Invasive lesions extend in breadth and depth within the vulval skin, and may eventually invade the urethra, vagina or anus. Multifocal disease is not unusual. Lymphovascular space invasion is associated with metastases to the regional lymph nodes, the superficial and deep inguinal nodes. Tumours on the labia majora, labia minora, fourchette and clitoris drain to the superficial and deep inguinal nodes and thence to the pelvic lymph nodes. Although lateral tumours usually involve the ipsilateral groin nodes initially, contralateral or bilateral nodal metastases can occur because of communication in the lymphatic network across the vulva. Central tumours, and those invading the urethra, vagina or anus may metastasise directly to pelvic lymph nodes. The obturator nodes are most frequently involved, followed by the external iliac, internal iliac and common iliac lymph nodes. Distant metastases, for example to liver, lung or bone, are uncommon.
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