M1: Distant metastasis (including pelvic lymph node metastasis) to the number of nodes involved, the morphology of the positive groin nodes is of prognostic significance. As demonstrated in several studies, significant negative predictors of survival are the size of the nodal metastasis, the proportion of the node replaced by tumor cells, and the presence of any extracapsular spread (62,70,75,76). Histologic grade, tumor thickness, depth of stromal invasion, and lymph–vascular space involvement contribute to the risk of lymph node involvement but are not independent predictors of survival (73).
Treatment After the pioneering work of Taussig and Way, en bloc radical vulvectomy and bilateral dissection of the groin and pelvic nodes were the standard treatment for most patients with operable vulvar cancer (6,7). When the disease involved the anus, rectovaginal septum, or proximal urethra, some type of pelvic exenteration was combined with the dissection.
Table 38.5 Five-Year Survival for Patients with Vulvar Carcinoma
FIGO, International Federation of Gynecology and Obstetrics. Modified from the FIGO Annual Report on the Results of Treatment in Gynecological Cancer using 1994 FIGO staging classification (31).
Although the survival rate improved markedly with this aggressive surgical approach, several factors led to modifications of this treatment plan. These factors are summarized as follows: 1.
An increasing proportion of patients present with early-stage disease—up to 50% of patients in many centers have tumors 2 cm in diameter or smaller.
2.
Concerns about the postoperative morbidity and associated long-term hospitalization common with the en bloc radical dissection.
3.
Increasing awareness of the psychosexual consequences of radical vulvectomy.
To individualize the patient’s care and determine the appropriate therapy, it is necessary to independently manage the primary lesion and groin lymph nodes. Before initiation of therapy, all patients should undergo colposcopy of the cervix, vagina, and vulva. Preinvasive (and rarely invasive) lesions may be present at other sites along the lower genital tract.
Management of the Primary Lesion
Microinvasive Vulvar Cancer (T1a) Tumors 2 cm or less in diameter with 1 mm or less invasion are appropriately treated with a wide local excision, which is as effective as radical surgery for the prevention of vulvar recurrences for these tumors (77). The excision should go sufficiently deep into the dermis that depth of invasion is fully assessed.
Early Vulvar Cancer (T1b) The modern approach to the management of patients with T1b carcinoma of the vulva should be individualized. There is no standard approach applicable to every patient, and emphasis is on performing the most conservative operation that is consistent with cure of the disease. Radical vulvectomy was considered the standard treatment for primary vulvar lesions, but this operation is associated with significant surgical morbidity and disturbances of sexual function and body image. Psychosexual sequelae are a major long-term morbidity associated with the treatment of vulvar cancer (37). One study reported that sexual arousal was reduced to the eighth percentile and body image was reduced to the fourth percentile for women who had undergone vulvectomy when compared with healthy adult women (66). Traditionally, the concern was that without an en bloc resection of vulva and groin nodes, intervening tissue left between the primary tumor and the regional lymph nodes contained
Table 38.6 Five-year Survival for Patients with Vulvar Squamous Cell Carcinoma by Number of Lymph Node Metastases
No. of Lymph Node Metastases No. of Patients 5-Year Survival (%)
FIGO, International Federation of Gynecology and Obstetrics. Modified from the FIGO Annual Report on the Results of Treatment in Gynecological Cancer (31).