Adenocarcinoma of the Vulva

How would you treat a 66 year old patient with an adenocarcinoma of the vulva with apocrine features and advanced nodal metastasis (inguinal, pelvic, possibly chest) on PET scan. The vulvar lesion is resected, the inguinal nodes are biopsied.  Thank you very much.

Brigitte Miller

Response # 1:  
Stage IV disease- I would offer carbo/taxol chemo std doses q3weeks , 3 cycles and repeat imaging- if responding continue to 6 cycles. Depending upon extent of disease and response to chemo would then consider consolidation palliative  RT to pelvis

Mary McCormack

Response # 2:  
This is not easy and we really need to know if the lung lesions are genuine. What does CT show

You do not tell us PS or fitness, renal hepatic function or cardiac status and past health

Assuming this is unresectable and she is fit, I would probaly use my preferred schedule of cisplatin at 70 mg/m2 plus a four day infusionof 5FU at 750 mg/m2 per day. This is active in squamous vulva and potentially will work in adeno.

An alternative is ECF which covers a multitude of adenocarcinomas. I am sure someone will suggest carboplatin and paclitaxel.

You can irradiate the groins +/- pelvis at the completion

Nick Reed

Response # 3:  
The "possible" nodal mets in the chest is important, I think.  I would favor trying to prove whether the chest is involved.  If there are positive lymph nodes above the diaphragm, I would start with chemotherapy.  Depending upon the size of the pelvic lymph nodes it may be reasonable to treat the pelvis and inguinal regions with RT for local control only (palliative intent).  If there are no involved nodes above the diaphragm, I would favor inguinal node dissection then chemoradiotherapy.  The Homesly article (Obstet Gynecol 1986;68:733) showed a survival benefit for postoperative RT versus surgery for women with > 2 positive inguinal lymph nodes.  I would add chemotherapy extrapolating from the cervix data set.  The update of G0G 92 by Rotman et al (IJROBP 2006;25:1) showed a favorable response of adenocarcinoma compared to squamous histology in early cervix cancer so a reasonable response may be achieved.

Kind Regards,

Dave Gaffney

Response # 4:  
Hi Brigitte,

Can you confirm the distant metastasis ? If not I would probably treat with combined chemotherapy and radiotherapy.

William Small, Jr., MD, FACRO

Response # 5:  
In our experience:

Chest/Lung metastases: chemotherapy and lymphadenectomy or regional radiotherapy.

No lung metastases: inguinal and pelvic lymphadenectomy + pelvic and inguinal radiotherapy.

No lung metastases but not able to lymphadencetomy: Chemo-radiotherapy and evaluation of surgery as rescue after chrt

Good luck!

Andres Poveda