Verrucous Carcinoma of the Vulva: A Case Report and Literature Review

Cervical verrucous cancer misdiagnosed with verrucous hyperplasia: A case report

Background

There are many different variants of squamous cell carcinoma (SCC), and verrucous carcinoma (VC) is a rare and highly differentiated SCC. Due to its preference of local invasion, regional lymphatic involvement rarely occurs. VC is difficult to diagnose using conventional pap smear or cervical punch biopsy, in which adequate stroma including bulbous rete pegs is required for a definitive diagnosis. Surgical management is recommended as the first-line treatment with radiotherapy forbidden due to the risk of anaplastic transformation.

Case report

We presented a 59-year-old Taiwanese female who had postmenopausal bleeding for three months with two consecutive normal pap smear and biopsy at other hospital. Pelvic examination showed a necrotic fungating cervical mass with upper 1/3 vaginal involvement. Colposcopic guided cervical biopsy and fractional dilatation and curettage revealed verrucous hyperplasia (VH) with negative high-risk HPV typing. Pelvic 3T magnetic resonance imaging (MRI) was arranged, and a 3.7 × 3.6 × 4.0 cm necrotic mass at the cervix with an enlarged left pelvic lymph node was found. Positron emission tomography with computed tomography (PET/CT) demonstrated avid uptake at the cervix and left pelvic lymph node. Surgical intervention was performed due to highly suspicious of cervical verrucous carcinoma with positive pelvic lymph node. The final pathologic report was a well-differentiated verrucous carcinoma, IIA2 by International Federation of Gynecology and Obstetrics (FIGO) classification.

Conclusion

VC is difficult to diagnose preoperatively, and surgical excision is recommended as the first-line treatment.

The reconstructive strategy for pelvic oncological surgery with various types of MS-VRAM flaps

BACKGROUND

Muscle-sparing vertical rectus abdominis myocutaneous (MS-VRAM) flaps are widely used in pelvic reconstruction. Aiming at optimal reconstructive outcomes, flap design and modification should be individualized to restore various kinds of defects.

OBJECTIVE

Summarize an empirical strategy about MS-VRAM selection for different pelvic and perineal reconstructions.

METHODS

Thirty patients who underwent total pelvic exenteration and pelvic reconstruction surgery from 2009 to 2017 were enrolled. The patients were divided into four groups according to the type of MS-VRAM-based flap used in the procedure: the modified long vertical flap (n = 10), the wrapping flap (n = 6), the de-epithelialized flap (n = 6), and the cork flap (n = 8). The follow-up period was 1 year after the surgery. Flap size, drainage volume, postoperative satisfaction, and complications were recorded, and postoperative photographs were collected.

RESULTS

All of the patients achieved satisfying effect under the targeted reconstruction strategy. Of the four groups, the accurate cork flap finally acquires higher satisfaction, the shortest hospital stay, and the least total drainage volume. Meanwhile, the incidence of complications was not increased compared with the other groups.

CONCLUSIONS

A new reconstructive strategy for pelvic reconstruction was established. Functional or non-functional reconstruction was accomplished by using various MS-VRAM flaps. Among them, the cork flap is the most economical flap to reconstruct pelvic floor defects with minimal tissue requirement and donor trauma.

Verrucous carcinoma of the vulva: Patterns of care and treatment outcomes

BACKGROUND

Verrucous vulvar carcinoma (VC) is an uncommon and distinct histologic subtype of squamous cell carcinoma (SCC). The available literature on VC is currently limited to case reports and small single institution studies.

AIMS

The goals of this study were to analyze data from the National Cancer Database (NCDB) to quantitate the incidence of VC and to investigate the effects of patient demographics, tumor characteristics, and treatment regimens on overall survival (OS) in women with verrucous vulvar carcinoma.

METHODS AND RESULTS

Patients diagnosed with vulvar SCC or VC between the years of 2004 and 2016 were identified in the NCDB. OS was assessed with Kaplan-Meier curves and the log-rank test. Construction of a Cox model compared survival after controlling for confounding variables. The reported incidence of SCC of the vulva has significantly increased since 2004 (p < .0001). In contrast, the incidence of VC has remained stable (p = .344) since 2004. Compared to SCC, VC was significantly more likely to be diagnosed in older women (p < .0001) and treated with surgery alone (p < .0001). However, on propensity score weighted analysis there was a trend toward improved 5-year OS in women with VC compared to those with SCC (63.4% vs. 57.7%, p = .0794). Multivariable Cox survival analysis showed an improvement in OS in VC patients treated with both primary site and regional lymph node surgery compared to primary site surgery alone (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.46-0.97, p = .0357).

CONCLUSION

Verrucous carcinoma is more likely to present in older women. Regional lymph node surgery in addition to primary site surgery significantly improves OS in VC patients.

