European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

Step-by-step combination of 99mTc and ICG with endoscopic near infrared cameras in SLN mapping early-stage vulvar cancer

Vulvar cancer guidelines recommend inguinal sentinel lymph node (SLN) biopsy as the standard of care for patients with unifocal squamous cell carcinoma tumors less than 4 cm and clinically non-suspicious nodes in the groin [1]. The use of radioactive tracer is mandatory, while the application of blue dye is optional [2]. Combination detection techniques have been established as the most accurate for early vulvar cancer, with increasing evidence supporting indocyanine green (ICG) as an alternative to blue dye [3], [4]. However, protocols for ICG use remain heterogeneous, and the optimal protocol is yet to be defined [5], [6]. This video article presents a stepwise demonstration of the SLN mapping technique using a combination of radioactive 99 m-Tc and ICG with endoscopic near-infrared (NIR) cameras in two cases. A 52-year-old woman diagnosed with T1 vulvar cancer, with no extravulvar disease, was scheduled for wide local tumor excision and bilateral inguinal SLN biopsy. The procedure began with 99 m-Tc detection, followed by ICG identification. A 25 mg vial of ICG was dissolved in 10 mL of sterile water, with 2 mL injected into four intradermal quadrants around the tumor. Ten minutes post-injection, a small incision in the groin was made, assisted by lymphoscintigraphy fluorescence imaging using the NIR/ICG-IMAGE1S™ system. Images of another IB FIGO stage vulvar cancer patient undergoing SLN inguinal procedure with the NIR Da Vinci Xi camera were also included. The sentinel nodes were accurately detected in both patients, with no involvement after histological study. The informed consent for this video was obtained from both patients.

Interventions for Prevention and Management of Gynecological Cancer-Related Lower Limb Lymphedema: A Systematic Scoping Review

OBJECTIVES

This scoping review aims to map out evidence on interventions for reducing lower limb lymphedema incidence and symptoms after gynecological cancer surgery.

METHODS

This scoping review followed the methods and protocol outlined by the Joanna Briggs Institute Methods Manual. Five databases, including Pubmed, Scopus, Web of Science, CINAHL, and PsycINFO were searched in January 2024.

RESULTS

The review included 15 interventions primarily designed to prevent and manage cancer-related lower extremity lymphedema. Most studies have examined the effect of interventions on the development of lymphedema-related symptoms and quality of life. Most studies tested complex decongestive therapy (CDT) (n = 6, 39.9%), including various techniques, such as manual lymphatic drainage, compression, exercise, and skincare. Of the interventions, 86.6% improved at least one outcome measurement, such as quality of life, lymphedema incidence, symptoms, and lower limb volume.

CONCLUSIONS

Limited evidence shows that the use of interventions appears to have the potential to reduce the risk and symptoms of lymphedema and improve the quality of life in women undergoing gynecological cancer treatment.

IMPLICATIONS FOR NURSING PRACTICE

Developing and testing comprehensive lymphedema education and management strategies in nursing practice is essential to optimize patient outcomes and enhance the quality of life for women undergoing gynecological cancer treatment.

Let's talk about sex: consensus guidelines of the GINECOR working group of the Spanish Society of Radiation Oncology: clinical recommendations after pelvic radiotherapy

PURPOSE

The present consensus statement was developed by the GINECOR working group on behalf of the Spanish Society of Radiation Oncology (SEOR). This document addresses sexual health management in patients with gynaecological cancer after pelvic radiotherapy.

METHODS

A modified two-round online Delphi study was conducted, where GINECOR members were surveyed on the diagnosis, treatment, and follow-up of sexual health problems. An expert panel of radiation oncologists, nurses and a gynaecologist participated in the Delphi study to reach a consensus, applying GRADE criteria to establish the level of agreement.

RESULTS

The consensus recommendations cover both diagnosis and treatment, with an emphasis on patient-reported outcome measures (PROMs). They highlight recommendations such as the systematic assessment of genitourinary, gastrointestinal, and sexual symptoms, and the use of several treatments after radiotherapy. Recommendations include pharmacological options like vaginal lubricants and hormone therapy, and mechanical interventions such as vaginal dilators and vibrators. These suggestions stem from both scientific evidence and clinical expertise.

CONCLUSION

This consensus statement describes a comprehensive, multidisciplinary approach developed to address the sexual needs and enhance the quality of life of patients with gynaecological tumours after pelvic radiotherapy. It offers specific recommendations for managing sexual issues, emphasizing the importance of specialized care and regular assessment. The document underscores the significance of proactive, patient-centered sexual health management in gynaecological cancer patients.

Controversies in vulvar cancer: revisiting the margin of error

Despite an oftentimes radical surgical approach when treating patients with early-stage vulvar cancer, local recurrence occurs in approximately 40% of cases. Surgery in this setting can result in significant morbidity; however, treatment failure is associated with high mortality rates. Historically, many guidelines recommended a tumor-free margin ≥8 mm in the surgical treatment of vulvar cancer, although this is largely consensus-based and supported by a few small retrospective case series. Recently, numerous retrospective studies have found no association between a tumor-free margin of <8 mm and locoregional recurrence. Emerging evidence suggests that the presence of differentiated vulvar intra-epithelial neoplasia and lichen sclerosis at the pathologic margin may also play a role in local recurrence; however, data are retrospective and heterogenous, and the definition of what a "safe" tumor-free margin is remains unclear. However, increasing evidence has failed to demonstrate the beneficial role of re-excision or adjuvant radiation in the setting of margins of <8 mm. These additional treatments are associated with significant morbidity and have a negative impact on patients' quality of life; thus, they should be reserved solely for patients with positive margins. One of the main challenges in finding the ideal tumor-free margin is that the rarity of vulvar cancer makes prospective and randomized controlled trials difficult to conduct. Therefore, it is imperative that we make a concerted effort as a field to collaborate across nations and institutions, promote centralization of care for rare tumors, and prioritize future work to better understand the nature of this disease.

Management of Patients with Vulvar Cancers: A Systematic Comparison of International Guidelines (NCCN-ASCO-ESGO-BGCS-IGCS-FIGO-French Guidelines-RCOG)

BACKGROUND

Vulvar carcinoma is an uncommon gynecological tumor primarily affecting older women. Its treatment significantly impacts the quality of life and, not least, aesthetics because of the mutilating surgery it requires.

OBJECTIVES

The management requires a multidisciplinary team of specialists who know how to care for the patient in her entirety, not neglecting psychological aspects and reconstructive surgery. How do the guidelines address multidisciplinarity, team surgical management, passing through preoperative diagnosis, and follow-up in such a challenging rare tumor to treat?

METHODS

To answer these questions, we compared the main scientific recommendations to identify similarities and differences in diagnostic and therapeutic management to provide an overview of the gaps that there are currently in European and American international recommendations in providing management guidance in a cancer that is both among the rarest and most difficult to manage. In this way, we aim to encourage an update in practices based on the latest scientific evidence.

RESULTS

A review of various international guidelines, some dating back to 2014, shows significant variation in approaches, ranging from initial diagnostic procedures to managing relapses. The most recent guidelines also lacked references to the latest literature, indicating that more robust scientific evidence is needed before new treatments, such as electrochemotherapy for palliation and reconstructive surgery post exenteration, can be widely adopted.

CONCLUSIONS

From the systematic comparison of the main international guidelines, a strong heterogeneity emerged in the diagnostic and therapeutic recommendations as well as for the multidisciplinary approach that today is essential. Our work certainly stimulated an update of the main guidelines.

Spatial transcriptomic analysis reveals significant differences in tumor microenvironment in HPV-dependent and HPV-independent vulvar squamous cell carcinoma

OBJECTIVE

Vulvar squamous cell carcinoma (VSCC) can be either HPV-dependent (HPVd) or HPV-independent (HPVi). HPVd VSCC typically occurs in younger women, has a more favorable prognosis, and develops from high-grade squamous intraepithelial lesions (HSIL). HPVi VSCC predominantly affects older women and arises within areas of chronic inflammation, particularly lichen sclerosis (LS). We utilized sequencing-based spatial transcriptomics to explore gene expression in a cohort of patients with HPVi and HPVd VSCC.

METHODS

We analysed gene expression in distinct areas (SCC, inflammation, LS, HSIL) from four early-stage VSCC cases (two HPVi, two HPVd) using the 10× Genomics Visium spatial transcriptomics platform. Cell-specific type expression was inferred using CIBERSORTx.

