Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

H. G. Schnürch; S. Ackermann; C. D. Alt; J. Barinoff; C. Böing; C. Dannecker; F. Gieseking; A. Günthert; P. Hantschmann; L. C. Horn; R. Kürzl; P. Mallmann; S. Marnitz; G. Mehlhorn; C. C. Hack; M. C. Koch; U. Torsten; W. Weikel; L. Wölber; M. Hampl

doi:10.1055/s-0042-103728

Geburtshilfe und Frauenheilkunde, Table of Contents

Geburtshilfe Frauenheilkd 2016; 76(10): 1035-1049
DOI: 10.1055/s-0042-103728

Guideline

GebFra Science

Georg Thieme Verlag KG Stuttgart · New York

Diagnosis, Therapy and Follow-up Care of Vulvar Cancer and its Precursors. Guideline of the DGGG and DKG (S2k-Level, AWMF Registry Number 015/059, November 2015

Diagnostik, Therapie und Nachsorge des Vulvakarzinoms und seiner Vorstufen. Leitlinie der DGGG und DKG (S2k-Level, AWMF-Registernummer 015/059, November 2015)

H. G. Schnürch

¹ehem. Frauenklinik Lukaskrankenhaus, Neuss

,

S. Ackermann

²Frauenklinik, Klinikum Darmstadt, Darmstadt

,

C. D. Alt

³Institut für Diagnostische und Interventionelle Radiologie, Universität Düsseldorf, Düsseldorf

,

J. Barinoff

⁴Klinik für Gynäkologie und Geburtshilfe, Markus Krankenhaus, Frankfurt am Main

,

C. Böing

⁵Katholisches Klinikum Oberhausen, Frauenklinik St. Clemens-Hospital, Oberhausen

,

C. Dannecker

⁶Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe der Universität München, Campus Großhadern, München, Munich

,

F. Gieseking

⁷Dysplasiezentrum in der Frauenarztpraxis Heussweg, Hamburg

,

A. Günthert

⁸Frauenklinik Luzerner Kantonsspital, Lucerne, Switzerland

,

P. Hantschmann

⁹Abteilung Gynäkologie und Geburtshilfe, Kreiskliniken Altötting – Burghausen, Altötting

,

L. C. Horn

¹⁰Institut für Pathologie des Universitätsklinikums Leipzig, Leipzig

,

R. Kürzl

¹¹ehem. Universitätsfrauenklinik Maistraße, Munich

,

P. Mallmann

¹²Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe der Universität Köln, Cologne

,

S. Marnitz

¹³Klinik und Poliklinik für Radioonkologie und Strahlentherapie der Universität Köln, Cologne

,

G. Mehlhorn

¹⁴Universitätsfrauenklinik Erlangen, Erlangen

,

C. C. Hack

¹⁴Universitätsfrauenklinik Erlangen, Erlangen

,

M. C. Koch

¹⁴Universitätsfrauenklinik Erlangen, Erlangen

,

U. Torsten

¹⁵Klinik für Gynäkologie und Zentrum für Beckenbodenerkrankungen, Vivantes Klinikum Neukölln, Berlin

,

W. Weikel

¹⁶Klinik für Gynäkologie und gynäkologische Onkologie, Universitätsfrauenklinik Mainz, Mainz

,

L. Wölber

¹⁷Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg

,

M. Hampl

¹⁸Klinik für Frauenheilkunde und Geburtshilfe des Universitätsklinikums Düsseldorf, Düsseldorf

› Author Affiliations

Abstract

Purpose: This is an official guideline, published and coordinated by the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO, Study Group for Gynecologic Oncology) of the Deutsche Krebsgesellschaft (DKG, German Cancer Society) and the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG, German Society for Gynecology and Obstetrics). The number of cases with vulvar cancer is on the rise, but because of the former rarity of this condition and the resulting lack of literature with a high level of evidence, in many areas knowledge of the optimal clinical management still lags behind what would be required. This updated guideline aims to disseminate the most recent recommendations, which are much clearer and more individualized, and is intended to create a basis for the assessment and improvement of quality care in hospitals.

Methods: This S2k guideline was drafted by members of the AGO Committee on Vulvar and Vaginal Tumors; it was developed and formally completed in accordance with the structured consensus process of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).

