Epidemiología del virus del papiloma humano / Epidemiology of human papillomavirus

Resumen La presente revisión narrativa fue realizada con el objeto de investigar y recopilar la información más reciente y relevante sobre la epidemiología del Virus del Papiloma Humano y su relación con las patologías asociadas a él, en especial la patología maligna del área genital femenina. La revisión de la literatura fue realizada electrónicamente en PubMed, Medline, ISI, DOAJ, Springer, Embase. Web of Knowledge, DOAJ, y Google Scholar para los artículos escritos en el idioma inglés. Los portales Scielo, Latindex, Imbiomed-L, Redalyc y Google Scholar fueron revisados en búsqueda de artículos escritos en el idioma español. La búsqueda incluyó las palabras claves: epidemiología del virus del papiloma humano, taxonomía viral, estructura del virus del papiloma humano, clasificación del virus del papiloma, nomenclatura del virus del papiloma humano, patologías asociadas al virus del papiloma humano, virus papiloma humano y cáncer del cuello uterino, virus del papiloma humano y cáncer de vulva, y virus del papiloma humano y cáncer de vagina. Se buscaron, revisaron y analizaron las publicaciones desde enero de 1987 hasta agosto de 2021. Esta revisión narrativa investigó la epidemiología del virus del papiloma humano y sus patologías asociadas, en especial las malignas del área genital femenina.

Abstract The present narrative review was conducted to investigate and to compile the most recent and relevant information about the epidemiology of the Human Papilloma Virus and its relationship with the pathologies associated with it. Literature searches were performed electronically in PubMed, Medline, ISI, DOAJ, Springer, Embase. Web of Knowledge, DOAJ, and Google Scholar for original articles written in the English language and Scielo, Latindex, Imbiomed-L, Redalyc, and Google Scholar for original articles written in the Spanish language. The searches included the keywords: epidemiology of human papillomavirus, viral taxonomy, the structure of human papillomavirus, classification of human papillomavirus, the nomenclature of human papillomavirus, pathologies associated to human papillomavirus, human papillomavirus and cervical, human papillomavirus and vulvar cancer and human papillomavirus and vaginal cancer Publications from January 1987 to August 2021 reviewed. This narrative review researched the epidemiology of the human papillomavirus and its pathologies associated especially the female genital area.

Hidradenoma papilífero de la vulva con componente de carcinoma in situ: reporte de caso y revisión de la bibliografía / Papilliferous hidradenoma of the vulva with carcinoma in situ component: case report and literature review

Resumen ANTECEDENTES: El cáncer de vulva es relativamente raro, representa menos del 1% de los tumores malignos de la mujer; su incidencia aumenta con la edad. La variedad más frecuente es el carcinoma escamoso (80 al 90%), seguido del melanoma. En este reporte se revisa un carcinoma de origen glandular, como el hidradenoma papilífero del tipo glándula mamaria (mammary-like) de la vulva. CASO CLÍNICO: Paciente de 50 años, con una lesión papular en la vulva de dos años de evolución, con crecimiento lento y progresivo, ocasional sensación de masa y dolor, con colposcopia negativa, sin antecedentes de patología mamaria y con una biopsia previa que reportó hidradenoma papilífero vulvar. Se trató con resección completa de la lesión, con anestesia regional, con bordes libres, no se identificó algún componente infiltrante. En la actualidad permanece sin evidencia de recaída ni requerimiento de tratamientos adicionales durante el seguimiento. CONCLUSIÓN: El hidradenoma papilífero es una lesión benigna, poco frecuente, relacionada con las glándulas anogenitales de tipo mammary-like, con buen pronóstico. El tratamiento recomendado es la escisión quirúrgica, que casi siempre es curativa.

Abstract BACKGROUND: Vulvar cancer is relatively rare, representing less than 1% of malignant tumors in women; its incidence increases with age. The most frequent variety is squamous cell carcinoma (80 to 90%), followed by melanoma. In this report we review a carcinoma of glandular origin, such as papilliferous hydradenoma of the vulva of the mammary gland (mammary-like) type. CLINICAL CASE: We present a 50-year-old patient with 2 years evolution of a papular lesion on the vulva with slow and progressive growth, intermitent sensation of mass and pain, with negative colposcopy, no history of breast pathology and with a previous biopsy that reported vulvar papilliferous hydradenoma. She was treated with complete resection of the lesion under regional anesthesia, with free margins, without identifying an infiltrating component and currently without evidence of relapse or requirement of additional treatments. CONCLUSION: Papilliferous hidradenoma is a rare benign lesion related to the mammary-like anogenital glands, with a good prognosis and its recommended treatment is surgical excision, which is generally curative.

Progress of researches on the value of magnetic resonance imaging in the diagnosis of gynecologic malignancies / 中国辐射卫生

Gynecologic cancer, a class of malignant tumors originating from female reproductive systems, consists of approximately 20% of all female malignancies, which severely affects female health and causes disease, economic, social and family burdens. Imaging tools, such as ultrasound, CT and magnetic resonance imaging (MRI), have been widely used in screening and clinical diagnosis of gynecologic cancers, which provide insights into the pre-surgical evaluation and treatment planning. This review summarizes the advances of MRI in the diagnosis of common gynecologic cancers, including endometrial cancer, cervical cancer, vulvar cancer and ovarian cancer.

