Vulvar cancer: epidemiology, clinical presentation, and management options

Gynecological cancers and urinary dysfunction: a comparison between endometrial cancer and other gynecological malignancies

The purpose of this paper is to provide a narrative overview of the available literature about voiding dysfunction in women with gynecological cancer before and after surgical, chemo- and radiotherapy treatments. Radical surgery, radiotherapy, and chemotherapy may cause lower urinary tract dysfunction such as stress and urge urinary incontinence, and voiding difficulties. However, nerve-sparing radical hysterectomy may be a valid surgical approach in order to reduce bladder innervation impairment and maintain normal urinary function. Also, newer radiotherapy techniques significantly reduce the number of adverse effects, including bladder dysfunction. Pelvic floor muscle physiotherapy and training with biofeedback and urethral bulking agents represent some additional therapies that can be used in oncologically treated patients with urinary symptoms in order to improve a significant aspect of their quality of life. Considering the important impact on the patients' quality of life, a full urogynecological evaluation should be considered as an important part of oncological treatment and follow-up.

The potential risk of contralateral non-sentinel groin node metastasis in women with early primary vulvar cancer following unilateral sentinel node metastasis: a single center evaluation in University Hospital of Düsseldorf

Background

Since the introduction of sentinel node biopsy (SLNB) in unifocal vulvar cancer (diameter of < 4 cm) and unsuspicious groin lymph nodes, the morbidity rate of patients has significantly decreased globally. In contrast to SLNB, bilateral inguinofemoral lymphadenectomy (IFL) has been associated with increased risk of common morbidities. Current guidelines (NCCN, ESGO, RCOG, and German) recommend that in cases of unilaterally positive sentinel lymph node (SLN), bilateral IFL should be performed. However, two recent publications by Woelber et al. and Nica et al. contradict the current guideline, since a significant rate of positive non sentinel lymph nodes in IFL contralaterally was not observed [Woelber et al. 0% (p = 0/28) and Nica et al. 5.3% (p = 1/19)].

Methods

A retrospective single-center analysis conducted in the University Hospital of Dusseldorf, evaluating vulvar cancer patients treated with SLNB from 2002 to 2018.

Results

22.2% of women (n = 4/18) were found to have contralateral IFL groin metastasis after an initial diagnosis of unilateral SLN metastasis. The depth of tumor infiltrating cells correlated significantly and positively with the rate of incidence of groin metastasis (p = 0.0038).

Conclusion

Current guideline for bilateral IFL should remain as the standard management. Therefore, this depth may be taken into account as an indication for bilateral IFL. The management of VC and SLNB should be performed in a high volume center with an experienced team in marking SLN and performing the adequate surgical procedure. Well conducted counseling of the patients outlining advantages but also potential oncological risks of this technique especially concerning rate of groin recurrence is critical.

A risk factor analysis of complications after surgery for vulvar cancer

Introduction

Despite the less frequent use of surgery in patients with vulvar cancer, the high rates of postoperative complications are still a matter of concern. The aim of the present study was to identify risk factors that influence postoperative complications rates in vulvar cancer and identify specific clinical parameters that may influence their incidence.

Materials

Patients who underwent curative-intent surgery for squamous cell carcinoma of the vulva from 2003 to 2018 were selected. All patient characteristics were analyzed as risk factors for the development of postoperative lymphocele, lymphedema, and wound dehiscence. The patients were followed up for 2 years postoperatively.

Results

The investigation comprised 121 patients, of whom 18.1% developed wound dehiscence, 17.7% a lymphocele, and 20.4% lymphedema. We found no significant evidence of an association between patient’s characteristics and postoperative complications. The depth of tumor invasion and the appearance of lymph-node metastasis were significantly associated with postoperative complications. Free resection margins of 5 mm or more were associated with a reduced risk of postoperative complications compared to resection margins less than 5 mm. No complications were encountered after sentinel node biopsy (SNB). Complication rates were associated with inguinofemoral lymphadenectomy, but not with the extent of lymphadenectomy. The development of a lymphocele or wound dehiscence may be correlated with the development of long-term lymphedema.

Conclusion

FIGO stage at diagnosis influences the risk of postoperative complications. The use of SNB minimized postoperative complications. Correlations between the free microscopic resection margin distance and the risk of postoperative wound dehiscence must be investigated further.

Radiotherapy and Its Intersections with Surgery in the Management of Localized Gynecological Malignancies: A Comprehensive Overview for Clinicians

Surgery, including minimally invasive surgery, and radiotherapy are key modalities in the treatment of gynecological malignancies. The aim of this review is to offer the multidisciplinary care team a comprehensive summary of the intersections of surgery and radiotherapy in the local treatment of gynecological malignancies. Recent advances in radiotherapy are highlighted. Relevant publications were identified through a review of the published literature. Ovarian, endometrial, cervical, vaginal, and vulvar cancer were included in the search. Current guidelines are summarized. The role of radiotherapy in adjuvant as well as definitive treatment of these entities is synthesized and put into context with surgery, focusing on survival and quality of life. Although these outcomes have improved recently, further research must be focused on the number of life years lost, and the potential morbidity encountered by patients.

HPV DNA/RNA detection in various oral and oropharyngeal biomaterials identifies active HPV infections also in non-neoplastic tonsils

Previous studies describe a correlation between HPV-positivity and non-smoking in TSCC; p16^INK4A-expression as surrogate-marker for HPV-DNA/RNA-positivity is discussed controversially. In the present study, these parameters are assessed prospectively. HPV-status of sputum and tonsillar-swabs was analyzed to determine their validity as surrogate-marker for tissue-HPV-status. TSCC- (n = 52) and non-neoplastic tonsillar tissue (n = 163) were analyzed. HPV-DNA- and HPV-RNA-status of total sputum, cellular fraction and supernatants, tonsillar-swabs and -tissue was determined by (RT)-PCR. Immunohistochemistry determined p16^INK4A-expression. 23/163 (14.2%) non-neoplastic tonsils were HPV-DNA-positive; five patients (3 HPV16, 2 HPV11) had active HPV-infections (HPV-RNA-positive), in all biomaterials. 140/163 (85.9%) patients were either HPV-DNA-positive or HPV-DNA-negative in all samples. 21/52 (40.4%) TSCC-tonsils were HPV-DNA-positive; 17 patients were HPV-RNA-positive (14 HPV16; 4 HPV18). 40/52 (76.9%) TSCC-patients were congruent in all biomaterials. p16^INK4A-expression alone would have misclassified the HPV-status of 14/52 (26.2%) TSCC-patients. This prospective study confirms the discrepancy between HPV-status and p16^INK4A-expression and the significant correlation between non-smoking and HPV-DNA-positivity. HPV-sputum- and/or swab-results do not consistently match tissue-results, possibly having (detrimental) consequences if those were used to assess tissue-HPV-status. In the 5 patients with active HPV infection in the non-neoplasitic tonsils, tonsillectomy likely prevented subsequent development of TSCC.

