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Ignatov T, Eggemann H, Burger E, Costa SD, Ignatov A. Adjuvant radiotherapy for vulvar cancer with close or positive surgical margins. J Cancer Res Clin Oncol 2015; 142:489-95. [DOI: 10.1007/s00432-015-2060-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 10/16/2015] [Indexed: 10/22/2022]
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Brown PD, Kline RW, Petersen IA, Haddock MG. Irradiation of the inguinal lymph nodes in patients of differing body habitus: A comparison of techniques and resulting normal tissue complication probabilities. Med Dosim 2004; 29:217-22. [PMID: 15324919 DOI: 10.1016/j.meddos.2003.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2003] [Accepted: 12/17/2003] [Indexed: 10/26/2022]
Abstract
The treatment of the inguinal lymph nodes with radiotherapy is strongly influenced by the body habitus of the patient. The effect of 7 radiotherapy techniques on femoral head doses was studied. Three female patients of differing body habitus (ectomorph, mesomorph, endomorph) were selected. Radiation fields included the pelvis and contiguous inguinal regions and were representative of fields used in the treatment of cancers of the lower pelvis. Seven treatment techniques were compared. In the ectomorph and mesomorph, normal tissue complication probability (NTCP) for the femoral heads was lowest with use of anteroposterior (AP) and modified posteroanterior (PA) field with inguinal electron field supplements (technique 1). In the endomorph, NTCP was lowest with use of AP and modified PA field without electron field supplements (technique 2) or a 4-field approach (technique 6). Technique 1 for ectomorphs and mesomorphs and techniques 2 and 6 for endomorphs were optimal techniques for providing relatively homogeneous dose distributions within the target area while minimizing the dose to the femoral heads.
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Affiliation(s)
- Paul D Brown
- Division of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
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Abstract
About 30-40% of vulvar cancers present with International Federation of Gynecology and Obstetrics (FIGO) (clinical) stage III or IV disease. Although surgical staging was introduced by FIGO in 1988 and hard data on this system are still relatively few, a review of our own patients suggests that this percentage of patients with advanced stage vulvar cancer probably still holds. We have considered carcinoma of the vulva to be locally advanced when the primary or recurring tumour cannot be locally managed by a radical vulvar resection. Current approaches to the treatment of locally advanced vulvar cancer include ultraradical surgery, radiotherapy, chemo-radiotherapy and a combination of treatment modalities. This chapter reviews the current approaches to the treatment of locally advanced vulvar cancer.
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Affiliation(s)
- Mitchel S Hoffman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL 33606, USA.
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Warszawski A, Suhr P, Warszawski N, Röttinger EM. Radiation treatment related factors influencing outcome in vulvar cancer patients. Int J Gynecol Cancer 2000; 10:7-12. [PMID: 11240645 DOI: 10.1046/j.1525-1438.2000.00006.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The objective of this research is to identify the impact of radiation treatment factors on survival in vulvar cancer patients. We performed a follow-up study on 60 women with squamous cell carcinoma of the vulva treated at the Department of Radiotherapy of the University of Ulm from 1980 to 1997. The follow-up time ranged from 0.5 to 17 years (mean 6.5 years). The irradiated volume included vulva and regional lymph nodes. The influence of treatment factors (tumor resection versus no tumor resection, treatment time, dose) on overall and disease-free survival was examined. In addition, applied doses were corrected for treatment time using the extended alpha/beta-model for calculating the biologically effective doses. The applied dose was 48.1 +/- 13.2 Gy (median: 50 Gy). Treatment time was 40.4 +/- 19.4 days (median: 38 days). 34/60 patients underwent surgery with complete resection of macroscopic tumor. 26 of 60 patients were resected incompletely or only a biopsy was taken. In univariate analysis prognostic factors influencing overall and disease-free survival were, along with T- and N-stage, treatment time, and biologically effective dose. In multivariate analysis, biologically effective dose was the only significant factor. We conclude that biologically effective dose and treatment time are important treatment factors influencing overall and disease-free survival vulvar cancer patients.
