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Harari CM, Brower JV, Gaffney DK, Bradley KA. Navigating the Complexities of Lymph Node Management in Vulvar Cancer: Insights and Perspectives. Pract Radiat Oncol 2024; 14:e220-e225. [PMID: 38336276 DOI: 10.1016/j.prro.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 01/30/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024]
Affiliation(s)
- Colin M Harari
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Jeffery V Brower
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Radiation Oncology Associates, Manchester, New Hampshire
| | - Dave K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Hospital, University of Utah, Salt Lake City, Utah
| | - Kristin A Bradley
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Pennington E, Bell S, Hill JE. Should video laryngoscopy or direct laryngoscopy be used for adults undergoing endotracheal intubation in the pre-hospital setting? A critical appraisal of a systematic review. JOURNAL OF PARAMEDIC PRACTICE : THE CLINICAL MONTHLY FOR EMERGENCY CARE PROFESSIONALS 2023; 15:255-259. [PMID: 38812899 PMCID: PMC7616025 DOI: 10.1002/14651858] [Citation(s) in RCA: 2725] [Impact Index Per Article: 1362.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The safety and utility of endotracheal intubation by paramedics in the United Kingdom is a matter of debate. Considering the controversy surrounding the safety of paramedic-performed endotracheal intubation, any interventions that enhance patient safety should be evaluated for implementation based on solid evidence of their effectiveness. A systematic review performed by Hansel and colleagues (2022) sought to assess compare video laryngoscopes against direct laryngoscopes in clinical practice. This commentary aims to critically appraise the methods used within the review by Hansel et al (2022) and expand upon the findings in the context of clinical practice.
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Affiliation(s)
| | - Steve Bell
- Consultant Paramedic, North West Ambulance Service NHS Trust
| | - James E Hill
- University of Central Lancashire, Colne, Lancashire
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3
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Thissen D, de Hullu JA, Janssen MJR, Aarts JWM. Can late lymphoscintigraphy be omitted in the sentinel node procedure in early-stage vulvar cancer? Acta Obstet Gynecol Scand 2022; 102:105-113. [PMID: 36412099 PMCID: PMC9780710 DOI: 10.1111/aogs.14476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/27/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION In the Netherlands, the sentinel lymph node procedure protocol consists of preoperative lymphoscintigraphy combined with intraoperative blue dye for identifying sentinel lymph nodes in early vulvar squamous cell carcinoma. This study aimed at investigating the role of early and late lymphoscintigraphy. MATERIAL AND METHODS From January 2015 to January 2019, early and late lymphoscintigraphies of 52 women were retrospectively analyzed. Lymphoscintigraphy was performed 30 minutes (early) and 2.5-4 hours (late) after vulvar injection of 99m Tc-labeled nanocolloid. We calculated the concordance correlation coefficient (CCC) between number of sentinel lymph nodes detected on both images using the Lins concordance coefficient and correlated with clinicopathological data. RESULTS Thirty-four women had a midline tumor and 18 had a lateral tumor. Detection rates with early and late scintigraphy were 88.5% and 98.1%, respectively. Median number of detected nodes was 1.0 (0-7) and 2.0 (0-7). Good statistical correlation between number of sentinel lymph nodes detected on early and late imaging was found (CCC = 0.76) in most patients. In 18 women (35%) a mismatch occurred: a higher number of nodes was detected on late imaging. In 11 of 18 women re-injection was performed because no sentinel lymph nodes were visualized on early images. Late imaging and intraoperative detection showed a good statistical correlation (CCC = 0.61). One woman showed an isolated groin recurrence despite negative sentinel lymph nodes. CONCLUSIONS This study showed good statistical correlations between early and late scintigraphy in most patients. However, in 35% of women late scintigraphy detected more nodes. In case of poor visualization after the first scintigraphy, re-injection should be considered. Late scintigraphy is probably helpful in confirming successful re-injection and in showing deviating lymph flow in women with failed mapping after the first injection and successful re-injection. Because missing metastatic sentinel lymph nodes often leads to a poor prognosis, we prefer optimal correlations between imaging and intraoperative identification. Hence, late scintigraphy cannot be safely omitted.
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Affiliation(s)
- Daniek Thissen
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Joanne A. de Hullu
- Department of Obstetrics and GynecologyRadboud University Medical CenterNijmegenthe Netherlands
| | - Marcel J. R. Janssen
- Department of Radiology and Nuclear MedicineRadboud University Medical CenterNijmegenthe Netherlands
| | - Johanna W. M. Aarts
- Department of Gynecological OncologyAmsterdam University Medical CenterAmsterdamThe Netherlands
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Wagner MM, van der Zee AGJ, Oonk MHM. History and Updates of the GROINSS-V Studies. Cancers (Basel) 2022; 14:1956. [PMID: 35454862 PMCID: PMC9033032 DOI: 10.3390/cancers14081956] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Maaike H. M. Oonk
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands; (M.M.W.); (A.G.J.v.d.Z.)
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5
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Abstract
Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors. A useful update for trainees and specialists regarding the diagnosis, staging, treatment, and some controversies in the management of vulvar neoplasms.
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Affiliation(s)
- Alexander B Olawaiye
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mauricio A Cuello
- Department of Gynecology, Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Linda J Rogers
- Division of Gynecological Oncology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.,South African Medical Research Council University of Cape Town Gynecological Cancer Research Centre (SA MRC UCT GCRC, Cape Town, South Africa
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6
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Tanis JB, Simlett-Moss AB, Ossowksa M, Maddox TW, Guillem J, Lopez-Jimenez C, Polton G, Burrow R, Finotello R. Canine anal sac gland carcinoma with regional lymph node metastases treated with sacculectomy and lymphadenectomy: Outcome and possible prognostic factors. Vet Comp Oncol 2021; 20:276-292. [PMID: 34590408 DOI: 10.1111/vco.12774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 01/04/2023]
Abstract
The staging system commonly used in canine anal sac gland carcinoma (ASGC) is a revised Tumour-Node-Metastasis (TNM) system published in 2007. This staging system consists in four stages and, for dogs with nodal metastases, the size of the metastatic lymph node (mLN) defines the N stage. However, we hypothesise that (1) the mLN size has no prognostic significance when the mLN can be excised, (2) a high number of mLNs is associated with poorer prognosis and (3) the measurement of the mLN on imaging is not reproducible. To investigate these hypotheses, medical records and diagnostic images of dogs with ASGC and mLN, treated with sacculectomy and lymphadenectomy, with or without chemotherapy, were reviewed. Interobserver variability for mLN measurement was assessed. Prognostic factors including mLN size and number were investigated. Time to documented progression (TDP) and disease-specific survival (DSS) were evaluated. Progression-free interval (PFI) was analysed with interval-censored data analysis. Fifty-seven dogs were included. The median PFI, TDP and DSS were 110 (95%CI 61.5-185.5), 196 (95%CI 162-283) and 340 days (95%CI 321-471), respectively. For measurement of the largest mLN, interobserver agreement was excellent but limits of agreement reached 39.7%. Neither the size of the largest mLN nor the use of adjuvant chemotherapy were associated with outcome. The number of mLNs was associated with outcome and having more than four mLNs was associated with shorter PFI (p < .001), TDP (p = .004) and DSS (p < .001). While mLN size measurement was not consistently reproducible and did not influence outcome in our cohort, number of mLNs did. Further studies are required for development of a revised staging system.
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Affiliation(s)
- Jean-Benoit Tanis
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
| | - Angharad B Simlett-Moss
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
| | - Malgorzata Ossowksa
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
| | - Thomas W Maddox
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
| | - James Guillem
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
| | | | - Gerry Polton
- North Downs Specialist Referrals, Bletchingley, UK
| | - Rachel Burrow
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK.,Northwest Veterinary Specialists, Runcorn, UK
| | - Riccardo Finotello
- Department of Small Animal Clinical Science, Institute of Infection, Veterinary and Ecological Science, University of Liverpool, Neston, UK
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7
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Gu H, Liu G, Li J, Chen J, Zhang X, Liu Z, Tu H. Long-term outcomes of individualized management after sentinel lymph-node biopsy for vulvar cancer. Int J Clin Oncol 2021; 26:784-793. [PMID: 33386557 DOI: 10.1007/s10147-020-01838-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The management for patients with vulvar cancer after sentinel lymph-node biopsy (SLNB) remains controversial. The aim of this study was to investigate the long-term outcomes of individualized management after SLNB for early stage vulvar cancer. METHODS The medical records of patients with vulvar cancer treated by surgery involving SLNB between 2004 and 2019 were retrospectively reviewed. During this period, the inguinofemoral lymphadenectomy (IL) were performed with individualized strategy, while the postoperative intensity-modulated radiotherapy was planned with a consistent policy. RESULTS We identified 138 patients with at least one sentinel node detected, of whom 64 underwent further IL while 74 had SLNB only. Nodal metastases (pN+) were confirmed in 22 patients with IL and 16 without. Radiotherapy was scheduled with the dose of 60-70 Gy for all pN+ patients and finally completed in 15 with IL and 15 without. The median follow-up time was 56 months (6-156 months). Recurrence was observed in 24 patients, of whom 10 were pN- at primary treatment. The 3-year overall survival (OS) was 97.2, 95.2, 68.3, and 71.8%; 3-year disease-free survival (DFS) was 94.5, 91.4, 60.2, and 59.2%, respectively, for patients with pN- and IL, pN- and SLNB, pN+ and IL, and pN+ and SLNB. Neither OS nor DFS showed significant difference between SLNB and IL in pN- (P = 0.564 for OS, P = 0.423 for DFS), or pN + patients (P = 0.920 for OS, P = 0.862 for DFS). CONCLUSIONS With appropriate adjuvant radiotherapy, SLNB alone provided similar long-term survival compared with IL for both patients with and without sentinel node metastasis.
