (technique 1). In the endomorph, NTCP was lowest with use of AP and modified PA field without electron field supplements (technique 2) or a 4-field approach (technique 6). Technique 1 for ectomorphs and mesomorphs and techniques 2 and 6 for endomorphs were optimal techniques for providing relatively homogeneous dose distributions within the target area while minimizing the dose to the femoral heads.

Contemporary management of penile cancer including surgery and adjuvant radiotherapy: an experience in Taiwan

This retrospective study reports on the treatment outcomes of 45 men with penile cancer and seeks to address the issue concerning the treatment of inguinal lymph nodes (LN). Of these 45 patients, five had verrucous carcinoma and the other 40 had squamous cell carcinoma. Eighteen patients had inguinal lymph nodes (LNs) metastasis and received treatments of inguinal LNs involving bilateral inguinal LN dissection or unilateral inguinal LN dissection with or without postoperative radiotherapy. The median follow-up was 37 months. The ultimate local and regional controls for patients with verrucous carcinoma were 100 and 100%, respectively. Among the 40 patients with squamous cell carcinoma, the overall local control rate was 90%. The 5-year overall survival (OS) and disease-free survival (DFS) rates of patients without or with pathological inguinal LN metastasis were 70 vs. 22% (p=0.01), and 55 vs. 16% (p=0.004), respectively. The regional failure rates after inguinal LN dissection for pathological inguinal LN metastasis were 11% (1/9) and 60% (3/5) in patients with and without adjuvant radiotherapy. This study demonstrates that verrucous carcinoma shows excellent treatment outcomes following surgery alone. Squamous cell carcinoma of the penis is associated with a high incidence of inguinal lymph node metastasis. Elective groin dissection is indicated for all penile cancer patients except those with verrucous carcinoma and pT1 cancer with well-differentiated tumor. For patients with pathologically positive inguinal LN metastasis, adjuvant radiotherapy can increase inguinal control in this study. It warrants further prospective trial to prove the value of adjuvant radiotherapy in patients with pathological documented inguinal LN metastasis in penile cancer.

Risk of occult inguinofemoral lymph node metastasis from squamous carcinoma of the vulva

PURPOSE

This study was undertaken to correlate preoperative primary tumor size and American Joint Committee on Cancer and International Federation of Gynecology and Obstetrics categories with the risk of subclinical metastases from squamous carcinoma of the vulva to inguinofemoral nodes in patients with a palpably negative groin preoperatively.

METHODS AND MATERIALS

Clinical notes, operative reports, and pathology reports from 1955 to 1990 were reviewed to assign retrospectively 1969 American Joint Committee on Cancer N(0) and N(1) and 1988 International Federation of Gynecology and Obstetrics T categories.

RESULTS

Of 446 patients with primary carcinoma of the vulva, 226 had a groin without features indicative of lymph node metastasis. Occult groin node metastases were detected in 15.2%, 30.0%, 24.5%, and 0% of patients with T(1), T(2), T(3), and T(4) cancers, respectively. Subclinical node metastases were found in 7.0%, 22.2%, 26.9%, 34.1%, and 20.0% of patients with primary cancers measuring 1.0 cm or less, 1.1 to 2.0 cm, 2.1 to 3.0 cm, 3.1 to 5.0 cm, and larger than 5 cm, respectively.

CONCLUSIONS

Efficacy assessment for elective groin node irradiation and quantitative description of the radiation dose-control relationship for subclinical disease should be based on estimates of the risk of subclinical disease within the target volume. This study may help to assess the effectiveness of current therapies.

Imaging in vulval cancer

Cancer of the vulva spreads locally and, almost without exception, to the regional nodes in the groin to the superficial then deep inguinal groups and the pelvic nodes in a step-wise fashion. Because the single most important prognostic factor is the presence or absence of nodal disease, accurate diagnosis of nodal involvement is paramount. In the past, the status of inguinal nodes in vulval cancer has been ascertained only following groin node dissection, except in those cases with clinically obviously groin nodes. However, as up to 70% of patients at all stages of disease have negative nodes histologically, and as up to 70% of patients have groin or lower-limb problems after radical groin surgery, this approach incurs 'unnecessary' surgery for the majority of patients with the attendant morbidity. Using new diagnostic imaging methods, detection and assessment of groin lymph nodes has been developing over the past few years with the ultimate intention of reducing groin node surgery in node-negative patients. In this chapter we review the role of imaging in patients with vulval cancer in which there is a greater role in the assessment of nodal disease rather than in the assessment of the cancer on the vulva.

