Prognosis and Survival Survival of patients with vulvar cancer correlates with FIGO stage (69). The prognosis for patients with early-stage disease is generally good (Table 38.5). The single most important prognostic factor is lymph node status (54–56,59,70,71). A report from the Mayo Clinic on 330 patients with primary squamous cell carcinoma of the vulva demonstrated a significant correlation between lymph node status and risk of treatment failure, especially in the first 2 years following initial therapy: 44.2% overall recurrence rate with positive versus 17.5% with negative lymph nodes. More than one-third of relapses presented 5 years or more after initial therapy (72). There is a strong negative correlation between the number of positive lymph nodes and survival (Table 38.6). Patients with negative lymph nodes have a 5-year survival rate of over 80%; for patients with positive nodes 5-year survival falls below 50%. The number of positive nodes is of critical importance: Patients with one microscopically positive lymph node have a prognosis similar to those with all negative lymph nodes, whereas patients with three or more positive nodes have a poor prognosis and a 2-year survival rate of 20% (73). The survival rate for patients with positive pelvic nodes is about 11% (74). In addition
Table 38.4 FIGO Staging and TNM classification for Vulvar Cancer (2008)
FIGO, International Federation of Gynecology and Obstetrics; TNM, tumor node metastasis.
FIGO Committee on Gynecologic Oncology. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obstet 2009;105:103–104 (31). American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. Chicago, Illinois: Springer New York, Inc., 2010.
∗The depth of stromal invasion is measured from the epithelial–stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.
aTNM Classification:
T: Primary tumor N: Regional lymph nodes (femoral and inguinal nodes) Tx: Primary tumor cannot be assessed Nx: Regional lymph nodes cannot be assessed T0: No evidence of primary tumor N0: No regional lymph node metastases Tis: Carcinoma in situ (preinvasive carcinoma) N1: One or two regional lymph node metastases with the following T1a: Lesions ≤2 cm in size, confined to the vulva or perineum features: and with stromal invasion ≤1mm N1a: One or two lymph node metastases each <5mm T1b: Lesions >2 cm in size or any size with stromal invasion N1b: One lymph node metastasis ≥5mm >1 mm, confined to the vulva or perineum N2: Regional lymph node metastases with the following features
T2: Tumor of any size with extension to adjacent perineal N2a: ≥3 lymph node metastases, each <5 mm in diameter structures (lower 1/3 of urethra, lower of 1/3 vagina, anal N2b: ≥2 lymph node metastases ≥5mm involvement) N2c: Lymph node metastases with extracapsular spread
T3: Tumor of any size with extension to any of the following: N3: Fixed or ulcerated regional lymph node metastasis upper 2/3 of urethra, upper 2/3 of vagina, bladder mucosa, M: Distant metastasis rectal mucosa, or fixed to pelvic bone M0: No distant metastasis