Radical vulvectomy. The decision for the incision

Reconstruction of the labia majora using a neurovascular pedicled pudendal thigh flap after extensive vulvectomy for primary extramammary Paget's disease: A case report

Key Clinical Message

A neurovascular pedicled pudendal thigh flap was used to reconstruct labial defect after extensive vulvectomy for primary extramammary Paget's disease. The flap was reliable for the superior skin and ideal for large labial defect reconstruction.

Abstract

Extramammary Paget's disease (EMPD), a rare type of intraepidermal carcinoma, predominantly affects the genitalia. Generally, the treatment for primary EMPD is wide surgical excision; however, large tissue defects after resection necessitate customized reconstruction. Previously, several reconstruction techniques have been outlined, such as local skin flaps (V-Y flaps), skin grafts, pedicled flaps, and free flaps. However, the complexity of EMPD management is due to the multiple flaps and techniques. In this case report, we applied a neurovascular pedicled pudendal thigh flap to reconstruct a labial defect in a 68-year-old woman using the technique of elevation and particularly the insetting of the flap. This pedicled flap was robust and reliable, producing a labium that was natural in appearance with good-quality skin cover and a protective sensation. The patient was satisfied with both the cosmetic appearance and normal sensation of the reconstructed labia. Additionally, the linear scar at the donor site was located along the inguinal fold, and the flap was accepted by the patient as an ideal tissue for reconstruction of the large labial defect.

Wound Complication Rates After Vulvar Excisions for Premalignant Lesions

OBJECTIVE

To assess the rate of wound complications and evaluate the effectiveness of antibiotic prophylaxis in vulvar wide local excision procedures.

METHODS

We performed a single-institution, retrospective cohort study of women undergoing vulvar surgery for premalignant lesions between January 2007 and January 2017. The primary outcome was a composite wound complication rate that included breakdown or infection within 8 weeks postoperatively. Data were analyzed using Fisher exact or χ test, Student t-test, and Poisson regression.

RESULTS

Wound complications occurred in 154 (28.7%) of the 537 patients. Mean age was 52 years; most patients were white (83.1%), cigarette smokers (65.2%), had no prior vulvar treatment (54.4%), and had a preoperative diagnosis of high-grade squamous intraepithelial lesion (vulvar HSIL) (70.0%). The presence of other predisposing factors was similar between groups. In multivariate analysis, smoking (odds ratio [OR] 1.64, 95% CI 1.14-2.38) and primary rather than repeat vulvar surgery (OR 1.99, 95% CI 1.31-3.01) were associated with increased risk for wound complications. There was no significant difference in wound complications between women who received preoperative antibiotics and those who did not (30.4% vs 27.4%, P=.45), although the mean length of wound separation in the antibiotic group was shorter (1 vs 2 cm, P=.03).

CONCLUSION

Wound complications are common among women undergoing surgery for vulvar HSIL, and interventional trials are warranted to evaluate the role of smoking cessation and prophylactic antibiotics to reduce postoperative morbidity.

Trends and Complications of Vulvar Reconstruction After Vulvectomy: A Study of a Nationwide Cohort

OBJECTIVES

The objective of this study was to determine complications associated with primary closure compared with reconstruction after vulvar excision and predisposing factors to these complications.

METHODS

Patients undergoing vulvar excision with or without reconstruction from 2011 to 2015 were abstracted from the National Surgical Quality Improvement Program database. Common Procedural Terminology codes were used to characterize surgical procedures as vulvar excision alone or vulvar excision with reconstruction. Patient characteristics and 30-day outcomes were used to compare the 2 procedures. Descriptive and univariate statistics were performed. Adjusted odds ratios and confidence intervals were calculated using a logistic regression model to control for potential confounders. Two-sided α with P < 0.05 was designated as significant.

RESULTS

A total of 2698 patients were identified; 78 (2.9%) underwent reconstruction. There were no differences in age, race, body mass index, diabetes, hypertension, tobacco use, heart failure, renal failure, or functional status between the 2 groups. American Society of Anesthesiologists class 3 and 4 patients and those with disseminated cancer were more likely to undergo reconstruction (both P < 0.001). On univariate analysis, reconstruction was associated with increased risk of readmission, surgical site infection, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, sepsis, septic shock, unplanned reoperation, longer hospital stay, need for skilled nursing or subacute rehab on discharge, and death within 30 days. On logistic regression analysis, disseminated cancer, American Society of Anesthesiologists classes 3 and 4 and reconstruction remained significant risk factors for readmission and any postoperative complication.

CONCLUSIONS

Patients undergoing vulvar excision with reconstruction are at increased risk for readmission and postoperative complications compared with those undergoing excision alone. Careful patient selection and efforts to optimize surgical readiness are needed to improve outcomes. Long-term data could help determine if these 30-day outcomes are a reliable measure of surgical quality in vulvar surgery.

