Radical vulvectomy with partial rectal resection and temporary colostomy as primary therapy for selected patients with vulvar carcinoma

The patient with carcinoma of the vulva may present with tumor involvement of the perirectal area. Traditional treatment has often involved ultraradical therapy including a radical vulvectomy with posterior or total pelvic exenteration in an effort to obtain adequate surgical margins. Five-year survival rates for these patients range from 20-50%, and major operative morbidity as well as psychological problems are associated with this extensive surgery. Five patients treated for a locally advanced vulvar carcinoma involving the perirectal area were thought to be candidates for a rectum-sparing procedure. They underwent a radical vulvectomy, bilateral inguinal lymphadenectomy, partial rectal resection, and a diverting colostomy. Four of the five patients agreed to a colostomy closure 6 months after their primary therapy; these four patients have resumed normal bowel function. All patients remain clinically free of tumor.     

Laparoscopically Assisted Vulvocolpohysterectomy and Abdominoperineal Resection with Sigmoid Vaginal Replacement

BackgroundIn this report, we discuss the feasibility of laparoscopy for the resection of recurrent invasive vulvar cancer involving the vagina and anus (stage IVA), requiring radical surgical treatment.MethodsSuccessive steps of surgery are discussed: laparoscopic mobilization of the uterus, colon, and rectum for a posterior compartment exenteration (radical vulvectomy, colpohysterectomy, and abdominoperineal resection) and primary neovaginal reconstruction with sigmoid vaginal replacement.ResultsDuration of surgery was 240 minutes. There was no postoperative complication except for a small dehiscence of the perineal wound that healed completely without intervention. The patient was discharged 10 days after surgery. One month after surgery, coloplasty showed a good perineal opening and a depth of 12 cm. Minimal prolapse of the mucous of the coloplasty and abundant secretion could be observed. Adjuvant radiotherapy was indicated.ConclusionsThis combination of laparoscopic techniques is a potential alternative for exenteration or abdominoperineal resection requiring vaginal reconstruction.     

The influence of some prognostic factors on the clinical outcome of patients with squamous cell carcinoma of the vulva.

The present paper examined the influence of patient age, surgical T stage, tumor size, tumor differentiation and lymphnodal status on the clinical outcome of 29 patients with primary vulvar squamous cell carcinoma treated with radical surgery. Eighteen patients underwent radical vulvectomy with bilateral inguinal-femoral lymphadenectomy alone; 10 patients had additional bilateral pelvic lymphadenectomy; another patient had additional bilateral pelvic lymphadenectomy and anterior pelvic exenteration for a carcinoma of the clitoris involving the urethra. Nine patients developed relapsing disease; the site of recurrence was local in 4 patients, inguinal in 2, both local and inguinal in one patient, pelvic in one, both pelvic and distant in one. Eight recurrences occurred within 24 months from surgery; another patient developed an inguinal recurrence 45 months after operation. The actuarial 5-year disease-free survival rates were as follows: 64% for patients younger than 70 years and 63% for patients 70 years of age or older (p = not significant); 79% for patients with surgical T1-T2 stage disease and 30% for those with surgical T3 stage disease (p = 0.01); 88% for patients with tumor size less than 3 cm and 31% for those with tumor size greater than 3 cm (p less than 0.001); 66% for patients with well or moderately differentiated tumor and 51% for those with poorly differentiated tumor (p = not significant); 82% for patients with negative groin lymph nodes and 39% for those with positive groin lymph nodes (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Stage III and IV squamous cell carcinoma of the vulva

From 1957 to 1975, 61 patients with FIGO Stage III and IV vulvar carcinoma underwent primary therapy at Roswell Park Memorial Institute and all have been followed for 5 years or until death. The 5- and 10-year survival for Stage III was 77 and 60%, respectively. The 5- and 10-year survival for Stage IV was only 7.1%. Of the Stage III recurrences, 73.3% occurred within the local operated area: urethra, vagina, anus, or perineum. In contrast, 61% of the recurrences in Stage IV were distant, i.e., outside of the operated area. Because of the high local recurrence rate for Stage III and the low survival and high rate of distant recurrences in Stage IV, new treatment plans are proposed for patients with Stage III or IV vulvar carcinoma.     