Prognostic value of lymph node ratio in surgically treated cases of vulvar cancer: a tertiary care centre experience

OBJECTIVE: This study aimed to study the patterns of recurrence in surgically treated cases of vulvar cancer (VC) and determine the factors associated with recurrence, with a special emphasis on lymph node ratio (LNR).METHODS: This retrospective study examined VC patients primarily treated with surgery at our institute from January 2005 to December 2015. Demographic data, clinical characteristics, surgicohistopathological data, adjuvant treatment, follow up, and recurrence site and treatment were studied.RESULTS: Among the 111 cases treated, a recurrence rate of 18.9% was noted. Recurrence was most commonly local (61.9%). On univariate and multivariable analyses of clinicopathological parameters, an LNR >20 had the highest hazard ratio for recurrence.CONCLUSION: LNR may provide useful prognostic information in VC patients with positive inguinal lymph node status.

Study of epidemiology, clinicopathological correlation, prognostic factors and management in squamous cell carcinoma of vulva

Background: Carcinoma of the vulva is rare cancer, pruritus is the most common and long-lasting reported symptom. It is found to be associated with HPV and HIV infection. Currently, a more individualized and less radical treatment is suggested. In this study we evaluated epidemiology, clinicopathological prognostic factors, HPV distribution and risk factors for metastases to lymph nodes. We also reviewed multidisciplinary clinical management carried out at our institute.Methods: It is a prospective study of 25 biopsy proven cases of Squamous Cell Carcinoma of Vulva, treated at our center from September 2014 to September 2016. We collected the data regarding the clinical presentation, histological details, treatment given, survival and complications. HPV 16 and 18 testing were done using PCR method. Median follow up of the patients are for 24 months.Results: The mean age of patients was 54.6 years. Commonest presentation was perineal itching (36%). HPV 16/18 were positive in 25% of the patients. Radical vulvectomy with bilateral groin dissection was done in 14/25 (56%) patients. Among these 14 patients, 35.7 % (5/14) has lymph node metastases, disease free survival was 63.6% and overall survival was 81.1% for median follow up of 24 months. About one third of the patient presented with locally advanced disease.  Six (24%) patients received only chemo radiation as a treatment.Conclusions: HPV and HIV infection increase the risk of vulvar cancer. Individualization of treatment is necessary. The use of preoperative chemoradiation in locally advanced disease might have promising results in future.

The age-adjusted Charlson comorbidity index as a predictor of survival in surgically treated vulvar cancer patients / 부인종양

OBJECTIVE: To evaluate the impact of age-adjusted Charlson comorbidity index (ACCI) in predicting disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) among surgically treated patients with vulvar carcinoma. The secondary aim is to evaluate its impact as a predictor of the pattern of recurrence. METHODS: We retrospectively evaluated data of patients that underwent surgical treatment for vulvar cancer from 1998 to 2016. ACCI at the time of primary surgery was evaluated and patients were classified as low (ACCI 0–1), intermediate (ACCI 2–3), and high risk (>3). DFS, OS and CSS were analyzed using the Kaplan-Meir and the Cox proportional hazard models. Logistic regression model was used to assess predictors of distant and local recurrence. RESULTS: Seventy-eight patients were included in the study. Twelve were classified as low, 36 as intermediate, and 30 as high risk according to their ACCI. Using multivariate analysis, ACCI class was an independent predictor of worse DFS (hazard ratio [HR]=3.04; 95% confidence interval [CI]=1.54–5.99; p < 0.001), OS (HR=5.25; 95% CI=1.63–16.89; p=0.005) and CSS (HR=3.79; 95% CI=1.13–12.78; p=0.03). Positive nodal status (odds ratio=8.46; 95% CI=2.13–33.58; p=0.002) was the only parameter correlated with distant recurrence at logistic regression. CONCLUSION: ACCI could be a useful tool in predicting prognosis in surgically treated vulvar cancer patients. Prospective multicenter trials assessing the role of ACCI in vulvar cancer patients are warranted.

Secondary healing strategy for difficult wound closure in invasive vulvar cancer: a pilot case-control study

