Verrucous carcinoma of the vulva: diagnosis and treatment

Carcinoma vulva: Ten years experience in a teaching institution of North India

Introduction

Vulvar carcinoma is primarily a disease of post-menopausal women. Surgery is a primary treatment strategy. Chemotherapy and radiotherapy are a part of multimodal therapy. Presently, there is a shift towards neoadjuvant chemotherapy or radiotherapy so as to decrease the surgical morbidities.

Objective

To study the surgical outcome and prognostic factors in Ca vulva patients.

Methodology

A retrospective analysis of 19 vulvar cancer patients, surgically treated at a teaching institution of Punjab (2009-2019).

Results

Mean age of the patients was 60.95 years. Ulcerative swelling (89.5%) over labia majora (73.7%) was the main presenting symptom. Radical vulvectomy-bilateral IFLN dissection was performed in 74% patients, hemivulvectomy-unilateral IFLN dissection in 21% patients and wide local excision in one patient. Squamous cell carcinoma was detected in all, and one had verrucous carcinoma. Thirty-seven per cent patients had FIGO stage III disease, 31.5% - stage II and 31.5% - stage I. On HPE, 78.57% (11/14) patients had positive nodes and two had ECS. Only 5/9 (55.5%) cases could receive PORT. Seven patients defaulted follow-up. Two developed nodal metastasis, and seven women developed recurrence. One patient with regional recurrence faced demise during RT course. In 10/19 regular follow-up patients, four are alive and disease free, five patients are on palliative chemoradiation, and one is undergoing adjuvant radiotherapy for regional recurrence. Estimated 5-year overall survival is 83.33%.

Conclusion

Tumour stage, nodal positivity and nodal ECS were poor prognostic factors. Radical surgery-extensive groin node dissection causes significant morbidity; hence, studies evaluating the role of neoadjuvant treatment are needed so as to modify current treatment practices. HPV vaccination as a preventive measure and a thorough and extensive evaluation of patients with suspicious signs in vulvar disease is needed.

Verrucous carcinoma of the vulva: Patterns of care and treatment outcomes

BACKGROUND

Verrucous vulvar carcinoma (VC) is an uncommon and distinct histologic subtype of squamous cell carcinoma (SCC). The available literature on VC is currently limited to case reports and small single institution studies.

AIMS

The goals of this study were to analyze data from the National Cancer Database (NCDB) to quantitate the incidence of VC and to investigate the effects of patient demographics, tumor characteristics, and treatment regimens on overall survival (OS) in women with verrucous vulvar carcinoma.

METHODS AND RESULTS

Patients diagnosed with vulvar SCC or VC between the years of 2004 and 2016 were identified in the NCDB. OS was assessed with Kaplan-Meier curves and the log-rank test. Construction of a Cox model compared survival after controlling for confounding variables. The reported incidence of SCC of the vulva has significantly increased since 2004 (p < .0001). In contrast, the incidence of VC has remained stable (p = .344) since 2004. Compared to SCC, VC was significantly more likely to be diagnosed in older women (p < .0001) and treated with surgery alone (p < .0001). However, on propensity score weighted analysis there was a trend toward improved 5-year OS in women with VC compared to those with SCC (63.4% vs. 57.7%, p = .0794). Multivariable Cox survival analysis showed an improvement in OS in VC patients treated with both primary site and regional lymph node surgery compared to primary site surgery alone (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.46-0.97, p = .0357).

CONCLUSION

Verrucous carcinoma is more likely to present in older women. Regional lymph node surgery in addition to primary site surgery significantly improves OS in VC patients.

Pembrolizumab in FIGO IVB Verrucous Carcinoma of the Vulva: A Case Report

Background

Vulvar cancer is the fourth most common gynecologic cancer, and prognosis is poor in advanced vulvar cancer patients. Treatment for advanced vulvar cancer has not been satisfactory. In this report, we firstly report a FIGO IVB vulva verrucous carcinoma patient who obtained good prognosis after systemic treatment.

Case Presentation

A patient was admitted to hospital due to her vulvar lesion persistent for past 14 years. The vulvar mass has widely invaded urethra, part of anus, the lower third of the vagina, bilateral superior and inferior branches of pubis, and bilateral internal and external muscles of obturator. Multiple metastatic lymph nodes were also found in the pelvic cavity. The histopathological studies confirmed vulvar verrucous carcinoma with a PD-L1 overexpression. After six courses of neoadjuvant chemotherapy and pembrolizumab, the patient underwent radical vulvectomy and achieved optimal cytoreduction. Postoperative pathology found no residual tumor. The patient then received one course of postoperative chemotherapy and pembrolizumab, underwent radiation therapy, and was disease free after 6 months follow-up.

Conclusion

Our individualized treatment strategy is successful. Pembrolizumab is safe and effective in the treatment of advanced vulvar verrucous carcinoma with PD-L1 overexpression.

