Treatment Of Vulval Lesions Microinvasive vulval cancer

Micro-invasive vulval cancer, which is defined as a single lesion measuring less than 2 cm in maximum diameter and with a depth of invasion less than or equal to 1.0 mm, is usually managed by complete local excision of the lesion only.

Invasive vulval cancer No clinical evidence of lymphadenopathy In stage I and II lesions with no clinical evidence of lymph node enlargement, a wedge biopsy is performed in order to assess the depth of invasion and rule out the presence of micro-invasive disease. If the depth of invasion is confirmed to be more than 1 mm then a radical local excision and unilateral inguinofemoral node dissection is the treatment of choice. Bilateral nodal dissection is indicated if the lesion is situated in the midline, if the labia minora are involved or there are positive ipsilateral lymph nodes. This is based on the observation that, in early lateral tumours, the incidence of positive contra-lateral nodes is less than 1%.2

Surgical removal should achieve lateral margins of at least 1 cm and deep margins should be to the inferior fascia of the urogenital diaphragm and the fascia over the symphysis pubis. If the lesion is close to the urethra, the lower 1 cm of the urethra may be removed with a low possibility of causing urinary incontinence. If histologically the surgical margins are less than 5 mm careful consideration should be given to radiotherapy.

In certain cases of locally advanced tumours, if the tumour does not appear to be resectable without requiring a stoma, pre-operative radiotherapy and chemotherapy should be considered prior to resection of the tumour bed.

Groin node dissection

A triple incision may be used safely and carries less morbidity than an en bloc approach. It is recommended that both the inguinal and femoral nodes be removed as resecting the inguinal node alone is associated with a higher incidence of groin recurrence.3 If there is more than one (or possibly two) nodal metastasis of less than 5 mm no adjuvant therapy is indicated. However, the patient should receive pelvic irradiation if there is one or more macro-metastases (larger than 10 mm), if there is extra-capsular spread or if there are two (or possibly three) or more micro-metastases.

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