Surgical Treatment of Vulvar Cancer 

  • Author: Robert V Higgins, MD; Chief Editor: Warner K Huh, MD   more...
 
Updated: May 17, 2011
 

History of the Procedure

Patients with vulvar cancer diagnosed in the early part of the 20th century usually died of disease. The overall survival rate for vulvar cancer after simple surgical excision was less than 25%. Attempts to improve outcomes for patients with vulvar cancer by performing more radical surgery were first described by Basset in 1912.[1] Way described an improved survival rate using an en bloc dissection radical vulvectomy with an inguinal and pelvic lymphadenectomy.[2] The Bassett-Way operation resulted in a 5-year survival rate of 74% as reported by Morley.[3] This success rate convinced most surgeons to use this operation for all patients with vulvar cancer regardless of tumor size. Major morbidity from this procedure included poor wound healing and long-term lymphedema.

Fred Taussig collected a large series of vulvar cancer cases from 1911-1940.[4] He initially started his series with a radical excision of the primary tumor with an en bloc dissection of the inguinal lymph nodes. Later, he modified his technique for patients with small lesions in an attempt to decrease operative morbidity. He used separate incisions for the groin dissection and the vulvar excision. This less radical operation for small lesions was not routinely used until Hacker reported his experience with 100 patients in 1981.[5] He reported using 3 separate incisions, as described by Taussig, for patients with clinical stage I disease. The 5-year survival rate was 97%.

Next

Problem

Vulvar carcinoma encompasses any malignancy that arises in the skin; glands; or underlying stroma of the perineum, including the mons, labia minora, labia majora, Bartholin glands, or clitoris. Tumors can also arise in ectopic breast tissue that can be located in the vulva along the milk line. Metastatic tumors have also been described but occur relatively infrequently.

For related information, see eMedicine's article on Malignant Vulvar Lesions.

Previous
Next

Epidemiology

Frequency

Cancer of the vulva is the fourth most common malignancy of the female genital tract. The American Cancer Society estimates 3,580 women were diagnosed with vulvar cancer in 2009.[6] Currently, approximately 75% of patients with vulvar carcinomas will be cured, making vulvar carcinoma responsible for approximately 900 deaths annually in the United States.

Unfortunately, the incidence of preinvasive disease of the vulva has almost doubled over the past decade, and this may translate into a marked increase in the incidence of invasive vulvar carcinoma in the future. Since vulvar cancer is rare and is not monitored by the World Health Organization, the global incidence of this disease is not precisely known.

Previous
Next

Etiology

The incidence of vulvar carcinoma has a bimodal peak. Currently, development of vulvar carcinoma in situ in young women is suggested to correlate to human papillomavirus (HPV) infection. In older women, the etiology of the carcinoma is attributed to chronic irritation or other poorly understood cofactors. Estimates indicate that women who smoke cigarettes have a 4- to 5-fold increase in the incidence of carcinoma in situ of the vulva and a 20% increase in vulvar carcinoma. The incidence of vulvar carcinoma in situ and vulvar carcinoma is higher in women with multiple sexual partners and in women with a history of HPV infection. For women who report a history of genital warts or HPV-related disease, the relative risk for carcinoma in situ is 18.5 and for invasive cancer is 14.5.

Previous
Next

Pathophysiology

The development of vulvar dysplasia and cancer in most patients is related to HPV infection. Certain strains of HPV are known to be more oncogenic than others. HPV types 16, 18, 31, 33, 35, 45, and 54 are more likely to be associated with cervical neoplasia and cancer and are suspected to also be responsible for vulvar cancers. The DNA from HPV 16 and 18 has been detected in up to 60% of patients with vulvar cancer.

