Prognosis of Vulvar Cancer
Lymph node status is the single most important prognostic factor in vulvar cancer, with patients having negative lymph nodes achieving 5-year survival rates exceeding 80%, while those with positive nodes drop to less than 50%, and patients with 4 or more positive nodes have survival rates as low as 13%. 1
Survival by Stage
The prognosis varies dramatically based on disease stage at presentation 1:
- Localized disease (Stages I-II): 5-year survival rate of 86%
- Regional/locally advanced disease (Stages III-IVA): 5-year survival rate of 57%
- Distant metastatic disease (Stage IVB): 5-year survival rate of 17%
Most patients present with early-stage (localized) disease, which carries a generally favorable prognosis 1.
Key Prognostic Factors
Primary Determinants of Survival
Lymph node involvement remains the most critical prognostic indicator 1:
- Node-negative patients: >80% 5-year survival 1
- Node-positive patients: <50% 5-year survival 1
- Four or more positive nodes: 13% 5-year survival 1
- Extracapsular extension: Associated with poorer prognosis 1
Additional Independent Prognostic Factors
Based on Gynecologic Oncology Group (GOG) data from 586 patients, the following factors independently predict survival 1:
- Primary tumor size: Larger tumors correlate with worse outcomes
- Depth of invasion: Greater depth predicts recurrence and reduced survival
- Tumor thickness: Increased thickness associated with worse prognosis
- Lymphovascular space invasion (LVSI): Presence predicts recurrence and reduced survival
- Surgical margin status: Critical for local control 1
Margin Status and Recurrence Risk
Surgical margin adequacy significantly impacts recurrence-free survival 1:
- Negative margins: 82% 4-year recurrence-free rate
- Close margins (<8 mm): 63% 4-year recurrence-free rate
- Positive margins: 37% 4-year recurrence-free rate
- Margins ≤5 mm: Highest risk of recurrence
Recurrence Patterns and Timing
Early vs. Late Recurrence
Recurrence risk is highest in the first 2 years post-treatment, but long-term surveillance is essential as nearly one-third of relapses occur after 5 years 1:
- Node-positive patients: 44.2% overall recurrence rate in first 2 years
- Node-negative patients: 17.5% overall recurrence rate in first 2 years
- Late recurrences (>5 years): Nearly 1 in 10 patients experience late recurrence
- Pattern of late recurrence: >95% are local recurrences; 13% include distant disease 1
Recurrence by Site and Salvageability
The anatomic site of recurrence dramatically affects salvageability and survival 1, 2:
- Local recurrences: May be salvageable with further treatment 1
- Groin recurrences: Generally fatal; groin relapses are rarely amenable to successful secondary treatment 1, 2
- Distant recurrences: Generally fatal 1
Recent data show median survival after recurrence treatment varies significantly 3:
- Local recurrence: 52 months median survival
- Groin recurrence: 8 months median survival
- Pelvic/distant recurrence: 5 months median survival
Stage-Specific Recurrence-Free Survival
Five-year recurrence-free survival rates by stage 3:
- Stage I: 67.9%
- Stage II: 60.0%
- Stage III: 42.1%
- Stage IV: 20.0%
Disease-Specific Survival by Stage
Five-year disease-specific survival rates 3:
- Stage I: 86.2%
- Stage II: 81.6%
- Stage III: 65.0%
- Stage IV: 42.9%
Critical Pitfalls in Prognostication
Groin node recurrences are almost universally fatal, emphasizing the critical importance of adequate initial nodal assessment and treatment 2. The false-negative rate for sentinel lymph node biopsy in appropriately selected patients (unifocal tumors <4 cm) is only 2%, with a 2-year groin recurrence rate of 2.3% and 3-year disease-specific survival of 97% 2.
Patients with sentinel node metastasis >2 mm who receive radiotherapy alone (without lymphadenectomy) have an unacceptably high 2-year isolated groin recurrence rate of 22%, necessitating completion lymphadenectomy followed by radiotherapy 2.
Human papillomavirus (HPV) status may influence presentation patterns, with HPV-positive tumors more commonly presenting with multifocal lesions and concurrent cervical neoplasia 1.