Regular ArticlePrognostic Factors for Groin Node Metastasis in Squamous Cell Carcinoma of the Vulva (A Gynecologic Oncology Group Study)
Abstract
From 1977 to 1984 the Gynecologic Oncology Group (GOG) conducted a prospective clinical and surgical staging protocol of squamous cell carcinoma of the vulva (n = 637). The patients with superficial (5 mm or less invasion) lesions were the subject of a previous report (n = 272). The subject of this report is on factors that predict groin node metastasis based on all 588 evaluable patients. Comparisons between the two reports are made. Almost half of this group (49.3%) had minimal tumor thickness (⩽5 mm). Almost one-third of patients had small vulvar lesions (⩽2 cm). Groin node metastasis was 18.9% for the ⩽2-cm diameter tumors and 41.6% for the >2-cm diameter lesions. The inaccuracy of clinical palpation of the groin nodes (23.9% false negative) largely accounts for underestimation of extent of disease. Body weight was not related to the sensitivity of detecting positive groin nodes (P = 0.26). Using the logistic model, independent predictors of positive groin nodes were identified (in order of importance): less tumor differentiation by GOG criteria (P < 0.0001), suspicious or fixed/-ulcerated nodes (P < 0.0001), presence of capillary-lymphatic involvement (P < 0.0001), older age (P = 0.0002), and greater tumor thickness (invasion) (P = 0.03). Lesion size and location were not independent predictors of positive groin nodes.
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Vulvar cancer management and wrangling recurrent disease: A report from the society of gynecologic oncology journal club
2023, Gynecologic Oncology ReportsThe 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.
Invasive cancer of the vulva
2023, DiSaia and Creasman Clinical Gynecologic OncologyInvasive vulvar cancer is a relatively rare tumor, accounting for 4% of all female genital malignant neoplasms. Although classically a disease of elderly women, the trend in recent years is an increasing prevalence among younger women, which cannot be accounted for by immune suppression alone. Human papillomavirus (HPV) is a key age-dependent risk factor that causes preinvasive disease in the form of vulvar intraepithelial neoplasia (VIN) that is often associated with a history of tobacco use. HPV-related VIN lesions are rarer in older women, and these malignancies may be associated with chronic vulvar dystrophies, such as lichen sclerosis, although a direct association remains unproven. Staging is determined surgically and impacts prognosis significantly, with early stages having favorable prognoses while advanced stages portend a much poorer prognosis. Early-stage cancers are managed surgically in most cases with radical excision and lymphadenectomy. Advances in techniques have favored decreasing radicality of surgery with closer margins and sentinel lymph node biopsy. Locally advanced tumors often require combined chemoradiation. Metastatic disease is treated with systemic therapies, traditionally with cytotoxic chemotherapy, though immunotherapy is gaining favorability as more encouraging data are resulting. Recurrences may be local or distant, and more than 80% will occur in the first 2 years after therapy, demanding initial close follow-up.
Bartholin gland carcinomas
2023, Diagnosis and Treatment of Rare Gynecologic CancersApproximately 6000 women are diagnosed with vulvar cancer annually. Vulvar cancer is a rare disease accounting for 5% of all gynecologic malignancies. Among vulvar cancers, Bartholin gland carcinomas are rarer still, accounting for 1%–7% of all vulvar tumors and less than 1% of all gynecologic cancers. The Bartholin gland (also known as Bartholin’s gland, or greater vestibular gland) was first described by the Danish anatomist Caspar Bartholin in 1675 and has the normal function of providing vulvovaginal lubrication. The Bartholin glands and ducts are located bilaterally at approximately the 4 and 8 o’clock positions in the labia minora, with duct openings just proximal to the introitus, and with an approximate size of 0.5–1 cm. Bartholin gland carcinomas occur in women with a median age of 53 years. The average tumor size at diagnosis is 39 mm. Approximately 17% of all patients are diagnosed with stage I disease, and 28% are diagnosed with stage II disease. Approximately 32% of patients are found to have stage III disease, in which disease has reached the inguinofemoral lymph nodes. Approximately 23% of patients are diagnosed with stage IV disease. Among patients who undergo primary surgical treatment, 5-year survival ranges from 70% to 93%. Here, we present a clinical case of Bartholin gland carcinoma. We address the epidemiology, pathology, diagnosis, work-up, staging, prognostic factors, treatment of primary disease (including lymph node sampling, treatment of stage III or IV disease, postsurgical treatment, and surveillance for recurrence), survival, and patterns of failure for this rare gynecologic malignancy.
Preoperative predictors of inguinal lymph node metastases in vulvar cancer – A nationwide study
2022, Gynecologic OncologyCitation Excerpt :Thus, histological groin node status is the most important independent prognostic factor [6]. Knowledge of preoperative risk factors of advanced disease is sparse but histologic, localisation, tumour size and premalignant vulvar disease have been suggested to increase the risk of advanced disease [7–9]. During the last decades, standard treatment for VSCC has been radical excision of the vulvar tumour combined with either sentinel node (SN) biopsy or inguinal lymph node dissection in the groins according to tumour size and depth of invasion.
