Prognostic factors in invasive squamous cell carcinoma of the vulva.

Histological malignancy grading and its correlation to prognosis were retrospectively investigated in 303 cases of squamous cell carcinoma of the vulva. A scoring system based on several variables is suggested. The scores and the individual histological variables were tested along with clinical factors with a view to predicting survival. Various histological variables including mode of invasion, depth of invasion and nuclear polymorphism, as well as the sum of the scores were good predictors of survival. The study revealed a significantly better survival rate in stage III if no metastases were suspected. An age factor was also found showing that cancer of the vulva has a worse prognosis in older women.     

Prognostic factors in squamous cell carcinoma of the vulva: a multivariate analysis

Based on 124 patients with squamous cell carcinoma of the vulva treated at the 1. Frauenklinik der Universit?t München from 1971 to 1980, the influence of pretreatment characteristics on survival was assessed. The patients underwent a simple vulvectomy with local and inguinal irradiation. All histologic specimens were worked up in the same manner, and all available specimens were reverified. Follow-up lasted from at least 2 up to 12 years post-treatment, with no dropouts. Using the Cox model of multivariate analysis, five pretreatment characteristics were found to most strongly influence survival: age, dissociated tumor growth, lymphatic spread, tumor thickness, and ulceration. These pretreatment characteristics were implemented in an algorithm for survival-oriented prognostic forecasting. Survival data as predicted from this algorithm correlated well with observed survival data. The validity of these prognostic factors needs to be examined in further studies using comparable patient populations and study designs.     

Patterns of inguinal groin metastases in squamous cell carcinoma of the vulva

OBJECTIVES: Assess the pattern of groin node metastases in squamous cell carcinoma (SCC) of the vulva in relation to the site of the primary lesion. Assess whether the identified pattern of lymphatic spread supports the current surgical practice of assessing contralateral nodes for lateral lesions with ipsilateral nodal involvement. METHODS: A retrospective study of surgically staged patients with primary SCC of the vulva between 1955 and 1990 was conducted. This cohort of patients was divided in 4 subgroups by location of primary lesion: unilateral, bilateral, midline, and patients with mediolateral lesions. All clinical and pathological data were reviewed and updated to the 1988 TNM vulvar classification. RESULTS: 320 patients met the inclusion criteria, and almost all of them (>95%) underwent bilateral groin assessment. Of the 108 patients with positive groin lymph-node (LN) involvement, 77 presented with unilateral and 24 with bilateral inguinofemoral involvement. Of the 163 patients presenting with only unilateral vulvar lesions, 48 had inguinofemoral node involvement: 37 with ipsilateral-only nodal metastases, 8 with bilateral LN invasion, and only 3 (1.8%) had isolated contralateral nodal metastases. None of these patients with unilateral vulvar lesion that was either < or = 2 cm in biggest diameter or with invasion < or = 5 mm had bilateral groin LN involvement at diagnosis. CONCLUSIONS: Ipsilateral lymphadenectomy is suitable for patients with unilateral lesions, distant from the midline, and either negative ipsilateral nodes, or with positive ipsilateral LN with lesions smaller than 2 cm.     

Some epidemiologic aspects of carcinoma of the vulva in Israel

A nationwide study of squamous cell carcinoma of the vulva in Israeli Jewish women has been conducted for a comparison of the incidence, the age pattern and the ethnic distribution of squamous cell carcinoma of the vulva to those of squamous cell carcinoma of the cervix. The mean annual incidence rates by age in squamous cell carcinoma of the vulva rise continuously to age 70+ while in squamous cell carcinoma of the cervix a plateau is reached at age 40 to age 69. In contrast to the relatively low incidence of squamous cell carcinoma of the cervix in Israeli Jewish women, the age-specific incidence rates of squamous cell carcinoma of the vulva are similar to those of white women in the United States. On the other hand, there is a trend to a higher incidence of both squamous cell carcinoma of the cervix and squamous cell carcinoma of the vulva in the North African ethnic group of Israeli Jewish women.     

