Vulvar cancer-continuing evolution in management

The Prognostic Role of the Surgical Margins in Squamous Vulvar Cancer: A Retrospective Australian Study

For the last 30 years at the Royal Hospital for Women, unifocal vulvar squamous cancers have been treated by radical local excision, aiming to achieve a histopathological margin of ≥8 mm, equating to a surgical margin of 1 cm. The need for a margin of this width has recently been challenged. We aimed to determine the long-term outcome following this conservative approach, and the relationship between vulvar recurrences and surgical margins. Data were obtained retrospectively on 345 patients treated primarily with surgery for squamous vulvar cancer between 1987 and 2017. Median follow-up was 93 months. Five-year disease-specific survival was 86%. Of 78 vulvar recurrences, 33 (42.3%) were at the primary site and 45 (57.7%) at a remote site. In multivariable analysis, a margin < 5 mm showed a higher risk of all vulvar (Hazard ratio (HR), 2.29; CI, 1.12-4.70), and primary site recurrences (subdistribution hazard ratio (SHR), 15.20; CI, 5.21-44.26), while those with a margin of 5 to <8 mm had a higher risk of a primary site recurrence (SHR, 8.92; CI, 3.26-24.43), and a lower risk of remote site recurrence. Excision margins < 8 mm treated by re-excision or radiation therapy had a significantly decreased risk of recurrence. Guidelines should continue to recommend a surgical margin of 1 cm.

Definitive radiotherapy for recurrent vulvar carcinoma after primary surgery: a two-institutional Italian experience

Objective:

To assess the clinical outcome of patients treated with radiotherapy (RT) for recurrent squamous cell carcinoma of the vulva after primary surgery.

Methods:

Fifty-six patients developed recurrent disease after surgery, consisting of deep total vulvectomy with inguino-femoral lymphadenectomy in 44 (78.6%) and deep partial vulvectomy with inguino-femoral lymphadenectomy in 12 (21.4%). All patients underwent RT at the Divisions of Radiotherapy, University of Pisa and ASST Cremona, between 1992 and 2016. Forty-three patients (76.8%) underwent external beam RT and 13 (23.2%) were treated with exclusive high-dose rate brachytherapy.

Results:

Five-year progression-free survival (PFS) and overall survival (OS) were 19% and 43%, respectively. Primary tumor size ⩽4 cm, early FIGO stage, and negative lymph node status were significantly associated with better PFS ( p = .005, p = .020 and p = .036, respectively) and OS ( p < .0001, p = .023 and p = .008, respectively). Patients with more than 1 positive lymph node at primary surgery had significantly worse PFS ( p = .028) and OS ( p = .001). Patients with local recurrence had significantly better PFS and OS ( p = .022, p = .002, respectively). RT total dose >54 Gy was associated with a lower risk of recurrence.

Conclusions:

Primary tumor size, FIGO stage, nodal status, and site of recurrent disease were significant predictors of clinical outcome in patients treated with RT for recurrent squamous cell carcinoma of the vulva.

Long-term oncological outcomes of patients with negative sentinel lymph node in vulvar cancer. Comparative study with conventional lymphadenectomy

INTRODUCTION

The aim of this study was to compare oncological outcomes and morbidity in patients with early-stage vulvar cancer with negative sentinel lymph node (SLN) biopsy vs negative inguinofemoral lymphadenectomy (IFL).

MATERIAL AND METHODS

Study with retrospectively collected data in patients with squamous cell vulvar carcinomas ≤ 4 cm without suspected inguinofemoral lymph node metastases. Only patients with negative nodes after histopathology procedure were followed. Patients who underwent only SLN were compared with patients who underwent IFL ± SLN to compare recurrences, survival rates and morbidity.

RESULTS

Ninety-three patients were eligible for follow up: 42 with negative SLN and 51 with negative IFL ± SLN. The median follow-up period was 60.4 months (range 6.7-160.7). The rate of isolated first groin recurrence was 4.8% in patients with negative SLN and 2.0% in patients with negative IFL ± SLN (P = 0.587) and the rates of first isolated local recurrence were 28.6% and 31.4%, respectively (P = 0.823). Only 1 patient (2.4%) in the group of negative SLN had distant recurrence. The disease-specific survival rate at 5 years was 83.3% in the negative SLN group and 92.2% in the negative IFL ± SLN group (P = 0.214). We observed a higher rate of wound breakdown and infection after IFL than SLN biopsy (17.6% vs 10.6%; P = 0.020) and lymphedema (33.3% vs 0%; P < 0.001).

