bubble_chart Overview

Microinvasive carcinoma of the vulva is an extremely early-stage vulvar invasive cancer, which can only be diagnosed based on microscopic pathological examination.

bubble_chart Diagnosis

The pathological diagnostic criteria are not yet fully standardized. Franklin and Warton initially proposed diagnostic criteria of lesions ≤2 cm and stromal invasion depth ≤5 mm, with no cases of lymph node metastasis in their reported cases. However, subsequent studies found that cases diagnosed by these criteria had a lymph node metastasis rate of 5%–33%, leading to the suggestion that the diagnostic standard should be an invasion depth ≤1 mm, which results in 0% lymph node metastasis. In recent years, many scholars have retained the diagnostic criteria of lesions ≤2 cm and invasion depth ≤5 mm but also recommend considering tumor differentiation, the presence of vascular space invasion, and other factors to determine the appropriate treatment plan. This approach aims to avoid unnecessary traditional radical vulvectomy with inguinal lymphadenectomy while preventing overly conservative surgery.

1. Early stages may be asymptomatic. Symptoms may include vulvar cutaneous pruritus, vulvar erosion, ulcers, or masses. If infection is present, there may be local exudate, bleeding, or pain. Advanced stages may be accompanied by urinary symptoms, difficulty defecating, weight loss, etc. 2. Tumors can occur in any part of the vulva, either as solitary or multiple lesions. The lesions may present as nodular, cauliflower-like, erosive, or ulcerative, with clear but irregular borders. The cancerous tissue is fragile, and the base is firm. 3. Pathological examination is required for definitive diagnosis. Biopsy or local lesion excision for pathological confirmation should be performed for vulvar swelling, persistent vulvar leukoplakia, erosions, ulcers, or other suspicious lesions. 4. Careful examination of bilateral inguinal lymph nodes for suspected metastasis is necessary. 5. Staging: According to the 1989 International Federation of Gynecology and Obstetrics (FIGO) staging system: - Stage 0 (TIS): Carcinoma in situ, intraepithelial tumor. - Stage I (T1N0M0): Cancer confined to the vulva and/or perineum, with a maximum diameter ≤2 cm, lymph nodes negative. - Stage II (T2N0M0): Cancer confined to the vulva and/or perineum, with a maximum diameter >2 cm, lymph nodes negative. - Stage III (T1N1M0, T2N1M0, T3N0M0, T3N1M0): Regardless of tumor size, cancer invades the urethra, vagina, or anus, with unilateral inguinal lymph node involvement (+). - Stage IVA (T1N2M0, T2N2M0, T3N2M0, T4N0M0): Cancer invades the upper urethra, bladder, or rectal mucosa, with pelvic and/or bilateral inguinal lymph node involvement (+). - Stage IVB (T1,2,3N1,2M1): Regardless of tumor size and lymph node metastasis extent, distant metastasis is present, including pelvic lymph node involvement (+).

bubble_chart Treatment Measures

Treatment

1. Surgical treatment begins with complete local tumor resection and comprehensive pathological examination to determine the surgical scope based on whether the results align with the biopsy findings.
   1. Partial vulvectomy: The resection includes 3cm of normal tissue beyond the tumor margin and 1cm or more of normal tissue on the inner periphery. This procedure is suitable for patients with well-differentiated tumors, no vascular space invasion, and no high-risk factors for lymph node metastasis.
   2. If vascular space invasion, poor tumor differentiation, or high-risk factors for lymph node metastasis are present, the surgical scope may be appropriately expanded as needed.
2. Radiotherapy is suitable for patients with severe cardiovascular disease, those too elderly to tolerate surgery, or cases where conservative surgical resection cannot meet treatment requirements. **Invasive Vulvar Squamous Cell Carcinoma** Vulvar invasive carcinoma accounts for about 4% of female genital tract malignancies, with 95% being squamous cell carcinoma, predominantly affecting elderly women.

1. **Surgery**: The approach is selected based on clinical staging and tumor location: - **Stage I**: - Tumor on one side of the vulva: Radical vulvectomy and ipsilateral inguinal lymphadenectomy. - Tumor in the midline of the vulva: Radical vulvectomy and bilateral inguinal lymphadenectomy. - **Stage II**: - Negative Cloquet’s lymph node (deep inguinal lymph node): Radical vulvectomy and bilateral superficial and deep inguinal lymph node (Cloquet’s lymph node) resection. - Positive ipsilateral Cloquet’s lymph node: Radical vulvectomy, bilateral superficial inguinal lymphadenectomy, and ipsilateral pelvic lymphadenectomy. - Positive bilateral Cloquet’s lymph nodes: Radical vulvectomy, bilateral inguinal and pelvic lymphadenectomy. - **Stage III**: - Fixed or skin-involved ipsilateral inguinal lymph node metastasis: Radical vulvectomy, bilateral inguinal and pelvic lymphadenectomy. - Tumor involving the anterior urethra: Radical vulvectomy, partial anterior urethral resection, and bilateral inguinal and pelvic lymphadenectomy. - Tumor involving anal skin and bilateral inguinal lymph node metastasis: Radical vulvectomy, anal skin resection, and bilateral inguinal and pelvic lymphadenectomy. - **Stage IV**: - Tumor involving the anal canal and/or rectum and/or lower rectovaginal septum: Radical vulvectomy, lower rectal and anal canal resection, colostomy, and bilateral inguinal and pelvic lymphadenectomy. - Tumor involving the upper urethra and/or bladder trigone: Radical vulvectomy, total urethral and partial bladder resection, urinary diversion, and bilateral inguinal and pelvic lymphadenectomy. *Note*: The above procedures are extensive. Preoperative evaluation of the patient’s overall condition and tolerance is essential to weigh risks and benefits carefully. 2. **Radiotherapy**: Often used as adjuvant or palliative treatment, applicable in the following cases: - (1) Elderly patients or those with severe internal diseases who cannot tolerate surgery. - (2) Cases where the tumor is too extensive for complete resection; palliative radiotherapy may be performed. - (3) Postoperative cases with lymph node metastasis or positive surgical margins may receive adjuvant radiotherapy. 3. **Chemotherapy**: Serves as adjuvant therapy for advanced or recurrent cases. Effective anticancer drugs include doxorubicin or epirubicin, bleomycin or pingyangmycin, cisplatin or carboplatin, 5-fluorouracil, and nitrogen mustard. Due to limited efficacy, intra-pelvic stirred pulse administration may be used to increase drug concentration in the tumor area and improve outcomes.