Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery

Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction-A Systematic Review and Meta-Analysis

BACKGROUND

Patients with advanced vulvoperineal cancer require a multidisciplinary treatment approach to ensure oncological safety, timely recovery, and the highest possible quality of life (QoL). Reconstructions in this region often lead to complications, affecting approximately 30% of patients. Flap design has evolved towards perforator-based approaches to reduce functional deficits and (donor site) complications, since they allow for the preservation of relevant anatomical structures. Next to their greater surgical challenge in elevation, their superiority over non-perforator-based approaches is still debated.

METHODS

To compare outcomes between perforator and non-perforator flaps in female vulvoperineal reconstruction, we conducted a systematic review of English-language studies published after 1980, including randomized controlled trials, cohort studies, and case series. Data on demographics and surgical outcomes were extracted and classified using the Clavien-Dindo classification. We used a random-effects meta-analysis to derive a pooled estimate of complication frequency (%) in patients who received at least one perforator flap and in patients who received non-perforator flaps.

RESULTS

Among 2576 screened studies, 49 met our inclusion criteria, encompassing 1840 patients. The overall short-term surgical complication rate was comparable in patients receiving a perforator (n = 276) or a non-perforator flap (n = 1564) reconstruction (p* > 0.05). There was a tendency towards fewer complications when using perforator flaps. The assessment of patients' QoL was scarce.

CONCLUSIONS

Vulvoperineal reconstruction using perforator flaps shows promising results compared with non-perforator flaps. There is a need for the assessment of its long-term outcomes and for a systematic evaluation of patient QoL to further demonstrate its benefit for affected patients.

A systematic review of female sexual function after surgery for locally advanced or recurrent colorectal cancer - first step to filling the knowledge gap

AIM

Locally advanced and recurrent colorectal cancer can require extended surgery, including reconstruction of the vagina. This complex surgery carries high morbidity. The aim of this study was to analyse the impact on female sexual functioning of pelvic exenteration (PE), with or without vaginal flap reconstruction, for locally advanced or recurrent colorectal cancer.

METHOD

The protocol with search strategies for PubMed (Medline), EMBASE and the Cochrane Library was registered in PROSPERO. Studies published from 2000 onwards meeting the inclusion criteria were considered. Study selection (Rayyan), data extraction, rating of evidence (GRADE) and risk of bias (ROBINS-I) were conducted independently by two reviewers.

RESULTS

Six of 2479 identified records were included: four retrospective and two cross-sectional studies. Of all 860 patients included, PE was performed in 314 patients. Seven hundred and thirty-two had rectal cancer (85.1%), 80 nonadvanced rectal cancer (10.9%), 393 locally advanced rectal cancer (53.7%) and 217 locally recurrent rectal cancer (29.6%); for 45 patients the type of rectal cancer remained unspecified (6.1%). Three studies reported on both preoperative and postoperative female sexual activity. Of the 153 women who were sexually active preoperatively, 64 (41.8%) reported postoperative sexual activity. The VRAM flap was used the most frequently and resulted in a sexual activity ratio of 18% postoperatively. Four studies, using six different validated questionnaires, reported mostly lowered sexual functioning postoperatively.

CONCLUSION

Most studies showed that PE can result in severe sexual dysfunction despite reconstruction. Future prospective studies can fill the current knowledge gap by assessing long-term sexual outcomes in women.

European Society of Gynaecological Oncology Guidelines for the Management of Patients with Vulvar Cancer - Update 2023

BACKGROUND

As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) first published in 2017 evidence-based guidelines for the management of patients with vulvar cancer.

OBJECTIVE

To update the ESGO guidelines based on the new evidence addressing the management of vulvar cancer and to cover new topics in order to provide comprehensive guidelines on all relevant issues of diagnosis and treatment of vulvar cancer.

METHODS

The ESGO Council nominated an international development group comprised of practicing clinicians who provide care to vulvar cancer patients and have demonstrated leadership through their expertize in clinical care and research, national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (18 experts across Europe). To ensure that the statements were evidence-based, new data identified from a systematic search were reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 206 international practitioners in cancer care delivery and patient representatives.

RESULTS

The updated guidelines cover comprehensively diagnosis and referral, staging, pathology, pre-operative investigations, surgical management (local treatment, groin treatment, sentinel lymph node procedure, reconstructive surgery), (chemo)radiotherapy, systemic treatment, treatment of recurrent disease (vulvar, inguinal, pelvic, and distant recurrences), and follow-up. Management algorithms are also defined.

