Vulvar

• age: > 75 years
• True / false: incidence of vulvar cancer is slightly higher in black women

  • false: incidence of vulvar cancer is slightly lower in black women
• Etiology:

  • HPV
  • smoking
  • weakened immune system (HIV)
  • history of precancerous conditions of vulva (ex. vulvar intraepithelial neoplasia)
  • skin conditions involving vulva (ex. lichen sclerosis)
• True / False: vulvar intraepithelial neoplasia (VIN) is a precursor to vulvar cancer

  • true: vulvar intraepithelial neoplasia is a precursor to vulvar cancer
• True / False: 70% of vulvar cancers are squamous cell carcinomas

  • false: 90% of vulvar cancers are squamous cell carcinomas
• Natural history:

  • most arise from: labia major and minor
  • other places: clitoris, perineum, urethra
  • features associated with nodal mets: tumour thickness, histologic grade, capillary like space involvement, depth of invasion, location of tumour, tumour size
  • hematogenous spread occurs late in disease
• Spread:

  • local:
  • along vulva and perineum
  • urethra
  • vagina
  • lymphatics:
  • superficial inguinal → deep inguinal → external iliac → common iliac → para aortic → cisterna chyli → thoracic duct
  • superficial inguinal → external iliac → common iliac → para aortic → cisterna chyli → thoracic duct
  • internal iliac → common iliac → para aortic → cisterna chyli → thoracic duct
  • hematogenous
  • liver, lung, bone
  • occurs after lymph node involvement
• Presentation:

  • pruritus and soreness in vulva
  • wart like growths on vulva or opening to vagina
  • ulcers
  • unusual bleeding that is not menstruation
• Diagnostic tests:

  • history and physical
  • may also do Pap test and HPV test
  • biopsy
  • excisional biopsy = if small
  • punch biopsy = if large
  • sentinel LN biopsy = prior to lymphadenectomy
  • imaging
  • ultrasound +/- fine needle aspiration cytology
  • MRI
• Prognostic indicator:

  • most important: stage
  • earlier stage = more favourable
  • SCC = more favourable
  • women who present with symptoms = less favourable
• Staging FIGO:

  • stage 1: confined to vulva
  • stage 2:
  • extension to lower 1 / 3 of urethra
  • lower 1 / 3 of vagina
  • lower 1 / 3 of anus + negative nodes
  • stage 3:
  • A: upper 2 / 3 urethra, vagina, bladder mucosa, rectal mucosa, regional nodes < 5 mm
  • B: regional nodes > 5 mm
  • C: regional nodes + extra capsular spread
  • stage 4:
  • A: pelvic bone, ulcerated regional node mets
  • B: distant mets
• Treatment overview:

  • primary: surgical
  • based on: staging and risk of nodal involvement
  • stage 1 - 2 vulvar squamous cell carcinoma:
  • conservative surgery
  • early stage + lateral: radial or hemivulvectomy +/- unilateral or bilateral lymphadenectomy
  • early stage + central: radial vulvectomy + bilateral lymphadenectomy +/- reconstruction
  • if close margins or positive nodes: RT adjuvant to surgery
  • stage 3 - 4:
  • radiation or chemo RT +/- vulvectomy +/- bilateral or unilateral lymphadenectomy
  • individualized treatment
• Radiation:

  • adjuvant to surgery if:
  • positive margins
  • lymphovascular invasion
  • negative but close margins (< 8 mm)
  • spray or diffuse pattern of invasion
  • depth of invasion > 1 mm
  • nodal involvement
• Stage 3 - 4 VSCC radiation:

  • volume: tumour, pelvis, inguinal nodes
  • radial RT: 50 Gy / 25 - 28 fr → 60 Gy to gross disease
  • palliative RT
• EBRT:

  • energy: 6 MV or 15 MV (if separation > 24 cm)
  • borders: include inguinal and iliac nodes + entire vulva
  • sup: L5 / S1 (internal and external iliac nodes) or L4 / L5 (common iliac nodes)
  • inf: 2 - 3 cm below vulvar marker (entire vulva)
  • lat: 1.5 cm lateral to pelvic brim (inguinal nodes)
  • + bolus → eliminate cold spot on vulva and inguinal nodes
  • fields: POP
  • historical: 2 phases
  • first: POP (pelvic + inguinal)
  • second: boost to inguinal nodes (via electrons)
• EBRT position:

  • supine
  • head on 10 cm sponge
  • hands on chest
  • frog leg position (for larger patients) → prevent self bolus
• EBRT OAR:

  • femoral neck
  • small bowel
  • rectum
  • bladder
• Chemo:

  • 5 FU or with cisplatin / mitomycin C
• Acute effects:

  • RT:
  • fatigue
  • erythema
  • vaginal narrowing
  • surgery:
  • wound infection
  • hematoma
  • seroma
• Chronic effects:

  • RT:
  • telangiectasia
  • atrophy of skin
  • dryness of mucosa in vagina and vulva
  • surgery:
  • lymphedema
  • chronic cellulitis of inguinal areas
  • sexual dysfunction
• Prognosis: average = 71%

  • localized: 86%
  • regional: 53%
  • distant: 19%