Radical vulvectomy and bilateral inguinal and femoral node dissection, with care taken to ensure tumor-free margins, is the standard therapy and has been associated with 5-year survival rates of 80% to 90%, depending on the size of the primary tumor. The definition of radical vulvectomy is being extended with the realization that the effect of radical surgery is limited by the closest resection margin rather than the achievement of total organ ablation.[1]

STANDARD TREATMENT OPTIONS:

1. Modified radical vulvectomy with bilateral inguinal node and femoral node dissection. The lines of surgical resection should clear the tumor by 10 mm.[2] The morbidity of this operation can be reduced by using separate groin incisions and unilateral or superficial lymphadenectomy for select early lesions.[3] Adjuvant local radiation therapy may be indicated for surgical margins less than 8 mm, capillary-lymphatic space invasion, and thickness greater than 5 mm, particularly if the patient also has positive nodes.[1,4]

   In a Gynecologic Oncology Group (GOG) randomized trial, radiation therapy to the groin for patients with clinical N0 disease led to an inferior survival secondary to an increased groin failure rate compared with groin dissection and adjuvant radiation therapy for positive groin nodes.[5] Unfortunately, because the clinical trial was poorly designed with regard to adequacy of dose at the depth of the groin nodes, the question of whether elective nodal radiation therapy has a better outcome than groin dissection was not satisfactorily answered. A retrospective study with similar patient numbers and superior radiation therapy design contradicts the GOG data and reports no significant survival advantage to groin dissection versus radiation therapy to the groin.[6] Therefore, radiation therapy to the groin for patients with clinical N0 disease is an alternative to groin dissection for women who refuse or are deemed medically unfit to withstand groin dissections.

2. For those few patients unable to tolerate radical surgery or deemed unsuitable for surgery because of site or extent of disease, radical radiation therapy may result in long-term survival.[6,7,8,9]

Current Clinical Trials

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage II vulvar cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References:

1. Thomas GM, Dembo AJ, Bryson SC, et al.: Changing concepts in the management of vulvar cancer. Gynecol Oncol 42 (1): 9-21, 1991.
2. Hacker NF, Van der Velden J: Conservative management of early vulvar cancer. Cancer 71 (4 Suppl): 1673-7, 1993.
3. Hoffman MS, Roberts WS, Lapolla JP, et al.: Recent modifications in the treatment of invasive squamous cell carcinoma of the vulva. Obstet Gynecol Surv 44 (4): 227-33, 1989.
4. Faul CM, Mirmow D, Huang Q, et al.: Adjuvant radiation for vulvar carcinoma: improved local control. Int J Radiat Oncol Biol Phys 38 (2): 381-9, 1997.
5. Stehman FB, Bundy BN, Thomas G, et al.: Groin dissection versus groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study. Int J Radiat Oncol Biol Phys 24 (2): 389-96, 1992.
6. Petereit DG, Mehta MP, Buchler DA, et al.: Inguinofemoral radiation of N0,N1 vulvar cancer may be equivalent to lymphadenectomy if proper radiation technique is used. Int J Radiat Oncol Biol Phys 27 (4): 963-7, 1993.
7. Slevin NJ, Pointon RC: Radical radiotherapy for carcinoma of the vulva. Br J Radiol 62 (734): 145-7, 1989.
8. Perez CA, Grigsby PW, Galakatos A, et al.: Radiation therapy in management of carcinoma of the vulva with emphasis on conservation therapy. Cancer 71 (11): 3707-16, 1993.
9. Kumar PP, Good RR, Scott JC: Techniques for management of vulvar cancer by irradiation alone. Radiat Med 6 (4): 185-91, 1988 Jul-Aug.