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The Clinical Relevance of p16 and p53 Status in Patients with Squamous Cell Carcinoma of the Vulva. JOURNAL OF ONCOLOGY 2020; 2020:3739075. [PMID: 32280343 PMCID: PMC7128067 DOI: 10.1155/2020/3739075] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/31/2020] [Accepted: 02/13/2020] [Indexed: 12/12/2022]
Abstract
Objective To investigate the prognostic significance of HPV status in vulvar squamous cell carcinomas (VSCC) and to determine whether preoperative determination of p16 or p53 status would have clinical relevance. Methods Patients treated for VSCC at a tertiary hospital in Sydney, Australia, from 2002 to 2014, were retrospectively evaluated (n = 119). Histological specimens were stained for p53 and p16 expression, and HPV status was determined by PCR detection of HPV DNA. Results HPV DNA was detected in 19%, p16 expression in 53%, and p53 expression in 37% of patients. Kaplan-Meier survival estimates indicated that p16/HPV-positive patients had superior five-year disease-free survival (76% versus 42%, resp., p = 0.004) and disease-specific survival (DSS) (89% versus 75% resp., p = 0.05) than p53-positive patients. In univariate analysis, nodal metastases (p < 0.001), tumor size >4 cm (p = 0.03), and perineural invasion (p = 0.05) were associated with an increased risk of disease progression and p16 expression with a decreased risk (p = 0.03). In multivariable analysis, only nodal metastases remained independent for risk of disease progression (p = 0.01). For DSS, lymph node metastases (p < 0.001) and tumor size (p = 0.008) remained independently prognostic. Conclusion The p16/HPV and p53 status of VSCC allows separation of patients into two distinct clinicopathological groups, although 10% of patients fall into a third group which is HPV, p16, and p53 negative. p16 status was not independently prognostic in multivariable analysis. Treatment decisions should continue to be based on clinical indicators rather than p16 or p53 status.
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Mitra S, Sharma MK, Kaur I, Khurana R, Modi KB, Narang R, Mandal A, Dutta S. Vulvar carcinoma: dilemma, debates, and decisions. Cancer Manag Res 2018; 10:61-68. [PMID: 29386916 PMCID: PMC5765975 DOI: 10.2147/cmar.s143316] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Vulvar carcinoma is a rare and aggressive gynecological malignancy. It affects elderly females, with the mean age at diagnosis being 55-60 years. Regional metastasis to inguinal lymph nodes is common. There is a high incidence of pelvic node involvement, especially in those with pathologically positive inguinal nodes. Surgery appears to be the only curative treatment option in the early stages of the disease. But in most patients, surgery is associated with considerable morbidities and psychosexual issues. Hence, in the quest for a less morbid form of treatment, multimodality approaches with various combinations of surgery, chemotherapy, and radiation therapy have been suggested for advanced vulvar cancers. Due to the low incidence of the disease, the level of evidence for the success of these treatment modalities is poor. In countries like India, a heterogeneous incidence of vulvar carcinoma exists across the country, with patients presenting at advanced stages when the option of surgery is often supplemented or replaced by chemotherapy and radiotherapy. In this review, we attempt to study the available published literature and trials and discuss the treatment options in various stages of vulvar carcinoma.
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Affiliation(s)
- Swarupa Mitra
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Manoj Kumar Sharma
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Inderjeet Kaur
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Ruparna Khurana
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Kanika Batra Modi
- Department of Genitourinary Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Raman Narang
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Avik Mandal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Soumya Dutta
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
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Nooij LS, Brand FAM, Gaarenstroom KN, Creutzberg CL, de Hullu JA, van Poelgeest MIE. Risk factors and treatment for recurrent vulvar squamous cell carcinoma. Crit Rev Oncol Hematol 2016; 106:1-13. [PMID: 27637349 DOI: 10.1016/j.critrevonc.2016.07.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/02/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022] Open
Abstract
Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.
