Richard J Slade

The management of vulval cancer.

Referral of women with vulval carcinoma to tertiary centres is now established practise in the UK. The centralisation of care for these women promotes the development of specialist teams of gynaecological oncologists, clinical oncologists, pathologists and clinical nurse specialists with expertise in the management of this relatively rare tumour. The primary care physician plays an essential role in the early detection and subsequent urgent referral of women with suspicious vulval lesions. Improved education and awareness campaigns may encourage women to report vulval symptoms early. Where vulval carcinoma is diagnosed at an early stage, surgical excision is likely to be curative. There is, however, a move away from radical surgery for all patients irrespective of stage of disease towards an individualised approach, which takes into account the size and position of the tumour. The challenge is to reduce morbidity associated with treatment without compromising on cure rates. Restricting groin lymphadenectomy to women with lymph node metastases may be possible with the advent of sentinel node technology and it is anticipated that expertise in this area will show significant advances over the coming years. There is still a place for radical surgery, often in combination with other treatment modalities, in the management of advanced or recurrent disease. This article will review the evidence for the current management of vulval carcinoma.

The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique.

OBJECTIVE To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery. TECHNIQUE Local anaesthetic (20 ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall. STUDY DESIGN We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n=51) or the surgical rectus sheath block (n=47) for post-operative pain relief. MAIN OUTCOME MEASURES (1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay. RESULTS The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0-1) vs. 2 (1-3), p<0.001], required less morphine post-operatively [12 mg (9-26) vs. 36 mg (30-48), p<0.001], had their PCAs discontinued earlier [24h (18-34) vs. 37 h (28-48), p<0.001] and went home earlier [4 days (3-4) vs. 5 days post-op (4-8), p<0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound. CONCLUSIONS The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further.

Thermal balloon ablation--a rare case of fibroid necrosis.

Introduction This case illustrates the fact that fibroid necrosis is a complication of thermal ablation. This complication has not been described in the medical literature in relation with thermal ablation. The use of thermal ablation for submucous fibroid-induced menorrhagia is considered inappropriate; however, no clear instruction is available for its use with cases of intramural fibroids where the cavity is regular. When such a potential complication results in hysterectomy, then the purpose of the procedure, which was the avoidance of major surgery, is defeated and appropriate counselling and consent should have been undertaken.

Aggressive angiomyxoma of the vulva and perineum: A case report

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Malignant melanoma of the uterus diagnosed at hysteroscopy

Zoon originally described plasma cell balanitis in 1952. Analogous conditions have been reported to involve the oral mucosa and rarely the vulva. This spectrum of idiopathic, inflammatory mucositis is known as plasma cell orificial mucositis. Patients with plasma cell vulvitis present with vulval soreness, pruritus, burning, vaginal discharge and bleeding. It is characterised by shiny, tender, red, sharply marginated plaques which can be multiple and situated virtually anywhere within the vulval area. Histology is characterised by epidermal oedema, haemosiderin deposition and dense plasma cell infiltrates in the dermis. Treatment is with topical steroids, as a cream for vulvitis or a pessary for vaginal disease. Treatment with etretinate and intralesional interferon alpha has also been reported (Morioka et al. 1988). Cameron et al. (1999) have previously reported a case of plasma cell vaginitis in 1999; they speculated that this represented a new clinical entity. We would like to suggest from this case that plasma cell vaginitis is a rare form of the plasma cell orificial mucositis spectrum, which may be seen in the presence, or absence of vulval involvement.

Balloon Cell Urethral Melanoma: Differential Diagnosis and Management.

Introduction. Primary malignant melanoma of the urethra is a rare tumour (0.2% of all melanomas) that most commonly affects the meatus and distal urethra and is three times more common in women than men. Case. A 76-year-old lady presented with vaginal pain and discharge. On examination, a 4 cm mass was noted in the vagina and biopsy confirmed melanoma of a balloon type. Preoperative CT showed no distant metastases and an MRI scan of the pelvis demonstrated no associated lymphadenopathy. She underwent anterior exenterative surgery and vaginectomy also. Histology confirmed a urethral nodular malignant melanoma. Discussion. First-line treatment of melanoma is often surgical. Adjuvant treatment including chemotherapy, radiotherapy, or immunotherapy has also been reported. Even with aggressive management, malignant melanoma of the urogenital tract generally has a poor prognosis. Recurrence rates are high and the mean period between diagnosis and recurrence is 12.5 months. A 5-year survival rate of less than 20% has been reported in balloon cell melanomas along with nearly 20% developing local recurrence. Conclusion. To the best of our knowledge, this case is the first report of balloon cell melanoma arising in the urethra. The presentation and surgical management has been described and a literature review provided.

Apronectomy combined with laparotomy for morbidly obese endometrial cancer patients.