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Affiliation(s)
- Haifeng Gu
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, China
| | - Guochen Liu
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, China
| | - Junyun Li
- Department of Radiology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Jieping Chen
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, China
| | - Xinke Zhang
- Department of Pathology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Zhimin Liu
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, China.
| | - Hua Tu
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-Sen University Cancer Center, 651 East Dongfeng Road, Guangzhou, China.
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8
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Vadi SK, Mittal BR. FDG PET/CT in Treatment Response Evaluation of Gynecological Malignancies. ATLAS OF CLINICAL PET-CT IN TREATMENT RESPONSE EVALUATION IN ONCOLOGY 2021:297-332. [DOI: 10.1007/978-3-030-68858-5_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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9
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Mukai Y, Koike I, Matsunaga T, Yokota NR, Kaizu H, Takano S, Sugiura M, Ito E, Miyagi E, Hata M. Outcome of Radiation Therapy for Locally Advanced Vulvar Carcinoma: Analysis of Inguinal Lymph Node. In Vivo 2020; 34:307-313. [PMID: 31882493 PMCID: PMC6984069 DOI: 10.21873/invivo.11775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/25/2019] [Accepted: 11/04/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM The aim of this study was to define the outcome of radiation therapy for vulvar carcinoma, and to investigate the effectiveness of therapeutic and prophylactic inguinal lymph node (ILN) irradiation. Because reports about the treatment of ILN were limited. PATIENTS AND METHODS Thirty consecutive vulvar carcinoma patients were treated using external beam radiation therapy (EBRT) for definitive disease (n=25) or postoperatively (n=5). Twenty-four (80%) had squamous cell carcinoma (SCC). Tumor stages (2002 UICC) ranged from 0 to IVB, with no distant metastases. RESULTS The median total prescribed dose for primary tumor was 64.8 Gy. The 2-year overall survival rate was 25.3%. The outcome was significantly better in patients with ILNs<30 mm (p=0.005) and patients receiving prescribed doses >60 Gy (p=0.002). CONCLUSIONS ILN diameters ≤30 mm and prescribed doses over 60 Gy were associated with ILN control in patients with vulvar carcinoma.
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Affiliation(s)
- Yuki Mukai
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Izumi Koike
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tatsuya Matsunaga
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naho Ruiz Yokota
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hisashi Kaizu
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shoko Takano
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Madoka Sugiura
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Eiko Ito
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Etsuko Miyagi
- Department of Obstetrics and Gynecology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masaharu Hata
- Department of Radiation Oncology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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10
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Abstract
Vulvar cancer is an uncommon gynecological malignancy primarily affecting postmenopausal women. There is no specific screening and the most effective strategy to reduce vulvar cancer incidence is the opportune treatment of predisposing and preneoplastic lesions associated with its development. While vulvar cancer may be asymptomatic, most women present with vulvar pruritus or pain, or have noticed a lump or ulcer. Therefore, any suspicious vulvar lesion should be biopsied to exclude invasion. Once established, the most common subtype is squamous cell carcinoma. Treatment of vulvar cancer depends primarily on histology and surgical staging. Treatment is predominantly surgical, particularly for squamous cell carcinoma, although concurrent chemoradiation is an effective alternative, particularly for advanced tumors. Management should be individualized, and carried out by a multidisciplinary team in a cancer center experienced in the treatment of these tumors.
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Affiliation(s)
- Linda J Rogers
- Division of Gynecological Oncology, Groote Schuur Hospital/University of Cape Town, Cape Town, South Africa.,South African Medical Research Council/University of Cape Town Gynaecological Cancer Research Centre (SA MRC/UCT GCRC), Cape Town, South Africa
| | - Mauricio A Cuello
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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11
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van der Velden J, Fons G. In response to Rydzewski NR et al. "Role of adjuvant external beam radiotherapy and chemotherapy in one versus two or more node-positive vulvar cancer: A National Cancer Database study". Radiother Oncol 2018; 131:242. [PMID: 30241790 DOI: 10.1016/j.radonc.2018.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Guus Fons
- Amsterdam UMC, Amsterdam, Netherlands
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12
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Lancellotta V, Kovács G, Tagliaferri L, Perrucci E, Colloca G, Valentini V, Aristei C. Age Is Not a Limiting Factor in Interventional Radiotherapy (Brachytherapy) for Patients with Localized Cancer. BIOMED RESEARCH INTERNATIONAL 2018; 2018:2178469. [PMID: 29581964 PMCID: PMC5822774 DOI: 10.1155/2018/2178469] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/04/2017] [Accepted: 12/25/2017] [Indexed: 01/23/2023]
Abstract
This review examines the role of interventional radiotherapy (IRT otherwise known as brachytherapy) in cancer treatment for elderly patients. Despite their advanced age and associated comorbidities, elderly patients should receive definitive cancer therapies, including surgery and radiotherapy (RT). In fact, RT becomes first-line option for patients who are not eligible for surgery (due to comorbidities, anticoagulant drugs, and risk of disfigurement) or those who refuse it. It emerged from this review of the literature as effective, simple, safe, and comfortable and was associated with good local control, low toxicity rates, and excellent cosmesis and provided a cost benefit. IRT may be used as sole treatment for small cancers or as a useful adjunct to surgery or external beam radiotherapy (EBRT) in more advanced (or lymph node positive) cases, especially when the aim is local control with adequate preservation of normal tissue function. As palliative treatment, IRT preserves quality of life and/or improves survival. It is to be hoped that this review will serve as a helpful guide for members of multidisciplinary teams that are involved in treating elderly patients with cancer.
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Affiliation(s)
- Valentina Lancellotta
- Radiation Oncology Section, Department of Surgery and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lübeck/UKSH-CL, Lübeck, Germany
| | - Luca Tagliaferri
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Roma, Italy
| | | | - Giuseppe Colloca
- Polo Scienze Oncologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Gruppo Italiano di Oncologia Geriatrica (GIOGER), Roma, Italy
| | - Vincenzo Valentini
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgery and Biomedical Sciences, University of Perugia and Perugia General Hospital, Perugia, Italy
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Mitra S, Sharma MK, Kaur I, Khurana R, Modi KB, Narang R, Mandal A, Dutta S. Vulvar carcinoma: dilemma, debates, and decisions. Cancer Manag Res 2018; 10:61-68. [PMID: 29386916 PMCID: PMC5765975 DOI: 10.2147/cmar.s143316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Vulvar carcinoma is a rare and aggressive gynecological malignancy. It affects elderly females, with the mean age at diagnosis being 55-60 years. Regional metastasis to inguinal lymph nodes is common. There is a high incidence of pelvic node involvement, especially in those with pathologically positive inguinal nodes. Surgery appears to be the only curative treatment option in the early stages of the disease. But in most patients, surgery is associated with considerable morbidities and psychosexual issues. Hence, in the quest for a less morbid form of treatment, multimodality approaches with various combinations of surgery, chemotherapy, and radiation therapy have been suggested for advanced vulvar cancers. Due to the low incidence of the disease, the level of evidence for the success of these treatment modalities is poor. In countries like India, a heterogeneous incidence of vulvar carcinoma exists across the country, with patients presenting at advanced stages when the option of surgery is often supplemented or replaced by chemotherapy and radiotherapy. In this review, we attempt to study the available published literature and trials and discuss the treatment options in various stages of vulvar carcinoma.
