Thick silk fibroin vascular graft: A promising tissue-engineered scaffold material for abdominal vein grafts in middle-sized mammals.

Abdominal vein replacement with synthetic tissue-engineered vascular grafts constructed from silk-based scaffold material has not been reported in middle-sized mammals. Fourteen canines that underwent caudal vena cava replacement with a silk fibroin (SF) vascular graft (15 mm long and 8 mm diameter) prepared with natural silk biocompatible thread were allocated to two groups, thin and thick SF groups, based on the graft wall thickness. The short-term patency rate and histologic reactions were compared. The patency rate at 2 weeks after replacement in the thin and thick SF groups was 50% and 88%, respectively (p = 0.04). CD31-positive endothelial cells covered the luminal surface of both groups at 4 weeks. The elastic modulus of the thick SF graft was significantly better than that of the thin SF graft (0.0210 and 0.0007 N/m2, p < 0.01). Roundness of thick SF groups (o = 0.8 mm) was better than thin SF (o = 2.0 mm). There was significant difference between the groups (p = 0.01). SF vascular grafts are a promising tissue-engineered scaffold material for abdominal venous system replacement in middle-sized mammals, with thick-walled grafts being superior to thin-walled grafts.

Characterization and promotion of endothelialization of Bombyx mori silk fibroin functionalized with REDV peptide.

In the development of small-diameter vascular grafts, it is crucial to achieve early-stage endothelialization to prevent thrombus formation and intimal hyperplasia. Silk fibroin (SF) from Bombyx mori is commonly used for such grafts. However, there is a need to expedite endothelialization post-implantation. In this study, we functionalized SF with Arg-Glu-Asp-Val (REDV) (SF + REDV) using cyanuric chloride to enhance endothelialization. The immobilization of REDV onto SF was confirmed and the amount of immobilized REDV could be calculated by 1H NMR. Furthermore, the conformational changes in Tyr, Ser, and Ala residues in [3-13C]Tyr- and [3-13C]Ser-SF due to REDV immobilization were monitored using 13C solid-state NMR. The REDV immobilized onto the SF film was found to be exposed on the film's surface, as confirmed by biotin-avidin system. Cell culture experiments, including adhesiveness, proliferation, and extensibility, were conducted using normal human umbilical vein endothelial cells (HUVEC) and normal human aortic smooth muscle cells (HAoSMC) on both SF and SF + REDV films to evaluate the impact of REDV on endothelialization. The results indicated a trend towards promoting HUVEC proliferation while inhibiting HAoSMC proliferation. Therefore, these findings suggest that SF + REDV may be more suitable than SF alone for coating small-diameter SF knitted tubes made of SF threads.

Bombyx mori Silk Fibroin and Model Peptides Incorporating Arg-Gly-Asp Motifs and Their Application in Wound Dressings.

Skin plays an important role in protecting the human body from the environment, dehydration, and infection. Burns, wounds, and disease cause the skin to lose its role, but tissue-engineered skin substitutes offer the opportunity to restore skin loss. Silk fibroin from Bombyx mori (SF) has proven to be an excellent wound dressing material. In this study, we aim to develop an excellent wound dressing material by introducing three-residue sequence Arg-Gly-Asp (RGD), which is the most well-known adhesion site of fibronectin, in the films of SF and the model peptide. Its usefulness as a wound dressing material was evaluated both in vitro and in vivo. First, we showed that the flexible structures of the RGD sequence are still maintained in SF with a rigid antiparallel ß-sheet structure using NMR in association with excellent wound dressings of SF containing RGD. Then, in in vitro experiments, two types of normal cells derived from human skin, normal human neonatal epidermal keratinocytes and normal human neonatal dermal fibroblasts, were used to evaluate the cell adhesion. On the other hand, in in vivo experiments, the study was conducted using a rat model of a whole skin layer defect wound. The results showed that the high-functionalized SF developed here has the potential to play a significant role in the field of wound dressings.

Structure of silk I (Bombyx mori silk fibroin before spinning) in the dry and hydrated states studied using 13C solid-state NMR spectroscopy.

