Skip to main content
UploadLanguage (EN)Support
BusinessMobileSocial MediaMarketingTechnologyArt & PhotosCareerDesignEducationPresentations & Public SpeakingGovernment & NonprofitHealthcareInternetLawLeadership & ManagementAutomotiveEngineeringSoftwareRecruiting & HRRetailSalesServicesScienceSmall Business & EntrepreneurshipFoodEnvironmentEconomy & FinanceData & AnalyticsInvestor RelationsSportsSpiritualNews & PoliticsTravelSelf ImprovementReal EstateEntertainment & HumorHealth & MedicineDevices & HardwareLifestyle
Uploaded byRahul254324
PPTX, PDF33 views

CA vulva management of carcinoma vulva.pptx

Management of CA vulva

Healthcare◦
Download to read offline
CARCINOMA VULVA PRESENTED BY- DR. RAHUL YADAV RESIDENT DOCTOR ATRCTRI,BIKANER
OUTLINE- 1. INTRODUCTION 2. RISK FACTORS 3. PATHOLOGY 4. PATTERN OF SPREAD 5. CLINICAL MANIFESTATION 6. WORK UP 7. STAGING 8. TREATMENT
INTRODUCTION- • Vulvar carcinoma is a rare malignancy. • Represents <1% of all the cancers diagnosed in women & <5%of all gyanecologic neoplasm. • Age group- 6th -7th decade (median age 65year)
LYMPHATIC DRAINAGE-
RISK FACTORS- YOUNG WOMEN ELDERLY WOMEN • STD”s •VULVAR DYSTROPHY • HPV-16,18,33 •LICHEN SCLEROSIS • HSV •CHRONIC VULVAR PRURITIS DERMATITIS • SMOKING ,ALCOHOL • IMMUNOSUPPRESSION H/O VIN,CIN,SCC CERVIX OBESITY GEOGRAPHICAL DISTRIBUTION-European countries
Pathogenesis- • Two primary mechanism involved in the carcinogenesis- -Human papilloma virus(16,18,33)-usual type VIN(uVIN) -Vulvar dystrophy including lichen sclerosis(LS) and squamous hyperplasia- differentiated VIN (dVIN) HISTOLOGICAL TYPES- 1. S.C.C –KERATINIZING &BASALOID 2. MELANOMA 3. ADENOCARCINOMA 4. PAGET DISEASE OF VULVA 5. VERRUCOUS CARCINOMA 6. OTHER-MERKEL CELL TUMORS,BASAL CELL CARCINOMA,TRANSITIONAL CELL CARCINOMA,SARCOMA.
PATTERN OF SPREAD- • LOCAL SPREAD- VAGINA -URETHRA -ANUS • LYMPHATIC SPREAD- INGUINAL FEMORAL PELVIC L.N • HEMATOGENOUS SPREAD- LUNG -LIVER -BONE
CLINICAL MANIFESTATION- • M/C –Vulvar pruritis vulvar swelling,lump,ulcer (single/multiple) • m/c site-labia majora • Pain,Discharge or Bleeding • Urinary /Rectal symptoms • very rare-erosive tumour growth from groin On examination-uni/multifocal lesion size proximity to midline(middle/lateral) involving urethra,clitoris,vagina ,anus  Complete pelvic assessement  Careful examination of inguinal lymph nodes ANY LESION OF VULVA WARRANTS A BIOPSY.
