Radiotherapy and chemoradiotherapy for carcinoma of the vulva

Radiation therapy for gynecologic malignancies during the COVID-19 pandemic: International expert consensus recommendations

OBJECTIVE

To develop expert consensus recommendations regarding radiation therapy for gynecologic malignancies during the COVID-19 pandemic.

METHODS

An international committee of ten experts in gynecologic radiation oncology convened to provide consensus recommendations for patients with gynecologic malignancies referred for radiation therapy. Treatment priority groups were established. A review of the relevant literature was performed and different clinical scenarios were categorized into three priority groups. For each stage and clinical scenario in cervical, endometrial, vulvar, vaginal and ovarian cancer, specific recommendations regarding dose, technique, and timing were provided by the panel.

RESULTS

Expert review and discussion generated consensus recommendations to guide radiation oncologists treating gynecologic malignancies during the COVID-19 pandemic. Priority scales for cervical, endometrial, vulvar, vaginal, and ovarian cancers are presented. Both radical and palliative treatments are discussed. Management of COVID-19 positive patients is considered. Hypofractionated radiation therapy should be used when feasible and recommendations regarding radiation dose, timing, and technique have been provided for external beam and brachytherapy treatments. Concurrent chemotherapy may be limited in some countries, and consideration of radiation alone is recommended.

CONCLUSIONS

The expert consensus recommendations provide guidance for delivering radiation therapy during the COVID-19 pandemic. Specific recommendations have been provided for common clinical scenarios encountered in gynecologic radiation oncology with a focus on strategies to reduce patient and staff exposure to COVID-19.

Definitive radiotherapy for recurrent vulvar carcinoma after primary surgery: a two-institutional Italian experience

Objective:

To assess the clinical outcome of patients treated with radiotherapy (RT) for recurrent squamous cell carcinoma of the vulva after primary surgery.

Methods:

Fifty-six patients developed recurrent disease after surgery, consisting of deep total vulvectomy with inguino-femoral lymphadenectomy in 44 (78.6%) and deep partial vulvectomy with inguino-femoral lymphadenectomy in 12 (21.4%). All patients underwent RT at the Divisions of Radiotherapy, University of Pisa and ASST Cremona, between 1992 and 2016. Forty-three patients (76.8%) underwent external beam RT and 13 (23.2%) were treated with exclusive high-dose rate brachytherapy.

Results:

Five-year progression-free survival (PFS) and overall survival (OS) were 19% and 43%, respectively. Primary tumor size ⩽4 cm, early FIGO stage, and negative lymph node status were significantly associated with better PFS ( p = .005, p = .020 and p = .036, respectively) and OS ( p < .0001, p = .023 and p = .008, respectively). Patients with more than 1 positive lymph node at primary surgery had significantly worse PFS ( p = .028) and OS ( p = .001). Patients with local recurrence had significantly better PFS and OS ( p = .022, p = .002, respectively). RT total dose >54 Gy was associated with a lower risk of recurrence.

Conclusions:

Primary tumor size, FIGO stage, nodal status, and site of recurrent disease were significant predictors of clinical outcome in patients treated with RT for recurrent squamous cell carcinoma of the vulva.

Risk factors and treatment for recurrent vulvar squamous cell carcinoma

Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.

[Vulvar cancer: survey of surgical practice in France. Do expert centers need?]

OBJECTIVE

Vulvar cancer is rare. In France, surgical management of this cancer is codified by national guidelines. The aim of this survey was to evaluate its surgical management regards to the French guidelines.

MATERIALS AND METHODS

Six hundred questionnaires were given to surgeons during two French congress in 2009. They focused on the surgeon (age, sex, occupation, center of work, practice of vulvar surgery, number of cancers treated individually and in the center), and the disease (initial work-up, surgical management and adjuvant therapy). Three case reports were also proposed, related to vulvar cancer management.

RESULTS

Seventeen percent of surgeons (n=102) answered the questionnaire. Only half of them (52.9%) managed vulvar cancer. Of them, 83.2% reported treated less than five cancers per year; 87.4% of centers treated less than 10 vulvar cancers per year. Only 8.7% of surgeons respected the guidelines for the three case reports. The compliance rate was 80.5% for case A; 63.7% for case B and 22.5% for case C. No difference in answers' conformity to the guidelines was found according to age of surgeons, experience, workplace, number of cancers treated per year and centers.

