The prevention and management of treatment related morbidity in vulval cancer

Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction-A Systematic Review and Meta-Analysis

BACKGROUND

Patients with advanced vulvoperineal cancer require a multidisciplinary treatment approach to ensure oncological safety, timely recovery, and the highest possible quality of life (QoL). Reconstructions in this region often lead to complications, affecting approximately 30% of patients. Flap design has evolved towards perforator-based approaches to reduce functional deficits and (donor site) complications, since they allow for the preservation of relevant anatomical structures. Next to their greater surgical challenge in elevation, their superiority over non-perforator-based approaches is still debated.

METHODS

To compare outcomes between perforator and non-perforator flaps in female vulvoperineal reconstruction, we conducted a systematic review of English-language studies published after 1980, including randomized controlled trials, cohort studies, and case series. Data on demographics and surgical outcomes were extracted and classified using the Clavien-Dindo classification. We used a random-effects meta-analysis to derive a pooled estimate of complication frequency (%) in patients who received at least one perforator flap and in patients who received non-perforator flaps.

RESULTS

Among 2576 screened studies, 49 met our inclusion criteria, encompassing 1840 patients. The overall short-term surgical complication rate was comparable in patients receiving a perforator (n = 276) or a non-perforator flap (n = 1564) reconstruction (p* > 0.05). There was a tendency towards fewer complications when using perforator flaps. The assessment of patients' QoL was scarce.

CONCLUSIONS

Vulvoperineal reconstruction using perforator flaps shows promising results compared with non-perforator flaps. There is a need for the assessment of its long-term outcomes and for a systematic evaluation of patient QoL to further demonstrate its benefit for affected patients.

Reconstruction of the Meatus Urethrae After Oncologic Vulvectomy: Outcome of 42 Vaginal Flap Advancements in 41 Women

BACKGROUND AND AIM

Resection of the distal part of the urethra is performed in 15% to 55% of women with vulvar cancer to achieve radicality of vulvectomy. Urinary reconstruction in these women may be complicated by urethral stenosis resulting from circular inset of the meatus. We report on our experience with 2 surgical techniques of noncircular inset to prevent such stenosis.

METHODS

From January 2005 to January 2020, 42 urethral meatus reconstructions were performed in 41 women after vulvectomy for (pre)malignant skin disorders by a "limited" (n = 17) or "extended" (n = 25) anterior vaginal wall advancement technique, including V-Y insertion of part of the vaginal flap in a posterior longitudinal urethrotomy. Preoperative characteristics, procedural details, and surgical outcomes were reviewed.

RESULTS

We observed 1 neomeatal stenosis and 1 case of partial vaginal wall flap necrosis as major complications following the "limited" technique and 1 circumferential neomeatal dehiscence and occlusion as major complication after the "extended" technique. Both the neomeatal stenosis and the dehiscence/occlusion are felt to have been preventable and not caused by a flaw of design of the advancement technique.

CONCLUSIONS

We advocate applying these vaginal wall advancement techniques to prevent circular inset of the neomeatus. The "extended" technique offers a solution in cases where the periurethral vulvar defect cannot be closed by transpositioning of labial skin.

The role of the sentinel lymph node in vulvar cancer

The aim of this study was to update clinical practice applications and technical procedures regarding sentinel lymph node (SLN) biopsy in vulvar cancer considering European experts' opinions from this field. Systematic data search performed using PubMed/medline database up to May 20, 2020. Focus was only for English language publications of original studies on SLN biopsy in vulvar cancer. Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and technical procedures of SLN biopsy in vulvar cancer. In early-stage vulvar cancer patients with a negative sentinel node the groin recurrence rate is low, survival is excellent, and treatment-related morbidity is minimal. We advise that sentinel node dissection, performed by a quality-controlled multidisciplinary team, should be part of the standard treatment in selected patients with early-stage vulvar cancer.

Vaginal flap for urethral neomeatus reconstruction after radical surgery for vulvar cancer: a retrospective cohort analysis

INTRODUCTION

Partial urethrectomy during radical surgery for vulvar cancer may help avoid adjuvant radiotherapy in some patients. This study aimed to evaluate surgical, oncologic, and urinary outcomes of a new surgical technique based on vaginal flap to perform neomeatus reconstruction after distal urethral resection in radical surgery for vulvar cancer.

METHODS

Retrospective cohort study between January 2005 and December 2017. We recorded data on pre- and post-operative urinary symptoms, surgical procedures, complications, adjuvant therapy, and follow-up of all patients who underwent surgery for vulvar cancer and had distal urethral resection and neomeatus reconstruction with the proposed technique. The reconstruction was based on the development of a vaginal flap in which a circular opening was created to become the neo-outlet of the urethra.

