A study of recurrence, complication and survival rates in patients with early stage vulval cancer undergoing sentinel lymph node sampling: a single-centre experience.

PURPOSE: Groin sentinel lymph node (SLN) identification and removal has become a standard of care for women with clinical early stage vulval cancer. There is evidence to support safe detection of the SLN with minimal morbidity. The purpose of this study is to report our experience of managing patients focusing on patient selection, adverse events, quality assurance of the procedure and any benefits and/or disadvantages to patients. METHODS: This was a retrospective study of patients with clinical early stage vulval cancer in a cancer centre over 5 years. Notes and hospital data were reviewed including admissions to emergency departments. Statistical software was used for the statistical analysis and the Kaplan Meier survival curve was generated to present survival rates. RESULTS: 61 cases were analysed. A total of 156 nodes have been removed and positive nodes were identified in 14 cases. In total, 9 women (14.75%) had disease recurrence within 5 years from primary surgery. Overall, 4 patients (6.5%) developed groin recurrence. In 3 of these patients there was isolated groin recurrence (4.9%). The median length of admission was 3 days and 6 cases were managed as day cases. CONCLUSIONS: Since the closure of the GROINNS-2 trial we have continued the procedure of SLN identification for women with clinical early stage vulval cancer. We have shown high level of adherence to our protocol and survival and complication rates comparable to other studies on the same field. There were a few patients managed as day-case which was of benefit to the patients.

Vulval extra-mammary Paget's disease: the master of disguise revealed.

Extra-mammary Paget's disease is a rare cancer affecting the anogenital region and can present with a myriad of symptoms. In women, the diagnosis of Paget's disease can be challenging as it mimics several other vulval conditions. It is important to promptly recognise this disease because of its potential association with synchronous tumours, such as colorectal adenocarcinoma. The mainstay of treatment is with immunomodulating therapies or surgery, but unfortunately the risk of recurrence is high and appears to be independent of treatment choice and tissue margin status. There is growing evidence to move away from traditional surgical excision to using topical therapy, such as imiquimod, as surgery can often be extensive and disfiguring with a prolonged recovery time. There is considerable psychosexual and physical morbidity associated with Paget's disease, largely owing to multiple surgical recurrences. As recurrences can occur several years after the initial presentation, long-term follow up of patients is recommended.

Radiotherapy Versus Inguinofemoral Lymphadenectomy as Treatment for Vulvar Cancer Patients With Micrometastases in the Sentinel Node: Results of GROINSS-V II.

PURPOSE: The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). METHODS: GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS: From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL (P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL. CONCLUSION: Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

Women's Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis.

Vulvodynia is the experience of idiopathic pain characterized by burning, soreness, or throbbing in the external female genitalia or vulva and is estimated to be experienced by 4-16% of the female population, yet only half of women seek help regarding their symptoms. Of the women who do seek help, only around 2% obtain a diagnosis. Therefore, the aim of the current study was to explore the experiences of women with vulvodynia on their journey toward diagnosis, by using semi-structured interviews and an interpretative phenomenological analysis (IPA) methodology. Eight women were interviewed, and their experiences were analyzed and interpreted into three master themes, each with constituent sub-themes: (1) The Journey Is a Battle, (2) "What Is Vulvodynia?": Ambivalence Toward Diagnosis, and (3) Patriarchy, Women, and Sex. Overall, women perceived a healthcare system which was dismissive and shaming, with an inadequate knowledge of vulvodynia. This in turn impacted on women's psychological well-being. Psychological understanding, one-to-one therapy, and consultation and training for healthcare professionals may help to improve the psychological well-being of women with vulvodynia.

Women's Subjective Experiences of Living with Vulvodynia: A Systematic Review and Meta-Ethnography.

