Recurrent vulvar case

[Pewl]

63y/o female diagnosed with vulvar ca 1 year ago s/p radical vulvectomy and bilateral groin dissection. The tumor was 8.5cm with 3mm margins and +LVSI. There was one positive node in each groin, but groins were clinically negative prior to surgery.

Then, this year she recurred at the primary site as well as radiographically in the groin. She underwent a second vulvectomy to remove a 5.5cm tumor which was found to be adherent to pelvic sidewall and pelvic bone. 1mm margin obtained. Groins were not addressed. Now she's sent to rad onc.

In retrospect if I had seen her after the first surgery I would have given her adjuvant RT up front. I don't think she's really salvageable at this point, but without RT I think local control will become a problem soon.

Has anyone here had a similar case?

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[Palex80]

Local control has been underestimated in vulvar cancer and it's sad we don't have good prospective and not even large retrospective studies.
This month long term results of the GRONINGEN study were published, showing high rates of local recurrence without RT in most patients. Let's hope the article raises awareness... http://www.sciencedirect.com/science/article/pii/S0090825815301384

 

[seper]

A large recurrence, but this scenario is commonly seen in practice IMO. If no distant mets, gotta treat her now aggressively.

 

[Pewl]

Agreed. There was even discussion about possibly getting med onc involved. Usually chemo is given concurrently with up front advanced disease or in the setting of 3+ nodes with high tumor burden. I personally haven't treated a vulvar with concurrent chemo yet. I wonder how well it's tolerated.

 

[Pewl]

Local control has been underestimated in vulvar cancer and it's sad we don't have good prospective and not even large retrospective studies.
This month long term results of the GRONINGEN study were published, showing high rates of local recurrence without RT in most patients. Let's hope the article raises awareness... http://www.sciencedirect.com/science/article/pii/S0090825815301384

I think the lack of good prospective data is due to the relative rarity of the disease. Although, I feel like tertiary centers see a lot of these! I'm not sure if gyn onc should consider doing a repeat groin dissection to remove the positive node. I think a second dissection will be morbid and adding radiation on top of that will probably lead to massive lymphedema. Will probably need to address the gross nodal disease in the groin with definitive RT.

 

[medgator]

Agreed. There was even discussion about possibly getting med onc involved. Usually chemo is given concurrently with up front advanced disease or in the setting of 3+ nodes with high tumor burden. I personally haven't treated a vulvar with concurrent chemo yet. I wonder how well it's tolerated.

Kinda like anal

 

[seper]

I treat 1-2 vulvar cases per year with weekly cisplatin. Just like in H&N cancer, mucositis and dermatitis are much more severe.

 

[Brim]

The big question is: Why didn't she receive post-op RT initially?

It's going to be hard to achieve local control... this can be disastrous. I would add concurrent cisplatin, boost the areas of adherence / pos margins to around 6480 if you can.