Diagnosis and management of vulvar cancer: A review

Treatment of vulvar cancer recurrence with electrochemotherapy: a case-control study

BACKGROUND

Electrochemotherapy (ECT) is a combined treatment method based on electroporation and simultaneous chemotherapy. In cases where radiotherapy has previously been used, surgery is often the only treatment option for vulvar cancer recurrence with potential resection of clitoris, vagina, urethra or anal sphincter. The unique advantage of ECT is its selectivity for cancer cells while sparing the surrounding healthy tissue. The aim of the study was to compare the ECT treatment of vulvar cancer recurrence for non-palliative purposes with surgical treatment.

MATERIALS AND METHODS

Eleven patients with single vulvar cancer recurrence were treated with ECT and followed up for 12 months. As a control group, 15 patients with single vulvar cancer recurrence were treated with wide local excision. The following data were collected, analyzed and compared: Age, body mass index, comorbidities, histological type, location and size of vulvar cancer recurrence, treatment history, details of procedures and hospital stay.

RESULTS

The probability curves for local tumor control did not differ between the ECT group and the surgical group (p = 0.694). The mean hospital stay and the mean duration of procedure were statistically significantly shorter in the ECT group (p < 0.001). There were no statistically significant differences between the ECT and surgical groups in terms of mean body mass index, associated diseases, previous treatments, presence of lichen sclerosus, p16 status, gradus, anatomical site of the tumor, and type of anesthesia.

CONCLUSION

In this case-control study, treatment of vulvar cancer recurrence with ECT for non-palliative purposes was comparable to surgical treatment in terms of effectiveness. The results need to be confirmed in larger randomized trials.

Current Preoperative Management of Vulvar Squamous Cell Carcinoma: An Overview

Vulvar carcinoma is a rare cancer affecting the genital tract, constituting 4% of gynecological tumors. Vulvar squamous cell carcinoma (VSCC) is the most common type. Diagnosis relies on biopsy during vulvoscopy, plus imaging such as ultrasonography (USG), magnetic resonance imaging (MRI) and positron emission tomography (PET). This review aims to lay out a thorough overview as to the current preoperative management of VSCC, both in case of vulvar and lymph node involvement. The data research was conducted using the following databases: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library from 2010 to 2024. The selection criteria included only original articles. Seventeen studies were assessed for eligibility. A concordance rate of 62.3% for vHSIL and 65.2% for carcinoma at vulvoscopy, with a sensitivity of 98%, specificity of 40%, PPV (Positive Predictive Value) of 37% and NPV (Negative Predictive Value) of 98% in identifying malignant lesions was found. Regarding the reliability of PET for staging and assessing lymph node involvement, a mean SUV (Standardized Uptake Value) for malignant vulvar lesions of 8.4 (range 2.5-14.7) was reported. In the case of MRI, useful for the evaluation of loco-regional infiltration and lymph node involvement, the ratio of the short-to-long-axis diameter and the reader's diagnostic confidence for the presence of lymph node metastasis yielded accuracy of 84.8% and 86.9%, sensitivity of 86.7% and 87.5%, specificity of 81.3% and 86.2%, PPV of 89.7% and 87.5% and NPV of 76.5% and 86.2%, respectively. A long lymph node axis >10 mm and a short diameter >5.8 mm were found to be predictors of malignancy. At USG, instead, the two main characteristics of potentially malignant lymph nodes are cortical thickness and short axis length; the combination of these ultrasound parameters yielded the highest accuracy in distinguishing between negative and positive lymph nodes. Despite the heterogeneity of the included studies and the lack of randomized clinical trials, this review provides a broad overview of the three imaging tools used for the presurgical management of VSCC. Nowadays, although MRI and PET represent the gold standard, ultrasound evaluation is taking on a growing role, as long as it is carried out by expert sonographer. The management of this rare disease should be always performed by a multidisciplinary team in order to precisely stage the tumor and determine the most suitable treatment approach.

Clinical outcomes with utilization of high-potency topical steroids in patients with lichen sclerosus-associated vulvar cancer

OBJECTIVES

To evaluate the impact of high-potency topical steroid use on risk of recurrence of lichen sclerosus-associated vulvar cancer.

METHODS

This is a retrospective cohort study evaluating patients with lichen sclerosus (LS)- associated vulvar squamous cell cancer (VSCC). Demographic and clinical outcome data were compared between two comparison groups: patients who received steroids, mainly clobetasol, and patients who did not receive steroids following treatment of LS-related vulvar cancer. Categorical variables were compared using Fisher's exact test or chi-square test. Continuous variables were compared using a two-sided student's t-test. Time to recurrence (TTR) and overall survival (OS) were analyzed using Kaplan-Meier survival plot and compared using Mantel-Cox log rank test. Cox proportional hazard regression models were conducted to generate hazard ratios for both TTR and OS. A p value of <0.05 was considered statistically significant.

