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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 3  |  Page : 412-415
 

A cohort study of vulvar cancer over a period of 10 years and review of literature


1 Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Radiotherapy, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication24-Feb-2017

Correspondence Address:
N Singh
Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.200656

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 » Abstract 

OBJECTIVE: The objective of this study was to study the risk factors, management protocols, and the outcome of vulvar cancer cases over a period of 10 years in a tertiary care hospital. METHODOLOGY: It is a retrospective cohort study. The hospital records of 41 patients with histologically proven vulvar cancer were studied from the Department of Obstetrics and Gynaecology and the Department of Radiotherapy (RT). The presence of risk factors, stage of disease, treatment modalities used, and disease outcomes in terms of survival were studied. The data collected were analyzed and compared with the published literature. RESULTS: The mean age for the diagnosis of vulvar cancer was 52 years and the peak incidence was seen in the age group of 50–70 years. Incidence was significantly more in multiparous (P = 0.001) and postmenopausal women (P = 0.007). An average of 4.1 cases were seen per year. Nearly, 97.56% of the cases were squamous cell carcinomas. Twenty cases belonged to the early stage of the disease (Stage I and II) whereas 21 cases had advanced disease (Stage III and IV). Nearly, 48.78% of the cases were primarily treated with surgery, 26.83% with RT, 7.3% with chemotherapy, and 17.07% with combined chemoradiation. Seventy-eight percent of the surgically treated cases had a mean survival of 5 years. Mean survival of 1 year was recorded in advanced disease cases. Limitation of the study was poor follow-up after treatment. CONCLUSION: Incidence of vulvar cancer is significantly high in multiparous and postmenopausal women. Conservative surgical treatment is the best option in the early stage of the disease (Stage I and II) and gives high survival rates whereas advanced disease treated with chemoradiation has a poor survival.


Keywords: Cancer vulva, chemotherapy, inguinofemoral lymphadenectomy, radical vulvectomy, radiotherapy


How to cite this article:
Singh N, Negi N, Srivastava K, Agarwal G. A cohort study of vulvar cancer over a period of 10 years and review of literature. Indian J Cancer 2016;53:412-5

How to cite this URL:
Singh N, Negi N, Srivastava K, Agarwal G. A cohort study of vulvar cancer over a period of 10 years and review of literature. Indian J Cancer [serial online] 2016 [cited 2017 Sep 20];53:412-5. Available from: http://www.indianjcancer.com/text.asp?2016/53/3/412/200656



 » Introduction Top


In India, 50–60% of all cancers among women are related mainly to the four organs; cervix uteri, breast, corpus uteri, and ovaries.[1] Vulvar cancer is one of the rare cancers of female reproductive tract representing about 4% of the gynecologic malignancies and 0.6% of all cancers in women.[2],[3] It is mainly seen in postmenopausal women, and the age-specific incidence increases with age.[2] The most common site of vulvar cancer is labia majora. Ninety percent of vulvar cancers are squamous cell type [4] which could be further divided into keratinizing, basaloid, or verrucous type.

The presenting complaints may be pruritus vulvae, ulceration, bleeding, discharge, pain, swelling, or leukoplakia. Diagnosis is made by clinical examination and vulvar biopsy. Treatment modalities depend on the stage of the disease and include surgery, radiotherapy (RT), and chemotherapy (CT). The surgical treatment involves individualized, conservative surgery with adequate resection of margins and groin node dissection.[5] The psychosexual sequel and morbidity associated with groin node dissection have led to more conservative surgical approach. Involvement of the inguinal lymph nodes is an important prognostic indicator of survival in these patients. The various risk factors associated with lymph node metastasis are age, clinical node status, tumor stage, thickness, depth of invasion, degree of differentiation, and lymphovascular space invasion.[3]

Being one of the less common types of genital cancer, there is a scarcity of literature about the changing trends in the methods of management, outcome of disease, and long-term survivals. Herein, we report a cohort study of vulvar cancer cases over a period of 10 years. This includes analysis of risk factors, treatment modalities, and survival rates of vulvar cancer in our institute.


 » Methodology Top


This is a retrospective cohort study of cases diagnosed as vulvar cancer in the King George Medical University from January 2004 to January 2014. Hospital records from the Department of Obstetrics and Gynaecology and the Department of RT were studied. Forty-one patients with histologically proven diagnosis of vulvar cancer were included in the analysis. The presence of risk factors, stage of disease, treatment modalities used, and disease outcomes in terms of complications and survival were tabulated. The data thus collected were analyzed and compared with the published literature.


