Preoperative chemoradiation for locally advanced carcinoma of the vulva
Introduction
Carcinoma of the vulva is an unusual gynecological malignancy accounting for only 5% of gynecological cancers per year with 3870 cases estimated to occur in 2005 [1]. For many years, the treatment was entirely surgical, often involving large en bloc resections with significant morbidity. Preoperative radiation has been used to decrease the extent of surgery required to clear advanced tumors or those located near critical midline structures. More recently, chemotherapy has been utilized to maximize the response to preoperative radiation therapy. The Gynecological Oncology Group (GOG) performed a prospective study to assess preoperative chemoradiation in patients with locally advanced disease [2], [3]. The first publication described the outcomes of patients with T3 or T4 primaries, irrespective of groin nodal status. Split course chemoradiation using a BID radiation schedule combined with 5-fluorouracil and cisplatin during the first and final weeks of radiotherapy resulted high rates of resectability and local control in these very unfavorable patients [2]. The second publication was limited to patients with N2/3 nodal disease, most of whom had extensive primary tumors [3]. Of the forty evaluable patients, thirty-eight became resectable, and 15/37 had a pathological complete response. The morbidity of treatment, including post-treatment groin dissection complications, was acceptable. Given this high rate of resectability and local control in patients with locally advanced nodal disease, the authors concluded that patients with less advanced disease should be considered for preoperative chemoradiation. This was the policy adopted at our institution. This study reviews the outcomes using a modified GOG treatment technique.
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Materials and methods
A retrospective review of 18 records of patients who underwent preoperative chemoradiation for squamous cell carcinoma of the vulva was undertaken with IRB approval (IRB-21-053). All patients were assessed jointly with a gynecological oncologist and staged using the FIGO clinical staging system without histological confirmation of positive groin nodes [4]. All patients received treatment at the Magee Women's Hospital of the University of Pittsburgh Medical Center. Patients were offered
Results
Seventeen patients were treated with preoperative chemoradiotherapy, and one received preoperative radiotherapy alone because of refusal to receive chemotherapy. Chemotherapy was delivered as specified on the GOG study during the first and last weeks of the course of external beam treatment (Fig. 1). All patients received treatment to the primary tumor and regional nodes except for one patient (treated to primary alone) who underwent a negative pretreatment groin dissection.
The patient
Discussion
Organ preservation and minimization of disfiguring surgery have been achieved in multiple tumor sites with the use of chemoradiation to downstage tumors preoperatively. Combined modality therapy for vulvar cancer has become an established treatment for advanced vulvar cancer or in cases in which the tumor is located in close proximity to the urethra or anus [2], [3], [5], [6], [7], [8]. Because this is an unusual gynecological malignancy, there are no large-scale trials available to document
Conclusion
Neoadjuvant chemoradiation for vulvar cancer is an excellent treatment option for patients with bulky or critically located tumors, resulting in a complete response in the majority of cases. The treatment is well tolerated, even in an elderly population. Up front treatment of both the primary tumor and regional nodes can be given with chemosensitization without excessive toxicity. The role of intensity-modulated radiation therapy technique appears to be feasible in the small subgroup of
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