Changing trends in the surgical treatment of invasive carcinoma of the vulva

Twenty-nine years experience with 346 patients with invasive carcinoma of the vulva is presented. More than 90 per cent had squamous carcinoma. The primary mode of treatment was surgical. Two hundred and ninety-six patients were treated primarily with surgical treatment, 120 underwent radical vulvectomy and bilateral groin and pelvic lymphadenectomy, 133 had radical vulvectomy with bilateral groin dissection and 390 receiving nonradical procedures. Thirteen patients had radical operations plus pelvic exenteration for advanced disease. There were no intraoperative deaths, but 16 (5.4 per cent) died within 28 days of the operation. The uncorrected over-all five year survival rate was 66 per cent. In the presence of negative nodes, it was 83 per cent and with positive nodes, it was 38 per cent. Fifty per cent of those treated with exenteration are alive and disease-free at five years or more. Since one-third of the patients presented with advanced disease (Stages III and IV), earlier diagnosis and prompt referral must be encouraged to improve surgical results.     

The side of groin node metastases in unilateral vulvar carcinoma

The purpose of this study was to analyze the occurrence of ipsilateral, bilateral and contralateral inguinofemoral node metastases in unilateral vulvar carcinoma. One hundred and eighty-five women with a T1 or T2 squamous cell carcinoma who underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy were surveyed. Inguinofemoral lymph node metastases were found in 23 (22.1%) out of the 104 patients with a unilateral primary tumor. These lymph node metastases were found solely on the ipsilateral side in 21 (91.3%) out of the 23 patients. One patient presented with bilateral extranodal growth in the groins. Another patient with a history of endometrial carcinoma had a right-sided vulvar tumor with contralateral groin node metastases. Half a year later, she was diagnosed with recurrent endometrial cancer on the right pelvic side-wall. Our study endorses clinical evidence that the preferential lymph flow is to the ipsilateral groin. Established lymph node metastases may disturb the normal lymph flow with contralateral metastases as a possible consequence.     

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)     

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.     

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.     

Surgical treatment of vulvar cancer.

59 (80%) of 74 patients with vulvar cancer treated at the University Department of Obstetrics and Gynecology in Ljubljana in the period 1973-85 underwent radical vulvectomy with bilateral inguinofemoral lymphadenectomy, and 15 (20%) patients single vulvectomy because of advanced age and poor general condition. Histologically there were 69 cases of squamous cell carcinoma, 1 adenocarcinoma, 3 malignant melanoma and 1 rhabdomyosarcoma. 52% of the patients were classified as Stage I, 41% Stage II and 7% Stage III. Positive inguinofemoral nodes were observed in 24% (6.5% in Stage I, 35% in Stage II and 80% in Stage III). The total 5 year survival rate was 70% (83% in Stage I, 61% in Stage II and 20% in Stage III). The 5 year survival rate in the patients with negative nodes was 80%, and in cases with positive nodes only 50% in spite of postoperative irradiation. None of the 3 patients with melanoma survived 2 years nor did the patient with rhabdomyosarcoma. There was no case of primary mortality. Nowadays the cure rate for vulvar cancer is higher especially owing to the improvement of operability. The problem of lymphatic and distant metastases still remains unresolved.     

Squamous carcinoma of the vulva: results of treatment, 1938 to 1976.

Clinical data on 264 patients with squamous cell carcinoma of the vulva seen between 1938 and 1976 are reported. Two hundred and four patients were "eligible" for 5 year assessment for a 55% survival rate. Patients treated with radical vulvectomy and bilateral lymphadenectomy had a corrected 5 year survival rate of 86% if the lymph nodes failed to show metastatic disease. Twenty-eight percent of the patients treated with lymphadenectomy had lymph node metastasis at the time of surgery. The presence of lymphatic metastasis appeared to be the most significant prognostic factor. The results obtained have led to a degree of individualization in current treatment policies, together with a re-evaluation of the possible role of radiotherapy.     

Behandlungsformen und-Ergebnisse beim invasiven Vulvakarzinom

Between 1970 and 1982, 113 patients were treated for invasive vulvar cancer in FIGO stages I-IV; 97 patients were available for follow-up. Forty-one patients (42.3%) underwent radical vulvectomy and lymphadenectomy, 21 underwent simple vulvectomy, and 12 (12.4%) had electric resection of the lesion; 42 patients (43.3%) received postoperative radiotherapy. The 5-year survival rate was 61.8% after surgery and radiotherapy. Five-year survival in stages I, II, and III was 85.3%, 60.7%, and 17.9%, respectively. Overall 5-year survival was 52.6%. Patients with small, highly differentiated squamous cell cancers, without lymph node involvement, did best.     