RESULTS

28,183 Visium spots were detected; each contained an estimated 20-50 cells. Reads per spot ranged from 9903 to 68,527. More genes were upregulated in HPVd (N = 601) than HPVi (N = 72) with distinct differences in Keratin and Collagen genes between etiologies. Gene expression was strikingly similar between SCC and adjacent inflammatory areas, regardless of etiology. IL-17 signaling was upregulated in HPVd samples. Surprisingly, CIBERSORTx inferred significantly more CD45+ cells in HPVi tissues than HPVd, especially CD4+ resting memory and follicular helper T cells in SCC areas. Immune cells moved from resting states in the pre-invasive tissues to activated states in the SCC and peri-tumoral inflammatory areas.

CONCLUSIONS

This study represents the first application of spatial transcriptomics in VSCC, with significantly more immune cells identified in HPVi SCC than in HPVd SCC. These data will act as a baseline for future studies.

Typing of Vulvar Squamous Cell Carcinoma: Why it is Important?

The classification of vulvar squamous cell carcinoma (VSCC), as in endometrial cancer, has shifted from the histology-based descriptors toward molecular-based identifiers. Recently, it has been reported that there are 3 genetically distinct and clinically significant subtypes of VSCC: HPV-associated VSCC, HPV-independent/p53 wild-type VSCC, and HPV-independent/p53-mutated VSCC. Each group has different prognostic implications as well as response to treatment, thus reinforcing the need for this 3-tier molecular classification. This molecular subtyping can easily be done on vulvar biopsies using p16 and p53 immunohistochemistry stains to further improve risk prediction and individualized treatment decisions, leading to better patient outcomes.

Prevalence and impact of vulvar lesions diagnosed prior to vulvar squamous cell carcinoma: A population-based cohort study

OBJECTIVE

To systematically explore vulvar pathology diagnosed prior to vulvar squamous cell carcinoma (VSCC), as well as the association with tumor characteristics, stage and survival outcome, with the aim of improving vulvar cancer prevention strategies.

METHODS

VSCC diagnosed between 2005 and 2019 were identified from a population-based cohort provided by the Dutch Nationwide Pathology Databank. Pathology reports were reviewed to identify vulvar pathology diagnosed before primary VSCC. Data on treatment, tumor stage and survival were collected from the Netherlands Cancer Registry. Prior vulvar pathology was correlated to tumor characteristics and stage. Cox's proportional hazards model was used to assess the impact of clinicopathological variables on survival.

RESULTS

A total of 1036 VSCC patients were identified, of whom most (73 %) had no prior biopsy-confirmed vulvar pathology. High-grade squamous intraepithelial lesion (HSIL) and differentiated vulvar intraepithelial neoplasia (dVIN) were diagnosed prior to VSCC in only 8 % and 2 % of cancer patients, respectively, while adjacent HSIL and adjacent dVIN were reported in 35 % and 22 % of surgical VSCC resection specimens, respectively. The remaining 17 % had a benign vulvar pathology diagnosis prior to cancer. Patients showed advanced staged tumors in 15 % and 9 % of patients with prior HSIL and dVIN, respectively, as compared to 32 % in patients without prior vulvar pathology (p < 0.001). There was no independent association between prior vulvar pathology and survival outcomes.

CONCLUSION

The vast majority of VSCC patients were not preceded by a pre-malignant lesion or other benign vulvar pathology, although such lesions were frequently identified adjacent to VSCC in resection specimens. Patients without prior vulvar pathology showed more advanced-stage tumors, which may contribute to less favorable outcomes.

Role of Age, Comorbidity, and Frailty in the Prediction of Postoperative Complications After Surgery for Vulvar Cancer: A Retrospective Cohort Study with the Development of a Nomogram

Surgery is the cornerstone of vulvar cancer treatment, but it is associated with a significant risk of complications that may impact prognosis, particularly in older patients with multiple comorbidities. The objective of this study was to evaluate the role of age, comorbidities, and frailty in predicting postoperative complications after vulvar cancer surgery and to develop a predictive nomogram. A retrospective cohort study was conducted, including patients who underwent surgery for vulvar cancer at two Italian institutions from January 2018 to December 2023. A logistic regression model for the rate of Clavien-Dindo 2+ 30-days complications was run, considering the age-adjusted Charlson Comorbidity Index (AACCI), body mass index (BMI), and frailty as exposures. Lesion characteristics and surgical procedures were considered as confounders. Among the 225 included patients, 50 (22.2%) had a grade 2+ complication. The predictive score of the nomogram ranged from 44 to 140. The AACCI (0-64 points) and BMI (0-100 points) were independently associated with a risk of complications. A nomogram including the AACCI and BMI predicts the risk of complications for patients undergoing surgery for vulvar cancer. The preoperative determination of the risk of complications enables surgical planning and allows a tailored peri- and postoperative management plan.

The Toulouse algorithm: vulvar cancer location-based reconstruction

Vulvar cancer is a rare malignancy, accounting for approximately 5% of all gynecological cancers, but its incidence has increased. The gold standard treatment is complete surgical resection with safety margins, which may vary according to histological subtype. This surgery often results in large defects, which may be challenging to repair international guidelines recommend that reconstructive procedures after vulvar cancer surgery should always be considered in cases where it will guarantee better functional and/or cosmetic results or when wound closure will be challenging. With the advancements of reconstructive procedures in oncologic surgery, perforator flaps represent the best option to reduce donor-site complications, and have all the advantages for vulvar reconstruction, by less demolitive procedures to maintain the patient's self-image and sexual function without impacting the oncological outcome. Various algorithms have been proposed in the literature for flap selection in vulvo-perineal reconstructive surgery (Gentileschi S, Servillo M, Garganese G, et al. Surgical therapy of vulvar cancer: how to choose the correct reconstruction? J Gynecol Oncol. 2016;27(6):e60. doi:10.3802/jgo.2016.27.e60; Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar reconstruction by perforator flaps: algorithm for flap choice based on the topography of the defect. Int J Gynecol Cancer. 2015;25(7):1322-1327. doi:10.1097/IGC.0000000000000481; Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54(2):184-190. doi:10.1097/01.sap.0000141381.77762.07; Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559-568. doi:10.1016/S1470-2045(0870147-5)). However, these often lack practicality as they are based on the size of the defect, listing all possible flaps that can be adopted without considering that some flaps should clearly be preferred because of their better aesthetic result. Moreover, most of these algorithms still recommend musculocutaneous flaps which are associated with greater donor-site morbidity, and which should therefore be considered only in selected cases when other flaps are not feasible. We present a simple and effective algorithm for flap selection in the field of vulvo-vaginal-perineal reconstruction for vulvar carcinomas, developed from our experience as a tertiary referral cancer center. This algorithm is based on the anatomical involvement of the vulvo-perineal region to provide more accurate anatomical restoration. It is versatile enough to be used in most cases of vulvo-vagino-perineal reconstructive surgery, leading to an improvement in the restoration of anatomy and function. Moreover, perforator flaps are proposed as the first option with different possibilities based on the location and the size of the defect.

Molecular Subtypes of Vulvar Squamous Cell Carcinoma: The Significance of HPV-Independent/p53 Wild Type

Vulvar carcinoma is a rare disease, meeting the criteria for a "rare cancer", but its incidence is increasing, especially in women <60 years of age. Squamous cell carcinoma (VSCC) accounts for the overwhelming majority of vulvar carcinomas and is the focus of this review. As with many cancers, the increased understanding of molecular events during tumorigenesis has led to the emergence of the molecular subclassification of VSCC, which is subclassified into tumors that arise secondary to high-risk human papillomavirus infection (HPV-associated, or HPVa) and those that arise independently of HPV (HPVi), most commonly in the setting of a chronic inflammatory condition of the vulvar skin. This latter group of HPVi VSCC arises in most cases secondary to mutations in TP53, but recently, attention has focused on the uncommon TP53 wild-type HPVi VSCC. These three molecular subtypes of VSCC (HPVa, HPVi p53 abnormal, and HPVi p53 wild type), as well as their precursor lesions, cannot be diagnosed based on a routine histopathological examination or immunostaining for p53 and p16 as surrogate markers for TP53 mutation and high-risk HPV infection, respectively, are required. The molecular subtyping of VSCC shows high reproducibility and provides important prognostic information. HPVa VSCC has the most favorable prognosis, while HPVi VSCC with TP53 mutations (p53abn) has the worst prognosis, and HPVi VSCC with wild-type TP53 (p53wt) has an intermediate prognosis. In this review, we discuss the evidence supporting this molecular subclassification and its implications for the diagnosis and treatment of VSCC and its precursors.

