Download PDF
Onkologie up2date 2019; 1(04): 363-382
DOI: 10.1055/a-0978-7841
Weitere Tumorentitäten
Georg Thieme Verlag KG Stuttgart · New York

Herausforderungen in der Therapie der Patientin mit Vulvakarzinom

Katharina Prieske
,
Linn Wölber
Further Information

Publication History

Publication Date:
18 November 2019 (online)

    Permissions and Reprints All articles of this category

In den letzten Jahren ist die Inzidenz des Vulvakarzinoms deutlich angestiegen. Wegen der oft unspezifischen Frühsymptome, sollte bei jeder Vorsorgeuntersuchung die Vulva gründlich inspiziert werden – auch bei jungen Patientinnen. Liegt eine Krebserkrankung vor, kommt der Qualität der Primärtherapie eine besondere Bedeutung zu. Entscheidend für die Prognose ist das Vorliegen von inguinofemoralen Lymphknoten.
Kernaussagen

  • Der Primärtumor sollte im Gesunden reseziert werden. Ein evidenzbasierter Grenzwert für den optimalen Resektionsrand ist durch aktuelle Studien nicht belegt.

  • Der zentrale Prognosefaktor beim Vulvakarzinom ist das Vorliegen von inguinofemoralen Lymphknotenmetastasen.

  • Als Voraussetzungen für die SNB gelten derzeit klinisch unauffällige Leistenlymphknoten, Tumordurchmesser < 4 cm und ein unifokaler Primärtumor sowie die Möglichkeit des pathologischen Ultrastagings.

  • Bei Metastasennachweis im SNL wird die komplette inguinofemorale LNE empfohlen. Eine alleinige Radiatio ist nach aktueller Wissenslage nicht ausreichend.

  • Die Qualität der Primärtherapie hat eine besondere Wichtigkeit. Leistenrezidive verlaufen oft letal.

  • Durch pelvines Lymphknotenstaging bei inguinalem Metastasennachweis kann eine pelvine Radiatio bei histologisch negativen Lymphknoten im Becken vermieden werden.

