1
|
Superficially Invasive Vulvar Squamous Cell Carcinoma: A 37-Year-Long Experience of a Tertiary Referral Center. Cancers (Basel) 2021; 13:cancers13153859. [PMID: 34359760 PMCID: PMC8345506 DOI: 10.3390/cancers13153859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022] Open
Abstract
Superficially, invasive vulvar squamous cell carcinoma (SISCCA) (FIGO stage IA) is a rare subset of vulvar cancer defined as a single lesion measuring ≤2 cm with a depth of invasion of ≤1.0 mm. This is a retrospective study performed on 48 patients with SISCCA, surgically treated between 1981 and 2018 at the S. Anna Hospital, University of Turin, to evaluate pathological characteristics and prognosis of these tumors. Ten patients (21%) recurred: seven (14%) as SISCCA and three (7%) as deeply invasive carcinoma. One case with perineural invasion and groin node metastasis at recurrence. No patient had groin lymph node metastases at initial diagnosis. Site of SISCCA, type of surgery, status of surgical margins, and histopathological features did not differ between recurrent and non-recurrent patients. We observed a non-significant trend towards an increase of recurrences in younger women (median age: 63 years vs. 70 years, p = 0.09), while, surprisingly, smaller tumors (<12 mm) were significantly related to tumor relapse (p = 0.03). Overall, SISCCA has a good long-term prognosis, regardless of the pathological characteristics and the type of surgical treatment. We recommend close follow-up, especially for younger patients and for small tumors, due to the possibility of recurrence or re-occurrence even after years.
Collapse
|
2
|
Serre E, Diguisto C, Body G, Raimond E, Bendifallah S, Touboul C, Graesslin O, Carcopino X, Ballester M, Daraï E, Ouldamer L. [Prognostic significance of groin lymph node ratio in vulvar squamous cell carcinoma]. ACTA ACUST UNITED AC 2020; 48:729-735. [PMID: 32339764 DOI: 10.1016/j.gofs.2020.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim was to review the clinical impact of lymph node ratio (LNR) of groin metastatic nodal disease in women with vulvar squamous cell carcinoma. MATERIAL AND METHODS Cohort study of women with vulvar squamous cell carcinoma, managed between January 2005 and December 2015, in five institutions in France with prospectively maintained databases (French multicenter tertiary care centers). POPULATION In total, 636 women managed for VSCC of whom 508 (79.9%) underwent surgical groin nodal staging. MAIN OUTCOME MEASURES Comparison of overall and recurrence free survival between women according to LNR. RESULTS In total, 176 women (34.6%) had at least one positive lymph node (LN). There was a significant differences for the 5-year overall survival and recurrence free survival rates between women with LNR>0.2 and women with LNR<0.2. CONCLUSION LNR seems to be a significant prognostic factor in women with vulvar squamous cell carcinoma.
Collapse
Affiliation(s)
- E Serre
- Department of Gynecology, CHU de Tours, Tours, France; Inserm U1069, Université François-Rabelais, Tours, France
| | - C Diguisto
- Department of Gynecology, CHU de Tours, Tours, France
| | - G Body
- Department of Gynecology, CHU de Tours, Tours, France; Inserm U1069, Université François-Rabelais, Tours, France
| | - E Raimond
- Department of Obstetrics and Gynecology, Institute Alix-de-Champagne, University Hospital, Reims, France
| | - S Bendifallah
- Department of Obstetrics and Gynecology, GRC-6 UPMC, Hôpital Tenon, Université Pierre et Marie-Curie, AP-HP, Paris 6, France; UMR S 707, Epidemiology, Information Systems, Modeling, Université Pierre et Marie-Curie, Paris, France
| | - C Touboul
- Department of Obstetrics and Gynecology, centre hospitalier intercommunal, Créteil, France
| | - O Graesslin
- Department of Obstetrics and Gynecology, Institute Alix-de-Champagne, University Hospital, Reims, France
| | - X Carcopino
- Department of Gynecological surgery, AP-HP, Marseille, France
| | - M Ballester
- Department of Obstetrics and Gynecology, Institute Alix-de-Champagne, University Hospital, Reims, France; Inserm UMR S 938, Université Pierre et Marie-Curie, Paris, France
| | - E Daraï
- Department of Obstetrics and Gynecology, GRC-6 UPMC, Hôpital Tenon, Université Pierre et Marie-Curie, AP-HP, Paris 6, France; Inserm UMR S 938, Université Pierre et Marie-Curie, Paris, France
| | - L Ouldamer
- Department of Gynecology, CHU de Tours, Tours, France; Inserm U1069, Université François-Rabelais, Tours, France.
