Vulvar cancer: epidemiology, clinical presentation, and management options

Recurrent fusion transcripts in squamous cell carcinomas of the vulva

Juxtaposition of two different genes or gene parts due to chromosomal rearrangement is a well-known neoplasia-associated pathogenetic mechanism. The detection and characterization of such tumorigenic fusions is of great importance both research-wise, diagnostically because they may be specific for distinct tumor entities, and because they may serve as therapeutic targets for antioncogenic drugs that interact directly with the molecular changes responsible for neoplastic transformation.

At present, more than 10,000 fusion transcripts have been reported in different types of neoplasia, with one tenth of them being identified in squamous cell carcinomas (SCC) of different locations. No recurrent fusion gene has to date been identified in SCC of the vulva.

We performed high-throughput paired-end RNA-sequencing of 12 vulvar SCC and found two recurrent fusions with the STIP1-CREB3L1 and ZDHHC5-GPR137 being present in two tumors each. The transcripts were detected only in the tumor samples, not in normal vulvar tissue from healthy donors used as control. The CREB3L1 and ZDHHC5 genes encode proteins involved in transcription suggesting that the chimeras may alter downstream events in their respective pathways. Expression analysis of the CREB3L1 gene showed the presence of two distinct groups of tumors, one having fusion and downregulation of the gene and the other showing upregulation of CREB3L1.

Challenges to delivery and effectiveness of adjuvant radiation therapy in elderly patients with node-positive vulvar cancer

OBJECTIVE

To examine adjuvant radiation therapy (RT) use, patterns of RT delivery, and clinical outcomes in older patients with node-positive vulvar cancer.

METHODS

Using SEER-Medicare linked data, we identified 444 patients (age≥66years) with node-positive squamous cell vulvar carcinoma, without distant metastases, and treated with primary surgery between 1991 and 2009. We used claims to examine RT use and the following delivery metrics: 1) completion of ≥20 fractions, 2) treatment duration <8weeks, 3) <1week of intra-treatment break, and 4) treatment interval from surgery to start of RT <8weeks. We tested associations between RT use and metrics with overall (OS) and cause-specific survival (CSS) using multivariate proportional hazards regression.

RESULTS

Median age was 78years (interquartile range [IQR]=74-83). Median follow-up was 17months (IQR=9-40). Three hundred six patients (69%) received RT. Three delivery metrics were associated with improved outcomes: completion of ≥20 fractions, treatment duration <8weeks, and <1week of intra-treatment break. Patients who achieved these 3 metrics demonstrated better disease outcomes compared with surgery alone (OS hazard ratio [HR] for death=0.62, 95% confidence interval [CI]=0.46-0.82, P=0.001; CSS HR=0.58, 95% CI=0.40-0.85,P=0.005). Patients not achieving RT metrics demonstrated marginal improvements in disease outcomes over surgery alone (OS HR=0.73, 95% CI=0.55-0.99,P=0.04; CSS HR=0.76, 95% CI=0.52-1.11, P=0.16). Notably, only 51% of patients who received RT achieved all benchmarks.

CONCLUSIONS

In this cohort of older women with node-positive vulvar cancer, achieving metrics for RT delivery was an important factor for optimizing disease benefits from treatment.

Vulva cancer in Ghana - Review of a hospital based data

•Seventy- 5% of vulvar cancer cases present with advance disease.•Definitive radiotherapy/chemoradiation is the main stay of treatment.•One third of patients default treatment.•Five year survival following radiotherapy was 36.7%.

Vulvar cancer in Tunisia: Epidemiological and clinicopathological features multicentric study

OBJECTIVE

To describe for the first time the epidemiologic and clinico-pathologic characteristics of vulvar cancer in Tunisia.

DESIGN

Two parts are distinguished in this study: Part1: Multicentric retrospective study about the characteristics of all cancer cases diagnosed during a 17-years period (January 1998-December 2014) in three departments of Gynecology and Obstetrics: one in south Tunisia and two in the capital. Part 2: To determine the Incidence trend of invasive vulvar cancer in North Tunisia 1994-2009, on the basis of North Cancer Registry of Tunisia.

RESULTS

A total of 76 cases of vulvar cancer were recorded. The median age at diagnosis was 65.4years and 86.9% of patients were more than 55years old. The symptomatology was dominated by vulvar pruritus in 48.7%. The average size of the tumor was 3.96cm. Stage III was the most frequent (53.7%) followed by stage II (28.3%). Only 10.4% of tumors were at stage I. The most common histologic type of vulvar malignancy was squamous cell carcinoma (SCC) (94.7%). Standardized incidence varied from 1.2/100 000 (1994) to 0.5/100 000 (2009). There was significant decrease of Standardized incidence (APC of -8.8% per year, 95% CI: -5.5%, -9.0%-p<0.001).

