Radiotherapy is not indicated in patients with vulvar squamous cell carcinoma and only one occult intracapsular groin node metastasis

Velden, J. van der; Pleunis, Noortje; Barlow, Ellen; Zijlmans, Henry; Hullu, Joanne de; Hacker, Neville F.; Fons, Guus

doi:10.1016/j.ygyno.2020.10.008

Cited by 12 publications

(13 citation statements)

References 25 publications

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“…The 5-year, disease-specific survival was 79% and overall survival was approximately 62%. The conclusion was that in such cases adjuvant radiotherapy can be safely omitted avoiding unnecessary toxicity and morbidity [ 149 ].…”

Section: Treatmentmentioning

confidence: 99%

Management of Early-Stage Vulvar Cancer

Pedrão

Guimarães

Possati-Resende

et al. 2022

Cancers

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Vulvar cancer is a rare gynecological malignancy since it represents 4% of all cancers of the female genital tract. The most common histological type is squamous cell carcinoma (90%). This type can be classified into two clinicopathological subtypes according to the etiology. The first subtype is associated with persistent human papillomavirus infection and is usually diagnosed in younger women. The second subtype is associated with lichen sclerosus condition, and in most cases is diagnosed in postmenopausal women. Currently, an increase in first subtype cases has been observed, which raised the concern about associated mortality and treatment morbidity among young women. Vulvar cancer treatment depends on histopathology grade and staging, but surgery with or without radiotherapy as adjuvant treatment is considered the gold standard. In recent decades, sentinel lymph node biopsy has been incorporated as part of the treatment. Therefore, we sought to review and discuss the advances documented in the literature about vulvar cancer focusing on the treatment of early-stage disease. Relevant articles, such as the GROINS-V studies and the GOG protocols, are presented in this review. Additionally, we discuss key points such as the evolution of treatment from invasive surgery with high morbidity, to more conservative approaches without compromising oncologic safety; the role of sentinel lymph node mapping in the initial staging, since it reduces the complications caused by inguinofemoral lymphadenectomy; the recurrences rates, since local recurrence is common and curable, however, groin-associated, or distant recurrences have a poor prognosis; and, finally, the long-term follow-up that is essential for all patients.

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Section: Treatmentmentioning

confidence: 99%

Management of Early-Stage Vulvar Cancer

Pedrão

Guimarães

Possati-Resende

et al. 2022

Cancers

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“…Finally, we report the results of Van Der Velden et al’s [ 40 ] study on 96 patients with single clinically occult intracapsular lymph node metastasis treated with no adjuvant radiotherapy after surgical procedure. All patients underwent radical local excision of the primary tumor and either unilateral or bilateral IFL.…”

Section: Resultsmentioning

confidence: 99%

“…Only one patient showed an isolated groin recurrence (on the contralateral side). The authors found that neither the size of the metastasis in the lymph node (<5 vs. ≥5 mm) nor the lymph node ratio had any impact on the groin recurrence rate and/or survival in this group of patients [ 40 ].…”

Section: Resultsmentioning

confidence: 99%

Adjuvant Radiotherapy for Groin Node Metastases Following Surgery for Vulvar Cancer: A Systematic Review

Ferrari,

Ismail,

Sabbagh

et al. 2024

Oncol.Rev.