RESULTS

Of a total of 200 patients with vulvar cancer operated with curative intent, 33 (16.5%) underwent distal urethral resection and neomeatus reconstruction during surgery (median age 73 (range 57-89) years; median body mass index 25.3 (range 16.3-36.4) kg/m²). Urethrectomy allowed the avoidance of adjuvant radiotherapy in 15/33 (45.5%) patients. No case of dehiscence was reported at the site of neomeatus. After a median follow-up of 39 (range 14-151) months, only one case of deviated urinary stream (3%) and no cases of neomeatus stricture were reported. Six (18.2%) patients developed or worsened urinary incontinence after urethral resection and neomeatus reconstruction, and there was no difference in the prevalence of urethral compressor muscle involvement during urethrectomy (p=0.19) and adjuvant radiotherapy (p=1.00). No recurrences were reported at urethral margins.

CONCLUSIONS

Distal urethral resection and neomeatus reconstruction seem to be associated with adequate healing and low complication rates, such as dehiscence, stenosis, and flux deviation/dribbling. New-onset or worsened urinary incontinence does not seem to be associated with urethral compressor muscle involvement during urethral resection or adjuvant radiotherapy.

Quality of Life and Sexual Functioning After Vulvar Reconstruction With the Lotus Petal Flap

OBJECTIVE

Resection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic.

METHODS

A cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women.

RESULTS

Twenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16-141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported.

CONCLUSIONS

Patients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.

Assessing Patient-reported Quality of Life Outcomes in Vulva Cancer Patients: A Systematic Literature Review

Objectives

Vulva cancer (VC) treatment carries a high risk of severe late effects that may have a negative impact on quality of life (QoL). Patient-reported outcome measures (PROMs) are increasingly used when evaluating disease- and treatment-specific effects. However, the adequacy of measures used to assess sequelae and QoL in VC remains unclear. The aims of the present study were to evaluate disease- and treatment-related effects as measured by PROMs in VC patients and to identify available VC-specific PROMs.

Methods/Materials

A systematic literature search from 1990 to 2016 was performed. The inclusion criterion was report of disease- and treatment-related effects in VC patients using PROMs in the assessment. Methodological and reporting quality was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. This systematic review was performed as part of phase 1 of the development of a European Organisation for Research and Treatment of Cancer QoL questionnaire for VC patients.

Results

The search revealed 2299 relevant hits, with 11 articles extracted including a total of 535 women with VC; no randomized controlled trials were identified. The selected studies exhibited great heterogeneity in terms of PROMs use. Twenty-one different instruments assessed QoL. Most of the questionnaires were generic. Different issues (sexuality, lymphedema, body image, urinary and bowel function, vulva-specific symptoms) were reported as potentially important, but the results were not systematically collected. Only one VC-specific questionnaire was identified but did not allow for assessment and reporting on a scale level.

Conclusions

Vulva cancer treatment is associated with considerable morbidity deteriorating QoL. To date, there is no validated PROM available that provides adequate coverage of VC-related issues. The study confirms the need for a VC-specific QoL instrument with sensitive scales that allows for broad cross-cultural application for use in clinical trials.

The Complementary Role of Imaging and Tumor Biomarkers in Gynecological Cancers: An Update of the Literature

Gynecological tumors, including endometrial, cervical and ovarian cancer, have increased in incidence over time. The widespread introduction of screening programs and advances in diagnostic imaging methods has lead to a progressive increase in gynecological cancer detection. Accurate diagnosis and proper monitoring of disease remain the primary target for a successful treatment. In the last years, knowledge about cancer biomarkers has considerably increased providing great opportunities for improving cancer detection and treatment. In addition, in the last few years there has been an important development of imaging techniques. Nowadays, a multimodal approach including the evaluation of serum tumor biomarkers combined with imaging techniques, seems to be the best strategy for assessing tumor presence, spread, recurrence, and/or the response to treatment in female cancer patients In this review we provide an overview of the application of biomarkers combined with novel imaging methods and highlight their roles in female cancer diagnosis and follow-up.

Vulvar carcinoma: dilemma, debates, and decisions

Vulvar carcinoma is a rare and aggressive gynecological malignancy. It affects elderly females, with the mean age at diagnosis being 55-60 years. Regional metastasis to inguinal lymph nodes is common. There is a high incidence of pelvic node involvement, especially in those with pathologically positive inguinal nodes. Surgery appears to be the only curative treatment option in the early stages of the disease. But in most patients, surgery is associated with considerable morbidities and psychosexual issues. Hence, in the quest for a less morbid form of treatment, multimodality approaches with various combinations of surgery, chemotherapy, and radiation therapy have been suggested for advanced vulvar cancers. Due to the low incidence of the disease, the level of evidence for the success of these treatment modalities is poor. In countries like India, a heterogeneous incidence of vulvar carcinoma exists across the country, with patients presenting at advanced stages when the option of surgery is often supplemented or replaced by chemotherapy and radiotherapy. In this review, we attempt to study the available published literature and trials and discuss the treatment options in various stages of vulvar carcinoma.

