Management of vulvar cancers
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)
Cancer of the vulva: an analysis of 155 cases
Am J Obstet Gynecol
(1940)Carcinoma of the vulva
Am J Obstet Gynecol
(1960)- et al.
Positive lymph nodes in vulvar squamous carcinoma
Gynecol Oncol
(1980) - et al.
Groin surgery and the sentinel lymph node
Best Pract Res Clin Obstet Gynaecol
(2003) - et al.
In situ and invasive vulvar cancer incidence trends (1973 to 1987)
Am J Obstet Gynecol
(1992) - et al.
Surgical therapy of T1 and T2 vulvar carcinoma: further experience with radical wide excision and selective inguinal lymphadenectomy
Gynecol Oncol
(1995) - et al.
Conservative and individualized surgery for early squamous carcinoma of the vulva: the treatment of choice for stage I and II (T1–2N0–1M0) disease
Gynecol Oncol
(1994) - et al.
Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva
Gynecol Oncol
(1990) - et al.
Lymph drainage from the vulva
Gynecol Oncol
(1983) - et al.
Contralateral groin node metastastasis following ipsilateral groin node dissection in vulval cancer: a case report
Gynecol Oncol
(2003)