Comparison of different histomorphological grading systems in vulvar squamous cell carcinoma

BACKGROUND

Histopathological biomarkers of carcinomas and their prognostic relevance, such as Broder's grading system (based on the total number of undifferentiated cells) or Bryne's grading system (rating morphological features at the tumor invasive front), have been repeatedly and successfully put to test. Since most studies focus on head and neck cancers or oral carcinomas, for squamous cell carcinoma of the vulva, no standardized and agreed on pathological tumor grading system, yielding prognostic significance, could be determined so far.

MATERIAL AND METHODS

To determine prognostic associations of different grading systems with regard to groin lymph node metastasis, 73 cases of vulvar carcinomas (VC) were re-examined within our study and Broder's and Bryne's grading system individually performed. To sub-classify between HPV-associated or HPV-independent VC, immunohistochemical p16 stainings were performed. Statistical relationships were evaluated using Spearman correlation and logistic regression analysis, validation was achieved by employment of the likelihood ratio test (LRT) and assessment of ROC curves/AUC values.

RESULTS

Within our cohort, Broder's grade I (40≈55%) and Bryne's grade II (48≈66%) were the most frequently assigned histological gradings. We determined a positive correlation of Bryne's grading with the extent of lymph node involvement in HPV-associated tumors and demonstrated the feasibility of Bryne's grading to predict the presence of carcinoma cells within groin lymph nodes (LRT p = 0.0066; AUC value≈0.91) in this cohort. On the other hand, our data suggest that especially HPV-independent tumors may not sufficiently be characterized by current standardly performed grading approaches.

CONCLUSION

Since only Bryne's grading system correlated positively with lymph node involvement in HPV-associated squamous cell carcinoma of the vulva, we propose to include it by name next to the distinct tumor entity on the histopathological report, allowing not only the interpretation of its prognostic relevance but also future research attempts.

Surgery after upfront chemoradiation in locally advanced squamous cell vulvar cancer: Analysis of postoperative outcomes and survival

OBJECTIVE

The aim of the study was to assess the survival rates and surgery-related toxicity in patients with locally advanced squamous cell vulvar cancer (LAVC) managed by upfront chemoradiation (CRT) with/without following by surgery. CRT is the primary treatment for patients with unresectable locally advanced squamous cell vulvar carcinoma (LAVC), followed by surgery in case of residual tumor.

METHODS

Patients with AJCC stage II-IV squamous cell vulvar carcinoma referred to Gynecologic Oncology Unit at Fondazione Policlinico Universitario Agostino Gemelli I.R.C.C.S. from January 2016 to February 2023, managed by upfront CRT, were included.

RESULTS

63 patients were included, 21 (33 %) had complete response (cCR) to CRT, 26 (41 %) had partial response (cPR), 1 (2 %) stable disease (cSD), 15 (24 %) had disease progression (cPD). In the whole population, cPR/SD and cPD were associated with reduced PFS (p < 0.001) and overall survival (OS) (p < 0.001), p16 expression was associated with improved PFS (p < 0.001) and OS (p = 0.001). Among patients with clinical residual disease after CRT, 23 patients undergoing surgery experienced improved PFS (p = 0.003) and OS (p = 0.003) compared to those receiving other treatments. Eight (35 %) patients experienced severe (grade ≥ III) postoperative complications; vulvar and groin wound dehiscence/infection were the most common complications; one (4 %) patient died in the postoperative. Patients with pathological residual disease experienced worse PFS (p = 0.013) and OS (p = 0.034).

CONCLUSIONS

Clinical response to CRT and p16 expression strongly predict survival in LAVC. Surgery for residual disease might be associated with improved survival but is burdened by high rates of complications. Pathologic residual disease correlates with high recurrence rates and poor survival.

HPV-Related Cancers in Bosnia and Herzegovina: A Comprehensive Review

This review assesses the burden of human papillomavirus (HPV)-related cancers in Bosnia and Herzegovina (BH), aiming to inform strategies for prevention and early detection. Despite the availability of highly effective HPV vaccines and screening programs, HPV-related cancers remain a significant public health burden worldwide. We conducted a comprehensive search of PubMed and GLOBOCAN to identify all available data on HPV prevalence/genotype and HPV-related malignancies in BH, including information on HPV vaccination and cervical cancer screening. A comprehensive literature search revealed limited data on HPV prevalence and HPV-related cancers, as well as the absence of a national HPV vaccination or cervical cancer screening program in BH. In the largest study with available data from BH, HPV prevalence was 43% among women undergoing routine gynecologic exams. HPV-16 was identified as the most common cause of cervical cancer. The HPV prevalence was 50% in head and neck cancer, with HPV-18 being the most prevalent subtype. HPV was detected in 80% of patients with colorectal cancer, and HPV-16 was the most common subtype. Conclusions. HPV-related cancers, particularly cervical cancer, represent a significant public health problem in BH. Implementation of a national HPV vaccination program, along with organized cervical cancer screening is essential to reduce HPV-related morbidity and mortality. Addressing systemic challenges, such as establishing a comprehensive cancer registry, is essential for effective HPV prevention and control. Raising public awareness about HPV infection, its consequences, and the importance of prevention is essential for vaccine acceptance and promoting healthy behaviors. By investing in HPV prevention, BH can significantly improve the health and well-being of its population, particularly women.

Transformative clinical trials in gynaecologic radiation oncology in 2023-2024: Shaping modern treatment practices

The field of gynaecologic oncology has evolved rapidly in recent years, largely driven by advances in both radiotherapy and systemic therapies. These innovations have reshaped the management of key gynaecologic cancers, including cervical, endometrial, vaginal, and vulvar cancers, leading to more personalized and effective treatment approaches. This review explores pivotal clinical trials conducted between 2023 and 2024 that have potentially modified current practices. Through an extensive analysis of randomized controlled trials and meta-analyses, we examine the evolving role of radiotherapy, the integration and sequencing of immunotherapy, and the refinement of neoadjuvant and adjuvant treatments based on molecular classifications. The combination of immunotherapy with chemoradiotherapy has shown promising outcomes, particularly in patients with locally advanced cervical cancer. For endometrial cancer, molecular profiling has enabled a more precise classification of tumour subtypes, leading to better-targeted adjuvant therapies that reduce unnecessary interventions and increase treatment efficacy. In parallel, radiotherapy has advanced with the increasing use of modern techniques such as intensity-modulated radiotherapy and more recently the developments of adaptive treatments in order to minimize exposure to healthy tissue, thereby reducing toxicity and enhancing patient quality of life. Integration of image-guided brachytherapy and expansion of capabilities with newer generation of brachytherapy applicators have also increased possibilities to achieve efficient local treatments, including in very advanced cases. However, despite progress in common gynaecologic cancers, the management of rare cancers such as vulvar and vaginal cancers continues to face challenges due to limited clinical research and treatment data. This review highlights the transformative potential of these innovations and emphasizes the need for continued research and personalized treatment strategies to optimize patient outcomes in gynaecologic oncology.

Assessing the Comparative Efficacy of Sentinel Lymph Node Detection Techniques in Vulvar Cancer: Protocol for a Systematic Review and Meta-Analysis

This systematic review and meta-analysis protocol aims to evaluate the comparative efficacy of different sentinel lymph node (SLN) detection techniques in the management of vulvar cancer. Vulvar cancer, though rare, predominantly affects older women and requires effective management strategies. The SLN technique has become a standard approach for early-stage cases, offering reduced morbidity compared to complete lymphadenectomy. Currently, various SLN detection methods exist, including the use of Technetium-99m (Tc99m), Indocyanine Green (ICG), and superparamagnetic iron oxide (SPIO), but there is a lack of comprehensive comparison of their efficacy. This review will systematically search relevant databases, including PubMed, Scopus, Cochrane, Web of Science and Embase following PRISMA guidelines, to gather data from clinical trials. The primary outcome will be the detection rates of SLN techniques with secondary outcomes examining patient characteristics and procedural factors. The analysis will utilize random-effects models to compare detection rates across studies. The results of this study aim to provide insights into the optimal SLN detection method with potential implications for clinical practice guidelines in vulvar cancer management. The protocol is registered under the PROSPERO registration number CRD42024590774.

