Journal of Cancer Research and Therapeutics Medknow Publications on behalf of the Association of Radiation Oncologists of India (AROI) ISSN: 0973-1482 EISSN: 1998-4138 Vol. 6, Num. 4, 2010, pp. 503-507

Journal of Cancer Research and Therapeutics, Vol. 6, No. 4, October-December, 2010, pp. 503-507

Original Article

Treatment outcome of patients with carcinoma of vulva: Experience from a tertiary cancer center of India

Daya Nand Sharma¹, Goura Kisor Rath¹, Sunesh Kumar², Neerja Bhatla², Parmod Kumar Julka¹, Puja Sahai¹

¹ Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
² Department of Gynecology and Obstetrics, All India Institute of Medical Sciences, New Delhi 110029, India

Correspondence Address: Daya Nand Sharma, F-39, Ansari Nagar, New Delhi 110029, India, sharmadn@hotmail.com

Code Number: cr10125

PMID: 21358089

DOI: 10.4103/0973-1482.77090

Abstract

Keywords: Clinical outcome, retrospective analysis, vulvar carcinoma

Introduction

Vulvar carcinoma (VC) is a relatively rare malignancy accounting for 3-5% of all gynecological malignancies. This is a disease of elderly women with the median age at diagnosis of 65-70 years. ^[1],[2] Regional metastasis to inguinal lymph nodes is common with a frequency of 6-50% reported in surgical series. Incidence of pelvic node metastases is about 30% in patients who have pathologically positive inguinal nodes. ^[3] The most important prognostic factor is the presence and number of inguinal node metastases. Other factors include extranodal tumor extension, tumor diameter, and depth of invasion, tumor thickness, lymphovascular space invasion, margin status, tumor grade and age. ^[3],[4],[5]

Patients with early stage disease are often managed with surgery alone, and adjuvant radiation therapy (RT) is offered to patients with close or positive margins or with inguinal lymph node metastases to reduce the locoregional recurrence and improve survival. ^[6],[7],[8] For patients with locally advanced disease, radical vulvectomy has been traditionally advocated but it is associated with significant morbidity. Therefore, the concept of organ preservation is emerging with multimodality approach, including preoperative or definitive treatment with chemoradiation. ^[8],[9],[10] At the same time, many patients who present in late age and have associated co-morbid conditions may not be suitable for aggressive treatments like radical surgery or chemoradiation. In such patients, definitive RT is a practical option for controlling the disease. RT can also provide effective palliation of symptoms in patients with far advanced disease, distant metastases or with medical co-morbidities.

The purpose of our retrospective analysis of 60 patients was to study the treatment results of VC and to review the reports in literature.

Materials and Methods

For this retrospective analysis, we retrieved the case records of all the VC patients who were treated at our center between 1998 and 2005. From each case record, we extracted the information regarding the patient′s demography, clinical details, diagnosis, treatment given, survival and complications. Patients with non-carcinoma histology like melanoma, sarcoma, etc., were excluded from the present analysis.

The initial pretreatment workup of the patients consisted of detailed clinical examination in the gynecologic oncology clinic by a team comprising gynecologist and radiation oncologist. Each patient was subjected to various routine hematological and radiological investigations. Computed tomography (CT)/magnetic resonance imaging (MRI) scan of the abdomino-pelvic region and cysto-sigmoidoscopy were done, if necessary. Staging was done according to FIGO system. ^[11] The selection of treatment modality was decided by the gynecologic oncology clinic team.

The usual treatment options contemplated for early stage disease were 1) wide local excision with or without inguinal node dissection; 2) radical vulvectomy with inguinal node dissection; and 3) definitive RT for patients not suitable for surgery. For advanced stage disease, various options were 1) radical vulvecomy plus bilateral inguinal node dissection followed by postoperative radiation therapy (PORT), if indicated; 2) definitive chemoradiation; 3) preoperative chemoradiation followed by surgery; and 4) palliative RT. Routine indications for PORT to local area included positive or close (<8 mm) margins, lymphovascular invasion, and depth of tumor invasion >5 mm. Patients with more than one involved inguinal node, extracapsular extension, or gross residual nodal disease were considered for PORT to both groins and the pelvis.

A variety of dose fraction schedules and techniques of RT were employed as per the clinical and surgico-pathological details. The dose of RT for microscopic disease (postoperative) was 45-50 Gy and for gross disease (definitive RT) was 60 Gy with conventional fractionation (1.8-2.0 Gy per fraction, 5 days a week). Two asymmetric AP-PA fields (wide anterior field for covering the inguinal nodes and narrow posterior field for the pelvic nodes) were used on either cobalt-60 or linear accelerator. Electrons were used for boosting the inguinal node region. Treatment volume varied from vulvar site to inguino-pelvic region depending upon various factors.

