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Management of Vulval Intraepithelial Neoplasia (VIN): A Review of Surgical and Therapeutic Medical Treatments
ABSTRACTS Outcome INSS Stage
1009 Survival GTR
Studies Odds ratio (95% CI)
PR
Event Total Event Total DFS 5 yr OS 5 yr DFS 5 yr OS 5 yr DFS 5 yr OS 5 yr
III + IV 332 III + IV 150 III 51 III 36 IV 137 IV 53
701 317 76 48 387 124
108 94 6 46 59 34
279 234 16 80 146 109
14 10 2 2 5 4
1.83 2.06 4.00 2.20 0.98 1.49
(1.12, 2.97) (1.23, 3.45) (1.23, 12.97) (1.00, 4.87) (0.63,1.52) (0.40, 5.57)
Conclusion: This study provides robust evidence to support GTR in children with Stage III NBL to improve survival (5 yr DFS). The heroic efforts of paediatric surgical oncologists to achieve GTR in stage IV NBL offer no clear survival benefits. 4. Management of Vulval Intraepithelial Neoplasia (VIN): A Review of Surgical and Therapeutic Medical Treatments Jessica Hui Cheah Lima, G. Limb, F. Sefrea a Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF b University of Glasgow Background: The incidence of Vulval Intraepithelial Neoplasia (VIN) is rising in the younger population. Progression risk to vulval cancer remains low (<5%) but not negligible. The management of VIN is not well established. Objective: To compare the efficacy of radical vulvectomy, wide local excision (WLE), CO2 laser ablation and various medical therapies in treatment of VIN. Methods: All the literature in Pubmed and Medline were examined. 3174 patients from retrospective and prospective trials from 1968 to April 2011 were analysed. Recurrence rates, disease-free intervals, histological regression rates, advantages and disadvantages of each treatment were examined. Results: Radical vulvectomy achieved lowest recurrence (mean recurrence 15.4%) with the longest disease-free interval. The combined technique of WLE and laser ablation was next best (mean recurrence 25%), followed by WLE (26%) and laser ablation (30% - when performed alone). The most effective medical therapy was imiquimod (short-term mean recurrence 29.5%), followed by photodynamic therapy, PDT
(43.8%). Therapeutic Human Papilloma Virus (HPV) vaccination showed a histological regression rate of 30-50%. Discussion: Vulvectomy is rarely performed nowadays due to severe psychosexual sequels. The current standard practice is WLE. Laser ablation is more cosmetically acceptable and should be considered in nonhair bearing lesions. Imiquimod and PDT are effective short-term, but require further studies to confirm long-term efficacy. HPV vaccination proves to be promising, but is highly dependent on individual immune response. Conclusion: There is no single best treatment in managing VIN. Specific treatment should be based on the nature of VIN, clinician’s experience, patients’ characteristics and preference. 5. The impact of primary surgery on Stage IV breast cancer Ella Harris, P. Cronin, M. Kell Breastcheck, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Introduction: The role of primary surgery in metastatic breast cancer is unclear. Several studies have suggested that there may be a survival benefit as a result of removal of the primary tumour. Here we have performed metaanalysis on available data to assess the role of surgery on oncological outcome in patients with stage IV breast cancer. Patients and Methods: A comprehensive search for published trials that examined outcome following removal of primary disease in stage IV breast cancer was performed using MEDLINE and cross referencing available data. Reviews of each study were conducted, and data were extracted. Primary outcome was overall survival related to surgical removal of primary disease. Results: We identified 15 relevant studies of which 10 were appropriate for analysis. Data was available on 28693 patients with stage IV disease, of whom 52.3% underwent removal of the primary carcinoma. Patients undergoing primary surgery in this setting were more likely to be alive at 3 years 40% vs. 22% (OR 2.32 CI 2.08-2.6, p<0.01, surgery vs. no surgery). Analysis of subgroups for selection to surgery or not, favours selection of low metastatic burden and favourable disease profile to surgery (p<0.01). Conclusion: Patients undergoing removal of primary carcinoma in the setting of stage IV breast cancer appear to have an improved overall survival. However the available data suggest that these surgical patients probably have better prognosis stage IV disease than those patients not undergoing surgery.