Impact of age on surgical excision margins for vulvar squamous cell carcinomas: A multicenter study by the francogyn group

INTRODUCTION

Vulvar cancer is a rare cancer, it most often affects older women, with tumours of more advanced size and stage than in younger patients. The first-line treatment for vulvar cancer is surgery. Current European and American guidelines recommend negative histological margins. As tumor size is greater in older patients, the aim of this study was to assess the impact of patient age on surgical excision margins in squamous cell carcinomas of the vulva.

MATERIAL AND METHOD

This was a retrospective multicenter observational study. A descriptive analysis of the population was performed and a univariate analysis was performed according to patient age. Survival data were plotted using the Kaplan-Meier method and compared using a log rank test. Survival was analyzed using a Cox model to calculate the Hazard Ratio.

RESULTS

Among the 547 patients included, there were 206 patients <65 years and 341 ≥ 65 years, including 135 ≥ 80 years. Median postoperative histological lesion size and interquartile range was greater in patients ≥65 years (30 mm [18-45] versus 26 mm [14-34], p < 0.001). Patients ≥65 years of age more often benefited from radical total vulvectomy (n = 103 (28.8 %) versus n = 44 (20.4 %), p = 0.03). However, negative surgical excision margins were identical between the 2 groups (n = 180 (87.4 %) versus n = 286 (83.9 %), p = 0.21). Revision surgery was performed more frequently in patients <65 years. Recurrence-free survival was better in patients aged <65 years (HR = 0.60; CI95 % (0.45-0.82), p = 0.001).

CONCLUSION

Despite larger tumour size, age is not a factor influencing the achievement of negative excision margins in squamous cell carcinomas of the vulva, at the cost of more radical surgery.

Suppressing Expression of SERPINE1/PAI1 Through Activation of GPER1 Reduces Progression of Vulvar Carcinoma

BACKGROUND/AIM

The serine proteinase inhibitor 1 (SERPINE1) gene codes for the plasminogen activator inhibitor 1 (PAI1) protein and is thought to play a tumor supportive role in various cancers. In this work we aimed to uncover the role PAI1 plays in the proliferation, migration, and invasion of vulvar cancer (VC), and define the protein's function as an oncogene or tumor suppressor.

MATERIALS AND METHODS

Through treatment with an agonist (G1) and antagonist (G36) of G-coupled estrogen receptor 1 (GPER1), an upstream regulator of SERPINE1 expression, and a forward transfection knockdown protocol, the expression of SERPINE1/PAI1 in VC cells was altered. The effects these altered SERPINE1/PAI1 levels had on tumor cell functions were then examined. Proliferation was analyzed using the resazurin assay, while migration was studied via the gap closure assay. Through colony- and tumor sphere- formation assays clonogenicity was tested, and western blots showed protein expression.

RESULTS

In A431 VC cells, when the levels of PAI1 were reduced via knockdown or treatment with G1, migration, proliferation, and colony growth was reduced. Treatment with G36 increased expression of PAI1 and increased migration and colony size in CAL39 cells.

CONCLUSION

Based on the findings in this study, suppressing PAI1 expression in VC cells appears to reduce their progression and tumorigenic potential. Therefore, PAI1 could possibly function as an oncogene in VC. GPER1 appears to be a suitable target for suppressing PAI1 in VC.

Intersecting Pathologies: Vulvar Cancer Complicated by a Fusobacterium necrophorum Infection

Vulvar cancer represents a small minority of annual cancer cases in America. This malignancy affects more than the physical health of the patient. This malignancy also has a negative impact on women's psychological and sexual health. This case pertains to a 49-year-old woman (G1P1001) who presented with right groin pain, fever, and chills for three days. She reported experiencing vaginal bleeding during the intercourse and had been able to palpate a mass inside her vagina for the past five years. A pelvic exam revealed a 6 cm tender mass on the left vaginal wall, which was friable and hemorrhagic on palpation, along with associated lymphadenopathy. The patient was taken to the operating room where the exophytic mass and lymphadenopathy were biopsied. Necrotic lymph nodes were removed and sent for pathology. Pathology confirmed moderately differentiated squamous cell carcinoma of the vulva. The lymph node pathology report also indicated that the necrotic nodes were infected with Fusobacterium necrophorum. Given the extent of the tumor, it was deemed largely inoperable, and the patient was recommended local radiation therapy. The patient was diagnosed with stage III vulvar cancer. This case highlights the intersection of gynecology-oncology and infectious disease, with a never-before-documented bacterial infection in the context of vulvar cancer. Fusobacterium necrophorum has been previously associated with colorectal cancers, liver abscesses, and ovarian abscesses. Further ingestion is needed to understand the role of this pathogen in the development of vulvar cancer.

Surgical outcomes and morbidity in open and videoendoscopic inguinal lymphadenectomy in vulvar cancer: A systematic review and metanalysis"

INTRODUCTION

Surgical evaluation of inguinal lymph nodes is essential to correctly guide the adjuvant treatment of vulvar cancer patients. Open inguinal lymphadenectomy (OIL) approach is the preferred route, while the videoendoscopic inguinal lymphadenectomy (VEIL) seems to be associated with better results. This meta-analysis aimed to compare the surgical outcomes of OIL vs VEIL in vulvar cancer.

METHODS

The meta-analysis was conducted according to the PRISMA guideline. The search string included the following keywords: "(vulvar cancer) AND ((inguinal) OR (femoral)) AND ((lymph node dissection) OR (lymphadenectomy))". Three double-blind researchers independently extracted data.

RESULTS

Seventeen studies were considered eligible for the analysis. Seven studies were included in the OIL group and ten studies in the VEIL group. A total of 372 groins were included in OIL group and 197 groins in VEIL group. 153 groins (41.1 %) in the OIL group and 25 groins (12.6 %) in the VEIL group developed major complications. The analysis of all lymphatic and wound complications showed that VEIL had a lower rate of lymphatic and wound complications. Estimated blood loss (p = 0.4), hospital stay (p = 0.18), time of drainage (p = 0.74), number of lymph node excised (p = 0.74) did not show significant difference between the two approaches.

CONCLUSIONS

VEIL route may be a valid alternative to OIL route with no differences in terms of surgical outcomes, except for operative time that is shorter for OIL. Future analysis of randomized controlled trials in this specific patient population are warranted to confirm these results.

Value of surgical lymph node assessment for patients with vulvar melanoma

OBJECTIVE

Investigate the utilization and outcomes of lymphadenectomy/ sampling (LND) for patients with vulvar melanoma.

MATERIALS AND METHODS

Patients diagnosed between 2004-2015 with vulvar melanoma with known depth of tumor invasion and no distant metastases were identified in the National Cancer Database. Based on pathology report patients who underwent inguinal lymph node sampling/dissection were identified. Clinico-pathological characteristics and overall survival were compared between the two groups.

RESULTS

A total of 1286 patients were identified; 62.8 % (n = 808) underwent lymphadenectomy/ sampling. Patients who underwent lymphadenectomy/ sampling were younger (median 66 vs 76 years, p < 0.001), more likely to have private insurance (42.9 % vs 27.8 %, p < 0.001), present with tumor ulceration (65.9 % vs 58.6 %, p = 0.01), have deeper tumor invasion (p < 0.001) and undergo radical vulvectomy (26.4 % vs 12.1 %, p < 0.001). Patients who underwent lymphadenectomy/ sampling had better overall survival compared to those who did not (median 49.08 vs 35.91 months respectively, p < 0.001). After controlling for patient age, race, insurance status, comorbidities, presence of tumor ulceration and Breslow depth of invasion performance of lymphadenectomy/ sampling was associated with better survival (hazard ratio: 0.78, 95 % confidence intervals: 0.67, 0.92).

CONCLUSION

For patients with vulvar melanoma with at least 1 mm invasion lymphadenectomy/ sampling was associated with better overall survival likely secondary to stage migration.

Prevalence and indicators of cure of Italian women with vulvar squamous cell carcinoma: A population-based study

OBJECTIVE

Five-year net survival and conditional survival from vulvar squamous cell carcinoma (VSCC) patients in Italy have shown no progress during the past three decades. This study aims to estimate the complete prevalence and multiple indicators of cure.

