MANAGEMENT OF VULVAR CARCINOMA
The management of early-stage vulvar carcinoma is predominantly surgery. The extent of the surgery, lymph node dissection, and groin evaluation along with margins are important issues that need individualization in approach.
Until the 1990s, all patients with vulvar cancer underwent en bloc radical vulvectomy and bilateral inguinofemoral lymphadenectomy through a butterfly incision. The aim was to remove all possible tissues, including the skin bridge between vulva and groins. This procedure was associated with high rates of survival, but it was associated with significant morbidity, such as poor wound healing, lymphedema, and adverse effects on body image and sexual function.23,24
In 1962, Byron et al,25 for the first time, introduced surgery through 3 separate groin and vulval incisions in place of the butterfly incision. This was called as the triple incision technique and was less extensive than the older butterfly technique. Studies by Ansink and van der Velden and by Heaps et al confirmed that this surgical technique produced similar overall results with reduced morbidities and skin bridge recurrences.26,27,28 But inspite of the better surgical technique, there was a growing interest in less radical surgeries to avoid the morbidities and improve the quality of life. In 1994, Burke et al and Farias-Eisner et al established that wide local excision (WLE) in place of total vulvectomy in early-stage vulvar cancer produced equal results without compromising the oncological safety.29,30There were 5 studies that compared radical or WLE to radical vulvectomy. None of these studies showed any difference in overall survival, disease free survival, or in local and distant recurrences (Table 1).
(To view a larger version of Table 1, click here.)
Lesions that are <2 cm in diameter and confined to the vulva, with stromal invasion ≤1.0 mm (FIGO stage IA) and with no lymphatic space invasion, are managed by WLE only with a tumor-free margin all-around of at least 1 cm. With close midline structures such as clitoris, urethra, or the anus, less wide margins may be considered.
The issue of margin status has also been a subject of controversies. While several studies31 had, in the past, demonstrated that a margin distance of <8 mm may cause higher risk of recurrence, more recent studies by Woelber et al show minimum importance of the tumor-free margin.32,33
However, a consensus prevails regarding groin node dissection, which may be avoided in these early stages, because the risk of lymph node metastases is negligible in this group.34 Ipsilateral inguinofemoral dissection should be included if the depth of invasion turns out to be >1 mm in the final pathology report.
When the depth of invasion is >1 mm (FIGO stage IB or more) or the maximum diameter of the tumor is >2 cm, dissection of the groin nodes should be mandatory. This is because the risk of lymph node metastasis rises beyond 1 mm invasion depth,7%–8% for 1.1–3.0 mm invasion, and 26%–34% for >3 mm invasion.35
In more advanced cases, local recurrence in the groin carries a very high mortality. Hence, appropriate groin management is of utmost importance. In case of enlarged groin nodes, either inguinofemoral lymphadenectomy followed by radiotherapy or groin node debulking followed by radiotherapy can be considered. Bilateral groin dissection is recommended for midline tumors and large lateral tumors, especially those involving the anterior labia minora. Bilateral groin dissection is also indicated if ipsilateral lymph nodes are positive.36
When imaging shows enlarged pelvic nodes, debulking of these nodes is recommended. For clinically positive lymph nodes, it has been suggested not to proceed with full lymphadenectomy, since the inguinal dissection with postoperative irradiation has the potential to cause severe lymphedema. In these cases, wherever possible, only the largest lymph nodes may be surgically removed before the patient is subjected to postoperative radiotherapy.37