Secondary post-oncologic vulvar reconstruction - a simplified algorithm

Introduction

Surgical treatment is the gold standard of care for vulvar cancer and is burdened by a high risk of wound complications due to the poor healing typical of the female genital area. Moreover, this malignancy has a high risk of local relapse even after wide excision. For these reasons, secondary reconstruction of the vulvoperineal area is a relevant and challenging scenario for gynecologists and plastic surgeons. The presence of tissue already operated on and undermined, scars, incisions, the possibility of previous radiation therapy, contamination of urinary and fecal pathogens in the dehiscent wound or ulcerated tumor, and the unavailability of some flaps employed during the primary procedure are typical complexities of this surgery. Due to the rarity of this tumor, a rational approach to secondary reconstruction has never been proposed in the literature.

Methods

In this observational retrospective study, we reviewed the clinical data of patients affected by vulvar cancer who underwent secondary reconstruction of the vulvoperineal area in our hospital between 2013 and 2023. Oncological, reconstructive, demographic, and complication data were recorded. The primary outcome measure was the incidence of wound complications. The secondary outcome measure was the indication of the different flaps, according to the defect, to establish an algorithm for decision-making.

Results

Sixty-six patients were included; mean age was 71.3 ± 9.4 years, and the mean BMI was 25.1 ± 4.9. The mean size of the defect repaired by secondary vulvar reconstruction was 178 cm² ± 163 cm². Vertical rectus abdominis myocutaneous (VRAM), anterolateral thigh (ALT), fasciocutaneous V-Y (VY), and deep inferior epigastric perforator (DIEP) were the flaps more frequently employed. We observed five cases of wound breakdown, one case of marginal necrosis of an ALT flap, and three cases of wound infection. The algorithm we developed considered the geometry and size of the defect and the flaps still available after previous surgery.

Discussion

A systematic approach to secondary vulvar reconstruction can provide good surgical results with a low rate of complications. The geometry of the defect and the use of both traditional and perforator flaps should guide the choice of the reconstructive technique.

Reconstruction of Acquired Defects of the External Genitalia: A 24-Patient, Single-Institution Experience

PURPOSE

Patients undergoing resection of the external genitalia are often faced with significant deformity and decreased quality of life. Plastic surgeons are tasked with the challenge of reconstructing these defects to minimize morbidity and increase patients' quality of life. The authors have set out to investigate the efficacy of local fasciocutaneous and pedicled perforator flaps in external genital reconstruction.

METHODS

A retrospective review was conducted of all patients undergoing reconstruction of acquired defects of the external genitalia from 2017 to 2021. In total, 24 patients met inclusion criteria for the study. Patients were allocated into 2 cohorts: patients with defects reconstructed using local fasciocutaneous flaps (FF) versus patients with defects reconstructed using pedicled islandized perforator flaps (PF). Comorbid conditions, ablative procedures, operative times, flap size, and complications were compared across all groups. Fisher exact test was used to analyze differences in comorbidities, while independent t tests were used to analyze age, body mass index, operative time, and flap size. Significance was set at P < 0.05.

RESULTS

Of the 24 patients included in the study, 6 underwent reconstruction with islandized PFs (either profunda artery perforator or anterolateral thigh), and 18 underwent reconstruction with FFs. The most common indication for reconstruction was vulvectomy for vulvar cancer, followed by radical debridement for infection, and lastly penectomy for penile cancer. The PF cohort had a significantly higher percentage of previously irradiated patients (50% vs 11.1%, P = 0.019). Although mean flap size was larger in the PF cohort, this difference did not reach statistical significance (176 vs 143.4 cm2, P = 0.5). Perforator flaps had significantly longer operative times when compared with FFs (237.33 vs 128.99 minutes, P = 0.003). Average length of stay was 6.88 days in FF and 5.33 days in PF (P = 0.624). Complication profile including flap necrosis, wound healing delays, and infection were similar between groups despite a significantly higher rate of prior radiation in the PF cohort.

CONCLUSIONS

Our data suggest that PFs such as profunda artery perforator and anterolateral thigh flaps are associated with longer operative times but may offer a suitable option for reconstruction of acquired defects of the external genital compared with local FFs, especially in the setting of prior radiation.

Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Reconstructive Surgery versus Primary Closure following Vulvar Cancer Excision: A Wide Single-Center Experience

Simple Summary

When it comes to advanced vulval cancer management, there is a critical quandary to consider. This is owing to the severe negative impact of demolitive surgery on women who are afflicted by both functional and psychological consequences of the procedure. Primary closure of vulvar and/or perineal defects can be accomplished without difficulty in many situations, but this is accompanied by tension of the skin closure and distortion of the anatomy. In these circumstances, reconstructive surgery will be required to restore the anatomical and functional characteristics of the vulva. In this paper, we share our substantial expertise of primary closure versus reconstruction after demolitive surgery of advanced vulvar cancer, and we discuss our findings in light of the literature.