Recommendations: 1. The incidence of disease must be taken into consideration. 2. The diagnostic pathway, which is determined by the initial findings, must be followed. 3. The clinical and therapeutic management of vulvar cancer must be done on an individual basis and depends on the stage of disease. 4. The indications for sentinel lymph node biopsy must be evaluated very carefully. 5. Follow-up and treatment for recurrence must be adapted to the individual case.

Zusammenfassung

Ziel: Offizielle Leitlinie, publiziert und koordiniert von der Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) in der Deutschen Krebsgesellschaft (DKG) und der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Vulvakarzinome nehmen an Anzahl stetig zu, während die Kenntnisse über das optimale klinische Management wegen der früheren Seltenheit und dem daraus resultierenden Mangel an Literatur-Evidenz dem Bedarf an vielen Stellen noch hinterherhinken. Dieses Leitlinien-Update soll die aktuell deutlich klareren und individualisierten Behandlungsempfehlungen möglichst weit verbreiten und die Grundlage für eine Qualitätsmessung und Qualitätssteigerung in Kliniken bieten.

Methoden: Die vorliegende S2k-Leitlinie wurde von den Mitgliedern der Kommission Vulva- und Vaginaltumoren der AGO entworfen und in einem methodisch überwachten Konsensusverfahren der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) strukturiert entwickelt und formal abgeschlossen.

Empfehlungen: 1. Beachtung der Inzidenz. 2. Einhaltung der abgestuften Diagnostik in Abhängigkeit vom Ausgangsstadium. 3. Individualisiertes klinisch-therapeutisches Management der Vulvakarzinome in Abhängigkeit vom Stadium. 4. Ausgewogene Indikationsstellung zur Sentinel-Lymphknoten-Biopsie. 5. Adaptierte Nachsorge und Behandlung im Rezidivfall.