Schlüsselwörter

Vulvakarzinom - Sentinel - Staging - Vulvektomie - Lymphonodektomie
 

  • Literatur

  • 1 Holleczek B, Sehouli J, Barinoff J. Vulvar cancer in Germany: increase in incidence and change in tumour biological characteristics from 1974 to 2013. Acta Oncol 2018; 57: 324-330
    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 Buttmann-Schweiger N, Klug SJ, Luyten A. et al. Incidence patterns and temporal trends of invasive nonmelanotic vulvar tumors in Germany 1999–2011. A population-based cancer registry analysis. PloS One 2015; 10: e0128073
    CrossrefPubMedGoogle Scholar
  • 4 Mahner S, Jueckstock J, Hilpert F. et al. Adjuvant therapy in lymph node-positive vulvar cancer: the AGO-CaRE-1 Study. J Natl Cancer Inst 2015; 107: pii:dju426 doi:10.1093/jnci/dju426
    CrossrefPubMedGoogle Scholar
  • 5 Way S. The anatomy of the lymphatic drainage of the vulva and its influence on the radical operation for carcinoma. Ann Royal College Surg Engl 1948; 3: 187-209
    Google Scholar
  • 6 Hampl M, Schnürch HG. et al. National German Guideline S2k: Diagnosis, Therapy and follow-up care of vulvar cancer and its precursors (2015). AWMF Registry No. 015/059. Im Internet: http://www.awmf.org Stand: 01.11.2015
    PubMedGoogle Scholar
  • 7 ESGO guidelines vulvar cancer (2016). Im Internet: https://guidelinesesgoorg/media/2016/08/ESGO-Vulvar-cancer-Complete-report-fxd2pdf Stand: 13.09.2016
    PubMedGoogle Scholar
  • 8 Chan JK, Sugiyama V, Pham H. et al. Margin distance and other clinico-pathologic prognostic factors in vulvar carcinoma: a multivariate analysis. Gynecol Oncol 2007; 104: 636-641
    CrossrefPubMedGoogle Scholar
  • 9 De Hullu JA, Hollema H, Lolkema S. et al. Vulvar carcinoma. The price of less radical surgery. Cancer 2002; 95: 2331-2338
    CrossrefPubMedGoogle Scholar
  • 10 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
  • 11 Woelber L, Choschzick M, Eulenburg C. et al. Prognostic value of pathological resection margin distance in squamous cell cancer of the vulva. Ann Surg Oncol 2011; 18: 3811-3818
    CrossrefPubMedGoogle Scholar
  • 12 Woelber L, Griebel LF, Eulenburg C. et al. Role of tumour-free margin distance for loco-regional control in vulvar cancer-a subset analysis of the Arbeitsgemeinschaft Gynakologische Onkologie CaRE-1 multicenter study. Eur J Cancer 2016; 69: 180-188
    CrossrefPubMedGoogle Scholar
  • 13 Hampl M, Langkamp B, Lux J. et al. The risk of urinary incontinence after partial urethral resection in patients with anterior vulvar cancer. Eur J Obstet Gynecol Reprod Biol 2011; 154: 108-112
    CrossrefPubMedGoogle Scholar
  • 14 Reade CJ, Eiriksson LR, Mackay H. Systemic therapy in squamous cell carcinoma of the vulva: current status and future directions. Gynecol Oncol 2014; 132: 780-789
    CrossrefPubMedGoogle Scholar
  • 15 Geisler JP, Manahan KJ, Buller RE. Neoadjuvant chemotherapy in vulvar cancer: avoiding primary exenteration. Gynecol Oncol 2006; 100: 53-57
    CrossrefPubMedGoogle Scholar
  • 16 Mak RH, Halasz LM, Tanaka CK. et al. Outcomes after radiation therapy with concurrent weekly platinum-based chemotherapy or every-3–4-week 5-fluorouracil-containing regimens for squamous cell carcinoma of the vulva. Gynecol Oncol 2011; 120: 101-107
    CrossrefPubMedGoogle Scholar
  • 17 Tans L, Ansink AC, van Rooij PH. et al. The role of chemo-radiotherapy in the management of locally advanced carcinoma of the vulva: single institutional experience and review of literature. Am J Clin Oncol 2011; 34: 22-26
    CrossrefPubMedGoogle Scholar
  • 18 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 Physics 1998; 42: 79-85
    CrossrefPubMedGoogle Scholar
  • 19 van Doorn HC, Ansink A, Verhaar-Langereis M. et al. Neoadjuvant chemoradiation for advanced primary vulvar cancer. Cochrane Database Syst Rev 2006; (03) CD003752
    PubMedGoogle Scholar
  • 20 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
  • 21 Homesley HD, Bundy BN, Sedlis A. et al. Prognostic factors for groin node metastasis in squamous cell carcinoma of the vulva (a Gynecologic Oncology Group study). Gynecol Oncol 1993; 49: 279-283
    CrossrefPubMedGoogle Scholar
  • 22 de Gregorio N, Ebner F, Schwentner L. et al. The role of preoperative ultrasound evaluation of inguinal lymph nodes in patients with vulvar malignancy. Gynecol Oncol 2013; 131: 113-117
    CrossrefPubMedGoogle Scholar
  • 23 Hinten F, van den Einden LC, Hendriks JC. et al. Risk factors for short- and long-term complications after groin surgery in vulvar cancer. Br J Cancer 2011; 105: 1279-1287
    CrossrefPubMedGoogle Scholar
  • 24 Levenback C, Burke TW, Gershenson DM. et al. Intraoperative lymphatic mapping for vulvar cancer. Obstet Gynecol 1994; 84: 163-167
    PubMedGoogle Scholar
  • 25 de Hullu JA, Doting E, Piers DA. et al. Sentinel lymph node identification with technetium-99 m-labeled nanocolloid in squamous cell cancer of the vulva. J Nuclear Med 1998; 39: 1381-1385
    Google Scholar
  • 26 Woelber L, Joosse SA, Grimm D. et al. Correlation of isotope count with sentinel node positivity in vulvar cancer. Int J Gynecol Cancer 2018; 28: 1403-1409
    CrossrefPubMedGoogle Scholar
  • 27 Klapdor R, Hillemanns P, Wolber L. et al. Outcome after sentinel lymph node dissection in vulvar cancer: a subgroup analysis of the AGO-CaRE-1 study. Ann Surg Oncol 2017; 24: 1314-1321
