Use of Negative Pressure Wound Therapy Systems after Radical Vulvectomy for Advanced Vulvar Cancer.

A retrospective cohort study was performed to evaluate the efficacy of negative pressure wound therapy in improving vulvectomy healing. Women who underwent radical vulvectomy with complete inguinofemoral lymphadenectomy for advanced vulvar cancer were divided into two groups according to immediate postoperative care: patients treated with negative pressure wound therapy using the device applied on the site of the wound (including vulva and inguinal region), and patients receiving conventional care. 18 patients were included in the study. 7 (38.9%) women were treated with negative pressure wound therapy immediately after the surgery and were included in the intervention group, and 11 (61.1%) patients were included in the control group. Women who received negative pressure wound therapy had significantly lower length of stay in the hospital (14.2 ± 4.7 versus 17.1 ± 6.1 days, mean difference -6.90 days, 95% confidence interval -11.91 to -1.89), and significantly lower length for wound healing (-31.90 days, 95% confidence interval -43.48 to -20.32). In conclusion, the utilization of the negative wound pressure therapy may contribute to reduce hospitalization after radical vulvectomy for vulvar cancer. Large and well-designed randomized trials with cost effectiveness analyses are needed to confirm these findings.

Vulvar cancer: surgical management and survival trends in a low resource setting.

BACKGROUND: This study aims to analyze risk factors, clinical profiles, treatment protocols, and disease outcomes in histologically proven resectable vulvar cancer (VC) patients according to tumor stage. This is a retrospective analysis of a prospectively collected database of 20 VC patients from May 2014 to June 2019. RESULTS: The mean age of VC diagnosis was 55 years, with a range of 38-84 years. The incidence was four cases per year. The disease incidence was significantly more in post-menopausal (65%) and multiparous (90%) women. According to FIGO staging of vulvar cancer, stages I, II, and III were assigned to 6, 1, and 11 patients respectively. Two patients suffered from stage IVa vulvar melanoma. All patients had undergone surgical interventions. Patients treated with only nonsurgical (chemotherapy/radiotherapy/chemo-radiotherapy) treatment modalities were excluded from the study. Fifteen patients were treated with wide local excision (WLE), bilateral inguinofemoral dissection (B/L IFLND), and primary repair. Four and one patients were treated with radical vulvectomy (RV) and modified radical vulvectomy (MRV) [with or without B/L IFLND and PLND] respectively. Reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps were done in two patients. Therapeutic groin nodal dissection was performed in 19 patients except in one patient who was treated by palliative radical vulvectomy. In the final histopathology reports, tumor size varies from 0.5 to 6.5 cm (mean 3.35 cm) with the predominance of squamous cell carcinoma (18 out of 20 patients). Only 10 out of 18 eligible patients received adjuvant treatment. Poor patient compliance has been one of the major reasons for adjuvant treatment attrition rate. Systemic and loco-regional metastasis occurred in 3 patients each arm respectively. Poor follow up of patients is the key limitation of our study. CONCLUSION: Vulvar cancer incidence was significantly high in post-menopausal and multiparous women. The most important prognostic factors were tumor stage and lymph node status. Oncological resection should be equated with functional outcome. The multidisciplinary team approach should be sought for this rare gynecological malignancy.

Endoscopic near infrared and indocyanine green to verify the viability of the subcutaneous flap for vulvar cancer.

INTRODUCTION: Vulvar cancer often requires radical vulvectomy with subsequent vulvar flap. Approximately in 20-60% of cases, there are post-operative complications ranging from infection to flap necrosis that often require reoperation. Several methods have been described to verify the vitality of the flap, but these are often expensive and require specific machinery that is not generally present in a gynecological clinic. In this case report, we present a viability verification of VY fasciocutaneous advancement flap for vulvar reconstruction by Endoscopic Near-Infrared and Indocyanine Green. METHODOLOGY: The patient was a 67-year-old woman with FIGO IB ≤ 4 cm squamous cell vulvar cancer with absence of inguinal lymphadenopathy. The lesion appeared about 35 mm from the lateral margin of the large left lip and extended to the left inguinocrural fold. The patient underwent left inguinal lymphadenectomy and left radical hemivulvectomy with a left fasciocutaneous medial-thigh advancement flap. For the flap evaluation, we endovenous administered 50 mg of Indocyanine Green diluted in 10 ml of saline solution. After 10 min we visualized the flap margin with a near-infrared laparoscopic view. The evaluation was repeated at the end of the surgical procedure and we confirmed the good vascularization of the flap. RESULTS: No early or late post-operative complications were obtained. There was no wound dehiscence, marginal necrosis or surgical site infection. CONCLUSIONS: Verifying the viability of the vulvar flap using near-infrared laparoscopic optics was easy to use, reproducible and highly economical technique. This could be a reproducible alternative to other more expensive techniques.

