Skin bridge recurrences in vulvar cancer: frequency and management

Abstract. Rose PG. Skin bridge recurrences in vulvar cancer: frequency and management.
The use of separate groin incisions has markedly reduced the rate of wound breakdown from radical vulvectomy. This retrospective review was undertaken to evaluate the frequency and management of skin bridge recurrences. Five cases of skin bridge recurrence in vulvar cancer were identified among 128 patients. Patient demographics, pathology, recurrence management, and follow-up were obtained from operative and clinical records and tumor registries.
Five cases of isolated skin bridge recurrence were studied, of which four patients had squamous cancer and one melanoma. Excluding one case referred at recurrence, this occurred in 2.4% of patients with squamous cell carcinoma and was more common in patients with positive nodes 3 of 41 patients versus 0 of 85, relative risk 3.07 (95% confidence interval 2.39–3.95). The median time to recurrence following surgery was 4.0 months (range 1–47 months). Four recurrences were treated by radical local excision alone, but 3 had already received radiation therapy. One patient developed a second skin bridge recurrence and was treated with a second radical local excision. Three patients are alive and recurrence-free 38+ to 56+ months (median 51+ months) following treatment for recurrence.
Skin bridge recurrences are rare and more common in patients with inguinal node metastasis. Local excision with or without radiation therapy is the most common therapy that has been employed. In the absence of other metastases local excision is associated with a good recurrence-free survival.     

Radical vulvectomy and bilateral groin lymphadenectomy utilizing separate groin incisions: report of a case with recurrence in the intervening skin bridge

Postoperative wound breakdown is very common following the en bloc dissection of the vulva and inguinal/femoral lymph nodes for carcinoma of the vulva. To decrease the incidence of wound morbidity, techniques have been described for performing the inguinal/femoral lymphadenectomy through separate groin incisions. This approach leaves a bridge of tissue between the vulvar excision and the lymph node dissection. A case of stage I squamous cell carcinoma of the vulva that was treated with a radical vulvectomy and bilateral inguinal/femoral lymphadenectomy utilizing separate groin incisions is presented. This patient later developed a recurrence in the tissue bridge between the vulvar and groin excisions. The mechanism for this recurrence is discussed.     

Hip disarticulation for recurrent vulvar cancer in the groin.

A patient with squamous cell carcinoma of the vulva treated with a radical vulvectomy and bilateral inguinal and femoral lymphadenectomies utilizing separate groin incisions, subsequently developed a recurrence in the skin bridge between the vulvar and groin excisions. Following groin irradiation with chemosensitization, the tumor progressed to involve the superior public ramus and femoral vessels. A left hip disarticulation and resection of a portion of the superior pubic ramus was performed. The patient has been free of disease for 3 years. The advantages of this procedure over a hemipelvectomy include shorter operative time, reduced blood loss, better fascial closure of the abdomen, and the creation of a stump which is more amendable to prosthetic fitting.     

Have patients with early squamous carcinoma of the vulva been overtreated in the past? The Norwegian experience 1977-1991

OBJECTIVE: To evaluate different surgical approaches in early squamous vulvar cancer. METHODS: Review of clinical and histopathologic data and follow-up information of 216 patients with clinical FIGO stage I-II disease, primarily treated by surgery from 1977-1991. RESULTS: Eighty-nine patients underwent radical vulvectomy with bilateral groin dissection by en bloc excision, 60 by the triple incision technique, 20 individualized vulvar surgery with uni-or bilateral groin dissection, and 47 vulvar surgery only. Groin metastases occurred in 9% stage I and 25% stage II disease. Groin involvement was not seen in stage I tumors with invasion depth < or =/=1 mm. Bilateral metastases occurred in medially located tumors of both stages, and laterally located stage II. Metastases were ipsilateral in lateral stage 1. Separate groin dissection significantly reduced morbidity. Sixty-six patients relapsed, 14 after more than 5 years. Vulvar recurrence was related to tumor diameter and the condition of the resection borders. The single most important predictor of death from vulvar cancer was the presence of inguinal femoral lymph node metastases. Conservative and individualized surgery did not compromise 5-year survival. CONCLUSIONS: A careful selection of patients fitted for less radical surgery is essential to avoid undertreatment. Groin dissection can be omitted in tumors with diameters < or =/=2 cm and invasion depth < or =/=1 mm. At least ipsilateral groin dissection is needed in all other cases. Groin dissection should be performed through separate incisions. Modified vulvectomy is appropriate provided radicality can be obtained. Long-time follow-up is important as recurrences can be seen many years after primary therapy.     

