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.

Surgery as primary treatment improved overall survival in vulvar squamous cancer: A single center study with 108 women

OBJECTIVE

To describe a single-center experience managing women with vulvar squamous cancer and analyze factors influencing their survival.

STUDY DESIGN

It is an observational longitudinal retrospective study that reviewed medical records of patients admitted for treatment at the University of Campinas between 2010 and 2019, followed up until June 2022. The final sample was 108 cases. The main outcomes were disease-free survival (DFS) and overall survival (OS). Other variables were age, stage, relapse, and race. Vital status was accessed by medical records, active search, or public online register. Survival analysis was performed by the Kaplan-Meier method and Log-rank Test, and Regression Cox-Model assessed risks.

RESULTS

The mean age in stages IA and IB were 65.0 years, and in stages II + III + IVA 71.1 years. Women 70 years or older were more related to diagnosis in stages II + III + IVA (p = 0.019). Progression was observed in 7 (16.7 %) patients in stage IB and 30 (65.2 %) in stage II + III + IVA. Both five-year (5y) DFS and OS were significantly different in stage IB and II + III + IVA (5y-DFS 70.5 % and 39.3 %, p = 0.024; 65.1 % and 24.3 %, p < 0.001). In stages II + III + IVA, most deaths happened before 24 months of follow-up. The primary treatment was surgery in 81.0 % of stage IB and 47.8 % of stage II + III + IVA. A higher OS was observed in patients treated primarily by surgery compared to radiotherapy in stage IB (p = 0.008), and in stages II + III + IVA (p = 0.013). Surgery followed or not by adjuvant radiotherapy was independently associated with a 60 % adjusted death protection compared to radiotherapy alone as primary treatment (0.40, 0.23;0.70).

CONCLUSIONS

Half of the patients have been diagnosed in stage I. The progression rate was high in the advanced stages of the disease. Overall survival by stage was improved when surgery was the primary treatment. Surgery was independently associated with death.

Feasibility of Introducing a Prehabilitation Program into the Care of Gynecological Oncology Patients-A Single Institution Experience

Prehabilitation is an upcoming strategy to optimize patient's functional capacity, nutritional status, and psychosocial well-being in order to reduce surgical complications and enhance recovery. This study aims to assess the feasibility of implementing a multimodal prehabilitation program into the standard care of gynecological oncology patients at an academic hospital in terms of recruitment, adherence, and safety, which were assessed by the number of patients eligible, recruitment rate, participation rate, and adherence to individual modalities. Data were derived from the F4S PREHAB trial, a single-center stepped-wedge trial implementing a multimodal prehabilitation program among various surgical specialties. All patients undergoing elective surgery as part of treatment for ovarian, uterine, and vulvar cancer at the Radboudumc, an academic hospital in The Netherlands, between May 2022 and September 2023 were considered eligible for the F4S PREHAB trial and, consequently, were included in this cohort study. The multimodal prehabilitation program comprised a physical exercise intervention, nutritional intervention, psychological intervention, and an intoxication cessation program. A total of 152 patients were eligible and approached for participation of which 111 consented to participate, resulting in a recruitment rate of 73%. Participants attended an average of six exercise sessions and adhered to 85% of possible training sessions. Respectively, 93% and 98% of participants adhered to the prescribed daily protein and vitamin suppletion. Ten participants were referred to a psychologist and completed consultations. Out of nine active smokers, two managed to quit smoking. A total of 59% adhered to alcohol cessation advice. No adverse events were reported. This study demonstrates that introducing a multimodal prehabilitation program into the standard care of gynecological oncology patients is feasible in terms of recruitment and adherence, with no serious adverse events.

Clinical and epidemiological characteristics of cancers associated with human papillomavirus in the regions of North-West Russia

