Radical Wide Local Excision Research Articles

Case Study: Epithelioid sarcoma of the vulva

Vulval epithelioid sarcoma is a rare, locally-aggressive malignant soft tissue tumour, which may present diagnostic diffi culties, both clinically and pathologically. This can result in a delay in appropriate treatment, which consists primarily of radical wide local excision of the tumour. We report a case of a recurrent epithelioid sarcoma of the vulva, with a discussion of the pathological features and management.

Fertility preserving surgery for carcinoma of the cervix

Cervical cancer remains the second most common female malignancy. Screening programmes have reduced the overall incidence, predominantly in the western world; however, this has led to a disproportionate rise in the incidence of early-stage disease, with a related increase in demand, for fertility-sparing techniques to be developed. Standard treatment for cervical cancer compromises fertility. A radical wide local excision of carefully selected early-stage tumours will allow conservation of the body of the uterus with a vaginoisthmic anastomosis enabling continuity of the vagina to be preserved following insertion of an isthmic cerclage suture. Pelvic node dissection may be performed at the same time by laparoscopic techniques. Over 900 cases have been performed and reported in the literature worldwide. Most have been carried out vaginally (radical vaginal trachelectomy and laparoscopic pelvic node dissection). A smaller number have been performed abdominally. There have been over 300 pregnancies reported with 196 live births. There has been a 10% significant prematurity rate with birth prior to 32 weeks. There have been 31 recurrences (4%), and 16 deaths (2%). Radical vaginal trachelectomy appears safe when performed in centres with appropriate experience of radical vaginal surgery and laparoscopic techniques. The impact of this new approach questions traditional teaching, thus preserving potential fertility in up until now impossible circumstances.

Conservative Surgery for Carcinoma of the Cervix

Cancer of the cervix is the second most common female cancer, with more than half a million cases worldwide occurring annually. Although screening programmes have significantly reduced the incidence and death rates in the western world, social pressures have led to the delay in childbearing, increasing numbers of cervix cancer present early in reproductive life and at an early stage. These women are often anxious to retain their fertility potential, if at all possible. Standard treatment is either radical hysterectomy or radiotherapy to the pelvis, both of which will inevitably compromise fertility, rendering future childbearing impossible. This has led to a questioning of the rationale for extensive surgery in all cases of early stage cervical cancer. The experience of reducing the radicality of surgery while not compromising its efficacy has been learnt from the current management of breast cancer. Such that this may be applied to cervical cancer. Accurate staging and measurement using magnetic resonance imaging can indicate the site and location of the tumour, allowing a radical wide local excision of early stage tumours to be carried out. This allows conservation of the corpus uteri with a potential for fertility preservation. An isthmic vaginal anastomosis maintains continuity of the vaginal canal after insertion of an isthmic cerclage. Laparoscopic pelvic lymphadenectomy completes the procedure. This technique combines aspects of the traditional radical vaginal hysterectomy plus the use of minimal access surgery to carry out the pelvic node dissection. A more invasive abdominal approach has also been described. Over 900 cases have been carried out and published, with 790 carried out vaginally (radical vaginal trachelectomy) and 116 abdominally. There have been over 300 pregnancies with 195 live births. Premature rupture of the membranes is a risk, with 10% of babies being significantly premature. Delivery is by classical caesarean section. Fertility rates are good with a low recurrence rate of 4%. Overall, radical vaginal trachelectomy seems to be a safe procedure in well-selected cases when carried out in centres with appropriate experience of radical vaginal surgery, and laparoscopic techniques. Obstetric management in high-risk feto-maternal units is necessary in view of the high risk of prematurity. This new approach preserves fertility in previously impossible situations and questions traditional management and teaching.

Current management of adolescent pilonidal disease

Background Controversy persists regarding the optimal management for adolescent pilonidal disease. We reviewed the outcome of wide local excision (WLE) vs unroofing and marsupialization (UM) for pilonidal disease. Methods A retrospective review 2002 to 2007 of adolescents undergoing surgical treatment of pilonidal disease was performed. Data were analyzed using Student's t test. Results Twenty-six patients were treated for pilonidal disease during this period. Average age was 16.7 years (range, 14-19 years) with 50% males. Nine patients underwent WLE and 17 had UM. Before initial evaluation, 44% of patients in the WLE group had drainage of acute abscess compared to 59% in the UM group ( P > .05). Postoperative complications in the WLE group (78%) were significantly higher compared to the UM group (0%). Median time for final healing was significantly higher in the WLE group (32 weeks) compared to the UM group (6 weeks). The reoperative rate was also significantly higher in the WLE group (56%) compared to the UM group (0%). No patient had recurrent disease after complete healing in either group. Conclusion Unroofing and marsupialization for primary pilonidal disease has a shorter time to heal and carries a lower complication and reoperative rate compared to WLE.