CONCLUSIONS

We report in the same population of patients with early-stage vulvar cancer that SLN biopsy does not have significantly higher rates of groin recurrences or lower survival rates compared with IFL. Moreover, the SLN procedure has less morbidity, which should encourage gynecologists to abandon IFL.

Adjuvant Radiotherapy in High-Risk Squamous Cell Carcinoma of the Vulva: A Two-Institutional Italian Experience

BACKGROUND

The aim of this study was to assess the treatment benefit and patterns of recurrence for patients with high-risk vulvar squamous cell carcinoma treated with surgery followed by adjuvant radiotherapy (RT).

PATIENTS AND METHODS

From January 1999 to June 2016, 51 patients underwent total or partial deep vulvectomy with inguinofemoral lymphadenectomy followed by adjuvant RT with 45-50 Gy in 25 fractions +/- a 4-10 Gy boost. 17 (33.3%) women received concomitant chemotherapy.

RESULTS

Median overall survival was 81 months. The 5-year disease-free survival and overall survival rates were 52 and 63%, respectively. In univariate and multivariate analysis, patients aged ≤ 76 years and those receiving an RT total dose of > 54 Gy had a significantly lower risk of progression (p = 0.044 and 0.045; p = 0.012 and 0.018, respectively) and death (p = 0.015 and 0.011; p = 0.015 and 0.026, respectively). There was a trend towards a lower risk of progression for patients with tumor size ≤ 4 (p = 0.098) and negative lymphovascular space involvement (p = 0.080). Also, there was a trend towards a higher risk of death (p = 0.075) for grade 3 tumors. Concomitant chemotherapy provided no significant benefit.

CONCLUSION

Only age and RT total dose are significant prognostic variables for squamous cell carcinoma of the vulva treated with primary surgery and adjuvant RT to improve local and locoregional control.

Clinico-pathological and biological prognostic variables in squamous cell carcinoma of the vulva

Several clinical-pathological parameters have been related to survival of patients with invasive squamous cell carcinoma of the vulva, whereas few studies have investigated the ability of biological variables to predict the clinical outcome of these patients. The present paper reviews the literature data on the prognostic relevance of lymph node-related parameters, primary tumor-related parameters, FIGO stage, blood variables, and tissue biological variables. Regarding these latter, the paper takes into account the analysis of DNA content, cell cycle-regulatory proteins, apoptosis-related proteins, epidermal growth factor receptor [EGFR], and proteins that are involved in tumor invasiveness, metastasis and angiogenesis. At present, the lymph node status and FIGO stage according to the new 2009 classification system are the main predictors for vulvar squamous cell carcinoma, whereas biological variables do not have yet a clinical relevance and their role is still investigational.

Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer

During the last decades there has been a continuing evolution in the surgical approach of squamous cell carcinoma of the vulva that has been traditionally treated with radical vulvectomy and bilateral inguinal-femoral lymphadenectomy. Patients with T1 tumour are usually treated with radical local excision, if the lesion is unifocal and the remainder of the vulva is normal. Patients with T1a disease have no risk of groin metastases and do not need lymphadenectomy, whereas those with T1b disease need ipsilateral inguinal-femoral lymphadenectomy if the lesion is lateral, and bilateral lymphadenectomy if the lesion is midline. Modifications of the surgical technique of deep femoral lymphadenectomy and the mapping of sentinel node can offer new interesting therapeutic perspectives. Postoperative adjuvant pelvic and groin irradiation is warranted for patients with two or more or macroscopically involved groin nodes. Locally advanced squamous cell carcinoma of the vulva has been long surgically treated with en-block radical vulvectomy and bilateral inguinal-femoral lymphadenectomy plus partial resection of urethra, vagina or anum, or by exenteration, with severe postsurgical complications, poor quality of life, and unsatisfactory survival rates. 5-Fluorouracil [5-FU] or 5-FU- and cisplatin-based chemotherapy concurrent with irradiation followed by tailored surgery represents an attractive therapeutic option for advanced disease, planned to avoid such ultra-radical surgical procedures and, hopefully, to improve patient outcome. Chemotherapy has also been used in neoadjuvant setting, with contrasting and generally unsatisfactory results, and in palliative treatment of patients with distant metastases. Surgery is the primary treatment also for vulvar malignancies other than squamous cell carcinoma, whereas the clinical usefulness of adjuvant irradiation or chemotherapy is still to be defined. Primary chemoradiation can be also used for advanced carcinoma of the Bartholin gland or for advanced adenocarcinoma associated with extramammary Paget's disease. The drugs used for chemotherapy of metastatic melanomas or sarcomas of the vulva are the same employed for the melanomas or sarcomas developed in other sites.

