Ca vulva management

Ca vulva management

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  Surgical techniques androle of lymphadenectomy in ca vulva Priyanka Malekar DNB first yr resident (surgical oncology) 24/2/2018 1
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  • Lymphatic drainage •Labia majora, labia minora, clitoris → superficial and deep inguinal nodes → secondarily to pelvic nodes • Clitoris - to external iliac nodes to obturator node via dorsal vein of clitoris Lymphatic drainage of perineum, clitoris and anterior labia minora are bilateral 2
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  Nodal mets • Singlemost important factor predicting outcome • 5 yr OS for pts with negative nodes – 83-100% • 5 yr OS for pts with positive nodes – 38-61% 5
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  Prognostic factors inlymph node involvement • Whether unilateral or bilateral • Depth of tumor • Number of positive nodes • Volume of tumour metastases • Level of metastatic nodal disease 6
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  Stage 1/ T1(early vulvar cancer) (no. of inguino-femoral mets. by infiltration depth) 11
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  T1a lesion (2cmin largest diameter) • T1 tumours with a <1mm depth of infiltration(stage1a) can be safely treated by wide local excision (1-2cms tumour free margin) without LND • If final pathology reveals invasion >1mm, ipsilateral groin dissection to be done • (the risk of local recurrence was 50% when the tumor-free margin was less than 8mm heaps et all) Heaps et al. Surgicopathologic variables predictive of local recurrence in SCC vulva.Gynecol Oncol 1990;38:309-315 12
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  Local recurrence… 13
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  Clinical T1b &T2 cancers without suspicious groin nodes • Modified radical surgery (triple incision) • Nodal involvement > 8% • Radical wide local excision + Inguinal LND • Midline lesions - bilateral inguinal dissection 14
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  • If clinicallypositive groin nodes are found in an ipsilateral dissection for a small primary lesion, dissection of the contralateral groin is advocated. – for lesions that are: 1. Unilateral 2. Unifocal 3. Not located in the anterior portion of the labia minora 4. No palpable lymphadenopathy in either groin 5. No lymph node metastases found at time of unilateral LND 17
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  • In nonmidline T1 tumors no patient had lymph node mets to the contralateral groin • DeSimone CP et al. The treatment of lateral T1 and T2 squamous cell carcinoma of the vulva confined to the labium majus or minus. Gynecol Oncol 2007;104:390–395. • Contralateral groin dissection unnecessary for patients with nonmidline lesions < 2 cm size and /or with negative ipsilateral nodes • Gonzalez et al. Patterns of inguinal groin metastases in squamous cell carcinoma of the vulva. Gynecol Oncol 2007;105:742–746. 18
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  Stage II • Radicallocal excision + bilateral inguinal node dissection • Large tumors may require modified radical vulvectomy 19
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  Stage III • Modifiedradical vulvectomy with bilateral inguinal node dissection • Adjuvant radiation therapy to the pelvis and groin 20
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  Stage IV • Pelvicexenteration OR • Preoperative neoadjuvant chemoradiation which improve operability or decrease the extent of surgery required
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  SURGERY • Pioneering worksby Taussig and Way • En bloc radical vulvectomy and bilateral dissection of groin and pelvic nodes introduced in 1940s • Became standard for operable vulvar cancer • Excellent survival and local control in 90% patients
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  Radical vulvectomy • Removalof entire vulva • To the level of deep fascia of thigh • Periosteum of pubis • Inferior fascia of urogenital diaphragm
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  Disadvantages • Altered appearanceand sexual function • Wound breakdown • Lymph cyst, lymphangitis • Lower limb oedema • Significant psychosexual consequences
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  Radical local excision •Depth of dissection same • Similar rates of local recurrence (7.2% vs 6.3%) • Less morbidity • Three incision technique
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  Surgical technique forca vulva 30
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  Role of RTin vulvar cancer • Post op RT to primary tumour and nodal beds based on pathologic poor prognostic features • Pre op RT with concurrent chemotherapy in loco regionally advanced disease with extension to midline structures. This is followed by function preserving surgery and inguinal dissection
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  ADJUVANT RT totumour • Adjuvant RT for primary tumour given 1. large tumours > 4 cms 2. positive or close surgical margins(< 8mm) 3. LVSI 4. Depth of stromal invasion > 5mm
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  ADJUVANT RT tonodal regions • Adjuvant RT for nodal regions given for 1. 2 or more microscopically positive nodes 2. 1 or more macroscopically positive nodes gross extracapsular extension 3. Residual nodal disease 4. If only a small number of nodes sampled
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  • Groin dissectionversus primary groin radiation in carcinoma of the vulva: a Gynecologic Oncology Group study. Stehman et al. 1992 • GOG 88 • RCT, N = 58 • Patients with squamous carcinoma of the vulva and nonsuspicious (N0-1) inguinal nodes randomised to receive either groin dissection or groin radiation after radical vulvectomy. • Closed prematurely - interim monitoring revealed an excessive number of groin relapses on the groin radiation regimen
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  ROLE OF ADJUVANTPOST OP RT • Kunos et al. Pelvic Radiation therapy compared with pelvic node resection for node positive vulvar cancer. Obstet Gynecol. 114:537-546.2009 • GOG 37 • RCT , N= 114 surgically treated patients (after radical local excision and bilateral inguinal lymphadenectomy)with positive groin nodes • Randomised to ipsilateral pelvic node dissection vs RT to bilateral pelvis and groins
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  • Overall Survival- 51% VS 41% • Cancer specific survival – 51% after RT 29% after LND • Benefit of RT significant in pts with gross nodal mets, 2 or more nodes, extracapsular spread • RT significantly reduced groin failures (5% vs 24%)
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  GOG 145 • Ongoingtrial • To evaluate the role of adjuvant RT to the nodal regions in patients with negative nodes but high risk features ( tr > 4 cms, positive margins, LVSI) • Results awaited
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  Post treatment surveillance •Low risk disease (early stage, treated with surgery alone) 6 monthly x 2yrs then annually • High risk disease (advanced stage, treated with neoadjuvant/adjuvant therapy) 3 monthly x 2 yrs 6 monthly x 3 yrs then annually
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  Recurrence • Local /inguinal / distant • Local recurrence – Re excision, good prognosis • Groin recurrence – worse prognosis • RT along with surgery or chemotherapy • 5 yr survival by site of recurrence Perineal – 60% Inguinal and pelvic – 27% Distant – 15%
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  GOG risk categories •Minimal – lesion < 2 cms negative groin nodes • Low - 1 positive groin node with lesion < 2 cms - negative nodes with >2 cms but < 8cms
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  • Intermediate –negative groin nodes with lesion > 8 cms 1 positive groin node with lesion >2cms 2 unilaterally positive nodes, lesion< 8 cms • High – 3 or more positive nodes 2 bilaterally positive nodes
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  5 yr survivalby GOG categories Category 5 yr survival Minimal 98% Low 87% Intermediate 75% High 29%
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  Summary • Stage IA– Radical local excision • Stage IB – Radical local excision + Ipsilateral Inguinal LND • Stage II – Radical local excision + Bilateral inguinal LND • Stage III – Modified radical vulvectomy + Bilateral inguinal LND
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  • Stage IVA– Preoperative chemoradiotherapy + Limited resection • Stage IVB – Palliative chemotherapy • Adjuvant RT to tumour and nodes for high risk pathologic factors • Sentinel node biopsy is a safe alternative to inguinal LND
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