Parallel Session 2 e Submitted Papers Monday 7th November 2011, 08:45 to 09:35 6. The efficacy of primary hormone therapy in breast cancer Mohamed Mohamud a , O. Olubunmi b , C. Walsh b , G.T. Royle b , R.I. Cutress b a University of Southampton, School of Medicine, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD b Southampton Breast Unit, Southampton University Hospitals NHS Trust Introduction: Approximately 80% of elderly women (age >70) with breast cancer are Oestrogen receptor positive (ER+ve), and a group of these patients are not fit for surgical treatment under a general anaesthetic (G.A.) due to co-morbidity. Studies evaluating primary hormone therapy (PHT) mostly predate Aromatase Inhibitors, and may not have fully evaluated the influence of co-morbidity in those not suitable for a G.A. Method: A retrospective cohort study comparing the efficacy of PHT in ER+ve breast cancer patients unfit for surgery (LREC 350/02/t). 106
consecutive patients with breast cancer treated at the Southampton Breast Unit with PHT only were identified and notes and electronic records reviewed. Co-morbidity was documented and Charlson’s index calculated using Comorbidity Index and Score of Charlson et al. Results: 78% of patients had a calculated expected <2% probability of 10 year survival due to age and co-morbidity. Overall actual survival was 20% at 4 years while breast cancer specific survival was 60%. In a multivariate model including radiological tumour size and radiological axillary nodal status, the core biopsy tumour grade predicted response to PHT with a doubling of the risk of treatment failure between grade 1 and 2, and between grade 2 and 3(HR 2.0; P¼0.031). Conclusion: Tumour grade is predictive of response to treatment. Comorbidity and age are the most significant determinants of survival. Most patients die with breast cancer rather than from breast cancer, but consideration should be given to local anaesthetic excision for those with grade 3 tumours unfit for G.A.
1009 Survival GTR
Studies Odds ratio (95% CI)
PR
Event Total Event Total DFS 5 yr OS 5 yr DFS 5 yr OS 5 yr DFS 5 yr OS 5 yr
III + IV 332 III + IV 150 III 51 III 36 IV 137 IV 53
701 317 76 48 387 124
108 94 6 46 59 34
279 234 16 80 146 109
14 10 2 2 5 4
1.83 2.06 4.00 2.20 0.98 1.49
(1.12, 2.97) (1.23, 3.45) (1.23, 12.97) (1.00, 4.87) (0.63,1.52) (0.40, 5.57)
Conclusion: This study provides robust evidence to support GTR in children with Stage III NBL to improve survival (5 yr DFS). The heroic efforts of paediatric surgical oncologists to achieve GTR in stage IV NBL offer no clear survival benefits. 4. Management of Vulval Intraepithelial Neoplasia (VIN): A Review of Surgical and Therapeutic Medical Treatments Jessica Hui Cheah Lima, G. Limb, F. Sefrea a Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF b University of Glasgow Background: The incidence of Vulval Intraepithelial Neoplasia (VIN) is rising in the younger population. Progression risk to vulval cancer remains low (<5%) but not negligible. The management of VIN is not well established. Objective: To compare the efficacy of radical vulvectomy, wide local excision (WLE), CO2 laser ablation and various medical therapies in treatment of VIN. Methods: All the literature in Pubmed and Medline were examined. 3174 patients from retrospective and prospective trials from 1968 to April 2011 were analysed. Recurrence rates, disease-free intervals, histological regression rates, advantages and disadvantages of each treatment were examined. Results: Radical vulvectomy achieved lowest recurrence (mean recurrence 15.4%) with the longest disease-free interval. The combined technique of WLE and laser ablation was next best (mean recurrence 25%), followed by WLE (26%) and laser ablation (30% - when performed alone). The most effective medical therapy was imiquimod (short-term mean recurrence 29.5%), followed by photodynamic therapy, PDT
