The general principles of tactics for managing patients with vulvar cancer are: surgical treatment for stage I disease, combined (surgical and radiation) for stage II and III, individual approach (combination of radiation, drug and surgical methods of treatment) for stage IV and relapse of the disease. Only with absolute contraindications to surgical intervention can radiation therapy be used as an independent treatment method in combination with or without chemotherapy. The method of choosing radiation treatment is now unanimously recognized as fast electron therapy with an energy of 10-15 MeV radiation, which can be carried out at any degree of propagation of the process (T1-T4). In electron therapy, average fractionation is used (ROD on the bed of the tumor 3 Gy, SOD – 50-60 Gy). Cessation criteria are the clinical presentation of vulvitis or complete tumor regression. Vulvit is stopped within 1-2 weeks. After which treatment continues. A dose of 60 Gy is the maximum for vulvar tissue. In the absence of sources generating fast electrons (linear electron accelerator, betatron), radiation treatment is carried out on gamma-therapeutic units. Remote radiation therapy is carried out on the installations “Rokus” Co-60, “Agat-R”, “Agat-S”, intracavitary treatment – on the apparatus “Selectron”, “Agat-VU”. The primary tumor with surrounding tissues is irradiated (ROD – 2.5-3 Gy, SOD – 30-35 Gy), after which radiation therapy can be supplemented with interstitial gamma therapy or close focus x-ray therapy. The optimal absorbed dose for interstitial gamma therapy is 60-70 Gy. In cases of spreading the tumor process to the vagina or urethra (TK), remote gamma therapy (DHT) is supplemented by intracavitary gamma therapy (HPT), SOD – 40-60 Gy. Radiation treatment for all stages of vulvar cancer is not effective enough. The overall 5-year survival rate is 29% with combined radiation therapy, 39% with electron therapy.
Stage 0 Vulvar Cancer
The choice of treatment depends on the spread of the process.
Methods of choice:
1. Wide local excision, laser treatment, or a combination thereof.
2. A vulvectomy with or without graft grafting.
3. “Fluorouracil” 5% cream (a positive result in 50-60%).
4. Photodynamic therapy.
After vulvectomy, 5-year survival is almost 100%, but vulvar cancer is rarely diagnosed at this stage.
Stage I Vulvar Cancer
Selection methods:
1. For microinvasive cancer (invasion up to 1 mm) not associated with VIN 3, a wide (5-10 mm) excision is indicated. In all other types of stage I vulvar cancer (with clinically undetectable lymph nodes and the absence of diffuse VIN 3), radical local excision with unilateral lymphadenectomy on the side of the tumor should be performed.
2. Vulvectomy with bilateral inguinal-femoral lymphadenectomy. Unilateral inguinal lymphadenectomy is the treatment of choice for early forms of vulvar cancer. In the presence of medical contraindications for inguinal lymphadenectomy, an alternative method of treatment is irradiation of the inguinal region with clinically negative lymph nodes (N0) (ROD – 2.5-3 Gy, SOD – 35-40 Gy).
3. If there are contraindications for radical vulvectomy due to the localization or spread of vulvar cancer, combined radiation therapy is performed. During therapy with fast electrons: the SOD on the tumor bed is 3 Gy, the SOD is 50-60 Gy. In the absence of such an opportunity, combined radiation therapy is carried out: on the primary focus – up to SOD – 60-65 Gy, on regional zones – up to SOD – 40 Gy.
A vulvectomy with bilateral inguinal-femoral lymphadenectomy provides a 5-year survival rate of up to 90%.
Stage II of vulvar cancer
Vulvectomy with bilateral inguinal-femoral lymphadenectomy is the standard treatment.
Methods of choice:
1. Vulvectomy with bilateral inguinal-femoral lymphadenectomy. Radiation therapy to the inguinal lymph nodes at the clinical stage N0 is an alternative to inguinal lymphadenectomy in the treatment of those women who have medical contraindications for performing inguinal lymphadenectomy (ROD – 2.5-3 Gy, SOD – 35-40 Gy).
