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Dzyubak O, Salman L, Covens A. Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer. Curr Oncol 2024; 31:394-402. [PMID: 38248111 PMCID: PMC10814897 DOI: 10.3390/curroncol31010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.
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Affiliation(s)
- Oleksandra Dzyubak
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, 610 University Ave., Toronto, ON M5G 2M9, Canada; (O.D.); (L.S.)
- Division of Gynecologic Oncology, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
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Nursing of Vulvar Cancer Radical Operation Combined with Laparoscopic Inguinal Lymph Node Dissection. Emerg Med Int 2022; 2022:8091114. [PMID: 36105671 PMCID: PMC9467793 DOI: 10.1155/2022/8091114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/23/2022] [Accepted: 07/29/2022] [Indexed: 11/17/2022] Open
Abstract
Purpose. The application, development, and care of radical surgery combined with laparoscopic inguinal lymph node dissection for vulvar cancer. Methods. We searched the PubMed, Web of Science, the Cochrane Library, and EMBASE databases for published literature on the care of radical surgery combined with laparoscopic inguinal lymph node dissection for vulvar cancer up to June 2022. We used the following search terms and terms: “vulvar cancer,” “injury,” “radical vulvar cancer surgery,” “laparoscopic inguinal lymph node dissection,” and “care.” Results. Laparoscopic inguinal lymph node dissection has become a new surgical method for the treatment of vulvar cancer, and it effectively avoids all the problems associated with traditional surgery. In addition, radical vulvar cancer surgery and laparoscopic inguinal lymph node dissection combined with high-quality nursing interventions can promote patients’ recovery and reduce the occurrence of complications, which has important clinical significance. Conclusion. This article reviews the application, development, and nursing care of radical vulvar cancer surgery combined with laparoscopic inguinal lymph node dissection.
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van Doorn HC, Oonk MHM, Fons G, Gaarenstroom KN, de Hullu J, van Rosmalen J, van Beekhuizen HJ. Sentinel lymph node procedure in patients with recurrent vulvar squamous cell carcinoma: a proposed protocol for a multicentre observational study. BMC Cancer 2022; 22:445. [PMID: 35461213 PMCID: PMC9034534 DOI: 10.1186/s12885-022-09543-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Standard groin treatment in recurrent vulvar cancer consists of uni- or bilateral inguinofemoral lymphadenectomy (IFL), whereas in the primary setting women with selected unifocal tumours will undergo a sentinel lymph node (SLN) procedure. The SLN procedure results in fewer short and long-term sequelae compared to IFL, but some concerns must first be considered. Lymph drainage of the vulvar region can be affected by a previous surgery, which might reduce the number of detectable SLN nodes (feasibility) but increase the chance of encountering aberrant lymph drainage patterns such as bilateral SLNs in lateral tumours or SLNs at unexpected locations. Therefore, the SLN procedure potentially carries a higher risk of groin recurrence if a tumour positive node is not retrieved, but may also improve outcomes for women with aberrant drainage patterns. Since the relative benefits and drawbacks of the SLN procedure are still unclear we will investigate the safety of the SLN procedure in women with a first recurrent vulvar cancer. In a simultaneously started registration study we prospectively gather information on women with a first recurrence of vulvar cancer ineligible for the SLN procedure. Method In this prospective multicentre observational study all women with a first recurrence of vulvar cancer will be asked to consent to the collection of information on their diagnostics, treatment and outcome, and to complete quality of life and lymph oedema questionnaires. Women with unifocal tumours smaller than 4 cm and unsuspicious groin nodes will be offered the SLN procedure, with follow-up every 3 months together with imaging at 6 and 12 months when the SLN is tumour negative. The primary outcome is groin recurrence within 2 years of initial surgery. A total of 150 women with negative SLNs will be required to demonstrate safety, a stopping rule will apply and an extensive statistical analysis has been designed. Discussion Should the SLN procedure prove feasible and safe in recurrent vulvar cancer, it will be available for implementation in clinics worldwide. The inclusion of women ineligible for the SLN procedure in the current prospective study will help to bridge knowledge gaps and define future research questions. Trial registration Medical Ethical Committee approval number NL70149.078.19 (trial protocol version 2.0, date March 2nd, 2020). Affiliation: Erasmus Medical Centre. Dutch trial register NL8467. Date of registration 19.03.2020.
