Download PDF
Geburtshilfe Frauenheilkd 2014; 74(3): 271-275
DOI: 10.1055/s-0033-1360145
DGGG Review
GebFra Science
Georg Thieme Verlag KG Stuttgart · New York

Therapy for Primary Vulvar Carcinoma

Therapie des primären Vulvakarzinoms
D. Herr
Frauenklinik, Universitätsklinikum Homburg/Saar, Homburg, Saar
,
I. Juhasz-Boess
Frauenklinik, Universitätsklinikum Homburg/Saar, Homburg, Saar
,
E. F. Solomayer
Frauenklinik, Universitätsklinikum Homburg/Saar, Homburg, Saar
› Author Affiliations
Further Information

Publication History

received 10 July 2013
revised 22 September 2013

accepted 27 September 2013

Publication Date:
09 April 2014 (online)

Also available at
   Permissions and Reprints

Abstract

The rather rare vulvar cancer is almost always a squamous cell carcinoma that mostly develops from an underlying VIN or HPV infection. In addition, lichen sclerosus et atrophicans, immune deficiency, nicotine abuse or anogenital intraepithelial neoplasias may play a role in the pathogenesis. Surgical therapy aims at an R0 resection in the sense of a complete vulvectomy or a radical local excision with, if necessary, plastic reconstruction. Also, the vulvar field resection with consideration of the compartment model has been discussed. Besides the classic inguinofemoral lymphadenectomy, in selected cases of vulvar cancer sentinel biopsies are performed by experienced surgeons in the larger centres. In contrast, systemic therapy plays only a subordinate role; in isolated cases down-staging by means of neoadjuvant chemotherapy may be useful. However, there is at present no indication for adjuvant chemotherapy. Neoadjuvant radiochemotherapy is also not to be recommended on account of its unfavourable ratio of efficacy to side effects. On the other hand adjuvant radiotherapy is indicated in cases of positive inguinal lymph nodes. According to the current data the indication should be made generously in such cases.

Zusammenfassung

Das eher seltene Vulvakarzinom ist fast immer ein Plattenepithelkarzinom, das meist auf dem Boden einer vulvären intraepithelialen Neoplasie (VIN) oder einer HPV-Infektion entsteht. Daneben sind auch der Lichen sclerosus et atrophicans, eine Immundefizienz, Nikotinabusus oder anogenitale intraepitheliale Neoplasien an der Pathogenese beteiligt. Die operative Therapie zielt auf eine R0-Resektion im Sinne einer kompletten Vulvektomie oder einer radikalen lokalen Exzision ggf. mit plastischer Rekonstruktion. Daneben wird zunehmend auch die Vulvafeldresektion unter Berücksichtigung des Kompartment-Modells diskutiert. Neben der klassischen inguinofemoralen Lymphonodektomie wird auch beim Vulvakarzinom die Sentinel-Biopsie in größeren Zentren und ausgewählten Situationen von erfahrenen Operateuren durchgeführt. Die Systemtherapie spielt dagegen eine nur untergeordnete Rolle; in Einzelfällen kann ein Downstaging durch eine neoadjuvante Chemotherapie sinnvoll sein. Für eine adjuvante Chemotherapie gibt es derzeit keine Indikation. Ebenfalls sollte eine neoadjuvante Radiochemotherapie aufgrund der ungünstigen Ratio an Effektivität und Nebenwirkungen vermieden werden. Im Gegensatz dazu ist eine adjuvante Bestrahlung aber bei positiven inguinalen Lymphknoten indiziert. Hierzu sollte die Indikation nach aktuellen Daten großzügig gestellt werden.

Key words

vulva - cancer - therapy

Schlüsselwörter

Vulva - Karzinom - Therapie

Supporting Information

 