| | | |
Collapse
|
3
|
Associated Lichen Sclerosis Increases the Risk of Lymph Node Metastases of Vulvar Cancer. J Clin Med 2020; 9:jcm9010250. [PMID: 31963481 PMCID: PMC7019519 DOI: 10.3390/jcm9010250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 01/24/2023] Open
Abstract
The most important prognostic factor in vulvar cancer is inguinal lymph node status at the time of diagnosis, even in locally advanced vulvar tumors. The aim of our study was to identify the risk factors of lymph node involvement in these women, especially the impact of lichen sclerosis (LS). We conducted a retrospective population-based cross-sectional study in two French referral gynecologic oncology institutions. We included all women diagnosed with a primary invasive vulvar cancer. Epithelial alteration adjacent to the invasive carcinoma was found in 96.8% (n = 395). The most frequently associated was LS in 27.7% (n = 113). In univariate analysis, LS (p = 0.009); usual type VIN (p = 0.04); tumor size >2 cm and/or local extension to vagina, urethra or anus (p < 0.01), positive margins (p < 0.01), thickness (p < 0.01) and lymphovascular space invasion (LVSI) (p < 0.01) were significantly associated with lymph node involvement. In multivariate analysis, only LS (OR 2.3, 95% CI [1.2-4.3]) and LVSI (OR 5.6, 95% CI [1.7-18.6]) remained significantly associated with positive lymph node. LS was significantly associated with older patients (p = 0.005), anterior localization (p = 0.017) and local extension (tumor size > 2 cm: p = 0.001). LS surrounding vulvar cancer is an independent factor of lymph node involvement, with local extension and LVSI.
Collapse
|
4
|
The Prevalence of Lichen Sclerosus in Patients With Vulvar Squamous Cell Carcinoma. Int J Gynecol Pathol 2017; 36:305-309. [DOI: 10.1097/pgp.0000000000000341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
5
|
Nooij LS, Brand FAM, Gaarenstroom KN, Creutzberg CL, de Hullu JA, van Poelgeest MIE. Risk factors and treatment for recurrent vulvar squamous cell carcinoma. Crit Rev Oncol Hematol 2016; 106:1-13. [PMID: 27637349 DOI: 10.1016/j.critrevonc.2016.07.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/02/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022] Open
Abstract
Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.
Collapse
Affiliation(s)
- L S Nooij
- Department of Gynecology, LUMC, Netherlands
| | | | | | | | - J A de Hullu
- Department of Gynecology, Radboud UMC, Netherlands
| | | |
Collapse
|
6
|
Adjacent Lichen Sclerosis predicts local recurrence and second field tumour in women with vulvar squamous cell carcinoma. Gynecol Oncol 2016; 142:420-6. [PMID: 27396942 DOI: 10.1016/j.ygyno.2016.06.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 06/23/2016] [Accepted: 06/26/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE In this study, we investigated if the presence of histologically abnormal epithelium adjacent to the primary tumour influenced the frequency, timing, and topography of local vulvar recurrences (LVR) following treatment for squamous cell carcinoma of the vulva (VSCC). METHODS The study population comprised a cohort of 201 consecutive cases with incident VSCC. LVR were categorised as local relapses (LR) if they occurred <2cm from the tumour margins, and as second field tumours (SFT) when ≥2cm from these margins. Univariable and multivariable competing risk modelling was performed to identify the prognostic factors associated with local disease recurrence. RESULTS The characterization of the epithelium adjacent to the invasive component was possible for 199 (99.0%) patients. Of these, 171 (85.9%) were found to have intraepithelial abnormalities found adjacent to the surgical specimen. Multivariable analyses revealed that, following adjustment, Lichen Sclerosis (LS) was associated with an increase in the incidence of LVR, LR and SFT (SHRs: 3.4, 2.7 and 4.4, respectively). Although the incidence of LR and SFT in women with LS associated VSCC was similar, the peak incidence of SFT occurred more than two years before that of LR. CONCLUSIONS Women with VSCC arising in a field of LS may continue to have an increased risk of developing LR and SFT for many years after resection of their primary tumour. Our study suggests that these women should be followed up more regularly so that LVR can be detected earlier; unless a more robust surveillance programme or chemopreventative treatments become available.