Modern treatment of vulvar cancer

Background Vulvar cancer accounts for 3-5% of malignant diseases of the female genital tract. The Slovenian incidence rate is 5.5/100,000, which means 57 new cases per year. The most common histological type (90%) is squamous cell carcinoma. Based on etiology, it can be classified into the first type which correlates with human papillomavirus (HPV) infection and the second type which is not associated with HPV. The most common and long-lasting symptom of vulvar cancer is pruritus. The preferred diagnostic procedure to confirm the diagnosis is a punch or incision biopsy. Surgery in combination with radiotherapy is the standard treatment for vulvar cancer. Sentinel lymph node biopsy with lymphoscintigraphy is now a standard part of surgical treatment. Chemotherapy is a palliative treatment option. Conclusions Vulvar cancer is a rare disease. Because of the pathogenesis, surgery and radiotherapy are the main treatment modalities. The sentinel node biopsy (SNB) represents a contemporary approach to the vulvar cancer treatment and significantly reduces morbidity. Improvements in treatment of vulvar cancer contributed to the decrease of mortality among Slovenian women.

[Vulvar squamous cell carcinoma in a HIV-1 infected patient with first-line antiretroviral therapy failure]

Le cancer de la vulve est une affection rarement rapportée dans la littérature. Chez la femme jeune, il est le plus souvent lié à l´infection par le papillomavirus humain (HPV) alors que chez les femmes ménopausées, chez qui ce cancer est plus fréquent, il serait lié à la carence œstrogénique. En outre, l´infection à VIH augmente le risque de survenue chez les femmes séropositives de néoplasies vulvaires du fait de la prévalence élevée de l´infection à HPV chez elles. Ainsi devant toute lésion suspecte de la vulve, une biopsie suivie d´un examen anatomo-pathologique devra être réalisée afin de poser le diagnostic. Nous rapportons le cas d´un carcinome épidermoïde de la vulve chez une patiente séropositive au VIH-1 en échec de traitement antirétroviral (ARV) de première ligne.

Preoperative biopsies as predictor for the necessity of inguinal lymph node surgery in squamous cell carcinoma of the vulva-a retrospective tertiary center analysis

Purpose

Squamous cell carcinoma of the vulva (SQCV) is the fifth common cancer in women. Necessity of inguinal lymph node surgery depends on the depth of stromal invasion, inducing lymph node surgery, if depth of invasion is more than 1 mm. In this study we tested the prediction of stromal infiltration depth by measurements in preoperative biopsies.

Methods

We analyzed whether a different operative strategy in respect to lymph node surgery would have been chosen based on the pre- or postoperative depth of stromal invasion for each patient. Examination of infiltration depth in preoperative biopsies and surgical specimen were compared.

Results

In total 77 patients were included in this study. Of those 89.6% showed different depths of stromal invasion comparing the pre- and postoperative specimen. Within seventeen patients (22.1%) preoperative depth was 1 mm or less and a postoperative depth was > 1 mm.

Conclusion

We pointed, that only in 77.9% of the patients who should have undergo lymph node surgery based on the postoperative depth of infiltration underwent this procedure. Consequentially in 22.1% of the cases a second operation could not be prevented with a preoperative taken biopsy as indicator for the necessity of lymph node surgery.

Patterns of first recurrence and outcomes in surgically treated women with vulvar cancer: results from FRANCOGYN study group

OBJECTIVE

Cancer of the vulva recurrences vary considerably over time and are influenced by several pathological, surgical and adjuvant therapeutic prognostic factors. However, limited information is available about patterns of disease recurrence and prognosis. We analysed patterns of vulvar cancer recurrence based on a large French multicentre database.

METHODS

Data of women with histologically proven squamous cell carcinoma (SCC) and other vulvar cancer treated between 1976 and 2016 were retrospectively abstracted from five institutions with prospectively maintained vulvar cancer databases in France. The endpoints were pattern of recurrence, recurrence free survival (RFS) and overall survival (OS). Time to the first recurrence in a specific site was evaluated by using cumulative incidence analysis (Gray's test) and competing risks regression analysis to estimate sub-distribution hazard ratios and 95% CIs.

RESULTS

In the whole population, recurrences were observed in 188 of the 617 women (30%) with local-regional, distant and multifocal recurrences in 18% (109/617), 3% (17/617), 10% (62/617), respectively. The median time to recurrence with Interquartile Range (IQR) was 13 months IQR [8-30]. The overall respective 3-years OS and RFS were 78.5% (IC95%: 74.5-82.5) and 75.5% (IC95%: 71.1-80.0). According to FIGO stage, lymph node status and positive lympho-vascular invasion (LVSI), pattern and time of loco-regional and distant recurrence were significantly different. There wasn't interaction between FIGO stage and LVSI in OS neither RFS (p=0.08 and 0.9 respectively).

CONCLUSION AND DISCUSSION

We report specific time and site patterns of first recurrence according to FIGO stage, lymph node status and lymphovascular invasion status. Positive LVSI is an important and independent prognostic factor. Defining patterns of recurrence may provide useful information for developing follow-up recommendations and designing therapeutic approaches.

In Vitro Organotypic Systems to Model Tumor Microenvironment in Human Papillomavirus (HPV)-Related Cancers

Despite the well-known role of chronic human papillomavirus (HPV) infections in causing tumors (i.e., all cervical cancers and other human malignancies from the mucosal squamous epithelia, including anogenital and oropharyngeal cavity), its persistence is not sufficient for cancer development. Other co-factors contribute to the carcinogenesis process. Recently, the critical role of the underlying stroma during the HPV life cycle and HPV-induced disease have been investigated. The tumor stroma is a key component of the tumor microenvironment (TME), which is a specialized entity. The TME is dynamic, interactive, and constantly changing-able to trigger, support, and drive tumor initiation, progression, and metastasis. In previous years, in vitro organotypic raft cultures and in vivo genetically engineered mouse models have provided researchers with important information on the interactions between HPVs and the epithelium. Further development for an in-depth understanding of the interaction between HPV-infected tissue and the surrounding microenvironment is strongly required. In this review, we critically describe the HPV-related cancers modeled in vitro from the simplified 'raft culture' to complex three-dimensional (3D) organotypic models, focusing on HPV-associated cervical cancer disease platforms. In addition, we review the latest knowledge in the field of in vitro culture systems of HPV-associated malignancies of other mucosal squamous epithelia (anogenital and oropharynx), as well as rare cutaneous non-melanoma associated cancer.

Unilateral versus bilateral lymph-nodal metastases and oncologic outcome in vulvar cancer patients

PURPOSE

To evaluate the difference in oncologic outcome between vulvar cancer patients with uni- and bilateral inguino-femoral lymph nodal involvement and to identify factors affecting their oncologic outcome MATERIALS AND METHODS: Patients who underwent inguino-femoral lymphadenectomy for vulvar cancer were classified into three groups according to their lymph nodal status at the histology analysis (negative, positive one side, positive bilaterally). PFS and OS survival were calculated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to analyze factors predicting overall survival and progression-free survival. Multivariable models were used for variables reporting a p value ≤ 0.1 at the univariate analysis. p values ≤ 0.05 were considered statistically significant.

RESULTS

One hundred and forty-six patients were considered for the analysis. Patients with bilaterally negative lymph nodes had significantly longer PFS and OS as compared to patients with unilateral and bilateral involvement. Patients with unilateral lymph nodal involvement had better PFS than patients with bilateral lymph nodal involvement. Among these patients, the difference in the OS approached but did not reach statistical significance. At the multivariate analysis, the tumor size affected PFS and lymph nodal involvement affected OS.