Abstract

(1) Background: plastic reconstruction in vulvar surgery can lead to a better treatment outcome than primary closure. This study aims to compare the preoperative parameters (co-morbidities and tumor size) and postoperative results (tumor free margins and wound healing) between the primary closure and reconstructive surgery after vulvar cancer surgery; (2) Methods: this is a retrospective analysis of prospectively collected data from 2009 to 2021 at a tertiary cancer institution; (3) Results: 177 patients were included in the final analysis (51 patients had primary closure PC and 126 had reconstructive surgery RS). About half (49%) of the PC patients had no co-morbidities (p = 0.043). The RS group had a 45 mm median maximal tumor diameter compared to the PC group’s 23 mm (p = 0.013). More than 90% of RS and 80% of PC had tumor-free margins (p = 0.1). Both groups had anterior vulvar excision as the most common surgery (52.4% RS vs. 23.5% PC; p = 0.001). Both groups had identical rates of wound healing disorders. In a median follow-up of 39 months; recurrent disease was found in 23.5% of PC vs. 10.3% in RS (p = 0.012). In terms of overall survival there was no significant difference between the both groups; (4) Conclusions: reconstructive vulvar surgery enables enhanced complete resection rates of larger vulvar tumors with better anatomical restoration and a comparable wound recovery in comparison to primary closure. This results in a lower recurrence rate despite the increased tumor volume.

Lymphatic Function of the Lower Limb after Groin Dissection for Vulvar Cancer and Reconstruction with Lymphatic SCIP Flap

Inguinofemoral lymphadenectomy, frequently performed for vulvar cancer, is burdened with substantial immediate and long-term morbidity. One of the most disabling treatment-related sequelae is lower limb lymphedema (LLL). The present study aims to describe the wound complications and the severity of LLL in patients who have undergone groin dissection for vulvar cancer and immediate inguinal reconstruction with the Lymphatic Superficial Circumflex Iliac Perforator flap (L-SCIP). We retrospectively reviewed the data of patients who underwent bilateral groin dissection and unilateral inguinal reconstruction with the L-SCIP. The presence and severity of postoperative LLL during the follow-up period were assessed by lymphoscintigraphy and limbs' volume measurement. In addition, immediate complications at the level of the inguinal area were registered. The changes between preoperative and postoperative limb volumes were analyzed by Student's t test. p values < 0.05 were considered significant. Thirty-one patients were included. The mean variation of volume was 479 ± 330 cc3 in the side where groin reconstruction had been performed, and 683 ± 425 cc3 in the contralateral side, showing smaller variation in the treated side (p = 0.022). Lymphoscintigraphy confirmed the clinical findings. Based on our results, inguinal reconstruction with L-SCIP performed at the same time of groin dissection in patients treated for vulvar cancer can provide a significant protective effect on LLL.

Building a Personalized Medicine Infrastructure for Gynecological Oncology Patients in a High-Volume Hospital

Gynecological cancers require complex intervention since patients have specific needs to be addressed. Centralization to high-volume centers improves the oncological outcomes of patients with gynecological cancers. Research in gynecological oncology is increasing thanks to modern technologies, from the comprehensive molecular characterization of tumors and individual pathophenotypes. Ongoing studies are focusing on personalizing therapies by integrating information across genomics, proteomics, and metabolomics with the genetic makeup and immune system of the patient. Hence, several challenges must be faced to provide holistic benefit to the patient. Personalized approaches should also recognize the unmet needs of each patient to successfully deliver the promise of personalized care, in a multidisciplinary effort. This may provide the greatest opportunity to improve patients' outcomes. Starting from a narrative review on gynecological oncology patients' needs, this article focuses on the experience of building a research and care infrastructure for personalized patient management.

The Vulvar Immunohistochemical Panel (VIP) Project: Molecular Profiles of Vulvar Squamous Cell Carcinoma

Simple Summary

This study investigated the immunohistochemical expression of 14 biological markers as potential prognostic/therapeutic factors in vulvar squamous cell carcinoma, comparing 53 node-negative (Group A) and 48 node-positive (Group B) patients. Our results show a significantly higher p16 expression (surrogate of HPV-related tumors) in the vulvar samples of non-metastatic patients. In Group B, PD-L1 positivity and high EGFR expression were found in the vast majority of vulvar and/or nodal specimens. VEGF showed strong/moderate-diffuse expression in almost 14% of all vulvar samples. A mutated p53 and over-expressed PD-L1 showed a significant association with nodal metastasis. Our results support a potential role of immune checkpoint inhibitors and anti-VEGF and anti-EGFR drugs, especially in patients with worse prognosis (metastatic, HPV-independent). A panel including EGFR, VEGF, PDL1, p16, and p53 might be performed routinely in primary tumor and repeated in case of lymph node metastases to identify changes in marker expression.

