Morbidity of Inguinofemoral Lymphadenectomy in Vulvar Cancer and Evolution of Operative Treatment

Vulvar cancer is the fourth most common gynecologic malignancy, accounting for 5 to 8% of all female genital tract malignancies (Stehman, 2007). It affects 4850 new patients annually in the United States (Siegel, Ma, Zou, & Jemal, 2014) and 3190 new patients in Germany (Kaatsch et al., 2013), with an annual estimated death rate of 1030 and 750, respectively, in the two countries (Kaatsch et al., 2013; Siegel et al., 2014). The incidence of the disease is on the rise, and has almost doubled in the last 10 years (Kaatsch et al., 2013), with a bimodal age distribution of a first peak at 45 to 50 years of age and a second peak at 70 to 75 years of age(Jones, Baranyai, & Stables, 1997). The main risk factor for developing vulvar cancer is human papilloma virus (HPV) infection, whereas 40 to 60% of vulval cancers and 90% of vulvar intraepithelial neoplasia (VIN) are related to HPV infection (Hampl, Deckers-Figiel, Hampl, Rein, & Bender, 2008). HPV subtypes 6, 16, 18, 31, and 33 are most related to the development of vulvar cancer, especially type 16, which has the largest share, approaching 50% of all the affected cases (Insinga, Liaw, Johnson, & Madeleine, 2008). The role of high risk HPV infections was thoroughly studied in cervical dysplasia as a precancerous lesion(Saccardi et al., 2014) that makes us convinced that there is much to be explored in the field of vulvar cancer. The role of HPV vaccination is well established in cervical cancer and its precancerous lesions(Gizzo, Noventa, & Nardelli, 2013) but still needs to be further explored in vulvar cancer. Moreover, the role of antiretroviral medications was explored in precancerous lesions of cervical cancer(Patrelli et al., 2013) while its role in the field of vulvar cancer is still unclear. Other possible risk factors of vulvar cancer are smoking and immune deficiency, whether inherited or acquired. The mainstay of treatment has always been operative, unless the tumor has already reached beyond local clearance so that palliative radiation therapy or combined radiochemotherapy remains the only possible option. Figure 1 shows a locally advanced vulvar cancer before (a) and after (b) a radical vulvectomy with bilateral inguinofemoral lymphadenectomy using a triple incision and abdominal wall flap to cover the resulting defect.