As experience with this combination therapy evolved, it appeared that external beam therapy is appropriate for most cases, with more selective use of brachytherapy. The extensiveness of the surgery is significantly modified. A limited vulvar resection is advocated, and bulky N2 and N3 nodes are resected without full groin lymphadenectomy to avoid the leg edema associated with groin lymphadenectomy and radiation. With this combined radiation-surgical approach, 5-year survival rates as high as 76% are reported (110). With the experience accrued, preoperative radiation, with or without concurrent chemotherapy, is regarded as the first treatment of choice for patients with advanced vulvar cancer who would otherwise require some type of pelvic exenteration or stoma. Neoadjuvant therapy is not justified in patients with tumors that can be adequately treated with primary radical vulvectomy and bilateral groin node dissection.
Management of the Lymph Nodes
Appropriate groin dissection is the single most important factor in decreasing the mortality from early vulvar cancer.
When assessing a patient for groin dissection, the following facts should to be kept in mind: 1.
The only patients with virtually no risk of lymph node metastases are those whose tumor is small and invades the stroma to 1 mm or less (T1a).
2.
Patients who develop recurrent disease in an undissected groin have a greater than 90% mortality (113).
3.
Based on the laterality of the vulvar lesions and the status of the ipsilateral groin, an ipsilateral or bilateral lymphadenectomy becomes necessary.
Groin dissection is associated with postoperative wound infection and breakdown. Although the incidence of wound breakdown is reduced significantly when separate incisions are used for the groin dissection, lymphocyst formation and chronic leg edema remain a major problem (Fig. 38.5) (78).
All patients whose tumors demonstrate more than 1 mm of stromal invasion or whose tumors are larger than 2 cm (T1b and above) require inguinal-femoral lymphadenectomy.
If there is any question regarding the need for inguinofemoral lymphadenectomy, a Keys biopsy or wedge biopsy of the primary tumor should be obtained, and the depth of invasion should be determined. If it is smaller than 1 mm on the wedge biopsy specimen, the entire lesion should be locally excised and analyzed histologically to determine the depth of invasion. If the lesion is 2 cm in diameter or smaller and there is no invasive focus larger than 1 mm, groin dissection may be omitted, provided there is no lymph–vascular space invasion and there are no clinically suspicious groin lymph nodes. An occasional patient with less than 1 mm of stromal invasion has documented groin node metastases, but the incidence is so low that it is of no practical significance (114,115).
Inguinal-Femoral Lymphadenectomy If groin dissection is indicated in patients with vulvar cancer, it should be a thorough inguinal-femoral lymphadenectomy. The GOG reported six groin recurrences among 121 patients with tumors 2 cm or less after a superficial (inguinal) dissection, although the removed inguinal nodes were negative, and a study from the M. D. Anderson Cancer Center reported a 9% groin recurrence rate in 104 patients with vulvar cancer and negative nodes on superficial inguinal lymphadenectomy (41,42). Whether all of these recurrences were in the femoral nodes is unclear, but both studies indicate that an incomplete groin dissection will increase the number of groin recurrences and mortality. GOG data indicate that radiation therapy cannot substitute for groin dissection followed by selective radiation as indicated, even in patients with clinically nonsuspicious lymph nodes (116). This GOG study was closed early because a significantly higher incidence of recurrences occurred in women who were receiving groin radiation therapy only (19% versus 0%). The dose of radiation was 5,000