Advanced Vulva Cancer
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Transcript of Advanced Vulva Cancer
Mansoor Raza MirzaMansoor Raza MirzaDept. of OncologyDept. of Oncology
Odense University HospitalOdense University HospitalOdense, DenmarkOdense, Denmark
Radiotherapy forRadiotherapy forAdvanced Vulva Advanced Vulva
CancerCancer
Stage III Stage III Tumor with adjacent spread to urethra, Tumor with adjacent spread to urethra,
vagina or anus vagina or anus or with unilateral lymphnode metastasesor with unilateral lymphnode metastases
Stage IVaStage IVaTumor invades upper urethra, bladder Tumor invades upper urethra, bladder
mucosa, rectal mucosa or pelvic bonemucosa, rectal mucosa or pelvic boneor bilateral node metastasesor bilateral node metastases
Stage IVbStage IVbDistant metastasesDistant metastases
Definition of Advanced Definition of Advanced Vulva CancerVulva Cancer
Kehrer E. Kehrer E. Soll das Vulvakarzinom operiert oderSoll das Vulvakarzinom operiert oder
bestrahlt werden? bestrahlt werden? Geburtshilfe Frauenheilkunde 48:346; 1918Geburtshilfe Frauenheilkunde 48:346; 1918
Disease extended beyond the boundaries Disease extended beyond the boundaries of surgical feasibilityof surgical feasibility
Radiotherapy was administered using Radiotherapy was administered using suboptimal dose /fractionation schedules suboptimal dose /fractionation schedules as well as primitive techniquesas well as primitive techniques
Boronow RC, Cancer, 1982; 49: 1085-91Boronow RC, Cancer, 1982; 49: 1085-91
n = 37n = 37
Median radiation dose 48 GyMedian radiation dose 48 Gy
No residual disease in 42% patients at No residual disease in 42% patients at the time of surgerythe time of surgery
5 yr. survival 75,6%5 yr. survival 75,6%
Stehman FB et al., IJROBP, 1992; 24: 389-Stehman FB et al., IJROBP, 1992; 24: 389-9696
Randomized Controlled Trial - GOGRandomized Controlled Trial - GOG
Radiotherapy vs SurgeryRadiotherapy vs Surgery
TT1-31-3 N N0-10-1 M M00
n=58 (27 in Rt arm)n=58 (27 in Rt arm)
Radiotherapy: 50 Gy at 3cmRadiotherapy: 50 Gy at 3cm
Results:Results:
Groin recurrence 5/27 (18.5%)Groin recurrence 5/27 (18.5%)
OS: 60% vs 86%OS: 60% vs 86%
Stehman FB et al., IJROBP, 1992; 24: 389-Stehman FB et al., IJROBP, 1992; 24: 389-9696
Manavi M et al., IJROBP, 1997; 38: 749-53Manavi M et al., IJROBP, 1997; 38: 749-53
Case control study Case control study
Radiotherapy vs ‘wait and see’Radiotherapy vs ‘wait and see’
TT11 N N0-10-1 M M00
n=135 (65 received Rt)n=135 (65 received Rt)
Radiotherapy: 45Gy at 5cm telecobaltRadiotherapy: 45Gy at 5cm telecobalt
Results:Results:
Groin recurrence 3/65 (4.6%)Groin recurrence 3/65 (4.6%)
OS: 93.7% vs 91.4%OS: 93.7% vs 91.4%
Manavi M et al., IJROBP, 1997; 38: 749-53Manavi M et al., IJROBP, 1997; 38: 749-53
Perez CA et al., IJROBP, 1998; 42: 335-44Perez CA et al., IJROBP, 1998; 42: 335-44
Observational Observational
TT1-31-3 N N0-30-3 M M00
n=68+18n=68+18
LE+Rt 14; Rt 19+18; RV+Rt 24; PV+Rt 11LE+Rt 14; Rt 19+18; RV+Rt 24; PV+Rt 11
Radiotherapy: 50-70Gy at 4cmRadiotherapy: 50-70Gy at 4cm
Results:Results:
Groin recurrence 10%Groin recurrence 10%
OS: ?OS: ?
Perez CA et al., IJROBP, 1998; 42: 335-44Perez CA et al., IJROBP, 1998; 42: 335-44
Van der Velden J, Ansink A, Van der Velden J, Ansink A, The Cochrane Database of Systemic The Cochrane Database of Systemic
Reviews Reviews Stehman FB et al.Stehman FB et al.Manavi M et al.Manavi M et al.Perez CA et al.Perez CA et al.
Conclusions:Conclusions:
Primary radiotherapy to the groin results in less morbidity Primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences but also in a higher number of groin recurrences compared with surgery. compared with surgery.
Surgery is still to be considered the cornerstone of therapySurgery is still to be considered the cornerstone of therapyfor the groin nodes. for the groin nodes.
Katz A et al., IJROBP, 2003; 57: 409-418Katz A et al., IJROBP, 2003; 57: 409-418
Retrospective analysis of one centre dataRetrospective analysis of one centre data
1980-1998 1980-1998
n=227 (stage III/VI 119; Stage I/II 67)n=227 (stage III/VI 119; Stage I/II 67)
LND 119; LND+Rt 57; Rt 51LND 119; LND+Rt 57; Rt 51
Radiotherapy:Radiotherapy:narrow inguinal fieldsnarrow inguinal fields
45/50Gy or 60Gy45/50Gy or 60Gy
Surgery:Surgery: superficial LNDsuperficial LND
Results: Results:
5 yrs groin recurrence: 16% vs 13% vs 16%5 yrs groin recurrence: 16% vs 13% vs 16%
OS: ?OS: ?