RESULTS

A total of 49 patients were included, with 36 patients receiving steroid treatment and 13 patients in the expectant management group. The median age of diagnosis was 68. The average BMI was 31.7 +/- 7.0. The median length of follow up was 41 months. The majority of patients were diagnosed with stage I VSCC. There was no difference in demographics or oncologic management of vulvar cancer between the two cohorts. Overall recurrence was decreased among patients who received steroid treatment when compared to patients who did not, 12 patients (33.3%) versus 9 patients (69.2%) respectively (p = 0.048).

CONCLUSIONS

High-potency topical steroid use following treatment of lichen sclerosus-associated vulvar squamous cell carcinoma is associated with decreased risk of recurrence and prolonged median time to recurrence.

The prognostic significance of primary tumor site in vulvar cancer: a population-based cohort study

OBJECTIVE

To investigate the association of primary tumor site with prognosis in vulvar cancer, stratified by vulvar squamous cell carcinoma (SCC) and non-SCC histological types.

METHODS

This population-based retrospective study enrolled patients with vulvar cancer from the Surveillance, Epidemiology, and End Results database between January 2000 and December 2018. The primary outcome was cancer-specific survival (CSS). The prognostic difference between labium majus, labium minus and clitoris groups was investigated using Kaplan-Meier analyses and Cox proportional hazards regression analyses.

RESULTS

A total of 3,465 eligible patients with vulvar cancer were included with a mean age of 54.5 years. Among the 1,076 (31.1%) patients with non-SCC, the multivariate Cox regression analyses showed that labium minus-sited disease (hazard ratio [HR]=1.85; 95% confidence interval [CI]=1.27-2.71; p=0.001) and clitoris-sited disease (HR=2.37; 95% CI=1.47-3.85; p<0.001) were significantly associated with worse CSS, compared with labium majus-sited disease. However, among the 2,389 (68.9%) patients with SCC, no significant association of primary tumor site with CSS was found (p>0.05). Kaplan-Meier analyses also showed that the primary tumor site had a significant prognostic effect in vulvar non-SCC (p<0.001) but not in vulvar SCC (p=0.330).

CONCLUSION

Among vulvar non-SCC, patients with labium minus-sited disease had a significantly worse prognosis than those with labium majus-sited disease, and a significantly better prognosis than those with clitoris-sited disease. Gynecologic oncologists should consider the prognostic effect of primary tumor site in vulvar non-SCC, and make optimal, personalized treatment and surveillance strategies based on different primary tumor sites.

The development of in vitro organotypic 3D vulvar models to study tumor-stroma interaction and drug efficacy

BACKGROUND

Vulvar squamous cell carcinoma (VSCC) is a rare disease with a poor prognosis. To date, there's no proper in vitro modeling system for VSCC to study its pathogenesis or for drug evaluation.

METHODS

We established healthy vulvar (HV)- and VSCC-like 3D full thickness models (FTMs) to observe the tumor-stroma interaction and their applicability for chemotherapeutic efficacy examination. VSCC-FTMs were developed by seeding VSCC tumor cell lines (A431 and HTB117) onto dermal matrices harboring two NF subtypes namely papillary fibroblasts (PFs) and reticular fibroblasts (RFs), or cancer-associated fibroblasts (CAFs) while HV-FTMs were constructed with primary keratinocytes and fibroblasts isolated from HV tissues.

RESULTS

HV-FTMs highly resembled HV tissues in terms of epidermal morphogenesis, basement membrane formation and collagen deposition. When the dermal compartment shifted from PFs to RFs or CAFs in VSCC-FTMs, tumor cells demonstrated more proliferation, EMT induction and stemness. In contrast to PFs, RFs started to lose their phenotype and express robust CAF-markers α-SMA and COL11A1 under tumor cell signaling induction, indicating a favored 'RF-to-CAF' transition in VSCC tumor microenvironment (TME). Additionally, chemotherapeutic treatment with carboplatin and paclitaxel resulted in a significant reduction in tumor-load and invasion in VSCC-FTMs.

CONCLUSION

We successfully developed in vitro 3D vulvar models mimicking both healthy and tumorous conditions which serve as a promising tool for vulvar drug screening programs. Moreover, healthy fibroblasts demonstrate heterogeneity in terms of CAF-activation in VSCC TME which brings insights in the future development of novel CAF-based therapeutic strategies in VSCC.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prognostic value of postoperative radiotherapy in patients with vulvar squamous carcinoma: findings based on the SEER database

INTRODUCTION

The role of postoperative radiotherapy in treating squamous cell carcinoma of the vulva remains controversial. This study evaluated the effect of radiotherapy on the survival of patients with postoperative squamous cell carcinoma of the vulva.

METHODS

Clinical and prognostic information on patients diagnosed with vulvar squamous cell carcinoma from 2010 to 2015 was collected from the Surveillance, Epidemiology, and Prognosis (SEER) database. A propensity score matching (PSM) approach was used to balance the differences in clinicopathological characteristics between groups. The impact of postoperative radiotherapy on overall survival (OS) and disease-specific survival (DSS) was assessed.