Collapse
|
7
|
|
8
|
Iacoponi S, Zapardiel I, Diestro MD, Hernandez A, De Santiago J. Prognostic factors associated with local recurrence in squamous cell carcinoma of the vulva. J Gynecol Oncol 2013; 24:242-8. [PMID: 23875074 PMCID: PMC3714462 DOI: 10.3802/jgo.2013.24.3.242] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Revised: 12/27/2012] [Accepted: 01/09/2013] [Indexed: 11/30/2022] Open
Abstract
Objective To analyze the prognostic factors related to the recurrence rate of vulvar cancer. Methods Retrospective study of 87 patients diagnosed of vulvar squamous cell carcinoma diagnosed at a tertiary hospital in Madrid between January 2000 and December 2010. Results The pathological mean tumor size was 35.1±22.8 mm, with stromal invasion of 7.7±6.6 mm. The mean free margin after surgery was 16.8±10.5 mm. Among all patients, 31 (35.6%) presented local recurrence (mean time 10 months; range, 1 to 114 months) and 7 (8%) had distant metastases (mean time, 5 months; range, 1 to 114 months). We found significant differences in the mean tumor size between patients who presented a relapse and those who did not (37.6±21.3 mm vs. 28.9±12.1 mm; p=0.05). Patients with free margins equal or less than 8 mm presented a relapse rate of 52.6% vs. 43.5% of those with free margin greater than 8 mm (p=0.50). However, with a cut-off of 15 mm, we observed a local recurrence rate of 55.6% vs. 34.5%, respectively (p=0.09). When the stromal invasion cut-off was >4 mm, local recurrence rate increased up to 52.9% compared to 37.5% when the stromal invasion was ≤4 mm (p=0.20). Conclusion Tumor size, pathologic margin distance and stromal invasion seem to be the most important predictors of local vulvar recurrence. We consider the cut-off of 35 mm of tumor size, 15 mm tumor-free surgical margin and stromal invasion >4 mm, high risk predictors of local recurrence rate.
Collapse
Affiliation(s)
- Sara Iacoponi
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | | | | | | |
Collapse
|
9
|
del Pino M, Rodriguez-Carunchio L, Ordi J. Pathways of vulvar intraepithelial neoplasia and squamous cell carcinoma. Histopathology 2012. [DOI: 10.1111/his.12034] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Marta del Pino
- Faculty of Medicine; Institute Clinic of Gynaecology, Obstetrics and Neonatology; Hospital Clinic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); University of Barcelona; Barcelona; Spain
| | - Leonardo Rodriguez-Carunchio
- Department of Pathology; Faculty of Medicine; CRESIB (Centre de Recerca en Salut Internacional de Barcelona); Hospital Clinic; University of Barcelona; Barcelona; Spain
| | - Jaume Ordi
- Department of Pathology; Faculty of Medicine; CRESIB (Centre de Recerca en Salut Internacional de Barcelona); Hospital Clinic; University of Barcelona; Barcelona; Spain
| |
Collapse
|
10
|
Canlorbe G, Rouzier R, Bendifallah S, Chéreau E. [Impact of sentinel node technique on the survival in patients with vulvar cancer: analysis of the Surveillance, Epidemiology, and End Results (SEER) database]. ACTA ACUST UNITED AC 2012; 40:647-51. [PMID: 22985904 DOI: 10.1016/j.gyobfe.2012.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 05/09/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Vulvar cancer is usually treated with vulvectomy and bilateral groin lymphadenectomy, which result in serious morbidities while only 30% of patients have positive nodes. The sentinel node technique has good sensitivity and specificity for detecting lymph node involvement while minimizing postoperative morbidity. The aim of this study was to evaluate the specific and overall survival impact of sentinel lymph node procedure versus inguinofemoral lymphadenectomy in patients with vulvar cancer. PATIENTS AND METHODS This is a retrospective study from the Surveillance, Epidemiology, and End Results (SEER) database on patients with vulvar squamous cell carcinoma, T1 or T2 stage, metastatis-free, followed between 2004 and 2008. RESULTS One thousand and thirty eight patients had a systematic groin lymphadenectomy and 56 a sentinel node technique (including 22 with an associated lymphadenectomy because of a positive sentinel node). There is no significant difference in overall or specific survival between the two groups. In multivariate analysis, age, T stage and nodal status are prognostic factors for overall and specific mortality (P<0.05). DISCUSSION AND CONCLUSION Sentinel node technique is not associated with an excess risk of mortality or recurrence.
Collapse
Affiliation(s)
- G Canlorbe
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Tenon, Assistance publique-Hôpitaux de Paris, 4, rue de la Chine, 75020 Paris, France
| | | | | | | |
Collapse
|
11
|
Screening and follow up of vulval skin disorders. Best Pract Res Clin Obstet Gynaecol 2011; 26:175-88. [PMID: 22189088 DOI: 10.1016/j.bpobgyn.2011.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Accepted: 11/03/2011] [Indexed: 02/06/2023]
Abstract
Vulval squamous cell carcinoma is relatively rare; however, up to 20% of women have significant vulval symptoms during their lifetime. Formal screening programmes for vulval disease have not been established. The evidence for the use of vulval cytology and vulvoscopy is reviewed. No randomised-controlled trials have compared follow-up regimens, and although a few consensus documents have been published, formal guidelines are lacking in Grade A evidence. With increasing pressure on healthcare resources, the possibility of identifying high-risk groups to optimise the use of follow up in specialist clinics is explored. Vulval disease is uncommon and there is no evidence that screening would decrease incidence. If high-risk groups can be identified, follow up should take place in specialised vulval clinics with experienced clinicians who are trained in vulval disease. Women with uncomplicated vulval conditions should be discharged to patient-initiated follow up or primary care. Central to the reduction of mortality and morbidity is increased awareness of vulval conditions among women and improved education of healthcare professionals, with particular understanding of the importance of physical examination.
