Pregnancy following radical vulvectomy and lymph node dissection for vulval carcinoma- A case report
                                                       

                                                         Savitha Shetty,  Tendai Musa,  Nirmal Vaithilingam

                        Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth Hospital   University  NHS Trust.

 

                                                                  INTRODUCTION

 

Vulval cancer is a rare disease with a crude incidence rate of 3.9/100 000. In the UK it is the 20th most common female cancer and 4th most common gynaecological cancer. Reports of either vulval carcinoma presenting during pregnancy, or of pregnancy following treatment of vulval cancer, are rare because the majority of  women with the condition are perimenopausal with completed familied, post-menopause or rendered infertile following treatment with radiotherapy and chemotherapy.   While most vulval cancer is still diagnosed in women aged over 70 years, there is  an increase in incidence in younger cohorts and its most likely due to an increase in human papilloma virus (HPV)-related VIN within those groups. With the increasing incidence of vulval carcinoma in younger women, we are  progressively more likely to encounter patients with either vulval carcinoma in pregnancy or pregnancy following treatment for vulval cancer.  The mean age of the patients with pregnancy after vulvar carcinoma treatment was 31.3+/- 4.9 years( 19-39 years).

 

                                                                    DISCUSSION

Modern management of vulval cancer is dictated by the size and site of the cancer and individualised to the patient.

In successfully treated vulvar cancer subsequent pregnancy is not shown to increase the risk of disease recurrence, and there appears to be no deleterious effects during antenatal period. In the literature, vulvar scarring following radical vulvectomy was the major reason for pregnant women undergoing caesarean section however, the obstetrical reasons were minor. The paucity of reported cases and larger data series in the literature has prevented the development of accepted management plans for either vulval carcinoma presenting in pregnancy or pregnancy following treated vulval cancer.

Predictable short- and long-term effects from treatment include psychosocial concerns; lymphoedema; altered sexual function and body image. Access to specialised psychosexual and psychosocial counselling services is required for women with vulval conditions including, but not limited to vulval cancer.

The impact of cancer and treatment can affect quality of life. Women should have the opportunity to explore ways of improving their quality of life through appropriate support and psychological services where available. It is the responsibility of all members of the healthcare team to give women appropriate information at each stage of their acre.

     

                                                                                  Case report

We present here a case report of a patient who was diagnosed with vulvar carcinoma in Eastbourne in 2020. The patient underwent radical vulvectomy and bilateral lymphadenectomy at the same place. In March of 2020, when the patient was early into her pregnancy at 12+4 weeks, she visited QAH with complaints of vulval abscess, which was diagnosed for the first time. She was treated for the same with oral Cotrimoxazole, and an MRI scan was done. The scan revealed a stable vulval bed abscess which extended to the mons pubis and the overlying skin. Throughout her period of pregnancy, the patient was treated many times for recurrent vulval abscesses. Eventually, a gynaecological oncologist reviewed her case and recommended reconstructive surgery to improve the drainage of the abscess. The safest delivery method recommended was a caesarean section. The patient underwent the surgery at 39+3 weeks, which proved to be a complicated procedure due to the distorted vulval anatomy caused by the previous radical vulvectomy. Catheterisation was not possible until the patient was anesthetised, as the external urethral orifice was challenging to identify due to pain. However, post-surgery, the patient made a full recovery, and an uneventful delivery was achieved. Currently, the patient is more than 12 weeks post-natal and has moved out of the area, making follow-up impossible.

 

                                                                                           Conclusion

Vulval carcinoma are extremely uncommon disease in reproductive age group. Management of pregnancy after vulvectomy is complicated, as results of paucity of available information, vulval scarring following radical surgery and psychological support of the women.

A conservative approach in managing vulval cancer might be a future challenge. These cases will get greater benefit by MDT approach consisting of obstetrics, anaesthetist and psychology team in providing optimum care during pregnancy.

 

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