Factors Associated With Long-term Survival in Locally-Advanced Squamous Cell Carcinoma of the Vulva Treated With Definitive Radiation Therapy

Abstract

Purpose/Objective(s)To determine tumor and treatment factors associated with local and distant failure (LF and DF) and overall survival (OS) in patients treated with definitive radiation therapy for locally advanced vulvar carcinoma.Materials/MethodsRecords of all patients treated for squamous cell carcinoma of the vulva between 1980 and 2011 were reviewed. Eighty-eight patients were identified whose only vulvar treatment was radiation therapy (RT) +/- chemotherapy (CT) due primarily to unresectable disease or co-morbidities. A clinical estimate of FIGO (2009) T stage was determined with review of clinical and radiographic data. The median prescribed dose of RT to the vulva was 64 Gy (range, 30-82); 51% of patients received concurrent CT. Significant associations of clinical and pathological factors with LF in the vulva and groin, DF, and OS were evaluated using univariate and multivariate analyses. Long term toxicities were scored. The median follow-up was 20 months (range, 1-225) for all 88 patients and 29 months (range, 1-225) for 61 patients who were disease-free at last evaluation.ResultsThe median age of all 88 patients was 67 years (yrs, range, 37-91). Clinical FIGO stages were T1 (10%), T2 (65%), or T3 (25%); 70% had clinically positive inguinal nodes. The median tumor size was 5 cm (range, 1-18). The OS rate for all patients was 50% at 5 yrs. The LF rate in the vulva for all patients was 25% at 5 yrs. At 5 years, 6 patients who did not complete RT had a significantly higher risk of LF in the vulva (100%) versus 20% for patients who completed RT (p < 0.0001). The LF rate in the groin for all patients was 10% at 5 yrs. Groin LF was associated with large tumor size (HR 1.20, p = 0.04). Factors not significantly correlated with vulva or groin LF were FIGO T stage, grade, nodal status, vulva dose, and use of concurrent CT. The 5-year DF rate was correlated with tumor size (HR 1.20, p = 0.01). The DF rate was significantly lower in patients who received concurrent CT (6%) than in those treated with RT alone (26%, p = 0.01). OS at 5 years was correlated with RT completion (52% vs 0% for 6 patients who did not complete RT, p = 0.04), primary tumor size (HR 1.08, p = 0.06), and administration of concurrent CT (62% vs 30%; p = 0.01). Multivariate analysis showed primary tumor size and concurrent CT to be significant independent predictors of OS, with a trend for RT completion (p = 0.07). Patients with vulva or groin LF had the same median OS as those who had DF (16 months). The incidence of late grade 3 and 4 toxicities was 4% for gastrointestinal and 10% for genitourinary.ConclusionsLocally advanced tumors can be cured with high dose RT with low morbidity. Local failure is as poor a prognosticator as distant failure in this disease. Prognostic factors for RT-treated disease are different than surgically-treated disease. Concurrent CT warrants continued investigation. Purpose/Objective(s)To determine tumor and treatment factors associated with local and distant failure (LF and DF) and overall survival (OS) in patients treated with definitive radiation therapy for locally advanced vulvar carcinoma. To determine tumor and treatment factors associated with local and distant failure (LF and DF) and overall survival (OS) in patients treated with definitive radiation therapy for locally advanced vulvar carcinoma. Materials/MethodsRecords of all patients treated for squamous cell carcinoma of the vulva between 1980 and 2011 were reviewed. Eighty-eight patients were identified whose only vulvar treatment was radiation therapy (RT) +/- chemotherapy (CT) due primarily to unresectable disease or co-morbidities. A clinical estimate of FIGO (2009) T stage was determined with review of clinical and radiographic data. The median prescribed dose of RT to the vulva was 64 Gy (range, 30-82); 51% of patients received concurrent CT. Significant associations of clinical and pathological factors with LF in the vulva and groin, DF, and OS were evaluated using univariate and multivariate analyses. Long term toxicities were scored. The median follow-up was 20 months (range, 1-225) for all 88 patients and 29 months (range, 1-225) for 61 patients who were disease-free at last evaluation. Records of all patients treated for