Vulvar Cancer

Question 1

What is the workup for vulva cancer

Answer 1

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

Question 2

What are the histologies of vulva cancer

Answer 2

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%

Question 3

Dscribe the staging for vulva cancer

Answer 3

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

Question 4

What is the risk of LN invovlement by FIGO stage

Answer 4

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

Question 5

How is VIN treated

Answer 5

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

Question 6

How is stage IA disease treated

Answer 6

Wide local excision ( No adjuvant therapy needed)

Question 7

How is stage IB- II treated?

Answer 7

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

Question 8

When is adjuvant RT needed to the vulva

Answer 8

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

Question 9

When is RT to nodes needed

Answer 9

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

Question 10

What is the treatment for stage III-IV disease

Answer 10

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

Question 11

Describe the different types of surgery

Answer 11

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

Question 12

Describe the RT simulation set up

Answer 12

 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.

Question 13

Describe Radiation Dose and volumes

Answer 13

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

Question 14

What are the doses/volumes for neoadjuvant

Answer 14

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%

Question 15

Describe toxicities of treatment

Answer 15

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

Question 17

Describe toxicity management

Answer 17

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

Question 18

Describe survival by stage

Answer 18

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%