Key words

vulvar cancer - diagnosis - therapy - vulvar intraepithelial neoplasia

Schlüsselwörter

Vulvakarzinom - Diagnostik - Therapie - VIN

Full Text

References

References
1 van Seters M, van Beurden M, de Craen AJ. Is the assumed natural history of vulvar intraepithelial neoplasia III based on enough evidence? A systematic review of 3322 published patients. Gynecol Oncol 2005; 97: 645-651
2 Stephenson RD, Denehy TR. Rapid spontaneous regression of acute-onset vulvar intraepithelial neoplasia 3 in young women: a case series. J Low Genit Tract Dis 2012; 16: 56-58
3 Fanning J, Lambert HC, Hale TM et al. Pagetʼs disease of the vulva: prevalence of associated vulvar adenocarcinoma, invasive Pagetʼs disease, and recurrence after surgical excision. Am J Obstet Gynecol 1999; 180: 24-27
4 Lam C, Funaro D. Extramammary Pagetʼs disease: summary of current knowledge. Dermatol Clin 2010; 28: 807-826
5 Funaro D, Krasny M, Lam C et al. Extramammary Paget disease: epidemiology and association to cancer in a Quebec-based population. J Low Genit Tract Dis 2013; 17: 167-174
6 Hampl M, Deckers-Figiel S, Hampl JA et al. New aspects of vulvar cancer: changes in localization and age of onset. Gynecol Oncol 2008; 109: 340-345
7 Chi CC, Kirtschig G, Baldo M et al. Topical interventions for genital lichen sclerosus. Cochrane Database Syst Rev 2011; (12) CD008240
8 Brinton LA, Nasca PC, Mallin K et al. Case-control study of cancer of the vulva. Obstet Gynecol 1990; 75: 859-866
9 Monk BJ, Burger RA, Lin F et al. Prognostic significance of human papillomavirus DNA in vulvar carcinoma. Obstet Gynecol 1995; 85: 709-715
10 Madsen BS, Jensen HL, van den Brule AJ et al. Risk factors for invasive squamous cell carcinoma of the vulva and vagina–population-based case-control study in Denmark. Int J Cancer 2008; 122: 2827-2834
11 Kutlubay Z, Engin B, Zara T et al. Anogenital malignancies and premalignancies: facts and controversies. Clin Dermatol 2013; 31: 362-373
12 HPV-Managementforum (HPV-MF), Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG). S3 Leitlinie – Impfprävention HPV-assoziierter Neoplasien, AWMF Registernummer 082/002. 2013 Online: http://www.awmf.org/uploads/tx_szleitlinien/082-002l_Impfpr%25C3%25A4vention_HPV_assoziierter_Neoplasien_2013-12.pdf last access: 26.03.2016
13 Hampl M, Sarajuuri H, Wentzensen N et al. Effect of human papillomavirus vaccines on vulvar, vaginal, and anal intraepithelial lesions and vulvar cancer. Obstet Gynecol 2006; 108: 1361-1368
14 De Vuyst H, Clifford GM, Nascimento MC et al. Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis. Int J Cancer 2009; 124: 1626-1636
15 Insinga RP, Liaw KL, Johnson LG et al. A systematic review of the prevalence and attribution of human papillomavirus types among cervical, vaginal, and vulvar precancers and cancers in the United States. Cancer Epidemiol Biomarkers Prev 2008; 17: 1611-1622
16 Bundesministerium für Gesundheit. Bekanntmachung eines Beschlusses des Gemeinsamen Bundesausschusses über die Änderung der Schutzimpfungs-Richtlinie (SI-RL): Umsetzung STIKO-Empfehlungen August 2014 und Anpassung an die Verordnung zur arbeitsmedizinischen Vorsorge (ArbMedVV). BAnz AT 2015. 03.02.2015 B2
17 Crum CP. Vulvar intraepithelial neoplasia: the concept and its application. Hum Pathol 1982; 13: 187-189
18 Hart WR. Vulvar intraepithelial neoplasia: historical aspects and current status. Int J Gynecol Pathol 2001; 20: 16-30
19 Reyes MC, Cooper K. An update on vulvar intraepithelial neoplasia: terminology and a practical approach to diagnosis. J Clin Pathol 2014; 67: 290-294
20 Crum CP, Herrington CS, McCluggage WG, Regauer S, Wilkinson EJ. Epithelial Tumors of the Vulva. In: Kurman RJ, Carcangiu ML, Herrington CS, Young RH, eds. WHO Classification of Tumours of the female reproductive Tract. Lyon: IARC Press; 2014: 233-242
21 Horn LC, Klostermann K, Hautmann S et al. HPV-associated alterations of the vulva and vagina. Morphology and molecular pathology. Pathologe 2011; 32: 467-475
22 Heller DS. Report of a new ISSVD classification of VIN. J Low Genit Tract Dis 2007; 11: 46-47