BACKGROUND The surgical management of morbidly (BMI >40) and super obese (BMI >50) women with endometrial cancer is challenging. The aim of this study was to describe the short and long term outcomes of apronectomy combined with laparotomy for endometrial cancer staging and tumour debulking. METHODS A retrospective case note review of morbidly obese patients undergoing combined apronectomy and laparotomy for suspected endometrial cancer between 2007 and 2009 was performed. Short term (operating time, estimated blood loss, complication rates, duration of hospital stay) and long term outcomes (weight profile over 24-month follow up period) were evaluated. RESULTS Twenty-one patients were identified with a median age of 58 years and a median BMI of 49 (range 37-64). Apronectomy combined with laparotomy took 192 min on average to complete, with a mean estimated blood loss of 497 ml. There were no intra-operative complications. Postoperative complications included anaemia (14% required a blood transfusion), urinary tract infection (5%) and wound complications (wound infection in 29% and partial wound dehiscence in 5%). The median post-operative stay was 9 days. At twenty-four months, one-third of patients were heavier (mean 5 kg, range 2-8 kg) but almost two-thirds of patients were considerably lighter than they had been pre-operatively (mean 13 kg lighter, range 9-17 kg). CONCLUSIONS Apronectomy combined with laparotomy was safe and well tolerated in this group of patients. Sustained weight loss by two-thirds of the patients over the two-year follow up period may reflect lifestyle changes instigated by individual patients following surgery. Combined apronectomy and laparotomy may provide an alternative to standard surgery for this challenging group of patients.

Gastrointestinal stromal tumour presenting as an ovarian tumour.

A previously fit and well 82-year-old woman presented with a 3month history of abdominal fullness and right-sided abdominal pain. She had no other symptoms and was systemically well. A pelvic ultrasound showed a large multicystic semisolid mass of probable ovarian origin. Neither ovary could be identified separately to the mass. An MRI scan subsequently confirmed a complex pelvic mass with areas of calcification, likely to represent ovarian pathology. There was no associated ascites, lymphadenopathy, omental or upper abdominal disease. Her carcinoembryonic antigen (CEA) was within normal limits at 1.7 and her CA125 level was mildly elevated at 69. At laparotomy, an 18 cm necrotic tumour was found arising from the proximal jejunum and an intraoperative opinion from a colorectal surgeon was sought. The tumour was excised and bowel continuity re-established by primary small bowel anastomosis. Her ovaries, fallopian tubes, uterus and cervix were normal in appearance and there was no associated omental or upper abdominal disease. Subsequent pathological examination of the resected specimen showed an 18 cm solid mass that was attached to the wall of the small bowel but spared the bowel mucosa. Histologically, the tumour was composed of fascicles of spindle cells (Figure 1). The spindle cells had elongated, moderately atypical nuclei. The mitotic activity was up to 5/50 high power fields. The tumour cells showed strong immunoreactivity with CD117 (c-kit) (Figure 2) and with CD34 (Figure 3). A pathological diagnosis of gastrointestinal stromal tumour (GIST) was made. The tumour was considered high risk for aggressive behaviour, in view of its large size and mitotic activity. Tumour deposits were also present in the pouch of Douglas biopsies, histologically. Further mutational analysis of the tumour revealed c-kit mutation in exon 11. The patient made a good recovery from surgery and she was referred to the medical oncologists for adjuvant chemotherapy. Discussion

Lipoleiomyosarcoma of the vagina

In January 2005 a 56-year-old woman (G1P1) presented to her GP with vaginal discomfort, associated with frequency of micturition. She smoked 10 – 15 cigarettes per day. A mid-stream specimen of urine (MSSU) was negative and no further action was taken. No pelvic assessment was undertaken. In May 2005, she attended for a routine cervical smear. There was some ‘difficulty’ in passing a Cusco’s speculum and she was referred to her local gynaecologist. At this time, a 4 cm mass was found arising from the anterior vaginal wall. An examination under anaesthesia (EUA) and cystoscopy was scheduled. While the bladder base appeared to be distended by the mass within the vagina, the mucosa was intact. Biopsy of the mass suggested a lipoleiomyosarcoma (see Figure 1), and the patient was referred to a surgeon in gynaecological oncology. An MRI confirmed the presence of a 5 cm solid mass, with heterogeneous signal, situated between the posterior aspect of the bladder and the anterior aspect of the upper vagina (see Figure 2). Although the bladder was compressed and displaced by this mass, there was no suggestion of frank invasion. An enlarged left common iliac lymph node (2.0 cm61.5 cm) was also noted. A CT of the chest and abdomen showed no para-aortic lymphadenopathy. In order to ensure complete removal, the patient was scheduled for anterior pelvic clearance, partial vaginectomy and urinary diversion (right-sided ileoconduit). The psychosexual dysfunction that can be associated with such surgery was discussed. A divorcee, she lived alone and did not seem concerned. The procedure went without complications and she made a good recovery. At laparotomy no enlarged lymph nodes (including common iliac) were found. Histology confirmed complete excision of lipoleiomyosarcoma, Trojani grade II (a three-grade system based on the evaluation of three parameters: tumour differentiation, mitotic rate and extent of tumour necrosis), with clear resection margins. No positive nodes were identified. The options for adjuvant therapy were discussed at review 6 – 8 weeks later. Chemotherapy may reduce the risk of relapse, but no survival benefit has been demonstrated. Radiotherapy would reduce the risk of local recurrence, but have no influence on distant metastases. A chest X-ray was clear, and a full body CT showed no residual disease or metasases. On balance, adjuvant therapy was withheld. The patient remains well 1 year later.

Vaginal vault reinnervation and symptoms of genital prolapse

Under these conditions, a sub-peritoneal drain could be inserted to prevent stagnation of serum. In 1973, Sapan and Solberg have advised the same preventive measures as well as regard for aseptic technique. Against this background, with more and more gynaecologists choosing not to close the pelvic peritoneum both at abdominal and vaginal hysterectomy, it will be of interest to note whether the incidence of tubal prolapse will increase in the future. Achieving meticulous haemostasis will remain the mainstay in the prevention of tubal prolapse. The role of prophylactic intraoperative antibiotics will also need to be evaluated.