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Chargari C, Wasserman J, Gabro A, Canlobre G, Spano JP, Uzan C, Maingon P. Vulvar Carcinoma: Standard of Care and Perspectives. J Clin Oncol 2024; 42:961-972. [PMID: 38315939 DOI: 10.1200/jco.23.01187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/24/2023] [Accepted: 11/14/2023] [Indexed: 02/07/2024] Open
Abstract
PURPOSE Treatment of vulvar carcinoma (VC) is challenging. The objectives of this review were to describe for clinicians the epidemiologic and clinical aspects of VC, the standard of care in terms of primary local treatment and systemic therapies, and the recent innovations and perspectives emerging from translational research in immuno-oncology. DESIGN We conducted a comprehensive review outlying the clinical aspects and biologic background of vulvar cancer, highlighting modern treatment strategies on the basis of a personalized approach. RESULTS Epidemiologic data showed a recent rise in incidence of VC, attributed to human papillomavirus. Surgery is the mainstay of primary treatment, but multimodal approaches are frequently required in the presence of adverse prognosis histopathologic factors. Chemoradiation is indicated when organ-sparing surgery is not feasible. However, inability to achieve high locoregional control rates in advanced cases and the morbidity associated with local treatments are still key issues. Recent clinical data showed the benefit of individualized strategies combining organ-sparing surgical strategies, less invasive lymph node staging procedures, and refinement in radiotherapy modalities. Among the most important research area, there is a sound rationale for testing modern systemic approaches such as immune checkpoint inhibitors in selected patients with recurrent and/or metastatic tumors. Although no specific data exist for VC, the role of supportive care and post-treatment rehabilitation strategies is also crucial. CONCLUSION There are still insufficient studies dedicated to patients with VC. Public health programs for prevention, screening, and early diagnosis are required, and clinical research should be strengthened to provide high-quality clinical evidence and improve patients' oncologic and functional outcomes.
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Affiliation(s)
- Cyrus Chargari
- Service d'oncologie radiothérapie, Hôpital Universitaire Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
| | - Johanna Wasserman
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
- Service d'oncologie médicale, Hôpital Universitaire Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
| | - Alexandra Gabro
- Service d'oncologie radiothérapie, Hôpital Universitaire Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
| | - Geoffroy Canlobre
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
- Service de chirurgie et cancérologie gynécologique et mammaire, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
- INSERM UMR S938, Biologie et Thérapeutique des cancers, Paris, France
| | - Jean-Philippe Spano
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
- Service d'oncologie médicale, Hôpital Universitaire Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
| | - Catherine Uzan
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
- Service de chirurgie et cancérologie gynécologique et mammaire, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
- INSERM UMR S938, Biologie et Thérapeutique des cancers, Paris, France
| | - Philippe Maingon
- Service d'oncologie radiothérapie, Hôpital Universitaire Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP) Sorbonne Université, Paris, France
- Institut Universitaire de Cancérologie (IUC), Sorbonne Université, Paris, France
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Macchia G, Lancellotta V, Ferioli M, Casà C, Pezzulla D, Pappalardi B, Laliscia C, Ippolito E, Di Muzio J, Huscher A, Tortoreto F, Boccardi M, Lazzari R, Perrone AM, Raspagliesi F, Gadducci A, Garganese G, Fragomeni SM, Ferrandina G, Morganti AG, Gambacorta MA, Tagliaferri L. Definitive chemoradiation in vulvar squamous cell carcinoma: outcome and toxicity from an observational multicenter Italian study on vulvar cancer (OLDLADY 1.1). LA RADIOLOGIA MEDICA 2024; 129:152-159. [PMID: 37700153 PMCID: PMC10808465 DOI: 10.1007/s11547-023-01712-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/22/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Vulvar carcinoma is a rather uncommon gynecological malignancy affecting elderly women and the treatment of loco-regional advanced carcinoma of the vulva (LAVC) is a challenge for both gynecologic and radiation oncologists. Definitive chemoradiation (CRT) is the treatment of choice, but with disappointing results. In this multicenter study (OLDLADY-1.1), several institutions have combined their retrospective data on LAVC patients to produce a real-world dataset aimed at collecting data on efficacy and safety of CRT. METHODS The primary study end-point was 2-year-local control (LC), secondary end-points were 2-year-metastasis free-survival (MFS), 2-year-overall survival (OS) and the rate and severity of acute and late toxicities. Participating centers were required to fill data sets including age, stage, histology, grading as well as technical/dosimetric details of CRT. Data about response, local and regional recurrence, acute and late toxicities, follow-up and outcome measures were also collected. The toxicity was a posteriori documented through the Common Terminology Criteria for Adverse Events version 5 scale. RESULTS Retrospective analysis was performed on 65 patients with primary or recurrent LAVC treated at five different radiation oncology institutions covering 11-year time interval (February 2010-November 2021). Median age at diagnosis was 72 years (range 32-89). With a median follow-up of 19 months (range 1-114 months), 2-year actuarial LC, MFS and OS rate were 43.2%, 84.9% and 59.7%, respectively. In 29 patients (44%), CRT was temporarily stopped (median 5 days, range 1-53 days) due to toxicity. The treatment interruption was statistically significant at univariate analysis of factors predicting LC (p: 0.05) and OS rate (p: 0.011), and it was confirmed at the multivariate analysis for LC rate (p: 0.032). In terms of toxicity profile, no G4 event was recorded. Most adverse events were reported as grade 1 or 2. Only 14 acute G3 toxicities, all cutaneous, and 7 late G3 events (3 genitourinary, 3 cutaneous, and 1 vaginal stenosis) were recorded. CONCLUSION In the context of CRT for LAVC, the present study reports encouraging results even if there is clearly room for further improvements, in terms of both treatment outcomes, toxicity and treatment interruption management.
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Affiliation(s)
- Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100, Campobasso, Italy
| | - Valentina Lancellotta
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy.
| | - Martina Ferioli
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | - Calogero Casà
- UOC Di Radioterapia Fatebenefratelli Isola Tiberina. Gemelli Isola, Rome, Italy
| | - Donato Pezzulla
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100, Campobasso, Italy
| | - Brigida Pappalardi
- Radiotherapy Unit, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Concetta Laliscia
- Division of Radiation Oncology, Department of New Technologies and Translational Research, University of Pisa, Pisa, Italy
| | - Edy Ippolito
- Radiation Oncology, Università Campus Bio-Medico, Rome, Italy
| | - Jacopo Di Muzio
- Dipartimento Di Oncologia P.O. S. Anna - SS Radioterapia, A.O.U "Città Della Salute E Della Scienza", Turin, Italy
| | - Alessandra Huscher
- Fondazione Poliambulanza, U.O. Di Radioterapia Oncologica "Guido Berlucchi", Brescia, Italy
| | - Francesca Tortoreto
- UOC Di Radioterapia Fatebenefratelli Isola Tiberina. Gemelli Isola, Rome, Italy
| | - Mariangela Boccardi
- Radiation Oncology Unit, Gemelli Molise Hospital, Università Cattolica del Sacro Cuore, 86100, Campobasso, Italy
| | - Roberta Lazzari
- Division of Radiotherapy, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Myriam Perrone
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Division of Oncologic Gynecology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
| | | | - Angiolo Gadducci
- Division of Gynecology and Obstetrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giorgia Garganese
- Dipartimento Scienze Della Salute Della Donna, del bambino e Di Sanità Pubblica, UOC Ginecologia Oncologica,, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy
- Dipartimento Scienze Della Vita E Sanità Pubblica, Sezione Di Ginecologia Ed Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Maria Fragomeni
- Dipartimento Scienze Della Salute Della Donna, del bambino e Di Sanità Pubblica, UOC Ginecologia Oncologica,, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy
| | - Gabriella Ferrandina
- Dipartimento Scienze Della Salute Della Donna, del bambino e Di Sanità Pubblica, UOC Ginecologia Oncologica,, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy
| | - Alessio Giuseppe Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Maria Antonietta Gambacorta
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore Sede Di Roma, 00168, Rome, Italy
| | - Luca Tagliaferri
- Dipartimento Di Diagnostica Per Immagini, Radioterapia Oncologica Ed Ematologia, UOC Radioterapia Oncologica, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, 00168, Rome, Italy
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Li M, Li J, Wang Z. Prognostic value of postoperative radiotherapy in patients with vulvar squamous carcinoma: findings based on the SEER database. BMC Womens Health 2023; 23:361. [PMID: 37420200 PMCID: PMC10329365 DOI: 10.1186/s12905-023-02522-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 06/30/2023] [Indexed: 07/09/2023] Open
Abstract
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).
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Affiliation(s)
- Miaomiao Li
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, No.99, Longcheng Street, Taiyuan, 030032, Shanxi, China
| | - Jing Li
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, No.99, Longcheng Street, Taiyuan, 030032, Shanxi, China
| | - Zanhong Wang
- Department of Obstetrics and Gynecology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, No.99, Longcheng Street, Taiyuan, 030032, Shanxi, China.
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Linz VC, Schwanbeck C, Krajnak S, Anic K, Jäkel J, Schwab R, Schmidt M, Schmidberger H, Hasenburg A, Battista MJ. Comparison of cisplatin and mitomycin C/5-FU as radiosensitisers in the treatment of locally advanced vulvar cancer: results of a retrospective, observational, single-institutional cohort study. J Cancer Res Clin Oncol 2023; 149:1391-1399. [PMID: 35451700 PMCID: PMC10020277 DOI: 10.1007/s00432-022-04006-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/01/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE We retrospectively investigated the widely used radiosensitisers cisplatin and mitomycin C/5-fluorouracil (5-FU) in patients with locally advanced vulvar cancer for outcome and toxicity. METHODS We screened the archive for patients treated with chemoradiation for vulvar cancer diagnosed between 01/2010 and 08/2021 at our institution. The impact of both radiosensitisers on prognosis was compared using Kaplan-Meier method and Cox-regression analysis. RESULTS One hundred and forty-three patients with vulvar cancer were screened. Twenty-nine patients received chemoradiation (mitomycin C/5-FU n = 14; cisplatin n = 12; others n = 3) as a primary, neoadjuvant or adjuvant treatment. Median follow-up was 15.5 months. Patients in the cisplatin group were older (mean age 54.4 vs. 70.7; p = 0.004). However, the mitomycin C/5-FU group had more advanced tumour stages. The 2-year recurrence-free survival (RFS) was comparable (44.5% vs. 33.3%; p = 0.932). The 2-year overall survival (OS) showed a numerical but not statistically significant difference in favour of the mitomycin C/5-FU group (59.7% vs. 31.7%; p = 0.37). 64.3% (9 out of 14) patients, who received mitomycin C/5-FU achieved clinical complete response (cCR) compared to 41.7% (5 out of 12) who received cisplatin (p = 0.505). Radiodermatitis was the most common adverse event in both groups (81%) and more severe in the mitomycin C/5-FU cohort. Myelotoxicity was frequently observed in both groups. Eighteen patients received an additional radiation boost with 10.0 (9-16) Gy and showed a significantly prolonged RFS (p = 0.027) and OS (p = 0.003). CONCLUSION Mitomycin C/5-FU may be considered in the treatment of young and healthy patients with locally advanced vulvar cancer.
