1. RADIOTHERAPYin VULVAR CANCER 2013 ANZGOG Kailash Narayan

3. Two patients developed a skin-bridge recurrence. Both had palpably suspicious nodes (N 2 ) and > 3 positive nodes.

4. VULVAR CANCER – GOG POSITIVE GROIN NODES PLND(55)RT (50) 2 years survival54%68% Groin recurrence24% 5% Pelvic recurrence 2% 7% Vulvar recurrence 9% 9% Distant mets 9% 9% Advantage only for N2, N3 nodes or >1 pos Homesley H et al, Obstet Gynecol 1986; 68:733.

5. 58 patients with squamous carcinoma of the vulva and non-suspicious(N0-1) inguinal nodes to receive Vulvectomy and either groin dissection or groin irradiation. Groin dissection versus groin radiation in carcinoma of the vulva: GOG study Stehman et al Int J Radiat Oncol Biol Phys. 1992;24(2):389-96. Int J Radiat Oncol Biol Phys. There were 5/25 (20.0%) patients with positive groin nodes in surgical arm (Expected rate 24%) These had post op RT, none relapsed in groin. There were 5/27 (18.5%) relapses in RT arm. The groin dissection regimen had significantly better progression-free interval (p = 0.03) and survival (p = 0.04). CONCLUSION: Radiation of the intact groins is significantly inferior to groin dissection in patients with squamous carcinoma of the vulva and N0-1 nodes

6. Depth Number +ve nodes% <1 mm16300.0 1.1–2 mm145117.7 2.1-3 mm131118.3 3.1-5 mm1012726.7 >5 mm381334.2 TOTAL5786210.7 Hacker, Hoffman, Magrina, Parker, Wilkinson, Boice, Ross, Rowley, and Struyk. Nodal Status in T 1 Vulvar Cancer

7. 5-YEAR SURVIVAL RELATED TO CHARACTERISTICS OF POSITIVE NODES PatientsSurvival %P Diameter Site < 5 mm 5 – 15 mm > 15 mm 11 12 15 90.9 41.6 20.6.001 Intra Extra 14 24 85.7 25.0 Origoni M et al, Gynecol Oncol 1992;45: 313 Prognostic value of pathological patterns of lymph node positivity in squamous cell carcinoma of the vulva Stage III and IVA FIGO

8. Death from Recurrence in an Undissected Groin Author Recurrence DOD Rutledge (1970) 43 Magrina (1979) 43 Hoffman (1983) 44 Hacker (1984) 33 Monaghan (1984) 44 Lingard (1992) 77 Case reports108 TOTAL3632 (89%)

9. MANAGEMENT OF ADVANCED VULVAR CANCER

10. Recommended external irradiation for both internal and external genital disease followed by excision of the tumour bed. Richard Boronow 1973

11. Preoperative radiotherapy in Vulvar cancer GOG Phase II; Moore DH et al; Red J.1998 T3 – T4 lesions (requiring exentrative surgery) n=74 47.6 Gy split course RT, concurrent 5FU, cis-plat 46.5 % CR 3 Patients had GI or GU diversions There are other similar studies involving un-resectable nodes becoming resectable post RT

12. Chemo-radiotherapy of Vulvar cancer

13. Advanced Vulvar Cancer Management of Lymph Nodes CT Scan of groins, pelvis and abdomen Complete groin dissection Operable suspicious nodes (N 2,N 3 ) Resect bulky nodes RT groin and pelvis Primary chemoradiation Surgical resection No suspicious nodes (N 0,N 1 ) Non-operable groin nodes

14. General perception of vulvar radiotherapy What is the proportion of vulvar cancer patients in the following categories? (Referral pattern) Primary Chemo-radiotherapy Adjuvant radiotherapy For recurrent cancer Palliative radiotherapy

15. VULVAR CANCER n=120 (2000 – 2008) PeterMac Chemo-radiotherapy n=21(17%) Adjuvant radiotherapy n=37(31%) For recurrent cancer n=44(37%) Palliative radiotherapy n=18(15%) Follow-up cut off date Jan 2011 Lost to follow-up n=5

16. VULVAR CANCER (2000 – 2008) PeterMac Chemo-radiotherapy n=2113(62%) Alive Node + 11(52%) 5(45%) died Node - 10(48%) 3(30%) died Adjuvant radiotherapy n=37 21(56%) Alive Node + 24(65%) 12(50%) died Node - 13(35%) 4(31%) died

17. DISEASE-SPECIFIC SURVIVAL Kaplan Meyer Curves Hyde S et al, 2004 1.0.8.6.4.2 0.0 Cum survival Follow-up (months) 02040 60 80 100 120 140 Nodal debulking N = 17 Groin dissection N =23 RHW Mercy Amsterdam

18. VULVAR CANCER Accepted Treatment policies Unilateral groin dissection for lateral T 1 lesions with negative ipsilateral nodes Nodal debulking for N2 or N3 nodes (ChemoRT, PET, Surg) Preoperative ChemoRT to avoid exenteration for advanced disease (Use of curative RT) PostopRT for multiple positive groin nodes or extracapsular spread (ChemoRT, PET, Surg) Most of these concepts are surgically inspired, based on FIGO staging but in a prognostically heterogeneous population

19. 12/16/20154-D Ca Cx Narayan