The Pedicled Flap of Adductor Longus, a New Technique for Inguinal Reconstruction

Introduction: Reconstruction surgeries of the inguinal area pose a challenge for oncological and orthopedic surgeons, especially after radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both. Although numerous surgical procedures have been reported, there is no report about a pedicle adductor longus flap method. The aim of this work is to show our experience about inguinal reconstruction with pedicled adductor longus flap and associated outcomes.Patients and Methods: A retrospective study of 16 patients with localized inguinal region interventions and reconstructed by adductor longus flap from March 2016 to July 2020. Patients' average age was 60.0 years (range = 38–79 years) and had postoperative follow-up of 10 months (ranging 2–19 months). All patients had unilateral inguinal region involvement—seven cases on the left and nine cases on the right. The patients' clinical course, operative course, and postoperative follow-up data were evaluated.Results: All 16 patients recovered well post-operatively and did not require any re-intervention. Four patients experienced negligible discomfort around the groin area. Five patients experienced a minor strength deficit in thigh adduction compared with that of preoperative strength in the same or contralateral leg. The aforementioned complications resolved during the postoperative course and had no functional impact on their activity of daily living. All adductor longus flaps survived, completely filled the inguinal dead space, and wounds healed uneventfully within 3 weeks except for three patients who suffered delayed wound healing for more than 4 weeks. Other common complications such as infection, seroma, or wound dehiscence were not encountered in this series.Conclusion: The adductor longus flap is a reliable alternative method for inguinal region reconstruction following radical local resection (RLR), radical inguinal lymph node dissection (RILND), or both.

VEILND (Video Endoscopic Inguinal Lymph Node Dissection) with Florescence Indocyanine Green (ICG): A Novel Technique to Identify the Sentinel Lymph Node in Men with ≥pT1G2 and cN0 Penile Cancer

Introduction. In men with ≥pT1G2 cN0, penile cancer lymph node sampling is recommended with either (1) scintigraphically labelled Dynamic sentinel lymph node biopsy (DSLNB) or (2) modified inguinal lymph node dissection (MILND). Although DSLNB is a minimally invasive technique, the false negative rate can be about 10%, and a further operative procedure is required if positive. Open MILND is a diagnostic and therapeutic option but has a much higher morbidity. A potential compromise is the technique of LND-VEILND (video endoscopic inguinal LND) that can be combined with ICG florescence marking of sentinel lymph node (SLN). We present a pilot study of ICG-VEILND. The aim was to validate the applicability of a combination ICG marking of SLN in VEILND (to increase probability to excise SLN) and determine the optimal timing and dosage of ICG. Materials and Methods. 15 patients with VEILND (24 groins) underwent ICG application with fluorescence near-infrared (NIR 803⟶830 nm) detection. ICG is applied subcutaneously adjacent to the penile cancer or residual stump of penis or suprapubic region (in a history of total penectomy: 5 cases). The dose of 1.25 mg (ICG) was applied in one case with invisible SLN, the dose of 2.5 mg in 1 mL in 8 cases, and 5 mg in the remaining 6 patients (10 groins). Results. Failure of marking SLN with ICG occurred in 25.0% of cases (6/24): due to application of 1.25 mg ICG, extensive metastasis to SLN, in 4 cases, the cause was unknown (16.7%, 4/24). In the short follow-up period, no local recurrence was seen in the pN0 ICG group. Conclusion. Fluorescence infrared image with ICG dye increases the probability of removal of the SLN during VEILND. The dose of ICG is 2.5 (5) mg diluted in 1 ml and can be applied preoperatively even in the suprapubic region in men with a history of total penectomy, with an unexplainable failure of ICG marking in 16.7%.

Tislelizumab Combination With Chemotherapy Successfully Converted Unresectable Advanced Penile Cancer Into Complete Surgical Excision: a Case Report and Literature Review

Background: Locally advanced Penile squamous cell carcinoma (PSCC) with unresectable inguinal lymph nodes has a poor prognosis, and benefits from surgical treatment alone. Effective conversion therapy regimens are urgently needed.Case Presentation: We report a locally advanced PSCC patient with bulky, fixed inguinal lymph node metastasis complicated within genial skin ulcers, who completed inguinal lymph node dissection and achieved pathologically complete response via conversion therapy by immunotherapy plus chemotherapy.Conclusion: For unresectable locally advanced PSCC, neoadjuvant immunotherapy combined with chemotherapy is a potential treatment approach. Biomarkers of immune efficacy need to be explored. At the same time, clinical trials are needed to test the notions.

