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Vulvar Cancer cases - Coggle Diagram

- - - - Heaps 1990
        If <8mm margin, recurrence is 48%
        
        LVSI positive had 38% recurrence
        
        vs 15% no LVSI
        
        Grootenhuis 2019
        N=49
        RT not associated with LR
        dVIN with or w/o LS
      - Postoperative Vulvar Dose
        Viswanathan 2013
        
        N = 300 pts
        
        Vulvar recurrence by margin status
        
        Close, negative, positive
        
        Close or positive margins associated with significantly increased risk of vulvar recurrence
        
        56 Gy shows good separation on recurrence
        
        NCDB Chapman 2017
        
        Beriwal
        
        3075 pts w/ scc
        
        s/o surgery
        
        positive margin
        
        35% received ajduvant RT
        
        greatest mortality reduction ≥ 54 Gy
        
        no surv benefit > 60 Gy
        
        For microscopic vocally positive 54-59Gy is good
        
        MDACC postoperative vulvar dose
        Margin negative 5-10mm w/ no high risk :” 45-50 Gy
        Positive Margin: 40-50 Gy to vulva, boost to high risk area to at least 60
        
        JY
        
        soft call to treat vulvar bed (BL groin) : 50 Gy
        
        Close margin 55 Gy (often part of SIB)
        
        Focally positive 60 Gy
        
        gross residual disease 64-66 Gy
        
        56 is harder to SIB than 55 Gy, 2.5 Gy/fx
      - GOG 37
        if pelvic node dissection shows positive nodes
        can pelvic RT replace pelvic LN dissection?
        
        n = 114 bl groin dissection
        
        PLND
        
        30% positive PLN
        
        Pelvic and Groin RT
        
        bl groin, external internal iliac)
        
        Adjuvant RT is more effective than groin dissection alone in controlling groin metastases.
        
        Pelvic RT is effective in reducing pelvic node recurrence (30% involvement)
        
        Dose to LN- postoperative MDACC
        microscopic, no ece, no radio graphic nodes: 45-50 Gy
        Gross nodes, no ECE: 50-56
        ECE:: 60-66 Gy
        Gross residual disease: 60-70 Gy
        JY
        Surprise micromet: 50
        
        CT identified but resected small node: 55 Gy
        
        Large ECE node : 55Gy
        
        Gross bulky : 60 Gy
- - - - Prediction risk from GROINSS-V
        
        N = 135 w/ SLN positive
        
        rate of non SN mets
        
        ITC : 4%
        
        ≤ 1mm : 10%
        
        5-10% : 38%
        
        >10 mm : 63%
        
        No cutoff below where chances of non SLN Mets are zero
      - GROINSS V-II
        
        N = 3222 w/ SLN positive
        
        50 pts receive RT 50 Gy /1.8 Gy fx
        
        after 91 recurrences the recurrences were too high and the study was amended
        
        ≤ 2mm (micromet): continue RT 50Gy
        
        > 2mm Macromet
        
        IFL
        
        If additional node positive and/or ECE: continue RT 50Gy
        
        Isolated groin recurrences
        
        Micromet
        
        SLN alone: 11% vs Adj RT 1.6%
        
        Macromet
        
        IFL +/- RT : 6.8% vs RT only : 22%
        
        LE >6 mo
        
        32% SLN + IFL
        
        SLN RT : 16%
        
        SLN 5.1%
        
        Inguinofemoral RT is safe
        
        Criticism
        
        only 5mm margin was used for CTV in groin nodes
        
        probably a geometric miss
        
        for large mets with ECE, 50 Gy is not adequate
        
        RTOG Nodal volumes
        Based on observed nodal mets
        
        look for edge of sartorius and pectinius muscles for lat and post borders
        
        most of the recurrences are medial to the femoral vessels
        
        Netherlands Trial Register
        ongoing trial
        
        met SLN, >2mm w/ w/o ECE
        
        OR met SLN, more than 1 SN w/ met ≤ 2mm
        
        concurrent chemo
        RT 56 Gy
    - - Can we omit SLN?
        
        GOG 88
        Groin RT vs dissection in cN0
        
        N = 52 T 1-3 No or N1 palpable but not suspicious SCC sp vulvectomy
        
        mFU = 3 years
        
        vulvectomy + groin LND w/ 50 Gy RT ipsi groin and pelvis if pN+
        
        20% had patho positive groin nodes
        
        vulvectomy only w/ bilateral going 50 Gy to 3 cm depth
        
        50% of the dose given by electron to decrease dose to femoral heads
        
        all 5 recurrences occurred in the RT only arm
        
        all occurred in the field
        
        all recurrences died. These are bad, hard to salvage
        
        Criticism
        Stehman 1992
        Koh 1993
        
        using 50 cervix patients with CT available
        
        depth of femoral vessels as a surrogate for nodes, measured
        
        depth 2.0cm-18.5cm
        
        Maybe… GOG 88 failures likely due to underdosing
- - - - GOG 205
        
        57.6 Gy w/ weekly Cis preop, everyone got surgery
        
        cCR 64%
        
        pCR 50%
        
        suggests dose response, but not good enough
        
        GOG 279
        64 Gy/ 32 fx w/ weekly cis/Gem
        
        cCR 71%
        
        pCR 73%
        
        further supports dose response
        
        but how high can the patient tolerate? We don’t know.
        
        RTOG Consensus
        
        up to 60
        :construction:
        MDACC
        JY
        
        64-66 Gy
    - - MDACC
        Steckline 2018
        
        60-70 Gy (median 66 Gy)
        
        mFU: 28 mo
        
        only 3 major late events, fem beck fx, G3 LE, thrombosis of iliac artery
        
        high dose acheievd high rate of LC w/o much toxicity
        
        GOG 279
        
        LN+ 64Gy to gross disease
      - CHT
        Shown in retrospectives to improve outcomes