Isolated skin bridge metastasis following modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy

Separate vulvar and groin incisions have significantly reduced the morbidity of vulvar cancer surgery. We describe a patient with FIGO stage II squamous vulvar cancer, who developed an ipsilateral tumor recurrence in the skin bridge between the vulva and the groin within 7 months of modified radical vulvectomy and bilateral inguinofemoral lymphadenectomy, using triple incisions. The recurrence was treated by wide local excision alone and she remains free of disease 2 years later. Although rare, the potential for failing to excise tumor emboli in the lymphatics of the skin bridge must be recognized when the triple incision technique is used in the surgical treatment of vulvar cancer.     

Radical vulvectomy and inguinal lymphadenectomy versus inguino-pelvic lymphadenectomy combined with radical vulvectomy and the role of radiotherapy

We studied 39 patients with stromal invasion exceeding 1 mm. Among them 3 underwent emivulvectomy and 8 simple vulvectomy; all had selective inguinal lymphadenectomy of one side the first and bilaterally the others. 17 women underwent radical vulvectomy and inguinal lymphadenectomy while 11 had radical vulvectomy and inguino-pelvic lymphadenectomy. Out of 21 patients with lymph nodal metastases, 11 had one side inguinal metastases, 2 had a single metastasis, 2 had double metastases, 1 had three metastases and 2 multiple ones. Survival rate decreased from 54.5% to 20.0% when patients had more than 3 monolateral inguinal metastases or bilateral ones, with increase of pelvic lymph nodal metastases; therefore, in those cases, pelvic lymphadenectomy can be associated to inguinal lymphadenectomy or, when the carcinoma is situated in the clitoridis, Bartolino's gland or vagina (the same could be done for melanoma of the vulva). The usefulness of radiotherapy is limited by the small response of vulvar tissue. In a series of 45 patients with clinical diagnosis of inguinal metastases, who could not undergo operation, only therapy, with electron beam therapy (9 meV) associated to inguinal fields (15 meV), had positive influence in 27% of the cases.     

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.     

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.     

Simple extrafascial trachelectomy and pelvic bilateral lymphadenectomy in early stage cervical cancer

Objective

To determine the feasibility and safety of simple extra-fascial trachelectomy plus pelvic lymphadenectomy in young patients affected by early stage cervical cancer.

Methods

We have prospectively identified all patients with early-stage cervical cancer (stages IA2-IB1) referred to our department. Inclusion criteria were: age ≤ 38 years, strong desire to maintain fertility, FIGO stage ≤ IB1, tumor size < 2 cm, no LVSI, no evidence of nodal metastasis. Surgical technique included two steps: laparoscopic pelvic lymphadenectomy and vaginal simple extrafascial trachelectomy. Patients were followed up for oncological and obstetrical outcomes.

Results

Fourteen patients were enrolled in the study. Median age was 32 years (range 28-37); histotype was squamous in 11/14 (79%) cases and adenocarcinoma in 3/14 cases (21%); FIGO stage was IA2 in 5/14 (36%) patients, IB1 in 9/14 (64%) patients; median tumor size was 17 mm (range 14-19); median operative time was 120 min (range 95-210). No severe intraoperative complications were recorded. Postoperative complications were observed in two patients. No recurrences were detected. One patient died for other disease. Eight patients became pregnant and 3 of them had a term delivery.

Conclusion

Low risk early-cervical cancer patients could be safely treated by simple extrafascial trachelectomy in order to maintain fertility. More studies are needed to better define the role of conservative and ultraconservative surgical approaches (i.e. conization) in this setting, either for fertility purposes or to minimize surgical complications.     

外阴癌淋巴结切除适应证和争议

外阴局部广泛切除术+腹股沟淋巴结切除术是目前外阴癌的基本手术方式。FIGO和NCCN指南均推荐FIGOⅠA期可不行腹股沟淋巴结切除术,所有ⅠB期或Ⅱ期患者,应该行腹股沟淋巴结切除术。晚期外阴癌在确定总体治疗方案前,应先明确腹股沟淋巴结状态,再确定后续处理方案。如果术前未发现可疑转移淋巴结,行双侧腹股沟、股淋巴结切除术;术前已明确淋巴结阳性者,建议仅切除肿大的淋巴结,术后给予腹股沟和盆腔放疗,最好避免系统性淋巴结切除术。在有关淋巴结切除的争议中,切除腹股沟、股淋巴结及采用三切口腹股沟横切口技术、保留大隐静脉等被大多数学者认可;但对于靠近中线但不侵犯中线的病灶是否可不切除双侧腹股沟淋巴结及外阴黑色素瘤、前庭大腺癌等少见病理类型的淋巴结切除指征尚有争议。     

