Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy

Background. This report consists of a retrospective analysis of 50 patients with primary invasive and 17 with recurrent histologically confirmed 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 vulvectomy followed by irradiation to the operative fields and inguinal–femoral/pelvic lymph nodes; 8 received similar postoperative radiation therapy after partial or simple vulvectomy; 16 patients had radiation therapy alone after biopsy; and 17 had recurrent tumors treated with radiation therapy alone. Results. In patients treated with biopsy/local excision, local tumor control was 92–100% in T1–3N0 disease, 40% in similar stages with N1–3, and 27% in recurrent tumors. Among patients treated with partial/radical vulvectomy and radiation therapy, primary tumor 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 with recurrent tumors. The actuarial 5‐year disease‐free survival rates were 87% for patients with T1N0 disease, 62% for those with T2–3N0 disease, 30% for those with T1–3N1 disease, and 11% for patients with recurrent tumors; there were no long‐term survivors with T4 or N2–3 disease. Four of 17 patients treated for postvulvectomy recurrent disease remain 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 patients) with 50.01–65 Gy. With T3–4 tumors treated with local excision and 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), regardless of dose level; in T3–4 tumors, it was 67% (four of six patients) with 50–60 Gy and 86% (six of seven) with 65–70 Gy. Differences were not statistically significant. There was no significant dose response for tumor control in the inguinal–femoral lymph nodes, with doses of 50 Gy being adequate for elective treatment of nonpalpable lymph nodes and 60–70 Gy controlling tumor growth in 75–80% of patients with N2–3 nodes when administered postoperatively, after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess. Conclusions. Wide local tumor excision and radiation therapy or irradiation alone in T1–2 tumors is an alternative treatment to radical vulvectomy in controlling vulvar carcinoma, with significantly less morbidity. In comparison with reported rates for surgery alone, radiation therapy after radical vulvectomy for locally advanced tumors improves tumor control at the primary site and regional lymphatics. Indications and techniques of radiation therapy are discussed.