Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy

Abstract

Background. This report consists of a retrospective analysis of 50 patients with primary invasive and 17 with recurrent histologically confirmed vulvar carcinoma treated with radiation therapy for locoregional disease. Methods. Of the patients with primary tumors, 13 were treated with wide local excision plus radiation therapy; 13 had radical vulvectomy followed by irradiation to the operative fields and inguinal–femoral/pelvic lymph nodes; 8 received similar postoperative radiation therapy after partial or simple vulvectomy; 16 patients had radiation therapy alone after biopsy; and 17 had recurrent tumors treated with radiation therapy alone. Results. In patients treated with biopsy/local excision, local tumor control was 92–100% in T1–3N0 disease, 40% in similar stages with N1–3, and 27% in recurrent tumors. Among patients treated with partial/radical vulvectomy and radiation therapy, primary tumor control was 90% in those with T1–3 tumors and any nodal stage, 33% in those with any T stage and N3 lymph nodes, and 66% in patients with recurrent tumors. The actuarial 5‐year disease‐free survival rates were 87% for patients with T1N0 disease, 62% for those with T2–3N0 disease, 30% for those with T1–3N1 disease, and 11% for patients with recurrent tumors; there were no long‐term survivors with T4 or N2–3 disease. Four of 17 patients treated for postvulvectomy recurrent disease remain disease‐free after local tumor excision and radiation therapy. In patients with T1–2 tumors treated with biopsy/wide tumor excision and radiation therapy with doses less than 50 Gy, the local tumor control was 75% (three of four patients), in contrast to 100% (13 of 13 patients) with 50.01–65 Gy. With T3–4 tumors treated with local excision and radiation therapy, tumor control occurred in none of three patients with doses less than 50 Gy and 66% (six of nine) with 50.01–65 Gy. In patients with T1–2 tumors treated with partial/radical vulvectomy and radiation therapy, local tumor control was 75% (six of eight), regardless of dose level; in T3–4 tumors, it was 67% (four of six patients) with 50–60 Gy and 86% (six of seven) with 65–70 Gy. Differences were not statistically significant. There was no significant dose response for tumor control in the inguinal–femoral lymph nodes, with doses of 50 Gy being adequate for elective treatment of nonpalpable lymph nodes and 60–70 Gy controlling tumor growth in 75–80% 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. Wide local tumor excision and radiation therapy or irradiation alone in T1–2 tumors is an alternative treatment to radical vulvectomy in controlling vulvar carcinoma, with significantly less morbidity. In comparison with reported rates for surgery alone, radiation therapy after radical vulvectomy for locally advanced tumors ...

Vulvar carcinoma

“…Debulking procedures in the groin commonly leave gross disease or risk vascular injury; preoperative radiotherapy or chemoradiotherapy is therefore given. The techniques for groin irradiation are described elsewhere [43,44]. Postirradiation resection may require muscle flap reconstruction such as a sartorius muscle or tensor fascia lata flap [45,46].…”

Prophylactic inguinal-femoral irradiation as an alternative to primary lymphadenectomy in treatment of vulvar carcinoma

“…Perez et al (9) reported that 80-95% of relapses were local or nodal. In their series 45% of the patients had recurrences after 5 years, 29% had local vulvar recurrence, 19% had groin recurrence, 4% had pelvic recurrence, and 4% had distant metastases.…”

“…If irradiation alone is used, additional doses are delivered after 45 Gy with reduced fields to complete 65-70 Gy (9). Some investigators have suggested treating patients with clinically negative groins with wide local excision of the vulva combined with radiotherapy of the groin only.…”

Conséquences gynécologiques de la radiothérapie pelvienne

“…La dose totale tolé-rable serait plus élevée au niveau de la partie supérieure du vagin qu'au niveau du vagin distal [31,32] : pour Hintz et al [31], la tolérance est de 140 Gy en association radiothérapie externe-curiethérapie au niveau de la muqueuse du vagin supérieur, alors qu'elle n'est que de 98 Gy au niveau du vagin distal ; ainsi, pour ces auteurs, 80 Gy seraient la doseseuil pour provoquer une fistule rectovaginale, alors qu'il faudrait 150 Gy pour aboutir à la constitution d'une fistule vésicovaginale. Dans une série de 141 patientes traitées par radiothérapie exclusive pour carcinome du vagin, Perez et al [33] constatent cinq fistules (4 %) pour une dose d'irradiation de 80 à 120 Gy. Les complications spécifiques de la curiethérapie sont liées à la dose délivrée et à la hauteur du vagin irradié.…”

“…À la dose quotidienne de 1,6 à 1,8 Gy (dose totale de 50 à 70 Gy), Perez et al [33] rapportent, sur une série de 67 patientes traitées pour cancer de la vulve (dont 17 récidives), deux cas de nécrose vulvaire (3 %).…”