Underwent Radical Vulvectomy Research Articles

Neoadjuvant chemotherapy with bevacizumab for locally advanced vulvar cancer

ObjectivesExternal beam radiation with sensitizing platinum is the recommended therapy for locally advanced vulvar cancers not amenable to curative surgery and is associated with considerable acute and chronic side effects....

Postoperative venous thromboembolism risk in patients with vulvar carcinoma: An analysis of the National surgical Quality Improvement Program (NSQIP) database

ObjectivesDue to low incidence of vulvar cancer (VC), incidence and predictors for development of venous thromboembolism (VTE) are poorly understood. We examined incidence and risk factors associated with VTE in patients undergoing surgery for VC. MethodsWe included patients who underwent surgery for VC from the National Surgical Quality Improvement Program database. VTE within the 30-day postoperative period was captured with Current Procedural Terminology codes. Baseline demographics and clinical characteristics were compared between patients with and without VTE. Univariable and multivariable-adjusted exact logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and VTE. ResultsWe identified 1414 patients undergoing procedures for VC from the NSQIP database. Overall, 11 (0.8 %) patients developed VTE. Univariable predictors of VTE included surgery type [compared with simple vulvectomy: radical vulvectomy only (OR = 7.97, 95 % CI = 1.44, infinity) and radical vulvectomy plus unilateral IFN (OR = 15.98, 95 % CI = 2.70, infinity)], unplanned readmission (OR = 11.56, 95 % CI = 2.74, 46.38), deep surgical site infection (OR = 16.05, 95 % CI = 1.59–85.50), and preoperative thrombocytosis (OR = 6.53, 95 % CI = 0.00, 34.86). In a multivariable-adjusted model, longer operative time (≥72 min OR = 11.33, 95 % CI = 1.58–499.03) and preoperative functional status [compared with complete independence: total dependence (OR = 53.88, 95 % CI = 0.85, infinity) and partial dependence (OR = 53.88, 95 % CI = 0.85, infinity)] were associated with VTE. ConclusionIn this cohort of patients with VC undergoing radical vulvectomy, VTE incidence was low. Surgery type, longer operative time, dependent functional status, and wound disruption were identified as risk factors. Our findings highlight opportunities for prophylactic intervention in certain patients.

The modified 5-item frailty index is a predictor of post-operative complications in vulvar cancer: a National Surgical Quality Improvement Program (NSQIP) analysis

ObjectiveTo determine whether frailty is associated with post-operative complications following surgery for vulvar cancer.MethodsThis retrospective study used a multi-institutional dataset from the National Surgical Quality Improvement Program (NSQIP) database (2014–2020)...

Vulvar Reconstruction Using Keystone Flaps Based on the Perforators of Three Arteries.

Various flaps are used to reconstruct skin and soft tissue defects of the vulva following resection of malignancies. Whenever possible, reconstruction using local flaps is the standard treatment. Here, we describe vulvar defect reconstruction using keystone flaps. Standard keystone flaps are based on randomly located vascular perforators. However, we designed a keystone flap that includes perforators of three named arteries (the anterior labial artery of the external pudendal artery, cutaneous branches of the obturator artery, and posterior labial artery of the internal pudendal artery) and the pudendal nerve, which accompanies the internal pudendal artery. Four patients with squamous cell carcinoma and extramammary Paget's disease of the vulva underwent radical vulvectomy and keystone flaps including perforators of three arteries. Depending on the morphology of the defects, keystone flaps were used with different designs. For elliptical and unilateral vulvar defects, a standard keystone flap was designed, and for defects on both sides of the vulva, a double opposing keystone flap was used. For oval defects, the omega variant keystone flap was designed, and when the morphology of the defect needed rotation of the flap, a rotational keystone flap was designed. All the patients showed good function and sensation, with an acceptable cosmetic appearance.

