Download Cancer vulva

Cancer vulva
MOUNIR M F ELHAO,
PROF OF OB &GYN. AIN SHAMS
UNIVERSITY,GYNEONCOLOGY
UNIT.
HISTORICAL.

The surgical treatment, back in the early
1900s Basset from France who adopted
a Hallstedian concept to the treatment
of vulvar cancer very similar what Dr.
Hallstead had adopted for breast cancer,
felt that wide surgical excision was the
best.
INCIDENCE.

Relatively rare, accounting for about 3 to
5% of all gynecologic malignancies.
INCIDENCE.

Fourth most common malignancy of
the female genital tract
INCIDENCE.

As the 6th , 7th decade of life and does
increase with increasing age.
INCIDENCE.

very high association with the high risk
HPV serotypes, specifically type 16 and
18.
PREDISPOSING FACTORS.

any chronic inflammatory condition,
herpes has been implicated, obesity,
diabetes, hypertension, prior
squamous cell carcinoma of the cervix,
vagina or the anal rectal area as well,
and then vulvar dystrophy probably
increases a woman’s risk.
ASSOCIATIONS.

associated vulvar dystrophies, they may
even have vulvar intraepithelial neoplasia,
they often times are incontinent there is
often a delay of 2 to16 months between
the onset of symptoms and the initial
presentation to the physician
SYMPTOMS.

Symptoms include chronic pruritus, a
lump or mass, pain, bleeding ulceration,
dysuria and leg edema
FACT:SURVIVAL

Survival rates in most series relates to
nodal involvement.
Intraepithelial lesions.

are treated a number of different ways,
it depends on the site, the age of the
patient and the size of the lesion. It is
proper to excise with a 3 to 4 mm
margin and then primarily close the
area.
In order to make a diagnosis

you need to get tissue, and wedge
biopsy, excisional biopsies,
colposcopy, it’s very important to
remember that you have to examine the
remainder of the genital tract looking for
vaginal lesions and also for cervical
dysplasia or early invasive cancer
because often times these can be
metastatic from another site,
Squamous cell carcinoma

is the most common followed by
melanomas, about just under 6% of the
time, Bartholin gland cancers are third,
basal cell carcinoma, you see some
sarcomas, you can very rarely see
invasive Paget’s disease.
SITES.

The most frequent sites are on the labia
majus, followed by the labium minorum,
and then some patient’s will have
combined lesions about 15%.
FACT.

the demarcation for micro invasion is
actually 1 mm or less.
Anatomy


The superficial inguinal lymph nodes lie along the
saphenous vein, deep to Camper's fascia and superficial
to the cribriform fascia which overlies the femoral
vessels. They are found in the triangle bounded by the
inguinal ligament superiorly, the border of the sartorius
muscle laterally, and the adductor longus muscle
medially. There are appoximately 10 superficial lymph
nodes.
The deep inguinal lymph nodes are located medial to
the femoral vein and under the cribriform fascia. There
are approximately 3 to 5 deep nodes. The superior-most
node is located under the inguinal ligament and is called
Cloquet's node
Drainage

The superficial inguinal lymph nodes
receive drainage from the vulva and
anus. The superficial nodes drain to
the deep inguinal lymph nodes, which
then drain superiorly to the external
iliac lymph nodes, then to the pelvic
lymph nodes and to the paraaortic
lymph nodes.
The TNM staging system is used.
T-0 Pre-malignant change.
T-1A A cancer less than 2.0cm in diameter and less than 1.0mm in
depth of invasion.
T-1B A cancer less than 2.0cm in diameter but greater than 1.0mm in
invasion.
T-2 Greater than 2.0cm in diameter.
T-3 Involves vagina, urethra or anus.
T-4 Involves bladder, rectum or pelvic bone.
N-0 No lymph nodes involved
. N-1 Lymph node metastases to one groin.
N-2 Lymph node metastases to both groins.
M-0 No distant metastases.
M-1 Any distant metastases.
The standard treatment
( Hallstedian concept )

, was block radical vulvectomy with
bilateral inguinal femoral
lymphadenectomies and we did selective
pelvic lymphadenectomies through
separate extra peritoneal incisions and this
basically is what has been called the
butterfly incision or the Texas longhorn
incision.
Why conservative surgery?

The rationale for conservative surgery
is that most of the metastases occur by
embolization and the early advocates of
the more conservative procedures in
their series found no metastatic lesions
in the skin bridge between the vulva
and the groin,
FACT: Current place of pelvic
lymphadenectomy?
No patients with negative groin nodes
Had positive pelvic nodes.
Positive bilateral groin nodes five year
survival <20 %

We omitted routine
pelvic lymphadenectomy,

patient’s who have positive nodes, ,
end up getting radiation therapy to the
whole pelvis anywhay.
Role of adjuvent radiotherapy?

Review of recurrence studies of in
Homesley,s study suggests that adjuvent
RT is more effective largely because groin
recurrences are reduced.
Should we do separate groin
incisions ?
Understanding that the mode ofmetastatic
spread is embolic rather than by
contiguous grouth allowed for threeincision technique..
 Less morbidity.
 No impact on survival.

(54% BREAKDOWN RATE WITH BUTTERFLY TECH.)
Is there a place for unilateral
inguinofemoral lymphadenectomy?
May be indicated in well lateralised early
tumors.
 No lymph-capillary space involvement.
 Negative groin nodes by frozen section.

What is the place of superficial
inguinal lymphadenectomy?
Above the cribriform fascia , mainly those
associated with great saphenous and
superficial epigastric veins.
 ONLY with low risk for LN metastasis.
 Tumors confined to labia majora.
 Negative superficial nodes on frozen
section.