Follow-up was done every month for the first 3 months, and then every 3 months till 1 year. Subsequently, they were followed up every 3-6 months. At every visit, clinical examination was performed and, if necessary, CT/MRI scans, to assess the disease status.

Statistical analysis was performed using the statistical software SPSS, version 11.5. The overall survival (OS) was calculated by Kaplan Meier survival method. ^[12] Acute morbidity was assessed as per the Radiation Therapy Oncology Group (RTOG) criteria. ^[13] Each patient, who was lost to follow-up after a certain period was censored at that point of time for survival analysis. OS was determined with respect to age (below and above 65 years), histopathological grade, stage of disease, treatment group, pathological lymph node status. Log rank test was used to find out the P value and a value of <0.05 was considered significant.

Results

A total of 60 case records were retrieved for this retrospective analysis. Various patient characteristics are given in [Table - 1]. Age ranged from 24 to 92 years with a median of 63 years. Majority of the patients (40/60) had advanced disease (stage III-IVA). Thirty-three patients underwent surgery (wide local excision 3, radical vulvectomy 30 patients). Nodal dissection was performed only in 22 patients. Butterfly incision was given in 9 patients, and triple incision was given in 13 patients. Lymphadenectomy consisted of removal of both superficial and deep nodes. In view of the expected postoperative morbidity due to associated co-morbid conditions like diabetes, obesity, etc., eight patients were not offered lymph node dissection and instead offered adjuvant RT. Three other patients expressed their unwillingness for lymph node dissection when explained about the expected postoperative morbidity and did not give consent for the same. Due to advanced disease at presentation and elderly age, 12 patients received palliative RT. Fifteen patients underwent definitive RT; 5 of them received concurrent chemotherapy with cisplatin 50 mg/m ² on a weekly basis.

Median follow-up period was 23 months (range 2-144 months). Out of 60 patients, 34 (57%) had no evidence of disease and 26 (43%) had failure. Of 26 failures, 25 were confined to locoregional site (vulva and inguino-pelvic area) and only one patient had distant metastases in lungs. The 5-year OS for all stages was 41% [Figure - 1]. As shown in [Figure - 2], the 5-year OS in stage I, II, III and IV was 100, 60, 41 and 0%, respectively. There was no significant difference in survival between the patients of <65 years of age and older patients (46% vs. 33%, respectively; P value 0.7) [Figure - 3]. Histopathological grade also had no significant impact on the survival [Figure - 4]. As evident from [Figure - 5], pathologically node positive patients had significantly inferior OS than node negative patients (27% vs. 86%, respectively; P = 0.042).

Of the 33 patients who underwent surgery, 8 (24%) had delayed wound healing. Of the 21 patients who received PORT or definitive RT, 3 (11%) had acute severe complications in the form of Grade IV skin toxicity. None of the five patients who received weekly cisplatin chemotherapy experienced severe hematological complications. Of the 22 patients who underwent inguinal node dissection, 2 developed lymphocele and 5 developed lymphedema.

Discussion

Due to the rarity of VC, there are no large randomized controlled trials and most treatment guidelines are based on small and retrospective studies in the literature. In developing countries, where most cancer patients present in advanced stages, VC is rarely studied and reported. In the last decade, there has been only one study ^[14] from India. Ours is the largest series so far being reported from India and the results of our study may reflect the Indian scenario.

About two-thirds of the patients in our series presented in advanced stage (stage III-IV) of the disease. This figure is almost the same to that noticed in the study by Bafna et al. ^[14] The median age of presentation in our study (63 years) is also approximately the same as noticed in the worldwide literature. ^[3]

The results of study may not be strictly comparable to that in the literature since a significant proportion had fairly advanced disease at presentation and 20% of our study population was treated with palliative RT. Yet, the 5-year OS of 41% in our series reflects a decent outcome.

Our results have revealed FIGO stage of disease at presentation and pathological node positivity to be the significant prognostic factors for survival. Age of patient and histopathological grade failed to show an impact on survival. Chemotherapy and preoperative radiotherapy was used in very few patients in our series and therefore impact of these factors on survival was not calculated. Similar to our study, Maggino et al. ^[15] also observed stage and presence of positive nodes as the significant prognostic factors but the number of positive nodes failed to affect the prognosis.