    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 Woelber L, Grimm D, Vettorazzi E. et al. Secondary sentinel node biopsy after previous excision of the primary tumor in squamous cell carcinoma of the vulva. Ann Surg Oncol 2013; 20: 1701-1706
    CrossrefPubMedGoogle Scholar
  • 30 Oonk MH, van Hemel BM, Hollema H. et al. Size of sentinel-node metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study. Lancet Oncol 2010; 11: 646-652
    CrossrefPubMedGoogle Scholar
  • 31 Stehman FB, Bundy BN, Dvoretsky PM. et al. Early stage I carcinoma of the vulva treated with ipsilateral superficial inguinal lymphadenectomy and modified radical hemivulvectomy: a prospective study of the Gynecologic Oncology Group. Obstet Gynecol 1992; 79: 490-497
    PubMedGoogle Scholar
  • 32 Andrews SJ, Williams BT, DePriest PD. et al. Therapeutic implications of lymph nodal spread in lateral T1 and T2 squamous cell carcinoma of the vulva. Gynecol Oncol 1994; 55: 41-46
    CrossrefPubMedGoogle Scholar
  • 33 Gonzalez Bosquet J, Magrina JF, Magtibay PM. et al. Patterns of inguinal groin metastases in squamous cell carcinoma of the vulva. Gynecol Oncol 2007; 105: 742-746
    CrossrefPubMedGoogle Scholar
  • 34 Woelber L, Eulenburg C, Grimm D. et al. The risk of contralateral non sentinel metastasis in patients with primary vulvar cancer and unilaterally positive sentinel node. Ann Surg Oncol 2016; 23: 2508-2514
    CrossrefPubMedGoogle Scholar
  • 35 Gordinier ME, Malpica A, Burke TW. et al. Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy. Gynecol Oncol 2003; 90: 625-628
    CrossrefPubMedGoogle Scholar
  • 36 Podratz KC, Symmonds RE, Taylor WF. Carcinoma of the vulva: analysis of treatment failures. Am J Obstet Gynecol 1982; 143: 340-351
    CrossrefPubMedGoogle Scholar
  • 37 Burke TW, Levenback C, Coleman RL. et al. Surgical therapy of T1 and T2 vulvar carcinoma: further experience with radical wide excision and selective inguinal lymphadenectomy. Gynecol Oncol 1995; 57: 215-220
    CrossrefPubMedGoogle Scholar
  • 38 Hacker NF, Eifel PJ, van der Velden J. Cancer of the vulva. Int J Gynaecol Obstet 2015; 131 Suppl 2: S76-S83
    CrossrefPubMedGoogle Scholar
  • 39 Stehman FB, Bundy BN, Thomas G. et al. Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys 1992; 24: 389-396
    CrossrefPubMedGoogle Scholar
  • 40 Hyde SE, Valmadre S, Hacker NF. et al. Squamous cell carcinoma of the vulva with bulky positive groin nodes-nodal debulking versus full groin dissection prior to radiation therapy. Int J Gynecol Cancer 2007; 17: 154-158
    CrossrefPubMedGoogle Scholar
  • 41 Boyce J, Fruchter RG, Kasambilides E. et al. Prognostic factors in carcinoma of the vulva. Gynecol Oncol 1985; 20: 364-377
    CrossrefPubMedGoogle Scholar
  • 42 Hacker NF, Van der Velden J. Conservative management of early vulvar cancer. Cancer 1993; 71: 1673-1677
    CrossrefPubMedGoogle Scholar
  • 43 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
  • 44 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
  • 45 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
  • 46 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
  • 47 Curry SL, Wharton JT, Rutledge F. Positive lymph nodes in vulvar squamous carcinoma. Gynecol Oncol 1980; 9: 63-67
    CrossrefPubMedGoogle Scholar
  • 48 Gill BS, Bernard ME, Lin JF. et al. Impact of adjuvant chemotherapy with radiation for node-positive vulvar cancer: A National Cancer Data Base (NCDB) analysis. Gynecol Oncol 2015; 137: 365-372
    CrossrefPubMedGoogle Scholar
  • 49 Woolderink JM, de Bock GH, de Hullu JA. et al. Patterns and frequency of recurrences of squamous cell carcinoma of the vulva. Gynecol Oncol 2006; 103: 293-299
    CrossrefPubMedGoogle Scholar
  • 50 Salom EM, Penalver M. Recurrent vulvar cancer. Curr Treat Options Oncol 2002; 3: 143-153
    CrossrefPubMedGoogle Scholar
  • 51 Lupi G, Raspagliesi F, Zucali R. et al. Combined preoperative chemoradiotherapy followed by radical surgery in locally advanced vulvar carcinoma. A pilot study. Cancer 1996; 77: 1472-1478
    CrossrefPubMedGoogle Scholar
  • 52 Witteveen PO, van der Velden J, Vergote I. et al. Phase II study on paclitaxel in patients with recurrent, metastatic or locally advanced vulvar cancer not amenable to surgery or radiotherapy: a study of the EORTC-GCG (European Organisation for Research and Treatment of Cancer-Gynaecological Cancer Group). Ann Oncol 2009; 20: 1511-1516
    CrossrefPubMedGoogle Scholar
  • 53 Prieske K, Haeringer N, Grimm D. et al. Patterns of distant metastases in vulvar cancer. Gynecol Oncol 2016; 142: 427-434
    CrossrefPubMedGoogle Scholar
  • 54 Monk BJ, Sill MW, McMeekin DS. et al. Phase III trial of four cisplatin-containing doublet combinations in stage IVB, recurrent, or persistent cervical carcinoma: a Gynecologic Oncology Group study. J Clin Oncol 2009; 27: 4649-4655
    CrossrefPubMedGoogle Scholar
  • 55 Woelber L, Hess S, Bohlken H. et al. EGFR gene copy number increase in vulvar carcinomas is linked with poor clinical outcome. J Clin Pathol 2012; 65: 133-139
    CrossrefPubMedGoogle Scholar
  • 56 Horowitz NS, Olawaiye AB, Borger DR. et al. Phase II trial of erlotinib in women with squamous cell carcinoma of the vulva. Gynecol Oncol 2012; 127: 141-146
    CrossrefPubMedGoogle Scholar