Management of vulvar cancers

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Abstract

Aim

The radical surgical approach in the treatment of vulvar cancer patients has led to a favorable prognosis for the majority of the patients with early stage squamous cell cancer. However, the morbidity is impressive, leading to more individualized treatment. The aim of this review is to give an overview of the management of vulvar cancer.

Methods

We have reviewed the literature on the modifications in treatment of vulvar cancer with the emphasis on surgery and radiotherapy for primary disease.

Results

While surgery is the cornerstone of treatment for early stage squamous cell vulvar cancer (with wide local excision and uni- or bilateral inguinofemoral lymphadenectomy via separate incisions as standard treatment), until now there has been a limited role for primary radiotherapy although this may be an attractive alternative for the inguinofemoral lymphadenectomy in the future. The sentinel lymph node procedure with the combined technique (preoperative lymphoscintigraphy with 99mtechnetium-labeled nanocolloid and Patente Blue) is a promising staging technique for patients with vulvar cancer. The clinical implementation of the sentinel lymph node procedure and the role of additional histopathological techniques of the sentinel lymph nodes have to be investigated. In advanced vulvar cancer, chemoradiation followed by surgery should be regarded as the treatment of first choice for these patients.

Conclusions

Due to the rarity of vulvar cancer it is quite clear that further studies will have to be performed by international collaborative groups. The sentinel lymph node procedure and primary radiotherapy are promising methods to reduce morbidity of treatment, but their safety needs to be studied in clinical trials.

Introduction

Vulvar cancer affects the external female genitalia and represents approximately 4% of all gynecologic malignancies. Mean age at presentation is about 70 years. Squamous cell carcinomas (SCC) account for 80% of cases, whereas melanomas, adenocarcinomas, basal cell carcinomas, and sarcomas are much less common.1

Squamous cell carcinoma of the vulva may spread by three routes. Initial spread occurs usually to the inguinofemoral lymph nodes (see Fig. 1 for an overview of the lymphatics of the vulva). The number of inguinofemoral lymph node metastases is the most important prognostic factor. Hematogenous spread is rare in early stage disease, while spread by direct extension also is infrequent. Since 1988 the staging system for vulvar cancer has been based on surgery and histopathology. Table 1 shows the present staging system.2 The involvement of the inguinofemoral lymph node status in the staging system points to its importance for prognosis. Stage IA vulvar cancer with a depth of invasion ≤1 mm was added because of the negligible risk on lymph node metastases.3, 4

In this paper we will give an overview of the treatment of the different stages of SCC of the vulva with a special focus on the surgical aspects. Moreover, developments in the sentinel lymph node procedure in early-stage SCC of the vulva will be briefly discussed.

Section snippets

Treatment in early-stage vulvar cancer

Surgery is first choice in the treatment of patients with SCC of the vulva. In the second half of the last century overall survival figures rose from 20% to over 60% after introduction of radical vulvectomy with en bloc bilateral inguinofemoral and pelvic lymphadenectomy instead of simple local excision, which then became the standard of care for a prolonged period.5, 6 Also in early-stage disease, all patients underwent complete inguinofemoral lymphadenectomy, although only 20–30% of the

Treatment of advanced vulvar cancer

Those cases in which the typical radical surgical excision of the vulva will not be sufficient to remove the cancer with adequate margins are considered to be locally advanced. These cases may also be associated with extensive and unresectable inguinal (and pelvic) nodal disease. Overall, locally advanced disease comprises about 30% of the all vulvar cancer cases. Fig. 4 shows an example of advanced disease.

Ultraradical surgery has been performed in patients with clinically resectable vulvar

Conclusion

The majority of patients with vulvar cancer have an early-stage SCC of the vulva and should be treated with a wide local excision with uni- or bilateral inguinofemoral lymphadenectomy. In cases of absence of suspicious lymph nodes in the groin, the sentinel lymph node procedure is a promising staging technique, but its safety has not been proven yet. In cases of suspicious lymph nodes, radical vulvectomy with en bloc inguinofemoral lymphadenectomy should be performed. In advanced vulvar cancer,

References (63)

  • J.Y. Lin et al.