Using advanced wound care and hyperbaric oxygen to manage wound complications following treatment of vulvovaginal carcinoma

Postoperative management of patients with vulvar cancer is associated with a high incidence of poor wound healing and radiation -induced late tissue necrosis. This case series demonstrates the impact on wound healing with the use of hyperbaric oxygen therapy and advanced wound care following radical vulvectomy and/or radiation therapy. A retrospective case series was performed of all patients from 2016 to 2017 with lower genital cancer who underwent radical surgery with or without chemoradiation treatment, experienced wound dehiscence or late tissue radionecrosis, and were treated with advanced wound care, including hyperbaric oxygen therapy (HBO). Five patients were included with a mean age of 63; four had squamous cell carcinoma and one patient had vaginal adenocarcinoma secondary to prior diethylstilbestrol exposure. Three patients underwent radical vulvectomy. All received pelvic radiation therapy, subsequently experienced wound complications, and were managed with advanced wound care and HBO. The mean reduction in wound area at the final wound follow up visit after completion of HBO therapy was found to be 76%, ranging 42-95%, with an average follow up of five months. The mean number of HBO sessions per patient was 58. Complete tissue granulation or significant improvement in tissue radionecrosis was present in all patients. Advanced wound care and hyperbaric oxygen therapy are beneficial in the management of postoperative wound complications. Prospective studies are needed to identify the optimal use of perioperative hyperbaric oxygen and appropriate wound care for patients with gynecologic malignancies.

Pelvic floor disorders in women with gynecologic malignancies: a systematic review

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders (PFDs) negatively affect quality of life in the general population, and their prevalence in gynecologic cancer survivors has not been systematically described. This study aimed to determine the prevalence of PFDs in cancer survivors. We hypothesized that the prevalence of PFDs in the gynecologic cancer population would be higher than in the general female population.

METHODS

We searched PubMed (1809 to present), EMBASE (1974 to present), and the Cochrane Central Register of Controlled Trials (CENTRAL) through May 2017. The search combined subject headings, title, and abstract words for gynecologic cancer, PFDs, and prevalence. Any studies evaluating the prevalence of PFDs in gynecologic malignancies were included.

RESULTS

A total of 550 articles met the designated search criteria and 31 articles were included in this review. In cervical cancer survivors, before treatment the prevalences of stress urinary incontinence (SUI), urgency urinary incontinence (UUI) and fecal incontinence (FI) were 24-29%, 8-18% and 6%, respectively, and after treatment the prevalences of SUI, UUI, urinary retention, FI, fecal urge, dyspareunia and vaginal dryness were 4-76%, 4-59%, 0.4-39%, 2-34%, 3-49%, 12-58% and 15-47%, respectively. In uterine cancer survivors, before treatment the prevalences of SUI, UUI and FI were 29-36%, 15-25% and 3%, respectively, and after treatment the prevalences of urinary incontinence (UI) and dyspareunia were 2-44% and 7-39%, respectively. In vulvar cancer survivors, after treatment the prevalences of UI, SUI and FI were 4-32%, 6-20% and 1-20%, respectively. In ovarian cancer survivors, the prevalences of SUI, UUI, prolapse and sexual dysfunction were 32-42%, 15-39%, 17% and 62-75%, respectively.

CONCLUSIONS

PFDs are prevalent in gynecologic cancer survivors and this is an important area of clinical concern and future research.

A review of complications associated with the surgical treatment of vulvar cancer

OBJECTIVE

The mainstay of treatment for most vulvar malignancies is surgery to the vulva with lymphadenectomy to the inguino-femoral areas, plus radiotherapy or/and chemotherapy for locally advanced, or recurrent disease. Treatment is associated with significant physical, sexual, and psychological morbidity. The high morbidity rate has resulted in a continuing shift in treatment paradigms that focus on treatments that reduce morbidity without compromising cure rates. This paper reviews the complications associated with contemporary surgical treatment for vulva cancer and discusses preventative strategies.

METHODS

A review of the English literature was undertaken for articles published between 1965 and August 31, 2012 to identify articles that assessed complications resulting from surgery to the vulva or groins in patients with vulva cancer. Two independent researchers selected and qualitatively analyzed the articles using a predetermined protocol.

RESULTS

The heterogeneity of articles and differences in definitions and outcomes made this unsuitable for meta-analysis. Most studies advocated for change in surgical technique to reduce complications associated with inguino-femoral lymphadenectomy and surgery to the vulva, with varying success. The most effective means of preventing complications is by omitting systematic lymph node dissection. This can be achieved safely through sentinel lymph node biopsy. Saphenous vein sparing, VTE prophylaxis, the use of flaps and grafts, and preoperative counseling are additional ways to decrease morbidity.

