Vulvar Cancer Flashcards
What is the workup for vulva cancer
Perform general gyn workup- H&P, pelvic exam, MRI of pelvis, CT CAP or PET, biopsy of lesion
What are the histologies of vulva cancer
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%
Dscribe the staging for vulva cancer
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
What is the risk of LN invovlement by FIGO stage
FIGO I : 8.9 – 15%
o FIGO II : 25.3 – 40%
o FIGO III : 31.1 – 80%
o FIGO IV : 62.5 – 100%
How is VIN treated
Local excision, skinning vulvectomy
Imiquimod, topical 5-FU
Laser ablation
How is stage IA disease treated
Wide local excision ( No adjuvant therapy needed)
How is stage IB- II treated?
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
When is adjuvant RT needed to the vulva
HEAPS criteria:
Margins <8mm (re-excise if possible; risk recurrence
= 30%)
- Also consider if LVSI, DOI >5mm, tumor size >4cm,
diffuse/spray histology
When is RT to nodes needed
- 2+ positive LNs
- ECE
- 1+ node w/ <12 dissected w/o SLNBx
Consider concurrent chemotherapy
What is the treatment for stage III-IV disease
Neoadjuvant chemoRT w/ concurrent
weekly cisplatin (40mg/m2)
Describe the different types of surgery
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
Describe the RT simulation set up
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.
Describe Radiation Dose and volumes
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
What are the doses/volumes for neoadjuvant
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%
Describe toxicities of treatment
Wound infection and dehiscence, moist desquamation, lymphedema, depression, loss of sexual function, femoral
head necrosis and fracture