Vulva

Question 1

Choose all correct answers:

a) squamous cell carcinoma accounts for 90% of vulvar cancers
b) micro invasive cancer is defined as < 3cm diameter and < 1mm depth of invasion
c) stage 1A and 1B cancers may be treated with WLE only
d) if final pathology shows depth of invasion >1mm or tumour margin <1cm and no inguinal lymphadenectomy was done at original surgery, should have second surgery to complete node dissection

Answer 1

a) true
b) false -<2cm diameter
c) false -stage 1A no nodes but 1B should have node dissection
d) true

Question 2

List potential complications of complete inguinofemoral groin node dissection

Answer 2

wound breakdown, infection, lymphadema, cellulitis

Question 3

Choose all correct answers:

a) if depth of invasion >1mm on biopsy, bilateral inguinal node dissection is always indicated
b) prognosis for patient with recurrence in non-dissected node is dismal with > 90% mortality
c) if ipsilateral groin nodes positive, then contralateral nodes should be dissected
d) performing node dissection through separate incisions decreases the risk of chronic lymphedema to less than 5%

Answer 3

a) false -ipsilateral only unless <1cm from midline (<2cm from midline according B&H)
b) true
c) true
d) false -en block incision risk is 30-65%, separate incisions 20%

Question 4

What are the indications for a pelvic node dissection in a patient with vulvar cancer?

Answer 4

a) clinically suspicious inguinal groin nodes
b) 3 or more positive inguinal nodes on the same side
(but evidence suggests radiation better than surgery for these patients)

Question 5

Choose all correct answers:

a) >90% of vulvar cancers are HPV+
b) usual type VIN lesions are related to HPV infection, whereas differentiated VIN are not
c) differentiated VIN are associated with smoking and tend to occur at a younger age
d) differentiated VIN has a higher risk of concurrent malignancy than usual VIN

Answer 5

a) false 40%
b) true
c) false -usual type =young, HPV, smoking with basaxoid or warty VIN
d) true 86% vs 28%

Question 6

Choose all correct answers:

a) Paget’s disease of the vulva tends to occur in women over age 60
b) Vulva is the most common location for extramammary Paget’s to occur
c) Vulvar Paget’s is an indication for screening for associated malignancies including mammography, CT abdo/pelvis, TV U/S, pap, colonoscopy, cystoscopy
d) a 1cm resection margin is recommended but margins are still frequently positive

Answer 6

a) true other risk factors include white race
b) true
c) true
d) true

Question 7

Choose all correct answers:

a) recurrent Paget’s disease of the vulva should be treated with radiation therapy
b) invasive paget’s disease with depth >1mm is an indication for radical vulvectomy + ipsilateral inguinofemoral lymphadenectomy
c) once resected with negative margins, Paget’s disease rarely recurs

Answer 7

a) false further surgical resection or topical imiquimod
b) true -treat same as squamous
c) false

Question 8

If squamous vulvar cancer suspected based on symptoms and clinical inspection, what would a complete physical exam include?

Answer 8

biopsy

palpation of groin nodes, Pap smear, colposcopy of cervix and vagina

Question 9

How does vulvar cancer spread (3 ways)?

Answer 9

1. direct extension
2. lymphatic embolization to regional lymph nodes
3. hematogenous (lungs, liver, bone)

Question 10

Where is Cloquet’s node?

Answer 10

inguinal node: beneath the inguinal ligament and most cephalic of femoral node group

Question 11

A patient has a 2cm vulvar lesion with 1.2mm depth of invasion which is involving the lower vagina. Groin node dissection was negative. What stage is this?

a) 1B
b) 2
c) 3A(i)
d) 3B(i)
e) 4A

Answer 11

b

stage 3 have positive nodes, lower vagina involvement makes this a stage 2

Question 12

A patient has a 4cm vulvar lesion with 1.2mm depth of invasion and no invasion to surrounding structures. Groin node dissection revealed 3 positive ipsilateral nodes each measuring less than 5mm. What stage is this?