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.     

The place of pelvic exenteration in the primary management of advanced carcinoma of the vulva

Over a 25-year period, 236 patients were treated surgically for carcinoma of the vulva. Of these, 13 (5%) were treated by radical vulvectomy with pelvic exenteration for Stage IV disease. Five of ten patients (50%) eligible for a 5-year survival were alive and well with no evidence of disease after this time. None of these five patients had lymph node metastases at the time of her surgery. A review of the English language literature from 1973 to date confirmed that the results with exenteration and radical vulvectomy in selected cases are good. Including our series, a total of 53 patients underwent this procedure, of whom 25 (47%) survived 5 years. In view of these findings, we feel that consideration should be given to the use of this procedure in patients with advanced, but resectable carcinoma of the vulva.     

Derzeitige Therapie des Vulvakarzinoms. Ergebnisse einer Umfrage an den deutschen Universitäts-Frauenkliniken

Treatments concepts for carcinoma of the vulva in German university clinics were surveyed in an inquiry made by letter. It was revealed that radical vulvectomy is standard therapy of invasive vulvar cancer. Patients with inguinal lymph-node metastases are treated by pelvic lymphadenectomy or radiation. Almost all clinics provide reconstructive procedures performed by a gynecologist and delineate an "early vulvar cancer" with less radical therapy. There is still some disagreement on the definition of criteria such as maximal tumor diameter and invasion.     

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.     

Successful salvage treatment of recurrent endometrial cancer with bulky central tumor and extensive lymph node metastasis. A case report

Recurrent endometrial cancer with both local and distant metastasis is very difficult to treat. A 55-year-old endometrial adenocarcinoma patient with bulky central recurrences and pelvic and inguinal lymph node metastases underwent laparotomy and paraaortic, pelvic and inguinal lymphadenectomy followed by concurrent chemoradiation (with cisplatin) to the paraaortic and inguinal lymph nodes as well as the whole pelvis. Neck and mediastinal lymph node metastasis emerged during treatment. Neck-node radiation and epirubicin was added followed by paclitaxel and carboplatin. Complete remission was achieved. Ten months later, isolated central re-recurrence happened and total pelvic exenteration was performed. The patient has survived without further recurrence for more than five years after the exenteration. Therefore, a multimodality approach with a combination of radical resection (even pelvic exenteration), radiotherapy and chemotherapy could be offered to well-selected patients with recurrent endometrial cancer despite out-of-field progression during therapy and in-field local failure to initial salvage treatment.     

Advanced primary carcinoma of the Bartholin gland: report of 18 patients

Conservative surgery plus radiotherapy for vulvar cancer has been established as a therapeutic alternative to extensive radical surgery and produces a similar cumulative 5-year survival. We retrospectively analyzed the cases of 18 patients with advanced primary carcinoma of the Bartholin gland treated with wide local excision (WLE) or radical vulvectomy and lymphadenectomy followed by radiotherapy (RT) at the University of Texas M. D. Anderson Cancer Center from January 1978 through December 1990. All patients have been observed for a minimum of 7 months (maximum follow-up, 15 years; median follow-up, 9 years). Of the 18 patients, 7 were treated with wide local excision (WLE) followed by radiation therapy (RT) (Group 1), 9 had radical vulvectomy (RV) followed by RT to the vulvar and inguinal-femoral and pelvic node areas (Group II), and 2 were treated with RT alone after biopsy of the tumor (Group III). The 5-year disease-free survival rates were 86%, 78%, and 50% for groups I, II, and III, respectively, and 83% for the whole group. Of 2 patients treated with RT alone, one lived for 6 years with no evidence of disease, and the other lived for 20 months. The rate of local tumor control was 100% for all three treatment groups. There were no significant differences among the treatment groups in rate of primary tumor control or 5-year disease-free survival rate (p=0.1300). The present study demonstrated WLE followed by RT is the best treatment for advanced primary carcinoma of the Bartholin gland. Less radical surgery plus RT produces good long-term survival and has fewer complications.     

