Surgical Treatment of Vulvar Cancer Workup

Updated: May 04, 2016
  • Author: Robert V Higgins, MD; Chief Editor: Warner K Huh, MD  more...
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Workup

Laboratory Studies

Routine preoperative laboratory studies for vulvar cancer include serum electrolyte evaluations and a complete blood cell count.

No special testing is needed, except as indicated by the patient's medical condition.

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Imaging Studies

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  • Imaging studies other than routine chest radiographs have not been helpful in the evaluation of women with vulvar carcinoma, except to evaluate specific symptoms or nodal enlargement.

  • A CT scan may be useful to help evaluate nodal spread in the pelvis in women with evidence of groin node metastasis, but the sensitivity of a CT scan to help detect pelvic lymphadenopathy is approximately 30%. Because of the low sensitivity of imaging in detecting pelvic node metastasis, some authors have suggested laparoscopic assessment of the pelvic lymph nodes as an alternative.

  • MRI can be used to evaluate lymphatic spread but is of limited use because of the expense and the difficulty of evaluating the pelvic nodal group.

  • Positron emission tomography (PET) scanning holds some promise in improving the sensitivity of detecting small nodal metastasis. PET is used in patients with vulvar cancer, but the clinical impact has not been established. [10]

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Other Tests

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  • Perform an ECG prior to surgery, if indicated.

  • Pulmonary function tests may be appropriate in women who smoke and are older than 50 years to help in perioperative management. Evaluation should also include an arterial blood gas analysis.

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Diagnostic Procedures

Colposcopy can be performed on the vulva but is more difficult than colposcopy of the cervix because of the large surface area of the vulva and the variability in premalignant lesions. Because of the keratinized skin, acetic acid should be placed for at least 5 minutes prior to colposcopy. To facilitate biopsy, EMLA (ie, eutectic mixture of local anesthetics) cream may be applied to ameliorate the pain from lidocaine injection. A punch biopsy tool can be used to take a representative sample of the vulva. A biopsy should be performed on all lesions to ensure that a cancer is not missed when multiple dysplastic lesions are present.

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Histologic Findings

Squamous carcinoma is the most common pathologic type of vulvar carcinoma. Various grading systems are described and may be prognostic. Other prognostic features include confluent growth patterns and lymph vascular involvement.

Melanoma accounts for approximately 10% of vulvar cancers. The staging and treatment is similar to other melanomas. Clark defined a classification system that describes prognosis based on invasion of melanoma to certain tissue levels. [11] This system has been modified by Chung for use in vulvar melanoma. [12] Similarly, the depth of invasion, as described by Breslow, can be used to predict prognosis. [13]

Sarcoma is relatively uncommon. Subtypes include leiomyosarcoma, malignant fibrous histiocytoma, and epithelioid sarcoma. In addition, a sarcoma can arise from any structure in the vulva; including blood vessels, skeletal muscle, and fat.

Basal cell carcinoma of the vulva is uncommon, but it can occur in elderly women. As with other basal cell carcinomas, local excision is usually curative.

Verrucous carcinoma resembles condylomata acuminata and is also called a Buschke-Lowenstein giant condyloma. This type of carcinoma is locally aggressive but does not have a propensity to spread via lymphatics. These tumors are thought to be associated with HPV type 6.

Adenocarcinoma may arise in the Bartholin gland, and it represents approximately 40% of tumor types from this location. This type of tumor may attain considerable size before detection. Removal of the Bartholin gland to exclude an underlying carcinoma is indicated for recurrent Bartholin gland abscesses or cysts or if asymptomatic enlargement occurs in persons older than 50 years.

Paget's disease usually manifests as a red, raised, pruritic lesion. Histologically, the lesion is noted to contain cells with prominent nuclei and an increased amount of cytoplasm. Paget's disease has been associated with underlying adenocarcinoma of the colon or sweat glands in 15% of cases. Although Paget's disease does not metastasize, because the histologic changes often extend past the gross extent on the skin, it is known to have a high rate of local recurrence. For this reason, a clinical margin of 2 cm is recommended at the time of excision.

Other carcinomas of the vulva are rare. Tumors can occur in the apocrine sweat glands, and breast carcinoma can also develop from ectopic breast tissue contained within the milk line that extends down into the vulva.

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Staging

The International Federation of Gynecology (FIGO) [14] and the American Joint Commission on Cancer Staging (AJCC) [15] have adopted surgical staging systems for vulvar carcinoma to incorporate the pathologic status of the inguinal lymph nodes.

The depth of invasion is defined as the measurement of the tumor from the epithelialstromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion. Microinvasive disease should be measured using this criteria. Caution in needed in interpretation of published studies which use tumor thickness, which is measured from the deepest invasion to the surface of the skin or tumor.

Table 1. Staging of vulvar cancer by FIGO (2008) and AJCC (2010) (Open Table in a new window)

TNM Categories

FIGO

Definition

TX

 

Primary tumor cannot be assessed

T0

 

No evidence of primary tumor

Tis*

 

Carcinoma in situ (preinvasive carcinoma)

T1a

IA

Lesions ≤2 cm confined to the vulva or perineum and with stromal invasion ≤1 mm†

T1b

IB

Lesions >2 cm, or any size with stromal invasion more than 1 mm, confined to the vulva or perineum

T2‡

II

Tumor of any size with extension to adjacent perineal structures (lower/distal one third of urethra, lower/distal one third of vagina, anal involvement)

T3§

IVA

Tumor 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 (Open Table in a new window)

Regional lymph nodes (N)*

TNM categories

FIGO stages

Definition

NX

 

Regional lymph nodes cannot be assessed

N0

 

No regional lymph node metastasis

N1

 

1or 2 regional lymph nodes with the following features:

N1a

IIIA

1 lymph node metastasis each ≤5 mm

N1b

IIIA

1 lymph node metastasis ≥5 mm

N2

IIIB

Regional lymph node metastasis with the following features:

N2a

IIIB

≥3 lymph node metastases each < 5 mm

N2b

IIIB

≥2 lymph node metastases ≥5 mm

N2c

IIIC

Lymph node metastasis with extracapsular spread

N3

IVA

Fixed or ulcerated regional lymph node metastasis

Distant metastasis (M)

TNM categories

FIGO stages

Definition

M0

 

No distant metastasis

M1

IVB

Distant metastasis (including pelvic lymph node metastasis)

Anatomic stage/prognostic groups

Stage 0

Tis

N0

M0

Stage I

T1

N0

M0

Stage IA

T1a

N0

M0

Stage IB

T1b

N0

M0

Stage II

T2

N0

M0

Stage IIIA

T1,T2

N1a, N1b

M0

Stage IIIB

T1, T2

N2a, N2b

M0

Stage IIIC

T1, T2

N2c

M0

Stage IVA

T1, T2

N3

M0

T3

Any N

M0

Stage IVB

Ant T

Any N

M1

* An effort should be made to describe the site and laterality of lymph node metastases.

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