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Abstract
The treatment of vulvar cancer is evolving from the single incision “en bloc” highly morbid resection of the entire vulva, groin, and pelvic nodes for all stages of this disease. Currently, micro-invasive disease is treated conservatively by wide local excision, and stage 1 and 2 disease by wide local excision and superficial groin dissection. Vulvar tumours of all stages which by locanan or size preclude both a one cm surgical margin and the sparing of critical midline anatomy; clitoris, urethra or anal sphincter, can now be considered for primary irradiation rather than surgery. This approach may preserve the function and anatomic integrity of these important structures. Surgico-pathologic factors can greatly assist in identifying those post-surgical patients at higher than normal risk of relapse, so that they can receive targeted, adjunctive therapy.
The extent of the psychological sequelae of the diagnosis and treatment of vulvar cancer is becoming known. Further information about these non-physical morbidities may help us to choose between the available treatment options, based on additional outcome measures including cost of treatment and patient preference.
At this time, our clinical goal is to maintain cure and local control rates and to minimize morbidity in early disease, while we attempt to improve local control and curability for patients with advanced disease. This will be achieved by 1) limiting the amount of tissue treated/excised for patients with early stage/good prognosis disease and, 2) by minimizing the physical and psychologic morbidity, without sacrificing curability, for patients with advanced disease or with adverse risk factors.
Résumé
La résection «en bloc», à morbidité extrêmement élevée, de la vulve, de l’aine et des ganglions pelviens, qui était systématique dans tous les cas de cancer de la vulve, quel qu’en soit le stade, n’a plus cours désormais. La maladie micro-invasive est maintenant traitée de manière conservatrice par une large excision locale, tandis que les stades 1 et 2 font l’objet d’une large excision locale et d’une dissection superficielle de l’aine. On préconise maintenant l’irradiation primaire plutôt que l’intervention chirurgicale, lorsque la tumeur vulvaire, quel que soit son stade, ne permet pas de laisser une marge chirurgicale de 1 cm et d’epargner les structures médianes critiques, le clitoris, l’urètre ou le sphincter anal, du fait de sa position ou de sa grosseur. Cette méthode permet de mieux préserver la fonction et l’intégrité anatomique de ces structures importantes. Des facteurs chirurgico-pathologiques peuvent faciliter grandement l’identification des patientes qui, après chirurgie, présentent un risque de récidive supérieur à la normale, de manière à pouvoir leur prescrire un traitement d’appoint ciblé.
On commence à reconnaître l’ampleur des séquelles psychologiques du diagnostic et du traitement du cancer de la vulve. Une connaissance plus approfandie de ces marbidités non physiques pourraient nous aider à choisir entre différentes options de traitement, en nous basant sur des facteurs supplémentaires tels que le coût du traitement et les préférences de la patiente.
À l’heure actuelle, notre objectif clinique est de maintenir les taux de guérison et de contrôle local et de minimiser la morbidité en début de maladie, tout en tentant d’améliorer le contrôle local et les possibilités de guérison dans les cas de maladie avancée. Cet objectif sera atteint 1) en limitant la quantité de tissus traités ou excisés pour les maladies à leur début/présentant un bon pronostic et 2) en minimisant la morbidité physique et psychologique, sans sacrifier cependant les possibilités de guérison, en cas de maladie avancée ou de facteurs de risque défavorables.
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© 1995 Published by Elsevier Inc.
