Management of Carcinoma Vulva

Topics

Anatomy

Epidemiology

Etiology

Pathology

Immunohistochemistry

VIN

Treatment is recommended for all women with vulvar HSIL (VIN usual type). Because of the potential for occult invasion, wide local excision should be performed if cancer is suspected.When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with excision, laser ablation, or topical imiquimod .Vaccinating girls with HPV vaccine before their initial sexual contact has been claimed to reduce incidence of VIN

Presentation

Investigations

PrognosisLN involvement – single most imp factor

-ve LN – 91% 5 yr survival

+ve LN – 52% 5 yr survival

Extent (number)

U/L vs B/L

Volume of tumor in involved nodes

Extracapsular extension

Level of metastatic disease in the nodal chain

Tumor size < 4 cm

Depth of invasion (5-9 mm) –

Surgical margin

< 8 mm – 43% LR

Growth pattern (infiltrative vs exophytic)

Vascular space invasion

Treatment

Early stage( I & II)

Surgery

SLNB

Indications of Lymph node DissectionIF LAD Tumor Size( cm) Stromal Invasion(mm)

No LAD reqd <= 2 cm <=1( LVSI –ve)

Ipsilateral LAD <=2cm <=1mm(LVSI +ve)

<=2cm >1mm

>2cm any

Bilateral LAD Midline Tumour<1cm

Involves Ant Labia Minora

+ve Ipsilateral LN ( lesion > 2cm and Depth more than 5 mm)

Radiotherapy

Large II and III stage

Pre Op Radiotherapy

Radiotherapy

Bolus

Contouring

Lesions involving Vagina

Lymph nodal Stations

Post operative

2 D planning

Pelvis + groin + vulvaSup. – absent pelvic Nmid SI jt(includes caudal Ext I N)

– pelvic N +ve/ N cephalad to ingligL3-L4 (includes Com. I N)Lat – pelvis 2 cm lateral to boney margin of pelvis

– groin extend lateral upto ant iliac crestInf – upper medial thigh/ 5cm below & parallel to inguinal lig

– extensive skin involvement additional 5 cm of skin flap to be included in target volume

Modifications

IMRT

Advantages Disadvantages

Ability to protect skin outside the PTV Controversies about target delineation –Groin,Skin bridge, Coverage of mons, Vaginal Coverage

Protection of central pelvic bowel, Air gaps- issues with optimization

Ability to protect femoral heads even in obese pts

Concurrent boosts

Brachytherapy

Side effects of radiotherapy

Follow up

Chemotherapy

Melanoma of vulva

Pagets disease

Review of literature

Our data show that the risk of non-sentinel-node metastases increases with size of sentinel-node metastasis. No size cutoff seems to exist below which chances of non-sentinel-node metastases are close to zero. Therefore, all patients with sentinel-node metastases should have additional groin treatment. The prognosis for patients with sentinel-node metastasis larger than 2 mm is poor, and novel treatment regimens should be explored for these patients.

Pre op RT

QUESTIONS???