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Invasive carcinoma of the vulva with lymph node metastasis
Invasive carcinoma of the vulva with lymph node metastasis CONRAD
G.
FREDERICK JUAN New
COLLINS, Y.
J. Orleans,
L.
M.D. LEE,
M.D.*
ROMAN-LOPEZ,
M.D.*
Louisiana
The subject of lymph node metastasis in invasive carcinoma of the vulva is presented from an evaluation of 23 years’ experience by the Department of Obstetrics and Gynecology, Tulane University School of Medicine. The clinical and histopathologic features of the evaluation and a discussion relating the significance of these features are presented.
INVASIVE
CARCINOMA
OF
from January, 19%, to October, 1969, by the Tulane Division of Obstetrics and Gynecology, Charity Hospital of Louisiana at New Orleans and the Tulane Vulva Clinic staff, 98 patients had benefit of complete therapy as prescribed by previously establishedproto~01”s‘9 *I lo*14,I5 and thus qualified for evaluation. Thirty one (or 31.6 per cent) of these 98 patients were found to have regional lymph node metastasis. It is the evaluation of this group that provides the basisfor this report. Patients’ records were made available for study from the Tulane Vulva Clinic, the Tulane School of Medicine, and the Tumor Registry and Medical Record Library of Charity Hospital of Louisiana at New Orleans. A greater portion of the statistical evaluation of this study is based upon the continuing characterization by this department of lesions of the vulva as to size. As in earlier reports’* sol* the measured diameter of 3 cm., greater or less,has been utiliied. All 5 year survival figures are uncorrected
THE
v u L v A has been extensively evaluated by the Tulane Obstetrical and Gynecological Service for the past 23 years. Numerous reports concerning our experience with this entity have been published.l-I8 Because of the continuing controversy regarding the extent of surgery required in the treatment of invasive carcinoma of the vulva, and because of the paucity of reports evaluating the significance of lymph node metastasis in this disease entity, it is felt that our experience in this field should be made available for study. Material
and
methods
Of 120 consecutive casesof invasive carcinoma of the vulva seen during the period From the Department of Obstetrics and Gynecology, Tulane University School of Medicine. Supported in part by United States Public Health Service Award, Cancer Control Senior Clinical Traineeship Project No. 77020-01-69. *Clinical Cancer Surgical Trainees.
446
Voiume Number
Invasive carcinoma
109 3
and are based upon a continual program of patient follow-up. Clinical
and
histopathologic
features
Age. The ages of these 31 patients varied from 35 to 85 years. The average age in this series was 58.2 years; the median age, 59.0 years. Fifteen of the 31 patients were Caucasian, with an average age of 63.0 years. The remaining patients were Negro, with an average age of 59.0 years. Presenting complaints. As can be seen in Table I, pruritus and the presence of a tumor or an ulcer were, by far, the most common of the presenting complaints. Duration of symptoms. In the evaluation of this parameter (Table I), 2 points noted were of significance. The completely asymptomatic lesion did not occur, and patient delay is still a significant factor in this disease. Thirty-one per cent of patients in this series had symptoms of their disease for greater than 12 months’ duration. Location and size of lesion. Eight of the 31 patients, or 25.8 per cent, had lesionson the anterior portion of the vulva and perineum. Thirteen patients, or 41.9 per cent, had lesions on the posterior portions of the vulva and perineum. Ten of 31, or 32.3 per cent, had combined anteroposterior lesions. Fifty per cent of the lesions were unilateral. Twenty-five of the 31 patients, 80.6 per cent, had lesions3 cm. or greater in size. Six patients, 19.4 per cent, had lesions less than 3 cm. in size. All lesions were measured in at least 2 diameters. Origin and histology. As shown in Table II, of 120 consecutive casesof invasive carcinoma of the vulva evaluated histologically, 104 caseswere noted to be of the 5 histologic types resulting in our 31 cases of positive nodes. Histologic lesionsof the vulvar integument were by far the most common in this series, the epidexmoid !&on specifically having the most frequent occurrence. Twenty-three of 92 casesof epidermoid carcinoma of the vulva resulted in nodal metastasis,an incidence of 1 in 4. Twenty
of vulva
447
Table I. Invasive carcinoma with lymph node metastasis,1946 to 1969 Presenting complaints Duration of symptoms I Comjlaint ( No. 1 Duration No. 0 7 9 11 6 16 11
None Discharge Bleeding Pruritis Pain Tumor Ulcer
Unknown No symptoms 6 months or less 6 to 12 months 1 to 2 years 2 to 5 years Over S-years
5 0 11 7 1 1 6
Table II. Histology, lesion size, and positive nodes Histologic type Vulva integument Epidermoid Malignant noma
Bartholin’s
mela-
Total cases
Lesion site <3
cm. ( >3
cm.