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Affiliation(s)
- L S Nooij
- Department of Gynecology, LUMC, Netherlands
| | | | | | | | - J A de Hullu
- Department of Gynecology, Radboud UMC, Netherlands
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Hacker NF, Barlow EL. Staging for vulvar cancer. Best Pract Res Clin Obstet Gynaecol 2015; 29:802-11. [DOI: 10.1016/j.bpobgyn.2015.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/27/2015] [Indexed: 11/16/2022]
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Study of biomolecular and clinical prognostic factors in patients with cancer of the vulva undergoing surgical treatment. Int J Gynecol Cancer 2015; 24:766-72. [PMID: 24552893 DOI: 10.1097/igc.0000000000000103] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cancers of the vulva account for 3% to 5% of all cancers of the female genital. This study was conducted to evaluate clinical, pathological, and molecular prognostic factors in patients with cancer of the vulva. METHODS Patients with squamous cell carcinoma of the vulva who had undergone surgical treatment at the Department of Pelvic Surgery and Gynecology Service, Aristides Maltez Hospital, between June 1993 and June 2011 were selected. Clinical, epidemiological, pathological, and molecular characteristics related to the prognosis of these patients were evaluated in relation to the prognosis. In the molecular evaluation, we studied the expression of p53 and matrix metalloproteinase 2 by immunohistochemistry. RESULTS Seventy-five patients were eligible for the study. In multivariable analysis, factors related to survival were as follows: tumor size larger than 4 cm (P = 0.014), an invasion depth greater than 2 mm (P = 0.023) and matrix metalloproteinase 2 expression in more than 50% of the tumor cells (P = 0.046). With the use of the relative risks of the factors identified in the multivariable analysis, a point count was developed for a prognostic classification (the score classifies patients into 3 categories). CONCLUSIONS A tumor size larger than 4 cm, an invasion depth greater than 2 mm, and metalloproteinase 2 expression in more than 50% of the tumor cells seem to be related to lower overall survival rate in patients with cancer of the vulva undergoing surgical treatment. A classification of the patient's prognosis can be performed using a point count based on these relative risks.
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Aragona AM, Soderini AH, Cuneo NA. Defining the concept of locally advanced squamous cell carcinoma of the vulva: a new perspective based on standardization of criteria and current evidence. J Gynecol Oncol 2014; 25:272-8. [PMID: 25142626 PMCID: PMC4195295 DOI: 10.3802/jgo.2014.25.4.272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 07/06/2014] [Indexed: 11/30/2022] Open
Abstract
The phrase "locally advanced carcinoma of the vulva" has often been mentioned in the literature, though not accurately defined, or even leading to the interpretation overlapping. Grounded on cervical cancer experience, we are able to state that designing a tailored primary strategy based on clinically measurable adverse prognostic factors represents the cornerstone of therapy. This fact urged us to rethink about the real usefulness of the concept of locally advanced squamous cell carcinoma of the vulva. We will refer to this concept as a clinical entity emerging from a rigorous workup which is a valuable guiding tool in the context of a thorough debate about the best primary treatment approach to be used. Furthermore, bulky tumors of the vulva have been associated with a worse prognosis on several occasions. Some authors have questioned the fact that tumor size has not been considered in the staging system. Finally, a standardized definition will help us compare the results obtained, which is extremely necessary given the worldwide low prevalence of this disease.
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Affiliation(s)
- Alejandro M Aragona
- Department of Gynecologic Oncology, Oncology Hospital of Buenos Aires Marie Curie, Buenos Aires, Argentina.; Unit of Gynecologic Oncology, Donacion Francisco Santojanni Hospital, Buenos Aires, Argentina.