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Affiliation(s)
- Swarupa Mitra
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Manoj Kumar Sharma
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Inderjeet Kaur
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Ruparna Khurana
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Kanika Batra Modi
- Department of Genitourinary Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Raman Narang
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Avik Mandal
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
| | - Soumya Dutta
- Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Center, New Delhi, India
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14
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Swanick CW, Eifel PJ, Huo J, Meyer LA, Smith GL. Challenges to delivery and effectiveness of adjuvant radiation therapy in elderly patients with node-positive vulvar cancer. Gynecol Oncol 2017; 146:87-93. [PMID: 28506563 DOI: 10.1016/j.ygyno.2017.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 05/04/2017] [Accepted: 05/05/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine adjuvant radiation therapy (RT) use, patterns of RT delivery, and clinical outcomes in older patients with node-positive vulvar cancer. METHODS Using SEER-Medicare linked data, we identified 444 patients (age≥66years) with node-positive squamous cell vulvar carcinoma, without distant metastases, and treated with primary surgery between 1991 and 2009. We used claims to examine RT use and the following delivery metrics: 1) completion of ≥20 fractions, 2) treatment duration <8weeks, 3) <1week of intra-treatment break, and 4) treatment interval from surgery to start of RT <8weeks. We tested associations between RT use and metrics with overall (OS) and cause-specific survival (CSS) using multivariate proportional hazards regression. RESULTS Median age was 78years (interquartile range [IQR]=74-83). Median follow-up was 17months (IQR=9-40). Three hundred six patients (69%) received RT. Three delivery metrics were associated with improved outcomes: completion of ≥20 fractions, treatment duration <8weeks, and <1week of intra-treatment break. Patients who achieved these 3 metrics demonstrated better disease outcomes compared with surgery alone (OS hazard ratio [HR] for death=0.62, 95% confidence interval [CI]=0.46-0.82, P=0.001; CSS HR=0.58, 95% CI=0.40-0.85,P=0.005). Patients not achieving RT metrics demonstrated marginal improvements in disease outcomes over surgery alone (OS HR=0.73, 95% CI=0.55-0.99,P=0.04; CSS HR=0.76, 95% CI=0.52-1.11, P=0.16). Notably, only 51% of patients who received RT achieved all benchmarks. CONCLUSIONS In this cohort of older women with node-positive vulvar cancer, achieving metrics for RT delivery was an important factor for optimizing disease benefits from treatment.
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Affiliation(s)
- Cameron W Swanick
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Patricia J Eifel
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jinhai Huo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Larissa A Meyer
- Department of Gynecologic Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Grace L Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States; Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
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15
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Affiliation(s)
- Neville F Hacker
- Gynecologic Oncology Cancer Centre, Royal Hospital for Women, Randwick, Australia
| | - Patricia J Eifel
- Department of Radiation Oncology, M.D. Anderson Cancer Center, Houston, TX, USA
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16
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High Incidence of Erysipelas After Surgical Treatment for Vulvar Carcinoma. Int J Gynecol Cancer 2016; 26:582-7. [DOI: 10.1097/igc.0000000000000625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Gaffney DK, King B, Viswanathan AN, Barkati M, Beriwal S, Eifel P, Erickson B, Fyles A, Goulart J, Harkenrider M, Jhingran A, Klopp A, Koh WJ, Lim K, Petersen I, Portelance L, Small W, Stewart A, Wiebe E, Wolfson A, Yashar C, Bosch W. Consensus Recommendations for Radiation Therapy Contouring and Treatment of Vulvar Carcinoma. Int J Radiat Oncol Biol Phys 2016; 95:1191-200. [PMID: 27130794 DOI: 10.1016/j.ijrobp.2016.02.043] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 01/05/2016] [Accepted: 02/11/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to develop a radiation therapy (RT) contouring atlas and recommendations for women with postoperative and locally advanced vulvar carcinoma. METHODS AND MATERIALS An international committee of 35 expert gynecologic radiation oncologists completed a survey of the treatment of vulvar carcinoma. An initial set of recommendations for contouring was discussed and generated by consensus. Two cases, 1 locally advanced and 1 postoperative, were contoured by 14 physicians. Contours were compared and analyzed using an expectation-maximization algorithm for simultaneous truth and performance level estimation (STAPLE), and a 95% confidence interval contour was developed. The level of agreement among contours was assessed using a kappa statistic. STAPLE contours underwent full committee editing to generate the final atlas consensus contours. RESULTS Analysis of the 14 contours showed substantial agreement, with kappa statistics of 0.69 and 0.64 for cases 1 and 2, respectively. There was high specificity for both cases (≥99%) and only moderate sensitivity of 71.3% and 64.9% for cases 1 and 2, respectively. Expert review and discussion generated consensus recommendations for contouring target volumes and treatment for postoperative and locally advanced vulvar cancer. CONCLUSIONS These consensus recommendations for contouring and treatment of vulvar cancer identified areas of complexity and controversy. Given the lack of clinical research evidence in vulvar cancer radiation therapy, the committee advocates a conservative and consistent approach using standardized recommendations.
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Affiliation(s)
- David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Hospital, Salt Lake City, Utah.
| | - Bronwyn King
- Department of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre and Epworth Radiation Oncology, Melbourne, Victoria, Australia
| | - Akila N Viswanathan
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Harvard Medical School, Boston, Massachusetts
| | - Maroie Barkati
- Department of Radiation Oncology, Centre hospitalier de l'universite de Montreal, Montreal, Quebec, Canada
| | - Sushil Beriwal
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Patricia Eifel
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Beth Erickson
- Department of Radiation Oncology, Proedtert and Medical College Clinical Cancer Center, Milwaukee, Wisconsin
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jennifer Goulart
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada
| | - Matthew Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - Anuja Jhingran
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Wui-Jin Koh
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Karen Lim
- Liverpool Cancer Therapy Centre, Radiation Oncology Unit, Sydney, New South Wales, Australia
| | - Ivy Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Lorraine Portelance
- Radiation Oncology Department, Miller School of Medicine, University of Miami, Miami, Florida
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - Alexandra Stewart
- St. Luke's Cancer Centre, Royal Surrey Country Hospital, Surrey, United Kingdom
| | - Ericka Wiebe
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Aaron Wolfson
- Radiation Oncology Department, Miller School of Medicine, University of Miami, Miami, Florida
| | - Catheryn Yashar
- Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California
| | - Walter Bosch
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri
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18
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Imoto S, Inamine M, Kudaka W, Nagai Y, Wakayama A, Nakamoto T, Ooyama T, Aoki Y. Prognostic factors in patients with vulvar cancer treated with primary surgery: a single-center experience. SPRINGERPLUS 2016; 5:125. [PMID: 26933624 PMCID: PMC4759437 DOI: 10.1186/s40064-016-1767-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 02/12/2016] [Indexed: 11/10/2022]
Abstract
Vulvar cancer is a relatively rare disease. The aim of this study was to investigate prognostic factors in vulvar squamous cell carcinoma patients treated with primary surgery. Forty cases of vulvar squamous cell carcinoma treated with primary surgery were retrospectively analyzed. Overall survival (OS) and disease-specific survival (DSS) were calculated using the Kaplan–Meier method and prognostic factors were analyzed by multivariate analyses. The median age was 68 years. The FIGO stage distribution was as follows: 18 cases (45.0 %) in stage I, four cases (10.0 %) in stage II, 15 cases (37.5 %) in stage III, and three cases (7.5 %) in stage IV. A radical local excision was performed in 15 patients, and radical vulvectomy in 25 patients, and seven of these patients were treated with postoperative RT. The 5-year DSS rate was 72.6 %, and the 5-year OS rate was 70.3 %. Age and surgical margin ≤5 mm were independent prognostic factors for OS, and positive inguinal LN metastasis and surgical margin ≤5 mm were identified as independent prognostic factors for DSS. Complete radical excision is important regardless of operation mode. Adjuvant treatment should be considered for inguinal LN positive patients.
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Affiliation(s)
- Sayaka Imoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Morihiko Inamine
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Wataru Kudaka
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Yutaka Nagai
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Akihiko Wakayama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Tomoko Nakamoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Takuma Ooyama
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
| | - Yoichi Aoki
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara, Okinawa, 903-0215 Japan
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Platt SL, Manley KM, Murdoch JB. Review of the current surgical management of vulval cancer. World J Obstet Gynecol 2016; 5:97-101. [DOI: 10.5317/wjog.v5.i1.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/03/2015] [Accepted: 01/07/2016] [Indexed: 02/05/2023] Open
Abstract
Currently in the United Kingdom, 1200 cases of vulval cancer are diagnosed per annum accounting for 6% of female genital cancers. Although classically a condition that affects older women and associated with lichen sclerosus, there has been a greater incidence of vulval squamous tumours in young women due to the increasing prevalence of promoting human papillomavirus (HPV). The advent of a vaccination programme against HPV 16 and 18, the main aetiological causes of vulval intraepithelial neoplasia and cervical intraepithelial neoplasia, may reduce the incidence in future generations. Primary surgery is the current gold standard treatment and although mortality rates have reduced by 40% since the 1970s, radical vulval resections are associated with significant morbidity such as wound breakdown, infection, lymphoedema and psychosexual consequences. Over the past decade there has been a move to less mutilating procedures in women diagnosed with early vulval cancer. This is in combination with the introduction of new surgical methods such as sentinel lymph node testing, more directed radiotherapy and chemotherapy options. These treatment methods are being assessed in clinical trials to determine their associated recurrence rates, survival rates and morbidity. Most vulval cancers are squamous cell in origin but, there are other histological subtypes including Paget’s disease and vulval melanoma which can require different management approaches. The objective of this paper is to review the current literature on the management of vulval cancer, summarise the new treatments which are being developed and the associated evidence.
