Complications and risk factors in vulvar cancer surgery – A population-based study

Influence of stage and age on survival of patients with vulvar cancer in Germany: a retrospective study

OBJECTIVES

To evaluate the 5-year survival rate of patients with vulvar cancer, taking into account prognostic factors (International Federation of Gynecology and Obstetrics (FIGO) stage and age) and the influence of lymph node involvement and tumour size as well as the correlation between FIGO stage and age at onset.

DESIGN

Retrospective cohort study.

SETTING

German cancer registries.

PARTICIPANTS

The study included 17 017 patients diagnosed with vulvar cancer between 2004 and 2014 with follow-up until 2017. Exclusion criteria were incomplete documentation, age<18 years and death certificate only.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was overall and relative survival according to FIGO stage and age and the distribution of FIGO stages by age group. Secondary outcomes analysed were tumour size and lymph node status as risk factors for mortality.

RESULTS

The median age at diagnosis was 70 years. The overall 5-year survival rate was 69.5% (95% CI: 68.7% to 70.3%). The 5-year relative survival rates ranged from 91.9% (95% CI: 90.5% to 93.3%) to 21.3% (95% CI: 15.6% to 27.0%) for FIGO I to FIGO IVB and from 89.2% (95% CI: 87.6% to 90.8%) to 68.0% (95% CI: 65.3% to 70.7%) for age groups <55 to >75 years. Younger patients were significantly more often diagnosed with a low FIGO stage (p<0.001). Lymph node status and tumour size were independent factors influencing survival (HR: 1.79 (95% CI: 1.73 to 1.84; p<0.001) and 1.88 (95% CI: 1.80 to 1.96); p<0.001, respectively). The median follow-up time was 57 months.

CONCLUSION

Notably, the steepest decline in survival occurred within the first 3 years after diagnosis. Patients with the highest FIGO stages and those in the oldest age group had the worst survival rates. Furthermore, patients in the oldest age group were more likely to be diagnosed at higher stages. Lymph node status and tumour size were additional independent prognostic factors for mortality.

Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study

OBJECTIVE

To assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer.

METHODS

This was a multicenter, retrospective, controlled study. Surgical outcomes and complication rates of women with invasive vulvar cancer who underwent radical surgery and vulvar reconstruction and those who underwent radical surgery without the reconstruction step were compared. Only patients who underwent bilateral or unilateral V-Y advancement fascio-cutaneous flaps were included in the reconstruction group. Univariate and multivariate logistic regression models were used to analyze predicting variables for their association with complication rates.

RESULTS

Overall, 361 patients were included: 190 (52%) underwent the reconstructive step after the excisional radical procedure and were compared with 171 (47.4%) who did not undergo the reconstructive step. At multivariate analysis, body mass index >30 kg/m2 (odds ratio (OR) 3.36, p=0.007) and diabetes (OR 2.62, p<0.022) were independently correlated with wound infection. Moreover, increasing age (OR 1.52, p=0.009), body mass index >30 kg/m2 (OR 3.21, p=0.002,) and International Federation of Gynecology and Obstetrics (FIGO) stages III-IV (OR 2.25, p=0.017) were independent predictors of wound dehiscence. A significant reduction in the incidence of postoperative wound complications among patients who underwent V-Y reconstructive flaps was demonstrated. This was correlated more significantly in women with lesions >4 cm.

CONCLUSIONS

The adoption of V-Y flaps in vulvar surgery was correlated with reduced surgical related complications, particularly in vulnerable patients involving large surgical defects following excisional radical procedures.

Postoperative venous thromboembolism risk in patients with vulvar carcinoma: An analysis of the National surgical Quality Improvement Program (NSQIP) database

Objectives

Due to low incidence of vulvar cancer (VC), incidence and predictors for development of venous thromboembolism (VTE) are poorly understood. We examined incidence and risk factors associated with VTE in patients undergoing surgery for VC.

Methods

We included patients who underwent surgery for VC from the National Surgical Quality Improvement Program database. VTE within the 30-day postoperative period was captured with Current Procedural Terminology codes. Baseline demographics and clinical characteristics were compared between patients with and without VTE. Univariable and multivariable-adjusted exact logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and VTE.