Prognostic factors for local recurrence of squamous cell carcinoma of the vulva: A systematic review

Background

In patients treated for early-stage squamous cell vulvar carcinoma local recurrence is reported in up to 40% after ten years. Knowledge on prognostic factors related to local recurrences should be helpful to select high risk patients and/or to develop strategies to prevent local recurrences.

Prognostic variables in the treatment of squamous cell carcinoma of the vulva

Records of 98 patients undergoing surgery for squamous cell carcinoma of the vulva between 1960 and 1982 were analyzed to evaluate and develop treatment policy. There were 32, 34, 26, and 6 patients in FIGO stages I-IV, respectively. Eighty-six patients underwent radical vulvectomy, 8 patients underwent less extensive procedures, and 4 underwent more extensive procedures. Eighty-seven patients underwent inguinal node dissection, and 40 underwent pelvic node dissection as well. Eight patients received external beam irradiation. Actuarial 5-year survival was 57%. Age, tumor size, FIGO (clinical) stage, surgically determined T and N stages, tumor differentiation, lymph vessel invasion, extent of surgical procedure, and adjuvant irradiation were analyzed to determine their effects on local control, freedom from distant metastases, and survival, using single variable and multivariate analysis. Local control was significantly related to FIGO stage; freedom from distant metastasis was significantly related to surgical N stage, tumor size, and surgical T stage; survival was significantly related to surgical N stage, tumor size, surgical T stage, age, and lymph vessel invasion. Metastatic involvement of inguinal lymph nodes was significantly correlated with tumor size and differentiation. Of 87 evaluable patients, 33 had inguinal node involvement, and of these, 17 developed recurrent disease. All 7 patients with pelvic node metastases had positive inguinal nodes, and all died; the cause of death could be determined in 5, of whom 4 manifested distant metastases. Pelvic lymphadenectomy conferred no survival benefit in this series, even in the presence of positive inguinal nodes. Local vulvar recurrence is a significant problem in patients with positive inguinal nodes, and postoperative irradiation should be directed to this area in these patients. Patients with vulvar recurrences, especially those occurring at least 2 years after surgery, can be successfully salvaged, and should therefore be treated aggressively.     

Management of carcinoma in situ of the vulva

Concern about multicentricity and occult invasion has led authorities to recommend total vulvectomy in the management of carcinoma in situ of the vulva (VCIS). Of these considerations, only occult invasion has sufficient import to contraindicate a more conservative therapeutic approach. VCIS is being diagnosed with increasing frequency in young women for whom the deforming and sexually crippling effects of vulvectomy are especially repugnant. Because of its distinctive success in localizing preinvasive and early invasive squamous neoplasia of the cervix, colposcopy and directed biopsy were employed in evaluating all patients seen in our vulva clinic since 1971. Of 27 consecutive patients considered to have VCIS, 24 were treated either by local excision, skinning vulvectomy, topical 5-fluorouracil (5-FU), or cryosurgery. In no instance was occult invasion missed on pretreatment evaluation, and only one patient has developed a new in-situ lesion following conservative surgical therapy. Topical 5-FU therapy was unsuccessful in six of six cases. These results demonstrate that total vulvectomy for VCIS can be replaced successfully with more conservative operations.     

Microinvasive squamous cell carcinoma of the vulva

Six patients with microinvasive squamous cell carcinoma of the vulva were evaluated. None of the patients had carcinoma that invaded the stroma to the depth of more than 3 mm. One had positive lymph nodes and died as a result of nodal involvement. The management of patients with vulvar carcinoma is discussed.     