Morbidity and recurrence with modifications of radical vulvectomy and groin dissection.

Vulvar carcinoma has been managed in recent years with modifications of radical vulvectomy and groin dissection. Separate groin incisions, superficial inguinal lymphadenectomy, unilateral groin dissection, and wide excision have been utilized to reduce the morbidity of treatment. In this study, the surgical management of 82 patients with vulvar squamous cell carcinoma was reviewed in order to assess morbidity and risk of recurrence. A modification of radical vulvectomy and groin dissection was employed in 67 patients, while 15 patients underwent classical en-bloc vulvar and groin dissection. Wound complications of the vulva occurred in 1 of 12 patients undergoing hemivulvectomy, in 8 of 55 undergoing radical vulvectomy, and in 7 of 15 who had en-bloc vulvar resection and groin dissection (P = 0.01). Among the 46 patients undergoing bilateral groin dissection through separate incisions, groin breakdown, lymphocyst, and lymphedema occurred in 10 (22%), 7 (15%), and 7 (15%), versus 0, 1 (7%), and 2 (13%) of the 15 who had unilateral groin dissection. Modification of vulvar resection did not increase the risk of local recurrence. Groin recurrence developed in 2 of 15 patients who underwent en-bloc groin dissection and in 1 of 46 who underwent bilateral groin dissection through separate incisions. Two of 15 who had a unilateral groin dissection recurred in the contralateral groin. The risk of recurrence as well as morbidity following modifications of radical vulvectomy with groin dissection should be considered when planning treatment.     

V--Y flap for perineal reconstruction following modified approach to vulvectomy in vulvar cancer.

OBJECTIVE: To evaluate a simple reconstructive procedure used in combination with a modified oncological approach to the treatment of invasive vulvar cancer. Local and systemic morbidity, length of hospital stay, local recurrence, and mortality were evaluated. METHODS: Between September 1995 and January 1997, 19 patients underwent radical vulvectomy and inguinal lymphadenectomy with a modified oncological approach. The modified approach consisted of a triple incision: two inguinal incisions, shorter and following force lines of the groin, and a third incision around the vulvar lesion. Vulvectomy included a 2-cm safety margin around the tumor, based on clinical examination and anatomical-pathological frozen sections of the specimen. This procedure was always followed by perineal reconstruction with V-Y flaps by the plastic surgery team. Median follow-up was 12 months. The complication rate and lengths of hospital stay were evaluated and compared with those in a similar group in which radical vulvectomy was performed associated with two long longitudinal incisions in the groin. The data were statistically analyzed. RESULTS: The perineal and inguinal dehiscence rates in group A (traditional approach) were 68.4% and 78.94%, respectively. The same rates in group B (modified approach), were 10.5% and 36.84%, respectively. Mean hospital stay was 39.5 days in group A (traditional) vs. 14.0 days in group B (modified). At 30 months' median follow-up, the rate of local recurrence in group A (traditional) was 42.0%; at 12 months' median follow-up, local recurrence in group B (modified) was 26.3%. CONCLUSIONS: In this study, the use of V-Y flaps in combination with a modified oncological approach significantly reduced local complication rates and lengths of hospital stay, while observing oncological principles.     

Patterns and frequency of recurrences of squamous cell carcinoma of the vulva

OBJECTIVE: To analyze patterns and frequency of recurrences of squamous cell carcinoma (SCC) of the vulva after wide local excision (WLE) and superficial inguinal lymphadenectomy with separate incisions and to identify prognostic factors for the development of recurrences. METHODS: Between January 1985 and December 1999, all 125 consecutive patients with primary SCC of the vulva, treated with WLE and superficial inguinal lymphadenectomy, were retrospectively analyzed. Recurrences were registered by localization as: local, skin bridge, groin or distant. RESULTS: A local recurrence was diagnosed in 29 (23%) patients, 11 (9%) developed a groin and 4 (3%) a distant recurrence. No skin bridge recurrences were identified. The 5 years local relapse-free survival was 70%. After a first local recurrence, 72% of these patients developed a second local recurrence. Adjusted for other predictors, older age (>74 years) is an independent risk factor for local recurrences (HR: 2.38; 95%-C.I.: 1.08-5.23) and stage III/IV cancer for developing groin/distant recurrences (HR: 3.03; 95%-C.I.: 1.0-9.18). CONCLUSION: WLE and superficial inguinal lymphadenectomy with separate incisions result in a high groin recurrence rate in this study; superficial lymphadenectomy should be replaced by deep inguinofemoral lymphadenectomy. After a local recurrence, 72% of the patients developed a second local recurrence. These patients are at high risk and need a close follow-up.     

