Elsevier

Gynecologic Oncology

Volume 109, Issue 3, June 2008, Pages 340-345
Gynecologic Oncology

New aspects of vulvar cancer: Changes in localization and age of onset

https://doi.org/10.1016/j.ygyno.2008.01.041Get rights and content

Abstract

Objective

To characterize the changes in incidence, age of disease onset, tumor site and patients characteristics in women with invasive vulvar cancer in a German University Hospital unit over a 28-year period.

Methods

The clinical records for women treated for invasive vulvar cancer from 01/1980 until 06/2007 were analyzed. We performed a retrospective analysis for three 9-year periods: 1/1980 to 02/1989; 3/1989 to 04/1998 and 05/1998 to 06/2007. For each cohort, the number of cases treated, age of disease onset, tumor site and further characteristics were extracted and statistically evaluated.

Results

A total of 224 patients with vulvar cancer were identified between 1/1980 and 6/2007. The number and mean age changed significantly over time: between 1/1980 and 02/1989 53 women with a mean age of 65.6 years were treated for invasive vulvar cancer, between 03/1989 and 04/1998 this number increased to 69 women with a mean age of 63.9 years and in the last period, 102 women with a mean age of 57.0 years were treated for vulvar cancer. The total increase was 192%. In the first period 11% of the women were aged 50 years or less compared with over 41% in the third period (p = 0.001). Two-third of the tumors women aged < 50 years were HPV-positive. Significant changes in the tumor site were observed; from labial position to the region between clitoris and urethra: 37% in the last period compared with 19% in the first period (p > 0.05).

Conclusions

Although in the literature the incidence of invasive cancer has been reported to be stable or only minimally increased, the results of this study show that the number of patients presenting with invasive vulvar cancer has doubled within the last three decades at one university hospital unit in Germany, with a nearly 4-time increase in younger patients (+ 372%) due to HPV high risk infection. The tumor localization changed significantly from the labia to the area between the clitoris and urethra. Assuming that these limited data reflect the general trend in the incidence of HPV-induced vulvar cancer, widely-implemented prophylactic quadrivalent HPV vaccination, which has been proven to be highly effective against anogenital disease, could make an important contribution to the reduction of the risk of vulvar carcinomas in younger women.

Introduction

In the United States vulvar cancer accounts for about 4% of cancers of the female reproductive organs with an estimated 3490 new cases diagnosed in 2007, and an estimated 880 women will die from vulvar cancer (www.cancer.org) The incidence is estimated to be 2.5 per 100,000 women per year, leading to about 1600 new cases per year in Germany (RKI, 2004); it is five times less frequent than cervical cancer (incidence 12 per 100,000 women per year).

Recent data show a striking increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion of the undifferentiated form of invasive vulvar carcinoma over the last 30 years in New Zealand [1], United States [2], [3], Norway [4] and Austria [5], [6]. In contrast, the overall incidence of invasive vulvar cancer has not changed in Austria [5], [6], whereas in the US population, an increase of 20% between 1973 and 2000 was reported in the study of Judson et al. published in 2006 [2].

The Department of Obstetrics and Gynecology of the University Hospital of Duesseldorf, Germany has a large unit for the diagnosis and treatment of dysplasia of the lower genital tract. We have anecdotally observed a striking trend towards younger women presenting with vulvar tumors, preferentially located in the area of the anterior vulva between clitoris and urethra. The tumors in these young females are mostly due to HPV infections [7], [8], [9], [10]. We recently reported on an 18-year old woman with a T3, HPV 52-positive invasive squamous vulvar cancer between clitoris and urethra [11], followed by the cases of two 25- and 32-year old women with large single lymph node metastases due to early invasive vulvar cancer located between clitoris and urethra (Hampl et al., submitted).

To validate these personal observations, we decided to perform a systematic, retrospective review of the clinicopathologic records for all women treated at our unit for invasive vulvar cancer between 1980 and 2007. The aim of this statistical evaluation was to validate the incidence of these tumors in a German university hospital unit, the changes in age, tumor stage and localization and suspected relation to HPV infection. Such data are not available for Germany so far.

Section snippets

Materials and methods

A total of 224 women presenting with invasive vulvar carcinoma between January 1980 and June 2007 were identified using the surgical documentation system of the Department of Obstetrics and Gynecology, University of Duesseldorf, Germany. We performed a retrospective analysis of patients' records for three nine-year periods: 1/1980 to 02/1989; 3/1989 to 04/1998 and 05/1998 to 06/2007. The three periods were of the same length (110 months) to have comparable data sets. For each cohort, we

Results

The results of this analysis are summarized in Table 1 and Fig. 1. Between 1/1980 and 2/1989 (cohort 1), 53 women were admitted and treated in our unit for primary invasive vulvar cancer. The mean age was 65.6 years (standard deviation 12.6, min 31 years, max 91 years). Six women (11%) were 50 years old or younger. In the second cohort between 03/1989 and 04/1998 (cohort 2), 69 women presented with this diagnosis, and had a mean age of 63.9 years (standard deviation 16.3, min 31 years, max

Discussion

The Department of Gynecology and Obstetrics at the University of Düsseldorf in Germany has been a referral center specialized in gynecologic oncology and treatment of lower genital tract intraepithelial neoplasia for decades. There seemed to be an increase in the number of young women presenting with invasive vulvar cancer, especially since the turn of the century without any obvious reason to think that the referral pattern had changed. Furthermore, other colleagues specialized in treating

Acknowledgments

We are grateful to Margret Haugh for revising and editing the manuscript. We thank Dipl. med. U. Schulz for the help in statistical evaluation of the data.

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