METHODS

Observed prevalence was estimated using 31 Italian cancer registries covering 47 % of Italian women. A subset of 22 cancer registries was used to estimate model-based long-term survival and indicators of cure, i.e., complete prevalence, cure fraction (CF), time to cure (TTC), proportion of 'already cured' patients, and cure prevalence.

RESULTS

In 2018, VSCC patients alive in Italy (complete prevalence) were 6620 or 22 per 100,000 women. The cure fraction (the proportion of newly diagnosed patients who will not die of VSCC) did not change between 2000 and 2010 both for all patients (32 %) and in each age group. The time to cure (5-year conditional net survival >95 %) was 11 years for patients aged ≥44 years, but excess mortality remained for >15 years in the other age groups. This led to a negligible (5 %) proportion of 'already cured' patients (living longer than time to cure). The proportion of patients alive <2 years (21 %) was the same as that of patients surviving ≥15 years. The cure prevalence (patients who will not die of VSCC) was 64 %. A considerable proportion of patients will not be cured even among those who survived ≥5 years.

CONCLUSION

There is an urgent need to reshape the current vulvar care model in Italy.

Preoperative prediction model of lymph node metastasis in the inguinal and femoral region based on radiomics and artificial intelligence

OBJECTIVE

To predict preoperative inguinal lymph node metastasis in vulvar cancer patients using a machine learning model based on imaging features and clinical data from pelvic magnetic resonance imaging (MRI).

METHODS

52 vulvar cancer patients were divided into a training set (n=37) and validation set (n=15). Clinical data and MRI images were collected, and regions of interest were delineated by experienced radiologists. A total of 1688 quantitative imaging features were extracted using the Radcloud platform. Dimensionality reduction and feature selection were applied, resulting in a radiomics signature. Clinical characteristics were screened, and a combined model integrating the radiomics signature and significant clinical features was constructed using logistic regression. Four machine learning classifiers (K nearest neighbor, random forest, adaptive boosting, and latent dirichlet allocation) were trained and validated. Model performance was evaluated using the receiver operating characteristic curve and the area under the curve (AUC), as well as decision curve analysis.

RESULTS

The radiomics score significantly differentiated between lymph node metastasis positive and negative patients in both the training and validation sets. The combined model demonstrated excellent discrimination, with AUC values of 0.941 and 0.933 in the training and validation sets, respectively. The calibration curve and decision curve analysis confirmed the model's high predictive accuracy and clinical utility. Among the machine learning classifiers, latent dirichlet allocation and random forest models achieved AUC values >0.7 in the validation set. Integrating all four classifiers resulted in a total model with an AUC of 0.717 in the validation set.

CONCLUSION

Radiomics combined with artificial intelligence can provide a new method for prediction of inguinal lymph node metastasis of vulvar cancer before surgery.

Future of sentinel node biopsy in ovarian cancer

PURPOSE OF REVIEW

The rationale on the use of sentinel lymph node (SLN) biopsy in the surgical staging of apparent early-stage ovarian cancer (OC) is supported by the fact that diagnostic and prognostic role of systematic staging lymphadenectomy has been determined but its therapeutic significance is still matter of controversy. Moreover, SLN biopsy represents an option to decrease intra- and postoperative morbidity. The present review aims to provide an overview on the current and future role of SLN in OC.

RECENT FINDINGS

Most recent evidence shows that the overall mean per patient SLN detection rate in case of indocyanine green (ICG) alone was 58.6% compared with 95% in case of ICG + technetium, and with 52.9% in case of technetium alone or in combination with blue dye ( P  < 0.001). Site of injection has been reported to be in both ovarian ligaments in majority of studies (utero-ovarian ligament and infundibulo-pelvic ligament), before or after ovarian mass removal, at time of primary or re-staging surgery and by minimally invasive or open approach. Cervical injection has been recently proposed to replace utero-ovarian injection. SLN detection rate in patients with confirmed ovarian malignancy varied across different studies ranging between 9.1% and 91.3% for the injection in the utero-ovarian ligament and migration to pelvic lymph nodes and between 27.3% and 100% for the injection in the infundibulo-pelvic ligament and migration to para-aortic lymph nodes. No intra- or postoperative complication could be attributed directly to SLN biopsy. The sensitivity and the accuracy of SLN in detecting lymphatic metastasis ranged between 73.3-100% and 96-100%, respectively. In up to 40% of positive SLNs, largest metastatic deposit was classified as micro-metastasis or isolated tumor cells, which would have been missed without ultrastaging protocol.

SUMMARY

SLN biopsy represents a promising tool to assess lymph node status in apparent early-stage OC. The type and volume of injected tracer need to be considered as appear to affect SLN detection rate. Ultrastaging protocol is essential to detect low volume metastasis. Sensitivity and accuracy of SLN biopsy are encouraging, providing tracer injection in both uterine and ovarian ligaments.

Different tracers for sentinel node detection in gynecologic oncology

PURPOSE OF REVIEW

In the past decade, sentinel lymph node (SLN) mapping has progressively substituted full lymphadenectomies in gynecologic oncology. In this article, we review the most relevant and the latest literature on this topic.

RECENT FINDINGS

In endometrial and cervical cancer, the current evidence further support the value of indocyanine green (ICG) as tracer of choice for SLN mapping. Experience in vulvar cancer is more limited, with ICG used together with technetium-99 m (Tc-99m) as a dual tracer but ICG, so far, has not been a game changer in this setting as it has been for cervical and endometrial cancer.

SUMMARY

For most gynecologic cancers, ICG fluorescence imaging is considered now a days the tracer of choice for lymphatic mapping. However, in early-stage vulvar cancer, SLN biopsy with radioactive tracer continues to be the standard-of-care in lymph node status assessment.

Benefits of sentinel node detection in cervical cancer

PURPOSE OF REVIEW

Sentinel lymph node biopsy (SLNB) is a widely used technique in other gynaecological tumours but has not yet been implemented as the gold standard technique for nodal staging in cervical cancer. Since the majority of evidence is derived from retrospective studies, this review aims to summarize the most recent evidence on this relevant topic.

RECENT FINDINGS

SLNB has demonstrated to be a well tolerated technique for lymph node staging in early-stage cervical cancer patients with promising future as exclusive lymph node assessment method avoiding full lymphadenectomy. Moreover, it allows ultrastaging and unfrequent drainage identification, which enables the detection of patients at a high risk of recurrence who would otherwise remain unnoticed. When compared with pelvic lymphadenectomy, SLNB is also associated with less intraoperative and postoperative complications, especially in terms of lymphedema formation.

SUMMARY

The available evidence suggests that SLNB offers numerous advantages over the standard pelvic lymphadenectomy reducing morbidity rates and increasing diagnostic accuracy. Three ongoing prospective trials will likely answer the controversies over these questions.

Does "One Size Fits All"? Rethinking FIGO Depth of Invasion Measurements in Vulvar Cancer

Depth of invasion (DOI) is an important diagnostic parameter in patients with vulvar carcinoma, where a cutoff value of 1 mm largely determines the tumor stage and the need for groin surgery. DOI measurement should be reproducible and straightforward. In light of the new recommendation on how to measure DOI in the International Federation of Gynecology and Obstetrics (FIGO) staging system 2021, an exploratory study was conducted on the current practice of DOI measurement in vulvar cancer. In this study of 26 selected cases, 10 pathologists with high exposure to vulvar cancer cases in daily practice assessed both the conventional (FIGO 2009) and alternative (FIGO 2021) DOI methods for applicability and preference. In this set of cases, the DOI measurement according to FIGO 2009 was generally considered easier to apply than the measurement according to FIGO 2021, with applicability being rated as "easy to reasonable" in 76.9% versus 38.5% of cases, respectively ( P =0.005). The preferred method was FIGO 2009 or tumor thickness in 14 cases and FIGO 2021 in 6 cases. No invasion was preferred in 1 case. For the remaining 5 cases, half of the pathologists opted for the FIGO 2009 method and half for the FIGO 2021 method. Although the FIGO 2009 method proved to be more readily applicable in most of the cases studied, the method may differ for each case. There may not be a "one size fits all" solution for all cases of vulvar cancer.

