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Medical and surgical interventions for the treatment of usual-type vulval intraepithelial neoplasia.The Cochrane Database of Systematic... Jan 2016Usual-type vulval intraepithelial neoplasia (uVIN) is a pre-cancerous condition of the vulval skin. Also known as high-grade VIN, VIN 2/3 or high-grade vulval squamous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Usual-type vulval intraepithelial neoplasia (uVIN) is a pre-cancerous condition of the vulval skin. Also known as high-grade VIN, VIN 2/3 or high-grade vulval squamous intraepithelial lesion (HSIL), uVIN is associated with high-risk subtype human papilloma virus (HPV) infection. The condition causes distressing vulval symptoms in the majority of affected women and may progress to vulval cancer, therefore is usually actively managed. There is no consensus on the optimal management of uVIN. High morbidity and recurrence rates associated with surgical treatments make less invasive treatments highly desirable.
OBJECTIVES
To determine which interventions are the most effective, safe and tolerable for treating women with uVIN.
SEARCH METHODS
We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 8 2015, MEDLINE and EMBASE (up to 1 September 2015). We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.
SELECTION CRITERIA
Randomised controlled trials (RCTs) that assessed medical and surgical interventions in women with uVIN. If no RCTs were available, we included non-randomised studies (NRSs) with concurrent comparison groups that controlled for baseline case mix in multivariate analysis.
DATA COLLECTION AND ANALYSIS
We used Cochrane methodology with two review authors independently extracting data and assessing risk of bias. Where possible, we synthesised data in meta-analyses using random-effects methods. Network meta-analysis was not possible due to insufficient data.
MAIN RESULTS
We included six RCTs involving 327 women and five NRSs involving 648 women. The condition was variously named by investigators as uVIN, VIN2/3 or high-grade VIN. Five RCTs evaluated medical treatments (imiquimod, cidofovir, indole-3 carbinol), and six studies (one RCT and five NRSs) evaluated surgical treatments or photodynamic therapy. We judged two RCTs and four NRSs to be at a high or unclear risk of bias; we considered the others at relatively low risk of bias. Types of outcome measures reported in NRSs varied and we were unable to pool NRS data. Medical interventions: Topical imiquimod was more effective than placebo in achieving a response (complete or partial) to treatment at five to six months post-randomisation (three RCTs, 104 women; risk ratio (RR) 11.95, 95% confidence interval (CI) 3.21 to 44.51; high-quality evidence). At five to six months, a complete response occurred in 36/62 (58%) and 0/42 (0%) women in the imiquimod and placebo groups, respectively (RR 14.40, 95% CI 2.97 to 69.80). Moderate-quality evidence suggested that the complete response was sustained at one year (one RCT, nine complete responses out of 52 women (38%)) and beyond, particularly in women with smaller VIN lesions. Histologically confirmed complete response rates with imiquimod versus cidofovir at six months were 45% (41/91) and 46% (41/89), respectively (one RCT, 180 women; RR 1.00, 95% CI 0.73 to 1.37; moderate-quality evidence). Twelve-month data from this trial are awaited; however, interim findings suggested that complete responses were sustained at 12 months. Only one trial reported vulval cancer at one year (1/24 and 2/23 in imiquimod and placebo groups, respectively). Adverse events were more common with imiquimod than placebo and dose reductions occurred more frequently in the imiquimod group than in the placebo group (two RCTs, 83 women; RR 7.77, 95% CI 1.61 to 37.36; high-quality evidence). Headache, fatigue and discontinuation were slightly more common with imiquimod than cidofovir (moderate-quality evidence). Quality of life scores reported in one trial (52 women) were not significantly different for imiquimod and placebo. The evidence of effectiveness of topical treatments in immunosuppressed women was scant. There was insufficient evidence on other medical interventions. Surgical and other interventions: Low-quality evidence from the best included NRS indicated, when data were adjusted for confounders, that there was little difference in the risk of VIN recurrence between surgical excision and laser vaporisation. Recurrence occurred in 51% (37/70) of women overall, at a median of 14 months, and was more common in multifocal than unifocal lesions (66% versus 34%). Vulval cancer occurred in 11 women (15.1%) overall at a median of 71.5 months (9 to 259 months). The risk of vulval cancer did not differ significantly between excision and laser vaporisation in any of the NRSs; however, events were too few for robust findings. Alternative surgical procedures that might be as effective include Cavitron ultrasonic surgical aspiration (CUSA) and loop electrosurgical excision (LEEP) procedures, based on low- to very low-quality evidence, respectively. Very low-quality evidence also suggested that photodynamic therapy may be a useful treatment option.We found one ongoing RCT of medical treatment (imiquimod) compared with surgical treatment.
