Figure 38.5 Skin incision for groin dissection through a separate incision. A line is drawn 1 cm above and parallel to the groin crease, and a narrow ellipse of skin is removed. (Revised from Berek JS, Hacker NF. Practical Gynecologic Oncology. 2nd ed. Baltimore, MD: Williams & Wilkins, 1994:418, with permission.) cGy given in daily 200-cGy fractions to a depth of 3 cm below the anterior skin surface. Although the radiation regimen prescribed was criticized extensively, other uncontrolled studies give no evidence for better groin control with radiotherapy (117,118). Surgery remains the treatment of choice for the groin for women with vulvar cancer.
Unilateral versus Bilateral Groin Dissection It is not necessary to perform a bilateral groin dissection if the primary lesion is unilateral and the ipsilateral lymph nodes are negative. In a patient with a unilateral lesion and negative ipsilateral groin nodes, the risk of contralateral lymph node metastasis is very low (36,48). In a study from the Mayo Clinic, 8 of 163 patients with unilateral vulvar cancers (4.8%) had bilateral lymph node metastases and only 3 (1.8%) had isolated contralateral lymph node metastases. None of the patients with unilateral vulvar lesions that were either 2 cm or less or had 5 mm or less depth of invasion had bilateral groin node involvement at diagnosis (48). There is an increase in the risk of contralateral nodal involvement proportional to the number of positive ipsilateral inguinal nodes (60,48). It is recommended that patients with any bulky or multiple microscopically positive ipsilateral groin lymph nodes undergo contralateral inguinal-femoral lymphadenectomy. Bilateral inguinal-femoral lymphadenectomy should be performed for midline lesions (clitoris, anterior labia minora, posterior fourchette) or those within 2 cm of the midline because of the more frequent contralateral lymph ﬂow from these regions (119).
Management of Bulky Groin Nodes All clinically or radiologically suspicious groin nodes should be resected. If nodal metastasis is confirmed by frozen section, the question arises whether a full inguinofemoral lymphadenectomy may be safely omitted to decrease morbidity without compromising survival. One small, retrospective, multi-institutional study suggests that targeted nodal debulking compared with full lymphadenectomy does not jeopardize survival when both are followed by groin and pelvic radiation (120). Patients with fixed, unresectable groin nodes should be treated with primary chemoradiation. If there is no other evidence of metastatic disease following chemoradiation, GOG data suggest that it may be appropriate to resect the residual nodes (121).