Vulval cancer final

Vulval cancer final

• 1.
  Dr Antima Rathore
• 2.
  Incidence  0.6 %of all malignancies  4 % of genital malignancies  Squamous cell carcinoma – 90 %
• 3.
  Types of Vulvarcancer
• 4.
  Anatomy of thevulva
• 5.
  Lymphatic drainage ofvulva
• 6.
  Lymphatic drainage ofthe vulva
• 7.
  Applied Anatomy  Singlemost prognostic marker – L N status  5 yr survival rate No LN - 90% LN - 50%  Superficial Inguinal Lymph node – Sentinal Lymph Node
• 9.
  Etiology  HPV  VIN CIN  Lichen sclerosis  Squamous hyperplasia  Immunodeficiency  History of genital warts  Smoking  Alcohol  Immunosuppression  H/O Cervical or Vaginal cancer  Northern Europe ancestry
• 10.
  Squamous cell cancer 90% Basaliod  Multifocal  Younger pt  HPV  VIN  Smoking Keratinising  Unifocal  Older patient  Lichen Sclerosis  Sq. Hyperplasia (>80% cases) Itch Scratch Cycle
• 11.
  Clinical features  Postmenopausalfemale (Mean Age – 65 yrs)  VIN  Vulval Pruritis  Lump or mass  Rare – bleeding/ulcerative lesions, discharge  Pain or dysuria  Large metastatic mass in groin  Other malignancies – HPV and smoking associated
• 12.
  Diagnosis  Any vulvallesion warrants biopsy  Punch biopsy  Wedge biopsy (include dermis)  Colposcopy – cervix and vagina  Labia majora & minora – 60%  Clitoris – 15%  Perineum – 10%  Multifocal – 5%  Extensive – 10%
• 13.
  Routes of Spread Direct extension  Lymphatic  Hematogenous
• 14.
  Staging IA Tumor confinedto the vulva or perineum, ≤ 2cm in size with stromal invasion ≤ 1mm, negative nodes IB Tumor confined to the vulva or perineum, > 2cm in size or with stromal invasion > 1mm, negative nodes II Tumor of any size with adjacent spread (1/3 lower urethra, 1/3 lower vagina, anus), negative nodes
• 15.
  Staging IIIA Tumor ofany size with positive inguino-femoral lymph nodes (i) 1 lymph node metastasis ≥ 5 mm (ii) 1-2 lymph node metastasis(es) < 5 mm IIIB (i) 2 or more lymph nodes metastases ≥ 5 mm (ii) 3 or more lymph nodes metastases < 5 mm IIIC Positive node(s) with extracapsular spread
• 16.
  Staging IVA (i) Tumorinvades other regional structures (2/3 upper urethra, 2/3 upper vagina), 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
• 17.
  Prognosis  Lymph nodesstatus  Lesion size  Histologic grade, tumor thickness, depth of stromal invasion, lymph- vascular space involvement, tumor ploidy  Stage I – 79%  Stage II – 59%  Stage III – 43%  Stage IV – 13%
• 18.
  Treatment
• 19.
   Table 33.4 부산백병원산부인과
• 21.
   Stage Ia– Microinvasive T1a Wide Local excision – deep upto dermis  Stage Ib & II – Early vulval cancer Radical local excision plus Ipsilateral groin node dissection - 1 cm negative margin - Extending up to inferior fascia of urogenital diaphragm - Separate incision technique Treatment
• 22.
  Treatment  Midline lesions Anterior– clitoris sparing surgery – 8mm margin  Periclitoral lesion in young pt – small field RT with concomitant chemosensitization  small lesion – 5000 cGy external radiation f/b biopsy
• 23.
  Treatment  Stage IIinvolving adjacent srtucture Radical vulvectomy or radical local excision Plus LN Dissection  Advanced disease Surgery plus RT plus concomitant chemo
• 24.
  Treatment  Clinicaly advancednodes – debulking of enlarged nodes &/or chemoradiation  Metastatic disease - palliation
• 25.
  부산백병원 산부인과
• 26.
  부산백병원 산부인과
• 27.
  부산백병원 산부인과
• 28.
  Closure of largedefects  Small defects – primary closure without tension  Large – left open to granulate  Full thickness skin flap – rhomboid or mons pubis flap  Myocutaneous flap – gracialis  Tensior fascia lata myocutaneous graft
• 29.
  Management of LN > 2 cm diameter  > 1 mm invasion  Surgery – trt of choice  Bilateral dissection - midline lesions, clitoris, post forchet - unilateral bulky LN / multiple microscopic LN  Bulky LN – debulking  Fixed unresectable LN - chemoradiation
• 30.
