Squamous cell carcinoma of the vulva: prognostic factors influencing survival

Prognostic value of lymph node ratio in surgically treated cases of vulvar cancer: a tertiary care centre experience

Objective

This study aimed to study the patterns of recurrence in surgically treated cases of vulvar cancer (VC) and determine the factors associated with recurrence, with a special emphasis on lymph node ratio (LNR).

Methods

This retrospective study examined VC patients primarily treated with surgery at our institute from January 2005 to December 2015. Demographic data, clinical characteristics, surgicohistopathological data, adjuvant treatment, follow up, and recurrence site and treatment were studied.

Results

Among the 111 cases treated, a recurrence rate of 18.9% was noted. Recurrence was most commonly local (61.9%). On univariate and multivariable analyses of clinicopathological parameters, an LNR >20 had the highest hazard ratio for recurrence.

Conclusion

LNR may provide useful prognostic information in VC patients with positive inguinal lymph node status.

Japan Society of Gynecologic Oncology guidelines 2015 for the treatment of vulvar cancer and vaginal cancer

BACKGROUND

Vulvar cancer and vaginal cancer are relatively rare tumors, and there had been no established treatment principles or guidelines to treat these rare tumors in Japan. The first version of the Japan Society of Gynecologic Oncology (JSGO) guidelines for the treatment of vulvar cancer and vaginal cancer was published in 2015 in Japanese.

OBJECTIVE

The JSGO committee decided to publish the English version of the JSGO guidelines worldwide, and hope it will be a useful guide to physicians in a similar situation as in Japan.

METHODS

The guideline was created according to the basic principles in creating the guidelines of JSGO.

RESULTS

The guidelines consist of five chapters and five algorithms. Prior to the first chapter, basic items are described including staging classification and history, classification of histology, and definition of the methods of surgery, radiation, and chemotherapy to give the reader a better understanding of the contents of the guidelines for these rare tumors. The first chapter gives an overview of the guidelines, including the basic policy of the guidelines. The second chapter discusses vulvar cancer, the third chapter discusses vaginal cancer, and the fourth chapter discusses vulvar Paget's disease and malignant melanoma. Each chapter includes clinical questions, recommendations, backgrounds, objectives, explanations, and references. The fifth chapter provides supplemental data for the drugs that are mentioned in the explanation of clinical questions.

CONCLUSION

Overall, the objective of these guidelines is to clearly delineate the standard of care for vulvar and vaginal cancer with the goal of ensuring a high standard of care for all women diagnosed with these rare diseases.

Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals. Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF). Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

Factors influencing primary treatment of midline vulvar cancers

OBJECTIVES

Advanced vulvar cancers involving midline structures pose a therapeutic challenge. Our objectives were to review the management and outcomes, and identify factors influencing primary treatment modality.

METHODS

Patients with midline vulvar cancers diagnosed from 1985 to 2012 were included in the analysis. Medical records were abstracted for demographics, clinico-pathological findings, treatment, and outcomes. Groin node status was defined by clinical findings or pathology. Survival was analyzed by Kaplan-Meier method and differences by log-rank test and Cox proportional hazards model. Factors influencing treatment modality were evaluated using stepwise logistic regression.

RESULTS

Forty-two patients were identified. Twenty-one underwent primary radical vulvectomy and 21 underwent primary radiation. Median tumor diameter was 3.4cm (range 2-9cm) for primary radical vulvectomy and 5cm (range 2.3-15cm) for primary radiation. Primary radiation was significantly associated with a tumor diameter ≥5cm (p=0.02), or when 2 or more midline (p=0.008) or 1 or more mucosal structures (p=0.03) were involved. On multivariate analysis, age and tumor diameter were predictors of progression-free survival (PFS) (p=0.02 and p=0.0004, respectively) and overall survival (OS) (p=0.03 and p=0.0005, respectively). Thirty-month OS for primary surgery and primary radiation was 74% and 71% (p=0.78), respectively. There were no differences in PFS or recurrence rates between the two treatment groups.

CONCLUSIONS

Clinical tumor diameter and the number of midline or mucosal structures involved influence selection of primary treatment modality. Survival outcomes and recurrence rates did not differ between treatment groups. Age and tumor diameter are important prognostic factors for survival.

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.