RESULTS

The study included 3571 patients with squamous cell carcinoma of the vulva, of whom 732 (21.1%) received postoperative radiotherapy. After propensity score matching, multivariate analysis showed that age, race, N stage, and tumor size were independent influences on overall survival and disease-specific survival of patients. Postoperative radiotherapy did not improve patients' overall survival or disease-specific survival. Further subgroup survival analysis showed that in patients with AJCC stage III, N1 stage, lymph node metastasis, and large tumor diameter (> 3.5 cm), postoperative radiotherapy resulted in a significant improvement in overall patient survival.

CONCLUSION

Postoperative radiotherapy is not indicated for all patients with postoperative vulvar cancer and has improved survival outcomes only for patients with AJCC stage III, N1, lymph node metastases and large tumor diameter (> 3.5 cm).

MicroRNAs as Potential Biomarkers in Gynecological Cancers

MicroRNAs are non-coding transcripts that, thanks to the ability to regulate the mRNA of target genes, can affect the expression of genes encoding tumor suppressors and oncogenes. They can control many important cellular processes, including apoptosis, differentiation, growth, division, and metabolism. Therefore, miRNAs play an important role in the development of many cancers, including gynecological cancers. Ovarian cancer, endometrial cancer, cervical cancer, and vulvar cancer are the most common cancers in women and are a frequent cause of death. The heterogeneity of the pathogenesis of these gynecological diseases makes the diagnostic process a significant obstacle for modern medicine. To date, many studies have been carried out, in which particular attention has been paid to the molecular pathomechanism of these diseases, with particular emphasis on miRNAs. To date, the changed profile of many miRNAs, which influenced the promotion of proliferation, migration, invasion processes and the simultaneous inhibition of programmed cell death, has been proven many times. Detailed understanding of the molecular effects of miRNAs in the above-mentioned gynecological cancers will enable the development of potential predictive and prognostic biomarkers, as well as the optimization of the diagnostic process.

Safety and Feasibility of Vulvar Cancer Treatment with Electrochemotherapy

Electrochemotherapy is a local ablative therapy used for the treatment of various superficial and deep-seated tumors. Electrochemotherapy involves the application of electric pulses locally to tumors to destabilize cell membranes and facilitate the entry of cytotoxic drugs, thereby enhancing their cytotoxicity locally. The aim of our study is to investigate the safety and feasibility of electrochemotherapy in patients with vulvar cancer recurrence used for nonpalliative purposes. Ten patients with single local vulvar cancer recurrence were treated with intravenous bleomycin, followed by a local application of electric pulses (electrochemotherapy) to the tumor. Adverse events were determined using the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The feasibility of treating vulvar cancer with electrochemotherapy was determined by an appropriate selection of electrodes based on the size and location of the tumor with safety margins included. Electrochemotherapy was feasible in all patients. No electrochemotherapy-related or other serious adverse events occurred. Our data suggest that electrochemotherapy is a feasible and safe technique for the treatment of vulvar cancer recurrence for nonpalliative purposes. Based on our results, electrochemotherapy might be a viable therapeutic tool for patients who would otherwise undergo surgery involving a mutilation of the external genitalia.

Vulvar basal cell carcinoma: A case report and literature review

INTRODUCTION AND IMPORTANCE

Basal cell carcinoma (BCC), is the most prevalent skin cancer with favorable prognosis, and lymphatic or hematogenous metastases are quite rare. Here we report an uncommon case of vulvar BCC.

CASE PRESENTATION

A 68-year-old woman with 5-year history of an asymptomatic lump on the right side of the vulva. The patient complained of progressive itching, pain, and color changes to brown for 3 months before visiting the clinic. Excisional biopsy revealed the lesion to be a BCC. After thorough negative metastasis work up the patient underwent a bilateral inguinofemoral lymphadenectomy and a wide local excision with a one-centimeter margin and final histology report confirmed the diagnosis of BCC. (HPV DNA and viral markers were negative, the bimanual exam was normal, both colposcopy and vaginoscopy were normal. There was no acetowhite lesion).

CLINICAL DISCUSSION

To avoid delayed diagnosis, any persistent lesion even asymptomatic, in the vulvar region, especially when pigmented, irritating, or expanding in size, should be biopsied and investigated histologically, regardless of the patient's age.

CONCLUSION

Any persistent lesion in the vulvar region, especially when pigmented, irritating, or expanding in size, should be biopsied and investigated histologically, regardless of the patient's age.

Electrochemotherapy with intravenous bleomycin for heavily pre-treated vulvar cancer patients

OBJECTIVE

The management of vulvar cancer recurrences is complicated by patients' advanced age and comorbidities. Bleomycin-based electrochemotherapy is a potential treatment option in this setting. However, no data on long-term outcomes are available. Therefore, a multicenter observational study was designed to evaluate the 5-year results in these patients.

METHODS

Data about patients and tumor characteristics, electrochemotherapy cycles, clinical response, and follow-up were recorded. Treatment procedures were performed according to the European Standard Operating Procedures of Electrochemotherapy (ESOPE) guidelines. Response was evaluated according to the Response Evaluation Criteria in Solid Tumors (RECIST) criteria.