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Affiliation(s)
- A. Warszawski
- Department of Radiotherapy, University of Ulm, Ulm, Germany
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Perez CA, Grigsby PW, Chao C, Galakatos A, Garipagaoglu M, Mutch D, Lockett MA. Irradiation in carcinoma of the vulva: factors affecting outcome. Int J Radiat Oncol Biol Phys 1998; 42:335-44. [PMID: 9788413 DOI: 10.1016/s0360-3016(98)00238-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE This report reviews the increasing role of radiation therapy in the management of patients with histologically confirmed vulvar carcinoma, based on a retrospective analysis of 68 patients with primary disease (2 in situ and 66 invasive) and 18 patients with recurrent tumor treated with irradiation alone or combined with surgery. METHODS AND MATERIALS Of the patients with primary tumors, 14 were treated with wide local excision plus irradiation, 19 received irradiation alone after biopsy, 24 were treated with radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes, and 11 received postoperative irradiation after partial or simple vulvectomy. The 18 patients with recurrent tumors were treated with irradiation alone. Indications and techniques of irradiation are discussed in detail. RESULTS In patients treated with biopsy/local excision and irradiation, local tumor control was 92% to 100% in Stages T1-3N0, 40% in similar stages with N1-3, and 27% in recurrent tumors. In patients treated with partial/radical vulvectomy and irradiation, primary tumor control was 90% in patients with T1-3 tumors and any nodal stage, 33% in patients with any T stage and N3 lymph nodes, and 66% with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for T1N0, 62% for T2-3N0, 30% for T1-3N1 disease, and 11 % for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 tumors. Four of 18 patients (22%) treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and irradiation. In patients with T1-2 tumors treated with biopsy/wide tumor excision and irradiation with doses under 50 Gy, local tumor control was 75% (3 of 4), in contrast to 100% (13 of 13) with 50.1 to 65 Gy. In patients with T3-4 tumors treated with local wide excision and irradiation, tumor control was 0% with doses below 50 Gy (3 patients) and 63% (7 of 11) with 50.1 to 65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and irradiation, local tumor control was 83% (14 of 17), regardless of dose level, and in T3-4 tumors, it was 62% (5 of 8) with 50 to 60 Gy and 80% (8 of 10) with doses higher than 60 Gy. The differences are not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes; doses of 50 Gy were adequate for elective treatment of nonpalpable lymph nodes, and 60 to 70 Gy controlled tumor growth in 75% to 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 Irradiation is playing a greater role in the management of patients with carcinoma of the vulva; combined with wide local tumor excision or used alone in T1-2 tumors, it is an alternative treatment to radical vulvectomy, with significantly less morbidity. Postradical vulvectomy irradiation in locally advanced tumors improves tumor control at the primary site and the regional lymphatics in comparison with reports of surgery alone.
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Affiliation(s)
- C A Perez
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO, USA
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6
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Zucali R, Raspagliesi F, Kenda R, Lozza L, Tana S, Valvo F. Radio-Chemotherapy of Vulvar Cancer. TUMORI JOURNAL 1998; 84:250-1. [PMID: 9620253 DOI: 10.1177/030089169808400225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Surgery alone, more or less demolitive, is the treatment of choice of vulvar cancers. Cure rates are high for early cancers only, while locally advanced tumors with or without inguinal adenopathies and recurrences have a bad prognosis. The excellent results of concurrent chemo-radiotherapy of anal cancers suggested to adopt the same approach for locally advanced vulvar cancers. The shrinkage of the tumor allowed surgery, often less demolitive than usual, and the pathological examination demonstrated an overall complete response in 40% of cases. Survival has been improved through this multidisciplinary approach. Patients not suitable for surgery obtained important remissions and an improved quality of life. Clinical experience at the Istituto Tumori of Milano is presented.
