Prognostic factors

The management of vulvar carcinoma is largely guided by the stage and the prognostic factors. While the most important prognostic factor is the presence and the number of inguinal node metastases, other factors include extra nodal tumor extension, tumor diameter, depth of invasion, tumor thickness, and lymphovascular space invasion. The margin status, tumor grade, and age of the patient8–10 are also of considerable significance in predicting the prognosis. The treatments offered in vulvar carcinoma also differ accordingly.

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The age of the patient merits particular emphasis, since according to the recent literature, between 1973 and 2000, the incidence of vulvar cancer has been found to be increasing (20%) in younger women.11 This change in pattern of incidence may be attributed partly to an increasing number of HPV infections in younger and sexually active women. Hence, less morbid and less radical surgeries are being considered for these young patients. Complete inguinofemoral node dissection leads to high rates of lymphedema (30%–70%) and wound dehiscence (20%–40%).12,13

Staging systems

Vulvar cancer has been classified using the TNM classification14 and the International Federation of Gynecology and Obstetrics (FIGO)15 staging systems by taking into account the size of the tumor (T), spread to lymph nodes (N), and spread to distant sites (M). The depth of invasion is generally defined from the epithelial–stromal junction of the most superficial adjacent dermal papilla to the deepest point of invasion of the tumor.16 The disease spreads initially to the inguinal and femoral nodes, which are considered as regional sites. The involvement of pelvic lymph nodes is considered as distant metastasis. As a part of the revision in the FIGO staging system, it has been recommended that not only the number of nodes with metastasis but also the size of metastasis and presence or absence of extranodal spread should be specified by the pathologist. The depth of invasion is defined as the measurement of the tumor from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

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Comparison of the staging systems

The FIGO staging system was last reviewed in 2009 by the FIGO Committee on Gynecologic Oncology in close collaboration with the American Joint Commission on Cancer and the Union of International Cancer Control.17 This resulted in an amalgamation of clinical, surgical, and pathological staging systems, and a new FIGO classification was proposed with the following 4 major changes:

  1. Vulvar carcinoma stages II (>2 cm) and IB (≤2 cm) were integrated because these 2 categories of patients did not show any differences in survival.18 Regardless of the diameter of the primary tumor, negative lymph node status was considered as low-risk criterion.19
  2. Stage III vulvar carcinoma represented a heterogeneous group of patients with both negative and positive lymph nodes. The former stage III patients with tumors involving the lower vagina and/or urethra with negative nodes are now classified as stage II,20 as they have a better prognosis.
  3. Patients with positive nodes are still classified as stage III. The number of the involved nodes along with the size of the metastasis and the presence or absence of extranodal growth has been taken into account in the new staging system. An increasing number of positive lymph nodes and a larger diameter of nodal metastases led to a worse survival rate. Stage III now consists of nodal metastases with extranodal spread. This category has an even worse prognosis compared with patients with metastases confined to the lymph nodes.21
  4. The laterality of positive nodes has been disregarded in the new FIGO staging because it is not an independent prognostic factor when a correction is made for a number of positive lymph nodes.22