General Flashcards
What is accuracy of physical exam for lymphadenopathy
False negative: 20%
False positive: 20%
What percent of positive groin nodes will have positive pelvic nodes
20%
How do you biopsy a concerning groin node
Fine need aspiration
What is the data for debulking clinically positive nodes vs. doing full IFL
Nooj et al 2015
Retrospective 84 patients: SLN, IFL, and debulking
O and PFS was similar across groups
Debulking had fewer complications (lymphocyst, lymphedema) compared to IFL (despite more debulking patients getting adjuvant radiation)
What is risk of lymph node disease if DOI is <1mm
<1%
What is risk of lymph node disease if DOI is 2mm, 3mm, 5mm?
2mm: 8%
3mm: 12-30%
5mm: 33%
GOG 33
What is the risk of lymph node disease if lesion is:
<1, 2, 3, and 4cm
<1cm: 8cm
2cm: 20%
3cm: 30%
4cm: 40%
What is stage I vulvar cancer
IA: Tumor confined to the vulva or perineum, ≤ 2 cm in size, stromal invasion ≤1mm⁎, negative nodes
IB: Tumor confined to the vulva or perineum, N2 cm in size or stromal invasion ≥1mm⁎, negative nodes
How do you tell depth of invasion
The depth of invasion is defined as the measurement of the tumor from the epithelial– stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.
What is stage II vulvar cancer
Tumor of any size with extension to adjacent perineal structure (lower urethra, lower third of vagina, anus), negative nodes
What is stage III vulvar cancer
Tumor of any size with or without extension to adjacent perineal structure (lower urethra, lower third of vagina, anus) with positive groin nodes
IIIa1 Node metastasis (≥ 5 mm) or 1–2 node metastasis/es (b 5 mm)
IIIb N2 node metastases (≥ 5 mm) or N 3 node metastases (b 5 mm)
IIIc Node metastases with extracapsular spread
What is stage IV vulvar cancer
IVa Tumor invades any of the following: upper urethral and/or vaginal mucosa,
bladder mucosa, rectal mucosa, or fixed to pelvic bone, or fixed or ulcerated
IVb groin nodes. Any distant metastasis, including positive pelvic nodes
What dose of RT do you use for groin RT
50 Gy for microscopic metastases
60 Gy for multiple positive nodes or extracapsular spread
Large vulvar tumors may require 60-70Gy
Do you add chemotherapy to adjuvant radiation
NCDB study of 1800 patients, majority with at least one positive LN, all had adjuvant RT, compared chemo and non-chemo groups
positive surgical margins (OR 1.70, 95% CI 1.31–2.20), higher lymph node positivity (≥ 4 involved nodes: OR 1.98, 95% CI 1.50–2.63), and stage IV disease (OR 1.63, 95% CI 1.31–2.04) were more likely to receive chemotherapy
3-year overall survival estimates of 46.9% (95% CI 44.2–49.6) no chemo and 53.9% with chemo (95% CI 49.4–58.4%, p = 0.001).
Delivery of adjuvant chemotherapy led to a 38% reduction in the risk of death
What is the strongest prognostic factor for vulvar cancer
Lymph node status
The 5-year overall survival (OS) rates range from 70 to 98% for patients with negative nodes to 12–41% for those with metastatic nodes.
Number, size, and ECE all contribute
AGO CARE1 (Retrospective 1047 patients): higher LNR were found to have larger tumor size (P
What is 5 year OS for different stages of vulvar cancer?
I: 90
II: 81
III: 68
IV: 20%
What kind of flaps can be used for pelvic exenteration
unilateral/bilateral gracilis myocutaneous flap, or a vertical rectus abdominis myocutaneous flap, or an anterolateral thigh flap, or a deep inferior epigastric artery perforator flap.
What can decrease risk of exposed vasculature after groin dissection
The transposition of the sartorius muscle over the uncovered femoral vessels may help in reducing postoperative complications and hernias.
