microscopic tumor foci in draining lymphatics. Experience with a separate incision technique for node dissection confirmed that metastases rarely occur in the skin bridge in patients without clinically suspicious nodes in the groin (78).
During the past 20 years, several investigators advocated a radical local excision rather than a radical vulvectomy for the primary lesion for patients with T1b tumors (37,49,79,80). Regardless of whether a radical vulvectomy or a radical local excision is performed, the surgical margins adjacent to the tumor are the same. An analysis of the literature indicates that the incidence of local invasive recurrence after radical local excision or radical hemivulvectomy is not higher than that after radical vulvectomy (36,49,74,81–83). This finding suggests that in the presence of an otherwise normal-appearing vulva, radical local excision is a safe surgical option, regardless of the size of the tumor or the depth of invasion. Based on cumulative data of 413 patients reported in four studies, an 8 mm or greater histopathological resection margin results in a high rate of local disease control (81,84–86). Of the 252 patients whose tumors were resected with margins of 8 mm or greater, 2.4% experienced a local recurrence, compared to 30.3% of the 161 patients whose margins were less than 8 mm. Neither clinical tumor size nor the presence of coexisting benign vulvar pathology correlated with local recurrence. It is important to bear in mind that paraffin-embedded tissue shrinks by about 25%. At the time of radical local excision, at least a 1-cm grossly negative margin, without putting the skin under tension, should be obtained and extended down to the level of the inferior fascia of the urogenital diaphragm.
When vulvar cancer arises in the presence of VIN, vulvar dystrophy, or some nonneoplastic epithelial disorder, treatment is inﬂuenced by the patient’s age. Elderly patients who often had many years of chronic itching may not be disturbed by the prospect of a vulvectomy. In younger women, it is desirable to conserve as much of the vulva as possible. Radical local excision should be performed for the invasive disease, and the associated intraepithelial disease should be treated in the manner most appropriate to the patient. For example, topical steroids may be required for lichen sclerosus or squamous hyperplasia, whereas VIN may require superficial local excision with primary closure or laser ablation.
Radical local excision is most appropriate for lesions on the lateral or posterior aspects of the vulva (Fig. 38.4). Midline lesions pose special challenges because of their proximity to clitoris, urethra, or anus. For anterior lesions, conservative clitoris-sparing surgery allows for excellent local control as long as pathological margins are at least 8 mm (87). For tumors that involve the clitoris or that are in close proximity to it, any type of surgical excision will have psychosexual consequences. In addition, marked edema of the posterior vulva may occur. For young patients with periclitoral lesions, the primary lesion can be treated with a small field of radiation therapy, possibly with concomitant sensitizing chemotherapy. Small vulvar lesions should respond very well to about 5,000 cGy external radiation, and biopsy can be performed after therapy to confirm the absence of any residual disease (61).
Early T2 Vulvar Cancer The indications for vulvar conservation can be extended to selected patients with early T2 tumors. The tumor-free margin should be the same, whether or not a radical vulvectomy or a radical local excision is performed. It seems both feasible and desirable to extend the indications for vulvar conservation, particularly for younger patients. Tumors that are suitable for a conservative resection are those involving the posterior vulva and lower vagina, where preservation of the anus, clitoris, and urethra is feasible.