(43.8%). Therapeutic Human Papilloma Virus (HPV) vaccination showed a histological regression rate of 30-50%. Discussion: Vulvectomy is rarely performed nowadays due to severe psychosexual sequels. The current standard practice is WLE. Laser ablation is more cosmetically acceptable and should be considered in nonhair bearing lesions. Imiquimod and PDT are effective short-term, but require further studies to confirm long-term efficacy. HPV vaccination proves to be promising, but is highly dependent on individual immune response. Conclusion: There is no single best treatment in managing VIN. Specific treatment should be based on the nature of VIN, clinician’s experience, patients’ characteristics and preference. 5. The impact of primary surgery on Stage IV breast cancer Ella Harris, P. Cronin, M. Kell Breastcheck, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Introduction: The role of primary surgery in metastatic breast cancer is unclear. Several studies have suggested that there may be a survival benefit as a result of removal of the primary tumour. Here we have performed metaanalysis on available data to assess the role of surgery on oncological outcome in patients with stage IV breast cancer. Patients and Methods: A comprehensive search for published trials that examined outcome following removal of primary disease in stage IV breast cancer was performed using MEDLINE and cross referencing available data. Reviews of each study were conducted, and data were extracted. Primary outcome was overall survival related to surgical removal of primary disease. Results: We identified 15 relevant studies of which 10 were appropriate for analysis. Data was available on 28693 patients with stage IV disease, of whom 52.3% underwent removal of the primary carcinoma. Patients undergoing primary surgery in this setting were more likely to be alive at 3 years 40% vs. 22% (OR 2.32 CI 2.08-2.6, p<0.01, surgery vs. no surgery). Analysis of subgroups for selection to surgery or not, favours selection of low metastatic burden and favourable disease profile to surgery (p<0.01). Conclusion: Patients undergoing removal of primary carcinoma in the setting of stage IV breast cancer appear to have an improved overall survival. However the available data suggest that these surgical patients probably have better prognosis stage IV disease than those patients not undergoing surgery.
Parallel Session 2 e Submitted Papers Monday 7th November 2011, 08:45 to 09:35 6. The efficacy of primary hormone therapy in breast cancer Mohamed Mohamud a , O. Olubunmi b , C. Walsh b , G.T. Royle b , R.I. Cutress b a University of Southampton, School of Medicine, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD b Southampton Breast Unit, Southampton University Hospitals NHS Trust Introduction: Approximately 80% of elderly women (age >70) with breast cancer are Oestrogen receptor positive (ER+ve), and a group of these patients are not fit for surgical treatment under a general anaesthetic (G.A.) due to co-morbidity. Studies evaluating primary hormone therapy (PHT) mostly predate Aromatase Inhibitors, and may not have fully evaluated the influence of co-morbidity in those not suitable for a G.A. Method: A retrospective cohort study comparing the efficacy of PHT in ER+ve breast cancer patients unfit for surgery (LREC 350/02/t). 106
consecutive patients with breast cancer treated at the Southampton Breast Unit with PHT only were identified and notes and electronic records reviewed. Co-morbidity was documented and Charlson’s index calculated using Comorbidity Index and Score of Charlson et al. Results: 78% of patients had a calculated expected <2% probability of 10 year survival due to age and co-morbidity. Overall actual survival was 20% at 4 years while breast cancer specific survival was 60%. In a multivariate model including radiological tumour size and radiological axillary nodal status, the core biopsy tumour grade predicted response to PHT with a doubling of the risk of treatment failure between grade 1 and 2, and between grade 2 and 3(HR 2.0; P¼0.031). Conclusion: Tumour grade is predictive of response to treatment. Comorbidity and age are the most significant determinants of survival. Most patients die with breast cancer rather than from breast cancer, but consideration should be given to local anaesthetic excision for those with grade 3 tumours unfit for G.A.