CONCLUSION

Vulvar cancer patients with bilateral positive lymph nodes have worse oncologic outcome as compared to patients with unilateral lymph nodal involvement; similarly, patients with unilateral lymph nodal involvement have worse oncological outcome as compared to patients with bilateral negative lymph nodes. Furthermore, tumor size and lymph nodal status are independent factors predicting recurrence rate and overall survival, respectively.

Study on collagen parameters in vulvar cancer and preneoplastic lesions by Second Harmonic Generation microscopy

The extracellular matrix plays an important role in cellular balance, and collagen fibers are its most important component. Over the last few years, second harmonic generation (SHG) microscopy has been used for the analysis of collagen fibers in several types of gynaecological cancers, such as breast and ovarian cancer. The value of collagen parameters obtained with this technique to gain insights on the physiopathology and on the prognostic evaluation of cancer has been advocated. Herein, we have characterized the collagen fibers in squamous cell carcinoma (VSCC) and preneoplastic lesions using the SHG microscopy. Collagen parameters, quantity, organization, and uniformity, of VSCC, adjacent skin of VSCC or preneoplastic lesions were compared with values obtained in normal tissue of healthy control. There was an evident decrease in the values of collagen fiber parameters in the VSCC. Increased quantity and uniformity of tumor associated collagen fibers were associated with the presence of lymph node metastases, which suggest a prognostic value of such parameters in the evaluation of vulvar cancer.

Impact of partnership status on clinical outcomes of patients with vulvar squamous cell carcinoma and performance of sentinel lymph node biopsy

OBJECTIVES

Vulvar squamous cell carcinoma is a rare malignancy and lymph node involvement is the most significant prognostic factor. We aimed to evaluate the association between partnership status and mortality from vulvar squamous cell carcinoma, cancer stage at the time of presentation, and the decision for sentinel lymph node biopsy.

METHODS

The US National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database was queried and different parameters were evaluated relative to partnership status. A total of 4851 patients with vulvar squamous cell carcinoma, >18 years of age, who presented between January 2010 to December 2015, were analyzed. Kaplan-Meier and Cox regression analyses were used to assess survival and hazard ratio. Multinomial regression analysis and χ² were utilized to evaluate odd ratios and significance of variables.

RESULTS

Most patients were unpartnered (58.5%), including never married (17.7%), divorced (13.8%), or widowed (27%). Partnered patients were mostly Caucasian (88.4%), insured (74%), and presented with stage I disease (57.2%), compared with unpartnered patients (79.1%), (61.7%), and (51.7%), respectively (p<0.01). The mean survival time (months) in partnered patients was longer, compared with unpartnered (p<0.001), and the difference between both groups increased from 9 months at stage I to 24 months at stage IV, which remained independently significant after adjusting the different variables. Cox regression showed that partnered patients had a lower hazard ratio than unpartnered patients (p<0.01). Mortality from vulvar squamous cell carcinoma increased with age at diagnosis, no surgery, and unemployment (p<0.01). Unpartnered patients were the least likely to undergo sentinel lymph node biopsy in early stages, compared with partnered (p<0.01). Univariate Cox regression analysis showed that not performing sentinel lymph node biopsy almost doubled the hazard ratio of vulvar squamous cell carcinoma (p<0.01).

CONCLUSIONS

Partnership status should be considered when counseling patients for vulvar squamous cell carcinoma therapy and when recommending screening and follow-up to optimize patient care.

Structure, Genome, Infection Cycle and Clinical Manifestations Associated with Human Papillomavirus

A small, non-enveloped, obligatory parasite, Human papillomavirus (HPV) is known to be the cause of a range of malignancies. These entail benign infections like genital warts as well as malignant, life-threatening conditions such as cervical cancer. Since a very high mortality rate is associated with HPV caused cancers (cervical cancer is a 2nd leading cause of death caused due to cancer among women globally), there is an escalating need to understand and search for ways to combat such medical conditions. Under the same light, the given article provides an insight into the world of this versatile pathogen. Distinct aspects related to HPV have been discussed here. Emphasis has been laid upon the composition, function and assembly of capsid proteins (structural studies) and various genetic elements and their gene products (genomic studies). The essence of the mechanism behind the development of persistent infection and modes responsible for the transmission of the infectious particles has been briefly covered. Finally, the review outlines various infections and diseases caused by HPV with a major focus on their clinical and histological manifestations.

The usefulness of high-frequency ultrasonography in the preoperative evaluation of vulvar cancer - a case series

Vulvar cancer is a malignancy of female lower genital tract with incidence of 1:100,000 in Poland. The most common types of vulvar cancers are squamous cell carcinoma and basal cell carcinoma. This study was approved by the board of the Clinical Unit of Obstetrics, Women’s Disease and Gynecological Oncology, United District Hospital, Collegium Medicum University of Nicolaus Copernicus in Toruń, Poland. This is a tertiary reference center. We analyzed cases of postmenopausal women diagnosed with vulvar cancer referred to our clinic for surgery. The aim of the study was to compare 48 MHz ultrasound images of vulvar cancer with histological images and assess the utility of high-frequency ultrasonography images in preoperative assessment. We examined 3 cases of squamous cell carcinoma and 1 case of basal cell carcinoma using 48 MHz DermaView high-frequency mechanical probe. We described typical ultrasonographic features of vulvar carcinoma, such as echogenicity, depth of infiltration, as well as we discussed limitations of this transducer. The 48 MHz frequency exhibits a promising value for the preoperative assessment of vulvar carcinoma. High-frequency ultrasonography can provide some important information, such as morphology, boundary, internal echo, and thus help choose adequate surgical approach.

Vulvar and vaginal neoplasia in women with inflammatory bowel disease

Immunosuppressive drugs are the cornerstone in the treatment of inflammatory bowel disease (IBD), however they are associated with an increased risk of extra-intestinal cancer. Whether the risk for female genital tract malignancies, including vulvar and vaginal cancer, is increased is less clear. Our aim was to investigate the risk of these malignancies in IBD-patients. Histopathological data of all IBD patients with a vulvar or vaginal (pre-)cancerous lesion were retrieved from the Dutch nationwide network and registry of histopathology and cytopathology from 1991 to 2015. Medical history was retrieved from patient records. Data from the Central Office for Statistics, the Dutch comprehensive cancer organization, and the IBDSL cohort were obtained to calculate the standardized, and age-adjusted incidence rates. Fifty-five patients met the inclusion criteria. A standardized incidence rate of 1.2(95% CI:0.8-1.7) for vulvar and vaginal carcinoma among adult female IBD was calculated, which did not significantly differ from the general population. The use of immunosuppressive therapy did not increase the occurrence of vulvovaginal malignancy, nor did it influence the recurrence rate. However, immunosuppressive drugs ever-users were on average 11 years younger at the time of their gynaecological diagnosis. Overall, our data do not support intensified screening for vulvar or vaginal malignancies in female IBD patients.

