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.     

Radical wide excision and selective inguinal node dissection for squamous cell carcinoma of the vulva

Limited resection of some vulvar cancers may provide cure rates equivalent to those obtained with radical vulvectomy and bilateral inguinal node dissection. Rapid recovery, fewer complications, and better functional result have been described as advantages to less extensive procedures. Since 1978, 32 patients with invasive squamous cell cancer of the vulva (depth greater than 1 mm) and clinically negative inguinal lymph nodes underwent radical wide excisions as primary therapy. Mean age at diagnosis was 61 years. Seventeen patients had T1 and 15 had T2 tumors. Resection of the primary lesion was tailored to lesion location and size, and dissection was carried to the deep perineal fascia. Twenty-two patients had unilateral superficial inguinal lymph node dissections, five with midline lesions had bilateral superficial dissections, and five had node samplings which included deep inguinal nodes. Depth of invasion ranged from 1.5 to 13.0 mm. Mean largest lesion dimension was 23 mm. Five-year lifetable survival for the entire group was 84%. Univariate analysis of potential prognostic variables showed no significant recurrence or survival differences for patient age (P = 0.56), symptom duration (P = 0.57), FIGO stage (P = 0.67), tumor grade (P = 0.20), tumor location (P = 0.26), depth of invasion (P = 0.56), or resection margin status (P = 0.63). Thirty-one percent of patients had perioperative complications, and 16% developed delayed complications. Mean hospital stay was 10 days. Three patients (10%) developed new or recurrent vulvar disease and underwent additional therapy. None have died of disease, although one is alive with persistent tumor. Radical wide excision and selective inguinal lymphadenectomy constitute a reasonable alternative to radical vulvectomy with bilateral inguinal node dissections for squamous tumors clinically limited to the vulva. Outcome may not be strongly influenced by lesion size or depth of invasion.     

Prognostic factors in early vulvar cancer

Prognostic parameters were evaluated in 22 patients with small (less than or equal to 2 cm) superficially invasive (less than 5 mm) squamous cell carcinoma of the vulva. Primary surgery included radical vulvectomy with bilateral superficial and deep inguinal lymph node dissection in 11 patients, and wide local excision with ipsilateral superficial inguinal lymph node dissection in 11 patients. Of the 22 patients studied, only 2 (9%) had lymph node metastases. Both patients had a single positive ipsilateral superficial inguinal node. Perineural invasion was strongly associated with lymph node metastases (P less than 0.01). In this group of patients, grade, depth of invasion, lymph-vascular space invasion, and lymphoplasmacytic infiltration were not predictive of lymph node metastases (P greater than 0.05). Two patients initially treated with wide local excision and ipsilateral superficial inguinal lymph node dissection developed recurrent vulvar neoplasia on the contralateral vulva, and both were successfully retreated by wide local excision. All patients are presently alive and well with no evidence of disease. None of the histomorphologic parameters studied were predictive of tumor recurrence. These data suggest that wide local excision with ipsilateral superficial inguinal lymphadenectomy is effective in the treatment of patients with small, superficially invasive carcinomas of the vulva.     

Malignant melanoma of the vulva and vagina: a report of 23 cases presenting in a 10-year period

In the 10-year period ending December 1991, 14 patients with primary melanoma of the vulva and nine with primary melanoma of the vagina were diagnosed and treated. Of the patients with vulval melanoma, three were treated surgically with wide local excision of the tumor alone, six had wide local excision with inguinal node dissection, and five had radical vulvectomy with inguinal node dissection. Four of the patients with vaginal melanoma had wide local excision; two had wide local excision with inguinal and or pelvic node dissection; and three had surgery that was more radical than this. Two years after diagnosis, all of the patients whose tumors were 2 mm thick or more had died, or were alive but had distant metastases. This was independent of the apparent surgical success of local excision of the disease. We consider that conservative procedures in the management of invasive melanoma of the lower female genital tract should be the rule, and that radical procedures should be reserved for palliation rather than cure.     

A clinicopathological study of 30 melanomas of the vulva.

Thirty cases of malignant melanomas of the vulva were studied for prognostic factors. Ulceration, tumor thickness, and positive inguinal lymph nodes were the most important prognostic factors. Morphometry did not demonstrate any prognostic meaning. Traditionally a radical vulvectomy and bilateral inguinal lymph node dissection were the therapy of choice, but this treatment modality did not show a better survival than less radical treatment. A low-risk and a high-risk group of patients have been identified for recurrence. The low-risk patient has a nonulcerative tumor, less than 3 mm thick, without clinical evidence of inguinal lymph node metastases, and should be treated by local excision with a 2- to 3-cm margin. The high-risk patient has a tumor which is ulcerative and/or more than 3 mm thick and should also be treated by local excision without elective inguinal node dissection. If clinical suspicion of inguinal lymph node metastases exists, an inguinal node dissection is advocated for better local control of the disease.     

