Management Of Vulvar Cancer Research Articles

Assessing the Comparative Efficacy of Sentinel Lymph Node Detection Techniques in Vulvar Cancer: Protocol for a Systematic Review and Meta-Analysis

This systematic review and meta-analysis protocol aims to evaluate the comparative efficacy of different sentinel lymph node (SLN) detection techniques in the management of vulvar cancer. Vulvar cancer, though rare, predominantly affects older women and requires effective management strategies. The SLN technique has become a standard approach for early-stage cases, offering reduced morbidity compared to complete lymphadenectomy. Currently, various SLN detection methods exist, including the use of Technetium-99m (Tc99m), Indocyanine Green (ICG), and superparamagnetic iron oxide (SPIO), but there is a lack of comprehensive comparison of their efficacy. This review will systematically search relevant databases, including PubMed, Scopus, Cochrane, Web of Science and Embase following PRISMA guidelines, to gather data from clinical trials. The primary outcome will be the detection rates of SLN techniques with secondary outcomes examining patient characteristics and procedural factors. The analysis will utilize random-effects models to compare detection rates across studies. The results of this study aim to provide insights into the optimal SLN detection method with potential implications for clinical practice guidelines in vulvar cancer management. The protocol is registered under the PROSPERO registration number CRD42024590774.

Use of Radiation Therapy in the Management of Vulvar Cancers—Identification and Management of Acute and Late Toxicities

Radiation therapy plays a critical role in the management of locally advanced vulvar cancers but can lead to a unique spectrum of side effects, with >25% of patients experiencing high-grade toxicities. The treatment phase requires meticulous perineal skincare and may require pharmacologic management of dysuria and cystitis, diarrhea, nausea, and dermatitis/mucositis. The addition of chemotherapy warrants close laboratory monitoring for hematologic and metabolic derangements.

Vulvar Cancer: Histopathologic Considerations and Nuances to Management

Vulvar cancer, although rare, poses significant challenges in diagnosis and treatment because of its histopathologic complexities and nuances. This paper reviewed key aspects of the management of vulvar cancer, focusing on histopathologic diagnosis, margin status interpretation, lymph node involvement assessment, and ongoing clinical trials.

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

ObjectivesTo evaluate the impact of high-potency topical steroid use on risk of recurrence of lichen sclerosus-associated vulvar cancer. MethodsThis is a retrospective cohort study evaluating patients with lichen sclerosus (LS)- associated vulvar squamous cell cancer (VSCC). Demographic and clinical outcome data were compared between two comparison groups: patients who received steroids, mainly clobetasol, and patients who did not receive steroids following treatment of LS-related vulvar cancer. Categorical variables were compared using Fisher's exact test or chi-square test. Continuous variables were compared using a two-sided student's t-test. Time to recurrence (TTR) and overall survival (OS) were analyzed using Kaplan-Meier survival plot and compared using Mantel-Cox log rank test. Cox proportional hazard regression models were conducted to generate hazard ratios for both TTR and OS. A p value of <0.05 was considered statistically significant. ResultsA total of 49 patients were included, with 36 patients receiving steroid treatment and 13 patients in the expectant management group. The median age of diagnosis was 68. The average BMI was 31.7 +/− 7.0. The median length of follow up was 41 months. The majority of patients were diagnosed with stage I VSCC. There was no difference in demographics or oncologic management of vulvar cancer between the two cohorts. Overall recurrence was decreased among patients who received steroid treatment when compared to patients who did not, 12 patients (33.3%) versus 9 patients (69.2%) respectively (p = 0.048). ConclusionsHigh-potency topical steroid use following treatment of lichen sclerosus-associated vulvar squamous cell carcinoma is associated with decreased risk of recurrence and prolonged median time to recurrence.

