Treatment Flashcards
(13 cards)
What is the Tx for vulvar CIS or VIN?
- superficial local excision.
- If the labia minora or clitoris is involved, consider laser
How should the primary of a pt with FIGO stage I or II vulvar cancer be treated?
WLE, which includes resection of the tumor + a gross 1.0-cm margin of normal tissue around it.
In a pt with a stage I or II vulvar cancer, does radical vulvectomy improve the LR rate over WLE?
- No. In a pt with stage I or II vulvar cancer, radical vulvectomy and WLE have similar recurrence rates (~ 7%). (Hacker NF et al., Cancer 1993)
What is the next step if margins are positive following surgical resection of vulvar cancer?
- Re-excise if possible; otherwise, give adj RT. Retrospective data suggests that adj RT improves LC and possibly survival. (Faul CM et al., IJROBP 1997)
How are the inguinal nodes treated in vulvar cancer stage IA? Stage IB? Stage II?
- Stage IA: lymph node evaluation is not necessary (consider for high-grade lesions).
- Stage IB: if the lesion is well lateralized, consider unilat dissection. If there is a midline lesion, then bilat groin nodal dissection is required. SLD for patients with tumor size < 4 cm. GROINSS-V II is evaluating the role for adjuvant RT in patients with SLD + groin.
- Stage II: Bilat LND is recommended
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In which vulvar cancer pts is adj RT to the bilat groin and pelvis indicated? What RCT explored this question?
- Adj RT to the bilat groin and pelvis is commonly recommended in pts with ≥ 2 micromets in inguinal nodes, a single node > 5 mm, or a single node with ECE.
- In GOG 37, 114 pts s/ p radical vulvectomy + bilat inguinal LND were randomized to RT to the pelvis and bilat groin vs. pelvic node dissection if node +. The dose was 45– 50 Gy. The 2-yr groin recurrence rate decreased with RT (5% vs. 24%), and there was an OS advantage for RT (68% vs. 54%). All the benefits of RT were for > 1 + node. The survival benefit appeared to be due to improved control in the groin. In pts with only 1 + node on the dissection, surgery and RT outcomes were similar. (Homesley HD et al., Obstet Gynecol 1986)
In pts with N0 vulvar cancer, does groin RT eliminate the need for inguinal LND? What RCT explored this question? Major criticisms?
- The need for inguinal node dissection in N0 vulvar cancer prior to groin RT is controversial.
- In GOG 88, 58 pts with cN0 vulvar cancer s/ p radical vulvectomy were randomized to bilat inguinal femoral and pelvic LND (+ nodes rcvd RT) vs. bilat groin-only EBRT (50 Gy). LR, PFS, and OS favored the LND arm. (Stehman FB et al., Cancer 1992)
Major criticisms of GOG 88:
- CT was not used for staging. 50 Gy may not be adequate for pts with gross nodes evident by CT.
- CT was not required for RT planning. Pts were treated with electron fields prescribed to a depth of 3 cm, which may not adequately cover the inguinal/ femoral nodal regions. Retrospective data suggest that adequate RT to groins can result in good LC (∼ 90%). (Katz A et al., IJROBP 2003)
What are the relative indications for adj RT to the primary site after WLE?
- The relative indications for adj RT to the primary site:
- Margins or close margins (< 8 mm fixed specimen or < 1 cm by frozen section)
- LVSI 3. DOI > 5 mm (Heaps JM et al., Gynecol Oncol 1990)
- The most important risk for local recurrence is + margin. Because morbidity of vulvar RT is high, it is not to be done lightly especially if local salvage possible with further excision should relapse occur.
What is the Tx approach for pts with stages III– IV vulvar cancer?
- Surgery (if –margins can be achieved) + PORT
- Neoadj CRT (phase II) → surgery for those initially unresectable
- Definitive CRT
What studies support neoadj CRT in initially unresectable vulvar cancer?
- GOG 101 was a phase II study of 73 pts with unresectable vulvar cancer given concurrent cisplatin/ 5-FU + RT. RT was bid to 47.6 Gy. 97% of pts were converted to resectable Dz. (Moore DH et al., IJROBP 1998)
Estimate the CR rate for unresectable vulvar cancer pts treated with definitive cisplatin/ 5-FU + RT.
- In small prospective trials, CR rates after definitive cisplatin/ 5-FU + RT vary from 47%– 80%.
- GOG 205 is an ongoing trial examining outcomes of T3 or T4 unresectable tumors that rcvd cisplatin and RT → surgery to gross residual Dz.
Estimate the 5-yr OS by FIGO stage.
- 5-yr estimated OS by FIGO stage:
- Stage I: 90%
- Stage II: 81%
- Stage III: 68%
- Stage IV: 20% (Gonzalez-Bosquet J et al., Gyn Oncol 2005)
What are the commonly used adj and definitive RT doses for vulvar cancer?
- Commonly used adj and definitive RT doses in vulvar cancer:
- –Margin, + LVSI: 45– 50.4 Gy
- Early ECE, close, or focally positive margins: 59.4 Gy
- Margin, gross residual, extensive ECE, + LN: 63– 66 Gy
- Unresectable Dz: 66– 70 Gy with concurrent weekly cisplatin or cisplatin/ 5-FU