Cutaneous Melanoma and Sentinel Lymph Node Biopsy

To the Editors: As authors of a similar article,1 we read with great interest the report by Koskivuo et al.,2 in the December issue of the Annals of Surgical Oncology. We enthusiastically support the basic rationale for this paper and the two researched patient groups, which have been correctly balanced for most of the important prognostic factors, such as Breslow thickness, ulceration status, and tumor site. However, some other methodological and other points may not have been entirely correctly addressed. In the previous study from our center,1 we compared two patient groups that consisted of node-positive patients. One group underwent wide local excision (WLE) and developed a regional lymph node metastasis for which we performed a therapeutic lymph node dissection (TLND). The other group had a positive sentinel node (SN) and underwent a completion lymph node dissection (CLND). Recently we have updated our follow-up information; the median follow-up time is now 5 8 months for the TLND group and 5 1 months for the SN+CLND group. When survival rates were calculated from the diagnosis date of the primary tumor, there seemed to be a trend towards a 14% survival benefit for the CLND group (P = 0.065). However, when patients with minimal SN tumor burden (according to the Rotterdam criteria <0.1 mm in maximum diameter3,4) were excluded, because their prognosis is identical to SN-negative patients, this survival benefit disappeared (P = 0.333). Treatment (WLE followed by TLND versus SN followed by CLND) was not an independent prognostic factor for survival.1 The initial paper from our institute1 was already scrutinized for its lack of follow-up balance between the two groups (the WLE-only group versus the SN-staged group), which is now 58 (+2) versus 51 (+14) months. The present study2 has an even greater misbalance in follow-up: a median of 7 4 months for the WLE versus 16 for SN group. It stands to reason to expect that the SN group will develop more recurrences and deaths. Even though the WLE group has a significantly longer follow-up, there seems to be a critical misbalance in nodal disease between the two groups. There were 72 nodal recurrences in the WLE group (11.7%) versus 50 positive SNs (16.4%). This is even without the nodal relapses (n = 5; 1.6%) in the SN group.2 This suggests that not all positive sentinel nodes will develop into palpable nodal disease. The authors state that improved regional disease control is an obvious therapeutic advantage of SN staging and immediate CLND. This statement can only be made in the context of a comparison of nodal recurrence rates after SN+CLND versus those after TLND. This comparison has not been made in the present study. Instead the authors compare the 1.6% nodal recurrences after SN+CLND with the 11.7% of patients that undergo a TLND after WLE only. This is obviously an incorrect comparison since the lymph node dissection in one group has already been performed and therefore this comparison does not make sense. Another important observation in light of another recent publication from Sheri et al.5 in the October edition of this same journal, but also in light of a study from our institute, is the rate and survival of patients in the Starz I tumor burden (<0.3 mm) category.6 The rate of Starz I patients was 9/49 (18%), which is virtually identical to the results from our institute.3, 4 More importantly was the observation of a 100% overall survival rate from this group, which is again a confirmation of the excellent survival of patients with minimal SN tumor burden from other series and recently from a multicenter experience presented at ECCO 14 in Barcelona in September 2007.3 Finally, we agree with the authors with regard to the fact that SN staging is necessary to provide the optimal treatment to melanoma patients. In the absence of effective chemo- or immunotherapy, such treatments need to be identified by the conduct of randomized controlled trials for which SN status is a crucial stratification. SN staging will have increasing competition however from ultrasound-guided fine-needle aspiration cytology (FNAC), which may be able to replace the current SN staging in most patients based on a trial in 400 patients as reported in the Presidential Session of the last ECCO meeting.7

Is Wide Local Excision for Pilonidal Disease Still Justified?

There is an ongoing debate regarding the optimal operation for chronic pilonidal disease. The current study analyzes the outcome of wide local excision (WLE) compared with unroofing and marsupialization (UM) as primary intervention for chronic pilonidal disease. A retrospective review of a single institution experience over a 5-year period was performed. Sixty-eight patients were treated for pilonidal disease. Their mean age was 25 years. There were 42 males (62%) and 26 females (38%). Twenty-six patients underwent WLE and 42 had UM. The type of operation was based on surgeon preference, but individual surgeons were consistent with their choice. Mean time for final healing was significantly higher for WLE compared with UM (21 vs. 6 weeks, P < 0.01). Postoperative complications and reoperative rate were significantly higher in the WLE group (P < 0.01). Nine patients in the WLE group (35%) required one or more reoperations compared with only one (2%) in the UM group (P < 0.01). This study demonstrates that WLE carries a high complication and reoperative rate. UM should be considered as the initial operation for most patients with pilonidal disease.

