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Radiation therapy for recurrence of vulvar cancer


Medical editor Kolbein Sundfør MD
Gynecological Oncologist
Oslo University Hospital

General

Patients with local or regional recurrence after a previous radical operation for vulvar cancer can, in many cases, be cured by radical radiation therapy. 

Radiation therapy may be the primary choice of treatment if radiation has not been given previously, but surgery should always be considered.  

Small metastases can also be treated with a curative goal, but the possibility for surgery with subsequent radiation should be considered first.  

In the case of brain metastases, stereotactic radiation treatment is indicated for 1 to 3 (maximum) metastases which are not too large. For solitary brain metastases, surgery may be considered. Multiple or large brain metastases are treated with total brain irradiation.

Treatment must be individualized, and treatment with the goal of local control may be appropriate even if there may be subclinical spreading to other organs. Margins and total dose must be adapted according to grade of risk and time perspective. 

Indication

  • Limited recurrence (is a heterogeneous group).

Goal

  • Curative or palliative for local control

Definitions

Target volume

 

Target volume definitions from ICRU
(International Commission on Radiation Units and Measurements)
GTV (Gross tumor volume) Palpable or visible/identifiable area of malignant growth. 
CTV (Clinical target volume) Tissue volume containing GTV and/or subclinical microscopic malignancy.
ITV (Internal Target Volume) Volume containing CTV and one inner margin taking into account inner movements and revisions of CTV.
PTV (Planning Target Volume) Geometric volume containing ITV and one Setup margin taking into account assumed variations for patient movements, variations in patient arrangement, and field modeling.

Preparation

The examinations should verify the extension of the tumor. For curative treatment, the same examination should be performed as for primary radiation therapy. At Oslo University Hospital (The Norwegian Radium Hospital), we recommend that the MRI is taken at our hospital due to treatment planning.

Radical radiation therapy is ordinarily given at a dosage of 64 to 70 Gy to the macroscopic tumor. A boost to a higher total dosage can be considered towards small areas.  

CT dosage-planned external radiation therapy can be combined with brachytherapy as part of a tumor boost if good coverage of the entire tumor volume can be achieved (endovaginal possibly interstitial brachytherapy for confined tumor). Brachytherapy is usually given subsequent to completed external radiation therapy including the external boost.  


Implementation

  • 1.8 - 2 Gy is given per fraction with 3–4 radiation fields toward the tumor  
  • The number of fractions will depend on the total dose.
  • Based on individual circumstances, cisplatin is given on day 1 of each cycle during the entire treatment period ( 6 cycles total). 

Follow-up

Most side effects occurring during treatment are due to healthy organs included in the radiation field.

Radiation therapy to the pelvis may cause:

  • Diarrhea and abdominal pain
  • Nausea, which may be enhanced by chemotherapy
  • Fatigue 
  • Irritation of the bladder mucosa. This may cause symptoms resembling a urinary tract infection such as frequent urination, burning, pain, and light bleeding. 
  • Change in bone marrow
  • Vaginal mucosa may be dry and sore, and stenoses may occur in the vagina. 
  • Skin reactions are rare with the appropriate multiple field technique. If a skin reaction should occur, it is usually in the gluteal fold.  
    • Do no rub the skin area treated with radiation; instead, gently pat it dry.
    • Avoid using creams or lotions in the irradiated area.
    • Allow the skin to air-dry.
    • Use gel, if needed.

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