CONCLUSION

Vulvar cancer in Tunisia is a rare disease, occurs mostly in elderly women, and is diagnosed at advanced stages. Our findings emphasize that a greater effort should be made to facilitate early diagnosis, as treatment in earlier stages is less extensive and potentially curative.

Brachytherapy as part of the conservative treatment for primary and recurrent vulvar carcinoma

PURPOSE

There are only scarce data on the place of brachytherapy (BT) for treatment of vulvar carcinoma. Our institutional experience of interstitial BT for vulvar carcinoma patients is reported.

METHODS AND MATERIALS

Clinical records of patients receiving low-dose-rate or pulsed-dose-rate BT as part of the primary treatment for primary/recurrent vulvar squamous cell carcinoma or as part of postoperative treatment between 2000 and 2015 were included. Patients, tumors, and treatment characteristics as well as clinical outcome were examined.

RESULTS

A total of 26 patients treated with BT were identified. BT was delivered as part of primary intent treatment for locally advanced/recurrent cancer in 11 patients and as part of postoperative treatment in 15 patients. Median age at time of BT was 63 years (range, 41-88 years). Pulsed-dose-rate and low-dose-rate were used in 15 patients and 11 patients, respectively. BT was performed as a boost to the tumor bed following external beam radiotherapy (n = 13) or as the sole irradiation modality (n = 13). Total median dose at the level of primary tumor was 60 GyEQD2 (range, 55-60 GyEQD2). With mean followup of 41 months (range, 5 months-11.3 years), 11 patients experienced tumor relapse, and in two of them, site of relapse was only local. Three-year estimated disease-free survival and overall survival rates were 57% (95% confidence interval: 45-69%) and 81% (95% confidence interval: 72-90%), respectively. All toxicities were Grade 2 or less.

CONCLUSIONS

Interstitial BT used as part of the primary or postoperative treatment of vulvar carcinoma is feasible with a satisfactory toxicity profile. Prognosis remains, however, dismal, with a high frequency of failures in patients with locally advanced tumors.

Labia Majora Share

Defects involving specialised areas with characteristic anatomical features, such as the nipple, upper eyelid, and lip, benefit greatly from the use of sharing procedures. The vulva, a complex 3-dimensional structure, can also be reconstructed through a sharing procedure drawing upon the contralateral vulva. In this report, we present the interesting case of a patient with chronic, massive, localised lymphedema of her left labia majora that was resected in 2011. Five years later, she presented with squamous cell carcinoma over the left vulva region, which is rarely associated with chronic lymphedema. To the best of our knowledge, our management of the radical vulvectomy defect with a labia majora sharing procedure is novel and has not been previously described. The labia major flap presented in this report is a shared flap; that is, a transposition flap based on the dorsal clitoral artery, which has consistent vascular anatomy, making this flap durable and reliable. This procedure epitomises the principle of replacing like with like, does not interfere with leg movement or patient positioning, has minimal donor site morbidity, and preserves other locoregional flap options for future reconstruction. One limitation is the need for a lax contralateral vulva. This labia majora sharing procedure is a viable option in carefully selected patients.

Recommendations for symptom management in women with vulvar neoplasms after surgical treatment: An evidence-based guideline

PURPOSE

To develop an evidence-based guideline for nurses and other health care professionals involved in pre- and postsurgical care of women with vulvar cancer (VC) or vulvar intraepithelial neoplasia (VIN).

METHODS

This evidence-based guideline was developed according to six domains of the methodological framework AGREE II. Literature research with focus on cancer care, symptom management and self-management/counselling was conducted from April to August 2013 in the databases CINAHL, Cochrane Library, PsycINFO, PubMed as well as in 14 international guideline databases. Interdisciplinary experts (n = 14) were involved in the development of the guideline from December 2013 to January 2014. This guideline is currently tested in the WOMAN-PRO II RCT (Clinical Trial No: NCT01986725).

RESULTS

For the definition of recommendations, five guidelines, one meta-analysis, two systematic reviews and two randomized controlled trials were included. In total, 24 recommendations were formulated to answer 22 clinical questions based on patients' perspective and experts' opinion. Evidence ranged from 3.5 to 5 (3.5 = weak evidence and/or clinical relevance, 5 = best evidence and/or clinical relevance). The recommendations were subsumed under different themes regarding physical, psychological and psychosocial aspects.

CONCLUSIONS

The clinical practice guideline developed in this study firstly provides recommendations for symptom management issues focusing on self-management interventions for women with VC or VIN. As an interdisciplinary guideline it should be used in addition to the existing medical guideline in the German speaking context.

Interstitial high-dose-rate brachytherapy in locally advanced and recurrent vulvar cancer

PURPOSE

The aim of the study was to report our experience with high-dose-rate interstitial brachytherapy (HDR-ISBT) in locally advanced and recurrent vulvar cancer.