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Affiliation(s)
- Valerie Catherine Linz
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Carina Schwanbeck
- Department of Radiooncology and Radiotherapy, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Slavomir Krajnak
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Katharina Anic
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Jörg Jäkel
- Department of Pathology University Medical Center, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Roxana Schwab
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Marcus Schmidt
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiooncology and Radiotherapy, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Annette Hasenburg
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Marco Johannes Battista
- Department of Gynaecology and Obstetrics, University Medical Centre of the Johannes Gutenberg-University Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Gien LT, Slomovitz B, Van der Zee A, Oonk M. Phase II activity trial of high-dose radiation and chemosensitization in patients with macrometastatic lymph node spread after sentinel node biopsy in vulvar cancer: GROningen INternational Study on Sentinel nodes in Vulvar cancer III (GROINSS-V III/NRG-GY024). Int J Gynecol Cancer 2023; 33:619-622. [PMID: 36653060 DOI: 10.1136/ijgc-2022-004122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Standard treatment of early-stage vulvar cancer is a radical, wide, local excision of the primary tumor and a sentinel lymph node (SLN) procedure for the groins. An inguinofemoral lymphadenectomy is no longer necessary for patients who have a negative SLN or micrometastasis (≤2 mm). When there is macrometastasis (>2 mm) in the SLN, an inguinofemoral lymphadenectomy is indicated; however, this procedure is associated with major morbidity, such as wound healing, lymphoceles, and lymphedema. PRIMARY OBJECTIVE To investigate the safety of replacing inguinofemoral lymphadenectomy by chemoradiation in patients with early-stage vulvar cancer with a macrometastasis (>2 mm) and/or extracapsular extension in the sentinel node. STUDY HYPOTHESIS Combination of 56 Gy of radiation to the inguinal site and concurrent cisplatin chemotherapy without completion inguinofemoral lymphadenectomy will be feasible and safe, with low groin recurrence rates. TRIAL DESIGN This is a single-arm, prospective phase II treatment trial with stopping rules for unacceptable groin recurrences. Eligible patients will receive 56 Gy of radiation to the involved inguinal site and chemotherapy with concurrent cisplatin. MAJOR INCLUSION/EXCLUSION CRITERIA Eligible patients undergoing sentinel node procedure will have stage I, unifocal, invasive (>1 mm depth of invasion) squamous cell carcinoma of the vulva with tumor size <4 cm, and no suspicious nodes on imaging. Those eligible for the trial are those with a metastasis >2 mm in the sentinel node and/or extracapsular extension, or more than one sentinel node with micrometastasis ≤2 mm. PRIMARY ENDPOINT Groin recurrence rate in the first 2 years after primary treatment. SAMPLE SIZE 157 patients with macrometastases in their SLN. ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS January 1, 2029. TRIAL REGISTRATION NUMBER NCT05076942.
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Affiliation(s)
- Lilian T Gien
- Department of Gynecologic Oncology, Odette Cancer Centre, Toronto, Ontario, Canada
| | | | - Ate Van der Zee
- Department of Gynecologic Oncology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Maaike Oonk
- Department of Gynecologic Oncology, University Medical Centre Groningen, Groningen, The Netherlands
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Macchia G, Casà C, Ferioli M, Lancellotta V, Pezzulla D, Pappalardi B, Laliscia C, Ippolito E, Di Muzio J, Huscher A, Tortoreto F, Boccardi M, Lazzari R, De Iaco P, Raspagliesi F, Gadducci A, Garganese G, Ferrandina G, Morganti AG, Tagliaferri L. Observational multicenter Italian study on vulvar cancer adjuvant radiotherapy (OLDLADY 1.2): a cooperation among AIRO Gyn, MITO and MaNGO groups. Radiol Med 2022; 127:1292-1302. [DOI: 10.1007/s11547-022-01538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/28/2022] [Indexed: 12/01/2022]
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Wagner MM, van der Zee AGJ, Oonk MHM. History and Updates of the GROINSS-V Studies. Cancers (Basel) 2022; 14:cancers14081956. [PMID: 35454862 PMCID: PMC9033032 DOI: 10.3390/cancers14081956] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 12/13/2022] Open
Abstract
Surgical management of vulvar cancer is associated with high morbidity rates. The main aim of the GROINSS-V studies is reducing treatment-related morbidity by finding safe alternative treatment options in early-stage vulvar cancer patients. This article reviews the history, results, and updates of the GROINSS-V studies. The first GROINSS-V study was a multicenter observational study (from 2000 to 2006), which investigated the safety and clinical applicability of the sentinel lymph node procedure in patients with early-stage vulvar cancer. GROINSS-V-I showed that omitting inguinofemoral lymphadenectomy was safe in early-stage vulvar cancer patients with a negative sentinel lymph node, with an impressive reduction in treatment-related morbidity. GROINSS-V-II, a prospective multicenter phase II single-arm treatment trial (from 2005 to 2016) investigated whether radiotherapy could be a safe alternative for inguinofemoral lymphadenectomy in patients with a metastatic sentinel lymph node. This study showed that radiotherapy in patients with sentinel lymph node micrometastases (≤2 mm) was safe in terms of groin recurrence rate and with less treatment-related morbidity. These results, published in August 2021, should be implemented in (inter)national treatment guidelines for vulvar cancer. GROINSS-V-III recently started including patients. This study investigates the effectiveness and safety of chemoradiation in patients with a macrometastasis (>2 mm) in the sentinel lymph node.
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Woelber L, Hampl M, zu Eulenburg C, Prieske K, Hambrecht J, Fuerst S, Klapdor R, Heublein S, Gass P, Rohner A, Canzler U, Becker S, Bommert M, Bauerschlag D, Denecke A, Hanker L, Runnebaumn I, Forner DM, Schochter F, Klar M, Schwab R, Koepke M, Kalder M, Hantschmann P, Ratiu D, Denschlag D, Schroeder W, Tuschy B, Baumann K, Mustea A, Soergel P, Bronger H, Bauerschmitz G, Kosse J, Koch MC, Ignatov A, Sehouli J, Dannecker C, Mahner S, Jaeger A. Risk for Pelvic Metastasis and Role of Pelvic Lymphadenectomy in Node-Positive Vulvar Cancer-Results from the AGO-VOP.2 QS Vulva Study. Cancers (Basel) 2022; 14:cancers14020418. [PMID: 35053582 PMCID: PMC8773532 DOI: 10.3390/cancers14020418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 02/05/2023] Open
Abstract
Simple Summary In node-positive vulvar squamous cell cancer, questions of when and how to perform pelvic lymphadenectomy (LAE) as well as the optimal extent of pelvic treatment in general have been surrounded by considerable controversy. In Germany, systematic pelvic LAE is currently recommended as a staging procedure in patients at risk for pelvic nodal involvement in order to prevent morbidity caused by pelvic radiotherapy (RT) in patients without histologically-confirmed pelvic involvement. However, the population at risk for pelvic metastases remains insufficiently described, resulting in the potential overtreatment of a considerable proportion of patients with groin-positive disease. This applies to the indication to perform surgical staging but also to adjuvant RT of the pelvis without previous pelvic staging. Our study aims to describe the risk for pelvic lymph node metastasis with regard to positive groin nodes and to clarify the indication criteria for pelvic treatment in node-positive vulvar cancer. Abstract The need for pelvic treatment in patients with node-positive vulvar cancer (VSCC) and the value of pelvic lymphadenectomy (LAE) as a staging procedure to plan adjuvant radiotherapy (RT) is controversial. In this retrospective, multicenter analysis, 306 patients with primary node-positive VSCC treated at 33 gynecologic oncology centers in Germany between 2017 and 2019 were analyzed. All patients received surgical staging of the groins; nodal status was as follows: 23.9% (73/306) pN1a, 23.5% (72/306) pN1b, 20.4% (62/306) pN2a/b, and 31.9% (97/306) pN2c/pN3. A total of 35.6% (109/306) received pelvic LAE; pelvic nodal involvement was observed in 18.5%. None of the patients with nodal status pN1a or pN1b and pelvic LAE showed pelvic nodal involvement. Taking only patients with nodal status ≥pN2a into account, the rate of pelvic involvement was 25%. In total, adjuvant RT was applied in 64.4% (197/306). Only half of the pelvic node-positive (N+) patients received adjuvant RT to the pelvis (50%, 10/20 patients); 41.9% (122/291 patients) experienced recurrent disease or died. In patients with histologically-confirmed pelvic metastases after LAE, distant recurrences were most frequently observed (7/20 recurrences). Conclusions: A relevant risk regarding pelvic nodal involvement was observed from nodal status pN2a and higher. Our data support the omission of pelvic treatment in patients with nodal status pN1a and pN1b.
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Affiliation(s)
- Linn Woelber
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg—Eppendorf, 20246 Hamburg, Germany; (K.P.); (J.H.); (A.J.)
- Colposcopy Center at the Jerusalem Hospital Hamburg, 20357 Hamburg, Germany
- Correspondence:
| | - Monika Hampl
- Department of Gynecology, University Medical Center Duesseldorf, 40225 Duesseldorf, Germany;
| | - Christine zu Eulenburg
- Department of Epidemiology, UMCG, Universität Groningen, 9713 Groningen, The Netherlands;
| | - Katharina Prieske
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg—Eppendorf, 20246 Hamburg, Germany; (K.P.); (J.H.); (A.J.)
