CC BY
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https://doi.org/10.29013/ESR-21-7.8-19-23
Polatova Djamila, Republican Specialized Scientific and Practical Medical Center of Oncology and Radiologyy Tashkent State Dental Institute, DSc in Medicine, Head of Oncology and Medical Radiology Department
Navruzova Visola, Tashkent State Dental Institute, PhD in Medicine, post-doctoral student in Oncology and Medical Radiology Department
INGUIN-PELVIC LYMPHODISSECTION IN THE TREATMENT OF METASTATIC LESION OF REGIONAL LYMPH NODES IN VULVA CANCER
Abstract. Knowledge of the prevalence of the cancer process and its microscopic signs helps to establish the stage of development of the disease helps to assess the likelihood of tumor recurrence and provides information that will allow the doctor to predict the therapeutic effect. In vulvar cancer, the tumor often spreads along the length and by metastasizing to regional lymph nodes (inguinal, femoral), and then to the pelvic lymph nodes. In malignant tumors, the level of lymph node damage, which can be determined by lymph node dissection, is of great importance for the choice of treatment method.
Keywords: lymph node dissection, lymphovascular invasive lesion.
Introduction undergoing total groin-femoral lymph node dissec-
The incidence of RC is less than half of one per- tion, especially in combination with radiation ther-cent of the global incidence of malignant tumors. In apy [4; 5; 6]. In this connection, it is necessary to 2018, there were 44.000 new cases of vulvar cancer conduct research in the field of developing criteria worldwide, while the number of deaths was about for conducting lymph node dissection in RC [7]. 15.000 cases. It should be noted that the incidence Materials and methods. An analysis was made of RV is higher in high-income countries such as Eu- of the results of examination and treatment of186 rope, North America and Oceania [1; 2; 3]. patients with vulvar cancer who were treated at the
The most important prognostic features of vul- RSSPMCO&R, MSRC named after P. A. Herzen -var carcinoma are tumor size, depth of invasion, the branch of the Federal State Budgetary Institu-lymph node status, and the presence of distant me- tion "NMITs Radiology" of the Ministry of Health tastases. Historically, the assessment of the status of Russia (Moscow, Russian Federation), as well as of the inguinal nodes required the performance of the clinic of Istinye University (Istanbul, Turkey) a standard inguinal lymphadenectomy for all types from 2011 to 2020.
of vulvar cancer. However, this procedure is associ- In vulvar cancer, the tumor often spreads along
ated with a high risk of developing lower extremity the length and by metastasizing to regional lymph lymphedema (approximately 30-70%) in patients nodes (inguinal, femoral), and then to the pelvic
lymph nodes. In malignant tumors, the level of dam- occurred in the adjacent areas of the lower third age to the lymph nodes is of great importance for of the vagina, in the rectal ligament. Later, invasion the choice of treatment method. Regional spread into the anorectal region developed.
Table 1.- Clinical features of vulvar cancer in patients included in the study
№ Clinical features Number of patients
1. Tumor stage pTla 17(9.1%)
pTlb 27(14.5%)
PT2 73(39.2%)
pT3 63(33.9%)
pT, 6(3.2%)
Metastases to lymph nodes Yes 76(40.9%)
No 110(59.1%)
2. Distant metastases M0 169(90.9%)
Mi 17(9.1%)
2. Stroma invasion: <1mm 29(15.6%)
>1mm 130(69.9%)
No data 27(14.5%)
3. Tumor gradation 1 22(11.8%)
2 124(66.7%)
3 40(21.5%)
4. Lymphovascular invasion Yes 18(9.7%)
No 139(74.7%)
No data 29(15.6%)
5. Vascular invasion Yes 27(14.5%)
No 143(76.9%)
No data 16(8.6%)
6. Stage FIGO I stage 69
II stage 60
III stage 36
IV stage 21
Patients with a tumor limited only to the vulva or vulva and perineum, 2 cm or less in size in the largest dimension with invasion of the underlying tissues up to 1 mm, occurred in 26.3% of cases.
Isolated lesions of the pelvic lymph nodes are possible with the localization of the tumor in the clitoris and areas adjacent to the clitoris. Lympho-vascular invasion was detected in 74.7% of patients, vascular in 76.9% of patients. In more than half, the tumor grade corresponded to G2.
More than 90% ofvulvar cancer had a squamous histological form (VSCC - vulvar squamous cell car-
Spread to the lymph nodes occurred first in the direction of the inguinal lymph nodes. In 32.8% of cases, metastases were diagnosed in regional, femoral and inguinal lymph nodes. Palpation of the inguinal region may reveal involvement of the lymph nodes, but histological findings are positive in only 40% of cases with palpable tumors. Of the 61 lymph nodes affected by metastases, 36(59%) of the cases were inflamed and fixed, in this case, although rare, adenopathy was a warning symptom. In a large number of cases, the nodes were palpated, often bilaterally, and were displaced.
cinoma), in other cases, glandular, adenosquamous and other forms (Table 2).
