Malignant tumors involving the vulva

Abstract

Of the 37 cases seen by us, operation was not recommended in 3 patients because of metastatic lesions to bone or lung found on routine x-ray study of the skeleton and lungs. Needless to say, such studies are essential in all cases of malignancy. In 2 cases considered resectable as a result of clinical and x-ray studies, at the time of operation, unexpected metastases were found to involve the psoas muscle or other retroperitoneal soft tissues and precluded any possibility of extensive resection, including eviscerectomy. One patient refused surgery. All, except one patient in whom resection was attempted only one week ago, failed to survive more than four months (Table VII). 7Foolow-up. Total cases, 37Refused surgery1Died in 1 monthNo therapy, surgery not advised due to3Died, 4 months, 2 months,metastasis to bone or lung1 month, respectivelySurgery attempted, not completed due to2(1) Died 1 monthdistant metastasis, nonresectable(1) Living 1 weekResectable, surgery completed31Of the 31 cases subjected to surgery, 4 had only radical vulvectomy. Radical pelvic gland dissection was not advised in these patients as multiple microscopic sections from the removed vulva showed the lesion to be intraepithelial in the sections studied. This is in keeping with our established policy in the study of malignancies of the vulva. When enough material of this type has been accumulated and followed for a sufficient period of time we will be able to state whether or not radical vulvectomy is sufficient in the management of intraepithelial carcinoma of the vulva so diagnosed by multiple sections from the resected vulva. Two patients with invasive carcinoma had radical vulvectomy but refused gland dissection. The follow-up on these cases of carcinoma of the vulva having had radical vulvectomy only is listed in Table VIII. 8Follow-up. Resectable, surgery completed, 31Radical vulvectomy, refused gland dissection2No recurrence(1) 38 months(2) 6 monthsRadical vulvectomy, gland dissection not advised4No recurrenceIntraepithelial carcinoma(1) 14 months(1) 16 months(1) 16 months(1) Dead∗Radical vulvectomy and radical gland dissection25∗Died fifteen days postoperatively from mural thrombus.Radical vulvectomy and radical pelvic gland dissection were performed on 25 cases. Additional procedures thought necessary to produce arrest or cure of the disease were carried out in 4 of these patients. The results are listed in Tables IX and X.It is to be noted that only one patient failed to survive operation. This patient died two weeks following radical vulvectomy from pulmonary embolism as a result of a mural thrombus. It is of interest that this patient had intraepithelial carcinoma and vulvectomy was the only procedure advised or carried out. None of the patients subjected to more extensive resection failed to survive the procedure.We believe that radiation therapy has no place in the treatment of vulvar lesions, including malignancy. In this series therapy was wholly surgical. Radiation therapy was not advised or used either preoperatively or postoperatively by us. In a few cases in the series radiation had been used elsewhere to benign or malignant vulvar lesions without improvement and only resulted in delay in surgical therapy. We think that improvement in five-year cure rates in malignancy of the vulva will be brought about only by prophylactic measures as previously described and utilization of more extensive surgery in cases of established vulvar malignancy.Modern anesthesia, blood transfusion, and antibiotics allow for extension of surgical attack with a very low operative mortality.9Follow-up. Radical vulvectomy and radical gland dissection, 25Radical vulvectomy and radical gland2.12Dead∗dissection only1Living 19 months.Recurrence18Living, no recurrenceUnder 6 months6 months-1 year31 year-2 years22 years-3 years33 years-4 years44 years-5 years4Radical vulvectomy and radical gland4All livingNo recurrencedissection plus other procedures(1) 24 months(1) 20 months(1) 21 months(1) 54 months∗(1) Carcinomatosis 9 months postoperatively. (1) Carcinoma of ovary 15 months postoperatively.10Follow-up. Radical vulvectomy and radical gland dissection plus added procedures, 4Added ProceduresA. Removal of Poupart's ligaments, segments of external oblique fascia and fascia lataNo recurrence 54 monthsB. Vaginal hysterectomy and vaginectomyNo recurrence 24 monthsC. Removal of bladder, urethra, uterus, tubes, ovaries, vagina, ligation of right external iliac vein (anterior eviscerectomy)No recurrence 21 monthsD. Removal of bladder, urethra, vagina, tubes, ovaries, uterus, rectum, anus, transplantation of ureters into signoid, midline colostomy (total eviscerectomy)No recurrence 20 months