Vulvamalignome: eine interdisziplinäre Betrachtung

Vulvamalignome stellen die vierthäufigste Gruppe von gynäkologischen Krebserkrankungen dar. Erste Ansprechpartner sind typischerweise niedergelassene Dermatologen und Gynäkologen. Mit der jeweiligen Fachexpertise findet die Diagnose und Therapie idealerweise interdisziplinär zwischen spezialisierten Dermatoonkologen und gynäkologischen Onkologen statt. Vulvamalignome sind überwiegend Erkrankungen des höheren Lebensalters, obwohl alle histologischen Subtypen auch bei Frauen unter 30 Jahren vorkommen. Die Diagnose erfolgt oft verzögert. Eine genaue Kartierung von Biopsien (Mapping) ist von großer Bedeutung, da Lokalisation und Entfernung von der Mittellinie in Abhängigkeit von der zugrunde liegenden Histologie das operative Vorgehen bestimmen. Plattenepithelkarzinome machen mehr als 76 % der Vulvamalignome aus und vulväre intraepitheliale Neoplasien (VIN) sind dabei wichtige Vorstufen. Der zweithäufigste Typ der Vulvakarzinome ist das Basalzellkarzinom. Melanome machen 5,7 % der vulvären Malignome aus und ihre Prognose ist schlechter als die der kutanen Melanome. Die meisten Studien zu Checkpoint-Inhibitoren und zielgerichteten Therapien haben Patientinnen mit vulvären Melanomen nicht ausgeschlossen. Die vorliegende Evidenz wird im folgenden diskutiert. Die Methode der Wahl bei lokal resezierbaren Vulvamalignomen ist die Exzision. Angesichts ihrer Seltenheit sollte die Behandlung in spezialisierten Zentren erfolgen, um eine optimale Krankheitskontrolle zu erreichen und Kontinenz und sexuelle Funktion bestmöglich zu erhalten.

Cerebral metastasis in recurrent squamous cell carcinoma of the vulva: case report and review of the literature

BACKGROUND

Distant metastases from squamous cell cancer of the vulva (VSCC) are encountered rarely and are associated with a poor prognosis. Cerebral metastases have only been described anecdotally.

CASE HISTORY

A 51-year old woman was diagnosed with hepatic metastases due to VSCC. Initial therapy comprised wide local excision of the primary tumor with inguino-femoral lymphadenectomy (LAE) followed by stereotactic radiation of the singular hepatic metastasis while adjuvant chemoradiation of the vulva and lymphatics was declined. 3 years later, she subsequently developed lung and cerebral metastases.

CONCLUSION

The course of metastatic disease in VSCC is poorly understood. Further knowledge of the metastatic patterns in vulvar cancer is required for guidance of future therapeutic interventions.

Vulvar malignancies: an interdisciplinary perspective

Vulvar cancer represents the fourth most common gynecologic malignancy and is often encountered by the general Dermatologist or Gynecologist. Dermatooncologists and Gynecologic Oncologists share expertise in this field and the diagnosis and treatment should ideally be interdisciplinary. All subtypes are typically seen in the later decades of life, although all histologic subtypes have been described in women younger than 30 years. The diagnosis is often delayed. Exact mapping of biopsies is of high importance, as the location and distance from the midline guides the surgical approach depending on the underlying histology. Squamous cell carcinoma accounts for more than 76 % of vulvar cancer with vulvar intraepithelial neoplasia being an important precursor. Basal cell carcinoma is the second most common vulvar malignancy. Melanoma accounts for 5.7 % of vulvar cancer and has a worse prognosis compared to cutaneous melanoma. Most of the trials on checkpoint inhibitors and targeted therapy have not excluded patients with vulvar melanoma and the preliminary evidence is reviewed in the manuscript.

Surgery remains the primary treatment modality of locally resectable vulvar cancer. In view of the rarity, the procedure should be performed in dedicated cancer centers to achieve optimal disease control and maintain continence and sexual function whenever possible.

Hypercalcemia and Extensive Chest Metastasis of Vulvar Squamous Cell Carcinoma

A 73-year-old woman with a diagnosis of vulvar carcinoma submitted to curative surgery 5 years previously, presented to the emergency department with prostration and vulvar haemorrhage. Although the gynaecological examination was unremarkable, she had a mass in the left chest wall and hypercalcemia. A CT scan of the thorax revealed a voluminous left hemithorax mass invading the mediastinum, lung, pleura and chest wall. Ultrasound-guided biopsy of the mass showed infiltration by a well-differentiated keratinizing squamous cell carcinoma (SCC). This case report describes an extremely rare metastatic pattern in vulvar SCC concomitant with paraneoplastic hypercalcemia.

MRI for Radiation Therapy Planning in Human Papillomavirus-associated Gynecologic Cancers

Locally advanced human papillomavirus (HPV)-associated gynecologic cancers, including cervical, vaginal, and vulvar cancers, are treated primarily with radiation therapy (RT). Cervical cancer remains a leading cause of cancer death among women worldwide. The superior soft-tissue resolution of MRI compared with other imaging modalities makes it an ideal modality for RT planning, execution, and follow-up of these malignancies. This superiority has been corroborated in the literature when comparing MRI-based RT planning to radiography-based conventional treatment planning approaches. In 2005, the Groupe Européen de Curiethérapie and the European Society for Radiation Therapy and Oncology guidelines underscored the central role of MRI for successful implementation of three-dimensional image-based cervical cancer brachytherapy. The delineation of both gross tumor volume and clinical tumor volume for brachytherapy is performed at the time of each brachytherapy application, on the basis of the findings depicted on anatomic MR images. Contemporary knowledge concerning the role of MRI for RT planning in HPV-associated gynecologic cancers warrants an understanding of the epidemiology and clinical manifestations of these cancers, as well as knowledge of MRI protocol for cancer staging, selection of RT candidates, brachytherapy implant assessment, posttreatment surveillance, and delineation of treatment-related complications. Technical requirements, patient preparation, and image acquisition protocols are detailed in this review, and imaging-based treatment protocols are summarized. Knowledge of these fundamental concepts enables the radiologist to play an important role in diagnosis, staging, and posttreatment follow-up, helping to guide radiation oncologists and other clinicians in the management of these malignancies.^©RSNA, 2019.

Left-Sided Intracardiac Tumors in a Case of Widespread Vulvar Cancer

Metastatic cardiac tumors associated with gynecological malignancies are rare. This report describes the case of stage-4 vulvar carcinoma that metastasized to the left ventricle of the heart. (Level of Difficulty: Intermediate.)

Multivariate analysis of prognostic factors in primary squamous cell vulvar cancer: The role of perineural invasion in recurrence and survival

OBJECTIVE

to assess the prognostic role in recurrence and survival of perineural invasion (PNI) in vulvar squamous cell cancer (VSCC).

METHODS

Patients underwent primary surgery for VSCC from January 2009 to December 2016 served as the study cohort. We collected demographic, clinical, pathological characteristics and follow-up data, and we compared them among PNI-negative versus -positivepatients. We calculated disease-free survival (DFS) and overall survival (OS) using Kaplan-Meier and univariate log-rank test. We conducted a multivariate analysis with cox-proportional hazard models for DFS and OS, including age, tumor size, depth of invasion, free tumor margin <8 mm, high-grade histology, lymph vascular space invasion, PNI, extracapsular lymph nodal disease, lymph nodal ratio >0.2 and FIGO Stage 2009 (Early I-II versus Advanced III-IV).

RESULTS

We found 74 patients with a PNI prevalence of 31.1%. The 5-year DFS was favourable for PNI-negative patients (72% versus 18%; p = 0.00). The 5-year OS was 75% versus 35% in favor of PNI-negative patients (p = 0.00). The subgroup analysis conducted among stage confirmed a decreased DFS and OS in PNI-positive patients. Multivariate analysis showed that PNI (HR 2.74; CI95% 1.10-7.13; p = 0.03) and extracapsular lymph nodal disease (HR 13.54; CI95% 2.87-64.07; p = 0.01) are independent prognostic factors for earlier recurrence. OS was significantly reduced in case of PNI (HR 4.93; CI95% 1.33-18.35; p = 0.01) and extracapsular lymph nodal disease (HR 10.63; CI95% 1.65-68.57; p = 0.01).