Surgical management of squamous cell vulvar cancer without clitoris, urethra or anus involvement

Vulvar cancers, which constitute 5% of all gynecologic cancers, are the fourth most common female genital cancers, preceded by uterine, ovarian and cervical cancers. The treatment methods employed for vulvar cancers have changed over the years, with previously applied radical surgical approaches, such as en bloc resection, being gradually suspended in favor of treatment approaches that require dissection of less tissue. While the removal of less tissue, which today's approaches have focused on, prevents morbidity, this method seems to result in higher risks of recurrence. It is therefore important that the balance between preventing the recurrence of the disease and forefending against postoperative complications and vulvar deformity be properly understood. As a working assumption, if patients with vulvar cancer are diagnosed at an early stage, properly evaluated and administered appropriate treatment, the most positive results can be obtained. This paper aims to highlight this assumption and demonstrate, through the provision of actual data, how to plan the treatment approach for patients who are diagnosed early. Statements extracted from the National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2016 Sub-Committees on vulvar squamous cell carcinoma and articles by the European Society of Gynaecological Oncology (ESGO) regarding Vulvar Cancer Recommendations were used to obtain updated information.

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Radical/wide local excision is an alternative to radical vulvectomy in selected patients.

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The aim of the tumor resection should be to achieve the adequate surgical border.

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Complete inguinofemoral lymphadenectomy is more advantageous in terms of recurrence.

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Recurrence is a particularly problematic feature of vulvar cancer cases.

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Saphenous vein preservation is contradictory, preservation is maybe more advantageous.

Vulvar Reconstruction by Perforator Flaps: Algorithm for Flap Choice Based on the Topography of the Defect

OBJECTIVE

Many techniques have been proposed to reconstruct acquired vulvar defects. In our experience, every type of vulvar defect can be repaired with 2 pedicled flaps, namely, the pedicle deep inferior epigastric perforator (DIEP) flap and the lotus petal flap (LPF).

MATERIALS AND METHODS

We report our reconstructive algorithm for vulvar reconstruction, based on the topography of the defect, applied in 22 consecutive patients from 2000 to 2012. According to the proposed algorithm, DIEP flap and LPF (monolateral or bilateral type) can repair all kinds of wide vulvar defects. Surgical defects were classified as type I (IA and IB) and type II in relation to the anatomy of the defect.

RESULTS

No major complications were reported in our series. All patients reported satisfactory results, both functionally and aesthetically.

CONCLUSIONS

We propose an easy classification of acquired vulvar defects separating the ones consequent only to the vulvar resection, with preservation of vagina (type I), by the wider defects after vaginal and vulvar resection (type II); type I can be subclassified into defects consequent to half-vulvar resection (type IA) or to total vulvar resection (type IB). Type I defects (IA and IB) can be reconstructed with monolateral or bilateral LPF; in type II resections, we have a great wound that required more tissue to fill the pelvic dead space, so we prefer pedicle DIEP flap.

Pelvic radiotherapy and sexual function in women

BACKGROUND

During the past decade there has been considerable progress in developing new radiation methods for cancer treatment. Pelvic radiotherapy constitutes the primary or (neo) adjuvant treatment of many pelvic cancers e.g., locally advanced cervical and rectal cancer. There is an increasing focus on late effects and an increasing awareness that patient reported outcomes (PROs) i.e., patient assessment of physical, social, psychological, and sexual functioning provides the most valid information on the effects of cancer treatment. Following cure of cancer allow survivors focus on quality of life (QOL) issues; sexual functioning has proved to be one of the most important aspects of concern in long-term survivors.

METHODS

An updated literature search in PubMed was performed on pelvic radiotherapy and female sexual functioning/dysfunction. Studies on gynaecological, urological and gastrointestinal cancers were included. The focus was on the period from 2010 to 2014, on studies using PROs, on potential randomized controlled trials (RCTs) where female sexual dysfunction (FSD) at least constituted a secondary outcome, and on studies reporting from modern radiotherapy modalities.

RESULTS

The literature search revealed a few RCTs with FSD evaluated as a PRO and being a secondary outcome measure in endometrial and in rectal cancer patients. Very limited information could be extracted regarding FSD in bladder, vulva, and anal cancer patients. The literature before and after 2010 confirms that pelvic radiotherapy, independent on modality, increases the risk significantly for FSD both compared to data from age-matched healthy control women and compared to data on patients treated by surgery only. There was only very limited data available on modern radiotherapy modalities. These are awaited during the next five years. Several newer studies confirm that health care professionals are still reluctant to discuss treatment induced sexual dysfunction with patients.

CONCLUSIONS

Pelvic radiotherapy has a persistent deteriorating effect on the vaginal mucosa impacting negatively on the sexual functioning in female cancer patients. Hopefully, modern radiotherapy modalities will cause less vaginal morbidity but results are awaited to confirm this assumption. Health care professionals are encouraged to address potential sexual dysfunction both before and after radiotherapy and to focus more on quality than on quantity.