Results

We identified 1414 patients undergoing procedures for VC from the NSQIP database. Overall, 11 (0.8 %) patients developed VTE. Univariable predictors of VTE included surgery type [compared with simple vulvectomy: radical vulvectomy only (OR = 7.97, 95 % CI = 1.44, infinity) and radical vulvectomy plus unilateral IFN (OR = 15.98, 95 % CI = 2.70, infinity)], unplanned readmission (OR = 11.56, 95 % CI = 2.74, 46.38), deep surgical site infection (OR = 16.05, 95 % CI = 1.59-85.50), and preoperative thrombocytosis (OR = 6.53, 95 % CI = 0.00, 34.86). In a multivariable-adjusted model, longer operative time (≥72 min OR = 11.33, 95 % CI = 1.58-499.03) and preoperative functional status [compared with complete independence: total dependence (OR = 53.88, 95 % CI = 0.85, infinity) and partial dependence (OR = 53.88, 95 % CI = 0.85, infinity)] were associated with VTE.

Conclusion

In this cohort of patients with VC undergoing radical vulvectomy, VTE incidence was low. Surgery type, longer operative time, dependent functional status, and wound disruption were identified as risk factors. Our findings highlight opportunities for prophylactic intervention in certain patients.

Treatment of vulvar cancer recurrence with electrochemotherapy: a case-control study

BACKGROUND

Electrochemotherapy (ECT) is a combined treatment method based on electroporation and simultaneous chemotherapy. In cases where radiotherapy has previously been used, surgery is often the only treatment option for vulvar cancer recurrence with potential resection of clitoris, vagina, urethra or anal sphincter. The unique advantage of ECT is its selectivity for cancer cells while sparing the surrounding healthy tissue. The aim of the study was to compare the ECT treatment of vulvar cancer recurrence for non-palliative purposes with surgical treatment.

MATERIALS AND METHODS

Eleven patients with single vulvar cancer recurrence were treated with ECT and followed up for 12 months. As a control group, 15 patients with single vulvar cancer recurrence were treated with wide local excision. The following data were collected, analyzed and compared: Age, body mass index, comorbidities, histological type, location and size of vulvar cancer recurrence, treatment history, details of procedures and hospital stay.

RESULTS

The probability curves for local tumor control did not differ between the ECT group and the surgical group (p = 0.694). The mean hospital stay and the mean duration of procedure were statistically significantly shorter in the ECT group (p < 0.001). There were no statistically significant differences between the ECT and surgical groups in terms of mean body mass index, associated diseases, previous treatments, presence of lichen sclerosus, p16 status, gradus, anatomical site of the tumor, and type of anesthesia.

CONCLUSION

In this case-control study, treatment of vulvar cancer recurrence with ECT for non-palliative purposes was comparable to surgical treatment in terms of effectiveness. The results need to be confirmed in larger randomized trials.

Long-term outcomes of vulvar or vaginal cancer patients undergoing laparoendoscopic single-site inguinal lymphadenectomy

INTRODUCTION

Laparoendoscopic single-site inguinal lymphadenectomy (LESS-IL), a minimally invasive technique, has been reported in patients with vulvar or vaginal cancer regarding its safety and feasibility. However, the long-term outcomes, especially oncologic outcomes, are still lacking. We aimed to evaluate the long-term outcomes of LESS-IL to confirm its safety further.

PATIENTS AND METHODS

Data were prospectively collected from patients with vulvar or vaginal cancer who underwent LESS-IL at our institution between July 2018 and June 2021. The patients were followed up for at least 12 months. All procedures were performed according to treatment standards. Short- and long-term complications and oncologic outcomes were analysed.

RESULTS

A total of 16 patients undergoing 28 LESS-IL procedures were identified, amongst whom 4 underwent unilateral LESS-IL. The median numbers of excised groin lymph nodes were 9.0 (6.5-11.8) and 10.5 (8.3-12.0) in each left and right groin, respectively. Short-term complications occurred in 4 (25%) patients, including 18.7% lymphocele and 6.3% wound infection. Long-term complications regarding lower-limb lymphoedema appeared in 6 (37.5%) patients. Most short- and long-term complications were Clavien-Dindo 1 or 2, accounting for 90% of all post-operative issues. After a median follow-up of 27 (21.3-35.8) months, only 1 (6.3%) patient had isolated inguinal recurrence at 13 months postoperatively. No local or distant recurrence occurred.

CONCLUSION

Our results suggest that LESS-IL is associated with little incidence of complications and promising oncologic outcomes, further demonstrating the safety and feasibility of the LESS-IL technique in patients requiring IL.

Time to extend the indication for sentinel node biopsy in vulvar cancer? Results from a prospective nationwide Swedish study

OBJECTIVE

To assess detection rates and negative predictive values of sentinel node biopsy in vulvar squamous cell carcinoma with tumors ≥4 cm, multifocal tumors, and in locally recurrent disease.