Work-up- 1. HISTORY &PHYSICAL EXAMINATION 2. ROUTINE BLOOD INVESTIGATION CBC,RFT,LFT VIRAL MARKERS (HIV TESTING) CERVICAL HPV & CYTOLOGIGAL TESTING 3. IMAGING- CXR –If abnormality suspected …..NCCT Pelvic CT/MRI PET-CT –for T2 or larger tumour or if metastasis is suspected in f/up 3-6 month to assess treatment response. COLPOSCOPY &VULVOSCOPY CYSTOSCOPY
4. PATHOLOGICAL STUDIES- PAP SMEAR –For cervical and vaginal cytology IF LESION IS NOT VISIBLE- VULVOSCOPY WITH 3% ACETIC ACID VISIBLE LESION-BIOPSY DEPTH OF INVASION MEASURE-
Staging-FIGO • FIGO STAGE – DESCRIPTION • I-TUMOR CONFINED TO THE VULVA &/OR PERINEUM IA - TUMOR SIZE <2 CM OR STROMAL INVASION <1 mm IB - TUMOR SIZE >2 CM OR STROMAL INVASION >1mm • II-TUMOR OF ANY SIZE WITH EXTENSION TO LOWER ONE-THIRD OF URETHRA, LOWER 1/3rd VAGINA,LOWER 1/3rd ANUS WITH NEGATIVE NODES • III-TUMOR OF ANY SIZE WITH EXTENSION TO UPPER PART OF ADJACENT PERINEAL STRUCTURES,OR WITH ANY NUMBER OF NON FIXED,NON ULCERATED LYMPH NODE IIIA - TUMOR OF ANY SIZE WITH DISEASE EXTENSION TO UPPER 2/3 rd OF URETHRA ,VAGINA,BLADDER MUCOSA,RECTAL MUCOSA OR REGIONAL LYMPH NODE ,METASTASIS <5 mm IIIB - REGIONAL LYMPH NODE METASTASIS >5 mm IIIC - REGIONAL LYMPH NODE METASTASIS WITH EXTRACAPSULAR SPREAD
• IV-TUMOR OF ANY SIZE FIXED TO BONE ,OR FIXED ,ULCERATED LYMPH NODE METASTASIS OR DISTANT METASTASIS IVA-DISEASE FIXED TO PELVIC BONE OR FIXED ULCERATED LYMPH NODE IVB-DISTANT METASTASIS  NOTE- Regional refers to inguinal and femoral lymph nodes Pelvic L.N. mets considerd as distant mets Treatment options- 1.Surgery – Wide local excision Radical vulvectomy + SLNB /LYMPHADENECTOMY Exenteration 2.Radiotherapy-PRE-OPERATIVE RT -ADJUVANT RT -DEFINITIVE RT OR CHEMORADIATION -PALLIATIVE RADIOTHERAPY 3.Systemic therapy –SINGLE AGENT OR MULTIPLE AGENT
TREATMENT- • EARLY STAGE-(Stage l & select stage ll)…..BIOPSY Stage IA Stage lb or select stage ll simple partial vulvectomy lateral lesion central lesion observation if margin negative If margin positive Radical partial vulvectomy and inguinofemoral LN evaluation (SLNB) or iguinofemoral lymphadenctomy
• LATERAL LESION-IPSILATERAL INGUINOFEMORAL L.N.EVALUATION SLNB OR I/L INGUINOFEMORAL LYMPHADENECTOMY • CENTRAL LESION –BILATERAL INGUINOFEMORAL LYMPHADENECTOMY SLNB OR B/L INGUINOFEMORAL LYMPHADENECTOMY IN BOTH LESIONS ASSESSEMENT OF PRIMARY TUMOR AND NODAL SURGICAL PATHOLOGY ADJUVANT THERAPY BASED ON PRIMARY TUMOR RISK FACTORS AND NODAL EVALUATION
PRIMARY TUMOR RISK FACTORS • MARGINS NEGATIVE POSITIVE MARGINS OBSERAVATION OR ADJ. RE-EXCISION UNRESECTABLE EBRT (based on other risk factors) NEGATIVE MARGIN POSITIVE ADJUVANT EBRT MARGIN Other tumor risk factors-tumor close margin,Tm size,LVSI,DOI,Pattern of invasion(spray/diffuse)
NODAL EVALUATION- • LNs NEGATIVE (Sentinel node(s) or inguinofemoral nodes) observe • SLN(s) positive single positive positive SLN complete inguinofemoral <2mm mets. >2mm mets. Lymphadencetomy (Preferred) EBRT +/- EBRT +/- CONCURRENT CT CONCURRENT CT • INGUINOFEMORAL LYMPHADENECTOMY EBRT (if >2 LN positive or WITH POSITIVE LN(s) extranodal extension)+/- CT
Locally advanced (Larger T2 ,T3;unresectable w/o removing proximal urethra/bladder /anus) • Radiologic imaging work-up Radiographically Radiologically suspicious nodes negative nodes (confined pelvic M1 ,LN disease) INGUINOFEMORAL INGUINOFEMORAL LYMPHADENECTOMY NOT DONE LYMPHADENECTOMY PERFORMED CONSIDER FINE NEEDLE ASPIRATION FOR ENLARGED NODE EBRT+CONCURRENT CT Larger T2 >4cm &/or involevement of urethra,vagina or anus
UNRESECTABLE NODES REGARDLESS OF T STAGE- • Radiological imaging to assess extent of disease consider FNA for enlarged nodes EBRT + CONCURRENT CT TO PRIMARY TUMOR/INGUINO FEMORAL LNs ,PELVIC LNs
METASTATIC DISEASE BEYOND PELVIS- • any T,any N with M1 beyond pelvis EBRT for locoregional control/symptom palliation &/or systemic therapy or Best supportive care
ADJUVANT RADIOTHERAPY- • Radiotherapy is often used in the treatment of patients of patients with vulvar cancer as adjuvant following initial surgery. • INDICATIONS FOR RT-  TO PRIMARY- POSITIVE MARGIN TO L.N.SITE- cL.N+ LVSI >2 pL.N+ CLOSE MARGIN(<8mm) ECE DOI>5 mm • Post op adjuvant therapy should be initiated as soon as adequate healing is achieved preferably within 6-8 weeks. TREATMENT VOLUME AND TECHNIQUE- 1.CONVENTIONAL RADIOTHERAPY (AP-PA FIELD) 2.3-D CONFORMAL /IMRT TARGET VOLUME IS DECIDED BY BOTH PHYSICAL EXAMINATION AND IMAGING.