Perineural Invasion Is an Independent Pathologic Indicator of Recurrence in Vulvar Squamous Cell Carcinoma

OBJECTIVES

Vulvar squamous cell carcinoma (vSCC) is a gynecologic malignancy diagnosed in nearly 4500 women in the United States each year. Current criteria for treatment planning provide inadequate assessment of aggressive vSCC cases, resulting in insufficient use of adjuvant treatments and high rates of vSCC recurrence. Perineural invasion (PNI) is a pathologic feature inconsistently included in the assessment of vSCC, because its relevance to clinical outcomes in these women is not well defined. The purpose of this study was to determine the association between PNI and relevant clinical parameters such as recurrence.

METHODS

A total of 103 cases of vSCC were evaluated for PNI using pathology report review and immunohistochemistry dual-chromogen staining for S100 and AE1/3. Medical records were reviewed for clinical and follow-up data. Data were analyzed using univariate and multivariate logistic regression statistical methods.

RESULTS

Patients with vSCC containing PNI had a greater risk for cancer recurrence than those whose tumors did not contain PNI (odds ratio=2.8, P=0.0290). There was no significant correlation between the presence of PNI and nodal involvement, stage, or lymphovascular invasion. Tumors with PNI had greater depth of invasion (DOI) (P=0.0047); however, DOI was not associated with recurrence (P=0.2220). When analyzed using a multivariable logistic regression model, PNI was an independent predictor of recurrence in vSCC (adjusted odds ratio=2.613, P=0.045).

CONCLUSIONS

PNI is an independent indicator of risk for recurrence in vSCC. The association of PNI with increased risk for recurrence, independent of DOI, nodal involvement, lymphovascular invasion, or stage, should encourage practicing pathologists to thoroughly search for and report the presence of PNI in vSCC.

The impact of surgery for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of treatment: a longitudinal, mixed methods study

OBJECTIVE

To measure the long-term impact of surgical treatment for vulval cancer upon health-related quality of life and pelvic floor outcomes during the first year of therapy.

METHODS

Prospective, longitudinal, mixed-methods study. Twenty-three women aged >18 years with a new diagnosis of vulval cancer were recruited. The EORTC QLQ C30, SF-36 and an electronic pelvic floor assessment questionnaire (ePAQ-PF) were administered at baseline (pre-treatment) and 3, 6, 9 and 12 months post-treatment. Mixed effects repeated measures models (all adjusted for age and BMI) were used to investigate changes over time and differences between cancer stage. Qualitative interviews were carried out with 11 of the women and analysed using a thematic approach.

RESULTS

Mean age was 59.9 years (SD = 15.3; range = 23.8-86.6 yrs). Mean BMI was 30.0 (SD = 4.5; range = 24.4-38.2). Sixteen women had early (Stage 1 to 2B), and seven women had advanced stage disease (Stage 3 to 4B). Questionnaire scores revealed that physical and social functioning, fatigue, pain and general sex life were significantly worse at 12 months than pre-treatment (p = < 0.05). Qualitative analysis revealed multiple treatment side effects which were perceived as severe and enduring. Women with advanced vulval cancer had significantly worse SF-36 mental health scores at 12 months compared to women with early stage disease (p = 0.037).

CONCLUSIONS

Surgery for vulval cancer has long-term implications which can be persistent 12 months post-treatment. High rates of morbidity relating to lymphoedema and sexual function re-enforce the need for specialist clinics to support women who suffer these complications. © 2015 The Authors. Psycho-Oncology published by John Wiley & Sons Ltd.

Emotional and sexual concerns in women undergoing pelvic surgery and associated treatment for gynecologic cancer

The surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, emotional well being, reproductive function, and overall quality of life (QoL). Fortunately, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae; however, these side effects of treatment are still prevalent. In this article, we provide an overview of the various standard-of-care pelvic surgeries and multimodality cancer treatments (chemotherapy and radiation therapy) by anatomic site and highlight the potential emotional and sexual consequences that can influence cancer survivorship and QoL. Potential screening tools that can be used in clinical practice to identify some of these concerns and treatment side effects and possible solutions are also provided. These screening tools include brief assessments that can be used in the clinical care setting to assist in the identification of problematic issues throughout the continuum of care. This optimizes quality of care, and ultimately, QoL in these women. Prospective clinical trials with gynecologic oncology populations should include patient-reported outcomes to identify subgroups at risk for difficulties during and following treatment for early intervention.

Laser CO2 treatment for vulvar lymphedema secondary to gynecological cancer therapy: A report of two cases and review of the literature

Vulvar lymphedema is an uncommon and disabling side-effect of pelvic lymphadenectomy and pelvic radiotherapeutic treatment for invasive genital cancer. Lymphorrhea, a complication of lymphedema, may be extremely distressing for patients due to the requirement to wear sanitary towels and as the pain and loss of elasticity of the vulvar skin and mucosa can cause discomfort during coitus. Surgical treatments of lymphorrhea and vulvar lymphedema secondary to gynecological cancer treatments remain controversial and are not currently considered to be the standard therapy. The present study reports two cases of vulvar lymphedema complicated by vulvar lymphorrhea in females who had undergone treatment for cervical and endometrial cancer, respectively; a review of the literature is also included. In the two present cases, vulvar lymphedemas were refractory to standard treatments, including decongestive therapy, manual lymph drainage, elastic bandaging, low-stretch bandaging, exercises and skin care. Laser CO₂ excision and vaporization of the whole skin and mucosal tissue of the vulva was successfully performed to treat the lymphorrhea and improve quality of life. Thus, the present two cases indicated that laser CO₂ surgery may present an additional therapy for the treatment of genital lymphedema that is refractory to other treatments.

