From evidence to practice: Real-world implementation of ESGO 2023 guidelines for adjuvant radiotherapy in vulvar cancer.

Abstract

Despite recent advances in the management of vulvar cancer (VC), adjuvant radiotherapy (RT) remains an area characterized by limited evidence, permissive recommendations, and substantial clinical variability. The 2023 ESGO guidelines aimed to standardize practice, yet their real-world implementation has not been systematically explored. An international cross-sectional survey was conducted among radiation oncologists with recognized expertise in gynecologic malignancies to assess adherence to ESGO 2023 recommendations and identify grey zones. A 23-item questionnaire covering five thematic domains was distributed to 75 specialists worldwide. A total of 54 of 75 radiation oncologists completed the survey; non-response was attributable to limited availability rather than explicit refusal. Respondents included 21 centers from Italy and 33 international centers across Europe, North America, South America, Asia, and Australia. Vulvar bed irradiation for local risk factors and/or nodal metastases was recommended by 31/54 respondents (57.4%). Groin irradiation strictly according to guideline criteria was reported by 27/54 centers (50%), while the remainder considered treatment for a single positive node or whenever the vulvar bed was irradiated. Inclusion of the ipsilateral external iliac region regardless of inguinal tumor burden was reported by 30/54 centers (55.6%). Concurrent chemotherapy was delivered according to guidelines by 21/54 respondents (38.9%) but was also used in sentinel node micrometastasis settings by 28/54 (51.9%) despite limited evidence; weekly cisplatin was selected by 47/54 (87.1%). Elective nodal doses aligned with recommendations in 43/54 centers (79.7%), whereas boost indications remained inconsistent, with only 27/54 (50%) delivering a boost for macrometastatic disease or extracapsular extension. Prophylactic RT was omitted by 36/54 centers (66.8%) when lymph node staging was not performed. This survey reveals marked variability and critical evidence gaps in adjuvant RT practice for VC. While prospective trials are needed, the findings highlight the urgency of multidisciplinary expert consensus to guide clinical decision-making in key grey zones.