title: Primary extramammary invasive Paget's vulvar disease: what is the standard, what are the challenges and what is the future for radiotherapy?
abstract: Primary invasive Extramammary Paget's vulvar disease is a rare tumor that is challenging to control. Wide surgical excision represents the standard treatment approach for Primary invasive Extramammary Paget's vulvar disease. The goal of the current study was to analyze the appropriate indications of radiotherapy in Primary invasive Extramammary Paget's vulvar disease because they are still controversial.
  
  
  
  We searched the Cochrane Gynecological Cancer Group Trials Register, Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE database up to September 2015. Radiotherapy was delivered as a treatment in various settings: i) Radical in 28 cases (range: 60-63 Gy), ii) Adjuvant in 25 cases (range: 39-60 Gy), iii) Salvage in recurrence of 3 patients (63 Gy) and iv) Neoadjuvant in one patient (43.3 Gy). A radiotherapy field that covered the gross tumor site with a 2-5 cm margin for the microscopic disease has been used. Radiotherapy of the inguinal, pelvic or para-aortic lymph node should be considered only for the cases with lymph node metastases within these areas. Radiotherapy alone is an alternative therapeutic approach for patients with extensive inoperable disease or medical contraindications. Definitive radiotherapy can be used in elderly patients and/or with medical contraindications. Adjuvant radiotherapy may be considered in presence of risk factors associated with local recurrence as dermal invasion, lymph node metastasis, close or positive surgical margins, perineal, large tumor diameter, multifocal lesions, extensive disease, coexisting histology of adenocarcinoma or vulvar carcinoma, high Ki-67 expression, adnexal involvement and probably in overexpression of HER-2/neu. Salvage radiotherapy can be given in inoperable loco-regional recurrence and to those who refused additional surgery.
authors.affiliation: Department of Radiotherapy, University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis, Larissa, 411 10, Greece. mariatolia@med.uth.gr.
authors.forename: Maria
authors.initials: M
authors.lastname: Tolia
authors.affiliation: Oncology Clinic, 401 General Military Hospital, Mesogeion 138 & Katehaki, 115 25, Athens, Greece.
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Tsoukalas
authors.affiliation: LITO Obstetrics, Gynaecology & Surgery Centre, 7-13 Mouson Str, Psychiko-Athens, 154 52, Greece.
authors.forename: Chrisostomos
authors.initials: C
authors.lastname: Sofoudis
authors.affiliation: Department of Food Science and Nutrition, University of the Aegean, Myrina, Lemnos, 814 40, Greece.
authors.forename: Constantinos
authors.initials: C
authors.lastname: Giaginis
authors.affiliation: Department of Radiation Oncology, University of Patra Medical School, Patra, 265 04, Greece.
authors.forename: Despoina
authors.initials: D
authors.lastname: Spyropoulou
authors.affiliation: Department of Radiation Oncology, University of Patra Medical School, Patra, 265 04, Greece.
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Kardamakis
authors.affiliation: Second Department of Radiology, Radiation Therapy Oncology Unit, University Hospital of Athens "ATTIKON", Rimini 1, Haidari, 124 64, Athens, Greece.
authors.forename: Vasileios
authors.initials: V
authors.lastname: Kouloulias
authors.affiliation: Department of Radiotherapy, University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis, Larissa, 411 10, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Kyrgias
mesh_terms: D005260:Female; D006801:Humans; D009364:Neoplasm Recurrence, Local; D010145:Paget Disease, Extramammary / Q000532:radiotherapy*; D011878:Radiotherapy / Q000379:methods / Q000592:standards*; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant; D016879:Salvage Therapy; D016896:Treatment Outcome; D014846:Vulvar Neoplasms / Q000532:radiotherapy*
keywords: Extramammary invasive Paget’s disease; Radiotherapy; Vulva