| | - Alejandro H Soderini
- Department of Gynecologic Oncology, Oncology Hospital of Buenos Aires Marie Curie, Buenos Aires, Argentina.; Unit of Gynecologic Oncology, Parmenio Pinero Hospital, Buenos Aires, Argentina
| | - Nicasio A Cuneo
- Department of Gynecologic Oncology, Oncology Hospital of Buenos Aires Marie Curie, Buenos Aires, Argentina
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Aragona AM, Cuneo NA, Soderini AH, Alcoba EB. An analysis of reported independent prognostic factors for survival in squamous cell carcinoma of the vulva: Is tumor size significance being underrated? Gynecol Oncol 2014; 132:643-8. [DOI: 10.1016/j.ygyno.2013.12.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/09/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
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Baiocchi G, Silva Cestari F, Rocha R, Lavorato-Rocha A, Maia B, Cestari L, Kumagai L, Faloppa C, Fukazawa E, Badiglian-Filho L, Sant'Ana Rodrigues I, Soares F. Prognostic value of the number and laterality of metastatic inguinal lymph nodes in vulvar cancer: Revisiting the FIGO staging system. Eur J Surg Oncol 2013; 39:780-5. [DOI: 10.1016/j.ejso.2013.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/25/2013] [Accepted: 03/04/2013] [Indexed: 11/28/2022] Open
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Perry LJ, Guralp O, Al-Niaimi A, Zucker NA, Kushner DM. False positive PET-CT scan and clinical examination in a patient with locally advanced vulvar cancer. GYNECOLOGIC ONCOLOGY CASE REPORTS 2013; 4:29-31. [PMID: 24371671 DOI: 10.1016/j.gynor.2012.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 12/27/2012] [Indexed: 10/27/2022]
Abstract
► PET-CT scan was positive for metastasis of vulvar cancer to lymph nodes however they were histologically negative. ► Frozen section analysis should be performed at the time of surgery to confirm status of suspicious lymph nodes.
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Affiliation(s)
- Latoya J Perry
- Department of Obstetrics and Gynecology, University of Oklahoma Stephenson Cancer Center, Oklahoma City, Oklahoma 73104, USA
| | - Onur Guralp
- Department of Obstetrics and Gynecology, Istanbul University Cerrahpasa School of Medicine, Istanbul 34340, Turkey
| | - Ahmed Al-Niaimi
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Noah A Zucker
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - David M Kushner
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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Fons G, Hyde SE, Buist MR, Schilthuis MS, Grant P, Burger MP, van der Velden J. Prognostic Value of Bilateral Positive Nodes in Squamous Cell Cancer of the Vulva. Int J Gynecol Cancer 2009; 19:1276-80. [DOI: 10.1111/igc.0b013e31819d58a1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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12
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Carcinoma of the Vulva. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
The objective of this review is to summarize the published data about squamous carcinoma of the vulva and to identify promising areas for future investigation. Rather than the routine use of complete radical vulvectomy, a radical wide excision of the vulvar lesion to achieve at least a 1-cm gross margin appears sufficient to treat the primary lesion. A surgical assessment of the groin is required for all patients who have invasion greater than 1 mm. Ipsilateral groin node dissection can be performed through a separate incision. All the nodal tissue medial to the vessels and above the fascia should be removed. Sentinel node evaluation may be a significant step forward, but the false-negative rate is not well enough defined to consider this a standard. Patients with positive inguinal nodes at groin dissection should receive radiation therapy to the ipsilateral groin and hemipelvis. For those patients who have unresectable primary disease or if nodes are palpably suspicious, fixed, and/or ulcerated preoperatively, chemoradiation is the preferred option. Exenterative procedures may rarely be required. Chemotherapy for recurrent or metastatic disease has not been proven to be of value. Although survival rates are high for those with negative nodes, the morbidity associated with standard radical techniques has prompted innovation. Adequately powered trials aimed at further reducing morbidity without compromising survival are underway.