Aggressive Behavior of Warty Squamous Cell Carcinoma of the Vagina Associated with Uterine Prolapsed: Unusual Report

Warty squamous cell carcinoma (WSCC), is a rare variant of squamous cell carcinoma that occurs mostly in younger women, but can occur in old women. It is due to human papillomavirus (HPV) infection. This rare entity has been described in several organs such as vulva, cervix, and penis. To the best of our knowledge WSCC of vagina associated with the third-degree of uterine prolapse has never been reported in the literature. We present an exceptional case of WSCC of vagina occurred in a 77-year-old woman with long disease duration. The physical exam found a large ulcer-budding lesion of the middle and lower third of the vagina that depends on the left vaginal wall. The full work-up concluded to stage IVA of FIGO classification, due to the bladder involvement. The patient underwent a hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic node dissection, left partial cystectomy with left ureteral reimplantation and total vaginectomy, followed by adjuvant radiotherapy. The patient had no recurrence during 8 years of regular follow-up. WSCC can express locally aggressive behavior, such we reported; despite it appears to be less aggressive than the typical well-differentiated squamous cell carcinoma. That leads to individualize WSCC from other verruciform neoplasms.

Vulvar Verrucous Carcinoma and Genital Condylomatosis

Verrucous carcinoma is a histopathological type of well-differentiated squamous cell carcinoma, clinically characterized by slow and continuous growth, having a local destructive character, but low metastasis potential. Condyloma acuminatum is a sexually transmitted infection caused mainly by subtypes 6 and 11 of HPV, with subtypes 16, 18 being involved in malignant transformation. We present the case of a 70-year-old woman, hospitalized for a vulvar and perineal vegetative, ulcerated, bleeding tumor, with onset 20 years ago. The therapeutic option was surgical excision of the lesions and long-term oncological monitoring.

Oral retinoid, acitretin, is effective in the management of resistant recurrent vulval verrucous carcinoma: A case report

Verrucous carcinomas are a rare variant of squamous cell carcinoma. Vulval verrucous carcinoma comprises only 1% of vulval malignancies. This case report discusses the successful management of aggressive recurrent vulval verrucous carcinoma with acitretin, an oral synthetic retinoid used to manage severe psoriasis, after multiple surgical interventions and radiotherapy had failed. This is the first reported case in which verrucous carcinoma had recurred in a musculocutaneous graft. To manage the recurrence, the patient underwent radiotherapy, which did not resolve the condition. The patient was then administered acitretin 25 mg once daily, which successfully resolved the condition, and the patient has been symptom free for 6 months. This report aims to propose the use of acitretin as a management option for recurrent verrucous carcinomas.

Vulvamalignome: eine interdisziplinäre Betrachtung

Vulvamalignome stellen die vierthäufigste Gruppe von gynäkologischen Krebserkrankungen dar. Erste Ansprechpartner sind typischerweise niedergelassene Dermatologen und Gynäkologen. Mit der jeweiligen Fachexpertise findet die Diagnose und Therapie idealerweise interdisziplinär zwischen spezialisierten Dermatoonkologen und gynäkologischen Onkologen statt. Vulvamalignome sind überwiegend Erkrankungen des höheren Lebensalters, obwohl alle histologischen Subtypen auch bei Frauen unter 30 Jahren vorkommen. Die Diagnose erfolgt oft verzögert. Eine genaue Kartierung von Biopsien (Mapping) ist von großer Bedeutung, da Lokalisation und Entfernung von der Mittellinie in Abhängigkeit von der zugrunde liegenden Histologie das operative Vorgehen bestimmen. Plattenepithelkarzinome machen mehr als 76 % der Vulvamalignome aus und vulväre intraepitheliale Neoplasien (VIN) sind dabei wichtige Vorstufen. Der zweithäufigste Typ der Vulvakarzinome ist das Basalzellkarzinom. Melanome machen 5,7 % der vulvären Malignome aus und ihre Prognose ist schlechter als die der kutanen Melanome. Die meisten Studien zu Checkpoint-Inhibitoren und zielgerichteten Therapien haben Patientinnen mit vulvären Melanomen nicht ausgeschlossen. Die vorliegende Evidenz wird im folgenden diskutiert. Die Methode der Wahl bei lokal resezierbaren Vulvamalignomen ist die Exzision. Angesichts ihrer Seltenheit sollte die Behandlung in spezialisierten Zentren erfolgen, um eine optimale Krankheitskontrolle zu erreichen und Kontinenz und sexuelle Funktion bestmöglich zu erhalten.

Vulvar malignancies: an interdisciplinary perspective

Vulvar cancer represents the fourth most common gynecologic malignancy and is often encountered by the general Dermatologist or Gynecologist. Dermatooncologists and Gynecologic Oncologists share expertise in this field and the diagnosis and treatment should ideally be interdisciplinary. All subtypes are typically seen in the later decades of life, although all histologic subtypes have been described in women younger than 30 years. The diagnosis is often delayed. Exact mapping of biopsies is of high importance, as the location and distance from the midline guides the surgical approach depending on the underlying histology. Squamous cell carcinoma accounts for more than 76 % of vulvar cancer with vulvar intraepithelial neoplasia being an important precursor. Basal cell carcinoma is the second most common vulvar malignancy. Melanoma accounts for 5.7 % of vulvar cancer and has a worse prognosis compared to cutaneous melanoma. Most of the trials on checkpoint inhibitors and targeted therapy have not excluded patients with vulvar melanoma and the preliminary evidence is reviewed in the manuscript.

Surgery remains the primary treatment modality of locally resectable vulvar cancer. In view of the rarity, the procedure should be performed in dedicated cancer centers to achieve optimal disease control and maintain continence and sexual function whenever possible.

Verrucous Carcinoma of the Vulva: A Case Report and Literature Review

Patient: Female, 50

Final Diagnosis: Verrucous carcinoma of the vulva

Symptoms: Itch • tumor

Medication: —

Clinical Procedure: Surgery

Specialty: Surgery