CONCLUSION

Despite technical advances, complications following surgical treatment for vulva cancer remain high. More research, particularly multi centered randomized controlled trials to improve the quality of evidence and studies that focus on complications as an outcome measure and analyze individual surgeon complication rates, are needed. Measures also need to be standardized throughout the gynecologic oncology community to allow for better comparison between studies.

Diagnosis and treatment options of vulvar cancer: a review

INTRODUCTION

Vulvar cancer is a rare malignancy in women. However, within the past decade, a distinct increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion, and an increase of vulvar cancer have been reported within Europe and the USA. Surgery is the first choice in treating patients with vulvar cancer, especially in its early stages. In an attempt to decrease the incidence of complications, research was made into modifications of the surgical procedure without compromising the prognosis. The replacement of radical vulvectomy by less wide local excision is one of these modifications. As vulvar cancer is relatively rare, it is possible to give evidence-based treatment recommendations, but usually on a low evidence level. Aim of this paper is to elucidate diagnostics and surgical treatment options in the management of vulvar cancer.

MATERIALS AND METHODS

We searched major databases (i.e. pubmed) with the following selection criteria: vulvar cancer, en bloc resection, triple incision, and sentinel node biopsy.

CONCLUSIONS

Today, the operative therapy is much less radical and more emphasized on individualized therapeutic concepts. The tendency is to leave the ultraradical surgical options which suffer from high morbidity towards less radical, minimal invasive techniques. Due to the rarity of the disease further studies will have to be performed by international collaborative groups.

Small-area analysis of incidence and localisation of vulvar cancer

Objective. Vulvar cancer is a rare disease mainly in older women. HPV and non-HPV induced vulvar cancer reflect two types of oncogenesis. Controversies exist on most recent developments in vulvar cancer incidence, patients, and disease characteristics. Changes in incidence, age of disease onset, and tumor site in women treated for primary vulvar cancer in a single German university hospital unit will be described. Methods. A retrospective analysis of patient records of women treated between 1994 and 2008 was performed. The fifteen-year-spanning period was divided into three five year-spanning cohorts. Descriptive and statistical analyses were performed. Results. 104 patients were identified: cohort-1 from 1994 to 1998 (11 patients); cohort-2 from 1999 to 2003 (21 patients); cohort-3 from 2004 to 2008 (72 patients). Mean age (years) was 73.18 (confidence interval (CI): 64.04; 82.33), 58.9 (CI: 52.24; 65.57), and 61.19 (CI: 57.27; 65.12), respectively. Vulvar cancer confined to the region between clitoris and urethra was seen more often in cohort-3 (n = 20) compared to cohort-1 (n = 0) or cohort-2 (n = 1). Conclusion. This analysis supports the notion of rising incidence of vulvar cancer and a changing pattern of anatomical local extension. Disease onset is not restricted to older women.

Systematic review and meta-analysis of the used surgical techniques to reduce leg lymphedema following radical inguinal nodes dissection

BACKGROUND

Inguinal nodes dissection is associated with high rates of morbidity, lymphedema in particular is a chronic disabling condition which is a common complication following this operation. Prevention or minimization of this condition is an important aim when considering this procedure. Many technical modifications are suggested for this purpose. This systematic review aims at assessing the efficacy of the available strategies to reduce the risk and severity of leg lymphedema.

METHODS

For this review, MEDLINE and EMBASE were searched to identify studies that reported surgical strategies designed to reduce complications of groin dissection and in particular leg lymphedema. Studies that reported outcome of long saphenous vein sparing, fascia preserving dissection, microvascular surgery, sartorius transposition and omental pedicle flap were located. Data were collected using predefined inclusion and exclusion criteria. A combined odds ratio was calculated combining studies suitable for meta-analysis using the random effect model.

RESULTS

The search result defined few studies that reported results of saphenous vein sparing technique; some of those studies were found suitable for meta-analysis based on the Newcastle-Ottawa scale for non-randomized studies. The meta-analysis showed significant reduction of lymphedema (odds ratio 0.24, 95% CI 0.11-0.53) and other complications of inguinal node dissection. There were no randomized studies to address this problem; there are also isolated studies that reported benefits of other techniques but none of them was suitable for meta-analysis.

CONCLUSION

Meta-analysis of the reported studies on sparing the long saphenous vein in inguinal nodes dissection suggests a reduced rate of lymphedema and other postoperative complications. Other methods that may be beneficial are fascia preserving dissection, pedicled omental flap and microsurgery; however sartorius transposition has not been shown to reduce the rate of complications. Randomized controlled trials are needed to prove the benefits of various technical modifications.

