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Vulvar Cancer

Chapter 17 – Gynaecological Cancer in the Senior Patient

Primary vulvar cancers represent about 4% of female genital tract malignancies. It is mainly a disease for women older than 60 years. The 2008 FIGO staging system is used.

Stage 0

Stage 0 represents a carcinoma in situ. The five-year survival is 100%. The preferred treatment is surgical excision of the lesion. Alternatively, after invasive disease has been ruled out, topical administration of 5-fluorouracil or imiquimod can be used.

Stage I

In stage I the tumour is confined to the vulva. Stage I can be divided into the following:

  • IA: The lesions are ≤2.0 cm in size, confined to the vulva or perineum and with stromal invasion <1.0 mm and no nodal metastasis(es). Treatment consists of wide local excision (tumour-free margin ≤1.0 cm) without lymph node dissection.
  • IB: The lesions are >2.0 cm in size or with stromal invasion ≤1.0 mm, confined to the vulva or perineum with negative nodes. Treatment consists of wide local excision or (hemi)vulvectomy (tumour-free margin ≤1.0 cm) with lymph node dissection.
    • The use of sentinel node biopsy is recommended for evaluation of the lymph nodes.
      • If the lymph node is involved, an inguinofemoral lymphadenectomy should be performed.
      • For centralised lesions, a bilateral inguinofemoral lymphadenectomy is indicated.
      • For lateralised lesion, an ipsilateral iguinofemoral lymphadenectomy is performed.
    • Adjuvant chemoradiation is indicated in patients with involved lymph nodes or margins, which cannot be re-resected. Cisplatin is preferably used as a radiation sensitiser.

Stage II

Stage II consists of a tumour of any size with extension to adjacent perineal structures (one-third of lower urethra, one-third of lower vagina, anus) without lymph node involvement.

Treatment is similar to that for stage IB.

Stage III

Stage III encompasses a tumour of any size with or without extension to adjacent perineal structures (one-third of lower urethra, one-third of lower vagina, anus) with involvement of inguinofemoral lymph nodes.

Stage III can be divided into the following:

  • IIIA: (i) one or two lymph node metastasis(es) (<5.0 mm) or (ii) one lymph node metastasis (≥5.0 mm)
  • IIIB: (i) three or more lymph node metastases (<5.0 mm) or (ii) two or more lymph node metastases (≥5.0 mm)
  • IIIC: positive lymph nodes with extracapsular spread

The treatment should be individualised. In selected patients, radical vulvectomy with bilateral inguinofemoral lymphadenectomy is indicated, which is sometimes preceded by neoadjuvant chemotherapy and postoperative radiotherapy. All other patients should be treated by definitive chemoradiation.

Stage IV

In stage IV the tumour invades other regional (two-thirds of upper urethra, two-thirds of upper vagina) or distant structures.

It can be divided into the following:

  • IVA: Tumour invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone or (ii) fixed or ulcerated inguinofemoral lymph nodes. Treatment: See stage III. In cases of fistulisation or centralised local disease, an exenteration can be considered.
  • IVB: Any distant metastasis(es) including pelvic lymph nodes. Treatment consists of palliative chemotherapy (e.g. cisplatin, carboplatin, paclitaxel, or topotecan) and can result in a response in up to 20% of patients.

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