Neoadjuvant chemotherapy in vulvar cancer: avoiding primary exenteration

OBJECTIVE: To determine whether neoadjuvant cisplatin and 5-fluorouracil chemotherapy can be used to preserve the anal sphincter and/or urethra in patients with advanced vulvar cancer involving these sites. METHODS: Fourteen patients with advanced vulvar cancer (1997-2003) involving the anal sphincter and/or urethra were given 3-4 cycles of neoadjuvant chemotherapy to attempt preservation of these pelvic structures rather than undergoing a primary pelvic exenteration. Following 3 cycles, a radical vulvectomy and groin lymph node dissection were planned. All patients had lesion size documented by measurement and photograph prior to and following chemotherapy. RESULTS: The median age was 63 years (range 39-88). Thirteen patients received a median of 3 cycles (range 2-4) of neoadjuvant chemotherapy. Ten patients received cisplatin and 5-fluorouracil, while three received cisplatin alone. The median time from diagnosis to surgery was 77 days (range 54-143). All patients with cisplatin and 5-fluorouracil chemotherapy underwent surgery except one patient who had a synchronous renal cell carcinoma and died prior to surgery. Patients receiving cisplatin alone showed no measurable response, while all patients receiving cisplatin and 5-fluorouracil demonstrated at least a partial response. Two patients had no residual invasive carcinoma on final pathology. All patients receiving cisplatin and 5-fluorouracil followed by surgery are disease-free, while two of three receiving cisplatin have progressive disease. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil. CONCLUSION: Neoadjuvant cisplatin and 5-fluorouracil in advanced vulvar cancer demonstrated a response rate of 100%. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil. Responders are disease-free at this time. This response rate demonstrates superior activity of 5-fluorouracil in vulvar cancer and spares these patients the morbidity of exenteration or radiation.     

Minimally invasive vulvar carcinoma: An indication for conservative surgical therapy

It has been proposed that squamous carcinoma of the vulva with 1 mm or less of stromal invasion can be treated with local resection without inguinal node dissection. A retrospective review of 255 cases of stages I and II vulvar carcinoma demonstrated 24 cases of minimally invasive carcinoma. All cases were subjected to detailed chart review and pathologic confirmation. Mean age at diagnosis was 60 years. Seven patients had a preoperative diagnosis of preinvasive disease, ten had stage I disease, and seven had stage II disease. Fifteen cases had associated vulvar carcinoma in situ. Treatment consisted of local excision in 2 patients, radical wide excision in 11, hemivulvectomy in 5, and radical vulvectomy in 6. Eleven patients had either unilateral or bilateral inguinal node dissection. Five-year life-table survival was 89%. Four patients (17%) developed recurrent dysplasia and four (17%) developed invasive recurrences. One invasive recurrence was in an inguinal node in a patient previously treated with a hemivulvectomy and negative ipsilateral superficial node dissection. Univariate analysis revealed no statistically significant associations between recurrence and age, symptom duration, margin status, location, FIGO stage, or coexisting VIN. Large areas of coexisting dysplasia and variable gross appearance make meaningful application of FIGO staging criteria difficult in lesions with minimal focal invasion. Wide excision or radical wide excision of lesions with "high-risk" VIN or those showing less than or equal to 1 mm of stromal invasion on biopsy is adequate therapy. If final pathologic review demonstrates deeper invasion, a selective lymph node dissection can be performed as a second procedure. Careful surveillance with liberal use of colposcopy and biopsies is indicated in these patients.     

Anterolateral Thigh Vastus Lateralis Myocutaneous Flap for Vulvar Reconstruction after Radical Vulvectomy: A Preliminary Experience

Background. There are many myocutaneous flap methods which have been reported for the immediate reconstruction of large vulvar defects created by deforming radical cancer surgery in the female perineum except for the anterolateral thigh vastus lateralis myocutaneous flap. The present report describes our preliminary experience with the use of this flap in a patient who underwent radical vulvectomy for locally advanced squamous cell carcinoma of the vulva.Case. A 75-year-old woman underwent radical vulvectomy with bilateral inguinal lymphadenectomy due to right vulvar squamous cell carcinoma. The large vulvar defect was immediately reconstructed by using anterolateral thigh vastus lateralis myocutaneous flap. The postoperative course was uneventful. In addition to the expected primary healing, the neovulva had a relatively normal appearance with satisfactory sensation and function and the donor defect was found to be minimal both functionally and aesthetically.Conclusion. This technique can be used as an alternative method for vulvar reconstruction after radical vulvectomy. Further studies are warranted to prove the efficacy of this myocutaneous flap in reconstructing large vulvar defects.     