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Affiliation(s)
- Frederick B Stehman
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Landrum LM, Lanneau GS, Skaggs VJ, Gould N, Walker JL, McMeekin DS, Gold MA. Gynecologic Oncology Group risk groups for vulvar carcinoma: Improvement in survival in the modern era. Gynecol Oncol 2007; 106:521-5. [PMID: 17540438 DOI: 10.1016/j.ygyno.2007.04.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Revised: 04/20/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with vulvar cancer were stratified into risk groups for survival based on surgicopathologic findings from a prospective study conducted by the Gynecologic Oncology Group from 1977-1984. The purpose of this study is to reassess these risk groups in patients treated in an era of contemporary management. METHODS Patients with vulvar carcinoma were identified from 1990-2005 for retrospective analysis. Charts were abstracted for clinical, histopathologic and surgical data, and patients stratified into four risk groups for survival based on the clinical size of tumor and extent of lymph node metastasis. Univariate and multivariate characteristics were evaluated and 5-year survival determined by Kaplan-Meier method. RESULTS 175 patients were identified that underwent surgical management with a median age at diagnosis of 59.9 years. Stage distribution included: I (n=89, 51%), II (n=53, 30%), III (n=29, 17%), and IV (n=4, 2%). Stratification into risk groups included: minimal (n=89, 51%), low (n=69, 40%), intermediate (n=11, 6%), and high (n=6; 3%). The survival rate was 100%, 97%, 82% and 100%, respectively, at median follow-up of 54.5 months. Comparatively, the survival rates for historic groups were 97.9%, 87.4%, 74.8% and 29.0%. Using multivariate analysis, age (p=0.04) and lymph node metastasis (p=0.009) were predictive of survival. CONCLUSIONS Survival among the minimal and low risk groups is preserved in spite of less radical surgery. 5-year survival rate for intermediate and high risk patients also appears to be improved. This is likely a result of advancement in adjuvant chemo-radiation and a younger patient population that presents with less advanced disease.
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Affiliation(s)
- Lisa M Landrum
- Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, Oklahoma University Health Sciences Center, PO Box 26901, WP2410, Oklahoma City, OK 73190, USA.
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Holm R, Knopp S, Suo Z, Tropè C, Nesland JM. Expression of EphA2 and EphrinA-1 in vulvar carcinomas and its relation to prognosis. J Clin Pathol 2006; 60:1086-91. [PMID: 17158642 PMCID: PMC2014830 DOI: 10.1136/jcp.2006.041194] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To examine the expression of EphA2 and EphrinA-1 in vulvar squamous cell carcinomas and investigate their prognostic relevance. METHODS Tumours from 224 patients with vulvar squamous cell carcinomas were investigated for expression of EphA2 and EphrinA-1 using single and double immunostaining methods. RESULTS High expression (strong/moderate staining intensity) of EphA2 and EphrinA-1 was observed in 114 (51%) and 126 (56%) vulvar carcinomas, respectively. In the three cases tested using the double immunostaining method, colocalisation of EphA2 and EphrinA-1 proteins was identified in the same neoplastic cells. High EphA2 expression was significantly correlated to high expression of EphrinA-1 (p<0.01) and cyclin A (p<0.01), large tumour size (p = 0.03), deep invasion (p<0.01) and higher FIGO stage (p = 0.05). A correlation between high EphrinA-1 expression and high levels of cyclin A (p<0.01) and p21 (p<0.01), deep invasion (p<0.01) and higher FIGO stage (p = 0.01) was also seen. In univariate analysis, high expression of EphrinA-1 was associated with poor survival (p = 0.03). However, in the multivariate analysis neither EphrinA-1 nor EphA2 were significantly correlated to survival. CONCLUSIONS EphA2 and EphrinA-1 were overexpressed in 51% and 56% of the vulvar squamous cell carcinomas, respectively, and high levels of EphA2 and EphrinA-1 proteins were associated with deep tumour invasion and high FIGO stage. However, EphA2 and EphrinA-1 were not independently associated with clinical outcome in vulvar carcinomas.
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Affiliation(s)
- R Holm
- Department of Pathology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway.
