Invasive carcinoma of the vulva. Changing trends in surgical management

Four hundred fifteen patients who had invasive carcinoma of the vulva were treated with primary surgery from July 1, 1955, through June 30, 1989. Three hundred seventy-six (90%) of the patients had squamous carcinoma. Two hundred fourteen patients (52%) had radical vulvectomy with inguinofemoral lymphadenectomy. Twenty-four patients (6%) underwent radical vulvectomy with pelvic exenteration for advanced disease, and 55 patients (13%) had nonradical operations. The remaining 122 patients (29%) underwent radical vulvectomy, inguinofemoral lymphadenectomy, and pelvic lymphadenectomy. The primary morbidity was associated with lymphedema (8.6%) and groin wound breakdown (54%). No intraoperative deaths occurred among the 415 patients treated surgically, but there were 17 deaths (4%) within 28 days of operation. The absolute 5-year survival rate was 85% in patients with negative inguinofemoral lymph nodes and 39% when these lymph nodes were positive for metastatic carcinoma. The overall absolute 5-year survival rate was 67%.     

Current vulvar cancer treatment in Bulgaria

PURPOSE OF INVESTIGATION: Our aim was to outline the treatment of carcinoma of the vulva at the National Oncological Centre in Sofia, Bulgaria. METHODS: We examined the records of 250 patients over a 10-year period treated at the Gynaecologic-Oncology Clinic of our Centre. RESULTS: There were 130 patients (52%) treated with surgery and radiation. There were 120 patients (48%) treated by surgery only. Thirty of these patients were treated by pelvic exenteration with radical vulvectomy. The five-year survival rate was 36% - 12 patients. The 1-year survival rate for all patients was 80% - 200 patients. The five-year survival rate was 50%. DISCUSSION: We have results similar to other clinics in the world working in this field. We now emphasize external radiation for advanced disease but the treatment must be individualized. CONCLUSION: We have outlined the treatment of carcinoma of the vulva at our Centre, over a 10-year period.     

Radical vulvectomy with partial rectal resection and temporary colostomy as primary therapy for selected patients with vulvar carcinoma

The patient with carcinoma of the vulva may present with tumor involvement of the perirectal area. Traditional treatment has often involved ultraradical therapy including a radical vulvectomy with posterior or total pelvic exenteration in an effort to obtain adequate surgical margins. Five-year survival rates for these patients range from 20-50%, and major operative morbidity as well as psychological problems are associated with this extensive surgery. Five patients treated for a locally advanced vulvar carcinoma involving the perirectal area were thought to be candidates for a rectum-sparing procedure. They underwent a radical vulvectomy, bilateral inguinal lymphadenectomy, partial rectal resection, and a diverting colostomy. Four of the five patients agreed to a colostomy closure 6 months after their primary therapy; these four patients have resumed normal bowel function. All patients remain clinically free of tumor.     

Preoperative radiotherapy followed by radical vulvectomy with inguinal lymphadenectomy for advanced vulvar carcinomas

A therapeutic alternative to exenteration for large locally advanced vulvar carcinoma involving the rectum, anus, or vagina is the use of preoperative radiation followed by radical surgery. Between 1980 and 1988, 13 patients with Stage III and 3 with Stage IV vulvar carcinoma involving the rectum/anus, urethra, or vagina were treated with 4000 rad to the vulva and 4500 rad to the inguinal and pelvic nodes followed by a radical vulvectomy and inguinal lymphadenectomy 4 weeks later. The overall 5 year cumulative survival was 45%. Twelve tumors regressed after radiation with 62.5% of the patients having visceral preservation while in 4 patients there was no major response to radiation and urinary or fecal diversion was required. Of the 6 recurrences 4 were central and 2 distant. Three patients with central recurrences had tumor within 1 cm of the vulvectomy margin. Complications included wet desquamation, inguinal wound separation, lymphedema, and urethral strictures. There were no operative deaths. It is concluded that the use of preoperative radiation followed by radical vulvectomy may be an alternative to pelvic exenteration in selected patients with advanced vulvar lesions.     

Changing trends in the surgical treatment of invasive carcinoma of the vulva

Twenty-nine years experience with 346 patients with invasive carcinoma of the vulva is presented. More than 90 per cent had squamous carcinoma. The primary mode of treatment was surgical. Two hundred and ninety-six patients were treated primarily with surgical treatment, 120 underwent radical vulvectomy and bilateral groin and pelvic lymphadenectomy, 133 had radical vulvectomy with bilateral groin dissection and 390 receiving nonradical procedures. Thirteen patients had radical operations plus pelvic exenteration for advanced disease. There were no intraoperative deaths, but 16 (5.4 per cent) died within 28 days of the operation. The uncorrected over-all five year survival rate was 66 per cent. In the presence of negative nodes, it was 83 per cent and with positive nodes, it was 38 per cent. Fifty per cent of those treated with exenteration are alive and disease-free at five years or more. Since one-third of the patients presented with advanced disease (Stages III and IV), earlier diagnosis and prompt referral must be encouraged to improve surgical results.     