The mechanism of HPV transformation into dysplasia and cancer is not well understood. Two gene products from HPV are known to immortalize cells in culture and are probably responsible for malignant transformation. The HPV E6 protein does have the ability to bind the host p53 protein. The HPV E7 protein binds the Rb gene product. The oncogenic viral types are thought to have a greater affinity for these cellular proteins, which would explain the increased risk of malignant transformation. Some infections may lead to integration of the viral DNA into the host, with disruption of the normal regulation of the E6 and E7 oncoproteins. This increased production of the E6 and E7 gene products could then result in oncogenic transformation.

Previous
Next

Presentation

Diagnosis of vulvar carcinoma is often delayed. Women neglect to seek treatment for an average of 6 months from the onset of symptoms. In addition, a delay in diagnosis often occurs after the patient presents to her physician. In many cases, a biopsy of the lesion is not performed until the problem fails to respond to numerous topical therapies. A biopsy should be performed when any discrete lesion of the vulva is discovered.

The most common presentation is a pruritic lesion of the vulva or a mass detected by the patient herself. However, early vulvar cancer may be asymptomatic and recognized only with careful inspection of the vulva. A biopsy should be performed on all visible lesions on the vulva. More advanced vulvar carcinomas present with bleeding, pain, or discharge.

A large squamous cell carcinoma of the vulva. NoteA large squamous cell carcinoma of the vulva. Note the small contralateral "kissing lesion" that can be seen with vulvar carcinomas. (Photograph courtesy of James B. Hall, MD) A large T2 carcinoma of the vulva crossing the midA large T2 carcinoma of the vulva crossing the midline and involving the clitoris. (Photograph courtesy of Tom Wilson)
Previous
Next

Indications

Choosing the proper surgical procedure for vulvar cancer is important. Patients with vulvar dysplasia can have a wide local excision. The advantage of this procedure is that the removed tissue is sent for pathologic examination. Pathologic examination allows for assessment of surgical margins and assures the absence of invasive disease. Ablative procedures can be used for dysplastic lesions if vulvar cancer can be excluded with reasonable certainty.

Patient with biopsy-proven squamous cell carcinoma of the vulva are usually candidates for surgical excision. Patients with a lesion involving the upper urethra or anus or is fixed to the pelvic bone can be treated with neoadjuvant radiation and chemotherapy prior to surgical intervention.[7] This type of therapy can allow future resection with preservation of the urethral or rectal sphincter in most cases. Radiation can also be used in an attempt to spare the clitoris.

Previous
Next

Relevant Anatomy

The vulva includes all external genital structures, including the mons pubis, labia majora, labia minora, clitoris, vaginal vestibule, perineum, and supporting structures exterior to the urogenital diaphragm.

The femoral triangle is bounded by the inguinal ligament superiorly, the adductor longus medially, and the sartorius laterally. The superficial groin nodes lie above the cribriform fascia in the femoral triangle. Careful dissection generally reveals 5 vessels in the femoral triangle above the cribriform fascia, the largest of which is the saphenous vein. Often, a lateral accessory saphenous vein can be identified. The other vessels include the superficial circumflex, the superficial epigastric, and the external pudendal. Below the cribriform fascia are the deep inguinal nodes. Three to 4 nodes can be found medial to the femoral vein. The most superior of these is the sentinel node to the pelvic lymphatics and is known as the node of Cloquet.

The lymphatics of the vulva and distal third of the vagina drain into the superficial inguinal node group and travel through the deep femoral lymphatics and the node of Cloquet to the pelvic nodal groups (see image below).[8] Direct spread to the deep nodal groups without metastasis to the superficial group has been documented using lymphatic mapping. This type of direct spread is uncommon and represents fewer than 5% of cases.

Diagram of lymphatic drainage of a lateral lesion.Diagram of lymphatic drainage of a lateral lesion. Most lymphatics flow through the superficial inguinal nodes, deep inguinal nodes, and the node of Cloquet to the pelvic lymph node chains. Deep inguinal node findings are positive approximately 3% of the time when superficial inguinal node findings are negative. Lymphatic mapping studies indicate that 13% of cases demonstrate findings consistent with flow to the pelvis that does not involve the node of Cloquet. If the lesion is in the anterior labia minor, then contralateral flow is demonstrated in 67% of cases.