Introduction. The leading role of the human papillomavirus in the etiopathogenesis of malignant neoplasms of some localizations is generally recognized. Vaccines that are used in the world and in Russia for the prevention of papillomavirus infection create the basis for the elimination of diseases associated with the human papillomavirus in the future. The aim of the study is to determine the regional, gender and age-specific features of cancers associated with the human papillomavirus to substantiate the development of a unified system of epidemiological surveillance and vaccination. Materials and methods. The retrospective epidemiological analysis of the incidence of cancers associated with the human papillomavirus and mortality due to these neoplasms in the regions of the North-Western Federal District of Russia in 20112020 was carried out based on data from Statistic Form 7 "Information on malignant neoplasms" and the Population cancer Registers of St. Petersburg (13,117 cases), Leningrad region (3204 cases) and the Kaliningrad region (2898 cases). Results. In the structure of cancers associated with the human papillomavirus in St. Petersburg, Leningrad and Kaliningrad regions, more than 90% of men had tumors of the oral cavity, oropharynx and larynx, more than 60% of women had cervical cancer. Regional and age-specific features of the incidence of cervical cancer and mortality from this pathology have been established. Statistically significant differences in the incidence of cancer of the head and neck, anus and anal canal in different age groups of the male and female population were revealed. Conclusion. As a result of the study, regional, gender and age-specific features of the incidence of human papillomavirus-associated malignant neoplasms in the North-West of Russia were established. These data should be used to develop a system of epidemiological surveillance of papillomavirus infection and vaccination program.

Quality of Life with Vulvar Carcinoma Treated with Palliative Electrochemotherapy: The ELECHTRA (ELEctroCHemoTherapy vulvaR cAncer) Study

Simple Summary

A multicenter prospective observational study was conducted on patients with vulvar cancer (VC) refractory or not amenable to standard therapies undergoing palliative electrochemotherapy (ECT) as per clinical practice. Electrochemotherapy with bleomycin improves quality of life in patients with recurrent vulvar cancer. The assessment was performed with a visual analog pain scale (VAS), EuroQol 5-Dimension 5-Level (EQ-5D-L5) and Functional Assessment of Cancer Therapy—Vulva cancer (FACT—V). To our knowledge, this is the first study reporting the impact of palliative ECT on QoL of VC patients, with a detailed evaluation of potential correlations between tumor characteristics and severity of and response to symptoms. This improvement is higher in patients with clinical response and for smaller and anterior lesions. Based on these results, ECT in VC should be considered as an effective option based on the favorable outcomes both in terms of response and QoL.

Abstract

The ELECHTRA (ELEctroChemoTherapy vulvaR cAncer) project was conceived to collect data on palliative electrochemotherapy (ECT) in vulvar cancer (VC) assessing patients’ outcomes (response and survival) and impact on quality of life (QoL). After reporting outcome data in 2019, here, we present the results on QoL. A multicenter prospective observational study was conducted on patients with VC refractory or not amenable to standard therapies undergoing palliative ECT as per clinical practice. The following questionnaires were administered before and after ECT (two and four months later, early and late follow-up): visual analog pain scale (VAS), EuroQol 5-Dimension 5-Level (EQ-5D-L5) and Functional Assessment of Cancer Therapy—Vulva cancer (FACT—V). Analyses were conducted on both the whole study population and by subgroups (clinical response after ECT and site, number and size of lesions). Questionnaires from 55 patients were evaluated. Compared to the baseline (6.1 ± 2.1), the VAS was significantly reduced at early (4.3 ± 2.5) and late follow-up (4.6 ± 2.8) (p < 0.0001). The FACT—V score improved significantly at early (9.6 ± 4.0) (p < 0.0001) and late follow-up (8.9 ± 4.1) (p < 0.0054) as compared to the baseline (7.1 ± 3.6). No EQ-5D-5L statistically significant changes were observed. Subgroup analyses showed worse QoL in patients with stable or progressive disease, posterior site and multiple or larger than 3 cm nodules. This is the first study reporting improved QoL in VC patients after palliative ECT. Based on these results, ECT in VC should be considered an effective option based on the favorable outcomes both in terms of response and QoL.

Age, treatment and prognosis of patients with squamous cell vulvar cancer (VSCC) - analysis of the AGO-CaRE-1 study

BACKGROUND

Despite an increasing incidence with simultaneous decreasing age of onset, vulvar squamous cell carcinoma (VSCC) is still a disease that mainly effects the elderly population. Data on the association of age with prognosis and treatment patterns in VSCC are sparse.

METHODS

This is an analysis of the AGO-CaRE-1 cohort. Patients with VSCC (FIGO stage ≥1B), treated at 29 cancer centers in Germany from 1998 to 2008, were included in a centralized database (n = 1618). In this subgroup analysis patients were analyzed according to age [<50 yrs. (n = 220), 50-69 yrs. (n = 506), ≥70 yrs. (n = 521)] with regard to treatment patterns and prognosis. Only patients with documented age, surgical groin staging and known nodal status were included (n = 1247). Median follow-up was 27.5 months.

