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Matanes E, Eisenberg N, Amajoud Z, Gupta V, Yasmeen A, Ismail S, Racovitan F, Raban O, Lau S, Salvador S, Gotlieb WH, Kogan L. Sentinel Lymph Node Sampling as an Alternative to Lymphadenectomy in Patients With Endometrial Cancer and Obesity. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1136-1144.e1. [PMID: 33984524 DOI: 10.1016/j.jogc.2021.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Although its use in endometrial cancer staging is relatively new, sentinel lymph node (SLN) sampling has been shown to be highly accurate and is associated with few complications. However, some studies report lower rates of detection with SLN sampling among patients with obesity. The aim of the current study is to evaluate the feasibility of SLN sampling in endometrial cancer for patients with obesity, and to determine whether omitting lymph node dissection (LND) in surgical staging using SLN sampling impacts oncologic outcomes. METHODS we conducted a retrospective study of patients with obesity (BMI ≥35 kg/m2), diagnosed with endometrial carcinoma between 2007 and 2017, that compared surgical and oncologic outcomes of 2 cohorts: patients who underwent LND and patients who underwent SLN without lymphadenectomy. The primary outcome was operative time. Secondary outcomes included intraoperative bleeding; lymph node assessment information; intraoperative and postoperative adverse events; and oncologic outcomes including progression-free survival (PFS), overall survival (OS), and disease-specific survival (DSS). PFS was defined as the time from surgery to the recurrence or death from any cause. OS was defined as time from diagnosis to death or the last date the patient was known to be alive, and DSS was defined as the time from the surgery to death from the disease. RESULTS Out of 223 patients with a median BMI of 40.6 kg/m2, 140 underwent LND and 83 underwent SLN alone. The median operative time for patients in the SLN group was shorter than that of patients in the LND group (190.5 [range 108-393] vs. 238 [131-440] min; P < 0.001), and the SLN group had lower median estimated blood loss than the LND group (30 [range 0-300] vs. 40 [range 0-800] mL; P = 0.03). At the 24-month follow-up cut-off, 98% of patients were alive and 95.5% were disease free, with no significant differences in OS, DSS, and PFS between the 2 groups (P = 0.7, P = 0.8, and P = 0.4, respectively). CONCLUSIONS In patients with obesity, omitting LND from surgical staging with SLN sampling was associated with shorter operative times and less bleeding and did not affect survival at 2 years.
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Affiliation(s)
- Emad Matanes
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec
| | - Neta Eisenberg
- Department of Obstetrics and Gynecology, Yitzhak Shamir Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Zainab Amajoud
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec
| | - Vishaal Gupta
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec
| | - Amber Yasmeen
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec
| | - Sara Ismail
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec
| | - Florentin Racovitan
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec
| | - Oded Raban
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec
| | - Susie Lau
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec
| | - Shannon Salvador
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Québec.
| | - Liron Kogan
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Québec; Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew
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Kogan L, Matanes E, Wissing M, Mitric C, How J, Amajoud Z, Abitbol J, Yasmeen A, López-Ozuna V, Eisenberg N, Lau S, Salvador S, Gotlieb WH. The added value of sentinel node mapping in endometrial cancer. Gynecol Oncol 2020; 158:84-91. [PMID: 32349874 DOI: 10.1016/j.ygyno.2020.04.687] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/14/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate long-term oncological outcomes and the added value of sentinel lymph node sampling (SLN) compared to pelvic lymph node dissection (LND) in patients with endometrial cancer (EC). METHODS During the evaluation phase of SLN for EC, we performed LND and SLN and retrospectively compared the oncologic outcome with the immediate non-overlapping historical era during which patients underwent LND. RESULTS From 2007 to 2010, 193 patients underwent LND and from December 2010 to 2014, 250 patients had SLN mapping with completion LND. Both groups had similar clinical characteristics. During a median follow-up period of 6.9 years, addition of SLN was associated with more favorable oncological outcomes compared to LND with 6-year overall survival (OS) of 90% compared to 81% (p = 0.009), and progression free survival (PFS) of 85% compared to 75% (p = 0.01) respectively. SLN was associated with improved OS (HR 0.5, 95% CI 0.3-0.8, p = 0.004), and PFS (HR 0.6, 95% CI 0.4-0.9, p = 0.03) in a multivariable analysis, adjusted for age, ASA score, stage, grade, non-endometrioid histology, and LVSI. Patients who were staged with SLN were less likely to have a recurrence in the pelvis or lymph node basins compared to patients who underwent LND only (6-year recurrence-free survival 95% vs 90%, p = 0.04). CONCLUSION Addition of SLN to LND was ultimately associated with improved clinical outcomes compared to LND alone in patients with endometrial cancer undergoing surgical staging, suggesting that the data provided by the analysis of the SLN added relevant clinical information, and improved the decision on adjuvant therapy.