- Colposcopy Center at the Jerusalem Hospital Hamburg, 20357 Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg—Eppendorf, 20251 Hamburg, Germany
| | - Johanna Hambrecht
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg—Eppendorf, 20246 Hamburg, Germany; (K.P.); (J.H.); (A.J.)
| | - Sophie Fuerst
- Department of Obstetrics and Gynecology, University Hospital, LMU—University of Munich, 80377 Munich, Germany; (S.F.); (S.M.)
| | - Ruediger Klapdor
- Department of Obstetrics and Gynecology, Hannover Medical School, 30625 Hannover, Germany;
| | - Sabine Heublein
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Paul Gass
- Department of Gynecology and Obstetrics, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, 91054 Erlangen, Germany;
| | - Annika Rohner
- Department of Gynecology, University Medical Center Tuebingen, 72076 Tuebingen, Germany;
| | - Ulrich Canzler
- Department of Gynecology and Obstetrics, University Hospital Dresden, Technische Universität Dresden, Dresden, Germany & National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany;
| | - Sven Becker
- Department of Gynecology and Obstetrics, University Medical Center Frankfurt, 60590 Frankfurt, Germany;
| | - Mareike Bommert
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte, 45136 Essen, Germany;
| | - Dirk Bauerschlag
- Department of Gynecology, University Medical Center Kiel, 24105 Kiel, Germany;
| | - Agnieszka Denecke
- Department of Gynecology, Medical Center Wolfsburg, 38440 Wolfsburg, Germany;
| | - Lars Hanker
- Department of Gynecology and Gynecologic Oncology, University Medical Center Luebeck, 23562 Luebeck, Germany;
| | - Ingo Runnebaumn
- Department of Gynecology, Jena University Hospital, 07743 Jena, Germany;
| | - Dirk M. Forner
- Department of Gynecology, Evangelisches Krankenhaus Kalk, 51103 Cologne, Germany;
| | - Fabienne Schochter
- Department of Obstetrics and Gynecology, University of Ulm Medical Center, 89081 Ulm, Germany;
| | - Maximilian Klar
- Department of Gynecology, University Medical Center Freiburg, 79106 Freiburg, Germany;
| | - Roxana Schwab
- Department of Gynecology, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Melitta Koepke
- Department of Obstetrics and Gynaecology, University Hospital Augsburg, 86156 Augsburg, Germany; (M.K.); (C.D.)
| | - Matthias Kalder
- Department of Gynecology and Obstetrics, University Hospital Marburg, 35043 Marburg, Germany;
| | - Peer Hantschmann
- Department of Gynecology and Obstetrics, Medical Center Altoetting, 84503 Altoetting, Germany;
| | - Dominik Ratiu
- Department of Gynecology, University Medical Center Koeln, 50937 Koeln, Germany;
| | - Dominik Denschlag
- Department of Gynecology, Hochtaunuskliniken, 61352 Bad Homburg, Germany;
| | - Willibald Schroeder
- Department of Gynecology, Medical Center Gynaecologicum Bremen, 28209 Bremen, Germany;
| | - Benjamin Tuschy
- Department of Gynecology, University Medical Center Mannheim, 68167 Mannheim, Germany;
| | - Klaus Baumann
- Department of Gynecology, Medical Center Ludwigshafen, 67063 Ludwigshafen, Germany;
| | - Alexander Mustea
- Department of Gynecology and Gynecologic Oncology, University Medical Center Bonn, 53127 Bonn, Germany;
| | - Philipp Soergel
- Department of Gynecology, University Medical Center Minden, 32429 Minden, Germany;
| | - Holger Bronger
- Department of Gynecology and Obstetrics, Technical University of Munich, 81675 Munich, Germany;
| | - Gerd Bauerschmitz
- Department of Gynecology, University Medical Center Goettingen, 37075 Goettingen, Germany;
| | - Jens Kosse
- Department of Gynecology, Sana Klinikum Offenbach, 63069 Offenbach am Main, Germany;
| | - Martin C. Koch
- Department of Gynecology, Medical Center Ansbach, 91522 Ansbach, Germany;
| | - Atanas Ignatov
- Department of Obstetrics and Gynecology, University Hospital Magdeburg, 39120 Magdeburg, Germany;
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological SurgeryNOGGO e.V., Charite Universitatsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Virchow Campus Clinic, Charité Medical University, 13353 Berlin, Germany;
| | - Christian Dannecker
- Department of Obstetrics and Gynaecology, University Hospital Augsburg, 86156 Augsburg, Germany; (M.K.); (C.D.)
| | - Sven Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU—University of Munich, 80377 Munich, Germany; (S.F.); (S.M.)
| | - Anna Jaeger
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg—Eppendorf, 20246 Hamburg, Germany; (K.P.); (J.H.); (A.J.)
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10
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Li JY, Arkfeld CK, Tymon-Rosario J, Webster E, Schwartz P, Damast S, Menderes G. An evaluation of prognostic factors, oncologic outcomes, and management for primary and recurrent squamous cell carcinoma of the vulva. J Gynecol Oncol 2021; 33:e13. [PMID: 34910394 PMCID: PMC8899873 DOI: 10.3802/jgo.2022.33.e13] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/30/2021] [Accepted: 11/14/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate prognostic factors, outcomes, and management patterns of patients treated for squamous cell carcinoma of the vulva. METHODS One hundred sixty-four women were retrospectively identified with primary squamous cell carcinoma of the vulva treated at our institution between 1/1996-12/2018. Descriptive statistics were performed on patient, tumor, and treatment characteristics. The χ² tests and t-tests were used to compare categorical variables and continuous variables, respectively. Recurrence free survival (RFS), overall survival (OS), and disease-specific survival (DSS) were analyzed with Kaplan-Meier estimates, the log-rank test, and Cox proportional hazards. RESULTS Median follow-up was 52.5 months. Five-year RFS was 67.9%, 60.0%, 42.1%, and 20.0% for stage I-IV, respectively. Five-year DSS was 86.2%, 81.6%, 65.0%, and 42.9% for stage I-IV, respectively. On multivariate analysis, positive margins predicted overall RFS (hazard ratio [HR]=3.55; 95% confidence interval [CI]=1.18-10.73; p=0.025), while presence of lichen sclerosus on pathology (HR=2.78; 95% CI=1.30-5.91; p=0.008) predicted local RFS. OS was predicted by nodal involvement (HR=2.51; 95% CI=1.02-6.13; p=0.043) and positive margins (HR=5.19; 95% CI=2.03-13.26; p=0.001). Adjuvant radiotherapy significantly improved RFS (p=0.016) and DSS (p=0.012) in node-positive patients. Median survival after treatment of local, groin, and pelvic/distant recurrence was 52, 8, and 5 months, respectively. CONCLUSION For primary treatment, more conservative surgical approaches can be considered with escalation of treatment in patients with concurrent precursor lesions, positive margins, and/or nodal involvement. Further studies are warranted to improve risk stratification in order to optimize treatment paradigms for vulvar cancer patients.
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Affiliation(s)
- Jessie Y. Li
- Yale University School of Medicine, New Haven, CT, USA
| | - Christopher K. Arkfeld
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Joan Tymon-Rosario
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Emily Webster
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Peter Schwartz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| | - Shari Damast
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Gulden Menderes
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
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11
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Tagliaferri L, Lancellotta V, Casà C, Fragomeni SM, Ferioli M, Gentileschi S, Caretto AA, Corrado G, Gui B, Colloca GF, Gambacorta MA, Morganti AG, Garganese G, Macchia G. The Radiotherapy Role in the Multidisciplinary Management of Locally Advanced Vulvar Cancer: A Multidisciplinary VulCan Team Review. Cancers (Basel) 2021; 13:cancers13225747. [PMID: 34830901 PMCID: PMC8616490 DOI: 10.3390/cancers13225747] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 02/07/2023] Open
Abstract
Locally advanced vulvar cancer (LAVC) is a challenging disease, requiring multidisciplinary management. The aim of this review is to propose an integrated clinical approach including radiotherapy (RT) in the multidisciplinary management of LAVC to customize the treatment. A review of the literature was conducted on PubMed, Scopus, and Cochrane library to acquire all relevant studies on RT in LAVC. Based on the available evidence, RT, with or without concurrent chemotherapy, has a relevant role as adjuvant and exclusive treatment or in the neoadjuvant setting. However, multicentric prospective trials are needed to define the best treatment options based on tumor and patient characteristics. A multidisciplinary and multidimensional assessment can also be useful to identify the most suitable approach, considering patients' age and comorbidities, in view of a better treatment personalization.
