Global incidence, risk factors and trends of vulvar cancer: A country-based analysis of cancer registries

Definitive intensity-modulated radiotherapy for organ preservation in vulvar cancer: A multicenter study

INTRODUCTION

To evaluate outcome and toxicity of definitive intensity-modulated radiation therapy (IMRT) for vulvar squamous cell cancers (VSCC).

METHODS

DRIVE (Definitive IMRT in Vulvar Cancer) multicenter cohort study analyzed VSCC treated with definitive-IMRT across institutions in US/Canada. Outcomes, toxicity, and patterns of failure were investigated. Locoregional control (LRC), metastasis-free survival (MFS) and overall survival (OS) were estimated using Kaplan-Meier methods. Univariable/multivariable analysis were conducted using Cox-regression method.

RESULTS

A total of 159 patients received definitive-IMRT between 2012 and 2022. Median age was 62-years (IQR 54-74). Forty (25 %) patients had stage I-II, and 119 (75 %) stage III-IV disease. Clinical or pathological nodal metastases were identified in 111 (70 %). Among 56 patients with available HPV/p16 status, 38(68 %) were positive. The median radiation dose was 64Gy, and 128 (80.5 %) patients received concurrent chemotherapy. Complete clinical response (CCR) was achieved in 73.6 % at primary and 77.3 % at regional nodes. Median OS was 73-months (95 %CI 45-100), with actuarial 2- and 5-year OS rates of 67.5 % and 58.3 %, respectively. The 5-year LC, RC, and MFS were 70.7 %, 86.2 %, and 81 %, respectively. Only 1 of the cN0 (1/48, 2 %) patients experienced regional failure. Predictors of inferior OS included age > 70-years (p = 0.03), diabetes (p = 0.01), node-positivity (p = 0.01), no chemotherapy (p = 0.009), and lack of CCR (p < 0.001). Planned treatment was completed by 94 % patients. Vaginal stenosis occurred in 40 %, and late grade 3-4 soft-tissue toxicity in 9 %.

CONCLUSION

Definitive-IMRT provides an excellent LRC with acceptable toxicity. High regional control in cN0 patients supports avoiding elective nodal surgery in those planned for definitive RT.

Symptom Experience After Surgical Treatment for Vulvar Cancer-A Scoping Review

BACKGROUND

Previous reviews have indicated a high burden of physical, emotional and sexual symptoms in women who have undergone surgery for vulvar cancer. Numerous surgical modifications have been made over the past few decades to limit post-operative symptoms. However, few reviews have investigated a wide range of symptoms in women with vulvar cancer. A comprehensive review of the literature examining these symptoms following advanced surgical treatment for vulvar cancer could contribute to an updated understanding of symptom experiences in these women.

AIM

To map the literature on women's symptom experiences after surgical treatment for vulvar cancer.

METHODS

A scoping review was conducted, following the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). The included studies provided independent analyses of women with vulvar cancer, utilised patient-reported outcome measures or qualitative data, were published between 2008 and 2024 and were in English, Danish, Norwegian or Swedish. Searches were conducted on February 20, 2024, in Embase, MEDLINE, CINAHL and PsycINFO. Data were thematically analysed as described by Braun and Clarke.

RESULTS

The following themes were identified in the 20 studies: lymphedema, sexuality and body image, pain, physical functioning, fatigue, urinary symptoms, emotional symptoms and support from relatives and healthcare professionals.

CONCLUSION

Women who have undergone surgery for vulvar cancer experience several physical and emotional symptoms. However, there is a shortage of qualitative studies that thoroughly explore the concept of symptom experience and quantitative studies that include vulvar-specific patient-reported outcome measures.

TRIAL AND PROTOCOL REGISTRATION

The protocol was preregistered on Open Science Framework on April 9, 2024, registration https://doi.org/10.17605/OSF.IO/429JW.

