Page 20 - ESGO - Vulvar cancer - Complete report_fxd2

None of the patients with a local recurrence died of vulvar cancer after a median follow-up of 38
months.

Three other studies48-50 documenting recurrence rates after radical/wide local excision were LoE 2+
identified (0%48 (0/18 patients with stage I), 23.1%49 (28/121 patients with stage I and II), and 10%50

(5/50 patients with stage I).

Only one study comparing quality of life of patients treated by wide local excision versus radical
vulvectomy was identified. In this retrospective (57 patients), Gunther et al.51 observed tendencies
for a better physical, role, emotional, and cognitive functioning, as well as global health status after
surgical treatment with wide local excision. Patients who underwent radical vulvectomy suffered
from a significant higher level of pain than those who underwent wide local excision. In addition,
these patients suffered from nausea/vomiting, fatigue, insomnia, appetite loss, and diarrhoea to a
higher degree (p > 0.05). It should be noted that after radical vulvectomy, 89% of patients have
sexual complications.

Omission of Inguinofemoral lymphadenectomy: the presence of pelvic node metastases is very rare in LoE 2+
the absence of inguinofemoral lymph node metastases. Thirty percent of all patients with vulvar
cancer have inguinofemoral metastases and 20% of these patients will have pelvic metastases,
too52,53. None of the seven identified studies49,54-59 described positive lymph nodes (or inguinal
recurrences after a minimal follow-up of two years) in patients with very early stage vulvar cancer,
where the primary lesion measures less than 2 cm in maximum diameter and the depth of invasion is
less than 1 mm (FIGO stage IA disease). Among the 30 patients who underwent surgery without
lymphadenectomy in the study published by Magrina et al.59, one developed groin, pelvic, and aortic
node metastases 7.5 years after initial operation and 3.5 years after experiencing a vulvar recurrence
(the primary lesion measured 2 x 1.5 cm, was moderately well differentiated, and was located to the
left of the clitoris with only 0.1 mm of invasion). In contrast, with infiltration of 1-2 mm, lymph
node metastases or inguinal recurrences were seen from 0 to 17%54-57.

Several case reports60-65 of regional lymph node recurrences following treatment for FIGO stage IA LoE 3
vulvar cancer have been published but no pattern of particular risk factors can be defined from this
small number of cases.

Superficial inguinal lymphadenectomy versus total inguinofemoral lymphadenectomy: as part of a LoE 2-
retrospective study enrolling 217 patients with stage I disease (5 mm or less invasion, no vascular
space involvement, and negative inguinal and femoral nodes), Stehman et al.66 reported a groin
recurrence in 7.3% of patients treated with superficial inguinofemoral lymphadenectomy versus 0%
recurrences in those treated with radical vulvectomy and bilateral inguinofemoral lymphadectomy
(historic controls). The recurrent-free interval was significantly lower for patients treated with
superficial inguinal lymphadenectomy compared to historic controls (84.2% (102/121) versus 91.8%
(90/98), p = 0.0028). For survival time, the difference did not reach statistical significance (87.6%
(106/121) versus 82.6% (81/98), p > 0.05).

Three uncontrolled studies50,67,68 evaluating outcomes of patients treated with superficial inguinal LoE 2+
lymphadenectomy were also identified. Among the 104 patients (stage I or II, depth of invasion

greater than 1 mm) treated with radical wide excision (negative margins) and superficial inguinal
lymphadenectomy, Gordinier et al.67 reported that nine patients experienced recurrent disease that
involved one or both of the groins (8.6%). Berman et al.50 reported outcomes of 50 patients with T1
vulvar cancers < 1 cm diameter with stromal invasion > 5 mm who underwent radical wide excision
and superficial inguinal lymphadenectomy. There were no isolated groin recurrences noted during a
follow-up period of 36 months. The third study68 reported that three of the 65 patients with stage I/II
vulvar cancer and a pathologically negative superficial inguinal lymphadenectomy recurred in the
inguinal region (4.6%).

 VULVAR CANCER - GUIDELINES 
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