外阴癌手术切口愈合不良的防治

外阴癌手术后切口愈合不良一直是妇科肿瘤医生所面临的挑战和难题。根据肿瘤特点和病情需要制定适宜的手术范围和手术方式,并在术前、术中及术后各个环节做好预防工作,是促进外阴癌手术切口愈合、减少切口相关并发症的根本措施。本文在分析切口愈合不良影响因素的基础上提出预防切口愈合不良的建议和措施,以供临床借鉴和参考。     

Evaluation of the Pfannenstiel incision for radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy

Abstract. Mendez LE, Cantuaria G, Angioli R, Mirhashemi R, Gabriel C, Estape R, Penalver M. Evaluation of the Pfannenstiel incision for radical abdominal hysterectomy with pelvic and para-aortic lymphandenectomy.
Radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy (RAH/P + PAL) has classically been described through a low midline vertical incision. Transverse incisions have been used with good results for various pelvic surgical procedures. Hesitancy has been encountered when utilizing these transverse incisions in gynecologic oncology patients. In most studies, muscle-splitting transverse incisions seem to be of equal efficacy as midline vertical incisions in regards to surgical exposure and clinicopathologic data obtained and are known to be superior in cosmesis and postoperative morbidity. A retrospective chart review was performed to identify 25 patients who underwent RAH/P + PAL for stage I carcinoma of the cervix from 1990 to 1998 through a nonmuscle splitting (Pfannenstiel) abdominal incision. All patients were seen and had follow-up in the Division of Gynecologic Oncology, University of Miami School of Medicine/Jackson Memorial Medical Center (Miami, FL). Data were collected on various clinical and surgical parameters including height/weight, operative time, blood loss, number of lymph nodes obtained, length of hospital stay, and postoperative complications. Analysis of the data revealed that operative time and average blood loss were within acceptable parameters. The yield at lymphadenectomy for pelvic and para-aortic lymph nodes was also respectable. Postoperative complications were minimal and there were no wound complications reported. Therefore, the Pfannenstiel incision can be safely utilized in a select group of patients undergoing RAH/P + PAL.     

Early clitoral carcinoma successfully treated by radiotherapy and bilateral inguinal lymphadenectomy

Abstract. Jones RW, Matthews JH. Early clitoral carcinoma successfully treated by radiotherapy and bilateral inguinal lymphadenectomy.
A 42 year-old female presented with an early stage IB squamous cell carcinoma involving the clitoris. She was treated with radical radiotherapy to the clitoris and peri-clitoral region and bilateral inguinal lymphadenectomy. The treatment was well tolerated. The vulvar appearance, sensation and orgasmic function have not been impaired. There has been no recurrence during five years of follow-up. Radiotherapy and bilateral inguinal lymphadenectomy are an effective therapeutic option in early stage IB carcinoma involving the clitoris in sexually active females.     

Comparison of recurrence after vulvectomy and lymphadenectomy with and without sentinel node biopsy in early stage vulvar cancer

OBJECTIVES: To determine the usefulness of sentinel lymph node biopsy in early stage vulvar cancer and to assess recurrences after surgical treatment with sentinel node identification or surgical treatment without sentinel node identification. METHODS: We reviewed the records of 55 patients with early stage vulvar cancer operated on between 1995 and 2005. A prospective series of 28 patients who underwent vulvectomy and lymphadenectomy with intraoperative sentinel lymph node identification between 2000 and 2005 (SLN group) was compared with a retrospective series of 27 patients who underwent vulvectomy and lymphadenectomy without sentinel node procedure between 1995 and 2000 (non-SLN group). Patients in the sentinel node identification group underwent preoperative lymphoscintigraphy (technetium-99 colloid albumin injection around the tumor) and intraoperative mapping with isosulfan blue dye. RESULTS: In the SLN group, 9 tumors were T1 and 19 were T2, with a total of 40 groins dissected and 9 positive nodes in 7 patients. Sixty-two sentinel lymph nodes were detected with a mean of 2.2 sentinel nodes per patient (range 0-4). A false negative case was found. In the non-SLN group, 7 tumors were T1 and 20 were T2, with a total of 49 groins dissected and 9 positive nodes in 6 patients. Recurrence occurred in 8 patients (28.6%) in the SLN group and in 6 (26.9%) in the non-SLN group (P=0.8). CONCLUSIONS: Sentinel lymph node identification in early stage vulvar cancer is a feasible. Analysis of recurrence may allow considering this procedure as a possible alternative to inguino-femoral lymphadenectomy.     

Radical vulvectomy and groin node dissection in a patient with chronic neutropenia—maintenance of leucocyte count using granulocyte colony-stimulating factor

A patient was referred for consideration of radical surgery in the presence of chronic neutropenia. We report the successful maintenance of an adequate neutrophil count during the perioperative period using Granulocyte colony-stimulating factor (GCSF), resulting in successful primary healing of the wounds in the absence of infective complications. The use of GCSF in gynecology is briefly reviewed.     

