Potential delay in the diagnosis of vulvar cancer and associated risk factors in women treated in German gynecological practices

Therapeutic effects of focused ultrasound on vulvar squamous intraepithelial lesions in rat

OBJECTIVE

In this study, we established a Sprague-Dawley rat model of vulvar squamous intraepithelial lesions and investigated the impact of focused ultrasound on the expression of hypoxia-inducible factor-1α (HIF-1α), vascular endothelial growth factor (VEGF) and mutant type p53 (mtp53) in the vulvar skin of rats with low-grade squamous intraepithelial lesions (LSIL).

MATERIALS AND METHODS

The vulvar skin of 60 rats was treated with dimethylbenzanthracene (DMBA) and mechanical irritation three times a week for 14 weeks. Rats with LSIL were randomly allocated into the experimental group or the control group. The experimental group was treated with focused ultrasound, while the control group received sham treatment.

RESULTS

After 14 weeks treatment of DMBA combined with mechanical irritation, LSIL were observed in 44 (73.33%) rats, and high-grade squamous intraepithelial lesions (HSIL) were observed in 14 (23.33%) rats. 90.91% (20/22) of rats showed normal pathology and 9.09% (2/22) of rats exhibited LSIL in the experimental group at four weeks after focused ultrasound treatment. 22.73% (5/22) of rats exhibited LSIL, 77.27% (17/22) of rats progressed to HSIL in the control group. Compared with the control-group rats, the levels of HIF-1α, VEGF and mtp53 were significantly decreased in experimental-group rats (p < 0.05).

CONCLUSIONS

These results indicate that DMBA combined with mechanical irritation can induce vulvar squamous intraepithelial lesion in SD rats. Focused ultrasound can treat LSIL safely and effectively, prevent the progression of vulvar lesions, and improve the microenvironment of vulvar tissues by decreasing the localized expression of HIF-1α, VEGF, and mtp53 in rats.

Epidemiologic characteristics and a prognostic nomogram for patients with vulvar cancer: results from the Surveillance, Epidemiology, and End Results (SEER) program in the United States, 1975 to 2016

OBJECTIVE

To elucidate clinical characteristics and build a prognostic nomogram for patients with vulvar cancer.

METHODS

The study population was drawn from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly assigned to training and validation sets. Cox proportional hazards model and competing risk model were used to identify the prognostic parameters of overall survival (OS) and cancer-specific survival (CSS) to construct a nomogram. The nomogram was assessed by concordance index (C-index), area under the curve (AUC), calibration plot, and decision curve analysis (DCA).

RESULTS

A total of 20,716 patients were included in epidemiological analysis, of whom 7,025 patients were selected in survival analysis, including 4,215 and 2,810 in training and validation sets, respectively. The multivariate Cox model showed that the predictors for OS were age, marital status, histopathology, differentiation and tumor node metastasis (TNM) stages, whether to undergo surgery and chemotherapy. However, the predictors for CSS were age, race, differentiation and TNM stages, whether to undergo surgery and radiation. The C-index for OS and CSS in the training set were 0.76 and 0.80. The AUC in the training set for 1-, 3- and 5-year OS and CSS were 0.84, 0.81, 0.80 and 0.88, 0.85, 0.83, respectively, which was similar in the validation set. The calibration curves showed good agreement between prediction and actual observations. DCA revealed that the nomogram had a better discrimination than TNM stages.

CONCLUSIONS

The nomogram showed accurate prognostic prediction in OS and CSS for vulvar cancer, which could provide guidance to clinical practice.

"Check Your Vulva"-A Patient Education and Virtual Vulva Care Pilot Project

OBJECTIVE

The aim of the study is to identify whether vulvar self-examination learned from a web site could lead to a self-identification of vulvar lesions and the feasibility of virtual vulvar care with patient submitted photos.

MATERIALS AND METHODS

The study used a prospective cohort design in a tertiary academic hospital over a 1-year period. Eligible participants who self-identified a vulvar lesion/skin changes were invited to send vulvar photos through a secure patient portal and schedule a phone consult to discuss diagnosis/management. Clinical data, photo interpretability, and patient satisfaction measures were collected. Self-referral patients versus vulva clinic waitlist patients were analyzed separately.