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Affiliation(s)
- Helena C van Doorn
- Department of Gynaecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Maaike H M Oonk
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Guus Fons
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Katja N Gaarenstroom
- Department of Obstetrics and Gynaecology, Leids University Medical Center, Leiden, The Netherlands
| | - Joanne de Hullu
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.,Department of Epidemiology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heleen J van Beekhuizen
- Department of Gynaecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
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Giannini A, D'Oria O, Chiofalo B, Bruno V, Baiocco E, Mancini E, Mancari R, Vincenzoni C, Cutillo G, Vizza E. The giant steps in surgical downsizing toward a personalized treatment of vulvar cancer. J Obstet Gynaecol Res 2021; 48:533-540. [PMID: 34962334 PMCID: PMC9302990 DOI: 10.1111/jog.15103] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/15/2021] [Accepted: 11/07/2021] [Indexed: 12/01/2022]
Abstract
The present article aims to highlight the importance of changes of personalized surgical treatment for vulvar cancer. Current international literature regarding surgical treatment of vulvar cancer was evaluated. This included several studies and systematic reviews. Radical surgery approach, such as en bloc resection, was the first therapeutic option and the standard care for many years, even if burdened with a high complication rate and frequently disfiguring. Taussing and Way introduced radical vulvectomy approach with en bloc bilateral inguinal-femoral lymphadenectomy; modified radical vulvectomy was developed, with a wide radical excision of the primary tumor. The role of inguinofemoral lymphadenectomy (mono or bilateral) changed in the years too, particularly with the advent of SLN biopsy as minimally invasive surgical approach for lymph node staging, in patients with unifocal cancer <4 cm, without suspicious groin nodes. More personalized and conservative surgical approach, consisting of wide local or wide radical excisions, is necessary to reduce complications as lymphedema or sexual disfunction. The optimal surgical management of vulvar cancer needs to consider dimensions, staging, depth of invasion, presence of carcinoma at the surgical margins of resection and grading, with the goal of making the treatment as individualized as possible.
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Affiliation(s)
- Andrea Giannini
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy.,Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Rome, Italy
| | - Ottavia D'Oria
- Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in "Translational Medicine and Oncology", Sapienza University, Rome, Italy
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Valentina Bruno
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Ermelinda Baiocco
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Emanuela Mancini
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Rosanna Mancari
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Cristina Vincenzoni
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Giuseppe Cutillo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
| | - Enrico Vizza
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCSS-Regina Elena National Cancer Unit Institute, Rome, Italy
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Baiocchi G, de Freitas RR, Bovolim G, Badiglian-Filho L, da Costa AABA, De Brot L. Immunohistochemical expression of ErbB/HER family proteins in patients with vulvar cancer. Int J Gynaecol Obstet 2021; 157:102-109. [PMID: 34270807 DOI: 10.1002/ijgo.13829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/14/2021] [Accepted: 07/12/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To investigate the immunohistochemical (IHC) expression of the ErbB/HER family in primary vulvar squamous cell carcinoma (VSCC). METHODS We analyzed a series of 125 patients who were surgically treated for VSCC from January 1980 to June 2016. All cases had lymph node (LN) staging and 80 had LN metastasis. A tissue microarray was built for epidermal growth factor receptor (EGFR), HER2, HER3, and HER4 IHC staining. RESULTS In the primary tumor we found positive expressions for EGFR, HER2, HER3, and HER4 in 5%, 0.9%, 0.9%, and 22.8%, respectively. For the LN metastasis, expressions of EGFR and HER4 were positive in 22.2% and 39.1%, respectively. No cases had positive staining for HER2 and HER3 in the LN metastasis. For HER4, positive expression correlated with smaller tumor sizes (P = 0.02). However, positive HER4 was related to adverse prognostic factors such as: histological grade (P = 0.012), presence of lymphovascular space invasion (40.9% vs 16.2%; P = 0.035), and perineural invasion (57.1% vs 16.7%; P = 0.006). Notably, all cases with LN metastasis had positive HER4 in the primary tumor (P < 0.001). ErbB/HER family expression was not related to worse survival. CONCLUSION EGFR, HER2, and HER3 were infrequently expressed in VSCC by IHC. HER4 IHC expression was found in 22.8% of cases and was related to adverse prognostic factors.
