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Reconstructive Surgery versus Primary Closure following Vulvar Cancer Excision: A Wide Single-Center Experience. Cancers (Basel) 2022; 14:cancers14071695. [PMID: 35406468 PMCID: PMC8997096 DOI: 10.3390/cancers14071695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 12/10/2022] Open
Abstract
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.
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Parpex G, Bucau M, Estevez JP, Raimond E, Ouldamer L, Carcopino X, Touboul C, Bendifallah S, Graesslin O, Lavoue V, Bolze PA, Koskas M. Impact of vulvar reconstruction on the accuracy of a nomogram for predicting local recurrence after surgery for vulvar cancer. Gynecol Oncol 2022; 165:143-148. [PMID: 35177278 DOI: 10.1016/j.ygyno.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/17/2022] [Accepted: 02/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND DATA Vulvar carcinoma is a rare disease accounting for 3%-5% of all gynaecological cancers. Although surgery is the standard treatment at an early stage, the outcomes are highly correlated with clear resection margins. Therefore, surgical defects can be important and require reconstruction. The aim of this study was to evaluate vulvar reconstructions using a previously validated nomogram predicting the risk of local recurrence at 2 years. METHODS Patients who underwent surgery for vulvar cancer between 1998 and 2017 were extracted from eight FRANCOGYN centres. We estimated the probability of local recurrence at 2 years using a previously validated nomogram and compared it with actual relapse in patients with or without vulvar reconstruction. Patients were clustered into tiertiles according to their nomogram score: low-, intermediate-, and high-risk for local relapse probability. RESULTS We reviewed 254 patients, of whom 49 underwent immediate vulvar reconstruction. The predicted and actual probability of two-year local relapse were 20.1% and 15.7%, respectively, with a concordance index of 0.75. In the low- and intermediate-risk groups, the difference between predicted and observed recurrence was less than 10% in patients with or without vulvar reconstruction. For the high-risk group, the difference reached 25% and observed recurrence probability was lower in patients who underwent vulvar plasty compared with those who did not (20.0% vs. 36.2%, respectively). Local recurrence-free survival rates following vulvar reconstruction were comparable at two years (82.1% vs. 84.8%, respectively, p = 0.26). CONCLUSION Vulvar reconstruction after surgical resection for vulvar cancer is safe. Vulvar reconstruction should be considered in aggressive cases to decrease local recurrence.
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Affiliation(s)
- Guillaume Parpex
- Department of Gynaecology and Obstetrics, Bichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France; Paris University, Paris, France.
| | - Margot Bucau
- Department of Pathology, Bichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France
| | - Juan Pablo Estevez
- Department of Gynaecology and Obstetrics, Bichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France
| | - Emilie Raimond
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne, Universitary Hospital of Reims, University of Reims Champagne Ardenne (URCA), 51092 Reims Cedex, France
| | - Lobna Ouldamer
- Department of Obstetrics and Gynaecology, Centre, Hospitalier Régional Universitaire de Tours, Hôpital Bretonneau, Tours, France
| | - Xavier Carcopino
- Hôpital Nord (APHM), Department of Obstetrics and Gynecology, Aix-Marseille Université (AMU), CNRS, IRD, IMBE, Marseille, France
| | - Cyril Touboul
- Paris University, Paris, France; Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France
| | - Olivier Graesslin
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne, Universitary Hospital of Reims, University of Reims Champagne Ardenne (URCA), 51092 Reims Cedex, France
| | - Vincent Lavoue
- Department de Gynaecology, Obstetrics and Reproductive Medicine, University Hospital of Rennes, Rennes, France; Faculty of Medicine, University of Rennes 1, Rennes, France
| | - Pierre-Adrien Bolze
- Université Lyon 1, Faculté de Médecine Lyon Sud, Hospices Civils de Lyon, Department of Gynaecologic Surgery and Oncology, Obstetrics, Hôpital Lyon Sud, Pierre Bénite, France
| | - Martin Koskas
- Department of Gynaecology and Obstetrics, Bichat University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), France; Paris University, Paris, France
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Elia J, Do NTK, Chang TNJ, Lai CH, Chou HH, Chang FCS, Huang JJ. Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps. J Reconstr Microsurg 2021; 38:10-26. [PMID: 33853124 DOI: 10.1055/s-0041-1727199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Jhonatan Elia