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Spiryda LB, Fuller AF, Goodman A. Aggressive locally recurrent vulvar cancer: review of cases presented to Massachusetts General Hospital 1990 to present. Int J Gynecol Cancer 2005; 15:884-9. [PMID: 16174240 DOI: 10.1111/j.1525-1438.2005.00151.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Isolated recurrences of squamous cell vulvar carcinoma treated by surgical re-excision have excellent outcomes. There is a subset of these patients who develop multiple local recurrences that are difficult to manage and have a high risk of dying from their cancers. We reviewed women presenting with vulvar cancer (200 patients) to Massachusetts General Hospital from 1990 to present and identified 12 women with aggressive, locally recurrent squamous cell carcinomas of the vulva. The identified women all had successful primary radical vulvectomy and groin node dissections with negative surgical margins (except patient 2) and lymph nodes with no lympho-vascular space invasion. Seven women had underlying lichen sclerosis. Eight had a history of vulvar intraepithelial neoplasia or persistent carcinoma in situ. Ten patients had greater than three recurrences after primary surgical therapy. One died of recurrent vulvar cancer 10 months after her initial diagnosis. Two patients died after three recurrences. The only unifying clinicopathologic factor among these women was persistent lichen sclerosis and persistent carcinoma in situ. Understanding the underlying mechanisms that predisposed these premalignant lesions to transform into carcinomas will help predict in which women these are likely to re-occur and may help determine which women require more aggressive initial treatment.
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Affiliation(s)
- L B Spiryda
- Division of Gynecology Oncology, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Gonzalez Bosquet J, Magrina JF, Gaffey TA, Hernandez JL, Webb MJ, Cliby WA, Podratz KC. Long-term survival and disease recurrence in patients with primary squamous cell carcinoma of the vulva. Gynecol Oncol 2005; 97:828-33. [PMID: 15896831 DOI: 10.1016/j.ygyno.2005.03.006] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2004] [Revised: 03/07/2005] [Accepted: 03/09/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To assess time to failure and sites of failure with extended follow-up of patients with squamous cell carcinoma (SCC) of the vulva. METHODS A retrospective analysis of 330 patients with primary SCC of the vulva treated at Mayo Clinic between 1955 and 1990 was conducted. The main outcome measures were the rates of treatment failure. The Kaplan-Meier method and the log-rank test were used to estimate the rates of overall survival, disease-free survival, and recurrence. The Cox proportional hazards model was used to assess independent variables as prognostic factors for treatment failure. RESULTS All 330 patients in the cohort underwent lymphadenectomy; 113 patients (34.2%) had involvement of the inguinofemoral nodes and 88 patients (26.7%) had treatment failure. Treatment failures occurred more frequently in patients who presented with inguinal metastasis at the primary surgery and during the first 2 years of follow-up. After 2 years, both groups, with or without positive inguinal nodes, had similar treatment failure rates. Most patients with disease recurrence in the groin died within the first 2 years of follow-up. Involvement of the inguinal nodes was the main independent predictive factor for survival, disease recurrence, and metastasis. CONCLUSIONS Most treatment failures occurred during the 2 years after initial surgical management. However, in 35% of patients, disease reoccurred 5 years or more after diagnosis, which demonstrates the need for long-term follow-up. Complete ipsilateral or bilateral inguinofemoral lymph node dissection ensures a thorough evaluation and treatment of the groin.
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Affiliation(s)
- Jesus Gonzalez Bosquet
- Division of Gynecologic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Lataifeh I, Nascimento MC, Nicklin JL, Perrin LC, Crandon AJ, Obermair A. Patterns of recurrence and disease-free survival in advanced squamous cell carcinoma of the vulva. Gynecol Oncol 2004; 95:701-5. [PMID: 15581985 DOI: 10.1016/j.ygyno.2004.08.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare patterns of recurrence and disease-free survival (DFS) of node-positive and node-negative patients with advanced vulval squamous cell carcinoma (SCC). METHODS Fifty-five patients with FIGO stage III/IVA vulval SCC who had surgery at the Queensland Centre for Gynaecological Cancer from 1989 to 1999 were included. Patients were grouped as follows: Group A, pT3 N0; Group B, pT3 N1; Group C, pT4 N2. Treatment included surgery +/- postoperative radiotherapy. Multivariate Cox models were calculated to identify independent prognostic factors. RESULTS After a median follow-up of 96 months, 25 patients (45.5%) experienced recurrence at the vulva (n = 2), pelvis (n = 8), or distant sites (n = 15). Recurrence in the pelvis and at distant sites was more likely for patients in groups B and C (P 0.003). At 5 years the probability of DFS was 66.6%, 35.3%, and 39.8% for patients in groups A, B, and C, respectively (P 0.085). Patients with negative nodes (n = 15), one microscopic positive node (n = 11), and two or more positive nodes (n = 29) had a probability of DFS of 66.6%, 67.3%, and 26.1% at 5 years, respectively (P 0.005). CONCLUSION Patients with > or =2 positive groin nodes are at risk for distant failure. The DFS of patients with negative groin nodes and those with only one microscopic positive node is very similar. The prognosis of patients with > or =2 positive unilateral or bilateral groin nodes is similar. The current FIGO staging system inaccurately reflects prognosis for patients with advanced vulval cancer. Clinical trials are warranted to investigate the benefit of systemic treatment.
