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Patterns of treatment failure in patients undergoing adjuvant or definitive radiotherapy for vulvar cancer
  1. Christina Steen Vorbeck1,
  2. Anuja Jhingran2,
  3. Revathy B Iyer3,
  4. Annika Loft4,
  5. Ann Klopp2,
  6. Mansoor Raza Mirza1,
  7. Angela Sobremonte5,
  8. Sastry Vedam6 and
  9. Ivan Richter Vogelius1
  1. 1 Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  2. 2 Division of Radiation Oncology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
  3. 3 Department of Diagnostic Radiology, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
  4. 4 Department of Clinical Physiology, Nuclear Medicine & PET, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  5. 5 Department of Radiation Oncology Medical Dosimetry, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
  6. 6 Department of Radiation Physics, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
  1. Correspondence to Ms Christina Steen Vorbeck, Copenhagen University Hospital, Rigshospitalet Department of Oncology, Copenhagen 2100, Denmark; christina.steen.vorbeck{at}


Objectives Knowledge of the detailed pattern of failure can be useful background knowledge in clinical decision making and potentially drive the development of new treatment strategies by increasing radiotherapy dose prescription to high-risk sub-regions of the target. Here, we analyze patterns of recurrence in patients with vulvar cancer treated with radiotherapy according to original planning target volumes and radiation dose delivered.

Methods We analyzed dose-planning and post-treatment recurrence scans from patients with vulvar cancer treated at two institutions from January 2009 through October 2014. We delineated the recurrences and merged the dose-planning and recurrence scans for each patient by using deformable co-registration. We estimated the center of each recurrence on the merged scans with the goal of relating them to the original dose plan.

Results We evaluated 157 patients who received radiotherapy for vulvar cancer. Median age was 68 years (range 29–91). Patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA-IVB were included. Twenty-nine patients had recurrent disease; 156 patients had squamous cell carcinoma and one patient had adenosquamous carcinoma of the vulva. Among the 157 patients, 37 patients with recurrent disease had recurrence scans available for review, for a total of 80 recurrence sites; 53% of the recurrences were located in the region to which the highest dose (60–70 Gy) had been prescribed. Patients who received definitive radiotherapy developed failure primarily in the high-dose region (80.5%), whereas patients who received adjuvant radiotherapy had a more scattered failure pattern (p<0.0001). Among the latter group, 29.5% failed in the high-dose region.

Conclusions Patients who received definitive versus adjuvant radiotherapy had different failure patterns, indicating that separate approaches are needed to improve both adjuvant and definitive radiotherapy for vulvar cancer.

  • radiotherapy
  • vulvar neoplasms

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  • Contributors All authors took part in the conception of the work and in the analyses of the data. Christina Steen Vorbeck and Ivan Richter Vogelius performed the statistical analyses. All authors took part in the interpretations and in revising the manuscript drafted by the first author, and all authors are in agreement with all aspects of the final manuscript.

  • Funding The study was supported by a grant from Kræftens Bekæmpelse (The Danish Cancer Society – grant number R124-A7834-15-S2). The study was supported in part by Cancer Center Support (Core) Grant P30 CA016672 from the National Institutes of Health to The University of Texas MD Anderson Cancer Center.

  • Competing interests CSV, IRV received a grant from Kræftens Bekæmpelse (The Danish Cancer Society).

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data are available upon reasonable request.