Brachytherapy - (2017) -

Brachytherapy as part of the conservative treatment for primary and

recurrent vulvar carcinoma
P. Castelnau-Marchand1, A. Escande1, R. Mazeron1, E. Bentivegna2, A. Cavalcanti2, S. Gouy2,
C. Baratiny1, P. Maroun1, P. Morice2, C. Haie-Meder1, C. Chargari1,3,4,*
1
Brachytherapy Unit, Radiation Oncology, Gustave Roussy, University Paris Saclay, Villejuif, France
2
Department of Surgery, Gustave Roussy, University Paris Saclay, Villejuif, France
3
French Military Health Services Academy, Paris, France
4
Institut de Recherche Biomedicale des Armees, Bretigny sur Orge, France

ABSTRACT PURPOSE: There are only scarce data on the place of brachytherapy (BT) for treatment of vulvar
carcinoma. Our institutional experience of interstitial BT for vulvar carcinoma patients is reported.
METHODS AND MATERIALS: Clinical records of patients receiving low-dose-rate or pulsed-
dose-rate BT as part of the primary treatment for primary/recurrent vulvar squamous cell carcinoma
or as part of postoperative treatment between 2000 and 2015 were included. Patients, tumors, and
treatment characteristics as well as clinical outcome were examined.
RESULTS: A total of 26 patients treated with BT were identified. BT was delivered as part of pri-
mary intent treatment for locally advanced/recurrent cancer in 11 patients and as part of postoper-
ative treatment in 15 patients. Median age at time of BT was 63 years (range, 41e88 years). Pulsed-
dose-rate and low-dose-rate were used in 15 patients and 11 patients, respectively. BT was per-
formed as a boost to the tumor bed following external beam radiotherapy (n 5 13) or as the sole
irradiation modality (n 5 13). Total median dose at the level of primary tumor was 60 GyEQD2
(range, 55e60 GyEQD2). With mean followup of 41 months (range, 5 monthse11.3 years), 11 pa-
tients experienced tumor relapse, and in two of them, site of relapse was only local. Three-year esti-
mated disease-free survival and overall survival rates were 57% (95% confidence interval: 45e
69%) and 81% (95% confidence interval: 72e90%), respectively. All toxicities were Grade 2 or
less.
CONCLUSIONS: Interstitial BT used as part of the primary or postoperative treatment of vulvar
carcinoma is feasible with a satisfactory toxicity profile. Prognosis remains, however, dismal, with a
high frequency of failures in patients with locally advanced tumors. Ó 2017 American Brachyther-
apy Society. Published by Elsevier Inc. All rights reserved.
Keywords: Brachytherapy; Vulvar carcinoma; Pulse dose rate; Low dose rate

Introduction ranges from excision or partial vulvectomy to radical vul-

Vulvar carcinoma is a rare cancer, accounting for
approximately 4% of all gynecologic tumors, but with
increasing incidence over the past 40 years (1e4). The pri-
mary intent treatment is surgery, with a radicality that
Received 13 November 2016; received in revised form 22 December
2016; accepted 12 January 2017.
Financial disclosure: The authors declare no conflict of interest relative
to this work.
* Corresponding author. Gustave Roussy Cancer Campus, 114, rue
Edouard Vaillant, 94805 Villejuif Cedex, France. Tel.: þ 33-1-42-11-45-
66; fax: þ 33-1-42-11-52-08.
E-mail address: cyrus.chargari@gustaveroussy.fr (C. Chargari).
1538-4721/$ - see front matter Ó 2017 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.brachy.2017.01.005
vectomy, depending on the tumor extent (5). Approxi-
mately 60% of vulvar cancers are diagnosed at an
advanced stage, when a conservative surgery cannot be per-
formed, because of frequent extension toward adjacent
perineal structures, including the lower vagina (1, 3, 6).
Radiotherapy has an important role in the primary, adju-
vant, or salvage treatment of patients who are not candi-
dates for surgery or who decline it. However, the vulvar,
vaginal, and perineal toxicities associated with external
beam radiotherapy (EBRT) are significant concerns and
limitations to this conservative strategy (3e5).
There are only scarce data on the place of brachytherapy
(BT) for treatment of vulvar carcinoma. Few retrospective
studies with vulvovaginal tumors suggested that BT could
2 P. Castelnau-Marchand et al. / Brachytherapy - (2017) -