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Affiliation(s)
- R Zucali
- Divisione di Radioterapia A, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
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7
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Faul CM, Mirmow D, Huang Q, Gerszten K, Day R, Jones MW. Adjuvant radiation for vulvar carcinoma: improved local control. Int J Radiat Oncol Biol Phys 1997; 38:381-9. [PMID: 9226327 DOI: 10.1016/s0360-3016(97)82500-x] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Local recurrence is a significant problem following primary surgery for advanced vulva carcinoma. The objectives of this study were to evaluate the impact of adjuvant vulvar radiation on local control in high risk patients and the impact of local recurrence on overall survival. METHODS AND MATERIALS From 1980-1994, 62 patients with invasive vulva carcinoma and either positive or close (less 8 mm) margins of excision were retrospectively studied. Thirty-one patients were treated with adjuvant radiation therapy to the vulva and 31 patients were observed after surgery. Kaplan-Meier estimates and the Cox proportional hazard regression model were used to evaluate the effect of adjuvant radiation therapy on local recurrence and overall survival. Independent prognostic factors for local recurrence and survival were also assessed. RESULTS Local recurrence occurred in 58% of observed patients and 16% in patients treated with adjuvant radiation therapy. Adjuvant radiation therapy significantly reduced local recurrence rates in both the close margin and positive margin groups (p = 0.036, p = 0.0048). On both univariate and multivariate analysis adjuvant radiation and margins of excision were significant prognostic predictors for local control. Significant determinants of actuarial survival included International Federation of Gynecologists and Obstetricians (FIGO) stage, percentage of pathologically positive inguinal nodes and margins of excision. The positive margin observed group had a significantly poorer actuarial 5 year survival than the other groups (p = 0.0016) and adjuvant radiation significantly improved survival for this group. The 2 year actuarial survival after developing local recurrence was 25%. Local recurrence was a significant predictor for death from vulva carcinoma (risk ratio 3.54). CONCLUSION Local recurrence is a common occurrence in high risk patients. In this study adjuvant radiation therapy significantly reduced local recurrence rates and may improve overall survival in certain subgroups. As salvage rates after developing local recurrence are poor adjuvant vulvar radiation should be considered for patients at risk after primary surgery.
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Affiliation(s)
- C M Faul
- Department of Radiation Oncology, Magee Women's Hospital, University of Pittsburgh Medical School, PA 15213, USA
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8
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Wang CJ, Chin YY, Leung SW, Chen HC, Sun LM, Fang FM. Topographic distribution of inguinal lymph nodes metastasis: significance in determination of treatment margin for elective inguinal lymph nodes irradiation of low pelvic tumors. Int J Radiat Oncol Biol Phys 1996; 35:133-6. [PMID: 8641909 DOI: 10.1016/s0360-3016(96)85021-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE To study the distribution of gross inguinal lymph node metastasis and, in particular, its correlation with major pelvic bony structures on a simulation film. METHODS AND MATERIALS Thirty-seven cases of low pelvic tumors having gross inguinal lymph node metastasis that were treated with radiation therapy between November 1987 and December 1992 were segregated for study. The patient's nodes were palpated and marked with lead wire before the simulation film was assumed to be the origin of the previously uninfested node. A total of 84 such labeled nodes was taken. The geometric center of the usually round or elliptical node on the film was obtained from these 37 cases. These centers were transferred to and mapped collectively on a new simulation film showing major pelvic bony structures of left hemipelvis and upper femur. RESULTS Distribution of gross inguinal lymph nodes was found confined to the following area, as related to major pelvic bony structure: laterally, just abutting the tangential line that passes through lateral border of the femoral head; medially: 3 cm away from the body's midline axis; superiorly: 1 cm below the line that joins both upper borders of the femoral head; inferiorly: 2.5 cm below the low borders of ischial tuberosity. According to this rectangular boundary, three nodes were out of the field, nine nodes near the border less than 1 cm margin. This area adequately covered 86% (72 of 84) of the studied nodes. CONCLUSION Distribution study is important in determining the treatment margin. In general, an additional 1-2 cm beyond the area described above is the recommended treatment margin for elective inguinal lymph nodes irradiation with high confidence level of coverage.