Prognostic factors and the significance of cytologic grading in invasive squamous cell carcinoma of the vulva: a clinicopathologic study

Clinical staging, tumor size, histologic differentiation, cytologic grading, depth of stromal invasion, and vascular channel involvement by tumor cells were studied in 42 patients with invasive squamous cell carcinoma of the vulva who were treated with radical vulvectomy and inguinal-femoral lymphadenectomy. All parameters were found to correlate well in predicting groin node metastasis. Cytological grading was found to be more significant compared to histologic grading in regard to nodal metastasis (P less than 0.02). No patient with cytologic or histologic grade 1 tumor and less than 5 mm stromal invasion was found to have nodal metastasis.     

Prognostic significance of groin lymph node metastases in squamous carcinoma of the vulva

A retrospective review of the clinical and histologic findings in 48 cases of stages I, II, and III (excluding T3) squamous carcinoma of the vulva with positive groin nodes reveals the prognostic significance of the size and number of the nodal metastases. Other factors such as the morphology of the lymph nodes and the histologic features of the primary neoplasm are not nearly as significant. Patients with only one or two small nodal metastases have an excellent outlook for survival providing that adequate margins can be obtained around the primary tumor and that thorough groin node dissections can be performed. These patients do not appear to need adjuvant radiation or pelvic node dissection. A further finding is that patients with unilateral labial carcinomas do not have metastases to the opposite groin in the absence of ipsilateral groin metastases, although six of 21 patients had metastases to both groins.     

Prognostic factors in uterine cervical carcinoma: a clinicopathological analysis

Abstract. A clinicopathological analysis of 235 patients with stage IB/IIA cervical carcinoma was performed. These patients represent all those treated between 1975 and 1989 inclusive by primary Wertheim's hysterectomy at St Mary's Hospital, Manchester. We found that a significantly higher proportion of tumors from patients under 40 years of age contained mucin and that overall the adenosquamous carcinomas had a significantly greater incidence of lymph node metastases ( P = 0.00049). Pelvic lymph node metastases had no effect on prognosis in these adenosquamous carcinomas but did in squamous carcinomas ( P = 0.0004) and adenocarcinomas ( P = 0.0001). Univariate log-rank analysis showed that variables associated with survival were: pregnancy at diagnosis ( P = 0.0238), lymphatic permeation ( P < 0.0001), vascular permeation ( P < 0.0001), lymph node metastases ( P < 0.0001), tumor volume ( P < 0.0001), canal length of tumor ( P = 0.0009), cervical stromal tumor-free rim ( P = 0.0027), parametrial extension ( P = 0.0008) and adequacy of excision ( P = 0.0389). In a multivariate regression analysis (Cox's regression model) lymphatic permeation, tumor volume, pregnancy at diagnosis and lymph node metastases were independent prognostic variables.     

Chemotherapy of squamous cell carcinoma of the vulva: A review

A review of published experience with chemotherapy for the treatment of recurrent or metastatic squamous cell carcinoma of the vulva found data for nine different drugs used as single agents. Only 75 patients have been treated. Bleomycin produced responses in 19 out of 31 patients, adriamycin in 4 out of 6 patients, and methotrexate in 2 out of 5 patients. Seven patients with squamous cell carcinoma of the vulva were treated with five different combination chemotherapy regimens. Responses only occurred with regimens which contained bleomycin and methotrexate.     

Prognostic parameters and clinical staging criteria in the epidermoid carcinoma of the vulva.

An evaluation and a critique of prognostic parameters and criteria involved in the classification and clinical staging of epidermoid carcinoma of the vulva are presented, comparing the FIGO system and a proposed more definitive system. Biostatistical as well as clinical evidence for an improved system is presented. The proposed system is based on statistically valid data, has good patient distribution, and an orderly progression for therapy and prognosis. In addition, it is well suited for computer programming and for the comparison of patients and therapy, as well as for delineating the natural history of vulvar cancer.     