be incorporated as part of the radiotherapeutic management
of these patients, either as a boost to the tumor after EBRT
or as sole irradiation modality. But most of these studies
had only a very low number of patients after excluding pri-
mary vaginal cancers (7e9).
We report our 15-year institutional experience of inter-
stitial BT for vulvar carcinoma patients. Patterns of relapse
and toxicities were examined.
Methods and materials
Inclusion criteria
Clinical records of patients treated in our institution and
receiving BT as part of the treatment of a histologically
proven primary or recurrent vulvar carcinoma between
2000 and 2015 were examined. Patients with sarcoma or
melanoma histology were not included. Patients and treat-
ments characteristics (previous surgery, EBRT technique,
BT characteristics) as well as treatment outcomes were
examined. The study was conducted in accordance with
the Helsinki Declaration.
coverage of target volumes. If required for adequate target
coverage, exterior surface needles could be used. Needles
were secondarily replaced by connecting plastic tubes
(Fig. 1).
For treatment planning, computed tomography scans
were acquired in the supine position, slice thickness
1.5 mm. Axial images were imported to the Plato BPS
treatment planning system (Nucletron, Veenendaal, The
Netherlands), and a three-dimensional set was recon-
structed. Before 2007, low-dose-rate (LDR) BT was used,
through 192Ir wires. From 2007, treatments were delivered
using pulsed dose rate (PDR) with 192Ir stepping sources.
Length of activation (for LDR treatment) or dwell positions
(for PDR treatments) in the implant catheters were chosen
depending on the clinical target volume to be treated. Doses
were prescribed at the reference isodose (85% of the min-
imal dose rate between the planes), according to the Paris

BT indications
Primary intent local treatment for vulvar carcinoma was
surgery consisting of partial vulvectomy or radical vulvec-
tomy with at least 0.8 cm margins. BT was delivered in two
indications:
(1) Patients who had a primary or recurrent locally
advanced vulvar carcinoma and who were not eligible for
a primary intent radical surgery (because of contraindica-
tion, patients refusal, or local extension requiring muti-
lating surgery) received EBRT to the vulva, groins, and
pelvic lymph nodes, then a BT boost. In case of pelvic
and/or inguinal nodal metastases, a concurrent chemo-
therapy could be delivered, depending on the patient’s gen-
eral medical condition.
(2) Patients who underwent a primary surgery and who
had an indication for postoperative treatment because of
microscopically involved margins (R1 margins) received
an adjuvant BT, alone or combined with EBRT (in case
of nodal metastases at lymph node dissection).

BT procedure
BT procedure was performed under general anesthesia
and consisted of a perineal interstitial implantation,
following the Paris system rules. In case of extension to
the lower part of the vagina, the vaginal mold technique
could be also used in combination with interstitial implan-
tation. The target volume encompassed the gross tumor vol-
ume (or the tumor bed in case of postoperative BT) plus a
safety margin ranging from 5 to 10 mm. The distance be-
tween needles varied between 12 and 16 mm, and the num-
ber of needles was determined to allow an adequate
Fig. 1. Illustration of an implantation for a vulvar cancer treated with
pulse-dose-rate brachytherapy. The patient presented with a bulky vulvar
cancer at diagnosis measuring more than 8 cm in greatest dimension,
involving the whole vulva. She had an excellent response to chemoradia-
tion (45 Gy in 25 fractions) but persistence of a multifocal residual disease.
A perineal interstitial implantation was done to cover the residual disease,
following the rules of parallelism between needles, then needles were re-
placed by plastic tubes. A total of four catheters in two planes were used,
including one catheter for plesiotherapy to appropriately cover the largest
tumor residue. A plastic template was used to maintain the geometry of
implant.
 P. Castelnau-Marchand et al. / Brachytherapy - (2017) - 3

