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Cancer of the external genitals is up to 8% in the
overall structure of the incidence of malignant neoplasms of female genital organs.
Under our observation there were 92 patients with vulvar dystrophy and
suspected cancer. The effectiveness of treatment of vulvar dystrophy (VIN I-II
degree) by the method of photodynamic therapy (PDT) 45.8 ± 4.7%. However,
dysplasia II-III degree, sclerotic changes with the formation of pronounced
horn scales prevents the full PDT and recurrence of the disease. Reconstructive
plastic surgery was performed using cryoapplication and «Harmonic» apparatus to
reduce blood loss and duration of lymphorrhoea in the postoperative period. The
use of new reconstructive plastic surgery, including with the use of abdominal
skin and fascial flap combined with vascularized lower segments of the rectus
muscles), have helped to reduce complications, improve cosmetic effect (patent
for invention № 2580665 from 11.11.14).
Keywords:
Cryoapplication, The apparatus “harmonics”, Plastic surgery, Abdominal
skin, Rectus muscles, Vulvular cancer
INTRODUCTION
Most often,
one woman can observe various pathological conditions that must be taken into
account and classified.
Able to
treat precancerous processes and prevent the development of cancer is
difficult, but the real problem of modern gynecology [7,8]. Some authors the
solution to this problem is associated with the development of methods for
cryosurgery, PDT and FDD [6]. Others believe that the organ-saving treatment of
patients with neurodystrophic process, with a vulvar intraepithelial neoplasia
and early cancer leads to relapse and therefore in need of radical treatment
[2,3].
However, to
date not solved the methodological aspects of detection and treatment of vulvar
dysplasias and early cancers of the vulva. In works on RV [3,7] indicate the
importance of magnifying diagnosis and morphological methods. At the same time,
stated that “the information content of the smears low” (up to 57% for summary
data). “Often smears find only Horny scales and elements of inflammation,
introducing the doctor astray.”
OBJECTIVE
Comprehensive
assessment and improvement of methods of diagnostics and treatment of vulvar
dysplasias and early cancers.
MATERIALS AND METHODS
With vulvar
dysplasia, sclerotic deprive and suspected cancer in regional oncologic
dispensary from 2012 directed 92 of the patient.
The
examination we carried out with the use of colposcope (15 fold increase),
allowing a high degree of confidence to select sites for target biopsy. Given
the multicentric growth, as a rule, morphological study of vulvar dystrophies
started with obtaining cytological material (smears and scrapings) from the
suspicious areas (Figure 1).
In the
literature available to us we have not found a description of the method of
collection of material for cytological examination vulvar dysplasias as it is
used for cytological screening of cervical cancer. Given that development of
foci of RV occurs on the background of sclerotic zoster and increased
keratinization of epithelial tissue, we used the technique of scraping with a
scalpel consisting of two steps: 1) removing (scraping) keratinized scales of
the epithelium of the 4-5 most suspicious areas; 2) scarification and receiving
cells from deeper layers within the basal layer before the “dewdrops” of blood.
The results
of cytological studies, we used incisional biopsy with a scalpel under local
infiltration anesthesia (0.5% p-p of novocaine or lidocaine). And only when
expressed scopinich and saucer-like forms of cancer a biopsy was performed by
conchotomy. As can be seen from Table 1,
the cytological examination in 79 of the 92 patients with aimed vulvar
dysplasia allowed at 76.0 ± 3.4% of cases to establish a correct diagnosis,
including 13 cases against this background, the cancer (stage 0-1), which is
significantly higher than according to the literature - 57% [1,2].
And only 20, 6 ± 1.5% were not informative.
Have a 3.2 ± 0.6% conclusion of catalogul was wrong. The sensitivity of
cytology in detecting different types of pathology NGOs amounted to 81.3 ± 3.9
and ranged from 76% in vulvar intraepithelial neoplasia (VIN) to 97% at the
pre-invasive forms of cancer.
PDT we
performed in 24 patients with diffuse vulvar dysplasia (VIN II-III) and PB to
prepare the surrounding tissues, including 2 patients at relapse RV. As shown
in Figure 2, dysplasia and sclerotic
zoster transferred to the skin of the thigh, which cannot be used for forming
skin-fascial flap without PDT. In their study, we used a second generation
sensitizer – fotoditazin. Session of PDT was performed using 1.5-2 h after intravenous
drip infusion of the drug (LLC “Veta-Grand”), on average, 1.0 mg/kg of body
weight in 100 ml of 0.9% solution of sodium chloride in terms of polystannanes
of the room. Laser irradiation with a semiconductor device “Atcus-2” at the
energy density of 80-250 j/cm2 of laser power output 1 W and the
exposure time from 10 to 30 min depending on the area affected areas by
scanning. Method involves generation of atomic (singlet) oxygen, leading to
death of the atypical cells. After 1.5-3 months came healing and tissue repair
without deformities in 9 women with barely visible scarring. Patients followed
from 1 year to 3 years. Five women with repeated photodynamic therapy, however,
complete cure has managed to achieve only two. Thus, the PDT allowed curing vulvar
dysplasia, only 11 of the 24 patients with I-II degree (45.8 ± 4.7%). The
renewal of the skin itch and residual lesions leukoplakia was observed in 13
women, due to the insufficient exposure of laser exposure on each zone,
especially when there are significant Horny scales. Besides, PDT by moving the
laser beam by hand does not allow avoiding subjectivity and thus relapse. In
such situations, in our opinion, requires an individual approach and combined
treatment. As noted by the women themselves after PDT was only a temporary
subjective effect, after which the itching resumed and they resorted to various
folk remedies.