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Affiliation(s)
- Liron Kogan
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Emad Matanes
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Michel Wissing
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, QC, Canada
| | - Cristina Mitric
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey How
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Zainab Amajoud
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeremie Abitbol
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Amber Yasmeen
- Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Vanessa López-Ozuna
- Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Neta Eisenberg
- Department of Obstetrics and Gynecology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Quebec, Canada
| | - Susie Lau
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada.
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Surgical management of squamous cell vulvar cancer without clitoris, urethra or anus involvement. Gynecol Oncol Rep 2017; 20:41-46. [PMID: 28275696 PMCID: PMC5331156 DOI: 10.1016/j.gore.2017.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/31/2017] [Accepted: 02/08/2017] [Indexed: 12/22/2022] Open
Abstract
Vulvar cancers, which constitute 5% of all gynecologic cancers, are the fourth most common female genital cancers, preceded by uterine, ovarian and cervical cancers. The treatment methods employed for vulvar cancers have changed over the years, with previously applied radical surgical approaches, such as en bloc resection, being gradually suspended in favor of treatment approaches that require dissection of less tissue. While the removal of less tissue, which today's approaches have focused on, prevents morbidity, this method seems to result in higher risks of recurrence. It is therefore important that the balance between preventing the recurrence of the disease and forefending against postoperative complications and vulvar deformity be properly understood. As a working assumption, if patients with vulvar cancer are diagnosed at an early stage, properly evaluated and administered appropriate treatment, the most positive results can be obtained. This paper aims to highlight this assumption and demonstrate, through the provision of actual data, how to plan the treatment approach for patients who are diagnosed early. Statements extracted from the National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2016 Sub-Committees on vulvar squamous cell carcinoma and articles by the European Society of Gynaecological Oncology (ESGO) regarding Vulvar Cancer Recommendations were used to obtain updated information. Radical/wide local excision is an alternative to radical vulvectomy in selected patients. The aim of the tumor resection should be to achieve the adequate surgical border. Complete inguinofemoral lymphadenectomy is more advantageous in terms of recurrence. Recurrence is a particularly problematic feature of vulvar cancer cases. Saphenous vein preservation is contradictory, preservation is maybe more advantageous.
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Özbay PÖ, Ekinci T, Yiǧit S, Yavuzcan A, Uysal S, Soylu F, Cakalagaoglu F. Investigation of prognostic significance of CD109 expression in women with vulvar squamous cell carcinoma. Onco Targets Ther 2013; 6:621-7. [PMID: 23776335 PMCID: PMC3681417 DOI: 10.2147/ott.s41069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The goal of this study was to investigate the between cluster of differentiation 109 (CD109) expression and tumor diameter, invasion depth, tumor grade, presence of lymph-node metastasis, and overall survival in patients with vulvar squamous cell carcinoma, which is the most common type of vulvar cancer. METHOD Twenty-six patients who underwent an operation for vulvar cancer between 1999 and 2009 in our clinic were included in this study. Immunohistochemical staining was performed on formalin-fixed and paraffin-embedded tissue. RESULT Tumor diameter was not found to be significantly associated with CD109 expression, intensity of cytoplasmic staining, or combined score (P = 0.325, P = 0.169, P = 0.352, respectively). Invasion depth and combined score were also not significantly correlated with CD109 expression (P = 0.324 and P = 0.174 respectively). There was a negative correlation between invasion depth and the intensity of cytoplasmic staining (P = 0.042). There was no significant correlation between tumor stage and CD109 expression, the intensity of cytoplasmic staining, and the combined score (P = 0.574, P = 0.389, P = 0.605, respectively). A significant positive correlation was observed between tumor grade and CD109 expression, the intensity of cytoplasmic staining, and the combined score (P = 0.003, P = 0.018, P = 0.008, respectively). No significant difference was found between the percentages of CD109 expression in patients with positive (48%) and negative (11%) lymph nodes (P = 0.058). The percentage of CD109 expression did not significantly differ in relation to overall survival (P = 0.483). CONCLUSION Comprehensive and more extensive studies are needed to examine the relationship between CD109 expression and vulvar malignant lesions.