Abstract

Introduction: The study’s aim was to investigate the immunohistochemical (IHC) expression of biological markers as potential prognostic/therapeutic factors in vulvar squamous cell carcinoma (VSCC). Methodology: A series of 101 patients surgically treated at our center from 2016 to 2020 were retrospectively enrolled: 53 node-negative (Group A) and 48 node-positive (Group B). A total of 146 samples, 101 from primary tumor (T) and 45 from nodal metastases (N), were investigated. The IHC panel included: p16, p53, MLH1, MSH2, MSH6, PMS2, PD-L1, CD3, HER2/neu, ER, PR, EGFR, VEGF, and CD31. The reactions were evaluated on qualitative and semi-quantitative scales. Generalized Linear Model (GLM) and cluster analysis were performed in R statistical environment. A distance plot compared the IHC panel of T with the correspondent N. Results: In Group A: p16-positive expression (surrogate of HPV-dependent pathway) was significantly higher (20.8% vs. 6.2%, p = 0.04). In Group B: PD-L1 positivity and high EGFR expression were found, respectively, in 77.1% and 97.9% patients (T and/or N). Overall, p16-negative tumors showed a higher PD-L1 expression (60.9% vs. 50.0%). In both groups: tumoral immune infiltration (CD3 expression) was mainly moderate/intense (80% vs. 95%); VEGF showed strong/moderate-diffuse expression in 13.9% of T samples; CD31, related to tumoral microvessel density (MVD), showed no difference between groups; a mutated p53 and over-expressed PD-L1 showed significant association with nodal metastasis, with Odds Ratios (OR) of 4.26 (CI 95% = 1.14–15.87, p = 0.03) and 2.68 (CI 95% = 1.0–7.19, p < 0.05), respectively; since all mismatch repair proteins (MMR) showed a retained expression and ER, PR, and HER2/neu were negative, they were excluded from further analysis. The cluster analysis identified three and four sub-groups of molecular profiles, respectively, in Group A and B, with no difference in prognosis. The molecular signature of each N and corresponding T diverged significantly in 18/41 (43.9%) cases. Conclusions: Our results support a potential role of immune checkpoint inhibitors and anti-VEGF and anti-EGFR drugs especially in patients with worse prognosis (metastatic, HPV-independent). A panel including EGFR, VEGF, PDL1, p16, and p53 might be performed routinely in primary tumor and repeated in case of lymph node metastases to identify changes in marker expression.

Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice

Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.

Individually Tailored Approach to Reconstruction of Complex Defects Using Versatility of the Lateral Circumflex Femoral Artery System-Based Pedicled Flaps

Lateral circumflex femoral artery (LCFA) system is one of the most versatile donor sites in the body. We present our experience with pedicled flaps from the LCFA system, including different components for a wide variety of etiologies and locations. Twenty-three consecutive pedicled flaps were performed on 22 patients (10 females and 12 males; age 4-71 years) between 2007 and 2015 by a single surgeon. Flap size, type, and composition were tailored according to the requirements of the defects, including (1) location; (2) surface area; (3) depth; (4) number of defects; (5) presence of exposed critical structures; (6) presence of exposed foreign bodies; (7) prior use of other options; (8) history of radiation; and (9) other comorbidities. Defect locations were 10 abdominal wall (including groin and pubis), 9 ischio-gluteo-trochanteric and 4 perineal. Defect sizes ranged from 6 × 6 to 30 × 35 cm. Maximum depth of wounds ranged between 7 and 18 cm. The flap sizes ranged from 9 × 6 to 38 × 20 cm. Two flaps were fasciocutaneous perforator, 4 were myocutaneous with "muscle sparing" vastus lateralis, 10 were myocutaneous with "segmental" vastus lateralis, 5 were myocutaneous "tri-muscle," 1 was "tri-muscle," and 1 was rectus femoris only. Donor sites were closed primarily in 20 cases and with split thickness skin grafting in 3 cases. All flaps survived completely without any partial loss or congestion. Pedicled flaps from the LCFA system can be tailored individually for a wide variety of etiologies and locations. Muscles can be harvested and used as "muscle sparing," "segmental," and "tri-muscle" to accommodate the requirements of the defects.

The role of brachytherapy (interventional radiotherapy) for primary and/or recurrent vulvar cancer: a Gemelli Vul.Can multidisciplinary team systematic review

OBJECTIVE

The aim of our systematic review was to assess the role of interventional radiotherapy (IRT, brachytherapy) in the management of primary and/or recurrent vulvar carcinoma.