Collapse
|
12
|
Is Differentiated Vulval Intraepithelial Neoplasia the Precursor Lesion of Human Papillomavirus-Negative Vulval Squamous Cell Carcinoma? Int J Gynecol Cancer 2011; 21:1297-305. [DOI: 10.1097/igc.0b013e31822dbe26] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
13
|
|
14
|
de Bie RP, van de Nieuwenhof HP, Bekkers RLM, Melchers WJG, Siebers AG, Bulten J, Massuger LFAG, de Hullu JA. Patients with usual vulvar intraepithelial neoplasia-related vulvar cancer have an increased risk of cervical abnormalities. Br J Cancer 2009; 101:27-31. [PMID: 19513077 PMCID: PMC2713690 DOI: 10.1038/sj.bjc.6605124] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Vulvar squamous cell carcinoma (SCC) originates the following two pathways, related to differentiated (d) vulvar intraepithelial neoplasia (VIN) or to human papillomavirus (HPV)-related usual (u) VIN. Multicentric HPV infections (cervix, vagina and vulva) are common. We hypothesise that patients with a uVIN-related vulvar SCC more often have cervical high-grade squamous intraepithelial lesions (HSILs) compared with women with dVIN-related vulvar SCC. Methods: All vulvar SCCs (201) were classified to be dVIN- (n=164) or uVIN related (n=37). Data with regard to the smear history and cervical histology were retrieved from PALGA, the nationwide Netherlands database of histo- and cytopathology. For HSIL cervical smears of which histology was taken, HPV DNA analysis on both the vulvar and cervical specimens was performed. Results: At least one smear was available in 145 (72%) of the 201 patients. Patients with a uVIN-related vulvar SCC more often had an HSIL compared with patients with a dVIN-related SCC (35 vs 2%, P<0.001). A total of 10 of the 13 HSILs were histologically assessed and identical HPV types were found in the vulva and cervix. Conclusion: These data emphasise the necessity to differentiate between dVIN- and uVIN-related vulvar tumours and to examine the entire lower female ano-genital tract once an uVIN-related lesion is found.
Collapse
Affiliation(s)
- R P de Bie
- Department of Obstetrics and Gynaecology (791), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
15
|
Eva LJ, Ganesan R, Chan KK, Honest H, Luesley DM. Differentiated-Type Vulval Intraepithelial Neoplasia Has a High-Risk Association With Vulval Squamous Cell Carcinoma. Int J Gynecol Cancer 2009; 19:741-4. [DOI: 10.1111/igc.0b013e3181a12fa2] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
|
16
|
Rogers LJ, Howard B, Van Wijk L, Wei W, Dehaeck K, Soeters R, Denny LA. Chemoradiation in Advanced Vulval Carcinoma. Int J Gynecol Cancer 2009; 19:745-51. [DOI: 10.1111/igc.0b013e3181a13021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
17
|
van de Nieuwenhof H, van der Avoort I, de Hullu J. Review of squamous premalignant vulvar lesions. Crit Rev Oncol Hematol 2008; 68:131-56. [DOI: 10.1016/j.critrevonc.2008.02.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2007] [Revised: 02/15/2008] [Accepted: 02/26/2008] [Indexed: 01/31/2023] Open
|
18
|
Raspollini MR, Asirelli G, Moncini D, Taddei GL. A comparative analysis of lichen sclerosus of the vulva and lichen sclerosus that evolves to vulvar squamous cell carcinoma. Am J Obstet Gynecol 2007; 197:592.e1-5. [PMID: 17714682 DOI: 10.1016/j.ajog.2007.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 01/31/2007] [Accepted: 04/05/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether the premalignant change in lichen sclerosus (LS) could be identified with immunohistochemical analyses. STUDY DESIGN Eight cases of histologically diagnosed vulvar LS, which showed, after a period of 10 months-9 years, an evolution to carcinoma of the vulva that was histologically documented, were compared with 8 cases of vulvar LS, for which follow-up information was available for at least 9 years. The proliferative index and the expression of tumor suppressors p16 and p53 were analyzed. RESULTS The difference of MIB1 labeling index of evolving or unchanged LS cases was significant (P = .005). The difference in the p53 of evolving or unchanged LS cases shows a trend towards association (P = .08). Both LS cases (evolving or unchanged) did not show p16 positive staining. CONCLUSION The evaluation of MIB1 and p53 may identify those vulvar LS cases with a high likelihood of evolving into squamous cell carcinoma, which would need careful periodic checks or adjunctive biopsies. The study must be confirmed by a larger number of cases to substantiate this observation.
