Four‐Specialty Surgical Management of Locally Advanced Inguinal Squamous Cell Carcinoma With Vascular Invasion: A Case Report

ABSTRACT

Locally advanced groin squamous cell carcinoma with vascular invasion is challenging. After immunotherapy failure, a multidisciplinary limb‐sparing surgery combining tumor resection, vascular reconstruction, and flap coverage achieved complete healing and no recurrence at 36 months, highlighting the role of coordinated surgical management in complex oncologic cases.

Key Clinical Message

Multidisciplinary surgical management can enable limb‐sparing treatment for locally advanced squamous cell carcinoma of the groin with vascular invasion, even after immunotherapy failure, achieving favorable oncologic and functional outcomes through coordinated resection, vascular reconstruction, and complex soft‐tissue coverage.

1. Introduction

Locally advanced squamous cell carcinoma (SCC) of the groin and proximal thigh remains a therapeutic challenge due to its potential invasion of major vascular structures and the complexity of reconstruction following wide excision. Although surgery remains the cornerstone of treatment, extensive resections are often considered unfeasible due to anticipated morbidity.

In this context, multidisciplinary surgical approaches may enable limb‐sparing strategies and improve both oncologic and functional outcomes. However, such complex procedures are rarely reported in the literature.

We present a case of locally advanced SCC requiring coordinated management across four surgical specialties, illustrating the feasibility and benefits of an aggressive multidisciplinary approach after immunotherapy failure.

2. Case History/Examination

A 60‐year‐old woman with no significant past medical history and no history of tobacco use presented with a progressively enlarging mass of the right proximal medial thigh evolving over approximately 1 year.

Magnetic resonance imaging (MRI) revealed a multilobulated mass measuring up to 41 mm in height, located adjacent to the femoral neurovascular bundle, with signs of progressive enlargement and perilesional infiltration. A biopsy performed after multidisciplinary sarcoma board discussion confirmed a well‐differentiated invasive squamous cell carcinoma. Staging investigations, including PET‐CT, demonstrated a locally advanced lesion with suspected external iliac lymph node involvement but no distant metastases (T4N+M0, stage IV according to American Joint Committee on Cancer (AJCC) 8th edition) [1].

3. Differential Diagnosis, Investigations and Treatment

Neoadjuvant immunotherapy with nivolumab was initiated off‐label following multidisciplinary discussion. This choice was guided not only by the locally advanced and initially unresectable nature of the squamous cell carcinoma, but also by the presence of concomitant suspicious lesions, including a Breast Imaging Reporting and Data System (BI‐RADS) 4 breast nodule and a thyroid nodule, raising concerns about potential synchronous malignancies. In this context, a PD‐1 inhibitor with broader oncologic indications was preferred (nivolumab, 480 mg intravenously every 4 weeks).

After five cycles, the tumor showed clear progressive enlargement documented on serial imaging, up to 87 mm (Figure 1), with cutaneous fistulization and radiological evidence of circumferential involvement of the femoral vessels, as well as metabolically active iliac lymphadenopathy (Figure 2). Following multidisciplinary tumor board reassessment, a limb‐sparing surgical strategy was proposed, combining oncologic resection, lymph node dissection, vascular reconstruction, and soft tissue coverage.

FIGURE 1.

Right thigh squamous cell carcinoma after five cycles of anti‐PD‐1 therapy.

FIGURE 2.

MRI (T1 Fat Sat + Gadolinium) showing muscle and femoral vessel infiltration after anti‐PD1 therapy.

Surgery was performed under general anesthesia with a coordinated four‐team approach. First, an en bloc oncologic resection was carried out by orthopedic oncologic surgeons with 15‐mm macroscopic margins. The procedure required resection of the femoral artery and vein, as well as adjacent muscular structures, including the Sartorius, Gracilis, part of the Adductor Longus, and the Tensor Fascia Lata. The femoral nerve was preserved after careful neurolysis, with more than 75% of its volume maintained.

Second, a right iliac lymph node dissection was performed through a retroperitoneal approach, including external, internal, and common iliac nodal basins. Several enlarged pathological nodes were identified, particularly in the external iliac region.

Third, vascular reconstruction was performed with a femoral–femoral end‐to‐end bypass using a vascular allograft. After graft preparation, termino‐terminal anastomoses were performed, with satisfactory restoration of arterial flow and no immediate leakage (Figure 3).

FIGURE 3.

Vascular reconstruction with allograft femoral–femoral bypass.

