How important is the pathological margin distance in vulvar cancer?

https://doi.org/10.1016/j.ejso.2015.09.024Get rights and content

Abstract

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.

Introduction

Vulvar cancer accounts for approximately 3%–5% of all gynecological malignancies.1 It usually affects women with a median age of 65–70 years,1, 2 and most cases are squamous cell carcinoma.1, 2 Surgery is the cornerstone treatment for vulvar cancer, and its prognosis is linked to inguinal lymph node (LN) metastasis.1, 2, 3, 4 The current management of vulvar cancer depends on the extent of disease and includes primary tumor resection with a safety margin and inguinofemoral LN staging.2, 4, 5 If LN metastasis is observed, the standard postoperative therapy is inguinal and pelvic radiotherapy.5 For patients who have unifocal disease, tumors up to 4 cm, and clinically negative groins, the sentinel node procedure should be offered. In cases with positive sentinel nodes, a complete inguinofemoral lymphadenectomy should be performed.2

Due to the low incidence of vulvar cancer, there are few evaluable randomized trials, and controversies remain regarding the best treatment approach. The ideal surgical margin is still debated—the current consensus is that final pathological margin should be at least 8 mm, which might correspond to intended surgical margins of 1–2 cm.2 This concept may drive to mutilation or neoadjuvant radiotherapy, especially in tumors that lie close to the clitoris, urethra, or anus. Thus, our aim was to determine the value of pathological free margin distance with regard to local recurrence (LR) in a retrospective series of patients with vulvar squamous cell carcinoma (VSCC) who were treated at our institution.

Section snippets

Methods

We analyzed a series of 205 patients who were treated for VSCC from April 1980 to October 2013 at AC Camargo Cancer Center. We excluded patients who received neoadjuvant treatment. Twelve (5.8%) patients received wide local resection, and the remaining subjects underwent radical vulvectomies. Because our primary objective was to correlate pathological free margin with LR, we included 37 (18%) patients who did not undergo inguinal lymphadenectomy for medical reasons and stage IA. Ten (4.9%)

Clinical and pathological characteristics

Clinical and pathological characteristics are listed in Table 1. The median age was 69 years (range: 28–91). The median tumor size was 4.2 cm (range: 0.3–18), and the median depth of invasion was 8.5 mm (range: 0.1–32). The median PFM distance was 10 mm (range: 1–65). Of 119 patients with lymphovascular invasion with evaluable data, 25 (21%) were positive. Of 118 patients with perineural invasion with evaluable data, 25 (21.2%) were positive. A total of 99 (63.1%), 43 (27.4%), and 15 (9.6%)

Discussion

In this study, we determined the effects of pathological surgical margin distance and other prognostic factors on local recurrence in 205 patients. Our data suggest no correlation between pathological margin distance and the risk of LR, in contrast to previous series.7, 8, 9

Even after the introduction of triple incision surgery, radical vulvectomy and the removal of all external genitalia remained the standard treatment for VSCC—until the development of radical local excision. No randomized

Conflict of interest statement

The authors declare no conflict of interest.

Cited by (35)

  • Prognostic role of perineural invasion in vulvar squamous cell carcinoma: A systematic review and meta-analysis

    2022, European Journal of Surgical Oncology
    Citation Excerpt :

    To date, only the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Society for Gynecology and Obstetrics (DGGG) have recommended to add the PNI assessment in routinely histopathological report of VSCC, even though its presence does not imply a more aggressive adjuvant treatment [39]. Several Authors have also described the association between PNI and the well-known aggressive pathological tumoral features: presence of lichen sclerosus, large tumor size, depth of invasion, stage III/IV disease, lymphatic vascular space invasion (LVSI), and intra- or extra-nodal spread [25–30]. No significant association to age, race/ethnicity, smoking history, histologic subtype, or grade have been described.

  • A review of prognostic factors in squamous cell carcinoma of the vulva: Evidence from the last decade

    2021, Seminars in Diagnostic Pathology
    Citation Excerpt :

    Even though 2 cm is the cut-off in formal staging systems, a greater number of studies (12 studies) used 4 cm as a cut-off value. In these studies, tumor size was prognostic for PFS (6 of 7 univariate analyses, 2 of 6 multivariate analyses) and OS (4 of 9 univariate analyses, 1 multivariate analyses).10,40–42,45,47,52,57,60,64,65,74 In 3 studies assessing tumor size as a continuous variable, only 1 study found tumor size was prognostic for both PFS and OS in the multivariate analysis.41,56,67

  • A review of prognostic factors in squamous cell carcinoma of the vulva: Evidence from the last decade

    2020, Seminars in Diagnostic Pathology
    Citation Excerpt :

    Amongst 13 studies, 8 univariate analyses [15,40,43,59,65,66] found LVSI to be prognostic for OS, but this was not supported by any multivariate analyses. 13 analyses (8 univariate [9,15,19,39,41,45,68], 4 multivariate [40,65,66] and 1 method not specified [10] ) did not find a statistically significant relationship between LVSI and OS. The studies did not distinguish between focal or extensive LVSI.

  • Multivariate analysis of prognostic factors in primary squamous cell vulvar cancer: The role of perineural invasion in recurrence and survival

    2019, European Journal of Surgical Oncology
    Citation Excerpt :

    Data in the literature regarding the role of PNI in vulvar cancer is lacking [9], although our findings confirm the most recent growing body of evidence [6]. Papers reviewing the presence of PNI are few and scanty, in fact, in literature, the prevalence rate of this pathological feature in VSCC ranges from 7.6% to 52% [5,6]. In our study, there are consecutive cases of VSCC and systematic evaluation of PNI brought to a prevalence rate of 31.1%, which is a not negligible quote of patients.

View all citing articles on Scopus
View full text