Perforator flaps for vulvar reconstruction: basic principles

BACKGROUND AND AIM

In vulvar cancer, the standard treatment is radical local excision, with immediate reconstruction. Reconstruction aims to restore anatomy and function of the external female genitalia, facilitating preservation of normal body image, sexual function, and micturition and defecation functions.

METHODS

The purpose of this paper is to describe the principles of perforator flaps for vulvar reconstruction.

RESULTS

Basic concepts, indications and operative technique are discussed and detailed.

CONCLUSIONS

In vulvar reconstruction, the use of perforator flaps is a superior surgical technique when compared to the use of conventional flaps.

Pembrolizumab in FIGO IVB Verrucous Carcinoma of the Vulva: A Case Report

Background

Vulvar cancer is the fourth most common gynecologic cancer, and prognosis is poor in advanced vulvar cancer patients. Treatment for advanced vulvar cancer has not been satisfactory. In this report, we firstly report a FIGO IVB vulva verrucous carcinoma patient who obtained good prognosis after systemic treatment.

Case Presentation

A patient was admitted to hospital due to her vulvar lesion persistent for past 14 years. The vulvar mass has widely invaded urethra, part of anus, the lower third of the vagina, bilateral superior and inferior branches of pubis, and bilateral internal and external muscles of obturator. Multiple metastatic lymph nodes were also found in the pelvic cavity. The histopathological studies confirmed vulvar verrucous carcinoma with a PD-L1 overexpression. After six courses of neoadjuvant chemotherapy and pembrolizumab, the patient underwent radical vulvectomy and achieved optimal cytoreduction. Postoperative pathology found no residual tumor. The patient then received one course of postoperative chemotherapy and pembrolizumab, underwent radiation therapy, and was disease free after 6 months follow-up.

Conclusion

Our individualized treatment strategy is successful. Pembrolizumab is safe and effective in the treatment of advanced vulvar verrucous carcinoma with PD-L1 overexpression.

Oral retinoid, acitretin, is effective in the management of resistant recurrent vulval verrucous carcinoma: A case report

Verrucous carcinomas are a rare variant of squamous cell carcinoma. Vulval verrucous carcinoma comprises only 1% of vulval malignancies. This case report discusses the successful management of aggressive recurrent vulval verrucous carcinoma with acitretin, an oral synthetic retinoid used to manage severe psoriasis, after multiple surgical interventions and radiotherapy had failed. This is the first reported case in which verrucous carcinoma had recurred in a musculocutaneous graft. To manage the recurrence, the patient underwent radiotherapy, which did not resolve the condition. The patient was then administered acitretin 25 mg once daily, which successfully resolved the condition, and the patient has been symptom free for 6 months. This report aims to propose the use of acitretin as a management option for recurrent verrucous carcinomas.

Non-HPV-related verrucous carcinoma of the endometrium: report of one case and review of literature

The clinicopathologic diagnosis and treatment of a case of endometrial verrucous carcinoma were analyzed, combined with the relevant literature for review and discussion. The patient was a 67-year-old postmenopausal woman who had recurrent vaginal bleeding with increased secretion. The gross morphology and histopathology of the uterine cavity tumor had typical characteristic changes of verrucous carcinoma. There was obvious inflammation in the tumor background and squamous differentiation in the residual endometrial gland basal reserve cells. Tumor cell immunohistochemistry showed wild-type P53, P16 negative expression and HPV molecular test was negative. The expression of p63 was positive in squamous differentiated reserve cells, and Ki67 showed high proliferative activity. Verrucous carcinoma of endometrium is a rare tumor with low malignancy, that belongs to a special subtype of squamous cell carcinoma. It is easily missed or misdiagnosed and has a long diagnosis cycle. The diagnosis should be combined with clinical data, imaging and pathology. The pathogenesis of the disease is not clear. Surgical treatment is the first treatment, and the clinical prognosis is good.

Transcatheter Arterial Chemoembolization Treatment for Vulvar Cancer: A Case Report

Vulvar cancer is a rare malignant tumor occurring in elderly postmenopausal women. At present, surgery is the main treatment for vulvar cancer. Chemotherapy alone has no obvious therapeutic effect as a treatment for vulvar cancer, so it is often combined with radiotherapy or surgery. Selective arterial infusion chemotherapy and embolization is rarely used for the treatment of vulvar cancer. A 63-year-old Tibetan woman underwent superselective arteriography and embolization. On the 7th day after the operation, the vulvar tumor was necrotic and fell off, and a skin defect at the left labia majora appeared. This patient had no other serious complications. Arterial embolization can block the blood supply to a vulvar tumor, has an obvious effect in reducing the tumor, and can even induce tumor necrosis and make the tumor fall off. However, the skin defect after necrosis and abscission does not heal easily, and even carries the risk of local bleeding, which should be paid attention to by the interventionalist and oncologist. The clinical effects of transcatheter arterial embolization for vulvar cancer still need to be studied by interventionalists and oncologists.