Validation of a nomogram for predicting outcome of vulvar cancer patients, primarily treated by surgery, in Korean population: multicenter retrospective study through Korean Gynecologic Oncology Group (KGOG-1010)

OBJECTIVE

Regarding vulvar cancer, a nomogram has been suggested for the prediction of relapse-free survival (RFS). While the nomogram has been developed and validated in a Western study, there was no validation in Korean population. Thus, we have undertaken the study to assess the applicability of nomogram for predicting RFS in Korean patients with vulvar cancer.

METHODS

A total of 204 cases newly diagnosed as vulvar cancer between 1982 and 2006 were identified. Among them 70 cases were not eligible due to inappropriate cell type (40 cases) and radiation as primary therapy (30 cases). Forty-four cases were not evaluable due to inadequate data and persistent disease. Finally a total of 90 patients primarily treated by surgery were included for analysis. Variables including age and the characteristics of primary tumor, nodal status, and surgical margin were collected for predicting RFS based on nomogram, which was compared with actual RFS. A calibration plot was drawn showing the actual versus predicted probability for 6 groups of patients segregated according to their predicted probabilities. In addition, discrimination of the nomogram was quantified with the concordance index.

RESULTS

Patients' mean age was 58 years and mean follow-up period was 47.9 months. Observed 2y- and 5y-RFS rates were 81% and 68%, respectively, corresponding to 79% and 72% in the original cohort. The trend line in calibration plot showed comparable concordance with an ideal line, having a slope of 1.04 for 2y-RFS (R(2)=.35) and 0.98 for 5y-RFS (R(2)=.80), respectively. The concordance index was 0.79 in the KGOG data set, which was improved to 0.82 with the data set limited to squamous cell carcinoma.

CONCLUSION

The nomogram provides the predictive capacity for relapse-free survival in Korean patients with vulvar cancer.

Aggressive locally recurrent vulvar cancer: review of cases presented to Massachusetts General Hospital 1990 to present

Isolated recurrences of squamous cell vulvar carcinoma treated by surgical re-excision have excellent outcomes. There is a subset of these patients who develop multiple local recurrences that are difficult to manage and have a high risk of dying from their cancers. We reviewed women presenting with vulvar cancer (200 patients) to Massachusetts General Hospital from 1990 to present and identified 12 women with aggressive, locally recurrent squamous cell carcinomas of the vulva. The identified women all had successful primary radical vulvectomy and groin node dissections with negative surgical margins (except patient 2) and lymph nodes with no lympho-vascular space invasion. Seven women had underlying lichen sclerosis. Eight had a history of vulvar intraepithelial neoplasia or persistent carcinoma in situ. Ten patients had greater than three recurrences after primary surgical therapy. One died of recurrent vulvar cancer 10 months after her initial diagnosis. Two patients died after three recurrences. The only unifying clinicopathologic factor among these women was persistent lichen sclerosis and persistent carcinoma in situ. Understanding the underlying mechanisms that predisposed these premalignant lesions to transform into carcinomas will help predict in which women these are likely to re-occur and may help determine which women require more aggressive initial treatment.

Long-term survival and disease recurrence in patients with primary squamous cell carcinoma of the vulva

OBJECTIVES

To assess time to failure and sites of failure with extended follow-up of patients with squamous cell carcinoma (SCC) of the vulva.

METHODS

A retrospective analysis of 330 patients with primary SCC of the vulva treated at Mayo Clinic between 1955 and 1990 was conducted. The main outcome measures were the rates of treatment failure. The Kaplan-Meier method and the log-rank test were used to estimate the rates of overall survival, disease-free survival, and recurrence. The Cox proportional hazards model was used to assess independent variables as prognostic factors for treatment failure.

RESULTS

All 330 patients in the cohort underwent lymphadenectomy; 113 patients (34.2%) had involvement of the inguinofemoral nodes and 88 patients (26.7%) had treatment failure. Treatment failures occurred more frequently in patients who presented with inguinal metastasis at the primary surgery and during the first 2 years of follow-up. After 2 years, both groups, with or without positive inguinal nodes, had similar treatment failure rates. Most patients with disease recurrence in the groin died within the first 2 years of follow-up. Involvement of the inguinal nodes was the main independent predictive factor for survival, disease recurrence, and metastasis.

