Changes in the management of vulval cancer

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

Objective:

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

Methods:

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

Results:

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

Conclusions:

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

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Tailoring the Treatment of Locally Advanced Squamous Cell Carcinoma of the Vulva: Neoadjuvant Chemotherapy Followed by Radical Surgery

Objective

To determine the feasibility of performing neoadjuvant chemotherapy (NCH) followed by radical surgery in patients with locally advanced squamous cell carcinoma of the vulva.

Methods

Prospective and multicenter trial. Thirty-five patients with a diagnosis of previously untreated locally advanced squamous cell carcinoma of the vulva were given 4 schemes of cisplatin-based NCH and 1 NCH regimen with single bleomycin. Then, they underwent radical surgery of the vulva if clinical response was 50% or more. Age, NCH schemes used, toxicity, response to treatment, type of radical surgery performed, and clinical outcome were evaluated.

Results

Thirty-three patients completed the proposed schemes, and 30 were assessed for radical surgery. Finally, 27 patients underwent radical surgery (radical vulvectomy or radical local excision plus bilateral inguinofemoral lymphadenectomy). In 2 cases of persistent rectal involvement, posterior pelvic exenteration was performed. Moreover, 24 of 27 patients remain with no evidence of disease to date. Toxicity was acceptable. Median age was 62 years (range, 54–72 years). Median follow-up was 49 months (range, 4–155 months).

Conclusions

The use of NCH in selected groups may increase surgical feasibility in initially inoperable patients, thus favoring organ preservation and less extensive resections. Adverse reactions were acceptable, and vulvoperineal deleterious effects that may occur after radiotherapy were consequently avoided.

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

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

Experience in the management of patients older than 80 years with vulval cancer

INTRODUCTION

Vulval cancer is a disease of an increasing elderly population and consequently comorbidities are common. These conditions may preclude the application of standard therapy.

OBJECTIVE

To review the outcome of women with vulval cancer older than 80 years comparing those who received recommended treatment (protocol-adherent) with those who did not (protocol-violated).

METHODS

A retrospective chart review of a consecutive series of patients discussed over a 6-year period at our Multidisciplinary Team meeting. Treatment was deemed protocol-adherent if the Royal College of Obstetricians and Gynaecologists guidelines were followed and protocol-violated if not. Outcome data were retrieved from case notes, primary care input, cancer registry database, and reviewed in terms of survival and recurrence.

RESULTS

Twenty-three cases of squamous cell carcinoma of the vulva were identified between 1999 and 2005 at Portsmouth Oncology Centre. Eight women were protocol-adherent and 15 women were not. Treatment decisions were made after individual discussion in conjunction with performance status. Protocol adherence was associated with a 25% recurrence rate and violation with a 53% recurrence rate. Median survival was shorter in the protocol-violated group compared with the adherent group (18 months vs 43.5 months respectively).

CONCLUSION

These data imply that this issue arises not infrequently, perhaps every 3 to 4 months at each gynecological oncology Multidisciplinary Team meeting in the UK. The higher recurrence rate and shorter median survival among the protocol-violated group supports the validity of the current Royal College of Obstetricians and Gynaecologists treatment guidelines in this elderly age group. A prospective scoring system should be evolved to ensure a more objective approach to such patients with considerable co-morbidities.

Management of melanomas of the female genital tract

PURPOSE OF REVIEW

The significant increase in cutaneous melanomas over the past 30 years has led to studies resulting in advances in their diagnosis, staging, surgical treatment, and adjuvant therapies. Similar approaches have been investigated in patients with far rarer malignant melanomas of the female genital tract. This review will summarize the current state of knowledge on the incidence, causes, presenting symptoms, prognostic factors, therapeutic approaches, and outcomes, site-by-site, for primary melanomas of the vulva, vagina, urethra, ovary, and the uterine cervix.

RECENT FINDINGS

Surgery remains the initial treatment of choice for localized melanomas of the female genital tract, with less radical, organ function preserving resections demonstrating similar control rates compared with more radical surgical approaches in vulva and possibly vaginal melanomas. Radiation therapy may play a role in the treatment of patients with close resection margins, regional nodal metastasis, or unresectable tumors. Sentinel lymph node studies, positron emission tomography and computed tomography scans for staging and evaluation of response, and adjuvant chemo or biochemotherapy warrant further investigation.

SUMMARY

The results of treatment for female genital tract melanomas remain poor. Although surgery remains the initial treatment of choice for localized disease, adjuvant local-regional, and systemic therapies are needed.

Sparing of saphenous vein during inguinal lymphadenectomy for vulval malignancies

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Utility of sentinel node biopsy in vulvar and vaginal melanoma: report of two cases and review of the literature

Sentinel node (SN) biopsy is widely applied for treatment planning of cutaneous melanoma. However, using this strategy in female lower genital tract tumors has not yet been established. We report two cases, one each of vulvar and vaginal melanoma who underwent SN biopsy and review the available literature. Our experience and available limited evidence suggests that this low morbidity technique can be used for obtaining prognostic information and hence treatment planning for this disease. However, a false negative rate perhaps in the order of 15% suggests that careful consideration is necessary before using sentinel lymph node biopsy in the management of vulvar and vaginal melanoma.

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

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

Challenging the concept of microinvasive carcinoma of the vulva: report of a case with regional lymph node recurrence and review of the literature

Background

It is widely accepted that vulvar carcinoma with a depth of invasion of less than one millimeter is sufficiently treated by vulvectomy or wide local excision without inguinal lymphadenectomy.

Case presentation

However, a patient with inguinal lymph node recurrence 21 months after radical vulvectomy for stage IA squamous cell carcinoma was observed.

Conclusion

According to a review of the literature, there are five additional cases of metastasizing vulvar cancer with a depth of invasion of less than one millimeter. Therefore, the definition of microinvasive carcinoma of the vulva based on depth of invasion alone may not be as reliable as previously thought and does not rule out inguinal lymph node involvement or recurrence. Consequently, the necessity of inguinal node dissection for microinvasive carcinoma needs to be discussed on an individual basis taking into account the age of the patient as well as the potential morbidity of extended surgery.

Groin angiosarcoma following radiotherapy for vulvar cancer

BACKGROUND

Angiosarcomas account for less than 2% of all sarcomas. However, they represent 15% of radiotherapy-induced sarcomas, usually associated to the treatment for breast cancer, cervical cancer, and lymphomas.

CASE REPORT

We report the case of a 56-year-old patient who developed a soft tissue angiosarcoma in the right groin 25 years after receiving radiotherapy for vulvar cancer. To our knowledge, this is the second case reported of a soft tissue angiosarcoma after radiotherapy for a vulvar cancer.

CONCLUSION

Postradiation sarcoma must be considered in patients with a history of a previous tumor when a soft tissue mass is seen in the previously irradiated field, especially if the latent period is more than 3 or 5 years. The correct histologic interpretation of such lesions is important because it may result in early identification of the secondary malignancy and may contribute to better management and improved prognosis.