Surgical management of Carcinoma of vulva: current trends

Abstract

Vulval cancer is relatively rare. It accounts for approximately 5% of malignancies of the female genital tract, with an incidence of 2.2 per 100,000 women. This is predominantly a disease of postmenopausal elderly women, with the peak incidence at 65 to 75 years. The vast majority of vulval carcinomas are of squamous origin, Melanoma is the second commonest malignancy arising in the vulva. Rarely adenocarcinomas arise from bartholin glands and in conjunction with Paget's disease of vulva. Better understanding of the prernalignant lesions like VIN, lichen sclerosis and Paget's disease has led to appropriate interventions in preventing vulval carcinoma. Laser ablation and topical agents are used to treat prernalignant lesions. Surgical options such as wide local excision, skinning vulvectomy and simple vulvectomy are also used in some patients. The time tested treatment modality for primary vulva] carcinoma is radical surgery. In older women with significant co-morbid factors radical surgery is associated with unacceptable morbidity. Attempts have been made to overcome this by less invasive procedures in selected cases. Wide local excision for early disease has replaced radical surgery since the latter part of the last century, as the local recurrence rate for wide local excision compares favourably with that following radical vulvectomy (7.2% Vs 6.3%). Adequate resection margin of more than 8 mm is recommended since local recurrence increases with a reduction of disease free margin (>8mm — 0%, 8-4.8mm- 8%, <4.8mm-54%). Triple incision technique to remove the vulval lesion and bilateral nodes is preferred due to less postoperative morbidity and better cosmetic outcome. However, if there is evidence of tumour within the skin bridge between the primary tumour and inguinal nodes at the time of surgery, a radical vulvectomy with en bloc inguinal node dissection should be considered. The benefit of surgical modifications such as sparing of the saphenous vein at the time of surgery to reduce the lower limb complications is inconclusive. Women with lesions of >1 mm invasion will have to undergo either ipsilateral or bilateral inguino^femoral lymphadenectomy depending on the laterality of the tumour and the status of the ipsilateral nodes. Pelvic lymph-node involvement is only likely if the inguinofemoral nodes are involved. In terms of survival, surgical removal of the pelvic nodes has not been found to be superior to radiotherapy. Significant morbidity associated with inguino-femoral lymphadenectomy has led to interest in assessing the groin nodes with CT or MRT prior to performing lymphedenectomy. Sentinel node mapping with methylene blue or 99TC has gained interest in this regard due to its sensitivity (58% -100%). In situations where the lateral excision margin would involve anus or urethra, pre-operative radiotherapy may have a role in allowing local control without loss of function. Adjuvant radiotherapy is recommended if an adequate resection margin cannot be achieved and if there are two or more positive inguinal nodes. Radical radiotherapy and chemotherapy with curative intent may be used for advanced cancer. Usually basal cell carcinoma and verrucous carcinoma of the vulva are only superficially invasive and are rarely associated with lymph node metastasis. Thus wide local excision will suffice. In malignant melanoma, the depth of tumour penetration is an important prognostic factor. Lymphadenectomy does not influence the outcome though resection of enlarged nodes may be of palliative benefit.