  Sentinal Lymph nodebiopsy Criteria 1) unifocal primary tumour of 4 cm or less in diameter with > 1 mm invasion 2) no obvious metastatic disease on physical examination/imaging
• 31.
  Postop management  Ambulationon day 1 or 2  DVT prevention  Subcutaneous heparin  pneumatic calf compression  Frequent dressing  Suction drainage of each side of the groin  Sitz bath
• 32.
  Early Postoperative Complications Groin wound infection, necrosis, breakdown  En bloc operation – 53-85%  Separate-incision approach – 44%  UTI  Lymphocyst  DVT  Pulmonary embolism  MI  Hemorrhage
• 33.
  Late Complications  Chroniclymphedema  Recurrent lymphagitis or cellulitis  Usually responds to oral antibiotics  SUI  Introital stenosis  Femoral hernia (uncommon)  Depression, altered body image and sexual dysfunction  Pubic osteomylitis  Fistula
• 34.
  Recurrent Vulvar cancer ≥ 3 LN - 2/3 of vulvar cancer recur within first 2 years from initial Tx.  Local recurrence  Margin status  Closer than 0.8cm -> 50% recur  Primary lesion larger than 4cm in diameter  Ipsilateral lymphovascular space invasion  Deep invasive tumour  Tx.  Additional surgery with myocutaneous graft  External beam therapy + interstitial needles with chemotherapy
• 35.
  Regional and DistantRecurrence  Difficult  Poor prognosis  Radiation  Chemotherapy  Bleomycin and methotrexate & lomustine  Bleomycin and mitomycin C  Cisplatin, vincristine & paclitaxel  Response  Usually disappointing  Long-term survival is very uncommon
• 36.
  Role of RadiationTherapy  primary vulval ca.  Advanced disease  LN meta – microscopic, gross  Possible roles for RTx.  Involved or close surgical margin  Small primary tumor - primary Tx.,  Particularly clitoral or periclitoral lesion
• 37.
  Melanoma  Rare  Incidence: 0.1-0.19/100,000women  Second most common of vulvar malignancy  Postmenopausal white women  No symptoms (most)  Itching, bleeding, groin mass  Labia minora, clitoris  Vulvar nevi are junctional, precursor lesion to melanoma; thus, should be removed
• 38.
  Histopathology  Mucosal lentiginousmelanoma  Flat freckle, quite extensive, superficial  Superficial spreading melanoma  Most common, superficial  Nodular melanoma  Most aggressive, raised lesion  Penetrate deeply  Metastasize widely  ¼ of cases of melanomas  Macroscopically amelanotic -> spread early
• 39.
  Staging
• 40.
  Treatment  More conservativesurgical management  Invasion  (<1mm) : Radical local excision alone  (>1mm) : en bloc resection of the primary tumor and regional groin node dissection recommended  1cm surgical margin (<0.76mm)  2cm surgical margin (1-4mm)
• 41.
  Treatment  10-year survivalrate  Lateral lesion (61%), medial lesion (37%)  Superfical lesion (Breslow tumor thickness <0.76mm )  Lymphadenectomy not indicated  Intermediate-thickness (1-4mm)  Observation showed a 5-year survival advantage who underwent lymph node dissection  Deeply invasive cutaneous melanoma (>4mm)  Benefit from regional lymphadenectomy  Chemotherapy : interferon – α , dacarbazine
• 42.
  Bartholin Gland Carcinoma Rare  Postmenopausal  Premenopausal  Honan’s criteria  The tumor is in the correct anatomic position  The tumor is located deep in the labium majus  The overlying skin is intact  There is some recognizable normal gland present
• 43.
  Bartholin Gland Carcinoma Signs and Symptoms  Vulvar mass or perineal pain  10% of patients may be mistaken for benign cysts or abscesses  Treatment  Radical vulvectomy with bilateral groin and pelvic LN dissection  Fixed, involves adjacent structures-> postop radiation and chemotherapy is preferable
• 44.
  Bartholin Gland Carcinoma Adenoid Cystic Carcinoma of Bartholin Gland  Other Adenocarcinomas  Adenosquamous Carcinoma  Basal cell carcinoma  Verrucous Carcinoma  Vulvar Sarcoma
• 45.
  Rare Vulvar Malignancies Lymphomas  Endodermal Sinus Tumor  Merkel Cell Carcinoma  Dermatofibrosarcoma Protuberans  Metastatic Tumors of the Vulva