Surgery and radiotherapy in vulvar cancer

The majority of patients with vulvar cancer have squamous cell carcinomas (SCC). The cornerstone of the treatment is surgery. Radical vulvectomy with "en bloc" inguinofemoral lymphadenectomy has led to a favorable prognosis but with impressive morbidity. Nowadays, treatment is more individualized with wide local excision with uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as the standard treatment for early stage patients with SCC of the vulva with depth of invasion >1 mm without suspicious groins. In case of more than one intranodal lymph node metastasis and/or extranodal growth, postoperative radiotherapy on the groins and pelvis is warranted. Until now there is a limited role for primary radiotherapy on the vulva and/or groins in early stage disease. The sentinel lymph node (SLN) procedure with the combined technique (preoperative lymphoscintigraphy with a radioactive tracer and intraoperative blue dye) is a promising staging technique for patients with early stage vulvar cancer. The safety of clinical implementation of the SLN procedure and the role of additional histopathological techniques of the SLNs need to be further investigated before its wide-scale application. Patients with advanced vulvar cancer are difficult to treat. One of the problems in patients with locally advanced vulvar cancer is the high incidence of concomitant bulky lymph nodes in the groin(s). Ultraradical surgery in case of resectable disease will lead to impressive morbidity because of the exenterative-type procedure. (Chemo)radiation with or without surgery should be regarded as the first choice for patients with locally advanced vulvar cancer only when primary surgery will necessitate performance of a stoma. Further studies are needed to determine the optimal combined modality treatment in these patients. Due to the fact that vulvar cancer is a rare disease, further clinical studies will only be possible, when international collaborative groups will join forces in order to perform clinical trials, in which different treatment options such as SLN procedure, primary radiotherapy on the groins and multimodality treatment for advanced disease will be investigated.

Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer

During the last decades there has been a continuing evolution in the surgical approach of squamous cell carcinoma of the vulva that has been traditionally treated with radical vulvectomy and bilateral inguinal-femoral lymphadenectomy. Patients with T1 tumour are usually treated with radical local excision, if the lesion is unifocal and the remainder of the vulva is normal. Patients with T1a disease have no risk of groin metastases and do not need lymphadenectomy, whereas those with T1b disease need ipsilateral inguinal-femoral lymphadenectomy if the lesion is lateral, and bilateral lymphadenectomy if the lesion is midline. Modifications of the surgical technique of deep femoral lymphadenectomy and the mapping of sentinel node can offer new interesting therapeutic perspectives. Postoperative adjuvant pelvic and groin irradiation is warranted for patients with two or more or macroscopically involved groin nodes. Locally advanced squamous cell carcinoma of the vulva has been long surgically treated with en-block radical vulvectomy and bilateral inguinal-femoral lymphadenectomy plus partial resection of urethra, vagina or anum, or by exenteration, with severe postsurgical complications, poor quality of life, and unsatisfactory survival rates. 5-Fluorouracil [5-FU] or 5-FU- and cisplatin-based chemotherapy concurrent with irradiation followed by tailored surgery represents an attractive therapeutic option for advanced disease, planned to avoid such ultra-radical surgical procedures and, hopefully, to improve patient outcome. Chemotherapy has also been used in neoadjuvant setting, with contrasting and generally unsatisfactory results, and in palliative treatment of patients with distant metastases. Surgery is the primary treatment also for vulvar malignancies other than squamous cell carcinoma, whereas the clinical usefulness of adjuvant irradiation or chemotherapy is still to be defined. Primary chemoradiation can be also used for advanced carcinoma of the Bartholin gland or for advanced adenocarcinoma associated with extramammary Paget's disease. The drugs used for chemotherapy of metastatic melanomas or sarcomas of the vulva are the same employed for the melanomas or sarcomas developed in other sites.

Management of vulvar cancers

AIM

The radical surgical approach in the treatment of vulvar cancer patients has led to a favorable prognosis for the majority of the patients with early stage squamous cell cancer. However, the morbidity is impressive, leading to more individualized treatment. The aim of this review is to give an overview of the management of vulvar cancer.

METHODS

We have reviewed the literature on the modifications in treatment of vulvar cancer with the emphasis on surgery and radiotherapy for primary disease.

RESULTS

While surgery is the cornerstone of treatment for early stage squamous cell vulvar cancer (with wide local excision and uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as standard treatment), until now there has been a limited role for primary radiotherapy although this may be an attractive alternative for the inguinofemoral lymphadenectomy in the future. The sentinel lymph node procedure with the combined technique (preoperative lymphoscintigraphy with (99m)technetium-labeled nanocolloid and Patente Blue) is a promising staging technique for patients with vulvar cancer. The clinical implementation of the sentinel lymph node procedure and the role of additional histopathological techniques of the sentinel lymph nodes have to be investigated. In advanced vulvar cancer, chemoradiation followed by surgery should be regarded as the treatment of first choice for these patients.