CONCLUSIONS

PNI is an independent prognostic factor for aggressive behavior and unfavorable course in VSCC and should be considered in adjuvant treatment planning.

HLA-G, HLA-E, and IDO overexpression predicts a worse survival of Tunisian patients with vulvar squamous cell carcinoma

Little is known about non-classical HLA molecules in vulvar squamous cell carcinoma (VSCC). Because of the indoleamine-2,3-dioxygenase (IDO) immune tolerant role in association with HLA-G, we evaluated the clinical and prognostic value of HLA-G, HLA-E, and IDO in VSCC. HLA-G, HLA-E, and IDO expression was determined by immunohistochemistry in VSCC and associated with clinicopathological parameters and disease outcome. These three molecules were highly represented in tumoral tissues vs healthy matched vulvar tissues (P = 0.0001). Significant differences in HLA-G expression in stages, tumor size, tumor invasion depth, and resection margins subgroups were reported (P < 0.05). At 5 years, the cumulative survival rates was of 79.8% in patients with HLA-Glow expression vs 12.5% in those with HLA-Ghigh expression (P < 3 × 10-5 ). Similarly, patients with IDOhigh expression were at a significantly reduced overall survival (OS) and disease-free survival (DFS) rates (P = 0.011 and 0.045, respectively). The overexpression of the three molecules together worsen survival rates of VSCC patients (OS: P = 0.000038, DFS: P = 0.000085). Altogether, our results showed that HLA-G, HLA-E, and IDO may represent novel candidate markers for patients' prognosis and potential targets for VSCC therapy.

Bioinformatics prediction and analysis of hub genes and pathways of three types of gynecological cancer

Cervical, endometrial and vulvar cancer are three common types of gynecological tumor that threaten the health of females worldwide. Since their underlying mechanisms and associations remain unclear, a comprehensive and systematic bioinformatics analysis is required. The present study downloaded GSE63678 from the GEO database and then performed functional enrichment analyses, including gene ontology and pathway analysis. To further investigate the molecular mechanisms underlying the three types of gynecological cancer, protein-protein interaction (PPI) analysis was performed. A biological network was generated with the guidance of the Kyoto Encyclopedia of Genes and Genomes database and was presented in Cytoscape. A total of 1,219 DEGs were identified for the three types of cancer, and 25 hub genes were revealed. Pathway analysis and the PPI network indicated that four main types of pathway participate in the mechanism of gynecological cancer, including viral infections and cancer formation, tumorigenesis and development, signal transduction, and endocrinology and metabolism. A preliminary gynecological cancer biological network was constructed. Notably, following all analysis, the phosphoinositide 3-kinase (PI3K)/Akt pathway was identified as a potential biomarker pathway. Seven pivotal hub genes (CCNA2, CDK1, CCND1, FGF2, IGF1, BCL2 and VEGFA) of the three gynecological cancer types were proposed. The seven hub genes may serve as targets in gynecological cancer for prevention and early intervention. The PI3K/Akt pathway was identified as a critical biomarker of the three types of gynecological cancer, which may serve a role in the pathogenesis. In summary, the present study provided evidence that could support the treatment of gynecologic tumors in the future.

[Understanding lower gynaecological cancer consultation delay and help-seeking behavior in patients over 65]

INTRODUCTION

Delays for consultation of more than six months exist for uterine cancer. Delays in diagnosis of more than five years exist for vulvar cancer. The peak incidence of these neoplasms appear after the age of 65 years. Patient's symptoms are characteristically swelling, vaginal bleeding or itching. This study aims to understand what is happening during this period for women over 65 years old. It also tries to identify triggers during the help-seeking period.

METHODS

Qualitative studies using semi-structured interviews with dual analyses (semio-pragmatic and psychodynamic) have been conducted on a population of older (65+) gynaecologic cancer patients, recruited from a French oncology centre.

RESULTS

Twelve patients were interviewed. Patients' courses of action were determined by the characteristics of their symptoms, their feelings and their emotions. Representations, subjective beliefs and past experiences were employed to make sense of their symptoms. The patient's friend and family circle had an important role in incentivizing the patient to seek consultation. Multiple factors affected the path towards consulting the doctor. The initial medical contact included several challenges. The patient would consult a doctor earlier if he had more information about his illness and if his relationship with the doctor was better.

CONCLUSION

Our findings are similar to those of other cancers. The peculiarity for this population appears to be the different representations of age-related changes in the reproductive system, and the taboo associated with this issue when facing friends and family.

Vulvar Cancer

This article reviews the epidemiology, diagnosis, and management of vulvar preinvasive lesions, squamous cell carcinoma, and melanoma. There is an emphasis on sentinel lymph node dissection for early stage disease and advances in chemoradiation for late-stage disease. A brief review of vulvar Paget disease is also included.

Conventional radiotherapy and intensity-modulated radiotherapy in carcinoma vulva: An experience from a tertiary medical center of India

Context

Vulvar cancer is one of the uncommon gynecological malignancies. Multimodality treatment with surgery, radiotherapy, and chemotherapy are required for treatment of the disease.

Aims

The aim of the study was to evaluate clinical outcome in patients of carcinoma vulva, treated at our institution.

Subjects and Methods

This was a retrospective-cohort study done in 50 patients with squamous cell carcinoma of the vulva, treated at our institution from January 2008 to December 2014. Data were analyzed on the basis of age, stage, type of treatment received, and treatment-related toxicity. Disease-free survival and overall survival were estimated.

Statistical Analysis Used

Kaplan-Meier survival analysis and Chi-square test were used for statistical analysis.

Results

Majority of the patients (52%) had presented with Stage III disease. Thirty-six of 50 patients underwent surgery: simple vulvectomy - 2, radical vulvectomy - 34, bilateral inguinal lymph node dissection was done in 32 patients, and 1 patient underwent ipsilateral-inguinal lymph node dissection. Among 40 patients who received radiotherapy and eight patients received palliative radiotherapy. Seventeen patients underwent intensity-modulated radiotherapy (IMRT) and 15 patients received conventional radiotherapy. Significantly less Grade 2 or more skin toxicity (P = 0.003) observed in patients who underwent IMRT. Among non-IMRT group, eight patients required treatment break during radiation. At a median follow-up time of 25.5 months, median overall survival was 31 months and median disease-free survival was 25 months. About 42% patients were alive and free of disease at last follow-up.

Conclusions

Modified radical vulvectomy with inguinal lymph node dissection followed by radiotherapy is the mainstay of management of locally advanced carcinoma vulva. Using IMRT, we could minimize the treatment related radiation toxicity and treatment breaks.

