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152 cases of squamous cell carcinoma of the vulva, operated at the National Cancer Institute of Milan have been analyzed for the purpose of assessing: the frequency of metastases in relation to the. local extent, site of the growth, and clinical and lymphography diagnosis. We reached the following conclusions: a) in T1N0 cancers, the incidence of inguinal metastases is less than 2.7 %. Therefore in unilateral T1N0 tumors a simple vulvectomy may be considered; b) in median tumors, metastases are always bilateral, and in the mixed ones (lateral and median) bilateral metastases are more frequent than unilateral metastases (31.4% vs. 12.9%); c) in unilateral tumors, inguinal metastases are homolateral or bilateral: we have never observed inguinal metastases contralateral to the primary growth. We think that inguinal lymphadenectomy should be bilateral in median or mixed tumors, while in unilateral cases it should be bilateral only in cases where at least homolateral metastases are present. We have never observed pelvic metastases in patients with negative pelvic lymphangiography and/or without inguinal metastatic nodes. Pelvic lymphadenectomy should be planned only in cases of metastases of ipsilateral inguinal nodes or if there are lymphographically positive nodes. We think that the surgical approach to cancer of the vulva should be planned taking into account the T, the N, and the Iymphographic or histologic peroperative diagnosis. In this way, radicality and, at the same time, saving of non-metastatic nodes, which can play an important role in preventing recurrences, could be achieved.

Many aspects of malignant melanoma of the vulva are still open questions and only appropriate clinical trials can supply the answers. However, we believe that the reporting of case-material can be of some use. Our series consists of 14 cases, that is 2% of all the melanomas observed. Most of the patients were past middle age, the average age being 59.7 years. The most frequent sites were the labium majus and the clitoris (5 cases per site); in 2 cases the urethral meatus was affected and in 2 cases the labium minus. There are virtually no subjective symptoms except for occasional reports of a burning sensation or pruritus. Terminal stranguria may be present in cases in which the urethral papilla is affected. The clinical diagnosis does not usually present serious difficulties. Cytomorphologic examination of the cells exfoliated by the tumor is highly reliable, sure in ulcerated cases. The histology of malignant melanoma of the vulva does not differ from that of other sites. Metastatisation to the regional lymph nodes is frequent; 8 of our cases already had lymph node metastases when first seen. Treatment depends on the anatomical extent of the disease. In cases without lymph node metastases the data of our series seem to indicate that radiotherapy can be at least a valid alternative to surgical removal. With regard to the treatment of clinically intact regional lymph nodes, a regional approach is ilioinguinal lymphadenectomy in the event of surgical attack on the primary melanoma, whereas if the primary melanoma is to be treated by radiotherapy lymphadenectomy should be performed only if lymph node metastases appear. As to whether lymphadenectomy should be uni- or bilateral, our data indicate that the cases in which the melanoma lies on the midline (urethral meatus and clitoris) have a high incidence of bilateral metastases and so in these cases lymphadenectomy should be bilateral. On the other hand, when the labium majus is affected, unilateral lymph node dissection is sufficient. In cases with clinically detectable regional metastases enlarged vulvectomy is always indicated. Cases with distant metastases should receive chemotherapy. The drug that has so far yielded the greatest number of regressions is 5-imidazolcarboxamide. The prognosis depends on the anatomical extent of the disease. In this series 2 of the 4 cases without metastases to the regional lymph nodes are living 5 years after surgery whereas none of the 7 patients with regional metastases is alive after 5 years.