Lymphatic mapping studies have also demonstrated that radioactive colloid injected into the vulva can accumulate more readily in the lateral external iliac nodes than in the medial group, which suggests that not all lymphatics flow to the medial pelvic nodes through the node of Cloquet. Studies suggest that 10-20% of lymphatic flow from the superficial node group travels directly to the pelvis without passage through the deep inguinal nodes. A direct pathway from the clitoris or vulva to the pelvic nodes has not been identified.

Previous
Next

Contraindications

Resection of the primary lesion is the treatment of choice because few alternatives to surgery are available for vulvar carcinoma. Regional or general anesthesia can be used for this type of surgery. Patients with inoperable primary tumors or fixed inguinal lymph nodes are candidates for preoperative treatment with chemotherapy and radiation. This treatment modality often reduces tumor volume and improves the chances for surgical resection. The morbidity of this regimen is substantial.[9]

Radiation alone can be used for palliation but should not be considered a curative treatment.

Previous
Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Robert V Higgins, MD  Clinical Associate Professor, Department of Obstetrics/Gynecology, University of North Carolina School of Medicine; Residency Program Director, Vice-Chairman of Academic Affairs, Associate Director of Gynecologic Oncology, Department of Obstetrics/Gynecology, Carolinas Medical Center

Robert V Higgins, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, North Carolina Medical Society, and Society of Gynecologist Oncologists

Disclosure: Merck Speaker's Bureau Honoraria Speaking and teaching

Coauthor(s)

R Wendel Naumann, MD  Clinical Assistant Professor of Obstetrics and Gynecology, University of North Carolina at Chapel Hill; Director, Minimally Invasive Surgery in Gynecologic Oncology; Associate Director, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Carolinas Medical Center

R Wendel Naumann, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and American College of Surgeons

Disclosure: Nothing to disclose.

James Hall, MD  Director, Division of Gynecologic Oncology, Blumenthal Cancer Center, Carolinas Medical Center; Clinical Professor, Department of Obstetrics and Gynecology, University of North Carolina

James Hall, MD is a member of the following medical societies: American Cancer Society, American College of Obstetricians and Gynecologists, and Society of Gynecologist Oncologists

Disclosure: merck Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; orthobiotek Honoraria Speaking and teaching

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michel E Rivlin, MD  Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

Warner K Huh, MD  Professor, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Senior Scientist, Comprehensive Cancer Center, University of Alabama School of Medicine

Warner K Huh, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American College of Surgeons, American Society of Clinical Oncology, Massachusetts Medical Society, and Society of Gynecologist Oncologists

Disclosure: MERCK Consulting fee Consulting; GSK Consulting fee Consulting; ROCHE PHARMA/DIAGNOSTICS Consulting fee Consulting; HOLOGICS Consulting fee Consulting; HELIX BIOPHARMA Consulting fee Consulting; COVIDIEN Consulting fee Consulting; INTUITIVE SURGICAL Surgical Proctor

References

  1. Basset A. Traitement chirurgical operatoire de l'epithelima primitif du clitoris indications-technique-resultats. Rev Chir. 1912;46:546.

  2. Way S. Carcinoma of the vulva. Am J Obstet Gynecol. Apr 1960;79:692-7. [Medline].

  3. Morley GW. Infiltrative carcinoma of the vulva: results of surgical treatment. Am J Obstet Gynecol. 1976;124:874-878.

  4. Taussig FJ. Cancer of the Vulva. Am J Obstet Gynecol. 1940;40:764.

  5. Hacker NF, Leuchter RS, Berek JS, et al. Radical vulvectomy and bilateral inguinal lymphadenectomy through separate groin incisions. Obstet Gynecol. Nov 1981;58(5):574-9. [Medline].