Comprehensive management of vulvovaginal cancers

Vulvar and vaginal cancers represent rare malignancies, with an incidence of 2.7 per 100,000 women for vulvar cancer, predominantly affecting women older than 60 years, although rising rates are observed in younger demographics. Approximately 90% of vulvar cancers are squamous cell carcinoma and frequently are associated with human papillomavirus (HPV) infection. Vaginal cancer, constituting less than 1% of all female cancers, similarly exhibit HPV-related trends. This review delineates the etiology, histopathology, and treatment strategies for carcinomas and vulvovaginal melanomas and sarcomas. Surgical intervention remains the primary treatment modality for vulvar cancer, involving tumor resection and inguinofemoral lymph node staging. For locally advanced vulvar carcinoma, chemoradiation is advised when exenterative surgery would be indicated. Recurrence rates within 2 years after diagnosis range from 12% to 37%. Unfortunately, systemic treatments for recurrent or metastatic disease are limited, with 5-year survival rates at approximately 20%. Current evidence primarily derives from retrospective studies or small phase 2 trials or otherwise is extrapolated from the treatment of cervical cancer. Enrollment in clinical trials is strongly advocated, along with prompt access to best supportive care to mitigate the effect of locoregional progression on quality of life. Moreover, the psychosocial implications of treatment on body image and sexuality necessitate careful consideration. Future HPV vaccination initiatives may reduce cancer incidence, although significant effects of such vaccination will manifest over decades, underscoring the urgent need to enhance treatment efficacy and minimize morbidity in vulvar and vaginal cancers.

Predictors and Patterns of Recurrence in Vulvar Cancer

OBJECTIVE

To identify prognostic factors predicting recurrence in vulvar cancer patients undergoing surgery.

METHODS

We retrospectively evaluated data from consecutive patients with vulvar cancer treated between 2002 and 2024 in 2 Italian centers. Basic descriptive statistics and multivariable analysis were used to create predictive models for patient outcomes. Five-year disease-free survival (DFS) and overall survival (OS) were analyzed using a Cox proportional hazards model.

RESULTS

The study included 283 patients diagnosed with vulvar cancer (239 with squamous cell carcinoma). The most frequent stages were stage I (50.9%) and stage III (30.4%). After a median follow-up of 27 months, 91 (32.2%) recurrences were observed, of which 20% were local, 6% were regional, and 6% were distant. The five-year DFS and OS were 46% and 60%, respectively. Multivariate analysis identified the presence of positive lymph nodes (hazard ratio [HR]: 3.54, 95% confidence interval [CI]: 1.04-12.08), age (HR: 1.02, 95% CI: 1-1.04), FIGO stage II (HR: 3.12, 95% CI: 1.24-7.87), and FIGO stage IV (HR: 3.85, 95% CI: 1.19-12.43) as factors associated with worse DFS. Positive nodes (HR: 2.64, 95% CI: 1.2-5.8) and tumor diameter >4 cm (HR: 1.89, 95% CI: 1.05-3.42) were associated with OS. FIGO stage >I was predictive of regional and distant recurrences, but no factor was found to correlate with local recurrence.

CONCLUSIONS

FIGO stage >I was predictive of regional and distant recurrences, while no factors influencing local recurrence were identified. Positive nodes, age, and FIGO stage >I correlated with DFS, whereas tumor diameter >4 cm and positive nodes influenced OS.

Trend, Epidemiology, and Clinical Characteristics of Vulvar Cancers in Lagos, Nigeria: A Facility-Based Study