OBJECTIVES: Despite the number of surgical advances and innovations in techniques over time, radical vulvectomy frequently results in substantial loss of tissue that cannot be primarily closed without tension, the mobilization of surrounding tissues or even the rotation of myocutaneous flaps. The aim of this study was to evaluate the feasibility of leaving the surgical vulvar open wound for secondary healing in situations where primary closure of the vulvar wound is not possible. METHODS: This case-control pilot study analyzed 16 women with a diagnosis of squamous cell carcinoma of the vulva who first underwent inguinofemoral lymphadenectomy, 6-week sessions of chemotherapy and 25 daily sessions of radiotherapy. Afterward, excision of the vulvar lesion with free margins was performed between January 2011 and July 2017. Twelve patients underwent primary closure of the wound (control), and in 4 patients, the surgical wound was left open for secondary healing by means of a hydrofiber (case). The inclusion criteria were a) FIGO-2009 stage II up to IIIC; b) squamous cell carcinoma; and c) no evidence of pelvic or extrapelvic disease or pelvic nodal involvement. The exclusion criteria were extrapelvic disease or pelvic nodal involvement, another primary cancer, or a poor clinical condition. ClinicalTrials.gov: NCT02067052. RESULTS: The mean age of the patients at the time of the intervention was 62.1. The distribution of the stages was as follows: II, n=6 (37 %); IIIA, n=1 (6%), IIIB, n=1 (6%) and IIIC, n=8 (51%). The mean operative time was 45 minutes. The hospital stay duration was 2 days. Full vulvar healing occurred after an average of 30 days in the control group and after an average of 50 days in the case group. CONCLUSION: A secondary healing strategy may be an option for the treatment of vulvar cancer in situations of non-extensive surgical wounds when primary closure of the wound is not possible.

Cáncer de vulva. Repercusiones del tratamiento quirúrgico: experiencia con 151 pacientes / Vulvar cancer. Impact of surgical treatment: experience with 151 patients

Resumen Objetivo: Reportar la experiencia institucional en el tratamiento quirúrgico de pacientes con cáncer de vulva de acuerdo con la clasificación vigente de la Federación Internacional de Ginecología y Obstetricia (FIGO). Materiales y métodos: Análisis retrospectivo de expedientes de pacientes con diagnóstico de carcinoma vulvar operadas con o sin coadyuvancia en el servicio de Oncología del Hospital General de México en un lapso de 34 años. Para el análisis estadístico se utilizó el programa Epi Info versión 7.2. Resultados: Se incluyeron 151 pacientes: 24 (16%) con lesiones preinvasoras o con mínima invasión, se intervinieron con escisiones locales o vulvectomías simples; 16 (15%) con cánceres invasores en quienes se efectuó cirugía conservadora de la vulva con o sin disección ganglionar unilateral. En 94 (62%) se efectuaron vulvectomías con linfadenectomías: 47 con cirugías en bloque y 47 mediante incisiones separadas. En 11 (%) pacientes se practicaron cirugías ultrarradicales: 6 resecciones abdominoperineales y 5 exenteraciones pélvicas. De 127 pacientes que tuvieron seguimiento, 62 (49%) evolucionaron 30 meses en promedio sin evidencia de enfermedad. Se incluyen 21/23 (91%) lesiones tempranas (VIN 2,3 y I- A); 37/49, (76%) de las invasoras en estadios IB-II; 13/41, (32%) de los estadios III (p = 0.00007) y 3/14 (21%) de los IV-A. Conclusiones: Si bien la tendencia actual se orienta a individualizar el tratamiento quirúrgico de pacientes con cáncer de vulva invasor, en esta serie solo en 15% fueron cirugías conservadoras. La metástasis ganglionar fue el factor pronóstico más desfavorable.

Abstract Objective: The present study is a review of our experience of the surgical options for vulvar cancer using The International Federation of Gynecology and Obstetrics (FIGO) classification. Materials and methods: Retrospective analysis of records of patients diagnosed with vulvar carcinoma operated with or without coadyuvance in the Oncology service of the General Hospital of Mexico in a span of 34 years. For the statistical analysis, the Epi Info version 7.2 program was used. Results: Patients were divided into groups, those with pre-invasion or minimal invasion disease were resolved with local excision or simple vulvectomy 24 (16%). Patients with invasive cancer were treated with conservative surgery with or without unilateral lymph node dissection 16 (15%); radical vulvectomy with inguino femoral lymphadenectomy 94 (62%) (47 block surgeries and 47 with separate incision); ultra-radical surgery 11 (7%) (6 abdomino-perineal resections and 5 pelvic exenterations). 127 patients had follow-up and 62 of them had a disease-free survival rate of 30 months (48.8%). The overall survival in pre-invasion or minimal invasion disease were 91.3% (21/23), in stage IB-II 75.5% (37/49), in stage III 31.7% (13/41) (p=0.00007) and in stage IVA 21.4% ( 3/14 ). Conclusions: Although a more individualized and less radical treatment is suggested, in this series only 14.5% of patients, could be resolved with conservative surgery. In addition, the lymph node status was the most important prognostic factor for survival.

Reconstrucción vulvoperineal en cáncer vulvar / Vulvoperineal reconstruction in vulvar cancer

Resumen ANTECEDENTES: Los estadios clínicos avanzados del cáncer vulvar representan un reto quirúrgico y un abordaje que requiere ser multidisciplinario, con cirugía plástica que provea márgenes quirúrgicos adecuados, con menor tasa de complicaciones, cierre primario de la herida e inicio temprano de la terapia oncológica coadyuvante. OBJETIVOS: Describir y exponer las alternativas de reconstrucción vulvoperineal para pacientes con cáncer vulvar, atendidas en el Instituto Nacional de Cancerología de México. MATERIALES Y MÉTODOS: Análisis descriptivo y retrospectivo de casos de pacientes a quienes se hizo reconstrucción vulvoperineal en el Instituto Nacional de Cancerología, México, entre enero y diciembre de 2015, por el mismo cirujano plástico. Se muestra el algoritmo basado en su experiencia. RESULTADOS: Se analizaron 11 casos de pacientes operadas con diferentes técnicas de reconstrucción vulvoperineal, por defectos quirúrgicos del cáncer vulvar y se expuso el algoritmo utilizado y la experiencia del cirujano. CONCLUSIONES: Se revisaron las diferentes alternativas de reconstrucción para subsanar defectos quirúrgicos en pacientes con cáncer vulvar. Los algoritmos de tratamiento quirúrgico previamente publicados son confusos y complejos, quizá por la baja incidencia del cáncer vulvar y las diversas opciones de procedimientos de reconstrucción.