A comparative study of radical vulvectomy and modified radical vulvectomy for the treatment of invasive squamous cell carcinoma of the vulva.

Forty-five patients who underwent a modified radical vulvectomy for invasive squamous cell carcinoma of the vulva were compared with forty-five patients who underwent radical vulvectomy for similar lesions. Vulvar wound infection and breakdown were infrequent in both groups. Anal incontinence developed postoperatively in five of the modified radical vulvectomy patients and in none of the radical vulvectomy patients. Urinary incontinence developed postoperatively in two of the modified radical vulvectomy patients and in seven of the radical vulvectomy patients. Possible reasons for these differences are discussed. One invasive local recurrence (2.2%) developed in the modified radical vulvectomy group and two (4.4%) local recurrences developed in the radical vulvectomy group. A modified radical vulvectomy appears to be efficacious for the vulvar phase of treatment of localized invasive squamous cell carcinoma of the vulva.     

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

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

Coexistence of verrucous and squamous carcinoma of the vulva

AIM: To evaluate the coexistence of verrucous and squamous carcinoma of the vulva and to assess the clinical course, survival and rate of recurrent disease of these patients. METHODS: The records of 17 patients who were diagnosed with verrucous carcinoma of the vulva over a 12-year period were studied retrospectively. Presence of genuine verrucous carcinoma or coexistence of verrucous and squamous carcinoma of the vulva on vulvar biopsies, results of histopathological assessment of final vulva and inguino-femoral node specimens and histological evaluation of recurrent disease specimens were the main outcome measures. RESULTS: Five of the 17 patients (29.5%) initially underwent radical vulvectomy and inguino-femoral lymphadenectomy. Histology of the specimens verified the coexistence of verrucous and squamous carcinomas in four of the five cases. Twelve women (70.5%) underwent simple vulvectomy for genuine verrucous carcinoma; in the final histology, 10 of these women (58.8%) were confirmed as having genuine verrucous carcinomas while two (11.7%) were found to have both verrucous and squamous carcinomas and were further managed by lymphadenectomy. None of our patients died of the disease. Three women (17.5%) presented with local relapse of the tumour, and were managed by wide local excision of the tumour. CONCLUSIONS: In the present study, 35% of patients with verrucous carcinomas of the vulva had coexistent squamous carcinoma. Separation of the cases of genuine verrucous carcinoma from coexistent verrucous and squamous tumours is based on the establishment of correct diagnosis by a large and deep vulvar biopsy as well as the meticulous assessment of the specimen by the pathologist. This will result in the decrease of the rate of over- and under-treatment of these patients.     

Squamous cell carcinoma of the vulva stage IA: long-term results

OBJECTIVE: The aim of this study was to evaluate the risk of metastases to lymph nodes and long-term results of radical and modified radical surgery in patients with a T1 squamous cell carcinoma of the vulva and 相似文献   

Treatment of vulvar carcinoma in situ with the CO2 laser

Between January 1960 and December 1982, 142 patients with carcinoma in situ of the vulva were treated at Cedars-Sinai Medical Center and UCLA Medical Center. Primary treatment consisted of wide excision in 45 patients; vulvectomy in 23 patients; topical chemotherapy in 9 patients; and CO2 laser therapy in 42 patients. Twenty-three patients were also treated with the CO2 laser for recurrent disease. Multifocal disease was present in 59% of the cases. Lesions involving the posterior vulva recurred most commonly, for both initial and recurrent disease. Results utilizing the CO2 are compared with the other methods of treating carcinoma in situ of the vulva. The CO2 laser is well suited for treatment of both multifocal and unifocal vulvar lesions, as it allows for maximal retention of vulvar integrity with no decrease in therapeutic efficacy.     

The value of groin palpation in epidermoid carcinoma of the vulva

During the years 1956–1974 258 patients with epidermoid carcinoma of the vulva were treated with radical vulvectomy and bilateral groin lymphadenectomy. Metastases to the superficial and/or deep inguinal lymph nodes were found in 100 cases (38.8%), only 64 of which were detected by clinical examination. In 40 more cases (15.5%) the groin lymph nodes were also suspected to be involved, but this could not be verified by microscopic examination. The 5-year actuarial survival rate was 41% for the patients with lymph node metastases. There was a statistically significant difference in the survival rate between the patients with palpable lymph node metastases as compared with those where the nodes were not suspected to be involved.     