Quality of life and sexual function after surgery in early stage vulvar cancer

OBJECTIVES AND METHODS

Vulvar carcinomas are rare genital malignancies. In a retrospective study on 21 patients factors influencing the quality of life and sexual function were investigated. All patients were interviewed according to the Female Sexual Function Index questionnaire (FSFI) and the Short Form 12(®) questionnaire (SF12).

RESULTS

We identified 21 patients that had been operated for vulvar carcinoma FIGO stage I or IIIa in the years 2006-2008. Patients that had adjuvant radiotherapy were excluded. 14 patients had been treated by a wide excision, the other 7 by a vulvectomy. 10 patients had undergone a total inguinal lymphadenectomy, 5 patients a sentinel node biopsy. In a multivariate analysis lymphadenectomy was the only factor influencing the patients' sexual function: Patients without lymphadenectomy or with sentinel node biopsy scored better in terms of sexual function, neither age nor the extend of the surgery resulted in a significant difference.

CONCLUSION

The lymphadenectomy has a negative influence on the patients' sexual function after surgical treatment for vulvar carcinoma. The indication for lymphadenectomy should hence be seen critically.

Cancer-related concerns among women with a new diagnosis of gynecological cancer: an exploration of age group differences

OBJECTIVE

The study aimed to characterize cancer-related concerns among women with a new diagnosis of gynecological cancer from a developmental life stage perspective. The study compared the degree of cancer-related concern between young women (45 years or younger), middle age women (46-64 years), and older women (65 years or older).

MATERIALS/METHODS

Data from women (N = 243) with a condition diagnosed as primary gynecological cancer who were participating in a randomized control trial were analyzed. Women completed a measure that assessed the degree of concern in 12 cancer-related domains (physical functioning, cancer treatment, emotional functioning, sexual functioning, disease progression/death, own well-being, partner well-being, relationship with spouse/partner, body image, relationship with others, employment, and finances). Multivariate comparisons were made between the 3 age groups on the cancer-related concerns.

RESULTS

There were age group differences in overall cancer-related concern and specific cancer-related domains. Young women reported the greatest cancer-related concern (P < 0.001). They reported greater concern over emotional functioning (P < 0.001) and sexual functioning (P < 0.001) compared to the middle- and older-age groups. Older women reported less concern over the impact of cancer on finances (P = 007). There were no differences between age groups in concern over physical impairment, cancer treatment, disease progression/death, own well-being, partner well-being, relationship with spouse/partner, body image, and relationship with others.

CONCLUSIONS

Age may play an important role in the impact of a gynecological cancer diagnosis in domains of functioning, specifically emotional functioning, sexual functioning, and finances. Other cancer-related areas may represent more universal degree of impact. Professionals may benefit from considering the impact of cancer from a developmental life stage perspective.

Holding back sharing concerns, dispositional emotional expressivity, perceived unsupportive responses and distress among women newly diagnosed with gynecological cancers

OBJECTIVE

Little attention has been paid to the role of holding back sharing concerns in the psychological adaptation of women newly diagnosed with gynecological cancers. The goal of the present study was to evaluate the role of holding back concerns in psychosocial adjustment and quality of life, as well as a possible moderating role for emotional expressivity and perceived unsupportive responses from family and friends.

METHOD

Two hundred forty-four women diagnosed with gynecological cancer in the past 8 months completed measures of holding back, dispositional emotional expressivity, perceived unsupportive responses from family and friends, cancer-specific distress, depressive symptoms and quality of life.

RESULTS

Emotional expressivity moderated the association between holding back and cancer-specific distress and quality of life, but not depressive symptoms. Greater holding back was more strongly associated with higher levels of cancer-related distress among women who were more emotionally expressive than among women who were less expressive. Perceived unsupportive responses did not moderate the associations between holding back and psychosocial outcomes.

CONCLUSION

Holding back sharing concerns was more common in this patient population than other cancer populations. Dispositional expressivity played a role in how harmful holding back concerns was for women, while unsupportive responses from family and friends did not.

A review of complications associated with the surgical treatment of vulvar cancer

OBJECTIVE

The mainstay of treatment for most vulvar malignancies is surgery to the vulva with lymphadenectomy to the inguino-femoral areas, plus radiotherapy or/and chemotherapy for locally advanced, or recurrent disease. Treatment is associated with significant physical, sexual, and psychological morbidity. The high morbidity rate has resulted in a continuing shift in treatment paradigms that focus on treatments that reduce morbidity without compromising cure rates. This paper reviews the complications associated with contemporary surgical treatment for vulva cancer and discusses preventative strategies.