system rules, and were reported after conversion into radio-
biologically weighted dose equivalent of 2 Gy/fraction (a/
b 5 10 Gy for tumor, half-time of 1.5 h). Dose rate was
kept below 10 Gy/d. For PDR treatments, hourly pulses
were used, 0.42 Gy per pulse (Fig. 2).
Followup and analysis
Followup was scheduled at 6e8 weeks after BT comple-
tion, then every 3 months during 2 years, then every
6 months during 3 years. Complications were prospectively
registered at each followup and retrospectively scored ac-
cording to the Common Terminology Criteria for Adverse
Events version 4. Acute toxicities were examined. Late
toxicity was defined as any toxicity occurring later than
6 months after BT. Failures were defined as persistent or
recurrent disease after followup of more than 3 months.
First sites of relapse were considered and classified into:
local (vulvar), regional (pelvic and/or inguinal nodal), or
distant (including para-aortic nodal failures). Disease-free
survival (DFS) and overall survival (OS) were estimated us-
ing KaplaneMeier method. Univariate analysis was per-
formed to estimate OS and DFS risk according to initial
nodal involvement status. Times were calculated from treat-
ment completion. Analyses were performed using
Statistical Package for the Social Sciences (SPSS Inc,
IBM company, Chicago).
Results
Patients and tumors
A total of 26 patients treated with BT were identified.
Eleven received BT as part of treatment of primary
(n 5 8)/recurrent (n 5 3) locally advanced disease, and
15 received BT as part of postoperative treatment.
Median age at time of BT was 63 years (range, 41e
88 years). All patients had a performance status of 0e1.
Tumor stages according to the International Federation
of Gynecology and Obstetrics (10) were as follows:
Stage I in 5 patients (tumor confined to the vulva or
perineum, negative nodes), Stage II in 8 patients (adjacent
spread, negative nodes), Stage III in 9 patients (positive
inguinal or pelvic nodes), Stage IVA in 1 patient
(tumor invading the regional structures, including the 2/3
upper vagina). Three patients who underwent surgery were
referred for treatment at time of relapse alone, and in this
situation, tumors were not staged according to FIGO.
All patients had SCC histology, well differentiated in 18,
moderately differentiated in 3, and poorly differentiated in

Fig. 2. Dosimetric process (from case described in Fig. 1). (a) Four catheters are digitized. Step source positions are activated to appropriately cover the
clinical target volume (in brown). A set of basal points is defined on the central plane (in blue). These points are the points with the minimal dose rate be-
tween the sources, inside the implanted volume. In yellow is digitized a gold seed placed inside the largest tumor residue. (b) Dose distribution. A dose of
15 Gy is prescribed at the reference isodose (85% of the basal isodose). The reference isodose is shown in yellow, in sagittal (left) or coronal view (right).
4 P. Castelnau-Marchand et al. / Brachytherapy - (2017) -