2. Patients who cannot perform a vulvectomy with inguinal-femoral lymphadenectomy due to the localization or spread of the tumor process and concomitant pathology are shown radical radiation therapy. Irradiation in the best case is carried out by fast electrons with an energy of 10-15 MeV, a SOD on the tumor bed – 2.5-3 Gy, SOD – 50-60 Gy. In the absence of electronic therapy, DHT is performed: on the primary focus – up to SOD – 60-65 Gy, on regional zones – up to SOD – 40 Gy (at N0), with N1-2 it can be continued to the maximum tolerated dose with a reduced field (maximum SOD – 60 Gy).
Five-year survival reaches 80-90%, depending on the size of the primary tumor.
Stage III Vulvar Cancer
Vulvectomy with inguinal-femoral lymphadenectomy is the standard treatment.
Methods of choice:
1. Vulvectomy with inguinal-femoral lymphadenectomy is performed after radiation therapy to the vulva with a large primary lesion. Local adjuvant radiation therapy at a dose of 45-50 Gy is indicated for stromal invasion of the tumor of more than 5 mm, especially with damage to the lymph nodes. Irradiation of the pelvis (with the inclusion of the iliac and obstructive lymph nodes) and inguinal areas is carried out in the presence of more than two metastases in the inguinal lymph nodes: ROD – 2 Gy on each side daily to SOD – 35-40 Gy.
2. Preoperative radiation therapy is carried out in some cases to increase the operability of the tumor and to reduce the volume of surgical intervention. A combination of preoperative radiation therapy at a dose of up to 55 Gy divided into 2 courses, which are carried out with an interval of 2 weeks, and chemotherapy at the beginning of each course according to the mitomycin-C regimen (15 mg / m2 on day 1) and 5-fluorouracil (750 mg / m2 daily for 5 days). In cases of spreading the tumor process to the vagina or urethra (TK), remote gamma therapy is supplemented by preoperative intracavitary gamma therapy, which is carried out endovaginally (apparatus type “AGAT-B”, ROD on the surface of the mucous membrane 5-7 Gy, irradiation rhythm 1-2 once a week, SOD – 45-60 Gy) or endourethrally in the same mode.
3. In case of contraindications for vulvectomy with inguinal-femoral lymphadenectomy, the only treatment method is combined radiation therapy. Radiation therapy can be combined with chemotherapy according to the scheme 5-fluorouracil or 5-fluorouracil with cisplatin. Four courses of chemotherapy and subsequent radiation therapy lead to a complete positive response in 53-89% of cases of initially inoperable tumors, and if necessary, exenterative surgery, the SOD should be 54-65 Gy.
Since squamous cell carcinoma is the most common morphological form of vulvar cancer, all drugs used in the treatment of cervical cancer are applicable for systemic chemotherapy.
Five-year survival with a unilateral single lesion of the lymph nodes is 70%, decreasing to 30% with more than three metastatic lymph nodes on the one hand.
Stage IV Vulvar Cancer
The most difficult task is the treatment of stage IV vulvar cancer patients. The spread of the tumor determines the implementation of superradical operations or chemoradiotherapy with palliative surgery.
Methods of choice:
1. Enhanced vulvectomy with pelvic exententation.
2. With a significant local spread of the process – surgical treatment in combination with preoperative radiation therapy. With stromal invasion of a tumor of more than 5 mm, local adjuvant radiation therapy at a dose of 45-50 Gy is indicated, especially with damage to the lymph nodes. Irradiation of the pelvis and inguinal areas is carried out if more than two inguinal lymph nodes are affected.
3. Irradiation of large primary tumors enables radical surgery. Effective radiation therapy at a dose of 55 Gy, which is combined with chemotherapy. Irradiation begins 10 days after chemotherapy with 5-fluorouracil (1 g / m2 daily iv from the 1st to 5th day) or 5-fluorouracil (1 g / m2 iv in the 1st to 5th day) with cisplatin (100 mg / m2 iv on the 1st day).
4. In case of contraindications for performing extended vulvectomy, radical radiation therapy is the method of choice. It can be carried out in combination with chemotherapy with 5-fluorouracil or 5-fluorouracil (1 g / m2 iv from the 1st to the 5th day) with cisplatin (100 mg / m2 iv in the 1st day). Radiation complications in the form of late fibrosis, atrophy, telangiectasia and necrosis can be minimized if radiation therapy is fractionated. The total dose is 54-65 Gy.
Long-term results of treatment remain unsatisfactory and do not exceed 10-20%.