    Morbidity and recurrence with modifications of radical vulvectomy and groin dissection

    Gynecol Oncol

    (1992)
  • P.J. Paley et al.

    The effect of sartorius transposition on wound morbidity following inguinal-femoral lymphadenectomy

    Gynecol Oncol

    (1997)
  • R. Rouzier et al.

    Inguinofemoral dissection for carcinoma of the vulva: effect of modifications of extent and technique on morbidity and survival

    J Am Coll Surg

    (2003)
  • P.L. Judson et al.

    A prospective, randomized study analyzing sartorius transposition following inguinal-femoral lymphadenectomy

    Gynecol Oncol

    (2004)
  • M.J. Schulz et al.

    Recurrent vulvar carcinoma in the intervening tissue bridge in early invasive stage I disease treated by radical vulvectomy and bilateral groin dissection through separate incisions

    Gynecol Oncol

    (1989)
  • W. Christopherson et al.

    Radical vulvectomy and bilateral groin lymphadenectomy utilizing separate groin incisions: report of a case with recurrence in the intervening skin bridge

    Gynecol Oncol

    (1985)
  • M.P. Burger et al.

    The importance of the groin node status for the survival of T1 and T2 vulval carcinoma patients

    Gynecol Oncol

    (1995)
  • H.D. Homesley et al.

    Assessment of current International Federation of Gynecology and Obstetrics staging of vulvar carcinoma relative to prognostic factors for survival (a GOG study)

    Am J Obstet Gynecol

    (1991)
  • A. Sedlis et al.

    Positive groin lymph nodes in superficial squamous cell vulvar cancer

    Am J Obstet Gynecol

    (1987)
  • N. Gould et al.

    Predictors of complications after inguinal lymphadenectomy

    Gynecol Oncol

    (2001)
  • M. Manavi et al.

    Does. T1, N0-1 vulvar cancer treated by vulvectomy but not lymphadenectomy need inguinofemoral radiation?

    Int J Radiat Oncol Biol Phys

    (1997)
  • C.A. Perez et al.

    Irradiation in carcinoma of the vulva: factors affecting outcome

    Int J Radiat Oncol Biol Phys

    (1998)
  • F.B. Stehman et al.

    Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study

    Int J Radiat Oncol Biol Phys

    (1992)
  • A. Katz et al.

    The role of radiation therapy in preventing regional recurrences of invasive squamous cell carcinoma of the vulva

    Int J Radiat Oncol Biol Phys

    (2003)
  • D.K. Abang Mohammed et al.

    Inguinal node status by ultrasound in vulvar cancer

    Gynecol Oncol

    (2000)
  • D.E. Cohn et al.

    Prospective evaluation of positron emission tomography for the detection of groin node metastases from vulvar cancer

    Gynecol Oncol

    (2002)
  • S.A. Sohaib et al.

    Imaging in vulval cancer

    Best Pract Res Clin Obstet Gynaecol

    (2003)
  • G. Sliutz et al.

    Lymphatic mapping of sentinel nodes in early vulvar cancer

    Gynecol Oncol

    (2002)
  • R.G. Moore et al.

    Sentinel node identification and the ability to detect metastatic tumor to inguinal lymph nodes in vulvar malignancies

    Gynecol Oncol

    (2003)
  • L.M. Puig-Tintoré et al.

    Further data on the usefulness of sentinel lymph node identification and ultrastaging in vulvar squamous cell carcinoma

    Gynecol Oncol

    (2003)
  • I. Lataifeh et al.

    Patterns of recurrence and disease-free survival in advanced squamous cell carcinoma of the vulva

    Gynecol Oncol

    (2004)
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