AUTHORS' CONCLUSIONS
Topical treatment (imiquimod or cidofovir) may effectively treat about half of uVIN cases after a 16-week course of treatment, but the evidence on whether this effect is sustained is limited. Factors predicting response to treatment are not clear, but small lesions may be more likely to respond. The relative risk of progression to vulval cancer is uncertain. However, imiquimod and cidofovir appear to be relatively well tolerated and may be favoured by some women over primary surgical treatment.There is currently no evidence on how medical treatment compares with surgical treatment. Women who undergo surgical treatment for uVIN have about a 50% chance of the condition recurring one year later, irrespective of whether treatment is by surgical excision or laser vaporisation. Multifocal uVIN lesions are at a higher risk of recurrence and progression, and pose greater therapeutic dilemmas than unifocal lesions. If occult cancer is suspected despite a biopsy diagnosis of uVIN, surgical excision remains the treatment of choice. If occult cancer is not a concern, treatment needs to be individualised to take into account the site and extent of disease, and a woman's preferences. Combined modalities may hold the key to optimal treatment of this complex disease.
Topics: Adult; Aminoquinolines; Antineoplastic Agents; Carcinoma in Situ; Cidofovir; Cytosine; Disease Progression; Female; Humans; Imiquimod; Indoles; Laser Therapy; Neoplasm Recurrence, Local; Organophosphonates; Photochemotherapy; Prospective Studies; Randomized Controlled Trials as Topic; Retrospective Studies; Treatment Outcome; Vulvar Neoplasms
PubMed: 26728940
DOI: 10.1002/14651858.CD011837.pub2 -
Surgical Oncology Dec 2017Vulvar cancer is a rare disease accounting for approximately 5% of female genital tract tumors worldwide. Currently surgery represents the mainstay alone or sometimes,... (Review)
Review
BACKGROUND
Vulvar cancer is a rare disease accounting for approximately 5% of female genital tract tumors worldwide. Currently surgery represents the mainstay alone or sometimes, in combination with chemo-radiotherapy, for locally advanced tumors and recurrent disease. However, significant physical and sexual impairment mostly due to anatomical distortion of external genitalia are a consequence of radical surgical treatment. Postoperative reconstruction after demolitive surgeries improves aesthetic and functional results, guarantees an adequate coverage of large tumors and assures safe surgical margin. The present study aimed to analyze feasibility and complication rates of fascio-cutaneous flap after excision for vulvovaginal malignancies.
METHODS
PubMed (MEDLINE), Web of Science, and CINAHL were searched for records of validated vulvovaginal reconstructive techniques after demolitive surgery for vulvar cancer. All cohorts were rated for quality using a scoring method taking into account the design of the study, the sample size and quality of report of surgical data and complications.
RESULTS
A total of 24 studies met all eligibility criteria for this systematic review. All the studies were realized between 1996 and 2015. The overall sample size was 443 patients. Two major group of flap according to type of movement were identified: Advancement Flap (V-Y Gluteal Fold Flap; Medial Thigh Flap) and Transpositional Flap (Lotus Petal Flap; Gluteal Thigh Flap; Gluteal Fold Flap and Anterolateral Thigh Flap). The overall complications rates reported for advancement (26.7% among 165 patients on 11 series) and transposition flaps (22.3% among 278 patients on 13 series) were comparable.
CONCLUSIONS
A tailored procedure, based on patients' characteristics, size and location of the defect is still the goal of a successful reconstructive surgery. Proper planning of the surgical procedures, knowledge of the different surgical options and technical skills are required in order to obtain reliable and satisfying results.
