Surgical management of vulvar cancer

Vulvar cancer is an uncommon disease, marked by typical long delays in diagnosis due to lack of awareness by doctors and patients. The most common histology is squamous, although melanoma, sarcoma and adenocarcinoma occur less frequently. The predictable spread pattern of vulvar cancer to regional then distant lymphatics has allowed for improvements in survival largely due to radical surgical intervention. However, the significant morbidity from radical surgery has led to the search for better prognostic indicators and complementary therapeutic modalities to modify the extent of surgery in both early and advanced disease. En bloc radical vulvectomy and bilateral inguinal-femoral lymphadenectomy are rarely performed today: an early invasive stage has been defined where only limited excision is required. The extent of and the indications for inguinal lymphadenectomy for various clinical tumors and role of separate incisions have been clarified. When disease has spread to more than one inguinal node, adjuvant radiotherapy has replaced pelvic lymphadenectomy as the standard. Inguinal radiotherapy without groin dissection does not appear to be adequate therapy for most patients. The use of chemotherapy and radiation to shrink large tumors to allow surgical resection continues to be evaluated but has demonstrated excellent results to date. The utility of newer techniques of sentinel node mapping is also being evaluated in squamous cancers and melanoma to limit the extent of lymphadenectomy in patients with clinically normally lymph nodes.