gynecology and obstetrics
Vulvar Cancer
Treatment of Vulvar Cancer
Wide excision and lymph node dissection except when stromal invasion is ≤ 1 mm Surgery, radiation therapy, and/or chemotherapy for stage III or IV cancer (See alsoNational Comprehensive Cancer Network (NCCN): NCCN Clinical Practice Guidelines in Oncology: Vulvar Cancer [Squamous Cell Carcinoma].) Wide (≥2 cm margin) radical excision of the local tumor is indicated when the tumor confined to the vulva with no extension to adjacent perineal structures. Lymph node dissection may be done when stromal invasion is > 1 mm but is unnecessary when stromal invasion is ≤ 1 mm. Radical vulvectomy is usually reserved for Bartholin gland adenocarcinoma. For lateralized lesions≤2 cm, unilateral wide local excision and unilateral SLN dissection is recommended. Lesions near the midline and most lesions>2 cm require bilateral SLN dissection. For tumors with extension to adjacent perineal structures such as the urethra, vagina, or anus, a modified radical vulvectomy is indicated independent of tumor size. Sentinel lymph node biopsy is a reasonable alternative to lymph node dissection for some women with squamous cell vulvar carcinoma. SLN mapping should not be considered if clinical findings suggest cancer has spread to lymph nodes in the groin. For SLN mapping, a tracer (blue dye, technetium-99 [99Tc],indocyanine green[ICG]) is injected intradermally around and in front of the leading edge of the vulvar carcinoma. Further evaluation of lymph nodes and treatment are based on the results of SLN biopsy or lymphadenectomy. If inguinofemoral nodes are negative, observation is reasonable. If one or more SLNs are positive, treatment depends on the size of the metastasis. For micrometastases (≤ 2 mm), inguinofemoral radiotherapy (50 Gy) is a safe alternative to inguinal lymphadenectomy. For macrometastases in an SLN (> 2 mm), inguinal lymphadenectomy is recommended to prevent isolated groin recurrence, although inguinal lymphadenectomy is associated with significant risks of morbidity, wound complications, lymphedema, and lymphoceles ( Treatment references ). An ongoing, single-arm, prospective phase II trial is evaluating the safety of replacing inguinofemoral lymphadenectomy with chemoradiation (56 Gy) in patients with early-stage vulvar cancer with a macrometastasis (> 2 mm) and/or extracapsular extension in the sentinel node ( For stage III, lymph node dissection followed by postoperative external beam radiation therapy and chemotherapy (chemoradiation)—preferablycisplatin; possiblyfluorouracil—is usually done before wide radical excision. The alternative is more radical or exenterative surgery. For stage IV, treatment is some combination of pelvic exenteration, radiation therapy, and systemic chemotherapy (cisplatin,carboplatin,cisplatinorcarboplatin/paclitaxel, orcisplatin/paclitaxelplusbevacizumab). 1.Oonk MHM, Slomovitz B, Baldwin PJW, et al: Radiotherapy versus inguinofemoral lymphadenectomy as treatment for vulvar cancer patients with micrometastases in the sentinel node: Results of GROINSS-V II.J Clin Oncol39 (32):3623–3632, 2021. doi: 10.1200/JCO.21.00006 2.Gien LT, Slomovitz B, Van der Zee A, Oonk M: Phase II activity trial of high-dose radiation and chemosensitization in patients with macrometastatic lymph node spread after sentinel node biopsy in vulvar cancer: GROningen INternational Study on Sentinel nodes in Vulvar cancer III (GROINSS-V III/NRG-GY024).Int J Gynecol Cancer33(4):619-622, 2023. doi: 10.1136/ijgc-2022-004122. PMID: 36653060 