As noted by
the women themselves after PDT was only a temporary subjective effect, after
which the itching resumed and they resorted to various folk remedies.
For cancer of the vulva in order to avoid
dispersion of tumor cells excision is always carried out radiowave scalpel and
apparatus “Harmonics”. In recent years, the excision of the tumor was preceded
by her credibilitate to t-185° using the apparatus ERBE, exposure 3-5 min (Figure 3). The results indicate the
prospects of this approach, allowing a fixed tumor, it is more convenient to
tighten and excise, to reduce blood loss.
To improve quality, the formation of the
amount of the external genitalia and reduce the lymphorrhea in recent times we
have developed a method rekonstruktivnoi erasers (Patent No. 2580665 for invention dated 11.11.14) of the external
genitalia through the mobilization of abdominal skin and fascial flap and the
lower segments of the rectus muscles along with epigastrica inferior (Figures 3a-3d).
Closure of the wound was carried out at the
beginning cross mobilized segments of direct muscles of a stomach on the
vascular pedicle. Last create the missing volume of the labia majora and
represent a unique plastic material for vascularization and lymph drainage. In
the region of the decussation of the muscles and the ends of the segment
performed the fixation to the muscles of the vagina with absorbable sutures so
that they hung over the mouth of the urethra and did not close the symphysis of
the pubic bones.
The next step was sutured fascia rectus
muscles of the abdominal wall. Then put 6-7 stitches by Donati on the skin of
the perineum and posterior vaginal wall tension in order to determine to what
level will the skin defect to be filled abdominal skin and fascial flap with no
tension (Figure 4).
Abdominal skin
and fascial flap was laid on the wound surface, adapting it by cutting off the
excess and sharp areas of the skin, stitches. Determining the projection of the
abdominal flap, adjacent to the pubis, imposes two provisory internal anchor
sutures to the periosteum, which is then stitched to the abdominal flap
(without the skin), forming the genital fold.
Then through a
separate puncture of the abdominal flap in the inguinal areas has introduced an
active drainage in the inguinal-femoral area. Then every 0.7-0.8 cm for the
tightness of stitches on the skin and the vaginal mucosa around the entire
circumference and nodal skin sutures for Donati in inguinal-femoral area.
Surgery was
performed in 14 women, mostly aged 45 to 55 years with abdominal obesity. The
process is localized on the skin and mucosa of the anterior half of the vulva.
In one case, focal leukoplakia was as an independent disease, in the other case
was diagnosed with the initial cancer. Healing was by primary intention, with
the exception of 1 woman (8.3 ± 1.4%) with obesity and diabetes type II. An
important aspect of reconstructive vulvectomy of the abdominal flap in
combination with the segments of the rectus muscle on the vascular pedicle was
the use of the apparatus “Harmonics” (Germany), which reduced bleeding and
duration of lymphorrhea in 2-3 days.
The use of cryoapplication,
the apparatus “Harmonics” and individual approach of wound closure, including
abdominal flap according to our technique allowed reducing mortality with a
tendency to increase morbidity (Figure
5).
CONCLUSION
1. The
treatment of choice for vulvar dystrophy (VIN I-II degree) is PDT, which is in
the diffuse forms the transition to the skin back of the thigh and with strong
Horny scales should be used in combination with reconstructive plastic.
2. The
use of reconstructive plastic surgery, including use of vascularized lower
segment of the rectus abdominis muscle is an individual method of choice in
young women with cancer of the vulva and vulvar dystrophies (VIN II-III), a way
of preventing the development of invasive forms of cancer, helps to reduce.
1.
Ashrafyan LA, Kharchenko N (2006) Vulvar cancer:
Etiopathogenic concept. In. Kiselev VI. Moscow, p: 192.
2.
Gubaidulina TN, Zharov VA, Chernova LF (2008) Efficiency
of surgical treatment of patients with background processes precancer and early
cancer of the vulva with the use of reconstructive plastic surgery. Surgery
2008: 48.
3.
Zharov AV, Vazhenin AV (2005) Optimization of the
treatment of patients with cancer of the vulva. Chelyabinsk 2005: 131.
4.
Buscema HHJ (1988) The predominance of human
papillomavirus type 16 in vulvar neoplasia. Obstet Gynecol 71: 601-606.
5.
Krikunova LI, Kaplan MA, Rykova EV (1999) The role of
photodynamic therapy in the treatment of vulvar cancer. 1st International
Conference, Obninsk, pp: 32-33.
6.
Urmancheyeva AF (2006) Epidemiology of cancer of the
vulva. Risk factors and prognosis. Pract Oncol 7: 189-196.
7.
Chulkova OV, Novikova EG, Sokolov VV, Chulkov E (2006)
Diagnosis and treatment of background and precancerous diseases of the vulva.
Pract Oncol 7: 197-204.
8.
Knapstein PG (1985) Erweiterte Behandlungsmoglichkeiten
das Vulvakarzinomas durch plastic reconstruktive Verfahren. Zbl.Gynekol 107:
1479-1487.
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