Treatment Flashcards
What would you do if you had a 5mm margin?
Re- resect: Surgical margin is powerful predictor of local recurrence. If tumor is < 8 mm from surgical margin on microscopic examination, incidence of local recurrence is almost 50%.8 mm fixed margin corresponds to 1 cm fresh margin and no local recurrence.o Half of local recurrences occur after 2 years, 25% after 4 years. More likely to be new tumors. If can’t resect–> RT for local control
What is a radical local excision?
resection of the primary tumor with 1 cm clinical margins laterally and a dissection down to the perineal membrane (also known as the deep fascia) of the urogenital diaphragm
How would you treat grossly positive nodes?
nodal debulking and then give chemoradiation.(Hyde 2007: debulking vs full groin dissection.both groups tx with postopRT–>no diff in OS.
What is early stage disease and how do you treat?
stage I and II: Radical local excision and inguinofemoral investigation
What is locally advanced disease and how do you treat?
stage III and IVA. If feasible–>surgery. If not feasible or non operable candidate–>chemoRT
If you had positive node on one side what should you do next?
GOG 37: 18% unsuspected contra lateral nodes positive
If pt had one + groin node, would you offer adjuvant radiation?
Creasman 1997: no benefit for rt for one + node (70 vs 50% for obs vs RT) but criticism is that RT group may have had poor prognostic factors like extra Capsular break through
If in vulvar ca, groin is + what would your fields be, dose?
4500 Gy EBRT to cover pelvic and inguinal (G0G 36: decreased groin recurrence 24–>5% and improved 2 yr survival 68–>54%
How do you treat Paget’s
- Because area involved can be much greater than lesion, some argue to take frozen section of most lateral lesion to ensure negative margins (Kodama 1995 reported reduction of recurrence by up to 50%). However, this has not been proven to improve survival or reduce recurrence in other studeis( dave fishman, PES 1995 and Curtain,
- Also may be multifocal
- Goal is achieve 2cm margins and resect down to fascia
is Paget’s a malignancy?
considered an adenocarcinoma in situ ( intraepithelial carcinoma) arising within epidermis. However, may be invasive Paget’s in 12% of cases (Fanning 1999).
Is rt as good as lnd for vulva?
GOG 88 (Stehman IJROBP’92) was then designed to test whether XRT could substitute for groin LND among patients with non-suspicious LNs (N0-1) – in the 1st 49 evaluable patients, there were 5/27 groin recurrences in the XRT group (18.5% failure), 0 in the LND group. The XRT design was flawed because the dose calculations were at a depth of 3 cm only.
If you have positive ing nodes do you need to radiate pelvic too ?
GOG 37 (Homesley Ob Gyn’86) took 114 patients with positive inguinal LNs from GOG 36 and treated them with either pelvic & groin XRT versus pelvic LND. A significant difference in survival favored the XRT arm (79% vs 54% 2-yr survival, 70% vs 51% PFS, improved local control in the groin 94.9% vs 76.4%) with the largest difference in survival occurring in those with either of 2 poor prognostic findings (clinically suspicious fixed ulcerated LNs or > 2 positive LNs).
What’s data for giving chemoRT for advanced vulvar ca, GOG 101
GOG 101 (Montana IJROBP’00, Moore IJROBP’98)– preoperative chemoradiation using cis (50 mg/m2) on day 1 + 5-FU (1000 mg/m2/day) for 4 days in advanced vulvar cancer (T3/T4 or unresectable N2/N3 nodes). Study reported 95% resectability of LNs, with 41% of LNs without residual disease; as for the primary tumor, 46.5% disappeared, 53.5% had gross residual cancer and almost all became resectable (only 2.8% had residual unresectable disease).
How to do groin dissection
See notes in iPhone under dictation of groin dissection
Embryonal rhabdosarcoma
- Rare pediatric tumor
- Sarcoma botyroides variant is most common malignant vaginal tumor in infants and children
- 90% in 85% survival
- Above also reduces need for radical resection from 100% to 13%