Moore DH et al., IJROBP, 1998; 42: 79-85Moore DH et al., IJROBP, 1998; 42: 79-85Montana GS et al., IJROBP, 2000; 48: 1007-Montana GS et al., IJROBP, 2000; 48: 1007-
1313Preoperative chemo-radiation (GOG) Preoperative chemo-radiation (GOG)
TT3-43-4 or N or N2-32-3
n=73+46n=73+46
Radiotherapy: Split courseRadiotherapy: Split course47,6Gy in 6-6.5 weeks47,6Gy in 6-6.5 weeks
Chemotherapy: Cis+5-FuChemotherapy: Cis+5-Fu
Response evaluation: 4-8 wks after end of treatmentResponse evaluation: 4-8 wks after end of treatment
Results:Results:Complete clinical remission 46.5% and 43%Complete clinical remission 46.5% and 43%
Primary radical Primary radical chemoradiotherapychemoradiotherapy
AuthorAuthorNN
Stage (n)Stage (n)
ChemoChemo--
theraptherapyy
RT dose RT dose (Gy)(Gy)
CompleteComplete
ResponseResponseLater Later
relapserelapse NEDNED
Thomas Thomas ((Gynecol Oncol 1989;34:263–7))
99 (advanced)(advanced) F,MF,M 40-6440-64 6 (67%)6 (67%) 33 N/AN/A
BerekBerek(Gynecol Oncol, (Gynecol Oncol, 1991; 42: 197-1991; 42: 197-201)201)
12 12
(III-8; IV-4)(III-8; IV-4) F,PF,P 44-5444-54 8 (67%)8 (67%) 00 7-607-60
RussellRussell (Gynecol (Gynecol Oncol, 1992; 47: Oncol, 1992; 47: 14-20)14-20)
1818 (II-1; III- (II-1; III- 10; IV-6)10; IV-6) F,P,MF,P,M 46,8-5646,8-56 16 (89%)16 (89%) 22 2-522-52
Koh Koh (Int J Radiat Oncol (Int J Radiat Oncol Biol Phys, 1993; Biol Phys, 1993; 26: 809-16)26: 809-16)
14 14
(III-4; IV-10)(III-4; IV-10) F,P,MF,P,M 34-63,134-63,1 8 (57%)8 (57%) 11 5-755-75
Cunningham Cunningham (Gynecol Oncol, (Gynecol Oncol, 1997; 66: 258-61)1997; 66: 258-61)
14 14
(III-9; IV-5)(III-9; IV-5) F,PF,P 50-6550-65 9 (64%)9 (64%) 11 7-817-81
Eifel Eifel (Gynecol Oncol, (Gynecol Oncol, 1995; 59: 51-6)1995; 59: 51-6)
1212 (II-1; (II-1; III/IV-11)III/IV-11) F,PF,P 40-5040-50 6 (50%)6 (50%) 11 17-3717-37
TotalTotal 7979 53 (67%)53 (67%) 8 (15%)8 (15%)
Radical chemoradiotherapy for Radical chemoradiotherapy for relapserelapse
AuthorAuthor NN ChemoChemo-therpy-therpy
RT dose RT dose (Gy)(Gy)
CompleteComplete
responseresponseLatter Latter
relapserelapse NEDNED
ThomasThomas ((Gynecol Oncol 1989;34:263–7)) 1515 F,MF,M 40-6440-64 88 00 N/AN/A
Russell Russell (Gynecol Oncol, (Gynecol Oncol, 1992; 47: 14-20)1992; 47: 14-20) 77 F,PF,P 54-7254-72 44 11 2-352-35
TotalTotal 2222 12 12 (55%)(55%) 11
Meta-analysis:
Van Doorn et al. The Cochrane Library, issue 4, 2002, Oxford
The NSGO trialThe NSGO trialNSGO – CC – 0301NSGO – CC – 0301
FIGO III & IV or unfavourably located lesion
or relapsed vulvar cancer
Locoregional RadiotherapyLocoregional Radiotherapywithwith
Concomitant chemoterapyConcomitant chemoterapy
Surgical resection of Surgical resection of any residual diseaseany residual disease
Surgical resection of local tumorSurgical resection of local tumorif possibleif possible
• Subclinical target volume (T & N site)Subclinical target volume (T & N site)50 - 56 Gy (<2 Gy/fraction)50 - 56 Gy (<2 Gy/fraction)
• Gross tumor volumeGross tumor volumeMin. 60 Gy (2 Gy/fraction)Min. 60 Gy (2 Gy/fraction)
Adequate doseAdequate dose
Adequate target Adequate target volumevolume
Adequate target Adequate target volumevolume
Necessary depthNecessary depth
Concomitant weekly cisplatin 40 mg/m2Concomitant weekly cisplatin 40 mg/m2
Concomitant radio-Concomitant radio-chemotherapychemotherapy
12 weeks after end of treatment12 weeks after end of treatment
When to evaluate resultsWhen to evaluate results
Dept. of OncologyDept. of OncologyOdense University HospitalOdense University Hospital
Odense, DenmarkOdense, Denmark
Thank youThank you