RESULTS

Fifty-one patients (mean age 82.31±7.28 years) with squamous cell vulvar cancer underwent electrochemotherapy (median number of sessions 1; range 1-4). 20 patients had complete response and 32% of these were disease-free after 2 years (median progression-free survival 16.8 months). In 13 patients with partial response the median progression-free survival was 15.36 months, while patients with stable or progressive disease showed tumor relapse after 6.95 and 3.26 months, respectively (p<0.001). Median overall survival was 18.77, 13.07, 6.73, and 11.13 months in patients with complete response, partial response, stable disease, and progressive disease, respectively (p=0.001).

CONCLUSION

Long-term follow-up of vulvar cancer patients showed reasonable tumor control after electrochemotherapy and improved progression-free survival and overall survival in responder subjects compared with non-responders. Further studies aimed at improving local response after electrochemotherapy are warranted. Thus, this approach represents a potential alternative for these patients.

An Unusual Case of Vulvar Involvement in the Course of Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis is a rare autoimmune disease with the presence of c-ANCA in most cases. It involves necrotizing inflammation in small and medium-sized vessels with multiple granulomas. The disease can affect many systems, but the typical triad of attacked systems are the upper and lower respiratory tracts and kidneys, with varying degrees of severity. Involvement of the respiratory tract may manifest, among other symptoms, as nasal crusting, nosebleeds, and dyspnea. Among patients with granulomatosis with polyangiitis, only less than 1% develop genitourinary system involvement. We present a case study of a 36-year-old woman with an 8-year-long GPA history and a lesion, which, due to its appearance and accompanying symptoms, aroused the suspicion of a neoplasm but was proven to be a granuloma with a nontypical location. The systemic disease was treated with glucocorticosteroids and cyclophosphamide. The lesion on the labium minus was surgically removed. We concluded that the macroscopic picture of GPA of the vulva and vulvar cancer is similar. The patient's medical history may help differentiate GPA and vulvar cancer. Although vulvar GPA is extremely rare, it should be considered in the differential diagnosis of vulvar lesions, especially those suspected to be oncological.

Treatment of vulvar basal cell carcinoma with Slow-Mohs micrographic surgery A case report

Vulvar Basal Cell Carcinoma (BCC) accounts for only 0.4% of all BCCs. We present a case of BCC that developed on the vulvar area with a pinkish lesion and pruritus for about 2 years and was successfully treated with Mohs micrographic surgery.

Nursing of Vulvar Cancer Radical Operation Combined with Laparoscopic Inguinal Lymph Node Dissection

Purpose. The application, development, and care of radical surgery combined with laparoscopic inguinal lymph node dissection for vulvar cancer. Methods. We searched the PubMed, Web of Science, the Cochrane Library, and EMBASE databases for published literature on the care of radical surgery combined with laparoscopic inguinal lymph node dissection for vulvar cancer up to June 2022. We used the following search terms and terms: “vulvar cancer,” “injury,” “radical vulvar cancer surgery,” “laparoscopic inguinal lymph node dissection,” and “care.” Results. Laparoscopic inguinal lymph node dissection has become a new surgical method for the treatment of vulvar cancer, and it effectively avoids all the problems associated with traditional surgery. In addition, radical vulvar cancer surgery and laparoscopic inguinal lymph node dissection combined with high-quality nursing interventions can promote patients’ recovery and reduce the occurrence of complications, which has important clinical significance. Conclusion. This article reviews the application, development, and nursing care of radical vulvar cancer surgery combined with laparoscopic inguinal lymph node dissection.

Management of Early-Stage Vulvar Cancer

Simple Summary

Vulvar cancer is a rare gynecological malignancy that affects mainly postmenopausal women. Recently, however, an alarming increase in the rates among young women has been observed due to human papillomavirus infection. The standard treatment for vulvar cancer is surgery with or without radiotherapy as adjuvant treatment. In recent decades, sentinel lymph node biopsy has been included as part of the surgical treatment. Thus, our objective was to review and discuss the advances found in the literature about early-stage vulvar cancer. For this, we searched PubMed for publications in the English language. Relevant articles, such as the GROINS-V studies, and the GOG protocols, are presented in this review exhibiting the evolution of early-stage vulvar cancer treatment and the decrease in surgical morbidity rates.