Topics: Female; Humans; Morbidity; Prognosis; Plastic Surgery Procedures; Surgical Flaps; Vaginal Neoplasms; Vulvar Neoplasms
PubMed: 29113672
DOI: 10.1016/j.suronc.2017.10.002 -
European Journal of Obstetrics,... Aug 2014Vulvar cancer is an extremely rare complication during pregnancy, and its effect on pregnancy and survival is not well understood. A systematic literature review was... (Review)
Review
Vulvar cancer is an extremely rare complication during pregnancy, and its effect on pregnancy and survival is not well understood. A systematic literature review was conducted in order to examine the fetal and maternal outcomes and optimal management of pregnancy complicated by vulvar cancer. PubMed/MEDLINE were used to identify case reports with searching keywords "pregnancy" and "vulvar cancer" between January 1955 and February 2014 that identified 36 cases for analysis. Mean age was 30.7. The most common presenting symptom and gestational age were vulvar mass/swelling (75.0%) and the second trimester of pregnancy (54.8%), respectively. Vulvar biopsy at the time of initial presentation to care during pregnancy was performed in only 46.7% of cases. Among delayed cases for biopsy, mean duration of delay was 12.8 weeks and the majority had a delay for more than 8 weeks (62.5%). The majority of vulvar cancer was squamous histology (47.2%) and stage I disease (60.0%). Vulvectomy and inguinal-femoral lymphadenectomy were performed in 97.1% and 63.9%, respectively. Abdominal delivery was recorded in 46.2% of cases. Live birth and full term delivery rates were 96.3% and 74.0%, respectively. For survival analysis, delay in diagnosis and advanced stage disease were commonly associated with decreased disease-free survival (5-year rate, delay in diagnosis >8 versus ≤8 weeks, 0% versus 69.1%, hazard ratio (HR) 7.86, 95% confidence interval (CI) 2.03-30.6, p=0.001; and stage III-IV versus stage I-II, 0% versus 59.8%, HR 3.35, 95% CI 1.16-9.68, p=0.011) and overall survival (5-year rate, delay in diagnosis >8 versus ≤8 weeks, 0% versus 67.1%, hazard ratio (HR) 14.8, 95% CI 1.77-124, p=0.001; and stage III-IV versus stage I-II, 0% versus 86.4%, HR 8.22, 95% CI 2.06-33.2, p<0.001). In conclusion, while the majority of cases resulted in good pregnancy outcomes, diagnosis of vulvar cancer during pregnancy is frequently delayed. Since delayed diagnosis is a significant prognosticator of decreased survival outcomes, early recognition is integral in the management of pregnancy complicated by vulvar cancer.
Topics: Adult; Cesarean Section; Disease-Free Survival; Female; Gestational Age; Humans; Pregnancy; Pregnancy Complications, Neoplastic; Pregnancy Outcome; Survival Analysis; Vulvar Neoplasms
PubMed: 24768232
DOI: 10.1016/j.ejogrb.2014.04.017 -
Medicine Dec 2022Granular cell tumor (GCT) of the vulva is an exceptionally rare female genital tract tumor. The majority of these are benign and there are no standardized surgical...
RATIONALE
Granular cell tumor (GCT) of the vulva is an exceptionally rare female genital tract tumor. The majority of these are benign and there are no standardized surgical techniques for the special site to reduce tension of the wound.
PATIENT CONCERNS
A 47-years-old Chinese woman experienced a nodule on her right vulva with itch sometimes in late 2018.
DIAGNOSES
Magnetic resonance imaging showed a high possibility of vulvar cancer. While Chest X-ray, abdominal sonography, and cystoscopy examination were unremarkable.
INTERVENTIONS
The patient underwent local complete resection of vulvar tumor under general anesthesia on March 24, 2022. The resection scope was approximately 4 cm × 3 cm × 3 cm. Due to the large surgical incision, Z-plasty was performed to achieve the primary closure for decreasing wound tension and improving aesthetic reduction.