Abstract BACKGROUND: Vulvar cancer is a relatively infrequent disease, that constitutes 1-5% of all gynecological cancers. Surgery is the mainstay treatment is adequate resection, and lymph node evaluation, often have a high risk of relapse that may reach 65%. ADVANCED: Stages are a surgical challenge and multidisciplinary ap proach with plastic surgery will provide adequate surgical margins, less complications, adequate wound closure, and early adjuvant treat ment starting; as well as excellent cosmetic results, with functional, psychological and sexual morbidity decreased. OBJECTIVES: To describe and present the alternatives of vulvoperineal reconstruction in vulvar cancer at Instituto Nacional de Cancerología, Mexico. METHODS: A retrospective descriptive analysis of eleven cases of vulvoperineal reconstruction in vulvar cancer was performed from January 2015 to December 2015, at Instituto Nacional de Cancerología, Mexico; for one plastic surgeon; and demonstrated the algorithm base don their experience. RESULTS: We performed 11 patients of vulvar reconstruction with different reconstructive techniques, such as gracilis flapping, pudend, with a high success rate. as well as, to propose an algorithm based in our experience with vulvar cancer reconstruction at Instituto Nacional de Cancerología, Mexico. CONCLUSION: The present article aims to review the reconstructive alternatives in Vulvar Cancer, several algorithms for surgical treatment have been published before; but they tend to be complex, in part be cause of the low incidence of Vulvar Cancer and the several options of reconstructive procedures.

Carcinoma basocelular invasivo de vulva en una adulta / Basal cellular invasive vulvar carcinoma in an adult woman

Se presenta el caso clínico de una fémina de 32 años con seropositividad del virus de inmunodeficiencia humana desde hacía 2 años, quien acudió a la consulta de Ginecología del Hospital Gubernamental de Mbabane, en Suazilandia, por presentar una lesión en el labio mayor derecho de la vulva, unido a prurito y adenopatías en la región inguinal derecha. La paciente fue evaluada en la consulta de Oncología, donde se le diagnosticó un carcinoma basocelular invasivo de vulva, clasificado en estadio III luego de realizar los exámenes complementarios necesarios; posteriormente fue remitida a Sudáfrica para recibir radioterapia y quimioterapia combinadas.

The case report of a 32 years female patient is presented with seropositivity of the human immunodeficiency virus for 2 years who came to the Gynecology Service of Mbabane Government Hospital, in Swaziland, due to a lesion in the right major lip of the vulva, together with pruritus and adenopathies in the right inguinal region. The patient was examined in the Oncology Service, where a basal cellular invasive vulvar carcinoma was diagnosed. It was classified in stage III after carrying out the necessary laboratory exams; later on she was transferred to South Africa to receive combined radiotherapy and chemotherapy.

Tendências e projeções da mortalidade pelos cânceres específicos ao gênero no Brasil / Trends and projections of mortality for specific cancers gender in Brazil

Os cânceres que acometem os órgãos genitais masculinos e femininos, em conjunto com o câncer de mama, são responsáveis por cerca de 20% dos óbitos por câncer no mundo. Conhecer os padrões de mortalidade por esses cânceres no Brasil, as mudanças que se produziram ao longo do tempo, os grupos mais vulneráveis e a carga de mortalidade que se apresentará no futuro são elementos básicos para a estruturação das ações assistenciais e de vigilância do câncer. O objetivo desse estudo foi analisar as tendências de mortalidade pelos cânceres que acometem órgãos que são específicos a cada gênero e projetar a mortalidade por esses cânceres até o ano de 2030, para o Brasil, regiões e estados da federação. Trata-se de um estudo ecológico de base populacional que analisou os óbitos, ocorridos no período 1996 a 2010, decorrentes dos cânceres de colo do útero, corpo do útero, mama feminina, ovários, vulva, vagina, próstata, pênis e testículos, registrados no Sistema de Informação sobre Mortalidade; as informações sobre população foram obtidas do Instituto Brasileiro de Geografia e Estatística. Foi aplicada a Regressão loglineal (Joinpoint regression) com taxas padronizadas (população mundial: ASR-W) para estimar o Annual Percentage Change (APC), o Average Annual Percentage Change (AAPC), o intervalo de confiança 95% e os pontos de inflexão da curva; as projeções foram calculadas através do programa Nordpred, inscrito no programa R, utilizando o modelo idade-período-coorte, analisando posteriormente se as mudanças que se produzirão no futuro serão decorrentes da exposição aos fatores de risco e/ou da estrutura da população exposta ao risco. Todas as análises também foram aplicadas para o conjunto de todos os óbitos por câncer (com exceção dos cânceres de pele não-melanoma).