Primary Vulval Mucinous Adenocarcinoma of Intestinal Type Masquerading as Bartholin's Cyst

Vulval carcinomas are rare and account for 3%–5% of female genital tract malignancies. Primary vulval adenocarcinoma of intestinal type is an extremely rare tumor which is considered metastatic until otherwise proven with very few case reports available in the literature. A 58-year-old woman presented with recurrent swelling in the genital region associated with pain. She had a past history of surgery done for Bartholin's cyst which was reported as adenocarcinoma. She underwent radical vulvectomy for the recurrent tumor which showed features of adenocarcinoma with glandular and papillary pattern with abundant extracellular mucin production and immunohistochemical (IHC) features favoring a diagnosis of primary vulval mucinous adenocarcinoma of intestinal type after excluding metastasis from other sites. As morphology cannot differentiate it from metastasis, a thorough investigation to rule out any primary in the gastrointestinal tract with a minimum IHC panel of markers including cytokeratin (CK) 20, CK7, carcinoembryonic antigen, and caudal-related homeobox 2 can help in confirming the diagnosis.

Videoendoscopic sentinel lymph node detection with icg and bilateral inguinofemoral lymphadenectomy in vulvar cancer comba-ozdemir technique.

ObjectiveThe authors present a surgical film for vulvar cancer surgery, which was performed via video endoscopy.MethodsAn 88-yearold woman with squamous cell carcinoma of the vulva and who underwent radical vulvectomy was treated with sentinel lymph node (SLN) and bilateral inguinofemoral lymphadenectomy, which is preferably performed via video endoscopic surgery with a near-infrared fluorescence video endoscopy system. SLN mapping was performed using indocyanine green and near-infrared fluorescence mapping.ResultsSLNs were detected in the left superficial inguinal area. The surgeons performed bilateral inguinofemoral lymphadenectomy.ConclusionNo postoperative early or late complications developed, and the patient was discharged 7 days after surgery. Stage 1B vulvar cancer was identified.

Subcutaneous Vulvar Flap Viability Evaluation With Near-Infrared Probe and Indocyanine Green for Vulvar Cancer Reconstructive Surgery: A Feasible Technique.

Introduction: Vulvar cancer is a rare condition affecting older women and accounts for 3–5% of all gynecological cancers. Primary surgical treatment involves the removal of a large amount of tissue for which reconstructive surgery is often necessary with a high rate of postoperative complications. Despite several techniques for the evaluation of vulvar flap viability have been proposed, many methods cannot be performed during surgery and require expensive devices often missing in a gynecological clinic. This study aims to verify the feasibility and the safety of the vulvar flap viability evaluation through a near-infrared endoscopic probe and Indocyanine green (ICG) tracer in a small group of patients and to evaluate long-term vulvar flap outcomes.Methods: Patients with primary vulvar cancer who required surgical treatment and subsequent vulvar flap reconstructive surgery were prospectively included in the study. A 25 mg ICG vial diluted in 20 ml of saline solution was intravenously infused before closing the skin edges of the flaps. All patients were given 0.2 mg/kg body weight of intravenous ICG. After 10–15 min, a near-infrared endoscopic probe was used to evaluate the vulvar flap viability.Results: Of the 18 patients who underwent radical vulvectomy for vulvar cancer during the study period, 15 were included in the analysis. All packaged surgical flaps showed tracer uptake on the surgical margin. No intro-operative complications were recorded neither surgery-related nor to dye infusion. No surgical infection, dehiscence, or necrosis was recorded.Conclusions: Vulvar flap viability assessment using Indocyanine green and a laparoscopic infrared probe is a feasible method. All cases included in the analysis showed a dye uptake on the surgical edge of the flap. Further, prospective studies are needed to confirm the method in clinical practice and to evaluate its superiority over simple subjective clinical evaluation.

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

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.

Use of Negative Pressure Wound Therapy Systems after Radical Vulvectomy for Advanced Vulvar Cancer

A retrospective cohort study was performed to evaluate the efficacy of negative pressure wound therapy in improving vulvectomy healing. Women who underwent radical vulvectomy with complete inguinofemoral lymphadenectomy for advanced vulvar cancer were divided into two groups according to immediate postoperative care: patients treated with negative pressure wound therapy using the device applied on the site of the wound (including vulva and inguinal region), and patients receiving conventional care. 18 patients were included in the study. 7 (38.9%) women were treated with negative pressure wound therapy immediately after the surgery and were included in the intervention group, and 11 (61.1%) patients were included in the control group. Women who received negative pressure wound therapy had significantly lower length of stay in the hospital (14.2 ± 4.7 versus 17.1 ± 6.1 days, mean difference −6.90 days, 95% confidence interval −11.91 to −1.89), and significantly lower length for wound healing (−31.90 days, 95% confidence interval −43.48 to −20.32). In conclusion, the utilization of the negative wound pressure therapy may contribute to reduce hospitalization after radical vulvectomy for vulvar cancer. Large and well-designed randomized trials with cost effectiveness analyses are needed to confirm these findings.