  6. Cancer Fact & Figures 2009. American Cancer Society. Available at www.cancer.org. Accessed 04-22-2010.

  7. Moore DH, Thomas GM, Montana GS. Preoperative chemoradiation for advanced vulvar cancer: a phase II study of the Gynecologic Oncology Group. Int J Radiat Oncol Biol Phys. Aug 1 1998;42(1):79-85. [Medline].

  8. Iversen T, Aas M. Lymph drainage from the vulva. Gynecol Oncol. Oct 1983;16(2):179-89. [Medline].

  9. van Doorn HC, Ansink A, Verhaar-Langereis MMJ, Stalpers LL. Neoadjuvant chemoradiation for advanced primary vulvar cancer (Review). The Cochrane Collaboration [serial online]. 2009;1:1-20. Accessed 04/23/2010. Available at http://www.thecochranelibrary.com.

  10. Grigsby, PW. Role of PET in gynecologic malignancy. Current Opinion in Oncology. 09/2009;21:420-424. [Medline].

  11. Clark WH Jr, From L, Bernardino EA, Mihm MC. The histogenesis and biologic behavior of primary human malignant melanomas of the skin. Cancer Res. Mar 1969;29(3):705-27. [Medline].

  12. Chung AF, Woodruff JM, Lewis JL Jr. Malignant melanoma of the vulva: A report of 44 cases. Obstet Gynecol. Jun 1975;45(6):638-46. [Medline].

  13. Breslow A. Thickness, cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma. Ann Surg. Nov 1970;172(5):902-8. [Medline].

  14. FIGO Committee on Gynecologic Oncology. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynecol Obst. 2009;105:103-104.

  15. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th. Chicago, Illinois: Springer New York, Inc; 2010.

  16. Trope C, Johnsson JE, Larsson G, Simonsen E. Bleomycin alone or combined with mitomycin C in treatment of advanced or recurrent squamous cell carcinoma of the vulva. Cancer Treat Rep. Apr-May 1980;64(4-5):639-42. [Medline].

  17. Deppe G, Bruckner HW, Cohen CJ. Adriamycin treatment of advanced vulvar carcinoma. Obstet Gynecol. Jul 1977;50(1 Suppl):13s-14s. [Medline].

  18. Shylasree TS, Bryant A, Howells RE. Chemoradiation for advanced primary vulval cancer. Cochrane Database Syst Rev. Apr 13 2011;4:CD003752. [Medline].

  19. Zhang SH, Sood AK, Sorosky JI, et al. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer. Oct 1 2000;89(7):1520-5. [Medline].

  20. Rouzier R, Haddad B, Dubernard G. Inguinofemoral dissection for carcinoma of the vulva: effect of modifications of extent and technique on morbidity and survival. J Am Coll Surg. Mar 2003;196(3):442-50. [Medline].

  21. Ansink A, Stegemen M, van der Velden K, Collingwood M. Surgical interventions for early squamous cell carcinoma of the vulva (Review). The Cochran Collaboration [serial online]. 2008;3:1-20. Accessed 4/15/2010. Available at http://www.thecochranelibrary.com.

  22. Homesley HD, Bundy BN, Sedlis A, Adcock L. Radiation therapy versus pelvic node resection for carcinoma of the vulva with positive groin nodes. Obstet Gynecol. Dec 1986;68(6):733-40. [Medline].

  23. van der Velden K, Ansink A. Primary groin irradiation versus primary groin surgery for early vulvar cancer (Review). The Cochrane Collection [serial online]. 2009;1:1-15. Accessed 4/15/2010. Available at http://www.thecochranelibrary.com.

  24. Decesare SL, Fiorica JV, Roberts WS, et al. A pilot study utilizing intraoperative lymphoscintigraphy for identification of the sentinel lymph nodes in vulvar cancer. Gynecol Oncol. Sep 1997;66(3):425-8. [Medline].