OUTCOMES
The final pathological diagnosis was benign GCT of the vulva and surgical margins were uninvolved. At 8 months follow-up, no new lesions were detected.
LESSONS
Surgery with negative resection margins is the mainstay for benign GCT of the vulva, while Z-plasty is appropriate for decreasing the tension of the wound and improving aesthetic reduction.
Topics: Female; Humans; Middle Aged; Granular Cell Tumor; Plastic Surgery Procedures; Pruritus; Vulva; Vulvar Neoplasms; Vulvectomy
PubMed: 36595970
DOI: 10.1097/MD.0000000000032568 -
European Journal of Surgical Oncology :... Nov 2014Groin dissection is commonly performed in patients with lower limb malignant conditions such as malignant melanoma, vulvar, penile, anal and scrotal carcinomas with an... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Groin dissection is commonly performed in patients with lower limb malignant conditions such as malignant melanoma, vulvar, penile, anal and scrotal carcinomas with an associated high complication rate. Numerous surgical strategies have been suggested to reduce morbidity. We aimed to systematically review one of those methods - fibrin sealant (FS) - in comparison to standard closure (SC) in reducing postoperative morbidity from groin dissection.
METHODS
A systematic search of the literature, study selection and data extraction using an independent screening process, assessment of risk of bias and statistical data analysis was performed. Only randomised controlled trials (RCTs) comparing fibrin sealant to standard care in patients with malignant disease undergoing groin dissection reporting at least one outcome measure relating to postoperative complications were included in the review.
RESULTS
A total of 6 RCTs were included. There were no statistically significant differences in postoperative surgical site infection (SSI) rates between FS and SC. The overall incidence of wound infection in the FS group was 32% (43/133) compared to 34% (45/132) in the SC group. (Pooled risk ratio = 0.0.94 [0.68, 1.32]; 95% CI; P = 0.74). The incidence of seroma for the FS group (30/133) and the SC group (30/132) did not differ (Pooled risk ratio = 1.03 [0.67, 1.58]; 95% CI; P value = 0.90). Complication rates were similar between groups.
CONCLUSION
Based on current evidence, fibrin sealant does not significantly reduce morbidity in patients undergoing groin dissection for the management of malignant disease when compared to standard closure techniques.
Topics: Fibrin Tissue Adhesive; Groin; Humans; Lymph Node Excision; Neoplasms; Postoperative Complications; Seroma; Surgical Wound Infection; Tissue Adhesives; Treatment Outcome; Wound Closure Techniques
PubMed: 25125341
DOI: 10.1016/j.ejso.2014.07.034 -
Precursor lesions of vulvar squamous cell carcinoma - histology and biomarkers: A systematic review.Critical Reviews in Oncology/hematology Mar 2020The precursor lesion of vulvar squamous cell carcinoma (VSCC), namely vulvar intraepithelial neoplasia (VIN), is classified as: human papillomavirus (HPV)-related high...
The precursor lesion of vulvar squamous cell carcinoma (VSCC), namely vulvar intraepithelial neoplasia (VIN), is classified as: human papillomavirus (HPV)-related high grade squamous intraepithelial lesion (HSIL), and HPV-independent differentiated VIN (dVIN). Traditionally, histology and immunohistochemistry (IHC) have been the basis of diagnosis and classification of VIN. HSIL shows conspicuous histological atypia, and positivity on p16-IHC, whereas dVIN shows less obvious histological atypia, and overexpression or null-pattern on p53-IHC. For both types of VIN, other diagnostic immunohistochemical markers have also been evaluated. Molecular characterization of VIN has been attempted in few recent studies, and novel genotypic subtypes of HPV-independent VSCC and VIN have been identified. This systematic review appraises the VSCC precursors identified so far, focusing on histology and biomarkers (immunohistochemical and molecular). To gain further insights into the carcinogenesis and to identify additional potential biomarkers, gene expression omnibus (GEO) datasets on VSCC were analyzed; the results are presented.