EVIDENCE ACQUISITION

A systematic research using PubMed, Scopus and Cochrane library was performed. ClinicalTrials.gov was searched for ongoing or recently completed trials, and PROSPERO was searched for ongoing or recently completed systematic reviews. Only full-text English-language articles related to IRT for treatment of primary or recurrent VC were identified and reviewed. Conference paper, survey, letter, editorial, book chapter and review were excluded. Time restriction (1990-2018) as concerns the years of the publication was considered.

EVIDENCE SYNTHESIS

Primary disease: the median 5-year LC was 43.5% (range 19-68%); the median 5-year DFS was 44.5% (range 44-81%); the median 5-year OS was 50.5% (range 27-85%). Recurrent disease: the median 5-year DFS was 64% (range 56-72%) and the median 5-year OS was 45% (range 33%-57%). Acute ≥ grade 2 toxicity was reported in three patients (1.6%). The severe late toxicity rates (grade 3-4) ranged from 0% to 14.3% (median 7.7%).

CONCLUSION

IRT as part of primary treatment for primary and/or recurrent vulvar cancer is associated with promising clinical outcomes.

Abdominal, perineal, and genital soft tissue reconstruction with pedicled anterolateral thigh perforator flaps

Background

Pedicled perforator flaps have become a contemporary alternative to muscle flaps for soft tissue reconstruction as they have reduced donor site morbidity, avoid the need for microsurgical transfer, and are versatile and reliable. The anterolateral thigh (ALT) flap was first introduced as a free flap and has since gained popularity as a pedicled flap. Here we review our experience using pedicled ALT flaps for regional soft tissue reconstruction.

Methods

We retrospectively reviewed all patients who underwent loco-regional soft tissue reconstruction using pedicled ALT flaps between March 2014 and October 2018, with the goal of identifying potential applications of pedicled ALT flaps. The following aspects of each case were reviewed: patient demographics, defect location and size, comorbidities such as previous radiotherapy, flap details, clinical follow-up, and postoperative complications.

Results

Our analysis demonstrates the versatility of pedicled ALT flaps in a variety of indications to successfully cover large abdominal, perineal, and genital soft tissue defects. Depending on the patient’s needs to achieve more bulk or stability in the reconstruction, the ALT flap was individually tailored with underlying muscle or fascia. The average follow-up was 7 months (range: 3–13 months).

Conclusions

Pedicled ALT flaps are a valuable reconstructive option for soft tissue defects located within the pedicle’s range, from the lower abdomen to the perianal region. These flaps are usually raised from a non-irradiated donor site and are sufficient for covering extensive soft tissue defects. Three-dimensional reconstruction of the defect using pedicled ALT flaps allows for anatomical function and minor donor sites.

Level of evidence: Level IV, therapeutic study.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

BACKGROUND

 Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications.

METHODS

 A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed.

RESULTS

 Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm². The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications.

CONCLUSION

 In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Safety and feasibility of single-incision radical vulvectomy: a novel approach for the treatment of vulvar cancer

Background

In the process of decreasing the morbidity of wound-related complications after vulvectomy and IL for treating vulvar malignancy, we performed a novel surgical procedure—single-incision radical vulvectomy (SIRV). Here, we share our initial experience and report its safety and feasibility.

Methods

Patients with advanced local vulvar tumors were sequentially enrolled in this prospective cohort study to undergo SIRV. While performing SIRV, routine radical vulvectomies were performed first. Subsequently, the flaps of the bridge area between the vulvectomy incisions and femoral triangles were separated and the lymph nodes underneath were removed. Anterior working spaces (AWS) before the femoral triangle were then made. The saphenous vein was carefully identified and retained, while the superficial and deep inguinal lymph nodes were removed from the medial to the lateral sides. After careful hemostasis, the wounds were sutured. Patient demographics, clinical data, pathologic data, operation time, node count, and complications were recorded.

Results

Ten patients underwent SIRV for vulvar cancer. Average hospital stay was 11.70±3.16 (range, 9–13) days. The average number of harvested lymph nodes was 7.59±3.62 (range, 3–15) and 15.14±3.63 (range, 11–20) for per side or both sides of the groin. Blood loss was ≤35 mL. Three patients developed inguinal lymphoceles and underwent needle aspirations. Two patients had impaired wound healing and achieved healing after dressing change. No other postoperative complications were noted during follow-up.

Conclusions

Compared with conventional open inguinal lymphadenectomy (COIL) and video endoscopic inguinal lymphadenectomy (VEIL), SIRV is a more minimally invasive procedure. Our short-term observations showed that SIRV is safe and feasible and has good future application prospects for vulvar cancer. However, definitive conclusions cannot be made. Therefore, long-term oncologic outcomes and large-scale clinical trials are warranted.

