The management of squamous cell vulval cancer: a population based retrospective study of 411 cases

To audit the epidemiology, management and outcome of vulval cancer in the West Midlands.

A retrospective population based study using information obtained from Cancer Intelligence Unit records.

The West Midlands Health Region.

Five hundred and six women with vulval carcinoma notified to the Cancer Intelligence Unit, during two three-year periods: 1980-1982 and 1986-1988; 411 women had a proven histological diagnosis of squamous cell carcinoma of the vulva.

Histology was available for 454/506 women (90%); 411/454 women (91%) had squamous cell carcinoma: these formed the study population. The women were treated at 35 hospitals, 16 of which averaged one case or less per year. The median age at diagnosis was 74 years. Presentation was delayed by more than one year in 63/284 women with data (22%), and 97/284 cases (34%) had more than one symptom. A biopsy was taken in 268 women (65%) and surgery was the primary treatment in 344/411 cases (84%). Fifteen different operations were used. Simple vulvectomy (35%) and radical vulvectomy with bilateral inguinal lymphadenectomy (34%) were the commonest surgical procedures; 190/344 (55%) had a lymphadenectomy; of these 102 women had negative node histology and 78 women had nodal metastases, with results not recorded in 10 cases. Overall, only 46% of all women (190/411) studied had a lymphadenectomy. Recurrence was recorded in 123/411 women (30% of the total). Univariate analysis showed significantly worse five-year survival for older age, advanced stage, incomplete excision, poor differentiation, lack of lymph node resection, positive lymph node pathology and treatment in a hospital with less than 20 cases in total. A multivariate analysis using Cox proportional hazards model identified the first five factors as independent predictors of five year survival. Omission of lymphadenectomy was independently associated with poorer survival (RR 2.17, 95% CI 1.53-3.07).

There is wide variation in the management of vulval cancer with inadequate usage of lymphadenectomy and many centres treating few cases. Survival analysis shows prognostic variables as expected; omission of lymphadenectomy adversely affects survival.