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Baird P, Drinkwater K, Forrest J, Stewart AJ. The Royal College of Radiologists National Vulvar Cancer Audit. Clin Oncol (R Coll Radiol) 2024; 36:e224-e234. [PMID: 38658266 DOI: 10.1016/j.clon.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/14/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
AIMS This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity. MATERIALS AND METHODS Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients. RESULTS 34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0. CONCLUSION This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.
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Affiliation(s)
- P Baird
- Belfast Health and Social Care Trust, Belfast, UK
| | | | - J Forrest
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - A J Stewart
- St Luke's Cancer Centre, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK.
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Chadha M, Shao T, Lit M, Gupta V, Zakashansky K, Zeligs K, Kolev V. Upfront boost to gross disease followed by elective pelvic radiation improves compliance to radiation therapy delivery metrics in locally advanced vulvar cancer. Gynecol Oncol Rep 2024; 52:101362. [PMID: 38495799 PMCID: PMC10940132 DOI: 10.1016/j.gore.2024.101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 03/19/2024] Open
Abstract
Locally advanced cancer of the vulva (LACV) is commonly diagnosed in older women (>65 years), and is treated using combined multimodality therapy (CMT) that includes radiation therapy (RT). Compliance to optimal RT metrics, including completion of > 20 fractions, overall treatment duration of < 8 weeks (56 days), and < 1 week intra-treatment break is associated with better disease outcomes. However, published results note that a significant number of patients with LACV do not adhere to these metrics. The aim of our study is to evaluate whether a modified sequence of RT delivery, treating the localized boost volume upfront followed by the larger elective nodal volume is associated with improved compliance to optimal RT delivery metrics.
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Affiliation(s)
- M. Chadha
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - T. Shao
- Department of Medicine, Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - M. Lit
- Division of Gynecology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - V. Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - K. Zakashansky
- Division of Gynecology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - K. Zeligs
- Division of Gynecology, Icahn School of Medicine at Mount Sinai, New York, United States
| | - V. Kolev
- Division of Gynecology, Icahn School of Medicine at Mount Sinai, New York, United States
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Morrison J, Baldwin P, Hanna L, Andreou A, Buckley L, Durrant L, Edey K, Faruqi A, Fotopoulou C, Ganesan R, Hillaby K, Taylor A. British Gynaecological Cancer Society (BGCS) vulval cancer guidelines: An update on recommendations for practice 2023. Eur J Obstet Gynecol Reprod Biol 2024; 292:210-238. [PMID: 38043220 DOI: 10.1016/j.ejogrb.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/10/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Jo Morrison
- Department of Gynaecological Oncology, GRACE Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK.
| | - Peter Baldwin
- Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Louise Hanna
- Department of Oncology, Velindre Cancer Centre, Whitchurch, Cardiff CF14 2TL, UK
| | - Adrian Andreou
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - Lynn Buckley
- Department of Gynae-Oncology, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, East Yorkshire HU16 5JQ, UK; Perci Health Ltd, 1 Vincent Square, London SW1P 2PN, UK. https://www.percihealth.com/
| | - Lisa Durrant
- Radiotherapy Department, Beacon Centre, Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton TA1 5DA, UK
| | - Katharine Edey
- Centre for Women's Health Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter EX2 5DW, UK
| | - Asma Faruqi
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK
| | - Christina Fotopoulou
- Department of Cellular Pathology, The Royal London Hospital, Barts Health NHS Trust, London E1 2ES, UK; Gynaecologic Oncology, Imperial College London Faculty of Medicine, London SW7 2DD, UK
| | - Raji Ganesan
- Department of Cellular Pathology, Birmingham Women's Hospital, Birmingham B15 2TG, UK
| | - Kathryn Hillaby
- Department Gynaecological Oncology, Cheltenham General Hospital, Gloucestershire, Hospitals NHS Foundation Trust, GL53 7AN, UK
| | - Alexandra Taylor
- The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
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Oonk MHM, Planchamp F, Baldwin P, Mahner S, Mirza MR, Fischerová D, Creutzberg CL, Guillot E, Garganese G, Lax S, Redondo A, Sturdza A, Taylor A, Ulrikh E, Vandecaveye V, van der Zee A, Wölber L, Zach D, Zannoni GF, Zapardiel I. European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023. Int J Gynecol Cancer 2023; 33:1023-1043. [PMID: 37369376 PMCID: PMC10359596 DOI: 10.1136/ijgc-2023-004486] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/20/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer. OBJECTIVE To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer. METHODS The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives. RESULTS The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.