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nicholas T K Do
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tommy N-J Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Frank C-S Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
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Tock S, Wallet J, Belhadia M, Hudry D, Ghesquière L, Narducci F, Leblanc E. Outcomes of the use of different vulvar flaps for reconstruction during surgery for vulvar cancer. Eur J Surg Oncol 2019; 45:1625-1631. [DOI: 10.1016/j.ejso.2019.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 04/07/2019] [Accepted: 04/16/2019] [Indexed: 12/19/2022] Open
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Fin A, Rampino Cordaro E, Guarneri GF, Revesz S, Vanin M, Parodi PC. Experience with gluteal V-Y fasciocutaneous advancement flaps in vulvar reconstruction after oncological resection and a modification to the marking: Playing with tension lines. Int Wound J 2018; 16:96-102. [PMID: 30303301 DOI: 10.1111/iwj.12997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/31/2018] [Indexed: 02/01/2023] Open
Abstract
Many post-vulvectomy vulvar reconstruction solutions, using local fasciocutaneous flaps where possible, have been proposed. We report the use of V-Y advancement flaps from the gluteal fold in medium to large vulvar reconstructions and a simple modification we made to the technique in order to minimise wound-related complications. Between 2006 and 2016, 30 vulvar reconstructions were performed via a total of 59 flaps, 24 of which were raised using the proposed modification to the plasty design. Short- and long-term (24 months) follow-up data were analysed, postoperative flap sensitivity was tested, and any arising complications were recorded. The mean age of patients treated was 75.3 years (51-92 years). The mean monolateral defect dimensions were 7.5 × 4.7 × 2.8 cm. Minor complications were recorded in 23% of patients (14% of flaps). One case of ostial stenosis occurred. Micturition and ambulation recovery was rapid, and flap sensitivity was fully restored 24 months after reconstruction. Scars were well hidden by natural soft tissue folds. The outcomes in this case series confirm that the gluteal V-Y advancement fasciocutaneous flap is a useful and simple technique for reconstructing even large vulvar defects. It has a low functional and aesthetic impact and enables rapid return to autonomy. Moreover, the simple modification to the V-Y flap proposed, designed to reduce tension at the apical part of the wound, appears to reduce the complication rate.
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Affiliation(s)
- Alessandra Fin
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
| | | | - Gianni F Guarneri
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
| | - Susanna Revesz
- Obstetrics and Gynecology Service, Ospedale Civile Sant'Antonio Abate, Udine, Italy
| | - Michele Vanin
- Obstetrics and Gynecology Service, Ospedale Civile Sant'Antonio Abate, Udine, Italy
| | - Pier C Parodi
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
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El-Sabbagh AH. Coverage of the scrotum after Fournier's gangrene. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2018; 7:Doc01. [PMID: 29423355 PMCID: PMC5803511 DOI: 10.3205/iprs000121] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Fournier’s gangrene is a necrotizing fasciitis caused by mixed aerobic and anaerobic bacteria and results in loss of skin and subcutaneous tissue in the perineal area. Coverage of testis varies from closure of the defect primarily, burying inside the thigh, using the remnants of the scrotum for tissue expansion and coverage by flaps. In this manuscript, scrotal advancement flaps and pudendal thigh flaps were used for coverage of the testis unilaterally or bilaterally according to the size of the defect following Fournier gangrene. Patients and methods: From June 2015 to March 2017, twelve cases were admitted to our department. The patients’ ages ranged from 37–59 years and they all had suffered from Fournier’s gangrene in the perineal area. Results: Of the twelve cases, two cases showed penile involvement. A skin graft was used for coverage of the penile shaft with excellent take. Four cases were closed primarily. This was applied to cases where loss of skin was less than 50%. The rest of the cases were reconstructed by pudendal thigh flap. The reconstructed cases were covered by bilateral pudendal thigh flap (4 cases) and unilateral pudendal thigh flap (4 cases). The follow-up extended up to 16 months. Conclusion: Scrotal advancement flap was suitable for small and medium size defects due to the elasticity of the scrotal skin. Pudendal thigh flap was efficient for the reconstruction of large defects of the scrotum.