Surgical treatment of carcinoma of the clitoris

Thirty-eight consecutive patients were treated with either vulvectomy (14) or in combination with groin dissection (24) according to the same treatment protocol. The crude 5-year survival was 50% and the corrected 5-year survival was 66%. Three patients died post-operatively. Endophytic tumor, poor degree of differentiation, and involvement of lymph nodes resulted in higher mortalities. No patient with involvement of deep inguinal or pelvic nodes could be cured. The study concludes that invasive squamous cell carcinoma of the clitoris should be treated, in the same was as the same tumor in other areas of the vulva, with radical surgery.     

Complications following combined surgery (radical vulvectomy versus wide local excision) and radiotherapy for the treatment of carcinoma of the vulva: report of 73 patients

Cancer of the vulva is uncommon, accounting for only 5% of all gynecologic malignancies, and usually occurs in women over 60 years of age. The historic treatment of choice for invasive squamous cell carcinoma of the vulva is radical vulvectomy with bilateral inguinal lymphadenectomy, which has produced excellent long-term survival. We retrospectively analyzed the complications of wide local excision plus postoperative radiotherapy compared with those of radical vulvectomy and bilateral lymphadenectomy plus pre-or postoperative radiotherapy in 73 patients with vulvar cancer. There were no significant differences among these treatments in terms of primary tumor control, 5-year disease-free survival, and overall survival. Based on these results, the best treatment alternative for advanced vulvar cancer is wide local excision plus radiotherapy, as this method retains the high survival of traditional therapy but has less morbidity.     

Relevance of microinvasion in carcinoma of the vulva.

Retrospective analysis of 22 cases of Stage I invasive carcinoma of the vulva showed 11 cases in which the depth of tumor invasion was 5 mm or less. All of these patients were treated with radical vulvectomy and lymphadenectomy. In 3 cases positive groin node metastases were discovered. A fourth patient with minimal stromal invasion (less than 5 mm) was prospectively managed with vulvectomy alone and subsequently developed groin node metastasis leading to death from disseminated tumor. Depth of the invasion alone, therefore, is not a reliable indicator of the likelihood of groin node involvement, and lymphadenectomy should continue to be considered for all patients with invasive squamous cell carcinoma of the vulva.     

Ergebnisse der elektrochirurgischen Vulvektomie mit postoperativer Bestrahlung der Inguinallymphknoten beim Vulvakarzinom

Zusammenfassung Die Behandlungsergebnisse von 669 eigenen Patientinnen mit invasivem Plattenepithelkarzinom der Vulva, die zwischen 1952 und 1982 behandelt wurden, werden dargestellt und analysiert. Die absolute 5-Jahres-Heilung betrug in diesem Patientinnengut 62%. Bei Bereinigung der interkurrent verstorbenen und verschollenen Patientinnen steigt das Behandlungsergebnis auf 70%. Alle Patientinnen wurden einheitlich mittels elektrochirurgischer Radikaloperation und postaktinischer Bestrahlung der Inguinallymphknoten behandelt.

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Radical vulvectomy using warm knife and irradiation of the inguinal lymph nodes for invasive squamous cell carcinoma of the vulva

Summary Clinical data on 669 patients with in vasive squamous cell carcinoma of the vulva were seen between 1952 and 1982. All of these patients were available for 5-year evaluation. The crude survival for these patients was 62%, and the “cleaned” 5-year survival for 585 patients was 70%. All patients were treated with radical vulvectomy using the warm knife and open-wound technique. Treatment of the regional lymph nodes was performed by irradiation alone. This simple surgical technique in combination with radiotherapy applied only to the inguinal lymph nodes gives an excellent result without the complications associated with aggressive surgery.

     

Early stage I carcinoma of the vulva treated with ipsilateral superficial inguinal lymphadenectomy and modified radical hemivulvectomy: a prospective study of the Gynecologic Oncology Group.

Although cure rates are high, the morbidity of radical operation for carcinoma of the vulva is substantial. Between 1983-1989, member institutions of the Gynecologic Oncology Group entered 155 patients in a prospective evaluation of modified radical hemivulvectomy and ipsilateral inguinal lymphadenecctomy for clinical stage I vulvar cancer. Only patients with neoplastic thickness of 5 mm or less, without vascular space invasion, and negative inguinal lymph nodes were eligible for this study. There have been 19 recurrences and seven deaths from disease among the 121 eligible and evaluable patients. Patients whose disease recurred on the vulva were frequently (eight of ten patients) salvaged by further operation. Five of the seven deaths due to cancer occurred among patients whose first recurrence was in the groin. Acute and long-term morbidity as well as hospital stay were each less than in the Group's previous experience in a comparable patient population treated with radical vulvectomy and bilateral inguinal-femoral lymphadenectomy. There was a significantly increased risk of recurrence but not death when compared with these same historic controls. Modified radical hemivulvectomy and ipsilateral inguinal lymphadenectomy is an alternative to traditional radical operation for these selected patients with stage I carcinoma of the vulva. The number of patients who experienced recurrence in the operated groin is of concern and may be attributable to the decision to leave the femoral nodes intact.     