squamous cell carcinoma of the vulva between 1980 and 2011 were reviewed. Eighty-eight patients were identified whose only vulvar treatment was radiation therapy (RT) +/- chemotherapy (CT) due primarily to unresectable disease or co-morbidities. A clinical estimate of FIGO (2009) T stage was determined with review of clinical and radiographic data. The median prescribed dose of RT to the vulva was 64 Gy (range, 30-82); 51% of patients received concurrent CT. Significant associations of clinical and pathological factors with LF in the vulva and groin, DF, and OS were evaluated using univariate and multivariate analyses. Long term toxicities were scored. The median follow-up was 20 months (range, 1-225) for all 88 patients and 29 months (range, 1-225) for 61 patients who were disease-free at last evaluation. ResultsThe median age of all 88 patients was 67 years (yrs, range, 37-91). Clinical FIGO stages were T1 (10%), T2 (65%), or T3 (25%); 70% had clinically positive inguinal nodes. The median tumor size was 5 cm (range, 1-18). The OS rate for all patients was 50% at 5 yrs. The LF rate in the vulva for all patients was 25% at 5 yrs. At 5 years, 6 patients who did not complete RT had a significantly higher risk of LF in the vulva (100%) versus 20% for patients who completed RT (p < 0.0001). The LF rate in the groin for all patients was 10% at 5 yrs. Groin LF was associated with large tumor size (HR 1.20, p = 0.04). Factors not significantly correlated with vulva or groin LF were FIGO T stage, grade, nodal status, vulva dose, and use of concurrent CT. The 5-year DF rate was correlated with tumor size (HR 1.20, p = 0.01). The DF rate was significantly lower in patients who received concurrent CT (6%) than in those treated with RT alone (26%, p = 0.01). OS at 5 years was correlated with RT completion (52% vs 0% for 6 patients who did not complete RT, p = 0.04), primary tumor size (HR 1.08, p = 0.06), and administration of concurrent CT (62% vs 30%; p = 0.01). Multivariate analysis showed primary tumor size and concurrent CT to be significant independent predictors of OS, with a trend for RT completion (p = 0.07). Patients with vulva or groin LF had the same median OS as those who had DF (16 months). The incidence of late grade 3 and 4 toxicities was 4% for gastrointestinal and 10% for genitourinary. The median age of all 88 patients was 67 years (yrs, range, 37-91). Clinical FIGO stages were T1 (10%), T2 (65%), or T3 (25%); 70% had clinically positive inguinal nodes. The median tumor size was 5 cm (range, 1-18). The OS rate for all patients was 50% at 5 yrs. The LF rate in the vulva for all patients was 25% at 5 yrs. At 5 years, 6 patients who did not complete RT had a significantly higher risk of LF in the vulva (100%) versus 20% for patients who completed RT (p < 0.0001). The LF rate in the groin for all patients was 10% at 5 yrs. Groin LF was associated with large tumor size (HR 1.20, p = 0.04). Factors not significantly correlated with vulva or groin LF were FIGO T stage, grade, nodal status, vulva dose, and use of concurrent CT. The 5-year DF rate was correlated with tumor size (HR 1.20, p = 0.01). The DF rate was significantly lower in patients who received concurrent CT (6%) than in those treated with RT alone (26%, p = 0.01). OS at 5 years was correlated with RT completion (52% vs 0% for 6 patients who did not complete RT, p = 0.04), primary tumor size (HR 1.08, p = 0.06), and administration of concurrent CT (62% vs 30%; p = 0.01). Multivariate analysis showed primary tumor size and concurrent CT to be significant independent predictors of OS, with a trend for RT completion (p = 0.07). Patients with vulva or groin LF had the same median OS as those who had DF (16 months). The incidence of late grade 3 and 4 toxicities was 4% for gastrointestinal and 10% for genitourinary. ConclusionsLocally advanced tumors can be cured with high dose RT with low morbidity. Local failure is as poor a prognosticator as distant failure in this disease. Prognostic factors for RT-treated disease are different than surgically-treated disease. Concurrent CT warrants continued investigation. Locally advanced tumors can be cured with high dose RT with low morbidity. Local failure is as poor a prognosticator as distant failure in this disease. Prognostic factors for RT-treated disease are different than surgically-treated disease. Concurrent CT warrants continued investigation.