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.     

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.     

Management of vulvar melanoma.

Considerable debate centers on the optimal treatment for vulvar melanoma, as well as those clinicopathological factors influencing prognosis. We reviewed 80 patients with vulvar melanoma seen between 1949 and 1990. Primary tumors were assessed according to Chung (47 patients) and Breslow (65 patients) microstaging systems. Fifty-nine patients (76%) underwent radical vulvectomy, ten patients (13%) had a partial vulvectomy, and nine patients (12%) had a wide local excision. Fifty-six also underwent inguinal node dissection. Median follow-up was 193 months. Median survival was 63 months. Ten-year survival by Chung level was as follows: I 100%; II, 81%; III, 87%; IV, 11%; V, 33%. Ten-year survival by tumor thickness was as follows: 0.75 mm, 48%; 0.75-1.5 mm, 68%; 1.51-3.0 mm, 44%; greater than 3.0 mm, 22%. Increased depth of invasion was associated with increased incidence of inguinal node metastasis. Cox regression analysis demonstrated prognostic significance for tumor thickness (P less than 0.001), inguinal node metastasis (P less than 0.001), and older age at diagnosis (P less than 0.001). Radical vulvectomy did not seem to improve survival over less radical procedures. Based on this experience, we recommend radical local excision for patients with malignant melanoma of the vulva. Patients who have more than a superficially invasive melanoma should also have inguinal lymph node dissection.     

Prognostic variables in the treatment of squamous cell carcinoma of the vulva

Records of 98 patients undergoing surgery for squamous cell carcinoma of the vulva between 1960 and 1982 were analyzed to evaluate and develop treatment policy. There were 32, 34, 26, and 6 patients in FIGO stages I-IV, respectively. Eighty-six patients underwent radical vulvectomy, 8 patients underwent less extensive procedures, and 4 underwent more extensive procedures. Eighty-seven patients underwent inguinal node dissection, and 40 underwent pelvic node dissection as well. Eight patients received external beam irradiation. Actuarial 5-year survival was 57%. Age, tumor size, FIGO (clinical) stage, surgically determined T and N stages, tumor differentiation, lymph vessel invasion, extent of surgical procedure, and adjuvant irradiation were analyzed to determine their effects on local control, freedom from distant metastases, and survival, using single variable and multivariate analysis. Local control was significantly related to FIGO stage; freedom from distant metastasis was significantly related to surgical N stage, tumor size, and surgical T stage; survival was significantly related to surgical N stage, tumor size, surgical T stage, age, and lymph vessel invasion. Metastatic involvement of inguinal lymph nodes was significantly correlated with tumor size and differentiation. Of 87 evaluable patients, 33 had inguinal node involvement, and of these, 17 developed recurrent disease. All 7 patients with pelvic node metastases had positive inguinal nodes, and all died; the cause of death could be determined in 5, of whom 4 manifested distant metastases. Pelvic lymphadenectomy conferred no survival benefit in this series, even in the presence of positive inguinal nodes. Local vulvar recurrence is a significant problem in patients with positive inguinal nodes, and postoperative irradiation should be directed to this area in these patients. Patients with vulvar recurrences, especially those occurring at least 2 years after surgery, can be successfully salvaged, and should therefore be treated aggressively.     

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.     

Recurrent vulvar carcinoma in pregnancy

BACKGROUND: Vulvar carcinoma is rare in the premenopausal age group. The incidence during pregnancy is even more uncommon. To date, no cases of recurrent vulvar carcinoma in pregnancy have been reported. We describe the first case of recurrent vulvar carcinoma during the same pregnancy. CASE: A 36-year-old G5P4004 presented with vulvar pain at 18 weeks of pregnancy. She had a 2.2-cm tender mass anterior to the left labium majus, of which a biopsy revealed invasive squamous cell carcinoma. At 23 weeks' gestation, she underwent a modified radical vulvectomy and bilateral inguinofemoral lymph node dissection. Eleven weeks later, she complained of a newly tender area to the right of the clitoris. A biopsy at that time demonstrated predominantly severe vulvar intraepithelial neoplasia (VIN III) with a small focus of invasive squamous cell carcinoma. A radical local excision was performed at 9 weeks postpartum. CONCLUSION: Careful surveillance is warranted as squamous cell carcinoma recurrence can occur quickly in the setting of pregnancy.     

A stage Ia vulvar carcinoma with an inguinal lymph node recurrence after local excision. A case report and literature review

A patient with a stage Ia vulvar squamous cell carcinoma (< 1 mm invasion) is reported in which an inguinal recurrence one and a half years after partial radical vulvectomy and superficial inguinal lymph node sampling was noted. After the initial biopsy showing a tumor invading 0.3 mm into the stroma, residual tumor could not be shown in the vulvectomy specimen nor in the superficial lymph nodes. A review of the literature indicates that this is only the second reported case of stage Ia vulvar carcinoma with lymph node metastases.     

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.     

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.     

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.     

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   

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.     

