Invasive cancer of the vulva

Primary small cell neuroendocrine carcinoma of the Bartholin's gland: A case report

Primary carcinoma of the Bartholin's gland (BG) is a rare malignancy. There are extremely rare cases of small cell neuroendocrine carcinoma (SCNC) of the BG reported in the English literature. A postmenopausal female presented with a 1-month history of increasing pain and swelling on the left vulva consistent with spontaneously bleeding. Pathology identified SCNC that arose in BG. The patient was treated with a radical wide local excision and bilateral inguinal lymph node dissection followed by six courses of chemotherapy. One month after primary treatment, without any pelvic recurrence or abnormal tumor markers indications, distant metastasis of the liver was diagnosed and VI hepatic lobectomy was performed. The patient maintained regular adjuvant chemotherapy every month under outpatient surveillance and has no local recurrence or distant metastasis.

Potential delay in the diagnosis of vulvar cancer and associated risk factors in women treated in German gynecological practices

The goal of this study was to estimate a potential delay in the diagnosis of vulvar cancer and identify associated risk factors in women treated in gynecological practices in Germany. The current study sample included 1,652 women from 218 gynecological practices who received an initial diagnosis of vulvar cancer (ICD 10: C51) between January 2000 and December 2015 (index date). After applying several exclusion criteria, 505 non-cancer controls were matched (1:1) to 505 vulvar cancer cases based on age, health insurance status, and index date. The primary outcome was the delay in vulvar cancer diagnosis in women who had received an initial diagnosis of diseases of Bartholin's gland, inflammation of vagina and vulva, or other specified noninflammatory disorders of vulva, including atrophy, hypertrophy, and cyst. A logistic regression model was used to estimate the association between vulvar cancer and pre-defined diagnoses. The mean age was 60.8 years (SD = 15.6 years), and 4.8% of women had private health insurance coverage. Inflammation of vagina and vulva was diagnosed 328 days (SD = 95 days) prior to the detection of vulvar cancer. This delay was 186 days (SD = 196 days) in patients affected by diseases of Bartholin’s gland and 300 days (SD = 116 days) in those with other specified noninflammatory disorders of vulva including atrophy, hypertrophy, and cyst. The risk of vulvar cancer was positively associated with inflammation of vagina and vulva (OR = 2.28) and other specified noninflammatory disorders of vulva (OR = 5.39). The mean potential delay of vulvar cancer diagnosis ranged from 186 to 328 days.

Vulvar Cancer in China: Epidemiological Features and Risk Analysis

Objective: Describe for the first time the clinical, epidemiological features of vulvar cancer in southwest China. Identify risk factors and provide reference for the prevention of vulvar cancer. Method: We retrospectively analyzed 885 patients admitted to the West China Second University Hospital for vulvar diseases between 2006 and 2016. Vulvar cancer patients with previously diagnosed vulvar nonneoplastic epithelial disorders (n=132) were analyzed and compared to those without prior history of vulvar nonneoplastic epithelial disorders (n=219). Comparisons were also made among cancer patients and non-cancer patients with vulvar nonneoplastic epithelial disorders (n=288) and vulvar squamous intraepithelial lesions (n=246). The risk factors leading to vulvar cancer for the patients with vulvar nonneoplastic epithelial disorder were analyzed by univariate analysis. Furthermore, differences of the epidemiological features of vulvar nonneoplastic epithelial disorders, vulvar squamous intraepithelial lesion and vulvar cancer were identified. Results: According to the univariate analysis, age, first coital age, educational level, smoking, history of vaginal atrophy, HPV infection, lesion sites of the upper vulva and histo-pathological changes are strongly positively correlated with vulvar cancer. By comparing the features of vulvar cancer with those of the vulvar nonneoplastic epithelial disorder and vulvar squamous intraepithelial lesion, we found that on average patients with vulvar cancer had the highest age (ranged from 50 to 59), the lowest first coital age and the highest number of pregnancies and births. The incidences of vulvar nonneoplastic epithelial disorder and vulvar cancer were 1/1000 and 2.5/100,000 respectively with an increasing trend during last 10 years. Conclusion: Age, first coital age, educational level, smoking, atrophic vagina history, HPV infection, lesion sites of the upper vulva and histo-pathological changes are the risk factors that lead to vulvar cancer. Vulvar nonneoplastic epithelial disorder, vulvar squamous intraepithelial lesion and vulvar cancer each has distinct epidemiological features. Prompt surgical intervention and subsequent treatments are the key to a better outcome of vulvar cancer.

Clitoral involvement of squamous cell carcinoma of the vulva: localization with the worst prognosis

OBJECTIVE

The overall 5-year survival of patients with vulvar squamous cell carcinoma (SCC) is 70%. The clinical impression is that localization of SCC on the clitoris may lead to worse prognosis. The aim of this study is to assess the disease specific survival (DSS) in patients with clitoral SCC compared to patients with SCC without clitoral involvement.

