Radiotherapy in vulvar cancer treatment

Czech version

Authors: I. Sirák; M. Hodek; J. Petera; Z. Zoul; M. Vošmik; J. Jansa
Authors‘ workplace: Klinika onkologie a radioterapie FN, Hradec Králové, přednosta prof. MUDr. J. Petera, Ph. D.
Published in: Ceska Gynekol 2013; 78(3): 257-262

Overview

Objective:
To provide an actual review of radiotherapy in the treatment of vulvar carcinoma.

Design:
A review article.

Setting:
Department of Oncology and Radiotherapy, University Hospital in Hradec Králové.

Methods:
A review article evaluating the application of ionizing radiation in the treatment of early and advanced vulvar carcinoma, based on the most significant previously published studies.

Conclusion:
Postoperative groin irradiation in patients with positive groin lymph-nodes improves local control, time to progression, and overall survival; especially in ≥ 2 positive nodes and in N2/3 initial findings. In case of positive inguinal nodes, radiotherapy of both groins and at least lower pelvic iliac node-chains should follow. Adjuvant irradiation of the primary remains controversial, except for positive resection margins where radiotherapy improves overall survival. Concurrent chemoradiotherapy seems to be appropriate primary treatment of advanced vulvar carcinomas, in attempt to avoid mutilating intervention or exenteration. Chemoradiation should be followed by subsequent surgery, including potential groin dissection in case of lymph-node involvement. Definitive chemoradiotherapy is of limited evidence, and radical dose escalation to the gross tumor is essential for its implementation. Modern radiotherapy techniques, especially with intensity modulation, are convenient for dose escalation.

Keywords:
vulvar carcinoma – radiotherapy – chemoradiation – IMRT – brachytherapy

Sources

1. Basta, A., Pitynski, K., Basta, P., et al. Sentinel node in gynaecological oncology. Rep Pract Oncol Radiother, 2005, 10(2), p. 91–94.

2. Beriwal, S., Coon, D., Heron, DE., et al. Preoperative intensity-modulated radiotherapy and chemotherapy for locally advanced vulvar carcinoma. Gynecol Oncol, 2008, 109(2), p. 291–295.

3. Bosquet, JG., Magrina, JF., Magtibay, PM., et al. Patterns of inguinal groin metastases in squamous cell carcinoma of the vulva. Gynecol Oncol, 2007, 105(3), p. 742–746.

4. Eifel, PJ. Radiotherapy versus radical surgery for gynecologic neoplasms: carcinomas of the cervix and vulva. Front Radiat Ther Oncol, 1993, 27, p. 130–142.

5. Faul, CM., Mirmow, D., Huang, Q., et al. Adjuvant radiation for vulvar carcinoma: improved local control. Int J Radiat Oncol Biol Phys, 1997, 38(2), p. 381–389.

6. Gaarenstroom, KN., Kenter, GG., Trimbos, JB., et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer, 2003, 13(4), p. 522–527.

7. Hacker, NF., Leuchter, RS., Berek, JS., et al. Radical vulvectomy and bilateral inguinal lymphadenectomy through separate groin incisions. Obstet Gynecol, 1981, 58(5), p. 574–579.

8. Heaps, JM., Fu, YS., Montz, FJ., et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecol Oncol, 1990, 38(3), p. 309–314.

9. Homesley, HD., Bundy, BN., Sedlis, A., et al. Prognostic factors for groin node metastasis in squamous cell carcinoma of the vulva (a Gynecologic Oncology Group Study). Gynecol Oncol, 1993, 49(3), p. 279–283.

10. Homesley, HD., Bundy, BN., Sedlis, A., Adcock, L. Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol, 1986, 68(6), p. 733–740.

11. Katz, A., Eifel, PJ., Jhingran, A., Levenback, CF. The role of radiation therapy in preventing regional recurrences of invasive squamous cell carcinoma of the vulva. Int J Radiat Oncol Biol Phys, 2003, 57(2), p. 409–418.

