Vulvar cancer surgery
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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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.
Surgery
Stage I Vulvar Cancer
- Wide excision (without lymph node dissection)
- 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 node(s).
Stage II Vulvar Cancer
- Radical local excision with bilateral inguinal node and femoral node dissection with a resection margin of at least 1 cm. 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 node(s).
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.
- Radical vulvectomy with inguinal and femoral node dissection followed by radiation therapy in patients with large primary lesions and narrow margins. Localized adjuvant radiation therapy consisting of 45 Gy to 50 Gy may also be indicated when there is capillary-lymphatic space invasion and a thickness of greater than 5 mm, particularly if the nodes are involved. Radiation therapy to the pelvis and groin is usually given if two or more groin nodes are involved.
Standard treatment options:
Radical vulvectomy and pelvic exenteration. Surgery followed by radiation therapy for large resected lesions with narrow margins. Localized adjuvant radiation therapy consisting of 45 Gy to 50 Gy may also be indicated when there is capillary-lymphatic space invasion and thickness greater than 5 mm.[1] Radiation therapy to the pelvis and groin is given if two or more groin nodes are involved.[2,3] Neoadjuvant radiation therapy or chemoradiation of large primary lesions to improve operability, followed by radical surgery.[4-10] For those patients unable to tolerate radical vulvectomy or who are deemed unsuitable for surgery because of site or extent of disease, radical radiation therapy may be associated with long-term survival.[11,12] When radiation therapy is used for primary definitive treatment of vulvar cancer, some physicians prefer to add concurrent 5-FU or 5-FU and cisplatin.[1,13-17]
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.[17] However, by largely extrapolating from regimens used for anal or cervical cancer, chemotherapy has been studied. Regimens have included various combinations of 5-fluorouracil, cisplatin, mitomycin-C, or bleomycin.[6,17,18] Given the advanced age and comorbidity of many patients with advanced or recurrent vulvar cancer, patient tolerance is a major consideration in the use of these agents. Physicians should offer eligible patients participation in clinical trials.
Information about ongoing clinical trials is available from the NCI website
Current