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Woelber L, Eulenburg C, Grimm D, Trillsch F, Bohlmann I, Burandt E, Dieckmann J, Klutmann S, Schmalfeldt B, Mahner S, Prieske K. The Risk of Contralateral Non-sentinel Metastasis in Patients with Primary Vulvar Cancer and Unilaterally Positive Sentinel Node. Ann Surg Oncol 2016; 23:2508-14. [DOI: 10.1245/s10434-016-5114-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Indexed: 11/18/2022]
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Hacker NF, Barlow EL. Staging for vulvar cancer. Best Pract Res Clin Obstet Gynaecol 2015; 29:802-11. [DOI: 10.1016/j.bpobgyn.2015.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/27/2015] [Indexed: 11/16/2022]
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Berger J, Scott E, Sukumvanich P, Smith A, Olawaiye A, Comerci J, Kelley JL, Beriwal S, Huang M. The effect of groin treatment modality and sequence on clinically significant chronic lymphedema in patients with vulvar carcinoma. Int J Gynecol Cancer 2015; 25:119-24. [PMID: 25415076 DOI: 10.1097/igc.0000000000000311] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Chronic lymphedema (CL) after inguinal lymph node dissection (ILND) or radiotherapy (RT) is a significant problem for vulvar cancer survivors. The treatment modality or combination of therapies that poses the greatest risk is not known. The objective of this study was to describe rates of clinically significant CL conferred by different groin treatment modalities. METHODS Medical records of vulvar cancer patients who had groin treatment with ILND, RT, or both were retrospectively reviewed. Each treated groin was considered individually, and divided into 4 treatment groups: ILND alone, ILND with adjuvant RT, neoadjuvant chemoradiation therapy (NCRT), or NCRT followed by ILND. Clinically significant CL was defined as that which required treatment and was recorded by laterality. Differences among groups were evaluated with χ(2) and Fisher exact test. RESULTS Between 2000 and 2010, 146 patients with vulvar cancer who underwent therapy to 1 or both groins were identified for a total of 266 treated groins. The rates of CL for single-modality treatment, ILND or NCRT, were 10.9% and 6.7%, respectively. Multimodal treatment resulted in higher rates of CL, 13.5% for ILND followed by RT and 17.2% for NCRT followed by ILND, although differences were not significant (P = 0.37). CONCLUSIONS Clinically significant CL was not different between treatment modalities in this study, but is underpowered. The results provide valuable information about treatment complications that will be useful for patient-centered counseling. Prospective evaluation of CL and its impact on quality of life is warranted.
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Affiliation(s)
- Jessica Berger
- *Division of Gynecologic Oncology, †Department of Obstetrics, Gynecology, and Reproductive Sciences, and ‡Department of Radiation Oncology, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA
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Erickson BK, Divine LM, Leath CA, Straughn JM. Cost-effectiveness analysis of sentinel lymph node biopsy in the treatment of early-stage vulvar cancer. Int J Gynecol Cancer 2014; 24:1480-5. [PMID: 25188883 PMCID: PMC6887568 DOI: 10.1097/igc.0000000000000222] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine the costs and outcomes of inguinal-femoral lymph node dissection (IF-LND) versus sentinel lymph node biopsy (SLNB) for the management of early-stage vulvar cancer. METHODS A cost-effectiveness model compared 2 different strategies for the management of early-stage vulvar cancer: (1) vulvectomy and SLNB and (2) vulvectomy and IF-LND. Probabilities of inguinal-femoral node metastases and recurrence rates associated with each strategy were estimated from published data. Actual payer costs of surgery and radiation therapy were obtained using 2012 CPT codes and Medicare payment information. Rates and costs of postoperative complications including lymphedema, lymphocyst formation, and infection were estimated and included in a separate model. Cost-effectiveness ratios were determined for each strategy. Sensitivity analyses were performed to evaluate pertinent uncertainties in the models. RESULTS For the estimated 3000 women diagnosed annually with early-stage vulvar cancer in the United States, the annual cost of the SLNB strategy is $65.2 million compared with $76.8 million for the IF-LND strategy. Three-year inguinal-femoral recurrence-free survival was similar between groups (96.9% vs 97.3%). This translates into a lower cost-effectiveness ratio for the SLNB strategy ($22,416), compared with the IF-LND strategy ($26,344). When adding complication costs to the model, cost-effectiveness ratios further favor the SLNB strategy ($23,711 vs $31,198). Sensitivity analysis revealed that the SLNB strategy remained cost-effective until the recurrence rate after a negative sentinel lymph node approaches 9%. CONCLUSIONS Sentinel lymph node biopsy is the most cost-effective strategy for the management of patients with early-stage vulvar cancer due to lower treatment costs and lower costs due to complications.
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Affiliation(s)
- Britt K. Erickson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura M. Divine
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Charles A. Leath
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - J. Michael Straughn
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
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Glaser S, Olawaiye A, Huang M, Beriwal S. Inguinal nodal region radiotherapy for vulvar cancer: are we missing the target again? Gynecol Oncol 2014; 135:583-5. [PMID: 25128606 DOI: 10.1016/j.ygyno.2014.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 07/30/2014] [Accepted: 08/04/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Scott Glaser
- University of Pittsburgh Cancer Institute, Department of Radiation Oncology, USA
| | | | - Marilyn Huang
- Division of Gynecologic Oncology - Magee Women's Hospital of UPMC, USA
| | - Sushil Beriwal
- University of Pittsburgh Cancer Institute, Department of Radiation Oncology, USA.
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Lawrie TA, Patel A, Martin‐Hirsch PPL, Bryant A, Ratnavelu NDG, Naik R, Ralte A, Cochrane Gynaecological, Neuro‐oncology and Orphan Cancer Group. Sentinel node assessment for diagnosis of groin lymph node involvement in vulval cancer. Cochrane Database Syst Rev 2014; 2014:CD010409. [PMID: 24970683 PMCID: PMC6457826 DOI: 10.1002/14651858.cd010409.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Vulval cancer is usually treated by wide local excision with removal of groin lymph nodes (inguinofemoral lymphadenectomy) from one or both sides, depending on the tumour location. However, this procedure is associated with significant morbidity. As lymph node metastasis occurs in about 30% of women with early vulval cancer, accurate prediction of lymph node metastases could reduce the extent of surgery in many women, thereby reducing morbidity. Sentinel node assessment is a diagnostic technique that uses traceable agents to identify the spread of cancer cells to the lymph nodes draining affected tissue. Once the sentinel nodes are identified, they are removed and submitted to histological examination. This technique has been found to be useful in diagnosing the nodal involvement of other types of tumours. Sentinel node assessment in vulval cancer has been evaluated with various tracing agents. It is unclear which tracing agent or combination of agents is most accurate. OBJECTIVES To assess the diagnostic test accuracy of various techniques using traceable agents for sentinel lymph node assessment to diagnose groin lymph node metastasis in women with FIGO stage IB or higher vulval cancer and to investigate sources of heterogeneity. SEARCH METHODS We searched MEDLINE (1946 to February 2013), EMBASE (1974 to March 2013) and the relevant Cochrane trial registers. SELECTION CRITERIA Studies that evaluated the diagnostic accuracy of traceable agents for sentinel node assessment (involving the identification of a sentinel node plus histological examination) compared with histological examination of removed groin lymph nodes following complete inguinofemoral lymphadenectomy (IFL) in women with vulval cancer, provided there were sufficient data for the construction of two-by-two tables. DATA COLLECTION AND ANALYSIS Two authors (TAL, AP) independently screened titles and abstracts for relevance, classified studies for inclusion/exclusion and extracted data. We assessed the methodological quality of studies using the QUADAS-2 tool. We used univariate meta-analytical methods to estimate pooled sensitivity estimates. MAIN RESULTS We included 34 studies evaluating 1614 women and approximately 2396 groins. The overall methodological quality of included studies was moderate. The studies included in this review used the following traceable techniques to identify sentinel nodes in their participants: blue dye only (three studies), technetium only (eight studies), blue dye plus technetium combined (combined tests; 13 studies) and various inconsistent combinations of these three techniques (mixed tests; 10 studies). For studies of mixed tests, we obtained separate test data where possible.Most studies used haematoxylin and eosin (H&E) stains for the histological examination. Additionally an immunohistochemical (IHC) stain with and without ultrastaging was employed by 14 and eight studies, respectively. One study used reverse transcriptase polymerase chain reaction analysis (CA9 RT-PCR), whilst three studies did not describe the histological methods used.The pooled sensitivity estimate for studies using blue dye only was 0.94 (68 women; 95% confidence interval (CI) 0.69 to 0.99), for mixed tests was 0.91 (679 women; 95% CI 0.71 to 0.98), for technetium only was 0.93 (149 women; 95% CI 0.89 to 0.96) and for combined tests was 0.95 (390 women; 95% CI 0.89 to 0.97). Negative predictive values (NPVs) for all index tests were > 95%. Most studies also reported sentinel node detection rates (the ability of the test to identify a sentinel node) of the index test. The mean detection rate for blue dye alone was 82%, compared with 95%, 96% and 98% for mixed tests, technetium only and combined tests, respectively. We estimated the clinical consequences of the various tests for 100 women undergoing the sentinel node procedure, assuming the prevalence of groin metastases to be 30%. For the combined or technetium only tests, one and two women with groin metastases might be 'missed', respectively (95% CI 1 to 3); and for mixed tests, three women with groin metastases might be 'missed' (95% CI 1 to 9). The wide CIs associated with the pooled sensitivity estimates for blue dye and mixed tests increased the potential for these tests to 'miss' women with groin metastases. AUTHORS' CONCLUSIONS There is little difference in diagnostic test accuracy between the technetium and combined tests. The combined test may reduce the number of women with 'missed' groin node metastases compared with technetium only. Blue dye alone may be associated with more 'missed' cases compared with tests using technetium. Sentinel node assessment with technetium-based tests will reduce the need for IFL by 70% in women with early vulval cancer. It is not yet clear how the survival of women with negative sentinel nodes compares to those undergoing standard surgery (IFL). A randomised controlled trial of sentinel node dissection and IFL has methodological and ethical issues, therefore more observational data on the survival of women with early vulval cancer are needed.
