Surgical Procedures of Preneoplastic and Neoplastic Conditions
Over the years, treatment of early vulvar neoplasia has shifted from a radical surgical approach to tissue-sparing surgery and preservation of sexual function. For malignant conditions, separate groin incisions for the inguinal-femoral lymphadenectomy ins
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Fabrizio Bogliatto and Jacob Bornstein
59.1 Background
59.2 Clinical Staging Implications
Surgical management represents the cornerstone of treatment for most of the vulvar premalignant and malignant lesions. Particularly, during the years, treatment of early vulvar neoplasia has shifted from a radical surgical approach to tissue- sparing surgery and preservation of sexual function [1, 2]. Knowledge and consistent application of less invasive surgery concepts, along with experience integrating radiation and chemotherapy in the pre- or postoperative treatment strategy [3–5], is what defines the modern surgical approach to vulvar lesions. The recent principles of ontogenetic theory of local tumor spread, focusing on embryologically defined compartments and sub-compartments rather than organs and structures, have a considerable impact on oncologic vulvar surgery in terms of local failure rate and severe disturbance of the patients’ body image.
Superficially invasive vulvar squamous cancer, stage IA (Table 59.1) [6], has essentially no risk of nodal metastases. In contrast, with tumors Table 59.1 FIGO staging of superficially invasive and invasive vulvar cancer after surgery 1 1 a 1b 2
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F. Bogliatto (*) Department of Obstetrics and Gynaecology, Lower Female Anourogenital Tract Network, Chivasso Civic Hospital, Turin, Italy
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J. Bornstein Department of Obstetrics and Gynecology Galilee Medical Center, Bar-Ilan University Faculty of Medicine, Nahariya, Israel
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Tumor confined to the vulva Lesions ≤2 cm in size, confined to the vulva or perineum and with stromal invasion ≤1.0 mm Lesions >2 cm in size with stromal invasion >1.0 mm, confined to the vulva or perineum Tumor of any size with extension to adjacent perineal structures (lower/distal 1/3 urethra, lower/distal 1/3 vagina, anal involvement) Tumor of any size with or without extension to adjacent perineal structures (lower/distal 1/3 urethra, lower/distal 1/3 vagina, anal involvement) with positive inguino-femoral lymph nodes (1) 1 lymph node metastasis greater than or equal to 5 mm (2) 1–2 lymph node metastasis(es) of less than 5 mm (1) 2 or more lymph nodes metastases greater than or equal to 5 mm (2) 3 or more lymph nodes metastases less than 5 mm Positive node(s) with extracapsular spread Tumor of any size with extension to any of the following: upper/proximal 2/3 of urethra, upper/proximal 2/3 vagina, bladder mucosa, rectal mucosa, or fixed to pelvic bone Any distant metastases including pelvic lymph nodes
© Springer International Publishing AG, part of Springer Nature 2019 J. Bornstein (ed.), Vulvar Disease, https://doi.org/10.1007/978-3-319-61621-6_59
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3 mm deep, the risk of nodal metastasis is approximately 12%. With a 5 mm depth of invasion, there is a reported risk of nodal metastases of approximately 15% [7]. Follow-up of women with vulvar superficially invasive carcinoma is essential. These women, although they have a relatively low risk of local recurrence, are at risk of having a “reoccurrence” of a new pr
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