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.     

A matched comparison of single and triple incision techniques for the surgical treatment of carcinoma of the vulva.

Thirty-two patients with invasive squamous cell carcinoma of the vulva (SCC) undergoing radical vulvectomy or radical local excision with bilateral superficial groin node dissection using a triple incision technique (TI) were matched for new FIGO stage, lymph node status, size of lesion, and site of lesion with patients with SCC undergoing traditional radical vulvectomy with en bloc bilateral groin (but not pelvic) node dissection using a single incision (SI) technique. Average operative time (134 min: 191 min), blood loss (424 ml: 733 ml), and hospital stay (9.7 days: 17.2 days) were significantly less in the TI group. After SI 6/32 (19%) patients and after TI 1/32 (3%) patients experienced complete breakdown of the groin wounds. There was no significant difference in overall survival (P = 0.56) or disease-free survival (P = 0.53) between the two groups. There was no significant difference in survival between the two groups by lesion size or by FIGO (1989) stage. Disease recurred in six patients after SI compared with seven after TI (P = 0.75). There were no skin bridge recurrences in the TI group. Two patients in each group had isolated vulvar recurrences and all four were successfully treated by local excision. These data indicate that outcome following TI surgery is essentially equal to that of SI in early-stage disease but major morbidity is much reduced.     

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.     

Malignant melanoma of the vulva: report of six cases and review of the literature.

Six patients with vulvar malignant melanoma are reported. They accounted for 5.2% of all females with vulvar malignancies diagnosed in the south of Israel between 1961 and 1997. Age ranged from 25 to 66 years. Presenting symptoms were pruritus, bleeding and ulcer. Lesion originated in the labia minora in four patients and the labia majora in two, and lesion size ranged from I to 8 cm. Five patients had nodular melanoma, and one had superficial spreading melanoma. Breslow depth ranged from 2.5 to 8 mm, Clark level was IV in four patients and III in two, and Chung level was IV in all patients. Two patients had radical vulvectomy and bilateral groin lymphadenectomy, one had wide local excision, and one refused surgery. The two patients who had radical hemivulvectomy and bilateral groin lymphadenectomy were given adjuvant active specific immunotherapy with allogeneic vaccine and have survived disease-free, whereas the remaining four patients died of disease. It is concluded that vulvar malignant melanoma is a rare and aggressive tumor. For patients who present with deep lesions (Breslow depth > 0.76 mm, Clark level > II, Chung level > II) the recommended treatment is wide radical local excision (or at the most, radical hemivulvectomy) and bilateral groin lymphadenectomy.     

Vulvar malignancy

Treatment of invasive vulvar malignancy has become more individualized during the past decade. In the past, radical vulvectomy with bilateral inguinofemoral lymphadenectomy was the standard therapy for invasive squamous cell carcinoma and melanoma of the vulva. This is no longer always the case. The treatment of stage I and stage II invasive squamous cell carcinoma of the vulva has become more individualized. Less radical surgery appears to produce the same results as ultraradical surgery. Wide local excision of early lesions associated with ipsilateral lymph node dissection appears to be adequate therapy in many cases. Likewise, treatment of early melanoma (0.75 mm in thickness) can be managed by wide local excision with or without groin dissection of the ipsilateral side. This more conservative approach has resulted in significantly fewer postoperative complications and has improved the self-image of many women undergoing treatment for vulvar malignancy.     

Vulvovaginal melanoma. A clinicopathologic study

A retrospective study was done on 14 patients with vulvar and vaginal melanoma treated at the New York University Medical Center from 1972 through 1984. Pathologic evaluation included a measurement of tumor volume, tumor thickness, growth pattern and cell type. The most common morphologic appearance was a superficial spreading growth pattern with a nevoid cell type, which seemed to correlate with a favorable outcome. Nodular growth pattern with an epithelioid cell type was less common and associated with a poorer prognosis and inguinal lymph node metastases. No patient had deep pelvic node metastases. Tumor thickness, as measured with Breslow's method, was inversely related to survival, as previously reported. We were able to define a low-risk group of patients, with tumor volume under 100 mm3. It appears that tumor volume, in addition to thickness and growth pattern, can contribute to the evaluation of vulvar melanoma. Evaluation of our findings in conjunction with those in the literature on cutaneous and vulvar melanomas led us to question the routine management of these lesions with radical vulvectomy plus inguinal and pelvic lymph node dissection.     

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.     

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.     