METHODS

A review of the English literature was undertaken for articles published between 1965 and August 31, 2012 to identify articles that assessed complications resulting from surgery to the vulva or groins in patients with vulva cancer. Two independent researchers selected and qualitatively analyzed the articles using a predetermined protocol.

RESULTS

The heterogeneity of articles and differences in definitions and outcomes made this unsuitable for meta-analysis. Most studies advocated for change in surgical technique to reduce complications associated with inguino-femoral lymphadenectomy and surgery to the vulva, with varying success. The most effective means of preventing complications is by omitting systematic lymph node dissection. This can be achieved safely through sentinel lymph node biopsy. Saphenous vein sparing, VTE prophylaxis, the use of flaps and grafts, and preoperative counseling are additional ways to decrease morbidity.

CONCLUSION

Despite technical advances, complications following surgical treatment for vulva cancer remain high. More research, particularly multi centered randomized controlled trials to improve the quality of evidence and studies that focus on complications as an outcome measure and analyze individual surgeon complication rates, are needed. Measures also need to be standardized throughout the gynecologic oncology community to allow for better comparison between studies.

Is bilateral lymphadenectomy for midline squamous carcinoma of the vulva always necessary? An analysis from Gynecologic Oncology Group (GOG) 173

OBJECTIVE

To determine which patients with near midline lesions may safely undergo unilateral groin dissection based on clinical exam and lymphoscintigraphy (LSG) results.

METHODS

Patients participating in GOG-173 underwent sentinel lymph node (SLN) localization with blue dye, and radiocolloid with optional LSG before definitive inguinal-femoral lymphadenectomy (LND). This analysis interrogates the reliability of LSG alone relative to primary tumor location in those patients who had an interpretable LSG and at least one SLN identified. Primary tumor location was categorized as lateral (>2cm from midline), midline, or lateral ambiguous (LA) if located within 2cm, but not involving the midline.

RESULTS

Two-hundred-thirty-four patients met eligibility criteria. Sixty-four had lateral lesions, and underwent unilateral LND. All patients with LA (N=65) and midline (N=105) tumors underwent bilateral LND. Bilateral drainage by LSG was identified in 14/64 (22%) patients with lateral tumors, 38/65 (58%) with LA tumors and in 73/105 (70%) with midline tumors. At mapping, no SLNs were found in contralateral groins among those patients with LA and midline tumors who had unilateral-only LSGs. However, in these patients groin metastases were found in 4/32 patients with midline tumors undergoing contralateral dissection; none were found in 27 patients with LA tumors.

CONCLUSION

The likelihood of detectable bilateral drainage using preoperative LSG decreases as a function of distance from midline. Patients with LA primaries and unilateral drainage on LSG may safely undergo unilateral SLN.

Quality of life in women with vulvar cancer submitted to surgical treatment: a comparative study

OBJECTIVES

To investigate the occurrence and severity of lymphoedema of the lower extremities (LLE), quality of life (QoL), and urinary and sexual dysfunction in women with vulvar cancer submitted to surgical treatment.

STUDY DESIGN

Twenty-eight patients with vulvar cancer submitted to vulvectomy and inguinofemoral lymphadenectomy and 28 healthy, age-matched women (control group) were evaluated. The occurrence and severity of LLE were determined by Miller's Clinical Evaluation. QoL, urinary function and sexual function were assessed by the EORTC QLQ-C30, SF-ICIQ and FSFI questionnaires, respectively. The differences between groups and correlations were assessed using Student's t-test, Chi-squared test, Mann-Whitney U-test and Spearman's rho test.

RESULTS

The groups were similar in terms of marital status, educational status, menopausal status, hormone therapy and height. The occurrence and severity of LLE were higher in women with vulvar cancer compared with the control group (p<0.001 and p = 0.003, respectively). A significant association was found between the severity of LLE and advanced age (p = 0.04), and the severity of LLE and higher body mass index (BMI; p = 0.04) in patients with vulvar cancer. In the patients with vulvar cancer, there was a significant correlation between the severity of LLE and worse QoL in the following domains: physical, cognitive, emotional, social, fatigue, pain, sleep and financial questions (p < 0.05). There was no difference in urinary function between the two groups (p = 0.113). Age and number of deliveries were the only variables associated with the occurrence of urinary incontinence (p = 0.01). Urinary incontinence was present in women with a mean age of 74.9 ± 4.6 years and a mean of 7.3 ± 1.3 normal deliveries. There was no difference between the groups in terms of the sexual function. Multivariate analysis showed an association between sexual function and age (p = 0.01), and sexual function and being in a stable relationship (p=0.02).

CONCLUSION

Patients submitted to vulvectomy or inguinofemoral lymphadenectomy for vulvar cancer are at higher risk of developing LLE compared with healthy, age-matched women. This has a negative effect on QoL, but does not interfere with urinary or sexual function.