Impact of age on tumor size in vulvar cancer: A multicenter study by the Francogyn group

OBJECTIVE

Vulvar cancer is a rare pathology affecting mainly elderly women. This study aims to evaluate the impact of age on tumor size in vulvar cancer.

MATERIAL AND METHODS

This was a multicenter retrospective observational study carried out between January 1, 1998, and December 31, 2020, in patients operated on for vulvar cancer. Univariate analysis was performed according to patients' age ≥ or <65 years. Factors associated with tumor size found to be significant according to age were then included in a multiple linear regression model.

RESULTS

Of the 382 patients included, there were 133 patients aged <65 years and 249 ≥ 65 years. Radical total vulvectomy surgeries were more frequently performed in women ≥65 years (n = 72 (28.9 %) versus n = 20 (15 %); p = 0.004). The median histological tumor size and interquartile range was 20 mm [13-29] in the <65 years and 30 mm [15-42] in patients ≥65 years (p = 0.001). Multiple linear regression showed that age ≥65 years had a regression coefficient of 7.15 95 % CI [2.32; 11.99] (p = 0.004), constituting a risk factor for larger histological tumour size. Patients aged ≥65 years old had a higher early complication rate (n = 150 (62 %) versus n = 56 (42.7 %), p = 0.001). They also had a greater risk of recurrence (HR = 1.89 (95%CI (1.24-2.89)), p = 0.003) with a worse overall survival (HR = 5.64 (95%CI (1.70-18.68)), p = 0.005).

CONCLUSION

Age is a risk factor for larger tumor size, leading to more radical surgery and a greater risk of complications in already fragile patients, with a greater risk of recurrence and an impact on overall survival.

ICG mapping of postoperative lymphatic leakage in the groin: a video article and literature review

Background

Inguinofemoral lymphoceles are a common postoperative complication after inguinofemoral lymphadenectomy (LNE) and a challenge for patients as well as physicians. We report here our preliminary experience in the surgical management of a recurrent lymphocele using indocyanine green (ICG) detection, followed by robotic-assisted closure of the lymphatic leaks.

Objectives

The aim of this article is to illustrate the surgical steps of ICG-assisted detection of inguinal lymphatic leaks and their surgical treatment by means of robot-assisted suturing. Furthermore, the feasibility of the approach will be evaluated.

Materials and methods

A 59-year-old woman with locally advanced squamous cell carcinoma of the vulva and previous conventional bilateral inguinofemoral LNE presented with symptomatic therapy-resistant lymphoceles in the groin. After a lengthy and frustrating course of standard therapy, she was offered the off-label option surgical treatment with ICG detection and subsequent robot-assisted ligation of the leaks, using the Da Vinci robotic system™.

Main outcome measures

Perioperative data, specific aspects of the surgical approach specifics, objective and subjective outcomes of the new approach.

Results

The procedure was performed as planned, with no intraoperative complications or device-related issues. The postoperative course was uneventful, and the patient developed no further lymphoceles.

Conclusion

Visualisation of the leakage by ICG combined with minimally invasive robotic-assisted laparoscopy is a promising therapy option. The pictures and videos demonstrate our experience in regard of the safety, feasibility, and usefulness of this procedure. Further studies will be needed, to prove the absolute efficacy of the technique and express a general recommendation in regard of this approach for the treatment of inguinofemoral lymphoceles.

Influence of stage and age on survival of patients with vulvar cancer in Germany: a retrospective study

OBJECTIVES

To evaluate the 5-year survival rate of patients with vulvar cancer, taking into account prognostic factors (International Federation of Gynecology and Obstetrics (FIGO) stage and age) and the influence of lymph node involvement and tumour size as well as the correlation between FIGO stage and age at onset.

DESIGN

Retrospective cohort study.

SETTING

German cancer registries.

PARTICIPANTS

The study included 17 017 patients diagnosed with vulvar cancer between 2004 and 2014 with follow-up until 2017. Exclusion criteria were incomplete documentation, age<18 years and death certificate only.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was overall and relative survival according to FIGO stage and age and the distribution of FIGO stages by age group. Secondary outcomes analysed were tumour size and lymph node status as risk factors for mortality.

RESULTS

The median age at diagnosis was 70 years. The overall 5-year survival rate was 69.5% (95% CI: 68.7% to 70.3%). The 5-year relative survival rates ranged from 91.9% (95% CI: 90.5% to 93.3%) to 21.3% (95% CI: 15.6% to 27.0%) for FIGO I to FIGO IVB and from 89.2% (95% CI: 87.6% to 90.8%) to 68.0% (95% CI: 65.3% to 70.7%) for age groups <55 to >75 years. Younger patients were significantly more often diagnosed with a low FIGO stage (p<0.001). Lymph node status and tumour size were independent factors influencing survival (HR: 1.79 (95% CI: 1.73 to 1.84; p<0.001) and 1.88 (95% CI: 1.80 to 1.96); p<0.001, respectively). The median follow-up time was 57 months.

CONCLUSION

Notably, the steepest decline in survival occurred within the first 3 years after diagnosis. Patients with the highest FIGO stages and those in the oldest age group had the worst survival rates. Furthermore, patients in the oldest age group were more likely to be diagnosed at higher stages. Lymph node status and tumour size were additional independent prognostic factors for mortality.

Notable surgical trials in gynecologic oncology: a 10-year overview

In the last decade, we have witnessed important advances in novel therapeutics in the management of gynecologic cancers. These studies have built on the findings from preexisting data and have provided incremental contributions leading to changes that have not only impacted the accuracy of cancer detection and its metastatic components but also led to improvements in oncologic outcomes and quality of life. Key landmark trials have changed the standard of care in cervix, uterine, and ovarian cancer. A number of these have been controversial and have generated significant debate among gynecologic oncologists. The main objective of this review was to provide an overview on each of these trials as a reference for immediate and consolidated access to the study aims, methodology, results, and conclusion.

Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study

OBJECTIVE

To assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer.

METHODS

This was a multicenter, retrospective, controlled study. Surgical outcomes and complication rates of women with invasive vulvar cancer who underwent radical surgery and vulvar reconstruction and those who underwent radical surgery without the reconstruction step were compared. Only patients who underwent bilateral or unilateral V-Y advancement fascio-cutaneous flaps were included in the reconstruction group. Univariate and multivariate logistic regression models were used to analyze predicting variables for their association with complication rates.

RESULTS

Overall, 361 patients were included: 190 (52%) underwent the reconstructive step after the excisional radical procedure and were compared with 171 (47.4%) who did not undergo the reconstructive step. At multivariate analysis, body mass index >30 kg/m2 (odds ratio (OR) 3.36, p=0.007) and diabetes (OR 2.62, p<0.022) were independently correlated with wound infection. Moreover, increasing age (OR 1.52, p=0.009), body mass index >30 kg/m2 (OR 3.21, p=0.002,) and International Federation of Gynecology and Obstetrics (FIGO) stages III-IV (OR 2.25, p=0.017) were independent predictors of wound dehiscence. A significant reduction in the incidence of postoperative wound complications among patients who underwent V-Y reconstructive flaps was demonstrated. This was correlated more significantly in women with lesions >4 cm.

CONCLUSIONS

The adoption of V-Y flaps in vulvar surgery was correlated with reduced surgical related complications, particularly in vulnerable patients involving large surgical defects following excisional radical procedures.

Molecular image-guided surgery in gynaecological cancer: where do we stand?

PURPOSE

The aim of this review is to give an overview of the current status of molecular image-guided surgery in gynaecological malignancies, from both clinical and technological points of view.

METHODS

A narrative approach was taken to describe the relevant literature, focusing on clinical applications of molecular image-guided surgery in gynaecology, preoperative imaging as surgical roadmap, and intraoperative devices.

RESULTS

The most common clinical application in gynaecology is sentinel node biopsy (SNB). Other promising approaches are receptor-target modalities and occult lesion localisation. Preoperative SPECT/CT and PET/CT permit a roadmap for adequate surgical planning. Intraoperative detection modalities span from 1D probes to 2D portable cameras and 3D freehand imaging.

CONCLUSION

After successful application of radio-guided SNB and SPECT, innovation is leaning towards hybrid modalities, such as hybrid tracer and fusion of imaging approaches including SPECT/CT and PET/CT. Robotic surgery, as well as augmented reality and virtual reality techniques, is leading to application of these innovative technologies to the clinical setting, guiding surgeons towards a precise, personalised, and minimally invasive approach.