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 value of groin palpation in epidermoid carcinoma of the vulva

During the years 1956–1974 258 patients with epidermoid carcinoma of the vulva were treated with radical vulvectomy and bilateral groin lymphadenectomy. Metastases to the superficial and/or deep inguinal lymph nodes were found in 100 cases (38.8%), only 64 of which were detected by clinical examination. In 40 more cases (15.5%) the groin lymph nodes were also suspected to be involved, but this could not be verified by microscopic examination. The 5-year actuarial survival rate was 41% for the patients with lymph node metastases. There was a statistically significant difference in the survival rate between the patients with palpable lymph node metastases as compared with those where the nodes were not suspected to be involved.     

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.     

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.     

Surgical treatment of carcinoma of the clitoris

Thirty-eight consecutive patients were treated with either vulvectomy (14) or in combination with groin dissection (24) according to the same treatment protocol. The crude 5-year survival was 50% and the corrected 5-year survival was 66%. Three patients died post-operatively. Endophytic tumor, poor degree of differentiation, and involvement of lymph nodes resulted in higher mortalities. No patient with involvement of deep inguinal or pelvic nodes could be cured. The study concludes that invasive squamous cell carcinoma of the clitoris should be treated, in the same was as the same tumor in other areas of the vulva, with radical surgery.     

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.     

Patterns of pelvic and paraaortic lymph node involvement in ovarian cancer

One hundred eighty patients with ovarian cancer underwent complete pelvic lymphadenectomy (n = 75) or pelvic and paraaortic lymphadenectomy (n = 105). Twenty-one patients underwent a preoperative biopsy of the scalene lymph nodes. The incidence of positive lymph nodes was 24% in stage I (n = 37), 50% in stage II (n = 14), 74% in stage III (n = 114), and 73% in stage IV (n = 15). Of the 105 patients who underwent pelvic and paraaortic lymphadenectomy, 13 (12%) had positive pelvic and negative paraaortic nodes and 10 (9%) had positive paraaortic and negative pelvic nodes. Positive scalene nodes were found in four patients (19%) later shown to have stage IV disease. One hundred forty patients were studied for number of involved nodes and node groups, size of nodal metastases, residual tumor, and survival. Of the 81 patients with positive nodes, most had only one or two positive node groups or one to three positive individual nodes. A few patients had seven to eight involved node groups with up to 44 positive nodes. Greater numbers of positive nodes were found in stage III than stage IV. The size of the largest nodal metastasis was not related to the clinical stage or survival, but did correlate with the number of positive nodes. Stage III patients with no residual tumor had a significantly lower rate of lymph node involvement than those with tumor residual (P less than 0.01). Actuarial 5-year survival rates of patients with stage III disease and no, one, or more than one positive nodes were 69, 58, and 28%, respectively.     

The modified radical vulvectomy with groin dissection: an eight-year experience

Fifty-one patients were admitted to a single practice at St. Joseph's Hospital between April 1, 1978, and April 1, 1986 with a diagnosis of squamous cell carcinoma of the vulva greater than 1 mm in depth. Five advanced lesions were treated with combinations of radiation and surgery. Four patients had recurrent squamous cell carcinoma. Of 42 patients treated surgically with intention of cure, 14 were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated in 26 instances with bilateral inguinofemoral lymphadenectomies in one of five different excision patterns individualized to the site of primary tumor. None of the 28 patients have had a recurrence. Five had positive nodes. Eight have died of unrelated causes. Lesions in 25 cases were stage I or II and in three cases they were stage III. Modified radical vulvectomy and bilateral groin dissection is a safe approach for most patients with stage I or II and occasionally even stage III lesions.     

Long-term survival and sequelae after surgical management of invasive cervical carcinoma diagnosed at the time of simple hysterectomy.

