A comparison of staging systems for squamous cell carcinoma of the vulva

Sentinel node biopsy in vulvar cancer: Implications for staging

In 2008, the first Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V) showed that omission of inguinofemoral lymphadenectomy is safe in patients with early-stage vulvar cancer and a negative sentinel node and it simultaneously decreases treatment-related morbidity. An important part of the sentinel node procedure is pathologic ultrastaging of the removed sentinel nodes. Subsequently, since the introduction of this procedure in the standard care of patients with early-stage vulvar cancer, more and smaller inguinofemoral lymph node metastases have been diagnosed. The clinical consequences of these micrometastases are not clear yet. With increasing size of the sentinel node metastasis, chances of non-sentinel node metastases increase and those of survival decrease. The size of lymph node metastases is included in the latest staging system for vulvar cancer, however at this moment without clinical implications. Furthermore, a separate category for micrometastases is not incorporated yet. More research is needed to determine the clinical consequences of the size of (sentinel) lymph node metastases.

Survival outcomes for patients with stage IVB vulvar cancer with grossly positive pelvic lymph nodes: time to reconsider the FIGO staging system?

OBJECTIVE

To evaluate treatment outcomes for patients with vulvar cancer with grossly positive pelvic lymph nodes (PLNs).

METHODS

From a database of 516 patients with vulvar cancer, we identified patients with grossly positive PLNs without distant metastasis at initial diagnosis. We identified 20 patients with grossly positive PLNs; inclusion criteria included PLN 1.5cm or larger in short axis dimension on CT/MRI (n=11), FDG-avid PLN on PET/CT (n=3), or biopsy-proven PLN disease (n=6). Ten patients were treated with chemoradiation therapy (CRT), 4 with RT alone, and 6 with various combinations of surgery, RT or CRT. Median follow-up time for patients who had not died of cancer was 47months (range, 4-228months).

RESULTS

Mean primary vulvar tumor size was 6.4cm; 12 patients presented with 2009 AJCC T2 and 8 with T3 disease. All patients had grossly positive inguinal nodes, and the mean inguinal nodal diameter was 2.8cm. The 5-year overall survival and disease specific survival rates were 43% and 48%, respectively. Eleven patients had recurrences, some at multiple sites. There were 9 recurrences in the vulva, but no isolated nodal recurrences. Four patients developed distant metastasis within 6months of starting radiation therapy.

CONCLUSIONS

Aggressive locoregional treatment can lead to favorable outcomes for many patients with grossly involved PLNs that is comparable to that of grossly involved inguinal nodes only. We recommend modification of the FIGO stage IVB classification to more accurately reflect the relatively favorable prognosis of patients with PLN involvement.

Validation of the FIGO 2009 staging system for carcinoma of the vulva

BACKGROUND

The previous (1988) International Federation of Gynecology and Obstetrics (FIGO) vulval cancer staging system failed in 3 important areas: (1) stage 1 and 2 disease showed similar survival; (2) stage 3 represented a most heterogeneous group of patients with a wide survival range; and (3) the number and morphology of positive nodes were not taken into account.

OBJECTIVE

To compare the 1988 FIGO vulval carcinoma staging system with that of 2009 with regard to stage migration and prognostication.

METHODS

Information on all patients treated for vulval cancer at the Queensland Centre for Gynecological Cancers, Australia, between 1988 to the present was obtained. Data included patients' characteristics as well as details on histopathology, treatments, and follow-up. We recorded the original 1988 FIGO stage, reviewed all patients' histopathology information, and restaged all patients to the 2009 FIGO staging system. Data were analyzed using the Kaplan-Meier method to compare relapse-free survival and overall survival.

RESULTS

Data from 394 patients with primary vulval carcinoma were eligible for analysis. Patients with stage IA disease remained unchanged. Tumors formerly classified as stage II are now classified as stage IB. Therefore, FIGO 2009 stage II has become rare, with only 6 of 394 patients allocated to stage II. Stage III has been broken down into 3 substages, thus creating distinct differences in relapse-free survival and overall survival. Prognosis of patients with stage IIIC disease is remarkably poor.

CONCLUSION

The FIGO 2009 staging system for vulval carcinoma successfully addresses some concerns of the 1988 system. Especially, it identifies high-risk patients within the heterogeneous group of lymph node-positive patients.

New FIGO staging system of vulvar cancer indeed provides a better reflection of prognosis

OBJECTIVE

To find out whether the new FIGO staging system (introduced 2009) indeed leads to a more specific prediction of the survival for patients with vulvar SCC.

METHODS

A retrospective study of 269 patients with vulvar SCC from 1988 to 2009. All patients were staged according the old and revised FIGO staging system by histopathological data. Overall survival (OS) and disease specific survival (DSS) were calculated.