Pedicled neurocutaneous anterolateral thigh flap for groin reconstruction - A case report.

Several different flaps based on the feeding vessels of sensitive nerves have been described in the limbs. This article reports the case of a neurocutaneous flap based on the lateral femoral cutaneous nerve (LFCN), employed for reconstruction of an inguinal defect. A 61-years-old female patient had undergone vulvectomy and bilateral inguinal lymphadenectomy for vulvar cancer with postoperative left groin wound breakdown. After a 3 weeks negative pressure therapy course, she presented a 10 × 4 cm skin and subcutaneous defect with undermined edges in the left inguinal area. Reconstruction with 14 × 6 cm pedicled left anterolateral thigh flap was planned. After the dissection of the vascular pedicle and of the sensitive nerve, complete thrombosis of both the veins and arterial spasm of perforating pedicle was detected. As the flap color was good, and slow marginal bleeding was present, we inspected the small vessels surrounding the nerve that were pulsating. To confirm the vascularization coming from the neural pedicle, we clamped the perforator and performed intraoperative indocyanine green (ICG) fluorescence angiography that showed a good fluorescence of the flap with a proximal to distal pattern of progression. The flap was transferred on the neural pedicle, survived completely, and wounds healed normally. Three months after surgery, the patient underwent radiotherapy, with uneventful course. In her last follow-up, 2 years after surgery, patient was free of disease and the flap showed normal scarring. This is the first case reported of a pedicled neurocutaneous flap based on the LFCN, indicating that in case of unsuitable perforators it could be an alternative pedicle.

Verrucous Carcinoma of the Vulva: A Case Report and Literature Review.

BACKGROUND Verrucous carcinoma (VC) of the vulva is a variation of squamous carcinoma (SCC). Etiology and treatment of VC are still unclear. CASE REPORT A 50-year-old female visited our clinic with a giant vulvar tumor (8 cm of diameter maximum). Biopsy revealed a suspicious well differentiation squamous cancer. PET/CT (positron emission tomography/computed tomography) scan found suspicious lymph node in bilateral iliac vessel region and bilateral inguinal region. She underwent radical vulvectomy and bilateral inguinal lymph node dissection, and bilateral pelvic lymph node dissection. Pathology turns out to be VC and no lymph nodes involvement. Due to the large defection, vulvar reconstruction was performed 5 weeks later using skin grafts and pudendal thigh flap. This patient was disease free after 12 months follow-up. CONCLUSIONS In patients with VC, a satisfactory biopsy is important and systemic inguinal lymphadenectomy might be omitted. For patients with large defection, flap-based reconstruction is recommended.

Trends and Complications of Vulvar Reconstruction After Vulvectomy: A Study of a Nationwide Cohort.

OBJECTIVES: The objective of this study was to determine complications associated with primary closure compared with reconstruction after vulvar excision and predisposing factors to these complications. METHODS: Patients undergoing vulvar excision with or without reconstruction from 2011 to 2015 were abstracted from the National Surgical Quality Improvement Program database. Common Procedural Terminology codes were used to characterize surgical procedures as vulvar excision alone or vulvar excision with reconstruction. Patient characteristics and 30-day outcomes were used to compare the 2 procedures. Descriptive and univariate statistics were performed. Adjusted odds ratios and confidence intervals were calculated using a logistic regression model to control for potential confounders. Two-sided α with P < 0.05 was designated as significant. RESULTS: A total of 2698 patients were identified; 78 (2.9%) underwent reconstruction. There were no differences in age, race, body mass index, diabetes, hypertension, tobacco use, heart failure, renal failure, or functional status between the 2 groups. American Society of Anesthesiologists class 3 and 4 patients and those with disseminated cancer were more likely to undergo reconstruction (both P < 0.001). On univariate analysis, reconstruction was associated with increased risk of readmission, surgical site infection, pulmonary complications, urinary tract infection, transfusion, deep venous thrombosis, sepsis, septic shock, unplanned reoperation, longer hospital stay, need for skilled nursing or subacute rehab on discharge, and death within 30 days. On logistic regression analysis, disseminated cancer, American Society of Anesthesiologists classes 3 and 4 and reconstruction remained significant risk factors for readmission and any postoperative complication. CONCLUSIONS: Patients undergoing vulvar excision with reconstruction are at increased risk for readmission and postoperative complications compared with those undergoing excision alone. Careful patient selection and efforts to optimize surgical readiness are needed to improve outcomes. Long-term data could help determine if these 30-day outcomes are a reliable measure of surgical quality in vulvar surgery.