Para o Brasil, a mortalidade pelos cânceres de pênis (APC=1,5% IC95% 0,7;2,3 p<0,05), testículos (APC=1,6% IC95% 0,5;2,8 p<0,05) e ovários (APC=0,8% IC95% 0,1; 1,5 p<0,05), mostraram tendência de aumento, enquanto os cânceres de vulva e vagina (APC=-0,1% IC95% -0,9; 0,7 p=0,8), corpo de útero (APC= -0,3 IC95% -1,0; 0,5 p=0,4), mama (APC=0,4% IC95% -0,2;1,0 p=0,2) e de próstata (AAPC= 1,1% IC95% -0,2; 2,4 p=0,1) apresentaram tendência de estabilidade. A mortalidade por câncer de colo de útero apresentou tendência de redução (APC=-1,7% IC95%-2,2; -1,1 p<0,05). A análise do agrupamento de todos os óbitos por câncer observou tendência de aumento na mortalidade para o sexo masculino até o ano de 2006 (APC= 1,2% IC95% 0,6;1,8 p<0,01), seguido de um período de estabilidade. Para o sexo feminino, a tendência é de estabilidade (APC=0,4% IC95% -0,2;-1,8 p=0,2). As taxas de mortalidade para todos os cânceres analisados mostraram, de maneira geral, tendência de redução nas regiões sul e sudeste, tendência de aumento nas regiões norte e nordeste, e estabilidade para a região centro oeste. Na projeção da mortalidade para o ano 2030, as regiões norte e nordeste responderão pelas maiores taxas de mortalidade para os cânceres analisados; todavia, para as demais regiões, será observada redução nas taxas em comparação com o último período observado. Destacase o câncer de testículo, para o qual será observado aumento de 33% na carga da mortalidade até o ano 2030. Para os demais cânceres, não serão observadas variações consideráveis nas taxas de mortalidade para o Brasil entre o último período observado e o último período projetado. A estrutura e o tamanho da população brasileira serão os fatores que explicarão os padrões de mortalidade por esses cânceres no futuro, embora para a região nordeste, as variações serão explicadas, em maior medida, pelo aumento do risco para esses cânceres.

Conclui-se, portanto, que existe uma marcante desigualdade na distribuição da mortalidade pelos cânceres específicos ao gênero no Brasil, onde as regiões mais pobres apresentam um quadro de aumento significativo do número de óbitos ao longo de uma série histórica, e que em 2030, essas regiões responderão pelas maiores taxas de mortalidade no país, com ênfase para os cânceres de pênis, testículos e ovários. (AU)

Cancers that attack male and female genital organs, along with breast cancer, are responsible for approximately 20% of cancer-related deaths in the world. Knowledge on the mortality patterns for these cancers in Brazil, the changes produced throughout time, the most vulnerable groups and the mortality burden in the future are basic elements for structuring assistance and vigilance actions for cancer. The objective of this study was to analyze the mortality trends of cancers that attack gender-specific organs, and project mortality until the year 2030, for Brazil, its geographic regions, and federation states. A population-based ecological study is presented herein, which analyzed deaths occurring within the period 1996-2010, due to cancers of the uterine cervix, uterine corpus, female breast, ovary, vulva, vagina, prostrate, penis and testicles, registered in the Mortality Information System. Data on population was obtained from the Brazilian Institute of Geography and Statistics. Joinpoint regression was applied with standardized rates (world population: ASR-W) to estimate the Annual Percentage Change (APC), the Average Annual Percentage Change (AAPC), the confidence interval 95% and the inflection points of the curve. The projections were calculated by the Norpred program, inscribed within the R program, utilizing the age-period-cohort model, with posterior analysis of whether the changes produced in the future will be consequences of exposition to risk factors and/or structure of the population exposed to risk. The analyses were also applied to the set of all cancer-related deaths (with exception for non-melanoma skin cancers). For Brazil, mortality due to cancers of penis (APC=1.5% CI95% 0.7;2.3 p<0.05), testicles (APC=1.6% CI95% 0.5;2.8 p<0.05) and ovary (APC=0.8% CI95% 0.1; 1.5 p<0.05) showed increasing trends, while cancers of vulva and vagina (APC=-0.1% IC95% -0.9; 0.7 p=0.8), uterine corpus (APC=-0.3 CI95% - 1.0; 0.5 p=0.4), breast (APC=0.4% CI95% -0.2;1.0 p=0.2) and prostrate (AAPC= 1.1% CI95% -0.2; 2.4 p=0.1) presented stable trends. Mortality due to cervical cancer presented reducing trends (APC=-1.7% ICI95%-2.2; -1.1 p<0.05). Analysis of the grouping of all cancer-related deaths presented increasing mortality trends for the male gender until the year 2006 (APC= 1.2% CI95% 0.6; 1.8 p<0.01), followed by a stability period. For females, the trend was stable (APC=0.4% CI95% -0.2;-1.8 p=0.2). The mortality rates for all analyzed cancers revealed, generally, reducing trends for the South and Southeast regions, increasing trends for the North and Northeast regions, and stability for the Midwest region. Mortality projections for the year 2030 indicate that the North and Northeast regions will suffer the highest mortality rates for the analyzed cancers; however, for the remaining regions, reduced rates will be observed in comparison with the last period analyzed. It must be highlighted that, for testicle cancer, there will be an increase of 33% in mortality burden until the year 2030. For the remaining cancers, significant variations will not be observed in mortality rates for the last observed period and the last projected period in Brazil. The structure and size of the Brazilian population are the factors explaining the mortality patterns for these cancers in the future, although for the Northeast region, the variations will be explained mostly by the increase in risk for these cancers. It is concluded that there is a pronounced inequality in the distribution of gender-specific cancer mortality in Brazil, where the poorer regions present a significant increasing situation of the number of deaths throughout a historical series. In 2030, these regions will present the highest mortality rates in the country, with emphasis on penis, testicle and ovarian cancers. (AU)

