Impact of the new FIGO 2009 staging classification for vulvar cancer on prognosis and stage distribution☆
Highlights
► New FIGO system does not provide an overall improved prognostic ability. ► Tumor diameter is an important factor and is not addressed for stages I and II. ► Number and diameter of LN metastases have limited influence on survival. ► Accurately dropped bilaterality as it does not appear to play a role in outcome.
Introduction
Vulvar cancer is the fourth most common gynecologic cancer and comprises 5% of malignancies of the female genital tract. In the United States, there are approximately 4340 new cases of vulvar cancer and 940 deaths from this disease annually [1]. Surgery is the mainstay of treatment for early stage vulvar cancer and the most important prognostic factor is the regional spread to lymph nodes or other distant metastatic sites [2], [3]. Some studies have shown that the incidence of vulvar cancer appears to be increasing particularly in young women [4], [5]. In 1988 the International Federation of Gynecology and Obstetrics (FIGO) modified the staging system for vulvar cancer to one based upon surgical pathologic factors recognizing the inaccuracy of clinical prediction of lymph node status [6]. The new surgical staging system was shown to be more accurate in assigning patients to their corresponding stage, and the resultant prognostic ability was improved compared to the prior clinical staging [7]. In 2009 the FIGO staging system for vulvar cancer was again revised making substantial changes to stage assignment [8], [9] (Table 1). The primary changes effectively shifted locoregional disease to the lower urethra, vagina or anus to stage II, effectively separating these cases from lymph node positive patients. Additionally, larger size, non-metastatic primary lesions were lumped with smaller lesions into stage I. The latter change could have consequences if tumor diameter is an important risk factor in non-metastatic cases: it would both decrease survival in stage I tumors and also lose an important factor in determine need for ongoing surveillance. Finally, the number of lymph nodes involved, and extent of involvement of nodes were more carefully sub-staged within stage III cases to presumably capture the impact of volume of metastatic disease.
The prime purposes of standardized staging systems are to allow accurate prognostication, identify groups at highest risk of failure, and thus most in need of more aggressive treatments/surveillance, and to compare outcomes across centers and countries. As such the impact of changes in FIGO staging systems should be carefully assessed to see if the new system accomplished those goals better than the prior system. The purpose of this study therefore was to measure the impact on prognostic classification of the new FIGO staging system relative to the 1988 staging in a well staged cohort of patients. A secondary goal was to determine if alternative sub-stage definitions should be considered in future classification systems.
Section snippets
Methods
This was a retrospective study: IRB approval was obtained from both institutions. Eligible cases included invasive squamous vulvar cancer patients who underwent staging surgery from two institutions (Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota and Department of Gynecology, Gynecologic Oncology and Gynecologic Endocrinology Medical University, Gdansk, Poland). Inclusion criteria required cases to have primary surgical management for invasive vulvar cancer to include
Results
A total of 468 patients met inclusion criteria. Cases were performed from 1955 to 1990 (Mayo Clinic, n = 394) and 1998–2008 (Medical University, Gdansk, Poland, n = 74). Fifteen of the cases with lymph node involvement had one missing slide but were staged according to surgical and pathology report reviews which contained sufficient detail for assignment: 6 cases had visible nodal metastases > 5 cm and were classified as having extracapsular spread; 8 cases were described as having multiple
Discussion
In the present study we attempt to show the effects of the new 2009 FIGO staging system for vulvar cancer using a large independent retrospective cohort from 2 centers. We observed that the new system down-stages 31% of cases, with a single case being up-staged due to grossly ulcerated lymph nodes. The new classification has grouped prior 1988 stages I and II into a single stage I, minimizing the effect of size on prognosis when the lesion is confined to the vulva or perineum: our data suggest
Conflict of interest statement
The authors declare that there are no conflicts of interest.
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Accepted for a plenary oral presentation at the SGO 43rd Annual meeting on women's cancer March 24–27, 2012, Austin, Texas.