Finally, soft‐tissue reconstruction was performed using a pedicled rectus abdominis musculocutaneous flap (Taylor flap) harvested from the contralateral side and based on the deep inferior epigastric vessels. The flap was tunneled subcutaneously to cover the defect and fill the dead space. Drains were placed, and the donor and recipient sites were closed in multiple layers. The total operative time was approximately 6 h. Blood loss was estimated at 450 mL, and the total length of hospitalization was 14 days (Figure 4).

FIGURE 4.

Immediate postoperative results of the Taylor flap.

4. Conclusion and Results (Outcome and Follow‐Up)

Histopathological examination revealed a well‐differentiated keratinizing invasive squamous cell carcinoma measuring 12 cm in greatest dimension, infiltrating the dermis, hypodermis, subcutaneous tissue, and muscle. Surgical margins were negative (R0), with a minimum deep margin of 2 mm and a minimum lateral margin of 7 mm. No lymphovascular or perineural invasion was identified. Among 18 lymph nodes examined, one metastatic lymph node (1.3 cm) without extracapsular extension was found (T4N1M0) or a stage IV classification.

The early postoperative course was notable for recurrent seromas requiring repeated aspiration, but no major complications occurred. Complete wound healing was achieved within 1 month. Adjuvant radiotherapy (60 Gy to the tumor bed and 54 Gy to regional lymph nodes) was initiated after complete wound healing (4 weeks) at a rate of five sessions per week for a total of 7 weeks.

At 36 months follow‐up, the patient remained free of local or distant recurrence. The functional outcome was satisfactory, with preserved ambulation. The Musculoskeletal Tumor Society (MSTS) score was estimated at 26/30 (87%), indicating good functional recovery. The Lower Extremity Functional Scale (LEFS) score was 65/80, reflecting mild residual functional limitation. The patient remained independent with an ECOG performance status of 1.

Vascular follow‐up using arterial Doppler demonstrated a stable moderate (40%–50%) stenosis of the reconstructed femoral axis without clinical impact. A secondary lower limb lymphedema developed postoperatively, consistent with International Society of Lymphology stage II, a common sequela after lymph node dissection and radiotherapy. It was managed conservatively with compression and physical therapy. Oncological follow‐up is conducted every 6 months for 3 years, then once a year.

We report a complex surgery of a locally advanced tumor with invasion of the femoral vessels (vascular surgery reconstruction), massive resection (orthopedic‐oncologist surgery), iliac lymph node removal (urologists), and soft tissue reconstruction (plastic surgeons). It also extends, to a different anatomic site, the multimodal logic recently formalized for advanced cutaneous SCC of the scalp [2, 3]: surgical resectability should be reassessed iteratively as systemic and radiation therapies modify tumor burden, rather than judged once and for all at presentation. We emphasized the medico‐surgical collaboration among six specialties, including four surgical specialties (plastic, orthopedic, vascular, and urology) and two medical specialties (dermatology and radiology). This case supports that vascular invasion should not be considered an absolute contraindication to limb‐sparing surgery. It is crucial to define and justify the criteria for non‐operability in a multidisciplinary consultation qualified to manage cutaneous cancers, in accredited hospitals with the appropriate technical facilities.

5. Discussion

This case highlights the complexity of managing locally advanced squamous cell carcinoma (SCC) involving the groin and proximal thigh, particularly when critical vascular structures are invaded. Such situations are uncommon and represent a major therapeutic challenge, often leading to consideration of non‐surgical management or radical procedures such as amputation [4].

The main difficulty in this case was the combination of tumor progression despite immunotherapy and direct invasion of the femoral vessels, traditionally considered a limiting factor for limb‐sparing surgery. Although immune checkpoint inhibitors have shown promising results in advanced cutaneous SCC, primary or secondary resistance remains a significant clinical issue, necessitating alternative strategies [5].

This pattern has been increasingly reported in the broader cutaneous SCC literature, where combined or sequential multimodal regimens (integrating surgery, radiotherapy and immune checkpoint inhibitors) have emerged as a strategy to overcome resistance to single‐modality treatment. Trignano et al. described a giant parietomastoid scalp SCC with calvarial invasion in which an initially incomplete oncologic resection, followed sequentially by cemiplimab and then by concurrent cemiplimab‐radiotherapy, ultimately allowed curative‐intent re‐excision with complete remission maintained at 2 years [2]. Similarly, Rodio et al., in a 7‐year series of 243 scalp cSCCs, formalized a multidisciplinary algorithm in which cemiplimab is incorporated as a rescue, neoadjuvant, or palliative option when curative surgery or radiotherapy alone are not feasible, often in synergy with radiotherapy [3]. Although both reports focus on the scalp, the underlying principle that immunotherapy failure does not preclude curative multimodal management, and that the sequence of modalities should be tailored rather than schematic, is directly applicable to other anatomic sites including the groin.

