Preoperative radiotherapy followed by radical vulvectomy with inguinal lymphadenectomy for advanced vulvar carcinomas

A therapeutic alternative to exenteration for large locally advanced vulvar carcinoma involving the rectum, anus, or vagina is the use of preoperative radiation followed by radical surgery. Between 1980 and 1988, 13 patients with Stage III and 3 with Stage IV vulvar carcinoma involving the rectum/anus, urethra, or vagina were treated with 4000 rad to the vulva and 4500 rad to the inguinal and pelvic nodes followed by a radical vulvectomy and inguinal lymphadenectomy 4 weeks later. The overall 5 year cumulative survival was 45%. Twelve tumors regressed after radiation with 62.5% of the patients having visceral preservation while in 4 patients there was no major response to radiation and urinary or fecal diversion was required. Of the 6 recurrences 4 were central and 2 distant. Three patients with central recurrences had tumor within 1 cm of the vulvectomy margin. Complications included wet desquamation, inguinal wound separation, lymphedema, and urethral strictures. There were no operative deaths. It is concluded that the use of preoperative radiation followed by radical vulvectomy may be an alternative to pelvic exenteration in selected patients with advanced vulvar lesions.     

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.     

外阴癌广泛切除术后患者外阴重建术的临床分析

目的探讨外阴癌广泛切除术后创面修复、外阴重建的手术治疗方法。方法回顾性分析2003年3月—2005年10月北京协和医院收治的14例外阴癌患者的临床资料,14例患者均行外阴广泛性局部扩大切除术,采用带蒂股前外侧皮瓣或下蒂腹直肌肌皮瓣修复外阴缺损创面,并行外阴重建术。结果14例行外阴重建术的患者中,有13例患者的皮瓣全部成活,于术后12～14 d切口拆线,切口Ⅰ期愈合,其中1例行股前外侧皮瓣转移修复术的患者腹股沟区手术切口发生感染,但其皮瓣及供区植皮Ⅰ期愈合;1例行股前外侧皮瓣转移修复术的患者皮瓣发生部分坏死,面积约4 cm×6 cm,经局部换药、创面植皮治疗,术后36 d完全愈合。14例患者接受了2～20个月的术后随访,重建后的外阴形态丰满,富有弹性,阴道口无狭窄,疤痕无明显挛缩。结论应用股前外侧皮瓣或腹直肌肌皮瓣转移修复外阴癌广泛切除术后的皮肤软组织缺损,进行外阴重建,可使患者在手术切除肿瘤后获得外阴解剖外观及部分功能的恢复,具有临床应用价值。     

Urinary incontinence following radical vulvectomy

Although incontinence has been reported after radical vulvectomy, its relationship to operative technique, anatomy, and treatment has not been defined. Twenty-one patients having vulvectomies for vulvar cancer were prospectively evaluated preoperatively and postoperatively with urodynamic function studies. A portion of the urethra was removed in four patients undergoing radical vulvectomy, and 14 had a vulvectomy excision that came within 1 cm of the distal urethra. Six patients (28%) developed a change of continence, with three developing total incontinence, two stress incontinence, and one urge incontinence. All four patients who had a portion of the urethra excised developed stress or total incontinence. The other two patients with incontinence (one total, one urge) had the vulvectomy excision that came close to the urethra. No patient had a change in continence when surgery did not involve or come close to the urethra. When the four patients with a distal urethral resection were compared with patients in whom the urethra was not excised, there was a significant decrease postoperatively in functional urethral length (P less than .0001), anatomical urethral length (P less than .0001), and distal urethral pressure transmission ratios in Q3 (P = .004), Q4 (P = .02), and Q5 (P = .005); but no difference in urethral support (Q-tip test), flow rates, residual urine, bladder capacity, maximal urethral pressure, resting closure pressure, or squeeze pressure. Histologic examination of urethral specimens demonstrated that a portion of the compressor urethrae muscle was often excised. Radical vulvectomy by itself does not cause incontinence, but it would appear that removal of a portion of the urethra increases the chance of incontinence.(ABSTRACT TRUNCATED AT 250 WORDS)     

Perineal reconstruction following radical vulvectomy

A method of reconstruction of the perineum necessitated by extensive scar formation following a radical vulvectomy is presented. Scarring had produced a complete bowel obstruction at the anal orifice. Emphysis is made on preoperative planning as a prerequisite to postoperative success.     