Abstract

Vulvar cancer is a rare gynecological malignancy since it represents 4% of all cancers of the female genital tract. The most common histological type is squamous cell carcinoma (90%). This type can be classified into two clinicopathological subtypes according to the etiology. The first subtype is associated with persistent human papillomavirus infection and is usually diagnosed in younger women. The second subtype is associated with lichen sclerosus condition, and in most cases is diagnosed in postmenopausal women. Currently, an increase in first subtype cases has been observed, which raised the concern about associated mortality and treatment morbidity among young women. Vulvar cancer treatment depends on histopathology grade and staging, but surgery with or without radiotherapy as adjuvant treatment is considered the gold standard. In recent decades, sentinel lymph node biopsy has been incorporated as part of the treatment. Therefore, we sought to review and discuss the advances documented in the literature about vulvar cancer focusing on the treatment of early-stage disease. Relevant articles, such as the GROINS-V studies and the GOG protocols, are presented in this review. Additionally, we discuss key points such as the evolution of treatment from invasive surgery with high morbidity, to more conservative approaches without compromising oncologic safety; the role of sentinel lymph node mapping in the initial staging, since it reduces the complications caused by inguinofemoral lymphadenectomy; the recurrences rates, since local recurrence is common and curable, however, groin-associated, or distant recurrences have a poor prognosis; and, finally, the long-term follow-up that is essential for all patients.

Biventricular cardiac metastasis from vulvar squamous cell carcinoma

Vulvar cancers make up just 3% to 5% of all gynecological cancers, and they are most typically found in postmenopausal women. Vulvar cancer distant metastases are uncommon and usually arise late. Only six cases of vulvar cancer metastasizing to the heart have been reported in the literature, and none of them included both the left and right ventricles. We describe the case of a 68-year-old patient diagnosed with vulvar cancer arising from lichen sclerosus, initially localized, treated with chemotherapy, surgery, and radiation therapy. Less than two months after the end of the treatment sequence, the patient returned to our clinic with bone pain. Imaging investigations have shown multiple disseminated metastases, but not in the heart at that moment. Chemotherapy was initiated, and after two cycles, the patient developed an arrhythmia (atrial fibrillation with rapid ventricular rate), which was later determined to be caused by cardiac metastases discovered by echocardiography and computed tomography. Vulvar cancer metastatic to the heart represents a rare clinical condition, requiring multidisciplinary care. The case's uniqueness is the biventricular metastasis, which resulted in STEMI despite angiographically normal epicardial coronary arteries

Squamous and Glandular Lesions of the Vulva and Vagina: What's New and What Remains Unanswered?

A number of changes have been introduced into the 5th Edition of the World Health Organization (WHO) Classification of squamous and glandular neoplasms of the vulva and vagina. This review highlights the major shifts in tumor classification, new entities that have been introduced, recommendations for p16 immunohistochemical testing, biomarker use, molecular findings and practical points for pathologists which will affect clinical care. It also touches upon several issues that still remain answered in these rare but undeniably important women's cancers.

Squamous Cell Carcinoma of the Vulva: A Survival and Epidemiologic Study with Focus on Surgery and Radiotherapy

Vulvar squamous cell carcinoma (SCC) is the most frequent vulvar neoplasia. While the primary role of surgery is widely accepted, large population studies are needed to compare survival between diverse treatment modalities and to identify independent prognostic factors to help council patients and guide oncological treatment. The U.S. National Cancer Index, Surveillance, Epidemiology and End Results (SEER) program data between 2000 and 2018 was screened for all squamous cell carcinoma affecting the vulva. Raw data was processed with IBM SPSS. Demographic, clinical-pathological and treatment data were studied. Overall survival (OS) was calculated using the Kaplan–Meier method and subgroups were compared using the log rank test. A multivariate cox regression was conducted to identify independent prognostic factors. A total of 11,360 patients were identified with a median age of 65. Median overall survival was 101 months. Surgery as a primary treatment is the therapeutic sequence associated with the best overall survival. Multivariate cox-regression did not meet proportional hazard assumption. Age, pathological grade, stage at diagnosis, treatment sequence and the use of chemotherapy were identified as independent prognostic factor. Surgery alone is the treatment sequence offering the best overall survival. Surgery should be offered to all eligible patients.

Vulvar High-Grade Squamous Intraepithelial Lesions and Cancer as a Risk Factor for Anal Cancer: A Review

OBJECTIVES

Anal squamous cell carcinoma (ASCC) has a higher incidence described in certain groups, namely, in women with vulvar high-grade squamous intraepithelial lesions (vHSILs) and/or human papillomavirus squamous cell carcinoma (VSCC). This review describes terminology, vHSIL, and VSCC in their association with ASCC and the published recommendations for early detection of this cancer in these women.

MATERIALS AND METHODS

A narrative review was conducted by the authors on vHSIL and VSCC as risk factors for ASCC.

RESULTS

The ASCC and VSCC incidence are increasing. Women with vHSIL and/or VSCC can present with ASCC at diagnosis, being one of the highest-risk groups. Suspicious symptoms include rectal bleeding, pain, and a sensation of an anal mass. Digital anorectal examination can help detect early ASCC. Sensitivity of anal cytology in women with vHSIL and VSCC seems low, with the exception of immunosuppressed women with genital neoplasia (cervix, vagina, and vulva). There are still insufficient data on high-resolution anoscopy in women with vHSIL and/or VSCC as a screening method.

CONCLUSIONS

Clinicians need be aware that women with vHSIL and VSCC comprise one of the highest-risk groups for ASCC. Inquiring suggestive symptoms of ASCC and a digital anorectal examination can help in the early detection of this type of cancer.

