Original Article Gynecol Obstet Invest 2013;75:53–60 DOI: 10.1159/000343758
Received: December 6, 2011 Accepted after revision: August 30, 2012 Published online: December 7, 2012
Characterization of Sociodemographic and Clinicopathological Features in Brazilian Patients with Vulvar Squamous Cell Carcinoma Beatriz de Melo Maia a Flávia Munhoz Cestari b André Mourão Lavorato-Rocha a Iara Sant’Ana Rodrigues a Glauco Baiocchi b Gustavo Cardoso Guimarães c José Vassallo a, e Mônica Stiepcich d Fernando Augusto Soares a Rafael Malagoli Rocha a a
Anatomic Pathology Department, b Gynecologic Oncology Department and c Pelvic Surgery Department, Hospital A.C. Camargo, and d Pathology Department, Fleury Institute, São Paulo, and e Laboratory of Investigative and Molecular Pathology, CIPED, State University of Campinas Medical School, Campinas, Brazil
Key Words Vulvar cancer ⴢ Treatment ⴢ Surgery ⴢ Demographics ⴢ Clinical pathology
Abstract Aim: To investigate sociodemographic and clinical-epidemiological profiles of patients with vulvar carcinoma in São Paulo, the largest city of Brazil, to establish a more consistent profile of these features once the incidence of vulvar carcinoma has risen considerably. Data regarding the epidemiological aspects of this tumor are scarce. Methods: A retrospective study was performed using 300 medical records from patients diagnosed with squamous cell carcinoma of the vulva and surgically treated at A.C. Camargo Hospital in São Paulo, Brazil, from 1978 to 2009. Results: The median age of onset was 70 years, ranging from 15 to 98 years, and most women were white (88.51%). Most patients (83.54%) had little or no schooling and had the lowest survival curve. Many patients were diagnosed in the early stages of the disease (57.09% FIGO IB), 59% had complications due to surgery and 43.71% had disease recurrence, of which about 70% died. Conclusions: Our study adds 300 Brazilian cases of vulvar
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carcinoma to the world literature. Given the high rate of disease recurrence and mortality in Brazil, we conclude that regular gynecologic evaluation and educational policies should be reinforced in order to raise awareness for vulvar cancer. Copyright © 2012 S. Karger AG, Basel
Introduction
Vulvar carcinoma is a disease that accounts for approximately 3–5% of all malignant tumors in the female genital tract [1–3] and has traditionally been considered a disease of elderly women (aged between 65 and 75 years) [4, 5]. However, in recent decades, its incidence has risen in younger women [6, 7], possibly due to the higher frequency of precursor lesions – vulvar intraepithelial lesions (VINs) – and their association with HPV infection [7, 8]. The incidence of vulvar carcinoma has risen considerably with a calculated increase of 2.4% per year from 1992 to 1998 [7, 9]. The National Cancer Institute (NCI) of the United States estimates that 4,490 new cases of vulvar cancer will be diagnosed in the USA in the year 2012, with 950 Beatriz de Melo Maia Anatomic Pathology Department Rua Antônio Prudente, 109. 1o Andar – Patologia Investigativa Liberdade, São Paulo, SP 01509-900 (Brazil) E-Mail beatriz.melomaia @ gmail.com
and education of patients with vulvar SCC (1978–2009, São Paulo, Brazil) 13.66%
13.33%
Sociodemographic variables
6% 1.66%
3.33%
1.66%
0.33%
20
1% 2% 2.66%
8%
11%
40
0.33%
Number of patients
60
17% 18%
Table 1. Sociodemographic features related to race, marital status,
15
– 20 19 – 25 24 – 30 29 – 35 34 –3 40 9 – 45 44 – 50 49 – 55 54 –5 60 9 – 65 64 – 70 69 –7 75 4 – 80 79 – 85 84 –8 9 90 +
0
Age at diagnosis (years)
Race White Black descent (mulatto) Black Marital status Single Married Divorced Widow Education Illiterate Elementary school High school College or over
n
%
262 31 3
88.51 10.47 1.01
39 158 8 86
13.40 54.29 2.74 29.55
99 109 34 7
39.76 43.78 13.65 2.81
Fig. 1. Vulvar carcinoma: age-specific incidence in São Paulo (1978–2009). Age groups for every 5 years related to the number of patients in the study. Please notice that the age group between 65 and 74 years has the highest number of women.
Materials and Methods
deaths [10]. In 1992, Recife, in northeast Brazil, appeared to be one of the cities with the highest incidence of vulvar carcinoma in the world, with a rate of 5.6 cases/100,000 women/year [11]. Between 2000 and 2005, Recife still had a high incidence when compared with other Brazilian cities (1.18 per 100,000 women/year). However, during this time period, São Paulo became the city with the highest incidence: 1.44 cases per 100,000 women/year. In São Paulo, the biggest city in the country (with an estimated population of about 19 million people for the greater São Paulo area), the relative frequency of vulvar carcinoma among all female cancers remained almost constant at 0.4–0.5% between the years 2000 and 2005, while the incidence of vulvar carcinoma in women younger than 60 years was less than 1.67. However, in those older than 60 years, the number of diagnosed cases has risen rapidly, and is now 20.87 in women older than 85 years [12]. In spite of the rising incidence of this disease, literature data regarding epidemiologic aspects of vulvar carcinoma are still scarce. Due to HPV infection, this incidence is likely to grow further in the next years, but data regarding the sociodemographic and clinicopathological features are few and mostly out of date for Brazil. Our large retrospective study was performed to update the information available on this neoplasm, with the aim of establishing clearer guidelines regarding the clinical management of these patients. 54
Gynecol Obstet Invest 2013;75:53–60
Sociodemographic and clinical-epidemiological profiles of 300 patients with squamous cell carcinoma (SCC) of the vulva were done. These patients were from various regions of Brazil, and surgically treated at the A.C. Camargo Hospital (São Paulo, Brazil) from 1978 to 2009. The study was approved by the Ethics Committee for Medical Research in this institution. The survey was based on information from patient’s medical files. All data were stored in a Windows Excel database. For quantitative variables, main summary measures such as mean, standard deviation, minimum and maximum values were presented, and the qualitative variables were presented to the respective distributions of absolute and relative frequencies. Kaplan-Meier survival curves were plotted and the log-rank test compared the results. Survival was calculated from the date of diagnosis to the date of death or last follow-up, and p was set at a !0.05 significance level. Software Prism 5 was used for statistical analyzes.
Results
Sample Description The sample consisted of 300 patients. The median age of onset was 70 years, mean age 68 years (SD = 12. 69), with a range of 15–98 years. Most patients were aged between 65 and 74 years, as shown in figure 1. When divided into two groups – younger (under 50 years) and older women (50 years or above) –, lower survival rates were shown for the group of older women (p = 0.0576, fig. 2a). Of the 300 patients, white women were statistically more numerous than non-white women: 88.51% were white and 11.48% de Melo Maia et al.
Survival proportions vs. education
Survival proportions vs. age 150