Radioguided sentinel lymph node detection in vulvar cancer

Lymph node status is the most important prognostic factor in vulvar cancer. Histologically, sentinel nodes may be representative of the status of the other regional nodes. Identification and histopathologic evaluation of sentinel nodes could then have a significant impact on clinical management and surgery. The aim of this study was to evaluate the feasibility and diagnostic accuracy of sentinel lymph node detection by preoperative lymphoscintigraphy with technetium-99 m-labeled nanocolloid, followed by radioguided intraoperative detection. Nine patients with stage T1, N0, M0, and 11 patients with stage T2, N0, M0 squamous cell carcinoma of the vulva were included in the study. Only three cases had lesions exceeding 3.5 cm in diameter. Sentinel nodes were detected in 100% of cases. A total of 30 inguinofemoral lymphadenectomies were performed, with a mean of 10 surgically removed nodes. Histological examination revealed 17 true negative sentinel nodes, 2 true positive, and 1 false negative. In our case series, sentinel lymph node detection had a 95% diagnostic accuracy, with only one false negative. Based on literature evidence, the sentinel node procedure is feasible and reliable in vulvar cancer; however, the value of sentinel node dissection in the treatment of early-stage vulvar cancer still needs to be confirmed.

Sentinel node localization by lymphoscintigraphy: a reliable technique with widespread applications

The concept of the sentinel lymph node (SN) represents an important contribution to guide appropriate surgery of cancer. Diagnostic non-invasive or minimally invasive procedures that provide accurate preoperative staging of the lymph node status are badly needed. The technique of SN biopsy, first developed with the purpose to select melanoma patients for regional node dissection, has been extended to other malignancies. Initial studies in breast carcinoma, conducted with vital blue dye, showed that the SN concept was biologically valid, although SN was missed in up to 30%-40% of cases. If a radioactive tracer is injected close to the tumor, then the SN can be identified by lymphoscintigraphy (LS), and a gamma ray detecting probe (GDP) can be used to locate the skin projection of SN and assist biopsy. These techniques are already used successfully in melanoma and breast carcinoma where the various parameters involved, such as the size of the radioactive particles, the injection site and injection volume, have recently been optimized. In a large series of breast cancer patients, the overall predictive value of the SNs biopsy guided by LS and GDP was 96.8%; in patients with small carcinomas (< 1.2 cm diameter), the concordance between SN and axillary status was 98.6%. In patients with melanoma, LS combined with GDP showed itself to be superior to the blue dye mapping. LS associated with GDP allowed the detection of SN in 98% of cases and 72 SNs in 54 basins were localized. Using blue dye instead, SN was stained only in 80% of patients (50 SNs in 40 basins). Lymphoscintigraphic techniques have shown promising results also in tumors such as vulva and tongue. In conclusion, LS is a simple nuclear medicine technique, relatively inexpensive and well accepted by patients. SN biopsy guided by a GDP is becoming widely adopted for a variety of neoplasms, contributing significantly to the search for less aggressive treatments in patients with early stages of cancer.

Patterns of recurrence in patients with squamous cell carcinoma of the vulva. A multicenter CTF Study

BACKGROUND

Invasive vulvar carcinoma is a rare disease with an incidence rate of 3-5% of all female genital neoplasms. The current study discusses the limited number of articles in the literature regarding the patterns of recurrence as well as the clinical outcome of patients with recurrent disease based on a consistent and consecutive series of cases.

METHODS

A common clinical chart focusing on the study of patterns of recurrence was used in five Italian gynecologic institutions with uniform criteria of surgical nomenclature, pathologic variables, and sites of recurrence. Between 1980-1994, 502 cases of primary invasive squamous carcinoma of the vulva were registered consecutively, treated, and considered for this multicentered study.

RESULTS

Of 502 patients, 187 (37.3%) developed a recurrence. Distribution of the recurrences by site was as follows: perineal, 53.4%; inguinal, 18.7%; pelvic, 5.7%; distant, 7.9%; and multiple, 14.2%. In a multivariate analysis, 3 characteristics appeared to be statistically correlated with the risk of recurrence: International Federation of Gynecology and Obstetrics Stage > II (P = 0.029), positive lymph nodes (P = 0.009), and vascular space invasion (P = 0.004). The 5-year survival rate was 60% for perineal recurrences, 27% for inguinal and pelvic recurrences, 15% for distant recurrences, and 14% for multiple recurrences.