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Affiliation(s)
- Glauco Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | - Graziele Bovolim
- Department of Anatomic Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | | | | | - Louise De Brot
- Department of Anatomic Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
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Pecorino B, Scibilia G, Ferrara M, Di Stefano AB, D'Agate MG, Giambanco L, Scollo P. Prognostic factors and surgical treatment in vulvar carcinoma: Single center experience. J Obstet Gynaecol Res 2020; 46:1871-1878. [PMID: 32700378 DOI: 10.1111/jog.14368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/04/2020] [Accepted: 06/10/2020] [Indexed: 11/29/2022]
Abstract
AIM Vulvar carcinoma represents 3-5% of all female genital cancers; the main surgical treatment is radical vulvectomy and inguinal lymphadenectomy. The aim of this study is to analyze prognostic factors in the patients underwent to primary surgery for vulvar carcinoma. METHODS One hundred and eighteen cases of vulvar carcinoma underwent surgery between 2006 and 2016 at Operative Unit of Gynecology and Obstetrics of Cannizzaro Hospital (Catania, Italy) were retrospective analyzed. Risk factors for relapse (age, tumor size, FIGO stage, type of surgery, lymphadenectomy, margins status, metastatic nodes and radiotherapy) were evaluated by logistic regression. Univariate analysis of prognostic factors (age, tumor size, FIGO stage, metastatic inguinal nodes and type of surgery) was obtained by Cox proportional hazard model. Overall survival was calculated by Kaplan-Meier curves either for the entire population and for comparison between positive and negative variables (margin status, nodes and radiotherapy) with log-rank test to determine significance. Statistical significance was reached for P < 0.05. RESULTS Type of surgery (radical local excision vs. radical vulvectomy) and positive inguinal nodes were identified as risk factors for relapse. Positive inguinal nodes and positive margins were identified as prognostic factors either for overall survival and disease specific survival; tumor size greater than 4 cm was identified as prognostic factors for overall survival. Overall survival was 38.4% and it was significantly higher in the patients with negative margins and nodes. CONCLUSIONS Nodes status, resection margins, age and type of surgery represent prognostic factors have to be considered for adjuvant treatment in the patients affected from vulvar carcinoma.
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Affiliation(s)
- Basilio Pecorino
- Gynecology and Obstetrics, Maternal and Child Department, Cannizzaro Hospital, Catania, Italy
| | - Giuseppe Scibilia
- Gynecology and Obstetrics, Maternal and Child Department, Cannizzaro Hospital, Catania, Italy
| | - Martina Ferrara
- Gynecology and Obstetrics, Maternal and Child Department, Cannizzaro Hospital, Catania, Italy
| | | | - Maria Gabriella D'Agate
- Gynecology and Obstetrics, Maternal and Child Department, Cannizzaro Hospital, Catania, Italy
| | - Laura Giambanco
- Department of Obstetrics and Gynecology, S.Antonio Abate Hospital, Trapani, Italy
| | - Paolo Scollo
- Gynecology and Obstetrics, Maternal and Child Department, Cannizzaro Hospital, Catania, Italy
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Kofler S, Kobleder A, Ott S, Senn B. The effect of written information and counselling by an advanced practice nurse on resilience in women with vulvar neoplasia six months after surgical treatment and the influence of social support, recurrence, and age: a secondary analysis of a multicenter randomized controlled trial, WOMAN-PRO II. BMC Womens Health 2020; 20:95. [PMID: 32375773 PMCID: PMC7203815 DOI: 10.1186/s12905-020-00965-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women with vulvar neoplasia often complain about physical and psychological distress after surgical treatment. Lack of information and support can influence resilience. Whether an information-related intervention through an advanced practice nurse supports resilience and which other factors affect resilience in women with vulvar neoplasia has never been investigated. METHODS The aims of this study were (a) to analyse whether counselling based on the WOMAN-PRO II program causes a significant improvement in the resilience scores of women with vulvar neoplasia compared to written information and (b) to identify the potential predictors of resilience. A randomized controlled trial was conducted in women with vulvar neoplasia (n = 49) 6 months after surgical treatment in four Swiss hospitals and one Austrian hospital. Analyses of resilience and its predictors were performed using a linear mixed model. RESULTS Thirty-six women (intervention I, n = 8; intervention II, n = 28) completed the randomized controlled trial. In total, 13 women (26.5%) dropped out of the trial. The resilience score did not differ significantly between the two interventions three and six months after randomisation (p = 0.759). Age (b = .04, p = 0.001), social support (b = .28, p = 0.009), counselling time (b = .03, p = 0.018) and local recurrence (b = -.56, p = 0.009) were identified as significant predictors of resilience in the linear mixed model analyses. CONCLUSION The results indicate that the WOMAN-PRO II program as single intervention does not cause a significant change in the resilience scores of women with vulvar neoplasia 6 months after surgery. Predictors that promote or minimise resilience have been identified and should be considered when developing resilience programs for women with vulvar neoplasia. A repetition of the study with a larger sample size is recommended. TRIAL REGISTRATION The WOMAN-PRO II program was registered in ClinicalTrials.gov NCT01986725 on 18 November 2013.