Answer 12

3B(i)
\+ nodes = 3
3 or more micro = B
no macro(>5mm) nodes = i

Question 13

A patient has 4cm vulvar lesion with 1.2mm depth of invasion. On physical exam there are fixed, ulcerated inguino-femoral lymph nodes. What stage is this?

Answer 13

4A(ii)

Question 14

Where should you make your incision for a groin node dissection?

Answer 14

linear incision 1cm above and parallel to groin crease along medial 3/4 of a line between ASIS and labiocrural fold
will encounter superficial circumflex iliac vessels

Question 15

What makes up the femoral triangle?

Answer 15

inguinal ligament, adducts longs, sartorial

Question 16

Choose all correct answers regarding vulvar cancer:

a) patients with any positive groin nodes should have adjuvant radiation therapy
b) size of positive nodes (<5mm vs 5-15mm vs >15mm) predicts survival
c) presence of extra capsular spread of node predicts poorer prognosis and is indication for groin and pelvic radiation
d) if clinically suspicious nodes seen on exam/CT are removed and negative for metastases on frozen section, a full groin dissection should be performed

Answer 16

a) false, if one micro metastasis (<5mm) can be observed after radical lymphadenectomy, insufficisent data on patients with 2 micrometastses
b) true
c) true
d) true

Question 17

Choose all correct answers regarding vulvar cancer:

a) primary radiation tx is reasonable for patients who would otherwise require a pelvic exenteration because of anal involvement
b) patients with more than 2 micro metastases, one macrometastases, or extracapsular spread should receive adjuvant radiation to the groins
c) adjuvant radiation to prevent local recurrence is necessary only if primary surgical margins are positive
d) radiation therapy may be a reasonable primary therapy for young patients with small tumours involving the clitoris

Answer 17

a) true
b) false radiation to groins and pelvic nodes
c) false -indicated for close margins (<5mm)
d) true

Question 18

Choose all correct answers regarding vulvar cancers:

a) most treatment failures are diagnosed within 2 years, mostly on the vulva
b) a remote vulvar recurrence is defined as being more than 2cm away from the primary tumour site
c) prognosis is worse for remote recurrence vs primary site recurrence
d) local recurrences can be treated with either surgical resection or radiation

Answer 18

a) true
b) true
c) false primary site recurrence worse
d) true

Question 19

Choose all correct answers regarding vulvar cancers:

a) 5-year survival for vulvar cancer (all comers) is <50%
b) survival correlates with clinical stage and node status
c) vulvar cancer patients can be discharged after 10 years of follow up

Answer 19

a) false 70%
b) true -number of involved nodes is single most important predictor
c) false -follow for life

Question 20

Outline your follow-up plan for a patient with vulvar cancer (how often, for how long)?

Answer 20

q 3 months for 2 years, q 6/12 for 5 years, annually for life

Question 21

What are the 3 histological types of vulvar melanoma?

Answer 21

1. superficial spreading melanoma
2. mucosal lentiginous melanoma (starts as freckle)
3. nodular melanoma (raised lesion that penates deeply and may metastasize widely)

Question 22

Choose all correct answers regarding vulvar cancer:

a) melanomas are staged in the same manner as squamous vulvar cancers (FIGO)
b) most melanomas present with itching and bleeding
c) prognosis of melanoma mostly related to diameter at presentation
d) radical surgery for melanoma has been shown to improve survival

Answer 22

a) false
b) false most are asymptomatic
c) false -depth of penetration is best predictor
d) false -conservative surgery with 1cm margin for primary lesion, lymphadenectomy if depth >1mm

Question 23

Choose all correct answers regarding vulvar cancer:

a) Bartholin gland carcinoma is second most common form of vulvar malignancy
b) treatment of Bartholin’s carcinoma includes radical excision of primary lesion and ipsilateral inguinofemoral lymphadenectomy
c) basal cell carcinoma of the vulva with depth 2mm is indication for ipsilateral lymphadenectomy
d) the vulva is a potential site of metastatic tumours from other disease sites, representing 8% of all vulvar tumours

Answer 23

a) false -basal cell more common
b) true
c) false, no nodes for basal cell radical excision only
d) true -cervix, endometrium, kidney, urethra most commonly