Malignant melanoma of the vulva: clinicopathological features

Abstract. From the files of the Scottish Melanoma Group, we have identified 41 cases of vulval malignant melanoma, which represents 1.7% of all the melanomas occurring in women in Scotland, during the period 1979–1989. Thirty-seven were aged 50 years or older with the mean age being 70 years. The average Breslow depth of the lesions was 6.0 mm, with 29 being greater than 3.0 mm in depth. Nineteen cases were polypoidal and 37 were ulcerated. Six patients had radical vulvectomy with lymph node dissection, three had biopsy and palliative treatment, and the majority of the remaining patients had local excision only, with surgical margins of less than 2 cm. The 5-year survival rate (available for 23 patients) is 21.7%, compared to 72% for cutaneous melanoma in females, in general, in the same population. In this series, the survival rate is poor, as the lesions occurred in elderly women and the melanomas were thick at presentation. Surgical treatment appears to have been rather conservative in those who were dead from their disease at 5 years.     

外阴癌39例手术治疗及预后分析

目的 总结我院治疗外阴癌的手术方式,分析与外阴癌预后有关的因素。方法 回顾性分析我院１９７９－１９９７年收治的３９例侵袭性外阴癌的临床资料。其中外阴病灶局部切除术５例、部分外阴根治术１３例及全外阴根治术２１例。应用ＳＰＳＳ地不同的手术方式秀关预后因素进行比较分析。结果 ３９例中鳞癌３３例,占８４．６％,其中高、中、低分化分别为２６、５、２例。临床分期为Ⅰ期７例（１７．９％）Ⅱ期１７例（４３．６％）     

Infectious morbidity after radical vulvectomy

Objective: This retrospective investigation describes the infectious morbidity of patients following radical vulvectomy with or without inguinal lymph node dissection.Methods: The charts of patients undergoing radical vulvectomy between January 1, 1986, and September 1, 1989, were reviewed for age, weight, cancer type, tumor stage, operative procedure(s), prophylactic antibiotic and its length of use, febrile morbidity, infection site, culture results, significant medical history, and length of use and number of drains or catheters used.Results: The study group was composed of 61 patients, 14 of whom underwent a radical vulvectomy and 47 who also had inguinal lymph node dissection performed. Twenty-nine patients (48%) had at least 1 postoperative infection. Five patients (8%) had 2 or more postoperative infections. The site and incidence of the infections were as follows: urinary tract 23%, wound 23%, lymphocyst 3%, lymphatics (lymphangitis) 5%, and bowel (pseudomembranous colitis) 3%. The most common pathogens isolated from both urine and wound sites were Pseudomonas aeruginosa, enterococcus, and Escherichia coli. A significant decrease in wound infection was demonstrated when separate incisions were made for inguinal lymph node dissection (P <0.05). The mean number of days to onset of postoperative infection for wound, urine, lymphatics, lymphocyst, and bowel were 11, 8, 57, 48, and 5, respectively.Conclusions: We conclude that the clinical appearance of post-radical vulvectomy infections is delayed when compared with other post-surgical wound infections. Second, utilizing separate inguinal surgical incisions may reduce infectious morbidity. Finally, tumor stage and type do not necessarily increase the infectious morbidity of radical vulvar surgery.     

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.     

Squamous cell carcinoma of the vulva stage IA: long-term results

OBJECTIVE: The aim of this study was to evaluate the risk of metastases to lymph nodes and long-term results of radical and modified radical surgery in patients with a T1 squamous cell carcinoma of the vulva and 相似文献   

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.     

Carcinoma of the vulva

The objective of this review is to summarize the published data about squamous carcinoma of the vulva and to identify promising areas for future investigation. Rather than the routine use of complete radical vulvectomy, a radical wide excision of the vulvar lesion to achieve at least a 1-cm gross margin appears sufficient to treat the primary lesion. A surgical assessment of the groin is required for all patients who have invasion greater than 1 mm. Ipsilateral groin node dissection can be performed through a separate incision. All the nodal tissue medial to the vessels and above the fascia should be removed. Sentinel node evaluation may be a significant step forward, but the false-negative rate is not well enough defined to consider this a standard. Patients with positive inguinal nodes at groin dissection should receive radiation therapy to the ipsilateral groin and hemipelvis. For those patients who have unresectable primary disease or if nodes are palpably suspicious, fixed, and/or ulcerated preoperatively, chemoradiation is the preferred option. Exenterative procedures may rarely be required. Chemotherapy for recurrent or metastatic disease has not been proven to be of value. Although survival rates are high for those with negative nodes, the morbidity associated with standard radical techniques has prompted innovation. Adequately powered trials aimed at further reducing morbidity without compromising survival are underway.