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Affiliation(s)
- Sabine Kofler
- Institute for Applied Nursing Sciences IPW-FHS, FHS St. Gallen, University of Applied Sciences, Rosenbergstrasse 59, 9001, St. Gallen, Switzerland.
| | - Andrea Kobleder
- Institute for Applied Nursing Sciences IPW-FHS, FHS St. Gallen, University of Applied Sciences, Rosenbergstrasse 59, 9001, St. Gallen, Switzerland
| | - Stefan Ott
- Lecturer for Business Mathematics and Statistics, University of Applied Sciences FHS St. Gallen, Rosenbergstrasse 59, 9001, St. Gallen, Switzerland
| | - Beate Senn
- Institute for Applied Nursing Sciences IPW-FHS, FHS St. Gallen, University of Applied Sciences, Rosenbergstrasse 59, 9001, St. Gallen, Switzerland
- Sydney Nursing School, The University of Sydney, Mallett Street 88, 2050, Camperdown, NSW, Australia
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Skanjeti A, Dhomps A, Paschetta C, Tordo J, Giammarile F. Sentinel Node Mapping in Gynecologic Cancers: A Comprehensive Review. Semin Nucl Med 2019; 49:521-533. [DOI: 10.1053/j.semnuclmed.2019.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Zongo N, Korsaga Somé N, Ouédraogo S, Ouédraogo AS, Zamané H, Zida M, Ouangre E, Sanou A, Niampa P, Lompo OM, Traoré A, Dem A. [Cancer of the vulva: Diagnostic stages, treatment and survival in a country with limited resources (Burkina Faso)]. Bull Cancer 2019; 106:1057-1063. [PMID: 31542167 DOI: 10.1016/j.bulcan.2019.07.008] [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: 04/30/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Vulvar cancer is rare and belatedly diagnosed in Africa. We describe its diagnostic stages, therapeutic and evolution features in a country with limited resources. METHODOLOGY Forty-seven cases of vulvar cancer diagnosed between 2013 and 2018 in Burkina Faso, were analyzed retrospectively. The diagnostic stages, therapeutic and evolution terms were considered. Survival was calculated through the Kaplan Meier Method and compared using the Logrank technique. RESULTS Stages IA and IB accounted for 10.6%. Radiotherapy was not available and chemotherapy was done in 9 cases. Full vulvectomy with bilateral inguino-femoral dissection was performed in 11 cases. Average survival was 41 months with a median of 52 months. The difference in survival according to the diagnostic stages were highly significant statistically (P=0.000). DISCUSSION Cancer of the vulva is rare and raises major therapeutic difficulties in countries with limited resources. Surgery is the only affordable weapon. Evolution would be better if radiochemotherapy was possible. CONCLUSION Radiochemotherapy cannot be done due to the lack of a radiotherapy unit and the high cost of cytotoxics. Surgery is largely palliative and/or mutilating. Survival is modest. An early diagnosis could help promote conserving treatments.
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Affiliation(s)
- Nayi Zongo
- CHU Yalgado, Ouedraogo, chirurgie viscérale, Ouagadougou, Burkina Faso.
| | - Nina Korsaga Somé
- CHU Yalgado Ouedraogo, dermatologie vénérologie, Ouagadougou, Burkina Faso
| | - Smaila Ouédraogo
- CHU Yalgado Ouedraogo, Santé publique, Ouagadougou, Burkina Faso
| | | | - Hyacinthe Zamané
- CHU Yalgado, Ouedraogo, gynéco-obstétrique, Ouagadougou, Burkina Faso
| | - Maurice Zida
- CHU Yalgado, Ouedraogo, chirurgie viscérale, Ouagadougou, Burkina Faso
| | - Edgard Ouangre
- CHU Yalgado, Ouedraogo, chirurgie viscérale, Ouagadougou, Burkina Faso
| | - Adama Sanou
- CHU Yalgado, Ouedraogo, chirurgie viscérale, Ouagadougou, Burkina Faso
| | - Pascal Niampa
- CHU Yalgado Ouedraogo, dermatologie vénérologie, Ouagadougou, Burkina Faso
| | | | - Adama Traoré
- CHU Yalgado Ouedraogo, dermatologie vénérologie, Ouagadougou, Burkina Faso
| | - Ahmadou Dem
- Institut de cancérologie Joliot Curie de Dakar, Sénégal
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Treatment Outcomes of Patients with Squamous Cell Carcinoma of the Vulva: The Largest Series from a Tertiary Care Hospital. Obstet Gynecol Int 2018; 2018:4723167. [PMID: 30250487 PMCID: PMC6140126 DOI: 10.1155/2018/4723167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 07/23/2018] [Accepted: 08/12/2018] [Indexed: 11/18/2022] Open
Abstract
Objective To evaluate the outcomes of squamous cell carcinoma (SCCA) of the vulva treated at our tertiary care center. Methods The medical records of SCCA patients treated between January 2006 and December 2015 were retrospectively reviewed. Results One hundred forty-five patients met the criteria with the median age of 57 years old, and 58.6% had an underlying disease. The distribution of stages was as follows: IA 6.2%, IB 21.4%, II 26.2%, IIIA 14.5%, IIIB 6.2%, IIIC 9.7%, IVA 9.0%, and IVB 6.9%. One hundred and nine patients underwent surgical intervention and radical local excision with bilateral groin node dissection as the most frequent procedure. Approximately half of the patients received combined treatment with surgery followed by radiation with or without chemotherapy. Recurrence developed in 127 patients after the median follow-up time of one year with the common sites in the groin and vulva region. However, no significant difference in survival occurred in patients with and without groin node recurrence (15 vs. 28 months, P=0.109). The five-year overall survival was 50.8%. Conclusions The survival of patients with SCCA vulvar cancer was modest. The common failure sites were groin and vulva regions with unfavorable outcomes.