METHODS

Between December 2019 and December 2022, patients with vulvar squamous cell carcinoma with tumors ≥4 cm (group 1), multifocal tumors (group 2), or a first local recurrence without or with previous groin treatment (groups 3 and 4, respectively) were included in a prospective, nationwide multicenter interventional pilot study. The participants underwent a sentinel node biopsy followed by inguinofemoral lymph node dissection. Detection rates, negative predictive values, the proportion of micrometastases, and isolated tumor cells were determined separately for each group.

RESULTS

In all, 64 women were included, 36 women in group 1 (56%), and 17 women in group 2 (27%). Due to the small number and heterogeneity of the 11 women in groups 3 and 4, they were excluded from further analyses. In groups 1 and 2, 25 women (47%) were diagnosed with node-positive disease, and in 16 women (64%) only in the sentinel nodes. The detection rates varied between 94.1-100% per patient and 84.1-85.3% per groin. No false-negative sentinel nodes were identified, giving a negative predictive value of 100% for group 1 (95% CI 91.2% to 100%) and for group 2 (95% CI 83.9% to 100%). Of the node-positive patients, 32% had micrometastasis or isolated tumor cells only. One third of the metastases were detected by ultrastaging. In 27% of the non-mapping groins, metastases were found in the lymphadenectomy specimen, and in 75% the metastases showed extranodal growth.

CONCLUSION

In this small cohort of patients, we provide further data that may widen the indication of the sentinel node technique to women with tumors ≥4 cm and multifocal tumors.

TRIAL REGISTRATION NUMBER

NCT04147780.

A study of recurrence, complication and survival rates in patients with early stage vulval cancer undergoing sentinel lymph node sampling: a single-centre experience

PURPOSE

Groin sentinel lymph node (SLN) identification and removal has become a standard of care for women with clinical early stage vulval cancer. There is evidence to support safe detection of the SLN with minimal morbidity. The purpose of this study is to report our experience of managing patients focusing on patient selection, adverse events, quality assurance of the procedure and any benefits and/or disadvantages to patients.

METHODS

This was a retrospective study of patients with clinical early stage vulval cancer in a cancer centre over 5 years. Notes and hospital data were reviewed including admissions to emergency departments. Statistical software was used for the statistical analysis and the Kaplan Meier survival curve was generated to present survival rates.

RESULTS

61 cases were analysed. A total of 156 nodes have been removed and positive nodes were identified in 14 cases. In total, 9 women (14.75%) had disease recurrence within 5 years from primary surgery. Overall, 4 patients (6.5%) developed groin recurrence. In 3 of these patients there was isolated groin recurrence (4.9%). The median length of admission was 3 days and 6 cases were managed as day cases.

CONCLUSIONS

Since the closure of the GROINNS-2 trial we have continued the procedure of SLN identification for women with clinical early stage vulval cancer. We have shown high level of adherence to our protocol and survival and complication rates comparable to other studies on the same field. There were a few patients managed as day-case which was of benefit to the patients.

Carcinoma vulva: Ten years experience in a teaching institution of North India

Introduction

Vulvar carcinoma is primarily a disease of post-menopausal women. Surgery is a primary treatment strategy. Chemotherapy and radiotherapy are a part of multimodal therapy. Presently, there is a shift towards neoadjuvant chemotherapy or radiotherapy so as to decrease the surgical morbidities.

Objective

To study the surgical outcome and prognostic factors in Ca vulva patients.

Methodology

A retrospective analysis of 19 vulvar cancer patients, surgically treated at a teaching institution of Punjab (2009-2019).

Results

Mean age of the patients was 60.95 years. Ulcerative swelling (89.5%) over labia majora (73.7%) was the main presenting symptom. Radical vulvectomy-bilateral IFLN dissection was performed in 74% patients, hemivulvectomy-unilateral IFLN dissection in 21% patients and wide local excision in one patient. Squamous cell carcinoma was detected in all, and one had verrucous carcinoma. Thirty-seven per cent patients had FIGO stage III disease, 31.5% - stage II and 31.5% - stage I. On HPE, 78.57% (11/14) patients had positive nodes and two had ECS. Only 5/9 (55.5%) cases could receive PORT. Seven patients defaulted follow-up. Two developed nodal metastasis, and seven women developed recurrence. One patient with regional recurrence faced demise during RT course. In 10/19 regular follow-up patients, four are alive and disease free, five patients are on palliative chemoradiation, and one is undergoing adjuvant radiotherapy for regional recurrence. Estimated 5-year overall survival is 83.33%.