In this context, the decision to proceed with surgery was based on multidisciplinary evaluation, balancing oncologic control against functional preservation. The coordinated involvement of multiple surgical specialties allowed a structured approach, ensuring complete tumor resection while maintaining limb viability.

Vascular invasion is often considered a contraindication to conservative surgery due to the technical challenges and potential morbidity associated with vascular reconstruction. However, previous studies in oncologic surgery have demonstrated that en bloc resection combined with vascular reconstruction can achieve acceptable oncologic and functional outcomes in selected patients [6, 7, 8].

Reconstruction of the large soft tissue defect represented another major challenge. Local or regional flaps were not feasible due to the extent of resection and the need for vascular sacrifice. Free flap reconstruction could have been considered but would have required microsurgical anastomoses in a compromised vascular environment. The use of a pedicled rectus abdominis musculocutaneous flap (Taylor flap) provided a reliable and well‐vascularized option, allowing both coverage of the defect and obliteration of dead space [9, 10]. A contralateral rectus abdominis pedicled flap could have been suggested, but the pivot point of the flap would be too far away, with poor spatial conformation of the flap to reach the loss of substance. An anterolateral pedicled thigh flap, rectus femoris, or vastus lateralis local flap would not be possible due to vascular resection. The sartorius muscle flap would be insufficient, as it would not be thick enough to fill the loss of substance. A free flap, such as a latissimus dorsi flap or a contralateral anterolateral thigh flap, would be possible but would require microsurgical anastomoses, which are at higher risk of failure due to postoperative radiation therapy.

The choice of vascular reconstruction was a key aspect of the surgical strategy. The use of a prosthetic graft was considered inappropriate in this setting due to the planned adjuvant radiotherapy, which is associated with an increased risk of delayed wound healing, graft infection, and potential long‐term complications such as pseudoaneurysm formation.

Autologous reconstruction using the ipsilateral saphenous vein was not feasible because of the involvement and alteration of the local venous network. The use of the contralateral saphenous vein could have been considered; however, this option was limited by concerns regarding vessel caliber adequacy and the potential morbidity associated with an additional surgical site.

In this context, the use of a vascular allograft represented a suitable alternative, allowing restoration of arterial continuity while minimizing infectious risk and avoiding additional donor‐site morbidity.

Alternative strategies, including high‐level amputation, would likely have resulted in significant functional impairment and reduced quality of life. In contrast, the limb‐sparing approach achieved both durable oncologic control and satisfactory functional outcome, as demonstrated by the absence of recurrence at 36 months and preserved ambulation.

From an oncologic perspective, complete resection with negative margins and limited nodal involvement without extracapsular extension are favorable prognostic factors [11]. The absence of lymphovascular and perineural invasion further supports the good outcome observed in this patient.

This case underscores the importance of multidisciplinary decision‐making in the management of complex oncologic cases. Structured algorithms developed for high‐risk and locally advanced cutaneous SCC, such as the one proposed by Rodio et al. [3] for scalp lesions, emphasize that the choice between curative surgery, radiotherapy, systemic therapy, and combined approaches should be guided by a dedicated tumor board, with formal risk stratification, reconstruction tailored to defect depth and patient status, and a defined fallback pathway when first‐line treatment fails. Although that algorithm was developed for the scalp, its hierarchical reasoning (curative surgery whenever feasible, systemic therapy and/or radiotherapy as rescue or adjuvant, and reconsideration of resectability after downstaging) proved directly transposable to the present groin case. It also challenges the traditional paradigm that vascular invasion precludes limb‐sparing surgery.

Author Contributions

Ugo Lancien: conceptualization, methodology, writing – original draft. Julien Verdier: conceptualization, methodology, writing – review and editing. Ismaël Chelghaf: writing – review and editing. François Lataste: conceptualization, validation. Pierre Perrot: supervision, writing – review and editing. Louis‐Marie Grout de Beaufort: writing – review and editing.

Funding

The authors have nothing to report.

Disclosure

Use of generative AI: Not applicable.

Ethics Statement

The authors have nothing to report.

Consent

The authors have obtained written informed consent from the patient(s).

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.