92 5
5 0
18 2
4
1
3
:
0
:
gland
Adenocarcinoma
Urethra Transitional Adenocarcinoma
three of the 31 casesof positive nodes, 74.2 per cent, were histologically epidermoid. Analysis of the other histologic types as to occurrence of metastasis because of size of sampleis probably not significant. Associated medical illness. Fifteen of 31 patients had a complicating medical illnessor illnesses. Hypertension, cardiovascular disease, and obesity led the list, but diabetes mellitus, anemia, and malnutrition played a significant role in patient responseto therapy. Obesity, especially, played an important role in the postoperative morbidity problem of wound infection and breakdown. Venereal disease,past or present. Four of the 31 patients, 12.8 per cent, had evidence of previous or concurrent history of venereal disease.The occurrence of more than one type of venereal infection in these patients was common. Second primary neoplasms.Seven patients,
448
Collins,
Lee,
and
Roman-Lopez Amer.
Table III.
Extent
of surgical
procedures No. of cases
Procedure Exenteration Total Anterior Posterior
procedures 1 3 3 7
Partial resection of urethra Partial or total vaginectomy Partial resection of levator ani muscles (unilateral and bilateral) Uterus and cervix Rectum
3 4 4 1 2
Table IV. Size of lesion and node metastasis, 1946 to 1969 Nodes Negative Positive Regional Inguinal Cloquets Femoral External iliac Common iliac Hypogastric Obturator Aortic Vena cava
)
<3
cm. 35 6 (15%)
)
>3,
cm.
32 (43.9%) 25
5”
23
00 0 0 1 0
h 5 3 72s 1 1
“One case bilateral involvement. +Seven cases bilateral involvement. $Two cases bilateral BTbree cases bilateral
involvement. involvement.
22.6 per cent, had a second primary neoplastic lesion either concurrent with the disease or diagnosed during follow-up. Two cases of adenocarcinoma of the ovary, 2 cases of adenocarcinoma of the uterine fundus, one case of epidermoid carcinoma of the anus, one case of carcinoma of the lung, and one case of adenocarcinoma of the urethra were found. Extent of surgical procedures. Besides the planned procedure, extensive vulvectomy, bilateral superficial and deep inguinal lymphadenectomy and bilateral deep pelvic lymphadenectomy, excision of contiguous tissues or organs involved, and exenteration were done
February J. Obstet.
1, 1971 Gynec.
in 12 of 31 patients (Table III) . Extensive procedures were performed for adenocarcinoma of the uterine fundus in the one instance of associated operation concerning the uterus and cervix. An anterior rectal wedge with repair and resection of the distal r/s of the rectum with a “pull-through procedure” was performed in one of the 2 instances concerning the rectum. Results
and
comments
Table IV shows the occurrence rate of metastasis in the general series of 98 patients with complete therapy, based on lesion size. Of patients with lesions less than 3 cm. in size, a one in 6 chance for metastasis is evident. Of patients with lesions 3 cm. or greater, a one in 2 chance of Iymph node involvement occurs. Of the 31 patients with node metastasis, 20 patients had inguinal node involvement only. Seven patients had inguinal and deep pelvic node involvement, and 4 patients had deep pelvic node involvement only. In evaluating the relationship of positive nodes to anatomic location of metastasis (Table IV), one will note that 27 of 31 patients had positive inguinal nodes, the most frequently involved site and the site of first nodal involvement in the majority of cases. In 11 instances of positive deep pelvic node involvement, 8 cases had involvement of the obturator nodes. However, in only 3 of the 8 cases of obturator node involvement were Cloquet’s or the external iliac nodes involved with cancer. In 4 instances, 12.9 per cent, one cancer of Bartholin’s gland, one cancer of the urethra, and 2 squamous cell cancers of the vulva, there was direct metastasis to the obturator nodes without involvement of the inguinal nodes. Metastatic involvement was bilateral in both cases in the last instance. Thus, the accepted practice of sampling, by frozen section of the node of Cloquet or Rosenmuller, as an indicator for the performance of deep pelvic lymphadenectomy, has no relative merit as deep pelvic node involvement occurs without the involvement of the inguinal nodes. Fig. 1 shows the anatomic distribution and
Volume Number
109 3
Invasive carcinoma
Right
Common External
of vulva
449
Left
iliac ; 2’
1
iliac-
Femoral -2Obturator- 3 ds . bilateral node involvement Cloquet
_ 2 Ii
”
”
”
lnquinal - 8 ‘I ‘I ” ” Al I other categories - I case bilateral node involvement Fig. 1. Positive nodes, anatomic distribution. frequency of lymph node group involvement in this series. Bilateral node group involvement occurred in 3 instances in the obturator node group, 2 instances with Cloquet’s node involvement, and 8 instances with inguinal node group involvement. Bilateral lymph node chain involvement, symmetrical or asymmetrical, was quite evident in 21 per cent of the patients with lesions 3 cm. in size or greater. If positive nodes were found, 48 per cent were then involved bilateraily. As previously reported,G every type of possible metastases occurred, though an orderly progression of lymph node chain involvement seemed apparent in most cases. Whenever the lesion was restricted to one side of the vulva, contralateral node metastasis was not found unless the ipsilateral group was also involved.