CONCLUSIONS

Most treatment failures occurred during the 2 years after initial surgical management. However, in 35% of patients, disease reoccurred 5 years or more after diagnosis, which demonstrates the need for long-term follow-up. Complete ipsilateral or bilateral inguinofemoral lymph node dissection ensures a thorough evaluation and treatment of the groin.

Patterns of recurrence and disease-free survival in advanced squamous cell carcinoma of the vulva

OBJECTIVE

To compare patterns of recurrence and disease-free survival (DFS) of node-positive and node-negative patients with advanced vulval squamous cell carcinoma (SCC).

METHODS

Fifty-five patients with FIGO stage III/IVA vulval SCC who had surgery at the Queensland Centre for Gynaecological Cancer from 1989 to 1999 were included. Patients were grouped as follows: Group A, pT3 N0; Group B, pT3 N1; Group C, pT4 N2. Treatment included surgery +/- postoperative radiotherapy. Multivariate Cox models were calculated to identify independent prognostic factors.

RESULTS

After a median follow-up of 96 months, 25 patients (45.5%) experienced recurrence at the vulva (n = 2), pelvis (n = 8), or distant sites (n = 15). Recurrence in the pelvis and at distant sites was more likely for patients in groups B and C (P 0.003). At 5 years the probability of DFS was 66.6%, 35.3%, and 39.8% for patients in groups A, B, and C, respectively (P 0.085). Patients with negative nodes (n = 15), one microscopic positive node (n = 11), and two or more positive nodes (n = 29) had a probability of DFS of 66.6%, 67.3%, and 26.1% at 5 years, respectively (P 0.005).

CONCLUSION

Patients with > or =2 positive groin nodes are at risk for distant failure. The DFS of patients with negative groin nodes and those with only one microscopic positive node is very similar. The prognosis of patients with > or =2 positive unilateral or bilateral groin nodes is similar. The current FIGO staging system inaccurately reflects prognosis for patients with advanced vulval cancer. Clinical trials are warranted to investigate the benefit of systemic treatment.

Carcinoma of the vulva

Vulvar cancer will probably become a more common disease as the population ages. It is primarily a disease of the elderly. Fortunately, most vulvar cancers remain localized for extended periods of time and can be treated adequately with radical surgery.

Tumor proliferation in squamous cell carcinoma of the vulva

Tumor proliferation is of important prognostic significance for several neoplasms. The very few previous studies on this parameter in vulvar carcinoma have shown contradictory results. The aim of this study was to determine the prognostic significance of tumor proliferation in vulvar carcinoma. Paraffin-embedded tissue of 74 squamous cell carcinomas of the vulva was immunostained for MIB-1, detecting Ki-67, and analyzed for staining patterns and the percentage of positive cells. There were three general staining patterns: a diffuse distribution (diffuse type), a localized staining at the infiltrating tumor border (infiltrating type), and a localized staining in basal parts of infiltrating tumor cell aggregates (basal type). The percentage of positive cells was not correlated with morphologic or clinical parameters, nor was it correlated with disease-free and overall survival. MIB-1 staining types were correlated with tumor type and grading. Tumors of diffuse and infiltrating type seemed to have more frequent lymph node metastasis (p = 0.053) and shorter disease-free survival (p = 0.076). In these tumors, overall survival time was reduced significantly (p = 0.02). In multivariate analysis, MIB-1 staining types were the most important factor for overall survival with an odds ratio of 4.73. In conclusion, distribution and not the percentage of proliferating cells is of prognostic significance in squamous cell carcinoma of the vulva.

Serum concentrations of squamous-cell carcinoma antigen and tissue polypeptide antigen in the follow-up of patients with vulvar cancer