Superparamagnetic iron oxide (SPIO) for sentinel lymph node detection in vulvar cancer

OBJECTIVES

Sentinel lymph node (SLN) detection with superparamagnetic iron oxide (SPIO) nanoparticles has been widely studied and standardized for breast and prostate cancer, but there is scarce evidence concerning its use in vulvar cancer. The objective of this study was to compare SLN detection using a SPIO tracer injected at the time of the surgery detected by a magnetometer, with the standard procedure of using a technetium 99 radioisotope (Tc99) detected by a gamma probe, in patients with vulvar cancer.

METHODS

The SPIO vulvar cancer study was a single-center prospective interventional non-inferiority study of SPIO compared to Tc99, conducted between 2016 and 2021 in patients who met the GROINSS-V study inclusion criteria for selective sentinel lymph node dissection in vulvar cancer.

RESULTS

We included 18 patients and a total of 41 SLNs. The level of agreement between tracers was 92.7% (80.6%-97.4%), corresponding to 38 out of 41 SLNs, which confirms the non-inferiority of SPIO compared to Tc99. The SLN detection rate per groin was 96.3 (81.7%-99.3) using Tc99 and 100% (87.5%-100%) using SPIO. Both tracers had a detection rate of 100% for positive lymph nodes.

CONCLUSIONS

The use of SPIO as a tracer for detecting SLNs in patients with vulvar cancer has shown to be non-inferior to that of the standard radiotracer, with the advantages of not requiring nuclear medicine and being able to inject it at the time of surgery after induction of anesthesia.

Role of ultrasound in detection of lymph-node metastasis in gynecological cancer: systematic review and meta-analysis

OBJECTIVE

To assess the diagnostic performance of transvaginal sonography (TVS) for the preoperative evaluation of lymph-node metastasis in gynecological cancer.

METHODS

This was a systematic review and meta-analysis of studies published between January 1990 and May 2023 evaluating the role of ultrasound in detecting pelvic lymph-node metastasis (index test) in gynecological cancer, using histopathological analysis as the reference standard. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled sensitivity, specificity and diagnostic odds ratio were estimated.

RESULTS

The literature search identified 2638 citations. Eight studies reporting on a total of 967 women were included. The mean prevalence of pelvic lymph-node metastasis was 24.2% (range, 14.0-65.6%). The risk of bias was low for most domains assessed. Pooled sensitivity, specificity and diagnostic odds ratio of TVS were 41% (95% CI, 26-58%), 98% (95% CI, 93-99%) and 32 (95% CI, 14-72), respectively. High heterogeneity was found between studies for both sensitivity and specificity.

CONCLUSION

TVS showed a high pooled specificity for the detection of pelvic lymph-node metastasis in gynecological cancer, but pooled sensitivity was low. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Setting-up a training programme for intraoperative molecular imaging and sentinel node mapping: how to teach? How to learn?

BACKGROUND

The current expansion of image-guided surgery is closely related to the role played by radio-guided surgery in supporting the sentinel node (SN) procedure during more than three decades. The so-called triple approach (lymphoscintigraphy, gamma probe detection and blue dye) was not only essential in the seminal validation of the SN procedure but also a first collective learning effort based on skill transfer and outcome-related evaluation which laid the fundaments to delineate the field of intraoperative molecular imaging (IMI) based on a similar multimodality approach and multidisciplinary practice.

METHODS

These elements are also becoming valid in the current incorporation of SPECT/CT and PET/CT to existing and new protocols of IMI procedures and SN mapping concerning other clinical applications. On the other hand, there is a growing tendency to combine novel modern technologies in an allied role with gamma guidance in the operating room following the development of hybrid tracers and multimodal detection approaches. Against this background, learning initiatives are required for professionals working in this area.

RESULTS

This objective has led to a group of European practitioners with large experience in SN mapping and IMI applications to give shape to a programme made up out of specific learning modules aimed to be used as a conductive thread in peripherical or centralised training instances concerning the topic.

CONCLUSION

The presented work, written as a tutorial review, is placed in an available prior-art context and is primarily aimed at medical and paramedical practitioners as well as at hardware and software developers.

The Royal College of Radiologists National Vulvar Cancer Audit

AIMS

This audit examined UK vulvar cancer practice from March 2018 to January 2019 and compared it to standards from national and international recommendations. Follow-up data collection in 2020 examined patient outcomes and toxicity.

MATERIALS AND METHODS

Audit standards were based on Royal College of Radiologists (RCR) guidance and published literature. A web-based questionnaire was sent to the audit leads at all cancer centres in the UK. Prospective data collection included patient demographics, tumour characteristics, radiotherapy indications, dosimetry, timelines, and follow-up data. The audit targets were 95% compliance with the RCR dose/fractionation schemes in definitive and adjuvant patients, 40% use of intensity modulated radiotherapy (IMRT), 100% of radical patients treated as category 1, and 95% use of gap compensation for category 1 patients.

RESULTS

34/54 UK radiotherapy centres (63%) completed data entry for 152 patients. 23 out of 34 (68%) centres submitted follow-up data for 94 patients. One indicator exceeded the audit target: 98% of radical patients received IMRT. The indicators of RCR dose/fractionation compliance for adjuvant/definitive radiotherapy were achieved by 80%/43% for the primary, 80%/86% for elective lymph nodes, and 21%/21% for pathological lymph nodes. The use of concomitant chemotherapy with radical radiotherapy in suitable patients was achieved by 71%. Other indicators demonstrated that 78% were treated as category 1 and 27% used gap compensation. Acute toxicity was mostly related to skin, gastrointestinal, and genitourinary sites. Grade 3 and Grade 4 toxicities were seen at acceptable rates within the radical and adjuvant groups. Late toxicity was mostly grade 0.

CONCLUSION

This audit provides a comprehensive picture of UK practice. IMRT is widely used in the UK, and treatment-related toxicity is moderate. The dose fractionation was very heterogeneous. The designation of vulvar cancer as category 1 was not regularly followed for radical/adjuvant patients, and there was minimal gap compensation during treatment.

Prognostic characteristics, recurrence patterns, and survival outcomes of vulval squamous cell carcinoma - A twelve-year retrospective analysis of a tertiary centre

INTRODUCTION

Vulval cancer is a rare gynaecological malignancy. In this study, we present a tertiary centre case analysis to examine the recurrence patterns and survival outcomes of vulval squamous cell carcinoma (SCC).

METHODS

This is a retrospective cohort study of women who received treatment at Oxford University Hospitals between February 2010 and July 2022 for primary vulval SCC.

RESULTS

We included 98 cases. The median age at diagnosis was 68 years. Human Papillomavirus (HPV) infection and lichen sclerosis were observed in 21 and 50 cases, respectively. Surgical excision was the primary treatment. Recurrence within 2 years was more common with advanced stage (p = 0.047, RR = 2.26) and extracapsular lymph node spread (p = 0.013, RR = 2.88). Local recurrence was not associated with a specific cut-off value for tumour-free margin. Poor survival outcomes were observed with higher grade (p = 0.01), advanced FIGO stage (p < 0.001), HPV-independent cancer (p = 0.048), lymph node involvement (p < 0.001, HR = 7.14), extracapsular spread (p < 0.001, HR = 7.93), lymphovascular space invasion (p = 0.002, HR = 3.17), tumour diameter wider than 23 mm (p = 0.029, HR = 2.53) and depth of invasion more than 6 mm (p = 0.006, HR = 3.62). Perineural invasion is associated with shorter disease-free survival. Five-year cancer-specific survival rates for stages I, III, and IV were 90.2%, 40.8%, and 14.3%, respectively.

CONCLUSION

Neoadjuvant chemotherapy with bevacizumab for locally advanced vulvar cancer

OBJECTIVES

External beam radiation with sensitizing platinum is the recommended therapy for locally advanced vulvar cancers not amenable to curative surgery and is associated with considerable acute and chronic side effects. Radical vulvectomy post-radiation for persistent disease is often compromised with poor wound healing. We describe clinical outcomes for patients who received neoadjuvant chemotherapy plus bevacizumab followed by radical vulvectomy for locally advanced vulvar cancer.