12. Koh, WJ., Wallace, HJ., Greer, BE., et al. Combined radiotherapy and chemotherapy in the management of local-regionally advanced vulvar cancer. Int J Radiat Oncol Biol Phys, 1993, 26(5), p. 809–816.

13. Kunos, C., Simpkins, F., Gibbons, H., et al. Radiation therapy compared with pelvic node resection for node-positive vulvar cancer. Obstet Gynecol, 2009, 114(3), p. 537–546.

14. Le, T., Elsugi, R., Hopkins, L., et al. The definition of optimal inguinal femoral nodal dissection in the management of vulva squamous cell carcinoma. Ann Surg Oncol, 2007, 14(7), p. 2128–2132.

15. Leiserowitz, GS., Russell, AH., Kinney, WK., et al. Prophylactic chemoradiation of inguinofemoral lymph nodes in patients with locally extensive vulvar cancer. Gynecol Oncol, 1997, 66(3), p. 509–514.

16. Marcos, S., Montero, A., Capuz, B., et al. HDR-plesiotherapy for the treatment of anogenital extramammary Paget‘s disease. Rep Pract Oncol Radiother, 2012, 17(3), p. 163–167.

17. Montana, GS., Thomas, GM., Moore, DH., et al. Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncologic group study. Int J Radiat Oncol Biol Phys, 2000, 48(4), p. 1007–1013.

18. Moore, DH., Ali, S., Koh, WJ., et al. A phase II trial of radiation therapy and weekly cisplatin chemotherapy for the treatment of locally-advanced squamous cell carcinoma of the vulva: A gynecologic Oncology Group Study. Gynecol Oncol, 2012, 124(3), p. 529–533.

19. Moore, DH., Thomas, GM., Montana, GS., et al. Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group. Int J Radiat Oncol Biol Phys, 1998, 42(1), p. 79–85.

20. Parthasarathy, A., Cheung, MK., Osann, K., et al. The benefit of adjuvant radiation therapy in single-node-positive squamous cell vulvar carcinoma. Gynecol Oncol, 2006, 103(3), p. 1095–1099.

21. Petereit, DG., Mehta, MP., Buchler, DA., et al. Inguinofemoral radiation of N0,N1 vulvar cancer may be equivalent to lymphadenectomy if proper radiation technique is used. Int J Radiat Oncol Biol Phys, 1993, 27(4), p. 963–967.

22. Sedlis, A., Homesley, HD., Bundy, BN., et al. Positive groin lymph nodes in superficial squamous cell vulvar cancer. A Gynecologic Oncology Group study. Am J Obstet Gynecol, 1987, 156(5), p. 1159–1164.

23. Shylasree, TS., Bryant, A., Howells, RE. Chemoradiation for advanced primary vulval cancer. Cochrane Database Syst Rev, 2011, Apr 13(4), CD003752.

24. Siller, BS., Alvarez, RD., Conner, WD., et al. T2/3 vulva cancer: a casecontrol study of triple incision versus en bloc radical vulvectomy and inguinal lymphadenectomy. Gynecol Oncol, 1995, 57(3), p. 335–339.

25. Stehman, FB., Bundy, BN., Thomas, G., et al. Groin dissection versus groin irradiation in carcinoma of the vulva: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys, 1992, 24(2), p. 389–396.

26. Tewari, K., Cappuccini, F., Syed, AMN., et al. Interstitial brachytherapy in the treatment of advanced and recurrent vulvar cancer. Am J Obstet Gynecol, 1991, 181(1), p. 91–98.

27. Van der Velden, J., Fons, G., Lawrie, TA. Primary groin irradiation versus primary groin surgery for early vulvar cancer. Cochrane Database Syst Rev, 2011, May 11(5), CD0022241.

28. Van der Zee, AG., Oonk, MH., De Hullu, JA., et al. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol, 2008, 26(6), p. 884–889.

29. Woelber, L., Choschzick, M., Eulenburg, C., et al. Prognostic value of pathological resection margin distance in squamous cell cancer of the vulva. Ann Surg Oncol, 2011, 18(13), p. 3811–3818.