Vulval carcinoma at the site of recent Bartholin gland excision: a rare case report

Around 2-7% of all vulvar cancers are represented by primary carcinomas of Bartholin gland. Here we are presenting such a rare case of carcinoma of Bartholin gland. 45/F P2L2 presented in our OPD with non-healing lesion in vulva for 2 months. She had history of Bartholin’s cyst excision (elsewhere), 2 months back (the exact time since when she is having the non-healing lesion in vulva). Diagnostic biopsy revealed it to be vulval squamous cell carcinoma. She was given two cycles of Neo adjuvant chemotherapy (Inj. Paclitaxel and Carboplatin). In view of better response to the treatment patient was planned for surgery. Patient underwent wide local excision with bilateral inguinofemoral lymphadenectomy. Although the majority of vulvar lesions are benign, especially in women younger than 50 years of age, any solid mass should be carefully evaluated for malignancy. Preferably biopsy of Bartholin gland should be considered if the patient is more than 40 years of age and should be mandatory in a menopausal woman.

Carcinoma vulva patterns of recurrence and treatment outcomes: A single-institution experience

Aim: The aim of this study was to evaluate the patterns of recurrence and outcomes in patients with vulvar cancer treated with surgery, with or without postoperative radiotherapy (RT) or RT alone. Materials and Methods: The hospital records were retrospectively analyzed from February 2007 to May 2016. All patients that had biopsy-proven carcinoma vulva were included for analysis. Surgery was done by simple or radical vulvectomy with or without lymph node dissection. Radical RT dose was 60 Gy (photons alone or with electron boost). Adjuvant RT was administered in case of node positivity or positive margins. Results: A total of 76 patients were diagnosed as squamous cell carcinoma of vulva. The median age was 59 years. About 59 patients were treated by surgery and 17 patients were treated by radical RT. The most common stage was IB. Adjuvant RT was administered in 10 patients. About 13 patients (22%) underwent inguinal lymphadenectomy. At a median follow-up of 35 months, 49 patients (64.4%) were alive, 27 died, and 6 patients were lost to follow-up. Locoregional recurrence rate was 24.5% in radical surgery group, 12% in surgery plus adjuvant RT group, and 47% in radical RT group. Distant metastasis rate was 4%. The progression-free survival at 3 years was 45.3% and 35.5% in the surgery group and radical RT group, respectively. Conclusion: Surgery resulted in favorable local control rates in early-stage carcinoma vulva. Adjuvant RT is indicated in case of nodal positivity or positive margins. Radical RT can be considered as an alternative in patients with comorbidities

A case of chronic and relapsing paget disease of the vulva

Abstract Extramammary Paget disease is a rare neoplastic condition that more commonly affects postmenopausal Caucasian women. Although the vulvar area is the most frequently affected location, it corresponds solely to 1 to 2% of all vulvar malignancies. A 72-year-old female patient was observed in our outpatient clinic with a 2-year history of an erythematous and pruritic plaque on the vulva. Histopathology and immunohistochemistry studies were compatible with extramammary Paget disease of the vulva. Associated neoplastic conditions were excluded. Due to multiple relapses, the patient was submitted to three surgical interventions, including a total vulvectomy, and to external radiotherapy. The present case illustrates the chronic and recurrent nature of extramammary Paget disease despite aggressive procedures as well as the challenge in obtaining tumor-free resection margins.

Study of epidemiology, clinicopathological correlation, prognostic factors and management in squamous cell carcinoma of vulva

Background: Carcinoma of the vulva is rare cancer, pruritus is the most common and long-lasting reported symptom. It is found to be associated with HPV and HIV infection. Currently, a more individualized and less radical treatment is suggested. In this study we evaluated epidemiology, clinicopathological prognostic factors, HPV distribution and risk factors for metastases to lymph nodes. We also reviewed multidisciplinary clinical management carried out at our institute.Methods: It is a prospective study of 25 biopsy proven cases of Squamous Cell Carcinoma of Vulva, treated at our center from September 2014 to September 2016. We collected the data regarding the clinical presentation, histological details, treatment given, survival and complications. HPV 16 and 18 testing were done using PCR method. Median follow up of the patients are for 24 months.Results: The mean age of patients was 54.6 years. Commonest presentation was perineal itching (36%). HPV 16/18 were positive in 25% of the patients. Radical vulvectomy with bilateral groin dissection was done in 14/25 (56%) patients. Among these 14 patients, 35.7 % (5/14) has lymph node metastases, disease free survival was 63.6% and overall survival was 81.1% for median follow up of 24 months. About one third of the patient presented with locally advanced disease.  Six (24%) patients received only chemo radiation as a treatment.Conclusions: HPV and HIV infection increase the risk of vulvar cancer. Individualization of treatment is necessary. The use of preoperative chemoradiation in locally advanced disease might have promising results in future.

