Vulva Cancer Radiation

Pre-operative ChemoRadiation Therapy:

Indications

  • Locally advance tumors where < 1 cm margin anticipated
    • encroach on anal sphincter, pubic arch, more than distal urethra
    • approach clitoris or extend more than minimally past the vaginal introitus.

GOG 101

  • Phase II Chemoradiation study
  • stage III and IV patients
  • ~ 50% complete response rate
  • 98% of the patient were resectable after chemoradiation

Groin Irradiation

GOG (Stehman 1992)

  • Higher rate of inguinal recurrence and death in the pre-op irradiated group
  • Criticized
    • Radiation group only inguinal nodes were treated
    • Positive pelvic nodes at lymphadenectomy, both the inguinal and pelvic nodes were treated.
    • Poor dose delivered to nodes
  • 46.5% had no visible vulvar cancer at the time of planed surgery
  • only 2.8% was unresectable
  • Retrospective trials suggest that radiation therapy can control microscopic disease.
    • Boronow
    • Brachytherapy +/- ERT -> Surg had 1/26 recurrence rate and no pelvic exenteration
    • Hacker et al. used preoperative ERT in advanced vulvar cancer with limited surgical resection 62% (five patients) were without evidence of recurrence with 15 months to 10 year follow-up.
  • Encouraged by the SCCA anus

Definitive Radiation

Indications

  • Medically inoperable patients
  • Locally advanced disease (may be part of pre-operative/definitive treatment).

Radiation Dose

  • Subclinical 45-50 Gy
  • Small superficial lesions 60-65 Gy
  • Primary/ Gross Disease 70 Gy

Radiation Field

  • No clinical inguinal nodes
    • Cover inguinal nodes
  • Clinical inguinal nodes
    • Cover pelvic nodes to L4/L5 (common iliac)
  • Frog-leg irradiation for vulva and inguinals if lesion is superifical
  • Interstitial irradiation used for boost as well as primary treatment

Post-operative Radiation Therapy:

Indications

  • Positive Lymph node (Homesley 1986)
  • More than 1 lymph node, Extracapsular extension, Grossly positive lymph node
  • 45-50 Gy to MP bilaterally
  • 68% vs. 54% 2-yr-OS (p = 0.03).
  • Margin less than 8 to 10 mm(Faul)
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