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Affiliation(s)
- Isam Lataifeh
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD 4029, Australia
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Knopp S, Bjørge T, Nesland JM, Tropé C, Scheistrøen M, Holm R. p16INK4a and p21Waf1/Cip1 expression correlates with clinical outcome in vulvar carcinomas. Gynecol Oncol 2004; 95:37-45. [PMID: 15385108 DOI: 10.1016/j.ygyno.2004.07.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Aberrant expression of the cell cycle kinase inhibitors p16, p21, and p27 has been associated with poor prognosis in a variety of human malignancies. Little is known, however, about their clinical impact in vulvar carcinoma patients. Thus, we analyzed a larger series of vulvar squamous cell carcinomas and compared the results with clinical outcome. METHODS A total of 224 vulvar squamous cell carcinomas were immunohistochemically investigated for expression of p16, p21, and p27 using the biotin-streptavidin-peroxidase method and the OptiMax Plus automated cell staining system. RESULTS High p16 (> or =5%) positive nuclear immunostaining was found in 69 (31%) cases, high p21 (any staining) protein levels was detected in 95 (42%) cases, and low p27 (< or =50% positive nuclei) staining was seen in 170 (76%) cases. High expression of p16 was related to lower patient age and low expression of p53. High expression of p16 indicated a better prognosis in the multivariate analysis (RR = 0.5, 95% CI = 0.2-1.0) and less risk of developing lymph node metastasis (OR = 0.3, 95% CI = 0.2-0.7). High level of p21 was significantly associated with shorter survival in patients staged FIGO I and II (RR = 3.4, 95% CI = 1.3-9.3). We found no significant correlation between the expression of p27 and any of the clinicopathological variables. CONCLUSIONS Our study indicates a prognostic relevance for p16 and p21 immunoreactivity. Low level of p16 protein and high level of p21 protein were associated with a shorter disease-related survival. We did not find p27 protein expression to be useful as a prognostic indicator in vulvar carcinoma patients.
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Affiliation(s)
- Synne Knopp
- Department of Pathology, The Norwegian Radium Hospital, University of Oslo, 0310 Oslo, Norway.
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Abstract
PURPOSE OF REVIEW The radical surgical approach in the treatment of vulvar cancer patients has led to a favourable prognosis for the majority of patients with early stage vulvar cancer. However, morbidity is impressive, leading to more individualized treatment. The authors have reviewed the most recent literature on the pros and cons of the modifications in treatment, including surgery and primary radiotherapy, for primary squamous cell carcinoma of the vulva and vulvar melanoma. RECENT FINDINGS The sentinel lymph node procedure is a promising method of staging in patients with early stage squamous cell carcinoma of the vulva and possibly for patients with vulvar melanoma, but its safety still has to be proved. Less radical surgery has led to a higher local and regional recurrence rate. There may be a role for primary radiotherapy of the groin in a selected group of patients. SUMMARY The authors have concluded that the individualization of treatment for vulvar cancer patients has led to a decrease in morbidity but an increase in recurrences. The increase in recurrences does not appear to compromise prognosis, probably because of the lack of power, based on the low incidence of vulvar cancer. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce the morbidity of treatment but their safety needs to be studied in randomized trials.
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Affiliation(s)
- Joanne A de Hullu
- Department of Gynecologic Oncology, University Medical Centre Nijmegen, Nijmegen, The Netherlands.