Secondary healing strategy for difficult wound closure in invasive vulvar cancer: a pilot case-control study

OBJECTIVES: Despite the number of surgical advances and innovations in techniques over time, radical vulvectomy frequently results in substantial loss of tissue that cannot be primarily closed without tension, the mobilization of surrounding tissues or even the rotation of myocutaneous flaps. The aim of this study was to evaluate the feasibility of leaving the surgical vulvar open wound for secondary healing in situations where primary closure of the vulvar wound is not possible. METHODS: This case-control pilot study analyzed 16 women with a diagnosis of squamous cell carcinoma of the vulva who first underwent inguinofemoral lymphadenectomy, 6-week sessions of chemotherapy and 25 daily sessions of radiotherapy. Afterward, excision of the vulvar lesion with free margins was performed between January 2011 and July 2017. Twelve patients underwent primary closure of the wound (control), and in 4 patients, the surgical wound was left open for secondary healing by means of a hydrofiber (case). The inclusion criteria were a) FIGO-2009 stage II up to IIIC; b) squamous cell carcinoma; and c) no evidence of pelvic or extrapelvic disease or pelvic nodal involvement. The exclusion criteria were extrapelvic disease or pelvic nodal involvement, another primary cancer, or a poor clinical condition. ClinicalTrials.gov: NCT02067052. RESULTS: The mean age of the patients at the time of the intervention was 62.1. The distribution of the stages was as follows: II, n=6 (37 %); IIIA, n=1 (6%), IIIB, n=1 (6%) and IIIC, n=8 (51%). The mean operative time was 45 minutes. The hospital stay duration was 2 days. Full vulvar healing occurred after an average of 30 days in the control group and after an average of 50 days in the case group. CONCLUSION: A secondary healing strategy may be an option for the treatment of vulvar cancer in situations of non-extensive surgical wounds when primary closure of the wound is not possible.

Cáncer de vulva. Repercusiones del tratamiento quirúrgico: experiencia con 151 pacientes / Vulvar cancer. Impact of surgical treatment: experience with 151 patients

Resumen Objetivo: Reportar la experiencia institucional en el tratamiento quirúrgico de pacientes con cáncer de vulva de acuerdo con la clasificación vigente de la Federación Internacional de Ginecología y Obstetricia (FIGO). Materiales y métodos: Análisis retrospectivo de expedientes de pacientes con diagnóstico de carcinoma vulvar operadas con o sin coadyuvancia en el servicio de Oncología del Hospital General de México en un lapso de 34 años. Para el análisis estadístico se utilizó el programa Epi Info versión 7.2. Resultados: Se incluyeron 151 pacientes: 24 (16%) con lesiones preinvasoras o con mínima invasión, se intervinieron con escisiones locales o vulvectomías simples; 16 (15%) con cánceres invasores en quienes se efectuó cirugía conservadora de la vulva con o sin disección ganglionar unilateral. En 94 (62%) se efectuaron vulvectomías con linfadenectomías: 47 con cirugías en bloque y 47 mediante incisiones separadas. En 11 (%) pacientes se practicaron cirugías ultrarradicales: 6 resecciones abdominoperineales y 5 exenteraciones pélvicas. De 127 pacientes que tuvieron seguimiento, 62 (49%) evolucionaron 30 meses en promedio sin evidencia de enfermedad. Se incluyen 21/23 (91%) lesiones tempranas (VIN 2,3 y I- A); 37/49, (76%) de las invasoras en estadios IB-II; 13/41, (32%) de los estadios III (p = 0.00007) y 3/14 (21%) de los IV-A. Conclusiones: Si bien la tendencia actual se orienta a individualizar el tratamiento quirúrgico de pacientes con cáncer de vulva invasor, en esta serie solo en 15% fueron cirugías conservadoras. La metástasis ganglionar fue el factor pronóstico más desfavorable.

Abstract Objective: The present study is a review of our experience of the surgical options for vulvar cancer using The International Federation of Gynecology and Obstetrics (FIGO) classification. Materials and methods: Retrospective analysis of records of patients diagnosed with vulvar carcinoma operated with or without coadyuvance in the Oncology service of the General Hospital of Mexico in a span of 34 years. For the statistical analysis, the Epi Info version 7.2 program was used. Results: Patients were divided into groups, those with pre-invasion or minimal invasion disease were resolved with local excision or simple vulvectomy 24 (16%). Patients with invasive cancer were treated with conservative surgery with or without unilateral lymph node dissection 16 (15%); radical vulvectomy with inguino femoral lymphadenectomy 94 (62%) (47 block surgeries and 47 with separate incision); ultra-radical surgery 11 (7%) (6 abdomino-perineal resections and 5 pelvic exenterations). 127 patients had follow-up and 62 of them had a disease-free survival rate of 30 months (48.8%). The overall survival in pre-invasion or minimal invasion disease were 91.3% (21/23), in stage IB-II 75.5% (37/49), in stage III 31.7% (13/41) (p=0.00007) and in stage IVA 21.4% ( 3/14 ). Conclusions: Although a more individualized and less radical treatment is suggested, in this series only 14.5% of patients, could be resolved with conservative surgery. In addition, the lymph node status was the most important prognostic factor for survival.