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Affiliation(s)
- Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
| | - Amit Patel
- University Hospitals Bristol NHS Foundation TrustGynaecological OncologySt Michaels HospitalSouthwell StreetBristolUKBS2 8EG
| | - Pierre PL Martin‐Hirsch
- Royal Preston Hospital, Lancashire Teaching Hospital NHS TrustGynaecological Oncology UnitSharoe Green LaneFullwoodPrestonLancashireUKPR2 9HT
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Nithya DG Ratnavelu
- Northern Gynaecological Oncology CentreGynaecological OncologyQueen Elizabeth HospitalSheriff HillGatesheadTyne and WearUKNE9 6SX
| | - Raj Naik
- Northern Gynaecological Oncology CentreQueen Elizabeth HospitalGatesheadTyne and WearUKNE9 6SX
| | - Angela Ralte
- Queen Elizabeth HospitalPathology DepartmentGatesheadUKNE9 6SX
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van de Nieuwenhof HP, Oonk MHM, de Hullu JA, van der Zee AGJ. Vulvar squamous cell carcinoma. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.09.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mahner S, Trillsch F, Kock L, Rohsbach D, Petersen C, Kruell A, Harter P, Jaenicke F, Woelber L. Adjuvant therapy in node-positive vulvar cancer. Expert Rev Anticancer Ther 2014; 13:839-44. [DOI: 10.1586/14737140.2013.811063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Richter S, Ruether JD, Wood L, Canil C, Moretto P, Venner P, Gingerich J, Emmenegger U, Eisen A, Zalewski P, Joshua A, Mukherjee SD, Heng D, Czaykowski P, Soulieres D, Blais N, Rendon R, Fleshner N, Crook JM, Sridhar SS. Management of carcinoma of the penis: Consensus statement from the Canadian Association of Genitourinary Medical Oncologists (CAGMO). Can Urol Assoc J 2013; 7:E797-811. [PMID: 24475001 PMCID: PMC3879728 DOI: 10.5489/cuaj.1794] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Suzanne Richter
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - J. Dean Ruether
- Medical Oncology, Southern Alberta Cancer Research Institute, Alberta Health Services, Calgary, AB
| | - Lori Wood
- Division of Medical Oncology, Queen Elizabeth II Heath Sciences Centre, Halifax, NS
| | - Christina Canil
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre; and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Patricia Moretto
- Department of Medicine, Division of Medical Oncology, The Ottawa Hospital Cancer Centre; and The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - Peter Venner
- Department of Oncology, University of Alberta, Cross Cancer Institute, Edmonton, AB
| | - Joel Gingerich
- Division of Medical Oncology, Cancer Care Manitoba, University of Manitoba, Winnipeg, MB
| | - Urban Emmenegger
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Research Institute, Toronto, ON
| | - Andrea Eisen
- Division of Medical Oncology, Odette Cancer Centre, Sunnybrook Research Institute, Toronto, ON
| | - Pawel Zalewski
- Division of Oncology, Lakeridge Health Centre, Toronto, ON
| | - Anthony Joshua
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | | | | | - Piotr Czaykowski
- Division of Medical Oncology, Cancer Care Manitoba, University of Manitoba, Winnipeg, MB
| | - Denis Soulieres
- Hematology and Medical Oncology Service, Department of Medicine, Centre Hospitalier de l’Universite de Montreal, Montreal, Montreal, QC
| | - Norman Blais
- Hematology and Medical Oncology Service, Department of Medicine, Centre Hospitalier de l’Universite de Montreal, Montreal, Montreal, QC
| | - Ricardo Rendon
- Department of Surgery, Dalhousie University, Halifax, NS
| | - Neil Fleshner
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - Juanita M. Crook
- BC Cancer Agency Sindi Ahluwalia Hawkins Centre for the Southern Interior, Kelowna, BC
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Kramer F, Hertel H, Hillemanns P. Use of the Sentinel Lymph Node Technique Compared to Complete Inguino-femoral Lymph Node Removal in Patients with Invasive Vulvar Cancer in Germany. Geburtshilfe Frauenheilkd 2013; 73:142-147. [PMID: 24771911 DOI: 10.1055/s-0032-1328133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 10/31/2012] [Accepted: 12/13/2012] [Indexed: 10/27/2022] Open
Abstract
In the current S2 guidelines, the standard surgical therapy for patients with vulvar cancer also includes inguino-femoral lymphadenectomy. However, in view of the severe side-effects associated with this approach such as problems with wound healing, lymphoceles and lymphoedema, the search is on for alternative treatments that could decrease treatment-associated morbidity and improve patients' quality of life, particularly for node-negative patients. The sentinel lymph node technique is currently the gold standard in the treatment of unifocal breast cancer (clinically negative axilla), and studies on the use of this technique in the treatment of vulvar cancer are promising. To date, the diagnostic accuracy of this method in vulvar cancer has only been evaluated in a single, one-arm, non-randomised, multicentre study. In preparation for a multicentre study, in 2010 we surveyed 41 German hospitals to investigate how often they used the sentinel lymph node technique compared to inguino-femoral lymphadenectomy. The hospitals were grouped according to hospital size and number of patients treated for vulvar cancer. The decision criteria to determine the type of procedure performed were also investigated. Finally, the hospitals were asked whether they would be willing to participate in a prospective clinical study to evaluate the sentinel lymph node technique in patients with vulvar cancer. The majority of surgeons questioned (73 %) already had some experience with this technique in patients with vulvar cancer. In our survey, 27 % of hospitals carried out inguino-femoral lymphadenectomy, 10 % used the sentinel lymph node technique, and 63 % used both methods. In 24 % of hospitals, the standard procedure consisted of the sentinel lymph node technique supplemented by inguino-femoral lymphadenectomy. Only 20 % of the institutions surveyed in our study carried out sentinel lymph node biopsy alone in accordance with the criteria of the consensus recommendations. The majority of the investigated institutions were willing to participate in a randomised prospective clinical study to evaluate the effectiveness of sentinel lymph node sampling in patients with vulvar cancer.