RESULTS

Of all 269 patients, a total number of 113 patients (42.4%) was restaged according to the new FIGO staging, mainly downstaged. In patients with negative nodes, tumor size was not predictive for OS (p = 0.475) and DSS (p = 0.915). Patients of old FIGO stage III and negative node status showed no difference in survival with the group mentioned above (OS p = 0.105 and DSS p = 0.743, respectively). An increasing number of positive lymph nodes (range 1-9) led to a decrease in survival in OS and DSS (p = 0.022 and p = 0.004 respectively). When corrected for the number of positive nodes, there was no difference in survival between patients with unilateral or bilateral lymph nodes. In patients with positive nodes, extranodal growth showed a significant worse survival compared to patients without extranodal growth (OS p < 0.001 and DSS p = 0.004).

CONCLUSION

The new FIGO staging system provides indeed a better reflection of prognosis for patients with vulvar SCC. An accurate description of clinical and histopathological data combined with information about which FIGO classification has been used is necessary to interpret the literature correctly and to keep the possibility to compare data of different studies.

Sparing of saphenous vein during inguinal lymphadenectomy for vulval malignancies

OBJECTIVE

This work was set out to investigate the effect of saphenous vein preservation during inguinal lymphadenectomy for patients with vulval malignancies.

METHODS

64 patients with vulval malignancies were allocated into two groups depending on their clinical stages, with one of them (31 patients included) being subjected to sparing of saphenous vein and the other to saphenous vein ligated surgery while treated with inguinal lymphadenectomy. The operative time, blood loss, 5-year survival rate, short- and long-term postoperative complications, 5-year survival rate and groin recurrence were selected as the monitored parameters, through which the above two groups were compared with each other using t test, chi2 and life table analysis.

RESULTS

(1) The median operative time for bilateral inguinal lymphadenectomy was 155 min (130-170 min) in the sparing group, compared to 140 min (120-170 min) in the excision group (P>0.05). The median intraoperative blood loss was 295 mL (100-450 mL) in the sparing group, and 270 mL (150-390 mL) in the excision group (P>0.05). (2) Short-term lower extremity lymphedema occurred with 27 patients (43.5%) in the sparing group and 44 patients (66.7%) in the excision group (P<0.01). Still, short-term lower extremity phlebitis was observed with 7 patients (11.3%) in the sparing group while 17 developed phlebitis (25.8%) in the excision group (P<0.05). However, there was no statistical difference in postoperative fever, acute cellulites, seroma, or lymphocyst formation. (3) Long-term complication occurrence rate decreased by about 50% in patients subjected to saphenous vein sparing surgery compared with those to ligated surgery, while there was no remarkable difference between two groups in the occurrence rates of phlebitis and deep venous thrombosis (P>0.05). (4) The overall 5-year survival rate was 67.3%, with 66.7% and 68.0% for the excision group and the sparing group, respectively (P>0.05).

CONCLUSION

The application of saphenous vein preservation technique during inguinal lymphadenectomy for patients with vulval malignancies could significantly decrease the occurrence rate of postoperative complications without compromising outcomes and should be widely put into clinical practice.

Carcinoma of the vulva

Vulvar cancer will probably become a more common disease as the population ages. It is primarily a disease of the elderly. Fortunately, most vulvar cancers remain localized for extended periods of time and can be treated adequately with radical surgery.

The management of squamous cell vulval cancer: a population based retrospective study of 411 cases

OBJECTIVE

To audit the epidemiology, management and outcome of vulval cancer in the West Midlands.

DESIGN

A retrospective population based study using information obtained from Cancer Intelligence Unit records.

SETTING

The West Midlands Health Region.

SAMPLE

Five hundred and six women with vulval carcinoma notified to the Cancer Intelligence Unit, during two three-year periods: 1980-1982 and 1986-1988; 411 women had a proven histological diagnosis of squamous cell carcinoma of the vulva.

RESULTS

Histology was available for 454/506 women (90%); 411/454 women (91%) had squamous cell carcinoma: these formed the study population. The women were treated at 35 hospitals, 16 of which averaged one case or less per year. The median age at diagnosis was 74 years. Presentation was delayed by more than one year in 63/284 women with data (22%), and 97/284 cases (34%) had more than one symptom. A biopsy was taken in 268 women (65%) and surgery was the primary treatment in 344/411 cases (84%). Fifteen different operations were used. Simple vulvectomy (35%) and radical vulvectomy with bilateral inguinal lymphadenectomy (34%) were the commonest surgical procedures; 190/344 (55%) had a lymphadenectomy; of these 102 women had negative node histology and 78 women had nodal metastases, with results not recorded in 10 cases. Overall, only 46% of all women (190/411) studied had a lymphadenectomy. Recurrence was recorded in 123/411 women (30% of the total). Univariate analysis showed significantly worse five-year survival for older age, advanced stage, incomplete excision, poor differentiation, lack of lymph node resection, positive lymph node pathology and treatment in a hospital with less than 20 cases in total. A multivariate analysis using Cox proportional hazards model identified the first five factors as independent predictors of five year survival. Omission of lymphadenectomy was independently associated with poorer survival (RR 2.17, 95% CI 1.53-3.07).

CONCLUSIONS

There is wide variation in the management of vulval cancer with inadequate usage of lymphadenectomy and many centres treating few cases. Survival analysis shows prognostic variables as expected; omission of lymphadenectomy adversely affects survival.