5. Median tumor greatest dimension was 4.1 cm (range, 1e External beam radiotherapy
8 cm).
Sixteen patients received EBRT (7 treated with radical
A total of 10 of 26 (36%) patients had lymph node
EBRT and 9 receiving postoperative EBRT). In all cases,
extension (5 diagnosed by surgery and 5 by imaging modal-
clinical target volumes included pelvic lymph nodes and
ities): 6 had unilateral inguinal lymph node involvement
bilateral groins. In 13 of them, EBRT fields also included
(including 1 patient with micrometastasis), 3 had bilateral
the vulva. Median dose to the pelvis and vulva was
inguinal lymph node metastases, and 1 had bilateral iliac
45 Gy (range 30e45 Gy) given in daily fractions, median
lymph node metastases.
dose of 1.8 Gy (range, 1.8 to 2 Gy) per fraction. Seven pa-
Patients and tumors characteristics are shown in Table 1.
tients received EBRT boost to macroscopically involved
lymph nodes, at total median target dose of 60 GyEQD2
Surgery (range 50e65 GyEQD2).
EBRT was delivered with photons from Cobalt machine
Eighteen patients (69%) had undergone vulvar surgery,
in 1 patient (two-dimensional technique). All the remaining
consisting of hemivulvectomy (n 5 11) or total vulvectomy
patients were treated with high megavoltage photons from
(n 5 7), including the 3 patients referred for relapse. Resec-
linear accelerator. Ten patients received conformal EBRT,
tion margins were microscopically involved in 17 of 18 pa-
and 5 patients received intensity-modulated radiotherapy.
tients (94%). Reoperation was performed in 4 of 17, with
Concurrent chemotherapy was delivered in 4 patients,
still microscopically involved margins in two of them. A to-
weekly cisplatin 40 mg/m2.
tal of 15 patients had microscopically incomplete margins
after definitive surgery.
Inguinal lymphadenectomy was performed in 15 pa- BT characteristics
tients, and 1 additional patient underwent a sentinel lymph All patients received interstitial BT. Interstitial BT was
node procedure. After surgical lymph node staging, 5 of 15 combined with endocavitary BT in 7 patients. PDR and
patients (33%) had histologically proven lymph node LDR were used in 15 patients and 11 patients, respectively.
metastases. BT was performed as a boost to the tumor bed following
EBRT in 13 patients (50%), median BT dose of 15
Table 1 GyEQD2 (range, 15e32.5 GyEQD2), to deliver a total dose
Patient and tumor characteristics of 60 GyEQD2 to the primary tumor taking into account the
Characteristics Total contribution of EBRT.
Number of patients 26 BT was given as the only irradiation modality to treat the
Performance status vulva in 13 patients (50%), median dose of 60 GyEQD2
0 16 (range, 55e60 GyEQD2). BT parameters are detailed in
1 10 Table 2.
Median age in years (range) 63 (41e88)
Differentiation
Well 18 Outcome
Intermediate 3
Poor 5 Mean followup was 41 months (range: 5 monthse
Largest dimension in mm (range) 41 (10e80) 11.3 years). At last followup, 11 patients (42%) experi-
FIGO staging enced tumor relapse with a median time interval of
I 5 6 months (range: 1.5 months to 3.9 years). A total of 10 pa-
II 8
III 9
tients experienced local relapse as first event (38% of total).
IVA 1 Local relapse was associated with synchronous extravulvar
Relapsed tumor 3 events in 8 of 10 patients, either regional (n 5 4), distant
Lymph node involvement (n 5 2), or both (n 5 2). Two patients with local relapse
None 16 only were salvaged by surgery and remain disease free after
Unilateral inguinal 6
Bilateral inguinal 3
22- and 77-month followup (Table 3).
Bilateral iliac 1 In details, among the 8 patients receiving BT as part of
Tumor extensiona primary treatment, four experienced local relapse, associ-
Labia only 2 ated in three of them with extravulvar failure (distant me-
Labia þ vagina 2 tastases in 2 patients and pelvic lymph node failure in 1
Labia þ clitoris 1
Labia þ clitoris þ vagina 1
patient). Among 3 patients treated at time of relapse, one
Vulvar fourchette þ vagina 2 experienced a second local failure, associated with pelvic
Vulvar fourchette þ para-anal 2 nodal failure, and another one experienced only distant fail-
Vulvar fourchette þ para-anal þ vagina 1 ure. Among 15 patients receiving a postoperative treatment,
No macroscopic residue (postoperative) 15 five experienced local failure, associated in four cases with
a
At the time of brachytherapy. distant events.
 P. Castelnau-Marchand et al. / Brachytherapy - (2017) - 5

