Vessel-preserving en-bloc excision of groin recurrence of vulval carcinoma with tensor fasciae latae flap reconstruction in a previously irradiated field

Abstract

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.