Reconstructive plastic surgery in the treatment of vulvar carcinomas.

OBJECTIVE: The results obtained using plastic surgery reconstruction in 207 patients with a primary or recurrent vulvar carcinoma were analyzed with regard to the surgical procedures applied, pre-treatment and post-operative findings, along with the long-term oncological disease course. STUDY DESIGN: Standardized data concerning the surgical procedures applied and clinical factors were collected in a databank and statistically analyzed. RESULTS: The flaps employed were termed either 'local' (cutaneous or fasciocutaneous; n=84) or 'regional' (myocutaneous, n=123). For local flaps, the rate of secondary healing was 31%, dropping to 20% for regional flaps. Such healing disturbances often affected the donor region and did not lead to lasting clinical problems such as stenosis or distortion. Severe disturbances of wound healing (loss of more than 10%) were not observed in local flaps, whereas such problems were encountered in 5.9% of regional flaps. Gluteal thigh flaps were most frequently applied and were also the most successful type of myocutaneous reconstruction. Therapy was selected on an individual basis according to tumor status. CONCLUSION: Plastic surgery reconstruction broadens the range of operative therapies available for the treatment of vulvar carcinomas, especially those at an advanced stage or recurrent tumors, and leads to a favorable oncological disease course as well as improved cosmetic results.

Surgical therapy of recurrent vulvar cancer.

OBJECTIVE: The success of various surgical interventions in 201 cases with recurrent vulvar carcinoma was examined in the light of patients' pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course. STUDY DESIGN: A databank of standardized clinical data was analyzed using statistical procedures. RESULTS: Therapy was selected on an individual basis according to tumor status. Recurrence at a site distant from the primary tumor, particularly in the inguinal region, indicated a markedly unfavorable prognosis. In contrast, tumors recurring locally did not exhibit any significant differences. Plastic surgery reconstruction led to improvements with respect to operability, wound healing, and survival. CONCLUSION: Individualized reconstructive surgery of the vulva leads to good results in patients with recurrent vulvar cancer. To an even greater extent than is the case for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives so that a more favorable oncological outcome and excellent cosmetic results may be expected.

The impact of treatment for genital cancer on quality of life and body image--results of a prospective longitudinal 10-year study.

OBJECTIVE: To evaluate the impact of treatment for genital cancer on quality of life and body image to determine patients' therapy-related needs for quality improvement of medical care before and after surgery. METHODS: We started to evaluate women with cervical cancer planned for pelvic exenteration in 1993 and integrated women planned for a Wertheim-Meigs surgery in 1995 before surgery, 4 and 12 months after surgery. Thanks to funding since 1999, more than 400 patients with a diagnosis of genital (n = 185) or breast (n = 217) cancer participated in this prospective study until July 2003. In this paper, we will focus on n = 129 women with cervical cancer. The assessment protocol included objective questionnaires for quality of life and body image (CARES; EORTC; Body image by Strauss and Appelt). The evaluation of quality of life incorporated five dimensions: physical and psychosocial health, marital and sexual status, and medical interaction. RESULTS: Before surgery, women with a Wertheim's procedure indicated significantly less problems concerning the quality of life global score (P = 0.002) and several subscales compared to women with a pelvic exenteration. After surgery, both groups indicated their sexual problems to be the greatest restriction in terms of quality of life, especially in women with non-reconstructive surgery as well as in women with adjuvant radio and/or chemotherapy. Concerning body image, attractiveness or self-confidence was significantly reduced postoperatively compared to the preoperative status for both groups (P = 0.000), and also worsened with the extent of treatment. Worries about the patient's family persisted over time and represented the most important item about all questions concerning quality of life as well as the fear of recurrence. CONCLUSION: This on-going study demonstrates the interferences between the treatment modality and the patient's quality of life, especially about sexuality and body image. Our results suggest not only to provide reconstructive surgery if possible, but also to integrate psychosocial information aspects on future quality of life outcome before surgery as well as to offer psychosocial support related to the extent of treatment modality after surgery.

The physician-patient relationship before cancer treatment: a prospective longitudinal study.

OBJECTIVES: To evaluate quality of life before surgery for genital cancer to determine risk factors that might influence the physician-patient relationship. METHODS: From 1993 until 2003, 129 women with cervical cancer entered this prospective study. Patients were contacted 1 to 5 days before surgery by a psychologist or psychotherapeutically trained physician on the surgical ward. The semistructured interview included questions on the patient's psychosocial well-being according to criteria of the biographic interview technique. The preoperative anxiety level was evaluated by the STAI and quality of life by the Cancer Rehabilitation Evaluation System (CARES) and EORTC questionnaires. Patients were assigned to groups undergoing pelvic exenteration (n = 62) or Wertheim procedure (n = 67). RESULTS: The preoperative anxiety level did not correlate with the treatment modality. Women with a high anxiety level complained of a lack of information which correlated with a dissatisfaction concerning the physician-patient relationship (r = 0.457, P = 0.001). Quality of life in terms of medical interaction and the need for information were indicated to be the most important aspects for cancer patients facing genital surgery. CONCLUSIONS: These data demonstrate the need for information strategies before surgery: first, to reduce anxiety by anticipating future quality of life outcome problems and, second, to improve medical interaction before stressful treatment options.

Carcinoma of the neovagina: case report and review of the literature.

BACKGROUND: Carcinoma of the vagina is a rare disease, and it is even more rare in the neovagina. Nevertheless, it has been well described. The aim of this report was to analyze the reported cases and to add observations concerning a risk profile for this rare occurrence of carcinoma. CASE REPORT: The 29-year-old patient's history included congenital absence of vagina as a result of Rokitansky-Kuster syndrome. In 1987, when the patient was 17 years old, a neovagina was constructed by dissection between the bladder and the rectum, according to the Warthon method, and the apex of the neovagina was covered with Dura-mater. In 1990 the patient underwent radiation treatment with brachytherapy three times in combination with surgical treatment, because of granulation tissue in the neovagina. In 1999 several specimens of the granulation tissue were removed and histological examination showed intermediate differentiated squamous cell carcinoma. Total exenteration with pelvic and lower paraaortic lymph node dissection was performed, and the patient received a continent neobladder (Mainz Pouch I), colostoma, and sigma neovagina. Two months later in January 2000 the patient showed local recurrence and after local excision the patient received radiotherapy. The follow-up to June 2001 showed no evidence of disease. CONCLUSION: All patients with vaginoplasty should undergo regular 1-year follow-ups, including smear analysis because of the possibility of the development of carcinoma. Granulation tissue arising in a neovagina should be biopsied and no prosthesis should be used until lesions have healed completely. Patients who have undergone radiation of the neovagina carry an additional risk.