Dosimetric evaluation and clinical outcome in post-operative patients of carcinoma vulva treated with intensity-modulated radiotherapy.

BACKGROUND: To compare dosimetric parameters of intensity‑modulated radiation therapy (IMRT) with 3D conformal radiotherapy (3DCRT) in post‑operative patients of vulvar cancer and to assess clinical outcome and toxicity with IMRT. MATERIALS AND METHODS: A total of 8 post‑operative patients of vulvar cancer were treated with IMRT. All patients were also planned by 3DCRT for comparison with IMRT. The two plans were compared in terms of conformity index, homogeneity index, tumor control probability (TCP) and normal tissue complication probability (NTCP) for the planning target volume and organs at risk (OAR). RESULTS: IMRT resulted in significantly lesser doses to rectum, bladder, bowel and femoral head as compared with 3DCRT plans. Mean conformity and homogeneity indices were better and within range with IMRT. The TCP was comparable between the two treatment plans and NTCP for rectum, bladder, bowel and femoral head was significantly less with IMRT as compared with 3DCRT. Treatment was well‑tolerated and none of the patients developed Grade 3 or higher toxicity. CONCLUSION: IMRT yielded superior plans with respect to target coverage, homogeneity and conformality while lowering dose to adjacent OAR as compared with 3DCRT. Thus, IMRT offers a reduction in NTCP while maintaining TCP.

Treatment outcomes of curative radiotherapy in patients with vulvar cancer: results of the retrospective KROG 1203 study

PURPOSE: We evaluated the prognostic factors and clinical outcomes of 56 patients with vulvar cancer treated with curative radiotherapy (RT) or concurrent chemoradiotherapy. MATERIALS AND METHODS: Overall survival (OS) and disease-free survival (DFS) were assessed retrospectively. Prognostic factors evaluated included age, International Federation of Gynecology and Obstetrics (FIGO) stage, TNM classification, tumor size, treatment modality, RT duration, and RT field. The association between the tumor human papillomavirus (HPV) status and survival was analyzed in 35 patients. RESULTS: During the median follow-up of 2.8 years (range, 0.3 to 18.9 years), 21 patients (37.5%) experienced treatment failure. Fifteen patients (27%) had local failure: nine (16%) local failure only, three (5%) locoregional failure, two (4%) local and distant failure, and one (2%) locoregional and distant failure. Of 56 patients, seven (13%) had persistent disease at the first follow-up at 2 months and all but one died within a year after completing RT. The 5-year OS and DFS were 51.6% and 44.0%, respectively. In multivariate analysis, clinical size > or =3 cm predicted a poor prognostic factor for DFS (p = 0.040) and age (> or =70 years) was poor prognostic for DFS (p = 0.032) and OS (p = 0.048). Patients with HPV-positive tumors tended to have better 5-year OS and DFS, but the differences were not significant statistically. CONCLUSION: Clinical size > or =3 cm was a significant prognostic factor for DFS. However, age was the most important prognostic factor for DFS and OS in patients treated with curative RT. Further studies are needed to determine which treatment should be considered for old age > or =70 years.

Role of paclitaxel and cisplatin as the neoadjuvant treatment for locally advanced squamous cell carcinoma of the vulva / 부인종양