A combination of tumour size, differentiation grade and location may identify a group of vulvar squamous cell cancer (VSCC) patients with a very low risk of inguinal lymph node metastasis. We aim to examine these findings in a large national cohort of VSCC patients.
Population based prospective data on VSCC patients treated with vulvectomy and primary groin surgery was obtained from the Danish Gynaecological Cancer Database. Univariate chi-square and multivariate logistic regression analysis were used. Statistical tests were 2-sided. P-values of <0.05 were considered statistically significant.
In all, 388 VSCC patients were identified. Of these 264 (63.3%) were node negative and 121 (36.7%) node positive. Increasing tumour size (diameter ≤ 2 cm vs. > 2 to 4 cm), grade (1 vs. 2–3) and location of tumour to clitoris were all associated with a significantly increased risk of inguinal lymph node metastasis OR 2.81(95% CI 1.52–5.20), OR 3.19 (95% CI 1.77–5.74) and OR 2.74 (95% CI 1.56–5.20), respectively. Previous vulvar disease was not associated with lymph node metastasis.
No lymph node metastasis was demonstrated in patients with grade 1 tumours, tumour size less than 2 cm and located outside the clitoris area (n = 51).
VSCC patients with grade 1 tumours, ≤ 2 cm and without clitoral involvement have a very low risk of inguinal lymph node metastasis. These patients may be spared inguinal lymph node staging to decrease operating time and peri- and postoperative morbidity in the future. However, studies validating our findings are needed.
Clinical value of metabolic PET parameters of primary vulvar carcinoma
2021, Revista Espanola de Medicina Nuclear e Imagen MolecularNuestro propósito es establecer el valor pronóstico de los parámetros metabólicos del tumor primario en pacientes diagnosticadas de carcinoma vulvar de células escamosas (VSCC) en las que se realizó un 18F-FDG PET/TC pretratamiento.
Estudio retrospectivo que incluyó 47 pacientes con un diagnóstico histopatológico confirmado de VSCC en las que se realizó un 18F-FDG PET/TC antes del tratamiento. Se registraron la fase de la enfermedad, la edad de diagnóstico y el valor estandarizado de captación máximo (SUVmax), los valore de SUVmean, del volumen de tumor metabólico (MTV) y de la glucólisis total de la lesión (TLG) del tumor primario, según una PET basal. Se evaluó la relación entre estos factores, la supervivencia libre de progresión (PFS) y la supervivencia global (OS).
La edad media de las 47 pacientes del estudio era de 69,6 ± 1,9 años. Entre las pacientes, 18 estaban en la fase inicial de la enfermedad y 29 estaban en fase avanzada. La edad y los valores de SUVmax, SUVmean, MTV y TLG estaban asociados de forma estadísticamente significativa con la OS y PFS. Además, se observó que OS y PFS era significativamente mayor en las pacientes en fases iniciales que en las pacientes en fase avanzada; en pacientes con un tamaño del tumor < 4 cm que en aquellas con un tamaño del tumor de ≥ 4 cm y en pacientes con metástasis de ganglios linfáticos negativa respecto a aquellas con metástasis ganglionar positiva.
Nuestros resultados sugieren que los parámetros de la PET son factores pronósticos del VSCC. Hasta donde sabemos, este estudio es el primero en investigar el valor pronóstico de los parámetros PET de los tumores primarios en pacientes con VSCC, y por esta razón, creemos que contribuye a la literatura especializada.
We aim to establish the prognostic value of metabolic parameters of the primary tumor in patients diagnosed with vulvar squamous cell carcinoma (VSCC) who underwent a pretreatment 18F FDG PET/CT scan.
This retrospective study included 47 patients with a histopathologically confirmed diagnosis of VSCC, and who underwent a 18F FDG PET/CT scan prior to treatment. The disease stage and age at diagnosis, the maximum standardized uptake value (SUVmax), SUVmean, metabolic tumor volume (MTV) and total lesion glycolysis (TLG) values of the primary tumor, based on a baseline PET scan, were recorded. The relationship between these factors, and progression-free survival (PFS) and overall survival (OS) was evaluated.
The mean age of the 47 study patients was 69.6 ± 1.9 years. Among the patients, 18 were in early stage of the disease and 29 were in the advanced stage. The age, and SUVmax, SUVmean, MTV and TLG values were statistically significantly associated with OS and PFS. Furthermore, it was noted that OS and PFS were significantly longer in the early stage patients than in the advanced stage patients, in patients with a tumor size < 4 cm than those with a tumor size ≥ 4 cm, and in patients with a negative lymph node metastasis than those with a positive lymph node metastasis.
Our findings suggest that PET parameters are prognostic factors for VSCC. To the best of our knowledge, this study is the first to investigate the prognostic value of the PET parameters of primary tumors in patients with VSCC, and as such, we believe it contributes to literature.
Reports From Four International Clinical Trials for Cancers of the Cervix, Uterus and Vulva, and a New Guideline for Cervical Cancer
2021, International Journal of Radiation Oncology Biology Physics