Treatment Of Vulvar Carcinoma Research Articles

Vulvar Carcinoma: Standard of Care and Perspectives.

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. 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. 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. 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.

Pregnancy and cesarean delivery after multimodal therapy for vulvar carcinoma: A case report.

Reports of pregnancy following treatment for vulvar carcinoma are extremely uncommon, as the main problem of subsequent pregnancy is vulvar scarring following radical surgery. We herein report the case of a patient who was diagnosed with stage I squamous cell carcinoma of the vulva at the age of 17 years and was treated with multimodal therapy, including neoadjuvant chemotherapy, wide local excision with bilateral inguinal lymph node dissection and adjuvant radiotherapy. The patient became pregnant spontaneously 9 years after her initial diagnosis and the antenatal course was good, except for mild acute pyelonephritis at 25 weeks of gestation. An elective caesarean section was performed at 38 weeks of gestation due to vulvar scarring following multimodal therapy, particularly radiotherapy. The patient remains alive and well, without signs of recurrence or metastasis 12 years after her diagnosis and treatment. Radical vulvectomy as well as multimodal therapy for vulvar carcinoma, particularly radiotherapy, may cause extensive skin scarring. The presence of vulvar scarring following multimodal therapy for vulvar carcinoma may increase the incidence of caesarean delivery.

Key concepts in management of vulvar cancer

Vulvar carcinoma is an uncommon tumor that is seen most often in older women. Subtle symptoms such as pruritus should prompt examination and targeted biopsy in all women as this disease can be successfully treated even in elderly, frail individuals. Vulvar cancer has a bimodal age distribution and is seen in both young and older women with risk factors including human papillomavirus (HPV) infection, smoking, and vulvar skin diseases (i.e., lichen sclerosus). This cancer is staged surgically, with an update in 2009 incorporating prognostic factors. The treatment of vulvar carcinoma has evolved to include more conservative surgical techniques that provide improved cure rates with emphasis on minimizing morbidity. Advanced and metastatic lesions are now treated with chemoradiation which produces substantial cure rates with decreased morbidity. Promising areas of research in vulvar cancer include refinement of sentinel lymph node biopsy, prevention of lymphedema, and preservation of sexual function following treatment.

Application of video endoscopic inguinal lymphadenectomy in radical vulvectomy for carcinoma

To evaluate the feasibility and safety of applying video endoscopic inguinal lymphadenectomy via hypogastric subcutaneous approach (VEIL-H) in the treatment of vulvar carcinoma. From September 2009 to December 2012, 15 patients with vulvar carcinoma underwent VEIL-H plus radical vulvectomy at many participating hospitals. All were treated surgically. Two of them underwent laparoscopic pelvic lymphadenectomy (LPL) upon the positive results of parotid operations with frozen section. The mean operative duration of VEIL-H (bilateral groin) were (80.8 ± 2.9) minutes. The mean total volume of blood loss in VEIL was (5.5 ± 0.4) ml, the mean drainage duration (6 ± 2) days and the average postoperative hospitalization (11 ± 4) days. The mean follow-up period was 13.0 months. One patient suffered local recurrence at Month 2 postoperation. VEIL-H is both feasible and safe in inguinal lymphadenectomy.

Prophylactic inguinal-femoral irradiation as an alternative to primary lymphadenectomy in treatment of vulvar carcinoma

In a complete geographic series of 294 cases of primary vulvar carcinomas prophylactic inguinal-femoral irradiation was used as a standard postoperative therapy. Inguinal lymph node dissection was performed in only 27 cases (9%) and was not part of the standard surgery. The histology was squamous cell carcinoma in 269 cases (92%). The primary surgery was total vulvectomy, partial vulvectomy, or local resection of the tumor. The main type of radiotherapy was adjuvant inguinal irradiation. Two separate, symmetrical and rectangular inguinal fields were irradiated with combined photon and electron beams. In the complete series 127 recurrences (43%) were recorded. Local (24%) and regional recurrences (19%) were most frequent. Type of surgery was not associated with the risk of tumor recurrence. The 5-year overall survival rate was 53% and the relapse-free survival (RFS) rate was 55%. Tumor grade was significantly (P=0.007) associated with the RFS. The inguinal RFS rate was 75% both for patients treated with adjuvant inguinal irradiation without lymphadenectomy and patients treated with primary lymph adenectomy +/- inguinal irradiation. Postoperative complications were recorded in 22%. Postoperative complications occurred most frequently in the subgroup undergoing inguinal lymphadenectomy. Chronic lymph edemas were the most serious late tissue reactions.

Minimierung der Operationsmorbidität. Die Sentinel-Lymphonodektomie beim Vulvakarzinom - Quo vadis?