FIGO stage at presentation was a significant prognostic factor, which is consistent with reports from literature. ^[3],[4],[5] Stage III-IV patients had a poor outcome as compared to stage I-II in our series [Figure - 2]. In 1991, the Gynecologic Oncology Group (GOG) reported a survival analysis of 588 patients and observed that 5-year survival in stage I, II, III, and IV was 98, 85, 74, and 31%, respectively. ^[5]

Histopathological grade has been regarded as an important prognostic factor in several studies ^[3],[4],[5] but it was not found significant in our series. Though radical vulvectomy was the commonest surgical procedure in our study due to advanced disease status, the recent trend is shifting toward conservative surgery with combined use of preoperative radiotherapy or chemo-radiotherapy. ^[8]

PORT is not routinely used in all VC patients but it has been shown to improve local control and survival in patients with close or positive margins (<8 mm), depth of invasion >5 mm, lymphovascular space invasion, two or more positive groin nodes and extracapsular extension. ^{[7],[16],[17]} In a retrospective series, adjuvant radiation significantly reduced the rate of local recurrence in patients with both close (<8 mm) and positive margins, from 58 to 16%. ^[7] In a GOG study, ^[16] patients with involved inguinal nodes after radical vulvectomy and bilateral inguinal node dissection were randomized to subsequent pelvic node dissection versus PORT. Dose of radiation was 45-50 Gy delivered bilaterally to the pelvic and inguinal nodes using anterior and posterior opposing fields. The study revealed a significant survival advantage for patients receiving PORT (2-year survival 68% vs. 54%, P = 0.03) and a lower rate of relapse (5% vs. 24%, P = 0.02).

Inguinal node metastasis is the most consistent prognostic factor in the literature. ^[3],[5],[18] Certain studies ^[5],[18] have shown a significant correlation between the number of positive nodes and survival. Most studies suggest more than two positive nodes as the significant number and therefore suggest PORT for such patients. Our study showed highly significant superior outcome in node negative patients as compared to node positive patients. A recent study by Landrum et al. ^[19] has not shown node as the significant prognostic factor. They have concluded in their study that lymph node status is not a predictor for OS or progression free survival (PFS) for advanced VC patients treated by primary surgery or chemoradiation.

According to recent literature, advanced VC is better treated initially with chemo-radiotherapy. ^[20],[21] Residual nodal disease can then be excised, a formal node dissection performed or boosted with further radiation. High rates of wound breakdown occur when operating in an irradiated field, and therefore boosting residual disease with radiation may potentially be a less morbid treatment option. ^[20],[21]

A GOG study ^[21] in 71 patients with advanced VC examined the feasibility and outcomes of preoperative chemo-radiotherapy in reducing the need for more radical surgery. Of the patients completing treatment, 46.5% had no visible vulvar disease at the time of planned surgery and only 2.8% had residual unresectable disease. This would be beneficial especially for patients with midline tumors in which excising any residual disease could still result in loss of clitoral or sphincter function, despite tumor regression.

Radiation can effectively palliate the symptoms (bleeding, ulceration, necrosis, pain, and malodorous discharge) in patients not suitable for radical treatment because of far advanced local disease, metastatic spread, or significant co-morbidites. A short course of palliative RT can produce dramatic regression of disease and give relief from symptoms. We recommend using a short course of RT with a dose of 20 Gy in five fractions over 1 week.

The acute morbidity of vulvar irradiation, especially after surgery, is substantial. ^[3] Common acute effects include moist skin desquamation, ulceration, wound complications, etc. Late radiation morbidity includes vulvar fibrosis, atrophy, telangiectasia, ulceration, and lymphedema. ^[3] Both acute and late radiation related morbidities can be potentially reduced with newer RT techniques like three-dimensional RT and intensity modulated RT (IMRT). Beriwal et al.^[22] studied the use of IMRT in 15 patients with VC and reported that none of the patients had grade III acute toxicity and 2-year survival was 100%. Future trials with larger patient population will further explore its potential in improving the results.

The only study from India so far was a retrospective analysis of 37 patients reported by Bafna et al.^[14] They could not draw any conclusion from their study due to small sample size but they observed worse prognosis with bilateral inguinal nodes and beneficial outcome with neo-adjuvant chemotherapy in advanced VC. In contrast, our study has revealed significant prognostic factors. The short median follow-up of 23 months in our series may be a limitation of study. However, poor follow-up in Indian female patients due to several factors like long traveling distances, low socioeconomic status, elderly age, etc., is not very unusual.

Conclusion

Ours is the largest series being reported from India so far. About two-thirds of the patients presented in advanced stage of the disease. The results have shown 5-year OS of 41% for all stages and 100-60% for stage I-II disease. Stage of the disease and pathological node positivity were found to be significant prognostic factors for survival. The use of preoperative chemotherapy/RT needs to be studied in our setup.

References

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