Squamous cell cancer of the vulva with occult lymph node metastases in the groin: the impact of surgical technique on recurrence pattern and survival

OBJECTIVE: The triple incision technique is an established surgical method of management for early vulvar cancer. There is only limited data available on the efficacy of this form of treatment for patients with occult inguinofemoral lymph node metastases. It was the objective of this study to obtain more insight into the efficacy of this treatment compared with the en bloc resection, when utilized in surgical pathological advanced disease. METHODS: A retrospective review was performed in patients with vulvar cancer in the presence of occult inguinofemoral lymph node metastases. Tumor diameter, extracapsular nodal spread, FIGO stage, number of positive lymph nodes, and type of treatment were analyzed in relation to recurrence pattern and survival in both univariate and multivariate analyses. RESULTS: There was no significant impact of surgical technique on disease-specific and overall survival. When corrected for other prognostic variables in a multivariate analysis, the type of surgical treatment was an independent predictor for vulvar recurrence (HR 0.10, 95% CI 0.02-0.44, P = 0.002) but not for inguinal/pelvic recurrence. CONCLUSION: The type of surgical technique did not influence disease-specific and overall survival in patients with occult inguinofemoral lymph node metastases. The triple incision technique is an independent poor prognostic variable for vulvar recurrence.     

Simple conization and lymphadenectomy for the conservative treatment of stage IB1 cervical cancer. An Italian experience

Objectives

Simple conization represents a plausible treatment scheme for managing stage IA1-2 tumors conservatively. However its curative potential has not been widely exploited as regards stage IB1 lesions. Recent studies suggest that, in selected circumstances, patients with stage IB1 disease undergoing radical hysterectomy could have been safely cured by simple hysterectomy and even by cervical conization.

Methods

Patients with stage IB1 cervical cancer desiring conservative management underwent simple conization and pelvic lymphadenectomy in three Italian institutes.

Results

Thirty-six women received the conservative treatment since 1995 to 2010. Median age was 31 (range 24-40) years and median tumor size was 11.7 mm (range 8-25 mm). Adenocarcinoma was present in 12 cases (33%) and grade 3 neoplasia in 5 (14%). Lymph-vascular space involvement was detected in five patients (14%). Eleven had already a child while two had experienced an early abortion and a fetal loss at second trimester.After a median follow-up of 66 months (range 6-168) only one pelvic lymphnodal relapse was observed. Twenty-one pregnancies occurred in 17 patients and 14 live babies have been born (two preterm at 27 and 32 weeks) while one is ongoing. Three first-trimester miscarriages, one second-trimester fetal loss, an ectopic pregnancy and a termination of pregnancy have been recorded.Five patients decided to undergo hysterectomy after 3-12 years after conservative therapy: in one residual microinvasive adenocarcinoma was found.

Conclusions

Cervical conization represents a feasible conservative management of stage IB1 cervical cancer and shows a low risk of relapse, provided that patients are selected carefully. Conization would be suitable to treat stage IB lesions smaller than 15-20 mm. with pathologic negative lymphnodes.     

Recurrent vulvar carcinoma in the intervening tissue bridge in early invasive stage I disease treated by radical vulvectomy and bilateral groin dissection through separate incisions

Early invasive stage I squamous cell carcinoma of the vulva treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy rarely recurs, particularly when the lymph nodes contain no metastatic tumor. Primary radical surgery in this patient utilized separate groin incisions, and recurrent tumor developed in the tissue bridge between the groin scar and the vulva. Reexploration showed numerous inguinofemoral nodes to subseqently contain recurrent carcinoma. Literature regarding early, "microinvasive," squamous cell carcinoma of the vulva is reviewed.     

Twelve-year experience with laparoscopic radical hysterectomy and pelvic lymphadenectomy in cervical cancer

Objectives

This study aims to evaluate the morbidity, oncological outcome, and prognostic factors of cervical cancer patients treated with laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH).

Methods

Patients with cervical cancer undergoing LRH at the First People's Hospital of Foshan between August 1998 and March 2010 were enrolled in this study. The medical records were reviewed.

Results

A total of 240 patients were identified. According to FIGO stage, the number of patients with stage Ia2, Ib1, Ib2, IIa, and IIb was 2, 163, 34, 35, and 6, respectively. The conversion rate was 1.25%. Intraoperative and postoperative complications occurred in 7.08% and 9.16% patients, respectively. Other medical problems included 74 cases (30%) of bladder dysfunction. Excluding the lost cases, the median follow-up of 221 cases was 35 months, and 5-year survival rate for Ia2, Ib1, Ib2, IIa was 100%, 82%, 66%, 60%, respectively. Univariate analysis showed factors impacting the survival rate were FIGO stage > Ib1, non-squamous histologic type, deep cervical stromal invasion, and lymph node metastasis (P = 0.027, 0.023, 0.007, 0.000). The Cox-proportional hazards regression analysis indicated that only lymph node metastasis (OR = 3.827, P = 0.000) was independent of poor prognostic factor. The 5-year survival rates in Ib1 were 88% with negative lymph nodes and 59% with positive lymph nodes (P = 0.000).