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Affiliation(s)
- C J Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Abstract
PURPOSE Controversies exist regarding the use of radiation therapy in the treatment of vulvar carcinoma. A retrospective review was performed to evaluate our institution's experience with surgery and radiation for this disease. METHODS AND MATERIALS The medical records of 47 patients treated for squamous cell carcinoma of the vulva at our institution (1974-1992) were reviewed for TNM stage (AJCC criteria), treatment modality, and associated 5-year local control and survival based on Kaplan-Meier analysis. RESULTS Twenty-eight patients (60%) presented with Stage I and II disease and their 5-year survival was 69%. Stage III patients accounted for 12 (25%) of the patients and their 5-year survival was 73%. Seven patients presented with Stage IV disease and five died within 13 months of diagnosis after predominantly palliative therapy. The 40 patients with Stages I, II, and III disease were treated aggressively and were further evaluated for treatment-modality-associated survival and local control. Radiation therapy was used as primary treatment in nine patients, of whom seven were treated with radiation alone and two were treated postoperatively after wide excision. Surgery alone was performed in 31 patients consisting of either radical vulvectomy (20 patients) or wide excision (11 patients). When comparing outcomes of radical vulvectomy vs. radiation therapy, we noted that the 5-year actuarial survivals were comparable (74% for either modality), despite the presence of more favorable prognostic factors in the group treated with radical vulvectomy. Patients treated with wide excision alone had a trend for a poorer 5-year actuarial survival (51%) and local control (50%). CONCLUSIONS Radical vulvectomy offers good locoregional control and survival. This retrospective review further supports the use of radiation therapy with conservative surgery as an alternative treatment option for patients with vulvar carcinoma treated with curative intent. In contrast, the use of wide excision alone should be performed with caution due to a higher locoregional failure rate. The role of appropriately prescribed radiation therapy should be further investigated in prospective clinical trials.
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Affiliation(s)
- J M Anderson
- Department of Radiation Oncology, University of Arizona, Tucson 85724, USA
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Dusenbery KE, Carlson JW, LaPorte RM, Unger JA, Goswitz JJ, Roback DM, Fowler JM, Adcock LL, Carson LF, Potish RA. Radical vulvectomy with postoperative irradiation for vulvar cancer: therapeutic implications of a central block. Int J Radiat Oncol Biol Phys 1994; 29:989-98. [PMID: 8083101 DOI: 10.1016/0360-3016(94)90393-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE/OBJECTIVE To report the long-term results of vulvectomy, node dissection, and postoperative nodal irradiation using a midline vulvar block in patients with node positive vulvar cancer. METHODS AND MATERIALS From 1971 through 1992, 27 patients with carcinoma of the vulva and histologically involved inguinal lymph nodes were treated postoperatively with radiation therapy after radical vulvectomy and bilateral lymphadenectomy (n = 25), radical vulvectomy and unilateral lymphadenectomy (n = 1), or hemivulvectomy and bilateral lymphadenectomy (n = 1). Federation Internationale de Gynecologic et d'Obstetrique stages were III (n = 14), IVA (n = 8), and IVB (n = 5) squamous cell carcinoma. Inguinal lymph nodes were involved with tumor in all patients (average number positive = 4, range 1-15). Postoperative irradiation was directed at the bilateral groin and pelvic nodes (n = 19), unilateral groin and pelvic nodes (n = 6), or unilateral groin only (n = 1). These 26 patients had the midline blocked. In addition, one patient received irradiation to the entire pelvis and perineum. Doses ranged from 10.8 to 50.7 Gy (median 45.5) with all patients except 1 receiving > or = 42.0 Gy. RESULTS Actuarial 5-year overall survival and disease-free survival estimates were 40% and 35%, respectively. Recurrences developed in 63% (17/27) of the patients at a median of 9 months from surgery (range 3 months to 6 years) and 15 of these have died; two patients with recurrences are surviving at 24 and 96 months after further surgery and radiation therapy. Central recurrences (under the midline block) were present in 13 of these 17 patients (76%), either as central only (n = 8), central and regional (n = 4), or central and distant (n = 1). Additionally, three patients developed regional recurrences and one patient developed a concurrent regional and distant relapse. One patient developed a squamous cell cancer of the anus under the midline block 54 months after the initial vulvar cancer and an additional patient developed transitional cell carcinoma of the ureter (outside the radiation field) 12 months after diagnosis. Factors associated with a decreased relapse-free survival included increasing Federation Internationale de Gynecologic et d'Obstetrique stage (p = 0.01) and invasion of the tumor into the subcutaneous (SC) fat or deep soft tissue (p = 0.05). Chronic lower extremity edema developed in four patients, but there have been no other complications. CONCLUSIONS Radical vulvectomy has often been considered sufficient central treatment for vulvar carcinoma, with postoperative irradiation directed only to the nodes. Although designed to protect the radiosensitive vulva, use of a midline block in this series resulted in a 48% (13/27) central recurrence rate, much higher than the 8.5% rate previously reported with this technique. Routine use of the midline block should be abandoned and, instead, postoperative irradiation volumes should be tailored to the individual patient.