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Affiliation(s)
- Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
| | - Valentina Lancellotta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
| | - Calogero Casà
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
- Correspondence: ; Tel.: +39-063015-4981
| | - Simona Maria Fragomeni
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.M.F.); (S.G.); (G.C.)
| | - Martina Ferioli
- Radiation Oncology Center, IRCCS Azienda Ospedaliero Universitaria di Bologna, DIMES, Alma Mater Studiorum—Bologna University, 40138 Bologna, Italy; (M.F.); (A.G.M.)
| | - Stefano Gentileschi
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.M.F.); (S.G.); (G.C.)
| | | | - Giacomo Corrado
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.M.F.); (S.G.); (G.C.)
| | - Benedetta Gui
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
| | - Giuseppe Ferdinando Colloca
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
| | - Maria Antonietta Gambacorta
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia—Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (L.T.); (V.L.); (B.G.); (G.F.C.); (M.A.G.)
| | - Alessio Giuseppe Morganti
- Radiation Oncology Center, IRCCS Azienda Ospedaliero Universitaria di Bologna, DIMES, Alma Mater Studiorum—Bologna University, 40138 Bologna, Italy; (M.F.); (A.G.M.)
| | - Giorgia Garganese
- Gynecology and Breast Care Center, Mater Olbia Hospital, 07026 Olbia, Italy;
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriella Macchia
- Unità Operativa di Radioterapia, Ospedale Gemelli Molise, Università Cattolica del Sacro Cuore, 86100 Campobasso, Italy;
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12
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Role of Chemotherapy in Vulvar Cancers: Time to Rethink Standard of Care? Cancers (Basel) 2021; 13:cancers13164061. [PMID: 34439215 PMCID: PMC8391130 DOI: 10.3390/cancers13164061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 01/12/2023] Open
Abstract
Simple Summary Vulvar cancer is a difficult clinical condition to treat. Although it is not one of the most frequently diagnosed cancers, its incidence is not negligible. Treatment depends on the extent of the disease and is currently based on surgery, radiotherapy and chemotherapy. The combination of these possible treatments, in the context of multidisciplinary discussions, is crucial. In this paper we present a review of the data available in the literature on the role of chemotherapy in the treatment of vulvar cancer, with a look at future perspectives. Abstract The actual role of chemotherapy in vulvar cancer is undeniably a niche topic. The low incidence of the disease limits the feasibility of randomized trials. Decision making is thus oriented by clinical and pathological features, whose relevance is generally weighted against evidence from observational studies and clinical practice. The therapeutic management of vulvar cancer is increasingly codified and refined at an individual patient level. It is of note that the attitude towards evidence sharing and discussion within a multidisciplinary frame is progressively consolidating. Viable options included in the therapeutic armamentarium available for vulvar cancer patients are frequently an adaption from standards used for cervical or anal carcinoma. Chemotherapy is more frequently combined with radiotherapy as neo-/adjuvant or definitive treatment. Drugs commonly used are platinum derivative, 5-fluorouracil and mitomicin C, mostly in combination with radiotherapy for radiosensitization. Exclusive chemotherapy in the neo-/adjuvant setting comprises platinum-derivative, combined with bleomicin and methotrexate, 5-fluorouracil, ifosfamide or taxanes. In advanced disease, current regimens include cisplatin-based chemoradiation, with or without 5-fluorouracil, or doublets with platinum in combination with a taxane. Our work is also enriched by a concise excursus on the biologic pathways underlying vulvar cancer. Introductory hints are also provided on targeted agents, a rapidly evolving research field.
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13
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Phase II study of definitive chemoradiation for locally advanced squamous cell cancer of the vulva: An efficacy study. Gynecol Oncol 2021; 163:117-124. [PMID: 34301412 DOI: 10.1016/j.ygyno.2021.07.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/06/2021] [Accepted: 07/11/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate feasibility of chemoradiation as alternative for extensive surgery in patients with locally advanced vulvar cancer and to report on locoregional control, toxicity and survival. METHODS In a multicenter, prospective phase II trial patients with locally advanced vulvar cancer were treated with locoregional radiotherapy combined with sensitizing chemotherapy (capecitabine). Treatment feasibility, percentage locoregional control, survival and toxicity were evaluated. RESULTS 52 patients with mainly T2/T3 disease were treated according to the study protocol in 10 centers in the Netherlands from 2007 to 2019. Full dose radiotherapy (tumor dose of 64.8Gy) was delivered in 92% and full dose capecitabine in 69% of patients. Most prevalent acute ≥ grade 3 toxicities were regarding skin/mucosa and pain (54% and 37%). Late ≥grade 3 toxicity was reported for skin/mucosa (10%), fibrosis (4%), GI incontinence (4%) and stress fracture or osteoradionecrosis (4%). Twelve weeks after treatment, local clinical complete response (cCR) and regional control (RC) rates were 62% and 75%, respectively. After 2 years, local cCR persisted in 22 patients (42%) and RC was 58%. Thirty patients (58%) had no evidence of disease at end of follow-up (median 35 months). In 9 patients (17%) extensive surgery with stoma formation was needed. Progression free survival was 58%, 51% and 45% and overall survival was 76%, 66%, 52% at 1,2, and 5 years. CONCLUSIONS Definitive capecitabine-based chemoradiation as alternative for extensive surgery is feasible in locally advanced vulvar cancer and results in considerable locoregional control with acceptable survival rates with manageable acute and late toxicity.
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14
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Akhtar M, Chishti U, Idress R. Bartholin gland carcinoma in a young female: a rare disease in an unusual age group. BMJ Case Rep 2021; 14:14/1/e236821. [PMID: 33431446 PMCID: PMC7802650 DOI: 10.1136/bcr-2020-236821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Primary Bartholin gland carcinoma (BGC) is an extremely rare disease. It typically presents in elderly women. It can be confused with Bartholin gland cyst, which is a benign condition leading to a delay in diagnosis and treatment. We are presenting a case report of BGC in a 35-year-old woman, which has created a diagnostic as well as therapeutic dilemma.
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Affiliation(s)
- Munazza Akhtar
- Obstetrics & Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | - Uzma Chishti
- Obstetrics & Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | - Romana Idress
- Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan
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15
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Hinduja RH, George K, Barthwal M, Pareek V. Radiation oncology in times of COVID-2019: A review article for those in the eye of the storm - An Indian perspective. Semin Oncol 2020; 47:315-327. [PMID: 32819712 PMCID: PMC7357513 DOI: 10.1053/j.seminoncol.2020.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 02/07/2023]
Abstract
The global COVID-2019 pandemic has presented to the field of radiation oncology a management dilemma in providing evidence-based treatments to all cancer patients. There is a need for appropriate measures to be taken to reduce infectious spread between the medical healthcare providers and the patient population. Such times warrant resource prioritization and to continue treatment with best available evidence, thereby reducing the risk of COVID-2019 transmission in times where the workforce is reduced. There has been literature presented in different aspects related to providing safety measures, running of a radiation department and for the management of various cancer subsites. In this article, we present a comprehensive review for sustaining a radiation oncology department in times of the COVID-2019 pandemic.
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Affiliation(s)
- Ritika Harjani Hinduja
- Associate Consultant, Department of Radiation Oncology, P.D Hinduja Hospital, Mumbai, India.
| | - Karishma George
- Junior Consultant, Department of Radiation Oncology, Vivekanand Cancer Hospital and Optimus Oncology Centre, Latur, India.
| | - Mansi Barthwal
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
| | - Vibhay Pareek
- Senior Resident, Department of Radiation Oncology, National Cancer Institute, AIIMS, New Delhi, India.
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16
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A phase 2 study of combined chemo-immunotherapy with cisplatin-pembrolizumab and radiation for unresectable vulvar squamous cell carcinoma. J Transl Med 2020; 18:350. [PMID: 32928237 PMCID: PMC7491059 DOI: 10.1186/s12967-020-02523-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/08/2020] [Indexed: 01/28/2023] Open
Abstract
Background Unresectable or metastatic vulvar cancer has relatively poor outcomes despite chemotherapy-sensitized radiation therapy and combination cytotoxic therapy. Despite the virus-associated and immunogenic nature of this disease, novel immunotherapy options that exploit this advantage are currently lacking. Platinum agents such as cisplatin have been shown to prime dendritic cells for T-cell costimulation, promote downregulation of inhibitory checkpoint molecules, and sensitize tumor cells to cytotoxic T-cell killing. Radiation therapy has also been shown to promote immunogenetic cell death as monotherapy and in combination with cisplatin. In combination with pembrolizumab, cisplatin-sensitized radiation is hypothesized to increase overall response rates and recurrence-free survival in patients with vulvar cancer, via induction of an anti-tumor inflammatory response. Methods We propose a single-arm phase II clinical trial of pembrolizumab combined with cisplatin-sensitized radiation therapy for women with unresectable, locally advanced, or metastatic vulvar cancer. The first three patients with locally advanced or unresectable disease will receive cycle 1 of pembrolizumab followed by a break and resumption of pembrolizumab at cycle 4 and as part of a safety cohort. All other patients, including the fourth patient with locally advanced/unresectable disease, will receive weekly cisplatin and pembrolizumab every 3 weeks, concurrently with daily radiation therapy. Following the completion of Cis-RT, patients will continue pembrolizumab maintenance for a total of 12 cycles. Archived tissue will be used for HPV status, MSI status, PD-L1, and TIL stratification post hoc. Imaging will be performed at baseline and every 3 cycles (21-day cycles) as per standard-of-care. Laboratory analysis will occur on the first day of each cycle. Discussion The combination of cisplatin-sensitized radiation and immune checkpoint blockade has not been evaluated in the upfront setting for vulvar cancer. In this rare malignancy, there are limited interventional clinical trials. This trial is designed to be as accessible as possible by allowing patients to receive cisplatin and radiation locally according to accepted standard-of-care while receiving pembrolizumab and adverse event monitoring at a centralized site. A robust suite of translational correlative studies has also been built into the trial to evaluate tumor-directed immune activation. Trial registration NCT04430699
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17
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Mukai Y, Koike I, Matsunaga T, Yokota NR, Kaizu H, Takano S, Sugiura M, Ito E, Miyagi E, Hata M. Outcome of Radiation Therapy for Locally Advanced Vulvar Carcinoma: Analysis of Inguinal Lymph Node. In Vivo 2020; 34:307-313. [PMID: 31882493 DOI: 10.21873/invivo.11775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM The aim of this study was to define the outcome of radiation therapy for vulvar carcinoma, and to investigate the effectiveness of therapeutic and prophylactic inguinal lymph node (ILN) irradiation. Because reports about the treatment of ILN were limited. PATIENTS AND METHODS Thirty consecutive vulvar carcinoma patients were treated using external beam radiation therapy (EBRT) for definitive disease (n=25) or postoperatively (n=5). Twenty-four (80%) had squamous cell carcinoma (SCC). Tumor stages (2002 UICC) ranged from 0 to IVB, with no distant metastases. RESULTS The median total prescribed dose for primary tumor was 64.8 Gy. The 2-year overall survival rate was 25.3%. The outcome was significantly better in patients with ILNs<30 mm (p=0.005) and patients receiving prescribed doses >60 Gy (p=0.002). CONCLUSIONS ILN diameters ≤30 mm and prescribed doses over 60 Gy were associated with ILN control in patients with vulvar carcinoma.