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A Prospective Assessment of Surgical Risk Factors in 114 Gluteal Fold Flap Reconstructions After Oncological Vulvoperineal Resection. Ann Plast Surg 2017; 79:53-59. [DOI: 10.1097/sap.0000000000000964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nooij LS, Brand FAM, Gaarenstroom KN, Creutzberg CL, de Hullu JA, van Poelgeest MIE. Risk factors and treatment for recurrent vulvar squamous cell carcinoma. Crit Rev Oncol Hematol 2016; 106:1-13. [PMID: 27637349 DOI: 10.1016/j.critrevonc.2016.07.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/02/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022] Open
Abstract
Recurrent disease occurs in 12-37% of patients with vulvar squamous cell carcinoma (VSCC). Decisions about treatment of recurrent VSCC mainly depend on the location of the recurrence and previous treatment, resulting in individualized and consensus-based approaches. Most recurrences (40-80%) occur within 2 years after initial treatment. Currently, wide local excision is the treatment of choice for local recurrences. Isolated local recurrence of VSCC has a good prognosis, with reported 5-year survival rates of up to 60%. Groin recurrences and distant recurrences are less common and have an extremely poor prognosis. For groin recurrences, surgery with or without (chemo) radiotherapy is a treatment option, depending on prior treatment. For distant recurrences, there are only palliative treatment options. In this review, we give an overview of the available literature and discuss epidemiology, risk factors, and prognostic factors for the different types of recurrent VSCC and we describe treatment options and clinical outcome.
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Affiliation(s)
- L S Nooij
- Department of Gynecology, LUMC, Netherlands
| | | | | | | | - J A de Hullu
- Department of Gynecology, Radboud UMC, Netherlands
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Neourethral meatus reconstruction for vulvectomies requiring resection of the distal part of the urethra. Eur J Surg Oncol 2015; 41:1664-70. [DOI: 10.1016/j.ejso.2015.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 07/01/2015] [Accepted: 07/23/2015] [Indexed: 11/19/2022] Open
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Nomura H, Maeda T, Usami T, Abe A, Yamamoto A, Matoda M, Okamoto S, Kondo E, Omatsu K, Kato K, Umayahara K, Utsugi K, Takeshima N, Sawaizumi M. Vulvar Reconstruction Following Surgery for Vulvar Cancer Using a Stepladder V-Y Advancement Medial Thigh Flap. Int J Gynecol Cancer 2015. [DOI: 10.1097/igc.0000000000000518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Recent trends in surgical and reconstructive management of vulvar cancer: review of literature. Updates Surg 2015; 67:367-71. [PMID: 26070991 DOI: 10.1007/s13304-015-0303-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 05/24/2015] [Indexed: 12/19/2022]
Abstract
Vulvar cancer (VC) is a rare disease. The most common histologic type is squamous-cell carcinoma. VC could be divided into two types: type one, commonly associated with HPV infection, occurs in young women and type two, associated with non-neoplastic lesions that usually occurs in older women. Previously VC was often treated with radical Vulvectomy. Today update in diagnostic and surgery technique, capable to identify early stages of disease and adaptation in surgery procedures, according to the stage of disease, age of patients and possible physical and psychological morbidity consequence, allow using less radical surgery approaches. That has led to decrease therapy-associated morbidity while preserving oncologic safety and improving psychosexual outcomes. Finally, several surgical treatments are available in case of VC and, despite radical surgery is often required, less radical surgery associated with reconstructive plastic surgery decreases some of short- and long-term associated complications.
