OQ: Vulvar Cancer Flashcards
When do you do SLND. False negative rate. Do you do both sides. How do you do it.
o <4 cm, clinically normal nodes, no prior surgery to groin/vulva, experience with SLN
o FNR- GOG 173: 8%, <4cm FNR 2%, GROINS-VI: 6%
o Risk of relapse for false neg node <3%
o Both sides - no, ipsilateral, same indications as IFLND
o How - Tc99 (1cc 2-3hrs prior), isosulfan blue 1% 3-4cc, peritumoral injection at 2, 5, 7, 10 oclock, 30 min prior, make incision over hotspot, send for ultrastaging, do prior to vulvectomy
o Tc99 half life 6 hrs
o If ipsilateral SLN is pos then do contralateral groin dissection or RT
o if SLN positive - see Vulva 4 NCCN.
Stage II vulvar cancer – how do you decide who to resect versus giving radiation therapy versus neodajuvant chemo RT?
o Preserving urethra, anus and can I get negative margins
o Depends on performance status and comorbidity
What is the evidence for neoadjuvant chemo RT for vulvar cancer? What is the evidence? Are there specific trials or is it just extrapolated from cervix?
o GOG 101
§ cis + 5-FU +RT (split course, 47 Gy)
§ NGR 48%, Complete path response 70%
Everyone gets surgery.
§ Gross residual 52% but 85% had complete resection, neg margins
§ 3% unresectable
§ 33% recurrence rate
o GOG 205
§ Cis 40 wkly + RT (57 Gy)
§ IFLND pre-op if resectable or non suspicious (???) - if negative then exclude inguinal node XRT
§ NGR 64%, Complete path 78%
§ 76% 2yr DFS
§ 38% recurrence rate, 55% wound complication rate
What do you do if pt appears to have had a complete clinical response?
Why do you do lots of biopsies?
If confirmed complete pathologic response what do you do?
What’s rate of wound breakdown if you do resection in radiated pt?
Lots of biopsies to look for recurrence and determine pathologic response and potentially diagnose microscopic residual disease. If confirmed CR you observe. Wound breakdown rate with resection is 55% from GOG 205.
How would you close a large defect after vulvar resection extending into the distal vagina.
o Rhomboid, Martius flap - small defect
o Gracilis, V-Y, TRAM/VRAM - larger: I would have plastics do a gracilis most likely.
What is the risk of lymphedema after groin dissection versus sentinel lymph node?
25% vs 1.9% (GROINSS-V)
You do a radical vulvectomy for someone with a 3 cm vulvar tumor, sentinel lymph node is positive. How do you manage positive sentinel lymph node?
o <= 2 mm, radiation therapy; > 2 mm, full IFLND
Nodes – who gets lymphadenectomy for vulvar cancer? Unilateral or bilateral nodes? Deep or superficial?
o criteria for SLN - unifocal, < 4 cm, clinically + radiologically negative node, no prior surgery of vulva / groin
o indication for uniliteral SLN / IFLND - 1) primary lesion < 2 cm; 2) lateral lesion (>= 2 cm from midline); 3) no palpable inguinofemoral lymph nodes
If ipsilateral groin is positive, the contralateral groin should be evaluated surgically and/or treated with EBRT. In select cases of a single, small volume, unilateral, positive inguinal node with a well-lateralized primary tumor <= 2cm and depth of invasion <=5mm and with a clinically negative contralateral groin examination, a contralateral inguinofemoral lympadenectomy or radiation may be omitted. VULVA-4
Do you just debulk grossly involved groin nodes or perform complete bilateral IFLND?
Hyde retrospective: “Forty patients from three separate databases who met these criteria were identified. Patients were treated either by a full inguino-femoral lymphadenectomy or by a debulking of the clinically involved inguinal lymph nodes. All patients received adjuvant radiotherapy to the groins. In these two groups, there was no difference in groin recurrence rate expressed as groin recurrence-free survival (P= 0.247). In a univariate analysis, both overall and disease-free survival were better in the group of patients treated by nodal debulking. However, in a multivariate analysis, other variables such as extracapsular growth were independent predictors for survival while the method of surgical dissection for the groin had no independent significant impact on survival.”
