Partial Vaginectomy Research Articles

Primary Mucinous Adenocarcinoma of the Vagina

Objective. Our goal was to report the management and symptoms of a patient who presented with primary mucinous adenocarcinoma of the vagina with an unusual histologic pattern.Methods. Our methods included a retrospective description of the management, a review of the literature, and critical evaluation of the treatment modalities available for this very uncommon tumor.Results. Initially posterior partial vaginectomy and abdominoperineal resection was performed with the creation of a permanent colostomy. A bilateral inguinal lymphadenopathy was performed 6 months later on the basis of a palpable enlarged lymph node. Radiotherapy was instituted thereafter. The patient remains disease-free 48 months after initial surgery and is satisfied with her quality of life.Conclusions. Primary mucinous adenocarcinoma of the vagina is a very rare tumor. Therefore individualized treatment is justified until larger series have been published.

Cavitational Ultrasonic Surgical Aspiration for the Treatment of Vaginal Intraepithelial Neoplasia

Objective. The aim of this study is to determine whether cavitational ultrasonic surgical aspiration (CUSA) is effective and safe for treating vaginal intraepithelial neoplasia (VAIN).Methods. We conducted a retrospective chart review of 46 patients who were treated with CUSA for VAIN in a single gynecologic oncology practice between 1981 and 1999.Results. At initial presentation, 39% of treated patients had grade I VAIN, 20% had grade II, and 41% had grade III. The mean duration of follow-up from initial CUSA treatment was 21 months. Twenty-nine patients (63%) were initially treated with CUSA, 7 patients (15%) with laser vaporization, 7 patients (15%) with surveillance by Papanicolaou smear, 1 patient (2%) with partial vaginectomy, 1 patient (2%) with 5-fluorouracil, and 1 patient (2%) with loop excision. Patients initially treated with CUSA had a higher percentage of grade III VAIN at diagnosis (48%) than did patients initially treated with other methods (29%). A significantly greater proportion of patients initially treated with CUSA had no recurrence of VAIN (66%) compared with patients initially treated with other methods (0%) (P < 0.0001). A significantly greater proportion of patients who were treated for recurrent disease with CUSA had no further recurrence (52%) compared with patients treated for recurrent disease with other methods (9%) (P < 0.001). No patient treated with CUSA reported adverse effects; 7 patients treated with other methods reported dysuria, burning, and pain.Conclusion. These initial data suggest that CUSA is a safe and effective method for treating VAIN and may be an appropriate treatment for many patients.

Primary Malignant Melanoma of the Uterine Cervix: Case Report and Review of the Literature

This is a case report and review of the literature on primary melanoma of the cervix. There have been only 26 published cases of primary cervical melanoma and most are poorly documented and doubtful. The patients' ages ranged from 26 to 78 years old with a mean age of 55 ± 13 years. The main presenting symptom was vaginal bleeding (83.0%). The majority of the patients, 88%, presented in stage I or II. Treatment varied from a simple excision of a cervical mass to a radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Our patient presented with vaginal bleeding and was diagnosed as having stage IIa cervical melanoma. She underwent a radical hysterectomy, partial vaginectomy, and pelvic and paraaortic lymph node dissection. She received adjuvant radiation therapy and her survival was 29 months. The prognosis of primary cervical melanoma is usually poor and unpredictable. We recommend a radical hysterectomy and vaginectomy, if necessary, to obtain negative surgical margins of at least 2 cm. We advocate lymphadenectomy only for grossly positive nodes.

Primary malignant melanoma of the uterine cervix: case report and review of the literature

Objective: To present a case of malignant melanoma of the uterine cervix and review the medical literature, evaluate the clinical presentations and prognosis, and establish a plan of management for this rare pathology. Methods: A case of cervical malignant melanoma treated at our institution was prospectively followed until her death. An extensive MEDLINE search was then performed to obtain all previous case reports on this entity. Information regarding age, clinical presentation, staging, pathology, lymphnode status, treatment, and survival was reviewed. Results: Our patient is a 70-year old white female who presented with a 4-month history of irregular vaginal bleeding. She was diagnosed with malignant melanoma of the cervix, stage IIa, for which she underwent a modified radical hysterectomy, partial vaginectomy, and pelvic and para-aortic lymph node dissection. She received adjuvant radiation therapy to the pelvis, total dose of 4500 cGy. The patient’s survival was 29 months. There have been only 24 published cases of primary cervical melanoma in the medical literature. The patients’ ages ranged from 39 to 78 years old. The main presenting symptom was vaginal bleeding (67%). The majority of the patients, 58%, presented in early stages (Ia to IIa). Treatment was varied, ranging from a simple excision of a mass to radical hysterectomy with lymph node dissection and adjuvant radiation or chemotherapy. Survival was widespread, even within the same stage. Conclusion: Cervical melanoma is a rare disease of which no prospective or retrospective studies exist, only case reports. Treatment controversies exist. We recommend radical surgical excision to obtain negative margins and lymphadenectomy only for grossly positive nodes. The prognosis is poor and unpredictable.