Treatment outcome in patients with vulvar cancer: comparison of concurrent radiotherapy to postoperative radiotherapy

Purpose

To evaluate outcome and morbidity in patients with vulvar cancer treated with radiotherapy, concurrent chemoradiotherapy or postoperative radiotherapy.

Materials and Methods

The records of 24 patients treated with radiotherapy for vulvar cancer between July 1993 and September 2009 were retrospectively reviewed. All patients received once daily 1.8-4 Gy fractions external beam radiotherapy to median 51.2 Gy (range, 19.8 to 81.6 Gy) on pelvis and inguinal nodes. Seven patients were treated with primary concurrent chemoradiotherapy, one patient was treated with primary radiotherapy alone, four patients received palliative radiotherapy, and twelve patients were treated with postoperative radiotherapy.

Results

Twenty patients were eligible for response evaluation. Response rate was 55% (11/20). The 5-year disease free survival was 42.2% and 5-year overall survival was 46.2%, respectively. Fifty percent (12/24) experienced with acute skin complications of grade III or more during radiotherapy. Late complications were found in 8 patients. 50% (6/12) of patients treated with lymph node dissection experienced severe late complications. One patient died of sepsis from lymphedema. However, only 16.6% (2/12) of patients treated with primary radiotherapy developed late complications.

Conclusion

Outcome of patients with vulvar cancer treated with radiotherapy showed relatively good local control and low recurrence. Severe late toxicities remained higher in patients treated with both node dissection and radiotherapy.

Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study

OBJECTIVE

To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.

DESIGN

Before-after pilot study with a duration of 5 months.

SETTING

University of Pennsylvania.

PARTICIPANTS

Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.

INTERVENTION

Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months.

MAIN OUTCOME MEASURES

The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.

RESULTS

Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life.

CONCLUSIONS

Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5 mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.

State of the Art of Sentinel Lymph Node Biopsy in Vulvar Carcinoma

Treatment for early-stage vulvar carcinoma has evolved from radical en bloc dissection to wide local incision with lymphadenectomy through separate groin incisions, to sentinel lymph node biopsy (SLNB). The morbidity of SLNB is far less than traditional inguinofemoral lymphadenectomy, with less lymphedema and sensory deficit, shorter hospital stays and fewer infections. A multidisciplinary approach is required, with success of the SLNB technique maximized when radiolabeled colloid is used, with blue dye added when further identification is needed. Frozen-section analysis, followed by ultrastaging of the nodal sample, minimizes the need for reoperations and decreases the risk of false negatives. We believe that SLNB will become the standard of care for treatment of early-stage vulvar carcinoma.

Long-term trajectories of psychological adaptation among women diagnosed with gynecological cancers

OBJECTIVE

Women diagnosed with gynecological cancers may cope with a difficult treatment regimen that includes multiple abdominal surgeries and courses of chemotherapy and/or radiation. Little attention has been paid to identifying what factors place women at risk for long-term problems with psychological adaptation. The goal of the present study was to identify a set of demographic, medical, and predisposing factors as well as cognitive and social processing strategies that predict the trajectory of psychological distress and well-being among women diagnosed with gynecological cancer.

METHODS

One hundred thirteen women on active treatment for gynecological cancer completed measures at baseline, 3, 6, and 9 months afterward.

RESULTS

Women with poorer physician-rated performance status and self-reported functional impairment, women who were Caucasian, women who have received previous psychological treatments, women who were less expressive of positive emotions, women who had unsupportive friends and family, and women who were less able to find something positive in the cancer experience reported poorer adaptation.

CONCLUSIONS

This study identified a set of risk factors for poor long-term psychological adaptation among women diagnosed with gynecological cancers. Healthcare professionals working with these women can use these risk factors to screen for patients who may require additional psychological services.

Lymphedema after gynecological cancer treatment : prevalence, correlates, and supportive care needs

BACKGROUND

Few studies have evaluated lymphedema after gynecological cancer treatment. The aim of this research was to establish prevalence, correlates, and supportive care needs of gynecological cancer survivors who develop lymphedema.

METHODS

In 2004, a population-based cross-sectional mail survey (56% response rate) was completed by 802 gynecological cancer survivors. The questionnaire included demographic questions, a validated, generic supportive care needs measure, and a supplementary, newly developed, lymphedema needs module.

RESULTS

Ten percent (95% confidence interval [CI], 8%-12%) of participants reported being diagnosed with lymphedema, and a further 15% (95% CI, 13%-17%) reported undiagnosed "symptomatic" lower limb swelling. Diagnosed lymphedema was more prevalent (36%) amongst vulvar cancer survivors. For cervical cancer survivors, those who had radiotherapy or who had lymph nodes removed had higher odds of developing swelling. For uterine and ovarian cancer survivors, those who had lymph nodes removed or who were overweight or obese had higher odds of developing swelling. Gynecological cancer survivors with lymphedema had higher supportive care needs in the information and symptom management domains compared with those who had no swelling.

