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LiFE re
Literature for ENYGO
Treatment of recurrent vulvar cancer
Editor María de los Reyes Oliver Pérez
Descriptive summary
Squamous cell carcinoma (SCC)
Surgical treatment: No randomised prospective studies are
reported.
The recently published PDQ cancer information summary for
health professionals [1] provides comprehensive, peer-reviewed,
evidence-based information about the treatment of vulvar cancer.
According to the authors, current management options for recurrent
vulvar cancer are:
W ide local excision with or without radiation in patients with
local recurrence.
R adical vulvectomy and pelvic exenteration in patients with local
recurrence.
S ynchronous radiation and cytotoxic chemotherapy with or with-
out surgery.
Van Doorn et al. [2] retrospectively assessed the feasibility of repeat other sites of recurrence.
sentinel lymph node (SLN) procedure in 27 patients with recurrent
vulvar SCC who were not able or willing to undergo inguinofemoral
lymphadenectomy as part of their treatment for recurrent disease.
The main reasons not to perform a repeat SLN procedure in these
patients is the assumption that the lymph flow might be altered
because of previous surgery or radiotherapy. Investigators reported
that in 77 % of patients and in 84 % of the groins the SLN procedure
was performed as planned compared to reported success rates of
more than 95 % in primary SLN procedures. In conclusion, the au-
thors emphasise that a repeat SLN procedure in recurrent vulvar SCC
is feasible to perform, but appears technically more challenging due
to the changes of the lymphatic drainage to the groins and fibrosis at
the vulvar and groin sites resulting in surgical complications.
Systemic treatment: No studies are reported.
Radiotherapy: Amsbaugh et al. [3] retrospectively reviewed 73
patients who received CT-planned interstitial brachytherapy (ISBT)
for gynaecologic cancers (including 21 recurrences). Of them, 8
had vulvar cancer. The indication for ISBT was vaginal or vulvar
involvement, pelvic sidewall involvement, anatomy not suitable for
intercavitary BT, and dose-escalation and dose shaping. Median
tumour size was 4 cm (range, 1.5-12.5 cm). With a median follow-up
of 12 months, grade 3 vaginal, urinary, and rectal toxicity occurred
in 17.8 %, 15.1 %, and 6.8 % of patients, respectively. No patients
experienced grade 4 or 5 toxicity. Patients with the vagina and vulva
as primary sites did not have a significantly different risk of death.
Continued on the next page 
International Journal of Gynecological Cancer, Volume 26, Supplement #1 Page 51
VULVAR CANCER
Overall survival (OS) was not significantly different for patients
receiving treatment for recurrent cancer compared with patients
treated at the first presentation (p = 0.408). Authors concluded that
ISBT is a safe treatment for gynaecologic malignancies.
Laliscia et al. [6] retrospectively assessed the clinical outcome of
31 patients with recurrent vulvar cancer treated with radiotherapy
as definitive treatment. The site of relapse was local in 15 women
(48.4 %), inguinal in 6 (19.3 %), local plus inguinal in 7 (22.6 %), and
distant plus local and inguinal in 3 (9.7 %). Long-term control was
achieved in only 20 % of the 15 local recurrences. Only 1 (16.7 %)
out of the 6 patients with groin recurrence and only 1 (14.3 %) out
of the 7 patients with local plus groin recurrence were recovered by
salvage treatment, and all 3 patients with distant recurrence died of
disease. Survival was significantly better for the patients with FIGO
I-II stage compared to those with stage III disease at presentation
(54 months vs. 23 months, p=0.005). There was a trend to better
survival for patients with local recurrence compared with those with
Treatment of metastatic disease: Alvarez et al. [4] presented the
first description of an aggressive surgical approach for the treatment
of a para-aortic nodal recurrence in vulvar cancer. Although the
patient died of multiple lung metastases 5 months after surgery,
authors suggest that an ultra-radical surgery could confer good
survival outcomes.
No SSC vulvar cancers:
An analysis of 38 patients with invasive vulvar Paget disease was
conducted by the authors of the VULCAN study [5], an international
multicentre retrospective study of patients diagnosed with vulvar
cancer. For local recurrence, the mean time to onset of recurrence
was 64.2 ± 7.2 months versus 44.9 ± 1.7 months for distant recur-
rence, and the mean overall survival time was 58.5±0.5 months.
Local recurrences were inversely associated with the caseload at the
treating centre (P=0.01). Distant recurrences were associated with
tumour size and FIGO stage (P<0.001). Adjuvant therapy (radiother-
apy or chemotherapy) was associated with a reduced risk of distant
metastases and increased overall survival (P<0.001).