Table 2 Table 3
Characteristics of treatments Clinical outcome
Indication n 5 26 Parameters n 5 26
Primary treatment 8
Median followup 41 months (5 months to 11.3 years)
Recurrent tumor 3 Total number of relapses 11 (42%)
Postoperative treatment 15 Vulvar only 2 (8%)
Surgery 18 Vulvar þ regional 4 (15%)
Number of surgical procedures
Vulvar þ metastatic 2 (8%)
1 14 Vulvar þ regional þ metastatic 2 (8%)
2 2 Metastatic only 1 (3%)
$3 2
Radicality
Hemivulvectomy 11
significant for DFS or OS in log-rank analysis (tested fac-
Radical vulvectomy 7
Definitive margins tors: lymph node status, tumor size, age).
Microscopically complete 3
Microscopically incomplete 15 Toxicity
Inguinal lymphadenectomy performed 15 (5)
(if yes: number of patients with pNþ) Acute toxicities, all of Grades 1e2, were encountered by
External beam radiotherapy (EBRT) 16 21 patients. A total of 16 patients without local relapse
Target volume
Pelvic lymph node and groins 16
were assessable for long-term toxicity. At last followup,
Pelvic lymph nodes, groins, and vulva 13 cutaneous late toxicities, all of Grade #2, were encoun-
Boost to macroscopic lymph nodes 7 tered by 5 patients (telangiectasia and/or vulvar pruritus).
Modality Three patients had Grade 2 late vaginal side effects: steno-
2D 1 sis (n 5 1), dyspareunia (n 5 1), and necrosis not requiring
3D conformal 10
Intensity-modulated radiotherapy 5
surgical treatment (n 5 1). Two patients who underwent
Concomitant chemotherapy 4 surgery as part of the oncologic treatments and who were
Brachytherapy (BT) 26 aged 88 and 90 years old at last followup, complained with
Treatment combination Grade 2 urinary dribbling, including one presenting also
Exclusive BT 1 Grade 2 fecal incontinence. No Grade 3 or higher delayed
BT þ EBRT 7
BT þ surgery 9
toxicity was encountered.
BT þ surgery þ EBRT 9
Sequence
Exclusive vulvar treatment 13 Discussion
Boost after vulvar EBRT 13
EQD2 median dose The very low incidence of vulvar cancer and the paucity of
15 Gy (boost) 9
data available in the literature make the optimal treatment of
25e30 Gy (boost) 4
55e60 Gy (exclusive vulvar treatment) 13 vulvar carcinoma uncertain, based on retrospective studies
Technique (8, 9, 11e14). Moreover, most patients are elderly and diag-
Interstitial 19 nosed at an advanced stage of the disease (15). Radical sur-
Interstitial þ endocavitary 7 gery is usually considered to be the standard upfront
Modality
treatment for tumors that are amenable to wide radical tumor
Pulsed dose rate 15
Low dose rate 11 excision, and radiotherapy has been proposed as a curative-
Dosimetric parameters
Median number of planes (range) 1 (1e2)
Median number of catheters (range) 3 (2e7)
Median treated volume in cc (range) 33 (4e362)
Median TRAK (range) 1.86 (0.23e12.4)
Median dose per day for LDR (range) 7.8 (5e20)
Number of pulses for PDR (range) 110 (45e150)
Median dose per pulse for PDR (range) 0.4 (0.4e0.5)
LDR 5 low dose rate; PDR 5 pulsed dose rate; TRAK 5 total refer-
ence air kerma; 2D 5 two dimensional; 3D 5 three dimensional.