CONVENTIONAL RADIOTHERAPY- • AP-PA fields with the patient in the supine position are recommended for the delivery of external beam. • Medium or high energy photon beams are used to irradiated the field. • Depending on whether the inguinofemoral lymph nodes &/or pelvic lymph nodes are to be included in the radiation volume ,different field configuration may be used. • Although there are no data regarding scar recurrence, it is common practice to include the inguinal node dissection scars in the radiation field.
FIELD ARRANGEMENT- • I) Use Wide AP that includes pelvic & inguinal areas & Narrow PA covering only pelvis( spares femoral heads) • The photon fields are weighted equally, and the inguinal dose is supplemented by separate AP electron fields matched to the pelvic field • Bolus material should be used to ensure adequate dose to the superficial portions of the groin
II) Wide AP & Narrow PA,with a partial transmission central block (in the AP field), (associated with high rate of central recurrence in stage III& IV) • The desired dose at a specified depth is delivered to the inguinal nodes through the AP field. • Advantages: -Eliminates the dosimetric problems of photon/electron field matching -Decrease potential for daily setup variation Disadvantage: -Difficult to design of a precise partial transmission block
• III) Matched AP/PA fields to include the primary & pelvic nodes and treating the groins through separate anterior electron fields. • Advantage : - relatively easy setup • Disadvantage : -Difficult to ensure an adequate dose at the match line, particularly when the match line is over gross disease.
3-D CONFORMAL TREATMENT- • 3-D Planning is essential to establish the location,extent and depth of the inguinal and pelvic lymph nodes as well as the primary. RT PLANNING CT SIMULATION- • SUPINE/FROG-LEG POSITION frog-leg position may be used to reduce skin folds in the inguinal regions,though this may be less important if IMRT is used. • Advanced immobilisation devices such as cradle ,bubble wrap or bariatric slings may be considered. • Both oral and iv contrast • Bladder and Bowel protocol fill • Radio –opaque marker should be placed • Customised bolus of 0.5 cm thickness for the vulvar region at simulation . • Images taken from L2 to mid thigh with with slice thickness of 3mm
Contouring- Entire vulva/post-op bed B/L Inguinofemoral nodes Pelvic lymph nodes GTV :-All gross disease on physical examination and imaging CTV PRIMARY:- • GTV +1 cm including the entire vulva ,excluding uninvolved bone ,muscle and adjacent organs Include vagina if vaginal involvement • If extensive urethral involvement include 2 cm of urethra proximal to primary GTV • CTV node-inguinal/pelvic nodes
CTV TOTAL- CTV primary plus CTV node (Inguinal,femoral and iliac blood vessels can be used as surrogates for nodes & 7 mm margin around vessels to define CTV-node) PTV-CTV upto 1.5-2 cm margin OARs –  BLADDER  BOWEL BEG  RECTUM  HEAD OF THE FEMUR
RT doses A) Vulvar primary Post operative I) Margin negative=45-50 Gy (25-28 #,1.8 Gy/#) II)Close margin= 54-60 Gy III)Positive margin/microscopic residual=54-60GY Definitive -60-70Gy(33-36 total fractions ,1.8 Gy/#)
• Nodal region I) Uninvolved nodal region- 45-50 Gy II) Resected nodal region-50-55 Gy III) (ECE) + : 54-64Gy IV) Gross residual /LN unresected- 60-70 Gy Once daily,1.8Gy /# ,5 times in a week. Breaks from treatment should be minimized.
Toxicity • Vulvar skin reaction • Urinary frequency and dysuria • Proctitis and diarrhoea • Late vulval fibrosis and atrophy • Lymphedema (occur in 30% pts when inguinofemoral surgery & RT are combined) • Urethral stenosis as a late effect • Femoral head necrosis -11% risk of necrosis at 5 yrs, if opposing AP/PA beams used in elderly pts
THANK YOU