  25. de Hullu JA, Hollema H, Piers DA, Verheijen RH, van Diest PJ, Mourits MJ, et al. Sentinel lymph node procedure is highly accurate in squamous cell carcinoma of the vulva. J Clin Oncol. Aug 2000;18(15):2811-6. [Medline].

  26. Martínez-Palones JM, Pérez-Benavente MA, Gil-Moreno A, Díaz-Feijoo B, Roca I, García-Jiménez A. Comparison of recurrence after vulvectomy and lymphadenectomy with and without sentinel node biopsy in early stage vulvar cancer. Gynecol Oncol. Dec 2006;103(3):865-70. [Medline].

  27. Ate GJ, Van der Zee, Oonk MH, De Hulla JA, Ansink AC, Vergote I, et al. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol. Feb 2008;26:884-89. [Full Text].

  28. Yoder BJ, Rufforny I, Massoll NA, Wilkinson EJ. Stage IA vulvar squamous cell carcinoma: an analysis of tumor invasive characteristics and risk. Am J Surg Pathol. May 2008;32(5):765-72. [Medline].

  29. Helm CW, Hatch K, Austin JM, et al. A matched comparison of single and triple incision techniques for the surgical treatment of carcinoma of the vulva. Gynecol Oncol. Aug 1992;46(2):150-6. [Medline].

  30. Judson PL, Jonson AL, Paley PJ, Bliss RL, Murray KP, Downs LS Jr, et al. A prospective, randomized study analyzing sartorius transposition following inguinal-femoral lymphadenectomy. Gynecol Oncol. Oct 2004;95(1):226-30. [Medline].

  31. Berman ML, Soper JT, Creasman WT, et al. Conservative surgical management of superficially invasive stage I vulvar carcinoma. Gynecol Oncol. Dec 1989;35(3):352-7. [Medline].

  32. Stehman FB, Bundy BN, Dvoretsky PM, Creasman WT. Early stage I carcinoma of the vulva treated with ipsilateral superficial inguinal lymphadenectomy and modified radical hemivulvectomy: a prospective study of the Gynecologic Oncology Group. Obstet Gynecol. Apr 1992;79(4):490-7. [Medline].

  33. Kirby TO, Rocconi RP, Numnum TM, Kendrick JE, Wright J, Fowler W, et al. Outcomes of Stage I/II vulvar cancer patients after negative superficial inguinal lymphadenectomy. Gynecol Oncol. Aug 2005;98(2):309-12. [Medline].

  34. Levenback C, Morris M, Burke TW, et al. Groin dissection practices among gynecologic oncologists treating early vulvar cancer. Gynecol Oncol. Jul 1996;62(1):73-7. [Medline].

  35. [Best Evidence] [Guideline] Kunos C, Simpkins F, Gibbons H, Tian C, Homesly H. Radiation therapy compared with pelvic node resection for node-positive vulvar cancer. Obstet Gynecol. September/2009;114:537-46.

  36. Tantipalakorn C, Robertson G, Marsden DE, Gebski V, Hacker NF. Outcome and Patterns of Recurrence for International Federation of Gynecology and Obstetrics (FIGO) Stages I and II Squamous Cell Vulvar Cancer. Obstet Gynecol. April/2009;113:895-901.

  37. Koutsky LA, Ault KA, Wheeler CM, Brown DR, Barr E, Alvarez FB. A controlled trial of a human papillomavirus type 16 vaccine. N Engl J Med. Nov 21 2002;347(21):1645-51. [Medline].

  38. [Best Evidence] Garland SM, Hernandez-Avila M, Wheeler CM, Perez G, Harper DM, Leodolter S. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med. May 10 2007;356(19):1928-43. [Medline].