How deep do you inject for sentinel lymph node?
o Intradermal. Technique (GROINSS-V protocol: The day before the operation or the morning of the day of the operation, 0.5 mL 30-100 MBqof 99m Tc-labeled nanocolloid with particle size < 80 nm is injected circumferentially intradermally on 4 locations around the primary tumor (each 0.05 mL 15 MBq 99m Tc-labeled nanocolloid). On the day or the afternoon after the injection of the radioactive trcer, following induction of anesthesia, 0.5-1 mL of the blue dye (Lymphozurin or Patent Blue V) is injected intradermally on the same 4 locations around the primary tumor approximately 5-10 minutes prior to the surgical proceudre.
· Pt with bulky vulvar tumor, evidence of positive pelvic node, what do you do.
o Depends on ability to get margins/anus/urethra and symptoms
o Resect any nodes >2cm
o Generally would do cis/RT first and biopsy and resect residual to allow for smaller surgery
Histology - how do you measure the depth of invasion in vulvar cancer?
The depth of stromal invasion is currently defined as the measurement (in millimeters of the tumor from the epithelial-stroma junction of the most adjacent superficial dermal papilla to the deepest point of invasion).
Picture of bony pelvis with lines drawn through it. Describe radiation fields for inguinal and pelvic radiation. what are the doses for radiation therapy of vulvar cancer? What dose to what area.
o (1.8 Gy/fx)
o NCCN:
§ Gross primary disease = 60-70 Gy
§ 1’ surgical bed (postop, neg margins) = 45-50 Gy
§ 1’ surgical bed (postop, close/positive margins) = 54-60 Gy
§ Uninvolved LN 45-50 Gy
§ Inguinal LN (positive but no extracapsular extension, no gross residual dz) = 50-55 Gy (pelvis + groin 50.4 Gy + boost to node)
§ Inguinal LN (extracapsular extension) = 54-64 Gy
§ Gross residual or unresectable LN 60-70 Gy
o Close margins - scar + 2cm margin = 54 Gy
o Microscopic margin/residual = 60 Gy
o NACT - 50 Gy → CR → bx
§ Boost 9 Gy if PR + resectable
§ Boost 18 Gy if PR/no response and unresectable up to 65 Gy
o If pos inguinals→ treat pelvis 45 Gy to to external/internal iliacs
o Nodes are 3-5 cm below skin, use CT to determine femoral vessel level and use this depth
o 3D:
§ Inguinals get 6mV low energy AP which spares 1.5 cm so you won’t miss superficial groin nodes
§ PA gets high energy (18 or 25 mV) to spare buttocks to 3cm
o Can also use electrons to boost nodes
o Also use IMRT to contour to gross tumor volume and clinical target volume
o Borders
§ Superior- inferior SI joint and extends horizontal line to ASIS (no higher than L4-L5 unless pelvic nodes involved otherwise 5 cm above + node)
§ Inferior- 2cm below border of tumor
§ Lateral- ASIS vertical line
§ Medial- 2 cm lateral to midline/obturator foramen
o IMRT borders/CTV
§ Extends laterally from femoral vessels to medial border of sartorius and rectus femoris muscles
§ Posteriorly to anterior vastus medialis muscle
§ Medially to pectineus muscle or 2.5-3 cm medialls from the vessels
§ Anterior sartorius muscle
§ Caudal is lesser trochanter of femur
o IMRT pelvic node CTV
§ Bilateral ext iliac, obturator, internal iliac regions with minimum of 7mm expansion to bone and muscle
·What is the organ you tried to protect from your radiation field in vulva?
Femoral head.
After surgery, pt with 2 positive groin nodes, what adjuvant radiation do you give?
o If resected, 50.4 Gy to groin and pelvis plus boost to inguinal LN bed and 45 Gy to pelvis if PET negative
o Cisplatin sensitization