Do you ever use preoperative radiation for locally advanced vulvar cancer?
Yes - can consider as External RT may downsize of the tumor in 70–85% of cases to reduce the need for exenteration
Boronow prospective 48 patient cohort (1987). 5y OS for primary cases 76% and 63% for recurrent cases. 4/48 patients underwent exenteration instead of all 48
Rotmensch 40 Gy to vulva and 45 to groins in 16 patients, 12 were able to have visceral preservation
Other studies: Hacker
Discuss use of preoperative chemo-RT for locally advanced vulvar cancer
Lupi 1996: Thirty-one patients with squamous cell carcinoma of the vulva were treated with two courses of combination chemotherapy mitomycin C, 15 mg/m2 intravenously (i.v.) on Day 1, and 5-fluorouracil, 750 mg/m2 i.v., in continuous 24-hour infusion on Days 1 to 5. Inguinal and pelvic lymph node chains and the vulva were irradiated (starting on the same day as the chemotherapy) up to a total dose of 36 Gy. After a 2-week interval, a second course of chemoradiotherapy was given (18 Gy on the vulvar region only). After 2 weeks, patients underwent radical surgery. ORR 90% primary, 100% recurrent
Landoni: 58 patients with primary or recurrent disease, treated with CCRT followed by wide local excision and inguinal lymphadenectomy in 42 cases, complete response in 36% of primary tumors and 67% with recurrent, 48% of inguinal nodes had complete response (primary) and 20% recurrent
Moore, Phase II GOG trial: 73 patients with Stg III or IV vulvar SCC. Treatment consisted of a planned split course of concurrent cisplatin/5-fluorouracil and radiation therapy followed by surgical excision of the residual primary tumor plus bilateral inguinal–femoral lymph node dissection. Following chemoradiotherapy, 33/71 (46.5%) patients had no visible vulvar cancer at the time of planned surgery and 38/71 (53.5%) had gross residual cancer at the time of operation. Only 3 had unresectable disease.
A meta–analysis of 5 studies of neoadjuvant CCRT [36,38,40,42,45] for advanced primary vulvar carcinoma, reported that the operability was achieved in 63 to 92% of cases treated with 5FU + CDDP or MMC, and only in 20% of those treated with BLEO
For locally advanced vulvar cancer, is definitive RT or CCRT better?
NCDB 1352 patients: 5y OS higher in CCRT (49%) than RT (27%) - benefit seen in + and neg nodes and across age group
NCDB definitive CCRT or RT is inferior to neoadjuvant followed by surgery - however, if patients received 55Gy or more outcomes were comparable
Can consider definitive CCRT as alternatives for patients who are not surgical candidates or patients with complete pathologic response (no subsequent surgery)
there is an ongoing Phase II trial of cis and gem CCRT (IMRT) in Stg III-IV vulvar SCC
For locally advanced vulvar cancer, what is data for neoadjuvant chemotherapy alone?
Considered experimental as regimens are not uniform and carry high toxicities.
EORTC: BLEO+lomustine+MTX 2 CR and 12 PR (of 25); ORR 56% - major hematologic toxicities and lung toxicity, surgery performed in 8/14 responders, 4 complete excision with negative margins, other 4 had pos margins or unresectable nodes thus underwent definitive RT
What dose of radiation do you use for definitive CCRT?
