1 Department of Medical and Surgical Sciences and Translational Medicine, PhD Course in “Translational Medicine and Oncology'', Sapienza University, 00185 Rome, Italy
2 Gynecologic Oncology Unit, Women Wealth Area, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
3 Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS-Regina Elena National Cancer Unit Institute, 00144 Rome, Italy
4 Unit of Gynecologic Oncology, ARNAS “Civico – Di Cristina – Benfratelli'', Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90133 Palermo, Italy
Academic Editor: Michael H. Dahan
Vulvar cancer (VC) accounts for 5% of all gynecologic cancer and the most common histological type is squamous cell carcinoma (up to 90%) [1].
The median age of VC is over 65 years, but in the past decades the incidence of VC in young women is rising, related to Human Papilloma Virus Infection (HPV) [2]. The staging of vulvar cancer is surgical, based on the 2009 Federation International de Gynecology et Obstetrique (FIGO) and American Joint Committee on Cancer (AJCC) Seventh Staging Edition TNM (Tumor, Node, Metastasis) staging [3].
Over the last years, the surgical treatment of VC tumor is changed, from
invasive technique to more conservative approach, and becoming as personalized as
possible. The original radical vulvectomy approach with en bloc bilateral
inguinal-femoral lymphadenectomy was burdened with a high complication rate:
infection, necrosis of tissues, pain, functional and body image distortion,
deterioration of sexual life and psychological health, making the postoperative
management of this tumor very difficult [4]. The modified radical vulvectomy
includes superficial and deep fascia lata, with separate incisions for tumor and
groin node dissection, sparing several complications [5]. Minimal resection
margins were introduced, limited to the tumor (from 1 to 2 cm according to Heaps’
study) [6]. Di Saia et al. [7] have shown that an alternative approach
for early VC is possible, including 20 patients affected by non- invasive VC and
comparing wide local excision with radical vulvectomy: the 18 patients who
underwent wide local excision have preserved sexual function, assessing prgasm
and dyspareunia. The National Comprehensive Cancer Network (NCCN) Guidelines
recommend re-excision of positive margins or those classified as close (
A big step in the personalized approach to vulvar cancer was represented by postoperative reconstruction [9, 10], based on patients’ characteristics and anatomy, with a big improvement of aesthetic results in these patients. The postoperative reconstruction includes two types of Flaps: Advancement Flap (V-Y Gluteal Fold Flap; Medial Thigh Flap) and Transpositional Flap (Lotus Petal Flap; Gluteal Thigh Flap; Gluteal Fold Flap and Anterolateral Thigh Flap [11, 12].
Despite different studies demonstrating feasibility of sentinel node (SLN)
biopsy in VC early stages, in more than 50% of the cases inguinofemoral
lymphadenectomy is still performed, with high-risk of complications (infection,
lymphedema and erysipelas/lymphangitis). Different studies tried to reduce
complications of deep lymphadenectomy [13], proposing preservation of the deep
fascia, video-endoscopic minimally invasive inguinal lymphadenectomy (VEIL) or
sartorius muscle transposition, without significative results. A recent study
tried to assess the feasibility and safety of a retrograde extraperitoneal
transinguinal novel approach to pelvic lymphadenectomy (TRIPLE) in vulvar cancer
patients [14]. Moreover, some specific anatomical sites, such as genital
lymphedema, are extremely intrusive in private life, creating discomfort and
psychological and there is no consensus about the kind and timing of treatment.
Currently SLN biopsy is the gold standard for surgical treatment of VC with size
Recurrence rate in VC is 15%–35% and surgery is the most adequate treatment of local recurrence, basing the type of surgery no only on the dimension of vulvar recurrence but on performance status of patients and previous treatment.
Surgical treatment of VC has evolved in the last years, trying to reduce mutilating results and promoting a personalized approach, considering sexual life and psychological compromission of these patients too.
AG—conceptualization; ASL and OD—writing original draft preparation; GC and VC—writing review and editing; EV—visualization; AG—supervision. All authors have read and agreed to the published version of the manuscript.
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This research received no external funding.
The authors declare no conflict of interest. ASL is serving as the Editorial Board members and Guest editors of this journal. OD and AG are serving as the Guest editors of this journal. We declare that OD, ASL and AG had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to MHD.
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