Characterization of A Rare Case of Vulvar Epithelioid Sarcoma with local recurrence and metastases

Introduction/Objective Epithelioid sarcoma (ES) is a rare, malignant mesenchymal neoplasm that has a known tendency for local recurrence, regional lymph node involvement, and distant metastases. Two histologic variants have been recognized: classic ES also known as the distal type, and proximal-type ES (PES). The classic ES is common in young adults. It occurs more frequently in the distal upper extremities followed by the distal lower limbs and has a male prevalence of 2:1. Conversely, PES commonly involves deep tissues in the pelvic region, including the genital area. It tends to occur in older patients and follows a more aggressive clinical course. In the female genital tract, PES occurs most frequently in the vulva. The incidence of primary sarcoma of the vulva accounts for 1.5-5% of all malignant tumors, making PES a very rare incidence. Methods/Case Report Here we report a 60-year-old female diagnosed with vulvar epithelioid sarcoma treated with a right radical vulvectomy and bilateral inguinal lymph node dissection in 2008. In 2017, further surgery and adjuvant radiation were given for local recurrence. In 2020, the patient developed left hip pain and was found to have an expansile lytic lesion in the left proximal femur. Extensive resection was performed. Grossly the vulvar lesion was nodular with diffuse hemorrhage, degeneration, and necrosis. Microscopically, the tumor cells had large vesicular nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm. Histologically, the morphology of the tumor cells are similar for the primary vulvar specimen and the bone metastases. Immunohistochemically, the tumor cells are positive for vimentin, GATA, FLI-1, SMA, SMHC, partially positive for CAM5.2, AE1/AE3, CD31, and CD163. Immunohistochemistry was negative for CDX2, CD56, S-100, TTF-1, CK5/6, CK20, P40, mammoglobin, MOC31, ER, CK7, CK903, HMB45, PAX8. A Ki-67 proliferative index was around 30-40%. NGS molecular testing detected a SMARCB1 mutation with loss of exons 1-3 and exons 7-9 supporting the diagnosis of epithelioid sarcoma. Results (if a Case Study enter NA) NA Conclusion In summary, we report a case of PES of the vulva in a 60 year old female. Grossly, the lesion was nodular with histology showing large vesicular nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm. It showed loss of INI1/SMARCB1 nuclear expression. The patient is receiving further adjuvant treatment and shows no new metastases.

Vulva and lower limb cancer: Results of inguinal lymph node staging on 81 cases

Background: The objective of this work completed at the Cancer Institute in Dakar is to report the results of inguinal lymph node dissection in cancers of the lower limb and of the lower genital tract. Methods: This is a retrospective study over a 10-year period. The parameters being studied are histological type, lymph node involvement, postoperative morbidity, recurrence, and survival. Results: 81 patients received surgery over a period of 7 years. The average age of our patients was 61. The sex ratio is 0.74 with 34 men and 47 women. There were 70 cases of cancer of the lower limbs (86%) and 11 cases of cancer of the vulva (14%). The most common histological type was squamous cell carcinoma (SCC) with 41 cases (51%). Clinical inguinal involvement was noted in 58 patients (72.5%) with palpable lymph nodes. All vulvar cancer patients developed histologically positive nodes. Melanoma patients were more susceptible to developing positive nodes. In sarcoma there were more matches between clinical and histological positive nodes. No vascular and nerve damage was reported. The average length of hospitalization was 5 days, with 3 days being the shortest stay, and 40 days the longest stay. Local complications consisted of suture releases in 9 cases, and 6 surgical necrosis of the wound. A seroma was found with an average duration of 35 days in 69 patients (85%). Postoperative deaths occurred in 5 cases (6%), 1 after a renal failure, 1 due to thromboembolic disease, 1 due to sepsis, and 2 deaths occurred after patients experienced respiratory distress. Conclusion: After five years of follow-up care, no patient presented chronic sequelae after inguinal dissection, 7 patients (8.75%) had local recurrence, and 4 patients (7.7%) had lymph node metastases. We recorded 33 cancer-related deaths (41%). Chronic complications, including lymphedema are underestimated and require better assessment methods for prevention and treatment.