Treatment

Question 1

Treatment for early tumours (Stage IA)

Answer 1

Wide local excision with 1cm margin

Question 2

Complications of radical vulvectomy and bilateral groin dissection

Answer 2

Loss of normal tissue and appearance
Impact on sexual function
50% incidence of wound breakdown
30% incidence of groin complications (breakdown, lymphocyst and lymphangitis)
10-15% leg lymphoedema

Question 3

Biopsy proven VSCC - DOI less than 1mm

Answer 3

WLE with photos or diagram

Question 4

Biopsy proven VSCC - DOI more than 1mm

Answer 4

Need inguinal node imaging (CT)

If primary lesion less than 4cm and no nodes seen - for SLNB (unilateral if more than 1cm from midline, otherwise bilat)

If MULTIFOCAL OR lesion equal or more than 4cm in size OR suspicious LN - for inguinal LND (unilat if more than 1cm from midline, bilat if not)

Question 5

When is en-bloc radical excision of the entire vulva

and the groin nodes indicated?

Answer 5

In the presence of large and/or fixed nodes where recurrence in the skin bridge is higher and there may still be a role for en-bloc resection.

Question 6

Stage IA

Answer 6

excision, rarely requiring reconstruction

Question 7

Stage IB

Answer 7

radical WLE
anterior vulvectomy if periclitoral
bilateral if close to the midline
can remove 1-2cm distal urethra if close to urethra
If posterior - may require posterior vulvectomy
large tumours - radical vulvectomy

Question 8

Stage II

Answer 8

Consideration of neoadjuvant chemotherapy to preserve anal sphincter
Excision to include distal urethra and vagina if necessary

Question 9

Stage III

Answer 9

As previous for IB and II

Question 10

Stage IV

Answer 10

Usually no surgical indication

Palliative procedures may be considered to ease
discomfort, which is otherwise difficult to control. In cases of fistulation of the tumour to bowel or bladder,
de-functioning stomas and/ or urinary diversions or nephrostomies can be considered.

Question 11

What margins should we aim for in situ and fixed specimen

Answer 11

1cm in situ - closer if really going to impact on function

> 2mm adequate in fixed specimen

Question 12

Bartholin’s gland carcinoma

Answer 12

Are deep so extensive dissection required. No known role for SNLB so ileoinguinal lymphadenectomy recommended

Question 13

Vulval BCC

Answer 13

wide local excision

Question 14

Treatment of vulval paget’s disease

Answer 14

Treatment for VPD consists mainly of surgery +/- lymphadenectomy, if there is evidence of >1 mm
depth of invasion.

Recurrent disease is common (60-70%) and is as frequent in those with microscopically clear margins compared to those with involved margins. (88). Further excision may
not reduce the risk of recurrence and alternatives, including imiquimod or watchful waiting, should be
strongly considered, if invasion is excluded.

Question 15

Treatment of vulval MM

Answer 15

Surgical management should consist of a wide local excision to achieve margins free of microscopic
disease by >1 mm (R0) in the least radical fashion.

If margins are microscopically involved (R1), further salvage surgery is normally
recommended. If this is not possible, or is declined, options involve:
• Watch and wait, treating recurrences as identified and appropriate at the time;
• Adjuvant radiotherapy with the aim of reducing local recurrence;
• Systemic therapy

SNLB may have a role if affecting treatment decisions

IFLD not shown to be of benefit

Nivolumab (PD-1 blocker) may be of help for recurrence free survival in node positive surgically resected cases.

Question 16

what is used for SLNB

Answer 16

indocyanine green fluorescence (ICG)

Question 17

drawbacks for ICG and strategies?

Answer 17

body habitus

combination ICG and radioisotopes

Question 18

Pre-op lymphoscintigraphy

what if a midline lesion only shows unilateral drainage?

Answer 18

Preoperative lymphoscintigraphy is currently employed by most centres and is advised to enable the preoperative identification of the number and location of sentinel nodes. For tumours that are truly midline (within 1 cm of midline), bilateral drainage should occur. Where only unilateral drainage is identified for midline tumours, inguinofemoral lymphadenectomy should be performed for the groin in which the technique has failed.

Question 19

Technique for inguinofemoral LND

Answer 19

Lymphadenectomy should include removal of the deep femoral nodes

Preservation of the saphenous vein may reduce the risk of post-operative complications and is recommended where feasible

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Question 20

What if they have bulky LN and are going for radiotherapy? What is a bulky LN?

Answer 20

The removal of bulky (>2 cm) pelvic nodes should be considered due to the limitations of radiotherapy in controlling bulky nodal disease

Question 21

Criteria for SLND and why

Answer 21

1. Unifocal disease (False negative rate higher for multifocal disease)
2. Depth of invasion >1 mm (Low risk LN metastasis if ≤1 mm)
3. Tumour <4 cm in vivo (>4 cm associated with higher false negative rate)
4. Representative peri-lesional injection is possible (Risk of false negative if non-representative injection)
5. Tumour should not encroach on urethra,
   anus or vagina (Representative injection not possible)
6. No clinical or radiological evidence of involved nodes (Cross sectional imaging recommended)

Question 22

When do perform a groin node dissection?

P31

Answer 22

Inguinofemoral lymphadenectomy remains the primary treatment modality for the groins in tumours of
>4 cm. Lymphadenectomy should include the medial, deep femoral nodes as omission of this group is
associated with a higher risk of groin node recurrence.