Can we omit groin node dissection
in superficial diseases?

Stage 1a have <1% for groin node
metastasis.

we do give postoperative radiation for
groin nodal metastases
Is there a place for preoperative
radiotherapy?

we give preop radiation therapy for
advanced disease.
Conclusions.
Now to run through management,
again
for stage I, it’s pretty much radical local
excision, and you want to try to
maintain at least a 1 cm margin and if
it’s truly a small lesion with less than a
mm invasion, it is felt that most of
those patient’s do not need to have
lymph nodes removed.
CONCLUSIONS.
For large stage II lesions, again,
depending on where it’s located, we do
a radical vulvectomy and bilateral
inguinal femoral lymphadenectomy, if
there are more than two lymph nodes
positive, the patient’s will get
postoperative whole pelvic radiation.

For stage III tumors, it depends on what’s
involved, you can do a radical excision which
often times becomes extended and you have
to take the distal vagina and even sometimes
the distal urethra and if you are going to treat
it surgically it needs to be combined with the
bilateral inguinal femoral lymphadenectomy
and again, if there is lymph node
involvement POST OPERATIVE
RADIOTHERAPY.
Conclusions.
 For
advanced disease, again you have to
individualize, add up with surgical clearance
for disease sometimes involves the anus,
rectum, proximal urethra and requires an
exenterative procedure with radical vulvectomy
and bilateral groin nodes and that particular
circumstance is very important that patient’s
are evaluated either with MRI, CAT scans and
possibly even a PET scan for metastatic
disease prior to undertaking such a large
procedure. The operative mortality is about 5 to
10%.
Conclusions.
Survival is also determined whether or
not the nodes are positive or negative,
and by which nodes are involved.
 If patient’s have negative groin nodes,
the five year survival is 90% and that’s
for stage I and stage II.
 If they have positive groin nodes,
survival drops about 57%.



If they have positive pelvic lymph nodes, it
drops to 20%. Unilateral positive groin
nodes is about 70% five year survival,
bilateral positive groin nodes, however,
drops down to 25% five year survival, and
then the increasing number of positive
nodes.
CONCLUSIONS.

and also the tumor diameter affects nodal
involvement, lymphatic vascular space
involvement and then overall survival.
Conclusions.




The Cochrane Database of Systematic Reviews 2006 Issue 1
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley &
Sons, Ltd.
Surgical interventions for early squamous cell carcinoma of the vulva
Ansink A, van der Velden J, Collingwood M
Plain language summary

Less extensive surgery for vulvar cancer appears
safe and limits mutilation

Vulvar cancer is rare, affecting mainly older women. Until the 1980s,
affected women underwent extensive, mutilating surgery. Groin nodes on
both sides as well as all vulvar tissue were removed. Recently surgeons
have carried out a smaller operation, leaving as much vulvar tissue as
possible behind. No randomized controlled trials have been conducted on
the safety of this reduced surgery, but from the available evidence it
appears to be safe to perform this smaller operation in most patients.
CONCLUSIONS.




The
Cochrane
Library
Cochrane review abstract and
plain language summary
This is an abstract and plain language summary of a regularly updated, systematic review
prepared and maintained by The Cochrane Collaboration. The full text of the review is available in
The Cochrane Library (ISSN 1464-780X).
The Cochrane Database of Systematic Reviews 2006 Issue 1
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Primary groin irradiation vs primary groin surgery for early
vulvar cancer

van der Velden J, Ansink A
Plain language summary
Insufficient evidence that radiotherapy works as well as surgery for vulvar cancer.
Cancer of the vulva is mainly a disease of elderly women. Surgery involves removal of the tumour
and surrounding lymph nodes, occasionally followed by radiotherapy. Although survival rates are
high if the tumour is found early enough, removal of the lymph nodes causes swelling, particularly
in the legs. Wound healing and sexual problems are also common. While radiotherapy is



effective in the short term, there is not enough evidence from trials to show
that it is as effective as surgery in preventing tumour regrowth in the groins.
What is the place of modified
radical vulvectomy?
main morbidity of radical vulvectomy is
sexual dysfunction and compromised
function of the anus and urethra.
 The main fear of about the modified
operation is the multicentricity of the
tumor.(20-30%).
 So reservethe operation to well localised
tumors,with 2 cm free margin.

How should we treat vulvar
carcinoma with perianal
involvement?
The main problem in these cases is to do
adequate resection with maintaining
sphincteric function.sometimes
 we may need to do more radical resection
and colostomy or
 preoperative radiotherapy.

what is the place of ultraradical
surgery?

Only in patients with clearly resectable
lesions and negative or one or two
microscopicaly positive nodes.
what is the place of neoadjuvent
chemotherapy?
Resuts are not encouraging for time being.
CONCLUSION.
1.Standard radical vulvectomy and bilateral
lymphadenectomy(Hallstedian
concept.)has compromised the life of
many women with cancer vulva.
2.In many well selected patients wide
excision with 2 cm margin with or without
node selection may suffice.
3.modified radical vulvectomy with bilateral
groin node dissection will give equaly good
results in the majority of cases.
4.Pelvic lymphadenectomy should be
abondoned except in a minority of
selected cases.
5.Radiotherapy should be given to the
groins and pelvis postoperatively only if
more than one groin nodesis positive for
metestatic disease.
6.ultraradical surgery selective .
7.In situ stage is almost 100% curable.and
FIGO stage 1 disease is 90% curable and
5 year survival rate.