Personalizing vulvar cancer workflow in COVID-19 era: a proposal from Vul.Can MDT

INTRODUCTION

Since the community spread of Coronavirus disease 2019 (COVID-19), the practice of oncologic care at our comprehensive cancer center has changed. Postponing cancer treatment without consideration of its implications could cost more lives than can be saved. In this special situation, we must continue to provide our cancer patients with the highest quality of medical services assuring the safety. This article provides general guidance on supporting curative treatment strategies in vulvar cancer patients.

METHODS

At our institution, a vulvar cancer multidisciplinary team (Vul.Can MDT) of specialists is responsible for personalized treatment of this disease. The phase 2 period necessarily requires specific procedures for both outpatient and inpatient pathways and to provide strategies concerning the management of vulvar cancer patients even in case of an eventually concomitant SARS-CoV-2 infection. In brief, an accurate remote and in person triage must be provided routinely and patients submitted to specific diagnostic tests prior to every major treatment or procedure (surgery, RT, and CT) or in case of suspicion for COVID-19 syndrome. The decisional workflow for these women often old and frail, have been rapidly adjusted by our Vul.Can MDT to mitigate the potential risks of COVID-19.

RESULTS

The team produced two types of recommendations concerning: (1) safety regulations of care pathways, patients and health care providers, (2) personalized treatment strategies. We present a protocol that can be applied in clinical practice: the flowcharts provided, include the modulation of treatment intensity designed for surgical procedures and radiation, stratified for FIGO stage of disease and intention.

CONCLUSION

We suggest that our proposals are applicable in this setting of patients, considering anyway current international recommendations and guidelines.

Versatility of the pedicled anterolateral thigh flap for surgical reconstruction, a case series

Background

The pedicled anterolateral thigh flap is a versatile flap that offers many advantages. These include a long and reliable pedicle that enables a wide arch of rotation, the possibility to harvest a large skin area, raising the flap with underlying fascia and muscle and minimal donor site morbidity.

Methods

From 2009 to 2018 nine patients were reconstructed with a pedicled anterolateral thigh flap. The flap was applied for coverage of knee infections, trochanteric defects, an abdominal defect, a gluteal defect, and a defect of the inguinal region. The patient group consisted of five males and four females. The age range was 30–90 years with a mean age of 61 years.

Results

Flap size ranged from 10 x 5 cm (50 cm²) to 15 x 30 cm (450 cm²) with a mean size of 222 cm². We experienced no flap loss. The donor site was closed directly in seven out of nine patients, and the remaining two patients were closed by split-thickness skin grafting. Satisfactory aesthetic and functional outcome was achieved in all patients.

Conclusion

Our experience illustrates the versatility in the clinical application of the pedicled anterolateral thigh flap. The many advantages of the flap, such as the long and reliable pedicle, a large area of skin that can be harvested, the potential to supercharge the flap and the minimal donor site morbidity highlights the diversity of defects that can be reconstructed using this flap.

Palliative electrochemotherapy in primary or recurrent vulvar cancer

OBJECTIVE

Since vulvar cancer is such a rare disease, the international experience with electrochemotherapy has been derived from only a few centers. The aim of this study was to evaluate clinical outcome and side effects profile with the use of electrochemotherapy in patients with primary or recurrent vulvar cancer.

METHODS

Data were retrospectively collected from November 2017 to November 2019 in two major Italian oncologic institutes: Regina Elena Institute and Fondazione Policlinico Universitario Agostino Gemelli IRCCS. Electrochemotherapy was offered in a palliative setting to patients with a primary or recurrent vulvar cancer who were not candidates for surgery or any other treatment, because of poor performance status or previous delivered treatments. All patients underwent general anesthesia. Electrical pulses were delivered using a pulse generator. Intravenous bleomycin was administered in conjunction with electrochemotherapy. Follow-up examinations were performed at 1, 3, and 6 months. Primary endpoint was to assess the response rate of electrochemotherapy as palliative treatment in patients with vulvar cancer.

RESULTS

A total of 15 patients were included in the study. Fourteen patients (93.3%) had a squamous cell carcinoma and one patient had vulvar carcinosarcoma. Ten patients (66.7 %) had a single lesion and 5 patients (33.3%) had multiple lesions. Median number of electrical pulses was 22 (range 3-42) and median operative time was 13 (range 7-20) min. No intra-procedure complications occurred. One patient had pneumonia during their post-operative stay. Overall response rate after 1 month was 80%. At the 3-month follow-up, 3 patients (20%) had disease progression, 3 patients (20%) had died from ongoing disease, 1 patient (6.7%) died for other reasons, whereas the other patients maintained their 1-month clinical response. A total of 8/13 patients (61.5%) were alive at 6-month follow-up, whereas 6/12 patients (50%) were alive at 1-year follow-up.