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Affiliation(s)
- F Kramer
- Gynecology and Obstetrics, Medical School Hanover, Hanover
| | - H Hertel
- Gynecology and Obstetrics, Medical School Hanover, Hanover
| | - P Hillemanns
- Gynecology and Obstetrics, Medical School Hanover, Hanover
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Xu LQ, Luo RZ, Sun XM, He JH, Zhang YN. Prognostic analysis of early-stage squamous cell carcinoma of the vulva. World J Surg Oncol 2013; 11:20. [PMID: 23351240 PMCID: PMC3579684 DOI: 10.1186/1477-7819-11-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 12/23/2012] [Indexed: 11/23/2022] Open
Abstract
Aim The aim of this study was to analyze prognostic factors of early-stage squamous cell carcinoma of the vulva. Methods A retrospective analysis was conducted on 35 patients who were treated for early-stage squamous cell carcinoma of the vulva at Sun Yat-sen University Cancer Center from January 1980 to December 2005. The Statistical Package for Social Science (SPSS) was used to compare the different strategies of operation and to analyze the prognostic factors. Results Thirty-five patients had early-stage squamous cell carcinoma of the vulva. Of these cases, 26 were well differentiated, seven were moderately differentiated, and two were poorly differentiated. The five-year survival rate was 77.1%. Five cases were in FIGO stage 1a and 30 cases were in stage 1b; median survival times were 182.3 months and 152.5 months, and the five-year survival rates were 100% and 81.5% (P >0.05), respectively. The five-year survival of the patients who underwent local excision; radical vulvectomy and en bloc resection of inguinofemoral lymphadenectomy; orradical vulvectomyen bloc resection of inguinofemoral lymphadenectomy, and pelvic lymph nodes was 50%, 81.8%, and 83.9%, respectively. For these cases, 74.3% of the tumors were medial while 25.7% were lateral, and the five-year survival rates of patients according to tumor location were 87.0% and 64.8% (P <0.05), respectively. The inguinal lymph node not increased and active were 16 cases (45.7%), and increased, active and hard were 17 cases (48.6%), and syncretic were two cases (5.7%), five-year survival rates were 73.3%, 92.9% and 50% (P <0.05), respectively. Of these cases, 74.3% of the tumors were cauliflower-like and 25.7% were nodular; five-year survival rates by tumor type were 91.3% and 66.7% (P <0.05), respectively. Conclusions For patients with early-stage squamous cell carcinoma of the vulva, surgical operation is the primary, yet the best, treatment. The related prognostic factors were tumor location (lateral/medial), stage, gross morphology, and clinical state of the inguinal lymph node.
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Affiliation(s)
- Li-Qun Xu
- Department of Gynecology, State Key Laboratory of Oncology in South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, 510060, P, R, China
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Sentinel Lymph Node Biopsy in Vulvar Cancer: A Health Technology Assessment for the Canadian Health Care Context. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:1053-1065. [DOI: 10.1016/s1701-2163(16)35435-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Lee J, Kim SH, Kim G, Yu M, Park DC, Yoon JH, Yoon SC. Treatment outcome in patients with vulvar cancer: comparison of concurrent radiotherapy to postoperative radiotherapy. Radiat Oncol J 2012; 30:20-6. [PMID: 23120740 PMCID: PMC3475959 DOI: 10.3857/roj.2012.30.1.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 03/12/2012] [Accepted: 03/21/2012] [Indexed: 11/11/2022] Open
Abstract
Purpose To evaluate outcome and morbidity in patients with vulvar cancer treated with radiotherapy, concurrent chemoradiotherapy or postoperative radiotherapy. Materials and Methods The records of 24 patients treated with radiotherapy for vulvar cancer between July 1993 and September 2009 were retrospectively reviewed. All patients received once daily 1.8-4 Gy fractions external beam radiotherapy to median 51.2 Gy (range, 19.8 to 81.6 Gy) on pelvis and inguinal nodes. Seven patients were treated with primary concurrent chemoradiotherapy, one patient was treated with primary radiotherapy alone, four patients received palliative radiotherapy, and twelve patients were treated with postoperative radiotherapy. Results Twenty patients were eligible for response evaluation. Response rate was 55% (11/20). The 5-year disease free survival was 42.2% and 5-year overall survival was 46.2%, respectively. Fifty percent (12/24) experienced with acute skin complications of grade III or more during radiotherapy. Late complications were found in 8 patients. 50% (6/12) of patients treated with lymph node dissection experienced severe late complications. One patient died of sepsis from lymphedema. However, only 16.6% (2/12) of patients treated with primary radiotherapy developed late complications. Conclusion Outcome of patients with vulvar cancer treated with radiotherapy showed relatively good local control and low recurrence. Severe late toxicities remained higher in patients treated with both node dissection and radiotherapy.
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Affiliation(s)
- Jayoung Lee
- Department of Radiation Oncology, St. Vincent's Hospital, The Catholic University of Korea School of Medicine, Suwon, Korea
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Bloemers MCWM, Portelance L, Ruo R, Parker W, Souhami L. A dosimetric evaluation of dose escalation for the radical treatment of locally advanced vulvar cancer by intensity-modulated radiation therapy. Med Dosim 2012; 37:310-3. [PMID: 22317848 DOI: 10.1016/j.meddos.2011.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 09/26/2011] [Accepted: 11/29/2011] [Indexed: 10/14/2022]
Abstract
The purpose of this planning study was to determine whether intensity-modulated radiation therapy (IMRT) reduces the radiation dose to organs at risk (OAR) when compared with 3D conventional radiation therapy (3D-CRT) in patients with vulvar cancer treated by irradiation. This study also investigated the use of sequential IMRT boost (seq-IMRT) and simultaneous integrated boost (SIB-IMRT) for dose escalation in the treatment of locally advanced vulvar cancer. Five vulvar cancer patients treated in the postoperative setting and 5 patients treated with definitive intent (def-group) were evaluated. For the postoperative group, 3D-CRT and IMRT plans to a total dose (TD) of 45 Gy were generated. For the def-group, 4 plans were generated: a 3D-CRT and an IMRT plan to a TD of 56.4 Gy, a SIB-IMRT plan to a TD of 56 Gy, and a SIB-IMRT with dose escalation (SIB-IMRT-esc): TD of 67.2 Gy. Mean dose and dose-volume histograms were compared using Student's t-test. IMRT significantly (all p < 0.05) reduced the D(mean), V30, and V40 for all OAR in the adjuvant setting. The V45 was also significantly reduced for all OAR except the bladder. For patients treated in the def-group, all IMRT techniques significantly reduced the D(mean), V40, and V45 for all OAR. The mean femur doses with SIB-IMRT and SIB-IMRT-esc were 47% and 49% lower compared with 3D-CRT. SIB-IMRT-esc reduced the doses to the OAR compared with seq-3D-CRT but increased the D(max.) for the small bowel, rectum, and bladder. IMRT reduces the dose to the OAR compared with 3D-CRT in patients with vulvar cancer receiving irradiation to a volume covering the vulvar region and nodal areas without compromising the dosimetric coverage of the target volume. IMRT for vulvar cancer is feasible and an attractive option for dose escalation studies.
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Affiliation(s)
- Monique C W M Bloemers
- Department of Radiotherapy, the Netherlands Cancer Institute, Amsterdam, the Netherlands.
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Pugh TJ, Lee AK. Role of radiation therapy for the treatment of lymph nodes in urologic malignancies. Urol Clin North Am 2011; 38:497-506, vii. [PMID: 22045180 DOI: 10.1016/j.ucl.2011.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Radiation therapy (RT) represents an important therapeutic component in the management of genitourinary (GU) malignancies. RT is used to treat patients with proven involvement of the regional lymph nodes or delivered electively to patients at risk for occult regional lymph node metastases. Advances in treatment planning and delivery of various types of RT provide the technology to precisely plan, target, and deliver RT with the goal of optimizing the radiation dose to the target while sparing normal tissue. This article provides an overview of the modalities, indications, and techniques of RT for treatment of the lymphatic basins in GU malignancies.
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Affiliation(s)
- Thomas J Pugh
- Division of Radiation Oncology, The University of Texas M.D. Anderson Cancer Center, 1840 Old Spanish Trail, Unit 0097, Houston, TX 77054, USA.
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Hinten F, van den Einden LCG, Hendriks JCM, van der Zee AGJ, Bulten J, Massuger LFAG, van de Nieuwenhof HP, de Hullu JA. Risk factors for short- and long-term complications after groin surgery in vulvar cancer. Br J Cancer 2011; 105:1279-87. [PMID: 21970884 PMCID: PMC3241565 DOI: 10.1038/bjc.2011.407] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The cornerstone of treatment in early-stage squamous cell carcinoma (SCC) of the vulva is surgery, predominantly consisting of wide local excision with elective uni- or bi-lateral inguinofemoral lymphadenectomy. This strategy is associated with a good prognosis, but also with impressive treatment-related morbidity. The aim of this study was to determine risk factors for the short-term (wound breakdown, infection and lymphocele) and long-term (lymphoedema and cellulitis/erysipelas) complications after groin surgery as part of the treatment of vulvar SCC. Methods: Between January 1988 and June 2009, 164 consecutive patients underwent an inguinofemoral lymphadenectomy as part of their surgical treatment for vulvar SCC at the Department of Gynaecologic Oncology at the Radboud University Nijmegen Medical Centre. The clinical and histopathological data were retrospectively analysed. Results: Multivariate analysis showed that older age, diabetes, ‘en bloc’ surgery and higher drain production on the last day of drain in situ gave a higher risk of developing short-term complications. Younger age and lymphocele gave higher risk of developing long-term complications. Higher number of lymph nodes dissected seems to protect against developing any long-term complications. Conclusion: Our analysis shows that patient characteristics, extension of surgery and postoperative management influence short- and/or long-term complications after inguinofemoral lymphadenectomy in vulvar SCC patients. Further research of postoperative management is necessary to analyse possibilities to decrease the complication rate of inguinofemoral lymphadenectomy; although the sentinel lymph node procedure appears to be a promising technique, in ∼50% of the patients an inguinofemoral lymphadenectomy is still indicated.