CONCLUSIONS

Due to the rarity of vulvar cancer it is quite clear that further studies will have to be performed by international collaborative groups. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce morbidity of treatment, but their safety needs to be studied in clinical trials.

Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma

OBJECTIVES

To compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal lymphadenectomy for vulvar carcinoma.

METHODS

A retrospective evaluation of patients with carcinoma of the vulva that underwent inguinal lymphadenectomy was performed. Operative reports were evaluated and patients were divided into those who had sparing of the saphenous vein versus ligation. Postoperative short- and long-term complications were compared between the two groups using Pearson chi squared analysis.

RESULTS

There were a total of 49 inguinal lymphadenectomies performed on 29 patients. The saphenous vein was spared in 18 (37%) groin dissections compared to 31(63%) in which the saphenous vein was ligated. The two groups were similar in regards to clinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodes dissected was similar. Cellulitis was more common in the vein-ligated group compared to the vein-spared group (45% vs. 0%; P < 0.001). Wound breakdown occurred in 25% of dissections where the saphenous vein was ligated versus 0% in dissections where the vein was spared (P = or < 0.02). Short-term edema (< or = 6 months) was similar between vein-ligated and vein-spared groups (67% vs. 72%, P < 1.0). Subsequently, chronic lymphedema (> 6 months) persisted in 38% of the vein-ligated group compared to 11% in the vein-spared group (P < 0.05). The incidence of recurrent disease was similar in both groups (19.3 % vs. 22.2% P < 0.1).

CONCLUSIONS

Routine preservation of the saphenous vein during inguinal lymphadenectomy for vulvar carcinoma may reduce the incidence of wound cellulitis, wound breakdown, and chronic lymphedema.

Use of prolene mesh in surgical treatment of tissue defects after radical inguinal and pelvic lymph node dissection in vulvar cancer--a brief report

Surgery is still the procedure of choice in treatment of advanced vulvar cancer. Radical vulvar surgery is often associated with severe vulvar and inguinal skin and fat-tissue deficits resulting from wide "butterfly" shape resection. Primary closure of large vulvar and inguinal defects is hampered by lack of tissue. The study presents the case of using prolene mesh in filling up the tissue defects over femoral vein and artery after radical excision of enlarged inguinal superficial, femoral, and pelvic nodes to prevent vessels in hiatus saphenus. It is the first report describing the use of prolene mesh in such a procedure.

Conservative clitoral preservation surgery in the treatment of vulvar squamous cell carcinoma

OBJECTIVE

To determine the safety and efficacy of clitoral-sparing surgery in women with squamous cell carcinoma (SCCA) of the anterior vulva not involving the clitoris.

METHODS

Patients with vulvar SCCA diagnosed between 1984 and 2000 were identified and data collected. In this descriptive analysis, women treated with complete radical vulvectomy were compared to those treated with clitoral-sparing modified radical vulvectomy. All slides were re-reviewed.

RESULTS

Of the 41 women with vulvar carcinoma, 13 had clitoral-sparing modified vulvectomies (group A) while the remaining 28 underwent complete radical vulvectomies (group B). The 13 patients in group A included, 8 with stage I, 2 stage II, 2 stage III, and 1 with stage IV disease. The two groups had similar demographic and pathologic prognostic factors. After a median follow-up of 59 months, no patients in group A had loco-regional failure.

CONCLUSION

Clitoral-sparing vulvar cancer surgery does not compromise the rate of loco-regional control in patients and may be offered to selected women.

Modern management of vulvar cancer

PURPOSE OF REVIEW

The radical surgical approach in the treatment of vulvar cancer patients has led to a favourable prognosis for the majority of patients with early stage vulvar cancer. However, morbidity is impressive, leading to more individualized treatment. The authors have reviewed the most recent literature on the pros and cons of the modifications in treatment, including surgery and primary radiotherapy, for primary squamous cell carcinoma of the vulva and vulvar melanoma.

RECENT FINDINGS

The sentinel lymph node procedure is a promising method of staging in patients with early stage squamous cell carcinoma of the vulva and possibly for patients with vulvar melanoma, but its safety still has to be proved. Less radical surgery has led to a higher local and regional recurrence rate. There may be a role for primary radiotherapy of the groin in a selected group of patients.

SUMMARY

The authors have concluded that the individualization of treatment for vulvar cancer patients has led to a decrease in morbidity but an increase in recurrences. The increase in recurrences does not appear to compromise prognosis, probably because of the lack of power, based on the low incidence of vulvar cancer. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce the morbidity of treatment but their safety needs to be studied in randomized trials.

Sclerotherapy with bleomycin for recurrent massive inguinal lymphoceles following partial vulvectomy and bilateral lymphadenectomy—Case report and literature review

BACKGROUND

Formation of lymphoceles following radical vulvectomy presents a formidable problem that is associated with high degree of morbidity. A variety of approaches have been described in the literature to treat this condition.

