Vulvar cancer surgery: Difference between revisions

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Latest revision as of 23:34, 5 May 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Monalisa Dmello, M.B,B.S., M.D. [2] Syed Musadiq Ali M.B.B.S.[3]

Overview

The feasibility of surgery depends on the stage of vulvar cancer at diagnosis.

Surgery

Vulvar intraepithelial neoplasia (VIN)

Separate excision of focal lesions^[1]
Wide local excision
Superficial skinning vulvectomy with or without grafting

Stage I Vulvar Cancer

Wide excision (without lymph node dissection)^[2]

A wide (1 cm margin) excision (without lymph node dissection) for microinvasive lesions (<1 mm invasion) with no associated severe vulvar dystrophy. For all other stage I lesions, if well lateralized, without diffuse severe dystrophy, and with clinically negative nodes, a radical local excision with complete unilateral lymphadenectomy. Candidates for this procedure should have lesions 2 cm or smaller in diameter with 5 mm or less invasion, no capillary lymphatic space invasion, and clinically uninvolved nodes.

Radical local excision with ipsilateral or bilateral inguinal and femoral node dissection

In tumor clinically confined to the vulva or perineum, radical local excision with a margin of at least 1 cm has generally replaced radical vulvectomy; separate incision has replaced en bloc inguinal node dissection, ipsilateral inguinal node dissection has replaced bilateral dissection for laterally localized tumors; and femoral lymph node dissection has been omitted in many cases.

Radical local excision and sentinel node dissection, reserving groin dissection for those with metastasis to the sentinel nodes.

Stage II Vulvar Cancer

Radical local excision with bilateral inguinal node and femoral node dissection with a resection margin of at least 1 cm.^[3]

Radical local excision with a margin of at least 1 cm has generally replaced radical vulvectomy, and separate incision has replaced en bloc inguinal node dissection. Large T2 tumors may require modified radical or radical vulvectomy. Adjuvant local radiation therapy may be indicated for surgical margins smaller than 8 mm, capillary-lymphatic space invasion, and thickness greater than 5 mm.

Radical excision and sentinel node dissection, reserving groin dissection for those with metastasis to the sentinel nodes.

Stage III Vulvar Cancer

Modified radical or radical vulvectomy with inguinal and femoral node dissection. Radiation therapy to the pelvis and groin is given if inguinal nodes are positive.^[4]

Stage IV Vulvar Cancer

Stage IVA^[5]

Radical vulvectomy and pelvic exenteration. Surgery followed by radiation therapy for large resected lesions with narrow margins.

Stage IVB

There is no standard treatment approach in the management of metastatic vulvar cancer. Local therapy must be individualized depending on the extent of local and metastatic disease. There is no standard chemotherapy for metastatic disease, and reports describing the use of this modality are anecdotal.

References

↑ Stage 0 Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015
↑ Stage I Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_76 Accessed on September 25, 2015
↑ Stage II Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_83 Accessed on September 25, 2015
↑ Stage III Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015
↑ Stage IV Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_96 Accessed on September 25, 2015

[xyz-1] Stage 0 Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015

[xxx-2] Stage I Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_76 Accessed on September 25, 2015

[zzz-3] Stage II Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_83 Accessed on September 25, 2015

[yyy-4] Stage III Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015

[abc-5] Stage IV Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_96 Accessed on September 25, 2015

[1]

[2]

[3]

[4]

[5]