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Affiliation(s)
- F Hinten
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen Medical Centre, HB Nijmegen, The Netherlands.
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van der Velden J, Fons G, Lawrie TA, Cochrane Gynaecological, Neuro‐oncology and Orphan Cancer Group. Primary groin irradiation versus primary groin surgery for early vulvar cancer. Cochrane Database Syst Rev 2011; 2011:CD002224. [PMID: 21563133 PMCID: PMC7154218 DOI: 10.1002/14651858.cd002224.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite changes in technique, morbidity after surgery for vulvar cancer is high and mainly related to the groin dissection. Primary radiotherapy to the groin is expected to result in lower morbidity. However, studies on the efficacy of primary radiotherapy to the groin in terms of groin recurrences and survival show conflicting results. OBJECTIVES To determine whether the effectiveness and safety of primary radiotherapy to the inguinofemoral lymph nodes in early vulvar cancer is comparable with surgery. SEARCH STRATEGY We searched The Cochrane Gynaecological Cancer Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE from 1966 to July 2010. SELECTION CRITERIA We selected randomised clinical trials (RCTs) comparing inguinofemoral lymph node dissection and primary radiotherapy of the inguinofemoral lymph nodes for patients with early squamous cell cancer of the vulva. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed study quality and extracted results. Primary outcome measures were the incidence of groin recurrences, patient survival and morbidity. MAIN RESULTS No new RCTs were identified by the updated search. Out of twelve identified papers only one met the selection criteria. From this one small RCT of 52 women, there was a trend towards increased groin recurrence rates (relative risk (RR) 10.21, 95% confidence interval (CI) 0.59 to 175.78), lower disease-specific survival rates (RR 3.70, 95% CI 0.87 to 15.80), less lymphoedema (RR 0.06, 95% CI 0.00 to 1.03) and fewer life-threatening cardiovascular complications (RR 0.08, 95% CI 0.00 to 1.45) in the radiotherapy group. Primary surgery was associated with a longer hospital stay than primary groin irradiation (RR 0.28, 95% CI 0.13 to 0.58). AUTHORS' CONCLUSIONS Primary radiotherapy to the groin results in less morbidity but may be associated with a higher risk of groin recurrence and decreased survival when compared with surgery. Due to the small numbers in this trial and criticisms regarding the depth of radiotherapy applied, corroboration of these findings by larger RCTs using a standardised radiotherapy method, is desirable. However, until better evidence is available, surgery should be considered the first choice treatment for the groin nodes in women with vulvar cancer. Individual patients not physically able to withstand surgery may be treated with primary radiotherapy.
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Affiliation(s)
- Jacobus van der Velden
- Academic Medical CentreDepartment of Obstetrics and GynaecologyPO Box 22660Meibergdreef 9AmsterdamNetherlands1105 AZ
| | - Guus Fons
- Academic Medical CentreDepartment of Gynaecologic OncologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Theresa A Lawrie
- Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupEducation CentreBathUKBA1 3NG
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De Nardi P, Carvello M, Canevari C, Passoni P, Staudacher C. Sentinel node biopsy in squamous-cell carcinoma of the anal canal. Ann Surg Oncol 2011; 18:365-370. [PMID: 20803079 DOI: 10.1245/s10434-010-1275-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Radiochemotherapy is the standard treatment for patients with carcinoma of the anal canal. Therefore, a surgical specimen is not usually obtained. Inguinal lymph node metastases cannot be accurately predicted by either clinical examination or imaging techniques. In this study, we applied the sentinel node technique in patients with anal canal squamous-cell carcinoma to determine whether this provided more reliable staging of tumors. METHODS From May 2007 to May 2009, we enrolled 11 patients (7 women) with a mean age 65 (range 39-80) years with squamous-cell carcinoma of the anal canal and clinically and radiologically negative groin lymph nodes. The patients were staged with endorectal ultrasound, computed tomographic scan, magnetic resonance imaging of the pelvis, and positron emission tomography. There were two T1, four T2, and five T3 tumors (International Union Against Cancer classification). Lymphoscintigraphy with peritumoral 99mTc colloid injection was performed 16 to 18 h before surgery. During the surgery, patent blue dye was injected peritumorally, and the sentinel inguinal node was identified by a handheld gamma probe and dye visualization. RESULTS The sentinel lymph node was detected in all 11 patients by scintigraphy; in 9 cases, the lymph node was in the inguinal region. All of these patients underwent radioguided node biopsy, and a total of 12 lymph nodes were removed. The average diameter of the resected nodes was 8 (range 4-20) mm. No serious complications occurred. In three patients, metastases were identified in the lymph node. CONCLUSIONS Sentinel node biopsy is a more accurate method than clinical or radiological techniques to stage the disease of patients with anal carcinoma.
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Affiliation(s)
- Paola De Nardi
- Department of Surgery, Scientific Institute San Raffaele Hospital, Milan, Italy.
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Mak RH, Halasz LM, Tanaka CK, Ancukiewicz M, Schultz DJ, Russell AH, Viswanathan AN. Outcomes after radiation therapy with concurrent weekly platinum-based chemotherapy or every-3–4-week 5-fluorouracil-containing regimens for squamous cell carcinoma of the vulva. Gynecol Oncol 2011; 120:101-7. [DOI: 10.1016/j.ygyno.2010.09.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 09/07/2010] [Accepted: 09/10/2010] [Indexed: 11/27/2022]
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Abstract
PURPOSE OF REVIEW The purpose of this review is to outline current controversies in management of early-stage vulvar cancer. The main focus will be on the procedures for assessing the sentinel node and the treatment of those with evidence of metastatic involvement. RECENT FINDINGS Assessment of the sentinel node has recently been introduced into the standard treatment of early-stage squamous cell vulvar cancer. The combination of a radioactive tracer and blue dye is the most accurate technique for sentinel node detection. Preoperative imaging is recommended to rule out gross nodal involvement and ultrasound with fine needle aspiration cytology by an experienced radiologist appears to have the highest sensitivity/specificity for detecting metastases, although large comparative studies are not available. All patients with sentinel node metastases require additional treatment to the groin, independent of the size of metastasis in the sentinel node and currently this involves inguinofemoral lymphadenectomy. Further research is ongoing to investigate the role of radiotherapy instead of lymphadenectomy. The little experience there is of sentinel node biopsy in vulvar melanoma suggests that the procedure is feasible and inclusion criteria should follow those of cutaneous melanoma. SUMMARY Sentinel node biopsy is safe in treatment of early-stage vulvar cancer. Ongoing studies are investigating the optimal additional treatment for patients with a positive sentinel node in terms of efficacy and morbidity.