RESULTS

Few people were interested in submitting vulvar photos online. Twenty-eight participants directly contacted the study, 8 consented, and 6 sent in vulvar photos. Forty four of 476 on the waitlist consented but only 24 of 44 sent in photos (5% of waitlist patients). The median time for a virtual assessment was 7 days for study participants while it was 18 months for the in-person usual care pathway. Most patient submitted photos were assessable. However, 60% participants needed help from another person to take the photos. More than 90% of patients required an in-person visit for their vulvar condition/concerns. While most patients were happy with the virtual process, 58% rated their satisfaction with the ease of taking photos of the genital region as "fair" or "poor."

CONCLUSIONS

Virtual care with photos/phone calls might be feasible, although most patients are unlikely to participate. Because of patient discomfort, unease with taking photos, and patient privacy concerns, vulvar care should continue to be in-person for most new consults.

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

BACKGROUND

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer.

OBJECTIVE

To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer.

METHODS

The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives.

RESULTS

The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Cannabidiol and Its Combinations with Nonsteroidal Anti-Inflammatory Drugs Induce Apoptosis and Inhibit Activation of NF-κB Signaling in Vulvar Squamous Cell Carcinoma

Vulvar squamous cell carcinoma (VSCC) is a rare malignancy with a relatively good prognosis. However, the prognosis remains poor for elderly patients and those with a significant depth of tumor invasion; thus, novel treatment modalities are needed. The aim of this study was to analyze the impact of cannabidiol (CBD) and its combination with NSAIDs, diclofenac (DIC) and ibuprofen (IBU) on VSCC cells. In this regard, the MTT test was applied for cytotoxicity analysis. Moreover, the influence of CBD, DIC and IBU, as well as their combinations, on apoptosis and cell cycle distribution were analyzed by flow cytometry. The mechanisms of action of the analyzed compounds, including their impact on NF-κB signaling, p53 and COX-2 expression were evaluated using Western blot. This study shows that CBD and its combinations with NSAIDs are cytotoxic to A431 cells, but they also reduce, in a dose-dependent manner, the viability of immortalized keratinocyte HaCaT cells, and human umbilical vein cell line, EA.hy926. Moreover, the compounds and their combinations induced apoptosis, diminished the NF-κB signaling activation and reduced COX-2 expression. We conclude that CBD and its combination with DIC or IBU are promising candidates for the adjuvant treatment of high-risk VSCC patients. However, their impact on non-cancerous cells requires careful evaluation.

High-risk human papillomavirus-associated vulvar neoplasia among women living with human immunodeficiency virus in Zambia

Background

Globally, women living with HIV have a higher risk of vulvar neoplasia than HIV-negative women. Vulvar neoplasia among women living with HIV has not previously been characterised in Zambia.

Objective

This study determined the clinical and pathologic features of vulvar neoplasia among women living with HIV at the University Teaching Hospital, Lusaka, Zambia.

Methods

We conducted a cross-sectional study of vulvar lesions among 53 women living with HIV who presented with vulvar lesions between July 2017 and February 2018. The study assessed clinical and histological characteristics and prevalence of high-risk human papillomavirus (HRHPV).

Results

Twenty-one patients were diagnosed with vulvar squamous cell carcinoma (VSCC), 20 with usual vulvar intraepithelial neoplasm (uVIN), and the rest with either benign lesions or non-neoplastic lesions (NNL). Participants' mean age was 40 years. Patients with VSCC were significantly older than those with NNL (mean (s.d.): 43 (21) vs 33 (10), p = 0.004). The prevalence of HRHPV was 88.9% in VSCC patients and 100.0% in high-grade squamous intraepithelial lesion patients. HPV16 was the most common (52.6%) genotype. The clinical features of neoplasia were similar to those of NNL.

Conclusion

VSCC was significantly more common among women aged ≥ 40 years. HRHPV in VSCC and high-grade squamous intraepithelial lesions was high. Women with vulvar lesions, especially those aged > 40 years, should be evaluated for vulvar cancer. Young girls should be vaccinated to prevent vulvar cancer.