MATERIAL AND METHODS

Between 2004 and 2014, fourteen women with locally advanced or recurrent vulvar cancer were treated using HDR-ISBT in our Centre. High-dose-rate interstitial brachytherapy was performed as a separate treatment or in combination with external beam radiotherapy (EBRT) (given prior to brachytherapy).

RESULTS

Patients were divided into: group I (n = 6) with locally advanced tumors, stages III-IVA after an incisional biopsy only, and group II (n = 8) with recurrent vulvar cancer after previous radical surgery. In group I, median follow up was 12 months (range 7-18 months); 1-year overall survival (OS) was 83%. Transient arrest of cancer growth or tumor regression was noticed in all patients but 4/6 developed relapse. Median time to failure was 6.3 months (range 3-11 months). The 1-year progression-free survival (PFS) was 33%. In group II, median follow up was 28 months (range 13-90 months). The 1-year and 3-year OS was 100% and 80%, respectively. The arrest of cancer growth or tumor regression was achieved in all patients. In 4/8 patients neither clinical nor histological symptoms of relapse were observed but 4/8 women experienced relapse. Median time to failure was 31 months (range 13-76 months). The 1-year and 3-year PFS was 100% and 62.5%, respectively. Two patients (14.3%) in group II had severe late toxicity (G3).

CONCLUSIONS

High-dose-rate interstitial brachytherapy is a well-tolerated treatment option in selected patients with advanced or recurrent vulvar cancer. It is a safe and effective treatment modality for advanced and recurrent vulvar cancer, yielding good local control with acceptable late treatment related side effects. In our study, patients with recurrent vulvar cancer had better results in HDR-ISBT treatment, probably because of the smaller tumor volume. This hypothesis should be verified in a larger group of patients.

Morbidity and mortality of vulvar and vaginal cancers: Impact of 2-, 4-, and 9-valent HPV vaccines

Vaginal and vulvar cancers do not account for a large proportion of gynecologic malignancies but their impact is significant. Both vaginal and vulvar lesions have precursors and display levels of dysplasia before progression to invasive disease. Human Papillomavirus (HPV) is a known causative agent of such dysplasia and can be detected now more readily than ever with adequate recognition techniques and provider awareness. Although HPV vaccination is still lagging compared to other recommended childhood vaccinations, the impact on lower genital tract neoplasia is promising. The bivalent and quadrivalent vaccines have been shown to be efficacious and the newest nonavalent vaccine should add even more of impact on coverage of cancer-causing HPV types. Although it is still early to show true clinical and population-based disease reduction due to low disease incidence and relatively short time of vaccine availability, the potential is noteworthy.

Disparities in Vulvar Cancer Reported by the National Cancer Database: Influence of Sociodemographic Factors

OBJECTIVE

To assess whether there is an association of patient sociodemographic factors with stage at diagnosis, treatment, and overall survival in patients with vulvar cancer in the National Cancer Database.

METHODS

This was a retrospective cohort study of patients with primary squamous vulvar carcinoma identified from the National Cancer Database (1998-2004). Multivariate logistic regression was conducted to examine risk factors associated with advanced-stage (stage III or IV) disease at diagnosis. Multivariable Cox regression models were performed to explore risk factors associated with 5-year all-cause mortality.

RESULTS

Of 11,153 patients, 42.3% (n=4,713) were diagnosed with stage I disease, 24.6% (n=2,745) stage II, 22.9% (n=2,556) stage III, and 10.2% (n=1,139) stage IV. Advanced stage was significantly associated with older age, nonprivate insurance, and treatment at a lower case volume center (P<.01). Of note, roughly 30% of patients with advanced-stage disease did not receive radiation therapy. Within the advanced stages, age 60 years or older and insurance type were associated with decreased survival (P<.01). In stage III disease, only black race and treatment at a community hospital were associated with a lower risk of death (P<.01).

CONCLUSION

Patient sociodemographic and clinical characteristics are significantly associated with vulvar cancer stage presentation, treatment, and survival. Unfortunately, within this disease, surgical approaches and adjuvant radiation do not appear consistent.

LEVEL OF EVIDENCE

II.

