THE MANAGEMENT OF SQUAMOUS-CELL VULVAL CANCER - A POPULATION-BASED RETROSPECTIVE STUDY OF 411 CASES

Objective To audit the epidemiology, management and outcome of vulval cancer in the West Midlands. Design A retrospective population based s tudy using information obtained from Cancer Intelligence Unit records. Setting The West Midlands Health Region. Sample 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 vulv a. Results Histology was available for 454/506 women (90%); 411/454 wo men (91%) had squamous cell carcinoma: these formed the study populati on. The women were treated at 35 hospitals, 16 of which averaged one c ase or less per year. The median age at diagnosis was 74 years. Presen tation 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 tak en in 268 women (65%) and surgery was the primary treatment in 344/411 cases (84%). Fifteen different operations were used. Simple vulvectom y (35%) and radical vulvectomy with bilateral inguinal lymphadenectomy (34%) were the commonest surgical procedures; 190/344 (55%) had a lym phadenectomy; of these 102 women had negative node histology and 78 wo men had nodal metastases, with results not recorded in 10 cases. Overa ll, only 46% of all women (190/411) studied had a lymphadenectomy. Rec urrence was recorded in 123/411 women (30% of the total). Univariate a nalysis showed significantly worse five-year survival for older age, a dvanced stage, incomplete excision, poor differentiation, lack of lymp h node resection, positive lymph node pathology and treatment in a hos pital with less than 20 cases in total. A multivariate analysis using Cox proportional hazards model identified the first five factors as in dependent predictors of five year survival, Omission of lymphadenectom y was independently associated with poorer survival (RR 2.17, 95% CI 1 .53-3.07). Conclusions There is wide variation in the management of vu lval cancer with inadequate usage of lymphadenectomy and many centres treating few cases. Survival analysis shows prognostic variables as ex pected; omission of lymphadenectomy adversely affects survival.