Our aim was to evaluate the clinical usefulness of serum concentrations of squamous-cell carcinoma antigen (SCC-Ag) and tissue polypeptide antigen (TPA) in the follow-up of patients with vulvar cancer. We measured SCC-Ag and TPA in 480 serum samples of 82 patients with squamous-cell vulvar cancer. Results were correlated with clinical data. SCC-Ag, TPA and the combination of SCC-Ag and TPA reached a sensitivity and specificity of 27%/97%, 28%/75% and 40%/73%, respectively. The sensitivity and specificity of the marker combination SCC-Ag and TPA was not significantly higher compared with SCC-Ag alone (McNemar's test, p = 0.6 and p = 0.09, respectively). Of the 35 patients with recurrent disease during follow-up, 19, 6 and 10 developed local, regional and distant recurrent disease, respectively. SCC-Ag showed lead-time effects in 26%, 75% and 50% and TPA in 25%, 0% and 33% of patients with local, regional and distant recurrent disease, respectively. The combination of SCC-Ag and TPA showed lead-time effects in 50%, 75% and 50% of patients with local, regional and distant recurrent disease, respectively. The difference between median lead-times of the combination of SCC-Ag and TPA and SCC-Ag alone was not statistically significant (Mann-Whitney U-test, p = 0.4). Our data show that serum SCC-Ag displays good sensitivity/specificity characteristics in the follow-up of vulvar cancer patients, with lead-time effects seen in 75% and 50% of patients with regional and distant recurrent disease, respectively. Furthermore, our data indicate that combining SCC-Ag with TPA is not a successful strategy to improve the sensitivity or the duration of lead-time effects in the follow-up of patients with vulvar cancer.

Irradiation in carcinoma of the vulva: factors affecting outcome

PURPOSE

This report reviews the increasing role of radiation therapy in the management of patients with histologically confirmed vulvar carcinoma, based on a retrospective analysis of 68 patients with primary disease (2 in situ and 66 invasive) and 18 patients with recurrent tumor treated with irradiation alone or combined with surgery.

METHODS AND MATERIALS

Of the patients with primary tumors, 14 were treated with wide local excision plus irradiation, 19 received irradiation alone after biopsy, 24 were treated with radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes, and 11 received postoperative irradiation after partial or simple vulvectomy. The 18 patients with recurrent tumors were treated with irradiation alone. Indications and techniques of irradiation are discussed in detail.

RESULTS

In patients treated with biopsy/local excision and irradiation, local tumor control was 92% to 100% in Stages T1-3N0, 40% in similar stages with N1-3, and 27% in recurrent tumors. In patients treated with partial/radical vulvectomy and irradiation, primary tumor control was 90% in patients with T1-3 tumors and any nodal stage, 33% in patients with any T stage and N3 lymph nodes, and 66% with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for T1N0, 62% for T2-3N0, 30% for T1-3N1 disease, and 11 % for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 tumors. Four of 18 patients (22%) treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and irradiation. In patients with T1-2 tumors treated with biopsy/wide tumor excision and irradiation with doses under 50 Gy, local tumor control was 75% (3 of 4), in contrast to 100% (13 of 13) with 50.1 to 65 Gy. In patients with T3-4 tumors treated with local wide excision and irradiation, tumor control was 0% with doses below 50 Gy (3 patients) and 63% (7 of 11) with 50.1 to 65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and irradiation, local tumor control was 83% (14 of 17), regardless of dose level, and in T3-4 tumors, it was 62% (5 of 8) with 50 to 60 Gy and 80% (8 of 10) with doses higher than 60 Gy. The differences are not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes; doses of 50 Gy were adequate for elective treatment of nonpalpable lymph nodes, and 60 to 70 Gy controlled tumor growth in 75% to 80% of patients with N2-3 nodes when administered postoperatively after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess.

CONCLUSIONS

Irradiation is playing a greater role in the management of patients with carcinoma of the vulva; combined with wide local tumor excision or used alone in T1-2 tumors, it is an alternative treatment to radical vulvectomy, with significantly less morbidity. Postradical vulvectomy irradiation in locally advanced tumors improves tumor control at the primary site and the regional lymphatics in comparison with reports of surgery alone.

Extracapsular growth of lymph node metastases in squamous cell carcinoma of the vulva. The impact on recurrence and survival

BACKGROUND

Patients with squamous cell carcinoma of the vulva who present with multiple positive groin lymph nodes have poor survival. Growth of cancer through the capsule of the groin lymph nodes recently has been identified as an important prognostic factor for survival in that patient group. The objective of this study was to determine the influence of several clinicopathologic parameters on the pattern of recurrence and survival.

