The assessment and surgical management of early-stage vulvar cancer

The treatment of early vulvar cancer has undergone a major paradigm shift from a radical surgical approach to tissue-sparing surgery and preservation of sexual function. Stage I and II tumours represent two-thirds of the cases, and 5-year survival rates reach 80–90%. These tumours, with clinically negative nodes, do not require metastatic work-up, and the patients are submitted to surgery. Stage IA tumours, with a depth of stromal invasion of less than 1 mm, have a very low risk of lymph node (LN) involvement (<1%) and are treated by radical (wide) local excision without the need for lymphadenectomy. The remaining patients with stage I or II disease undergo radical (wide) local excision of the vulvar lesion, accompanied by some sort of inguinal lymphadenectomy. Evaluation of the lymph nodes using sentinel node mapping appears promising and is extensively reviewed. It should probably include serial sectioning and immunohistochemistry to detect micrometastases, although their true clinical importance remains to be determined. Molecular detection methods that reveal cancer cells in sites not detectable by routine histology have been introduced to evaluate sentinel lymph nodes and may eventually become part of the routine metastatic work-up.