CASE

An 82-year-old woman developed massive inguinal lymphoceles following partial vulvectomy and inguinal lymphadenectomy for cancer vulva. The lymphoceles involved wide surface areas extending to both flanks, and accumulation of lymph was very rapid at a rate of 1 l daily. The condition failed to respond to continuous drainage and compression for 6 weeks, but responded quickly to sclerotherapy using bleomycin without any significant side effects.

CONCLUSION

Intracavitary bleomycin could be used safely and effectively in huge rapidly accumulating lymphoceles.

Vulvar squamous cell carcinoma: guidelines for early diagnosis and treatment

The incidence of vulvar squamous cell carcinoma (SCC), the most common vulvar cancer in women, is increasing worldwide. Furthermore, despite the increasing prevalence, this disease is commonly misdiagnosed by physicians. Unfortunately, late-stage vulvar SCC has a poorer prognosis compared with early vulvar neoplasia and requires aggressive therapy such as radical surgical intervention. Therefore, early diagnosis by physicians is critical to reduce both the mortality and morbidity rates of vulvar SCC. This review discusses the etiology, clinical characteristics, and diagnostic staging of vulvar SCC. Treatment options are reviewed, including novel topical immunotherapies such as imiquimod.

Groin surgery and the sentinel lymph node

Vulvar cancer is a rare disease. Squamous-cell carcinomas account for 90% of vulvar cancers. The main mode of spread is lymphogenic to the inguinofemoral lymph nodes. Therefore, elective uni- or bilateral inguinofemoral lymphadenectomy is part of the standard treatment in combination with radical (wide) local excision of the vulvar tumour. Lymph drainage studies in relation to the biological behaviour of vulvar cancer are presented, as well as the anatomy and surgery of the groin. The sentinel lymph node procedure is a relatively new method of staging in vulvar cancer which may lead to the omission of inguinofemoral lymphadenectomy in those patients identified as not having inguinofemoral lymph node metastases. The accuracy of this technique appears to be high, but its safety still has to be proven. Moreover, the role of additional histopathological techniques for the examination of the sentinel lymph nodes needs to be established.

The prevention and management of treatment related morbidity in vulval cancer

The traditional and the most common management of primary vulval cancer is radical surgery of the vulva and radical groin lymphadenectomy (unilateral or bilateral). Adjuvant radiotherapy is used in poor prognosis cases. Rare vulval cancers, locally advanced cancers and recurrent vulval cancers often are treated with a combination of surgery, radiation therapy and chemotherapy. The treatments, while often curative, are associated with considerable morbidity, which, until recently, has not been well publicized or quantified. Increasingly, younger patients are presenting with extensive and often multi-focal pre-invasive disease and with vulval cancer. Long-term post-treatment physical, sexual and psychological morbidity is of major concern. There is more onus on clinicians to provide less radical but equally curative treatment, while also reducing morbidity. There is also the need to provide treatment and treatment modification based on supporting evidence. For a rare disease such as vulval cancer it is more difficult to generate data and to conduct trials on treatment modifications. Although surgical modifications have been made, the morbidity of radical surgery for vulval cancer is considerable. The prevention and management of treatment-related morbidity will continue to challenge the gynaecological oncology team.

Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions

The focus of this study was to document postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate incisions. Data from 172 consecutive patients with newly diagnosed carcinoma of the vulva were studied. One hundred and one patients primarily treated with modified radical vulvectomy and complete inguinofemoral lymphadenectomy using separate groin incisions (n = 187) were included in this study. One or more complications were documented in 77 of the 101 (76%) patients. Complications after groin dissection were observed in 66% of the patients. The main complications were wound breakdown (17%) and/or infection (39%) of the groin, lymphocyst formation (40%), and lymphedema (28%). In 98 of 187 (52%) groin dissections, one or more complications were documented. The presence of lymph node metastases, postoperative radiation, age older than 65 years, and removal of the vena saphena magna were not significant risk factors for the occurrence of complications. The occurrence of early complications after groin dissection was significantly related to the late-complication lymphedema (P = 0.002). Our results confirm relatively high rates of wound breakdown, infection, lymphocyst formation, and lymphedema even with separate groin incisions. The occurrence of early complications was related to lymphedema. No other risk factors could be identified.

Vulvar carcinoma. The price of less radical surgery

BACKGROUND

The objective of this study was to determine whether modifications in the treatment of patients with vulvar carcinoma influence the rates of recurrence and survival.