Patient operability by the clinica evaluation of inguinal node involvement by palpation or other means was again found to be inadequate. Fig. 2 shows the relationship between the location of the lesion on the vulva and node metastasis. In lesions less than 3 cm. in size, the tendency is toward unilateral metastasis, if any. There was only one instance of deep node involvement, a case of adenocarcinoma of the Bartholin’s gland. Bilateral inguinal node involvement occurred once in an epidermoid lesion in the upper ‘/3 of the left labia minora. Fig. 3 shows this relationship in vulvar lesions 3 cm. or greater in size. Metastases in this category were more frequently bilateral as stated earlier. Seven of the 8 instances of bilateral inguinal node involvement occurred in this category. Analysis of
450
Collins, Lee, and Roman-Lopez
of lesions
<
3 cm.
*l Case deep node involy?ent **2Cases ” ” 01 Case bilateral node i nvolveme 8 1 Case bilateral i Fig. 3. Location
of lesions
>
February J. obstet.
1,197l oymc.
these patients with deep pelvic node involvement shows a marked tendency for the more central lesionsas indicated on the illustration, 8 of 11 cases,to have early bilateral positive inguinal nodesand positive deep pelvic nodes. Six of these caseswere in the area of the clitoris, urethra, and upper ys of the labia minora and majora; 2 were in the bilateral vulvovaginoperineal area. Also included in these central quadrants are 3 of the 4 cases of direct deep-node metastasis.These 3 cases were in the 3 cm. or greater category. This, again, refutes nodal sampling as an indicator for deep pelvic lymphadenectomy, especially in lesionsin these anatomic sites. It is of interest that no other correlation between location of, and histology of, the lesion and frequency of node metastasiswas found except in adenocarcinoma of the Bartholin’s gland. All 4 caseshad node metastasis, and it is in this group of patients where, again, location of lesion rather than lesion size may be of significance.
, &;5al Fig. 2. Location
Amer.
3 cm.
Volume Number
109 3
Invasive carcinoma
of vulva
vived 5 or more years. In lesions 3 cm. or greater in size, 16.7 per cent survived 5 or more years. In evaluation of 5 year survival with respect to age, 17 patients were less than 60 years of age. Of these, 2 survived 5 years. Of 14 patients who were more than 60 years of age, 3 survived 5 years. Our results show, we feel, that age alone does not play a significant role in 5 year survival results. Of 20 patients who had inguinal lymph node metastasisonly, 4 survived 5 years for a 20 per cent 5 year survival. Of the 7 patients with both inguinal and deep node involvement, one survived 5 years for a 14.3 per cent 5 year survival. Of the 4 patients with direct deep pelvic node metastasisonly, there were no 5 year survivors. Location of lesion, except in those lesions involving the aforementioned central vulvovaginoperineal quadrants and in adenocarcinoma of the Bartholin’s gland, was not found to be of significance. Lesion size, rather, was again found to be of significance. In evaluating the histology of the lesion as to survival, no patient with invasive carcinoma of the vulva with positive lymph node metastasis,other than epidermoid carcinoma, survived longer than 2 years. In epidennoid lesions, lesion size seemedto be of greatest significance. Adenocarcinoma of the Bartho-
Recurrences. Of the 31 patients with positive nodes, 5 patients were listed as operative deaths. The remaining 26 patients were then considered for evaluation of recurrence. Evidence of recurrence was accepted when noted by the diagnostic parameters of radiography, biopsy, secondary operative procedures, or postmortem examination. Seven of the 26 patients, 26.9 per cent, were found to be free of their diseaseduring this follow-up. Two patients, 7.7 per cent, were found to have had evidence of local recurrence only. Ten patients, or 38.5 per cent, were found to have had systemic recurrence only, and 7 patients, or 26.9 per cent, showed combined local and systemic recurrence. Analysis of recurrences as to lesion size and histology is shown in Table V. Again, in the epidermoid lesions,the prognostic significance of lesion size is seen. The significance of the central lesions,as noted earlier, is again seen in the systemic and combined groupings of recurrence. All epidermoid lesions, except one, were of the combination variety as defined in location of lesion. Survival. In regard to survival (Table VI), 20.8 per cent of patients in this seriessurvived 5 or more years. Comparing positive nodes and lesion size, with lesions less than 3 cm. in size, 33.3 per cent of patients sur-