  39. The FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med. May 10 2007;356(19):1915-27. [Medline].

  40. Gardasil [package insert]. Whitehouse Station, NJ: Merck and Co.; 2008. [Full Text].

  41. Stehman FB, Look KY. Carcinoma of the vulva. Obstet Gynecol. Mar 2006;107(3):719-33. [Medline].

  42. Abitbol MM. Carcinoma of the vulva: improvements in the surgical approach. Am J Obstet Gynecol. Oct 15 1973;117(4):483-9. [Medline].

  43. Bauer HM, Ting Y, Greer CE, et al. Genital human papillomavirus infection in female university students as determined by a PCR-based method. JAMA. Jan 23-30 1991;265(4):472-7. [Medline].

  44. Brinton LA, Nasca PC, Mallin K, et al. Case-control study of cancer of the vulva. Obstet Gynecol. May 1990;75(5):859-66. [Medline].

  45. Burke TW, Levenback C, Coleman RL, et al. Surgical therapy of T1 and T2 vulvar carcinoma: further experience with radical wide excision and selective inguinal lymphadenectomy. Gynecol Oncol. May 1995;57(2):215-20. [Medline].

  46. Christopherson W, Buchsbaum HJ, Voet R, Lifschitz S. Radical vulvectomy and bilateral groin lymphadenectomy utilizing separate groin incisions: report of a case with recurrence in the intervening skin bridge. Gynecol Oncol. Jun 1985;21(2):247-51. [Medline].

  47. Gonzalez Bosquet J, Magrina JF, Gaffey TA, Hernandez JL, Webb MJ, Cliby WA, et al. Long-term survival and disease recurrence in patients with primary squamous cell carcinoma of the vulva. Gynecol Oncol. Jun 2005;97(3):828-33. [Medline].

  48. Green MS, Naumann RW, Elliot M, et al. Sexual dysfunction following vulvectomy. Gynecol Oncol. Apr 2000;77(1):73-7. [Medline].

  49. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. Jan-Feb 2000;50(1):7-33. [Medline].

  50. Hacker NF, Berek JS, Lagasse LD. Microinvasive carcinoma of the vulva. Obstet Gynecol. Jul 1983;62(1):134-5. [Medline].

  51. Hacker NF, Berek JS, Lagasse LD, et al. Individualization of treatment for stage I squamous cell vulvar carcinoma. Obstet Gynecol. Feb 1984;63(2):155-62. [Medline].

  52. Heaps JM, Fu YS, Montz FJ, et al. Surgical-pathologic variables predictive of local recurrence in squamous cell carcinoma of the vulva. Gynecol Oncol. Sep 1990;38(3):309-14. [Medline].

  53. Homesley HD, Bundy BN, Sedlis A, et al. Assessment of current International Federation of Gynecology and Obstetrics staging of vulvar carcinoma relative to prognostic factors for survival (a Gynecologic Oncology Group study). Am J Obstet Gynecol. Apr 1991;164(4):997-1003; discussion 1003-4. [Medline].

  54. Hopkins MP, Reid GC, Morley GW. The surgical management of recurrent squamous cell carcinoma of the vulva. Obstet Gynecol. Jun 1990;75(6):1001-5. [Medline].

  55. Hoskins WJ, Perez CA, Young RC. Principles and Practice of Gynecologic Oncology. 1997.

  56. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, et al. Cancer statistics, 2008. CA Cancer J Clin. Mar-Apr 2008;58(2):71-96. [Medline].

  57. Kelley JL 3rd, Burke TW, Tornos C, et al. Minimally invasive vulvar carcinoma: an indication for conservative surgical therapy. Gynecol Oncol. Mar 1992;44(3):240-4. [Medline].

  58. Klemm P, Marnitz S, Köhler C, Braig U, Schneider A. Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes. Gynecol Oncol. Oct 2005;99(1):101-5. [Medline].

  59. Leminen A, Forss M, Paavonen J. Wound complications in patients with carcinoma of the vulva. Comparison between radical and modified vulvectomies. Eur J Obstet Gynecol Reprod Biol. Dec 2000;93(2):193-7. [Medline].