METHODS

A review of 71 patients with squamous cell carcinoma of the vulva and positive lymph nodes was performed to assess the independent prognostic value of a number of variables for survival. Variables analyzed included tumor size, stage, number of positive lymph nodes, extracapsular growth of lymph node metastasis, the greatest dimension of tumor in the lymph nodes, the percentage of replacement of the lymph nodes by tumor, clinical lymph node status, and laterality of positive lymph nodes.

RESULTS

Using the Mantel-Cox test, extracapsular growth of lymph node metastases (P = 0.00), two or more positive lymph nodes (P = 0.02), and greater than 50% replacement of lymph nodes by tumor (P = 0.03) were predictors of poor survival. No difference was found between the groups with two positive lymph nodes and those with three or more. Extracapsular growth of lymph node metastases was the most significant independent predictor for survival. Distant metastases occurred in 7 of 15 patients (48%) who had a combination of extranodal spread, lymph node replacement greater than 50%, and three or more positive lymph nodes.

CONCLUSION

Extracapsular growth of lymph node metastases in the groin is the most important predictor for poor survival in patients with squamous cell carcinoma of the vulva. Because of the predominant distant failure pattern in a subgroup of patients who have a combination of extranodal spread, multiple positive lymph nodes, and lymph nodes replaced by tumor greater than 50%, a future study of the effectiveness of systemic therapy for vulvar cancer must include these patients.

Prognostic significance of lymph node variables in squamous cell carcinoma of the vulva

BACKGROUND

In patients with squamous cell carcinoma of the vulva, lymph nodal, surgicopathologic variables have been studied rarely, although lymph node status is by far the most important prognostic factor. This study was designed to investigate surgicopathologic variables of lymph node metastases to evaluate their prognostic significance.

METHODS

In 75 patients with inguinal and/or pelvic lymph node metastases from squamous cell carcinoma of the vulva, the following parameters were studied: size and location of the tumor, depth of invasion, grade, lymph-vascular space involvement (LVSI), local immune reaction, presence and degree of dystrophic changes in the surrounding skin, FIGO stage, number of positive lymph nodes, greatest dimension of the metastasis within the lymph node, percentage of lymph node replacement, number of lymph nodes with replacement greater than 50%, number of lymph nodes replaced completely by tumor, extracapsular spread, and active immunologic response within the lymph node.

RESULTS

Among the variables related to the primary carcinomas, only size of the tumor and LVSI were correlated with survival (P < 0.003 and P < 0.02, respectively). On the contrary, all pathologic variables regarding the lymph nodes significantly influenced survival by univariate analysis. On multivariate analysis, extracapsular spread was the most significant independent prognostic factor (P < 0.0004), followed by FIGO stage (P < 0.03). For patients with only one positive lymph node, the most important prognostic factor was the greatest dimension of the metastasis within the lymph node (P < 0.01).

CONCLUSIONS

These data, if confirmed in larger series, can contribute to a more accurate identification of low and high risk patients and, therefore, to a more appropriate employment of adjuvant therapies.

FIGO stage, histology, histologic grade, age and race as prognostic factors in determining survival for cancers of the female gynecological system: an analysis of 1973-87 SEER cases of cancers of the endometrium, cervix, ovary, vulva, and vagina

The prognostic impact of FIGO stage, histology, histologic grade, age and race in survival for cancers of the female gynecological (cervix, endometrium, ovary, vulva, vagina) were examined using cases obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program that were diagnosed between 1973 and 1987. Utilizing Cox proportional hazards modeling and relative survival rates analysis of 17,119 cases of cervical cancer indicated that the International Federation of Gynecology and Obstetrics (FIGO) stage, histology, histological grade, lymph node status, and age at diagnosis were all independently prognostic. No evidence was found of survival differences between squamous cell carcinoma and adenocarcinoma. Younger women were not found to have a poorer prognosis, survival declined with increased age. Analysis of 41,120 cases of endometrial cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnostic, and race were all prognostic factors. Clear cell adenocarcinoma, leiomyosarcoma, and mixed mullerian tumors were all found to have poorer prognosis. Analysis of 21,240 cases of ovarian cancer indicated that FIGO stage, histology, histologic grade, lymph node status, age at diagnosis, presence of ascites, and race were all prognostically significant. Analysis of 2,575 cases of vulvar cancer indicated that FIGO stage, histology, histologic grade, age, and race were all prognostically significant. Analysis of 916 cases of vaginal cancer indicated that FIGO stage, histologic grade, lymph node status, and age are all prognostically significant. Additional analysis of the data by combinations of independent prognostic factors indicates that the interaction of factors may be more predictive of outcome than any one factor separately.