Vulvar cancer management and wrangling recurrent disease: A report from the society of gynecologic oncology journal club

The Society of Gynecologic Oncology (SGO) Journal Club webinar series is an open forum that invites national experts to discuss the literature pertaining to important topics in the management of gynecologic cancers. On August 14th, 2023, SGO hosted a journal club focused on the management of upfront and recurrent vulvar cancer. Our discussants included Dr. Brian M Slomovitz from Mount Sinai Medical Center in Miami Beach, Dr. Emi Yoshida from the University of California San Francisco Helen Diller Family Comprehensive Cancer Center, and Dr. Lilian Gien from the University of Toronto Sunnybrook Odette Cancer Center. During the discussion,we reviewed the progression of vulvar cancer surgery from en bloc resection of the vulva and groins, to partial radical vulvectomy and sentinel lymph nodes. We also reviewed the management of node positive vulvar cancer including published and accruing Groningen International Study on Sentinel Nodes in Vulvar Cancer (GROINSS) trials and other sentinel trials from the Gynecologic Oncology Group (GOG). Here we will also review the literature on the management of recurrent vulvar cancer, highlighting current treatment options and ongoing clinical trials. The following is a report of the journal club presentation.

Management of Vulvar Cancer Our Clinical Experiences

Background/Aim: Vulvar cancer is a rare malignancy. It frequently affects postmenopausal women. There is no specific screening for vulvar cancer. Treatment is often surgical. The risk of recurrence is high. Lymph node involvement is an important prognostic factor in vulvar cancer. The primary purpose of this study is to share our institutional experience in managing vulvar cancer patients. Materials and Methods: This study is a retrospective study. The study was ultimately conducted with 39 participants. Descriptive analyzes are frequency, percentage, minimum/maximum values, mean, standard deviation, and median. Risk factors for relapse were evaluated by binary logistic regression analysis. Cox regression analyses analyzed analyzes of factors related to survival. Survival analyzes were calculated using the Kaplan-Meier method, and significant differences were determined by the Log Rank (Mantel-Cox) test. P&lt;0.05 was considered statistically significant in the analyses. Results: Half of the patients (n=19; 50.0%) had vulvar mass complaints. While lesions related to vulvar cancer were observed in 13 participants before cancer diagnosis, no lesions were observed in 25 participants (65.8%). Squamous cell carcinoma was detected in 31 (81.6%) participants. Eleven (28.2%) participants had a recurrence. According to the logistic regression analysis, it was determined that the risk factors included in the model did not have statistically significant effects. Cox regression analysis was performed to determine the effects of factors on overall survival. It was determined that the factors included in the models did not have a statistically significant effect. Conclusion: Vulvar cancer is a type of cancer with limited prospective data. Therefore, it poses severe difficulties in treatment. Limited data on vulvar cancer necessitates the development of treatment paradigms. This means that we need to continue to study the disease.

Current status of vulvar cancer in Japan: analysis of the Japanese Gynecologic Oncology Group nationwide survey study.

This review provides an overview of the current status of vulvar cancer in Japan, focusing specifically on the findings from the Japanese Gynecologic Oncology Group nationwide survey study. The author offers a comprehensive summary of the current status of vulvar cancer in Japan, along with an exploration of the molecular mechanisms underlying the disease. Notably, the review highlights the concerning upward trend of vulvar cancer in older age groups and advanced stages in Japan. The author concludes that addressing these challenges may require the centralization of resources and expertise. By bridging knowledge gaps and identifying areas for improvement, this review contributes to enhancing the understanding and management of vulvar cancer in Japan.

Sentinel lymph node mapping in the modern management of gynaecological malignancy

Key content Sentinel lymph node (SLN) biopsy is an alternative to systematic lymphadenectomy in the surgical staging of gynaecological malignancy. It is recommended in the management of vulval cancer and is increasingly used in endometrial and cervical cancer. SLN failed mapping algorithms require that side‐specific lymphadenectomy should be performed in the case of failed mapping, and that suspicious lymph nodes are removed. Ultrastaging protocols improve detection of lymph‐node metastasis and should be used for the pathological processing of SLNs. Learning objectives To understand the rationale, use and evidence for SLN biopsy in women with vulval, cervical and endometrial malignancy. To appreciate the concepts behind the technical performance of SLN biopsy. To understand the pathological processing of SLN samples and the implications this may have for the interpretation of results and adjuvant therapy. Ethical issues How to manage adjuvant therapy decisions in the context of micrometastases or isolated tumour cells in positive pelvic SLNs in cervical or endometrial cancer when the evidence‐base is limited.

