RADIOTHERAPYRADIOTHERAPY

inin

VULVARVULVAR CANCERCANCER

2013 ANZGOG

Kailash Narayan

Two patients developed a skin-bridge recurrence.

Both had palpably suspicious nodes (N2) and > 3 positive nodes.

VULVAR CANCER – GOG POSITIVE GROIN NODES

PLND(55) RT (50)

2 years survival 54% 68%

Groin recurrence 24% 5%Pelvic recurrence 2% 7%Vulvar recurrence 9% 9%Distant mets 9% 9%

Advantage only for N2, N3 nodes or >1 pos

Homesley H et al, Obstet Gynecol 1986; 68:733.

 58 patients with squamous carcinoma of the vulva and non-suspicious(N0-1) inguinal nodes to receive Vulvectomy and either groin dissection or groin irradiation.

Groin dissection versus groin radiation in carcinoma of the vulva: GOG study

Stehman et al Int J Radiat Oncol Biol Phys. 1992;24(2):389-96.

There were 5/25 (20.0%) patients with positive groin nodes in surgical arm (Expected rate 24%) These had post op RT, none relapsed in groin.

There were 5/27 (18.5%) relapses in RT arm.

The groin dissection regimen had significantly better progression-free interval (p = 0.03) and survival (p = 0.04).

CONCLUSION: Radiation of the intact groins is significantly inferior to groin dissection in patients with squamous carcinoma of the vulva and N0-1 nodes

Depth Number +ve nodes %

<1 mm 163 0 0.0

1.1–2 mm 145 11 7.7

2.1-3 mm 131 11 8.3

3.1-5 mm 101 27 26.7

>5 mm 38 13 34.2

TOTAL 578 62 10.7

Hacker, Hoffman, Magrina, Parker, Wilkinson, Boice, Ross, Rowley, and Struyk.

Nodal Status in T1 Vulvar Cancer

5-YEAR SURVIVAL RELATED TO CHARACTERISTICS OF POSITIVE NODES

Patients Survival % PDiameter

Site

< 5 mm5 – 15 mm> 15 mm

111215

90.941.620.6

.001

.001IntraExtra

1424

85.725.0

Origoni M et al, Gynecol Oncol 1992;45: 313

Prognostic value of pathological patterns of lymph node positivity in squamous cell carcinoma of the vulva Stage III and IVA FIGO

Death from Recurrence in an Undissected Groin

Author Recurrence DOD

Rutledge (1970) 43

Magrina (1979) 4 3

Hoffman (1983) 44

Hacker (1984) 3 3

Monaghan (1984) 4 4

Lingard (1992) 7 7

Case reports 10 8

TOTAL 36 32 (89%)

MANAGEMENT OF MANAGEMENT OF ADVANCED VULVAR ADVANCED VULVAR

CANCERCANCER

Recommended external irradiation for both internal and external genital disease followed by excision of the tumour bed.

Richard Boronow 1973

Preoperative radiotherapy in Vulvar cancer

GOG Phase II; Moore DH et al; Red J.1998

T3 – T4 lesions (requiring exentrative surgery)

n=74

47.6 Gy split course RT, concurrent 5FU, cis-plat

46.5 % CR

3 Patients had GI or GU diversions

There are other similar studies involvingun-resectable nodes becoming resectable post RT

Chemo-radiotherapy of Vulvar cancer

Advanced Vulvar CancerManagement of Lymph Nodes

CT Scan of groins, pelvis and abdomen

Complete groin dissection

Operable suspicious nodes

(N2,N3)

Resect bulky nodes

RT groin and pelvis

Primary chemoradiation

Surgical resection

No suspicious

nodes (N0,N1)

Non-operable

groin nodes

General perception of vulvar radiotherapy

What is the proportion of vulvar cancer patients in the following categories? (Referral pattern)

Primary Chemo-radiotherapy

Adjuvant radiotherapy

For recurrent cancer

Palliative radiotherapy

VULVAR CANCERn=120 (2000 – 2008) PeterMac

Chemo-radiotherapy n=21(17%)

Adjuvant radiotherapy n=37(31%)

For recurrent cancer n=44(37%)

Palliative radiotherapy n=18(15%)

Follow-up cut off date Jan 2011Lost to follow-up n=5

VULVAR CANCER (2000 – 2008) PeterMac

Chemo-radiotherapy n=21 13(62%) Alive

Node + 11(52%) 5(45%) died

Node - 10(48%) 3(30%) died

Adjuvant radiotherapy n=37 21(56%) Alive

Node + 24(65%) 12(50%) died

Node - 13(35%) 4(31%) died

DISEASE-SPECIFIC SURVIVALKaplan Meyer Curves

Hyde S et al, 2004

1.0

.8

.6

.4

.2

0.0

Cu

m s

urv

ival

Follow-up (months)0 20 40 60 80 100 120 140

Nodal debulking N = 17

Groin dissection N =23

RHWMercy

Amsterdam

VULVAR CANCERAccepted Treatment policies

Unilateral groin dissection for lateral T1 lesions with negative ipsilateral nodes

Nodal debulking for N2 or N3 nodes (ChemoRT, PET, Surg)

Preoperative ChemoRT to avoid exenteration for advanced disease (Use of curative RT)

PostopRT for multiple positive groin nodes or extracapsular spread (ChemoRT, PET, Surg)

Most of these concepts are surgically inspired, based on FIGO staging but in a prognostically heterogeneous population

04/21/23 4-D Ca Cx Narayan