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Affiliation(s)
- K E Dusenbery
- Department of Therapeutic Radiology/Radiation Oncology, University of Minnesota Hospital and Clinics, Minneapolis 55455
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Harrington KJ, Lambert HE. Current issues in the non-surgical management of primary vulvar squamous cell carcinoma. Clin Oncol (R Coll Radiol) 1994; 6:331-6. [PMID: 7826928 DOI: 10.1016/s0936-6555(05)80277-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- K J Harrington
- Department of Clinical Oncology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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Robert Lee W, Mark McCollough W, Mendenhall WM, Marcus RB, Parsons JT, Million RR. Elective inguinal lymph node irradiation for pelvic carcinomas the university of florida experience. Cancer 1993. [DOI: 10.1002/1097-0142(19930915)72:6<2058::aid-cncr2820720643>3.0.co;2-u] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Koh WJ, Wallace HJ, Greer BE, Cain J, Stelzer KJ, Russell KJ, Tamimi HK, Figge DC, Russell AH, Griffin TW. Combined radiotherapy and chemotherapy in the management of local-regionally advanced vulvar cancer. Int J Radiat Oncol Biol Phys 1993; 26:809-16. [PMID: 8344850 DOI: 10.1016/0360-3016(93)90496-i] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE To determine, in a retrospective single institutional study, the role of concurrent radiotherapy and chemotherapy in the treatment of local-regionally advanced vulvar cancer. METHODS AND MATERIALS From 1984 to 1991, 20 patients with locally extensive primary or recurrent carcinoma of the vulva were treated with initial combined radiotherapy and chemotherapy. Seven patients had Federation Internationale de Gynecologie et d'Obstretrique Stage III disease, 10 had Stage IV disease, and three were treated for recurrent disease. None of these patients were considered candidates for primary radical vulvectomy and groin node dissection. Median radiation doses to regions of microscopic disease and gross tumor were 40 Gy (range 30-54 Gy) and 54 Gy (34-70.4 Gy), respectively. All patients received 2 or 3 cycles of 5-Fluorouracil concurrently with radiotherapy. In addition, five patients received Cis-platinum, and one Mitomycin-C. Median at-risk follow-up interval was 37 months. RESULTS Ten patients had complete resolution of tumor to initial chemoradiotherapy, and eight of these have remained free of tumor relapse. Eight other patients had partial responses, with tumor bulk reduced by > 50%, while the remaining two patients had local-regionally progressive disease. Six of the patients with partial responses had residual tumor successfully resected, although four subsequently recurred. For the entire group of 20 patients, the actuarial 3- and 5-year local control rates were 48% each, and the corresponding disease-specific survival rates were 59% and 49%. There was a suggestion that better local control was obtained in patients who received gross tumor radiation doses > or = 50 Gy. Skin reaction was the major acute toxicity and responded well to conservative management. Long-term sequalae were limited to skin and subcutaneous atrophy. CONCLUSION These results indicate that initial combined radiotherapy and chemotherapy is effective in the management of advanced vulvar cancer.
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Affiliation(s)
- W J Koh
- Department of Radiation Oncology, University of Washington Medical Center, Seattle 98195
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Perez CA, Grigsby PW, Galakatos A, Swanson R, Camel HM, Kao MS, Lockett MA. Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy. Cancer 1993; 71:3707-16. [PMID: 8490921 DOI: 10.1002/1097-0142(19930601)71:11<3707::aid-cncr2820711139>3.0.co;2-u] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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 improves tumor control at the primary site and regional lymphatics. Indications and techniques of radiation therapy are discussed.