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Affiliation(s)
- Pelin Özün Özbay
- Department of Obstetrics and Gynecology, Dogubeyazıt State Hospital, Aǧrı
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, izmir
| | - Tekin Ekinci
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, izmir
- Department of Obstetrics and Gynecology, Kozluk State Hospital, Batman
| | - Seyran Yiǧit
- Department of Pathology, Atatürk Training and Research Hospital, Izmir
| | - Ali Yavuzcan
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, izmir
- Department of Obstetrics and Gynecology, Düzce University Faculty of Medicine, Düzce, Turkey
| | - Selda Uysal
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, izmir
| | - Ferit Soylu
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, izmir
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Mathevet P. [Current treatments of vulvar cancer]. ACTA ACUST UNITED AC 2012; 41:519-25. [PMID: 22580162 DOI: 10.1016/j.jgyn.2012.03.011] [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: 12/07/2011] [Revised: 03/13/2012] [Accepted: 03/28/2012] [Indexed: 11/18/2022]
Abstract
Vulvar cancers are rare genital tumors. Their etiology is better understood. The management of these tumors has benefitted from recent therapeutic advances that decrease the morbidity of the treatments. Surgery is still the major curative option. But the limitation of the vulvar resections and the development of the sentinel-node technique have led to lower surgical morbidity and sequellas without increasing the risk of recurrence. Also improvements in radiotherapeutic treatment have been observed. Currently radiotherapy is realized in association with surgery in case of presence of risk factors of recurrence, or in place of surgery when this treatment is not possible or is too much aggressive. Morbidity of radiotherapy has largely decreased and association with chemotherapy leads probably to increased efficacy.
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Affiliation(s)
- P Mathevet
- Service de gynécologie, hôpital Femme-Mère-Enfant, université Lyon-I, 59, boulevard Pinel, 69677 Bron cedex, France.
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Dittmer C, Fischer D, Diedrich K, Thill M. Diagnosis and treatment options of vulvar cancer: a review. Arch Gynecol Obstet 2011; 285:183-93. [PMID: 21909752 DOI: 10.1007/s00404-011-2057-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Vulvar cancer is a rare malignancy in women. However, within the past decade, a distinct increase in the incidence of vulvar intraepithelial neoplasia (VIN) as a precursor lesion, and an increase of vulvar cancer have been reported within Europe and the USA. Surgery is the first choice in treating patients with vulvar cancer, especially in its early stages. In an attempt to decrease the incidence of complications, research was made into modifications of the surgical procedure without compromising the prognosis. The replacement of radical vulvectomy by less wide local excision is one of these modifications. As vulvar cancer is relatively rare, it is possible to give evidence-based treatment recommendations, but usually on a low evidence level. Aim of this paper is to elucidate diagnostics and surgical treatment options in the management of vulvar cancer. MATERIALS AND METHODS We searched major databases (i.e. pubmed) with the following selection criteria: vulvar cancer, en bloc resection, triple incision, and sentinel node biopsy. CONCLUSIONS Today, the operative therapy is much less radical and more emphasized on individualized therapeutic concepts. The tendency is to leave the ultraradical surgical options which suffer from high morbidity towards less radical, minimal invasive techniques. Due to the rarity of the disease further studies will have to be performed by international collaborative groups.