Complete groin dissection is established in the operative standard procedure in treatment of vulvar carcinoma. For lateral localized carcinomas without node metastases only ipsilateral dissection is necessary. But in early tumor stages most of the patients are node negative and no oncologic benefit can be postulated although operative morbidity is high. Only for carcinomas with depth of infiltration less than 1 mm it is possible to avoid groin dissection. Studies demonstrate that clinical and apparative diagnostic procedures do not predict lymph node involvement accurately. Thus the concept of sentinel-lymphonodectomy has been evaluated in the last years in vulvar carcinoma. With > 95 % detection rate was very high and false negative cases have been reported only very rarely. Because results with the first patients in Germany showed similar results the AGO developed a concept for an observational study which will avoid complete groin dissection in sentinel node negative T1-T2N0 vulvar carcinoma. Before participation is possible e learning phase has to be completed. Exact control of the patients should look for reduction of operative morbidity with equivalent oncologic effectiveness.

Intensity-Modulated Radiotherapy for the Treatment of Vulvar Carcinoma: A Comparative Dosimetric Study with Early Clinical Outcome

Intensity-Modulated Radiotherapy for the Treatment of Vulvar Carcinoma: A Comparative Dosimetric Study with Early Clinical Outcome

Sarcoma in Association with Multimodality Management of Vulvar Cancer: Two Case Reports

Background. Radiation-induced or -associated sarcoma is a rare event which has been well described in the literature. However, this entity has been infrequently described in association with genital tract malignancies. To our knowledge it has never been described in association with the management of vulvar cancer.Cases. Two different cases of sarcoma developing after primary management for vulvar cancer are presented, the first being a case of angiosarcoma developing in the lower abdominal wall 36 months after initial therapy and the second a case of fibrosarcoma developing on the vulva 7 years after multimodality treatment.Conclusion. Radiation-associated sarcoma after treatment for vulvar carcinoma is a rare event. A multimodality treatment of carcinoma of the vulva should not be withheld because of fear of sarcomagenesis.

Complete Groin Lymphadenectomy with Preservation of the Fascia Lata in the Treatment of Vulvar Carcinoma

Objective. The goal of this study was to assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata (GNDPFL).Methods. This study is a retrospective chart review of 60 patients with Stage I–IV vulvar carcinoma who underwent radical vulvectomy and GNDPFL between 1990 and 1998. All superficial inguinal nodes and the deep femoral nodes on the anterior and medial surfaces of the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and the cribriform fascia over the femoral artery.Results. Of the 60 study patients, 14 patients had Stage I disease, 20 Stage II, 21 Stage III, and 5 Stage IV. The mean number of nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the sixty study patients (34%) had malignant nodes on groin dissection. Of these 21 patients, 2 experienced cancer recurrence in the groins. Our study describes a groin recurrence rate of 7.6% in patients with fewer than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles.Conclusions. The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable to radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.

Complete groin node dissection with preservation of the fascia lata in the treatment of vulvar carcinoma

Objective: To assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata.Methods: Charts of 60 patients with stages I–IV vulvar carcinoma who underwent radical vulvectomy and complete groin node dissection with preservation of the fascia lata between 1990 and 1998 were reviewed retrospectively. The superficial inguinal nodes and the deep femoral nodes medial to the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and most of the femoral sheath.Results: Of the 60 patients studied, 14 patients had stage I disease, 20 patients had stage II, 21 patients had stage III, and 5 patients had stage IV. The mean number of groin nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. Twenty (51%) of these 39 patients had stage II disease, and 69% had invasion greater than 2 mm at the primary site. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the 60 study patients (34%) had malignant nodes on groin dissection. Two of these 21 patients experienced cancer recurrence in the groins. Our study describes a groin recurrence of 7.6% in patients with less than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles.Conclusions: The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable with radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.

Vulvar carcinoma

Purpose : Controversies exist regarding the use of radiation therapy in the treatment of vulvar carcinoma. A retrospective review was performed to evaluate our institution's experience with surgery and radiation for this disease. Methods and Materials : The medical records of 47 patients treated for squamous cell carcinoma of the vulva at out institution (1974–1992) were reviewed for TNM stage (AJCC criteria), treatment modality, and associated 5-year local control and survival based on Kaplan-Meier analysis. Results : Twenty-eight patients (60%) presented with Stage I and II disease and their 5-year survival was 69%. Stage III patients accounted for 12 (25%) of the patients and their 5-year survival was 73%. Seven patients presented with Stage IV disease and five died within 13 months of diagnosis after predominantly palliative therapy. The 40 patients with Stages I, II, and III disease were treated aggressively and were further evaluated for treatment-modality-associated survival and local control. Radiation therapy was used as primary treatment in nine patients, or whom seven were treated with radiation alone and two were treated postoperatively after wide excision. Surgery alone was performed in 31 patients consisting of either radical vulvectomy (20 patients) or wide excision (11 patients). When comparing outcomes of radical vulvectomy vs. radiation therapy, we noted that the 5-year actuarial survivals were comparable (74% for either modality), despite the presence of more favorable prognostic factors in the group treated with radical vulvectomy. Patients treated with wide excision alone had a trend for a poorer 5-year actuarial survival (51%) and local control (50%). Conclusion : Radical vulvectomy offers good locoregional control and survival. This retrospective review further supports the use of radiation therapy with conservative surgery as an alternative treatment option for patients with vulvar carcinoma treated with curative intent. In contrast, the use of wide excision alone should be performed with caution due to a higher locoregional failure rate. The role of appropriately prescribed radiation therapy should be further investigated in prospective clinical trials.