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Zhang W, Zeng A, Yang J, Cao D, Huang H, Wang X, You Y, Chen J, Lang J, Shen K. Outcome of vulvar reconstruction by anterolateral thigh flap in patients with advanced and recurrent vulvar malignancy. J Surg Oncol 2015; 111:985-91. [PMID: 25974742 DOI: 10.1002/jso.23908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 03/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Wei Zhang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Ang Zeng
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Huifang Huang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Xiaojun Wang
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Yan You
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jie Chen
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Keng Shen
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
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Alkatout I, Schubert M, Garbrecht N, Weigel MT, Jonat W, Mundhenke C, Günther V. Vulvar cancer: epidemiology, clinical presentation, and management options. Int J Womens Health 2015; 7:305-13. [PMID: 25848321 PMCID: PMC4374790 DOI: 10.2147/ijwh.s68979] [Citation(s) in RCA: 118] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
EPIDEMIOLOGY Vulvar cancer can be classified into two groups according to predisposing factors: the first type correlates with a HPV infection and occurs mostly in younger patients. The second group is not HPV associated and occurs often in elderly women without neoplastic epithelial disorders. HISTOLOGY Squamous cell carcinoma (SCC) is the most common malignant tumor of the vulva (95%). CLINICAL FEATURES Pruritus is the most common and long-lasting reported symptom of vulvar cancer, followed by vulvar bleeding, discharge, dysuria, and pain. THERAPY The gold standard for even a small invasive carcinoma of the vulva was historically radical vulvectomy with removal of the tumor with a wide margin followed by an en bloc resection of the inguinal and often the pelvic lymph nodes. Currently, a more individualized and less radical treatment is suggested: a radical wide local excision is possible in the case of localized lesions (T1). A sentinel lymph node (SLN) biopsy may be performed to reduce wound complications and lymphedema. PROGNOSIS The survival of patients with vulvar cancer is good when convenient therapy is arranged quickly after initial diagnosis. Inguinal and/or femoral node involvement is the most significant prognostic factor for survival.
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Affiliation(s)
- Ibrahim Alkatout
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Melanie Schubert
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Nele Garbrecht
- Institute for Pathology, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Marion Tina Weigel
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Walter Jonat
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Christoph Mundhenke
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Veronika Günther
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Affiliation(s)
| | - David Luesley
- Pan-Birmingham Gynaecological Cancer Centre; City Hospital; Dudley Road; Birmingham; B18 7QH; UK
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Woelber L, Trillsch F, Kock L, Grimm D, Petersen C, Choschzick M, Jaenicke F, Mahner S. Management of patients with vulvar cancer: a perspective review according to tumour stage. Ther Adv Med Oncol 2013; 5:183-92. [PMID: 23634196 PMCID: PMC3630479 DOI: 10.1177/1758834012471699] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Treatment of patients with vulvar cancer is challenging for gynaecologic oncologists. Owing to the localization in a sensitive area, surgical radicality and the indication for adjuvant treatment have to be balanced with psychosocial aspects to treat patients adequately. Clinical management is therefore highly dependent on the tumour stage. For patients with early-stage disease (FIGO I-II) therapy mainly concentrates on surgery with resection of the primary tumour and staging of the groin lymph nodes. In intermediate-stage vulvar cancer (FIGO III), advanced disease is expressed by affected inguinofemoral lymph nodes bringing radical lymphadenectomy and adjuvant therapy as well as radiation or chemoradiation into the focus of treatment. For locally advanced or metastatic vulvar cancer (FIGO IV) neoadjuvant or definitive chemoradiation has to be considered besides surgery. Owing to the low incidence of the disease, the level of evidence for different treatment modalities is poor. This review therefore puts different recommendations of clinical management in context and highlights the need for future trials.