Sclerotherapy with bleomycin for recurrent massive inguinal lymphoceles following partial vulvectomy and bilateral lymphadenectomy-Case report and literature review

BACKGROUND: Formation of lymphoceles following radical vulvectomy presents a formidable problem that is associated with high degree of morbidity. A variety of approaches have been described in the literature to treat this condition. CASE: An 82-year-old woman developed massive inguinal lymphoceles following partial vulvectomy and inguinal lymphadenectomy for cancer vulva. The lymphoceles involved wide surface areas extending to both flanks, and accumulation of lymph was very rapid at a rate of 1 l daily. The condition failed to respond to continuous drainage and compression for 6 weeks, but responded quickly to sclerotherapy using bleomycin without any significant side effects. CONCLUSION: Intracavitary bleomycin could be used safely and effectively in huge rapidly accumulating lymphoceles.     

Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma

OBJECTIVES: To compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal lymphadenectomy for vulvar carcinoma. METHODS: A retrospective evaluation of patients with carcinoma of the vulva that underwent inguinal lymphadenectomy was performed. Operative reports were evaluated and patients were divided into those who had sparing of the saphenous vein versus ligation. Postoperative short- and long-term complications were compared between the two groups using Pearson chi squared analysis. RESULTS: There were a total of 49 inguinal lymphadenectomies performed on 29 patients. The saphenous vein was spared in 18 (37%) groin dissections compared to 31(63%) in which the saphenous vein was ligated. The two groups were similar in regards to clinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodes dissected was similar. Cellulitis was more common in the vein-ligated group compared to the vein-spared group (45% vs. 0%; P < 0.001). Wound breakdown occurred in 25% of dissections where the saphenous vein was ligated versus 0% in dissections where the vein was spared (P = or < 0.02). Short-term edema (< or = 6 months) was similar between vein-ligated and vein-spared groups (67% vs. 72%, P < 1.0). Subsequently, chronic lymphedema (> 6 months) persisted in 38% of the vein-ligated group compared to 11% in the vein-spared group (P < 0.05). The incidence of recurrent disease was similar in both groups (19.3 % vs. 22.2% P < 0.1). CONCLUSIONS: Routine preservation of the saphenous vein during inguinal lymphadenectomy for vulvar carcinoma may reduce the incidence of wound cellulitis, wound breakdown, and chronic lymphedema.     

Perineal reconstruction following extended radical vulvectomy.

Extended radical vulvectomy frequently leaves a large perineal defect. Myocutaneous flaps allow a single stage reconstruction of a functional perineum and vagina.     

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.     

The video endoscopy inguinal lymphadenectomy for vulvar cancer: A pilot study

Objective

This prospective pilot study aims to validate feasibility, efficacy and safeness of the innovative technique of video endoscopy inguinal lymphadenectomy (VEIL) and compare it to open inguinal lymphadenectomy (OIL) in the staging and treatment of vulvar cancer (VC).

The electrosurgical operation of vulvar carcinoma with postoperative irradiation of inguinal lymph nodes

The results of treatment in the department of 607 patients with invasive squamous cell carcinoma of the vulva between 1952 and 1980 is described and analyzed. The absolute 5-year cure rate in these patients was 60.3%. Particular attention was given to lymph node status (TNM system) in the analysis of the last 141 patients treated. The absolute 5-year survival rate was 67% for the N0-N1 patients and 43% for the N2-N3 patients. Patients were treated uniformly by means of electrosurgical operation and postactinic irradiation of the inguinal lymph nodes. Operative lymphadenectomy was performed only in 5% of cases when the diameter of inguinal lymph nodes was greater than 2 cm. This simple surgical technique, in combination with irradiation of inguinal lymph nodes, gives excellent results and avoids the complications associated with inguinofemoral lymphadenectomy. Owing to its combination of electrosurgical operation of the vulva and irradiation of the inguinal regions as a standard procedure, the treatment involves extremely low strain on the patient and is almost free of complications. This seems to be particularly important as the results of our treatment are not less satisfactory than those of more aggressive procedures.     

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.     

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.     

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%.     

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.     

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.