A new international survey published in Radiotherapy and Oncology shows that implementation of the ESGO 2023 guidelines for adjuvant radiotherapy in vulvar cancer remains highly variable, especially in areas where evidence is limited or recommendations are permissive.
The study, titled “From evidence to practice: Real-world implementation of ESGO 2023 guidelines for adjuvant radiotherapy in vulvar cancer,” explored how radiation oncologists apply ESGO recommendations in daily clinical practice.
Why This Study Matters
Vulvar cancer is rare, and adjuvant radiotherapy decisions are often complex.
Treatment must balance the risk of locoregional recurrence against potential toxicity, including skin morbidity, wound complications, lymphedema, and long-term functional effects.
Although the ESGO 2023 guidelines aimed to standardize care, several areas remain clinically challenging, including close margins, nodal irradiation, boost indications, concurrent chemotherapy, and management of surgically unstaged groins.
Study Design
The authors conducted an international cross-sectional survey among radiation oncologists with expertise in gynecologic malignancies.
A 23-item questionnaire was sent to 75 specialists worldwide. In total, 54 radiation oncologists completed the survey.
Respondents included 21 centers from Italy and 33 international centers across Europe, North America, South America, Asia, and Australia.
The survey assessed five major domains:
Vulvar bed irradiation
Lymph node irradiation
Concurrent radiosensitizing chemotherapy
Dose, boost, and bolus strategies
Radiotherapy for surgically unstaged lymph node sites
Key Findings
The study found that adherence was strongest when ESGO recommendations were directive, but variability increased in grey zones.
For vulvar bed irradiation, 57.4% of respondents recommended treatment in the presence of local risk factors and/or nodal metastases. However, more than one-third did not consider nodal positivity alone enough to justify vulvar bed irradiation.
For groin irradiation, only 50% followed guideline criteria strictly. Others considered treatment for a single positive node or whenever the vulvar bed was irradiated.
Pelvic nodal irradiation also varied. More than half of respondents included the ipsilateral external iliac region whenever inguinofemoral nodes were irradiated, regardless of nodal burden.
Chemotherapy Use
Concurrent radiosensitizing chemotherapy was another area of inconsistency.
Only 38.9% of respondents used chemotherapy strictly according to ESGO guidance, mainly for more than one positive node or extracapsular extension.
However, 51.9% reported using chemotherapy in sentinel node micrometastasis settings, despite limited evidence.
When chemotherapy was used, there was strong agreement on the agent: weekly cisplatin was selected by 87.1% of respondents.
Dose and Boost Strategies
Elective nodal dose was one of the more consistent areas. Most centers, 79.7%, used 45 to 50.4 Gy for elective inguinofemoral irradiation.
Boost indications were less consistent. Only 50% delivered a nodal boost for macrometastatic disease or extracapsular extension, while others limited boost use to extracapsular extension only or omitted it after lymphadenectomy.
For the vulvar bed, dose and boost strategies varied, especially in cases of close margins. This reflects the lack of a universally accepted definition of “close” margins and differences between international recommendations.
Bolus use was also variable and not clearly addressed by ESGO. Most respondents avoided bolus for groin fields, while vulvar bolus use depended on skin dose coverage, superficial risk, or margin concerns.
Surgically Unstaged Groins
The study also highlighted uncertainty around patients who do not undergo complete groin surgical staging.
When groin surgery was omitted in clinically node-negative frail patients without pathologic risk factors, 66.8% of respondents did not add prophylactic radiotherapy.
In other surgically unstaged scenarios, practice varied widely, reflecting a need for clearer guidance and multidisciplinary decision-making.
Clinical Takeaway
This survey shows a clear gap between guideline recommendations and real-world implementation of adjuvant radiotherapy in vulvar cancer.
Importantly, the variability should not be interpreted simply as poor guideline adherence. Much of it reflects genuine evidence gaps, especially in rare clinical scenarios where prospective data are limited.
The authors call for radiotherapy-specific prospective studies and multidisciplinary expert consensus to provide interim guidance while stronger evidence is being developed.
For now, the message is clear: ESGO 2023 guidelines provide an important framework, but real-world vulvar cancer radiotherapy still depends heavily on clinical judgment, institutional experience, and multidisciplinary discussion.
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