Topics: Biomarkers, Tumor; Carcinoma in Situ; Carcinoma, Squamous Cell; Female; Humans; Papillomaviridae; Papillomavirus Infections; Vulvar Neoplasms; Uterine Cervical Dysplasia
PubMed: 32058913
DOI: 10.1016/j.critrevonc.2020.102866 -
Journal of the American Academy of... Mar 2022
Meta-Analysis
Topics: Female; Humans; Lasers; Lichen Sclerosus et Atrophicus; Vulvar Diseases; Vulvar Lichen Sclerosus; Vulvar Neoplasms
PubMed: 33684499
DOI: 10.1016/j.jaad.2021.02.081 -
American Journal of Obstetrics and... Oct 2021A sentinel lymph node biopsy is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer, but its value in high-grade endometrial... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
A sentinel lymph node biopsy is widely accepted as the standard of care for surgical staging in low-grade endometrial cancer, but its value in high-grade endometrial cancer remains controversial. The aim of this systematic review and meta-analysis was to evaluate the performance characteristics of sentinel lymph node biopsy in patients with endometrial cancer with high-grade histology (registered in the International Prospective Register of Systematic Reviews with identifying number CRD42020160280).
DATA SOURCES
We systematically searched the MEDLINE, Epub Ahead of Print, MEDLINE In-Process & Other Non-Indexed Citations, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase databases all through the OvidSP platform. The search was performed between January 1, 2000, and January 26, 2021. ClinicalTrials.gov was searched to identify ongoing registered clinical trials.
STUDY ELIGIBILITY CRITERIA
We included prospective cohort studies in which sentinel lymph node biopsy were evaluated in clinical stage I patients with high-grade endometrial cancer (grade 3 endometrioid, serous, clear cell, carcinosarcoma, mixed, undifferentiated or dedifferentiated, and high-grade not otherwise specified) with a cervical injection of indocyanine green for sentinel lymph node detection and at least a bilateral pelvic lymphadenectomy as a reference standard. If the data were not reported specifically for patients with high-grade histology, the authors were contacted for aggregate data.
METHODS
We pooled the detection rates and measures of diagnostic accuracy using a generalized linear mixed-effects model with a logit and assessed the risk of bias using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.
RESULTS
We identified 16 eligible studies of which the authors for 9 of the studies provided data on 429 patients with high-grade endometrial cancer specifically. The study-level median age was 66 years (range, 44-82.5 years) and the study-level median body mass index was 28.6 kg/m (range, 19.4-43.7 kg/m). The pooled detection rates were 91% per patient (95% confidence interval, 85%-95%; I=59%) and 64% bilaterally (95% confidence interval, 53%-73%; I=69%). The overall node positivity rate was 26% (95% confidence interval, 19%-34%; I=44%). Of the 87 patients with positive node results, a sentinel lymph node biopsy correctly identified 80, yielding a pooled sensitivity of 92% per patient (95% confidence interval, 84%-96%; I=0%), a false negative rate of 8% (95% confidence interval, 4%-16%; I=0%), and a negative predictive value of 97% (95% confidence interval, 95%-99%; I=0%).
CONCLUSION
Sentinel lymph node biopsy accurately detect lymph node metastases in patients with high-grade endometrial cancer with a false negative rate comparable with that observed in low-grade endometrial cancer, melanoma, vulvar cancer, and breast cancer. These findings suggest that sentinel lymph node biopsy can replace complete lymphadenectomies as the standard of care for surgical staging in patients with high-grade endometrial cancer.
Topics: Adenocarcinoma, Clear Cell; Carcinoma, Endometrioid; Carcinosarcoma; Coloring Agents; Endometrial Neoplasms; Female; Humans; Indocyanine Green; Lymph Node Excision; Neoplasm Grading; Neoplasms, Cystic, Mucinous, and Serous; Sentinel Lymph Node; Sentinel Lymph Node Biopsy
PubMed: 34058168
DOI: 10.1016/j.ajog.2021.05.034 -
Current Medical Research and Opinion Jun 2016To perform a meta-analysis examining the survival of patients with vulvar cancer based on the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To perform a meta-analysis examining the survival of patients with vulvar cancer based on the 2009 International Federation of Gynecology and Obstetrics (FIGO) staging system.