23 Sideri M, Jones RW, Wilkinson EJ et al. Squamous vulvar intraepithelial neoplasia: 2004 modified terminology, ISSVD Vulvar Oncology Subcommittee. J Reprod Med 2005; 50: 807-810
24 Wilkinson E, Teixeira M. Tumors of the Vulva. In: Tavassoli F, Devilee P, eds. Pathology and Genetics of Tumors of the Breast and female genital Organs. World Health Organization Classification of Tumour. Lyon: IARC Press; 2003: 313-334
25 Lawrence WD. ADASP recommendations for processing and reporting of lymph node specimens submitted for evaluation of metastatic disease. Virchows Arch 2001; 439: 601-603
26 Hunt JL, Baloch ZW, LiVolsi VA. Sentinel lymph node evaluation for tumor metastasis. Semin Diagn Pathol 2002; 19: 263-277
27 Horn LC, Einenkel J, Hockel M et al. [Recommendations for the handling and oncologic pathology report of lymph node specimens submitted for evaluation of metastatic disease in gynecologic malignancies]. Pathologe 2005; 26: 266-272
28 Woelber L, Eulenburg C, Choschzick M et al. Prognostic role of lymph node metastases in vulvar cancer and implications for adjuvant treatment. Int J Gynecol Cancer 2012; 22: 503-508
29 Tantipalakorn C, Robertson G, Marsden DE et al. Outcome and patterns of recurrence for International Federation of Gynecology and Obstetrics (FIGO) stages I and II squamous cell vulvar cancer. Obstet Gynecol 2009; 113: 895-901
30 Lataifeh I, Nascimento MC, Nicklin JL et al. Patterns of recurrence and disease-free survival in advanced squamous cell carcinoma of the vulva. Gynecol Oncol 2004; 95: 701-705
31 Beller U, Quinn MA, Benedet JL et al. Carcinoma of the vulva. FIGO 26th Annual Report on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet 2006; 95 (Suppl. 01) S7-S27
32 Chan JK, Sugiyama V, Pham H et al. Margin distance and other clinico-pathologic prognostic factors in vulvar carcinoma: a multivariate analysis. Gynecol Oncol 2007; 104: 636-641
33 Cheng X, Zang R, Wu X et al. Recurrence patterns and prognostic factors in Chinese patients with squamous cell carcinoma of the vulva treated with primary surgery. Int J Gynecol Cancer 2009; 19: 158-162
34 National Institutes of Health. NIH State-of-the-Science Conference Statement on improving end-of-life care. NIH consensus and state-of-the-science statements 2004; 21: 1-26
35 Tan J, Chetty N, Kondalsamy-Chennakesavan S et al. Validation of the FIGO 2009 staging system for carcinoma of the vulva. Int J Gynecol Cancer 2012; 22: 498-502
36 Aragona AM, Cuneo NA, Soderini AH et al. An analysis of reported independent prognostic factors for survival in squamous cell carcinoma of the vulva: is tumor size significance being underrated?. Gynecol Oncol 2014; 132: 643-648
37 Hacker NF, Eifel PJ, van der Velden J. Cancer of the vulva. Int J Gynaecol Obstet 2012; 119 (Suppl. 02) S90-S96
38 Oonk MH, Hollema H, de Hullu JA et al. Prediction of lymph node metastases in vulvar cancer: a review. Int J Gynecol Cancer 2006; 16: 963-971
39 Raspagliesi F, Hanozet F, Ditto A et al. Clinical and pathological prognostic factors in squamous cell carcinoma of the vulva. Gynecol Oncol 2006; 102: 333-337
40 van der Velden J, van Lindert AC, Lammes FB et al. Extracapsular growth of lymph node metastases in squamous cell carcinoma of the vulva. The impact on recurrence and survival. Cancer 1995; 75: 2885-2890
41 Hyde SE, Valmadre S, Hacker NF et al. Squamous cell carcinoma of the vulva with bulky positive groin nodes-nodal debulking versus full groin dissection prior to radiation therapy. Int J Gynecol Cancer 2007; 17: 154-158
42 Fons G, Hyde SE, Buist MR et al. Prognostic value of bilateral positive nodes in squamous cell cancer of the vulva. Int J Gynecol Cancer 2009; 19: 1276-1280
43 Xu LQ, Luo RZ, Sun XM et al. Prognostic analysis of early-stage squamous cell carcinoma of the vulva. World J Surg Oncol 2013; 11: 20
44 Zanvettor PH, Filho DF, Soares FA et al. Study of biomolecular and clinical prognostic factors in patients with cancer of the vulva undergoing surgical treatment. Int J Gynecol Cancer 2014; 24: 766-772