Nowadays, much attention has been paid to Bombyx mori silk fibroin (SF) by many researchers because of excellent physical properties and biocompatibility. These superior properties originate from the structure of SF and therefore, the structural analysis is a key to clarify the superiority. Here we concentrated on silk I structure (SF structure before spinning). We showed that silk I* (the structure of (GAGAGS)n which is a main part of SF) is a repeated type II ß-turn, neither α-helix nor random coil, from the conformation-dependent 13C NMR chemical shift data. This conclusion is different from that obtained using IR by many researchers. Next, the formation of silk I* structure was investigated at molecular level using 13C solid-state NMR spectroscopy. Three kinds of 13C INEPT, CP/MAS and DD/MAS NMR spectra were observed for SF, [3-13C]Ser- and [3-13C]Tyr-SF, the crystalline fraction obtained by chymotrypsin treatment of SF and their model peptide with silk I structures in the dry and hydrated states. Especially, the presence of the sequences containing Tyr, (((GX)m1GY)m2 where X = A or V) with random coil conformations adjacent to (GAGAGS)n is an essence to get water-soluble SF and the formation of silk I* structure of (GAGAGS)n.

Structure of Silk I (Bombyx mori Silk Fibroin before Spinning) -Type II ß-Turn, Not α-Helix.

Recently, considerable attention has been paid to Bombyx mori silk fibroin by a range of scientists from polymer chemists to biomaterial researchers because it has excellent physical properties, such as strength, toughness, and biocompatibility. These appealing physical properties originate from the silk fibroin structure, and therefore, structural determinations of silk fibroin before (silk I) and after (silk II) spinning are a key to make wider applications of silk. There are discrepancies about the silk I structural model, i.e., one is type II ß-turn structure determined using many solid-state and solution NMR spectroscopies together with selectively stable isotope-labeled model peptides, but another is α-helix or partially α-helix structure speculated using IR and Raman methods. In this review, firstly, the process that led to type II ß-turn structure by the authors was introduced in detail. Then the problems in speculating silk I structure by IR and Raman methods were pointed out together with the problem in the assignment of the amide I band in the spectra. It has been emphasized that the conformational analyses of proteins and peptides from IR and Raman studies are not straightforward and should be very careful when the proteins contain ß-turn structure using many experimental data by Vass et al. In conclusion, the author emphasized here that silk I structure should be type II ß-turn, not α-helix.

Chain-folded lamellar structure and dynamics of the crystalline fraction of Bombyx mori silk fibroin and of (Ala-Gly-Ser-Gly-Ala-Gly)n model peptides.

Solid-state NMR is a powerful analytical technique to determine the composite structure of Bombyx mori silk fibroin (SF). In our previous paper, we proposed a lamellar structure for Ala-Gly copolypeptides as a model of the crystalline fraction in Silk II. In this paper, the structure and dynamics of the crystalline fraction and of a better mimic of the crystalline fraction, (Ala-Gly-Ser-Gly-Ala-Gly)n (n = 2-5, 8), and 13C selectively labeled [3-13C]Ala-(AGSGAG)5 in Silk II forms, were studied using structural and dynamical analyses of the Ala Cß peaks in 13C cross polarization/ magic angle spinning NMR and 13C solid-state spin-lattice relaxation time (T1) measurements, respectively. Like Ala-Gly copolypeptides, these materials have lamellar structures with two kinds of Ala residues in ß-sheet, A and B, plus one distorted ß-turn, t, formed by repetitive folding using ß-turns every eighth amino acid in an antipolar arrangement. However, because of the presence of Ser residues at every sixth residue in (AGSGAG)n, the T1 values and mobilities of B decreased significantly. We conclude that the Ser hydroxyls hydrogen bond to adjacent lamellar layers and fix them together in a similar way to Velcro®.

Packing Structure of Antiparallel ß-Sheet Polyalanine Region in a Sequential Model Peptide of Nephila clavipes Dragline Silk Studied Using 13C Solid-State NMR and MD Simulation.

Packing structures of polyalanine regions, which are considered to be the reason for the extremely high strength of spider dragline silks, were studied using a series of sequential peptides: (Glu)4GlyGlyLeuGlyGlyGlnGlyAlaGly(Ala)nGlyGlyAlaGlyGlnGlyGlyTyrGlyGly(Glu)4 (n = 3-8) using 13C solid-state NMR spectroscopy. The conformations of (Ala)n in the freeze-dried peptides changed gradually with increasing n from random coils to α-helices with partial antiparallel ß-sheet (AP-ß) structures. Conversely, all the insolubilized peptides, n = 6-8 after low-pH treatment and n = 4-8 after formic acid/methanol treatment, formed AP-ß structures with significant amounts of staggered packing arrangements. These results are different from previously obtained results for pure alanine oligopeptides, that is, AP-ß (Ala)n formed rectangular packing for less than n = 6 but staggered packings for n ≥ 7. The 13C-labeled peptides were also used to confirm the staggered packing arrangements from NMR dynamics. Furthermore, a MD simulation supported the observed results.