CONCLUSIONS

Electrochemotherapy is a feasible, easy to perform, and reproducible procedure in patients with primary or recurrent vulvar cancer who are unable to undergo surgery. Survival after 1 year in this population was 50%. Electrochemotherapy may have a role in the management of vulvar cancer, especially as palliative treatment when other therapies are no longer applicable.

Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature

Reconstruction following total vulvectomy is a reconstructive challenge. Previously described techniques typically require bilateral flaps and the associated donor site morbidity. We present a case of reconstruction after radical total vulvectomy using a single split anterolateral thigh (ALT) perforator flap with a design that optimizes perfusion while allowing for primary donor site closure. A 68-year-old female with a history of vulvar squamous cell carcinoma who had previously undergone vulvectomy and radiation therapy presented with local recurrence. The patient required a radical total vulvectomy, resulting in a 12 × 10 cm vulvar defect. A 2-perforator ALT flap (25 × 7 cm) was harvested, split transversely, and then inset in a circumferential manner around the vulva. This approach contrasts with previous reports, which split the ALT flap longitudinally or centrally, and can compromise perfusion and/or preclude primary donor site closure. The patient healed without complication with 6 months of follow-up. The described approach allows for total vulvectomy reconstruction using a single ALT flap with a perforator configuration that maximizes perfusion while obviating the need for donor site grafting.

Ultrasound morphometric and cytologic preoperative assessment of inguinal lymph-node status in women with vulvar cancer: MorphoNode study

OBJECTIVE

To assess the accuracy of preoperative ultrasound examination for predicting lymph-node (LN) status in patients with vulvar cancer.

METHODS

This was a single-institution retrospective observational study of all women with a histological diagnosis of vulvar cancer triaged to inguinal surgery within 30 days following ultrasound evaluation between December 2010 and January 2016. For each groin examined, 15 morphological and dimensional sonographic parameters associated with suspicion for LN involvement were examined. A morphometric ultrasound pattern (MUP) was expressed for each groin, classifying the inguinal LN status into five groups (normal; reactive-but-negative; minimally suspicious/probably negative; moderately suspicious; and highly suspicious/positive) according to subjective judgment, followed by stratification as positive or negative for metastasis according to morphometric binomial assessment (MBA). In cases of positive MBA, fine-needle aspiration cytology was performed. Combining the information obtained from MUP and cytologic results, a binomial final overall assessment (FOA) was assigned for each groin. The final histology was considered as the reference standard. Comparison was performed between patients with negative and those with positive LNs on histology, and receiver-operating-characteristics curves were generated for statistically significant variables on univariate analysis, to evaluate their diagnostic ability to predict negative LN status.

RESULTS

Of 144 patients included in the analysis, 87 had negative inguinal LNs and 57 had positive LNs on histology. A total of 256 groins were analyzed, of which 171 were negative and 85 showed at least one metastatic LN on histology. The following parameters showed the greatest accuracy, with the best balance between specificity and sensitivity, in predicting negative LN status: cortical (C) thickness of the dominant LN (cut-off, 2.5 mm; sensitivity, 90.0%; specificity, 77.9%); short-axis (S) length of the dominant LN (cut-off, 8.4 mm; sensitivity, 63.9%; specificity, 90.6%); C/medulla (M) thickness ratio of the dominant LN (cut-off, 1.2 mm; sensitivity, 70.4%; specificity, 91.5%), the combination of S length and C/M thickness ratio (sensitivity, 88.9%; specificity, 82.4%); and the FOA analysis (sensitivity, 85.9%; specificity, 84.2%).

CONCLUSIONS

Preoperative ultrasound assessment, with or without the addition of cytology, has a high accuracy in assessing inguinal LN status in patients with vulvar cancer. In particular, the combination of two ultrasound parameters (S length and C/M thickness ratio) provided the greatest accuracy in discriminating between negative and positive LNs. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Fusion of ultrasound and 3D single-photon-emission computed tomography/computed tomography to identify sentinel lymph nodes in vulvar cancer: feasibility study

OBJECTIVE

To evaluate the feasibility of fusion of ultrasound imaging and three-dimensional (3D) single-photon-emission computed tomography/computed tomography (SPECT/CT) in detecting sentinel lymph nodes in women with vulvar cancer.

METHODS

This was a prospective pilot single-center study. Patients with vulvar cancer who were candidates for sentinel lymph-node biopsy were enrolled between December 2018 and February 2019. Fusion imaging virtual navigation using 3D SPECT/CT and ultrasound was performed to investigate the tumor-draining lymph node. All clinical, imaging, surgical and histological information was collected prospectively and entered into a dedicated Excel file. Feasibility and success of fusion imaging virtual navigation and time needed to perform the three steps of fusion imaging were evaluated.