Table V. Recurrences Diameter
None
<3 >3
1 Epi. 5 Epi. I Adeno.
)
Local
only
1
Systemic
1 Epi. 1 Epi.
1 1 1 1 6
Barth.
Epi. Adeno. Adeno. Trans. Epi.
only
Combined
I
1 Adeno. Barth. 1 Melanoma 5 Epi.
Barth. urethra urethra
Table VI. Size of lesion, node metastasis,and survival
I Sire of lesion’
I (
Positive Eligible
No. of cases
Cases
< 3 cm. > 3 cm.
2:
6 18
Total
31
24
451
nodes
5 yr. (
Not
Survived
Cases
eligible 1
5 yr. Living
i
0 7
0 1
5
7
1
452
Collins,
Lee,
and
Roman-Lopez
Amer.
lin’s gland, in this series, was found to be a highly malignant lesion with grave prognosis. Early inguinal and/or deep pelvic node metastasis occurred regardless of lesion size, duration of symptoms, or the age of the patient. In the 8 patients with a second malignant neoplasm, there was one 5 year survivor who died at 7 years with adenocarcinoma of the lung; all others died within 3 years.
February J. Obstet.
1, 1971 Gynec.
In evaluating recurrence, the average surviva1 of patients with recurrence was 15 months. Without recurrence, the average surviva1 was 7 years and 8 months, the longest survivor in this category being 23 years post operation, and she was completely free of her disease.
REFERENCES
1.
Barclay,
D.
OBSTE?.
GYNE&
L.,
and 86:
Collins, 95,
C. G.:
AMER.
J.
11.
1983.
2.
Barclav. D. L.. Collins. C. G.. and Macev. H. B.,’ jr.: Obitet. Gynkc. 24: 329, 1964. ” 3. Barclay, D. L., Collins, C. G., and Hansen, L. A.:.Clin. Obstet. Gynec. 10; 641, 1967. 4. Birch. H. W.. and Collins. C. G.: T. Louisiana Med.‘Soc. lli: 296, 1959.’ ” 5. Birch, H. W., and Collins, J. H.: Southern Med. J. 53: 473, 1960. 6. Cassidy, R. E., Braden, F. R., and Cerha, H. T.: AMER. J. OBSTET. GYNEC. 74: 361, 1957. 7. Collins, C. -G., Collins, J. H., Nelson, E. W., Smith. R. C.. and MacCallum. E. A.: AMER. J. OB~TET. ~YNEC. 62: 1198, i951. 8. Collins, C. G., Kushner, J., Lewis, G. N., and Lapointe, R.: Obstet. Gynec. 6: 339, 1955. 9. Collins, C. G., Collins, J. H., Nelson, E. W., Lewis, G. N., and Cassidy, R. E.: Obstet. Gynec. 8: 18, 1956. 10. Collins, C. G., Collins, J. H., Cassidy, R. E., and Burman, R. G.: Dallas Med. J, 43: 675, 1958.
12.
13. 14. 15. 16. 17.
18.
Collins, C. G., Collins, J. H., Barclay, D. L., and Nelson, ‘E. W.: AMER. J. OBSTET. GYNEC. 87: 672, 1963. Collins, C. G., and Barclay, D. L.: Clinical Obstetrics and Gynecology, New York, 1963, Paul B. Hoeber, Inc., Medical Book Division of Harper & Row, Publishers. Collins, C. G., and Barclay, D. L.: Cancer, Philadelphia, 1965, W. B. Saunders Comuanv. Collins, C. G., Hansen, L. H., and Thkridt, E.: Obstet. Gvnec. 28: 158. 1966. Collins, J. H., &man, R. G.1 and Mathews, N. M.: Amer. J. Surg. 92: 37, 1956. Collins, J. H.: AMER. J. OBSTET. GYNEC. 79: 1207, 1960. Collins, J. H., Birch, H., Pailet, M., and Avent, J.: ADIER. J. OBSTET. GYNEC. 80: 167, 1960. Collins, J. H., Barclay, D. L., and Collins, G. G.: AMER. J. OBSTET. GYNEC. 84: 1135, 1962.