Toward Understanding the Silk Fiber Structure: 13C Solid-State NMR Studies of the Packing Structures of Alanine Oligomers before and after Trifluoroacetic Acid Treatment.

Polyalanine (poly-A) sequences with tightly packed antiparallel ß sheet (AP-ß) structures are frequently observed in silk fibers and serve as a key contributor to the exceptionally high-fiber tensile strength. In general, the poly-A sequence embedded in the amorphous glycine-rich regions has different lengths depending on the fiber type from spiders or wild silkworms. In this paper, the packing structures of AP-ß alanine oligomers with different lengths were studied using 13C solid-state NMR as a model of the poly-A sequences. These included alanine oligomers with and without the protection groups (i.e., 9-fluorenylmethoxycarbonyl and polyethylene glycol groups at the N- and C-terminals, respectively). The fractions of the packing structures as well as the conformations were determined by deconvolution analyses of the methyl NMR peaks. Trifluoroacetic acid was used to promote the staggered packing structures, and the line shapes changed significantly for oligomers without the protected groups but only slightly for oligomers with the protected groups. Through NMR analysis of the 3-13C singly labeled alanine heptamer and refined crystal structure of the staggered packing units, a possible mechanism of the staggered packing formation is proposed for the AP-ß alanine heptamer.

Anaplastic ependymoma arising from the lower segment of the uterine corpus: Case report and literature review.

To the best of our knowledge, there are currently no reports on primary uterine ependymoma. We operated on a 38-year-old woman suspected with uterine fibroids; surgical findings led to the diagnosis of primary anaplastic ependymoma of the uterus. Most extraneural ependymomas arising from the ovary and perigenital peritoneum occur in women of reproductive age and express estrogen and progesterone receptors. The etiology of such tumors is unknown, and a treatment strategy has not been established yet. Therefore, it is essential to accumulate cases for identifying mechanisms underlying the pathogenesis and disease progression to facilitate diagnosis and development of an effective treatment.

Conformational change of 13C-labeled 47-mer model peptides of Nephila clavipes dragline silk in poly(vinyl alcohol) film by stretching studied by 13C solid-state NMR and molecular dynamics simulation.

For determination of the conformation of irregular sequences in glycine-rich region of the Nephila clavipes spider dragline silk, the combination of 13C selectively labeled model peptides for the typical primary structure and their 13C solid-state NMR observations is very useful (T. Asakura et al. Macromolecules. 51 (2018) 3608-3619). However, spiders produce the fiber through the stretching process in nature and therefore, it is difficult to study conformational change by stretching as mimic using the model peptides because these are generally in the powder form. In this paper, 13C selectively labeled three model peptides, (Glu)4(Ala)6GlyGly12Ala13Gly14GlnGlyGlyTyrGlyGlyLeuGlySerGlnGly25Ala26Gly27ArgGly-GlyLeuGlyGlyGlnGly35Ala36Gly37(Ala)6(Glu)4 with three underlined 13C labeled blocks and their poly(vinyl alcohol) blend films were prepared and the conformational changes of these peptides were monitored by stretching of the films using 13C solid-state NMR. In addition, the molecular dynamics simulation was done to evaluate change in the conformation of the sequence by stretching theoretically. The fractions of ß-sheet of Ala36 and Gly37 residues in glycine-rich region adjacent to the C-terminal (Ala)6 sequence increased significantly by stretching compared with those of other 13C labeled Ala and Gly residues.

Silk fibroin produced by transgenic silkworms overexpressing the Arg-Gly-Asp motif accelerates cutaneous wound healing in mice.

We investigated the effect of silk fibroin (SF) on wound healing in mice. SF or an amorphous SF film (ASFF) prepared from silk produced by the wild-type silkworm Bombyx mori (WT-SF, WT-ASFF) or by transgenic worms that overexpress the Arg-Gly-Asp (RGD) sequence (TG-SF, TG-ASFF) was placed on 5-mm diameter full-thickness skin wounds made by biopsy punch on the back of 8-12 week-old BALB/c mice. Each wound was covered with WT-ASFF and urethane film (UF), TG-ASFF plus UF, or UF alone (control). Wound closure, histological thickness, the area of granulation tissue, and neovascularization were analyzed 4, 8, and 12 days later. The effect of SF on cell migration and proliferation was examined in vitro by scratch- and MTT-assay using human dermal fibroblasts. Wound closure was prompted by TG-ASFF, granulation tissue was thicker and larger in ASFF-treated wounds than the control, and neovascularization was promoted significantly by WT-ASFF. Both assays showed that SF induced the migration and proliferation of human dermal fibroblasts. The effects of TG-ASFF and TG-SF on wound closure, granulation formation, and cell proliferation were more profound than that of WT-ASFF and WT-SF. We document that SF accelerates cutaneous wound healing, and this effect is enhanced with TG-SF. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 107B: 97-103, 2019.