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Affiliation(s)
- Linn Woelber
- Department of Gynaecology and Gynaecologic Oncology, University Medical Centre Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Beriwal S, Shukla G, Shinde A, Heron DE, Kelley JL, Edwards RP, Sukumvanich P, Richards S, Olawaiye AB, Krivak TC. Preoperative Intensity Modulated Radiation Therapy and Chemotherapy for Locally Advanced Vulvar Carcinoma: Analysis of Pattern of Relapse. Int J Radiat Oncol Biol Phys 2013; 85:1269-74. [DOI: 10.1016/j.ijrobp.2012.11.012] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Revised: 11/05/2012] [Accepted: 11/06/2012] [Indexed: 11/30/2022]
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Hage JJ, Beurden MV. Reconstruction of acquired perineovulvar defects: a proposal of sequence. Semin Plast Surg 2012; 25:148-54. [PMID: 22547972 DOI: 10.1055/s-0031-1281484] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Acquired perineovulvar defects are usually the result of excision of vulvar intraepithelial neoplasia (VIN) or invasive squamous cell carcinoma. Because both VIN and vulvar carcinoma have a tendency toward local recurrence, future reconstructive options should be reckoned with during treatment of the primary and all subsequent (pre-) malignant perineovulvar lesions. Hence, a proposal of sequence of reconstructive options for these defects is called for. In cases where local skin flaps suffice, these are preferably designed in such a fashion as not to sever the branches of the internal pudendal vascular system. In cases where either a pudendal thigh flap or an infragluteal flap may be used to close the perineovulvar defect, the pudendal thigh flap is to be preferred to preserve the infragluteal flap for future use. Only when these flaps no longer are available or sufficient to cover the defect should the gluteal thigh flap be applied. The use of myocutaneous flaps is rarely indicated to close isolated superficial perineovulvar defects.
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Radical Excision of Vulval Disease and Multidisciplinary Tissue Flap Reconstruction. Int J Gynecol Cancer 2012; 22:323-7. [DOI: 10.1097/igc.0b013e318232c4be] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Haynes DF. Trans-pubic abdominal flap for reconstruction of the labia majora. J Plast Reconstr Aesthet Surg 2011; 64:1537-9. [PMID: 21489893 DOI: 10.1016/j.bjps.2011.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 03/12/2011] [Indexed: 11/18/2022]
Abstract
A flap is described for recreation of the labia majora. The flap was designed for a young woman who developed vulvar squamous cell carcinoma in-situ after immunosuppression for treatment of juvenile rheumatoid arthritis. The patient underwent removal of the labia majora, and was reconstructed with a bi-lobed abdominal flap tunneled through the mons pubis. The flap produced a normal genital contour and has functioned well to seven years follow-up.
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Affiliation(s)
- Daniel F Haynes
- Department of Surgery, East Tennessee State University, 325 North State of Franklin Road, Johnson City, TN 37604, USA.
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Vulvar field resection: Novel approach to the surgical treatment of vulvar cancer based on ontogenetic anatomy. Gynecol Oncol 2010; 119:106-13. [DOI: 10.1016/j.ygyno.2010.06.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 06/18/2010] [Accepted: 06/19/2010] [Indexed: 11/21/2022]
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Incorporating pelvic/vaginal reconstruction into radical pelvic surgery. Gynecol Oncol 2009; 115:154-163. [DOI: 10.1016/j.ygyno.2009.05.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2009] [Revised: 05/26/2009] [Accepted: 05/28/2009] [Indexed: 11/20/2022]
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Staiano JJ, Wong L, Butler J, Searle AE, Barton DP, Harris PA. Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease – A 12 year experience. J Plast Reconstr Aesthet Surg 2009; 62:346-51. [DOI: 10.1016/j.bjps.2007.12.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 12/19/2007] [Accepted: 12/26/2007] [Indexed: 11/24/2022]
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Stroup AM, Harlan LC, Trimble EL. Demographic, clinical, and treatment trends among women diagnosed with vulvar cancer in the United States. Gynecol Oncol 2008; 108:577-83. [PMID: 18155274 PMCID: PMC2350205 DOI: 10.1016/j.ygyno.2007.11.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 10/22/2007] [Accepted: 11/15/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Describe the treatment and survival patterns among a population-based sample of vulvar cancer patients diagnosed in the United States in 1999. METHODS Cases were identified for the National Cancer Institute's Patterns of Care Study (POC) using the Surveillance, Epidemiology, and End Results Program (SEER). A stratified random sample of non-Hispanic white, non-Hispanic black, and Hispanic women age 20 years and older was selected from cases reported by 11 SEER registries. Analyses of the association between vulvar cancer and key demographic, clinical, and hospital characteristics by stage were performed. Cox proportional hazards was used to estimate the odds of death due to cancer. All estimates were weighted, and analyses were conducted with SUDAAN. RESULTS Ninety percent of cases were diagnosed with in situ or early-stage invasive disease. Older patients were more likely to present at advanced stages. Twenty-five percent of women with Stage III-IV vulvar cancer received chemotherapy plus radiation. We noted widespread use of radical local excision among women with Stage I/II cancer, but 46-54% with invasive disease underwent a radical or total vulvectomy. Factors associated with cancer death were limited to age and stage. Women 75 years and older were at higher risk compared to women aged 20-49 years and the risk of death increased with advancing stage. CONCLUSIONS Vulvar cancer is diagnosed at early stages. Late-stage disease is associated with a significant increase in mortality. Radical surgery was still commonly performed in 1999. Radiation was more common in women diagnosed at late stage, while the use of chemoradiation remained limited.