Paciente con miasis vulvovaginal posterior a vulvectomía simple / Patient with Vulvo Vaginal Mycosis after Single Vulvectomy

Las miasis son infestaciones en vertebrados vivos causados por las larvas de diversas especies de moscas (dípteros). El objetivo del trabajo es presentar la evolución de este caso por ser una enfermedad muy rara en Cuba. Se presenta una paciente femenina, piel blanca, de 70 años de edad y antecedentes de hipertensión arterial crónica. Hace nueve meses le fue diagnosticado un proceso neoformativo de vulva, motivo por el cual fue intervenida quirúrgicamente hace 39 días en otro centro hospitalario. Ahora acude al cuerpo de guardia por constatarse aumento de volumen en la zona quirúrgica, prurito intenso y secreciones fétidas. Por este motivo fue ingresada para estudio y tratamiento en sala. Se le diagnosticó miasis vulvovaginal. Tuvo una evolución satisfactoria en sala gracias a las curas locales y el tratamiento con antibióticos(AU)

The myiasis are infestations in living vertebrates caused by the larvae of several species of flies (Diptera). The aim of this paper is to present the evolution of this case as a very rare disease in Cuba. A case is presented of a female patient, white skin, 70 years old having a history of chronic hypertension. Nine months earlier, she had been diagnosed with vulvar neoformative process, for which she underwent surgery -39 days before this consultation in another hospital. She went to the emergency room due to an increased volume in the surgical area, severe itching, and fetid secretions. She was admitted in hospital for study and treatment. She was diagnosed vulvovaginal miasis. She had a satisfactory evolution thanks to local cures and treatment with antibiotics(AU9

Clinical application of sartorius tendon transposition during radical vulvectomy: a case control study of 58 cases at a single institution / 부인종양

OBJECTIVE: The aim of this study was to investigate the clinical effects of sartorius tendon transposition versus sartorius transposition during bilateral inguinal lymphadenectomy of radical vulvectomy. METHODS: A total of 58 vulvar cancer patients who had surgery from May 2007 to October 2013, in which 30 patients received sartorius transposition and 28 patients received sartorius tendon transposition. All patients were matched by age, body mass index, stage, histology, and grade. Intraoperative variables and postoperative complications, recurrence, progression-free survival (PFS), and overall survival (OS) and postoperative life quality were compared and analyzed. RESULTS: No significant differences were found at median surgical times and amounts of bleeding (p=0.316 and p=0.249, respectively), neither at the incidences of groin cellulitis and lymphocele (p=0.673 and p=0.473, respectively), but the recovery times of the inguinal wounds were shorter (p=0.026) and the incidences of wound break and chronic lymphedema were significantly decreased in the tendon transposition group (p=0.012 and p=0.022, respectively). Postoperative quality of life in tendon transposition group was significantly improved as indicated by the EORTC QLQ-C30 questionnaire. Recurrences were similar (p=0.346) and no significant differences were found at PFS and OS (p=0.990 and p=0.683, respectively). CONCLUSION: Compared to sartorius transposition, sartorius tendon transposition during inguinal lymphadenectomy led to improved patient recovery, reduced postoperative complications, and improved life quality without compromising the outcomes.

Vulvar Elephantiasis of Filarial Origin: A Case Report.

Lymphedema is accumulation of lymph in the soft tissue due to obstruction of lymphatics. Lymphedema can be primary or secondary. Filariasis caused by Wuchereria bancrofti and Brugia malayi is one of the secondary causes of lymphedema. Longstanding lymphedema can lead to ‘elephantiasis’. Elephantiasis of female genitalia is extremely rare. We present one such case of a 40-year-old lady having giant vulvar elephantiasis of filarial origin managed successfully by surgery (vulvectomy with vulvoplasty).

Pregnancy following vulvar squamous cell carcinoma: a report of two cases / 부인종양

Pregnancy following squamous cell carcinoma of the vulvar is rare. Its rarity is reflected by a paucity of cases reported in the literature. We report two cases of pregnancy following diagnosis and treatment for vulvar squamous cell carcinoma, and review eleven prior reported cases. In successfully treated vulvar cancer subsequent pregnancy is not shown to increase the risk of disease recurrence, and there appears to be no deleterious effects during the antenatal period. It is possible, when considering prior reports, that prior vulvectomy may increase the likelihood of delivery by caesarean section, though modifications in the surgical management of vulvar carcinoma may have decreased this risk.