From 1956 to 1988, 27 women (median age, 60 years) found to have occult invasive carcinoma of the cervix at total hysterectomy underwent radical reoperation consisting of radical parametriectomy, upper vaginectomy, and pelvic lymphadenectomy. Residual disease was present at reexploration in 4 (15%) of the 27 patients: in the pelvic lymph nodes in 2, in the parametrium in 1, and in the vagina and a para-aortic node in 1. All patients were followed a minimum of 18 months; there were no deaths within 3 months of operation. However, 2 (7%) of the 27 patients developed ureterovaginal fistulas. Recurrent disease was observed in 6 (22%) of the patients: 2 had successful salvage procedures, and 4 died of disease, all within 4 years of reoperation. Recurrence correlated with the presence of residual disease at reoperation and with nonsquamous histologic findings. At a median follow-up of 8.4 years, 23 of the 27 patients were alive and disease-free. The 5-year absolute survival estimate (Kaplan-Meier) was 82%. Radical reoperation can be performed safely in selected patients who have early-stage invasive carcinoma of the cervix at the time of total hysterectomy with the expectation of an acceptable rate of long-term disease-free survival.     

A new approach to vulvar squamous cell carcinoma: two-year follow-up of a case report

BACKGROUND: Vulvar carcinoma is relatively rare gynaecologic malignancy. The most prevalent vulvar cancer is squamous cell carcinoma. It is not uncommon for patients to delay seeking medical attention or for physicians to delay diagnosing the condition. This delay results in many cases being diagnosed in advanced stage. The sentinel lymph node "concept" is attractive in vulvar cancer because it has the potential to avoid a radical vulvectomy associated with uni- or bilateral inguinofemoral lymphadenectomy and, thus, to avoid the morbidity associated with formal groin dissection. CASE REPORT: A case of an 88-year-old woman with advanced local vulvar cancer is presented. A study of the inguinal-femoral lymph nodes was also conducted with intraoperative vital blue dye peritumoral injection and as the sentinel node was found to be negative for malignant metastasis, a radical vulvectomy without bilateral inguinofemoral lymphadenectomy and without additional treatment (chemotherapy and/or radiotherapy) was performed. Follow-up was performed at one, three, six, nine, 12, 18 and 24 months. No local recurrence or distant metastasis was found. CONCLUSION: The sentinel lymph node procedure allows a less aggressive treatment to be carried out in patients with invasive vulvar cancer thus reducing the complications and morbidity of treatment. Moreover, reducing the operative stress can change the overall survival and reduce the mortality linked to complications and postoperative stress.     

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.     

Optimal version of I and II stages vulvar carcinoma--surgical treatment

In gynaecological clinic years during 1970-1986, 270 vulval carcinoma patients (I stage 12.6%; II 50.3%; III 29.3%; IV 7.8%) underwent treatment. 34.8% patients age was 60-69, 32.2% 70-79. Average age 66 years. In 70% patients diagnostic epidermoidal, 22.2% low differentiated cancer and 1 case (0.4%) adenocarcinoma. 187 patients underwent total vulvectomy (additional telecurie therapy 18 patients, 2 chemotherapy), 54 total vulvectomy + regional lymphadenectomy, 29 chemo (6), radio (3), symptomatic (20) therapy. 5-year recovery generally equated 40.1% (vulvectomy + lymphadenectomy 58.4%; vulvectomy only 35.8%), at I-II stage 52.1% (vulvectomy + lymphadenectomy 85.7%; vulvectomy 50.0%), at III stage 11.4% (vulvectomy + lymphadenectomy 42.9%; vulvectomy 6.7%), at IV stage 0%. T1 regional lymph nodes involvement, clinical signs (N1, N2, N3) were present in 24.1% patients, T2 36.1%, T3 70.8%. Out of marked 92 patients, lymphadenectomy was performed in 54, mainly with T1 and T2. Histological metastases observed in 48.1%, i.e. no more than 14% T1 and T2 patients. Considering the above raised question rised - it is justifiable in I and II stage patients with negative lymph nodes, regarding advanced age and concomitant diseases, perform protracted traumatic operation. But without histology it's hard to decide lymph nodes condition. Taking into account certain stage characteristic of metastatic spreading, in our clinic from 1985 in T1 and T2 vulval carcinoma without (N0) and/or with (N1, N2) regional lymph nodes involvement signs modified less traumatic one stage extensive vulvectomy with bilateral inguinal lymphadenectomy is performed. Suboperational morphological (cytology, histology) lymph nodes study is conducted. Upon metastases discovery dissection is carried out on femoral lymph nodes as wall.(ABSTRACT TRUNCATED AT 250 WORDS)