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Affiliation(s)
- Yuki Mukai
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Izumi Koike
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tatsuya Matsunaga
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naho Ruiz Yokota
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hisashi Kaizu
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shoko Takano
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Madoka Sugiura
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Eiko Ito
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masaharu Hata
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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18
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Locally advanced squamous cell carcinoma of the vulva: A challenging question for gynecologic oncologists. Gynecol Oncol 2020; 158:208-217. [PMID: 32460996 DOI: 10.1016/j.ygyno.2020.05.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/13/2020] [Indexed: 01/13/2023]
Abstract
Squamous cell carcinoma of the vulva is a rare female malignancy, with an incidence increasing with age. Unfortunately, one third of the patients are diagnosed with locally advanced disease, which constitutes a clinical challenge for the clinicians who treat these patients. The main challenges are represented by: 1. The primary site of the disease, which can be proximal to anatomical structures like the anal canal posteriorly, or the urethra and the bladder anteriorly, that in some circumstances cannot be spared without a bowel and/or urinary stoma; 2. The locoregional nodes that can be involved by the tumor, and they can be bulky, fixed or ulcerated; 3. The clinical condition of the patient, who may carry several comorbidities. Treatment modalities include radiation with or without chemotherapy, and surgery. In order to preserve the bowel and the urinary function without a permanent stoma, a personalized management with a multimodality approach is warranted. In this systematic review, we first clarify the different definitions of "locally advanced vulvar carcinoma". Secondly, we evaluated the different treatment modalities described in the literature, and the impact of the different treatment strategies on prognosis and on preservation of bowel/urinary function. Finally, we offer a possible algorithm that may help the clinicians in treating patients with these uncommon and challenging situations with a multidisciplinary approach.
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Gultekin M, Sari SY, Yazici G, Hurmuz P, Yildiz F, Ozyigit G. Gynecological Cancers. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-97145-2_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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20
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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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Rao YJ, Chin RI, Hui C, Mutch DG, Powell MA, Schwarz JK, Grigsby PW, Markovina S. Improved survival with definitive chemoradiation compared to definitive radiation alone in squamous cell carcinoma of the vulva: A review of the National Cancer Database. Gynecol Oncol 2017; 146:572-579. [DOI: 10.1016/j.ygyno.2017.06.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/14/2017] [Accepted: 06/17/2017] [Indexed: 11/28/2022]
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Forner DM, Mallmann P. Neoadjuvant and definitive chemotherapy or chemoradiation for stage III and IV vulvar cancer: A pooled Reanalysis. Eur J Obstet Gynecol Reprod Biol 2017; 212:115-118. [DOI: 10.1016/j.ejogrb.2017.03.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 03/16/2017] [Accepted: 03/18/2017] [Indexed: 11/16/2022]
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O'Donnell RL, Verleye L, Ratnavelu N, Galaal K, Fisher A, Naik R. Locally advanced vulva cancer: A single centre review of anovulvectomy and a systematic review of surgical, chemotherapy and radiotherapy alternatives. Is an international collaborative RCT destined for the "too difficult to do" box? Gynecol Oncol 2016; 144:438-447. [PMID: 28034465 DOI: 10.1016/j.ygyno.2016.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 12/01/2016] [Accepted: 12/08/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Treatment of locally advanced vulva cancer (LAVC) remains challenging. Due to the lack of randomised trials many questions regarding the indications for different treatment options and their efficacy remain unanswered. METHODS In this retrospective study we provide the largest published series of LAVC patients treated with anovulvectomy, reporting oncological outcomes and morbidity. Additionally, a systematic literature review was performed for all treatment options 1946-2015. RESULTS In our case series, 57/70 (81%) patients were treated in the primary setting with anovulvectomy and 13 patients underwent anovulvectomy for recurrent disease. The median overall survival (OS) was 69months (1-336) with disease specific survival of 159months (1-336). Following anovulvectomy for primary disease, time to progression and OS were significantly higher in node negative disease (10 vs. 96months; 19 vs. 121months, p<0.0001). Post-surgical complications were observed in 36 (51.4%), the majority of which were Grade I/II infections. There was one peri-operative death. Review of the literature showed that chemotherapy, radiotherapy or combination treatments are alternatives to surgery. Evidence relating to all of these consisted mostly of small retrospective series, which varied considerably in terms of patient characteristics and treatment schedules. Significant patient and treatment heterogeneity prevented meta-analysis with significant biases in these studies. It was unclear if survival or morbidity was better in any one group with a lack of data reporting complications, quality of life, and long term follow-up. However, results for chemoradiation are encouraging enough to warrant further investigation. CONCLUSIONS There remains inadequate evidence to identify an optimal treatment for LAVC. However, there is sufficient evidence to support a trial of anovulvectomy versus chemoradiation. Discussions and consensus would be needed to determine trial criteria including the primary outcome measure. Neoadjuvant chemotherapy or radiotherapy alone may be best reserved for the palliative setting or metastatic disease.
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Affiliation(s)
- Rachel Louise O'Donnell
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; Northern Institute for Cancer Research, Newcastle University, Medical School, Framlington Place NE2 4AH, UK. Rachel.O'
| | - Leen Verleye
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
| | - Nithya Ratnavelu
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
| | - Khadra Galaal
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
| | - Ann Fisher
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK.
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The Role of Radiation Therapy in Vulvar Cancer: Review of the Current Literature. TUMORI JOURNAL 2016; 103:422-429. [DOI: 10.5301/tj.5000529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2016] [Indexed: 11/20/2022]
Abstract
The purpose of this article is to discuss the current role of radiation therapy in vulvar cancer and especially to review the recent literature relative to the use of intensity-modulated radiotherapy (IMRT) in disease management. Owing to the low incidence of vulvar cancer, at present there are no available results of cooperative prospective trials. As evidenced in dosimetric and preliminary retrospective clinical studies, the use of IMRT has resulted in superior normal tissue sparing and lower rates of acute and chronic toxicities compared to previous studies that used conventional approaches. Data on long-term outcomes in these patients remain limited.
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Imoto S, Inamine M, Kudaka W, Nagai Y, Wakayama A, Nakamoto T, Ooyama T, Aoki Y. Prognostic factors in patients with vulvar cancer treated with primary surgery: a single-center experience. SPRINGERPLUS 2016; 5:125. [PMID: 26933624 PMCID: PMC4759437 DOI: 10.1186/s40064-016-1767-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/12/2016] [Indexed: 11/10/2022]
Abstract
Vulvar cancer is a relatively rare disease. The aim of this study was to investigate prognostic factors in vulvar squamous cell carcinoma patients treated with primary surgery. Forty cases of vulvar squamous cell carcinoma treated with primary surgery were retrospectively analyzed. Overall survival (OS) and disease-specific survival (DSS) were calculated using the Kaplan–Meier method and prognostic factors were analyzed by multivariate analyses. The median age was 68 years. The FIGO stage distribution was as follows: 18 cases (45.0 %) in stage I, four cases (10.0 %) in stage II, 15 cases (37.5 %) in stage III, and three cases (7.5 %) in stage IV. A radical local excision was performed in 15 patients, and radical vulvectomy in 25 patients, and seven of these patients were treated with postoperative RT. The 5-year DSS rate was 72.6 %, and the 5-year OS rate was 70.3 %. Age and surgical margin ≤5 mm were independent prognostic factors for OS, and positive inguinal LN metastasis and surgical margin ≤5 mm were identified as independent prognostic factors for DSS. Complete radical excision is important regardless of operation mode. Adjuvant treatment should be considered for inguinal LN positive patients.
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Affiliation(s)
- Sayaka Imoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Morihiko Inamine
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Wataru Kudaka
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Yutaka Nagai
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Akihiko Wakayama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Tomoko Nakamoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Takuma Ooyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
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Kim Y, Kim JY, Kim JY, Lee NK, Kim JH, Kim YB, Kim YS, Kim J, Kim YS, Yang DS, Kim YJ. Treatment outcomes of curative radiotherapy in patients with vulvar cancer: results of the retrospective KROG 1203 study. Radiat Oncol J 2015; 33:198-206. [PMID: 26484303 PMCID: PMC4607573 DOI: 10.3857/roj.2015.33.3.198] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/01/2015] [Accepted: 08/24/2015] [Indexed: 11/03/2022] Open
Abstract
PURPOSE We evaluated the prognostic factors and clinical outcomes of 56 patients with vulvar cancer treated with curative radiotherapy (RT) or concurrent chemoradiotherapy. MATERIALS AND METHODS Overall survival (OS) and disease-free survival (DFS) were assessed retrospectively. Prognostic factors evaluated included age, International Federation of Gynecology and Obstetrics (FIGO) stage, TNM classification, tumor size, treatment modality, RT duration, and RT field. The association between the tumor human papillomavirus (HPV) status and survival was analyzed in 35 patients. RESULTS During the median follow-up of 2.8 years (range, 0.3 to 18.9 years), 21 patients (37.5%) experienced treatment failure. Fifteen patients (27%) had local failure: nine (16%) local failure only, three (5%) locoregional failure, two (4%) local and distant failure, and one (2%) locoregional and distant failure. Of 56 patients, seven (13%) had persistent disease at the first follow-up at 2 months and all but one died within a year after completing RT. The 5-year OS and DFS were 51.6% and 44.0%, respectively. In multivariate analysis, clinical size ≥3 cm predicted a poor prognostic factor for DFS (p = 0.040) and age (≥70 years) was poor prognostic for DFS (p = 0.032) and OS (p = 0.048). Patients with HPV-positive tumors tended to have better 5-year OS and DFS, but the differences were not significant statistically. CONCLUSION Clinical size ≥3 cm was a significant prognostic factor for DFS. However, age was the most important prognostic factor for DFS and OS in patients treated with curative RT. Further studies are needed to determine which treatment should be considered for old age ≥70 years.