Essentiality of Trace Elements in Pregnancy, Fertility, and Gynecologic Cancers-A State-of-the-Art Review

Gynecological neoplasms pose a serious threat to women's health. It is estimated that in 2020, there were nearly 1.3 million new cases worldwide, from which almost 50% ended in death. The most commonly diagnosed are cervical and endometrial cancers; when it comes to infertility, it affects ~48.5 million couples worldwide and the number is continually rising. Ageing of the population, environmental factors such as dietary habits, environmental pollutants and increasing prevalence of risk factors may affect the reproductive potential in women. Therefore, in order to identify potential risk factors for these issues, attention has been drawn to trace elements. Trace mineral imbalances can be caused by a variety of causes, starting with hereditary diseases, finishing with an incorrect diet or exposure to polluted air or water. In this review, we aimed to summarize the current knowledge regarding trace elements imbalances in the case of gynecologic cancers as well as female fertility and during pregnancy.

Developing and Validating Novel Nomograms for Predicting the Overall Survival and Cancer-Specific Survival of Patients With Primary Vulvar Squamous Cell Cancer

Background: To develop and validate novel nomograms for better predicting the overall survival (OS) and cancer-specific survival (CSS) of patients with vulvar squamous cell cancer (VSCC).

Methods: A retrospective analysis using a population-based database between 2004 and 2016 was carried. A 10-fold cross-validation with 200 repetitions was used to choose the best fit multivariate Cox model based on the net-benefit of decision curve analysis. Net-benefit, Harrell's C concordance statistic (C-statistic) of calibration plot, and area under the receiver operating characteristic curve (AUC) were used to evaluate the model prediction accuracy. Nomograms of the OS and CSS were generated based on the best fit model.

Results: Of the 6,792 patients with VSCC, 5,094 (75%) and 1,698 (25%) were allocated to the training and validation cohort, respectively. All the variables were balanced between the training and validation cohorts. Age, insurance, tumor size, pathological grade, radiotherapy, chemotherapy, invasion depth, lymphadenectomy, sentinel lymph nodes biopsy, surgery, N stage, and M stage were in the best fit model for generating nomograms. The decision curve analysis, calibration plot, and receiver operating characteristic (ROC) curve show the better prediction performance of the model compared to previous studies. The C-statistics of our model for OS prediction are 0.80, 0.83, and 0.81 in the training, validation, and overall cohorts, respectively, while for CSS prediction are 0.83, 0.85, and 0.84. The AUCs for 3- and 5-year OS are the same and are 0.81, 0.83, and 0.81 in the training, validation, and overall cohorts, respectively. The AUCs for 3- and 5-year CSS are 0.78 and 0.80, 0.79 and 0.80, and 0.79 and 0.80 in those three cohorts.

Conclusions: Our model shows the best prediction accuracy of the OS and CSS for patients with vulvar cancer (VC), which is of significant clinical practice value.

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

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

Safety and Benefit Of Sentinel Lymph Nodes Biopsy Compared to Regional Lymph Node Dissection in Primary Vulvar Cancer Patients Without Distant Metastasis and Adjacent Organ Invasion: A Retrospective Population Study

Background

The safety and benefit of sentinel lymph node biopsy (SLNB) compared with regional lymph node dissection (RLND) and no lymph nodes removed (NA) in patients with vulvar squamous cell cancer (VSCC) was not well studied.

Methods

A retrospective analysis on VSCC patients without distant metastasis and adjacent organ invasion from the Surveillance, Epidemiology, and End Results Program database between 2004 and 2016 was carried out. Within subgroups stratified by negative (LN−) or positive (LN+) regional lymph node findings, inverse probability weighting (IPW) adjusted multivariate Fine-Gray compete risk (CR) model and accelerated failure time (AFT) model was used to investigate the factors associated with and cancer-specific survival (CSS) and overall survival (OS).

Results

Of the 3,161 VSCC patients treated with surgery, 287 (9.1%) underwent SLNB, 1,716 (54.3%) underwent RLND, and 1,158 (36.6%) had no regional lymph nodes removed. As illustrated by IPW adjusted multivariate regressions, SLNB was significantly associated with prolonged CSS (LN−, adjusted sub-proportional hazard ratio [sHR] = 0.42; 95% confidence interval [CI], 0.19–0.93; P=0.032; LN+, adjusted sHR = 0.29; 95% CI, 0.16–0.54, P<0.001) and OS (LN−, adjusted time ratio [TR] = 1.38; 95% CI, 0.82–2.32; P=0.226; LN+, adjusted TR = 2.68; 95% CI, 1.73–4.14; P<0.001), although the effect of SLNB on OS was not significant within the LN− cohort. Moreover, SLNB led to improved CSS (adjusted sHR = 0.40; 95% CI, 0.23–0.70; P = 0.001) and OS (adjusted TR=1.15, 95% CI 0.76-1.73, P=0.279) compared with NA. Age was a significant prognostic factor of CSS and OS, whereas tumor size, surgery type, and invasion depth were not.