MRI evaluation of vulvar squamous-cell carcinoma in fresh radical local excision specimens for cancer localization and prediction of surgical tumor-free margins

In the surgical treatment of vulvar squamous-cell carcinoma (VSCC), tumor-free margins of 8 mm or more are considered adequate. However, limited perioperative information on the tumor-free margins other than the surgeon's own estimation is available. The purpose of this study was therefore to investigate the feasibility of ex vivo MRI in localizing VSCC and to assess the surgical tumor-free margins in fresh radical local excision (RLE) specimens to guide the surgeon during resections. Nine patients with biopsy-proven VSCC scheduled for RLE were prospectively included. Intact fresh specimens were scanned using a 7 T preclinical MR-scanner. Whole mount H&E-stained slides were obtained every 3 mm and correlated with ex vivo MRI. A pathologist annotated VSCC and minimal tumor-free margins (3 o'clock, 9 o'clock, basal) on the digitalized histological slides. An observer with knowledge of histology (the non-blinded annotation) and a radiologist blinded to histology (the blinded annotation) separately performed annotation of the same features on ex vivo MRI. Linear correlation and agreement of the ex vivo MRI measurements with histology were assessed. Diagnostic performance for VSCC localization and identification of margins less than 8 mm was expressed as positive and negative predictive values (PPV, NPV). In 153 matched ex vivo MRI slices, the observer correctly identified 79/91 margins as less than 8 mm (PPV 87%) and 110/124 margins as 8 mm or greater (NPV 89%). The radiologist correctly annotated absence of VSCC in 73/81 (NPV 90%) and presence in 65/72 (PPV 90%) slices. Sixty-four of 90 margins were correctly identified as less than 8 mm (PPV 71%) and 83/102 margins as 8 mm or greater (NPV 81%). Both non-blinded and blinded annotations were linearly correlated and demonstrated good agreement with histology. Accurate localization of VSCC and measurements of the surgical tumor-free margins in fresh RLE specimens using ex vivo MRI seems feasible. High diagnostic performance in VSCC localization and identification of margins less than 8 mm suggest ex vivo MRI to be clinically applicable.

Vulvar cancer in Iran: Retrospective study over 20 years (1998-2018)

Background

We did not have any data about vulvar cancer - as a fourth cause of gynecological cancer in the worldwide - in our country.

Study Design

Our study is designed to evaluate the frequency, stage and outcome of patients with vulvar cancer.

Materials and Methods

In this retrospective observational study, we studied patients' records with diagnosis of vulvar cancer who referred to department of gynecology oncology, Emam-Khomeini Hospital (EKH), Tehran, Iran, between January 1998 and December 2018. A total of 106 cases of vulvar cancers were found in the records of outpatient oncology clinic of medical university of Tehran university. Survival was estimated using the Kaplan-Meier analysis with SPSS version of 24.

Results

Mean age of the 106 patients in the study was 59.2 years. The most site of tumor involvement was major labial (39.1%). Vulvar cancer significantly was more in multiparous (P < 0.001) and menopause patients (P < 0.001). Squamous Cell Carcinoma was the most pathology of vulvar cancer (72.2%). Ninety patients (84.9%) had surgery as a primary treatment and 48 (53.3%) of these patients received adjuvant radiotherapy or chemoradiation after surgery. Mean duration of patient's follow up was 82.4 ± 68.3 month. Five-year survival of our patients in all stages was 71%.

Conclusions

Our findings are located between developed and underdeveloped countries. Our patients are diagnosed nearly in earlier stages of disease and 84.9%t of them had surgery as a primary treatment, so earlier surgery resulted in good survival of patients.

Vulvar malignant melanoma: Pathogenesis, clinical behaviour and management: Review of the literature

Vulvar malignant melanoma (VMM) is a rare disease, accounting for 5% of all vulvar malignancies and is characterized by low survival and high recurrence rates. It is considered as a distinct entity of mucosal melanoma. Prognostic factors are higher age, advanced Breslow thickness, and lymph node involvement whilst central localization and ulceration status are still under debate. Surgery is the cornerstone for the treatment of primary VMM, however, it can be mutilating due to the anatomical location of the disease. Elective lymph node dissection is not part of standard care. The value of sentinel lymph node biopsy in VMM is still being studied. Radiation therapy and chemotherapy as adjuvant treatment do not benefit survival. Immunotherapy in cutaneous melanoma has shown promising results but clinical studies in VMM are scarce. In metastatic VMM, checkpoint inhibitors and in case of BRAF or KIT mutated metastatic VMM targeted therapy have shown clinical efficacy. In this review, we present an overview of clinical aspects, clinicopathological characteristics and its prognostic value and the latest view on (adjuvant) therapy and follow-up.

HPV16 viral characteristics in primary, recurrent and metastatic vulvar carcinoma

Vulvar carcinoma is the fourth most common gynecological malignancy. Two separate carcinogenic pathways are suggested, where one is associated with the human papillomavirus (HPV) and HPV16 the most common genotype. The aim of this study was to evaluate HPV-markers in a set of primary tumors, metastases and recurrent lesions of vulvar squamous cell carcinomas (VSCC). Ten HPV16-positive VSCC with metastatic regional lymph nodes, distant lymphoid/hematogenous metastases or local recurrent lesions were investigated for HPV genotype, HPV16 variant, HPV16 viral load, HPV16 integration and HPV16 E2BS3 and 4 methylation. In all 10 analyzed case series, the same HPV genotype (HPV16), HPV16 variant and level of viral load were detected in all lesions within a patient case. Primary tumors with a high E2/E6 ratio were found to have fewer vulvar recurrences and/or metastases after diagnosis and treatment. Also, a significantly lower viral load was evident in regional lymph nodes compared to primary tumors. The data presented strengthens the evidence for a clonal HPV-induced pathway for vulvar carcinoma.

Smoking-Induced SLPI Expression Hinders HPV Infections Also in Squamous Cell Carcinomas of the Vulva

In HNSCC, protein- and mRNA-expression of the antileukoproteinase SLPI are significantly inverse correlated with HPV-infection suggesting that elevated expression of SLPI protects against HPV-infections. Moreover, SLPI-expression is up-regulated in HNSCC-patients reporting a smoking habit. Here, we investigate the described correlation in other HPV-driven cancers, namely vulvar squamous cell carcinoma (VSCC). FFPE samples of 99 VSCC were analyzed by PCR for HPV-DNA-expression and by RT-qPCR for SLPI-mRNA-expression. Of 99 VSCC 10 (10.1%) are HPV-positive; 9 were HPV16; 1 HPV18; all were E6/E7 mRNA-positive. 33 of the 99 patients (33.3%) reported a smoking habit; 7 (21.1%) of these were HPV-positive. Of 66 (66.7%) non-smokers 3 (4.5%) were HPV-positive. SLPI-expression was 4.0-fold lower in HPV-positive than HPV-negative patients. Smoking resulted in 2.3-fold higher SLPI expression. The data presented here indicate that SLPI plays a pivotal role in HPV-infection not only in HNSCC but also in VSCC and possibly also in other HPV-driven cancers. This however, needs to be analyzed in future studies. Furthermore these data lead to the hypothesis that the smoking induced SLPI-increase is systemic rather than local, as assumed based on the HNSCC data.

Treatment Outcomes of Patients with Squamous Cell Carcinoma of the Vulva: The Largest Series from a Tertiary Care Hospital

Objective

To evaluate the outcomes of squamous cell carcinoma (SCCA) of the vulva treated at our tertiary care center.

Methods

The medical records of SCCA patients treated between January 2006 and December 2015 were retrospectively reviewed.