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Affiliation(s)
- A M Stroup
- University of Utah, Utah Cancer Registry, 650 Komas Drive, Suite 106B, Salt Lake City, Utah 84108, USA.
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Fanfani F, Garganese G, Fagotti A, Lorusso D, Gagliardi ML, Rossi M, Salgarello M, Scambia G. Advanced vulvar carcinoma: Is it worth operating? A perioperative management protocol for radical and reconstructive surgery. Gynecol Oncol 2006; 103:467-72. [PMID: 16647747 DOI: 10.1016/j.ygyno.2006.03.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 02/25/2006] [Accepted: 03/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the means whereby the results could be improved and the morbidity and side-effects minimized, of radical and extensive surgery performed together with plastic reconstruction, in the treatment of locally advanced and relapsed vulvar carcinoma. METHODS Between May 2000 and November 2004, twenty-three patients with locally advanced or relapsed vulvar carcinoma underwent major radical or extended vulvectomy, requiring reconstructive surgery. A consistent protocol for the perioperative management of these patients, including precautionary measures to reduce the rate of early complications, was introduced in the second study period (from November 2003) to verify the benefit on surgical outcome. RESULTS An analysis of the medical reports showed an improvement in the median time of the postoperative course and related morbidity as a consequence of a strict application of the management protocol, with consequent decrease of early complications. CONCLUSIONS Reconstructive surgery, which broadens the spectrum of available operative therapy in primary and locally recurrent vulvar cancer, is characterized by a high complication rate. The application of a strict perioperative protocol could reduce the number and the clinical impact of such complications.
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Affiliation(s)
- Francesco Fanfani
- Department of Oncology, Division of Gynecologic Oncology, Catholic University of Sacred Heart, Campobasso, Italy
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Weikel W, Schmidt M, Steiner E, Knapstein PG, Koelbl H. Surgical therapy of recurrent vulvar cancer. Am J Obstet Gynecol 2006; 195:1293-302. [PMID: 16681985 DOI: 10.1016/j.ajog.2006.03.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Revised: 03/08/2006] [Accepted: 03/08/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The success of various surgical interventions in 201 cases with recurrent vulvar carcinoma was examined in the light of patients' pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course. STUDY DESIGN A databank of standardized clinical data was analyzed using statistical procedures. RESULTS Therapy was selected on an individual basis according to tumor status. Recurrence at a site distant from the primary tumor, particularly in the inguinal region, indicated a markedly unfavorable prognosis. In contrast, tumors recurring locally did not exhibit any significant differences. Plastic surgery reconstruction led to improvements with respect to operability, wound healing, and survival. CONCLUSION Individualized reconstructive surgery of the vulva leads to good results in patients with recurrent vulvar cancer. To an even greater extent than is the case for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives so that a more favorable oncological outcome and excellent cosmetic results may be expected.
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Affiliation(s)
- Wolfgang Weikel
- Department of Obstetrics and Gynecology, Ludwigshafen, Germany.
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Gadducci A, Cionini L, Romanini A, Fanucchi A, Genazzani AR. Old and new perspectives in the management of high-risk, locally advanced or recurrent, and metastatic vulvar cancer. Crit Rev Oncol Hematol 2006; 60:227-41. [PMID: 16945551 DOI: 10.1016/j.critrevonc.2006.06.009] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2006] [Revised: 05/30/2006] [Accepted: 06/22/2006] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Angiolo Gadducci
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 56, Pisa 56127, Italy.
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