Conclusions

SLNB leads to significantly prolonged CSS and OS in VSCC surgery patients without distant metastasis and adjacent organ invasion than RLND, except for the similar OS in the LN− cohort. SLNB could be carried out preferentially for VSCC surgery patients without distant metastasis and adjacent organ invasion, irrespective of tumor size, surgery type, invasion depth, and regional lymph nodes metastasis. Further prospective clinical trials are warranted to confirm the findings of this study.

Towards gender equity in artificial intelligence and machine learning applications in dermatology

There has been increased excitement around the use of machine learning (ML) and artificial intelligence (AI) in dermatology for the diagnosis of skin cancers and assessment of other dermatologic conditions. As these technologies continue to expand, it is essential to ensure they do not create or widen sex- and gender-based disparities in care. While desirable bias may result from the explicit inclusion of sex or gender in diagnostic criteria of diseases with gender-based differences, undesirable biases can result from usage of datasets with an underrepresentation of certain groups. We believe that sex and gender differences should be taken into consideration in ML/AI algorithms in dermatology because there are important differences in the epidemiology and clinical presentation of dermatologic conditions including skin cancers, sex-specific cancers, and autoimmune conditions. We present recommendations for ensuring sex and gender equity in the development of ML/AI tools in dermatology to increase desirable bias and avoid undesirable bias.

Viruses and Skin Cancer

Advances in virology and skin cancer over recent decades have produced achievements that have been recognized not only in the field of dermatology, but also in other areas of medicine. They have modified the therapeutic and preventive solutions that can be offered to some patients and represent a significant step forward in our knowledge of the biology of skin cancer. In this paper, we review the viral agents responsible for different types of skin cancer, especially for solid skin tumors. We focus on human papillomavirus and squamous cell cancers, Merkel cell polyomavirus and Merkel cell carcinoma, and human herpesvirus 8 and Kaposi’s sarcoma.

Surgical Management of Vulvar Melanoma: A Case Series

Vulvar malignant melanoma is the second most common subtype of vulvar cancer, accounting for 5-10% of all vulvar cancers. The prognosis is still very poor, although some advances have been achieved in the last years. One of the most significant changes in its management has been the development of less invasive surgical techniques that diminish the risk of postoperative morbidity and long-lasting sequelae. In this article, we review the surgical management of the pathology, based on the comment of 3 cases with vulvar melanoma treated at our institution.

Development and validation of nomograms predicting cancer-specific survival of vulvar cancer patients: based on the Surveillance, Epidemiology, and End Results Program

OBJECTIVE

To explore potential prognostic factors and develop nomograms to predict the cancer-specific survival of patients with vulvar squamous cell carcinoma (SCC) and patients with vulvar melanoma.

METHODS

Cases of vulvar SCC and melanoma were retrieved from the Surveillance, Epidemiology, and End Results (SEER) Program, and randomly segregated into training and test sets. Based on the training set, univariate and multivariate Cox proportional hazard regressions evaluate the association between key demographic/clinical characteristics and vulvar cancer survival. Potential prognostic factors were included to construct nomograms for the prediction of 3-year and 5-year survival probabilities.

RESULTS

Age, tumor size, stage, surgery, and chemotherapy were potential factors associated with vulvar cancer survival. The C-indices for the training and test sets were 0.82 and 0.81 for SCC, and 0.73 and 0.70 for melanoma. Calibration curves revealed correlated agreements between nomogram-based probability and actual survival status.

CONCLUSION

Nomograms were developed to predict cancer-specific survival of patients with vulvar cancer, accordingly identifying the subgroup at high risk of cancer-specific mortality.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

BACKGROUND

 Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications.

METHODS

 A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed.

RESULTS

 Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm². The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications.

CONCLUSION

 In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Multizonal anogenital neoplasia in women: a cohort analysis

BACKGROUND

There is currently a lack of information on full anogenital evaluation of women with a previous history of anogenital neoplasia.

METHODS

Retrospective analysis of the Homerton Anogenital Neoplasia Service records from January 2012 to March 2017, to identify all new referrals of women with previous anogenital neoplasia, who had had at least one complete examination of all anogenital sites. Multizonal anogenital disease (MZD) was defined as the presence of high-grade squamous intraepithelial lesions (HSIL)/carcinoma concurrently at two or more of the following sites/zones: perianus, anal canal, vulva, vagina or cervix.

RESULTS

253 women were included, mean age was 47 (SD=15) years and median duration of follow-up was 12 (IQR=21) months. Fifty-six women (22%) were diagnosed with MZD at first assessment and/or during follow-up. Current smokers (RR=1.84, 95% CI 1.21-2.79, p=0.004) and women on immunodulators/immunosuppressive drugs (RR=2.57, 95% CI 1.72-3.86, p<0.001) had an increased risk for MZD. The risk was lower for women without a previous history of anogenital high-grade lesions/cancer compared to those with this history (RR=0.06, 95% CI 0.01-0.45, p=0.006).