OBJECTIVE: The therapeutic outcomes of patients with advanced vulvar cancer are poor. Multi-modality treatments including concurrent chemoradiation or different regimens of neoadjuvant chemotherapy (NACT), and surgery have been explored to reduce the extent of surgery and morbidity. The present single-institution trial aimed to evaluate the efficacy and toxicity of paclitaxel and cisplatin in locally advanced vulvar cancer. METHODS: From 2002 to 2009, 10 patients with stage III-IV locally advanced squamous cell carcinoma of the vulva were prospectively treated with 3 courses of paclitaxel-ifosfamide-cisplatin or paclitaxel-cisplatin. Nine of them subsequently underwent radical local excision or radical partial vulvectomy and bilateral inguino-femoral lymphadenectomy. RESULTS: The clinical response rate of all enrolled patients was 80%, whereas the pathological responses included 1 case with complete remission, 2 with persistent carcinoma in situ, and 6 invasive cancer cases with tumor shrinkage of more than 50%. Four patients had positive nodes. Forty percent of patients experienced grade 3-4 bone marrow toxicity, which was successfully managed with granulocyte-colony stimulating factor, even in cases of elderly patients. Median progression-free survival after surgery was 14 months (range, 5 to 44 months). Six of the 7 recurrent cases were local, and 3 of them were treated with salvage surgery while the other 3 received radiation with or without chemotherapy. After a median follow-up period of 40 months (range, 5 to 112 months), 55.5% of patients remained alive with no evidence of disease, including 2 long-term survivors after recurrence at 5 and 9 years. CONCLUSION: Based on the high response rate and manageable toxicity, NACT with paclitaxel and cisplatin with or without ifosfamide followed by surgery could be considered as a therapeutic option for locally advanced vulvar cancer.

Enfermedad de Paget extensa de la vulva: Presentación de un caso y propuesta de manejo conservador / Extensive Paget's disease of the vulva: Case report and a conservative management proposal

La enfermedad de Paget extramamaria (EPE) es una patología maligna observada, sobre todo, en áreas donde existe alta densidad de glándulas apocrinas. Presentamos el caso clínico de una paciente de 68 años de edad, atendida en la Clínica de Colposcopia del Servicio de Oncología, del Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, con diagnóstico de enfermedad de Paget a nivel vulvar, vagina, región de periné y región perianal, manejada con sesiones de vaporización con láser, con evolución satisfactoria. Dado que es una enfermedad poco frecuente, más común en el sexo femenino y en la raza blanca, con mayor incidencia en la séptima década de la vida, como es el caso de nuestra paciente, el objetivo de este trabajo es presentar una revisión de la evaluación clínica, haciendo énfasis en el diagnóstico diferencial, uso de colposcopia para diagnóstico y tratamiento conservador fraccionado con vaporización de láser. La baja incidencia de la enfermedad de Paget de la vulva, vagina, periné y región perianal, así como la ausencia de informes sobre la posibilidad de tratamiento no quirúrgico, motivan a informar a la comunidad científica sobre el manejo con vaporización láser, con la intención de evitar la morbilidad que puede traer consigo el manejo quirúrgico convencional.

Extramammary Paget's disease (EPD) is a malignant disease observed, especially in areas with high density of apocrine glands. We report a case of a patient of 68 years old, attended at the Colposcopy Clinic of Oncology, National Institute of Perinatology Isidro Espinosa de los Reyes, diagnosed with Paget's disease of the vulva, vagina, perineum region and perianal region, and managed with laser vaporization sessions with satisfactory outcome. Since it is a rare disease, more common in females and in whites, with the highest incidence in the seventh decade of life, as is the case of our patient, propose in this paper to present a review of the clinical evaluation with emphasis on the differential diagnosis, use of colposcopy for diagnosis and dividing up conservative treatment with laser vaporization of the disease. The low incidence of Paget's disease of the vulva, vagina, perineum and perianal region, and the absence of reports on the possibility of nonsurgical treatment encouraged to inform the scientific community about the management with laser vaporization, with the intention of avoiding morbidity that can lead to the conventional surgical maneuvers.

Série de casos de neoplasia intraepitelial vulvar tratados com imiquimode / Case series of vulvar intraepithelial neoplasia treated with imiquimod

O termo neoplasia intraepitelial vulvar (NIV) inclui as lesões precursoras do câncer de vulva, sendo divididas em NIV escamosa e não escamosa. A NIV escamosa compreende a NIV tipo usual, a qual se encontra relacionada à infecção pelo HPV, à multicentricidade de lesões, à atividade sexual e ao fumo,sendo mais frequentemente observada em mulheres jovens. Já a NIV diferenciada está relacionada ao líquen escleroso, não estando associada à infecção induzida por HPV, nem ao comportamento sexual, acometendo pacientes mais idosas. A NIV não escamosa está relacionada à doença de Paget e ao melanoma in situ. O tratamento padrão da NIV é cirúrgico e consiste na excisão ampla da lesão com margem de segurança. Este estudo objetiva avaliar ouso do imiquimode creme a 5% no tratamento da NIV tipo usual de forma isolada e/ou, associado ao procedimento cirúrgico. O imiquimode já é utilizadocom eficácia no tratamento de lesões condilomatosas genitais. Além disso, tem-se mostrado eficaz em lesões de NIV tipo usual.

The term vulvar intraepithelial neoplasia (VIN) includes the precursor lesions of vulvar cancer, being divided into squamous VIN and non-squamous VIN. The squamous VIN refers to the usual type VIN, which is related to HPV infection, multicentricity of lesions, sexual activity and smoking beingmore frequently observed in young woman. The VIN differentiated type, which is related to vulvar dermatoses, such as lichen sclerosus, is not associated with HPV-induced infection or sexual behavior and affects older patients. Thenon-squamous VIN is related to Paget's disease and melanoma in "situ".The standard VIN's treatment is a surgical wide excision of the lesion with a safety margin. This study aims to test the use of imiquimod 5% cream in thetreatment of usual type VIN isolated, and/or associated with surgical procedure. The imiquimod is already successfully used in the treatment of genital condylomatous lesions. Moreover, it has been shown to be effective in usual type VIN lesions.