Carcinoma of the vulva (1981-1985): analysis of a radio-surgical approach

Carcinoma of the vulva has recently been the subject of renewed interest of gynecologists and oncologists. That which is commonly defined as the "choice" treatment is a radical vulvectomy with bilateral inguinal lymphadenectomy and, in the case of lymph node metastases, pelvic lymphadenectomy. The usefulness of the pelvic dissection has, however, been disputed and various Authors have proposed an alternative treatment consisting of radical vulvectomy and inguinal lymphadenectomy with external radiotherapy on the inguinal and pelvic lymph nodes, in the case of N+. The present report describes 56 patients with vulvar carcinoma treated at the Regina Elena National Cancer Institute of Rome, 42 of whom were submitted to radical surgery. In 14 of these patients, metastases in the inguinal lymph nodes were found: 10 were submitted to radiotherapy (with TCT or low voltage linear accelerator for a total of 50 Gy over a 5-week period), while the remaining 4 were not treated with any further therapy. Although the survey includes only a limited number of patients, the results obtained certainly favor radio-surgical treatment, also considering data reported in international literature regarding pelvic lymphadenectomy. The actuarial 5-year survival rates for the patients treated with surgery plus radiotherapy is 50% and the recurrence rate is 20%. Although a greater experience is certainly warranted in this field, we believe it may be stated (also on the basis of a recent study conducted by the Gynecologic Oncology Group) that radiotherapy represents a valid alternative to pelvic dissection if an adequate patients selection is made.     

Laparoscopic radical parametrectomy and partial vaginectomy for recurrent endometrial cancer

BACKGROUND: Endometrial cancer recurrences in the vagina after surgery and radiation therapy are traditionally treated with pelvic exenteration. However, this operation is associated with significant morbidity and mortality, and thus alternative surgical options should be explored. CASE: We present a case of laparoscopic resection of recurrent endometrial cancer at the vaginal apex in the setting of prior brachytherapy and 32P intraperitoneal therapy. CONCLUSION: Laparoscopic radical parametrectomy and partial vaginectomy may be an option for patients with small central recurrences of endometrial cancer.     

Complications following combined surgery (radical vulvectomy versus wide local excision) and radiotherapy for the treatment of carcinoma of the vulva: report of 73 patients

Cancer of the vulva is uncommon, accounting for only 5% of all gynecologic malignancies, and usually occurs in women over 60 years of age. The historic treatment of choice for invasive squamous cell carcinoma of the vulva is radical vulvectomy with bilateral inguinal lymphadenectomy, which has produced excellent long-term survival. We retrospectively analyzed the complications of wide local excision plus postoperative radiotherapy compared with those of radical vulvectomy and bilateral lymphadenectomy plus pre-or postoperative radiotherapy in 73 patients with vulvar cancer. There were no significant differences among these treatments in terms of primary tumor control, 5-year disease-free survival, and overall survival. Based on these results, the best treatment alternative for advanced vulvar cancer is wide local excision plus radiotherapy, as this method retains the high survival of traditional therapy but has less morbidity.     

