Impact of partnership status on clinical outcomes of patients with vulvar squamous cell carcinoma and performance of sentinel lymph node biopsy

Sentinel Lymph Node Techniques in Urologic Oncology: Current Knowledge and Application

Lymph node (LN) metastases have a significant negative impact on the prognosis of urological malignancies. Unfortunately, current imaging modalities are insufficient when it comes to detecting micrometastases; thus, surgical LN removal is commonly used. However, there is still no established ideal lymph node dissection (LND) template, leading to unnecessary invasive staging and the possibility of missing LN metastases located outside the standard template. To address this issue, the sentinel lymph node (SLN) concept has been proposed. This technique involves identifying and removing the first group of draining LNs, which can accurately stage cancer. While successful in breast cancer and melanoma, the SLN technique in urologic oncology is still considered experimental due to high false-negative rates and lack of data in prostate, bladder, and kidney cancer. Nevertheless, the development of new tracers, imaging modalities, and surgical techniques may improve the potential of the SLN procedures in urological oncology. In this review, we aim to discuss the current knowledge and future contributions of the SLN procedure in the management of urological malignancies.

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

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

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

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

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

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

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Radiotherapy Plus Chemotherapy Is Associated With Improved Survival Compared to Radiotherapy Alone in Patients With Primary Vaginal Carcinoma: A Retrospective SEER Study

Background

The efficacy of radiotherapy plus chemotherapy (RTCT) versus radiotherapy alone (RT) in the treatment of primary vaginal carcinoma has been controversial. We aimed to evaluate the up-to-date efficacy of RTCT on primary vaginal carcinoma in a real-world cohort.

Methods

We performed a retrospective analysis in patients with primary vaginal carcinoma retrieved from the Surveillance, Epidemiology, and End Results Program database from 2004 to 2016. Kaplan-Meier survival curves were plotted and compared by the log-rank test. Inverse probability weighting (IPW)-adjusted multivariate Cox proportional hazards and Fine-Gray competing-risk model was applied.

Results

Of the 1,813 qualified patients with primary vaginal carcinoma from 2004 to 2016, 1,137 underwent RTCT and 676 underwent RT. The median survival time was 34 months for the RT group and 63 months for the RTCT group. RTCT was significantly associated with improved overall survival (unadjusted HR = 0.71, 95% CI 0.62-0.82, p < 0.001; adjusted HR = 0.73, 95% CI 0.63-0.84, p < 0.001) and cancer-specific survival (unadjusted sHR = 0.81, 95% CI 0.69-0.95, p = 0.012; adjusted sHR = 0.81, 95% CI 0.69-0.96, p = 0.016). Age, histological type, tumor size, surgery, and FIGO stage were all independent prognostic factors for survival (p < 0.05 for all). Subgroup analysis demonstrated that RTCT was significantly associated with better survival in most subgroups, except for those with adenocarcinoma, tumor size <2 cm, or FIGO stage I. Moreover, sensitivity analysis did not alter the beneficial effects of RTCT.

Conclusion

RTCT is significantly correlated with prolonged survival in patients with primary vaginal carcinoma. RTCT should be applied to most patients with primary vaginal carcinoma instead of RT alone, except for those with adenocarcinoma, tumor size <2 cm, or FIGO stage I.