Prognostic impact of reduced tumor-free margin distance on long-term survival in FIGO stage IB/II vulvar squamous cell carcinoma.

OBJECTIVE: We aimed to identify the minimum tumor-free margin distance conferring long-term oncological safety in patients diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage IB/II vulvar squamous cell carcinoma (VSCC). METHODS: This was a retrospective cohort study in patients with stage IB/II VSCC treated at a single institution in Turin, Italy. The main aim was to identify the minimum tumor-free margin distance that confers oncological safety in early-stage VSCC. Patients were divided in groups according to tumor-free histological margin distance to compare survival outcomes. Overall survival (OS), disease-specific survival (DSS), and recurrence rate (RR) were estimated by the Kaplan-Meier method for the newly proposed and the currently recommended 8 mm margin cut-off. Log-rank test was used to compare survival between groups. RESULTS: One hundred and fourteen patients met the study criteria. Median age was 68 years and median follow-up was 80 months. The minimum margin distance that conferred long-term oncological safety was 5 mm. OS, DSS were significantly lower in the <5 mm group when compared with the ≥5 mm group (p=0.002 and p=0.033, respectively) although no difference in RR was observed between groups. Analysis at the 8-mm cut-off indicated there is no difference in OS, DSS, or RR between groups. CONCLUSION: FIGO stage IB/II VSCC patients' prognosis is affected by margin distance. Long-term survival is significantly reduced in patients with tumor-free margins <5 mm, even in the absence of lymph node metastasis. Thus, these patients should be offered further surgical or adjuvant treatment.

Carcinoma escamoso de vulva / Vulvar squamous carcinoma

El cáncer de vulva es una neoplasia relativamente rara, supone 5 por ciento de todos los cánceres ginecológicos. Su etiología, en general, se desconoce, pero existen pruebas que categorizan el virus del papiloma humano como un factor causal. En Cuba representa menos de 1 por ciento de todos los tumores malignos de la mujer, con su máxima aparición en la pos menopausia. Presentamos un caso de carcinoma escamoso de vulva diagnosticado en la atención primaria de salud. Se trata de una fémina de 65 años de edad, mestiza, fumadora inveterada, primeras relaciones sexuales a los 20 años, múltiples parejas sexuales, la mayoría desprotegidas, citología realizada en el año 2014 negativa, quien acudió a su consultorio, perteneciente al Policlínico Docente Efraín Mayor Amaro, del Cotorro, por presentar aumento de volumen en sus genitales, en ocasiones le producía prurito. Al examen físico se constató lesión verrugosa en el labio mayor derecho de aproximadamente 4 cm de diámetro, de contornos irregulares, no dolorosa a la palpación. Se interconsulta con Ginecología donde se indica exámenes complementarios, que demostraron en la citología actual, una displasia leve, NIC I, HPV. En consulta de Patología de cuello se realiza biopsia por ponche que se informa como: Carcinoma escamoso moderadamente diferenciado verrugoso. Posteriormente fue remitida a consulta de oncología para tratamiento quirúrgico, siguiendo los protocolos marcado por el comité oncológico de la Federación Internacional de Ginecólogos y Obstetras (FIGO). Se reafirma que el diagnóstico temprano es importante, debiéndose realizar mediante evaluación clínico e histopatológica, garantizando su tratamiento oportuno(AU)

Vulvar cancer is a relatively rare neoplasm, accounting for 5 percent of all gynecological cancers. The etiology is unknown, but there are tests that categorize by preference the human papillomavirus (HPV) as a causal factor. In Cuba, it represents less than 1 percent of all malignant tumors in women, and the maximum appearance in post menopause. We present the case of a patient over 65 years of age, mestizo, and incorrigible smoker. She had her first sexual intercourses at age 20, most of them unprotected, she had multiple sexual partners. The cytology performed in 2014 was negative. She came to consultation due to an increase in the volume of her genitals, which sometimes caused itching. In pathology consultation, punch biopsy is performed, which is reported as moderately differentiated verrucous squamous carcinoma. She was then taken on an Oncology consult for surgical treatment, following the protocols marked by the oncologic committee of the International Federation of Gynecologists and Obstetrics (FIGO). Early diagnosis is important and should be carried out through clinical and histopathologically evaluation to ensure timely treatment(AU)

A vulvar mass as the first presentation in colorectal carcinoma: An unusual site of metastasis masquerading a primary cancer.