CONCLUSION

Despite some limits of our study, it appears that vulvar cancer management is often not conform to the French guidelines raising concerns on their insufficient diffusion and creation of expert centers.

Diagnosis and treatment options of vulvar cancer: a review

INTRODUCTION

Vulvar cancer is a rare malignancy in women. However, within the past decade, a distinct increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion, and an increase of vulvar cancer have been reported within Europe and the USA. Surgery is the first choice in treating patients with vulvar cancer, especially in its early stages. In an attempt to decrease the incidence of complications, research was made into modifications of the surgical procedure without compromising the prognosis. The replacement of radical vulvectomy by less wide local excision is one of these modifications. As vulvar cancer is relatively rare, it is possible to give evidence-based treatment recommendations, but usually on a low evidence level. Aim of this paper is to elucidate diagnostics and surgical treatment options in the management of vulvar cancer.

MATERIALS AND METHODS

We searched major databases (i.e. pubmed) with the following selection criteria: vulvar cancer, en bloc resection, triple incision, and sentinel node biopsy.

CONCLUSIONS

Today, the operative therapy is much less radical and more emphasized on individualized therapeutic concepts. The tendency is to leave the ultraradical surgical options which suffer from high morbidity towards less radical, minimal invasive techniques. Due to the rarity of the disease further studies will have to be performed by international collaborative groups.

Advanced vulvar carcinoma: Is it worth operating? A perioperative management protocol for radical and reconstructive surgery

OBJECTIVE

The aim of this study was to characterize the means whereby the results could be improved and the morbidity and side-effects minimized, of radical and extensive surgery performed together with plastic reconstruction, in the treatment of locally advanced and relapsed vulvar carcinoma.

METHODS

Between May 2000 and November 2004, twenty-three patients with locally advanced or relapsed vulvar carcinoma underwent major radical or extended vulvectomy, requiring reconstructive surgery. A consistent protocol for the perioperative management of these patients, including precautionary measures to reduce the rate of early complications, was introduced in the second study period (from November 2003) to verify the benefit on surgical outcome.

RESULTS

An analysis of the medical reports showed an improvement in the median time of the postoperative course and related morbidity as a consequence of a strict application of the management protocol, with consequent decrease of early complications.

CONCLUSIONS

Reconstructive surgery, which broadens the spectrum of available operative therapy in primary and locally recurrent vulvar cancer, is characterized by a high complication rate. The application of a strict perioperative protocol could reduce the number and the clinical impact of such complications.

Surgery and radiotherapy in vulvar cancer

The majority of patients with vulvar cancer have squamous cell carcinomas (SCC). The cornerstone of the treatment is surgery. Radical vulvectomy with "en bloc" inguinofemoral lymphadenectomy has led to a favorable prognosis but with impressive morbidity. Nowadays, treatment is more individualized with wide local excision with uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as the standard treatment for early stage patients with SCC of the vulva with depth of invasion >1 mm without suspicious groins. In case of more than one intranodal lymph node metastasis and/or extranodal growth, postoperative radiotherapy on the groins and pelvis is warranted. Until now there is a limited role for primary radiotherapy on the vulva and/or groins in early stage disease. The sentinel lymph node (SLN) procedure with the combined technique (preoperative lymphoscintigraphy with a radioactive tracer and intraoperative blue dye) is a promising staging technique for patients with early stage vulvar cancer. The safety of clinical implementation of the SLN procedure and the role of additional histopathological techniques of the SLNs need to be further investigated before its wide-scale application. Patients with advanced vulvar cancer are difficult to treat. One of the problems in patients with locally advanced vulvar cancer is the high incidence of concomitant bulky lymph nodes in the groin(s). Ultraradical surgery in case of resectable disease will lead to impressive morbidity because of the exenterative-type procedure. (Chemo)radiation with or without surgery should be regarded as the first choice for patients with locally advanced vulvar cancer only when primary surgery will necessitate performance of a stoma. Further studies are needed to determine the optimal combined modality treatment in these patients. Due to the fact that vulvar cancer is a rare disease, further clinical studies will only be possible, when international collaborative groups will join forces in order to perform clinical trials, in which different treatment options such as SLN procedure, primary radiotherapy on the groins and multimodality treatment for advanced disease will be investigated.