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The Role of Pathological Margin Distance and Prognostic Factors After Primary Surgery in Squamous Cell Carcinoma of the Vulva. Int J Gynecol Cancer 2018; 28:623-631. [DOI: 10.1097/igc.0000000000001195] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectiveThe aim of this study was to determine the impact of clear surgical margin distance and other factors associated with the recurrence and survival of patients with squamous cell carcinoma of the vulva.Methods/MaterialsA total of 107 patients operated for vulvar carcinoma from 1996 to 2016 were included in the analysis. Patients were divided into subgroups with clear pathological margin of 2 mm or less, greater than 2 to less than 8 mm, and 8 mm or greater for the analysis of the prognostic impact of the clear margin distance. Data were analyzed using the Kaplan-Meier method and Cox proportional hazards regression.ResultsThe median age of the patients was 66 years. The median follow-up was 69 months. The labia majora and/or labia minora were the most common sites of involvement. Radical local excision and radical vulvectomy were performed in 96 and 11 patients, respectively. Thirty-nine patients received adjuvant radiotherapy. The overall recurrence rate was 46%. At 231 months, the actuarial local recurrence rate was 18.6%. Patients with clear pathological margin of 2 mm or less had significantly higher local recurrence risk. Five-year disease-free survival was 32.7%. Older age and adjuvant chemotherapy were found as independent prognostic factors for disease-free survival.ConclusionOur data suggest that a more than 2 mm tumor-free margins is associated with better local control. In addition, older age is an independent prognostic factor for survival.
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Predictors and Patterns of Local, Regional, and Distant Failure in Squamous Cell Carcinoma of the Vulva. Am J Clin Oncol 2017; 40:235-240. [PMID: 25503429 DOI: 10.1097/coc.0000000000000138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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13
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Modified Gluteal Fold V-Y Advancement Flap for Reconstruction After Radical Vulvectomy. Int J Gynecol Cancer 2016; 26:1300-6. [DOI: 10.1097/igc.0000000000000765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
ObjectiveTo describe the surgical technique of the V-Y cutaneous supra-fascial (modified) gluteal advancement flaps for reconstruction after radical vulvectomy and to assess the outcome of patients according to their clinical characteristics.MethodsBetween January 2006 and July 2012, 36 V-Y flaps were performed in 21 patients to cover the defect after radical surgery of primary vulvar cancers. Surgery duration, blood loss, hospital stay, and wound healing were assessed according to patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the initial defect size.ResultsMedian patient age, BMI, and ASA score were 80 (range, 31–91), 28 (range, 18–36), 3 (range, 1–3), respectively. Median surgery duration and blood loss were 180 minutes (range, 60–275) and 400 mL (range, 100–1000), respectively. Median operating time was higher in patients ASA3 than ASA less than 3, 200 versus 120 minutes (P = 0.038). Median initial defect size was higher in patients with BMI greater than 28 than 28 or less, 92 versus 55 cm2 (P = 0.004). Local scar defect was observed in 16 patients (76%), mild, less than 10 cm2 in 10 patients. Median wound healing duration was higher in patients with bilateral than unilateral flap, 16 versus 9.5 days (P = 0.034).ConclusionsThe V-Y cutaneous suprafascial gluteal advancement flap for vulvar reconstruction after vulvectomy is an easy, safe, and reliable procedure. However, even mild local scar defect after bilateral flap may impact on wound healing and hospital stay, in elderly and ASA3 patients.
