Prognostic role of lymph node metastases in vulvar cancer and implications for adjuvant treatment.

OBJECTIVE: Lymph node metastases are the most important prognostic factor for recurrence and survival in vulvar cancer. However, information regarding the impact of the number of positive nodes in vulvar cancer is inconsistent, and so are recommendations when to apply adjuvant radiotherapy. METHODS: One hundred fifty-seven consecutive patients with primary squamous cell cancer of the vulva treated at our center were analyzed. All patients underwent primary surgery by triple incision resulting in complete tumor resection. RESULTS: Median age was 61 years; 49 patients (31%) had lymph node metastases; 21 patients had 1, 13 had 2, and 15 had more than 2 positive lymph nodes. Thirty-two percent of the patients received adjuvant radiotherapy. The risk of lymph node metastases increased with age, greater tumor size, deeper invasion, and higher tumor grade. Median follow-up was 36 months; 23 patients (14.6%) developed disease recurrence (61% vulva, 35% groins, and 4% both). Compared with node-negative patients, survival in all node-positive patients was significantly impaired (P < 0.001; disease-free patients after 2 years: 88% in node-negative patients; 60%, 43%, and 29% in patients with 1, 2, and >2 affected nodes, respectively), whereas no significant difference between the node-positive subgroups could be demonstrated regarding disease-free survival. In multivariate analysis, lymph node status remained the most important prognostic factor regarding disease-free survival, but the effect of positive nodes differed significantly dependent on adjuvant treatment (P = 0.001). In patients without adjuvant radiotherapy to the groins/pelvis, the number of metastatic nodes was highly relevant for prognosis (hazard ratio, 1.752; P < 0.001), whereas this effect disappeared in patients who were treated with adjuvant radiotherapy (hazard ratio, 0.972; P = 0.828). CONCLUSIONS: The negative impact of lymph node metastases is already evident in patients with only 1 affected lymph node. In patients receiving adjuvant radiotherapy, the negative effect of additional lymph node metastases is reduced; adjuvant treatment might therefore be beneficial in patients with only 1 positive node.

Adjuvant therapy in node-positive vulvar cancer.

Due to an increasing incidence with concurrently decreasing age at onset, vulvar cancer represents a current challenge for gynecologic oncologists. Positive lymph nodes of the groins have been proven to be the most important prognostic factor for affected patients, significantly impairing overall survival. Distinct criteria for indication of adjuvant therapy following primary tumor resection and groin surgery are still under debate. At present, only patients with two or more positive lymph nodes are treated with adjuvant radiotherapy despite growing evidence that patients with only one nodal macrometastasis already have a significantly worse outcome and might benefit from adjuvant treatment. This review discusses existing evidence focusing on different therapeutic approaches and their potential indication in vulvar cancer. Based on the available data the need for future trials is being elaborated.

Prognostic factors and treatment options in patients with leptomeningeal metastases of different primary tumors: a retrospective analysis.

PURPOSE: Leptomeningeal metastases (LM) are associated with very poor prognosis and data on outcome are limited. We evaluated prognostic factors and treatment options in patients (pts) with LM of different malignancies in a single center experience. METHODS: Single center data on characteristics, treatment and outcome of 135 consecutive pts (73 solid tumors and 62 hematologic malignancies) with LM between 1989 and 2005 were retrospectively analyzed. RESULTS: Treatment consisted of systemic chemotherapy (SC) plus intrathecal chemotherapy (ITC) in 28%, ITC alone in 22%, radiotherapy (RT) plus ITC in 12% and other modalities (SC, RT, SC + RT) in 7%. Thirteen percent of pts received supportive care only (4% not evaluable on treatment). Median survival from diagnosis of LM was 2.5 months. Univariate analysis revealed age >50, interval between diagnosis of primary tumor and LM ≤12 months, lung cancer and malignant melanoma, and Karnofsky performance status ≤70 as significant negative predictors for overall survival. Positive predictive factors were response in cerebrospinal fluid and application of SC. In multivariate analysis, only SC was significantly associated with longer median survival (5.6 vs. 1.7 months). CONCLUSIONS: In patients with LM an age >50, performance status ≤70%, interval between diagnosis of primary tumor and LM ≤12 months, primary tumor (lung cancer, malignant melanoma) and lack of cytologic response present negative prognostic factors. Systemic chemotherapy is significantly associated with longer survival time than local treatment modalities.