OBJECTIVE: To demonstrate a case with a vulvar metastasis masquerading a primary vulvar malignancy. The clinical and histological features, mechanism, and impact to the prognosis are discussed. CASE REPORT: A 58-year-old woman presented to gynecologist for abnormal vaginal discharge. A vulvar nodule was noticed during physical examination. Biopsy showed adenocarcinoma (ADC) and she was referred for further survey under the impression of Bartholin duct ADC. Later she was further found to also have a colorectal tumor with liver metastasis and subsequently received surgery under the suspicion of a double primary cancer involving the colon and vulva. The pathology revealed colorectal ADC with both hepatic and vulvar metastasis. CONCLUSION: Secondary tumor in female genital tract is unusual and vulvar metastasis is the rarest kind. The clinical manifestation may be perplexing especially if a patient is presented with a nonspecific gynecological symptom such as abnormal vaginal discharge without any past history.

Transient Reactive Eruptive Lymphangiectasia Following Partial Vulvectomy for Chronic Acquired Lymphangioma.

A 64-year-old white woman was originally diagnosed with histiocytic lymphoma in 1977. She had bilateral lymph node biopsies of the groin, chemotherapy, and radiation therapy after her diagnosis had been confirmed pathologically. She was treated with prednisone and vincristine.

An alternative approach to gynecological wound healing.

An 89-year-old woman was reffered to our Clinic with vulvar cancer. She also suffered from obesity [with body mass index (BMI) 35 kg/m2], persistent hypertension, diabetes mellitus type 2 treated with oral medications. In 2015 she underwent a surgery due to endometrial carcinoma. Total abdominal hysterectomy with bilateral salphingoophorectomy, omentectomy and pelvical node dissection was performed (histopathology revealed adenocarcinoma serosum G2; FIGO stage Ib). In January 2016 after vulvar ulceration biopsy plano-epithelial squamous vulvar cancer was diagnosed. She was referred to surgery. She has undergone an operation in October 2016. She was admitted to gynaecological unit at our institution. Physical examination revealed mutilated vulva with excised labia major, labia minor, and narrowing of vaginal orifice. The right side shown tumor 2.5 cm in diameter, with slough area and no deep infiltration and satellital nodule on the left labia majora 1cm in diameter. The cervix, vaginal wall, rectum and anus appeared normal. There were no enlarged lymph nodes at the inguinal area.

The lymphatic superficial circumflex iliac vessels deep branch perforator flap: A new preventive approach to lower limb lymphedema after groin dissection-preliminary evidence.

OBJECTIVE: Groin dissection is the procedure with the highest risk of lower limb lymphedema.As lymph stasis causes irreversible alterations to the limb over time,therapies should be administered in early stages,or better yet, lymphatic drainage impairment should be prevented.We developed a new preventive approach to lymphedema after groin dissection, and we report our preliminary experience. PATIENTS AND METHODS: We enrolled 5 patients undergoing bilateral groin dissection for vulvar cancer. Preoperative study of lower limbs lymphatic function was obtained by lymphoscintigraphy, with lymphatic transport index, indocyanine green (ICG) lymphography, and volume measurement with lower extremity lymphedema (LEL) index calculation. At the end of lymphadenectomy, one groin was closed in the standard way. On the other side, a lymphatic flap pedicled on the distal perforator of the deep branch of the superficial circumflex iliac vessels, was transposed into the groin region. Lymphatic function examination of the limbs was repeated 6 months after surgery. RESULTS: Before surgery no patient showed lymphatic drainage impairment at lymphoscintigraphy or lymphography, LEL index was in every limb lower than 250 (mean: 217.3 ± 13.83). After surgery the limbs treated with the flap showed no pathological swelling, LEL-index < 250 (mean: 235.4 ± 13.069), linear pattern at lymphography, and normal lymphoscintigraphy. The untreated limbs showed from moderate to severe edema with 265 < LEL-index < 310 (mean: 283 ± 16.3), diffuse dermal backflow at lymphography and interruption of lymph flow, with dermal backflow, at lymphoscintigraphy. Mean difference between preoperative and postoperative volumes was 64.8 ± 25.1 in the untreated side and 19 ± 11.7 in the side with the flap. The difference between preoperative and postoperative volumes compared between the treated and untreated side was statistically significant (P < .01). CONCLUSION: Our preliminary evidence suggests that this flap can prevent lymphedema after groin dissection. Further studies are necessary to confirm these results.

Aggressive Angiomyxoma of the Vulva Mimicking Clitoromegaly in a Young Child.