Therapeutic alternative to primary exenteration for advanced vulvovaginal cancer

While not a common clinical problem, locally advanced vulvovaginal cancer represents a difficult management problem. Few report more than a limited experience in managing such cases, and current therapy has usually been by two surgical methods: (1) Conventional: this is not truly conservative surgery, but rather involves radical vulvectomy with excision of a segment of the vagina and/or urethra, but visceral preservation. (2) Extended: this involves primary exenteration with en bloc radical vulvectomy, groin dissection, and pelvic node dissection. This has gained prominence in many centers in recent years.For selected cases, a combined radiotherapeutic and surgical approach may be considered a therapeutic alternative to primary exenteration. It theoretically treats the cancer and its regional spread patterns, and at the same time preserves bladder and rectal function.Any therapeutic alternative to primary exenteration must offer theoretical or practical advantages, must recognize and evaluate potential shortcomings, and its efficacy must be validated by clinical results. The apparent advantages of this combined therapeutic approach over primary pelvic exenteration with radical vulvectomy includes: (1) bladder and/or rectal preservation, (2) less primary mortality, (3) less primary operative morbidity. The theoretical disadvantages to this alternative include: (1) potential for local failure at the vulvectomy margin which transects actual or potential areas of cancer extension, even though preoperatively irradiated, (2) potential for the transformation of the cancer to a more virulent form, (3) potential for fistula formation because of surgery in an irradiated field.The rationale for this therapeutic alternative is discussed in detail and the results in a preliminary series of cases are described.     

Carcinoma of the vulva. Clinicopathologic factors involved in inguinal and pelvic lymph node metastasis

Eighty-five women with vulvar squamous cell carcinoma were subjected to radical vulvectomy with bilateral inguinal and femoral node dissection or to radical vulvectomy with bilateral inguinofemoral and deep pelvic node dissection. The association between lymph node status (metastatic or not) and several parameters was analyzed: tumor location, size and clinical stage; tumor thickness, histologic grade and mitotic index; blood vessel, lymphatic and perineural infiltration; and lymphocytic and plasma cell infiltrates. There were no metastases to the pelvic lymph nodes without previous inguinal lymph node involvement. Unilateral vulvar carcinomas did not have contralateral metastatic nodes when there was no ipsilateral nodal involvement. Lymphatic vessel infiltration showed a statistically significant correlation with inguinal node metastases (P less than .05). No correlation was found between lymph node metastasis and tumor size, clitoral invasion, tumor thickness, histologic grade, blood vessel and perineural infiltration, lymphocytic and plasma cell infiltrates, and mitotic index.     

Carcinoma of the vulva: a retrospective review of 37 cases at a regional cancer centre in South India.

A retrospective review of 37 cases of carcinoma of the vulva presenting between 1996 and 2000 has been carried out. Thirty-three cases were managed with curative intent and four cases with advanced loco-regional disease were managed with palliative intent. The surgical treatment consisted of wide excision in one case, radical vulvectomy (RV) in six cases, radical vulvectomy and bilateral groin node dissection (RV+BGND) in 25 cases and radical vulvectomy and unilateral groin node dissection in one case. Nine of these 33 women also received adjuvant chemotherapy preoperatively in the hope of achieving better tumour-free surgical margins. Eight cases had a partial response and one case achieved complete response; the surgical margins were free in all these patients. One case received neoadjuvant radiotherapy to the vulva and pelvis followed by RV+BGND, which revealed no residual tumour. Overall, 26/33 cases had groin/inguinal node dissection and 23 (88.4%) of them had groin wound dehiscence. Thirteen of these 26 patients (50%) had inguinal node metastases (Stage III, four patients; Stage IV, nine patients). All the patients with negative nodes were free of disease while three of four patients with Stage III and two of nine patients with Stage IV with nodal metastases remained free of disease. The only patient with Stage III disease plus inguinal node metastases who recurred had multiple positive nodes with extracapsular spread. It appears that although bilateral involvement of the inguinal lymph nodes carries a worse prognosis, unilateral involvement with or without vaginal involvement carries an excellent prognosis provided multiple nodes are not involved. The role of neoadjuvant chemotherapy as compared to neoadjuvant radiotherapy, in locally advanced tumours, needs to be explored further.     

Operative management of early invasive epidermoid carcinoma of the vulva.

The clinical records and surgical specimens of 60 patients with squamous cancers of the vulva less than 2 cm in size (TI) were studied. Fifty-eight patients had stromal invasion 5 mm. or less in depth. Three of the 60 patients (5 per cent) had pelvic lymph node metastases; two of these three showed invasion of vascular channels; the third patient's tumor showed cellular anaplasia. In an effort to reduce patient morbidity in radical surgery for vulvar carcinoma, while achieving comparable survival data, an operative approach less radical than radical vulvectomy, inguinal dissections, and/or pelvic lymphadenectomy is proposed for selected patients.