 » Results Top


[Table 1] shows the demographic profile of the 41 cases diagnosed over a period of 10 years. The mean age for diagnosis of vulvar cancer was 52 years, and the peak incidence was seen in the age group of 50–70 years. Disease incidence was significantly more in multiparous women as compared to nulliparous women (P = 0.001) and postmenopausal women as compared to premenopausal women (P = 0.007).
Table 1: Demographic profile of vulvar cancer cases (n=41)

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[Table 2] shows the yearly distribution of all cases. An average of 4.1 cases were seen per year. Peak incidence was seen in the year 2007. Out of the 41 cases, 40 (97.56%) cases were of squamous cell type which included two cases of verrucous carcinoma which is a rare subtype of squamous cell carcinoma. The only nonsquamous variety seen was Bowen's disease in one patient.
Table 2: Annual distribution of vulvar cancer cases

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[Table 3] shows the distribution of cases according to the stage of disease and primary treatment modality. Out of the 41 cases, 48.78% of the cases were primarily treated with surgery, 26.83% with RT, 7.3% with CT, and 17.07% with combined RT and CT. Among postoperative complications, one 70-year-old diabetic patient had wound breakdown which healed with local dressing over a week and one patient developed lymphedema in the right leg.
Table 3: Clinical stage of vulvar cancer and primary treatment

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[Table 4] shows the details of twenty cases treated with surgery as a primary modality. Stage of the disease was determined preoperatively by clinical assessment. One case of microinvasive disease underwent wide local excision. Another case of Stage Ib underwent excisional biopsy. Eleven cases of clinical Stage Ia (clinically nonpalpable groin nodes) underwent simple vulvectomy. Pathological nodal status was not available in these 12 cases for complete staging of the disease. Seven cases of clinical Stage Ib or II underwent radical or modified radical vulvectomy with inguinofemoral lymphadenectomy.
Table 4: Outcome of vulvar cancer cases treated surgically (n=20)

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[Table 5] shows the details of cases treated with RT and CT. These were advanced stage cases unsuitable for surgery.
Table 5: Outcome of cases treated by radiotherapy and chemotherapy

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 » Discussion Top


Vulvar cancer is the 20th most common female cancer,[6] mainly seen in elderly women. Okolo et al.[7] studied 78 cases of vulvar cancer from 1981 to 2008. The mean age in this study was 49.7 years with a peak incidence in the fifth decade. In our study, the mean age was similar (52 years), but the peak incidence was seen in the sixth and seventh decades. The most common type of vulvar cancer is squamous cell carcinoma accounting for about 90% of the cases; the remaining types are Paget's disease, Bartholin's gland tumors, adenocarcinoma, and basal cell carcinoma.[2] Okolo et al.[7] showed that 73.61% of vulvar cancers in their study were squamous cell type. In our study, all cases except one were squamous cell carcinoma accounting for 97.56% of the cases.

The management of vulvar cancer has evolved from primary surgical approach to chemoradiation. The surgical management has become more conservative due to the well-recognized morbidity with radical vulvectomy and extensive groin dissection and psychosexual sequelae. In this study, all the early (Stage I and II) cases were primarily treated with surgery and late (Stage III and IV) cases with chemoradiation.

According to the International Federation of Gynecology and Obstetrics guidelines, treatment of microinvasive vulvar cancer (Stage Ia) is wide local excision. Groin dissection is not necessary for such lesions.[2] In this study, one case of microinvasive carcinoma underwent wide local excision with no groin dissection as per the recommendations.

Resection of primary tumor and groin lymph node dissection is recommended using separate groin and vulvar incisions (triple incision technique) to reduce morbidity and to improve primary healing.[2] This technique was utilized in all cases with groin dissection. Appropriate groin treatment is the single most important factor in reducing mortality from early vulvar cancer.[8] It is recommended that both inguinal and femoral nodes should be removed, and appropriate dissection includes removal of at least 8–10 nodes. In our study, six cases of Stage II underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy and one had ipsilateral lymphadenectomy. All groin dissections included both inguinal and femoral lymphadenectomy.

Frozen section technique plays an important role in decreasing the surgical morbidity because one can confirm disease-free margins and nodal status during surgery. Frozen section facility has recently become available in our institute and was utilized in two of our cases. In the first case with unilateral disease, ipsilateral inguinofemoral lymphadenectomy was performed and nodes were sent for frozen section evaluation. Since no evidence of nodal metastasis was seen, contralateral groin dissection was deferred. In the second case, disease appeared close to the urethra and clitoris. Frozen section of the resected tumor margins confirmed adequate surgical dissection. None of our cases suffered from any serious complication in the postoperative period and thus, the surgical morbidity in our cases was low.

Eleven cases in the present study were treated primarily by simple vulvectomy without inguinofemoral nodal dissection. Six of these cases received adjuvant RT and one received chemoradiation. These cases indicate that incomplete surgery and adjuvant RT could have been avoided if nodal dissection was complete and showed the absence of metastasis.

