Markman M, Glass T, Smith HO, et al. Phase II trial of single agent carboplatin followed by dose-intense paclitaxel, followed by maintenance paclitaxel therapy in stage IV ovarian, fallopian tube, and peritoneal cancers: a Southwest Oncology Group trial. Gynecol Oncol 2003;88:282–288.
495.
Rose PG, Rodriguez M, Walker J, et al. A phase I trial of prolonged oral etoposide and liposomal doxorubicin in ovarian, peritoneal, and tubal carcinoma: a Gynecologic Oncology Group Study. Gynecol Oncol 2002;85:136–139.
Christine H. Holschneider Jonathan S. Berek
Vulvar lesions require biopsy to avoid delay in diagnosis.
The modern approach to patients with vulvar cancer is multidisciplinary and individualized.
Management of the primary lesion and groin nodes is determined separately.
Most T1,T2, and early T3 lesions can be managed with radical local excision.
Large T3 and T4 primary tumors are best treated with chemoradiation followed by more limited surgical resection.
When groin dissection is indicated, it should be a thorough inguinofemoral lymphadenectomy.
The potential role of the sentinel lymph node procedure to eliminate the need of a complete inguinofemoral lymphadenectomy is being investigated.
The single most important prognostic factor is lymph node status: 5-year survival without groin node metastases is greater than 90%; with groin node metastases 5-year survival is 50%.
Postoperative radiation decreases the risk of groin recurrence in patients with multiple positive inguinofemoral lymph nodes.
Recurrence in the groin is almost universally fatal.
With 4,340 new cases and 940 deaths annually in the United States, vulvar cancer is uncommon, representing about 4% of malignancies of the female genital tract and 0.6% of all cancers in women (1,2). Squamous cell carcinomas account for about 90% of all primary vulvar malignancies, whereas melanomas, adenocarcinomas, basal cell carcinomas, and sarcomas are less common. The incidence of in situ vulvar cancer is increasing worldwide, primarily because of the increasing occurrence in young women, who account for 75% of the cases. The overall rate of invasive vulvar carcinoma is increasing, but at a much lower rate (3,4). In women younger than 50 years, there is a striking increase in the incidence of in situ and invasive squamous cell carcinoma of the vulva (5).
Following the reports of Taussig in the United States and Way in Great Britain, radical vulvectomy and en bloc groin dissection, with or without pelvic lymphadenectomy, was standard treatment for all patients with operable disease (6,7). Postoperative morbidity was high and prolonged hospitalization common. During the past 25 years, there were significant advances in the management of vulvar cancer, reﬂecting a paradigm shift toward a more conservative surgical approach without compromised survival and with markedly decreased physical and psychological morbidity: 1.
Individualization of treatment for all patients with invasive disease.
2.
Vulvar conservation for patients with unifocal tumors and an otherwise normal vulva.
3.
Omission of the groin dissection for patients with microinvasive tumors (T1a, ≤2 cm diameter and ≤1 mm of stromal invasion).
4.
Elimination of routine pelvic lymphadenectomy.
5.
Investigation of the role of the sentinel lymph node procedure to eliminate requirement for complete inguinofemoral lymphadenectomy.
6.
The use of separate incisions for the groin dissection to improve wound healing.
7.
Omission of the contralateral groin dissection in patients with lateral T1 lesions and negative ipsilateral nodes.