METHODS

All consecutive patients with primary vulvar SCC treated with surgery at the Department of Gynaecologic Oncology at the Radboud university medical centre (Radboudumc) between March 1988 and January 2012, were analysed. The clinical and histopathological characteristics and DSS rates of patients with (N = 72) and without clitoral SCC (N = 275) were compared. Furthermore, patients with clitoral involvement were compared to patients with perineal SCCs (N = 52) and other central SCCs without clitoral and/or perineal involvement (N = 117).

RESULTS

Patients with clitoral SCC more often had larger and deeper invaded tumours, lymphovascular space involvement (LVSI), positive surgical margins and a higher percentage of positive lymph nodes. Kaplan-Meier survival analyses showed worse DSS in patients with a clitoral SCC compared to patients without clitoral involvement. Multivariable analysis showed that not clitoral involvement, but invasion depth, differentiation grade and lymph node status are independent prognostic factors.

CONCLUSIONS

Patients with clitoral SCC have worse survival compared to patients without clitoral involvement. This is probably caused by unfavourable histopathological characteristics of the tumour rather than the localization itself. Prospective studies are needed to further assess the influence of localization of the vulvar SCC on prognosis.

Surgery and radiotherapy in vulvar cancer

The majority of patients with vulvar cancer have squamous cell carcinomas (SCC). The cornerstone of the treatment is surgery. Radical vulvectomy with "en bloc" inguinofemoral lymphadenectomy has led to a favorable prognosis but with impressive morbidity. Nowadays, treatment is more individualized with wide local excision with uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as the standard treatment for early stage patients with SCC of the vulva with depth of invasion >1 mm without suspicious groins. In case of more than one intranodal lymph node metastasis and/or extranodal growth, postoperative radiotherapy on the groins and pelvis is warranted. Until now there is a limited role for primary radiotherapy on the vulva and/or groins in early stage disease. The sentinel lymph node (SLN) procedure with the combined technique (preoperative lymphoscintigraphy with a radioactive tracer and intraoperative blue dye) is a promising staging technique for patients with early stage vulvar cancer. The safety of clinical implementation of the SLN procedure and the role of additional histopathological techniques of the SLNs need to be further investigated before its wide-scale application. Patients with advanced vulvar cancer are difficult to treat. One of the problems in patients with locally advanced vulvar cancer is the high incidence of concomitant bulky lymph nodes in the groin(s). Ultraradical surgery in case of resectable disease will lead to impressive morbidity because of the exenterative-type procedure. (Chemo)radiation with or without surgery should be regarded as the first choice for patients with locally advanced vulvar cancer only when primary surgery will necessitate performance of a stoma. Further studies are needed to determine the optimal combined modality treatment in these patients. Due to the fact that vulvar cancer is a rare disease, further clinical studies will only be possible, when international collaborative groups will join forces in order to perform clinical trials, in which different treatment options such as SLN procedure, primary radiotherapy on the groins and multimodality treatment for advanced disease will be investigated.

Treatments patterns of vulvar cancer in the elderly

OBJECTIVE

To evaluate treatment patterns of vulvar cancer in patients over 80 years.

MATERIAL AND METHODS

Between 1979 and 1999, the Geneva Tumor Registry identified 230 women with vulvar cancer. Treatment of patients over 80 years and younger were compared. Kaplan-Meier analysis was used to determine disease specific cumulative survival.

RESULTS

Young women are more likely to present in situ lesions compared to their older counterparts. Majority of vulvar cancers were observed in women >or=80 (p<0.001) at more advanced stages. Elderly women have either no treatment, either unconventional or inadequate treatments. The Mantel-Haentzel analysis shows a 23.4 OR (IC (95%) 2.9-186.6) of not being treated if the patient is over 80. Specific 5-years survival was 93% in stage I, compared to 21% in stage IV.

CONCLUSION

Patients over 80 years are diagnosed at more advanced stages. Less aggressive treatments decrease outcome.

Changes in the management of vulval cancer

Vulval carcinoma is relatively rare. The disease spreads from the vulva through embolization to the locoregional lymphatic station, the inguinofemoral nodes. Prior to this event cure can be achieved, but rarely predicted with certainty. This chapter reviews current therapeutic knowledge and recognizes the increasing importance of individualization of a treatment plan. The adoption of these principles will hopefully evolve a pattern of care that leads to a decrease in morbidity for those women with early tumours and less morbid but more effective strategies for those with advanced disease.