Collapse
Affiliation(s)
- Maria Rosaria Raspollini
- Department of Human Pathology and Oncology, University of Florence School of Medicine, Florence, Italy.
| | | | | | | |
Collapse
|
19
|
Abstract
The objective of this review is to summarize the published data about squamous carcinoma of the vulva and to identify promising areas for future investigation. Rather than the routine use of complete radical vulvectomy, a radical wide excision of the vulvar lesion to achieve at least a 1-cm gross margin appears sufficient to treat the primary lesion. A surgical assessment of the groin is required for all patients who have invasion greater than 1 mm. Ipsilateral groin node dissection can be performed through a separate incision. All the nodal tissue medial to the vessels and above the fascia should be removed. Sentinel node evaluation may be a significant step forward, but the false-negative rate is not well enough defined to consider this a standard. Patients with positive inguinal nodes at groin dissection should receive radiation therapy to the ipsilateral groin and hemipelvis. For those patients who have unresectable primary disease or if nodes are palpably suspicious, fixed, and/or ulcerated preoperatively, chemoradiation is the preferred option. Exenterative procedures may rarely be required. Chemotherapy for recurrent or metastatic disease has not been proven to be of value. Although survival rates are high for those with negative nodes, the morbidity associated with standard radical techniques has prompted innovation. Adequately powered trials aimed at further reducing morbidity without compromising survival are underway.
Collapse
Affiliation(s)
- Frederick B Stehman
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
| | | |
Collapse
|
20
|
Raspollini MR, Asirelli G, Taddei GL. The role of angiogenesis and COX-2 expression in the evolution of vulvar lichen sclerosus to squamous cell carcinoma of the vulva. Gynecol Oncol 2007; 106:567-71. [PMID: 17560634 DOI: 10.1016/j.ygyno.2007.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 04/25/2007] [Accepted: 05/10/2007] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We aimed to determine whether premalignant changes in vulvar lichen sclerosus (LS) could be identified by analysing markers of angiogenesis and the expression of the enzyme cyclooxygenase-2 (COX-2). METHODS Eight cases of histologically diagnosed vulvar LS, which showed an evolution to carcinoma of the vulva histologically documented, were compared to 10 cases of vulvar LS, for which follow-up information was available for at least 9 years, and to 10 cases of LS adjacent to squamous cell carcinoma (SCC) of the vulva. The microvessel density (MVD), and the expression of vascular endothelial growth factor (VEGF) and of COX-2 were analysed. RESULTS Difference of MVD between unchanged LS cases and LS cases evolving to SCC and LS adjacent to SCC cases was statistically significant (P=0.008, Wilcoxon Mann-Whitney test). Difference of VEGF and COX-2 expression between unchanged LS cases and LS cases evolving to SCC and LS adjacent to SCC cases were statistically significant (P=0.007 and P=0.01, respectively; Fisher's exact test). CONCLUSIONS Our study addresses the possibility that immunohistochemical studies may add information to permit the identification of LS as a precursor lesion that has a greater potential to evolve into SCC. These data may identify characteristics of vulvar LS disclosing alterations that indicate the further development to cancer; therefore, it may allow the identification of a group of LS patients who need a careful follow-up and adjunctive biopsies.
Collapse
Affiliation(s)
- Maria Rosaria Raspollini
- Department of Human Pathology and Oncology, School of Medicine University of Florence, Viale G.B. Morgagni, 85. 50134 Florence, Italy.
| | | | | |
Collapse
|
21
|
Rotsztejn H, Trznadel-Budźko E, Jesionek-Kupnicka D. Do Langerhans cells play a role in vulvar epithelium resistance to squamous cell carcinoma? Arch Immunol Ther Exp (Warsz) 2007; 55:127-30. [PMID: 17417693 PMCID: PMC2765642 DOI: 10.1007/s00005-007-0016-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 07/17/2006] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Langerhans cells (LCs) are a very important part of the skin immune system. MATERIALS AND METHODS Skin biopsies taken from 13 women after the removal of vulvar squamous cell carcinoma (SCC) who had not been treated earlier for any vulvar diseases were investigated. The control group consisted of 12 women who underwent a plastic surgical operation of the vulva region. Immunohistochemical staining was performed on formalin-fixed, paraffin-embedded tissues samples using antihuman CD1a antibody (NCL-CD1a-235, Novocastra). RESULTS This study showed a large decrease in LCs in vulvar SCC. CONCLUSIONS It is postulated that the reduction in the number of LCs may be one of the reasons for a higher tendency of carcinogenesis in the vulvar region. Their role as a main element of the skin immune system in the initiation of this process needs further investigation. It is possible that research on LCs in the skin will cast a new light on their role and even contribute to the prophylaxis and treatment of skin and mucosa carcinomas.
