Homesley HD Gynecol Oncol. 1993 Jun;49(3):279-83.

From 1977 to 1984 the Gynecologic Oncology Group (GOG) conducted a prospective clinical and surgical staging protocol of squamous cell carcinoma of the vulva (n = 637). The patients with superficial (5 mm or less invasion) lesions were the subject of a previous report (n = 272). The subject of this report is on factors that predict groin node metastasis based on all 588 evaluable patients. Comparisons between the two reports are made. Almost half of this group (49.3%) had minimal tumor thickness (< or = mm). Almost one-third of patients had small vulvar lesions (< or = cm). Groin node metastasis was 18.9% for the < or = 2-cm diameter tumors and 41.6% for the > 2-cm diameter lesions. The inaccuracy of clinical palpation of the groin nodes (23.9% false negative) largely accounts for underestimation of extent of disease. Body weight was not related to the sensitivity of detecting positive groin nodes (P = 0.26). Using the logistic model, independent predictors of positive groin nodes were identified (in order of importance): less tumor differentiation by GOG criteria (P < 0.0001), suspicious or fixed/-ulcerated nodes (P < 0.0001), presence of capillary-lymphatic involvement (P < 0.0001), older age (P = 0.0002), and greater tumor thickness (invasion) (P = 0.03). Lesion size and location were not independent predictors of positive groin nodes.

Extracapsular growth of lymph node metastases in squamous cell carcinoma of the vulva. The impact on recurrence and survival.

BACKGROUND. Patients with squamous cell carcinoma of the vulva who present with multiple positive groin lymph nodes have poor survival. Growth of cancer through the capsule of the groin lymph nodes recently has been identified as an important prognostic factor for survival in that patient group. The objective of this study was to determine the influence of several clinicopathologic parameters on the pattern of recurrence and survival. METHODS. A review of 71 patients with squamous cell carcinoma of the vulva and positive lymph nodes was performed to assess the independent prognostic value of a number of variables for survival. Variables analyzed included tumor size, stage, number of positive lymph nodes, extracapsular growth of lymph node metastasis, the greatest dimension of tumor in the lymph nodes, the percentage of replacement of the lymph nodes by tumor, clinical lymph node status, and laterality of positive lymph nodes. RESULTS. Using the Mantel-Cox test, extracapsular growth of lymph node metastases (P = 0.00), two or more positive lymph nodes (P = 0.02), and greater than 50% replacement of lymph nodes by tumor (P = 0.03) were predictors of poor survival. No difference was found between the groups with two positive lymph nodes and those with three or more. Extracapsular growth of lymph node metastases was the most significant independent predictor for survival. Distant metastases occurred in 7 of 15 patients (48%) who had a combination of extranodal spread, lymph node replacement greater than 50%, and three or more positive lymph nodes. CONCLUSION. Extracapsular growth of lymph node metastases in the groin is the most important predictor for poor survival in patients with squamous cell carcinoma of the vulva. Because of the predominant distant failure pattern in a subgroup of patients who have a combination of extranodal spread, multiple positive lymph nodes, and lymph nodes replaced by tumor greater than 50%, a future study of the effectiveness of systemic therapy for vulvar cancer must include these patients.

Fonseca-Moutinho JA, J Reprod Med. 2000 Aug;45(8):672-8.

Gonzalez Bosquet J  Gynecol Oncol. 2007 Jun;105(3):742-6

OBJECTIVES: Assess the pattern of groin node metastases in squamous cell carcinoma (SCC) of the vulva in relation to the site of the primary lesion. Assess whether the identified pattern of lymphatic spread supports the current surgical practice of assessing contralateral nodes for lateral lesions with ipsilateral nodal involvement. METHODS: A retrospective study of surgically staged patients with primary SCC of the vulva between 1955 and 1990 was conducted. This cohort of patients was divided in 4 subgroups by location of primary lesion: unilateral, bilateral, midline, and patients with mediolateral lesions. All clinical and pathological data were reviewed and updated to the 1988 TNM vulvar classification. RESULTS: 320 patients met the inclusion criteria, and almost all of them (>95%) underwent bilateral groin assessment. Of the 108 patients with positive groin lymph-node (LN) involvement, 77 presented with unilateral and 24 with bilateral inguinofemoral involvement. Of the 163 patients presenting with only unilateral vulvar lesions, 48 had inguinofemoral node involvement: 37 with ipsilateral-only nodal metastases, 8 with bilateral LN invasion, and only 3 (1.8%) had isolated contralateral nodal metastases. None of these patients with unilateral vulvar lesion that was either < or = 2 cm in biggest diameter or with invasion < or = 5 mm had bilateral groin LN involvement at diagnosis. CONCLUSIONS: Ipsilateral lymphadenectomy is suitable for patients with unilateral lesions, distant from the midline, and either negative ipsilateral nodes, or with positive ipsilateral LN with lesions smaller than 2 cm.