At last followup, 16 patients were alive without disease,

4 were alive with progressive disease, and 6 had died (4 of
cancer cause). At 3 years, estimated DFS was 57% (95%
confidence interval [CI]: 45e69%) and OS was 81%
(95% CI: 72e90%) (Fig. 3). No prognostic factor was Fig. 3. KaplaneMeier estimated survival curves.
6 P. Castelnau-Marchand et al. / Brachytherapy
intent alternative to surgery for patients who are contraindi-
cated for surgery because of comorbidities or who refuse
radical vulvectomy. The use of primary radiation for locally
advanced vulvar cancer has dramatically increased over the
past 20 years. An exploration of SEER data showed an in-
crease from 18% to 30% from 1988 to 2008 (16). In 1998,
a Phase II study of the Gynecologic Oncology Group has
shown that a preoperative chemoradiotherapy decreased
the need for a more radical surgery, including pelvic exenter-
ation, in patients with T3eT4 tumor not amenable to stan-
dard radical vulvectomy because of tumor bulk (17). In a
series reported by Boronow et al. (18), 42.5% of the patients
undergoing surgery after neoadjuvant irradiation had no ev-
idence of tumor on vulvectomy specimen. In the Canadian
studies, 48% of the patients had complete clinical response
after neoadjuvant chemoradiotherapy, and 71% of them
had no sign of residual disease in the resected specimen
(19). Surgery has therefore been abandoned in patients expe-
riencing complete response, and EBRT  concurrent chemo-
therapy is now delivered as exclusive primary intent
treatment in locally advanced tumors (16, 20).
Another indication of radiotherapy is the adjuvant
setting, to reduce the risk of locoregional recurrence in pa-
tients with marginal resection or lymph node metastases.
Although the optimal dose to be delivered remains uncer-
tain, retrospective data suggest that doses $56 Gy are asso-
ciated with a decrease in the risk of vulvar recurrence (21).
According to 2016 guidelines of National Cancer Compre-
hensive Network, patients with lymph node metastases in
the groin are also indicated for postoperative irradiation
of bilateral groin and pelvic lymph nodes (22). Homesley
et al. (23) reported an improvement in the 2-year survival
in patients with positive groin nodes receiving postopera-
tive radiotherapy to the groins and pelvic nodes, compared
to that those treated with only lymph node dissection.
There are only few reports on the possibility to perform
interstitial BT as part of the primary treatment or adjuvant
treatment of vulvar carcinoma, and most of those used
LDR. Pohar et al. examined the outcome of 34 patients
treated with LDR-BT for a vulvar cancer on an 18-year
time interval and treated for initial (n 5 21) or recurrent
disease (n 5 13). At 5 years, estimated local control rate
was 47% (95% CI: 23e73%), and estimated actuarial OS
was 29% (95% CI: 15e49%). Probability of local control
at 5 year was higher in patients treated at first presentation
(80 vs. 19%, p 5 0.04) (8). Tewari et al. performed a multi-
center retrospective analysis of 11 patients receiving inter-
stitial BT with (n 5 5) or without (n 5 6) EBRT for locally
advanced (n 5 5) or recurrent (n 5 6) vulvar carcinoma.
Local control was achieved in all patients, but 10 of 11 pa-
tients died of cancer at a mean interval of 33 months from
the time of treatment. Two patients experienced local ne-
crosis, and 1 had rectovaginal fistula (9). More recently,
 ˛ czka et al. (14) published the results of high
Kellas-Sle
dose-rate (HDR) BT for locally advanced primary
(n 5 6) or recurrent after surgery vulvar cancer (n 5 8).
- (2017) -
Estimated 1-year PFS rate was 33%. Authors concluded
that HDR-BT was effective for locally advanced or recur-
rent vulvar cancer as option modality in selected patients.
The largest experience of HDR-BT was recently published
by Mahantshetty et al., who reported on the outcome of 38
patients receiving definitive radiation (n 5 29), postopera-
tive BT (n 5 6), or salvage treatment (n 5 3). With a me-
dian followup of 30 months, 29 patients (76.3%) were
disease free. At 5 years, estimated disease-free survival
and local control rates were 51% and 77%, respectively
(24).
Very few data are available for PDR, which combines
the theoretical properties of LDR-BT and the advantages
of HDR-BT for radioprotection. Seeger et al. published
the results of interstitial PDR-BT in 22 patients with vulvo-
vaginal malignancies treated with or without EBRT,
including 9 patients with vulvar cancer. The median total
dose of PDR-BT administered to patients with vulvar carci-
noma was 55 Gy. Complete remission at 6 months was
achieved in 7 of 9 patients with vulvar cancer. The main