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Makar AP, Scheistroen M, van den Weyngaert D, Tropé CG. Surgical management of stage I and II vulvar cancer: the role of the sentinel node biopsy. Review of literature. Int J Gynecol Cancer 2001; 11:255-62. [PMID: 11520362 DOI: 10.1046/j.1525-1438.2001.011004255.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Recognition of the psychosexual consequences of radical vulvectomy and better understanding of the lymphatic drainage and histopathologic features of vulvar cancer have led to a more conservative surgical approach, especially in patients with early-stage disease. Every patient with early vulvar cancer should be managed individually and the risk of conservative therapy balanced against the dangers and advantages of more radical therapy. The results of the sentinel node (SN) procedure in early cancer of the vulva are encouraging, and it might be possible in the near future to avoid the morbidity of inguino-femoral lymphadenectomy. This article reviews surgical management of early vulvar cancer and the place of SN biopsy.
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Affiliation(s)
- A P Makar
- Department Gynecologic Oncology, Middelheim Hospital, Antwerp, Belgium
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Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000. [DOI: 10.1002/1097-0142(20001001)89:7<1520::aid-cncr15>3.0.co;2-n] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Leys CM, Hartenbach EM, Hafez GR, Mahvi DM. Screening for occult nodal metastasis in squamous cell carcinoma of the vulva. Int J Gynecol Pathol 2000; 19:243-7. [PMID: 10907173 DOI: 10.1097/00004347-200007000-00008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Metastases to inguinofemoral lymph nodes in patients with carcinoma of the vulva alter the prognosis and treatment of this disease. Our goal was to determine if immunohistochemical staining could reveal occult metastatic nodal disease not detected with routine hematoxylin and eosin staining. We retrospectively examined a total of 110 lymph nodes from 10 patients who had undergone lymph node dissection and found to have all negative nodes. Paraffin embedded lymph nodes were immunostained with a monoclonal antibody directed against multiple low- and high-molecular weight cytokeratins. Micrometastases were not detected in any lymph nodes examined with immunohistochemistry. All positive and negative controls yielded satisfactory results. It is concluded that immunohistochemistry with cytokeratin antibodies does not provide greater sensitivity than routine hematoxylin and eosin staining for the detection of nodal metastases in vulvar carcinoma.
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Affiliation(s)
- C M Leys
- Department of Surgery, University of Wisconsin Medical School, Madison 53792, USA
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24
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Abstract
Slow but steady progress has been made in the earlier diagnosis and better treatment of gynecological cancers, particularly over the last 50 years. Cervical cytology screening programs, where implemented, have led to a remarkable reduction in both the incidence and mortality from clinically invasive cervical cancer. This relatively simple technology has been truly one of the major success stories of modern medicine, but unfortunately this technique has not been uniformly applied to all women in the world, particularly to women in developing countries. New research into cervical cancer etiology, the role of HPV, and the development of vaccines against this virus offer a great hope particularly for developing countries. In addition, the combination of radiotherapy and chemotherapy has resulted in a marked improvement in outcome results for women with advanced cervical cancer. Ovarian cancer has seen the development of effective chemotherapy strategies for this disease. Currently this disease remains one of the major scourges in industrialized countries but the continued evolution of knowledge with regard to optimum sequencing of chemotherapeutic agents and surgery offers the prospect for better outcomes, less morbidity and a better quality of life. Ongoing research into the development of newer chemotherapeutic agents and a better understanding of the actual mechanisms regarding the efficacy of chemotherapy and drug resistance offers great promise for the future. Endoscopic surgery for staging and also for therapy shows promise for improved quality of life as well as outcomes for patients in the future and offers the challenge of trying to make this technology readily available to all women in the world. As we gain a better understanding of the molecular basis of disease and health we will truly be able to intervene in a preventive mode in the new millennium.