Pretreatment sonographic evaluation of inguinal lymph nodes in patients with vulvar malignancy.

The state of the inguinal nodes is a major prognostic factor in vulvar carcinoma. Because of new surgical trends with selective inguinal lymphadenectomy, the preoperative evaluation of inguinal lymph nodes is essential for adequate treatment of vulvar carcinoma. To evaluate the adequacy of clinical examination and high-frequency transducer sonography in detecting metastatic inguinal lymph nodes, we studied 25 patients with vulvar malignancy who underwent operation. Histopathologically proved lymph node metastases were found in 11 (22%) of 50 inguinal areas studied. All of the suspected metastases were in patients with stage III-IV disease. The inguinal lymph node metastases were found by sonography in nine (82%), by preoperative palpation in one (9%), and by operative palpation in six (55%) of 11 areas. The difference between sonography and palpation was statistically significant (P < 0.01). The sensitivity and specificity were 82% and 87% for sonography, 9% and 100% for preoperative palpation, and 55% and 90% for operative palpation.

Wide local excision in the treatment of vulvar carcinoma in situ: A reappraisal

A retrospective study of 56 patients treated for carcinoma in situ of the vulva over a 24-year period has shown a relative increase in the occurrence of this neoplasm. Only 6.7% of patients in the first 14 years of the study period were less than 35 years of age, as compared with 29.3% in the last decade. In the earlier years of the study, simple vulvectomy was the primary treatment, and 81.3% of the patients were disease-free at 5 years. Wide local excision, used in the later years, resulted in a rate of 46.2% with no evidence of disease. Involvement of surgical margins played a significant role in this increased incidence of recurrence. Only one patient, originally treated by simple vulvectomy, later developed early stromal invasion. A wide local excision technique should be strongly considered as initial management of this multifocal neoplasm. Close follow-up is mandatory. Recurrence of disease may be treated with appropriate wide excision.

Treatment of vulvar carcinoma in situ with the CO 2 laser

Between January 1960 and December 1982, 142 patients with carcinoma in situ of the vulva were treated at Cedars-Sinai Medical Center and UCLA Medical Center. Primary treatment consisted of wide excision in 45 patients; vulvectomy in 23 patients; topical chemotherapy in 9 patients; and CO 2 laser therapy in 42 patients. Twenty-three patients were also treated with the CO 2 laser for recurrent disease. Multifocal disease was present in 59% of the cases. Lesions involving the posterior vulva recurred most commonly, for both initial and recurrent disease. Results utilizing the CO 2 are compared with the other methods of treating carcinoma in situ of the vulva. The CO 2 laser is well suited for treatment of both multifocal and unifocal vulvar lesions, as it allows for maximal retention of vulvar integrity with no decrease in therapeutic efficacy.

The use of dinitrochlorobenzene in the treatment of vulvar carcinoma in situ

Topical immunotherapy of vulvar carcinoma in situ (CIS) is attractive because the disease is often recurrent, multifocal, rarely invades, easily monitored for response, and affects a younger population. The sensitization, challenge, and topical use of DNCB (dinitrochlorobenzene) is described. Six patients with histopathologically proven CIS of the vulva, who failed to respond to surgery and/or topical 5-fluorouracil (Efudex), were studied. Five of the six patients had disappearance or marked improvement in their disease grossly and microscopically. Although DNCB therapy is proposed as a viable alternative to traditional modes of therapy, careful evaluation of local and systemic reactions are necessary to determine its “long-term” effectiveness.

Virus-modified homologus tumor-cell extract in the treatment of vulvar carcinoma

Eight patients with squamous carcinoma of the vulva and two or more positive nodes have received adjunctive immunotherapy with a virus modified homologous cell extract. Seven of eight patients received radiation therapy in addition. Cells derived from the SW962 vulvar carcinoma cell line were infected with PR8/A/34 strain of influenza and a membrane extract was used for immunization. The extract was administered by the intradermal route weekly for three doses and then biweekly for up to 2 years. Each dose is equivalent to 1.5 mg protein. None of the patients have recurred and durations of remission are 24, 24, 22, 22, 21, 16, 7, and 2 months respectively. This compares favourably with similar groups of patients who were treated with surgery alone (22/33 recurred, median recurrence time 14.8 months) or surgery plus radiation therapy (8/9 recurrences, median recurrence time 11.0 months). No serious side effects have occurred with more than 200 doses of extract. Post immunization monitoring has indicated good in vitro and in vivo immunological responses and antibody titers to PR8 increased significantly in five of eight patients.