Association between obesity and vulvar cancer recurrence: an analysis of the AGO-CaRE-1 study

ObjectiveObesity is associated with worse survival and an increased risk of relapse in several malignancies. The influence of obesity on vulvar cancer recurrence has not been previously described. The primary...

The diagnostic challenge of primary adenocarcinoma of the vulva: a case report

The diagnosis and classification of primary adenocarcinoma of the vulva is a complicated and understudied area, as this is a rare histological subtype of vulvar cancers. The differential diagnoses include extramammary Paget disease with invasion, adenocarcinoma arising from mammary-like glands, skin adnexal structures as well as Bartholin’s glands in the vicinity. We report a case of extramammary Paget disease which first presented as primary vulvar adenocarcinoma. The patient was a 71-year-old woman who presented with a swelling at the external genitalia. Clinical examination revealed a right vulvar lump, with eczematous features on the overlying skin. The lump was biopsied and was called Paget disease with underlying adenocarcinoma. Subsequently, the patient underwent radical vulvectomy and bilateral groin and pelvis dissection. The resection specimen was reported as extramammary Paget disease, with dermal invasion forming a poorly differentiated adenocarcinoma showing strong HER-2 expression on immunohistochemistry. This case illustrates the diagnostic challenge in the classification of primary vulvar adenocarcinoma. Positivity for HER-2 has been reported in Paget-associated vulvar adenocarcinoma and might offer potentially actionable targets on the selection of therapy, especially in advanced metastatic disease.

The influence of obesity on tumor recurrence in vulvar cancer patients.

e17130 Background: Obesity is associated with worse patients’ survival in several cancer entities. Vulvar cancer as well as obesity show increasing incidence over the last years. The influence of obesity on prognosis of vulvar cancer patients is not clear. However, knowledge about this may have consequences on prevention, treatment, and follow-up. Methods: This is an analysis of the large AGO-CaRE-1 study. Patients suffering from squamous cell vulvar cancer (UICC stage IB and higher), treated in 29 cancer centers between 1998 and 2008, were categorized in a database, in order to analyze treatment patterns and prognostic factors in a retrospective setting. Results: In total, 849 patients with documented height and weight were divided into two groups depending on their body mass index (BMI, < 30 vs. ≥30 kg/m²). There was no difference in the baseline variables (age, tumor diameter, depth of infiltration, tumor stage, nodal invasion, tumor grade) between both groups (p > 0.05). However, we identified differences regarding ECOG status and preexistent comorbidities (cardiovascular, dementia) towards healthier patients with BMI < 30 kg/m². Treatment variables (R0 resection, chemotherapy, radiotherapy, continuation of adjuvant therapy) did not differ (p > 0.05). Patients with BMI ≥30 kg/m² underwent radical vulvectomy more often (61.1 % vs. 51.8%, p = 0.042). During follow-up, there was a higher recurrence rate in the group having a BMI ≥30 kg/m² (43.4%, vs. 28.3%, p < 0.01) due to an increased rate of local recurrences (33.3% vs. 18.5%, p < 0.01). The rate of groin and distant recurrences was similar between both groups (p > 0.05). Noteworthy, we observed a significantly shorter disease free survival (DSF) of the obese patients in univariate analysis (HR 1.362, 95%CI 1.093-1.696, p = 0.006). Even in multivariate Cox-regression analysis including age, ECOG, tumor stage, type of surgery, nodal invasion, tumor grade, and comorbidities patients with BMI ≥30 kg/m² had a significantly shorter DFS (HR 1.811, 95%CI 1.005-3.262, p = 0.048). Conclusions: In this first large study about the association between obesity and prognosis of vulvar cancer patients, we observed that a BMI ≥30kg/m² was associated with shorter DFS, mainly attributed to a higher risk for local recurrence.