Lymph node recurrence following stage IA vulvar carcinoma: two cases and a short overview of literature

Stage IA vulvar carcinoma is not supposed to metastasize to the lymph nodes. Therefore, it is assumed that these lesions can be safely treated by less aggressive methods than macroinvasive carcinomas. However, in this case report, two patients are described who had vulvar lesions with a depth of invasion of less than 1 mm and developed lymph node metastases in the groin despite radical wide local excision of their lesions. Both the patients underwent lymphadenectomy and received postoperative radiation therapy on the groins. Neither of the two patients died of vulvar carcinoma. Thus, we conclude that vigilance for the occurrence of lymph node metastases remains necessary after radical, local excision in stage IA vulvar cancer. However, this case report also shows that adequate treatment of groin node metastases can result in a very good long-term survival.

Management of Squamous Cell Cancer of the Vulva

ObjectivesTo review and make recommendations regarding the management of early and advanced squamous cell cancer of the vulva. OptionsRadical vulvectomy and groin dissection or more conservative surgery in early squamous cell vulvar cancer; chemotherapy and radiation followed by consideration of surgery in advanced disease. OutcomesRisk of inguinal lymph node metastases, risk of tumour recurrence, patient morbidity, patient survival. EvidenceFollows the quality of evidence assessment of the Canadian Task Force on the Periodic Health Examination (Table 1). Recommendations1.Stage IA lesions (≤ 2cm diameter and≤1mm stromal invasion) can be managed by radical local tumour excision without inguinofemoral node dissection. (II-2B)2.Stage IB unilateral lesion (≤ 2cm diameter, > 1mm stromal invasion and ≥ 1cm from the midline) is treated by radical wide local excision completed by an ipsilateral inguinofemoral node dissection; a central lesion (within 1cm from the midline) requires bilateral inguinofemoral node dissection. (II-2B)3.Patients with either three or more micrometastases in the groin with node size>10mm, with extracapsular spread, or with bilateral microscopic groin metastases should receive postoperative bilateral groin and pelvic radiation. (II-2B)4.Advanced cancer of the vulva should be treated with primary radiation and concomitant chemotherapy, followed by consideration of surgical resection. (II-2B)

Groin recurrence following Stage 1A squamous cell carcinoma of the vulva

Background.It has been well established that stage 1 squamous cell carcinomas of the vulva with a depth of stromal invasion less than 1 mm have a <1% risk of lymph node involvement. The treatment for these stage 1A tumours has therefore been to perform radical wide local excision without removal of groin nodes. Case.We present two cases of stage 1A microinvasive cancer of the vulva that presented with groin recurrence 3 months and 3 years following their primary surgery respectively. Conclusion.The current management of stage 1A tumours may need to be re-evaluated to include some form of lymph node assessment in view of these rare but nonetheless aggressive tumours.

Merkel cell carcinoma of the Bartholin's gland

Background. There are a few cases of “small cell neuroendocrine carcinoma” of the Bartholin's gland as well as Merkel cell carcinoma of the vulva reported in the gynecologic oncology literature, most with aggressive clinical behavior. Merkel cells were originally described in the epidermis with neuroendocrine properties. Merkel cell carcinoma is different from the neuroendocrine small cell (oat cell) tumor arising in the lung and other internal organs based on morphology and immunohistochemistry. Case. A 49-year-old female was diagnosed with a FIGO stage I Merkel cell carcinoma of the Bartholin's gland. The tumor originated from the duct and stained with endocrine markers and cytokeratin 7 and 20. She was treated with radical wide local excision and bilateral inguinal lymph node dissection followed by radiation therapy to the pelvis, perineum, vulva, and inguinal regions. Two years after the diagnosis, she is alive with no evidence of recurrent disease. Conclusion. This is a case of Merkel cell carcinoma of the Bartholin's gland discovered in the early stage with a survival of 2 years following diagnosis and treatment with no evidence of disease recurrence.

Long-term outcome of patients with perianal Paget's disease.