Vulvar carcinoma with 0.5 mm of invasion and associated inguinal lymph node metastasis

A case of vulvar carcinoma with 0.5 mm of invasion treated by radical wide local excision only, which later developed ipsilateral inguinal lymph node recurrence, is presented. This represents the least amount of invasion reported resulting in inguinal lymph node metastasis. Review of the literature of stage I vulvar carcinoma with less than 1 mm of invasion indicates that this phenomenon occurs in only 1.6% of all patients who have undergone inguinal lymphadenectomy. Although this represents the second report of ipsilateral inguinal nodal metastasis associated with less than 1 mm of invasion, we continue to perform radical wide local excision without ipsilateral inguinal lymphadenectomy until more cases demonstrate a higher incidence of lymph node involvement.

Radical vulvectomy. The decision for the incision

BACKGROUND

An analysis of survival and complications related to the type of radical vulvectomy operation performed is reported.

METHODS

Clinical records and pathology reports were reviewed for the time period 1975-1989. The operation, complications, and site of recurrent disease were recorded.

RESULTS

The following types of surgical vulvectomies were used: radical vulvectomy (28 cases), the technique with three separate incisions (42 cases), and en bloc radical vulvectomy (94 cases). There was no significant difference in survival between the patients receiving en bloc radical vulvectomy or three separate incisions when analyzed by stage of disease. The following numbers of local/regional recurrences occurred among patients receiving the following treatment regimens: radical vulvectomy, seven; the technique with three separate incisions, six; and en bloc radical vulvectomy, five. Three patients treated by the separate-incision technique had a bridge recurrence. Complications were more frequent in those receiving the en bloc technique compared with those receiving the technique with three separate incisions: wound breakdown, 64% versus 38%, respectively (P = 0.005); wound infection, 20% versus 12%, respectively (P = 0.4); wound cellulitis, 21% versus 14%, respectively (P = 0.4); and lymphocyst formation, 28% versus 14%, respectively (P = 0.08). Drain placement or prophylactic antibiotics did not reduce wound infection or wound breakdown significantly. The most common sites of metastatic disease were the lungs and subcutaneous tissues of the leg. Hypercalcemia occurred in four patients, with the sites of metastatic disease being the subcutaneous tissue of the thigh (three patients) and pubic bone (one patient).

CONCLUSIONS

The technique with three separate incisions provides satisfactory survival results with less morbidity compared with the en bloc technique of radical vulvectomy.

Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy

BACKGROUND

This report consists of a retrospective analysis of 50 patients with primary invasive and 17 with recurrent histologically confirmed vulvar carcinoma treated with radiation therapy for locoregional disease.

METHODS

Of the patients with primary tumors, 13 were treated with wide local excision plus radiation therapy; 13 had radical vulvectomy followed by irradiation to the operative fields and inguinal-femoral/pelvic lymph nodes; 8 received similar postoperative radiation therapy after partial or simple vulvectomy; 16 patients had radiation therapy alone after biopsy; and 17 had recurrent tumors treated with radiation therapy alone.

RESULTS

In patients treated with biopsy/local excision, local tumor control was 92-100% in T1-3N0 disease, 40% in similar stages with N1-3, and 27% in recurrent tumors. Among patients treated with partial/radical vulvectomy and radiation therapy, primary tumor control was 90% in those with T1-3 tumors and any nodal stage, 33% in those with any T stage and N3 lymph nodes, and 66% in patients with recurrent tumors. The actuarial 5-year disease-free survival rates were 87% for patients with T1N0 disease, 62% for those with T2-3N0 disease, 30% for those with T1-3N1 disease, and 11% for patients with recurrent tumors; there were no long-term survivors with T4 or N2-3 disease. Four of 17 patients treated for postvulvectomy recurrent disease remain disease-free after local tumor excision and radiation therapy. In patients with T1-2 tumors treated with biopsy/wide tumor excision and radiation therapy with doses less than 50 Gy, the local tumor control was 75% (three of four patients), in contrast to 100% (13 of 13 patients) with 50.01-65 Gy. With T3-4 tumors treated with local excision and radiation therapy, tumor control occurred in none of three patients with doses less than 50 Gy and 66% (six of nine) with 50.01-65 Gy. In patients with T1-2 tumors treated with partial/radical vulvectomy and radiation therapy, local tumor control was 75% (six of eight), regardless of dose level; in T3-4 tumors, it was 67% (four of six patients) with 50-60 Gy and 86% (six of seven) with 65-70 Gy. Differences were not statistically significant. There was no significant dose response for tumor control in the inguinal-femoral lymph nodes, with doses of 50 Gy being adequate for elective treatment of nonpalpable lymph nodes and 60-70 Gy controlling tumor growth in 75-80% of patients with N2-3 nodes when administered postoperatively, after partial or radical lymph node dissection. Significant treatment morbidity included one rectovaginal fistula, one case of proctitis, one rectal stricture, four bone/skin necroses, four vaginal necroses, and one groin abscess.