Squamous carcinoma of the vulva: results of treatment, 1938 to 1976.

Clinical data on 264 patients with squamous cell carcinoma of the vulva seen between 1938 and 1976 are reported. Two hundred and four patients were "eligible" for 5 year assessment for a 55% survival rate. Patients treated with radical vulvectomy and bilateral lymphadenectomy had a corrected 5 year survival rate of 86% if the lymph nodes failed to show metastatic disease. Twenty-eight percent of the patients treated with lymphadenectomy had lymph node metastasis at the time of surgery. The presence of lymphatic metastasis appeared to be the most significant prognostic factor. The results obtained have led to a degree of individualization in current treatment policies, together with a re-evaluation of the possible role of radiotherapy.     

Adenoid cystic carcinoma of the Bartholin's gland: the University of Michigan experience

Adenoid cystic carcinoma of the Bartholin's gland has been encountered in 11 patients at the University of Michigan Medical Center since 1936. At the time of presentation the average age was 48.9 years, the lesion size was between 0.5 to 4 cm. The presenting symptoms were pain and/or pruritis associated with a solitary mass. Early in this series, excisional biopsy was used to treat eight patients. The last three patients have been treated with a radical vulvectomy and unilateral or bilateral groin lymph node dissection. Local recurrence has occurred in five patients and distant recurrence in four patients. In spite of the high recurrence rate, 5- and 10-year survival has been high with all seven evaluable patients surviving 5 and 10 years. However, adenoid cystic carcinoma of the vulva is associated with late recurrences and metastases: three patients were dead of disease at 12, 15 and 31 years after initial diagnosis.     

Minimally invasive vulvar carcinoma: An indication for conservative surgical therapy

It has been proposed that squamous carcinoma of the vulva with 1 mm or less of stromal invasion can be treated with local resection without inguinal node dissection. A retrospective review of 255 cases of stages I and II vulvar carcinoma demonstrated 24 cases of minimally invasive carcinoma. All cases were subjected to detailed chart review and pathologic confirmation. Mean age at diagnosis was 60 years. Seven patients had a preoperative diagnosis of preinvasive disease, ten had stage I disease, and seven had stage II disease. Fifteen cases had associated vulvar carcinoma in situ. Treatment consisted of local excision in 2 patients, radical wide excision in 11, hemivulvectomy in 5, and radical vulvectomy in 6. Eleven patients had either unilateral or bilateral inguinal node dissection. Five-year life-table survival was 89%. Four patients (17%) developed recurrent dysplasia and four (17%) developed invasive recurrences. One invasive recurrence was in an inguinal node in a patient previously treated with a hemivulvectomy and negative ipsilateral superficial node dissection. Univariate analysis revealed no statistically significant associations between recurrence and age, symptom duration, margin status, location, FIGO stage, or coexisting VIN. Large areas of coexisting dysplasia and variable gross appearance make meaningful application of FIGO staging criteria difficult in lesions with minimal focal invasion. Wide excision or radical wide excision of lesions with "high-risk" VIN or those showing less than or equal to 1 mm of stromal invasion on biopsy is adequate therapy. If final pathologic review demonstrates deeper invasion, a selective lymph node dissection can be performed as a second procedure. Careful surveillance with liberal use of colposcopy and biopsies is indicated in these patients.     

Paget's disease of the vulva--a review of our experience

OBJECTIVE: The aim of our study was to review our experience with Paget's disease of the vulvar relative to initial examination, treatment and oncological outcome. METHODS: Ten women with extramammary Paget's diseases of the vulva were treated during the 10-year period. The charts of these patients were reviewed and data were collected regarding patient demographics, symptoms, previous Paget's disease, surgical treatments and time to recurrence. RESULTS: Eight women (80%) were treated with wide local excision or partial vulvectomy, and two patients (20%) required radical resection for invasive adenocarcinoma. The group of women who had invasive diseases also underwent inquinofemoral lymphadenectomy and no lymphatic metastases were noted. Three women (30%) experienced recurrence. The mean time to relapse was 30 months (range 3-88 months). CONCLUSION: Recurrence is very common and long-term monitoring is recommended with careful examination of any abnormal vulvar lesion.