Results

One hundred forty-five patients met the criteria with the median age of 57 years old, and 58.6% had an underlying disease. The distribution of stages was as follows: IA 6.2%, IB 21.4%, II 26.2%, IIIA 14.5%, IIIB 6.2%, IIIC 9.7%, IVA 9.0%, and IVB 6.9%. One hundred and nine patients underwent surgical intervention and radical local excision with bilateral groin node dissection as the most frequent procedure. Approximately half of the patients received combined treatment with surgery followed by radiation with or without chemotherapy. Recurrence developed in 127 patients after the median follow-up time of one year with the common sites in the groin and vulva region. However, no significant difference in survival occurred in patients with and without groin node recurrence (15 vs. 28 months, P=0.109). The five-year overall survival was 50.8%.

Conclusions

The survival of patients with SCCA vulvar cancer was modest. The common failure sites were groin and vulva regions with unfavorable outcomes.

Nanoparticle Conjugation of Human Papillomavirus 16 E7-long Peptides Enhances Therapeutic Vaccine Efficacy against Solid Tumors in Mice

Treatment of patients bearing human papillomavirus (HPV)-related cancers with synthetic long-peptide (SLP) therapeutic vaccines has shown promising results in clinical trials against premalignant lesions, whereas responses against later stage carcinomas have remained elusive. We show that conjugation of a well-documented HPV-E7 SLP to ultra-small polymeric nanoparticles (NP) enhances the antitumor efficacy of therapeutic vaccination in different mouse models of HPV⁺ cancers. Immunization of TC-1 tumor-bearing mice with a single dose of NP-conjugated E7LP (NP-E7LP) generated a larger pool of E7-specific CD8⁺ T cells with increased effector functions than unconjugated free E7LP. At the tumor site, NP-E7LP prompted a robust infiltration of CD8⁺ T cells that was not accompanied by concomitant accumulation of regulatory T cells (Tregs), resulting in a higher CD8⁺ T-cell to Treg ratio. Consequently, the amplified immune response elicited by the NP-E7LP formulation led to increased regression of large, well-established tumors, resulting in a significant percentage of complete responses that were not achievable by immunizing with the non-NP-conjugated long-peptide. The partial responses were characterized by distinct phases of regression, stable disease, and relapse to progressive growth, establishing a platform to investigate adaptive resistance mechanisms. The efficacy of NP-E7LP could be further improved by therapeutic activation of the costimulatory receptor 4-1BB. This NP-E7LP formulation illustrates a "solid-phase" antigen delivery strategy that is more effective than a conventional free-peptide ("liquid") vaccine, further highlighting the potential of using such formulations for therapeutic vaccination against solid tumors. Cancer Immunol Res; 6(11); 1301-13. ©2018 AACR.

Therapeutic vaccines and immune checkpoints inhibition options for gynecological cancers

Treatments for gynecological cancer include surgery, chemotherapy, and radiation. However, overall survival is not improved, and novel approaches are needed. Immunotherapy has been proven efficacious in various types of cancers and multiple approaches have been recently developed. Since numerous gynecological cancers are associated to human papilloma virus (HPV) infections, therapeutic vaccines, targeting HPV epitopes, have been developed. The advancing understanding of the immune system, regulatory pathways and tumor microenvironment have produced a major interest in immune checkpoint blockade, Indeed, immune checkpoint molecules are important clinical targets in a wide variety of tumors, including gynecological. In this review, we will describe the immunotherapeutic targets and modalities available and review the most recent immunotherapeutic clinical trials in the context of gynecological cancers. The synergic results obtained from the combination of HPV therapeutic vaccines with radiotherapy, chemotherapy, or immune checkpoint inhibitors, may underlie the potential for a novel therapeutic scenario for these tumors.

A rare case of vulvar squamous cell carcinoma; case presentation

Objectives. Vulvar cancer is a rare gynecological malignancy, with an incidence of 1.5 per 100 000 women/year. The most common vulvar cancer is developed in squamous cells, the most encountered type of skin cells. Case report. We report a case of a 72-year-old female admitted in the Department of Plastic Surgery of Emergency Clinical Hospital “Prof. Dr. Agrippa Ionescu” with a 5/4.2 cm painful ulcerated tumoral mass located in the vulvar area. The lesion slowly increased in size over the past 12 months. The tumour was surgically removed with oncological safety margins and sent for histopathological evaluation. The histopathological examination revealed an ulcerated squamous carcinoma with lymphovascular and perineural invasion, but with negative margins. Postoperative results were favorable, and no local or general complications were observed. Conclusion. We highlight this case due to its unusual presentation in the clitoral area. Moreover, considering the potential for recurrence we point out the importance of the radical vulvectomy with regional lymphadenectomy and histopathological examination, in order to put a precise diagnosis and ensure the best possible treatment for the patient.

A Comparative Study of Video Endoscopic Inguinal Lymphadenectomy and Conventional Open Inguinal Lymphadenectomy for Treating Vulvar Cancer

OBJECTIVE

This study aims to compare the complications, oncological outcomes, cosmetic satisfaction, and quality of life experienced by women with vulvar cancer undergoing video endoscopic inguinal lymphadenectomy (VEIL) versus conventional open inguinal lymphadenectomy (COIL).

PATIENTS AND METHODS

Forty-eight consecutive patients with vulvar cancer who underwent COIL (n = 27) or VEIL (n = 21) at the Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China between 2003 and 2016 were included in this retrospective cohort study. The perioperative data, postoperative complications, oncological outcomes, cosmetic satisfaction, and quality of life of the COIL and VEIL groups were compared.

RESULTS

Twenty patients (74.1%) in the COIL group and 19 patients (90.5%) in the VEIL group returned for follow-up after the operation. The median follow-up time was 73 months (8-162 months) for the COIL group and 28 months (8-58 months) for the VEIL group. The inguinal lymph node yield in the VEIL group was comparable with that in the COIL group (15 ± 5 vs 18 ± 6, P = 0.058). The VEIL and COIL groups had a similar 2-year recurrence rate (10.5% vs 10%, P = 0.957) and 2-year disease-specific survival rate (95.5% vs 93.3%, P = 0.724). The wound complication rate was significantly lower in the VEIL group than the COIL group (4.8% vs 55.6%, P = 0.000). The VEIL group had higher body image scores (16.27 ± 1.20 vs 13.16 ± 0.87, P < 0.0001) and cosmetic scores (20.13 ± 0.98 vs 16.92 ± 0.72, P < 0.0001) than the COIL group. The patients in the VEIL group had higher life quality scores on the Functional Assessment of Cancer Therapy-Vulvar questionnaire than those in the COIL group (165.9 ± 6.3 vs 160.5 ± 6.0, P = 0.026).

CONCLUSIONS

Compared with COIL, VEIL can effectively reduce postoperative wound complications and improve patients' cosmetic satisfaction and life quality without compromising therapeutic efficacy. Hence, we believe that VEIL is a good alternative to COIL for vulvar cancer patients when surgical expertise is available.

Vulvar cancer in Germany: increase in incidence and change in tumour biological characteristics from 1974 to 2013

BACKGROUND

The incidence of vulvar cancer in Germany is increasing. Moreover, gynaecological oncologists reported observing increasing numbers of women presenting with small tumours. The aim of the present study is to validate this observation on a population level and to extend available incidence data.

MATERIAL AND METHODS

Data from the population-based Saarland Cancer Registry were used and included 1136 women diagnosed with invasive vulvar cancer (ICD-9 codes: 181.1-181.4, ICD-10 code: C51) between 1974 and 2013. Multiple imputation methodology was used to overcome loss of precision and potential bias resulting from incomplete data. Incidence trends were investigated with regard to age at diagnosis, tumour size and clinical stage, morphology and histopathologic grade.