65Gy - CR rates are 25-72%, relapse in 1/3 of patients
What is the “one liner from GROINSS-VI
Omission of IFL is safe in patients with negative SN with isolated recurrence rate of 2.3% and lower morbidity
If SLN micromet, underwent IFL with 3.6% groin recurrence
Discuss GROINSS-VII
Methods: Single arm Phase II, early stage vulvar cancer planned for WLE and SLN (radiotracer and blue dye -> if H&E negative then ultrastaging; allowed unilateral if <1cm from midline and no crossing on LSG, if midline did both sides), if positive : 50Gy RT to IF and external iliacs within 6 weeks of surgery 5Fx/week
Inclusion: <4cm, preoperative imaging with neg nodes or if >15mm neg FNA
Primary endpoint: Isolated groin recurrence at 24m
Results:
- Micromet less than or equal to 2mm: 126 had RT - 3 recurred (1.6% compared to 3.6% in GROINSSVI), 16 underwent IFL (5 with RT) 1 recurred, 18 no treatment (2 recurred); 3.8% recurrence at 2y (12% for those patients who had pos SLN and no adjuvant therapy)
Macromet: 51 underwent RT (11 recurred) 105 underwent IFL (59 with RT, 7 recurred), 6 no treatment (1 recurred); 22% groin recurrence rate RT alone vs 7% IFL +/- RT - no difference in disease specific survival
- 2.7% groin recurrence rate if SLN negative (likely due to not all SLN being removed and incorrect path read)
- Most common AE was diarrhea at 4-6w and 6mo; lymphedema low 4-5% compared to 20-30%
- Death rate at 2y: SLN neg 2.1%, 6.5% micromet, 25% macromet
Conclusion: For Micromet, there is better morbidity for micromet managed by RT alone than IFL and similar groin recurrence rate
What is ultrastaging for SLN
one section per 500 nanometers
Discuss LN metastasis size
Micromet: Less than or equal to 2mm
Macro met: >2mm
One liner for GROINSS-VII
Adjuvant RT for SN micromet results in lower groin recurrence rate with acceptable morbidity
If macromet (>2mm), adjuvant RT alone (50Gy) is not appropriate as sole treatment
Confirmed that omiting IFL for patients with <4cm vulvar cancer and neg SN is safe
What is GROINS-VIII
Assessing adjuvant chemoRT compared to adjuvant RT increased dose 50-> 56Gy)
What is your work up of vulvar melanoma
Clinical assessment with pelvic examination
CT and/or MRI of the primary site of disease,
CT of the chest, abdomen, and pelvis and/or positron emission tomography (PET)-CT imaging to assess for the presence of distant disease
Brain MRI
What are side effects of 5FU
Can get flu like symptoms for mucosal
Can you do sentinel LN assessment in patients with prior excision?
Nica et al
Retrospective of 130 patients who underwent WLE or scar excision (24 patients) if not visible tumor + SLN. Injected with Tc99 and lymphazurin - those with scar injection ALL mapped
There were no significant differences between primary surgery and scar injection groups in the proportion of recurrences by location or the time to recurrence
Crosbie et al 2010
Tc99 + blue dye, included 15 patients with prior excision
On average, more SLN were identified in patients with their primary vulval lesion in situ compared with those whose tumour had previously been excised (2.6 vs. 1.8, p = 0.03)
One patient with prior excision had a false negative node (midline lesion)
What do you inject for sentinel LN?
40 MBq 99mTc-labelled HAS nanocolloid (Solco Nanocoll™) in a total volume of 0.2 ml injected intradermally at four locations around the primary tumour or scar.
Where do vulvar cancers occur
40% labia majora
20% labia minora
10% periclitoral
10% …
Margins of femoral triangle
Inguinal ligament
Sartorius
Adductor Longus
Floor of femoral triangle
iliacus
Pectineus
Adductor longus
psoas tendon
What separates superficial and deep nodes
Cribiform fascia
HPV vaccine in vulvar dysplasia?
Yes because they are at risk of cervical dysplasia
Risk of occult cancer in VIN III?
~20-30%
Aldara logistics?
Apply at night 3x per week and see in 8 weeks
Aquafor in the mornings and barrier to prevent spreading!
If abrasions - take 1 week break, recheck if ok restart twice weekly vs break until barrier heals over
GOG 36
Analysis of 580 patients with radical vulvectomy and bilateral groin dissection
Looked at clinicopathologic factors for survival
Worse survival with positive LN< increasing number of LN, and bilateral positive LN, larger tumor size
Risk of LN positivity by LVSI
25% negative
75% positive