G.
FREDERICK JUAN New
COLLINS, Y.
J. Orleans,
L.
M.D. LEE,
M.D.*
ROMAN-LOPEZ,
M.D.*
Louisiana
The subject of lymph node metastasis in invasive carcinoma of the vulva is presented from an evaluation of 23 years’ experience by the Department of Obstetrics and Gynecology, Tulane University School of Medicine. The clinical and histopathologic features of the evaluation and a discussion relating the significance of these features are presented.
INVASIVE
CARCINOMA
OF
from January, 19%, to October, 1969, by the Tulane Division of Obstetrics and Gynecology, Charity Hospital of Louisiana at New Orleans and the Tulane Vulva Clinic staff, 98 patients had benefit of complete therapy as prescribed by previously establishedproto~01”s‘9 *I lo*14,I5 and thus qualified for evaluation. Thirty one (or 31.6 per cent) of these 98 patients were found to have regional lymph node metastasis. It is the evaluation of this group that provides the basisfor this report. Patients’ records were made available for study from the Tulane Vulva Clinic, the Tulane School of Medicine, and the Tumor Registry and Medical Record Library of Charity Hospital of Louisiana at New Orleans. A greater portion of the statistical evaluation of this study is based upon the continuing characterization by this department of lesions of the vulva as to size. As in earlier reports’* sol* the measured diameter of 3 cm., greater or less,has been utiliied. All 5 year survival figures are uncorrected
THE
v u L v A has been extensively evaluated by the Tulane Obstetrical and Gynecological Service for the past 23 years. Numerous reports concerning our experience with this entity have been published.l-I8 Because of the continuing controversy regarding the extent of surgery required in the treatment of invasive carcinoma of the vulva, and because of the paucity of reports evaluating the significance of lymph node metastasis in this disease entity, it is felt that our experience in this field should be made available for study. Material
and
methods
Of 120 consecutive casesof invasive carcinoma of the vulva seen during the period From the Department of Obstetrics and Gynecology, Tulane University School of Medicine. Supported in part by United States Public Health Service Award, Cancer Control Senior Clinical Traineeship Project No. 77020-01-69. *Clinical Cancer Surgical Trainees.
446
Voiume Number
Invasive carcinoma
109 3
and are based upon a continual program of patient follow-up. Clinical
and
histopathologic
features
Age. The ages of these 31 patients varied from 35 to 85 years. The average age in this series was 58.2 years; the median age, 59.0 years. Fifteen of the 31 patients were Caucasian, with an average age of 63.0 years. The remaining patients were Negro, with an average age of 59.0 years. Presenting complaints. As can be seen in Table I, pruritus and the presence of a tumor or an ulcer were, by far, the most common of the presenting complaints. Duration of symptoms. In the evaluation of this parameter (Table I), 2 points noted were of significance. The completely asymptomatic lesion did not occur, and patient delay is still a significant factor in this disease. Thirty-one per cent of patients in this series had symptoms of their disease for greater than 12 months’ duration. Location and size of lesion. Eight of the 31 patients, or 25.8 per cent, had lesionson the anterior portion of the vulva and perineum. Thirteen patients, or 41.9 per cent, had lesions on the posterior portions of the vulva and perineum. Ten of 31, or 32.3 per cent, had combined anteroposterior lesions. Fifty per cent of the lesions were unilateral. Twenty-five of the 31 patients, 80.6 per cent, had lesions3 cm. or greater in size. Six patients, 19.4 per cent, had lesions less than 3 cm. in size. All lesions were measured in at least 2 diameters. Origin and histology. As shown in Table II, of 120 consecutive casesof invasive carcinoma of the vulva evaluated histologically, 104 caseswere noted to be of the 5 histologic types resulting in our 31 cases of positive nodes. Histologic lesionsof the vulvar integument were by far the most common in this series, the epidexmoid !&on specifically having the most frequent occurrence. Twenty-three of 92 casesof epidermoid carcinoma of the vulva resulted in nodal metastasis,an incidence of 1 in 4. Twenty
of vulva
447
Table I. Invasive carcinoma with lymph node metastasis,1946 to 1969 Presenting complaints Duration of symptoms I Comjlaint ( No. 1 Duration No. 0 7 9 11 6 16 11
None Discharge Bleeding Pruritis Pain Tumor Ulcer
Unknown No symptoms 6 months or less 6 to 12 months 1 to 2 years 2 to 5 years Over S-years
5 0 11 7 1 1 6
Table II. Histology, lesion size, and positive nodes Histologic type Vulva integument Epidermoid Malignant noma
Bartholin’s
mela-
Total cases
Lesion site <3
cm. ( >3
cm.