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Affiliation(s)
- Youngkyong Kim
- Proton Therapy Center, National Cancer Center, Goyang, Korea
| | - Joo-Young Kim
- Proton Therapy Center, National Cancer Center, Goyang, Korea
| | - Ja Young Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nam Kwon Lee
- Department of Radiation Oncology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Seok Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Juree Kim
- Department of Radiation Oncology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea
| | - Yeon-Sil Kim
- Department of Radiation Oncology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Sik Yang
- Department of Radiation Oncology, Korea University Medical Center, Korea University College of Medicine, Seoul, Korea
| | - Yeon-Joo Kim
- Proton Therapy Center, National Cancer Center, Goyang, Korea
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Mahner S, Prieske K, Grimm D, Trillsch F, Prieske S, von Amsberg G, Petersen C, Mueller V, Jaenicke F, Woelber L. Systemic treatment of vulvar cancer. Expert Rev Anticancer Ther 2015; 15:629-37. [DOI: 10.1586/14737140.2015.1037837] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Impact of adjuvant chemotherapy with radiation for node-positive vulvar cancer: A National Cancer Data Base (NCDB) analysis. Gynecol Oncol 2015; 137:365-72. [PMID: 25868965 DOI: 10.1016/j.ygyno.2015.03.056] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/30/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND For node-positive vulvar cancer, adjuvant radiotherapy has an established benefit, whereas the impact of chemotherapy is unknown. A National Cancer Data Base (NCDB) analysis was conducted to determine patterns of care and evaluate the survival impact of adjuvant chemotherapy. METHODS The NCDB was queried for vulvar cancer patients diagnosed from 1998-2011 who underwent extirpative surgery with confirmed inguinal nodal involvement treated with adjuvant radiotherapy. Patients with inadequate follow-up or non-squamous histologies were excluded. Chi-square test, logistic regression analysis, log-rank test and multivariable Cox proportional regression modeling with adjustment using propensity score with inverse probability of treatment weights (IPTW) were conducted to establish factors associated with utilization and survival. RESULTS A total of 1797 patients were identified: 26.3% received adjuvant chemotherapy and 76.6% had 1-3 involved lymph nodes. Adoption of adjuvant chemotherapy significantly increased over time, from 10.8% in 1998 to 41.0% in 2006 (p<0.001). Lower utilization was seen in older patients, Northeast or Southern facilities, and patients with more extensive nodal dissection, whereas greater number of involved nodes, stage IVA disease and positive surgical margins led to a higher probability of receiving chemotherapy. Unadjusted median survival without and with adjuvant chemotherapy was 29.7months and 44.0months (p=0.001). On IPTW-adjusted Cox proportional regression modeling, delivery of adjuvant chemotherapy resulted in a 38% reduction in the risk of death (HR 0.62, 95% CI 0.48-0.79, p<0.001). CONCLUSION In a large population-based analysis, adjuvant chemotherapy resulted in a significant reduction in mortality risk for node-positive vulvar cancer patients who received adjuvant radiotherapy.
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Mahner S, Jueckstock J, Hilpert F, Neuser P, Harter P, de Gregorio N, Hasenburg A, Sehouli J, Habermann A, Hillemanns P, Fuerst S, Strauss HG, Baumann K, Thiel F, Mustea A, Meier W, du Bois A, Griebel LF, Woelber L. Adjuvant therapy in lymph node-positive vulvar cancer: the AGO-CaRE-1 study. J Natl Cancer Inst 2015; 107:dju426. [PMID: 25618900 PMCID: PMC4356703 DOI: 10.1093/jnci/dju426] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background: Women with node-positive vulvar cancer have a high risk for disease recurrence. Indication criteria for adjuvant radiotherapy are controversial. This study was designed to further understand the role of adjuvant therapy in node-positive disease. Methods: Patients with primary squamous-cell vulvar cancer treated at 29 gynecologic cancer centers in Germany from 1998 through 2008 were included in this retrospective exploratory multicenter cohort study. Of 1618 documented patients, 1249 had surgical groin staging and known lymph node status and were further analyzed. All statistical tests were two-sided. Results: Four hundred forty-seven of 1249 patients (35.8%) had lymph node metastases (N+). The majority of N+ patients had one (172 [38.5%]) or two (102 [22.8%]) positive nodes. The three-year progression-free survival (PFS) rate of N+ patients was 35.2%, and the overall survival (OS) rate 56.2% compared with 75.2% and 90.2% in node-negative patients (N-). Two hundred forty-four (54.6%) N+ patients had adjuvant therapy, of which 183 (40.9%) had radiotherapy directed at the groins (+/-other fields). Three-year PFS and OS rates in these patients were better compared with N+ patients without adjuvant treatment (PFS: 39.6% vs 25.9%, hazard ratio [HR] = 0.67, 95% confidence interval [CI[= 0.51 to 0.88, P = .004; OS: 57.7% vs 51.4%, HR = 0.79, 95% CI = 0.56 to 1.11, P = .17). This effect was statistically significant in multivariable analysis adjusted for age, Eastern Cooperative Oncology Group, Union internationale contre le cancer stage, grade, invasion depth, and number of positive nodes (PFS: HR = 0.58, 95% CI = 0.43 to 0.78, P < .001; OS: HR = 0.63, 95% CI = 0.43 to 0.91, P = .01). Conclusion: This large multicenter study in vulvar cancer observed that adjuvant radiotherapy was associated with improved prognosis in node-positive patients and will hopefully help to overcome concerns regarding adjuvant treatment. However, outcome after adjuvant radiotherapy remains poor compared with node-negative patients. Adjuvant chemoradiation could be a possible strategy to improve therapy because it is superior to radiotherapy alone in other squamous cell carcinomas.
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Affiliation(s)
- Sven Mahner
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Julia Jueckstock
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Felix Hilpert
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Petra Neuser
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Philipp Harter
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Nikolaus de Gregorio
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Annette Hasenburg
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Jalid Sehouli
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Annika Habermann
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Peter Hillemanns
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Sophie Fuerst
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Hans-Georg Strauss
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Klaus Baumann
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Falk Thiel
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Alexander Mustea
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Werner Meier
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Andreas du Bois
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Lis-Femke Griebel
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
| | - Linn Woelber
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany (SM, LFG, LW); Department of Obstetrics and Gynecology, University Hospital Munich Maistrasse, Munich, Germany (JJ); Department of Obstetrics and Gynecology, University Medical Center Kiel, Kiel, Germany (FH); KKS Philipps University Marburg, Marburg, Germany (PN); Department of Gynecology and Gynecologic Oncology Kliniken Essen-Mitte, Essen, Germany (PH, AdB); Department of Obstetrics and Gynecology, University of Ulm Medical Center, Ulm, Germany (NdG); Department of Gynecology and Gynecologic Oncology, University Hospital Freiburg, Freiburg, Germany (AHas); Department of Gynecology, Charité University Medicine Berlin Campus Virchow, Berlin, Germany (JS); Department of Obstetrics and Gynecology, University Hospital Magdeburg, Magdeburg, Germany (AHab); Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany (PH); Department of Obstetrics and Gynecology, Grosshadern University Hospital, Munich, Germany (SF); Department of Gynecology, University Hospital Halle, Halle, Germany (HGS); Department of Gynecology and Gynecologic Oncology, Philipps University Marburg, Marburg, Germany (KB); Department of Gynecology, University Hospital Erlangen, Erlangen, Germany (FT); Department of Obstetrics and Gynecology, University Hospital Greifswald, Greifswald, Germany (AM); Department of Obstetrics and Gynecology, Evangelical Hospital Duesseldorf, Duesseldorf, Germany (WM)
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Deppe G, Mert I, Winer IS. Management of squamous cell vulvar cancer: A review. J Obstet Gynaecol Res 2014; 40:1217-25. [DOI: 10.1111/jog.12352] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/06/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Gunter Deppe
- Department of Obstetrics and Gynecology; Wayne State University; Detroit Michigan USA
- Division of Gynecologic Oncology; Wayne State University; Detroit Michigan USA
| | - Ismail Mert
- Department of Obstetrics and Gynecology; Wayne State University; Detroit Michigan USA
| | - Ira S. Winer
- Department of Obstetrics and Gynecology; Wayne State University; Detroit Michigan USA
- Division of Gynecologic Oncology; Wayne State University; Detroit Michigan USA
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Systemic therapy in squamous cell carcinoma of the vulva: Current status and future directions. Gynecol Oncol 2014; 132:780-9. [DOI: 10.1016/j.ygyno.2013.11.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/11/2013] [Accepted: 11/20/2013] [Indexed: 02/01/2023]
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Mahner S, Trillsch F, Kock L, Rohsbach D, Petersen C, Kruell A, Harter P, Jaenicke F, Woelber L. Adjuvant therapy in node-positive vulvar cancer. Expert Rev Anticancer Ther 2014; 13:839-44. [DOI: 10.1586/14737140.2013.811063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Woelber L, Trillsch F, Kock L, Grimm D, Petersen C, Choschzick M, Jaenicke F, Mahner S. Management of patients with vulvar cancer: a perspective review according to tumour stage. Ther Adv Med Oncol 2013; 5:183-92. [PMID: 23634196 PMCID: PMC3630479 DOI: 10.1177/1758834012471699] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Treatment of patients with vulvar cancer is challenging for gynaecologic oncologists. Owing to the localization in a sensitive area, surgical radicality and the indication for adjuvant treatment have to be balanced with psychosocial aspects to treat patients adequately. Clinical management is therefore highly dependent on the tumour stage. For patients with early-stage disease (FIGO I-II) therapy mainly concentrates on surgery with resection of the primary tumour and staging of the groin lymph nodes. In intermediate-stage vulvar cancer (FIGO III), advanced disease is expressed by affected inguinofemoral lymph nodes bringing radical lymphadenectomy and adjuvant therapy as well as radiation or chemoradiation into the focus of treatment. For locally advanced or metastatic vulvar cancer (FIGO IV) neoadjuvant or definitive chemoradiation has to be considered besides surgery. Owing to the low incidence of the disease, the level of evidence for different treatment modalities is poor. This review therefore puts different recommendations of clinical management in context and highlights the need for future trials.
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Affiliation(s)
- Linn Woelber
- Department of Gynaecology and Gynaecologic Oncology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Deppe G, Mert I, Belotte J, Winer IS. Chemotherapy of vulvar cancer: a review. Wien Klin Wochenschr 2013; 125:119-28. [PMID: 23519539 DOI: 10.1007/s00508-013-0338-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 02/15/2013] [Indexed: 12/11/2022]
Abstract
Squamous cell carcinoma of the vulva is a rare disease with good prognosis if diagnosed early. The standard primary therapy is surgery. Neoadjuvant radiation or chemotherapy has been used to achieve resectability of the tumor and to decrease the radicality of the surgery. Chemotherapy with platinum compounds, paclitaxel and targeted therapy (erlotinib) has shown activity. International collaborative trials are needed to identify the best therapeutic strategy for patients with squamous cell cancer of the vulva who are not candidates for primary surgery or concomitant chemoradiation. We review the various treatment options available to patients with advanced or recurrent squamous cell cancer of the vulva.
