If clinically evident groin metastases, any extracapsular spread or two or more microscopically positive groin nodes are found, the patient is at increased risk of groin and pelvic recurrence and should receive postoperative groin and pelvic irradiation. In 1977, the GOG initiated a prospective trial in which patients with positive groin nodes were randomized to either ipsilateral pelvic node dissection or bilateral pelvic plus groin irradiation (60). The survival rate for the radiation group (68% at 2 years) was significantly better than the survival rate for the pelvic lymphadenectomy group (54% at 2 years) (p = 0.03). The survival advantage was limited to patients with clinically evident groin nodes or more than one microscopically positive groin node. Groin recurrence occurred in 3 of 59 patients (5%) treated with radiation, compared with 13 of 55 (23.6%) patients treated with lymphadenectomy (p = 0.02). Four patients who received radiation had a pelvic recurrence, compared with one who had lymphadenectomy. These data indicate no benefit from pelvic irradiation compared with pelvic lymphadenectomy for the prevention of pelvic recurrence, but they do highlight the value of groin irradiation in preventing groin recurrence in patients with multiple positive groin nodes.
Recurrent Vulvar Cancer Recurrence of vulvar cancer correlates closely with the number of positive groin nodes (57). Patients with fewer than three positive nodes, particularly if the nodes are only microscopically involved, have a low incidence of recurrence at any site, whereas patients with three or more positive nodes have a high incidence of local, regional, and systemic recurrences (57,60).
Most recurrences of vulvar cancer occur within the first 2 years from initial therapy, with groin recurrences occurring sooner (median time to recurrence 6 to 7 months) than vulvar recurrences (median time to recurrence 3 years) (72,145–147). About one-third of vulvar cancer relapses present 5 or more years after initial therapy (72). In a long-term follow-up study at the Mayo Clinic, nearly 1 in 10 patients with vulvar cancer had a late (longer than 5 years) reoccurrence of disease (72). Over 95% of those late relapses had local reoccurrences (same site recurrence or second primary vulvar site). Because of this propensity for late local reoccurrence, regular and long-term careful examinations of the vulva and groin constitute the cornerstone of posttreatment surveillance for these patients.
The published literature on the management and outcome of recurrent disease is limited. The timing and primary site of recurrence is critical to the prognosis postrecurrence. Although groin recurrences tend to occur early and are nearly always fatal, 5-year overall survival rates of 50% to 70% are reported for patients with surgically treated isolated vulvar recurrences and more than 60% of patients with local recurrence or reoccurrence were alive at 20 years in the Mayo Clinic long-term follow-up study (72,147,148).
Local Recurrence Margin status at the time of radical resection of the vulvar cancer is the most powerful predictor of local vulvar recurrence, with an almost 50% recurrence risk with margins closer than 0.8 cm (84). Margin status does not predict survival (71). Local vulvar recurrences are likely in patients with primary lesions larger than 4 cm in diameter, especially if lymph–vascular space invasion is present, and in patients with deeply invasive tumors (141,149,150). When detected early, isolated local failure is usually treatable by additional surgical therapy, often with a myocutaneous graft to cover the defect (34,41,49,78,151). Radiation therapy, particularly a combination of external beam therapy plus interstitial needles, at times combined with chemotherapy, is used to treat vulvar recurrences (152).