En bloc radical vulvectomy and lymphadenectomy with modifications of separate groin incisions.

A new modification of radical vulvectomy and lymphadenectomy through separate groin incisions involves dissection of the intervening skin bridge and allows an en bloc dissection. The results in 26 women treated with this technique are compared with those of seven treated with separate incisions without an en bloc dissection. All 33 women had squamous carcinoma of the vulva and were treated between 1985-1989. The incidence of advanced disease was high, with nodal metastases present in 52% of cases. Dissection of the tissue beneath the skin bridge did not alter the morbidity of the procedure in terms of the incidence of wound infection, number of units of blood transfused, or duration of hospitalization. The only case of an isolated recurrence in the skin bridge occurred in a woman who did not have an en bloc dissection, although there was no significant difference in the overall local recurrence rate between the groups. Further evaluation with larger numbers is required, but we suggest that an en bloc dissection using separate incisions may reduce the risk of isolated recurrence in the skin bridge, particularly in patients with advanced disease.     

Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer

BACKGROUND:Recurrent vulvar cancer involving the femoral artery after groin radiation is usually considered inoperable. A patient with such recurrent vulvar cancer successfully treated by femoral vascular graft and rectus abdominis myocutaneous flap reconstruction with limb salvage is described. CASE: A 51-year-old woman had recurrent vulvar cancer involving the right femoral vessels 6 months after a radical vulvectomy plus inguinal lymphadenectomy and postoperative pelvic and groin radiation. Radical en bloc excision of tumor along with the involved femoral artery and vein followed by Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction led to a complete remission. However, occlusion of the grafted vessels occurred 21 months following bypass surgery. Since the compensatory collaterals were established, debridement and removal of the occluded graft were carried out. The patient has been clinically free of disease for more than 48 months since graft reconstruction surgery. CONCLUSION: It is highlighted that aggressive tumor resection with limb salvage is feasible even for patients with vulvar cancer of the groin recurrence involving the femoral artery after primary surgery and groin radiation.     

Verrucous carcinoma of the vulva

We reported a case of verrucous carcinoma of the vulva, (VCV) presented at an 71 year old caucasian woman, who was admitted to University of Chile Clinical Hospital, December 11, 1987. She had complained of vulvar itching, pain and a tumor at left labium mayor during the last ten years. The tumor was removed, and then a simple vulvectomy with bilateral superficial lymphadenectomy through separate groin incisions was performed. All the 27 inguinal nodes were free of metastasis, and the vulvar skin presented a mixed dystrophy with light atypia (VIN I). She is alive and well one year after surgical treatment.     

Vulvar squamous cell carcinoma. Prognostic factors for local recurrence after primary en bloc radical vulvectomy and bilateral groin dissection

OBJECTIVE: To evaluate clinical prognostic factors for local recurrence of vulvar squamous cell carcinoma after primary surgical treatment. STUDY DESIGN: Of 104 patients treated for squamous cell carcinoma of the vulva in an 11-year period (1987-1997) at the Portuguese Cancer Institute, we selected for study 56 patients who meet the following criteria: (1) International Federation of Gynecology and Obstetrics (FIGO) stage Ib-IVa, (2) primary treatment of en bloc radical vulvectomy and bilateral groin dissection, and (3) follow-up reports. Files were retrieved for retrospective analysis. Fifteen patients (26.8%) had local recurrence at the fifth year. At the 24th month, 11 patients had local recurrence, and 31 were in follow-up, without recurrence. We evaluated age at initial diagnosis, date of surgical treatment, tumor size, results of tumor macroscopy, histologic differentiation, groin lymph node status, FIGO stage, resection limits, adjuvant radiotherapy, duration of stay, associated vulvar skin disease, date of detection of recurrence, site/sites of recurrence and follow-up status at the 24th month after surgical treatment between the 11 patients with local recurrence and 31 in follow-up without recurrence. RESULTS: The 11 patients with local recurrence had a significant initial FIGO stage, IVa (P = .049) and a significant association with the number of groin lymph nodes containing metastasis in comparison to the 31 patients without local recurrence. No other statistically compared data were significant. CONCLUSION: These results suggest that vulvar squamous cell carcinoma local recurrence after a primary surgical procedure is related to poor tumor prognostic factors (number of groin nodes containing tumor metastasis and FIGO stage IVa). On multivariate analysis, the presence of metastasis in two or more groin nodes was a powerful factor related to local recurrence. Postoperative radiotherapy to the vulva for such patients with a high risk of local recurrence is advisable.     