92 5
5 0
18 2
4
1
3
:
0
:
gland
Adenocarcinoma
Urethra Transitional Adenocarcinoma
three of the 31 casesof positive nodes, 74.2 per cent, were histologically epidermoid. Analysis of the other histologic types as to occurrence of metastasis because of size of sampleis probably not significant. Associated medical illness. Fifteen of 31 patients had a complicating medical illnessor illnesses. Hypertension, cardiovascular disease, and obesity led the list, but diabetes mellitus, anemia, and malnutrition played a significant role in patient responseto therapy. Obesity, especially, played an important role in the postoperative morbidity problem of wound infection and breakdown. Venereal disease,past or present. Four of the 31 patients, 12.8 per cent, had evidence of previous or concurrent history of venereal disease.The occurrence of more than one type of venereal infection in these patients was common. Second primary neoplasms.Seven patients,
448
Collins,
Lee,
and
Roman-Lopez Amer.
Table III.
Extent
of surgical
procedures No. of cases
Procedure Exenteration Total Anterior Posterior
procedures 1 3 3 7
Partial resection of urethra Partial or total vaginectomy Partial resection of levator ani muscles (unilateral and bilateral) Uterus and cervix Rectum
3 4 4 1 2
Table IV. Size of lesion and node metastasis, 1946 to 1969 Nodes Negative Positive Regional Inguinal Cloquets Femoral External iliac Common iliac Hypogastric Obturator Aortic Vena cava
)
<3
cm. 35 6 (15%)
)
>3,
cm.
32 (43.9%) 25
5”
23
00 0 0 1 0
h 5 3 72s 1 1
“One case bilateral involvement. +Seven cases bilateral involvement. $Two cases bilateral BTbree cases bilateral
involvement. involvement.
22.6 per cent, had a second primary neoplastic lesion either concurrent with the disease or diagnosed during follow-up. Two cases of adenocarcinoma of the ovary, 2 cases of adenocarcinoma of the uterine fundus, one case of epidermoid carcinoma of the anus, one case of carcinoma of the lung, and one case of adenocarcinoma of the urethra were found. Extent of surgical procedures. Besides the planned procedure, extensive vulvectomy, bilateral superficial and deep inguinal lymphadenectomy and bilateral deep pelvic lymphadenectomy, excision of contiguous tissues or organs involved, and exenteration were done
February J. Obstet.
1, 1971 Gynec.
in 12 of 31 patients (Table III) . Extensive procedures were performed for adenocarcinoma of the uterine fundus in the one instance of associated operation concerning the uterus and cervix. An anterior rectal wedge with repair and resection of the distal r/s of the rectum with a “pull-through procedure” was performed in one of the 2 instances concerning the rectum. Results
and
comments
Table IV shows the occurrence rate of metastasis in the general series of 98 patients with complete therapy, based on lesion size. Of patients with lesions less than 3 cm. in size, a one in 6 chance for metastasis is evident. Of patients with lesions 3 cm. or greater, a one in 2 chance of Iymph node involvement occurs. Of the 31 patients with node metastasis, 20 patients had inguinal node involvement only. Seven patients had inguinal and deep pelvic node involvement, and 4 patients had deep pelvic node involvement only. In evaluating the relationship of positive nodes to anatomic location of metastasis (Table IV), one will note that 27 of 31 patients had positive inguinal nodes, the most frequently involved site and the site of first nodal involvement in the majority of cases. In 11 instances of positive deep pelvic node involvement, 8 cases had involvement of the obturator nodes. However, in only 3 of the 8 cases of obturator node involvement were Cloquet’s or the external iliac nodes involved with cancer. In 4 instances, 12.9 per cent, one cancer of Bartholin’s gland, one cancer of the urethra, and 2 squamous cell cancers of the vulva, there was direct metastasis to the obturator nodes without involvement of the inguinal nodes. Metastatic involvement was bilateral in both cases in the last instance. Thus, the accepted practice of sampling, by frozen section of the node of Cloquet or Rosenmuller, as an indicator for the performance of deep pelvic lymphadenectomy, has no relative merit as deep pelvic node involvement occurs without the involvement of the inguinal nodes. Fig. 1 shows the anatomic distribution and
Volume Number
109 3
Invasive carcinoma
Right
Common External
of vulva
449
Left
iliac ; 2’
1
iliac-
Femoral -2Obturator- 3 ds . bilateral node involvement Cloquet
_ 2 Ii
”
”
”
lnquinal - 8 ‘I ‘I ” ” Al I other categories - I case bilateral node involvement Fig. 1. Positive nodes, anatomic distribution. frequency of lymph node group involvement in this series. Bilateral node group involvement occurred in 3 instances in the obturator node group, 2 instances with Cloquet’s node involvement, and 8 instances with inguinal node group involvement. Bilateral lymph node chain involvement, symmetrical or asymmetrical, was quite evident in 21 per cent of the patients with lesions 3 cm. in size or greater. If positive nodes were found, 48 per cent were then involved bilateraily. As previously reported,G every type of possible metastases occurred, though an orderly progression of lymph node chain involvement seemed apparent in most cases. Whenever the lesion was restricted to one side of the vulva, contralateral node metastasis was not found unless the ipsilateral group was also involved.