Current Approaches to the Management of Sentinel Node Procedures in Early Vulvar Cancer in Germany: A Web-Based Nationwide Analysis of Practices.

Lymph node involvement is the most important prognostic factor for recurrence and survival in vulvar cancer. Sentinel node (SN) procedure can be offered in well-selected patients with early vulvar cancer. This study aimed to assess current management practices with respect to the sentinel node procedure in women with early vulvar cancer in Germany. A Web-based survey was conducted. Questionnaires were e-mailed to 612 gynecology departments. Data were summarized as frequencies and analyzed using the chi-square test. A total of 222 hospitals (36.27%) responded to the invitation to participate. Among the responders, 9.5% did not offer the SN procedure. However, 79.5% evaluated SNs by ultrastaging. In vulvar cancer of the midline with unilateral localized positive SN, 49.1% and 48.6% of respondents, respectively, would perform ipsilateral or bilateral inguinal lymph node dissection. Repeat SN procedure was performed by 16.2% of respondents. For isolated tumor cells (ITCs) or micrometastases, 28.1% and 60.5% of respondents, respectively, would perform inguinal lymph node dissection, whereas 19.3% and 23.8%, respectively, would opt for radiation without further surgical intervention. Notably, 50.9% of respondents would not initiate any further therapy and 15.1% would opt for expectant management. The majority of German hospitals implement the SN procedure. However, only 79.5% of respondents performed ultrastaging and only 28.1% were aware that ITC may affect survival in vulvar cancer. There is a need to ensure that the management of vulvar cancer follows the latest recommendations and clinical evidence. Deviations from state-of-the-art management should only be after a detailed discussion with the concerned patient.

Clinico-pathological Characteristics and Treatment Modalities of Vulvar Cancer: A Retrospective Analysis

Background: Vulvar cancer is one of the rare malignancies of the female genital tract. Vulvar cancer is predominantly a disease of post-menopausal multiparous women. Objective: The aim of this study was to analyse and report the clinico-pathological features and treatment modalities of patients with vulvar cancer treated at National Institute of Cancer Research and Hospital (NICR&amp;H), Dhaka, Bangladesh. Methods: This was a cross- sectional observational study conducted among 96 vulvar cancer cases treated at National Institute of Cancer Research and Hospital (NICR&amp;H), Dhaka, Bangladesh from 2015 to 2020. The medical records of patients with vulvar cancer were retrospectively reviewed after obtaining approval from the Institutional Review Board (IRB). Clinical details of all vulvar cancer patients and treatment given were collected from the hospital records and were reviewed retrospectively. Results: A total of 96 patients with vulvar cancer were included for this retrospective analysis. The median age was 50 years (range, 12- 85 years) with a mean (±SD) of 50.50±15.12 years. Stages of the disease were: stage I: 27.1% patients; stage II: 22.9% patients; stage III: 30.3% patients; stage IV: 16.7% patients; and unknown stage: 3.1% patient as per International Federation of Gynecology and Obstetrics (FIGO) staging system. Histopathologically, squamous cell carcinoma (SCC) was the most common histologic type (84.4%) followed by adenocarcinoma (5.2%), melanoma (4.2%), basal cell carcinoma (3.1%), and others (3.1%). Most of the patients (45.8%) were treated by surgery with or without adjuvant radiotherapy. About 24.0% of patients were treated primarily by radiotherapy and/or chemo-radiotherapy. Conclusion: Management of vulvar cancer requires multidisciplinary team approach, which is available only in tertiary care centres. The treatment of vulvar cancer is surgery, radiotherapy, chemo- radiotherapy or a combination therapy. Treatment should be individualised based on lesions location and histological type. Bangladesh Med Res Counc Bull 2022; 48(1): 64-70