Table 2.- Histological structure of vulvar cancer
№ Histological structure Number of patients
1. Bartholin gland carcinoma. 1 (0.5%)
2. Warty carcinoma. 5 (2.7%)
3. Squamous cell carcinoma. 109 (58.6%)
4. Squamous intraepithelial neoplasia, Grade 3. 39 (20.9%)
5. Basal cell carcinoma. 17 (9.1%)
6. Adenocarcinoma. 9 (4.8%)
7. Pagets disease. 4 (2.2%)
8. Adenosquamous cell carcinoma 2 (1.1%)
Inguinal-femoral lymph node dissection. This type of operation is one of the most common types oflymphadenectomy used in oncological practice. In addition to tumors of the vulva, this operation is also performed for various tumors of the lower extremities, genital organs, and other localizations. The technique for performing this type of operation is well developed. In the traditional version, the operation is started with two semi-oval incisions from the anterior superior surface of the ilium, parallel to the inguinal fold, with a dissection of the skin and subcutaneous fat. The incision was completed near the tendon of the external oblique muscle of the abdomen. The skin and adipose tissue were separated from the aponeurosis of the external oblique muscle to the center of the Scarpov's triangle. Pupartov's ligament was transected, while the fascia of the oblique muscle was
Table 3.- Distribution of patients radical inguinal-femoral
removed. Gradually dissecting the tissue from the tubercle of the pubic bone to the top of the femoral triangle, a tissue block was isolated from the tissue and lymph nodes of the femoral triangle and femoral canal. The block was removed by crossing the legs.
The indication for lymph node dissection was a tumor located in the clitoral region, a tumor larger than 2 cm, invasion into the surrounding tissues of more than 5 mm, multifocal tumor growth, and poorly differentiated G-4 intraepithelial carcinoma.
Results. The operation was performed in 61(32.8%) patients (Table 3). Of the 61 patients, 23 patients underwent bilateral lymph node dissection, which accounted for 37.7% of the total number of patients with inguinal-femoral lymph node dissection. Thus, 84 operations were performed to remove lymph nodes from the regional pool.
with vulvar cancer subjected to lymph node dissection
№ Clinical characteristics HPV-27 HPV+34
1 2 3 4
1. Stage FIGO
II stage 19(%) 14
III stage 8(%) 13(%)
IV stage 7(%)
2. Tumor localization
Large labia 9(%) 11(%)
Posterior commissure 3(%) 3(%)
Periurethral zone 1(%) 2(%)
2
4
2. Clitoris
Several anatomical zones
2(%) 4(%)
JM.
1(%) 8(%) 9(%)
3. Histological type
Squamous cell carcinoma. Squamous intraepithelial neoplasia, Grade 3
Adenocarcinoma
19 (% 7 (% 1
22 (% 12 (%
35 of these (18.8%) patients underwent surgery in the standard, traditional technique, with a wide excision of the skin of the inguinal-femoral zone. In 26 patients (13.9%), the operation was performed using endoscopic technique. The operations were performed according to the standard technique, using equipment for endoscopic surgery manufactured by Karl Storz Endoscopie (Germany). When accessing the space of adipose tissue, a retractor for
subcutaneous endoscopic surgery Bird and Emory (Snowden Pericer, USA) was used.
The operation to remove the lymph nodes from the inguinal - femoral zone is not very difficult to perform. Despite the development of all aspects of this operation, in the postoperative period, as in other operations, complications were observed associated with the peculiarity of surgical aggression, the characteristics of the patient's body (Table 4).
Table 4.- Postoperative complications after inguinal-femoral lymph node dissection (n=84)
№ Postoperative complications Number of cases
1. Suppuration of the wound 17(20.2%)
2. Divergence of seams 3(3.6%)
3. Lymphostasis 9(10.7%)
1
3
The operation was performed in 61(32.8%) patients (Table 4.8). Of the 61 patients, 23 patients underwent bilateral lymph node dissection, which accounted for 37.7% of the total number of patients with inguinal-femoral lymph node dissection. Thus, 84 operations were performed to remove lymph nodes from the regional basin.
When analyzing the long-term results of lymph node dissection, the following features were revealed: in patients with a poorly differentiated histological form of the tumor, with lesions of several
anatomical tumors, with lesions of the clitoris, in the presence oflymphovascular invasion in 7(18.4%) of 38 patients who underwent unilateral lymph node dissection within the next 8 months after operations, metastases occurred in the opposite inguinal zone.
Conclusion. Thus, the indication for bilateral inguinal-femoral lymph node dissection should be, in addition to confirmed metastases in the inguinal region, a low-grade histological form of vulvar cancer, damage to several anatomical zones, lymphovas-cular invasion, and clitoris lesion.
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