The Effect of V-Y Advancement Flap after Vulvectomy in Patients with Vulvar Cancer / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study is to evaluate the clinical effect of V-Y advancement flap after vulvectomy in patients with vulvar cancer. Local and systemic morbidity, the degree of satisfaction after operation, length of hospital stay were evaluated. PATIENTS AND METHODS: From March 2001 to september 2002, five patients with invasive vulvar cancer were eligible for this study. All the patients underwent radical vulvectomy with groin lymph nodes dissection. All of them were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteous maximus muscle. RESULTS: Flap survival was 100%. There were no major complication including wound infection, wound disruption, urinary tract infection, and seroma in the femoral triangle. Functional outcome was excellent in all patients. CONCLUSION: The V-Y advancement flap provides a straight-forward and simple safe reliable method as a common approach in radical vulvectomy.

A Case of Vulvar reconstruction with Gluteal Fasciocutaneous Island Sensory Flap after Radical Vulvectomy in the Patient with Vulvar Cancer / 대한산부인과학회잡지

Invasive carcinoma of the vulva is currently accounting for 3-5% of female genital tract malignancy. Standard treatment for vulvar cancer is radical vulvectomy or radical local excision with inguinal lymphadenectomy. Radical vulvectomy is often complicated by problems associated with inadequate closure of large skin defects leading to postoperative skin necrosis. Adequate morphofunctional reconstruction of the vulva has to be considered as an integral part of treatment of vulvar cancer. The present report describes our experience with the use of gluteal fasciocutaneous island sensory flap in a patient who underwent radical vulvectomy with bilateral inguinal lymphadenectomy for stage II vulvar cancer. There were no postoperative complications. The donor site scar, concealed in the gluteal fold, was acceptable. The neovulva had a relatively normal appearance with satisfactory sensation and function. Based on our experience with gluteal fasciocutaneous island sensory flap, this technique is compatible with inguino-femoral lymphadenectomy, and allows for a adequate morphofunctional reconstruction and provides good local sensibility.

Clinical Significance of Sentinel Lymph Node Detection in Vulvar Cancer / 대한산부인과학회잡지

OBJECTIVE: The purpose of this study is to evaluate the validity of sentinel lymph node detection and the possibility of clinical application in treatment of vulvar cancer patients. PATIENTS AND METHODS: From March 2001 to January 2002, four patients with vulvar cancer were eligible for this study. All the patients were preoperative technetium-99 m colloid albumin and intraoperative isosulfan blue dye injection intradermally at the junction of tumor mass and normal skin. Superficial lymphatic channels and groin lymph node dissections were made to detect sentinel lymph node and then complete inguinofemoral lymph nodes dissection was performed. All the sentinel lymph nodes were sent to pathologic department for frozen biopsy. RESULTS: Ten sentinel lymph nodes were identified in one-hundred and ten groin lymph nodes. All the ten sentinel lymph nodes showed benign. There was no case that non-sentinel lymph nodes were positive in the presence of negative sentinel lymph nodes by frozen biopsy (negative predictive value was 100%). CONCLUSION: Sentinel lymph nodes detection by combination use of technetium-99 m colloid albumin and isosulfan blue dye injection was simple and accurate in our preliminary study. To reduce postoperative morbidity, lymphedema and to minimize extensive inguinofemoral lymph nodes dissection, sentinel lymph node frozen biopsy may be a reasonable alternatives and a suitable method for limited control of vulvar cancer. This preliminary study showed the possibility of clinical application of sentinel lymph node detection in vulvar cancer surgery.

Leucoplakia vulvae

Fifteen cases of leukoplakia of the vulva among Filipinos are presented, with an incidence of 0.3% during a six-year periodThe disease is most frequent in the fourth, fifth, and sixth decades of life, the majority of the patients being near or past the menopauseThe duration of the symptoms before patients seek medical advice is notoriously long, an average of 6.3 yearsPruritus vulvae is the most prominent and constant symptomCarcinoma coexisted with every fourth case of leucoplakia vulvaeComplete vulvectomy was the operation of choice. (Summary)

Leucoplakia vulvae

1) Fifteen cases of leucoplakia of the vulva among Filipinos are presented, with an incidence of 0.3% during a six-year period2) The disease is most frequent in the fourth, fifth, and sixth decades of life, the majority of the patients being near or past the menopause3) The duration of the symptoms before patients seek medical advise is notoriously long, an average of 6.3 years4) Pruritus vulvae is the most prominent and constant symptom5) Carcinoma coexisted with every fourth case of leucoplakia vulvae6) Complete vulvectomy was the operation of choice. (Summary)