title: Locally advanced vulva cancer: A single centre review of anovulvectomy and a systematic review of surgical, chemotherapy and radiotherapy alternatives. Is an international collaborative RCT destined for the "too difficult to do" box?
abstract: BACKGROUND
  Treatment of locally advanced vulva cancer (LAVC) remains challenging. Due to the lack of randomised trials many questions regarding the indications for different treatment options and their efficacy remain unanswered.
  
  
  METHODS
  In this retrospective study we provide the largest published series of LAVC patients treated with anovulvectomy, reporting oncological outcomes and morbidity. Additionally, a systematic literature review was performed for all treatment options 1946-2015.
  
  
  RESULTS
  In our case series, 57/70 (81%) patients were treated in the primary setting with anovulvectomy and 13 patients underwent anovulvectomy for recurrent disease. The median overall survival (OS) was 69months (1-336) with disease specific survival of 159months (1-336). Following anovulvectomy for primary disease, time to progression and OS were significantly higher in node negative disease (10 vs. 96months; 19 vs. 121months, p<0.0001). Post-surgical complications were observed in 36 (51.4%), the majority of which were Grade I/II infections. There was one peri-operative death. Review of the literature showed that chemotherapy, radiotherapy or combination treatments are alternatives to surgery. Evidence relating to all of these consisted mostly of small retrospective series, which varied considerably in terms of patient characteristics and treatment schedules. Significant patient and treatment heterogeneity prevented meta-analysis with significant biases in these studies. It was unclear if survival or morbidity was better in any one group with a lack of data reporting complications, quality of life, and long term follow-up. However, results for chemoradiation are encouraging enough to warrant further investigation.
  
  
  CONCLUSIONS
  There remains inadequate evidence to identify an optimal treatment for LAVC. However, there is sufficient evidence to support a trial of anovulvectomy versus chemoradiation. Discussions and consensus would be needed to determine trial criteria including the primary outcome measure. Neoadjuvant chemotherapy or radiotherapy alone may be best reserved for the palliative setting or metastatic disease.
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; Northern Institute for Cancer Research, Newcastle University, Medical School, Framlington Place NE2 4AH, UK. Electronic address: Rachel.O'Donnell@newcastle.ac.uk.
authors.forename: Rachel Louise
authors.initials: RL
authors.lastname: O'Donnell
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK. Electronic address: Leen.Verleye@kce.fgov.be.
authors.forename: Leen
authors.initials: L
authors.lastname: Verleye
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK. Electronic address: Nithya.Ratnavelu@ghnt.nhs.uk.
authors.forename: Nithya
authors.initials: N
authors.lastname: Ratnavelu
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK. Electronic address: K.Galaal@nhs.net.
authors.forename: Khadra
authors.initials: K
authors.lastname: Galaal
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK. Electronic address: Ann.Fisher@ghnt.nhs.uk.
authors.forename: Ann
authors.initials: A
authors.lastname: Fisher
authors.affiliation: Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK. Electronic address: Raj.Naik@ghnt.nhs.uk.
authors.forename: Raj
authors.initials: R
authors.lastname: Naik
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D059248:Chemoradiotherapy; D005260:Female; D006801:Humans; D000070516:Intersectoral Collaboration; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D014844:Vulva / Q000601:surgery*; D014846:Vulvar Neoplasms / Q000628:therapy*
keywords: Anovulvectomy; Chemoradiation; Colostomy; Exenteration; Locally advanced vulval cancer (LAVC)