Collapse
Affiliation(s)
- Helena Rotsztejn
- Section of Dermatology, Research Institute of the Polish Mother's Memorial Hospital, Rzgowska 281/284, 93-338 Łódź, Poland.
| | | | | |
Collapse
|
22
|
Ayhan A, Guvendag Guven ES, Guven S, Sakinci M, Kucukali T. Medical treatment of vulvar squamous cell hyperplasia. Int J Gynaecol Obstet 2006; 95:278-83. [PMID: 17010347 DOI: 10.1016/j.ijgo.2006.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 06/23/2006] [Accepted: 06/27/2006] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia. METHODS Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy. RESULTS The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy. CONCLUSION Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.
Collapse
Affiliation(s)
- A Ayhan
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | | | | | | |
Collapse
|
23
|
van Seters M, ten Kate FJW, van Beurden M, Verheijen RHM, Meijer CJLM, Burger MPM, Helmerhorst TJM. In the absence of (early) invasive carcinoma, vulvar intraepithelial neoplasia associated with lichen sclerosus is mainly of undifferentiated type: new insights in histology and aetiology. J Clin Pathol 2006; 60:504-9. [PMID: 16714399 PMCID: PMC1994523 DOI: 10.1136/jcp.2005.031989] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Differentiated vulvar intraepithelial neoplasia (VIN) is presumed to be the precursor of invasive squamous cell carcinoma (SCC) of the vulva. It is commonly assumed that differentiated VIN is related to lichen sclerosus (LS). However, evidence for this is limited to a small number of studies describing epithelial alterations adjacent to vulvar SCC. AIM To study the histology and human papillomavirus (HPV) status in patients with a history of both LS and VIN without coexistent SCC. METHODS Original biopsy specimens and surgical specimens of patients retrieved from the pathology files were revised for the presence of LS, VIN and (early) invasive SCC, specifically focused on the two different types of VIN: differentiated and undifferentiated. Thereafter, VIN lesions were tested for the presence of HPV DNA. RESULTS Twenty-seven patients fulfilled the criteria for LS and VIN without SCC. In all 27 patients, LS was found to be related to undifferentiated VIN. Grading yielded the following results: VIN 1 (n=10), VIN 2 (n=11) and VIN 3 (n=6). Additionally, VIN lesions from 26 patients could be tested for the presence of HPV DNA. HPV DNA, predominantly type 16, was present in 8 (31%) of them. Seven of these eight patients had VIN 2 or 3. During follow-up, three patients progressed to (early) invasive carcinoma. In two of these patients, differentiated VIN was observed overlying early invasive SCC. CONCLUSIONS VIN related to LS without coexisting SCC is likely to be undifferentiated, in contrast to what was previously thought. HPV DNA was demonstrated in 31% of the lesions, and was strongly related to high-grade VIN.
Collapse
Affiliation(s)
- M van Seters
- Department of Gynaecology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
24
|
Rouzier R, Preti M, Haddad B, Martin M, Micheletti L, Paniel BJ. Development and Validation of a Nomogram for Predicting Outcome of Patients With Vulvar Cancer. Obstet Gynecol 2006; 107:672-7. [PMID: 16507940 DOI: 10.1097/01.aog.0000198639.36855.e9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To construct and validate a nomogram to predict relapse-free survival of patients treated for vulvar cancer. METHODS Data from 244 patients treated for vulvar cancer at a single institution (Creteil, France) were used as a training set to develop and calibrate a nomogram for predicting relapse-free survival and local relapse-free survival. We used bootstrap resampling for the internal validation and we tested the nomogram on an independent validation set of patients (Torino, Italy) for the external validation. RESULTS The nomograms were based on a Cox proportional hazards regression model. Covariates for the relapse-free survival model included age, T stage, number of metastatic nodes, bilateral lymph node involvement, omission of the lymphadenectomy, margin status, lymphovascular space invasion, and depth of invasion. The concordance indices were 0.85 and 0.83 in the training set before and after bootstrapping, respectively, and 0.83 in the validation set. The predictions of our nomogram discriminated better than did the International Federation of Gynecology and Obstetrics stage (0.83 compared with 0.78, P = .01). The calibration of our nomogram was good. In the validation set, 2-year and 5-year relapse-free survival were well predicted with less than 5% difference between the predicted and observed survivals for each quartile. A nomogram for predicting local relapse was also developed. CONCLUSION We have developed nomograms for predicting distant and local relapse of vulvar cancer at 2 and 5 years and validated them both internally and externally. These nomograms will be freely available on the International Society for the Study of Vulvovaginal Disease Web site. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Roman Rouzier
- Department of Gynecology and Obstetrics, Centre Hospitalier Intercommunal de Créteil, University Paris 12, Créteil, France.