Conclusions

Our data demonstrate that LRH can be performed in stage Ia2-Ib1 or less advanced node negative cervical cancer patients without compromising survival. The feasibility of LRH for more advanced patients needs further investigations.     

子宫颈浸润癌介入、手术、再介入治疗30例临床探讨

目的　根据女性盆腔血管解剖学和生理学特点以及介入放射学理论 ,子宫颈癌对化疗药物的敏感性 ,应用介入、手术、再介入的方法治疗子宫颈浸润癌 ,观察其消长变化 ,评价该治疗方案在临床上的应用价值。方法　子宫颈浸润癌Ⅰb -Ⅲ期患者 30例 ,术前常规行盆腔介入治疗。介入后 1 4d左右 ,行子宫颈癌根治术 ,术后根据临床分期分别再介入 3～ 6次。结果　治疗后追踪随访 1～ 6年 ,全部未见复发征象。结论　本组临床观察结果初步肯定介入、手术、再介入方法在治疗子宫颈浸润癌方面是有前途的     

Radical hysterectomy and pelvic lymphadenectomy for early invasive cancer of the cervix — 14-year experience

During a 14-year period, 397 radical hysterectomies and pelvic lymphadenectomies were performed for early invasive carcinoma of the cervix. Twenty-one patients were in stage IA₂ with lymphatic/vascular channel permeation (5.2%), 340 in stage IB (85.6%) and 34 in early stage 2A disease (8.5%). Eighteen patients (4.5%) were pregnant. Adenocarcinoma comprised 26.9% of cases. The mean operative time was 4.14 h; the intraoperative blood loss was less than 1.51 in 77.3% patients. There was no operative mortality; one patient died 3 weeks after surgery from clostridium difficile enterocilitis. Eleven patients (2.7%) developed venous thrombosis; severe lymphedema occurred in four (1%). The incidence of uretero-vaginal fistula was 0.2% and that of vesico-vaginal fistula 0.5%. Ovarian metastases were noted in 4.3% of cases with adenocarcinoma. Sixty-six patients had positive nodes (16.6%). Five-year survival in patients with more than 2 positive nodes was 68%. The use of adjuvant chemotherapy in patients with 'high risk' factors resulted in survival rates approaching those without risk factors. Neo-adjuvant chemotherapy was used in 10 patients with large bulky tumors; the results were favorable. Recurrences occurred in 47 patients (11.8%); 36 patients have died (9.1%). Age did not appear to influence survival. The overall 5-year survival was 92.2%.     

Comparison of midline and Pfannenstiel incision for radical hysterectomy with pelvic and paraaortic lymphadenectomy in cervical carcinoma

AIM: To compare Pfannenstiel and midline incisions with respect to efficacy and early postoperative surgical site complications in patients with early stage cervical carcinoma. METHODS: Patients with cervical carcinoma who underwent radical hysterectomy during 1995-2004 are retrospectively reviewed. There were 40 patients in the Pfannenstiel group and 71 patients in the midline group. Patients' age, type of incision, operative time, hospitalization length, postoperative surgical site complications, pre and postoperative Hb levels, number of extracted pelvic and paraaortic lymph nodes were the variables collected from the patients' files and oncology follow-up forms. RESULTS: Mean age (53.5+/-6.96 vs 55.9+/-10.5, P=0.2) and preoperative Hb levels of patients (12.52+/-1.48 vs 12.94+/-1.34, P=0.17) were not statistically different in midline and Pfannenstiel groups, respectively. Operative time (141.8+/-36 vs 135.8+/-31 min), number of extracted lymph nodes in pelvic (23.05+/-9.7 vs 23.5+/-8.07) and paraaortic areas (3.17+/-1.68 vs 2.66+/-1.15) were not significantly different among the midline and Pfannenstiel groups, respectively (P>0.05). Although postoperative incisional complications were more common in the midline group, this difference did not reach a significant level (11.3% vs 7.5%, P=0.52). Duration of hospitalization was not significantly different between the midline and Pfannenstiel groups, respectively (6.3+/-2.69 vs 6.2+/-2.72 days, P=0.21). Multivariate analysis revealed postoperative Hb levels to be significantly different among the groups (P=0.017, OR=1.59, 95% CI: 1.08-2.35). CONCLUSION: Pfannenstiel incision can be used for radical hysterectomy with pelvic and paraaortic lymphadenectomy in selected patients with cervical carcinoma, without any negative influence on optimal resectability of tumor and surgical morbidity.