Primary groin irradiation versus primary groin surgery for early vulvar cancer

Background

Despite changes in technique, morbidity after surgery for vulvar cancer is high and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy to the groin in terms of groin recurrences and survival show conflicting results.

Objectives

To determine whether the effectiveness and safety of primary radiotherapy to the inguino-femoral lymph nodes is comparable with surgery.

Search strategy

The Cochrane Gynaecological Cancer Group Specialized Register and the Cochrane Central Register of Controlled Trials (CENTRALl) were searched using the criteria set by the Cochrane Gynaecological Cancer Group (The Cochrane Library Issue 4, 2006). A MEDLINE (1966 to 2006) and EMBASE (1988 to 2006) search using the Mesh Heading ´vulvar neoplasms´ and textword ´vulva´ was performed. Publications on the effectiveness of primary radiotherapy treatment of early squamous cell carcinoma of the vulva were selected.

Selection criteria

Randomized clinical trials (RCTs), case-control and observational studies comparing inguino-femoral lymph node dissection and primary radiotherapy of the inguino-femoral lymph nodes in patients with early squamous cell cancer of the vulva.

Outcome measures were incidence of groin recurrences, survival and morbidity.

Data collection and analysis

Two authors independently assessed study quality and extracted results.

Main results

Out of nine identified papers only three met the selection criteria. From these studies (RCT, one case-control and one observational study) it became clear from the RCT that the incidence of groin recurrences after primary radiotherapy is higher compared with surgery. Survival was also worse in the radiotherapy group. The other two studies showed a higher than expected number of groin recurrences after primary radiotherapy. Morbidity after primary radiotherapy was lower compared with surgery. The conclusion of the RCT was criticized on the grounds of the depth of the radiotherapy administered. The depth of three centimetres used in the RCT, is too shallow to administer an optimal dose to the deeper groin nodes.

Authors' conclusions

As shown in the RCT (Stehman 1992), primary radiotherapy to the groin results in less morbidity but also in a higher number of groin recurrences compared with surgery. Although the technique of radiotherapy in the RCT was criticized, other uncontrolled data do not give evidence for a similar or better groin control for radiotherapy when compared to surgery. This means that surgery is still to be considered the first choice treatment for the groin nodes in women with vulvar cancer. Individual patients not physically able to withstand surgery can be treated with primary radiotherapy.