Ulceronecrotic cancer of the vulva

Vulvar cancer is rare accounting for less than 5% of gynecological cancers. It mainly affects elderly women. We here report the case of a 70-year old woman. Clinical symptoms were dominated by vulvar pruritis evolving over a 6-years period, neglected by the patient. This lesion preferentially affects labia majora. The patient had ulceronecrotic lesion involving right labia majora and extending to the ipsilateral labia minora. Diagnosis was based on vulvar biopsy which showed squamous cell carcinoma, the most common histologic type. Abdominal-pelvic MRI showed Stage III A squamous cell carcinoma according to 2009 FIGO classification. The patient underwent radical vulvectomy associated with bilateral inguinal lymphadenectomy followed by external radiotherapy.

Abdominoperineal Excisions in the Treatment Regimen for Advanced and Recurrent Vulvar Cancers-Analysis of a Single-Centre Experience.

Vulva cancer is the fourth leading gynaecological malignancy, accounting for approximately 4% of all gynaecological cancers. Surgery represents the treatment of choice, and cases of advanced or recurrent vulvar cancers are to date a major challenge to multidisciplinary teams. Abdominoperineal excision (APE) in combination with vulvectomy and inguinal lymphadenectomy is the only curative treatment option. Patients' files of all women with squamous cell carcinoma of the vulva who underwent abdominoperineal resection were retrospectively reviewed with special regards to technical challenges the general surgeon will face. Seven women were enrolled in this retrospective study with a median age of 71years (range 56-79years). In six patients, the pelvic floor after abdominoperineal excision could be closed by direct suture of the levator muscles. One woman underwent abdominoperineal resection with closure of the defect using a vertical rectus abdominis myocutaneous (VRAM) flap. All women underwent radical vulvectomy, in five patients in combination with bilateral inguinal lymph node dissection. Operation time was 377min (range 130-505min). The median overall survival after surgery was 27months (range 4-84months), with a calculated 5-year survival rate of 42%. Women with negative lymph nodes revealed a longer survival time after surgery compared to women with lymph node metastases (15.5 vs. 72months; p = 0.09). Abdominoperineal excisions represent a powerful tool in the multidisciplinary treatment regimen of advanced or recurrent vulvar cancer. Reconstruction of the pelvic floor usually does not require myocutaneous flaps, even when facing large tumours. Despite high complication rates, radical surgery was a feasible treatment with long-term survival potential without mortality.

Surgical outcomes in patients undergoing radical vulvectomy

Surgical outcomes in patients undergoing radical vulvectomy

Does plastic surgical consultation improve the outcome of patients undergoing radical vulvectomy for squamous cell carcinoma of the vulva?

ObjectivesTo analyze margin status and prognostic factors for complications in patients undergoing vulvectomy for invasive squamous cell cancer (iSCC) with and without plastic-assisted closure. MethodsDemographic and clinical data were collected on 94 patients with iSCC who underwent vulvectomy between 2004 and 2013. All pathology slides were re-reviewed by two gynecologic pathologists. Data were analyzed using XLSTAT-Pro v2014.2.02. ResultsOf 88 eligible patients, 15 (17%) had plastic-assisted vulvar closure and 73 (83%) did not. There were significantly more patients in the plastics group with recurrent disease (53% v 10%) and history radiation therapy prior to surgery (40% versus 5%). Plastic-assisted closure was associated with larger tumors (3.73cm versus 2.03cm, p<0.01) and a higher frequency of adequate margins (53% versus 29%, p=0.06). For tumors ≥3.0cm, plastic-assisted closure was significantly associated with adequate margins (44% versus 6%, p=0.03). Prior radiation use was associated with plastic-assisted closure, larger tumors, older age, and recurrent disease. Complications occurred in 36 patients (41%) and significantly more occurred in those with plastic-assisted closure (67% versus 36%, p=0.04). On multivariate analysis including age, tumor size, recurrent disease, plastic-assisted closure, and history of radiation, only history of radiation therapy was a significant predictor of complications (OR=17, 95%CI 2.05–141.35; p=0.01). ConclusionsPlastic-assisted vulvectomy closure was more often utilized in cases involving past radiation therapy and larger tumors. Plastic-assisted closure significantly increased the frequency of adequate margins in tumors ≥3cm and did not impact complications.