CONCLUSIONS

Multizonal assessment was important to diagnose occult areas of disease and should be especially considered in current smokers, pharmacologically immunocompromised and those with a previous history of anogenital HSIL/cancer.

Cutaneous and Mucosal Melanomas of Uncommon Sites: Where Do We Stand Now?

Melanomas arising at uncommon sites include a group of lesions related to unusual localizations in specific ethnic groups. The rarity of the disease often represents a limit to the participation of patients in specific trials. However, this peculiar genetic scenario has important therapeutic implications regarding new oncologic therapies. The aim of this article is to review the clinical features, somatic alterations and therapeutic options for melanomas of uncommon sites. They can be classified as cutaneous and mucosal lesions affecting the nail apparatus, palms/soles, oral mucosa, genital area and scalp. The prognosis may be worse compared to melanomas of other districts, and a prompt diagnosis may dramatically influence the outcome. Dermatologists and oncologists should therefore distinguish this melanoma subgroup in terms of surgical intervention and medical treatment. Due to the lack of mutations in genes usually found in cutaneous melanomas, the discovery of novel targets is required to develop new strategies and to change the prognosis of non-responders or wild-type patients.

Update on human papilloma virus - part I: epidemiology, pathogenesis, and clinical spectrum

Infection with human papilloma virus (HPV) is related to a great number of cutaneous and mucosal manifestations. The spectrum of HPV ranges from inapparent infections, through various clinical benign presentations including cutaneous and mucosal disease, to malignant and premalignant conditions. New HPV types are currently described in the literature; many of them are characterized as high-risk types due to their oncogenic potential. Knowledge regarding their epidemiology and pathogenesis is important to understand not only infection and disease processes, but also to formulate the clinical and laboratory basis for diagnosis, therapeutics, and prophylactic measures. This non-systematic review aims to discuss and to update those aspects, with an emphasis on relevant topics for dermatologists. HPV infection and related diseases in the Brazilian scenario are highlighted, including common dermatologic conditions seen at clinics as well as the condition of a public health problem as a sexually transmitted infection. The oncogenicity of the virus and the variety of clinical outcomes - especially in the immunocompromised individuals - are addressed.

[The clinical study of partial perineum area and wound repair in males]

Objective

To explore the suitable division of male genitalia subunits and the effectiveness of large-area perineum defect repair under its guidance.

Methods

According to the anatomical and functional characteristics of male genitalia, the subunit division scheme was proposed: area Ⅰ, glans penis; area Ⅱ, body of penis; area Ⅲ, scrotum; area Ⅳ, scrotum. Between April 2017 and July 2019, 12 patients with large genitalia defects were treated, with an average age of 60.9 years (range, 57-66 years) and an average disease duration of 2.7 years (range, 2-5 years). The defect area involved area Ⅰ in 1 case, area Ⅱ in 7 cases, area Ⅲ in 5 cases, and area Ⅳ in 8 cases; the size of area ranged from 6 cm×4 cm to 23 cm×16 cm. The causes of defect included 3 cases of trauma, 6 cases of Paget disease, 2 cases of squamous cell carcinoma, 1 case of spindle cell tumor. According to the design of the corresponding repair scheme, the main repair methods were to rotate and advance the skin flap and pedicled skin flap in the same area. When the defect was large, the free skin flap transplantation, free skin grafting, and free mucosa transplantation were used to repair the defect.

Results

All the patients were followed up 6-13 months with an average of 8.6 months. Skin flap, skin graft, and mucosa survived in one stage in 10 patients; infection occurred in 1 case after the scrotal flap of area Ⅲ was transferred to repair the defect in area Ⅱ, 1 case had distal venous crisis at 2 days after repair area Ⅲ defect used free anterolateral thigh flap, and after active treatment, the condition improved. The appearance of the receiving area and the supplying area was good, and the local feeling was recovered satisfactorily. The range of motion of hip joint was good in 10 cases, and 2 cases were slightly stretched but did not affect normal life. All patients had normal urination and defecation function, and were satisfied with the treatment effectiveness.

Conclusion

The subunits of male genitalia can be used to guide the repair of the defect, which can better restore the physiological appearance and function, and has positive clinical significance.

A successfully treated malignant melanoma arising in a large congenital vulvar blue nevus

An atypical cellular blue nevus, a benign mass, may sometimes transform into a malignant melanoma. Here, we report a rare case of melanoma arising in a large congenital vulvar blue nevus. A 28-year-old Chinese woman presented to our hospital with a chief complaint of a vulvar mass that had persisted for 8 years. The patient underwent extensive local excision, followed by reconstructive surgery of the female reproductive tract. The mass was diagnosed as being a vulvar malignant melanoma. Postoperatively, the patient received interferon immunotherapy and recovered without complications. No evidence of recurrence was observed after 32 months of follow-up. Our case thus shows that comprehensive treatment with surgery supplemented by immunotherapy can be effective against a malignant melanoma arising in a vulvar blue nevus.