| | | | | | | | | | | |
Collapse
|
25
|
Olejek A. Use of prolene mesh in surgical treatment of tissue defects after radical inguinal and pelvic lymph node dissection in vulvar cancer--a brief report. Int J Gynecol Cancer 2006; 16:448-51. [PMID: 16445677 DOI: 10.1111/j.1525-1438.2006.00501.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Surgery is still the procedure of choice in treatment of advanced vulvar cancer. Radical vulvar surgery is often associated with severe vulvar and inguinal skin and fat-tissue deficits resulting from wide "butterfly" shape resection. Primary closure of large vulvar and inguinal defects is hampered by lack of tissue. The study presents the case of using prolene mesh in filling up the tissue defects over femoral vein and artery after radical excision of enlarged inguinal superficial, femoral, and pelvic nodes to prevent vessels in hiatus saphenus. It is the first report describing the use of prolene mesh in such a procedure.
Collapse
Affiliation(s)
- A Olejek
- Department of Gynecology and Obstetrics, Silesian Medical University, ul. Batorego 15, 41-902 Bytom, Poland.
| |
Collapse
|
26
|
Abstract
In a busy dermatologic practice, it may be frustrating to encounter a vulvar disease patient, who must fully disrobe for examination. Further, the wet mounts, cultures, biopsies, and patient education required for treatment of vulvar disorders take up considerable time. However, most patients will respond to appropriate therapy, and can be very gratifying to treat.
Collapse
Affiliation(s)
- Kelly D Werlinger
- Freeman-Cockerell Dermatopathology Laboratories, 2330 Butler Street, Suite 115, Dallas, TX 75235-9330, USA
| | | |
Collapse
|
27
|
Preti M, Rouzier R, Mariani L, Wilkinson EJ. Superficially Invasive Carcinoma of the Vulva: Diagnosis and Treatment. Clin Obstet Gynecol 2005; 48:862-8. [PMID: 16286832 DOI: 10.1097/01.grf.0000179668.14187.3a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mario Preti
- Department of Obstetrics and Gynecology, University of Torino, Torino, Italy.
| | | | | | | |
Collapse
|
28
|
Affiliation(s)
- R Rouzier
- Centre Hospitalier Intercommunal de Creteil, Creteil, France.
| | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- C Renaud-Vilmer
- Spécialiste des Centres anti-cancéreux, Centre René-Huguenin, Saint-Cloud
| | | | | |
Collapse
|
30
|
van der Velden J, Schilthuis MS, Hyde SE, Ten Kate FJW, Burger MPM. Squamous cell cancer of the vulva with occult lymph node metastases in the groin: the impact of surgical technique on recurrence pattern and survival. Int J Gynecol Cancer 2004; 14:633-8. [PMID: 15304159 DOI: 10.1111/j.1048-891x.2004.14415.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The triple incision technique is an established surgical method of management for early vulvar cancer. There is only limited data available on the efficacy of this form of treatment for patients with occult inguinofemoral lymph node metastases. It was the objective of this study to obtain more insight into the efficacy of this treatment compared with the en bloc resection, when utilized in surgical pathological advanced disease. METHODS A retrospective review was performed in patients with vulvar cancer in the presence of occult inguinofemoral lymph node metastases. Tumor diameter, extracapsular nodal spread, FIGO stage, number of positive lymph nodes, and type of treatment were analyzed in relation to recurrence pattern and survival in both univariate and multivariate analyses. RESULTS There was no significant impact of surgical technique on disease-specific and overall survival. When corrected for other prognostic variables in a multivariate analysis, the type of surgical treatment was an independent predictor for vulvar recurrence (HR 0.10, 95% CI 0.02-0.44, P = 0.002) but not for inguinal/pelvic recurrence. CONCLUSION The type of surgical technique did not influence disease-specific and overall survival in patients with occult inguinofemoral lymph node metastases. The triple incision technique is an independent poor prognostic variable for vulvar recurrence.