METHODS
Medline, PubMed, and Cochrane databases were searched until 20 March 2015 for prospective or retrospective studies using the terms vulvar cancer, prognostic/prognosis, survival, recurrence, lymph nodes (LNs), inguinal lymphadenectomy/excision, and staging. The primary outcome was 5 year overall survival (OS), and secondary outcomes were 5 year disease-free survival (DFS) and progression-free survival (PFS).
RESULTS
Fourteen retrospective studies were included. The 5 year OS rate decreased with increasing 2009 FIGO stage and number of LN metastasis. FIGO stage I, II, III, and IV patients had 5 year OS rates of 84.0%, 74.6%, 47.8%, and 9.4%, respectively. Pooled estimates showed that the 5 year OS was 84.5% for patients without LN metastasis, and for patients with ≥3 LN metastases the 5 year OS rate was 30.1%. Similarly, the overall 5 year DFS and PFS decreased with the increasing number of LN metastases. The 5 year DFS rate was 87.2% for patients with no LN metastasis and for patients with ≥3 LN metastases was 35.4%. The 5 year PFS rate was 86.6% for patients with no LN metastasis and for patients with ≥3 LN metastases was 27.6%.
LIMITATIONS
All studies were retrospective studies. DFS and PFS rates in patients with different 2009 FIGO stages and with different mean tumor sizes were not examined due to a limited number of reports.
CONCLUSIONS
More advanced 2009 FIGO stage and greater number of LN metastases are associated with worse outcomes in patients with vulvar cancer.
Topics: Disease-Free Survival; Female; Humans; Lymph Node Excision; Neoplasm Recurrence, Local; Neoplasm Staging; Prognosis; Survival Rate; Vulvar Neoplasms
PubMed: 26959073
DOI: 10.1185/03007995.2016.1162147 -
Asian Pacific Journal of Cancer... Sep 2018Background: Human papillomavirus (HPV) infection is associated with cervical cancer; however, it is controversial whether it is involved in non-cervical genital cancers.... (Meta-Analysis)
Meta-Analysis
Background: Human papillomavirus (HPV) infection is associated with cervical cancer; however, it is controversial whether it is involved in non-cervical genital cancers. Objective: This study aimed to evaluate articles on the prevalence of HPV in penile cancer, vulvar cancer, colorectal cancer, prostate cancer and anal canal cancer in studies conducted in Brazil. Methods: The study was conducted in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analysis Statement. Comprehensive searches for HPV and cancer for the years 2006 to 2016 were conducted in two databases (PubMed and Web of Knowledge) and Google Scholar system. We also tracked the references of all eligible articles to identify additional non-captured publications through online surveys. Results: Eighteen studies, with a combined sample size of 1,552 patients were analyzed. The overall prevalence of HPV was 43% (95% CI: 36–51%; p < 0.001). The pooled prevalence of HPV in penile cancer was 42% (95% CI: 32–55%; p < 0.001), in colorectal cancer it was 67% (95% CI: 64–70%; p < 0.001) and in vulvar cancer 43% (95% CI: 34–55%; p < 0.001). HPV 16 was the most prevalent in all sites evaluated, with prevalence estimated at 54% (95% CI: 44–66%; p < 0.001), followed by genotypes 33 (21%; 95% CI: 17–28; p < 0.001), 6 (15%; 95% CI: 8–26%; p < 0.001), 11 (13%; 95% CI: 5–32%; p < 0.001) and 18 (12%; 95% CI: 7–22%; p < 0.001), respectively. The pooled prevalence of single infection was 82% and infection by multiple genotypes of HPV was 22%. Conclusion: Our study demonstrated a high prevalence of HPV in non-cervical genital cancers in Brazil, with predominance of genotype 16, providing evidence for the need for preventive and control measures to avoid future harm to the population.
Topics: Brazil; Female; Genitalia; Humans; Papillomaviridae; Papillomavirus Infections; Prevalence; Urogenital Neoplasms; Uterine Cervical Neoplasms
PubMed: 30255688
DOI: 10.22034/APJCP.2018.19.9.2359