Vulvodynia, the experience of an idiopathic pain in the form of burning, soreness, or throbbing in the vulval area, affects around 4-16% of the population. The current review used systematic search strategies and meta-ethnography as a means of identifying, analyzing, and synthesizing the existing literature pertaining to women's subjective experiences of living with vulvodynia. Four key concepts were identified: (1) Social Constructions: Sex, Women, and Femininity: Women experienced negative consequences of social narratives around womanhood, sexuality, and femininity, including the prioritization of penetrative sex, the belief that it is the role of women to provide sex for men, and media portrayals of sex as easy and natural. (2) Seeking Help: Women experienced the healthcare system as dismissive, sometimes being prescribed treatments that exacerbated the experience of pain. (3) Psychological and Relational Impact of Vulvodynia: Women experienced feeling shame and guilt, which in turn led to the experience of psychological distress, low mood, anxiety, and low self-esteem. Moreover, women reported feeling silenced which in turn affected their heterosexual relationships and their peer relationships by feeling social isolated. (4) A Way Forward: Women found changing narratives, as well as group and individual multidisciplinary approaches, helpful in managing vulvodynia. The findings of the review conclude that interventions at the individual level, as well as interventions aimed at equipping women to challenge social narratives, may be helpful for the psychological well-being of women with vulvodynia.

The day we started HPV triage.

AIMS: Following the introduction of the triage test in cervical screening, which was designed to identify a subgroup who were at risk of underlying high-grade cervical intraepithelial neoplasia (CIN), there has been a significant change in the number and profile of cervical biopsies. In this study, analysis of the progressive change in diagnostic categories has been performed to identify the impact of the triage test on the service. METHODS: Cases referred for colposcopy, with corresponding subsequent tissue diagnoses, were identified by electronic search of the histopathology accession database using suitable coding terms for the period between October and April of four consecutive years. A likelihood ratio test was devised to assess the significance of the observed progressive increase in total numbers of cervical biopsies. RESULTS: As anticipated from the pilot studies, implementation of the new guidelines led to a significant increase in the number of women referred for colposcopy. However, the annual increase was greater than expected. During this period, there was a change in the profile of histological diagnoses, characterised by: conspicuous rise in the number of cervical biopsies reported as 'human papillomavirus change only' or 'CIN1' (21-29% and 12-21%, of the total cervical biopsies, respectively); fall in mean CIN scores. CONCLUSIONS: The change in guidelines has led to an increase in patients referred for colposcopy; in turn this has led to an increase in number of specimens (particularly those with lower grades of dysplasia) submitted for histological assessment. This change of workload profile has implications for resourcing services for colposcopy and histopathology.

Women's experiences of using vaginal trainers (dilators) to treat vaginal penetration difficulties diagnosed as vaginismus: a qualitative interview study.

BACKGROUND: Recent research has highlighted controversies in the conceptualisation, diagnosis and treatment of vaginismus. Vaginal trainers are currently the most widely used treatment. Critiques have highlighted concerns that the evidence-base of its effectiveness is limited, with controlled trials reporting disappointing results, and its prescription promotes 'performance-based' sexuality which may be detrimental. Despite this, little has been done to seek women's views about their treatment. This study set out to explore women's experiences of vaginismus treatment with vaginal trainers, and to use their voices to propose guidelines for improving treatment. METHODS: 13 women who had used vaginal trainers for vaginal penetration difficulties diagnosed as vaginismus were recruited through a specialist clinic, university campuses, and online forums. The women took part in semi-structured individual interviews (face-to-face/telephone/Skype), which were audio-recorded, transcribed verbatim and analysed using Thematic Analysis. RESULTS: Four superordinate themes were elicited and used to draft 'better treatment' guidelines. Themes were: (1) Lack of knowledge, (2) Invalidation of suffering by professionals, (3) Difficult journey, and (4) Making the journey easier. This paper describes themes (3) and (4). Difficult Journey describes the long and arduous 'Journey into treatment', including difficulties asking for help, undergoing physical investigations and negotiating 'the system' of medical referrals. It also describes the sometimes demoralising process of 'being in treatment', which includes emotional and practical demands of treatment. Making the journey easier highlights the importance of and limits to 'partner support'. 'Professional support' comprises personal qualities of professionals/therapeutic relationship, the value of specialist skills and knowledge and the need for facilitating couple communication about vaginismus. 'Peer support/helping each other' describes the importance of supportive vaginimus networks and sharing tips with other women. CONCLUSIONS: Accessing effective treatment for vaginal penetration difficulties is difficult. The practical and emotional demands of using vaginal trainers may be underestimated by professionals, resulting in inadequate provision of support and information in practice. At times vaginal trainers may be prescribed to women who are unlikely to benefit from this treatment in isolation. Core communication skills like non-judgemental listening are important for supporting women through treatment. However professionals also need greater specialist knowledge, which in turn requires more detailed research. New ways to disseminate specialist knowledge and suggestions for further research are discussed.