Conclusion

Tumour stage, nodal positivity and nodal ECS were poor prognostic factors. Radical surgery-extensive groin node dissection causes significant morbidity; hence, studies evaluating the role of neoadjuvant treatment are needed so as to modify current treatment practices. HPV vaccination as a preventive measure and a thorough and extensive evaluation of patients with suspicious signs in vulvar disease is needed.

The modified 5-item frailty index is a predictor of post-operative complications in vulvar cancer: a National Surgical Quality Improvement Program (NSQIP) analysis

OBJECTIVE

To determine whether frailty is associated with post-operative complications following surgery for vulvar cancer.

METHODS

This retrospective study used a multi-institutional dataset from the National Surgical Quality Improvement Program (NSQIP) database (2014-2020) to analyze the relationship between frailty, procedure type, and post-operative complications. Frailty was determined using the modified frailty index-5 (mFI-5). Univariate and multivariable-adjusted logistic regression analyses were performed.

RESULTS

Of 886 women, 49.9% underwent radical vulvectomy alone, and 19.5% and 30.6% underwent concurrent unilateral or bilateral inguinofemoral lymphadenectomy, respectively; 24.5% had mFI ≥2 and were considered frail. Compared with non-frail women, those with an mFI ≥2 were more likely to have an unplanned readmission (12.9% vs 7.8%, p=0.02), wound disruption (8.3% vs 4.2%, p=0.02), and deep surgical site infection (3.7% vs 1.4%, p=0.04). On multivariable-adjusted models, frailty was a significant predictor for minor (OR 1.58, 95% CI 1.09 to 2.30) and any complications (OR 1.46, 95% CI 1.02 to 2.08). Specifically, for radical vulvectomy with bilateral inguinofemoral lymphadenectomy, frailty was significantly associated with major (OR 2.13, 95% CI 1.03 to 4.40) and any complications (OR 2.10, 95% CI 1.14 to 3.87).

CONCLUSION

In this analysis of the NSQIP database, nearly 25% of women undergoing radical vulvectomy were considered frail. Frailty was associated with increased post-operative complications, especially in women concurrently undergoing bilateral inguinofemoral lymphadenectomy. Frailty screening prior to radical vulvectomy may assist in patient counseling and improve post-operative outcomes.

Human amniotic membrane for myocutaneous dehiscence after a radical surgical treatment of vulvar cancer: A case report

Background

The application of the amniotic membrane could have a favourable effect on tissue repair and regeneration. We report the first case of implant of an amniotic membrane in a patient affected by myo-cutaneous dehiscence, after a radical surgical treatment for vulvar cancer.

Methods

We describe a case of a 74-years-old patient affected by vulvar cancer. After radiotherapy, the patient underwent to an anterior pelvic exenteration with uretero-ileo-cutaneostomy by Wallace, bilateral pelvic lymphadenectomy, omental biopsies, omental flap, bilateral inguinal lymphadenectomy, resection of ulcerated left inguinal lesion, reconstruction with left gracilis muscle flap and locoregional V-Y advancement flap. The patient developed a myo-cutaneous dehiscence. Two months after the surgery, following an accurate curettage of the wound and negative pressure therapy, a patch of human amniotic membrane was implanted.

Results

The surgical procedure was easy, feasible and did not require long operating room times. No intraoperative or postoperative complications occurred. The results obtained were encouraging with a marked improvement in the surgical wound.

Conclusion

the use of amniotic membranes was safely and easily performed to promote the healing of complicated surgical wounds.

Model-Based Computational Analysis on the Effectiveness of Enhanced Recovery after Surgery in the Operating Room with Nursing

Objective

In order to better understand the relative surgical process, this work used a model-based computational analysis on the effectiveness of enhanced recovery after surgery (ERAS) in the operating room with nursing.

Methods

A total of 360 surgical patients in the First Affiliated Hospital, Sun Yat-sen University, from the period June 2020 to March 2021, were randomly divided into two groups, namely, observation group and control group, with 180 cases in each group. Routine nursing was used in the control group, while ERAS was implemented in the observation group from the point of view of four aspects, namely, preoperative visit, intraoperative cooperation, postoperative return visit, and psychological intervention.

Results

Postoperative complications, average hospital stay, nursing satisfaction, and postoperative quality of life in the observation group were significantly better than those in the control group (all p < 0.05).

Conclusion

The application of ERAS for surgical patients can enhance team awareness, optimize the process of cooperation, reduce surgical complications and improve nursing quality, and prognosis, and it is worth popularizing in the operating room.