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Comment on: Does the number of nodes removed impact survival in vulvar cancer patients with node-negative disease? Madeleine Courtney-Brooks, Paniti Sukumvanich, Sushil Beriwal, Kristin K. Zorn, Scott D. Richard, Thomas C. Krivak. Gynecological Oncology 117 (2010) 308-311. Gynecol Oncol 2010; 120:160; author reply 160-1. [PMID: 21040951 DOI: 10.1016/j.ygyno.2010.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 09/28/2010] [Indexed: 11/24/2022]
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Management of the Lymph Nodes in Penile Cancer. Urology 2010; 76:S43-57. [DOI: 10.1016/j.urology.2010.03.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Revised: 03/01/2010] [Accepted: 03/01/2010] [Indexed: 02/05/2023]
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Radiation therapy compared with pelvic node resection for node-positive vulvar cancer: a randomized controlled trial. Obstet Gynecol 2009; 114:537-546. [PMID: 19701032 DOI: 10.1097/aog.0b013e3181b12f99] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To report long-term survival and toxicity of radiation compared with pelvic node resection for patients with groin node-positive vulvar cancer. METHODS A Gynecologic Oncology Group protocol enrolled 114 patients randomly allocated to postoperative pelvic and groin radiation (45-50 Gy, n=59) or to ipsilateral pelvic node resection (n=55) after radical vulvectomy and inguinal lymphadenectomy. Retrospective analyses for 114 enrolled patients included both risk of progression and death after treatment and assessment of toxicity. RESULTS Median age was 70 years. Median survivor follow-up was 74 months. The relative risk of progression was 39% in radiation patients (95% confidence interval [CI] 0.17-0.88, P=.02). Fourteen intercurrent deaths occurred after radiation as compared with only two after pelvic node resection, narrowing 6-year overall survival (51% compared with 41%, hazard ratio 0.61 [95% CI 0.30-1.3], P=.18). However, the cancer-related death rate was significantly higher for pelvic node resection compared with radiation (51% compared with 29% at 6 years, hazard ratio 0.49 [95% CI 0.28-0.87], P=.015). Six-year overall survival benefit for radiation in patients with clinically suspected or fixed ulcerated groin nodes (P=.004) and two or more positive groin nodes (P<.001) persisted. A ratio of more than 20% positive ipsilateral groin nodes (number positive/number resected) was significantly associated with contralateral lymph node metastasis, relapse, and cancer-related death. Late chronic lymphedema (16% compared with 22%) and cutaneous desquamation (19% compared with 15%) were balanced after radiation and pelvic node resection. CONCLUSION Radiation after radical vulvectomy and inguinal lymphadenectomy significantly reduces local relapses and decreases cancer-related deaths. Late toxicities remained similar after radiation or pelvic node resection. LEVEL OF EVIDENCE I.
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El-Ghobashy A, Saidi S. Sentinel lymph node sampling in gynaecological cancers: Techniques and clinical applications. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2009; 35:675-85. [DOI: 10.1016/j.ejso.2008.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2008] [Revised: 09/02/2008] [Accepted: 09/03/2008] [Indexed: 11/26/2022]
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Gungor T, Simsek A, Bilge U, Mollamahmutoglu L. Skin graft failure mimicking abscess masking local recurrence of vulvar cancer: a case report. Arch Gynecol Obstet 2008; 279:239-41. [PMID: 18506457 DOI: 10.1007/s00404-008-0689-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 05/06/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Vulvar cancer is a rare gynecological malignancy and its local recurrence is even more uncommon. To date, no cases of recurrent vulvar cancer in split thickness graft area have been reported. We describe the first case of such recurrence. CASE A 65-year-old G4P3013 presented with vulvar mass and itching. She had a 2 x 2-cm sized mass on clitoris and an ulcerated bulgy mass of 2 x 2.5 cm size was localized on left labia majora, of which a biopsy revealed invasive squamous cell carcinoma. She underwent a radical vulvectomy and bilateral inguinofemoral lymph node dissection via separate incisions. Her postoperative course was complicated by wound separation which was cored with a split thickness skin graft. Patient was advised to integrate her treatment with radiotherapy, but she refused it. Two months later, she consulted for a painful swelling in the operation field. The swelling resembled an abscess formation so it was drained and an outpatient antibiotic treatment was prescribed. At her second visit, it was noted that the above-mentioned lesion was persisting and so fine needle aspiration biopsy (FNAB) was performed and a local recurrence was retrieved beneath the graft failure. Then she underwent a wide local excision and adjuvant radiotherapy was initiated after patient's approval. CONCLUSION Careful surveillance is warranted as squamous cell carcinoma recurrence can even occur beneath the split thickness skin graft, especially in conjunction with graft failure. And for high risk patients adjuvant radiotherapy is critically important for avoiding recurrences.
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Affiliation(s)
- Tayfun Gungor
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Dr Zekai Tahir Burak Woman Health, Education, and Research Hospital, Ankara, Turkey
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Van der Zee AGJ, Oonk MH, De Hullu JA, Ansink AC, Vergote I, Verheijen RH, Maggioni A, Gaarenstroom KN, Baldwin PJ, Van Dorst EB, Van der Velden J, Hermans RH, van der Putten H, Drouin P, Schneider A, Sluiter WJ. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol 2008; 26:884-9. [PMID: 18281661 DOI: 10.1200/jco.2007.14.0566] [Citation(s) in RCA: 510] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To investigate the safety and clinical utility of the sentinel node procedure in early-stage vulvar cancer patients. PATIENTS AND METHODS A multicenter observational study on sentinel node detection using radioactive tracer and blue dye was performed in patients with T1/2 (< 4 cm) squamous cell cancer of the vulva. When the sentinel node was found to be negative at pathologic ultrastaging, inguinofemoral lymphadenectomy was omitted, and the patient was observed with follow-up for 2 years at intervals of every 2 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS From March 2000 until June 2006, a sentinel node procedure was performed in 623 groins of 403 assessable patients. In 259 patients with unifocal vulvar disease and a negative sentinel node (median follow-up time, 35 months), six groin recurrences were diagnosed (2.3%; 95% CI, 0.6% to 5%), and 3-year survival rate was 97% (95% CI, 91% to 99%). Short-term morbidity was decreased in patients after sentinel node dissection only when compared with patients with a positive sentinel node who underwent inguinofemoral lymphadenectomy (wound breakdown in groin: 11.7% v 34.0%, respectively; P < .0001; and cellulitis: 4.5% v 21.3%, respectively; P < .0001). Long-term morbidity also was less frequently observed after removal of only the sentinel node compared with sentinel node removal and inguinofemoral lymphadenectomy (recurrent erysipelas: 0.4% v 16.2%, respectively; P < .0001; and lymphedema of the legs: 1.9% v 25.2%, respectively; P < .0001). CONCLUSION In early-stage vulvar cancer patients with a negative sentinel node, the groin recurrence rate is low, survival is excellent, and treatment-related morbidity is minimal. We suggest that sentinel node dissection, performed by a quality-controlled multidisciplinary team, should be part of the standard treatment in selected patients with early-stage vulvar cancer.
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Affiliation(s)
- Ate G J Van der Zee
- Department of Obstetrics and Gynecology, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, the Netherlands.
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Abstract
The objective of this review is to summarize the published data about squamous carcinoma of the vulva and to identify promising areas for future investigation. Rather than the routine use of complete radical vulvectomy, a radical wide excision of the vulvar lesion to achieve at least a 1-cm gross margin appears sufficient to treat the primary lesion. A surgical assessment of the groin is required for all patients who have invasion greater than 1 mm. Ipsilateral groin node dissection can be performed through a separate incision. All the nodal tissue medial to the vessels and above the fascia should be removed. Sentinel node evaluation may be a significant step forward, but the false-negative rate is not well enough defined to consider this a standard. Patients with positive inguinal nodes at groin dissection should receive radiation therapy to the ipsilateral groin and hemipelvis. For those patients who have unresectable primary disease or if nodes are palpably suspicious, fixed, and/or ulcerated preoperatively, chemoradiation is the preferred option. Exenterative procedures may rarely be required. Chemotherapy for recurrent or metastatic disease has not been proven to be of value. Although survival rates are high for those with negative nodes, the morbidity associated with standard radical techniques has prompted innovation. Adequately powered trials aimed at further reducing morbidity without compromising survival are underway.
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Affiliation(s)
- Frederick B Stehman
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Fanfani F, Garganese G, Fagotti A, Lorusso D, Gagliardi ML, Rossi M, Salgarello M, Scambia G. Advanced vulvar carcinoma: Is it worth operating? A perioperative management protocol for radical and reconstructive surgery. Gynecol Oncol 2006; 103:467-72. [PMID: 16647747 DOI: 10.1016/j.ygyno.2006.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 02/25/2006] [Accepted: 03/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the means whereby the results could be improved and the morbidity and side-effects minimized, of radical and extensive surgery performed together with plastic reconstruction, in the treatment of locally advanced and relapsed vulvar carcinoma. METHODS Between May 2000 and November 2004, twenty-three patients with locally advanced or relapsed vulvar carcinoma underwent major radical or extended vulvectomy, requiring reconstructive surgery. A consistent protocol for the perioperative management of these patients, including precautionary measures to reduce the rate of early complications, was introduced in the second study period (from November 2003) to verify the benefit on surgical outcome. RESULTS An analysis of the medical reports showed an improvement in the median time of the postoperative course and related morbidity as a consequence of a strict application of the management protocol, with consequent decrease of early complications. CONCLUSIONS Reconstructive surgery, which broadens the spectrum of available operative therapy in primary and locally recurrent vulvar cancer, is characterized by a high complication rate. The application of a strict perioperative protocol could reduce the number and the clinical impact of such complications.
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Affiliation(s)
- Francesco Fanfani
- Department of Oncology, Division of Gynecologic Oncology, Catholic University of Sacred Heart, Campobasso, Italy
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