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Hannes S, Nijboer JM, Reinisch A, Bechstein WO, Habbe N. Abdominoperineal Excisions in the Treatment Regimen for Advanced and Recurrent Vulvar Cancers-Analysis of a Single-Centre Experience. Indian J Surg 2016; 77:1270-4. [PMID: 27011549 DOI: 10.1007/s12262-015-1273-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Accepted: 04/14/2015] [Indexed: 11/25/2022] Open
Abstract
Vulva cancer is the fourth leading gynaecological malignancy, accounting for approximately 4 % of all gynaecological cancers. Surgery represents the treatment of choice, and cases of advanced or recurrent vulvar cancers are to date a major challenge to multidisciplinary teams. Abdominoperineal excision (APE) in combination with vulvectomy and inguinal lymphadenectomy is the only curative treatment option. Patients' files of all women with squamous cell carcinoma of the vulva who underwent abdominoperineal resection were retrospectively reviewed with special regards to technical challenges the general surgeon will face. Seven women were enrolled in this retrospective study with a median age of 71 years (range 56-79 years). In six patients, the pelvic floor after abdominoperineal excision could be closed by direct suture of the levator muscles. One woman underwent abdominoperineal resection with closure of the defect using a vertical rectus abdominis myocutaneous (VRAM) flap. All women underwent radical vulvectomy, in five patients in combination with bilateral inguinal lymph node dissection. Operation time was 377 min (range 130-505 min). The median overall survival after surgery was 27 months (range 4-84 months), with a calculated 5-year survival rate of 42 %. Women with negative lymph nodes revealed a longer survival time after surgery compared to women with lymph node metastases (15.5 vs. 72 months; p = 0.09). Abdominoperineal excisions represent a powerful tool in the multidisciplinary treatment regimen of advanced or recurrent vulvar cancer. Reconstruction of the pelvic floor usually does not require myocutaneous flaps, even when facing large tumours. Despite high complication rates, radical surgery was a feasible treatment with long-term survival potential without mortality.
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Affiliation(s)
- Sabine Hannes
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Johanna M Nijboer
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Alexander Reinisch
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Wolf O Bechstein
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Nils Habbe
- Department of General- and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Repeat sentinel lymph node procedure in patients with recurrent vulvar squamous cell carcinoma is feasible. Gynecol Oncol 2016; 140:415-9. [DOI: 10.1016/j.ygyno.2016.01.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 11/19/2022]
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Liu CE, Lu Y, Yao DS. Feasibility and Safety of Video Endoscopic Inguinal Lymphadenectomy in Vulvar Cancer: A Systematic Review. PLoS One 2015; 10:e0140873. [PMID: 26496391 PMCID: PMC4619862 DOI: 10.1371/journal.pone.0140873] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 10/01/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To systematically review previous studies and to evaluate the feasibility and safety of video endoscopic inguinal lymphadenectomy (VEIL) in vulvar cancer. METHODS We conducted a comprehensive review of studies published through September 2014 to retrieve all relevant articles. The PubMed, EMBASE, Web of Science, Cochrane Library, Wan Fang Data and Chinese National Knowledge Infrastructure databases were systematically searched for all relevant studies published in English or Chinese through September 2014. Data were abstracted independently by two reviewers, and any differences were resolved by consensus. RESULTS A total of 9 studies containing 249 VEIL procedures involving 138 patients were reviewed. Of the 249 VEIL procedures, only 1 (0.4%) was converted to an open procedure for suturing because of injury to the femoral vein. The range of operative time was 62 to 110 minutes, and the range of estimated blood loss was 5.5 to 22 ml. The range of the number of harvested lymph nodes was 7.3 to 16. The length of hospital stay varied from 7 to 13.6 days across reports. The incidence of lymph node metastasis was 19.7% (27/138), and the recurrence rate was 4.3% (3/70) within 3 to 41 months of follow-up. One or more short-term complications were documented in 18 of 138 (13.0%) patients. Complications after VEIL were observed in 14 (10.13%) patients and in 15 (6.0%) of the VEIL cases, including major lymphocyst formation in 9 (3.6%), lymphorrhea in 2 (0.8%), inguinal wound infection without wound breakdown in 3 (1.2%) and lymphedema in 1 (0.4%). CONCLUSIONS VEIL appears to be a feasible procedure in the management of vulvar cancer. There may be potential benefits that result in lower morbidity compared to traditional methods, but this has yet to be objectively proven.