  60. Lorincz AT, Reid R, Jenson AB, et al. Human papillomavirus infection of the cervix: relative risk associations of 15 common anogenital types. Obstet Gynecol. Mar 1992;79(3):328-37. [Medline].

  61. McCall AR, Olson MC, Potkul RK. The variation of inguinal lymph node depth in adult women and its importance in planning elective irradiation for vulvar cancer. Cancer. May 1 1995;75(9):2286-8. [Medline].

  62. Menczer J, Fintsi Y, Arbel-Alon S. The presence of HPV 16, 18 and p53 immunohistochemical staining in tumor tissue of Israeli Jewish women with cervical and vulvar neoplasia. Eur J Gynaecol Oncol. 2000;21(1):30-4. [Medline].

  63. Miller B, Morris M, Levenback C, et al. Pelvic exenteration for primary and recurrent vulvar cancer. Gynecol Oncol. Aug 1995;58(2):202-5. [Medline].

  64. Piura B, Masotina A, Murdoch J, et al. Recurrent squamous cell carcinoma of the vulva: a study of 73 cases. Gynecol Oncol. Feb 1993;48(2):189-95. [Medline].

  65. Podratz KC, Symmonds RE, Taylor WF. Carcinoma of the vulva: analysis of treatment failures. Am J Obstet Gynecol. Jun 1 1982;143(3):340-51. [Medline].

  66. Podratz KC, Symmonds RE, Taylor WF, Williams TJ. Carcinoma of the vulva: analysis of treatment and survival. Obstet Gynecol. Jan 1983;61(1):63-74. [Medline].

  67. Schulz MJ, Penalver M. Recurrent vulvar carcinoma in the intervening tissue bridge in early invasive stage I disease treated by radical vulvectomy and bilateral groin dissection through separate incisions. Gynecol Oncol. Dec 1989;35(3):383-6. [Medline].

  68. Sedlis A, Homesley H, Bundy BN, et al. Positive groin lymph nodes in superficial squamous cell vulvar cancer. A Gynecologic Oncology Group Study. Am J Obstet Gynecol. May 1987;156(5):1159-64. [Medline].

  69. Siller BS, Alvarez RD, Conner WD, et al. T2/3 vulva cancer: a case-control study of triple incision versus en bloc radical vulvectomy and inguinal lymphadenectomy. Gynecol Oncol. Jun 1995;57(3):335-9. [Medline].

  70. Terada KY, Coel MN, Ko P, Wong JH. Combined use of intraoperative lymphatic mapping and lymphoscintigraphy in the management of squamous cell cancer of the vulva. Gynecol Oncol. Jul 1998;70(1):65-9. [Medline].

  71. Wagner W, Prott FJ, Weissmann J. Vulvar carcinoma: a retrospective analysis of 80 patients. Arch Gynecol Obstet. 1999;262(3-4):99-104. [Medline].

  72. Wharton JT, Gallager S, Rutledge FN. Microinvasive carcinoma of the vulva. Am J Obstet Gynecol. Jan 15 1974;118(2):159-62. [Medline].

  73. Wilkinson EJ. Superficial invasive carcinoma of the vulva. Clin Obstet Gynecol. Mar 1985;28(1):188-95. [Medline].

  74. Wilkinson EJ. The 1989 presidential address. International Society for the Study of Vulvar Disease. J Reprod Med. Nov 1990;35(11):981-91. [Medline].