Clinical experience with conservative surgery for vaginal endodermal sinus tumor

Two cases of vaginal endodermal sinus tumor (EST), a rare pediatric malignancy, were managed with conservative surgery followed by adjuvant chemotherapy. The first case involved a 9-month-old girl with EST of the vagina, who was treated with a partial vaginectomy and VAC regimen (vincristine, actinomycin D, cyclophosphamide) during a 2-year period. The serum alpha-fetoprotein (AFP) level returned to normal after excision of the tumor, and it remained normal throughout the treatment period. There was no evidence of disease 30 months after diagnosis. The second case involved an 8-month-old girl with EST of the vagina, who was treated with local excision of the mass through a vaginotomy. The VAC regimen was administered, but the serum AFP level remained elevated. A follow-up abdominopelvic computed tomography scan, taken 4 months after the operation, showed local recurrence of the tumor. The VAC regimen was then changed to a BEP regimen (bleomycin, etoposide, cisplatin). The serum AFP level returned to normal after 2 courses of the new regimen, and no tumor was visible on the follow-up magnetic resonance imaging study. For vaginal EST, primary conservative surgery and adjuvant chemotherapy are attractive measures to preserve both reproductive and sexual function. The extent of conservative surgery requires at least a partial vaginectomy. Simple tumor excision may not be adequate to achieve cure or to prevent local recurrence, even with adjuvant chemotherapy. The serum AFP level is useful for diagnosing and monitoring vaginal EST in the infant.

Short gracilis myocutaneous flaps for vulvoperineal and inguinal reconstruction.

From October of 1990 to April of 1993, 16 short gracilis myocutaneous flaps and 1 short gracilis muscular flap were used to reconstruct vulvoperineal, inguinal, perineal, and ischial soft-tissue defects. Five of the 6 bilateral myocutaneous flaps were used for vulvoperineal reconstruction after radical vulvectomy combined with partial vaginectomy and one radical vulvectomy. Four unilateral myocutaneous flaps and one muscular flap were used for inguinal, suprapubic, ischial, and perineal reconstruction after release of contracted scar or excision of an ischial pressure sore. The immediate complications consisted of partial necrosis of the distal third of the cutaneous tissue in 6 patients, 1 superficial cutaneous necrosis, and superficial wound infection in 7 patients. The muscular portion of the flaps all survived. The follow-up period was from 6 to 27 months. The short gracilis flap has greater mobility than the classically described gracilis flap. On the basis of the functional and cosmetic results, the short gracilis flap is an excellent alternative to the more bulky classic gracilis flap.

Late Recurrence of Clear Cell Adenocarcinoma of the Vagina and Cervix: A Report of Three Cases

Three patients with clear cell adenocarcinomas who developed recurrent disease after a prolonged disease-free interval are presented. The first patient developed a recurrence in the lung 7 years and 3 months after wide local excision and pelvic radiotherapy for clear cell adenocarcinoma of the vagina. She then underwent thoracotomy and chemotherapy and has remained free of disease for more than 13 years after treatment of the recurrence. The second patient with clear cell adenocarcinoma of the vagina developed recurrent disease at the apex of the vagina 5 years after radical hysterectomy, bilateral pelvic lymphadenectomy, and partial vaginectomy. She then underwent exploratory laparotomy, partial vaginectomy, and vaginal irradiation and has been free of disease in follow-up for 6 months. The third patient underwent radical hysterectomy, bilateral pelvic lymphadenectomy, and total vaginectomy for clear cell adenocarcinoma of the cervix that also involved two-thirds of the vagina. Four years and 6 months after this operation, she underwent an exploratory laparotomy, with complete resection of recurrent disease in the abdomen in continuity with a left nephrectomy. Following surgery, she was treated with abdominal and pelvic radiotherapy and chemotherapy and remained clinically free of disease for 1 year, but subsequently developed an unresectable pelvic mass. Despite further chemotherapy, she died 5 years and 10 months after the initial diagnosis.