  • References

  • 1 Hampl M, Deckers-Figiel S, Hampl JA et al. New aspects of vulvar cancer: changes in localization and age of onset. Gynecol Oncol 2008; 109: 340-345
    CrossrefPubMedGoogle Scholar
  • 2 Judson PL, Habermann EB, Baxter NN et al. Trends in the incidence of invasive and in situ vulvar carcinoma. Obstet Gynecol 2006; 107: 1018-1022
    CrossrefPubMedGoogle Scholar
  • 3 Maclean AB. Vulval cancer: prevention and screening. Best Pract Res Clin Obstet Gynaecol 2006; 20: 379-395
    CrossrefPubMedGoogle Scholar
  • 4 Beckmann MW, Bader W, Bechtold I et al. [Financing and financial problems of care and structures in the field of gynaecology and obstetrics in the year 2011 – DRG system and inpatient care with urogynaecology and benign and malign gynaecological surgery, second paper of the financing commission of the DGGG e.V. – Part II]. Geburtsh Frauenheilk 2011; 71: 497-510
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Joura EA, Losch A, Haider-Angeler MG et al. Trends in vulvar neoplasia. Increasing incidence of vulvar intraepithelial neoplasia and squamous cell carcinoma of the vulva in young women. J Reprod Med 2000; 45: 613-615
    PubMedGoogle Scholar
  • 6 Insinga RP, Liaw KL, Johnson LG et al. A systematic review of the prevalence and attribution of human papillomavirus types among cervical, vaginal, and vulvar precancers and cancers in the United States. Cancer Epidemiol Biomarkers Prev 2008; 17: 1611-1622
    CrossrefPubMedGoogle Scholar
  • 7 Jones RW, Baranyai J, Stables S. Trends in squamous cell carcinoma of the vulva: the influence of vulvar intraepithelial neoplasia. Obstet Gynecol 1997; 90: 448-452
    CrossrefPubMedGoogle Scholar
  • 8 Hacker NF. Radical resection of vulvar malignancies: a paradigm shift in surgical approaches. Curr Opin Obstet Gynecol 1999; 11: 61-64
    CrossrefPubMedGoogle Scholar
  • 9 Heaps JM, Fu YS, Montz FJ et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecol Oncol 1990; 38: 309-314
    CrossrefPubMedGoogle Scholar
  • 10 Hockel M, Schmidt K, Bornmann K et al. Vulvar field resection: novel approach to the surgical treatment of vulvar cancer based on ontogenetic anatomy. Gynecol Oncol 2010; 119: 106-113
    CrossrefPubMedGoogle Scholar
  • 11 Hacker NF, Berek JS, Lagasse LD et al. Management of regional lymph nodes and their prognostic influence in vulvar cancer. Obstet Gynecol 1983; 61: 408-412
    PubMedGoogle Scholar
  • 12 Iversen T, Aalders JG, Christensen A et al. Squamous cell carcinoma of the vulva: a review of 424 patients, 1956–1974. Gynecol Oncol 1980; 9: 271-279
    CrossrefPubMedGoogle Scholar
  • 13 Kramer F, Hertel H, Hillemanns P et al. Use of the sentinel lymph node technique compared to complete inguino-femoral lymph node removal in patients with invasive vulvar cancer in Germany. Geburtsh Frauenheilk 2013; 73: 142-147
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Podratz KC, Symmonds RE, Taylor WF. Carcinoma of the vulva: analysis of treatment failures. Am J Obstet Gynecol 1982; 143: 340-351
    CrossrefPubMedGoogle Scholar
  • 15 Raspagliesi F, Ditto A, Fontanelli R et al. False-negative sentinel node in patients with vulvar cancer: a case study. Int J Gynecol Cancer 2003; 13: 361-363
    CrossrefPubMedGoogle Scholar
  • 16 Coleman RL, Ali S, Levenback CF et al. Is bilateral lymphadenectomy for midline squamous carcinoma of the vulva always necessary? An analysis from Gynecologic Oncology Group (GOG) 173. Gynecol Oncol 2013; 128: 155-159
    CrossrefPubMedGoogle Scholar
  • 17 Curry SL, Wharton JT, Rutledge F. Positive lymph nodes in vulvar squamous carcinoma. Gynecol Oncol 1980; 9: 63-67
    CrossrefPubMedGoogle Scholar
  • 18 Green jr. TH. Carcinoma of the vulva. A reassessment. Obstet Gynecol 1978; 52: 462-469
    PubMedGoogle Scholar
  • 19 Wharton JT, Gallager S, Rutledge FN. Microinvasive carcinoma of the vulva. Am J Obstet Gynecol 1974; 118: 159-162
    PubMedGoogle Scholar
  • 20 Klemm P, Marnitz S, Kohler C et al. Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes. Gynecol Oncol 2005; 99: 101-105
    CrossrefPubMedGoogle Scholar
  • 21 Magrina JF, Webb MJ, Gaffey TA et al. Stage I squamous cell cancer of the vulva. Am J Obstet Gynecol 1979; 134: 453-459
    PubMedGoogle Scholar
  • 22 van der Velden J, van Lindert AC, Lammes FB et al. Extracapsular growth of lymph node metastases in squamous cell carcinoma of the vulva. The impact on recurrence and survival. Cancer 1995; 75: 2885-2890
    CrossrefPubMedGoogle Scholar
  • 23 Boran N, Kayikcioglu F, Kir M. Sentinel lymph node procedure in early vulvar cancer. Gynecol Oncol 2003; 90: 492-493
    CrossrefPubMedGoogle Scholar
