Pre-Pandemic Sentinel Lymph Node Biopsy In Vulvar Cancer: 4-Year Single Centre Audit

Introduction and aims of the study: In early vulvar cancer, lymph node status is the most important prognostic factor. Sentinel lymph node biopsy (SLNB) is the minimally invasive procedure that lead to the most significant reduction in the classical high morbidity associated with the sistematic inguinal-femoral lymphadenectomy. Besides quality control, the aim of this study is to document the overall experience around SLNB at this referral Centre before the Covid pandemic, in order to monitor and possibly prevent future related changes. Methods: Retrospective analysis of patient files in cases where SLNB was performed as part of the treatment for vulvar cancer at the authors’ Department, from January, 2016 to December, 2019. A single surgeon performed the SLNB with the combined technique (technetium and patent blue). Data collected included demographics, pathology, accuracy, surgery and perioperative results, feasibility and survival. Results: 18 patients with vulvar squamous cell cancer were enrolled in the study. Median age was 68 years, average BMI 27.5kg/m2, 61.1% were married and Charlson score ≥5 was 55.6%. Primary site was labia majora in 44.4% and mid-line was affected in 27.8%. FIGO stage IB in 72.2% of cases, mean tumour diameter was 20.2 (7-39)mm. SLNB was bilateral in 27.8%, 1 out of 38 nodes removed was positive and average number of nodes per patient was 2.1. Mean hospital stay was 13.2 days, blood loss 72ml and no surgical complications. There was a single case of groin recurrence in 45.1 months mean follow-up time and 2 cases of non-related deaths. 33.3% and 5.6% patients had short and long-term postoperative complications, respectively, mostly infectious. Conclusions: SLNB is a reliable and safe minimally invasive technique that should be performed by experienced gynaecological oncologists in well-equipped and multidisciplinary Centres. The Covid pandemic is believed to be causing severe difficulties in the management of patients with vulvar cancer, from diagnosis to follow-up and treatment of recurrences. This study allows a future comparison with positive results at this Centre, possibly reflecting other similar scenarios in Europe.

Differential diagnosis of malformations of lymphatic vessels in dermatological practice

Lymphangiomas (LG) are uncommon, rare congenital anomalies or acquired lymphatic dilations of a benign flow that can involve the skin [1, 2]. There are main groups of lymphangiomas: 1) a superficial variant, characterized by grouped vesicles (circumscriptum lymphangioma), 2) a deeper variant in the form of a cavernous lymphangioma. The prevalence of LG may be focal or diffuse. Secondary acquired LG with a rarer frequency are known [3, 4]. LG can be one of the manifestations of a symptom complex, for example, Gorham-Stout syndrome, which is characterized by progressive osteolysis [5]. The rare occurrence of LG, clinical diversity, undulating course of congenital forms, the possibility of an acquired nature of the disease causes a high risk of diagnostic errors in establishing the final diagnosis. At the Department of Dermatovenereology, Cosmetology and Additional Professional Education of Smolensk State Medical University for the period from 2018 to 2021, 5 patients (age from 5 to 17 years) with LG were observed. Of these: in four children, the disease existed from birth, in one girl it had an acquired character and developed after covid infection [4]. Gender characteristics: 4 girls (5, 6, 12 and 17 years old) and 1 boy (9 years old). All patients are urban residents. The time to establish the final diagnosis from the moment of seeking medical help ranged from 15 months to 12 (!) years, the average value being 6.5 years. The range of diagnoses of LG 'masks': herpetic infection, molluscum contagiosum, atopic dermatitis, contact dermatitis, epidermolysis bullosa. A frequent change in diagnoses was established in the same patient. Clinical case 1. The boy is 12 years old. The debut of skin lesions from birth and progression to 3 years of age, then spontaneous regression within 4 years (without signs of dermatosis). From 7 years to the present, there has been an increase in the number of rashes. Localization: the skin of the lateral surface of the trunk. Features of the rash: flesh-colored and/or reddish- purple bubbles. A pathognomonic symptom of 'frog calves' is found. The frequent autodestructive effect on the rash provokes its subsequent progression. Family history: his father is a liquidator of the atomic catastrophe in Chernobyl. Previous diagnoses: molluscum contagiosum, herpes zoster. Clinical case 2. The girl is 17 years old. The debut of the disease from birth. Lack of progression up to 5 years of age (up to 5 years of age did not apply to dermatologists). At the age of 5, she began to engage in rhythmic gymnastics (she continues to practice professionally at the present time) and noted an active increase in the number and size of the elements of the rash. She repeatedly consulted dermatologists: diagnoses of molluscum contagiosum (laser removal), herpetic infection (courses of antiherpetic therapy without effect) were assumed. The diagnosis was established 12 years after the moment of seeking medical help. Unilateral location of the rash along the inner surface of the right upper limb with transition to the axillary region;on the right lateral surface of the body, the right inguinal-femoral fold and the inner surface of the right thigh. Focuses of a rash in the form of different sizes of vesicular elements with a tendency to lymphorrhea and oozing, areas of maceration around. Single elements with a hemorrhagic component. The patient notes an increase in the inflammatory response and vesicle lymphorrhea after each workout. Dermatoscopy: yellow-pink lacunae alternating with single dark red lacunae. Histological examination: multiple dilated lymphatic vessels in the papillary and reticular dermis. Clinical case 3. Girl 6 years old. Sick from birth. The diagnosis of LG of the genitals was established at the age of 1, 5 years. Due to the localization of the rash in the external genital area, the girl's parents (at the age of 1 month) consulted an obstetrician-gynecologist, who suggested a hemangioma and referred to a dermatologist. The disease is of a family nature her grandmother (on the maternal side) and her lder brother have similar rashes on the skin of the trunk and in the mouth. The diagnosis was verified by histological examination. The pathological process is localized in the area of the labia majora and labia minora: multiple vesicular rashes with translucent contents, easily traumatized and accompanied by itching, were found. Conclusions: LG is a multidisciplinary problem, which is caused by mimicry of manifestations, varied localization and prevalence of the rash. To verify the diagnosis, the following algorithm should be followed: 1) the debut more often at birth or in the first months of life (with the exception of acquired forms of LG);2) the nature of evolution: a stable state or slow progression in the absence of traumatic factors;3) clinical features: the formation of grouped deep vesicles that resemble 'frog eggs'. The color of the bubbles is transparent or red-purple due to the hemorrhagic component. LG lesions may have hemangioma components. It should be remembered about the frequent localization of LG on the mucous membrane of the cheeks, tongue and floor of the oral cavity, which can manifest itself as bleeding from the elements of the rash when chewing or when providing dental care;4) biopsy reveals dilated lymphatic vessels in the upper layers of the dermis.