Advanced Silk Fibroin Biomaterials and Application to Small-Diameter Silk Vascular Grafts.

As the incidences of cardiovascular diseases have been on the rise in recent years, the need for small-diameter artificial vascular grafts is increasing globally. Although synthetic polymers such as expanded polytetrafluoroethylene or poly(ethylene terephthalate) have been successfully used for artificial vascular grafts ≥6 mm in diameter, they fail at smaller diameters (<6 mm) due to thrombus formation and intimal hyperplasia. Thus, development of vascular grafts for small diameter vessel replacement that are <6 mm in diameter remains a major clinical challenge. Silk fibroin (SF) from Bombyx mori silkworm is well-known as an excellent textile and also has been used as suture material in surgery for more than 2000 years. Many attempts to develop small-diameter SF vascular grafts with <6 mm in diameter have been reported. Here, research and development in small-diameter vascular grafts with SF are reviewed as follows: (1) the heterogeneous structure of SF fiber (Silk II), including the packing arrangements and type II ß-turn structure of SF (Silk I*) before spinning; (2) SF modified by transgenic silkworm, which is more suitable for vascular grafts; (3) preparation of small-diameter SF vascular grafts; (4) characterization of SF in the hydrated state, including dynamics of water molecules by nuclear magnetic resonance; and (5) evaluation of the SF grafts by in vivo implantation experiment. According to the findings, SF is a promising material for small-diameter vascular graft development.

Unusual Dynamics of Alanine Residues in Polyalanine Regions with Staggered Packing Structure of Samia cynthia ricini Silk Fiber in Dry and Hydrated States Studied by 13C Solid-State NMR and Molecular Dynamics Simulation.

Recently, the wild silkworm and spider dragline silks have been paid considerable attention as potentially valuable biomedical materials. Samia cynthia ricini is one of the wild silkworms and the primary structure of the silk fibroin (SF) consists of tandemly repeated polyalanine (poly-A:(A)12,13). Here, we report the unusual dynamical character observed in Ala Cß groups in the poly-A region which forms an antiparallel-ß-sheet structure with a staggered packing arrangement. The 13C spin-lattice relaxation ( T1's) and spin-spin relaxation times ( T2's) of Ala Cß peaks in S. c. ricini SF fibers were observed in dry and hydrated states. The lowest field peak in Ala Cß of the poly-A region showed 2 times longer T1 value and shorter correlation time than the other Ala Cß peaks of the staggered packing structure, suggesting unusually fast hopping in methyl groups. Molecular dynamics simulations indicated that two of the Ala Cß carbons out of eight existing in the unit cell of the staggered packing structure exhibited the fastest hopping motion in spite of the shortest Cß-Cß distance, indicating a geared hopping motion. T2 values of the hydrated and dry Ala Cß peaks showed a similar value, indicating that the backbone motion of S. c. ricini SF fiber is not significantly affected by hydration.

3D 14 N/1 H Double Quantum/1 H Single Quantum Correlation Solid-State NMR for Probing the Parallel and Anti-Parallel Beta-Sheet Arrangement of Oligo-Peptides at Natural Abundance.