METHODS

Between 1982 and 1997, 253 patients with T1 and T2 invasive squamous cell carcinoma of the vulva were treated by essentially the same team of gynecologic oncologists, and 168 patients (Group I) underwent radical vulvectomy with en bloc inguinofemoral lymphadenectomy. Standard therapy was changed in 1993, and 85 patients (Group II) underwent wide local excision with inguinofemoral lymphadenectomy through separate incisions. The rates of recurrence and survival were compared between both groups.

RESULTS

In Group II, the overall recurrence rate (33.3%) within 4 years was increased compared with Group I (19.9%; P = 0.03). In Group II, 5 of 79 patients (6.3%) developed fatal groin or skin bridge recurrences compared with 2 of 159 patients (1.3%) in Group I (P = 0.029); this did not result in a difference in overall survival. In Group II, 40 of 79 patients had tumor free margins measuring <or= 8 mm, resulting in 9 local recurrences; whereas 39 of 79 patients had tumor free margins measuring > 8 mm, resulting in no local recurrences (P = 0.002).

CONCLUSIONS

The current study showed that fatal recurrences in either the groin or the skin bridge were more frequent after wide local excision and inguinofemoral lymphadenectomy through separate incisions; however, probably due to lack of power, this did not result in shorter survival. In 40 of 79 patients, the histologic margins measured <or= 8 mm, resulting in a high risk of local recurrences. Therefore, the authors recommend obtaining surgical margins of 2 cm for the local treatment of patients with vulvar carcinoma.

Treatment of recurrent inguinal lymphocele by lymphatic leakage mapping and subsequent ligation of lymphatic vessel endings: a case report

BACKGROUND

Different approaches have been attempted in both prophylaxis and treatment of recurrent inguinal lymphoceles; however, to date none have been consistently effective. We hereby report our preliminary experience with mapping of the lymphatic leakage followed by ligation of these mapped vessels for resolution of a recurrent inguinal lymphocele.

CASE

A 73-year-old woman underwent an anterior modified radical vulvectomy with bilateral inguinofemoral lymph node dissection due to squamous cell carcinoma of the vulva. Postoperatively she presented with a recurrent inguinal lymphocele unresponsive to several treatment measures. After 8 weeks, the patient underwent lymphatic leakage mapping and subsequent ligation of lymphatic vessel endings, which resolved her recurrent lymphocele.

CONCLUSION

Lymphatic mapping and ligation of afferent lymphatics may be a useful method for treating recurrent lymphoceles after inguinofemoral lymph node dissection. Further studies are warranted to prove the absolute efficacy of this technique.

Infectious diseases in gynecologic oncology: an overview

The increasing trend of a multimodal therapeutic approach in gynecologic oncology in the last few years has markedly changed the nature, frequency, and clinical presentation of infectious diseases. Despite the improved diagnostic tools, refined surgical technique, and routine use of prophylactic antibiotics, the morbidity and mortality of infectious complications remain significant. The rational use of available treatment resources, the recognition of risk factors, and increased awareness of host-cancer interactions should reduce the incidence of these serious infectious complications. The improved prevention and more efficient treatment of infections in the gynecologic oncology patient will not only improve prognosis but also have a significant economic impact as well.

Wound complications in patients with carcinoma of the vulva. Comparison between radical and modified vulvectomies

OBJECTIVE

To evaluate complications after different vulvectomies performed because of vulvar cancer.

STUDY DESIGN

Retrospective analysis of 149 patients who underwent vulvectomy.

RESULTS

Wound infections was found in 58%. Overweight, central or bilateral location of the tumor, and non-radical surgery were significant predictors of wound infections. Patients with a wound infection had more often wound breakdown (P<0.001), prolonged healing time (P<0.000), and lymphedema (P<0.001) than patients without infection. Antimicrobial prophylaxis did not prevent wound infection. Wound infections were found in 75% after radical en bloc vulvectomy (RV) and in 47% after modified vulvectomies (MV) (P<0.001). Also wound breakdown (47 versus 20%) (P<0.001) and lymphedema (48 versus 12%) (P<0.0001) were more common in RV group than in MV group. Lymphocysts were found in 7%, and showed no association with wound infection or type of operation. The mean hospital stay was 26 days in patients with wound infection and 12 days in patients without infection, 31 days in RV group and 12 days in MV group, respectively.

CONCLUSIONS

Wound infections are major determinants for both acute and late complications. Postoperative complications reduce with increasing use of modified vulvectomies.

Squamous vulvar cancer: a clinically based individualization of treatment

OBJECTIVE

The aim of the study was to evaluate treatment results in 211 patients with previously untreated squamous cell vulvar cancer who were primary managed by surgery at the Gynecologic Oncology Unit of Alexandra Hospital, in terms of en bloc radical vulvectomy (N = 105), modified radical vulvectomy with three different incisions technique (N = 60), and radical hemivulvectomy (N = 46) with inguinofemoral lymphadenectomy.