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Affiliation(s)
- C Dittmer
- Department of Obstetrics and Gynaecology, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
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The management of vulval cancer. Cancer Treat Rev 2009; 35:533-9. [DOI: 10.1016/j.ctrv.2009.01.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 01/10/2009] [Accepted: 01/19/2009] [Indexed: 11/18/2022]
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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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de Hullu JA, van der Zee AGJ. Surgery and radiotherapy in vulvar cancer. Crit Rev Oncol Hematol 2006; 60:38-58. [PMID: 16829120 DOI: 10.1016/j.critrevonc.2006.02.008] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2005] [Revised: 01/30/2006] [Accepted: 02/28/2006] [Indexed: 12/01/2022] Open
Abstract
The majority of patients with vulvar cancer have squamous cell carcinomas (SCC). The cornerstone of the treatment is surgery. Radical vulvectomy with "en bloc" inguinofemoral lymphadenectomy has led to a favorable prognosis but with impressive morbidity. Nowadays, treatment is more individualized with wide local excision with uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as the standard treatment for early stage patients with SCC of the vulva with depth of invasion >1 mm without suspicious groins. In case of more than one intranodal lymph node metastasis and/or extranodal growth, postoperative radiotherapy on the groins and pelvis is warranted. Until now there is a limited role for primary radiotherapy on the vulva and/or groins in early stage disease. The sentinel lymph node (SLN) procedure with the combined technique (preoperative lymphoscintigraphy with a radioactive tracer and intraoperative blue dye) is a promising staging technique for patients with early stage vulvar cancer. The safety of clinical implementation of the SLN procedure and the role of additional histopathological techniques of the SLNs need to be further investigated before its wide-scale application. Patients with advanced vulvar cancer are difficult to treat. One of the problems in patients with locally advanced vulvar cancer is the high incidence of concomitant bulky lymph nodes in the groin(s). Ultraradical surgery in case of resectable disease will lead to impressive morbidity because of the exenterative-type procedure. (Chemo)radiation with or without surgery should be regarded as the first choice for patients with locally advanced vulvar cancer only when primary surgery will necessitate performance of a stoma. Further studies are needed to determine the optimal combined modality treatment in these patients. Due to the fact that vulvar cancer is a rare disease, further clinical studies will only be possible, when international collaborative groups will join forces in order to perform clinical trials, in which different treatment options such as SLN procedure, primary radiotherapy on the groins and multimodality treatment for advanced disease will be investigated.
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Affiliation(s)
- J A de Hullu
- Department of Gynaecologic Oncology, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands.
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Preti M, Rouzier R, Mariani L, Wilkinson EJ. Superficially Invasive Carcinoma of the Vulva: Diagnosis and Treatment. Clin Obstet Gynecol 2005; 48:862-8. [PMID: 16286832 DOI: 10.1097/01.grf.0000179668.14187.3a] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Mario Preti
- Department of Obstetrics and Gynecology, University of Torino, Torino, Italy.
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Thangavelu A, Andrew A, Buxton EJ. Groin recurrence following Stage 1A squamous cell carcinoma of the vulva. Gynecol Oncol 2005; 101:172-4. [PMID: 16274738 DOI: 10.1016/j.ygyno.2005.09.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 09/27/2005] [Accepted: 09/30/2005] [Indexed: 11/15/2022]
Abstract
BACKGROUND It has been well established that stage 1 squamous cell carcinomas of the vulva with a depth of stromal invasion less than 1 mm have a <1% risk of lymph node involvement. The treatment for these stage 1A tumours has therefore been to perform radical wide local excision without removal of groin nodes. CASE We present two cases of stage 1A microinvasive cancer of the vulva that presented with groin recurrence 3 months and 3 years following their primary surgery respectively. CONCLUSION The current management of stage 1A tumours may need to be re-evaluated to include some form of lymph node assessment in view of these rare but nonetheless aggressive tumours.
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Affiliation(s)
- Amudha Thangavelu
- Department of Obstetrics and Gynaecology, St. James' University Hospital, Beckett Street, Leeds LS9 7TF, UK.
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