What is the staging and management approach for a vulvar cancer with a tumor size of 2.0 cm in its greatest dimension and a depth of invasion of 1.1 cm, classified as squamous cell carcinoma?

Staging and Management of Vulvar Squamous Cell Carcinoma (2.0 cm, 1.1 cm Depth of Invasion)

Based on the tumor characteristics provided, this vulvar squamous cell carcinoma is classified as FIGO stage IB (T1b) and requires radical local excision or modified radical vulvectomy with bilateral inguinofemoral lymph node evaluation.

Staging Classification

The tumor characteristics include:

• 2.0 cm in greatest dimension
• 1.1 cm depth of invasion
• Squamous cell carcinoma histology

According to the NCCN guidelines 1:

• This tumor is classified as T1 (≤2 cm) with >1 mm depth of invasion
• The significant depth of invasion (1.1 cm) places this in stage IB (T1b)
• This represents early-stage disease but requires lymph node evaluation due to the depth of invasion exceeding 1 mm

Primary Surgical Management

Tumor Resection

• Radical local excision or modified radical vulvectomy with 1-2 cm margins 1
• The depth of resection should extend to the urogenital diaphragm 1
• Efforts should be made to obtain adequate surgical margins (1-2 cm) to reduce recurrence risk 1

Lymph Node Evaluation

• Bilateral inguinofemoral lymph node evaluation is required 1
• Options include:
  • Sentinel lymph node (SLN) biopsy (preferred for eligible patients)
  • Bilateral inguinofemoral lymph node dissection
• SLN criteria: unifocal tumor <4 cm, clinically non-suspicious nodes, no previous vulvar surgery 1
• If SLNs are not detected on either side, inguinofemoral lymph node dissection is required for that side 1

Adjuvant Therapy Considerations

Adjuvant therapy decisions are based on surgical pathology findings:

1. If negative lymph nodes:

   • Observation is recommended if margins are adequate (≥8 mm) 1, 2
   • Consider adjuvant radiation for close margins (<8 mm) that cannot be re-excised 1

2. If positive lymph nodes:

   • For sentinel node metastasis ≤2 mm: Post-operative radiotherapy 2
   • For sentinel node metastasis >2 mm: Inguinofemoral lymphadenectomy followed by post-operative radiotherapy 2
   • Consider chemoradiation for multiple positive lymph nodes 1

Imaging Considerations

• Pelvic MRI may be useful to confirm tumor size and extent 1
• For T1 tumors with >1 mm invasion, imaging is primarily used to assess lymph node status rather than for primary tumor evaluation 1
• Consider whole body PET/CT or chest/abdominal/pelvic CT if metastasis is suspected 1

Follow-up Recommendations

• Physical examination every 3-6 months for 2 years, then every 6-12 months for 3-5 years, then annually 1
• Cervical/vaginal cytology screening as indicated
• Imaging based on symptoms or examination findings suspicious for recurrence

Important Considerations

• Lymph node status is the most important determinant of survival 1
• The 1.1 cm depth of invasion is a significant risk factor for recurrence and lymph node metastasis
• Close follow-up is essential as recurrence rates can be significant (up to 40-50%) 2
• Surgical approach has evolved from radical en bloc procedures to more conservative approaches with separate incisions for primary tumor and lymph nodes 1

This approach prioritizes oncologic outcomes while attempting to minimize treatment-related morbidity through appropriate surgical techniques and targeted adjuvant therapy based on pathologic findings.