RADIATION-THERAPY IN MANAGEMENT OF CARCINOMA OF THE VULVA WITH EMPHASIS ON CONSERVATION THERAPY

Background. This report consists of a retrospective analysis of 50 pat ients with primary invasive and 17 with recurrent histologically confi rmed vulvar carcinoma treated with radiation therapy for locoregional disease. Methods. Of the patients with primary tumors, 13 were treated with wide local excision plus radiation therapy; 13 had radical vulve ctomy followed by irradiation to the operative fields and inguinal-fem oral/pelvic lymph nodes; 8 received similar postoperative radiation th erapy after partial or simple vulvectomy; 16 patients had radiation th erapy alone after biopsy; and 17 had recurrent tumors treated with rad iation therapy alone. Results. In patients treated with biopsy/local e xcision, local tumor control was 92-100% in T1-3N0 disease, 40% in sim ilar stages with N1-3, and 27% in recurrent tumors. Among patients tre ated with partial/radical vulvectomy and radiation therapy, primary tu mor control was 90% in those with T1-3 tumors and any nodal stage, 33% in those with any T stage and N3 lymph nodes, and 66% in patients wit h recurrent tumors. The actuarial 5-year disease-free survival rates w ere 87% for patients with T1N0 disease, 62% for those with T2-3N0 dise ase, 30% for those with T1-3N1 disease, and 11% for patients with recu rrent tumors; there were no long-term survivors with T4 or N2-3 diseas e. Four of 17 patients treated for postvulvectomy recurrent disease re main disease-free after local tumor excision and radiation therapy. In patients with T1-2 tumors treated with biopsy/wide tumor excision and radiation therapy with doses less than 50 Gy, the local tumor control was 75% (three of four patients), in contrast to 100% (13 of 13 patie nts) with 50.01-65 Gy. With T3-4 tumors treated with local excision an d radiation therapy, tumor control occurred in none of three patients with doses less than 50 Gy and 66% (six of nine) with 50.01-65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and radiation therapy, local tumor control was 75% (six of eight), regardl ess of dose level; in T3-4 tumors, it was 67% (four of six patients) w ith 50-60 Gy and 86% (six of seven) with 65-70 Gy. Differences were no t statistically significant. There was no significant dose response fo r tumor control in the inguinal-femoral lymph nodes, with doses of 50 Gy being adequate for elective treatment of nonpalpable lymph nodes an d 60-70 Gy controlling tumor growth in 75-80% of patients with N2-3 no des when administered postoperatively, after partial or radical lymph node dissection. Significant treatment morbidity included one rectovag inal fistula, one case of proctitis, one rectal stricture, four bone/s kin necroses, four vaginal necroses, and one groin abscess. Conclusion s. Wide local tumor excision and radiation therapy or irradiation alon e in T1-2 tumors is an alternative treatment to radical vulvectomy in controlling vulvar carcinoma, with significantly less morbidity. In co mparison with reported rates for surgery alone, radiation therapy afte r radical vulvectomy for locally advanced tumors improves tumor contro l at the primary site and regional lymphatics. Indications and techniq ues of radiation therapy are discussed.