Changes in the management of vulval cancer

Vulval carcinoma is relatively rare. The disease spreads from the vulva through embolization to the locoregional lymphatic station, the inguinofemoral nodes. Prior to this event cure can be achieved, but rarely predicted with certainty. This chapter reviews current therapeutic knowledge and recognizes the increasing importance of individualization of a treatment plan. The adoption of these principles will hopefully evolve a pattern of care that leads to a decrease in morbidity for those women with early tumours and less morbid but more effective strategies for those with advanced disease.

Radiotherapy and chemoradiotherapy for carcinoma of the vulva

Radiotherapy may be used in the treatment of vulval cancer as an alternative to surgery in unfit patients, as an adjuvant to surgery in patients with poor prognosis tumours and for the treatment of inoperable, recurrent and metastatic disease. High-energy X-rays, electrons and both superficial mould and interstitial brachytherapy may be integrated in the regimen to produce the maximum tumour control and minimum morbidity. Concomitant chemoradiotherapy has a high response rate and may be used before surgery to reduce the morbidity of otherwise sphincter-sacrificing procedures. This chapter presents the historical development of radiotherapy for vulval cancer, the role of radiotherapy in the treatment of the primary tumour and also the loco-regional nodes, both for prophylaxis and for proven node metastasis. Techniques for delivering radiotherapy are then discussed and are followed by protocols detailing radiotherapy and chemotherapy doses for different clinical situations.

Stage IV carcinoma of the Bartholin gland managed with primary chemoradiation

BACKGROUND

Optimal management of carcinoma of the Bartholin gland is not yet defined. Patients with locally advanced disease have historically been managed by radical and, occasionally, exenterative surgery. Although the management of advanced vulvar cancer has shifted toward conservative management with primary chemoradiation, there is limited information on the similar approach to the management of advanced Bartholin's gland carcinoma.

CASE

We present a woman with stage IVA basaloid squamous carcinoma of the Bartholin gland. She was managed with primary chemoradiation in an attempt to spare her the morbidity associated with exenterative surgery. We discuss a rationale for the use of chemoradiation in advanced Bartholin's gland carcinoma.

CONCLUSION

Conservative management of advanced carcinoma of the Bartholin gland with primary chemoradiation may be appropriate while sparing patients the sequelae of exenterative surgery.

How iliopelvic lymphoscintigraphy can affect the definition of planning target volume in radiation therapy of pelvic and testicular tumors

PURPOSE

External beam radiation therapy (EBRT) of most intrapelvic and testicular tumors has been generally performed with large fields encompassing both the primary disease and lymphatic drainage. This study was carried out to map the pelvic and periaortic lymphatics by means of iliopelvic lymphoscintigraphy (IPL) in preparation for radiotherapy planning.

METHODS AND MATERIALS

Between January 2000 and October 2001, 70 patients scheduled for EBRT (61 operated on, 52 females, 18 males, mean age 61, range, 24-80), affected with uterine (43), rectal (11), testicular (8), anal (4), penile (2), and vulvar (2) cancers were enrolled in the study. IPL was performed by injection of 99mtechnetium-nanocolloids in the bipedal (70 cases) or bipedal plus perianal (20 cases) sites. The sensitivity of IPL in mapping the lymphatic anatomy was evaluated first. Then three radiation oncologists scored the modifications induced by IPL on the planning target volume (PTV) which had been previously delineated only on the basis of bony landmarks. The original fields were classified "inadequate" if they failed to match the new PTV by more than 1 cm.