Radical vulvectomy and bilateral inguinal-femoral lymphadenectomy through separate incisions—experience with 100 cases

Over a 6-year period 100 patients with vulvar cancer were treated by radical vulvectomy and bilateral inguinal femoral lymphadenectomy performed through separate incisions. The average age of the patients was 68.8 years. Ninety patients had squamous carcinoma, six had melanoma and four had other vulvar malignancies. FIGO staging was stage 1–46, stage II-25, and stage III-23, and stage IVa-6. Twenty-seven patients were found to have spread of tumor to groin nodes, 21 unilateral and six bilateral. For patients with squamous carcinomas, groin nodes were positive in four of 45 (8.9%) with tumor diameter < 2 cm vs. 17 of 42 (40.5%) with tumors> 2 cm. In 60 patients with unilateral squamous tumors, no isolated contralateral node metastases were found, however two of 13 patients (15.4%) with positive ipsilateral nodes had positive contralateral nodes also. One patient with negative nodes developed bilateral recurrent tumor in the skin bridges and subsequently died. Overall 5-year survival corrected for death from intercurrent illness was 74.6%. Corrected survival by stage for squamous carcinomas was as follows: stage I-96.7%, stage II-85%, stage III-45.8% and stage IV-50%.     

A modified triple incision technique for women with locally advanced vulvar cancer: a description of the technique and outcomes

Objective

Women with locally advanced vulvar carcinoma have an excellent chance of a cure by undergoing a radical vulvectomy with an “en bloc” inguinofemoral lymphadenectomy, but the morbidity associated this surgical approach is substantial. To achieve an outcome comparable with the traditional radical method in terms of oncologic safety, and an improved post-operative quality of life, we modified the classic triple-incision technique and suggested it as an alternative for these patients. The aim of this study was to report this new technique.

Study design

Between January 2004 and November 2009, 24 patients with clinical stage T2 (≥4 cm) or T3 invasive vulvar cancer underwent surgical treatment with our modified triple incision technique. Their clinical and surgical complications and follow-up data were retrospectively reviewed.

Results

The post-surgical complications were as follows: lymphoedema in 45.8%, wound breakdown in 20.8% and cellulitis in 8.3%. After a median follow-up of 35.5 months, three (12.5%) patients developed a recurrence in the skin bridge (2/24, 8.3%) or lungs (1/24, 4.2%). All patients suffering from skin bridge recurrences were salvaged by local re-resection. Four (16.7%) cases of death were noted: three (12.5%) patients died of non-cancer-related diseases and one (4.2%) died from a multifocal pulmonary metastasis; no evidence of vulvar or groin disease was observed at these patients’ last follow-up.

Conclusion

The modified triple-incision technique described in this preliminary study appears to be safe, feasible and tolerable for patients with a locally advanced vulvar cancer, and offers an acceptable morbidity.     

Skin metastases from vulvar cancer: a fatal event

BACKGROUND: Cutaneous metastases from a vulval cancer are exceptional with only 4 reported cases in the literature. CASE: The present case is a patient who had a radical vulvectomy with bilateral groin node dissection for a vulvar cancer stage Ib. After 9 months she a local recurrence, which was treated with radiotherapy. An anterior exenteration was performed 8 months later for a second local recurrence. Three months thereafter she had skin metastases at her thighs and calves. Chemotherapy was started; yet the lesions slowly increased. The treatment was discontinued and she died 4 months later. CONCLUSIONS: Skin metastases must be considered a preterminal event with no well-established treatment. They could be caused by retrograde permeation of tumor cells after the destruction of the local draining system.     

Limb sparing surgery for vulvar groin recurrence: A case report and review of the literature

Abstract. Sevin B-U, Abendstein B, Oldenburg WA, O'Connor M, Waldorf J, Klingler JP, Knudsen MJ. Limb sparing surgery for vulvar groin recurrence: a case report and review of the literature.
Hemipelvectomy was successfully avoided in a patient with extensive necrotic groin recurrence of vulvar cancer after prior radiation therapy. Tumor-free resection margins were achieved by wide excision of the recurrence including resection of the pubic bone and adjacent muscles. After resection of the femoral artery, blood supply to the leg was restored by an extra-anatomic axillopopliteal bypass. A myocutaneous flap from the contralateral rectus abdominis was used for primary wound closure. Limb salvage was achieved and the patient experienced pain relief, excellent cosmesis, and independent gait. Aspects of treatment options, even though primarily palliative, in groin recurrence of vulvar carcinoma are discussed.     