Background Vulvar cancer (VC) is a rare gynecological cancer (GC) that is not commonly studied. Because of its location, vulvar symptoms are not frequently brought to the clinician's attention. Many women are not aware of VC and frequently attribute its early symptoms to other benign causes. In addition, little is known about the disease epidemiology and clinical characteristics in Lagos, Nigeria. Objectives  Our study aimed to describe the trend, epidemiology, and clinical characteristics of VC in Lagos, Nigeria. Materials and methods Records of women with VC who presented to Lagos University Teaching Hospital between January 2010 and December 2019 were retrieved, and information on their socio-demographic and clinical characteristics was obtained for analysis. Data analysis was done using IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Results VC accounted for 4.0% of all GC managed in the hospital. There was a rising trend in the number of VCs managed during the study period, with 75.9% of cases managed in the last five years. The mean ± SD age of women with VC was 52.2 ± 11.8 years, with 27 (60.0%) above 50 years old. The majority had low-level occupations, 35 (77.8%), multiple sexual partners, 29 (64.4%); history of genital warts, 35 (77.8%); vulvar skin lesions, 40 (88.9%), and were menopausal, 26 (57.8%). The most common presenting symptom was vulvar swelling 32 (71.1%) and 20 (44.4%) presented with stage III disease. Squamous cell carcinoma was the most common histological type, 35 (77.8%), while the use of only surgery, 15 (33.3%), chemotherapy, 4 (8.9%), radiotherapy, 4 (8.9%), and chemoradiation, 4 (8.9%), were the most common treatment modalities. Conclusion VC accounts for 4.0% of GC in Lagos, Nigeria, and its prevalence is rising. Women with VC are usually advanced in age, postmenopausal, have a history of multiple sexual partners, and frequently present in advanced-stage disease. There is a need to increase awareness about the disease and support its care to improve health outcomes.

High Risk of HPV-Related Preneoplastic and Neoplastic Vulvar Lesions in Women Living With HIV

OBJECTIVE

The authors aimed to investigate the epidemiology of human papilloma virus (HPV)-related preneoplastic and neoplastic vulvar lesions in a large cohort of women living with HIV (WLWH).

MATERIALS AND METHODS

The authors retrospectively selected 1,796 WLWH who had a gynecological examination, cervical cytology, high-risk (HR-) HPV test, vulvoscopy, and colposcopy with targeted biopsies when necessary between 1987 and 2020 at 2 Italian institutions. Univariable and multivariable regression analyses were carried out to test the association of the anamnestic and clinical data with the development of precancerous and cancerous lesions.

RESULTS

At baseline, 348 (19.4%) of 1,796 WLWH had genital warts, 30 (1.7%) had vulvar high-grade intraepithelial neoplasia (VHSIL), and 2 (0.1%) had squamous cell carcinoma of the vulva. Among 895 WLWH who had more than 1 year of follow-up, the authors found 40 (4.5%) new cases of VHSIL and 7 (0.8%) cases of vulvar cancer. The cumulative incidence of VHSIL and vulvar cancer was respectively 0.56 and 0.10 per 100 person-years. Risk factors independently associated with the development of vulvar HSIL and cancer included history of injection drug use ( p < .01), genital warts at baseline ( p < .001), HR-HPV test positivity at diagnosis ( p < .001), and severe immunodepression (CD4 cell count <200 cells/mL) at diagnosis ( p < .01).

CONCLUSIONS

WLWH are at high risk of vulvar high-grade intraepithelial neoplasia and cancer, especially those with severe immunodepression. A careful inspection of vulva, perineum and anus, possibly with the aid of colposcopy, should become part of the surveillance protocol of HIV-infected women.

Exosomal ncRNAs in reproductive cancers†

Extracellular vesicles, particularly exosomes, play a pivotal role in the cellular mechanisms underlying cancer. This review explores the various functions of exosomes in the progression, growth, and metastasis of cancers affecting the male and female reproductive systems. Exosomes are identified as key mediators in intercellular communication, capable of transferring bioactive molecules such as microRNAs, proteins, and other nucleic acids that influence cancer cell behavior and tumor microenvironment interactions. It has been shown that non-coding RNAs transported by exosomes play an important role in tumor growth processes. Significant molecules that may serve as biomarkers in the development and progression of male reproductive cancers include miR-125a-5p, miR-21, miR-375, the miR-371 ~ 373 cluster, and miR-145-5p. For female reproductive cancers, significant microRNAs include miR-26a-5p, miR-148b, miR-205, and miRNA-423-3p. This review highlights the potential of these noncoding RNAs as biomarkers and prognostics in tumor diagnostics. Understanding the diverse roles of exosomes may hold promise for developing new therapeutic strategies and improving treatment outcomes for cancer patients.