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Affiliation(s)
- Gunter Deppe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Harper Professional Building, 4160 John R, Suite 721, Detroit, MI, USA
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Gaudineau A, Weitbruch D, Quetin P, Heymann S, Petit T, Volkmar P, Bodin F, Velten M, Rodier JF. Neoadjuvant chemoradiotherapy followed by surgery in locally advanced squamous cell carcinoma of the vulva. Oncol Lett 2012. [PMID: 23205089 DOI: 10.3892/ol.2012.831] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Alternative therapies have been sought to alleviate mutilation and morbidity associated with surgery for vulvar neoplasms. Our prime objective was to assess tumor absence in pathological vulvar and nodal specimens following neoadjuvant chemoradiotherapy in locally advanced vulvar neoplasms. Data were retrospectively collected from January 2001 to May 2009 from 22 patients treated with neoadjuvant therapy for locally advanced squamous cell carcinoma of the vulva. Neoadjuvant treatment consisted of inguino-pelvic radiotherapy (50 Gy) in association with chemotherapy when possible. Surgery occurred at intervals of between 5 to 8 weeks. The median age of patients at diagnosis was 74.1 years. All patients were primarily treated with radiotherapy and 15 received a concomitant chemotherapy. Additionally, all patients underwent radical vulvectomy and bilateral inguino-femoral lymphadenectomy. Tumor absence in the vulvar and nodal pathological specimens was achieved for 6 (27%) patients, while absence in the vulvar pathological specimens was only achieved for 10 (45.4%) patients. Postoperative follow-up revealed breakdown of groin wounds, vulvar wounds and chronic lymphedema in 3 (14.3%), 7 (31.8%) and 14 cases (63.6%), respectively. Within a median follow-up time of 2.3 years [interquartile range (IQR), 0.6-4.6], 12 (54.6%) patients experienced complete remission and 6 cases succumbed to metastatic evolution within a median of 2.2 years (IQR, 0.6-4.6), with 1 case also experiencing perineal recurrence. Median survival time, estimated using the Kaplan-Meier method, was 5.1 years (IQR, 1.0-6.8). We suggest that neoadjuvant chemoradiotherapy may represent a reliable and promising strategy in locally advanced squamous cell carcinoma of the vulva.
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Role of chemotherapy in the management of vulvar carcinoma. Crit Rev Oncol Hematol 2012; 82:25-39. [DOI: 10.1016/j.critrevonc.2011.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 03/24/2011] [Accepted: 04/21/2011] [Indexed: 10/18/2022] Open
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Woelber L, Kock L, Gieseking F, Petersen C, Trillsch F, Choschzick M, Jaenicke F, Mahner S. Clinical management of primary vulvar cancer. Eur J Cancer 2011; 47:2315-21. [PMID: 21733674 DOI: 10.1016/j.ejca.2011.06.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 05/31/2011] [Accepted: 06/03/2011] [Indexed: 10/18/2022]
Abstract
AIMS Vulvar cancer is a rare disease with increasing incidence over the last decades. Treatment includes surgical, radio- and chemotherapeutical options; however, due to the low incidence of the disease and the lack of randomised trials many questions regarding indication of different treatment approaches remain unanswered. This article discusses the current literature to elaborate recommendations for the management of primary vulvar cancer in clinical routine. METHODS We reviewed the available literature on treatment of invasive vulvar cancer with emphasis on therapeutic strategies such as surgery and radio/chemotherapy. RESULTS Surgery of the primary tumour and the groins remain the cornerstone of treatment in vulvar cancer with a strong trend towards a less radical approach in early stage disease. Complete vulvectomy was replaced by radical local excision with plastic reconstruction and the sentinel node technique was implemented to avoid the morbidity of complete groin dissection in node negative patients. In patients with advanced primary disease, treatment decisions are still a challenge. Criteria for the indication and performance of chemo/radiotherapy of the vulva/groins/pelvis are still not fully established and vary between different countries and institutions due to the low level of evidence. Often an individualised therapeutic approach aside from guidelines is necessary to treat these patients adequately. CONCLUSIONS To enable reasonable treatment decisions and avoid unnecessary morbidity, treatment in specialised centres should be intended at any time. Clinical studies performed by several study groups on an international level are urgently needed to further improve therapy.
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Affiliation(s)
- Linn Woelber
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.
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Abstract
BACKGROUND Vulval cancer is a rare gynaecological cancer. There is no standard approach for treating locally advanced primary vulval cancer (FIGO stage III and IV). Combined treatment modalities have been developed using radiotherapy, chemotherapy and surgery. The advantages and disadvantages of such treatment is not well evaluated. OBJECTIVES To evaluate the effectiveness and safety of neoadjuvant and primary chemoradiation for women with locally advanced primary vulval cancer compared to other primary modalities of treatment such as primary surgery or primary radiation. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 3), Cochrane Gynaecological Cancer Group Trials Register, MEDLINE and EMBASE (to July 2009). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. SELECTION CRITERIA Randomised controlled trials (RCTs) or non-randomised studies that included multivariate analyses of chemoradiation in women with locally advanced, primary squamous cell carcinoma of the vulva. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. An adjusted hazard ratio (HR) for overall survival was calculated for one non-randomised study and risk ratios (RRs) were used in an RCT to compare five-year death rates and adverse events in women who received neoadjuvant, primary chemoradiation or primary surgery. Adverse events were also reported more extensively in a further non-randomised study. All results were displayed in single study analyses. MAIN RESULTS One RCT and two non-randomised studies that allowed for multivariate analyses met the inclusion criteria and included a total of 141 women.One RCT found that neoadjuvant chemoradiation did not appear to offer longer survival compared to primary surgery in advanced vulval tumours (RR = 1.29, 95% confidence interval (CI) 0.87 to 1.91). There was also no statistically significant difference in survival between primary chemoradiation and primary surgery in a study that included 63 women (pooled adjusted HR= 1.09, 95% CI 0.37 to 3.17) and in another study that only included 12 eligible women and compared the same interventions (HR was non-informative when statistical adjustment was made).Adverse events were extensively reported in only one study, which found no statistically significant difference in risk of adverse events between primary chemoradiation and primary surgery due to the very small numbers in each group. In the RCT there was no observed statistically significant difference between neoadjuvant chemoradiation and primary surgery. Adverse events were not reported in the largest study of 63 women. Quality of life (QoL) was not reported in any of the included studies. All studies were at high risk of bias. AUTHORS' CONCLUSIONS Women with advanced vulval tumours showed no significant difference in overall survival or treatment-related adverse events when chemoradiation (primary or neoadjuvant) was compared with primary surgery.The retrospective studies had a high risk of bias as the entry criteria for primary chemoradiation was based on inoperability or tumour requiring exenteration.The radiochemotherapy regimens varied widely. There was no data on QoL.There is no standard terminology for 'operable and inoperable vulval cancer', and for 'primary and neoadjuvant chemoradiation'. Stratification according to unresectability of the primary tumour and/or lymph nodes is needed, for good quality comparison.
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Affiliation(s)
- T S Shylasree
- Tata Memorial CentreGynaecological Oncology Division, Department of Surgical OncologyDr Ernest Borges Marg, ParelMumbaiIndia400012
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Robert EJ Howells
- Cardiff and Vale University Health BoardSouth East Wales Gynaecological Oncology Centre (SEWGOC)CardiffSouth WalesUK
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The role of chemo-radiotherapy in the management of locally advanced carcinoma of the vulva: single institutional experience and review of literature. Am J Clin Oncol 2011; 34:22-6. [PMID: 20087157 DOI: 10.1097/coc.0b013e3181cae6a1] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To retrospectively investigate the outcome and toxicity of concurrent chemo-radiotherapy in the treatment of locally advanced vulvar cancer (LAVC). PATIENTS AND METHODS Between 1996 and 2007, 28 consecutive patients with LAVC were treated with chemoradiation (20 primary tumors and 8 loco-regional recurrences). Treatment consists of 2 separate courses of external-beam radiotherapy (40 Gy-2 weeks split-20 Gy). During each course of radiotherapy, 5-fluorouracil (1000 mg/m/d), was given as a continuous intravenous infusion over the first 4 days, and mitomycin-C (10 mg/m on day 1), as a bolus intravenous injection. Outcome measures were rates of complete and partial response, loco-regional control, progression-free survival, overall survival, and toxicity. RESULTS The median follow-up was 42 months and the median age of patients was 68 years. Twenty patients (72%) achieved complete remission, 4 patients (14%) partial remission, for an overall response rate of 86%. Four patients (14%) had progressive disease directly after chemo-radiotherapy. The actuarial rates of loco-regional control, progression-free survival and overall survival at 4 years were 75%, 71%, and 65%, respectively. There was no treatment break for acute toxicity. Vulvar desquamation was the main acute treatment-related side effect (93%). Three patients developed transient grade 2 neutropenia or thrombocytopenia. Mild skin fibrosis and atrophy (n = 6, 21%), radiation ulcer (n = 4, 14%, in one patient treatment was needed), telangectasia (n = 3, 11%), and lymphoedema (n = 2, 7%) were the most common late toxicity of chemoradiation. CONCLUSION These data support the use of concurrent chemoradiotherapy as an effective alternative to primary ultra-radical surgery to treat LAVC with an acceptable toxicity profile.