  • 24 Decesare SL, Fiorica JV, Roberts WS et al. A pilot study utilizing intraoperative lymphoscintigraphy for identification of the sentinel lymph nodes in vulvar cancer. Gynecol Oncol 1997; 66: 425-428
    CrossrefPubMedGoogle Scholar
  • 25 de Hullu JA, Hollema H, Piers DA et al. Sentinel lymph node procedure is highly accurate in squamous cell carcinoma of the vulva. J Clin Oncol 2000; 18: 2811-2816
    PubMedGoogle Scholar
  • 26 Fons G, ter Rahe B, Sloof G et al. Failure in the detection of the sentinel lymph node with a combined technique of radioactive tracer and blue dye in a patient with cancer of the vulva and a single positive lymph node. Gynecol Oncol 2004; 92: 981-984
    CrossrefPubMedGoogle Scholar
  • 27 Van der Zee AG, Oonk MH, De Hullu JA et al. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol 2008; 26: 884-889
    CrossrefPubMedGoogle Scholar
  • 28 Levenback CF, Ali S, Coleman RL et al. Lymphatic mapping and sentinel lymph node biopsy in women with squamous cell carcinoma of the vulva: a gynecologic oncology group study. J Clin Oncol 2012; 30: 3786-3791
    CrossrefPubMedGoogle Scholar
  • 29 Bellati F, Angioli R, Manci N et al. Single agent cisplatin chemotherapy in surgically resected vulvar cancer patients with multiple inguinal lymph node metastases. Gynecol Oncol 2005; 96: 227-231
    CrossrefPubMedGoogle Scholar
  • 30 Shimizu Y, Hasumi K, Masubuchi K. Effective chemotherapy consisting of bleomycin, vincristine, mitomycin C, and cisplatin (BOMP) for a patient with inoperable vulvar cancer. Gynecol Oncol 1990; 36: 423-427
    CrossrefPubMedGoogle Scholar
  • 31 Durrant KR, Mangioni C, Lacave AJ et al. Bleomycin, methotrexate, and CCNU in advanced inoperable squamous cell carcinoma of the vulva: a phase II study of the EORTC Gynaecological Cancer Cooperative Group (GCCG). Gynecol Oncol 1990; 37: 359-362
    CrossrefPubMedGoogle Scholar
  • 32 Wagenaar HC, Colombo N, Vergote I et al. Bleomycin, methotrexate, and CCNU in locally advanced or recurrent, inoperable, squamous-cell carcinoma of the vulva: an EORTC Gynaecological Cancer Cooperative Group Study. European Organization for Research and Treatment of Cancer. Gynecol Oncol 2001; 81: 348-354
    CrossrefPubMedGoogle Scholar
  • 33 Benedetti-Panici P, Greggi S, Scambia G et al. Cisplatin (P), bleomycin (B), and methotrexate (M) preoperative chemotherapy in locally advanced vulvar carcinoma. Gynecol Oncol 1993; 50: 49-53
    CrossrefPubMedGoogle Scholar
  • 34 Geisler JP, Manahan KJ, Buller RE. Neoadjuvant chemotherapy in vulvar cancer: avoiding primary exenteration. Gynecol Oncol 2006; 100: 53-57
    CrossrefPubMedGoogle Scholar
  • 35 Domingues AP, Mota F, Durao M et al. Neoadjuvant chemotherapy in advanced vulvar cancer. Int J Gynecol Cancer 2010; 20: 294-298
    CrossrefPubMedGoogle Scholar
  • 36 Boronow RC, Hickman BT, Reagan MT et al. Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations. Am J Clin Oncol 1987; 10: 171-181
    CrossrefPubMedGoogle Scholar
  • 37 Scheistroen M, Trope C. Combined bleomycin and irradiation in preoperative treatment of advanced squamous cell carcinoma of the vulva. Acta Oncol 1993; 32: 657-661
    CrossrefPubMedGoogle Scholar
  • 38 Eifel PJ, Morris M, Burke TW et al. Prolonged continuous infusion cisplatin and 5-fluorouracil with radiation for locally advanced carcinoma of the vulva. Gynecol Oncol 1995; 59: 51-56
    CrossrefPubMedGoogle Scholar
  • 39 Landoni F, Maneo A, Zanetta G et al. Concurrent preoperative chemotherapy with 5-fluorouracil and mitomycin C and radiotherapy (FUMIR) followed by limited surgery in locally advanced and recurrent vulvar carcinoma. Gynecol Oncol 1996; 61: 321-327
    CrossrefPubMedGoogle Scholar
  • 40 Moore DH, Thomas GM, Montana GS et al. Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group. Int J Radiat Oncol Biol Phys 1998; 42: 79-85
    CrossrefPubMedGoogle Scholar
  • 41 Montana GS, Thomas GM, Moore DH et al. Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study. Int J Radiat Oncol Biol Phys 2000; 48: 1007-1013
    CrossrefPubMedGoogle Scholar
  • 42 Gerszten K, Selvaraj RN, Kelley J et al. Preoperative chemoradiation for locally advanced carcinoma of the vulva. Gynecol Oncol 2005; 99: 640-644
    CrossrefPubMedGoogle Scholar
  • 43 Shylasree TS, Bryant A, Howells RE. Chemoradiation for advanced primary vulval cancer. Cochrane Database Syst Rev 2011; (4) CD003752
    PubMedGoogle Scholar
  • 44 Homesley HD, Bundy BN, Sedlis A et al. Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol 1986; 68: 733-740
    PubMedGoogle Scholar
  • 45 Barnes EA, Thomas G. Integrating radiation into the management of vulvar cancer. Semin Radiat Oncol 2006; 16: 168-176
    CrossrefPubMedGoogle Scholar