Giulio Ricotta

Use of the genito-crural island perforator flap in vulvar reconstruction: a single-center experience

Vulvar cancer represents 5% of all gynecological malignancies, but its incidence has increased. Management of early stages requires radical local excision, with simultaneous reconstruction when direct suturing is not indicated. The genito-crural island perforator flap is a reliable option that can be considered in most vulvar reconstruction cases, combining limited morbidity and preservation of aesthetic and functional vulvar concerns. This monocentric, retrospective single-arm study includes patients treated between 2021 and 2025, who underwent vulvar cancer surgical resection with genito-crural island perforator flap reconstruction. The study aims to highlight the feasibility and surgical results of this flap in terms of wound healing, hospitalization duration, and post-operative outcomes. Of the 27 patients included, 19 had bilateral genito-crural island perforator flap reconstruction, resulting in a total of 46 flaps. A total of 59.3% of patients had no risk factors for impaired healing, despite an occasionally advanced age (median 61 years, range; 35-81) and patients often being overweight (median 27.7kg/m Genito-crural island perforator flap is a simple and reliable procedure, enabling rapid healing with short post-operative recovery, low morbidity, and satisfactory functional and morphological outcome. In our practice as a tertiary cancer center, we routinely use this flap.

The Toulouse algorithm: vulvar cancer location-based reconstruction

Vulvar cancer is a rare malignancy, accounting for approximately 5% of all gynecological cancers, but its incidence has increased. The gold standard treatment is complete surgical resection with safety margins, which may vary according to histological subtype. This surgery often results in large defects, which may be challenging to repair international guidelines recommend that reconstructive procedures after vulvar cancer surgery should always be considered in cases where it will guarantee better functional and/or cosmetic results or when wound closure will be challenging. With the advancements of reconstructive procedures in oncologic surgery, perforator flaps represent the best option to reduce donor-site complications, and have all the advantages for vulvar reconstruction, by less demolitive procedures to maintain the patient's self-image and sexual function without impacting the oncological outcome. Various algorithms have been proposed in the literature for flap selection in vulvo-perineal reconstructive surgery (Gentileschi S, Servillo M, Garganese G, et al. Surgical therapy of vulvar cancer: how to choose the correct reconstruction? J Gynecol Oncol. 2016;27(6):e60. doi:10.3802/jgo.2016.27.e60; Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar reconstruction by perforator flaps: algorithm for flap choice based on the topography of the defect. Int J Gynecol Cancer. 2015;25(7):1322-1327. doi:10.1097/IGC.0000000000000481; Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54(2):184-190. doi:10.1097/01.sap.0000141381.77762.07; Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559-568. doi:10.1016/S1470-2045(0870147-5)). However, these often lack practicality as they are based on the size of the defect, listing all possible flaps that can be adopted without considering that some flaps should clearly be preferred because of their better aesthetic result. Moreover, most of these algorithms still recommend musculocutaneous flaps which are associated with greater donor-site morbidity, and which should therefore be considered only in selected cases when other flaps are not feasible. We present a simple and effective algorithm for flap selection in the field of vulvo-vaginal-perineal reconstruction for vulvar carcinomas, developed from our experience as a tertiary referral cancer center. This algorithm is based on the anatomical involvement of the vulvo-perineal region to provide more accurate anatomical restoration. It is versatile enough to be used in most cases of vulvo-vagino-perineal reconstructive surgery, leading to an improvement in the restoration of anatomy and function. Moreover, perforator flaps are proposed as the first option with different possibilities based on the location and the size of the defect.

Pelvic exenteration for vulvar cancer: contemporary outcomes from a multinational cohort study

Women with vulvar cancer are considerably older than those with other gynaecological malignancies, raising concerns about the tolerability of radical surgery. Yet, for locally advanced or recurrent disease, pelvic exenteration may be the only curative option. Robust evidence to guide decision-making in this population is lacking. This multicentre observational cohort study used data from the COREPEX registry including women who underwent anterior or total pelvic exenteration between 2005 and 2023 across 20 European tertiary referral centres. The primary outcome was overall survival (OS); secondary outcomes were progression-free survival (PFS) and major postoperative complications. Associations were assessed using multivariable Cox and binomial regression models adjusted for relevant covariates. Among 861 women, 79 (9.2%) had vulvar cancer. Median follow-up was 49 months for OS and 40 months for PFS. Women with vulvar cancer were older and more often overweight. Five-year OS was 32% (95% CI, 19-46) in vulvar cancer versus 29% (95% CI, 25-34) in other cancers, adjusted HR 1.05 (95% CI, 0.75-1.46). Five-year PFS was 34% versus 29%, adjusted HR 0.96 (95% CI, 0.69-1.34). Major complications occurred in 33% vs 29%, adjusted RR 1.12 (95% CI, 0.77-1.58). Lymph node metastases, positive margins, and recurrent or persistent disease independently predicted poorer survival. Despite their older age, women with vulvar cancer had survival and morbidity comparable to those with other gynaecological malignancies. These findings support pelvic exenteration as a curative option for selected women with vulvar cancer when complete resection is feasible.

Outcomes of low-risk endometrial cancer with isolated tumor cells in the sentinel lymph nodes: a prospective, multi-center, single-arm, observational study (ENDO-ITC study)

It is unclear whether isolated tumor cells (ITCs) in sentinel lymph nodes (SLNs) adversely affect prognosis, especially in low-risk endometrial cancer. In a retrospective study, we showed a worse recurrence-free survival for low-risk endometrial cancer with ITCs than the node-negative group. Our aim is to evaluate whether the likelihood of disease recurrence differs between a prospective cohort of patients with low-risk endometrial cancer with ITCs and an historical cohort with negative SLNs. We hypothesize that patients with low-risk endometrial cancer and ITCs will have a worse recurrence-free survival than patients who are node-negative. This is a prospective, multi-center, single-arm observational study. Consecutive patients with low-risk endometrial cancer with ITCs in the SLNs will be accrued. Observation only will be suggested after surgery. We will include patients with endometrial cancer undergoing pelvic SLN biopsy and ultra-staging with the following characteristics: endometrioid histology, grades 1 to 2, <50% myometrial invasion, without substantial/extensive lympho-vascular space invasion. ITCs in SLNs are defined as tumor cell aggregates ≤0.2 mm or <200 cells. The primary end point is recurrence-free survival, measured from the date of surgery to the date of recurrence, death, or last disease evaluation. With a sample size of 132 women with low-risk endometrial cancer and ITCs, a 1-sided log-rank test achieves 85% power at a 0.05 significance level to detect an HR of 2.1. The expected number of events during the study is 17.3. The study duration will be 60 months: 24 for enrollment and 36 for follow-up. The results are expected in 2029. ClinicalTrials.gov: NCT06689956.