Declining use of inguinofemoral lymphadenectomy in the treatment of clinically negative, pathologic node positive vulvar cancer

PurposeThe management of vulvar cancer with clinically negative groin lymph nodes but with positive sentinel lymph node biopsy (SLNB) is controversial, with options including inguinofemoral lymphadenectomy (IFL) and/or adjuvant chemotherapy and radiotherapy. We used the National Cancer Database (NCDB) to examine trends in the management of clinically node negative, pathologically node positive (cN-/pN+) patients. MethodsThe NCDB was used to identify cN-/pN+ vulvar cancer patients. Demographic and clinical data were compared with chi-squared and Wilcoxon rank-sum tests. OS was analyzed with the Kaplan-Meier method and log-rank test. Cox proportional hazards regression was used to determine factors associated with OS. ResultsA total of 885 cN-/pN+ vulvar cancer patients were identified between 2012 and 2016, during which the rate of SLNB alone increased from 3.6% to 11.7%, while the rate of IFL +/− SLNB decreased from 89.7% to 78.1% (p < 0.05). Radiation was used in 68.5% and 64.6% of the SLNB-alone and IFL +/− SLNB cohorts, respectively, with chemoradiation in 37.1% and 33.6%, respectively. OS was not different between patients who received SLNB-alone vs. IFL +/− SLNB (p = 0.644). Receipt of chemotherapy and radiation was associated with improved OS (p < 0.001). ConclusionsAmong cN-/pN+ vulvar cancer patients in the NCDB, the practice of performing IFL decreased over time as SLNB-alone became more common and the majority received radiation +/− chemotherapy. There was no difference in OS between SLNB-alone vs. IFL +/− SLNB. Patients treated with adjuvant chemoradiation had improved survival. Whether the favorable outcomes in the SLNB-alone cohort may be attributed to radiotherapy dose escalation or use of chemotherapy warrants further study.

History and Updates of the GROINSS-V Studies.

Simple SummarySurgical 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 patients with early-stage vulvar cancer. This article reviews the history, results, and updates of the GROINSS-V studies.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.

Development of a management guidewheel for vulvar cancer

Ismail’s Cancer Vulva Management Guidewheel is designed to enable physicians to refer to a quick and comprehensive reference to recommendations on the management of vulvar cancer at various stages. The wheel consists of patient characteristics, including the FIGO stage and the possible treatment modalities available along with alternatives. We compared guidelines on the management of vulvar cancer by international health organizations including the National Comprehensive Cancer Network (NCCN), the Society of Gynecologic Oncology (SGO), the European Society of Gynaecological Oncology (ESGO), the European Society of Urogenital Radiology (ESUR), the British Gynaecological Cancer Society (BGCS), the Royal College of Obstetricians and Gynaecologists (RCOG), the Japanese Society of Gynecologic Oncology (JSGO), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the International Federation of Gynecology and Obstetrics (FIGO). Their respective recommendations have been compared and carefully integrated on the guidewheel.

The giant steps in surgical downsizing toward a personalized treatment of vulvar cancer.

The present article aims to highlight the importance of changes of personalized surgical treatment for vulvar cancer. Current international literature regarding surgical treatment of vulvar cancer was evaluated. This included several studies and systematic reviews. Radical surgery approach, such as en bloc resection, was the first therapeutic option and the standard care for many years, even if burdened with a high complication rate and frequently disfiguring. Taussing and Way introduced radical vulvectomy approach with en bloc bilateral inguinal‐femoral lymphadenectomy; modified radical vulvectomy was developed, with a wide radical excision of the primary tumor. The role of inguinofemoral lymphadenectomy (mono or bilateral) changed in the years too, particularly with the advent of SLN biopsy as minimally invasive surgical approach for lymph node staging, in patients with unifocal cancer <4 cm, without suspicious groin nodes. More personalized and conservative surgical approach, consisting of wide local or wide radical excisions, is necessary to reduce complications as lymphedema or sexual disfunction. The optimal surgical management of vulvar cancer needs to consider dimensions, staging, depth of invasion, presence of carcinoma at the surgical margins of resection and grading, with the goal of making the treatment as individualized as possible.