CONCLUSIONS

In the current study the prognostic factors found to have statistical significance as prognostic factors for risk of recurrence were tumor dimension, lymph node involvement, and stromal and vascular space invasion. The presence of inguinal lymph node metastases was predictive of multiple and distant recurrences with a low rate of incidence of isolated perineal recurrence (27%) compared with negative lymph node cases (57.5%). Survival analysis of recurrent disease showed that the surgical resection of local recurrences may provide acceptable results (51% at 5 years). This observation may justify a follow-up program aimed at identifying those patients with early local recurrence suitable for radical resection.

Sentinel node biopsy in early vulvar cancer

Lymph node pathologic status is the most important prognostic factor in vulvar cancer; however, complete inguinofemoral node dissection is associated with significant morbidity. Lymphoscintigraphy associated with gamma-probe guided surgery reliably detects sentinel nodes in melanoma and breast cancer patients. This study evaluates the feasibility of the surgical identification of sentinel groin nodes using lymphoscintigraphy and a gamma-detecting probe in patients with early vulvar cancer. Technetium-99m-labelled colloid human albumin was administered perilesionally in 37 patients with invasive epidermoid vulvar cancer (T1-T2) and lymphoscintigraphy performed the day before surgery. An intraoperative gamma-detecting probe was used to identify sentinel nodes during surgery. A complete inguinofemoral node dissection was then performed. Sentinel nodes were submitted separately to pathologic evaluation. A total of 55 groins were dissected in 37 patients. Localization of the SN was successful in all cases. Eight cases had positive nodes: in all the sentinel node was positive; the sentinel node was the only positive node in five cases. Twenty-nine patients showed negative sentinel nodes: all of them were negative for lymph node metastases. Lymphoscintigraphy and sentinel-node biopsy under gamma-detecting probe guidance proved to be an easy and reliable method for the detection of sentinel node in early vulvar cancer. This technique may represent a true advance in the direction of less aggressive treatments in patients with vulvar cancer.

Skin bridge recurrences in vulvar cancer: frequency and management

Rose PG. Skin bridge recurrences in vulvar cancer: frequency and management. The use of separate groin incisions has markedly reduced the rate of wound breakdown from radical vulvectomy. This retrospective review was undertaken to evaluate the frequency and management of skin bridge recurrences. Five cases of skin bridge recurrence in vulvar cancer were identified among 128 patients. Patient demographics, pathology, recurrence management, and follow-up were obtained from operative and clinical records and tumor registries. Five cases of isolated skin bridge recurrence were studied, of which four patients had squamous cancer and one melanoma. Excluding one case referred at recurrence, this occurred in 2.4% of patients with squamous cell carcinoma and was more common in patients with positive nodes 3 of 41 patients versus 0 of 85, relative risk 3.07 (95% confidence interval 2.39-3.95). The median time to recurrence following surgery was 4.0 months (range 1-47 months). Four recurrences were treated by radical local excision alone, but 3 had already received radiation therapy. One patient developed a second skin bridge recurrence and was treated with a second radical local excision. Three patients are alive and recurrence-free 38+ to 56+ months (median 51+ months) following treatment for recurrence. Skin bridge recurrences are rare and more common in patients with inguinal node metastasis. Local excision with or without radiation therapy is the most common therapy that has been employed. In the absence of other metastases local excision is associated with a good recurrence-free survival.

Surgical management of vulvar cancer

Vulvar cancer is an uncommon disease, marked by typical long delays in diagnosis due to lack of awareness by doctors and patients. The most common histology is squamous, although melanoma, sarcoma and adenocarcinoma occur less frequently. The predictable spread pattern of vulvar cancer to regional then distant lymphatics has allowed for improvements in survival largely due to radical surgical intervention. However, the significant morbidity from radical surgery has led to the search for better prognostic indicators and complementary therapeutic modalities to modify the extent of surgery in both early and advanced disease. En bloc radical vulvectomy and bilateral inguinal-femoral lymphadenectomy are rarely performed today: an early invasive stage has been defined where only limited excision is required. The extent of and the indications for inguinal lymphadenectomy for various clinical tumors and role of separate incisions have been clarified. When disease has spread to more than one inguinal node, adjuvant radiotherapy has replaced pelvic lymphadenectomy as the standard. Inguinal radiotherapy without groin dissection does not appear to be adequate therapy for most patients. The use of chemotherapy and radiation to shrink large tumors to allow surgical resection continues to be evaluated but has demonstrated excellent results to date. The utility of newer techniques of sentinel node mapping is also being evaluated in squamous cancers and melanoma to limit the extent of lymphadenectomy in patients with clinically normally lymph nodes.