Chi_Principles and Practice of Gynecologic Oncology 8e

Chapter 2.2 ■ Vulvar Cancer: Anatomy, Natural History, and Patterns of Spread 13

Iliac

Obturator

Vesical

Deep

Iliacus

Poupart ligament

Presymphyseal plexus

Superficial

Clitoris

Labia

Sartorius

Adductor longus

Fourchette

Perineum

B

C

❚ Figure 2.2-1. ( continued ) B Nodes between the femoral artery and the vein. Lymph nodes between the vessels are common in the pelvis but not in the groin. C Direct drainage from the clitoral area of the vulva to both groin and pelvic lymph nodes.

a negative SLN procedure, the risk of pelvic LN metastases or dis tant metastases is low (9,10). Rodríguez-Trujillo et al found that only one patient (1/93; 1.1%) had a distant metastasis after a nega tive SLN or inguinofemoral dissection (11). In lateralized vulvar cancer (medial border of the tumor > 1 cm from the virtual midline), LN metastases are usually located in the ipsilateral groin. Contralateral metastases in patients with lateralized vulvar cancer are rare and occur mainly in tumors greater than 4 cm (12). They have also been described in 0% to 6.5% of patients with early-stage vulvar SCC (tumors ≤ 4 cm). In these patients, isolated contralateral LN metastases are only found when the tumor is located 1 cm or less from the midline (13,14). Midline tumors (tumors within 1 cm of the midline) have bilateral lymphatic flow and more often give rise to bilateral groin LN me tastases (15). Distant metastases are rare. Approximately 2% to 7% of patients with vulvar cancer present with distant metastases at some point, but at presentation a risk close to zero is observed (16). Distant metastases can occur because of further lymphatic spread and/or hematogenous dissemination. Prieske et al found that distant me tastases are unilocal in 65% of the cases (16). The most common sites for distant metastases are lung, liver, and bone (16). Spread beyond the inguinofemoral LNs is considered stage IVB. R eferences 1. Plentl AA, Friedman EA. Lymphatic system of the female genitalia: the morphologic basis of oncologic diagnosis and therapy. Major Probl Ob stet Gynecol . 1971;2:1-223. 2. Iversen T, Aas M. Lymph drainage from the vulva. Gynecol Oncol . 1983;16(2):179-189. 3. De Hullu J, Oonk MH, Ansink AC, et al. Pitfalls in the sentinel lymph node procedure in vulvar cancer. Gynecol Oncol . 2004;94(1):10-15. 4. Klapdor R, Wölber L, Hanker L, et al. Predictive factors for lymph node metastases in vulvar cancer. An analysis of the AGO-CaRE-1 multi center study. Gynecol Oncol . 2019;154(3):565-570.

5. Dabi, Y., Gosset, M., Bastuji-Garin, S., Mitri-Frangieh, R., Bendifallah, S., Darai, E., Paniel, B. J., Rouzier, R., Haddad, B., & Touboul, C. (2020). As sociated Lichen Sclerosis Increases the Risk of Lymph Node Metastases of Vulvar Cancer. J Clin Med, 9 (1). https://doi.org/10.3390/JCM9010250 6. Rasmussen CL, Sand FL, Hoffmann Frederiksen M, Kaae Andersen K, Kjær SK. Does HPV status influence survival after vulvar cancer? Int J Can cer . 2018;142(6):1158-1165. 7. Wakeham K, Kavanagh K, Cuschieri K, et al. HPV status and favourable outcome in vulvar squamous cancer. Int J Cancer . 2017;140(5):1134-1146. 8. Hinten F, Molijn A, Eckhardt L, et al. Vulvar cancer: two pathways with different localization and prognosis. Gynecol Oncol . 2018;149(2):310-317. 9. Woelber L, Hampl M, Eulenburg CZ, et al. Risk for pelvic metastasis and role of pelvic lymphadenectomy in node-positive vulvar cancer-results from the AGO-VOP.2 QS vulva study. Cancers (Basel) . 2022;14(2):418. 10. Woelber L, Bommert M, Prieske K, et al. Pelvic lymphadenec tomy in vulvar cancer—does it make sense? Geburtshilfe Frauenheilkd . 2020;80(12):1221-1228. 11. Rodríguez-Trujillo A, Fusté P, Paredes P, et al. Long-term oncological outcomes of patients with negative sentinel lymph node in vulvar cancer. Comparative study with conventional lymphadenectomy. Acta Obstet Gy necol Scand . 2018;97(12):1427-1437. 12. Nica A, Covens A, Vicus D, et al. Sentinel lymph nodes in vulvar can cer: management dilemmas in patients with positive nodes and larger tu mors. Gynecol Oncol . 2019;152(1):94-100. 13. Winarno AS, Mondal A, Martignoni FC, Fehm TN, Hampl M. The potential risk of contralateral non-sentinel groin node metastasis in women with early primary vulvar cancer following unilateral sentinel node metas tasis: a single center evaluation in University Hospital of Düsseldorf. BMC Womens Health . 2021;21(1):23. 14. Ignatov T, Gaßner J, Bozukova M, et al. Contralateral lymph node me tastases in patients with vulvar cancer and unilateral sentinel lymph node metastases of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG). Acta Obstet Gynecol Scand . 2021;100(8):1520-1525. 15. Coleman RL, Ali S, Levenback CF, et al. Is bilateral lymphadenec tomy for midline squamous carcinoma of the vulva always necessary? An analysis from Gynecologic Oncology Group (GOG) 173. Gynecol Oncol . 2013;128(2):155-159. 16. Prieske K, Haeringer N, Grimm D, et al. Patterns of distant metastases in vulvar cancer. Gynecol Oncol . 2016;142(3):427-434.

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