CONCLUSIONS

This population-based study provided evidence that lymphedema is a morbidity experienced by a significant proportion of gynecological cancer survivors and that there are considerable levels of associated unmet needs. Women at risk of lymphedema would benefit from instructions about early signs and symptoms and provision of referral information.

Psychosexual function and impact of gynaecological cancer

A diagnosis of gynaecological cancer and its treatment are usually associated with many physical and psychological changes, both as a result of the diagnosis itself and of the usual treatments of surgery, radiotherapy and/or several months of chemotherapy. Patients often experience symptoms such as fatigue, abdominal swelling and pain, and suffer from emotional distress and disturbances of their life style. Sexual functioning can also be affected. Often there are physiological difficulties, such as vaginal dryness, together with psychological distress and relationship problems. This chapter discusses the ways in which gynaecological cancer can impact sexual functioning, and presents findings from a research project that was undertaken to begin to understand how sexual functioning can be affected by ovarian cancer. The article also makes recommendations for how health-care professionals can help women to cope better with psychosexual dysfunction following a diagnosis of a gynaecological cancer.

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.

Quality of life and gynecologic malignancies

In 2005, an estimated 79,480 new cases of gynecologic malignancies will be diagnosed, and almost 29,000 women will die. Treatment of gynecologic malignancies involves a combination of surgery, chemotherapy, and/or radiotherapy, all of which may affect a woman's physical, social, and emotional well-being. Although specific effects on quality of life (QOL) depend on disease site, treatment-, and patient-specific factors, common QOL issues include changes in physical functioning due to side effects of treatment, psychological distress due to fear and anxiety of recurrence, sexual dysfunction associated with anatomic and physiologic changes of treatment, and, for younger women, loss of childbearing potential. As new diagnostic and treatment strategies for gynecologic malignancies are developed, research efforts should include QOL consequences. Further studies are needed to develop strategies for identifying women at risk for serious QOL disruption so that effective interventions to assist these women can be designed.

Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes

OBJECTIVE

At present, no clear guidelines for the treatment of patients with vulvar cancer and positive groin nodes exist. In general, the decision for additional pelvic radiation is based on findings by imaging techniques and/or the number of groin nodes involved. The aim of this case series was to demonstrate that histologic result of laparoscopic removed pelvic lymph nodes can be used to select patients who should not undergo pelvic irradiation.

METHODS

From July 1997 to October 2004, 12 consecutive patients with primary or recurrent vulvar cancer underwent laparoscopic pelvic lymphadenectomy following primary or secondary surgical treatment.

RESULTS

There were 8 patients with primary cancer of the vulva and 4 patients with recurrent disease in the inguinal and/or pelvic lymph nodes. The mean age was 61 (26-83) years and the mean body-mass-index was 27.1 (20.8-36.6). Positive groin nodes were found in five patients on the right side and in five patients on the left side; in one patient, positive groin nodes were present in both sides. In another patient with a history of vulvar cancer and positive groin nodes the CT-scan indicated the presence of positive iliac and paraaortic lymph nodes. Only in two patients tumor involved lymph nodes were diagnosed by laparoscopic pelvic lymphadenectomy (one left-sided, one right-sided). The number of harvested pelvic lymph nodes was 13.7 (5-20) in unilateral and 27.8 (16-37) in bilateral lymphadenectomy. The histologic examination of removed pelvic lymph nodes confirmed pelvic radiation in only 2 out of 12 patients, whereas 10 patients were spared from whole pelvis irradiation.

CONCLUSION

With respect to small sample size, laparoscopic lymphadenectomy seems to be a good tool to avoid unnecessary pelvic radiation in patients with vulvar cancer and confirmed positive groin nodes.

Sexual function after treatment for gynecological malignancy

PURPOSE OF REVIEW

This review summarizes current knowledge about the nature of sexual dysfunction in gynecological cancers, highlighting recent publications on disease effects, treatment effects, and communication issues.

RECENT FINDINGS

Recent studies have shown the impact of radiotherapy on sexual function in cervical cancer and have highlighted differences in the levels and duration of sexual problems in women with early stage compared with advanced, recurrent, or persistent disease. Qualitative studies in cervical and endometrial cancer have highlighted women's concerns in relation to femininity, fears of sexual relations, and the importance of communication with the woman's partner. Similar findings have been obtained in studies of ovarian cancer. Predictors of sexual function in ovarian cancer have been suggested by a recent study, with risk factors for poorer sexual functioning being age, treatment, time since treatment, poor self esteem/body image, physical symptoms, poor performance status, depression, and anxiety. Similar risk factors have been highlighted in vulval cancer. Communication issues have been discussed, with some preliminary exploration of the benefits of group therapy and psychosexual counseling.

SUMMARY

Recent research is helping us to understand more about the impact of the different types of gynecological cancer and its treatment on sexual functioning, with information being provided about key risk factors and predictors of sexual dysfunction that can be used to guide appropriate advice and support. The assessment and treatment of sexual functioning must become part of the standard care of women diagnosed with gynecological cancer.