management of carcinoma vulva
TRANSCRIPT
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???