RESULTS

The age-standardised incidence rate of vulvar cancer increased from 1.6 cases per 100,000 women per year in 1974-78 to 7.9 in 2009-13, representing an increase across all age groups. Since 1989-93, an almost exclusive increase in the incidence of small tumours ≤2 cm in the greatest dimension from 1.2 to 6.6 and of squamous cell carcinomas from 1.7 to 7.1 was observed, whereas the number of larger tumours and other invasive cancers remained rather constant. Patients aged ≥75 years generally suffered from more advanced tumours at the time of diagnosis.

CONCLUSIONS

An increase in vulvar cancer incidence of a size as observed in this study has not been reported thus far for any other European region. Furthermore, the analyses confirmed the observation of increasing numbers of women presenting with small tumours. The results of the age-specific analyses point to both human papillomavirus infection and non-infectious factors as explanations for the observed increase in squamous cell carcinomas.

MiR-223-5p works as an oncomiR in vulvar carcinoma by TP63 suppression

MiR-223-5p has been previously mentioned to be associated with tumor metastasis in HPV negative vulvar carcinomas, such as in several other tumor types. In the present study, we hypothesized that this microRNA would be important in vulvar cancer carcinogenesis and progression. To investigate this, we artificially mimicked miR-223-5p expression in a cell line derived from lymph node metastasis of vulvar carcinoma (SW962) and performed in vitro assays. As results, lower cell proliferation (p < 0.01) and migration (p < 0.001) were observed when miR-223-5p was overexpressed. In contrast, increased invasive potential of these cells was verified (p < 0.004). In silico search indicated that miR-223-5p targets TP63, member of the TP53 family of proteins, largely described with importance in vulvar cancer. We experimentally demonstrated that this microRNA is capable to decrease levels of p63 at both mRNA and protein levels (p < 0.001, and p < 0.0001; respectively). Also, a significant inverse correlation was observed between miR-223-5p and p63 expressions in tumors from patients (p = 0.0365). Furthermore, low p63 protein expression was correlated with deeper tumor invasion (p = 0.0491) and lower patient overall survival (p = 0.0494). Our study points out miR-223-5p overexpression as a putative pathological mechanism of tumor invasion and a promising therapeutic target and highlights the importance of both miR-223-5p and p63 as prognostic factors in vulvar cancer. Also, it is plausible that the evaluation of p63 expression in vulvar cancer at the biopsy level may bring important contribution on prognostic establishment and in elaborating better surgical approaches for vulvar cancer patients.

Linking type 2 diabetes and gynecological cancer: an introductory overview

Type 2 diabetes (T2D) is a chronic disease with a growing prevalence and a leading cause of death in many countries. Several epidemiological studies observed an association between T2D and increased risk of many types of cancer, such as gynecologic neoplasms (endometrial, cervical, ovarian and vulvar cancer). Insulin resistance, chronic inflammation and high free ovarian steroid hormones are considered the possible mechanisms behind this complex relationship. A higher risk of endometrial cancer was observed in T2D, even though this association largely attenuated after adjusting for obesity. A clear relationship between the incidence of cervical cancer (CC) and T2D has still not be determined; however T2D might have an impact on prognosis in patients with CC. To date, studies on the association between T2D and ovarian cancer (OC) are limited. The effect of pre-existing diabetes on cancer-specific mortality has been evaluated in several studies, with less clear results. Other epidemiological and experimental studies focused on the potential role of diabetes medications, mainly metformin, in cancer development in women. The correct understanding of the link between T2D and gynecologic cancer risk and mortality is currently imperative to possibly modify screening and diagnostic-therapeutic protocols in the future.

Pubic Hair Shaving Is Correlated to Vulvar Dysplasia and Inflammation: A Case-Control Study

Objective

The risk factors for vulvar dysplasia and infections are not fully known. In this study, we aimed to investigate the correlation between pubic hair shaving and the occurrence of vulvar inflammation, dysplasia, and cancer.

Methods

This study was performed between January 2013 and December 2016 in which a standardized questionnaire concerning genital hair shaving was administered to vulvar dysplasia and cancer patients and healthy participants. The presence of human papilloma virus (HPV) infection and the occurrence of genital inflammation were documented.

Results

We recruited 49 patients with vulvar dysplasia or cancer and 234 healthy women as a control group. Smoking, HPV infection, genital inflammation, and complete pubic hair removal were significantly more common in the vulvar dysplasia/cancer group. Pubic hair shaving per se presented a clear association with vulvar dysplasia/cancer. Shaving the labia majora in particular showed also an association.

Conclusion

Our findings suggest that partial or complete pubic hair shaving using a razor is correlated with and could be a potential risk factor for the development of genital inflammation, vulvar dysplasia, and malignancies. These results need to be confirmed in larger studies. HPV status and genital inflammation should be documented by medical personnel.

Vitamin D and VDR in Gynecological Cancers-A Systematic Review

In recent years, a vast amount of studies have centered on the role of vitamin D in the pathogenesis of certain types of cancers such as breast, colorectal and lung cancer. Increasing evidence suggests that vitamin D and its receptor play a crucial role in the development of gynecological cancers. In this review, we systematically analyzed the effect of vitamin D and the vitamin D receptor on endometrial, ovarian, cervical, vulvar and vaginal cancer. Our literature research shows that vitamin D levels and vitamin-D-related pathways affect the risk of gynecological cancers. Numerous ecological studies give evidence on the inverse relationship between UVB exposure and gynecological cancer risk. However, epidemiologic research is still inconclusive for endometrial and ovarian cancer and insufficient for rarer types of gynecological cancers. The vitamin D receptor (VDR) is upregulated in all gynecological cancers, indicating its influence on cancer etiology. The VDR polymorphism FokI (rs2228570) seems to increase the risk of ovarian cancer. Other nuclear receptors, such as the RXR, also influence gynecological cancers. Although there is limited knowledge on the role of the VDR/RXR on the survival of endometrial, cervical, vulvar or vaginal cancer patients, some studies showed that both receptors influence survival. Therefore, we suggest that further studies should focus on the vitamin D- and its hetero dimer receptor RXR in gynecological cancers.

Genital diseases in the mature woman

Vulvovaginal conditions are common in mature women. This reflects age-related changes in immunity and skin barrier function of vulvovaginal tissues. Vaginal atrophy is commonly complicated by dryness and inflammation, which makes postmenopausal atrophic vaginitis a virtually ubiquitous condition. The differential of vaginitis includes inflammatory, infectious, and malignant diseases, plus drug hypersensitivity. Atrophic vaginitis is treated with estrogen replacement therapy. Vulvovaginal malignant melanoma occurs predominantly in postmenopausal women and carries a poor prognosis. Similarly, the incidence of vulvovaginal malignancies, such as squamous cell carcinoma and extramammary Paget disease, rises exponentially after 65 years of age. Early diagnosis of these malignancies is of utmost importance. Lichen sclerosus et atrophicus and vulvovaginal candidosis are among the most common postmenopausal vulvovaginal conditions. Lichen sclerosus et atrophicus is associated with significant morbidity, and its management can be challenging. The incidence of vulvovaginal candidosis increases in patients on estrogen replacement therapy.