Abstract
Simple SummarySquamous cell carcinoma of the vulva is a rare disease, but cure rates are good if managed appropriately. The need for radical vulvectomy was initially challenged about 40 years ago for lesions 1−2 cm diameter. Since then, there has been progressive acceptance of radical local excision for most unifocal squamous vulvar cancers. Originally, a surgical margin of 3 cm around the primary cancer was considered appropriate. Subsequently, a 1 cm margin was generally accepted, but this has become the subject of recent debate. The aims of this study were to determine survival following conservative vulvar resection, and to determine the clinicopathological predictors associated with vulvar recurrence, focusing on the surgical margin. In multivariable analysis, primary site recurrences were increased in patients with margins < 8 mm, and all vulvar and primary site recurrences in patients with margins < 5 mm. Treatment of close or positive margins decreased the risk of recurrence.For the last 30 years at the Royal Hospital for Women, unifocal vulvar squamous cancers have been treated by radical local excision, aiming to achieve a histopathological margin of ≥8 mm, equating to a surgical margin of 1 cm. The need for a margin of this width has recently been challenged. We aimed to determine the long-term outcome following this conservative approach, and the relationship between vulvar recurrences and surgical margins. Data were obtained retrospectively on 345 patients treated primarily with surgery for squamous vulvar cancer between 1987 and 2017. Median follow-up was 93 months. Five-year disease-specific survival was 86%. Of 78 vulvar recurrences, 33 (42.3%) were at the primary site and 45 (57.7%) at a remote site. In multivariable analysis, a margin < 5 mm showed a higher risk of all vulvar (Hazard ratio (HR), 2.29; CI, 1.12−4.70), and primary site recurrences (subdistribution hazard ratio (SHR), 15.20; CI, 5.21−44.26), while those with a margin of 5 to <8 mm had a higher risk of a primary site recurrence (SHR, 8.92; CI, 3.26−24.43), and a lower risk of remote site recurrence. Excision margins < 8 mm treated by re-excision or radiation therapy had a significantly decreased risk of recurrence. Guidelines should continue to recommend a surgical margin of 1 cm.
Highlights
Squamous cell carcinoma of the vulva (VSCC) is a rare disease, but cure rates are good if the primary tumour and groin lymph nodes are managed appropriately [1]
We identified significant differences in local recurrence rates related to pathological margin distance and the location of a recurrence on the vulva
Our study has demonstrated that conservative vulvar resection in 80% and bilateral inguino-femoral lymphadenectomy in 35.6% of patients with squamous cell carcinoma of the vulva is associated with an excellent survival
Summary
Squamous cell carcinoma of the vulva (VSCC) is a rare disease, but cure rates are good if the primary tumour and groin lymph nodes are managed appropriately [1]. Cancers 2020, 12, 3375 radical vulvectomy was the standard of care for the primary tumour, it caused serious psychosexual morbidity [2]. The main argument against performing a more conservative vulvar operation was that multicentricity occurred in 20−30% of cases, and more conservative procedures would result in more vulvar recurrences [3]. This concern has been explained by the concept of field cancerization [4]. There has been a slow acceptance of radical local excision for most unifocal squamous vulvar cancers [7,8], the change in management has never been subjected to a prospective, randomized trial
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