Vulvar Cancer Flashcards

1
Q

What is the workup for vulva cancer

A

Perform general gyn workup- H&P, pelvic exam, MRI of pelvis, CT CAP or PET, biopsy of lesion

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2
Q

What are the histologies of vulva cancer

A

SCC: 90%
65-80% are HPV negative, keratinizing, differentiated tumors associated with vulvar dystrophy /lichen sclerosis

20-35% are HPV positive, classic, warty or bowenoid type. The HPV positive type has better LC and OS than HPV negative

Melanoma- 10%

Sarcomas- rate 1-2%

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3
Q

Dscribe the staging for vulva cancer

A

AJCC FIGO Description
T1a IA Tumor ≤2.0cm and DOI ≤1mm
T1b IB Tumor >2.0cm or DOI >1mm
T2 II Extension into adjacent perineal structures (lower 1/3 urethra, lower 1/3 vagina, anus)
N0 (i+) Isolated tumor cells <0.2mm
N1a IIIA 1-2 LN metastases <5mm
N1b 1 LN metastases ≥ 5mm
N2a IIIB 3+ LN metastases <5mm
N2b 2+ LN metastases ≥ 5mm
N2c IIIC Any LNs with Extracapsular spread
T3 IVA Extension into upper urethra and/or vagina, bladder mucosa, rectal mucosa, or tumor is fixed to
pelvic bone
N3 Fixed/ulcerated inguinofemoral lymph nodes
M1 IVB Any distant metastases, including pelvic lymph nodes

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4
Q

What is the risk of LN invovlement by FIGO stage

A

FIGO I : 8.9 – 15%
o FIGO II : 25.3 – 40%
o FIGO III : 31.1 – 80%
o FIGO IV : 62.5 – 100%

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5
Q

How is VIN treated

A

Local excision, skinning vulvectomy
Imiquimod, topical 5-FU
Laser ablation

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6
Q

How is stage IA disease treated

A

Wide local excision ( No adjuvant therapy needed)

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7
Q

How is stage IB- II treated?

A

Radical local excision or modified radical
vulvectomy w/ inguinal SLNBx
- SLNBx has sensitivity 91.7%,
false negative rate 3.7%

This is followed by adjuvant RT based on risk factors

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8
Q

When is adjuvant RT needed to the vulva

A

HEAPS criteria:
Margins <8mm (re-excise if possible; risk recurrence
= 30%)
- Also consider if LVSI, DOI >5mm, tumor size >4cm,
diffuse/spray histology

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9
Q

When is RT to nodes needed

A
  • 2+ positive LNs
  • ECE
  • 1+ node w/ <12 dissected w/o SLNBx
    Consider concurrent chemotherapy
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10
Q

What is the treatment for stage III-IV disease

A

Neoadjuvant chemoRT w/ concurrent
weekly cisplatin (40mg/m2)

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11
Q

Describe the different types of surgery

A

Skinning vulvectomy – removes the top layer of vulvar skin. Reconstructed with skin graft.
o Simple vulvectomy – removes entire labia (labia majora, minora) +/- clitoris
o Hemivulvectomy – for well lateralized lesions with adequate margins
o Modified radical vulvectomy – removes vulva and surrounding inguinal nodes with 3 incisions (1 vulvar
and 2 groin incisions)
o Radical vulvectomy – 1 “butterfly incision” removes vulva, clitoris, inguinal nodes, and tissue in between

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12
Q

Describe the RT simulation set up

A

 Head first, supine, frog leg with a vac lok
 Full bladder, empty rectum
 Wire mark on anus, vaginal introitus, and mark extent of tumor or surgical scar
 1cm bolus to vulva, cut in an hourglass or rectangle. Bolus inguinal regions if skin involvement.
 Utilize TLD on skin for first few fractions to ensure adequate skin dose.

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13
Q

Describe Radiation Dose and volumes

A

CTV4500/25fx = vulva + inguinal LN + pelvic LN
o External iliac, internal iliac, obturator
o If node positive -> add common iliacs
o If proximal ½ vaginal involvement -> add presacral
o If anal involvement -> add perirectal

CTV5000/25fx = gross tumor/bed + 2cm; involved soft tissues + 2-3cm
* CTV5625/25fx = gross pelvic lymph nodes + 3mm
* CTV6250/25fx = gross inguinal lymph nodes or ECE + 3mm
* PTVtumor = 7-10mm expansions
* PTVelective = 5mm expansions

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14
Q

What are the doses/volumes for neoadjuvant

A

Sequential:
* CTV4500/25fx = vulva + inguinal LN + pelvic LNs
* CTV5760/32fx (additional 1260/7fx) to gross + 2cm
 With weekly concurrent cisplatin (40mg/m2) IV
 Biopsy after treatment – if pathologic complete response, can observe rather than resect. If
partial response, can give additional radiation, resect, give chemotherapy, or supportive care.
 Path CR rate ~50%

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15
Q

Describe toxicities of treatment

A

Wound infection and dehiscence, moist desquamation, lymphedema, depression, loss of sexual function, femoral
head necrosis and fracture

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16
Q
A
17
Q

Describe toxicity management

A

Assess groins and vulva at least once weekly
o Recommend excellent hygiene via sitz baths and whirlpools
o Recommend Aquaphor and Silvadene

18
Q

Describe survival by stage

A

Lymph node negative 5-yr OS = 80 – 100%
- Lymph node positive 5-yr OS = 40 – 60%
- Stage I 5-yr OS = 80%
- Stage II 5-yr OS = 60%
- Stage III 5-yr OS = 45%
- Stage IV 5-yr OS = 30%