Management of Vulvar Cancer

Vulvar cancer is an uncommon malignancy and accounts for around 5% of all gynecologic cancers. Incidence rates have increased for young adults and may be linked to increasing HPV prevalence. Treatment of vulvar cancer has evolved from 'en-bloc' surgery with high morbidity to more conservative approaches without compromising oncological safety. In recent years sentinel node evaluation has been advocated in early stage cancers to reduce complications of inguino-femoral lymphadenectomy. Minimising extent of radical excision for the vulvar growth and separate incisions for groin dissection have reduced the number of wound breakdowns, infection, lymphocoele and chronic lymphedema but complication rate is still as high as 60%. Incorporating sentinel node evaluation into clinical practice has brought down complications to less than 10% for both lymphedema and wound infection. Role of imaging is increasing in vulvar cancer, especially for locally advanced disease as a result of transition from exenterative and extensive surgery to use of neoadjuvant chemoradiation and a less moribund approach to management. Locally advanced vulvar cancer includes large primary tumors or locally advanced disease i.e. FIGO stages III and IV. Treatment decision here is still a challenge as there is no standard recommended treatment strategy. Neoadjuvant chemoradiation is an effective modality for locally advanced vulvar cancer, as it reduces tumor size and renders the lesion operable. Primary chemoradiation without post treatment surgery has been used as an alternative treatment to avoid extensive radical surgery and complex reconstructive procedures.