Preventing endometrial cancer risk in polycystic ovarian syndrome (PCOS) women: could metformin help?

Current data indicate that there is a significant risk of endometrial cancer (EC) in women with polycystic ovarian syndrome (PCOS), although further research needed to clarify the exact molecular mechanisms. Endometrial hyperplasia is a premalignant condition that usually heralds EC and it shares identical risk factors with EC. Metabolic syndrome with a triad of obesity, hyperinsulinaemia and diabetes, which is commonly observed in PCOS appears to be a key mechanism in EC pathogenesis. Measures to improve insulin resistance could therefore play a role in reducing the risk of EC in women with PCOS. Metformin is an insulin sensitising agent which is safe, widely available and currently licensed for type-2 diabetes. It has been clearly shown in both animal and human studies that metformin is of value in reversing endometrial hyperplasia. Metformin may therefore prevent EC in PCOS. This article reviews the use of metformin in reducing EC risk in PCOS and makes a case for future research on this topic.

Clinical outcome of atypical endometrial hyperplasia diagnosed on an endometrial biopsy: institutional experience and review of literature.

The aims of this study were: (1) to review the rate of concurrent endometrial cancer in patients with a preoperative diagnosis of atypical endometrial hyperplasia (AEH); and (2) to determine the features of concurrent endometrial carcinoma and their impact on the subsequent management of AEH. We reviewed a retrospective series of 219 AEHs diagnosed locally in routine practice, over 24 years, and followed by a repeat biopsy or hysterectomy. Another series of 65 cases with a malignant diagnosis on preoperative sampling was included as a control group. Clinicopathologic parameters were obtained. In addition, published data on the risk of malignancy and features of malignant tumors after a diagnosis of AEH were collected and analyzed. This study reported on 2571 patients diagnosed in 31 published studies in addition to the current one. This showed a wide variation in the positive predictive value (PPV) of AEH in detecting endometrial cancer (6% to 63%) with an overall PPV of 37%. This variation is not only based on the differences among studies but also on the degree of atypia [mild/moderate (PPV 13%) or severe (PPV 50%)], the type of subsequent intervention (biopsy vs. hysterectomy), and more importantly the time period of diagnosis (around 20% in studies published before 1990s and up to 40% to 48% in recently published cases). Of the benign outcome cases, nearly 40% to 50% showed AEH with a potential risk of progressing to invasive carcinoma in 25% of cases. Malignant tumors after AEH diagnosis are associated with features of good prognosis with endometrioid morphology, lower grade, and early stage. Although the overall PPV of AEH is 37%, a figure of 40% to 48% is expected in the cases currently diagnosed in routine practice. Providing qualifying criteria for AEH will help identify its different associated risks and therefore should be included in routine pathology reports whenever possible. Unless there is a clinical contraindication, hysterectomy should be performed to treat concurrent carcinoma and to reduce the risk of subsequent carcinoma in nonmalignant cases with residual AEH.

Do surgical techniques used in groin lymphadenectomy for vulval cancer affect morbidity rates?

OBJECTIVE: To determine the complication rates associated with differing surgical techniques for groin node dissection for vulval cancer. MATERIALS AND METHODS: We performed a retrospective case note review of patients undergoing groin node dissection for vulval cancer between 2001 and 2009 at Nottingham University Hospitals NHS Trust. RESULTS: Notes for 56 patients undergoing a total of 98 groin node dissections were examined. Sixty-four percent of the patients had at least one complication from surgery. The use of suction drains was not associated with an increase in complications. However, when drains were used, a short duration of use was associated with high rates of wound breakdown and a long duration of use was associated with higher rates of lymphedema. The use of staples for skin closure was associated with an increased risk of lymphocysts and chronic lymphedema. The greater the number of nodes collected at lymphadenectomy, the higher the risk of lymphocysts and lymphedema. CONCLUSIONS: We recommend the use of subcuticular suture for wound closure. Patients who undergo lymphadenectomy with a node count per groin of more than 7 should be closely monitored for lymphedema and referred promptly to specialist services. The prolonged use of suction drainage may increase the risk of lymphedema.

The management of vulval pain syndromes.

Vulval problems are common in gynaecological practice. Pain syndromes of the vulva should be considered once infection and dermatological causes of vulval symptoms have been excluded. This article covers vulval vestibulitis and dysaesthetic vulvodynia, the two subgroups of vulval pain syndromes.