Patient operability by the clinica evaluation of inguinal node involvement by palpation or other means was again found to be inadequate. Fig. 2 shows the relationship between the location of the lesion on the vulva and node metastasis. In lesions less than 3 cm. in size, the tendency is toward unilateral metastasis, if any. There was only one instance of deep node involvement, a case of adenocarcinoma of the Bartholin’s gland. Bilateral inguinal node involvement occurred once in an epidermoid lesion in the upper ‘/3 of the left labia minora. Fig. 3 shows this relationship in vulvar lesions 3 cm. or greater in size. Metastases in this category were more frequently bilateral as stated earlier. Seven of the 8 instances of bilateral inguinal node involvement occurred in this category. Analysis of
450
Collins, Lee, and Roman-Lopez
of lesions
<
3 cm.
*l Case deep node involy?ent **2Cases ” ” 01 Case bilateral node i nvolveme 8 1 Case bilateral i Fig. 3. Location
of lesions
>
February J. obstet.
1,197l oymc.
these patients with deep pelvic node involvement shows a marked tendency for the more central lesionsas indicated on the illustration, 8 of 11 cases,to have early bilateral positive inguinal nodesand positive deep pelvic nodes. Six of these caseswere in the area of the clitoris, urethra, and upper ys of the labia minora and majora; 2 were in the bilateral vulvovaginoperineal area. Also included in these central quadrants are 3 of the 4 cases of direct deep-node metastasis.These 3 cases were in the 3 cm. or greater category. This, again, refutes nodal sampling as an indicator for deep pelvic lymphadenectomy, especially in lesionsin these anatomic sites. It is of interest that no other correlation between location of, and histology of, the lesion and frequency of node metastasiswas found except in adenocarcinoma of the Bartholin’s gland. All 4 caseshad node metastasis, and it is in this group of patients where, again, location of lesion rather than lesion size may be of significance.
, &;5al Fig. 2. Location
Amer.
3 cm.
Volume Number
109 3
Invasive carcinoma
of vulva
vived 5 or more years. In lesions 3 cm. or greater in size, 16.7 per cent survived 5 or more years. In evaluation of 5 year survival with respect to age, 17 patients were less than 60 years of age. Of these, 2 survived 5 years. Of 14 patients who were more than 60 years of age, 3 survived 5 years. Our results show, we feel, that age alone does not play a significant role in 5 year survival results. Of 20 patients who had inguinal lymph node metastasisonly, 4 survived 5 years for a 20 per cent 5 year survival. Of the 7 patients with both inguinal and deep node involvement, one survived 5 years for a 14.3 per cent 5 year survival. Of the 4 patients with direct deep pelvic node metastasisonly, there were no 5 year survivors. Location of lesion, except in those lesions involving the aforementioned central vulvovaginoperineal quadrants and in adenocarcinoma of the Bartholin’s gland, was not found to be of significance. Lesion size, rather, was again found to be of significance. In evaluating the histology of the lesion as to survival, no patient with invasive carcinoma of the vulva with positive lymph node metastasis,other than epidermoid carcinoma, survived longer than 2 years. In epidennoid lesions, lesion size seemedto be of greatest significance. Adenocarcinoma of the Bartho-
Recurrences. Of the 31 patients with positive nodes, 5 patients were listed as operative deaths. The remaining 26 patients were then considered for evaluation of recurrence. Evidence of recurrence was accepted when noted by the diagnostic parameters of radiography, biopsy, secondary operative procedures, or postmortem examination. Seven of the 26 patients, 26.9 per cent, were found to be free of their diseaseduring this follow-up. Two patients, 7.7 per cent, were found to have had evidence of local recurrence only. Ten patients, or 38.5 per cent, were found to have had systemic recurrence only, and 7 patients, or 26.9 per cent, showed combined local and systemic recurrence. Analysis of recurrences as to lesion size and histology is shown in Table V. Again, in the epidermoid lesions,the prognostic significance of lesion size is seen. The significance of the central lesions,as noted earlier, is again seen in the systemic and combined groupings of recurrence. All epidermoid lesions, except one, were of the combination variety as defined in location of lesion. Survival. In regard to survival (Table VI), 20.8 per cent of patients in this seriessurvived 5 or more years. Comparing positive nodes and lesion size, with lesions less than 3 cm. in size, 33.3 per cent of patients sur-
