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Vulva ca sep course quick revision 2012
1. Vulvar Cancer
with special guest
VIN
Professor Khalid Sait (FRCSC)
Chairman of Scientific chair of Prof. Basalamah for
gynecological cancer
Director of Gynecology oncology unit
Faculty of medicine
King Abdulaziz university
Jeddah, Saudi Arabia
2. Epidemiology
4% of gential tract malignancies
Mean age 65 is decreasing
Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal
3. Epidemiology
4% of gential tract malignancies
Mean age 65 is decreasing
Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal
4. Epidemiology
4% of gential tract malignancies
Mean age 65 is decreasing
Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal
5. Risk Factors
Smoking
Vulvar dystrophy
VIN
HPV 16 and 18
Immunodeficiency
Previous cervical cancer
Northern European
Radiation
8. Diagnosis
Vulvoscopy
Enhances examination
Useful in selecting sites for biopsy
Acetic acid
Can enhance lesions
Makes clinically unimportant HPV
obvious
Toludine blue
Not used clinically
15. Condylomatous
• Least common
• Papillary form: Undulating or
spiking surface
• Hyperkeratosis, parakeratosis
• Mitotic figures and abnormal
maturation
• Surface keratinocytes with
koilocytosis, binucleation or
multinucleation
Parakeratosis: nuclei in surface keratin, sign of high turnover
Koilocytosis: HPV effect, hyperchromatic/ “raisin” nuclei, vacuoles in cytoplasm
16. Differentiated (simplex) type
• Easy to miss
• Almost looks normal
• Full thickness but large abnormal cells
confined to the parabasal and basal
portion of the rete pegs with
eosinophilic cytoplasm
• Mild nuclear atypia
• Keratin pearl formation may be present
17. VIN 2
VIN 1
VIN 3
HPV only- not neoplastic
Untreated
Progresses to
Cancer
Variable rates
Women > 30 yrs
Treated
VIN Natural History
Spontaneous regression
Can occur
Women < 30 yrs
Risk of subsequent
malignancy 2.5-7%
Risk of invasion
at treatment 18-22%
18. Preinvasive neoplasia - VIN
“Early and effective treatment, elimination of smoking and
long-term follow-up of all patients with VIN is imperative.”
Local excision: local 0.5cm margin, epidermis and dermis
Skinning vulvectomy: multifocal, epidermis only
Laser ablation: multifocal 1-3mm depth
5FU: multifocal
Imiquimod:
Only AFTER appropriate biopsies to rule out
invasive disease
19. •Surface epithelium
• only possible with laser
• Epidermis & papillary dermis
• Condylomata
• Epidermis & part of reticular
dermis
• VIN
• To fascia
• Malignancy
Principles of excision
4th plane
20. Surgery: Wide local excision
Commonest surgical
modality
Excise skin with 5mm
margins
22. Surgery: Skinning vulvectomy
Introduced 1968
Rutledge and Sinclair
Extensive often multifocal
lesions
Especially in hair bearing
areas
Removal of large area of
vulva skin
5 mm margins
Shallow layer of skin removed
Split thickness skin graft
used to fill defect
23. Surgery: Skinning vulvectomy
Problems
Extensive surgery
Sexual dysfunction post op
Recurrence
Up to 39 %
Can occur in grafted areas
Does provide a pathological specimen when
invasion is a concern
Can be used in association with laser
24. Vulva-Laser
Usually use “superpulse”
Less thermal damage
Less carbonization than lowering the energy and
using a continuous waveform
27. Other Treatments
Photodynamic therapy
using topically applied 5-aminolevulinic acid.
Limited experience and availability
Labour intensive
5FU (Efudex cream)
Painful –not recommended
Imiquimod cream 5% (Aldara)
promising
5% cream applied 3X a week for 8 weeks or more,
continue 2 weeks after disappearance
27
28. Preinvasive neoplasia -
VIN
30% of women will have recurrence
Especially:
- high grade
- multifocal
- positive margins
Therefore long-term follow up is necessary
29. Paget’s Vulva
Often multifocal erethematous-whithe plaques
<10 % have an associated cancer, Colon, Bladder,
endomerium
10-20% have associated invasive Pagets or vulvar Ca
35. Paget’s:Therapy
Excision:
Wide local excision, 2 cm into subcutaneous tissues
Suspicion of invasion treated with radical excision
Medical therapy:
? imiquimod
37. Surgical staging is preferable because the inguinal
femoral lymph node status is the most important
predictor of over all prognosis
38. Stage I: tumor confined to the vulva
IA: lesions ≤ 2 cm in size, confined to the vulva or
perineum and with stromal invasion ≤ 1.0 mm with
negative node.
IB: lesions > 2 cm in size or with stromal invasion >
1.0 mm, confined to the vulva or perineum with
negative node
FIGO 2010 staging of vulvar
cancers
39. Stage II: Tumor of any size with extension to
adjacent perineal structures (1/3 lower urethra, 1/3
lower vagina and/or extension to the anus) with
negative nodes.
40. Stage III: tumor of any size with or without extension to the
adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive
inguino-femoral lymph nodes.
IIIA: (i) 1 lymph node metastasis ≥ 5 mm
(ii) 1–2 lymph node metastasis(es) < 5 mm
IIIB: (i) 2 or more lymph node metastases ≥ 5 mm
(ii) 3 or more lymph node metastases < 5 mm
IIIC: Positive node(s) with extracapsular spread
41. Stage IV: tumor invades other regional (2/3 upper urethra or
vagina), or distant structures.