Groin recurrence after micrometastasis in a sentinel lymph node in a patient with vulvar cancer

BACKGROUND: The sentinel lymph node concept is attractive in vulvar cancer because of the potential to avoid the morbidity associated with formal groin dissection. CASE: An 84-year-old patient with a T2 carcinoma of the anterior vulva underwent surgery including bilateral sentinel node excision after identification with technetium-labeled nanocolloid. Frozen section histology showed a tumor deposit <1 mm in diameter in a left groin node whereas four nodes in the right groin were apparently negative. Completion lymphadenectomy was performed only for the left groin. Final histology including serial sectioning showed a micrometastasis in one of seven nodes from the right groin; no further treatment was given. Sixteen months postoperatively the patient developed a recurrence in the right groin; the left groin was free of tumor. CONCLUSION: This case indicates that groins with a micrometastasis detected by sentinel lymph node excision require further treatment.     

Salvage hemipelvis radiotherapy with fertility preservation in an adolescent with recurrent vulvar carcinoma

BACKGROUND: To preserve fertility, hemi-pelvis irradiation was chosen for locoregional groin recurrence of vulvar cancer in an adolescent. CASE: A case of squamous cell vulvar carcinoma in uncommonly young patient is presented. First surgical management (local excision of T1N0M0 tumor of the right labia minora) was performed at the age of 16.5 years. Further therapy included wide local resection of recurrent local lesion, two subsequent ipsilateral groin dissections of nodal metastases (with extranodal spread at the first instance), and ipsilateral pelvic lymphadenectomy. The patient was administered external beam irradiation of 45 Gy to the hemi-pelvis followed by 10.8 Gy boost to the right inguinal region. After 6.5 years from the completion of radiotherapy the patient is free of disease. She managed to conceive but the labor was premature and the infant died in its 7th week of life. CONCLUSION: In this case salvage hemi-pelvic irradiation for groin metastases of vulvar cancer has proved to be an effective treatment, allowing preservation of hormonal and obstetric functions. Partial post-irradiation damage of the uterus might have caused premature labor. Thus, special obstetric care is advisable in such situations.     

Operative Therapie des Vulvakarzinoms

The standard primary therapy for vulvar cancer is surgery. There have been important changes in the last decades especially concerning reduced radicality. Whereas en bloc resection of the whole vulva together with the inguinofemoral lymph nodes with the skin of the groins was previously routinely performed, the current approach is more adapted to the tumor stage. Separate triple incision in the vulva and the groins is the established standard procedure for carcinomas which are confined to the vulva. For T1 carcinomas which are definitively unilateral and node negative, ipsilateral groin dissection is sufficient. Localized carcinomas can be treated by radical local excision with good anatomical reconstruction results and oncological safety. Furthermore, current data permit the introduction of sentinel lymph node biopsy for node negative carcinomas with a diameter of less than 4 cm under certain structural prerequisites and quality criteria.     

Complete groin lymphadenectomy with preservation of the fascia lata in the treatment of vulvar carcinoma

OBJECTIVE: The goal of this study was to assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata (GNDPFL). METHODS: This study is a retrospective chart review of 60 patients with Stage I-IV vulvar carcinoma who underwent radical vulvectomy and GNDPFL between 1990 and 1998. All superficial inguinal nodes and the deep femoral nodes on the anterior and medial surfaces of the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and the cribriform fascia over the femoral artery. RESULTS: Of the 60 study patients, 14 patients had Stage I disease, 20 Stage II, 21 Stage III, and 5 Stage IV. The mean number of nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the sixty study patients (34%) had malignant nodes on groin dissection. Of these 21 patients, 2 experienced cancer recurrence in the groins. Our study describes a groin recurrence rate of 7.6% in patients with fewer than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles. CONCLUSIONS: The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable to radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.     

Single large inguinal lymph node metastasis in human papillomavirus-induced early invasive vulvar cancer of the anterior fourchette in two young women

The incidence of human papillomavirus (HPV)-induced vulvar cancer in young women is increasing and often presents as microinvasive or early invasive tumors in a grade 3 vulvar intraepithelial neoplasia. So far, the risk of lymph node metastases in early invasive vulvar carcinoma (depth of invasion 1.1-2.0 mm) is reported to be less than 8%. We present 2 cases of young women with early invasive vulvar cancers (depth of invasion 1.5 and 2.0 mm) induced by HPV 16 and 42. In both cases, the cancers are located between the clitoris and urethra and are each accompanied by one groin macro-metastatic lymph node. This case report highlights the necessity for complete inguinofemoral lymphadenectomy and/or adequate radiation therapy of the groin in early invasive tumors in young women to prevent cancer recurrence in the groin. Additionally, the indication for a sentinel node procedure in these specific cases requires particular caution.