Primary Malignant Melanoma of the Uterine Cervix: Two Case Reports and A Centuryʼs Review

Primary malignant cervical melanoma is diagnosed by the presence of junctional melanocytic abnormality and the absence of distant metastasis. Amelanotic and poorly differentiated tumors can often be diagnosed with the HMB-45 immunoperoxidase stain which is very specific for melanoma. Early reported cases were treated with simple excision followed many times by radiation therapy. Radical hysterectomy, pelvic lymphadenectomy, and partial vaginectomy have been advocated by some contemporary investigators. Radiation can be used as adjuvant or palliative treatment; its efficacy is not well established. Few patients have been treated with modern chemotherapy. No patient has been treated with immunotherapy. Primary malignant cervical melanoma carries a very poor prognosis. Most patients succumb from their disease within 2 years. One patient has survived 14 years. The small number of reported cases makes it difficult to evaluate the efficacy of any treatment modality.

Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery

The short gracilis myocutaneous flap derives its blood supply from terminal branches of the obturator artery, and the vascular pedicle derived from the medial femoral circumflex artery is sacrificed. Twenty-one short gracilis myocutaneous flaps were used for vulvovaginal reconstructions in 11 patients undergoing radical pelvic surgery: bilateral flaps in nine patients for neovaginal construction after pelvic exenterations, bilateral flaps in one patient for vulvovaginal reconstruction after radical vulvovaginectomy, and a unilateral flap in one patient for vulvovaginal reconstruction after radical vulvectomy with partial vaginectomy. Major complications consisted of bilateral flap necrosis occurring in one patient who had received preoperative irradiation to the vulva and groin combined with chemotherapy. Minor degrees of necrosis (less than 5%) and/or separation of vaginal suture lines occurred in five patients without marked loss of the flaps. Vaginal caliber and depth are excellent in ten patients (91%) after follow-up of 1-22 months. The short gracilis flap is an excellent alternative to the more bulky gracilis flap, which derives its blood supply from perforating branches of the femoral artery. Based on our experience, the short gracilis flap provides adequately vascularized tissue for vulvovaginal reconstruction in patients after radical pelvic surgery, but should not be used in patients who have received extensive groin irradiation.

Ultrasound Surveillance of the Cervix During Pregnancy in Diethylstilbestrol-exposed Offspring

Twenty-three diethylstilbestrol (DES)-exposed patients were evaluated through 27 pregnancies to determine their eligibility for admission to a prospective protocol that combined serial ultrasound surveillance of the lower uterine segment-cervical complex with periodic pelvic examinations to diagnose cervical incompetency. Of these, 21 pregnant women, including seven vaginectomy patients, were matched to 84 low-risk controls to determine the following: 1) the effect of DES exposure on reproductive performance, 2) the efficacy of ultrasound selection of cerclage candidates, and 3) the influence of previous partial vaginectomy on reproductive outcome. Five DES-exposed patients were diagnosed as having cervical incompetency and had cerclages placed. There were no missed diagnoses of cervical incompetency. The DES-exposed patients delivered statistically earlier in gestation than did controls (268 +/- 13 versus 276 +/- 10 days). It was not evident that this difference was important clinically, as there were no neonatal deaths, very low birth weight infants, second-trimester losses, or deliveries before 252 days (36 weeks) among the study patients. Previous vaginectomy did not affect the frequency of the diagnosis of cervical failure or the neonatal outcome. After ultrasound surveillance and treatment for incompetent cervix, a majority of our patients delivered at term without cerclage placement. Therefore, routine cerclage placement is not recommended. Knowledge of the ultrasound criteria for diagnosing cervical incompetency is required.

Vaginal Neoplasms in Infancy: The Combined Role of Chemotherapy and Conservative Surgical Resection