Perianal Paget's disease (PPD) is a rare intraepithelial adenocarcinoma with a significant rate of recurrence after treatment and high risk of progression to an invasive cancer. Fourteen patients with a mean follow-up longer than 5 years were studied to determine the outcome after surgical treatment. The immunohistochemical accumulation of p53 protein also was assessed in tissue specimens to evaluate its prognostic role in patients with PPD. Four patients were excluded because of progression to invasive malignancy at the time of diagnosis. Two patients underwent local excision (LE) with macroscopic clearance of the surgical margins; the remaining eight patients underwent wide local excision (WLE), i.e., > 1 cm microscopic clearance of the surgical margins. The actuarial 8-year recurrence rate for patients treated with LE and WLE was 100% and 50% (SE = 17.7), respectively. Progression to invasive carcinoma occurred after a median time of 56 months (range 23-72) in two patients treated with LE and in one of eight patients treated with WLE. All four patients with recurrence after WLE were successfully treated (no further recurrence) with a second WLE. Actuarial 8-year survival was 0% in the LE group and 40% (SE = 21.9) in the WLE group. There was no p53 protein accumulation in any of the ten patients with PPD. Survival of patients with PPD treated by WLE was higher than that for those treated with LE. Thus, wide local excision is recommended over limited local excision as a preferred treatment for PPD. Follow-up longer than 5 years seems to be indicated because of the risk of late progression to invasive cancer. When PPD does recur, a second WLE may be curative. The absence of accumulated p53 protein suggests that this marker may not have a prognostic role in PPD.

Role of elective lymph node dissection in stage I malignant melanoma: evaluation by matched pair analysis.

The role of elective lymph node dissection (ELND) in clinical stage I malignant melanoma continues to be controversial. We present a matched pair analysis of 375 patients treated in the Department of Dermatology in Kassel between 1979 and 1991 by wide local excision (WLE) plus ELND. Multivariate analysis revealed tumor thickness, level of invasion, age, sex, and localization as independent prognostic factors, and 375 patients treated by WLE alone were matched as controls to the patients treated by ELND and WLE. There was no significant benefit from WLE plus ELND compared to WLE alone in the total group as shown by the 5-year survival rates (87.3% versus 86.4%) and 10-year survival rates (80.1% versus 77.82%). Increased survival rates were noted for tumor thicknesses 1.51-4.0 mm for the WLE plus ELND group, as shown by the 10-year survival rates of 73.1% versus 60.3%. However, these data were not significant (p = 0.14). Disease-free survival rates were significantly higher in the group treated by additional ELND for all tumor thicknesses (p < 0.05) and even more in intermediate tumor thicknesses of 1.51-4.0 mm (p < 0.001). A significant benefit of elective lymph node dissection was detected for malignant melanoma of the trunk (all tumor thicknesses), as shown by the 5-year survival rates of 92.0% versus 79.7% and 10-year survival rates of 80.4% versus 45.16% (p < 0.05). Malignant melanoma of the extremities revealed no significant differences in survival rates. We conclude that there is a certain benefit from ELND in clinical stage I malignant melanoma for tumor thicknesses of 1.51-4.00 mm. Especially in malignant melanoma of the trunk, WLE plus ELND was more beneficious than WLE alone.

Prognostic indicators for invasive carcinoma of the vulva

Three hundred sixty-five patients with invasive squamous cell carcinoma of the vulva have been treated at M.D. Anderson Cancer Center between 1944 and 1990. We undertook a rigorous review of the medical records, and a Cox proportional hazards model was applied to examine predictors of both failure to survive and recurrence. Significant predictors of both failure to survive and recurrence included tumor size, clinical stage, therapy aim, pelvic or inguinal nodal metastases, and positive margins. We then undertook an analysis of Stage I and II lesions treated with a curative aim to see if there was a difference in survival or in disease-free interval between those patients treated with radical vulvectomy and those treated with radical wide local excision. There was no survival advantage from the radical vulvectomy procedure. We conclude that careful selection may allow us to choose some patients for less radical procedures.

Elective regional lymph node dissection in malignant melanoma

In patients with malignant melanoma elective regional lymph node dissection (ELND) is controversial. This retrospective study evaluated differences in prognosis in patients who were treated with or without ELND. 168 patients were included who initially presented with stage I melanoma (without palpable regional lymph nodes), and who had a minimum observation period of at least 5 years, or had died of malignant melanoma within 5 years of diagnosis. In 66 patients a wide local excision (WLE) followed by ELND was done. In 102 cases only a WLE was done. Assignment of patients to the two groups was non-random but there was no significant difference in age, sex, type and location of primary tumour and depth of invasion. No significant difference was found in survival of the two groups. The 5 year survival of the WLE group was 85.7% and that of the WLE plus ELND group was 89.1%. The 10 year survival rate was 77.9% and 73.1%, respectively. Neither in the whole series nor after sub-division of the patients into three classes according to Breslow depth of invasion (up to 1.5, 1.51–2.5, and greater than 2.5 mm) was a significant influence of ELND on the survival of patients apparent. Cox's regression model did not show ELND as a prognostic factor. ELND cannot be recommended as a routine treatment in patients with stage I melanoma.