RADICAL VULVECTOMY WITH POSTOPERATIVE IRRADIATION FOR VULVAR CANCER -THERAPEUTIC IMPLICATIONS OF A CENTRAL BLOCK

Purpose/Objective: To report the long-term results of vulvectomy, node dissection, and postoperative nodal irradiation using a midline vulva r block in patients with node positive vulvar cancer. Methods and Mate rials: From 1971 through 1992, 27 patients with carcinoma of the vulva and histologically involved inguinal lymph nodes were treated postope ratively with radiation therapy after radical vulvectomy and bilateral lymphadenectomy (n = 25), radical vulvectomy and unilateral lymphaden ectomy (n = 1), or hemivulvectomy and bilateral lymphadenectomy (n = 1 ). Federation Internationale de Gynecologic et d'Obstetrique stages we re III (n = 14), IVA (n = 8), and IVB (n = 5) squamous cell carcinoma. Inguinal lymph nodes were involved with tumor in all patients (averag e number positive = 4, range 1-15). Postoperative irradiation was dire cted at the bilateral groin and pelvic nodes (n = 19), unilateral groi n and pelvic nodes (n = 6), or unilateral groin only (n = 1). These 26 patients had the midline blocked. In addition, one patient received i rradiation to the entire pelvis and perineum. Doses ranged from 10.8 t o 50.7 Gy (median 45.5) with all patients except 1 receiving 142.0 Gy. Results: Actuarial 5-year overall survival and disease-free survival estimates were 40% and 35%, respectively. Recurrences developed in 63% (17/27) of the patients at a median of 9 months from surgery (range 3 months to 6 years) and 15 of these have died; two patients with recur rences are surviving at 24 and 96 months after further surgery and rad iation therapy. Central recurrences (under the midline block) were pre sent in 13 of these 17 patients (76%), either as central only (n = 8), central and regional (n = 4), or central and distant (n = 1). Additio nally, three patients developed regional recurrences and one patient d eveloped a concurrent regional and distant relapse. One patient develo ped a squamous cell cancer of the anus under the midline block 54 mont hs after the initial vulvar cancer and an additional patient developed transitional cell carcinoma of the ureter (outside the radiation fiel d) 12 months after diagnosis. Factors associated with a decreased rela pse-free survival included increasing Federation Internationale de Gyn ecologic et d'Obstetrique stage (p = 0.01) and invasion of the tumor i nto the subcutaneous (SC) fat or deep soft tissue (p = 0.05). Chronic lower extremity edema developed in four patients, but there have been no other complications. Conclusions: Radical vulvectomy has often been considered sufficient central treatment for vulvar carcinoma, with po stoperative irradiation directed only to the nodes. Although designed to protect the radiosensitive vulva, use of a midline block in this se ries resulted in a 48% (13/27) central recurrence rate, much higher th an the 8.5% rate previously reported with this technique. Routine use of the midline block should be abandoned and, instead, postoperative i rradiation volumes should be tailored to the individual patient.