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.     

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.     

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)     

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.     

Radical vulvectomy for squamous cell carcinoma of the vulva

Twenty-one patients with squamous cell carcinoma of the vulva who were subjected to radical vulvectomy and inguinal-pelvic lymphadenectomy were studied. The overall mortality rate was 24%. Operative- and tumor-related mortalities were 9.5% and 14.2%, respectively. Recurrence was seen in 5 patients. The most common complication was wound infection and breakdown.     

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.     

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 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.     

Coexistence of verrucous and squamous carcinoma of the vulva

AIM: To evaluate the coexistence of verrucous and squamous carcinoma of the vulva and to assess the clinical course, survival and rate of recurrent disease of these patients. METHODS: The records of 17 patients who were diagnosed with verrucous carcinoma of the vulva over a 12-year period were studied retrospectively. Presence of genuine verrucous carcinoma or coexistence of verrucous and squamous carcinoma of the vulva on vulvar biopsies, results of histopathological assessment of final vulva and inguino-femoral node specimens and histological evaluation of recurrent disease specimens were the main outcome measures. RESULTS: Five of the 17 patients (29.5%) initially underwent radical vulvectomy and inguino-femoral lymphadenectomy. Histology of the specimens verified the coexistence of verrucous and squamous carcinomas in four of the five cases. Twelve women (70.5%) underwent simple vulvectomy for genuine verrucous carcinoma; in the final histology, 10 of these women (58.8%) were confirmed as having genuine verrucous carcinomas while two (11.7%) were found to have both verrucous and squamous carcinomas and were further managed by lymphadenectomy. None of our patients died of the disease. Three women (17.5%) presented with local relapse of the tumour, and were managed by wide local excision of the tumour. CONCLUSIONS: In the present study, 35% of patients with verrucous carcinomas of the vulva had coexistent squamous carcinoma. Separation of the cases of genuine verrucous carcinoma from coexistent verrucous and squamous tumours is based on the establishment of correct diagnosis by a large and deep vulvar biopsy as well as the meticulous assessment of the specimen by the pathologist. This will result in the decrease of the rate of over- and under-treatment of these patients.     

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.     

Vulvar squamous cell carcinoma. Prognostic factors for local recurrence after primary en bloc radical vulvectomy and bilateral groin dissection

OBJECTIVE: To evaluate clinical prognostic factors for local recurrence of vulvar squamous cell carcinoma after primary surgical treatment. STUDY DESIGN: Of 104 patients treated for squamous cell carcinoma of the vulva in an 11-year period (1987-1997) at the Portuguese Cancer Institute, we selected for study 56 patients who meet the following criteria: (1) International Federation of Gynecology and Obstetrics (FIGO) stage Ib-IVa, (2) primary treatment of en bloc radical vulvectomy and bilateral groin dissection, and (3) follow-up reports. Files were retrieved for retrospective analysis. Fifteen patients (26.8%) had local recurrence at the fifth year. At the 24th month, 11 patients had local recurrence, and 31 were in follow-up, without recurrence. We evaluated age at initial diagnosis, date of surgical treatment, tumor size, results of tumor macroscopy, histologic differentiation, groin lymph node status, FIGO stage, resection limits, adjuvant radiotherapy, duration of stay, associated vulvar skin disease, date of detection of recurrence, site/sites of recurrence and follow-up status at the 24th month after surgical treatment between the 11 patients with local recurrence and 31 in follow-up without recurrence. RESULTS: The 11 patients with local recurrence had a significant initial FIGO stage, IVa (P = .049) and a significant association with the number of groin lymph nodes containing metastasis in comparison to the 31 patients without local recurrence. No other statistically compared data were significant. CONCLUSION: These results suggest that vulvar squamous cell carcinoma local recurrence after a primary surgical procedure is related to poor tumor prognostic factors (number of groin nodes containing tumor metastasis and FIGO stage IVa). On multivariate analysis, the presence of metastasis in two or more groin nodes was a powerful factor related to local recurrence. Postoperative radiotherapy to the vulva for such patients with a high risk of local recurrence is advisable.     

Value of four models for selecting patients for local excision of invasive squamous cell carcinoma of the vulva

For 75 women with squamous cell carcinoma of the vulva who underwent radical vulvectomy and inguinofemoral lymphadenectomy, the authors assessed the efficacy of four models for selecting patients who could have been treated adequately with local excision of the tumor. Each of the three models proposed by Andreasson and Nyboe covered 25% of the patients, none of whom had groin metastases or died of cancer. Local recurrence in the vulva occurred in 10%. A model suggested by the International Society for the Study of Vulvar Disease covered almost 10% of the patients. One of seven patients had groin metastases, none died of cancer, and one of seven developed local recurrence in the vulva. The criteria of the clinically best suited model are tumor not situated on the clitoris and less than 4 cm in diameter, with only slight hyperchromasia. This model ought to be tested in a randomized study.     