Adjuvant Radiation in Early Stage Vulvar Cancer: A Review of Indications and Optimal Dose

Vulvar cancer is a relatively rare gynecologic malignancy for which surgery remains the cornerstone of treatment. A wide local excision is the goal for treatment with curative intent in patients with early stage vulvar cancer, given that there are adverse pathologic features shown to increase risk of local recurrence. Specifically, the presence of positive or close margins of < 8 mm or 2 or more positive nodes have been shown to significantly increase the risk of recurrence and have informed guidelines for risk-adapted adjuvant radiation, although the optimal dose for adjuvant radiation is yet to be established. Given the rarity of vulvar cancer, guidelines regarding the indications and dose for adjuvant radiation are based largely on retrospective studies. The purpose of this review is to summarize the evidence underlying the current indications for adjuvant radiation in early stage vulvar cancer as well as to determine the optimal dose for adjuvant radiation.

Integrin αvβ6 as a Target for Tumor-Specific Imaging of Vulvar Squamous Cell Carcinoma and Adjacent Premalignant Lesions

Surgical removal of vulvar squamous cell carcinoma (VSCC) is associated with significant morbidity and high recurrence rates. This is at least partially related to the limited visual ability to distinguish (pre)malignant from normal vulvar tissue. Illumination of neoplastic tissue based on fluorescent tracers, known as fluorescence-guided surgery (FGS), could help resect involved tissue and decrease ancillary mutilation. To evaluate potential targets for FGS in VSCC, immunohistochemistry was performed on paraffin-embedded premalignant (high grade squamous intraepithelial lesion and differentiated vulvar intraepithelial neoplasia) and VSCC (human papillomavirus (HPV)-dependent and -independent) tissue sections with healthy vulvar skin as controls. Sections were stained for integrin αvβ6, CAIX, CD44v6, EGFR, EpCAM, FRα, MRP1, MUC1 and uPAR. The expression of each marker was quantified using digital image analysis. H-scores were calculated and percentages positive cells, expression pattern, and biomarker localization were assessed. In addition, tumor-to-background ratios were established, which were highest for (pre)malignant vulvar tissues stained for integrin αvβ6. In conclusion, integrin αvβ6 allowed for the most robust discrimination of VSCCs and adjacent premalignant lesions compared to surrounding healthy tissue in immunohistochemically stained tissue sections. The use of an αvβ6 targeted near-infrared fluorescent probe for FGS of vulvar (pre)malignancies should be evaluated in future studies.

Cancer of the vulva: 2021 update

Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors.

A useful update for trainees and specialists regarding the diagnosis, staging, treatment, and some controversies in the management of vulvar neoplasms.

Vulvar Cancer with Cutaneous and Breast Metastases

Vulvar cancer accounts for about 5% of cancer of female genitalia. It may initially present as benign symptoms resulting in potential delay in diagnosis. Few cases of distant metastases to skin or breast have been reported. We present the case of a 76-year-old female with possible delay in diagnosis of her squamous cell carcinoma of vulva. After 4 months of the diagnosis, she presented with concurrent cutaneous and breast metastases.

Cancer of the vulva

Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized, and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors.

Time between suspected and confirmed diagnoses of Crohn's disease and ulcerative colitis in patients followed in gastroenterological practices in Germany

AIMS

The goal of the present study was to analyze the time between suspected and confirmed diagnoses of Crohn's disease (CD) and ulcerative colitis (UC) in patients followed in gastroenterological practices in Germany.

METHODS

The study included individuals who received a suspected diagnosis of CD or UC (index date) and were followed in 47 gastroenterological practices in Germany between January 2007 and December 2016. The main outcome measure of the study was the time between suspected and confirmed diagnoses of CD and UC. Covariables included age, sex, and type of health insurance (private or statutory). A multivariate linear regression model was used to analyze the impact of the different variables on the time between suspected and confirmed diagnoses of CD and UC.

RESULTS

The study included 2657 patients with a suspected diagnosis of CD and UC between 2007 and 2016. The mean age was 39.7 (SD 15.9) and 41.3 (16.8) in the CD and UC groups, respectively. Median time between suspected and confirmed diagnoses was 46 days in the CD group and 43 days in the UC group. Median time ranged from 8 to 112 days in the different gastroenterology practices and was significantly shorter in individuals with private health insurance coverage than in those with statutory health insurance.

CONCLUSIONS

Median time between suspected and confirmed diagnoses of CD or UC was around 45 days in patients followed in gastroenterological practices in Germany. Health insurance was the only factor to have a significant impact on this time.