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Affiliation(s)
- Chai-e Liu
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Guang Xi Medical University, Nanning, People’s Republic of China
| | - Yan Lu
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Guang Xi Medical University, Nanning, People’s Republic of China
| | - De-Sheng Yao
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Guang Xi Medical University, Nanning, People’s Republic of China
- * E-mail:
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Baiocchi G, Mantoan H, de Brot L, Badiglian-Filho L, Kumagai LY, Faloppa CC, da Costa AABA. How important is the pathological margin distance in vulvar cancer? Eur J Surg Oncol 2015; 41:1653-8. [PMID: 26507171 DOI: 10.1016/j.ejso.2015.09.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/17/2015] [Accepted: 09/27/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The ideal pathological margin in vulvar squamous cell carcinoma (VSCC) is still debated. Our aim was to analyze the value of tumor-free pathological margin distance with regard to local recurrence in VSCC. METHODS We analyzed a series of 205 patients who were treated for VSCC from January 1980 to November 2007. Patients were categorized into 3 groups, based on pathological free margin (PFM): <3 mm (n = 18); ≥3 and <8 mm (n = 61); and ≥8 mm (n = 126). RESULTS The median age was 69 years. The median PFM was 10 mm (range: 1-65). Of 168 patients who underwent lymphadenectomy, 64 (38.1%) developed LN metastasis. After a median follow-up of 36.2 months, 78 (38%) cases recurred-47 (60.2%) experienced a local recurrence (LR). LR occurred in 16.7% of patients with a PFM of <3 mm, 24.6% with a PFM ≥3 and <8 mm, and 22.2% of those with a PFM ≥8 mm (p = 0.77). PFM did not correlate with LR when analyzed continuously (p = 0.98). The 5-year disease-free survival (DFS) for LR was 79.6%. Margin distance did not negatively impact DFS (p = 0.94); the presence of perineural invasion was the only variable that negatively influenced DFS (p = 0.009). CONCLUSIONS Although our results suggest no correlation between LR and pathological margin distance, the tumor-free resection margin remains significant with regard to locoregional control in vulvar cancer. A more conservative surgical approach may be considered in certain situations, such as margins near the clitoris, urethra, and anus.
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Affiliation(s)
- G Baiocchi
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil.
| | - H Mantoan
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - L de Brot
- Department of Anatomic Pathology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - L Badiglian-Filho
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - L Y Kumagai
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - C C Faloppa
- Department of Gynecologic Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
| | - A A B A da Costa
- Department of Medical Oncology, AC Camargo Cancer Center, Sao Paulo, Brazil
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Li L, Kou X, Feng X, Liu F, Chao H, Wang L. Clinical application of sartorius tendon transposition during radical vulvectomy: a case control study of 58 cases at a single institution. J Gynecol Oncol 2015; 26:320-6. [PMID: 26404124 PMCID: PMC4620369 DOI: 10.3802/jgo.2015.26.4.320] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/09/2015] [Accepted: 06/28/2015] [Indexed: 11/30/2022] Open
Abstract
Objective The aim of this study was to investigate the clinical effects of sartorius tendon transposition versus sartorius transposition during bilateral inguinal lymphadenectomy of radical vulvectomy. Methods A total of 58 vulvar cancer patients who had surgery from May 2007 to October 2013, in which 30 patients received sartorius transposition and 28 patients received sartorius tendon transposition. All patients were matched by age, body mass index, stage, histology, and grade. Intraoperative variables and postoperative complications, recurrence, progression-free survival (PFS), and overall survival (OS) and postoperative life quality were compared and analyzed. Results No significant differences were found at median surgical times and amounts of bleeding (p=0.316 and p=0.249, respectively), neither at the incidences of groin cellulitis and lymphocele (p=0.673 and p=0.473, respectively), but the recovery times of the inguinal wounds were shorter (p=0.026) and the incidences of wound break and chronic lymphedema were significantly decreased in the tendon transposition group (p=0.012 and p=0.022, respectively). Postoperative quality of life in tendon transposition group was significantly improved as indicated by the EORTC QLQ-C30 questionnaire. Recurrences were similar (p=0.346) and no significant differences were found at PFS and OS (p=0.990 and p=0.683, respectively). Conclusion Compared to sartorius transposition, sartorius tendon transposition during inguinal lymphadenectomy led to improved patient recovery, reduced postoperative complications, and improved life quality without compromising the outcomes.
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Affiliation(s)
- Lei Li
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China.