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Affiliation(s)
- C A Perez
- Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, MO 63108
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15
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Tilmans AS, Sutton GP, Look KY, Stehman FB, Ehrlich CE, Hornback NB. Recurrent squamous carcinoma of the vulva. Am J Obstet Gynecol 1992; 167:1383-9. [PMID: 1442996 DOI: 10.1016/s0002-9378(11)91722-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study reviews experience at Indiana University with recurrent squamous carcinoma of the vulva over an 18-year period from 1971 to 1989. The pattern of recurrence, time interval to recurrence, and efficacy of salvage therapy are evaluated in the context of the primary tumor. STUDY DESIGN This is a retrospective study of 40 patients, 21 of whom underwent primary therapy for invasive squamous carcinoma of the vulva at Indiana University. RESULTS Vulvar recurrences were observed in 17 patients (43%), the groin was involved in 12 (30%), whereas pelvic and distant recurrences were observed in 2 (5%) and 9 (22.5%) patients, respectively. Salvage surgery and/or radiotherapy were successful in 25 patients (62.5%) alive from 1 to 144 months (median 8 months) from secondary therapy. Survival after retreatment varied significantly by site of recurrence (p = 0.002), tumor grade (p = 0.009), and interval to recurrence (p < 0.001). Best outcomes were in patients with initial stage I or II disease (International Federation of Gynecology and Obstetrics), grade 1 tumors, local failure, and interval to relapse of > 16 months' duration. Two of 12 patients with groin recurrences were salvaged with surgery and radiotherapy. CONCLUSION Long-term follow-up of patients with vulvar cancer and careful restaging at the time of recurrence are mandatory. Although local and nodal recurrences may be controlled with surgery and/or radiotherapy, regional recurrences are usually fatal.
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Affiliation(s)
- A S Tilmans
- Department of Radiation Oncology, Indiana University Medical Center, Indianapolis 46202-5274
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Hopkins MP, Reid GC, Vettrano I, Morley GW. Squamous cell carcinoma of the vulva: prognostic factors influencing survival. Gynecol Oncol 1991; 43:113-7. [PMID: 1743551 DOI: 10.1016/0090-8258(91)90055-a] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
One hundred seventy-two cases of patients with squamous cell cancer of the vulva treated at the University of Michigan Medical Center from 1975 to 1988 are reported. The mean age was 66 years with a range of 21 to 101 years. The distribution by stage included Stage I, 65; Stage II, 44; Stage III, 50; and Stage IV, 13 patients. Groin node dissections performed on 145 patients showed negative nodes, 58%; unilateral positive nodes, 28%; and bilateral positive nodes, 14%. The distribution of patients with positive nodes was influenced by stage: Stage I, 14%; Stage II, 23%; Stage III, 72%; Stage IV, 92%. The overall cumulative 5-year survival was 71% and this was significantly influenced by stage of disease: Stage I, 94%; Stage II, 91%; Stage III, 36%; Stage IV, 26%. Stages I/II and III/IV were combined for analysis. In Stages I/II, survival was significantly influenced by tumor grade while size, patient age, and lymph node status did not influence survival. In Stage III/IV, survival was significantly influenced by tumor size, node status, and number of positive nodes while grade, patient age, and tumor location did not influence survival. Squamous cell cancer of the vulva is effectively treated with radical surgery but advanced-stage disease with regional metastases significantly alters survival.
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Affiliation(s)
- M P Hopkins
- Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor
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Efficacy of 5-Fluorouracil by Continuous Infusion and Other Agents as Radiopotentiators for Gynecological Malignancies. CONCOMITANT CONTINUOUS INFUSION CHEMOTHERAPY AND RADIATION 1991. [DOI: 10.1007/978-3-642-84186-6_33] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Dembo AJ, Balogh JM. Advances in radiotherapy in the gynecologic malignancies. SEMINARS IN SURGICAL ONCOLOGY 1990; 6:323-7. [PMID: 2263807 DOI: 10.1002/ssu.2980060606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
We review, for their wider applicability, four advances in the radiotherapeutic management of the gynecologic malignancies. Attempts at improving upon results obtained with radiotherapy by the addition of chemotherapy have usually followed one of two temporal strategies: Sequential chemotherapy-radiotherapy (so-called neo-adjuvant chemotherapy), or chemotherapy given concurrently with radiotherapy. The pros and cons of both models are discussed. Recent work suggests that there is a differential response between the acutely reacting normal tissues, as well as tumor, and the late-reacting normal tissues, which is dependent upon the radiation fraction size. The rationale and some important clinical applications are reviewed. Advances in brachytherapy include the high dose rate treatment and the use of rigid templates to guide the accurate placement of the interstitial implant. The controversies surrounding these approaches require further study before the precise place of these techniques is known. Finally, in vulvar cancer, the addition of radiotherapy to surgery is being studied to permit less radical operations in early disease, and greater local tumor control in advanced disease.
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Affiliation(s)
- A J Dembo
- Division of Radiation Oncology, Toronto-Bayview Regional Cancer Centre, Ontario, Canada
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