Management of vulval cancer

No abstract available

Role of Chemotherapy in Vulvar Cancers: Time to Rethink Standard of Care?

Simple SummaryVulvar 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. 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.

Is There a Place for Immune Checkpoint Inhibitors in Vulvar Neoplasms? A State of the Art Review

Vulvar cancer (VC) is a rare neoplasm, usually arising in postmenopausal women, although human papilloma virus (HPV)-associated VC usually develop in younger women. Incidences of VCs are rising in many countries. Surgery is the cornerstone of early-stage VC management, whereas therapies for advanced VC are multimodal and not standardized, combining chemotherapy and radiotherapy to avoid exenterative surgery. Randomized controlled trials (RCTs) are scarce due to the rarity of the disease and prognosis has not improved. Hence, new therapies are needed to improve the outcomes of these patients. In recent years, improved knowledge regarding the crosstalk between neoplastic and tumor cells has allowed researchers to develop a novel therapeutic approach exploiting these molecular interactions. Both the innate and adaptive immune systems play a key role in anti-tumor immunesurveillance. Immune checkpoint inhibitors (ICIs) have demonstrated efficacy in multiple tumor types, improving survival rates and disease outcomes. In some gynecologic cancers (e.g., cervical cancer), many studies are showing promising results and a growing interest is emerging about the potential use of ICIs in VC. The aim of this manuscript is to summarize the latest developments in the field of VC immunoncology, to present the role of state-of-the-art ICIs in VC management and to discuss new potential immunotherapeutic approaches.

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer

ObjectiveA retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomyMethodsPatients diagnosed between January 2012 and December...

Cold Atmospheric Pressure Plasma (CAP) as a New Tool for the Management of Vulva Cancer and Vulvar Premalignant Lesions in Gynaecological Oncology.

Vulvar cancer (VC) is a specific form of malignancy accounting for 5–6% of all gynaecologic malignancies. Although VC occurs most commonly in women after 60 years of age, disease incidence has risen progressively in premenopausal women in recent decades. VC demonstrates particular features requiring well-adapted therapeutic approaches to avoid potential treatment-related complications. Significant improvements in disease-free survival and overall survival rates for patients diagnosed with post-stage I disease have been achieved by implementing a combination therapy consisting of radical surgical resection, systemic chemotherapy and/or radiotherapy. Achieving local control remains challenging. However, mostly due to specific anatomical conditions, the need for comprehensive surgical reconstruction and frequent post-operative healing complications. Novel therapeutic tools better adapted to VC particularities are essential for improving individual outcomes. To this end, cold atmospheric plasma (CAP) treatment is a promising option for VC, and is particularly appropriate for the local treatment of dysplastic lesions, early intraepithelial cancer, and invasive tumours. In addition, CAP also helps reduce inflammatory complications and improve wound healing. The application of CAP may realise either directly or indirectly utilising nanoparticle technologies. CAP has demonstrated remarkable treatment benefits for several malignant conditions, and has created new medical fields, such as “plasma medicine” and “plasma oncology”. This article highlights the benefits of CAP for the treatment of VC, VC pre-stages, and postsurgical wound complications. There has not yet been a published report of CAP on vulvar cancer cells, and so this review summarises the progress made in gynaecological oncology and in other cancers, and promotes an important, understudied area for future research. The paradigm shift from reactive to predictive, preventive and personalised medical approaches in overall VC management is also considered.

Multidisciplinary personalized approach in the management of vulvar cancer – the Vul.Can Team experience

IntroductionMultidisciplinary treatment strategy involving adjuvant radiotherapy for advanced vulvar cancer could be useful in offering the best personalized clinical approach. In 2013, the VULvar CANcer Multi-Disciplinary Team (Vul.Can MDT) was...