Global burden and trends in pre- and post-menopausal gynecological cancer from 1990 to 2019, with projections to 2040: a cross-sectional study

BACKGROUND

The global burden and trends in gynecological cancer (GC) by menopausal status worldwide remain unclear.

METHODS

Data on the number of incident cases and deaths, as well as age-standardized rates (ASR) and risk factors for GC in pre- and post-menopausal women were obtained from the Global Burden of Disease (GBD) Study 2019. The estimated annual percent change was calculated to quantify the temporal trend of GC burden by menopausal status between 1990 and 2019. The Bayesian age-period-cohort model was used to predict the trends in age-standardized incidence and mortality rates for pre- and post-menopausal GC during 2020-2040.

RESULTS

In 2019, an estimated 400 146 pre-menopausal and 879 476 post-menopausal GC cases were newly diagnosed worldwide, with ~111 420 and 442 821 GC-related deaths occurring in each menopausal group, respectively. The majority of both pre- and post-menopausal GC cases in low-to-middle-SDI regions was due to cervical cancer. In high- and high-middle-SDI regions, pre-menopausal GC was primarily attributed to cervical cancer, while post-menopausal GC was mainly attributed to uterine cancer. Additionally, the contribution of uterine cancer to GC was higher among post-menopausal women than pre-menopausal women, across all SDI levels and geographical regions. ASIRs either remained stable or increased from 1990 to 2019 worldwide for both pre- and post-menopausal GC [an average change of 0.03% (95% CI -0.02 to 0.08) and 0.09% (0.05-0.13) per year, respectively]. However, the age-standardized mortality rates (ASMRs) declined by an annual average of 0.86% (95% CI -0.92 to -0.8) and 0.63% (95% CI -0.66 to -0.6) globally during the same period. The risk-attributable proportion of post-menopausal GC deaths was higher than that of pre-menopausal GC and increased with increasing SDI. The projections indicate an increasing trend in the burden of pre-menopausal GC from 2020 to 2040, while the burden of post-menopausal GC is expected to decline.

CONCLUSIONS

GC continues to be a significant public health concern worldwide, with notable regional and demographic disparities in the burden based on menopausal status. Policymakers and healthcare providers must be proactively aware of these evolving trends and tailor age-appropriate and region-specific screening strategies, as well as allocate resources accordingly.

Burden of cancers in six female organs in China and worldwide

BACKGROUND

Cancers in female organs remain a substantial burden in China and worldwide. GLOBOCAN 2022 has recently updated the estimates of cancer burden. This study aims to depict the profiles of disease burden and to compare the age-specific rates of cancers in female organs in China with those in other countries.

METHODS

The latest estimates of incidence and mortality of cancers in female organs from various regions and countries were extracted from the GLOBOCAN 2022 database. We compared the proportion of total cases or deaths for cancers affecting six female organs and other tumor types in China and globally. Correlation analysis was conducted to evaluate the relationship between age-standardized incidence rate (ASIR) or age-standardized mortality rate (ASMR) and the Human Development Index (HDI). Additionally, age-specific rate curves were plotted for ten exemplary countries with different income levels.

RESULTS

Globally, there are varying burdens of female organ cancers, with higher incidence rates in Northern America and elevated rates of cervical cancer in Africa. Female organ cancers in China remain a significant burden due to their large proportion of the six tumors. A positive correlation between socioeconomic development and the incidence of breast, uterine corpus, ovarian, and vulvar cancers was noted, whereas a negative association between the HDI tiers and mortality rates was found for cervical and vaginal cancers. In 2022, Chinese women aged 50-54 years are experiencing high incidence rates of breast, cervix uteri, corpus uteri, and ovarian cancers.