 
Previous
Next
 
Diagram of lymphatic drainage of a lateral lesion. Most lymphatics flow through the superficial inguinal nodes, deep inguinal nodes, and the node of Cloquet to the pelvic lymph node chains. Deep inguinal node findings are positive approximately 3% of the time when superficial inguinal node findings are negative. Lymphatic mapping studies indicate that 13% of cases demonstrate findings consistent with flow to the pelvis that does not involve the node of Cloquet. If the lesion is in the anterior labia minor, then contralateral flow is demonstrated in 67% of cases.
A large T2 carcinoma of the vulva crossing the midline and involving the clitoris. (Photograph courtesy of Tom Wilson)
Specimen after removal with at least 1 cm margins around the tumor. (Photograph courtesy of Tom Wilson)
The surgical defect after a radical vulvectomy specimen is removed. (Photograph courtesy of Tom Wilson)
The surgical defect is closed after a radical vulvectomy. (Photograph courtesy of Tom Wilson)
A large squamous cell carcinoma of the vulva. Note the small contralateral "kissing lesion" that can be seen with vulvar carcinomas. (Photograph courtesy of James B. Hall, MD)
A specimen from a traditional single-incision radical hysterectomy. Most radical vulvectomies are now performed through 3 incisions, with the groin nodes removed separately from the vulvectomy specimen. (Photograph courtesy of James B. Hall, MD)
Closure of a large single-incision radical vulvectomy. The complete wound breakdown rate from this procedure is often greater than 50%. (Photograph courtesy of James B. Hall, MD)
A specimen from a primary exenteration for a stage IVA vulvar cancer involving the rectum. Many of these large tumors are now treated with adjuvant chemotherapy and radiation prior to surgery, with preservation of rectal sphincter function. (Photograph courtesy of James B. Hall, MD)
Table 1. Staging of vulvar cancer by FIGO (2008) and AJCC (2010)
TNM CategoriesFIGODefinition
TXPrimary tumor cannot be assessed
T0No evidence of primary tumor
Tis*Carcinoma in situ (preinvasive carcinoma)
T1aIALesions ≤2 cm confined to the vulva or perineum and with stromal invasion ≤1 mm†
T1bIBLesions >2 cm, or any size with stromal invasion more than 1 mm, confined to the vulva or perineum
T2‡IITumor of any size with extension to adjacent perineal structures (lower/distal one third of urethra, lower/distal one third of vagina, anal involvement)
T3§IVATumor of any size with extension to any of the following: upper/proximal two thirds of urethra, upper/proximal two thirds of vagina, bladder mucosa, rectal mucosa, or fixed to pelvic bone
* FIGO staging no longer includes Stage 0 (Tis).



† The depth of invasion is defined as the measurement of the tumor from the epithelial-stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.



‡ FIGO uses the classification T2/T3. This is defined as T2 in TNM.



§ FIGO uses the classification T4. This is defined as T3 in TNM.



Table 2. Tumor Regional Lymph Node Involvement and Metastasis Categories and FIGO Stages
Regional lymph nodes (N)*
TNM categoriesFIGO stagesDefinition
NXRegional lymph nodes cannot be assessed
N0No regional lymph node metastasis
N11or 2 regional lymph nodes with the following features:
N1aIIIA1 lymph node metastasis each ≤5 mm
N1bIIIA1 lymph node metastasis ≥5 mm
N2IIIBRegional lymph node metastasis with the following features:
N2aIIIB≥3 lymph node metastases each < 5 mm
N2bIIIB≥2 lymph node metastases ≥5 mm
N2cIIICLymph node metastasis with extracapsular spread
N3IVAFixed or ulcerated regional lymph node metastasis
Distant metastasis (M)
TNM categoriesFIGO stagesDefinition
M0No distant metastasis
M1IVBDistant metastasis (including pelvic lymph node metastasis)
Anatomic stage/prognostic groups
Stage 0TisN0M0
Stage IT1N0M0
Stage IAT1aN0M0
Stage IBT1bN0M0
Stage IIT2N0M0
Stage IIIAT1,T2N1a, N1bM0
Stage IIIBT1, T2N2a, N2bM0
Stage IIICT1, T2N2cM0
Stage IVAT1, T2N3M0
T3Any NM0
Stage IVBAnt TAny NM1
* An effort should be made to describe the site and laterality of lymph node metastases.
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.