RESULTS

Ten lymph-node sites were evaluated in five consecutive women with a histological diagnosis of vulvar cancer. Fusion imaging virtual navigation was feasible and completed successfully for all (10/10) draining sites. Median overall time to perform fusion imaging was 32 (range, 25-40) min and the time decreased from the first to the last examination.

CONCLUSIONS

The present study demonstrated that fusion imaging virtual navigation using 3D SPECT/CT and ultrasound is feasible and able to detect sentinel lymph nodes in women with vulvar carcinoma. Fusion imaging using ultrasound for detection of sentinel lymph nodes opens up multiple diagnostic and therapeutic opportunities in gynecological oncology. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

SPECT/CT and fusion ultrasound to target the efferent groin lymph node for lymphatic surgery

INTRODUCTION

Pelvic lymphadenectomy (PL) causes changes to the inguinal lymph nodes with progressive loss of immune and lymphatic pump function. Efferent lymphatic vessel-to-venous anastomosis (ELVA) has been reported to address this problem. The aim of this report was to describe the feasibility of the SPECT/CT combined with ultrasound fusion imaging (UFI) to target the groin efferent lymph node (GELN) for ELVA.

PATIENTS AND METHODS

Twelve patients with lower limb lymphedema after PL were scheduled for peripheric lymphaticovenular anastomosis (LVA) combined with ELVA. All-patients were clinically ISL-stage1, with good visualization of the inguinal lymph nodes at preoperative lymphoscintigraphy. The mean patient age was 55.4 years and the mean BMI was 25.5.The mean limb circumference (MLC) was calculated before surgery and 1 year after surgery. The LymQoL-Leg questionnaire was administered before surgery and 6 months after surgery. Before surgery, the GELN was identified by SPECT/CT and its location was marked on the skin by UFI virtual navigation. Peripheric LVA sites were planned by ultrasound and indocyanine green (ICG) lymphography. Pre and postoperative MLC and LymQoL-Leg scores were compared.

RESULTS

In all-patients, the SPECT/CT succeeded at detecting and targeting the GELN. In all-patients, real-time anatomical coregistration with US was feasible, and it was possible to mark on the groin skin the depth and position of the GELN on the skin at the groin. During surgery, in every patient, we found the GELN marked before surgery and performed ELVA. We also performed two or three peripheric LVAs in every patient. The mean value of MLC decreased (38.2 ± 2.13 cm vs. 36.33 ± 2.14 cm; p = .04) and the mean score of the LymQoL-Leg questionnaire improved (9.3 ± 1.7 vs. 7.7 ± 1.1; p = .02).

CONCLUSION

SPECT/CT combined with UFI is feasible for the preoperative identification of GELN for ELVA.

Surgical treatment of vulvar cancer: Impact of tumor-free margin distance on recurrence and survival. A multicentre cohort analysis from the francogyn study group

OBJECTIVE

In vulvar cancer, it is admitted that tumor-free margin distance is one of the most important element for locoregional control. It is currently recommended to surgically remove the tumor with at least an 8 mm tumor-free margin. The aim of this study was to evaluate the impact of tumor-free margin distance on recurrence and survival in vulvar cancer.

MATERIAL AND METHODS

From 2005 to 2016, 112 patients surgically treated for a vulvar squamous cell cancer were included in a retrospective multicenter study. Overall, disease-free and metastasis-free survivals were analyzed according to tumor-free margin distance.

RESULTS

Patients were divided into three groups: group 1 (margin <3 mm, n = 47); group 2 (margin ≥3 mm to < 8 mm, n = 48) and group 3 (margin ≥8 mm, n = 17). During the study, 26,8% patients developed recurrence (n = 30) after a median of 8 months (1-69). Analysis of 5-year overall survival, as well as disease-free and metastasis-free survivals, did not reveal a difference between groups. We performed a subgroup analysis in patients with a tumor-free margin <8 mm (group 1 and 2). It showed that histological lesions observed closest to the edge of the specimen were more often invasive or in situ carcinoma lesions in group 1 than in group 2, in which VIN lesions were mainly observed at this location. After re-excision, no patients in group 1 and 50% (n = 2) patients in group 2 developed recurrence.

CONCLUSION

This study did not reveal a significant impact of tumor-free margin distance on recurrence and survival in vulvar cancer. Moreover, the benefit of re-excision seems stronger when tumor-free margins are positive or very close (<3 mm), cases in which invasive or in situ lesions are often present closest to the edge of the specimen.

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.

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.

Surgical therapy of vulvar cancer: how to choose the correct reconstruction?

Objective

To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.

Methods

We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.

Results

We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.

Conclusion

The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.