This retrospective review of nine infants treated for vaginal tumors between 1964 and 1986 identifies the spectrum of lesions and examines the trend toward more conservative surgical therapy. Our patients' ages ranged from 1 to 30 months. Symptoms of vaginal bleeding or protruding tissue prompted examination under general anesthesia in all cases. Two children had benign protruding polypoid masses treated by simple excision. Seven had malignant tumors, two with endodermal sinus lesions and five with embryonal rhabdomyosarcoma. Early in this series, surgical therapy for embryonal rhabdomyosarcoma consisted of either anterior or complete pelvic exenteration, with adjuvant chemotherapy given in two of the three patients. One patient was operated on prior to the development of effective chemotherapy, and died of recurrent tumor 14 months after surgery. A second patient died from cardiac failure secondary to adriamycin toxicity 6 years after initial therapy. A third patient underwent total pelvic exenteration followed by successful reanastomosis of the colon to the anal verge. This patient, a female, is the oldest survivor and is free of disease 14 years after therapy. The most recent therapeutic approach used in two patients with embryonal rhabdomyosarcoma consisted of local tumor excision followed by postoperative chemotherapy. Both patients are alive and disease-free 9 and 11 years after therapy. Two patients with endodermal sinus tumor were treated with chemotherapy after simple excisional biopsy. They were then followed with serial vaginal biopsies at 3-month intervals. One required a partial vaginectomy for local recurrence 21 months after initial presentation. Both patients are alive and disease-free 18 months and 4 years after surgery.

Clinical Staging and Treatment Results in Rhabdomyosarcoma of the Female Genital Tract among Children and Adolescents

From 1972 to 1984, 47 children and adolescents with primary tumors of the female genital tract were treated with eight different Intergroup Rhabdomyosarcoma Study (IRS I-II) protocols. These included patients with vaginal (28), uterine (ten), or vulval (nine) rhabdomyosarcoma or undifferentiated sarcomas. The mean age of patients with primary vaginal tumors was younger than 2 years. All were of the embryonal histologic subtype. The majority of these patients were treated with initial chemotherapy (vincristine, dactinomycin, +/- cyclophosphamide, +/- Adriamycin [(ADR) doxorubicin]) followed by delayed hysterectomy and/or partial vaginectomy. Among 26 patients with localized vaginal tumors, there have been six relapses resulting in one tumor-related death and one therapy-related death. The five patients with nonfatal relapse have been disease-free for from 2.5 to 6.5 years (mean, 4.4 years) since salvage therapy was commenced. The 19 patients without relapse have been continuously disease-free for 1.5 to 12 years (mean, 5.34 years: median, 6 years). No patient that received ADR initially relapsed. Ten patients, with a mean age greater than 13 years, had primary uterine sarcomas and were treated by the same chemotherapy regimens. Six with polypoid localized lesions, removed before chemotherapy, have remained disease-free for 2.5 to 6.5 years. Four, with more extensive local lesions or disseminated disease, treated with chemotherapy only, died 2 to 11 months from diagnosis. Nine patients with rhabdomyosarcomas of the vulva (age, 1-19 years) were managed by the same chemotherapy regimens +/- radiotherapy. Resection was carried out initially or after chemotherapy. Eight of these have been disease-free from 4 to 10 years (mean, 6.4 years); and one is alive with probable disease at 2.5 years.

Vaginal neoplasms in infancy: The combined role of chemotherapy and conservative surgical resection

This retrospective review of nine infants treated for vaginal tumors between 1964 and 1986 identifies the spectrum of lesions and examines the trend toward more conservative surgical therapy. Our patients' ages ranged from 1 to 30 months. Symptoms of vaginal bleeding or protruding tissue prompted examination under general anesthesia in all cases. Two children had benign protruding polypoid masses treated by simple excision. Seven had malignant tumors, two with endodermal sinus lesions and five with embryonal rhabdomyosarcoma. Early in this series, surgical therapy for embryonal rhabdomyosarcoma consisted of either anterior or complete pelvic exenteration, with adjuvant chemotherapy given in two of the three patients. One patient was operated on prior to the development of effective chemotherapy, and died of recurrent tumor 14 months after surgery. A second patient died from cardiac failure secondary to adriamycin toxicity 6 years after initial therapy. A third patient underwent total pelvic exenteration followed by successful reanastomosis of the colon to the anal verge. This patient, a female, is the oldest survivor and is free of disease 14 years after therapy. The most recent therapeutic approach used in two patients with embryonal rhabdomyosarcoma consisted of local tumor excision followed by postoperative chemotherapy. Both patients are alive and disease-free 9 and 11 years after therapy. Two patients with endodermal sinus tumor were treated with chemotherapy after simple excisional biopsy. They were then followed with serial vaginal biopsies at 3-month intervals. One required a partial vaginectomy for local recurrence 21 months after initial presentation. Both patients are alive and disease-free 18 months and 4 years after surgery.