Out of the seven cases who underwent radical or modified radical vulvectomy with inguinofemoral lymphadenectomy, only two cases needed adjuvant RT; one due to positive lymph nodes and one for inadequate surgical margin. While deciding for adjuvant treatment with RT alone or CT and RT, many factors such as age, kidney function, and comorbid conditions were also taken into consideration.

Bellati et al.[9] studied the acute and long-term morbidity, recurrence rate, and overall survival in 14 patients with multiple groin lymph node metastases treated with postoperative CT (cisplatin) and no RT. They concluded that radical surgery followed by CT, in patients with multiple lymph node metastases, is a feasible strategy. In 2016, the national comprehensive cancer network [10] has released new guidelines for the management of vulvar cancer that recommend adjuvant local therapy for positive margins and to groin and pelvis for metastatic nodal involvement.

In our study, 11 cases of Stage III were treated with RT (Theratron 780) whereas two cases of Stage III and five cases of Stage IV were treated with chemoradiation using concurrent cisplatin 50 mg weekly with radiation. In advanced stages, concurrent CT was added to suitable patients only. A total dose of 60–70 Gy is given by combining external beam radiation and brachytherapy.

Seven out of twenty surgically treated patients were lost to follow-up. Survival rate in surgically treated patients under follow-up is 76.9%, with a mean survival of 5 years. Survival rate, among ten cases treated with chemoradiation, is 30% with a mean survival of 12 months. The results confirm a high survival with early stage of the disease. Three advanced disease cases took only CT. One of them is surviving with a follow-up of 12 months.

The main drawback and limitation of our study was inadequate (65%) follow-up rate. Survival and recurrence rates could not be completely evaluated. This is because many patients resided in remote peripheral areas. The financial constraints, lack of communication and transport facilities made the regular follow-up difficult.


 » Conclusion Top


The study concludes that the mean age of vulvar cancer is 52 years with a peak incidence in the sixth-seventh decades. Incidence is significantly high in multiparous and postmenopausal women. Surgical treatment is the best option in the early stage of disease (Stage I and II) and gives high survival rates. Complete treatment must be ensured in both surgical and chemoradiation options.

Acknowledgment

The study was conceived by Prof. Nisha Singh. Data were collected by Dr. Gargi Agarwal, Dr. Neha Negi, and Prof. Kirti Srivastava. Data analysis and manuscript writing were done by Prof. Nisha Singh and Dr. Neha Negi. We acknowledge the contribution of all doctors and patients of the Department of Obstetrics and Gynecology and the Department of Radiotherapy who managed the patients at various levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Consolidated Report of Hospital Based Cancer Registries 2001-3, National Cancer Registry Program. New Delhi: Indian Council of Medical Research; 2007.  Back to cited text no. 1
    
2.
Hacker NF, Eifel PJ, van der Veldenc J. FIGO cancer report 2012. Cancer of the vulva. Int J Gynecol Obstet 2012;119 Suppl 2:S90-6.  Back to cited text no. 2
    
3.
American Cancer Society. Cancer facts and Figures 2015. Atlanta, GA: American Cancer Society; 2015.  Back to cited text no. 3
    
4.
Eifel PJ, Berek JS, Markman MA. Cancer of the cervix, vagina, and vulva. In: DeVita VT Jr., Lawrence TS, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology. 9th ed.. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. p. 1311-44.  Back to cited text no. 4
    
5.
Royal College of Obstetrics and Gynaecology. Guidelines for the diagnosis and management of vulvar carcinoma. British Gynaecological cancer society: Royal College of Obstetrics and Gynaecology; 2014.  Back to cited text no. 5
    
6.
Cancer Research UK. Vulvar Cancer Incidence Statistics. Available from: http://www.cancerresearchuk.org [Last accessed on 2014 Apr 23].  Back to cited text no. 6
    
7.
Okolo CA, Odubanjo MO, Awolude OA, Akang EE. A review of vulvar and vaginal cancers in Ibadan, Nigeria. N Am J Med Sci 2013;6:76-81.  Back to cited text no. 7
    
8.
Hacker NF. Vulvar cancer. In: Berek JS, Hacker NF, editors. Berek and Hacker's Gynecologic Oncology. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 536-75.  Back to cited text no. 8
    
9.
Bellati F, Angioli R, Manci N, Angelo Zullo M, Muzii L, Plotti F, et al. Single agent cisplatin chemotherapy in surgically resected vulvar cancer patients with multiple inguinal lymph node metastases. Gynecol Oncol 2005;96:227-31.  Back to cited text no. 9
    
10.
NCCN Clinical Management Guidelines in Oncology, Vulvar Cancer (Squamous Cell Carcinoma) Version 1; 2016. Available from: http://www.NCCN.org. [Last accessed on 2016 Feb 02].  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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