The beta (ß)-sheet structures of oligopeptides and polypeptides can be formed in anti-parallel (AP) and parallel (P) forms, which is an important feature to understand such structures. In principle, P- and AP-ß-sheet structures can be identified by the presence (AP) or absence (P) of inter-strand 1 HNH /1 HNH correlations on a diagonal in the corresponding 2D 1 H double quantum (DQ)/1 H single quantum (SQ) spectrum due to the different inter-strand 1 HNH /1 HNH distances between the two arrangements. However, the 1 HNH /1 HNH peaks overlap with the 1 HNH3+ /1 HNH3+ peaks, which always give cross-peaks regardless of the ß-sheet arrangement. The 1 HNH3+ /1 HNH3+ peaks disturb the observation of the presence/absence of 1 HNH /1 HNH correlations and the assignment of 1 HNH and 1 HNH3+ is not always available. Here, 3D 14 N/1 H DQ/1 H SQ correlation solid-state NMR experiments at fast magic angle spinning (70 kHz) are introduced to distinguish AP- and P-ß-sheet structures. The 14 N dimension allows the distinction of 1 HNH /1 HNH peaks from 1 HNH3+ /1 HNH3+ peaks with clear assignments of 1 HNH and 1 HNH3+ . In addition, the high natural abundance of 1 H and 14 N enables 3D 14 N/1 H DQ/1 H SQ experiments of oligo-alanines (Ala3-6 ) in four hours without isotope labelling.

Comparison of the knitted silk vascular grafts coated with fibroin sponges prepared using glycerin, poly(ethylene glycol diglycidyl ether) and poly(ethylene glycol) as porogens.

Development of a small-diameter artificial vascular graft is urgent because existing materials often occlude within a short time. We have shown that small-diameter vascular graft using Bombyx mori silk fibroin is a potential candidate. Silk fibroin grafts are fabricated by coating silk fibroin on the knit tube prepared from silk fibroin fibers. However, there is a serious problem that the coated silk fibroin portion hardens when alcohol is used for insolubilization of the coated silk fibroin. This hardening prevents the desired biodegradation of the coated silk fibroin. In this study, we improved the silk fibroin coating method of the knit silk fibroin tube. Namely, the silk fibroin sponge coating was performed using glycerin, poly(ethylene glycol diglycidyl ether) or poly(ethylene glycol). In addition, silk fibroin grafts were prepared avoiding dryness during the coating process and were kept in the hydrated state until implantation into the abdominal aorta was complete. After implantation of the hydrated silk fibroin grafts, grafts were taken out at two weeks or three months, and histopathological examination was performed. The grafts coated with three types of silk fibroin sponges had a higher tissue infiltration rate than alcohol-treated grafts and were superior in the formation of smooth muscle cell and vascular endothelial cell remodeling. Biodegradations of the silk fibroin grafts prepared using the three types of silk fibroin sponge coatings and alcohol-treated silk fibroin grafts were also examined with protease XIV in vitro, and the grafts were observed by scanning electron microscopy before and 24 h after biodegradation. Faster biodegradations were observed for grafts coated with the three types of silk fibroin sponges. 13C solid-state nuclear magnetic resonance studies showed that the conformation of the silk fibroin sponge prepared using porogen was a random coil with high mobility in the hydrated state. We believe that small-diameter silk fibroin vascular grafts coated with quick biodegradable silk fibroin sponges can be developed based on these findings.

Distinct solvent- and temperature-dependent packing arrangements of anti-parallel ß-sheet polyalanines studied with solid-state 13C NMR and MD simulation.

Polyalanine (polyA) sequences are well known as the simplest sequence that naturally forms anti-parallel ß-sheets and constitute a key element in the structure of spider and wild silkworm silk fibers. We have carried out a systematic analysis of the packing of anti-parallel ß-sheets for (Ala)n, n = 5, 6, 7 and 12, using primarily 13C solid-state NMR and MD simulation. HFIP and TFA are frequently used as the dope solvents for recombinant silks, and polyA was solidified from both HFIP and TFA solutions by drying. An analysis of Ala Cß peaks in the 13C CP/MAS NMR spectra indicated that polyA from HFIP was mainly rectangular but polyA from TFA was mainly staggered. The transition from the rectangular to the staggered arrangement in (Ala)6 was observed for the first time from the change in the Ala Cß peak through heat treatment at 200 °C for 4 h. The removal of the bound water was confirmed by thermal analysis. This transition could be reproduced by MD simulation of (Ala)6 molecules at 200 °C after removal of the bound water molecules. In this way, the origin of the stability of the different packing arrangements of polyA was clarified.

Refined Crystal Structure of Samia cynthia ricini Silk Fibroin Revealed by Solid-State NMR Investigations.