RESULTS

IPL sensitivity in showing the inguinal, external iliac, common, and periaortic lymphatics was 100%, 90%, 80%, and 70% in anterior-posterior (A-P) projections, and 100%, 80%, 70%, and 60% in lateral projections respectively. For the presacral and hypogastric ones the sensitivity was 40%. When compared with bony landmarks, IPL changed the delineation of PTV in 24 of 70 A-P P-A fields (34%) and 22 of 58 (38%) lateral fields. Furthermore, 8/12 (67%) lymphadenectomies resulted in being incomplete. No IPL-related toxicity was observed.

CONCLUSION

IPL is a safe, inexpensive (cost: 100 Euros), and effective method to map the lymphatic chains. In the A-P scintigrams these structures were detected in 85% (70-100%) of the patients referred for total pelvis irradiation, and this figure could be higher in subjects not operated on. IPL can also give a reliable evaluation of the lymphadenectomies in order to schedule the proper treatments after surgery. Finally, IPL may change the conventional PTV for pelvic irradiation in about 36% (34-38%) of the cases; therefore, the fields should be tailored more around the lymphatic landmarks than the bony landmarks.

MR imaging of carcinoma of the vulva

OBJECTIVE

The aim of this study was to describe the MR imaging features of cancer of the vulva and to determine the accuracy of MR imaging in staging the disease.

MATERIALS AND METHODS

We reviewed the MR images of 22 patients (range, 21-85 years; median, 74 years) with cancer of the vulva who were treated at our institution between 1995 and 2000. Note was made of the primary tumor size, site, signal characteristics, enhancement, and local extension and of lymph node number, size, and position. The MR imaging features were correlated with surgical and pathologic findings.

RESULTS

The tumors were isointense to muscle on T1-weighted images and showed intermediate-to-high signal intensity on T2-weighted scans. After IV gadolinium was administered to four patients, tumor enhancement was seen in two (50%). MR imaging correctly staged the primary site in 14 (70%) of the 20 patients. If superficial inguinal nodes 10 mm or greater in short-axis diameter are considered abnormal, then the sensitivity for detection of malignant nodes was 40% and the specificity, 97%. If deep inguinal nodes 8 mm or greater in short-axis diameter are considered abnormal, then the sensitivity for detection of malignant nodes was 50% and the specificity, 100%.

CONCLUSION

MR imaging is highly specific for the detection of nodal involvement in patients with cancer of the vulva but correlates only moderately with clinicopathologic staging of the primary tumor.

Surgical management of stage I and II vulvar cancer: the role of the sentinel node biopsy. Review of literature

Recognition of the psychosexual consequences of radical vulvectomy and better understanding of the lymphatic drainage and histopathologic features of vulvar cancer have led to a more conservative surgical approach, especially in patients with early-stage disease. Every patient with early vulvar cancer should be managed individually and the risk of conservative therapy balanced against the dangers and advantages of more radical therapy. The results of the sentinel node (SN) procedure in early cancer of the vulva are encouraging, and it might be possible in the near future to avoid the morbidity of inguino-femoral lymphadenectomy. This article reviews surgical management of early vulvar cancer and the place of SN biopsy.

A technique for inguinal node boost using photon fields defined by asymmetric collimator jaws

A technique is described for treating inguinal nodes when using radiotherapy in the control of pelvic malignancies. A posterior photon field treats the pelvis. A wider anterior photon field treats pelvis and inguinal nodes. An anterior photon boost to nodes is delivered using asymmetric collimator jaws moved across center line. Advantages of this technique include simplicity of setup and treatment (a single isocenter is retained, and no transmission block is needed), minimal dose inhomogeneity, reduced dose to femoral necks reducing the risk of femoral fracture, low risk of nodal underdose, and elimination of dosimetric difficulties inherent in electron beam boosts.

Primary groin irradiation vs primary groin surgery for early vulvar cancer

BACKGROUND

Despite changes in technique, morbidity after surgical treatment for vulvar cancer is considerable and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy for the groins in terms of groin recurrences and survival show conflicting results.

OBJECTIVES

To determine whether the effectiveness and safety of primary radiotherapy to the inguino-femoral lymph nodes is comparable with surgery

SEARCH STRATEGY

The literature search was carried out using the criteria set by the Cochrane Gynaecological Cancer Group. A MEDLINE and EMBASE search using the Mesh Heading 'vulvar neoplasms' and textword 'vulva' was performed. Publications on the effectiveness of primary radiotherapy treatment of early squamous cell carcinoma of the vulva were selected.

