Gynae- Vulva

Question 1

What clinical and histologic tumour characteristics are predictors of nodal involvement in Vulval Ca?

Answer 1

(in order of importance)
- Clinical nodal status (palpable vs non palpable)
- Grade
- capillary lymphatic space involvement
- tumour thickness
- patient age

• tumour size (not sure of relative importance)
• invasion into urethra, anus

Question 2

What is inguinal nodal involvement a predictor for?

Answer 2

Pelvic nodal involvement
Isolated pelvic nodal involvment is rare so status of inguinal nodes determines the management of pelvic nodes

Question 3

Should women with pelvic nodal metastasis be treated with aggressive local therapy?

Answer 3

Yes.
Pelvic nodal involvement currently classified as metastatic dz but 1/4-1/3 of patients are still potentially curable.

MD Anderson- 5yr OS with involved pelvic LN 43% when treated with aggressive local therapy (Thaker NG, et al. Gynae Oncol. 2015)

Question 4

Most common sites of distant Mets for Vulval Ca

Answer 4

Lung, Liver, Bone.
Haematogenous spread generally occurs late.
Median OS with distant mets 6mo

Question 5

What is the most important prognostic factor in patients with vulval CA

Answer 5

LN involvement
(Size of met in LN, number of positive LN, extracapsular extension (ECE) of dz = all associated with worse prognosis)

Question 6

Do HPV associated Vuval Ca have better or worse prognosis

Answer 6

Better

Question 7

Proportion of Ca arising in each part of the vulva

Answer 7

70%- Labia M and m
15%- clitoris
5%- perineum and fourchette
5%- prepuce Bartholin’s glands and urethra
5%- too extensive at presentation to classify

Question 8

What factors are associated with local recurrence in Vulva after radical vulvectomy?

Answer 8

tumour size >4cm
Capillary lymphatic space involvement

NOT depth of invasion

Question 9

Indication for adjuvant post op RT in vulvar RT?

Answer 9

Increased LR with + margin, margin <8 mm pathologically
or <1 cm clinically, LVSI, and depth > 5 mm.

Heaps (Gynecol Oncol 1990): review of surgical-pathologic
factors predictive of LR for 135 pts with vulvar
CA.

Question 10

When is a Wide local excision indicated?

Answer 10

T1 and T2 <4cm with less than Imm invasion
Inguinalfemoral node evaluation not recommended

Question 11

When is radical vulvectomy indicated?

Answer 11

Large or multifocal lesions in whom preservation of normal vulvar tissue is not possible or would not serve a functional/reconstructive benefit

Question 12

When is extended radical vulvectomy +- pelvic exenteration indicated?

Answer 12

When anus, vagina, or urethra is involved

Question 13

When is a larger resection that WLE (but not vulvectomy) recommended? (the brady book doesn’t call this a hemi vulvectomy but it might be)

Answer 13

> 1mm invasion, any size tumour
If well lateralised (>2cm from midline) only ipsilateral groin evaluation needed

Question 14

What is the morbidity associated with a full inguinofemoral nodal dissection?

Answer 14

• Wound break down (but can heal by secondary intention)
• Lower limb lymphoedema&raquo_space; difficult to treat, can lead to significant disability

…need to identify those in whom the nodal dissection can be reduced or removed without compromising dz control