Vulvar Cancer

JP presents a case of Vulvar Cancer - 60 yo WF with vulvar pruritis x 1 year.  SCC 7mm diam, 1.5cm depth.  deep margin at resection was 2mm.  T1bNx.  Then underwent a bilateral inguinal node dissection - negative.

Questions what to treat if at all, nodes, primary?

Vulvar cancer 3-5% of gyn malignancies.  3500/year.  80-90% scc.  Occaisional bartholin glands Adenocarcinomas.  Most HPV related.  Smoking, Lichen Sclerosis.  

IA <=2cm primary <=1mm invasion

IB <=2cm primary >1mm invasion

II >2cm

III unilateral inguinal nodes, lower urethra, vagina, anus (N1)

IVA bilater inguinal, upper urethra/bladder, rectum, pubic bone (T4 or N2)

IVB pelvic nodes, DM

"single incision" - radical vulvectomy and bil inguinal dissection- 50% incidence breakdown, 10-15% extremity lymphedema

"triple incision" for excision of primary and for each LN sampling

local recurrence series: 

UCLA Heaps Gyn Onc 1990 - 135 pt with inv SCC of vulva.  (majority I or II)  margins >= 8mm was 0% LR, <8mm>

Also associated 9.1mm invasion, tumor thickness >1cm, keratinization >= 25%, mitosis >10/HPF

Pittsburg 1997 Faul IJROBP - 62 with close of postive margins (<8mm).>

close margins LR 33% obs vs 5% RT (SS)

pos margins LF 76% obs vs 32% RT (SS)

Case: Treated primary to 50Gy at 2Gy/fx  AP/PA. 

New Case:

35 yo with HIV/AIDS, vulvar mass for 3 weeks.  R mass extending to clitoris.  biopsy +SCC.  PET CT demonstrated activity in primary and bilateral nodes.  Rad Hemi- Vulvecomy with L inguinal Dissection.  4cm primary with 8mm invasion, margin was 2mm.  1/2 LN positive on the Left.  Staged as pT2N1 (though R not dissected).

Treating the Pelvis:

nodal risks

for tumors of >= 2cm, risk of inguinal nodes are dependent on depth of invasion: <1mm> 5mm 37.5%.

Cloquet's node: most superior deep inguinal node.

GOG 37: Homseley 1986. 

s/p radical vulvectomy & bil superficial and deep inguinal dissection found to have + inguinal LNs 

114 pts randomized to:

Pelvic node dissection - PLND (15/53 patients had + pelvic LNs)

RT (45-50 Gy to inguinal nodes and pelvic nodes BUT NOT vulvar region)

50% of patients were cN0 (PE not sensitive for groin node mets) 

Groin recurrence PLND 13/55 vs  RT 3/59 (p=0.02) 

OS (2) PLND 54% vs RT 68% (p=0.03) 

on subset analysis those with only 1 node positive did not benefit from RT.

GOG 88: Stehman 1992. 

Resectable vulvar SCC; Excluded T1 lesions unless LVI or >5mm invasion; s/p radical vulvectomy

58 pts randomized to 

Bilateral groin dissection, RT if positive

Bilateral groin irradiation 

50 Gy/ 25fx, with 50% of dose given with 12-13 MeV electrons; Rx'd to 3 cm 

5/25 patients had + nodes in Arm A and were treated with RT

OS (88% disection vs 66% RT) and DFS (92% disection vs 70% RT) were better in the dissected + selective RT arm, with a large portion of local failures of the RT arm were in the groin.

University of Washington Anatomic Study

Examined CT scan of 50 patients undergoing treatment for Gynecologic Cancer

Koh IJROBP 1993;27:969-974

demonstrates that in most of the patients in GOG 88 were probably undertreated as most nodal basins are much deeper than 3cm.

 

to be continued...

Vulvar Cancer - GOG 37 and GOG 88

In re to conference this AM, there were some questions and confusion between the GOG 37 and 88 trials. Here are my notes on these two important trials -

Pelvic Nodal Control: GOG 37 (Homesley et al. OB Gyn 1986;68:733 PMID:3785783)

•Resectable vulvar SCC

•s/p radical vulvectomy & bil superficial and deep inguinal dissection found to have + inguinal LNs

•114 pts randomized to:

–Pelvic node dissection - PLND (15/53 patients had + pelvic LNs)

–RT (45-50 Gy to inguinal nodes and pelvic nodes BUT NOT vulvar region)

•50% of patients were cN0 (PE not sensitive for groin node mets)

•Groin recurrence PLND 13/55 vs RT 3/59 (p=0.02)

•OS (2) PLND 54% vs RT 68% (p=0.03)

Subgroup analysis showed benefit primarily to RT when >1 node was invovled, which has become standard for many gyn-oncs, however, this was a subgroup and should be interpreted with all of the standard caveats.

Inguinal Nodal Control: GOG 88(Stehman et al. IJROBP 1992;24:389)

•Resectable vulvar SCC; Excluded T1 lesions unless LVI or >5mm invasion; s/p radical vulvectomy

•58 pts randomized to

–Bilateral groin dissection, RT if positive

–Bilateral groin irradiation

•50 Gy/ 25fx, with 50% of dose given with 12-13 MeV electrons; Rx'd to 3 cm

•5/25 patients had + nodes in Arm A

OS and DFS were better in the dissected + selective RT arm, with a large portion of local failures in the RT arm in the groin.

However- the standard critique of this study is that RT was Rx'd to 3cm, which is clearly insufficient in many cases. See Koh IJROBP 1993;27:969-974 for a good discussion of this.

So there you go. GOG 37 is about pelvic nodes and GOG 88 is about inguinal.