RESULTS

At first diagnosis, women ≥70 yrs. presented with more advanced tumor stages (<0.001), larger tumor diameter (<0.001), poorer ECOG status (<0.001), more frequent HPV negative tumors (p = 0.03) as well as a higher rate of nodal involvement (<0.001). Disease recurrence occurred significantly more often in elderly patients (p = 0.001) and age as well as ECOG status, microscopic residual resection, tumor stage, grading, and (chemo)radiation were independent prognostic factors for death or recurrence in multivariate analysis. 2-year disease-free survival rates were 59.3% (≥70 yrs), 65.8% (50-69 yrs) and 81.1% (<50 yrs), respectively (p < 0.001).

CONCLUSIONS

Older women with VSCC present with advanced tumor stages at first diagnosis and have an increased risk of recurrence as well as a decreased 2-year DFS in comparison to younger patients. Potential reasons could be self-awareness and/or more aggressive tumor biology due to HPV independent disease.

A prognostic nomogram based on lymph node ratio for postoperative vulvar squamous cell carcinoma from the Surveillance, Epidemiology, and End Results database: a retrospective cohort study

Background

Vulvar carcinoma is a rare gynecological malignancy. The most commonly used staging system for vulvar cancer is the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system. Nevertheless, it does not incorporate many indispensable prognostic parameters, which prominently influence vulvar cancer patient survival. Thus, the development of a prediction model for evaluating survival prognosis in postoperative vulvar squamous cell cancer patients is of vital importance.

Methods

Data from 2,166 patients with pathologically confirmed diagnosis of vulvar squamous cell carcinoma from 2004 to 2015 were acquired from the Surveillance, Epidemiology, and End Results (SEER) database. Thirty percent of the patients were randomly assigned to the validation group, and the remainder were used to develop the nomogram. Parameters that significantly correlated with overall survival (OS) were used to create the nomogram. Concordance index (C-index), calibration curve, and decision curve analysis (DCA) were used to assess the predictive accuracy and discriminability of the nomogram model. Additionally, the C-index and DCA of the nomogram and the FIGO staging system were compared.

Results

Following multivariate analysis of the training cohort, independent factors for OS, including race, age at diagnosis, marital status, FIGO stage, tumor diameter, and lymph node ratio (LNR), were included in the nomogram model. The calibration curve indicated a high correlation between the nomogram-predicted and observed survival probability. The C-index of the nomogram in the training cohort was 0.772 (95% CI: 0.752–0.792), statistically superior to the C-index value of the FIGO staging system (0.676, 95% CI: 0.654–0.698). In DCA, compared to the FIGO staging system, this nomogram showed a greater net benefit and a wider range of threshold probability. Results were verified by an internal validation cohort.

Conclusions

Our nomogram, based on LNR, showed superior prognostic predictive accuracy compared with the FIGO staging system for predicting OS in postoperative vulvar squamous cell carcinoma patients.

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer

OBJECTIVE

A retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomy METHODS: Patients diagnosed between January 2012 and December 2015 with vulvar squamous cell carcinoma of less than 4 cm in size, with invasion of at least 1 mm, who underwent sentinel lymph node biopsy, lymphadenectomy, or both were identified from the National Cancer Database. Overall survival was evaluated following generation of Kaplan-Meier curves and compared with the log-rank test for patients who had at least 1 month of follow-up. A Cox model was constructed to control for confounders.

RESULTS

A total of 1583 patients were identified; 304 patients (19.2%) underwent sentinel lymph node biopsy alone. Sentinel lymph node biopsy utilization increased 13.9% between 2012 and 2015. Patients who underwent sentinel node biopsy alone were less likely to have comorbidities compared with those undergoing lymphadenectomy only or sentinel node biopsy with lymphadenectomy (25.3% vs 32.9% vs 31.9%, p=0.042), had smaller tumors (median 1.6 vs 2.0 vs 2.0 cm, p<0.001), and were less likely to have positive lymph nodes (11% vs 19.6% vs 28.1%, p<0.001). There was no difference in 3 year overall survival between the three groups (86.3% vs 82.1% vs 77.9%, p=0.26). After controlling for age, race, insurance, comorbidities, lymph node metastases, and tumor size, sentinel lymph node biopsy alone was not associated with worse overall survival compared with lymphadenectomy (HR 0.86, 95% CI 0.57 to 1.32). The sentinel node only group had shorter inpatient stays compared with lymphadenectomy only (median 1 vs 2 days, p<0.001) and a lower rate of unplanned readmission (1.7% vs 5.0%, p=0.010).