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Affiliation(s)
- Maaike H M Oonk
- University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Sven Mahner
- University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | | | - Daniela Fischerová
- Charles University First Faculty of Medicine, Prague, Czech Republic
- General University Hospital in Prague, Prague, Czech Republic
| | | | | | - Giorgia Garganese
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sigurd Lax
- Hospital Graz II, Graz, Austria
- Johannes Kepler Universitat Linz, Linz, Austria
| | | | | | | | - Elena Ulrikh
- Almazov National Medical Research Center, Saint Petersburg, Russian Federation
| | | | - Ate van der Zee
- University Medical Center Groningen, Groningen, The Netherlands
| | - Linn Wölber
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana Zach
- Karolinska University Hospital, Stockholm, Sweden
- Karolinska Institutet Eugeniavägen, Stockholm, Sweden
| | - Gian Franco Zannoni
- Catholic University of the Sacred Heart, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Nguyen NT, Zhao X, Ponzini M, Wilson M, Leiserowitz G, Brooks RA. Time to completion of radiation treatment in locally advanced squamous cell carcinoma of the vulva and the impact on survival. Gynecol Oncol 2022; 167:159-166. [PMID: 36154760 PMCID: PMC10030377 DOI: 10.1016/j.ygyno.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether radiation completion within a planned timeframe in locally advanced squamous cell vulvar cancer impacts overall survival (OS). METHODS The National Cancer Database from 2004 to 2017 was used to identify women ≥18 years old with stage II-IVA squamous cell vulvar cancer. We included women who received radiation alone (RT) or concurrent chemoradiation (CRT) for initial vulvar cancer treatment. Primary outcome was overall survival associated with time of delay in radiation completion. RESULTS There were 2378 women identified (n = 856 RT and n = 1522 CRT). Median age was 67 (IQR 56-78), majority (88.35%) were white with advanced stage III or IVA (72.29%) disease. Median radiation dose was 5720 c-Gray (IQR 5040-6300). Radiation completion with delay ≥7 days resulted in reduction in survival compared to delay of <7 days (unadjusted HR 1.183 [95%CI: 1.066-1.313], p = 0.0016). When delays extended to ≥14 days compared to <14 days there was increased hazard of death (unadjusted HR: 1.263 [95%CI:1.126-1.416], p < 0.0001). Survival improved for patients with <7 versus ≥7 days delay whether treatment was with RT (median OS: 34.9 months versus 21.6 months, p < 0.01) or CRT (Median OS:58 months versus 41.3 months, p < 0.01). Stage IVA disease was associated with the greatest increase in hazard of death (HR 1.759 [95%CI 1.517-2.039], p < 0.0001) compared to stage II. CONCLUSION Radiation completion with <7 days delay is associated with improved overall survival, independent of concurrent chemotherapy. This suggest that strategies to minimize delays in radiation are crucial in locally advanced vulvar cancer.
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Affiliation(s)
- Nancy T Nguyen
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of California Davis, Sacramento, CA, USA.
| | - Xiao Zhao
- Department of Radiation Oncology, University of California Davis, Sacramento, CA, USA
| | - Matthew Ponzini
- Department of Public Health, Division of Biostatistics, University of California Davis, Sacramento, CA, USA
| | - Machelle Wilson
- Department of Public Health, Division of Biostatistics, University of California Davis, Sacramento, CA, USA
| | - Gary Leiserowitz
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of California Davis, Sacramento, CA, USA
| | - Rebecca A Brooks
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of California Davis, Sacramento, CA, USA
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Lukovic J, Han K. Postoperative management of vulvar cancer. Int J Gynecol Cancer 2022; 32:338-343. [DOI: 10.1136/ijgc-2021-002463] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 12/06/2021] [Indexed: 11/03/2022] Open
Abstract
The primary treatment for resectable vulvar cancer includes wide local excision of the primary tumor and surgical lymph node assessment. Following surgery, up to 40–50% of patients develop a local recurrence. Historically, the strongest predictor of local recurrence is a positive or close margin (defined as <8 mm), although recent studies question the importance of margin status. Post-operative radiotherapy to the vulva is recommended for all women with a positive margin where re-excision is not possible. Radiotherapy may also be considered in the setting of risk factors for local recurrence: close margin, lymphovascular invasion, large tumor size, and/or depth of invasion >5 mm. Nodal assessment is an important component of vulvar cancer management. A negative sentinel node is associated with a low false-negative predictive value (2% in patients with vulvar tumor <4 cm in GOG 173), 2-year groin recurrence rate of 2.3%, and 3-year disease-specific survival rate of 97% in patients with unifocal vulvar tumor <4 cm in the GROningen INternational Study on Sentinel nodes in Vulvar Cancer (GROINSS-V I) study. Thus, patients with tumor size <4 cm (without additional local risk factors) and negative sentinel node can be observed. Patients with sentinel node metastasis ≤2 mm can be treated with post-operative radiotherapy (2-year isolated groin recurrence rate of 1.6% in GROINSS-V II), as a safe alternative to lymphadenectomy. Patients with sentinel node metastasis >2 mm following sentinel node biopsy should undergo inguinofemoral lymphadenectomy followed by post-operative radiotherapy—based on the GROINSS-V II study, the 2-year isolated groin recurrence rate remains unacceptably high (22%) with radiotherapy alone. Retrospective studies suggest that the addition of concurrent chemotherapy to radiotherapy may improve survival. The ongoing GROINSS-V III study is investigating concurrent chemotherapy and radiotherapy dose escalation. The main goal of these post-operative treatments is to reduce the risk of local, and especially groin, recurrences, which are almost universally fatal.
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Barry PN, Ling DC, Beriwal S. Definitive chemoradiation or radiation therapy alone for the management of vulvar cancer. Int J Gynecol Cancer 2022; 32:332-337. [DOI: 10.1136/ijgc-2021-002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 10/27/2021] [Indexed: 11/04/2022] Open
Abstract
Vulvar cancer is rare, and unresectable disease provides a therapeutic conundrum. Although definitive surgery remains the mainstay for curative treatment of vulvar cancer, a minority of patients present with advanced disease for which surgical resection would be extraordinarily morbid. Pre-operative and definitive radiation with radiosensitizing systemic therapy allows such patients an opportunity for cure. In this review, we explore the origins of pre-operative radiation, current treatment standards for pre-operative and definitive chemoradiation, and future directions.
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Fotopoulou C, Krivak TC, Chang SJ. Innovations in surgery and peri-operative care: A technical gimmick or true oncology advance? Gynecol Oncol 2021; 161:1-3. [PMID: 33762085 DOI: 10.1016/j.ygyno.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 11/28/2022]
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