CONCLUSIONS

Cancers in female organs continue to be a significant health concern for women in China and worldwide. It is crucial to implement comprehensive prevention strategies tailored to address the increasing trend among younger individuals and reduce regional disparities.

Differentiated vulvar intraepithelial neoplasia long-term follow up and prognostic factors: An analysis of a large historical cohort

INTRODUCTION

Differentiated vulvar intraepithelial neoplasia (dVIN) is a high-risk preinvasive vulvar lesion and precursor of human papillomavirus-independent vulvar squamous cell carcinoma (VSCC). Due to its rarity, literature data on its malignant potential are scant. The aim of the study is to assess the risk of developing VSCC in patients surgically treated for dVIN not associated with VSCC (solitary dVIN) and the risk of VSCC recurrence in patients treated for dVIN associated with VSCC (dVIN-VSCC) at first diagnosis.

MATERIAL AND METHODS

A historical cohort study was performed in a northern Italy referral center for vulvar neoplasms. All consecutive women surgically treated for histologically confirmed dVIN from 1994 to 2021 were collected. Primary outcome was cancer risk or recurrent cancer risk, secondary outcomes were risk factors associated with VSCC development or recurrence. Kaplan-Meier method and log-rank test were used to estimate cancer risk or recurrent cancer risk differences and uni- and multivariate Cox regression analyses to identify risk factors associated with VSCC development in solitary dVIN and recurrence of dVIN-VSCC.

RESULTS

Seventy-six patients with dVIN at preoperative biopsy were included: at excisional specimens 44 were solitary dVIN and 32 were dVIN-VSCC. The absolute risk of VSCC development after solitary dVIN treatment was 43.2% with median time to to VSCC diagnosis of 25.4 months (range 3.5-128.0 months). VSCC recurrence absolute risk in treated dVIN-VSCC patients was 31.3% with median time to VSCC recurrence of 52.9 months (range 6.5-94.8 months). At uni- and multivariate regression analyses, only compliant topical ultrapotent corticosteroid treatment after solitary dVIN excision showed an ability to prevent VSCC development. No protective effect by corticosteroid treatment was shown for VSCC recurrence in dVIN-VSCC patients. Smoking was associated with higher cancer recurrence risk in dVIN-VSCC patients on both uni- and multivariate regression analyses.

CONCLUSIONS

Patients with dVIN have a high risk of developing both primary and recurring VSCC. Early recognition, long-term follow up, and compliant ultrapotent topical corticosteroid treatment are recommended.

Vulvar Carcinoma: Standard of Care and Perspectives

PURPOSE

Treatment of vulvar carcinoma (VC) is challenging. The objectives of this review were to describe for clinicians the epidemiologic and clinical aspects of VC, the standard of care in terms of primary local treatment and systemic therapies, and the recent innovations and perspectives emerging from translational research in immuno-oncology.

DESIGN

We conducted a comprehensive review outlying the clinical aspects and biologic background of vulvar cancer, highlighting modern treatment strategies on the basis of a personalized approach.

RESULTS

Epidemiologic data showed a recent rise in incidence of VC, attributed to human papillomavirus. Surgery is the mainstay of primary treatment, but multimodal approaches are frequently required in the presence of adverse prognosis histopathologic factors. Chemoradiation is indicated when organ-sparing surgery is not feasible. However, inability to achieve high locoregional control rates in advanced cases and the morbidity associated with local treatments are still key issues. Recent clinical data showed the benefit of individualized strategies combining organ-sparing surgical strategies, less invasive lymph node staging procedures, and refinement in radiotherapy modalities. Among the most important research area, there is a sound rationale for testing modern systemic approaches such as immune checkpoint inhibitors in selected patients with recurrent and/or metastatic tumors. Although no specific data exist for VC, the role of supportive care and post-treatment rehabilitation strategies is also crucial.

CONCLUSION

There are still insufficient studies dedicated to patients with VC. Public health programs for prevention, screening, and early diagnosis are required, and clinical research should be strengthened to provide high-quality clinical evidence and improve patients' oncologic and functional outcomes.