CONCLUSIONS

The utilization of sentinel lymph node biopsy is increasing in the management of vulvar cancer and is associated with superior perioperative outcomes without impacting overall survival.

Survival disparities in vulvar cancer patients in Commission on Cancer®-accredited facilities

OBJECTIVES

To investigate survival disparities and prognostic factors in vulvar cancer by age at diagnosis.

METHODS

Women who underwent surgery and were diagnosed with stage I-IV vulvar cancer from 2004 to 2014 in the National Cancer Database were eligible. Proportions were compared using Chi-Square test. Survival was evaluated using Cox analysis.

RESULTS

There were 18,207 eligible women. Median age at diagnosis was 64 years, and 31% diagnosed ≥75 years old were categorized as elderly. Most vulvar cancers were diagnosed at stage I and with squamous histology. Diagnosis with higher stage or non-squamous histology was more common in elderly vs. non-elderly patients (P < 0.001). Survival was 3.5 times worse in the elderly than the non-elderly (P < 0.0001). Risk of death for each 5-year increment in age increased by 22% for non-elderly and 43% for elderly patients (P < 0.0001). The prognostic value of comorbidity score, stage, regional node assessment and histology was smaller in elderly vs. non-elderly women (each P < 0.05). Adjuvant chemoradiotherapy (CTRT) use in the elderly vs. non-elderly was rare for stage I-II disease (3% vs. 2%) and more common for stage III-IV disease (6% vs. 43%), respectively (P < 0.0001). The survival disadvantage for elderly patients persisted following no adjuvant therapy, radiotherapy or chemotherapy alone, or CTRT (P < 0.0001). In stage III-IV disease, survival was superior following CTRT vs. radiotherapy when diagnosed <75 years (HR = 0.80, 95% CI = 0.69-0.93) but not in the elderly (HR = 0.99, P > 0.05).

CONCLUSIONS

Age-associated risk of death increased at different rates in vulvar cancer and was larger in elderly vs. non-elderly patients. The impact of other prognostic factors was smaller in elderly vs. non-elderly women. The survival benefit of CTRT over radiotherapy in stage III-IV did not extend to the elderly.

Comparison of two types of the triple incision technique in the treatment of patients with locally advanced vulvar cancer

Objective: In 2012, we proposed and described a modified triple incision technique (MTIT) for vulvar cancer patients with locally advanced disease. The MTIT has undergone a series of modifications, and a modified MTIT (M-MTIT) has been developed. The purpose of this study was to introduce the M-MTIT and compare it with the MTIT. Study design: This was a retrospective cohort study. Fifty-seven vulvar cancer patients with clinical stage T2 (≥ 4 cm) or T3 disease were included. Of these patients, 28 underwent the MTIT and 29 underwent the M-MTIT. Data on surgery-related complications and survival outcomes were compared. Results: Patients who were treated with the M-MTIT developed significantly less surgery-related morbidities than patients treated with the MTIT (24.1% vs. 60.7%, P = 0.005). Wound breakdown was the most common complication in our cohort, which occurred less frequently in the M-MTIT group than in the MTIT group (10.3% vs. 35.7%, P = 0.022). Multivariate logistic regression analysis identified the M-MTIT as an independent predictor of a reduced risk of wound breakdown. The incidence of other complications, including lymphedema, wound infection and cellulitis, was lower in the M-MTIT group than in the MTIT group; however, the differences did not reach statistical significance. The median follow-up time of this study was 33 months. Kaplan-Meier survival graphs did not show significant differences in recurrence-free survival or overall survival between the two groups. Conclusions: The M-MTIT correlates with lower morbidity rates than the MTIT and does not compromise oncological safety. The M-MTIT can be considered a safe and feasible option for vulvar cancer patients with locally advanced disease.