Samia cynthia ricini is one of the wild silkworms and its silk fibroin (SF) consists of alternatively repeating poly-l-alanine (PLA) sequences as crystalline domain and glycine-rich sequences as noncrystalline domain; the structure is similar to those of spider silk and other wild silkworm silks. In this paper, we proposed a new staggered model for the packing arrangement of the PLA sequence through the use of the Cambridge Serial Total Energy Package program and a comparison of the observed and calculated chemical shifts of the PLA sequence with the Gauge Including Projector Augmented Wave method. The new model was supported by the interatomic distance information from the cross peaks of Ala Cß dipolar-assisted rotational resonance (DARR) spectrum of the PLA sequences in S. c. ricini SF fiber. In addition, three 13C NMR peaks observed in the ß-sheet region were assigned to the carbons with different environments in the same model, but not assigned to different ß-sheet structures.

Packing arrangement of 13C selectively labeled sequence model peptides of Samia cynthia ricini silk fibroin fibers studied by solid-state NMR.

Samia cynthia ricini (S. c. ricini) is one of the wild silkworms. Their silk fibroins have been paid attention as potentially valuable biomedical materials as well as Bombyx mori silk fibroins, but detailed information on the packing arrangement of the fibers is still not currently well understood at a molecular level. In this study, 34 mer model peptides, GGAGGGYGGDGG(A)12GGAGDGYGAG with different 13C labeled positions have been synthesized as a typical sequence of the primary structure of S. c. ricini silk fibroins made up of tandemly repeated sequences of polyalanine as the crystalline region and glycin-rich sequences as the non-crystalline region. The heterogeneous structure was obtained from the determination of the fraction of several conformations depending on the position of the Ala residue by 13C cross polarization/magic angle spinning NMR. The packing arrangement was studied by 13C dipolar assisted rotational resonance NMR and packing in a staggered arrangement rather than a rectangular arrangement of this peptide with an anti-parallel ß-sheet structure was clarified, which is in good agreement with our previous report on the packing arrangement of (Ala)7 with an anti-parallel ß-sheet structure.

13C NMR characterization of hydrated 13C labeled Bombyx mori silk fibroin sponges prepared using glycerin, poly(ethylene glycol diglycidyl ether) and poly(ethylene glycol) as porogens.

There is a need to prepare softer and highly flexible Bombyx mori silk fibroin (SF) sponges for the development of biomaterials that are biodegradable and with stiffness that matches sponges and soft tissues. In this paper, we prepared SF sponges using glycerin (Glyc), poly(ethylene)glycol diglycidyl ether (PGDE) and poly(ethylene)glycol (PEG) as porogens. The detailed characterization of the hydrated SF sponges was done using three 13C solid state NMR techniques, viz.,13C refocused insensitive nuclei enhanced by polarization transfer (r-INEPT) NMR, 13C cross polarization/magic angle spinning (CP/MAS) NMR, and 13C dipolar decoupled-magic angle spinning (DD/MAS) NMR. These three NMR methods gave respective information on fast motion, slow motion, and both fast and slow motions for the local structure and dynamics of the hydrated SF sponges. There was no significant difference in the r-INEPT spectra of the three hydrated SF sponges. On the other hand, there were significant differences among the 13C CP/MAS NMR spectra of the three sponges. The fractions of two kinds of ß-sheet structure, two kinds of random coil conformations with mobile and immobile motions, and the Silk I* (type II ß-turn) conformation were determined for the Ser residues in the 13C DD/MAS NMR spectra. Similarly, the fractions of several conformations were also determined for Tyr, Ala and Gly residues in SF, which showed significant differences among the three hydrated sponges. The relationship between the local structure of these hydrated SF sponges and their mechanical properties was also briefly discussed.

Pregnancy and cesarean delivery after multimodal therapy for vulvar carcinoma: A case report.

Reports of pregnancy following treatment for vulvar carcinoma are extremely uncommon, as the main problem of subsequent pregnancy is vulvar scarring following radical surgery. We herein report the case of a patient who was diagnosed with stage I squamous cell carcinoma of the vulva at the age of 17 years and was treated with multimodal therapy, including neoadjuvant chemotherapy, wide local excision with bilateral inguinal lymph node dissection and adjuvant radiotherapy. The patient became pregnant spontaneously 9 years after her initial diagnosis and the antenatal course was good, except for mild acute pyelonephritis at 25 weeks of gestation. An elective caesarean section was performed at 38 weeks of gestation due to vulvar scarring following multimodal therapy, particularly radiotherapy. The patient remains alive and well, without signs of recurrence or metastasis 12 years after her diagnosis and treatment. Radical vulvectomy as well as multimodal therapy for vulvar carcinoma, particularly radiotherapy, may cause extensive skin scarring. The presence of vulvar scarring following multimodal therapy for vulvar carcinoma may increase the incidence of caesarean delivery.