CO2 laser surgery for vulvar intraepithelial neoplasia. Excisional,destructive and combined techniques

OBJECTIVE: To evaluate CO2 laser excision, vaporization and combined techniques for treatment of vulvar intraepithelial neoplasia (VIN). STUDY DESIGN: Thirty-nine cases of VIN 3, 15 cases of VIN 2 and 9 of VIN 1, for a total of 63 patients with histologically proven VIN, underwent laser excision or vaporization under colposcopic guidance, using local anesthesia, in an outpatient setting or after day-surgery admission. Clinical aspects, cervical intraepithelial neoplasia (CIN) and vaginal intraepithelial neoplasia (VaIN) association, types of CO2 laser treatment, follow-up, recurrences and second treatments were evaluated. RESULTS: Twenty-seven (41.3%) patients underwent laser vaporization, and 37 (58.7%) with VIN 3, underwent laser excision or the combined technique. Colposcopic and biopsy examinations of patients with VIN revealed three cases of CIN 3 and nine cases of VaIN 3; two patients had concomitant VIN 3, CIN 3 and VaIN 3. Local anesthesia, using 2% carbocaine, and outpatient or day-surgery treatments were possible in all cases. A small incidence of intraoperative complications (4.8%) and absence of postoperative complications were observed. A single session was curative in 76.9% of patients treated with laser vaporization and in 78.4% of those treated with laser excision. Eleven cases of recurrent VIN and two cases of invasive vulvar carcinoma were observed during follow-up. A second laser procedure was carred out in all cases of relapsed VIN, with an overall cure rate of 96.8% after two treatments. Radical vulvectomy associated with inguinal-femoral lymphadenectomy was performed in the two cases of invasive carcinoma. CONCLUSION: CO2 laser surgery permits treatment of VIN in an outpatient or day-surgery setting under local anesthesia with excellent cosmetic and functional results. The treatment can also be adjusted to the patient's specific needs, with the possibility of calibrating the depth of the vaporized and removed tissues. Excisional treatment is the preferred method because it permits histologic evaluation of the excised tissue and detection of possible occult early invasion.     

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.     

Robot-assisted Sentinel Lymph Node Mapping and Inguinal Lymph Node Dissection Using Near-infrared Fluorescence in Vulvar Cancer

The surgical treatment of vulvar cancer has undergone many changes over the last century. The morbidity of open inguinal incisions prompts the search for a minimally invasive approach to lymph node dissection. This study reports the outcomes of 4 patients with vulvar cancer undergoing robotic sentinel lymph node (SLN) mapping and lymph node (LN) dissection with near-infrared fluorescence. From 2015 to 2017, 3 patients with squamous cell carcinoma of the vulva underwent robot-assisted SLN mapping and inguinal LN dissection. One patient with a vulvar melanoma had robotic bilateral SLN mapping only. The da Vinci Xi System with Firefly technology (Intuitive Surgical, Sunnyvale, CA) and indocyanine green radiotracer was used in all cases. Eight groins underwent robot-assisted SLN mapping, 6 of which underwent inguinal LN dissection. The average operating time was 234 minutes with vulvectomy. The mean blood loss was 124 mL. The operative time decreased, and the lymph node yield increased with each case. There were no wound separations or long-term negative outcomes, such as persistent lymphedema or recurrence. This case series of robot-assisted SLN mapping and inguinal lymph node dissection shows the safety and feasibility of this new technique in vulvar cancer. It may be a valid approach to reduce short- and long-term morbidity.     

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.     

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.     

Is the assumed natural history of vulvar intraepithelial neoplasia III based on enough evidence? A systematic review of 3322 published patients

OBJECTIVE: To establish the true natural history of VIN III from literature data. METHODS: In a systematic review, data of women with VIN III indexed in several computer databases were pooled. The effect of treatment was correlated with recurrences and progression of VIN III. RESULTS: Ninety-seven articles met the inclusion criteria. Data of 3322 patients were available. The mean age at diagnosis of VIN III was 46. This decreased over time, although not significantly (P = 0.08). Recurrences were seen as often after local excision as after vulvectomy. The percentage of recurrences was lower, but not absent, after free surgical margins than after involved surgical margins (P < 0.001). 6.5% of the 3322 patients progressed to an invasive vulvar carcinoma. Occult carcinomas were diagnosed in 3.2% of patients and 3.3% carcinomas were diagnosed during follow-up. The mean age at diagnosis of invasive vulvar carcinoma was 52 years. Nine percent of 88 untreated patients progressed in 12 to 96 months to invasive vulvar carcinoma. Only 1.2% of the 3322 patients showed complete regression, mostly during the first 10 months after diagnosis, 41% of which was related to pregnancy. CONCLUSION: Evidence exists that VIN III may progress to invasive vulvar carcinoma. However, the available literature suggests that the progression rate to invasive vulvar carcinoma is low. The incidence of invasion as found in this systematic review is probably even too high, because overreporting of (micro)invasive cases cannot be excluded. Only a prospective registration using a standardized pathology examination will provide information about the real natural history of VIN III.     

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％）