Collapse
Affiliation(s)
- J van der Velden
- Department of Gynecology and Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
31
|
Abstract
The incidence of vulvar squamous cell carcinoma (SCC), the most common vulvar cancer in women, is increasing worldwide. Furthermore, despite the increasing prevalence, this disease is commonly misdiagnosed by physicians. Unfortunately, late-stage vulvar SCC has a poorer prognosis compared with early vulvar neoplasia and requires aggressive therapy such as radical surgical intervention. Therefore, early diagnosis by physicians is critical to reduce both the mortality and morbidity rates of vulvar SCC. This review discusses the etiology, clinical characteristics, and diagnostic staging of vulvar SCC. Treatment options are reviewed, including novel topical immunotherapies such as imiquimod.
Collapse
Affiliation(s)
- Stephen K Tyring
- UTMB Center for Clinical Studies, University of Texas Medical Branch, 301 University Boulevard, Route 1070, Galveston, TX 77555, USA.
| |
Collapse
|
32
|
Abstract
This review addresses recent and important advances in our knowledge of several uncommon or rare disorders of the vulva including Paget's disease, vulva intraepithelial neoplasia, lichen sclerosus and squamous hyperplasia and their relationship to squamous carcinoma. Emphasis is placed on the two biologically different types of squamous carcinoma related and unrelated to human papillomavirus infection. Finally, the relatively recent concept of the sentinel node as applied to vulva carcinoma is discussed.
Collapse
Affiliation(s)
- H Fox
- Department of Pathological Sciences, University of Manchester, Manchester, UK
| | | |
Collapse
|
33
|
Rouzier R, Haddad B, Dubernard G, Dubois P, Paniel BJ. Inguinofemoral dissection for carcinoma of the vulva: effect of modifications of extent and technique on morbidity and survival. J Am Coll Surg 2003; 196:442-50. [PMID: 12648697 DOI: 10.1016/s1072-7515(02)01895-1] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of modifications of extent (medial inguinal and medial femoral lymphadenectomy, inguinal lymphadenectomy, inguinal and medial femoral lymphadenectomy, and inguinofemoral lymphadenectomy) and surgical technique of lymphadenectomy (including sartorius transposition, preservation of the fascia lata, and preservation of the saphenous vein) on morbidity, groin recurrence, and survival in patients with vulvar carcinoma. STUDY DESIGN A retrospective review of 194 patients with primary squamous cell cancer of the vulva was conducted. Clinical, surgical, histopathologic, postoperative short- and longterm complications, and followup data were collected from patient records. RESULTS Inguinal lymphadenectomy and medial inguinal and medial femoral lymphadenectomy produced about half fewer nodes than did other surgical procedures. On the other hand, number of lymph nodes removed did not differ notably between inguinofemoral lymphadenectomy and inguinal and medial femoral lymphadenectomy. Logistic regression showed that obesity was associated with increased risk of cellulitis. Age greater than 70, obesity, and extent of lymphadenectomy increased wound breakdown risk. Factors associated with leg edema persisting for more than 6 months were: extent of lymphadenectomy, sartorius transposition, and adjuvant irradiation of groin area. With a mean followup time of 38 months, neither groin recurrence rate nor disease-specific survival markedly differed according to technique of lymphadenectomy. CONCLUSION Techniques of lymphadenectomy with preservation of fascia lata and saphenous vein are associated with a decreased risk of postoperative morbidity without jeopardizing outcomes.
Collapse
Affiliation(s)
- Roman Rouzier
- Department of Surgery, Institute Gustave Roussy, Villejuif, France
| | | | | | | | | |
Collapse
|
34
|
Rouzier R, Haddad B, Plantier F, Dubois P, Pelisse M, Paniel BJ. Local Relapse in Patients Treated for Squamous Cell Vulvar Carcinoma. Obstet Gynecol 2002. [DOI: 10.1097/00006250-200212000-00004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
35
|
Abstract
The incidence of human papilloma virus-related vulvar intraepithelial neoplasia is increasing worldwide. This is associated with an increasing incidence of invasive vulvar cancer in young women. Undifferentiated vulvar intraepithelial neoplasia has an invasive potential; a subset of very young patients with pigmented lesions and spontaneous regression has been described. Differentiated vulvar intraepithelial neoplasia is human papilloma virus negative and affects older women, who are at risk of invasive cancer. Chromosomal changes and angiogenesis may play a role in carcinogenesis. Immunocompromised women bear a substantial risk of vulvar intraepithelial neoplasia. These facts demand the awareness of both women and physicians, because there is evidence of diagnostic delays in patients with vulvar cancer. The standard treatment is surgical excision, which may be combined with laser treatment in extensive disease. Preliminary results of topical antiviral agents and photodynamic therapy are available, but remain to be confirmed by prospective, placebo-controlled studies.
Collapse
Affiliation(s)
- Elmar A Joura
- Department of Gynecology and Obstetrics, University of Vienna, Vienna, Austria.
| |
Collapse
|