This is because unrecognised disease in the inguinofemoral lymph nodes is nearly always fatal. Patients treated with both complete inguinofemoral lymph node dissection and external beam radiotherapy to groin nodes suffer the morbidity of both treatments with a higher risk of lymphoedema and cellulitis.ĭespite significant surgical morbidity and a low frequency of lymph node metastases, an elective inguinofemoral lymphadenectomy is regarded as standard of care. 14 Patients are also subjected to groin radiotherapy if cancer metastasis is detected on histopathological examination of lymph nodes. 13 These complications can be incapacitating with major impact on sexual and psychological function. 13 In the long term, lymphoedema of the legs with increased risk for erysipelas occurs in 30% to 70% of patients. 13 In the short term, wound healing in the groin is compromised by infection and breakdown in 20% to 40% of patients. 11 However, as only 25% – 35% of patients with early-stage disease will have lymph node metastases, 7, 12 and the remaining 65% – 75% possibly do not benefit from elective inguinofemoral lymphadenectomy while risking significant morbidity. 7 The efficacy of this treatment is good, with reported groin recurrence rates varying between 1% and 10%. Traditionally, the management of vulval cancer involves radical surgery which includes the excision of the primary lesion and unilateral or bilateral superficial and deep inguinofemoral lymphadenectomy. This project will assess if nodal biopsy can be accurately and efficiently performed to direct the need for further lymphadenectomy. 10 However, only around 30% of these operated cases will have evidence of nodal involvement 7 the rest being node negative. In absolute terms, this means that in any one year there will be a requirement for 700–750 groin lymph node dissections in the UK. At the time of presentation, up to 25% of patients with vulval cancer are stage I, and of these, 30% are stage Ia. In stage Ia, this likelihood is almost zero, and rises once invasion extends beyond 1 mm depth. The likelihood of metastasis is related to the size and the depth of the primary tumour. Nodal assessment with biopsy is currently not routinely performed in practice. 9 Morbidity from lymphadenectomy is high with significant negative impact on the Quality of Life (QoL). 7 Those patients with primary lesions not more than 2 cm, who are inguinal node negative have a 98% 5-year survival rate, while those with any size lesion and three or more unilateral nodes or two or more bilateral nodes associated have a 29% 5-year survival rate. 8 Overall, about a third of patients with operable disease have nodal spread. 7 The inguinal lymph node status has been identified as the single most important factor in predicting mortality attributable to vulval cancer. The standard treatment for squamous cell carcinoma of the vulva is radical surgery, which in all but stage Ia or superficially invasive disease includes inguinofemoral lymphadenectomy. Vulval cancer is curable when diagnosed at an early stage. 2 This trend has been observed in many countries, and has been linked to the rising incidence of vulval intraepithelial neoplasia (VIN) in young women caused by infection with HPV. The proportion of women diagnosed with this cancer under the age of 50 rose from 6% in 1975 to 15% in 2006. 4 Although its peak incidence is in the 7th decade, there has been a significant increase in rates of vulval cancer in younger women. 2 Squamous cell carcinomas (SCC) account for more than 90% of vulval cancers 3 the other 10% include melanomas, sarcomas, basal cell carcinomas and adenocarcinomas. 2 Mortality data from 2007 shows 384 deaths in the UK. 1 In the UK, it affects approximately 1,063 women every year with a 1 in 316 lifetime risk of developing vulval cancer. Vulval cancer accounts for approximately 3–5% of all gynaecological malignancies and 1% of all cancers in women, with an incidence rate of 1–2/100,000.
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