IVA: cancer invades any of the following:
(i) upper urethral and/or vaginal mucosa, bladder mucosa,
rectal mucosa, or fixed to pelvic bone.
(ii) fixed or ulcerated inguino-femoral lymph nodes
IVB: any distant metastasis including pelvic lymph nodes
42. Principles of treatment
Treatment should be individualized for each
patient.
A full pre-operative work-up, including colposcopy
of cervix, vagina and vulva, should be performed to
assess the extent of subclinical disease.
Preinvasive disease should be removed with the
primary lesion, if feasible.
43. Principles of treatment
Surgery attempts to
1) Stage (i.e., assess the extent of
disease and hence the prognosis).
2) Debulk a) Primary Tumor
b) Lymph Nodes
Conservative surgery is preferred
over radical surgery as long as
prognosis is not adversely affected.
44. Principles of treatment
Vulvar cancers spread by embolozation, not
permeation so tissue between tumor and LNs need
not be ressected (i.e., en bloc).
When recurrence occurs locally, it reflects the
behaviour of the disease, not inadequate ressection.
45. Principles of treatment
Positive margin need re-excision
Positive groin node two or more microscopic , one or more
macroscopic, any extra-capsular spread need adjuvant
radiation.
Elimination of routine pelvic lymphadenectomy in case of positive
groin node i.e. pelvic radiation( GOG).
Adjuvant radiation required to the vulva in locally advanced
disease after excision.
Chemotherapy may be useful in the treatment of locally
advanced disease( to avoid urostomy or if there is bone
involvement) /distant metastases and recurrent disease in
groin.
46. Requirment for unilateral
LND
UNIFOCAL
Lateral more than 1 cm from the mid line
Not located in the ant. Portion of the labia minora
No palapable groin node in both side
No l. node mets found at the time of the unilat LND
48. Treatment
Surgery LN Radiation Chemotherapy
IA(T1)
<= 1 mm
invasion
Radical local
Excison
- - -
IB
(T1)
> 1 mm
invasion
Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
III (T3 –
late)
IV (T4)
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
49. Treatment
Radical local excision:
• A wide (1-2 cm margins) and deep (to the inferior fascia of the urogenital diaphragm)
excision of the primary tumor
• Closure: primary two layers
Surgery LN Radiation Chemotherapy
IA(T1)
<= 1 mm
invasion
Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
50. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB
(T1)
> 1 mm
invasion
Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop +
Recurrence Rexcison + +
Radical local excision:
Radical Vulvectomy
•
•
51. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
Radical Vulvectomy +/- myo-cutaneous flab
•
53. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
III (T3 –
late)
IV (T4)
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop Cis or 5FU
Recurrence Rexcison ? ?
Exenteration:
• En bloc dissection from:
• the cardinal ligaments laterally
• the broad ligaments of the rectum
posteriorly
• the supralevator attachments of the
bladder, urethra & vagina anteriorly
• the perineum around vagina & anus
caudally
• Reconstruct vagina with gracilis myocutaneous
flap
• 10% operative mortality
54. •Surface epithelium
• only possible with laser
• Epidermis & papillary dermis
• Condylomata
• Epidermis & part of reticular
dermis
• VIN
• To fascia
• Malignancy
Principles of excision
4th plane
58. 6. Primary Closure/ Graft
7. Post operative
• Analgesia
• Sitz baths
• Stool softner
• Bedrest
• DVT prophylaxis
• +/- Drains
Principles of excision
59. Radical Vulvectomy (
Basset’s operation)
Antoine Basset (1882-1951) Paris
First to publish 147 cases of vulval cancer which he called cancer of the clitoris
Rev Chir 1912
‘’ The evolution of the disease appears to be rather rapid without
surgical treatment, at least after the tumour is ulcerated, and the
prognosis is then always fatal. It is still very somber after
the mutilating operation, because of great frequency of local,
and above all nodal, recurrence. But this seems amenable to
improvement by early and systemic extirpation including all
the lymphatics and nodes that drain the clitoris ‘’
60. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
Groin (Inguinal and Femoral)
LN Dissection:
• Linear incision medial 4/5ths
between ASIS and pubic tubercle
• Dissect between fascia lata and
superficial fascia, preserving tissue
above
• Tie off saphenous vein
• Inguinal: above fascia lata, 2cm
above inguinal ligament, medially by
adductor longus, laterally by sartorius
• Femoral: Below fascial lata, medial
to femoral vein at opening of the
femoral ring
62. Inguinal LN Dissection
High perioperative morbidity:
Requires 3-4 days of bed rest, wound breakdown 50%,
lymphocele, lymphedema, infection, bleeding, DVT
• Can some low-risk
women avoid full LN
dissection?
Sentinel Node Biopsy
63. Sentinel Node Biopsy
• Used in breast CA and melanoma
• Two methods:
– Radiolabelled human albumin and gamma-detecting probe
Possible 91-100% NPV: 100%
– Isosulfan blue dye Possible 56-75% NPV: 96-100%
64. Key Points
VIN is a condition of increasing importance with multiple
methods of treatment
At least two possible etiologies are considered for vulvar
cancer. One is related to infection with oncogenic HPV ,
other is related to maturation disorders
Management must address local control and regional
( nodal ) disease
The evolution of management has been driven by desire
to reduce morbidity whilst maintaining disease control
Vulvar cancer is a challenging disease to treat. Its rarity
has mindered attempts to improve management through
clinical trials