Invasive carcinoma of the vulva. Changing trends in surgical management

Four hundred fifteen patients who had invasive carcinoma of the vulva were treated with primary surgery from July 1, 1955, through June 30, 1989. Three hundred seventy-six (90%) of the patients had squamous carcinoma. Two hundred fourteen patients (52%) had radical vulvectomy with inguinofemoral lymphadenectomy. Twenty-four patients (6%) underwent radical vulvectomy with pelvic exenteration for advanced disease, and 55 patients (13%) had nonradical operations. The remaining 122 patients (29%) underwent radical vulvectomy, inguinofemoral lymphadenectomy, and pelvic lymphadenectomy. The primary morbidity was associated with lymphedema (8.6%) and groin wound breakdown (54%). No intraoperative deaths occurred among the 415 patients treated surgically, but there were 17 deaths (4%) within 28 days of operation. The absolute 5-year survival rate was 85% in patients with negative inguinofemoral lymph nodes and 39% when these lymph nodes were positive for metastatic carcinoma. The overall absolute 5-year survival rate was 67%.     

Relevance of microinvasion in carcinoma of the vulva.

Retrospective analysis of 22 cases of Stage I invasive carcinoma of the vulva showed 11 cases in which the depth of tumor invasion was 5 mm or less. All of these patients were treated with radical vulvectomy and lymphadenectomy. In 3 cases positive groin node metastases were discovered. A fourth patient with minimal stromal invasion (less than 5 mm) was prospectively managed with vulvectomy alone and subsequently developed groin node metastasis leading to death from disseminated tumor. Depth of the invasion alone, therefore, is not a reliable indicator of the likelihood of groin node involvement, and lymphadenectomy should continue to be considered for all patients with invasive squamous cell carcinoma of the vulva.     

Pregnancy-associated invasive squamous cell carcinoma of the vulva in a 28-year-old, HIV-negative woman. A case report

BACKGROUND: The incidence of invasive squamous cell carcinoma of the vulva in women under 40 years of age has been increasing, particularly in association with human papillomavirus. Invasive vulvar carcinoma is rare in women under 30, as is an association with pregnancy. We report on a 28-year-old woman who was diagnosed with invasive squamous cell carcinoma of the vulva during pregnancy. CASE: The patient, gravida 5, para 4105, HIV negative, presented to the emergency room with vulvar pain. She had delivered a term infant three months earlier at another institution and was diagnosed with squamous cell carcinoma of the vulva at that time. At this admission, a 4.0-cm, ulcerated lesion involving the left labium minus was noted. The patient underwent examination under anesthesia with bilateral inguinal lymph node dissection, cone biopsy, radical vulvectomy and excision of perianal lesions. CONCLUSION: This case demonstrates the need to biopsy all suspicious vulvar lesions, even in young and pregnant women.     

Vulvar invasive squamous cell carcinoma occurring in a young woman with systemic lupus erythematosus

BACKGROUND: Although several studies have demonstrated a possible relationship between systemic lupus erythematosus (SLE) and non-Hodgkin's lymphoma, Hodgkin's lymphoma, leukemia and several solid tumors, it is still debatable whether SLE patients have an increased incidence of cancer overall. CASE: We describe a 25-year-old patient with SLE who developed invasive squamous cell carcinoma of the vulva. The patient underwent radical vulvectomy and bilateral groin sentinel lymph node dissection and until to date, one year after surgery, she is alive without evidence of recurrent disease. CONCLUSIONS: Only three cases of vaginal/vulvar cancer associated with SLE have previously been mentioned in the literature, but not described in detail. This is the first detailed case report in the literature of vulvar invasive squamous cell carcinoma occurring in a SLE patient. It can only be speculated that the SLE itself and/or the treatment with immunosuppressive drugs provoked malignant transformation and the development of vulvar squamous cell carcinoma in such a young patient.     

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.     

Non mutilant radical vulvectomy vs radical vulvectomy

20 women, matched for age, site of primary tumor, histotype and stage, have been selected among patients affected with vulvar carcinoma for a study comparing classic radical vulvectomy vs "non mutilant" radical surgery. Detailed results actually available are discussed, showing that "non mutilant" technique gives results comparable to classic radical vulvectomy in terms of survival and recurrence rate; with minor functional and aesthetic damage, minor side effects and shorter post operative course.     

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.