TYPE OF STUDY

Randomized clinical trials, case-control and observational studies of primary radiotherapy of the groin Type of participants: Patients with early squamous cell cancer of the vulva Type of interventions: inguino-femoral lymph node dissection and primary radiotherapy of the inguino-femoral lymph nodes. Type of outcome measurements: incidence of groin recurrences, survival and morbidity

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted results

MAIN RESULTS

Out of nine reviewed papers only three met the selection criteria. From these studies, (one randomised controlled trial [RCT] one case-control and one observational study) it became clear from the RCT that the incidence of groin recurrences after primary radiotherapy is higher compared with surgery. survival was also worse in the radiotherapy group. The other two studies showed a higher than expected number of groin recurrences after primary radiotherapy. Morbidity after primary radiotherapy was lower compared with surgery. The conclusion of the RCT was criticized on the grounds of the depth of the radiotherapy administered. The depth of 3 cm used in the RCT, is too shallow to administer an optimal dose to the deeper groin nodes.

REVIEWER'S CONCLUSIONS

As shown in an RCT, primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences compared with surgery. Although the technique of radiotherapy in the RCT was criticized, other uncontrolled data do not give evidence for a similar or better groin control for radiotherapy when compared to surgery. This means that surgery is still to be considered the cornerstone of therapy for the groin nodes in women with vulvar cancer. Individual patients not fit enough to withstand surgery can be treated with primary radiotherapy.

Irradiation in carcinoma of the vulva: factors affecting outcome

PURPOSE

This report reviews the increasing role of radiation therapy in the management of patients with histologically confirmed vulvar carcinoma, based on a retrospective analysis of 68 patients with primary disease (2 in situ and 66 invasive) and 18 patients with recurrent tumor treated with irradiation alone or combined with surgery.

METHODS AND MATERIALS

Of the patients with primary tumors, 14 were treated with wide local excision plus irradiation, 19 received irradiation alone after biopsy, 24 were treated with radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes, and 11 received postoperative irradiation after partial or simple vulvectomy. The 18 patients with recurrent tumors were treated with irradiation alone. Indications and techniques of irradiation are discussed in detail.

RESULTS

In patients treated with biopsy/local excision and irradiation, local tumor control was 92% to 100% in Stages T1-3N0, 40% in similar stages with N1-3, and 27% in recurrent tumors. In patients treated with partial/radical vulvectomy and irradiation, primary tumor control was 90% in patients with T1-3 tumors and any nodal stage, 33% in patients with any T stage and N3 lymph nodes, and 66% with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for T1N0, 62% for T2-3N0, 30% for T1-3N1 disease, and 11 % for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 tumors. Four of 18 patients (22%) treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and irradiation. In patients with T1-2 tumors treated with biopsy/wide tumor excision and irradiation with doses under 50 Gy, local tumor control was 75% (3 of 4), in contrast to 100% (13 of 13) with 50.1 to 65 Gy. In patients with T3-4 tumors treated with local wide excision and irradiation, tumor control was 0% with doses below 50 Gy (3 patients) and 63% (7 of 11) with 50.1 to 65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and irradiation, local tumor control was 83% (14 of 17), regardless of dose level, and in T3-4 tumors, it was 62% (5 of 8) with 50 to 60 Gy and 80% (8 of 10) with doses higher than 60 Gy. The differences are not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes; doses of 50 Gy were adequate for elective treatment of nonpalpable lymph nodes, and 60 to 70 Gy controlled tumor growth in 75% to 80% of patients with N2-3 nodes when administered postoperatively after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess.

CONCLUSIONS

Irradiation is playing a greater role in the management of patients with carcinoma of the vulva; combined with wide local tumor excision or used alone in T1-2 tumors, it is an alternative treatment to radical vulvectomy, with significantly less morbidity. Postradical vulvectomy irradiation in locally advanced tumors improves tumor control at the primary site and the regional lymphatics in comparison with reports of surgery alone.