pattern of relapse was regional or distant failure, reported
in 6 of 9 patients (25). In the present cohort of patients,
we report a 62% local control rate, which is in the range
of local control rates observed in the literature with very
advanced tumors (half of patients had stage IIIeIVA or
recurrent disease, and more than one-third had nodal metas-
tases) (26). Lataifeh et al. have reported on 55 patients
treated for stage IIIeIVA disease and undergoing surgery
 postoperative EBRT. Recurrences in the vulva were re-
ported in 25 patients (45.5%) (27). However, it is difficult
to compare with surgical series because most frequently,
BT was proposed when surgery was contraindicated
because of local tumor burden or because of high morbidity
probability. Another issue is that for postoperative indica-
tions (15 of 26 patients in our series), the definition of
target volume is more difficult than when treatment is
delivered as primary intent, with a growth tumor volume
easier to define clinically. This might account for the
observed frequency of local recurrences. Although this is
one of the largest series of patients with vulvar carcinoma
treated with BT, it suffers from the same biases noted on
previous reports on BT; specifically, low patient numbers
and the heterogeneity of clinical presentations and treat-
ments delivered. Indeed, treatments were individualized
to the tumors characteristics, resulting in various therapeu-
tic modalities implemented within few case series, which
does not allow us to draw definitive conclusions on the
optimal management for locally advanced disease. In our
experience, all patients were treated with curative intent,
but according to various indications: primary treatment
(n 5 8), recurrent tumor (n 5 3), or postoperative irradia-
tion (n 5 15). Although the outcome of patients was poor,
there were long-term survivors, including patients who
were treated for locally advanced disease and the 2 patients
who experienced local failure only were salvaged with
radical surgery.
 P. Castelnau-Marchand et al. / Brachytherapy
The finding that most patients with recurrence experi-
enced distant failures highlights the need to improve the
primary staging and management of regional nodal metas-
tases, as part of a multimodal strategy involving surgical in-
guinofemoral node dissection or sentinel procedure (28,
29). In our experience, the impact of lymph node extension
on outcome did not reach statistical significance in log-rank
analysis, but this is certainly due to limitation of numbers.
In fact, groin node invasion is an important prognostic fac-
tor of survival, and a study has shown that inguinal lympha-
denectomy performed during vulvectomy was superior to
primary radiotherapy of inguinal area, in terms of groin re-
lapses (30). Intensifying the systemic treatment can also be
an option, but it should be kept in mind that patients fol-
lowed for vulvar cancer are often old and vulnerable, which
can limit treatment options.
The advantages of BT are to deliver a highly focused
dose in a short overall treatment time, allowing for the de-
livery of curative intent irradiation doses while relatively
sparing organs at risk from irradiation, which is a signifi-
cant concern in the elderly. Low toxicity rates were
observed in this study, with no patient presenting acute or
late Grade O2 toxicity, despite bulky tumors and conse-
quently bulky volumes implanted. This is potentially a
result of a particular attention paid to implantation and
dosimetry procedures, based on Paris system, and also of
a dose rate which did not exceed 10 Gy per day (7, 31).
Therefore, PDR-BT as part of multimodal treatment of
vulvar carcinoma seems to be an adequate alternative to
LDR-BT in this rare situation of vulvar cancer, with accept-
able acute and delayed toxicity rates. However, it should be
highlighted that these patients, all treated in a Comprehen-
sive Cancer Center, represent a selected cohort of patients
whose tumors characteristics have made them good candi-
dates for BT to have no observed Grade 3 toxicities in the
26 cases reported. The risk of severe toxicity could be high-
er in poorly selected patients.
Conclusion
Our results suggest that interstitial BT can be used as
part of the primary or adjuvant treatment of vulvar carci-
noma and is associated with a satisfactory toxicity profile.
However, prognosis of patients remains poor, and most pa-
tients experiencing local recurrence had also synchronous
distant failure. The therapeutic management of vulvar car-
cinoma should remains multidisciplinary, as part of a multi-
modal strategy.
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