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Mak RH, Halasz LM, Tanaka CK, Ancukiewicz M, Schultz DJ, Russell AH, Viswanathan AN. Outcomes after radiation therapy with concurrent weekly platinum-based chemotherapy or every-3–4-week 5-fluorouracil-containing regimens for squamous cell carcinoma of the vulva. Gynecol Oncol 2011; 120:101-7. [DOI: 10.1016/j.ygyno.2010.09.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 09/07/2010] [Accepted: 09/10/2010] [Indexed: 11/27/2022]
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Eckert F, Fehm T, Bamberg M, Müller AC. Small cell carcinoma of vulva: curative multimodal treatment in face of resistance to initial standard chemotherapy. Strahlenther Onkol 2010; 186:521-4. [PMID: 20803181 DOI: 10.1007/s00066-010-2160-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2010] [Accepted: 04/21/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND PURPOSE Extrapulmonary small cell carcinoma (EPSCC) is a rare disease, which has a slightly better prognosis than small cell lung cancer, but still dismal. Gynecologic small cell malignancies tend to show a better survival than similar histologies of other regions. However, of five reported cases of vulvar manifestation only one patient was disease-free at the time of publication with limited follow-up. CASE REPORT The authors describe a case of locally advanced small cell vulva carcinoma infiltrating the anal sphincter and urethra with spread to inguinal lymph nodes treated by radiochemotherapy and regional hyperthermia. After three cycles of carboplatin/ etoposide, computed tomography and magnetic resonance imaging indicated only little regressive transformations but overall stable disease. Surgical options were excluded. Therefore, curative radiotherapy to a total dose of > 65 Gy to macroscopic tumor, chemotherapy with cisplatin weekly, and regional hyperthermia were performed. Acute severe toxicity was limited to skin reactions. Despite the disadvantageous situation with inguinal lymph node metastases and chemoresistance, the multimodal therapy yielded a 5-year disease-free survival. CONCLUSION Thus, the trimodal regimen of radiochemotherapy plus regional hyperthermia offered a curative chance in spite of resistance to the standard chemotherapy for irresectable, locally advanced small cell carcinoma of the vulva. Therefore, this approach merits further evaluation for limited disease of EPSCC.
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Affiliation(s)
- Franziska Eckert
- Department of Radiooncology, Eberhard Karls University of Tübingen, Tübingen, Germany
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Chemoradiation in Gynaecological Cancer. Clin Oncol (R Coll Radiol) 2009; 21:566-72. [DOI: 10.1016/j.clon.2009.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2009] [Accepted: 06/17/2009] [Indexed: 11/23/2022]
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Moore DH. Chemotherapy and radiation therapy in the treatment of squamous cell carcinoma of the vulva: Are two therapies better than one? Gynecol Oncol 2009; 113:379-83. [DOI: 10.1016/j.ygyno.2009.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 01/10/2009] [Accepted: 01/15/2009] [Indexed: 10/21/2022]
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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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Lutgens L, Lambin P. Biomarkers for radiation-induced small bowel epithelial damage: An emerging role for plasma Citrulline. World J Gastroenterol 2007; 13:3033-42. [PMID: 17589917 PMCID: PMC4172608 DOI: 10.3748/wjg.v13.i22.3033] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Reduction of cancer treatment-induced mucosal injury has been recognized as an important target for improving the therapeutic ratio as well as reducing the economic burden associated with these treatment related sequellae. Clinical studies addressing this issue are hampered by the fact that specific objective parameters, which enable monitoring of damage in routine clinical practice, are lacking. This review summarizes pros and cons of currently available endpoints for intestinal injury. The metabolic background and characteristics of plasma citrulline, a recently investigated biomarker specifically for small intestinal injury, are discussed in more detail.
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Affiliation(s)
- Ludy Lutgens
- Department of Radiation Oncology (Maastro), GROW Research Institute, University of Maastricht, Tanslaan 12, 6202 AZ Maastricht, The Netherlands.
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Abstract
Case report from Mayo Clinic: Locally advanced Bartholin gland carcinoma
Tumors of the Bartholin gland are rare, comprising less than 5% of all vulvar malignancies. Treatment is largely based on that of vulvar and anal squamous cell carcinomas. A case of invasive, grade 4, poorly differentiated squamous cell carcinoma of the Bartholin gland is presented. Our patient, a 47-year-old woman, had a history significant for cervical intraepithelial neoplasia treated with conization, type 2 diabetes mellitus, and tobacco use. The course of treatment included preoperative radiotherapy plus 5-fluorouracil and cisplatin chemotherapy, followed by restaging and posterior exenteration in combination with vaginal reconstruction.
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Fanfani F, Garganese G, Fagotti A, Lorusso D, Gagliardi ML, Rossi M, Salgarello M, Scambia G. Advanced vulvar carcinoma: Is it worth operating? A perioperative management protocol for radical and reconstructive surgery. Gynecol Oncol 2006; 103:467-72. [PMID: 16647747 DOI: 10.1016/j.ygyno.2006.03.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 02/25/2006] [Accepted: 03/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the means whereby the results could be improved and the morbidity and side-effects minimized, of radical and extensive surgery performed together with plastic reconstruction, in the treatment of locally advanced and relapsed vulvar carcinoma. METHODS Between May 2000 and November 2004, twenty-three patients with locally advanced or relapsed vulvar carcinoma underwent major radical or extended vulvectomy, requiring reconstructive surgery. A consistent protocol for the perioperative management of these patients, including precautionary measures to reduce the rate of early complications, was introduced in the second study period (from November 2003) to verify the benefit on surgical outcome. RESULTS An analysis of the medical reports showed an improvement in the median time of the postoperative course and related morbidity as a consequence of a strict application of the management protocol, with consequent decrease of early complications. CONCLUSIONS Reconstructive surgery, which broadens the spectrum of available operative therapy in primary and locally recurrent vulvar cancer, is characterized by a high complication rate. The application of a strict perioperative protocol could reduce the number and the clinical impact of such complications.
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Affiliation(s)
- Francesco Fanfani
- Department of Oncology, Division of Gynecologic Oncology, Catholic University of Sacred Heart, Campobasso, Italy
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de Hullu JA, van der Zee AGJ. Surgery and radiotherapy in vulvar cancer. Crit Rev Oncol Hematol 2006; 60:38-58. [PMID: 16829120 DOI: 10.1016/j.critrevonc.2006.02.008] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Revised: 01/30/2006] [Accepted: 02/28/2006] [Indexed: 12/01/2022] Open
Abstract
The majority of patients with vulvar cancer have squamous cell carcinomas (SCC). The cornerstone of the treatment is surgery. Radical vulvectomy with "en bloc" inguinofemoral lymphadenectomy has led to a favorable prognosis but with impressive morbidity. Nowadays, treatment is more individualized with wide local excision with uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as the standard treatment for early stage patients with SCC of the vulva with depth of invasion >1 mm without suspicious groins. In case of more than one intranodal lymph node metastasis and/or extranodal growth, postoperative radiotherapy on the groins and pelvis is warranted. Until now there is a limited role for primary radiotherapy on the vulva and/or groins in early stage disease. The sentinel lymph node (SLN) procedure with the combined technique (preoperative lymphoscintigraphy with a radioactive tracer and intraoperative blue dye) is a promising staging technique for patients with early stage vulvar cancer. The safety of clinical implementation of the SLN procedure and the role of additional histopathological techniques of the SLNs need to be further investigated before its wide-scale application. Patients with advanced vulvar cancer are difficult to treat. One of the problems in patients with locally advanced vulvar cancer is the high incidence of concomitant bulky lymph nodes in the groin(s). Ultraradical surgery in case of resectable disease will lead to impressive morbidity because of the exenterative-type procedure. (Chemo)radiation with or without surgery should be regarded as the first choice for patients with locally advanced vulvar cancer only when primary surgery will necessitate performance of a stoma. Further studies are needed to determine the optimal combined modality treatment in these patients. Due to the fact that vulvar cancer is a rare disease, further clinical studies will only be possible, when international collaborative groups will join forces in order to perform clinical trials, in which different treatment options such as SLN procedure, primary radiotherapy on the groins and multimodality treatment for advanced disease will be investigated.
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Affiliation(s)
- J A de Hullu
- Department of Gynaecologic Oncology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Gadducci A, Cionini L, Romanini A, Fanucchi A, Genazzani AR. Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer. Crit Rev Oncol Hematol 2006; 60:227-41. [PMID: 16945551 DOI: 10.1016/j.critrevonc.2006.06.009] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 05/30/2006] [Accepted: 06/22/2006] [Indexed: 11/25/2022] Open
Abstract
During the last decades there has been a continuing evolution in the surgical approach of squamous cell carcinoma of the vulva that has been traditionally treated with radical vulvectomy and bilateral inguinal-femoral lymphadenectomy. Patients with T1 tumour are usually treated with radical local excision, if the lesion is unifocal and the remainder of the vulva is normal. Patients with T1a disease have no risk of groin metastases and do not need lymphadenectomy, whereas those with T1b disease need ipsilateral inguinal-femoral lymphadenectomy if the lesion is lateral, and bilateral lymphadenectomy if the lesion is midline. Modifications of the surgical technique of deep femoral lymphadenectomy and the mapping of sentinel node can offer new interesting therapeutic perspectives. Postoperative adjuvant pelvic and groin irradiation is warranted for patients with two or more or macroscopically involved groin nodes. Locally advanced squamous cell carcinoma of the vulva has been long surgically treated with en-block radical vulvectomy and bilateral inguinal-femoral lymphadenectomy plus partial resection of urethra, vagina or anum, or by exenteration, with severe postsurgical complications, poor quality of life, and unsatisfactory survival rates. 5-Fluorouracil [5-FU] or 5-FU- and cisplatin-based chemotherapy concurrent with irradiation followed by tailored surgery represents an attractive therapeutic option for advanced disease, planned to avoid such ultra-radical surgical procedures and, hopefully, to improve patient outcome. Chemotherapy has also been used in neoadjuvant setting, with contrasting and generally unsatisfactory results, and in palliative treatment of patients with distant metastases. Surgery is the primary treatment also for vulvar malignancies other than squamous cell carcinoma, whereas the clinical usefulness of adjuvant irradiation or chemotherapy is still to be defined. Primary chemoradiation can be also used for advanced carcinoma of the Bartholin gland or for advanced adenocarcinoma associated with extramammary Paget's disease. The drugs used for chemotherapy of metastatic melanomas or sarcomas of the vulva are the same employed for the melanomas or sarcomas developed in other sites.
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Affiliation(s)
- Angiolo Gadducci
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 56, Pisa 56127, Italy.
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