Verrucous carcinoma of the uterine cervix: Report of a case with follow-up of [formula omitted] years

A case of verrucous carcinoma of the uterine cervix was reported with a long-term follow-up and close observation. The patient was a 73-year-old, Japanese female, who had a suspicious Papanicolaou smear on routine examination. The cervix was replaced by a papillary mass, which was diagnosed as benign papilloma. The patient was followed every 6 months with cytology, colposcopy, and punch biopsy. No cytologic or microscopic diagnosis of invasive squamous cell carcinoma was made during the entire follow-up period. Total abdominal hysterectomy and partial vaginectomy were performed after 6 1 2 years' follow-up, and the tumor was finally diagnosed as verrucous carcinoma. The patient is alive and well 4 years after the operation.

Hysterectomy for carcinoma in situ and sexual function

Forty-four multiparous women treated for carcinoma in situ of the uterine cervix were interviewed more than 1 year later to establish the effects of vaginal hysterectomy on sexual function. Thirty-eight women received a total vaginal hysterectomy and partial vaginectomy and six women received a total vaginal hysterectomy only. The patients were further subdivided into an age 30 to 49 subgroup to control for age. The study patients experienced no statistically significant decrease in sexual enjoyment, ability to attain orgasm, coital opportunity, frequency of intercourse, or coital desire. Similar results were found in the age-controlled subgroup. Vaginal alterations were not present whether or not partial vaginectomy was performed. The authors conclude that vaginal hysterectomy, with or without partial vaginectomy, does not significantly alter the sexual lives of multiparous women treated for carcinoma in situ .

Radical hysterectomy preceded by pelvic irradiation

A total of 124 patients, who had prior pelvic irradiation, had radical hysterectomy performed at the University of Minnesota Hospitals from 1939 to 1977. The patients fall into two groups: those who had pelvic radiation and radical hysterectomy as primary therapy and those who had radical hysterectomy for postradiation persistent or recurrent cancer of the cervix. A major objective of this report is to describe the incidence, management, and long-term follow-up of patients with complications. Pelvic irradiation followed by radical hysterectomy as primary therapy for cancer of the cervix cannot be justified because of the high risk of urinary tract complications, some of which eventually result in demise of the patient. Radical hysterectomy for postradiation persistent or recurrent cancer is an acceptable procedure for early disease. It would appear from this experience that many patients with small cervical or vaginal postradiation neoplasms can be successfully managed with more conservative procedures such as simple hysterectomy and partial vaginectomy. The value of pelvic lymphadenectomy was not demonstrated. Exenterative procedures are becoming more frequently indicated for eradication of malignancies, with a reduction of long-term urinary tract complications.

In utero exposure to DES. Evaluation and followup of 199 women.

Among 199 women from 12 to 30 years of age who had been exposed to DES in utero, the colposcopic evaluation of the vagina and cervix was considered normal for only 13.6%. The incidence of colposcopically detected lesions was not related to the trimester of DES exposure, the patient's age, use of oral contraceptives, or presenting symptoms. Areas of punctation, mosaic patterns, white epithelium, and keratosis were not considered areas of adenosis. Cervical bands, hoods, cock's combs, etc., were considered as part of the cervix. Under this definition adenosis of the vagina was diagnosed in only 14.1% of the patients. Eight (4.0%) women were found to have cervical intraepithelial neoplasia (CIN), Grade 3 lesions, and an additional 36 (14.1%) women were found to have CIN, Grade 1 lesions based on the light microscopy evaluation of directed biopsies. There were no cases of clear cell adenocarcinoma. It appears that women with in utero DES exposure may be at a higher risk of developing squamous neoplasia compared with non-DES-exposed women.

VAGINAL HYSTERECTOMY AND PARTIAL VAGINECTOMY FOR CARCINOMA IN SITU OF THE UTERINE CERVIX.

VAGINAL HYSTERECTOMY AND PARTIAL VAGINECTOMY FOR CARCINOMA IN SITU OF THE UTERINE CERVIX.

Intraepithelial carcinoma, dysplasia, and exfoliation of cancer cells in the vaginal mucosa

One hundred and fifty-one women had positive cancer smears among a selected group of 663 who were carefully followed. Although apparently cured of cervicouterine disease, uncompleted study of the 151 women has already disclosed 15 cases of vaginal intraepithelial carcinoma and 12 of dysplasia. Exfoliation of cancer cells frequently ceased after punch biopsy and partial vaginectomy. This unexpected frequency of positive vaginal smears and tissue suggests these vaginal neoplasms have a low invasion potential and supports the field theory of carcinogenesis.