| | - Xinxin Kou
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaojie Feng
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Fenghua Liu
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongtu Chao
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
| | - Liying Wang
- Department of Gynecologic Oncology, Affiliated Tumor Hospital of Zhengzhou University, Zhengzhou, China
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de Melo Maia B, Ling H, Monroig P, Ciccone M, Soares FA, Calin GA, Rocha RM. Design of a miRNA sponge for the miR-17 miRNA family as a therapeutic strategy against vulvar carcinoma. Mol Cell Probes 2015; 29:420-426. [PMID: 26297962 DOI: 10.1016/j.mcp.2015.08.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/30/2015] [Accepted: 08/16/2015] [Indexed: 01/06/2023]
Abstract
Dysregulation of microRNAs has been studied thoroughly, and has been observed in a variety of tumors including vulvar carcinomas, a rare type of gynecological tumor with increasing incidence. However, very few therapeutic alternatives have reached the clinical setting, and there is an urgent unmet need to develop novel strategies for patients with this tumor type. Thus, a microRNA (miRNA) sponge for the miR-17 miRNA family was designed, synthesized and validated in vitro in order to explore a new therapeutic strategy based on inhibiting this oncogenic miRNA family in vulvar cancer. Members of the miR-17 family were evaluated for expression in a vulvar tumor cell line (SW954) and 20 HPV negative formalin-fixed paraffin-embedded (FFPE) samples by quantitative real-time PCR (qRT-PCR). Six in tandem, bulged sequences that were complementary to these miRNAs were designed, synthesized, cloned, and transfected into SW954 cells. A luciferase reporter assay with a psiCheck2 vector was used to test the specificity of the sponge sequences for miR-17 family miRNA binding. Taqman qRT-PCR was used to test how the sponges affected miRNA expression. In FFPE samples, higher expression of miR-20a and miR-106a correlated with deeper tumor invasion (P = 0.0187 and P = 0.0404, respectively). The luciferase reporter assay validated the specificity of the sponge for miR-17 family members. Using qRT-PCR, we confirmed this specificity with decreased expression in 5 (out of six) miRNAs of the miR-17 family in SW954 cells. Although our results are preliminary, these results demonstrate that these miRNA sponges are potent inhibitors of the miR-17 family of miRNAs in SW954. Therefore, this miRNA-specific sponge may be developed into a novel therapeutic treatment for patients with vulvar cancer.
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Affiliation(s)
- Beatriz de Melo Maia
- Molecular Morphology Laboratory, AC Camargo Cancer Center, São Paulo, SP, Brazil; Department of Experimental Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Hui Ling
- Department of Experimental Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Paloma Monroig
- Department of Experimental Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Maria Ciccone
- Department of Experimental Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Fernando A Soares
- Department of Anatomic Pathology, AC Camargo Cancer Center, São Paulo, SP, Brazil.
| | - George A Calin
- Department of Experimental Therapeutics, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA; The Center for RNA Interference and Non-Coding RNAs, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Rafael M Rocha
- Molecular Morphology Laboratory, AC Camargo Cancer Center, São Paulo, SP, Brazil.
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Senn B, Kobleder A, Raphaelis S, Mueller MD, Kammermann B, White K, Eicher M. Prevention and Reduction of Complications in Women with Vulvar Cancer: Development of an Algorithm for Safer Multidisciplinary Care. ACTA ACUST UNITED AC 2015. [DOI: 10.4236/jct.2015.610090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Comino R, Coronado PJ, Cararach M, Nieto A, Martinez-Escoriza JC, Salamanca A, Torres-Garcia LM, Vidart JA, Mendoza N, Torne A, Sánchez-Borrego R. Spanish consensus on vulvar disorders in postmenopausal women. Maturitas 2014; 80:226-33. [PMID: 25529938 DOI: 10.1016/j.maturitas.2014.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 11/19/2014] [Accepted: 11/20/2014] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The consequences of vulvar disorders in terms of health, sexuality, and quality of life are usually undervalued, with disparities in the conceptual, diagnosis and treatment criteria. AIM The objective of this guide will be to analyse the factors associated with the diagnosis and treatment of vulvar disorders and to provide recommendations for the most appropriate diagnostic and therapeutic measures. METHODOLOGY A panel of experts from various Spanish scientific societies related to sexual health (Spanish Menopause Society [SMS] and the Asociación Española de Patología Cervical y Colposcopia [AEPCC]) met to reach a consensus on these issues and to decide the optimal timing and methods based on the best evidence available. RESULTS We recommend a biopsy of all vulvar lesions with an uncertain diagnosis, especially with asymmetry, irregular borders, variegated and irregular colour and diameter >6mm. For vulvodynia, we recommend the use of lubricants or topical treatments with lidocaine or bupivacaine, amitriptyline, baclofen or triamcinolone. For vulvar epithelial disorders, we recommend beginning with topical corticosteroids of moderate to high potency. For sexual dysfunction, a multidisciplinary approach is the best management strategy in these patients.
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Matsuo K, Whitman SA, Blake EA, Conturie CL, Ciccone MA, Jung CE, Takiuchi T, Nishimura M. Feto-maternal outcome of pregnancy complicated by vulvar cancer: a systematic review of literature. Eur J Obstet Gynecol Reprod Biol 2014; 179:216-23. [DOI: 10.1016/j.ejogrb.2014.04.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 03/26/2014] [Accepted: 04/08/2014] [Indexed: 01/07/2023]
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