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Background: Lymph node metastasis in vulvar cancer is a critical prognostic factor associated with higher recurrence and decreased survival. A survival benefit is reported with adjuvant radiotherapy but with potential significant morbidity. We aim to clarify whether there is high-quality evidence to support the use of adjuvant radiotherapy in this setting.Objectives: The aim of the study was to assess the effectiveness and safety of adjuvant radiotherapy to locoregional metastatic nodal areas.Search Methods: We conducted a comprehensive and systematic literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the National Cancer Institute. We considered only randomized controlled trials (RCTs).Main Results: We identified 1,760 records and finally retrieved only one eligible RCT (114 participants with positive inguinofemoral lymph nodes). All women had undergone radical vulvectomy and bilateral inguinal lymphadenectomy and had been randomized to adjuvant radiotherapy or to intraoperative ipsilateral pelvic lymphadenectomy without adjuvant radiotherapy. At 6 years, the overall survival (OS) was 51% versus 41% in favor of radiotherapy (HR 0.61; 95% CI 0.30–1.3) without significance and with very low certainty of evidence. At 6 year, the cumulative incidence of cancer-related deaths was 29% versus 51% in favor of adjuvant radiotherapy (HR 0.49; 95% CI 0.28–0.87). Recurrence-free survival at 6 years was 59% after adjuvant radiotherapy versus 48% after pelvic lymphadenectomy (HR 0.39; 95% CI 0.17–0.88). Three (5.3%) versus 13 (24.1%) groin recurrences were noted, respectively, in the adjuvant radiotherapy and pelvic lymphadenectomy groups. There was no significant difference in acute toxicities for pelvic lymphadenectomy compared to radiotherapy. In women with positive pelvic lymph nodes (20%), the OS at 6 year was 36% compared with 13% in favor of adjuvant radiotherapy. Late cutaneous toxicity rate appeared to be greater after radiotherapy (19% vs. 15%) but with less chronic lymphedema (16% vs. 22%).Conclusion: There is only very low-quality evidence on administering adjuvant radiotherapy for inguinal lymph node metastases. Although the identified study was a multicenter RCT, there was a reasonable imprecision and inconsistency because of small study numbers, wide confidence intervals in the data, and early trial closure, resulting in downgrading of the evidence.

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“…NCCN 4 2022 [17] Any nodes that are grossly enlarged or suspicious for metastases during the unilateral inguino-femoral lymphadenectomy should be evaluated by frozen section pathology intraoperatively in order to tailor the extent and laterality of the lymphadenectomy. DGGG 5 2015 [18] Systematic inguino-femoral lymphadenectomy (= surgical staging of the inguinal region) must always include removal of both the superficial (inguinal) and the deep (femoral) lymph nodes below the cribriform fascia (expert consensus).…”

Section: Guidelines Regarding the Treatment Of Bulky Lymph Nodes In T...mentioning

confidence: 99%

“…The standard treatment for patients with squamous cell cancer of the vulva and a depth of invasion > 1 mm consists of a radical local excision of the primary tumor and either lymph node evaluation by sentinel node dissection (SLN) or primary inguinal femoral lymph node dissection (IFL) [3]. Adjuvant radiotherapy is recommended in patients with metastases in the nodes, with the exception of patients with a single clinically occult intracapsular metastasis [4].…”

Section: Introductionmentioning

confidence: 99%

Selective Removal of Only Clinically Suspicious Positive Lymph Nodes Instead of a Complete Inguino-Femoral Lymph Node Dissection in Squamous Cell Carcinoma of the Vulva

Fons

Thuijs

Tjiong

et al. 2023

Cancers

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Background. The oncological safety of only removing bulky, positive groin lymph nodes followed by radiotherapy without performing a complete inguino-femoral node dissection (IFL) in squamous cell cancer of the vulva is based on two small studies. The aim of this study was to confirm the oncological safety of this treatment policy. Methods. The survival of consecutive patients with clinically suspicious and pathologically positive groin nodes treated with the selective removal of these nodes followed by radiotherapy was compared with the survival in historical controls matched for the variables extranodal spread and diameter of the metastasis > 15 mm and treated with a complete IFL. Results. There was no difference in disease-specific survival between patients treated with debulking (n = 40) versus complete IFL (n = 37) (43.1% vs. 44.8%, p = 0.336, respectively). Overall, survival and groin recurrence-free survival did not differ between the groups either. Conclusion. This retrospective study in a cohort of women with vulvar cancer corroborates previous smaller studies that have shown that the selective removal of suspicious inguinal nodes yields similar oncological outcomes compared with patients matched for important prognostic variables and treated with a complete IFL when both are followed by radiotherapy.

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Radiotherapy is not indicated in patients with vulvar squamous cell carcinoma and only one occult intracapsular groin node metastasis

Cited by 12 publications

References 25 publications

Management of Early-Stage Vulvar Cancer

Management of Early-Stage Vulvar Cancer

Adjuvant Radiotherapy for Groin Node Metastases Following Surgery for Vulvar Cancer: A Systematic Review

Selective Removal of Only Clinically Suspicious Positive Lymph Nodes Instead of a Complete Inguino-Femoral Lymph Node Dissection in Squamous Cell Carcinoma of the Vulva

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