Aggressive angiomyxoma (AAM) is a rare soft tissue tumor of mesenchymal origin that chiefly involves the vulvar and perineal region. In 90% of cases, AAM presents in women of reproductive age with a peak incidence in the fourth decade of life. To date, AAM of the vulva in young children and infancy has never been reported. We present a case of AAM of the vulva that was initially interpreted as clitoromegaly in a 3-year-old girl.

Modified Gluteal Fold V-Y Advancement Flap for Reconstruction After Radical Vulvectomy.

OBJECTIVE: To describe the surgical technique of the V-Y cutaneous supra-fascial (modified) gluteal advancement flaps for reconstruction after radical vulvectomy and to assess the outcome of patients according to their clinical characteristics. METHODS: Between January 2006 and July 2012, 36 V-Y flaps were performed in 21 patients to cover the defect after radical surgery of primary vulvar cancers. Surgery duration, blood loss, hospital stay, and wound healing were assessed according to patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the initial defect size. RESULTS: Median patient age, BMI, and ASA score were 80 (range, 31-91), 28 (range, 18-36), 3 (range, 1-3), respectively. Median surgery duration and blood loss were 180 minutes (range, 60-275) and 400 mL (range, 100-1000), respectively. Median operating time was higher in patients ASA3 than ASA less than 3, 200 versus 120 minutes (P = 0.038). Median initial defect size was higher in patients with BMI greater than 28 than 28 or less, 92 versus 55 cm (P = 0.004). Local scar defect was observed in 16 patients (76%), mild, less than 10 cm in 10 patients. Median wound healing duration was higher in patients with bilateral than unilateral flap, 16 versus 9.5 days (P = 0.034). CONCLUSIONS: The V-Y cutaneous suprafascial gluteal advancement flap for vulvar reconstruction after vulvectomy is an easy, safe, and reliable procedure. However, even mild local scar defect after bilateral flap may impact on wound healing and hospital stay, in elderly and ASA3 patients.

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

Total vaginectomy and radical vulvectomy for extension of extra-mammary Paget's disease.

Extra-mammary Paget's disease of the vulva is a rare non-invasive adenocarcinoma that usually occurs in postmenopausal women. Histologically, it often extends beyond the visible lesion, leading to positive surgical margins and frequent recurrences, but can be managed by simple vulvectomy or wide local excision. Although current evidence supports the use of radical surgery as an alternative to the generally performed wide local excision in the treatment of widely extended extra mammary Paget's disease of the vulva, nonetheless there controversy still exists regarding the extent of an adequate resection margin. Here the authors present a case of successful radical vulvectomy with total vaginectomy without adjuvant treatment on a delayed diagnosis of extra-mammary Paget's disease, extending from the vulva to the apex of vagina.

Tumor de la vulva, vulvectomía radical / Vulvar tumor, total vulvectomy

Los tumores de la vulva no son una rareza entre los cánceres que afectan a las féminas, pero tampoco son de los más frecuentes. Se presenta el caso de una mujer de 59 años, que en el año 2000 se le diagnostica carcinoma epidermoide del clítoris, en 2004 se vuelve a intervenir por recidiva tumoral, y en 2009 acude a nuestra consulta nuevamente y es cuando se decide realizarle vulvectomía y resección de vagina y todo el sistema ginecológico. Concluyó la intervención con una talla vesical extraperitoneal. El tumor se extiende hasta la porción inicial de la vagina y uretra. Se trata de un tumor maligno, bien diferenciado, que se ha comportado en una forma no habitual, con recidivas locales, cuando en apariencia el tumor había sido resecado en toda su extensión, y en esta última oportunidad, a pesar de ser un estadio avanzado, no hemos encontrado metástasis ni multicentricidad del tumor. La evolución posoperatoria fue sin complicaciones y se dio de alta al quinto día(AU)

The vulvar tumors are not uncommon among the different types of cancer involving females, but neither are the more frequent ones. This is the case of a female aged 59 that in 2000 is diagnosed with epidermoid carcinoma of clitoris, in 2004 is re-operated on by tumor relapse, and in 2009 she came again to our consultation and a vulvectomy, vagina resection and all gynecological system are carried out. Intervention concluded with an extraperitoneal vesical cutting. The tumor extends up to the initial portion of vagina and urethra. It is a malignant and well-differentiated tumor behaved in non habitual way with local relapses, when apparently the tumor was resected in all its extent, and in this last change, despite and advanced stage, there were neither tumor metastases nor multi-centralization. The postoperative course was free of complications receiving the discharge at fifth day(AU)