45 Royal College of Obstetricians and Gynaecologists. Guidelines for the diagnosis and management of vulval carcinoma. British Gynaecological Cancer Society; 2014. Online: http://www.rcog.org.uk/womens-health/clinical-guidance/vulval-carcinoma-guidelines-diagnosis-and-management last access: February 2015
46 Viswanathan C, Kirschner K, Truong M et al. Multimodality imaging of vulvar cancer: staging, therapeutic response, and complications. AJR Am J Roentgenol 2013; 200: 1387-1400
47 Land R, Herod J, Moskovic E et al. Routine computerized tomography scanning, groin ultrasound with or without fine needle aspiration cytology in the surgical management of primary squamous cell carcinoma of the vulva. Int J Gynecol Cancer 2006; 16: 312-317
48 de Gregorio N, Ebner F, Schwentner L et al. The role of preoperative ultrasound evaluation of inguinal lymph nodes in patients with vulvar malignancy. Gynecol Oncol 2013; 131: 113-117
49 Abang Mohammed DK, Uberoi R, de B Lopes A et al. Inguinal node status by ultrasound in vulva cancer. Gynecol Oncol 2000; 77: 93-96
50 Cohn DE, Dehdashti F, Gibb RK et al. Prospective evaluation of positron emission tomography for the detection of groin node metastases from vulvar cancer. Gynecol Oncol 2002; 85: 179-184
51 Kataoka MY, Sala E, Baldwin P et al. The accuracy of magnetic resonance imaging in staging of vulvar cancer: a retrospective multi-centre study. Gynecol Oncol 2010; 117: 82-87
52 Bipat S, Fransen GA, Spijkerboer AM et al. Is there a role for magnetic resonance imaging in the evaluation of inguinal lymph node metastases in patients with vulva carcinoma?. Gynecol Oncol 2006; 103: 1001-1006
53 Sohaib SA, Richards PS, Ind T et al. MR imaging of carcinoma of the vulva. AJR Am J Roentgenol 2002; 178: 373-377
54 Hawnaur JM, Reynolds K, Wilson G et al. Identification of inguinal lymph node metastases from vulval carcinoma by magnetic resonance imaging: an initial report. Clin Radiol 2002; 57: 995-1000
55 Singh K, Orakwue CO, Honest H et al. Accuracy of magnetic resonance imaging of inguinofemoral lymph nodes in vulval cancer. Int J Gynecol Cancer 2006; 16: 1179-1183
56 Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009; 105: 103-104
57 Wittekind C, Meyer H. UICC TNM Klassifikation maligner Tumoren. Weinheim: Wiley-Blackwell; 2010
58 Gentile M, Bianchi P, Sesti F et al. Adjuvant topical treatment with imiquimod 5 % after excisional surgery for VIN 2/3. Eur Rev Med Pharmacol Sci 2014; 18: 2949-2952
59 van Seters M, van Beurden M, ten Kate FJ et al. Treatment of vulvar intraepithelial neoplasia with topical imiquimod. N Engl J Med 2008; 358: 1465-1473
60 Mahto M, Nathan M, OʼMahony C. More than a decade on: review of the use of imiquimod in lower anogenital intraepithelial neoplasia. Int J STD AIDS 2010; 21: 8-16
61 Pepas L, Kaushik S, Bryant A et al. Medical interventions for high grade vulval intraepithelial neoplasia. Cochrane Database Syst Rev 2011; (4) CD007924
62 Terlou A, van Seters M, Ewing PC et al. Treatment of vulvar intraepithelial neoplasia with topical imiquimod: seven years median follow-up of a randomized clinical trial. Gynecol Oncol 2011; 121: 157-162
63 Frega A, Sesti F, Sopracordevole F et al. Imiquimod 5 % cream versus cold knife excision for treatment of VIN 2/3: a five-year follow-up. Eur Rev Med Pharmacol Sci 2013; 17: 936-940
64 Hockel M, Dornhofer N. Anatomical reconstruction after vulvectomy. Obstet Gynecol 2004; 103: 1125-1128
65 Gaarenstroom KN, Kenter GG, Trimbos JB et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003; 13: 522-527
66 Hinten F, van den Einden LC, Hendriks JC et al. Risk factors for short- and long-term complications after groin surgery in vulvar cancer. Br J Cancer 2011; 105: 1279-1287
67 Soliman AA, Heubner M, Kimmig R et al. Morbidity of inguinofemoral lymphadenectomy in vulval cancer. ScientificWorldJournal 2012; 2012: 341253
68 Benedet JL, Turko M, Fairey RN et al. Squamous carcinoma of the vulva: results of treatment, 1938 to 1976. Am J Obstet Gynecol 1979; 134: 201-207