Table V. Recurrences Diameter
None
<3 >3
1 Epi. 5 Epi. I Adeno.
)
Local
only
1
Systemic
1 Epi. 1 Epi.
1 1 1 1 6
Barth.
Epi. Adeno. Adeno. Trans. Epi.
only
Combined
I
1 Adeno. Barth. 1 Melanoma 5 Epi.
Barth. urethra urethra
Table VI. Size of lesion, node metastasis,and survival
I Sire of lesion’
I (
Positive Eligible
No. of cases
Cases
< 3 cm. > 3 cm.
2:
6 18
Total
31
24
451
nodes
5 yr. (
Not
Survived
Cases
eligible 1
5 yr. Living
i
0 7
0 1
5
7
1
452
Collins,
Lee,
and
Roman-Lopez
Amer.
lin’s gland, in this series, was found to be a highly malignant lesion with grave prognosis. Early inguinal and/or deep pelvic node metastasis occurred regardless of lesion size, duration of symptoms, or the age of the patient. In the 8 patients with a second malignant neoplasm, there was one 5 year survivor who died at 7 years with adenocarcinoma of the lung; all others died within 3 years.
February J. Obstet.
1, 1971 Gynec.
In evaluating recurrence, the average surviva1 of patients with recurrence was 15 months. Without recurrence, the average surviva1 was 7 years and 8 months, the longest survivor in this category being 23 years post operation, and she was completely free of her disease.
REFERENCES
1.
Barclay,
D.
OBSTE?.
GYNE&
L.,
and 86:
Collins, 95,
C. G.:
AMER.
J.
11.
1983.
2.
Barclav. D. L.. Collins. C. G.. and Macev. H. B.,’ jr.: Obitet. Gynkc. 24: 329, 1964. ” 3. Barclay, D. L., Collins, C. G., and Hansen, L. A.:.Clin. Obstet. Gynec. 10; 641, 1967. 4. Birch. H. W.. and Collins. C. G.: T. Louisiana Med.‘Soc. lli: 296, 1959.’ ” 5. Birch, H. W., and Collins, J. H.: Southern Med. J. 53: 473, 1960. 6. Cassidy, R. E., Braden, F. R., and Cerha, H. T.: AMER. J. OBSTET. GYNEC. 74: 361, 1957. 7. Collins, C. -G., Collins, J. H., Nelson, E. W., Smith. R. C.. and MacCallum. E. A.: AMER. J. OB~TET. ~YNEC. 62: 1198, i951. 8. Collins, C. G., Kushner, J., Lewis, G. N., and Lapointe, R.: Obstet. Gynec. 6: 339, 1955. 9. Collins, C. G., Collins, J. H., Nelson, E. W., Lewis, G. N., and Cassidy, R. E.: Obstet. Gynec. 8: 18, 1956. 10. Collins, C. G., Collins, J. H., Cassidy, R. E., and Burman, R. G.: Dallas Med. J, 43: 675, 1958.
12.
13. 14. 15. 16. 17.
18.
Collins, C. G., Collins, J. H., Barclay, D. L., and Nelson, ‘E. W.: AMER. J. OBSTET. GYNEC. 87: 672, 1963. Collins, C. G., and Barclay, D. L.: Clinical Obstetrics and Gynecology, New York, 1963, Paul B. Hoeber, Inc., Medical Book Division of Harper & Row, Publishers. Collins, C. G., and Barclay, D. L.: Cancer, Philadelphia, 1965, W. B. Saunders Comuanv. Collins, C. G., Hansen, L. H., and Thkridt, E.: Obstet. Gvnec. 28: 158. 1966. Collins, J. H., &man, R. G.1 and Mathews, N. M.: Amer. J. Surg. 92: 37, 1956. Collins, J. H.: AMER. J. OBSTET. GYNEC. 79: 1207, 1960. Collins, J. H., Birch, H., Pailet, M., and Avent, J.: ADIER. J. OBSTET. GYNEC. 80: 167, 1960. Collins, J. H., Barclay, D. L., and Collins, G. G.: AMER. J. OBSTET. GYNEC. 84: 1135, 1962.