Preliminary experience of performing a video endoscopic inguinal lymphadenectomy using a hypogastric subcutaneous approach in patients with vulvar cancer.

To evaluate the feasibility and surgical outcome of video endoscopic inguinal lymphadenectomy (VEIL) using a hypogastric subcutaneous approach, 21 patients with vulvar cancer who underwent this procedure were included in the present study. Between December 2010 and March 2013, 21 consecutive patients with vulvar cancer underwent radical vulvectomy and VEIL using a hypogastric subcutaneous approach. The intraoperative and post-operative results and follow-up data were retrospectively analyzed. No intraoperative complications occurred. The mean duration of surgery for the endoscopic inguinal lymphadenectomies was 130 min (range, 80–180 min), with a mean estimated blood loss of 103 ml (range, 30–350 ml). The mean lymph node yield was 15 (range, 10–22 lymph nodes). The suction drains were removed after a mean duration of 7 days (range, 5–11 days). No skin-related complications were observed in the groin region and a lymphocele was only observed in 1/21 (4.8%) patients. After a mean follow-up period of 17 months (range, 3–31 months), recurrence was found in only one patient. All the patients were alive at the time of publication. Based on our preliminary experience, performing VEIL using a hypogastric subcutaneous approach is a safe and feasible technique for patients with vulvar cancer. These results indicate that this surgical technique may decrease the post-operative morbidity of lymphadenectomy without compromising the therapeutic efficacy. Future prospective studies with a greater sample size and a longer duration of follow-up are required.

Impact of radical operative treatment on the quality of life in women with vulvar cancer – A retrospective study

ObjectivesFor patients undergoing vulva surgery the quality of life (QoL) is generally accepted as an important outcome parameter in addition to long-term survival, mortality and complication rates. Less radical operative treatment can reduce morbidity and thereby improve quality of life. This study focuses on outcome in terms of QoL in patients comparing wide local excision (WLE) with radical vulvectomy and waiver of lymphonodectomy (LNE) with inguinofemoral lymphonodectomy. MethodsIn a retrospective single-center study from 2000 to 2010, 199 patients underwent surgery for vulvar cancer. To assess QoL, the EORTC QLQ-C30 and a tumor-specific module questionnaire were sent to all patients in the follow-up period. ResultsWomen who underwent WLE have a superior QoL with regard to global health status and physical, role, emotional and cognitive functioning than those who underwent radical vulvectomy. Less radical surgery also implies less fatigue, nausea/vomiting, pain, insomnia, appetite loss, diarrhea and financial difficulties. After radical vulvectomy 89% of patients have sexual complications. ConclusionRadical operative treatment, such as radical vulvectomy, causes deterioration in the QoL of these patients. An individualized, less radical surgery must be the aim in the treatment of vulvar cancer.

Perineal reconstruction with an extrapelvic vertical rectus abdominis myocutaneous flap.

Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion. A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction. The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months. Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.

Metastatic vulvar carcinoma

To the Editor: A 67-year-old woman presented to our clinic with a 2-month history of tender, painful, skin-colored and violaceous papules and nodules on the upper aspect of her right thigh, associated with a prominent lymphedema (Fig 1). Before consultation, the patient was treated with oral acyclovir for a herpes zoster infection. Two weeks afterward, the condition showed no improvement, rather the lesions diffused to the entire lower extremities. Five months before clinical presentation, the patient underwent radical vulvectomy with bilateral inguinal lymphadenectomy for a stage III squamous cell carcinoma (SCC) of the vulva. After surgery, she was treated with 5 cycles of cisplatin and 5-fluoracil. A skin biopsy specimen of a violaceous papule demonstrated dermal infiltration with evidence of lymphatic invasion (Fig 2), consistent with a cutaneous metastasis of vulvar SCC. A total body computed tomography scan showed enlarged lymph nodes in the right iliac region. Due to a progressive and rapid clinical deterioration, the patient died 3 months afterward. Fig 2Metastatic vulvar carcinoma. Photomicrograph showing tumor cells within dermal lymph vessel (arrows), stained with immunoperoxidase method with antibody against human lymphatic vessel endothelial hyaluronan receptor-1 (×63 objective.) View Large Image Figure Viewer Download Hi-res image