@@ Line 1: / Line 1: @@
-{{CMG}}
+{{CMG}}{{AE}}{{MD}}{{sali}}
 {{Vulvar cancer}}
+__NOTOC__
 ==Overview==
-[[Surgery]] is a mainstay of therapy and usually accomplished by use of a [[radical vulvectomy]], removal of vulvar tissue as well as the removal of lymph nodes from the inguinal and femoral areas. Complications of such surgery include wound infection, sexual dysfunction, edema and thrombosis. Surgery is significantly more extensive when vulvar cancer has spread to adjacent organs such as urethra, vagina, and rectum. In cases of early vulvar carcinoma the surgery may be less radical and disfiguring and consist of wide excision or a simple vulvectomy.
+The feasibility of surgery depends on the stage of vulvar cancer at [[diagnosis]].
+==Surgery==
+====Vulvar intraepithelial neoplasia (VIN)====
+:* Separate excision of focal lesions<ref name="xyz">Stage 0 Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015</ref>
+:* Wide local excision
+:* Superficial skinning vulvectomy with or without grafting
+===Stage I Vulvar Cancer===
+:* Wide excision (without lymph node dissection)<ref name="xxx">Stage I Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_76 Accessed on September 25, 2015</ref>
+::: A wide (1 cm margin) excision (without lymph node dissection) for microinvasive lesions (<1 mm invasion) with no associated severe vulvar [[dystrophy]].  For all other stage I lesions, if well lateralized, without diffuse severe [[dystrophy]], and with clinically negative nodes, a radical local excision with complete unilateral lymphadenectomy. Candidates for this procedure should have lesions 2 cm or smaller in diameter with 5 mm or less invasion, no capillary lymphatic space invasion, and clinically uninvolved nodes.
+:* Radical local excision with ipsilateral or bilateral inguinal and femoral node dissection
+::: In tumor clinically confined to the [[vulva]] or [[perineum]], radical local excision with a margin of at least 1 cm has generally replaced [[radical vulvectomy]]; separate incision has replaced en bloc [[inguinal]] node dissection, ipsilateral inguinal node dissection has replaced bilateral dissection for laterally localized tumors; and [[femoral]] lymph node dissection has been omitted in many cases.
+:* Radical local excision and sentinel node dissection, reserving groin dissection for those with metastasis to the sentinel nodes.
-Stage I Vulvar Cancer
+===Stage II Vulvar Cancer===
+:*Radical local excision  with bilateral [[inguinal]] node and [[femoral]] node dissection  with a resection margin of at least 1 cm.<ref name="zzz">Stage II Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_83 Accessed on September 25, 2015</ref>
-Standard treatment options:
+:::Radical local excision with a margin of at least 1 cm has generally replaced radical vulvectomy, and separate incision has replaced en bloc inguinal node dissection. Large T2 tumors may require modified radical or radical vulvectomy. Adjuvant local radiation therapy may be indicated for surgical margins smaller than 8 mm, capillary-lymphatic space invasion, and thickness greater than 5 mm.
+:* Radical excision and sentinel node dissection, reserving groin dissection for those with [[metastasis]] to the sentinel nodes.
-:1. A wide (1 cm margin) excision (without lymph node dissection) for microinvasive lesions (<1 mm invasion) with no associated severe vulvar dystrophy.  For all other stage I lesions, if well lateralized, without diffuse severe dystrophy, and with clinically negative nodes, a radical local excision with complete unilateral lymphadenectomy. Candidates for this procedure should have lesions 2 cm or smaller in diameter with 5 mm or less invasion, no capillary lymphatic space invasion, and clinically uninvolved nodes.
+===Stage III Vulvar Cancer===
-:2. Radical local excision with ipsilateral or bilateral inguinal and femoral node dissection. In tumor clinically confined to the vulva or perineum, radical local excision with a margin of at least 1 cm has generally replaced radical vulvectomy; separate incision has replaced en bloc inguinal node dissection, ipsilateral inguinal node dissection has replaced bilateral dissection for laterally localized tumors; and femoral lymph node dissection has been omitted in many cases.
+:* Modified radical or radical vulvectomy with inguinal and femoral node dissection. [[Radiation therapy]] to the [[pelvis]] and [[groin]] is given  if inguinal nodes are positive.<ref name="yyy">Stage III Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_70 Accessed on September 25, 2015</ref>
-:3. Radical local excision and sentinel node dissection, reserving groin dissection for those with metastasis to the sentinel node(s).
+===Stage IV Vulvar Cancer===
-Some investigators recommend radical excision and groin nodal radiation therapy as a means to avoid the morbidity of lymph node dissection.  However, it is not clear whether radiation therapy can achieve the same local control rates or survival rates as lymph node dissection in early-stage disease.  A randomized trial to address this issue in patients with clinically localized vulvar disease was stopped early as a result of  early emergence of worse outcomes in the radiation therapy arm. (:4. Radical radiation therapy for patients unable to tolerate surgery or deemed unsuitable for surgery because of site or extent of disease.
+:* Stage IVA<ref name="abc">Stage IV Vulvar Cancer. National Cancer Institute. http://www.cancer.gov/types/vulvar/hp/vulvar-treatment-pdq#section/_96 Accessed on September 25, 2015</ref>
+:::Radical vulvectomy and pelvic exenteration. Surgery followed by radiation therapy for large resected lesions with narrow margins.
+:* Stage IVB
+:::There is no standard treatment approach in the management of [[metastatic]] vulvar cancer. Local therapy must be individualized depending on the extent of local and metastatic disease.  There is no standard chemotherapy for metastatic disease, and reports describing the use of this modality are anecdotal.
 ==References==
 {{Reflist|2}}
 [[Category:Types of cancer]]
+[[Category:Gynecology]]
+ [[Category:Up-To-Date]]
+[[Category:Oncology]]
+[[Category:Medicine]]
 [[Category:Gynecology]]