How important is the pathological margin distance in vulvar cancer?

PURPOSE: The ideal pathological margin in vulvar squamous cell carcinoma (VSCC) is still debated. Our aim was to analyze the value of tumor-free pathological margin distance with regard to local recurrence in VSCC. METHODS: We analyzed a series of 205 patients who were treated for VSCC from January 1980 to November 2007. Patients were categorized into 3 groups, based on pathological free margin (PFM): <3 mm (n = 18); ≥3 and <8 mm (n = 61); and ≥8 mm (n = 126). RESULTS: The median age was 69 years. The median PFM was 10 mm (range: 1-65). Of 168 patients who underwent lymphadenectomy, 64 (38.1%) developed LN metastasis. After a median follow-up of 36.2 months, 78 (38%) cases recurred-47 (60.2%) experienced a local recurrence (LR). LR occurred in 16.7% of patients with a PFM of <3 mm, 24.6% with a PFM ≥3 and <8 mm, and 22.2% of those with a PFM ≥8 mm (p = 0.77). PFM did not correlate with LR when analyzed continuously (p = 0.98). The 5-year disease-free survival (DFS) for LR was 79.6%. Margin distance did not negatively impact DFS (p = 0.94); the presence of perineural invasion was the only variable that negatively influenced DFS (p = 0.009). CONCLUSIONS: Although our results suggest no correlation between LR and pathological margin distance, the tumor-free resection margin remains significant with regard to locoregional control in vulvar cancer. A more conservative surgical approach may be considered in certain situations, such as margins near the clitoris, urethra, and anus.

Prognostic value of the number and laterality of metastatic inguinal lymph nodes in vulvar cancer: revisiting the FIGO staging system.

OBJECTIVE: Inguinal lymph node (LN) metastasis is an important prognostic factor in vulvar cancer. Our aims were to analyze the prognostic value of LN metastasis with regard to the number of LNs that were involved and their laterality and compare these results with the current FIGO staging system. METHODS: A retrospective analysis was performed in a series of 234 individuals who underwent inguinal lymphadenectomy for vulvar squamous cell carcinoma from January 1980 to February 2010. RESULTS: The mean age was 68 years. One hundred seven (45.7%) patients had LN metastasis. Despite the FIGO staging, we did not observe any significant difference in the risk of recurrence or death between patients with 1 positive LN and ≥ 2 positive LNs. Moreover, there was no difference in outcome between the presence of 1 and 2 positive LNs. On categorizing patients into 3 groups-absence of LN involvement, 1-2 positive LNs, and ≥ 3 positive LNs-we achieved a significantly better prognostic correlation for progression-free survival, disease-specific survival, and overall survival. Extracapsular spread retained a prognostic role for the risk of recurrence in multivariate analysis. Further, for patients with ≥ 2 positive LNs, the presence of bilateral positive LNs did not negatively impact the risk of recurrence or death compared with those with unilateral positive LNs. CONCLUSIONS: Our data suggest that the prognostic effect of bilateral LNs reflects the worse prognosis of multiple positive LNs. Regarding prognosis, LN involvement should be categorized into 2 groups-1-2 positive LNs and ≥ 3 positive LNs.

Does the count after inguinofemoral lymphadenectomy in vulvar cancer correlate with outcome?

BACKGROUND: Inguinal lymph node (LN) metastasis is an important prognostic factor in vulvar cancer. Our aim was to determine the prognostic value of the number of resected LNs in inguinofemoral lymphadenectomy. METHODS: A retrospective analysis was performed in a series of 158 individuals who underwent bilateral inguinofemoral lymphadenectomy for vulvar squamous cell carcinoma from January 1980 to February 2010. RESULTS: The mean age was 67 years (range: 15-90). Median tumor size was 5 cm (range: 1-18). A median of 22.5 inguinal LNs (range: 2-57) was resected. Thirteen (8.2%) patients had <12 LNs resected, and 145 (91.8%) had ≥ 12 LNs resected. Eighty (50.6%) patients had LN metastasis, with a median of 2 positive LNs (range: 1-16). Of those with positive LNs, 19 (23.8%), 23 (28.8%), and 38 (47.5%) patients had 1, 2, and 3 or more positive LNs, respectively. Thirty-three (41.2%) patients had bilateral LN metastasis. For patients without LN involvement, we failed to observe any significant difference between patients with <12 LNs and ≥ 12 LNs that were resected with regard to risk of recurrence (p=0.97) and death from cancer (p=0.43) in 5 years. However, resection of <12 LNs in patients with positive LNs negatively impacted the risk of recurrence (p=0.003) and death from cancer (p=0.043). CONCLUSIONS: Resection of fewer than 12 LNs in vulvar cancer has a negative impact on outcome for patients with positive inguinal LNs.

Prognostic factors in pelvic exenteration for gynecological malignancies.

OBJECTIVES: Analyze morbidity, mortality and prognostic factors after pelvic exenteration (PE) for gynecological malignancies. METHODS: We reviewed a series of 107 individuals who underwent PE at A.C. Camargo Cancer Hospital from August 1982 to September 2010. RESULTS: Median age was 56.4 years. Primary tumor sites were uterine cervix in 73 cases (68.2%); vaginal, 10 (9.3%); endometrial, 14 (13.1%); vulvar, 7 (6.5%); and uterine sarcomas, 3 (2.8%). Median tumor size was 5.5 cm. Total PE was performed in 56 cases (52.3%), anterior in 31 (29.9%), posterior in 10 (9.3%) and lateral extended in 10. Median operation time, blood transfusion and hospital stay length were 420 min (range: 180-780), 900 ml (range: 300-4500) and 13 days (range: 4-79), respectively. There was no intra-operative death. Fifty-seven (53.3%) and 48 (44.8%) patients had early and late complications, respectively. Five-year progression free survival (PFS), overall survival (OS) and cancer specific survival (CSS) were 35.8%, 27.4% and 41.1%, respectively. Endometrial cancer had better 5-year OS (64.3%) than cervical cancer (23.1%). Lymph node metastasis negatively impacted PFS, CSS and OS. Presence of perineural invasion negatively impacted PFS and CSS. No variable retained the risk of recurrence or death in the multivariate analysis. CONCLUSIONS: PE has acceptable morbidity and mortality and may be the only method that can offer long-term survival in highly selected patients.