METHODS

We performed retrospective analyses of all patients at our institution who underwent radical vulvectomy from January 2015 to November 2023. Of 113 patients, 13 patients underwent neoadjuvant chemotherapy. Demographics and clinicopathologic data were extracted, and descriptive statistical analyses were performed. Cases with neoadjuvant chemotherapy plus bevacizumab were further evaluated for response, adverse effects, and survival.

RESULTS

Neoadjuvant chemotherapy was administered to 13 patients with stage II-IV disease that involved the urethra, vagina, or anus. Lesion sizes ranged from 4 to 20 cm (median 7 cm). Patients received 2-6 cycles of carboplatin or cisplatin, paclitaxel, and bevacizumab. Nine (69.2%) patients had partial pathologic responses, and four patients had complete responses. All patients had negative surgical margins. Ten (76.9%) patients had radiographic evidence of inguinal lymph node metastasis prior to neoadjuvant chemotherapy, and four had residual nodal disease. Only one patient developed a superficial groin seroma. Three patients developed recurrence, two locally and one distant, and there was one death. The median follow-up was 23 months (range 6-84 months).

CONCLUSIONS

Neoadjuvant chemotherapy using combination platinum/paclitaxel/bevacizumab was efficacious for locally advanced vulvar cancer, resulting in complete resections, negative margins, and excellent wound healing. A multi-institutional phase II trial is warranted to validate these findings.

Imaging in Vulval Cancer

Vulval cancer is a rare gynaecological cancer, accounting for 3% of all gynaecological malignancies, with 47,000 cases in 2022 globally. Various imaging modalities are widely used in conjunction with clinical assessment in the diagnosis and staging of vulval cancers; however, there is significant heterogeneity in which modalities are recommended in international guidelines, reflecting the paucity of evidence in this area. We reviewed the current evidence for the role of imaging in vulval cancer. A systematic search of the literature was performed on the PubMed database using the MeSH terms 'vulval neoplasm' and 'diagnostic imaging'. We found that there is insufficient evidence to support the routine use of imaging for primary vulval tumours. For nodal assessment, there is no ideal imaging modality with sensitivity or specificity that is superior to other modalities. For distant metastases, CT CAP and FDG-PET/CT have the most evidence to support their use. In conclusion, the evidence for role of imaging in vulval cancer is limited by the heterogeneity of the study design and diagnostic criteria used in each study and the small sample size and retrospective nature of most studies.

High concordance of molecular subtyping between pre-surgical biopsy and surgical resection specimen (matched-pair analysis) in patients with vulvar squamous cell carcinoma using p16- and p53-immunostaining

OBJECTIVE

Vulvar squamous cell carcinoma (VSCC) can be stratified into three molecular subtypes based on the immunoexpression of p16 and p53: HPV-independent p53-abnormal (p53abn) (most common, biologically aggressive), HPV-associated, with p16-overexpression (second most common, prognostically more favourable) and more recently recognised HPV-independent p53-wildtype (p53wt) (rarest subtype, prognostically intermediate). Our aim was to determine whether molecular subtypes can be reliably identified in pre-operative biopsies and whether these correspond to the subsequent vulvectomy specimen.

METHODS

Matched-paired pre-surgical biopsies and subsequent resection specimen of 57 patients with VSCC were analysed for the immunohistochemical expression of p16 and p53 by performing a three-tiered molecular subtyping to test the accuracy rate.

RESULTS

Most cases 36/57 (63.2%) belonged to the HPV-independent (p53-abn) molecular subtype, followed by HPV-associated 17/57 (29.8%) and HPV-independent (p53wt) 4/57 (7.0%). The overall accuracy rate on biopsy was 91.2% (52/57): 97.3% for p53-abnormal, 94.1% for p16-overexpression and 50% for p16-neg/p53-wt VSCC. Incorrect interpretation of immunohistochemical p53 staining pattern was the reason for discordant results in molecular subtyping in all five cases. In one case there was an underestimation of p53 pattern (wildtype instead of abnormal/aberrant) and in one case an overestimation of the p53 staining pattern (abnormal/aberrant instead of wildtype). In 3/5 there was a "double positive" staining result (p16 overexpression and abnormal/aberrant p53 staining pattern). In that cases additional molecular workup is required for correct molecular subtyping, resulting in an overall need for molecular examination of 3/57 (3.5%).

CONCLUSIONS

Compared to the final resections specimen, the three-tiered molecular classification of VSCC can be determined on pre-surgical biopsies with a high accuracy rate. This enables more precise surgical planning, prediction of the response to (chemo) radiation, selection of targeted therapies and planning of the optimal follow-up strategy for patients in the age of personalised medicine.

Treatment of vulvar cancer recurrence with electrochemotherapy: a case-control study

BACKGROUND

Electrochemotherapy (ECT) is a combined treatment method based on electroporation and simultaneous chemotherapy. In cases where radiotherapy has previously been used, surgery is often the only treatment option for vulvar cancer recurrence with potential resection of clitoris, vagina, urethra or anal sphincter. The unique advantage of ECT is its selectivity for cancer cells while sparing the surrounding healthy tissue. The aim of the study was to compare the ECT treatment of vulvar cancer recurrence for non-palliative purposes with surgical treatment.

MATERIALS AND METHODS

Eleven patients with single vulvar cancer recurrence were treated with ECT and followed up for 12 months. As a control group, 15 patients with single vulvar cancer recurrence were treated with wide local excision. The following data were collected, analyzed and compared: Age, body mass index, comorbidities, histological type, location and size of vulvar cancer recurrence, treatment history, details of procedures and hospital stay.

RESULTS

The probability curves for local tumor control did not differ between the ECT group and the surgical group (p = 0.694). The mean hospital stay and the mean duration of procedure were statistically significantly shorter in the ECT group (p < 0.001). There were no statistically significant differences between the ECT and surgical groups in terms of mean body mass index, associated diseases, previous treatments, presence of lichen sclerosus, p16 status, gradus, anatomical site of the tumor, and type of anesthesia.

CONCLUSION

In this case-control study, treatment of vulvar cancer recurrence with ECT for non-palliative purposes was comparable to surgical treatment in terms of effectiveness. The results need to be confirmed in larger randomized trials.

Current Preoperative Management of Vulvar Squamous Cell Carcinoma: An Overview

Vulvar carcinoma is a rare cancer affecting the genital tract, constituting 4% of gynecological tumors. Vulvar squamous cell carcinoma (VSCC) is the most common type. Diagnosis relies on biopsy during vulvoscopy, plus imaging such as ultrasonography (USG), magnetic resonance imaging (MRI) and positron emission tomography (PET). This review aims to lay out a thorough overview as to the current preoperative management of VSCC, both in case of vulvar and lymph node involvement. The data research was conducted using the following databases: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library from 2010 to 2024. The selection criteria included only original articles. Seventeen studies were assessed for eligibility. A concordance rate of 62.3% for vHSIL and 65.2% for carcinoma at vulvoscopy, with a sensitivity of 98%, specificity of 40%, PPV (Positive Predictive Value) of 37% and NPV (Negative Predictive Value) of 98% in identifying malignant lesions was found. Regarding the reliability of PET for staging and assessing lymph node involvement, a mean SUV (Standardized Uptake Value) for malignant vulvar lesions of 8.4 (range 2.5-14.7) was reported. In the case of MRI, useful for the evaluation of loco-regional infiltration and lymph node involvement, the ratio of the short-to-long-axis diameter and the reader's diagnostic confidence for the presence of lymph node metastasis yielded accuracy of 84.8% and 86.9%, sensitivity of 86.7% and 87.5%, specificity of 81.3% and 86.2%, PPV of 89.7% and 87.5% and NPV of 76.5% and 86.2%, respectively. A long lymph node axis >10 mm and a short diameter >5.8 mm were found to be predictors of malignancy. At USG, instead, the two main characteristics of potentially malignant lymph nodes are cortical thickness and short axis length; the combination of these ultrasound parameters yielded the highest accuracy in distinguishing between negative and positive lymph nodes. Despite the heterogeneity of the included studies and the lack of randomized clinical trials, this review provides a broad overview of the three imaging tools used for the presurgical management of VSCC. Nowadays, although MRI and PET represent the gold standard, ultrasound evaluation is taking on a growing role, as long as it is carried out by expert sonographer. The management of this rare disease should be always performed by a multidisciplinary team in order to precisely stage the tumor and determine the most suitable treatment approach.