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Affiliation(s)
- J L Benedet
- Divisions of Gynecologic Oncology, BC Cancer Agency and University of British Columbia, Vancouver, BC, Canada
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25
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Abstract
Radical surgery has resulted in impressive cure rates in women with locally advanced vulvar carcinoma. Unfortunately, morbidity mostly related to inguinofemoral lymphadenectomy, is common. The present review discusses innovations in the management of vulvar disease with attempts to reduce attendant morbidity.
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Affiliation(s)
- E C Grendys
- Gynecologic Oncology, University of South Florida School of Medicine, H. Lee. Moffitt Cancer and Research Center, Tampa 33612, USA
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Faul, Miramow, Gerszten, Huang, Edwards. Isolated local recurrence in carcinoma of the vulva: prognosis and implications for treatment. Int J Gynecol Cancer 1998. [DOI: 10.1046/j.1525-1438.1998.09867.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
BACKGROUND In patients with squamous cell carcinoma of the vulva, lymph nodal, surgicopathologic variables have been studied rarely, although lymph node status is by far the most important prognostic factor. This study was designed to investigate surgicopathologic variables of lymph node metastases to evaluate their prognostic significance. METHODS In 75 patients with inguinal and/or pelvic lymph node metastases from squamous cell carcinoma of the vulva, the following parameters were studied: size and location of the tumor, depth of invasion, grade, lymph-vascular space involvement (LVSI), local immune reaction, presence and degree of dystrophic changes in the surrounding skin, FIGO stage, number of positive lymph nodes, greatest dimension of the metastasis within the lymph node, percentage of lymph node replacement, number of lymph nodes with replacement greater than 50%, number of lymph nodes replaced completely by tumor, extracapsular spread, and active immunologic response within the lymph node. RESULTS Among the variables related to the primary carcinomas, only size of the tumor and LVSI were correlated with survival (P < 0.003 and P < 0.02, respectively). On the contrary, all pathologic variables regarding the lymph nodes significantly influenced survival by univariate analysis. On multivariate analysis, extracapsular spread was the most significant independent prognostic factor (P < 0.0004), followed by FIGO stage (P < 0.03). For patients with only one positive lymph node, the most important prognostic factor was the greatest dimension of the metastasis within the lymph node (P < 0.01). CONCLUSIONS These data, if confirmed in larger series, can contribute to a more accurate identification of low and high risk patients and, therefore, to a more appropriate employment of adjuvant therapies.
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Affiliation(s)
- D Paladini
- Regional Department of Gynaecologic Oncology, Queen Elizabeth Hospital, Gateshead, United Kingdom
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Harrington KJ, Lambert HE. Current issues in the non-surgical management of primary vulvar squamous cell carcinoma. Clin Oncol (R Coll Radiol) 1994; 6:331-6. [PMID: 7826928 DOI: 10.1016/s0936-6555(05)80277-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- K J Harrington
- Department of Clinical Oncology, Royal Postgraduate Medical School, Hammersmith Hospital, London, UK
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Lanciano RM, Corn BW. Groin node irradiation for vulvar cancer: treatment planning must do more than scratch the surface. Int J Radiat Oncol Biol Phys 1993; 27:987-9; discussion 991. [PMID: 8244835 DOI: 10.1016/0360-3016(93)90480-j] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Ayhan A, Tuncer ZS, Akarin R, Yücel I, Develioğlu O, Mercan R, Zeyneloğlu H. Complications of radical vulvectomy and inguinal lymphadenectomy for the treatment of carcinoma of the vulva. J Surg Oncol 1992; 51:243-5. [PMID: 1434654 DOI: 10.1002/jso.2930510408] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Forty-two patients with invasive carcinoma of the vulva, subjected to radical vulvectomy and inguinal lymphadenectomy, were evaluated retrospectively. The mean age of patients was 61.6 years. Fifteen patients (35.7%) had complicating medical diseases, the histopathological diagnoses were squamous carcinoma (n = 39), undifferentiated carcinoma (n = 1), and malignant melanoma (n = 2). The postoperative morbidity and mortality rates were found to be 73.8% and 11.6%, respectively.
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Affiliation(s)
- A Ayhan
- Department of Obstetrics and Gynecology, Hacettepe University, School of Medicine, Ankara, Turkey
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