A New Flap for 3-Dimensional Vulvar and Vaginal Reconstruction: The "Butterfly Flap"

PURPOSE: Traditional radical surgery for vulvar cancer produces severe skin and soft tissue defects in the vulvar and vaginal area. Vulvoperineal V-Y advancement fasciocutaneous flaps have limitations in advancement and tension at the wound margin and vaginal orifice area, causing wound disruption or vaginal wall exposure. Therefore, we designed the "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap for 3-dimensional reconstruction of vagina and vulvar area. METHODS: A 27 year-old female was diagnosed with vulvar intraepithelial neoplasia. Radical vulvectomy and full-thickness-skin-graft was performed. We designed a vulvo-perineal V-Y advancement fasciocutaneous flap as the greater wing and inguinal rotational skin as the lesser wing. After flap elevation, the inguinal flap was rotated 180degrees to reconstruct the labia major and vaginal orifice. The perineum was reconstructed using V-Y advancement flaps. RESULTS: The flap survived completely, without any complications. After 6 months, the patient was able to perform normal sexual activities and after 18 months, the patient was able to give birth to normal child by caesarean section. CONCLUSION: The traditional vulvoperineal V-Y advancement fasciocutaneous flap is thin, reliable, easily elevated and matches local skin quality. However, the vaginal wall becomes exposed due to limited advancement and tension of the flap. The "Butterfly flap" using a vulvoperineal V-Y advancement fasciocutaneous flap and an inguinal rotational skin flap is useful for the release of vaginal orifice contracture, reconstruction of the labia major, and 3-dimensional reconstruction of vagina and vulvar area.

Combined open surgical and endovascular management of ruptured femoral artery from recurrent vulvar cancer / 부인종양

We report on the case of a 50-year-old woman with exsanguinating haemorrhage from the common femoral artery as a complication of recurrent vulvar cancer in the groin which was managed successfully with combined open surgical and endovascular intervention. She survived another three months and died from progressive disease without further episodes of bleeding. This complication is rare, presents dramatically, and is usually a terminal event. For those cases where intervention is considered appropriate, the option of combined open surgical and endovascular repair should be kept in mind.

Pregnancy following vulvar squamous cell carcinoma: a report of two cases / 부인종양

Pregnancy following squamous cell carcinoma of the vulvar is rare. Its rarity is reflected by a paucity of cases reported in the literature. We report two cases of pregnancy following diagnosis and treatment for vulvar squamous cell carcinoma, and review eleven prior reported cases. In successfully treated vulvar cancer subsequent pregnancy is not shown to increase the risk of disease recurrence, and there appears to be no deleterious effects during the antenatal period. It is possible, when considering prior reports, that prior vulvectomy may increase the likelihood of delivery by caesarean section, though modifications in the surgical management of vulvar carcinoma may have decreased this risk.

Problems and pitfalls in vulvar and cervical cancer sentinel node scintigraphy

After the introduction for penile cancer, the sentinel lymph node imaging is increasingly applied in various types of cancer. After the initial learning phase, 105 patients with vulvar and 24 with cervical cancer have been investigated. In vulvar cancer all the imaged sentinel nodes were discovered by the portable probe intraoperatively. No false negative sentinel node was observed. The most critical issue is the tracer application. Performed strictly intradermally, the sentinel node shows up immediately. Concomitant use of isosulfan blue dye did not improve the results and was stopped therefore. Similarly, more superficial (intra/subendothelial) application brings up better results as compared to deeper injection in cervical cancer patients. No false negative results were seen. Apparently, an almost 100%detection is possible. Our findings clearly show that tracer application is the key for successful imaging. If not done properly, sentinel node may appear later or may even more likely be missed.

Após a introdução para câncer do pênis, a imagem do linfonodo sentinela é cada vez mais aplicada nos diversos tipos de câncer. Após a fase inicial de aprendizagem, 105 pacientes com câncer vulvar e 24 com câncer cervical foram investigados. No câncer vulvar todas as imagens de nodos sentinela foram descobertas por sonda portátil durante o exame. Nenhum nodo sentinela falso negativo foi observado. A questão mais crítica é a aplicação do traçador. Realizada pela via intradérmica, o nodo sentinela surge imediatamente. O corante isosulfan blue não melhora os resultados e seu uso concomitante foi abandonado. Do mesmo modo, a aplicação mais superficial (intra/subendotelial) apresenta melhores resultados quando comparada com a administração mais profunda em pacientes com câncer cervical. Não foram observados resultados falsos negativos. Aparentemente, uma detecção de aproximadamente 100% é possível. Nossos achados mostram claramente que a administração do traçador é um ponto chave para uma imagem com qualidade. Se não for feita corretamente, o nodo sentinela pode aparecer tardiamente ou pode até ser perdido.