Non-invasive diagnostic techniques in the diagnosis of squamous cell carcinoma

Squamous cell carcinoma is the second most common cutaneous malignancy after basal cell carcinoma. Although the gold standard of diagnosis for squamous cell carcinoma is biopsy followed by histopathology evaluation, optical non-invasive diagnostic tools have obtained increased attention. Dermoscopy has become one of the basic diagnostic methods in clinical practice. The most common dermoscopic features of squamous cell carcinoma include clustered vascular pattern, glomerular vessels and hyperkeratosis. Under reflectance confocal microscopy, squamous cell carcinoma shows an atypical honeycomb or disarranged pattern of the spinous-granular layer of the epidermis, round nucleated bright cells in the epidermis and round vessels in the dermis. High frequency ultrasound and optical coherence tomography may be helpful in predominantly in pre-surgical evaluation of tumor size. Emerging non-invasive or minimal invasive techniques with possible application in the diagnosis of squamous cell carcinoma of the skin, lip, oral mucosa, vulva or other tissues include high-definition optical coherence tomography, in vivo multiphoton tomography, direct oral microscopy, electrical impedance spectroscopy, fluorescence spectroscopy, Raman spectroscopy, elastic scattering spectroscopy, differential path-length spectroscopy, nuclear magnetic resonance spectroscopy, and angle-resolved low coherence interferometry.

Aberrant promoter methylation of SH3GL2 gene in vulvar squamous cell carcinoma correlates with clinicopathological characteristics and HPV infection status

OBJECTIVE

This study attempted to examine the methylation status of SH3GL2 gene in different types of human vulvar lesions and its correlation with clinicopathological parameters.

METHODS

Immunohistochemical analysis was used to identify the expression status of SH3GL2 in vulvar squamous cell carcinoma (VSCC), vulvar intraepithelial neoplasia (VIN) and benign vulvar squamous epithelium tissues. Bisulfite genomic sequencing method was used to detect methylation status of the SH3GL2 gene. Clinicopathological correlation of the alterations was analysed by the chi-square tests.

RESULTS

Immunohistochemical analysis showed expression of SH3GL2 in VSCC was significantly downregulated than that in VIN and normal vulvar tissues. In accordance with higher frequency of methylation status in SH3GL2, statistical analysis showed methylation status of SH3GL2 was closely related to tumor TNM stage (P=0.003), but not related to age, tumor volume, tumor differentiation, lymph node metastasis and VIN grade. High-methylation status of SH3GL2 showed significant association with HPV infection status.

CONCLUSIONS

Our results indicated that the methylation status of SH3GL2 gene was associated with the TNM staging and HPV infection status of VSCC, suggesting that it might play a synergistic role in the development of VSCC.

The role of RhoA in vulvar squamous cell carcinoma: a carcinogenesis, progression, and target therapy marker

Ras homologue gene family member A (RhoA) is involved in tumor mobility, invasion, and metastasis. We detected RhoA expression in vulvar squamous cell carcinoma (VSCC) tissue, measured RhoA expression in the VSCC cell phenotype, and measured the expression of the relevant molecules after RhoA small interfering RNA (siRNA) transfection in SW962 cells. RhoA has a higher expression level in VSCC than normal vulva skin tissue and was positively associated with the International Federation of Gynecology and Obstetrics (FIGO) stage and differentiation; besides, VSCC patients with lymph node metastasis had higher positive RhoA expression. RhoA messenger RNA and protein expression was significantly reduced in the RhoA siRNA transfectants as compared with the negative control (NC) and mock-transfected cells (p < 0.05). The RhoA siRNA transfectants lead to low growth, G1 arrest, high apoptosis, low migration and invasion (p < 0.05), and suppressed lamellipodia formation as compared to NC and mock-transfected cells. Besides, matrix metalloproteinase-2 (MMP2), MMP9, and cyclinA1 protein expression was downregulated, while that of Bax was upregulated in the RhoA siRNA transfectants (p < 0.05). SW962 cell proliferation rates were significantly lovastatin dose-dependent. Lovastatin caused G1 arrest, high apoptosis, low migration and invasion (p < 0.05), and suppression of lamellipodia formation. Similar to the RhoA siRNA transfectants, lovastatin treatment downregulated RhoA, MMP2, MMP9, and cyclinA1 protein expression, while upregulating that of Bax as compared to that of the NC (p < 0.05). Abnormal RhoA expression in vulvar carcinoma is involved in tumor proliferation and invasion and may be a treatment target. The RhoA inhibitor lovastatin alters VSCC cell migration and proliferation and may be effective for treating VSCC.

Recent trends in surgical and reconstructive management of vulvar cancer: review of literature

Vulvar cancer (VC) is a rare disease. The most common histologic type is squamous-cell carcinoma. VC could be divided into two types: type one, commonly associated with HPV infection, occurs in young women and type two, associated with non-neoplastic lesions that usually occurs in older women. Previously VC was often treated with radical Vulvectomy. Today update in diagnostic and surgery technique, capable to identify early stages of disease and adaptation in surgery procedures, according to the stage of disease, age of patients and possible physical and psychological morbidity consequence, allow using less radical surgery approaches. That has led to decrease therapy-associated morbidity while preserving oncologic safety and improving psychosexual outcomes. Finally, several surgical treatments are available in case of VC and, despite radical surgery is often required, less radical surgery associated with reconstructive plastic surgery decreases some of short- and long-term associated complications.