Screening for occult nodal metastasis in squamous cell carcinoma of the vulva

Metastases to inguinofemoral lymph nodes in patients with carcinoma of the vulva alter the prognosis and treatment of this disease. Our goal was to determine if immunohistochemical staining could reveal occult metastatic nodal disease not detected with routine hematoxylin and eosin staining. We retrospectively examined a total of 110 lymph nodes from 10 patients who had undergone lymph node dissection and found to have all negative nodes. Paraffin embedded lymph nodes were immunostained with a monoclonal antibody directed against multiple low- and high-molecular weight cytokeratins. Micrometastases were not detected in any lymph nodes examined with immunohistochemistry. All positive and negative controls yielded satisfactory results. It is concluded that immunohistochemistry with cytokeratin antibodies does not provide greater sensitivity than routine hematoxylin and eosin staining for the detection of nodal metastases in vulvar carcinoma.

Diagnosis and treatment delay in gynecological malignancies. Does it affect outcome?

Delay of diagnosis and treatment of malignant tumors is perceived as unfavorably affecting outcome. However, tumor behavior may be determined early in the histogenesis process and the outcome may be more a function of the biologic properties of the tumor than of our ability to make an early diagnosis. The objective of the present review is to evaluate data concerning the effect of diagnosis and treatment delay on outcome in gynecological malignancies. A medline search including the terms diagnosis delay, treatment delay, outcome, vulvar carcinoma, cervical carcinoma, endometrial carcinoma and ovarian carcinoma was conducted and all pertinent articles in the English language were included. Relatively few investigations deal with the effect of diagnosis and treatment delay on prognostic factors and on outcome in invasive gynecological malignancies. The reviewed data do not seem to indicate an unequivocal deleterious effect of a delay of several weeks or even several months in patients with some gynecological malignancies. Intentional delay of diagnosis or treatment of gynecologic malignancies is unjustified; however, the data presented should encourage a closer scrutiny and possibly a revision of the concept of "early" diagnosis and of the notion that delay of any duration has a definite, unfavorable effect on outcome.

Selected epidemiological time trends of vulvar carcinoma in Israel

Recently, considerable demographic changes have occurred in Israel. The purpose of the present population-based nationwide epidemiological study of carcinoma of the vulva was to assess changes over time in incidence, relative frequency, age pattern and ethnic distribution. The study group included all 257 Jewish females with histologically confirmed neoplasms of the vulva diagnosed in Israel during the ten year period from 1985 to 1994. Data were obtained from the Israeli Cancer Registry and compared with data from a previous study covering a 13 year period (1961 to 1973). The relative frequency of carcinoma in situ (CIS) of the vulva increased significantly during the later period (from 5.4% to 12.8%), while that of invasive vulvar carcinoma declined significantly (from 80.6% to 69.6%). Regarding invasive vulvar carcinoma, a significant decrease in the age-adjusted standardized rates and in the mean annual incidence rate in the 70+ age group was found. The ethnic distribution pattern of invasive vulvar carcinoma did not change and remained similar to that of cervical carcinoma, namely a trend for higher incidence among women born in North Africa. The increased frequency of vulvar CIS is attributed mainly to a greater propensity to perform vulvar biopsies. The possibility of a consequent decline of vulvar carcinoma cannot be ruled out.

Tumor angiogenesis in vulvar squamous cell carcinoma

OBJECTIVE

Angiogenesis has been shown to correlate positively with the presence of metastatic disease in some tumors, but has not been studied in invasive vulvar squamous cell carcinoma. Fifty cases of invasive vulvar squamous cell carcinoma were studied in an effort to correlate angiogenesis with stage, survival, and pattern of invasion.

METHODS

These patients were diagnosed between 1987 and 1993. Microvessels were identified immunohistochemically using antibody to Factor VIII, and areas of greatest microvessel density associated with tumor were counted. The pattern of invasion was categorized as "spray," "pushing," or "mixed." The mean microvessel count was correlated with surgical and clinical stage, pattern of invasion, and survival.

RESULTS

Mean microvessel counts in surgical stage I/II cases (31.1 +/- 7.3) were not significantly different from stage III/IV cases (26.3 +/- 8.6) (P = 0.089). Similarly mean microvessel counts in clinical stage I/II cases (31.6 +/- 11.9) were not significantly different from stage III/IV cases (27.0 +/- 8.7) (P = 0.198). Seventeen patients who died of disease had mean counts of 26.1 +/- 6.4, while 21 patients alive with or without evidence of disease had counts of 31.1 +/- 10.8 (P = 0.087). Mean microvessel counts did not vary significantly with the spray pattern (30.1 +/- 8. 7), pushing pattern (31.4 +/- 12.9), or mixed pattern of invasion (31.4 +/- 12.9) (P = 0.920).

CONCLUSIONS

Tumor angiogenesis in vulvar squamous cell carcinoma does not correlate positively with stage, survival, or pattern of invasion and cannot be used as a prognostic indicator.