CONCLUSIONS

Wide local tumor excision and radiation therapy or irradiation alone in T1-2 tumors is an alternative treatment to radical vulvectomy in controlling vulvar carcinoma, with significantly less morbidity. In comparison with reported rates for surgery alone, radiation therapy after radical vulvectomy for locally advanced tumors improves tumor control at the primary site and regional lymphatics. Indications and techniques of radiation therapy are discussed.

Pelvic exenteration for the treatment of vulvar cancer

BACKGROUND

Advanced vulvar cancer can be treated by pelvic exenteration.

METHODS

A clinical review of patients treated by exenteration surgery for vulvar cancer was performed.

RESULTS

From 1950 through 1989, 19 patients underwent pelvic exenteration for advanced or recurrent squamous cell cancer of the vulva. The mean age was 53 years (median, 50 years; range, 40-74 years). The cumulative 5-year survival was 60%. Fourteen patients had posterior exenteration; 2 had anterior exenteration; and 3 had total exenteration. The survival was significantly influenced by lymph node status. When lymph nodes were not involved, 10 of 14 patients survived, whereas all 5 patients with lymph node involvement died of disease (P = 0.002). When exenteration was performed as primary therapy, 7 of 11 patients survived, whereas 3 of 8 survived when exenteration was performed for recurrent disease (P = 0.4). The extent of vulvar involvement did not influence survival (P = 0.99). There was no mortality, but ten patients had complications, including vesicovaginal fistula (three); stomal hernia (two); abscess (one); stress urinary incontinence (one); deep venous thrombosis (one); conduit leak (one); enterocutaneous fistula (one); and small intestinal obstruction (one).

CONCLUSIONS

Acceptable survival for advanced or recurrent vulvar cancer can be achieved with pelvic exenteration, but the presence of metastatic disease to lymph nodes markedly decreases survival.

A comparison of staging systems for squamous cell carcinoma of the vulva

A review of 172 patients with squamous cell cancer of the vulva treated at the University of Michigan Medical Center from 1975-1989 was performed to compare the 1988 FIGO Staging System to the 1970 FIGO Staging System. The stage distribution according to the 1970 FIGO Staging System was stage I, 65; stage II, 44; stage III, 50; and stage IV, 13. The cumulative 5-year survival under the old system was stage I, 94%; stage II, 91%; stage III, 36%; and stage IV, 26%. The distribution changed under the 1988 FIGO system to stage I, 58; stage II, 36; stage III, 49; stage IVA, 16; and stage IVB, 13. The cumulative survival also changed to stage I, 94%; stage II, 89%; stage III, 71%; stage IVA, 19%; and stage IVB, 8%. The new FIGO stage distribution shifted for the worse due to the influence of positive lymph nodes found at the time of surgery. The survival was then analyzed for death from all causes. This was markedly decreased when compared to the cumulative corrected survival. This relates to the high number of other primary malignancies and the age of the patients. Among these 172 patients, other primary malignancies included squamous cell cancer of the cervix (11), squamous cell cancer of the vagina (2), endometrial cancer (3), squamous cell cancer of the lung (2), colon cancer (3), and others (6). An additional 5 patients died from myocardial infarction within 2 years of diagnosis. The new 1988 FIGO Staging System provides for better discrimination of survival between stages than the 1970 FIGO Staging System.