The place of pelvic exenteration in the primary management of advanced carcinoma of the vulva

Over a 25-year period, 236 patients were treated surgically for carcinoma of the vulva. Of these, 13 (5%) were treated by radical vulvectomy with pelvic exenteration for Stage IV disease. Five of ten patients (50%) eligible for a 5-year survival were alive and well with no evidence of disease after this time. None of these five patients had lymph node metastases at the time of her surgery. A review of the English language literature from 1973 to date confirmed that the results with exenteration and radical vulvectomy in selected cases are good. Including our series, a total of 53 patients underwent this procedure, of whom 25 (47%) survived 5 years. In view of these findings, we feel that consideration should be given to the use of this procedure in patients with advanced, but resectable carcinoma of the vulva.     

Microinvasive squamous carcinoma of the vulva: present status and reassessment

A retrospective analysis of 24 patients with early invasive squamous carcinoma was performed. No nodal metastases were noted in these patients. Based on a review of the literature, no absolute definition of microinvasive carcinoma could be formulated, but a treatment outline has been formulated based on depth of invasion for Stage I lesions.     

Surgical management of invasive carcinoma of the vulva utilizing a lower abdominal midline incision

An approach to radical vulvectomy and bilateral lymphadenectomy utilizing a lower abdominal midline incision is presented. Nineteen patients were operated on for invasive vulvar carcinoma utilizing this technique, while fifteen patients were operated on with the more traditional transverse incision for groin dissection. When evaluated by intraoperative and postoperative parameters, the two techniques gave roughly identical results. The midline approach can be particularly valuable in those situations where celiotomy is to be performed at the time of radical vulvectomy.     

Prognostic factors in Paget's disease of the vulva: a study of 21 cases.

Twenty-one cases of vulvar Paget's disease were studied to assess possible prognostic indicators, including presence and depth of invasion, status of resection margins, tumor DNA cell content, and immunoreactivity for p53 and estrogen receptor proteins. Immunostaining for cytokeratin 7 (CK7), cytokeratin 20 (CK20), and gross cystic disease fluid protein-15 (GCDFP) were also performed. Patients were 45 to 82 years of age (mean, 66.9 years). Ten of 21 patients (47.6%) had invasive Paget's disease. Dermal invasion was < or = 1 mm in 7 of 10 cases and 2 mm, 3 mm, and 8 mm in the remaining three invasive tumors. Of the seven patients with minimally invasive Paget's disease (< or = 1 mm depth of invasion), five are alive with no evidence of disease, one died of an unrelated illness, and one is alive with biopsy-proven in situ Paget's disease, having refused operative treatment. Of the three patients with more than minimally invasive Paget's disease (> 1 mm), all had nodal metastases; one patient is alive with no evidence of disease, one died of undertermined causes, and one died of metastatic Paget's disease. The remaining 11 patients had Paget's disease confined to the epidermis and its adnexal structures. Seven of these patients were alive at last follow-up with no evidence of disease. Of the remaining four patients, one died of metastatic cervical cancer, one died of metastatic bladder cancer, one died of an unrelated illness, and one patient is alive with biopsy-proven in situ Paget's disease and awaiting operative treatment. Twenty of the 21 cases represented primary vulvar Paget's disease while one represented possible local spread from a cervical adenocarcinoma. The immunoprofiles were GCDFP+/CK7+/CK20- in 14 cases, GCDFP+/CK7+/CK20+ in 4 cases, and GCDFP-/CK7+/CK20- in 2 cases. All tumors were estrogen receptor-negative. Immunostaining for p53 was positive in 16 tumors and negative in four tumors. Seven of 12 (58%) patients with positive margins experienced local recurrence of Paget's disease, while the disease recurred in 1 of 4 patients with negative margins. Recurrence was observed in 3 of 5 patients with diploid tumors and in 4 of 10 patients with aneuploid tumors. Neither of these differences is statistically significant. This study supports the recognition of a category of minimally invasive vulvar Paget's disease that has a low risk of distant metastasis and death caused by disease. Status of surgical resection margins, tumor cell DNA ploidy, estrogen receptor expression, and p53 immunoreactivity are not predictive of local recurrence.