69 Hopkins MP, Reid GC, Vettrano I et al. Squamous cell carcinoma of the vulva: prognostic factors influencing survival. Gynecol Oncol 1991; 43: 113-117
70 Lin JY, DuBeshter B, Angel C et al. Morbidity and recurrence with modifications of radical vulvectomy and groin dissection. Gynecol Oncol 1992; 47: 80-86
71 Klemm P, Marnitz S, Kohler C et al. Clinical implication of laparoscopic pelvic lymphadenectomy in patients with vulvar cancer and positive groin nodes. Gynecol Oncol 2005; 99: 101-105
72 Shylasree TS, Bryant A, Howells RE. Chemoradiation for advanced primary vulval cancer. Cochrane Database Syst Rev 2011; (4) CD003752
73 Geisler JP, Manahan KJ, Buller RE. Neoadjuvant chemotherapy in vulvar cancer: avoiding primary exenteration. Gynecol Oncol 2006; 100: 53-57
74 Oonk MH, de Hullu JA, Hollema H et al. The value of routine follow-up in patients treated for carcinoma of the vulva. Cancer 2003; 98: 2624-2629
75 Oonk MH, van Hemel BM, Hollema H et al. Size of sentinel-node metastasis and chances of non-sentinel-node involvement and survival in early stage vulvar cancer: results from GROINSS-V, a multicentre observational study. Lancet Oncol 2010; 11: 646-652
76 Woelber L, Grimm D, Vettorazzi E et al. Secondary sentinel node biopsy after previous excision of the primary tumor in squamous cell carcinoma of the vulva. Ann Surg Oncol 2013; 20: 1701-1706
77 Van der Zee AG, Oonk MH, De Hullu JA et al. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer. J Clin Oncol 2008; 26: 884-889
78 Maggino T, Landoni F, Sartori E et al. Patterns of recurrence in patients with squamous cell carcinoma of the vulva. A multicenter CTF Study. Cancer 2000; 89: 116-122
79 Woolderink JM, de Bock GH, de Hullu JA et al. Patterns and frequency of recurrences of squamous cell carcinoma of the vulva. Gynecol Oncol 2006; 103: 293-299
80 Regauer S. Residual anogenital lichen sclerosus after cancer surgery has a high risk for recurrence: a clinicopathological study of 75 women. Gynecol Oncol 2011; 123: 289-294
81 Gordinier ME, Malpica A, Burke TW et al. Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy. Gynecol Oncol 2003; 90: 625-628
82 Cormio G, Loizzi V, Carriero C et al. Groin recurrence in carcinoma of the vulva: management and outcome. Eur J Cancer Care (Engl) 2010; 19: 302-307
83 de Hullu JA, Hollema H, Lolkema S et al. Vulvar carcinoma. The price of less radical surgery. Cancer 2002; 95: 2331-2338
84 Hassanzade M, Attaran M, Treglia G et al. Lymphatic mapping and sentinel node biopsy in squamous cell carcinoma of the vulva: systematic review and meta-analysis of the literature. Gynecol Oncol 2013; 130: 237-245
85 Coulter J, Gleeson N. Local and regional recurrence of vulval cancer: management dilemmas. Best Pract Res Clin Obstet Gynaecol 2003; 17: 663-681
86 Husain A, Akhurst T, Larson S et al. A prospective study of the accuracy of 18Fluorodeoxyglucose positron emission tomography (18FDG PET) in identifying sites of metastasis prior to pelvic exenteration. Gynecol Oncol 2007; 106: 177-180
87 Hopkins MP, Morley GW. Pelvic exenteration for the treatment of vulvar cancer. Cancer 1992; 70: 2835-2838
88 Hoffman MS, Cavanagh D, Roberts WS et al. Ultraradical surgery for advanced carcinoma of the vulva: an update. Int J Gynecol Cancer 1993; 3: 369-372
89 Chiantera V, Rossi M, De Iaco P et al. Morbidity after pelvic exenteration for gynecological malignancies: a retrospective multicentric study of 230 patients. Int J Gynecol Cancer 2014; 24: 156-164
90 Miller B, Morris M, Levenback C et al. Pelvic exenteration for primary and recurrent vulvar cancer. Gynecol Oncol 1995; 58: 202-205
91 Weikel W, Schmidt M, Steiner E et al. Surgical therapy of recurrent vulvar cancer. Am J Obstet Gynecol 2006; 195: 1293-1302
92 Salom EM, Penalver M. Recurrent vulvar cancer. Curr Treat Options Oncol 2002; 3: 143-153
93 Hruby G, MacLeod C, Firth I. Radiation treatment in recurrent squamous cell cancer of the vulva. Int J Radiat Oncol Biol Phys 2000; 46: 1193-1197

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