1. Mansoor Raza Mirza Dept. of Oncology Odense University Hospital Odense, Denmark Radiotherapy for Advanced Vulva Cancer

2. Stage III Tumor with adjacent spread to urethra, vagina or anus or with unilateral lymphnode metastases Stage IVa Tumor invades upper urethra, bladder mucosa, rectal mucosa or pelvic bone or bilateral node metastases Stage IVb Distant metastases Definition of Advanced Vulva Cancer

5. Randomized Controlled Trial - GOG Radiotherapy vs Surgery T 1-3 N 0-1 M 0 n=58 (27 in Rt arm) Radiotherapy: 50 Gy at 3cm Results: Groin recurrence 5/27 (18.5%) OS: 60% vs 86% Stehman FB et al., IJROBP, 1992; 24: 389-96

7. Stehman FB et al., IJROBP, 1992; 24: 389-96

8. Case control study Radiotherapy vs ‘wait and see’ T 1 N 0-1 M 0 n=135 (65 received Rt) Radiotherapy: 45Gy at 5cm telecobalt Results: Groin recurrence 3/65 (4.6%) OS: 93.7% vs 91.4% Manavi M et al., IJROBP, 1997; 38: 749-53

9. Manavi M et al., IJROBP, 1997; 38: 749-53

10. Observational T 1-3 N 0-3 M 0 n=68+18 LE+Rt 14; Rt 19+18; RV+Rt 24; PV+Rt 11 Radiotherapy: 50-70Gy at 4cm Results: Groin recurrence 10% OS: ? Perez CA et al., IJROBP, 1998; 42: 335-44

11. Perez CA et al., IJROBP, 1998; 42: 335-44

12. Stehman FB et al. Manavi M et al. Perez CA et al. Conclusions: Primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences compared with surgery. Surgery is still to be considered the cornerstone of therapy for the groin nodes. Van der Velden J, Ansink A, The Cochrane Database of Systemic Reviews

13. Retrospective analysis of one centre data 1980-1998 n=227 (stage III/VI 119; Stage I/II 67) LND 119; LND+Rt 57; Rt 51 Radiotherapy: narrow inguinal fields 45/50Gy or 60Gy Surgery: superficial LND Results: 5 yrs groin recurrence: 16% vs 13% vs 16% OS: ? Katz A et al., IJROBP, 2003; 57: 409-418

14. Preoperative chemo-radiation (GOG) T 3-4 or N 2-3 n=73+46 Radiotherapy: Split course 47,6Gy in 6-6.5 weeks Chemotherapy: Cis+5-Fu Response evaluation: 4-8 wks after end of treatment Results: Complete clinical remission 46.5% and 43% Moore DH et al., IJROBP, 1998; 42: 79-85 Montana GS et al., IJROBP, 2000; 48: 1007-13

15. Primary radical chemoradiotherapy 8 (15%) 53 (67%) 79 Total 17-37 7-81 5-75 2-52 7-60 N/A NED 1 1 1 2 0 3 Later relapse 6 (50%) 9 (64%) 8 (57%) 16 (89%) 8 (67%) 6 (67%) Complete Response 40-50 F,P 12 (II-1; III/IV-11) Eifel (Gynecol Oncol, 1995; 59: 51-6) 50-65 F,P 14 (III-9; IV-5) Cunningham (Gynecol Oncol, 1997; 66: 258-61) 34-63,1 F,P,M 14 (III-4; IV-10) Koh (Int J Radiat Oncol Biol Phys, 1993; 26: 809-16) 46,8-56 F,P,M 18 (II-1; III- 10; IV-6) Russell (Gynecol Oncol, 1992; 47: 14-20) 44-54 F,P 12 (III-8; IV-4) Berek (Gynecol Oncol, 1991; 42: 197-201) 40-64 F,M 9 (advanced) Thomas (Gynecol Oncol 1989;34:263–7) RT dose (Gy) Chemo- therapy N Stage (n) Author

16. Radical chemoradiotherapy for relapse Meta-analysis: Van Doorn et al. The Cochrane Library, issue 4, 2002, Oxford 1 12 (55%) 22 Total 2-35 N/A NED 1 0 Latter relapse 4 8 Complete response 54-72 F,P 7 Russell (Gynecol Oncol, 1992; 47: 14-20) 40-64 F,M 15 Thomas (Gynecol Oncol 1989;34:263–7) RT dose (Gy) Chemo-therpy N Author

17. The NSGO trial NSGO – CC – 0301 FIGO III & IV or unfavourably located lesion or relapsed vulvar cancer Locoregional Radiotherapy with Concomitant chemoterapy Surgical resection of any residual disease Surgical resection of local tumor if possible

19. Adequate target volume

20. Adequate target volume

21. Necessary depth

22. Concomitant weekly cisplatin 40 mg/m2 Concomitant radio-chemotherapy

23. 12 weeks after end of treatment When to evaluate results

24. Dept. of Oncology Odense University Hospital Odense, Denmark Thank you