METHODS

The surgical stage of disease, nodal status, lesion location and focality, marginal status, tumor size, physical and performance status, surgical modality used, and finally complications and recurrence rates were the analyzed factors for both survival and disease remission.

RESULTS

The overall 5-year survival was 70.1%. The 5-year survival for node-positive patients was 53.8% versus 79.7% for node-negative patients. Unifocal lesions had a 5-year survival of 76% compared with 50% of multifocal lesions. Posterolateral lesions had a better 5-year survival than that of anterior central lesions (79.5% vs 54. 4%). The marginal status of the surgical specimen was a significant predictor of both survival and recurrence. There was a significant difference in complications related to the en bloc radical vulvectomy in terms of wound breakdown, infection, and wound cellulitis.

CONCLUSIONS

Modified radical procedures are equally effective with the en bloc radical vulvectomy for the management of early (stage I/II) vulvar cancer. In advanced disease concervative surgery in an individualized approach could also effectively be applied.

Inguinal node status by ultrasound in vulva cancer

OBJECTIVE

The objective of this study was to determine the value of ultrasound in preoperative assessment of groin node status in vulva cancer.

MATERIALS AND METHODS

Women with clinically uninvolved groins who were undergoing groin node dissection for vulva cancer in our department over an 18-month period were recruited into the study. A preoperative scan of each groin to be dissected was performed to identify any suspicious lymph nodes containing metastases. Suspicious nodes were defined by two sonographic criteria: short axis diameter (>8 mm) and a long axis/short axis ratio (L/S </= 2). Each suspicious node was sampled by ultrasound-guided fine-needle aspiration (FNA).

RESULTS

Twenty women, with an average age of 70 years, consented to the study. Seventeen had bilateral groin node dissection and three had unilateral groin node dissection. Six (16%) of the seventeen dissected groins contained metastases. Short axis had a better overall accuracy (89%) but failed to detect a singular micrometastasis. The L/S ratio identified all positive groins but had a high false-positive rate (62%) and an overall accuracy of 67%. The combination of both criteria did not improve the overall accuracy when compared with the individual criterion. FNA was not diagnostic in three, representative in two, and falsely negative in one.

CONCLUSION

Although L/S ratio has a lower overall accuracy, it correctly identified all groins with metastases. This has a great impact on treatment and prognosis. Its high false-positive rate may be improved by more diagnostic FNA. These sonographic criteria show good potential for segregating those with groin metastases requiring surgical treatment from those with uninvolved nodes. This experience has to be expanded to prove its clinical effectiveness.

V--Y flap for perineal reconstruction following modified approach to vulvectomy in vulvar cancer

OBJECTIVE

To evaluate a simple reconstructive procedure used in combination with a modified oncological approach to the treatment of invasive vulvar cancer. Local and systemic morbidity, length of hospital stay, local recurrence, and mortality were evaluated.

METHODS

Between September 1995 and January 1997, 19 patients underwent radical vulvectomy and inguinal lymphadenectomy with a modified oncological approach. The modified approach consisted of a triple incision: two inguinal incisions, shorter and following force lines of the groin, and a third incision around the vulvar lesion. Vulvectomy included a 2-cm safety margin around the tumor, based on clinical examination and anatomical-pathological frozen sections of the specimen. This procedure was always followed by perineal reconstruction with V-Y flaps by the plastic surgery team. Median follow-up was 12 months. The complication rate and lengths of hospital stay were evaluated and compared with those in a similar group in which radical vulvectomy was performed associated with two long longitudinal incisions in the groin. The data were statistically analyzed.

RESULTS

The perineal and inguinal dehiscence rates in group A (traditional approach) were 68.4% and 78.94%, respectively. The same rates in group B (modified approach), were 10.5% and 36.84%, respectively. Mean hospital stay was 39.5 days in group A (traditional) vs. 14.0 days in group B (modified). At 30 months' median follow-up, the rate of local recurrence in group A (traditional) was 42.0%; at 12 months' median follow-up, local recurrence in group B (modified) was 26.3%.

CONCLUSIONS

In this study, the use of V-Y flaps in combination with a modified oncological approach significantly reduced local complication rates and lengths of hospital stay, while observing oncological principles.

Posterior exenteration through groin incision in a patient with stage III vulvar carcinoma

During performance of bilateral groin incisions, an abdominal incision and a colostomy has the potential risks of devascularization of the lower abdominal wall and infection. A patient with locally advanced vulvar carcinoma requiring a posterior exenteration is presented. The posterior exenteration was performed by developing an abdominal skin flap from the groin incisions. This approach offers adequate exposure and a unique solution to the potential problems associated with combining an abdominal skin incision with bilateral groin incisions and end-descending sigmoid colostomy. In addition, this approach may be cosmetically more acceptable.