Perez C A, Grigsby P W, Chao C, Galakatos A, Garipagaoglu M, Mutch D, Lockett M A
Radiation Oncology Center, Mallinckrodt Institute of Radiology, Washington University Medical Center, St. Louis, MO, USA.
Int J Radiat Oncol Biol Phys. 1998 Sep 1;42(2):335-44. doi: 10.1016/s0360-3016(98)00238-7.
This report reviews the increasing role of radiation therapy in the management of patients with histologically confirmed vulvar carcinoma, based on a retrospective analysis of 68 patients with primary disease (2 in situ and 66 invasive) and 18 patients with recurrent tumor treated with irradiation alone or combined with surgery.
Of the patients with primary tumors, 14 were treated with wide local excision plus irradiation, 19 received irradiation alone after biopsy, 24 were treated with radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes, and 11 received postoperative irradiation after partial or simple vulvectomy. The 18 patients with recurrent tumors were treated with irradiation alone. Indications and techniques of irradiation are discussed in detail.
In patients treated with biopsy/local excision and irradiation, local tumor control was 92% to 100% in Stages T1-3N0, 40% in similar stages with N1-3, and 27% in recurrent tumors. In patients treated with partial/radical vulvectomy and irradiation, primary tumor control was 90% in patients with T1-3 tumors and any nodal stage, 33% in patients with any T stage and N3 lymph nodes, and 66% with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for T1N0, 62% for T2-3N0, 30% for T1-3N1 disease, and 11 % for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 tumors. Four of 18 patients (22%) treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and irradiation. In patients with T1-2 tumors treated with biopsy/wide tumor excision and irradiation with doses under 50 Gy, local tumor control was 75% (3 of 4), in contrast to 100% (13 of 13) with 50.1 to 65 Gy. In patients with T3-4 tumors treated with local wide excision and irradiation, tumor control was 0% with doses below 50 Gy (3 patients) and 63% (7 of 11) with 50.1 to 65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and irradiation, local tumor control was 83% (14 of 17), regardless of dose level, and in T3-4 tumors, it was 62% (5 of 8) with 50 to 60 Gy and 80% (8 of 10) with doses higher than 60 Gy. The differences are not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes; doses of 50 Gy were adequate for elective treatment of nonpalpable lymph nodes, and 60 to 70 Gy controlled tumor growth in 75% to 80% of patients with N2-3 nodes when administered postoperatively after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess.
Irradiation is playing a greater role in the management of patients with carcinoma of the vulva; combined with wide local tumor excision or used alone in T1-2 tumors, it is an alternative treatment to radical vulvectomy, with significantly less morbidity. Postradical vulvectomy irradiation in locally advanced tumors improves tumor control at the primary site and the regional lymphatics in comparison with reports of surgery alone.
基于对68例原发性疾病患者（2例原位癌和66例浸润癌）以及18例仅接受放疗或联合手术治疗的复发性肿瘤患者的回顾性分析，本报告综述了放射治疗在外阴癌组织学确诊患者管理中的作用日益增加。
在原发性肿瘤患者中，14例接受了广泛局部切除加放疗，19例活检后仅接受放疗，24例接受根治性外阴切除，随后对手术区域及腹股沟-股部/盆腔淋巴结进行放疗，11例在部分或单纯外阴切除术后接受术后放疗。18例复发性肿瘤患者仅接受放疗。详细讨论了放疗的适应证和技术。
在接受活检/局部切除及放疗的患者中，T1 - 3N0期局部肿瘤控制率为92%至100%，N1 - 3期类似阶段为40%，复发性肿瘤为27%。在接受部分/根治性外阴切除及放疗的患者中，T1 - 3肿瘤且任何淋巴结分期的患者原发性肿瘤控制率为90%，任何T分期且N3淋巴结患者为33%，复发性肿瘤患者为66%。精算5年无病生存率，T1N0为87%，T2 - 3N0为62%，T1 - 3N1疾病为30%，复发性肿瘤患者为11%；T4或N2 - 3肿瘤无长期存活者。18例接受外阴切除术后复发性疾病治疗的患者中（22%），4例在局部肿瘤切除及放疗后仍无疾病复发。在接受活检/广泛肿瘤切除及放疗且剂量低于50 Gy的T1 - 2肿瘤患者中，局部肿瘤控制率为75%（4例中的3例），而剂量为50.1至65 Gy时为100%（13例中的13例）。在接受局部广泛切除及放疗的T3 - 4肿瘤患者中，剂量低于50 Gy时肿瘤控制率为0%（3例患者），50.1至65 Gy时为63%（11例中的7例）。在接受部分/根治性外阴切除及放疗的T1 - 2肿瘤患者中，无论剂量水平如何，局部肿瘤控制率为83%（17例中的14例），在T3 - 4肿瘤患者中，50至60 Gy时为62%（8例中的5例），剂量高于60 Gy时为80%（10例中的8例）。差异无统计学意义。腹股沟-股部淋巴结的肿瘤控制无明显剂量反应；50 Gy的剂量足以对不可触及的淋巴结进行选择性治疗，60至70 Gy在部分或根治性淋巴结清扫术后给予时，可使75%至80%的N2 - 3淋巴结患者的肿瘤生长得到控制。显著的治疗并发症包括1例直肠阴道瘘、1例直肠炎、1例直肠狭窄、4例骨/皮肤坏死、4例阴道坏死和1例腹股沟脓肿。
放疗在外阴癌患者的管理中发挥着越来越大的作用；与广泛局部肿瘤切除联合或用于T1 - 2肿瘤单独治疗时，它是根治性外阴切除的替代治疗方法，并发症明显较少。与单纯手术报告相比，局部晚期肿瘤根治性外阴切除术后放疗可改善原发部位和区域淋巴结的肿瘤控制。
