Stage I Vulvar Squamous Cell Carcinoma with Early Relapse and Rapid Disease Progression

Case Reports in Oncological Medicine
10 Jul, 2019 ,

This is a case report of a woman who experienced a rapid, chemorefractory tumor progression after surgery for stage IB vulvar squamous cell carcinoma (SCC). She presented with a  painful vulvar lesion. The patient underwent right hemivulvectomy & later a bilateral inguinofemoral lymph node dissection. However, just one month later, the patient developed a local recurrence with a 3 cm nodule in the right vulvar area and a 0.8 cm lesion in the clitoris. A wide local excision was performed and histopathology examination revealed a poorly differentiated vulvar SCC in both lesions. A restaging CT scan of the chest, abdomen, and pelvis showed multiple bilateral pulmonary metastases and multiple inguinal and pelvic lymph node involvement.

 

 

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A 70-year-old woman presented at the gynecology unit of our hospital complaining about a painful vulvar lesion in May 2017. She had no significant medical history. Physical examination revealed an exophytic and ulcerative vulvar mass, approximately 4 cm in diameter, localized on the right labium majus at less than 2 cm from the midline, without palpable inguinal lymph nodes bilaterally. An incisional biopsy was performed, and histology revealed an invasive poorly differentiated vulvar SCC. A total-body CT scan performed to stage the disease resulted in negative for distant metastases.

The patient underwent right hemivulvectomy in order to obtain wide tumor-free pathological margins in June 2017. Concomitant inguinal lymph node dissection was not performed due to the patient’s refusal (risk of lymphedema). Histopathologic findings confirmed a poorly differentiated vulvar SCC arising on a background of lichen sclerosus. The size of the invasive SCC lesion was 4.5 cm with a depth of invasion of 2.7 mm and no lymphovascular invasion. All surgical margins of the lesion were tumor-free (more than 1 cm).

She was addressed to our oncology unit in July 2017. We required a disease restaging by abdominal and pelvic MRI scan and chest CT scan. No evidence of distant metastases resulted from the imaging studies. Therefore, we suggested locoregional lymph node dissection in order to define the pathologic stage of the tumor and to plan postoperative adjuvant radiotherapy to the groin just in case of lymph node involvement.

In August 2017, a bilateral inguinofemoral lymph node dissection was performed with all nodes (twelve) resulting in negative for the metastatic spread on conventional hematoxylin-eosin staining. The tumor was staged as FIGO stage IB, and the patient was addressed to strict follow-up.

However, just one month later (September 2017), the patient developed a local recurrence with a 3 cm nodule in the right vulvar area and a 0.8 cm lesion in the clitoris. A wide local excision was performed and histopathology examination revealed a poorly differentiated vulvar SCC in both lesions.

A restaging CT scan of the chest, abdomen, and pelvis showed multiple bilateral pulmonary metastases and multiple inguinal and pelvic lymph node involvement.

Because of recurrence, systemic chemotherapy was started with carboplatin (AUC5 day 1 every 3 weeks) and paclitaxel (80 mg/m2 days 1 and 8 every 3 weeks). After 3 cycles, a total body CT scan showed the progression of metastatic disease in the lungs, lymph nodes, and liver. Moreover, a painful erythematosus nodule appeared on the skin of the right groin and right thigh.

Because of disease progression, second-line chemotherapy with capecitabine (1000 mg/m2 bid, days 1-14 every 21 days) was started (December 2017). After 3 cycles of treatment, the patient presented ulceration and fistulization of the groin lesion and new skin nodules in the right thigh associated with extremities lymphedema. She complained of perineal pain and analgesic therapy was prescribed. Moreover, palliative radiotherapy to inguinal metastases (30 Gy in 10 fractions) was performed.

A reevaluation CT scan (February 2018) revealed the further progression of the disease with multiple liver metastases, multiple excavated lesions in the lungs, and matted metastatic iliac/inguinal lymph nodes.

The patient died one month later, in March 2018, because of respiratory failure.