Vulva/Vagina

Question 1

In a patient with a lateralized 3 cm vulvar cancer, what is the most important factor in determining to perform bilateral groin node dissection?
a) DOI >2mm
b) size>2 cm
c) pos groin unilateral groin node
d) LVSI

Answer 1

c) pos groin unilateral groin node

Question 2

Biopsy shows VIN III with a focus of SCCA w/ 0.8mm invasion, what do you do next?

Answer 2

If this was an excision, you may observe. For this biopsy, you would then excise.

Question 3

How do you treat a 2cm mid vaginal SCCA?

Answer 3

Radiate
only surgery if <2cm

Question 4

1cm vulvar lesion with 2 positive LN in the right groin. What is the next step in management?
a) bilateral groin RT
b) bilateral groin RT +Pelvic XRT
c) Systemic chemo

Answer 4

b) bilateral groin RT +Pelvic XRT

NCCN: In both the locally advanced and postoperative settings, especially when there is ≥1 LN clinically suspicious or pathologically positive, the bilateral inguinal and pelvic lymphatic regions are typically included in the CTV

Question 5

What stage – vulvar lesion with two pos 6 mm LNs

Answer 5

IIIB

Question 6

What stage – vulvar lesion with 2 positive LN with extracapsular spread?

Answer 6

IIIC (remember: extraCapsular)

Question 7

Treatment of non-healing vulvar ulcer or radiation induced hemorrhagic cystitis?

Answer 7

Hyperbaric oxygen

In severe cases best choice for cystitis is cysto with fulguration of bleeding vessels, followed by hyperbaric/intravesical instillation of alum or formalin/systemic pentosan polysulfate (elmiron)

Question 8

Nerve supply to the vulva

Answer 8

Pudendal nerve and genital branch of genfem

Question 9

8 cm defect between the vulva and the anus, what’s the best flap?
a) Gracilis
b) VRAM
c) rhomboid

Answer 9

a) Gracilis

Question 10

Order of fascial plane in the inferior dissection of radical vulvectomy

Answer 10

Colle’s facia, inferior then superior fascia of the urogenital diaphragm

Question 11

Which patients with bartholin’s gland adeno need LND?

Answer 11

All, 20% risk of LN mets

Question 12

Depth of laser tx in hair bearing areas?

Answer 12

3mm

Question 13

Laser depth in non hair bearing areas?

Answer 13

1 mm. In hair bearing areas, laser proceudres must ablate hair follicles, which can contain vulvar HSIL(VIN usual type) and extend into the subcutaneous fat or 3mm or more. Consequently large vulvar HSIL lesions over hair bearing areas may be preferentially treated with surgical excision.

Question 14

Role for LND for vulvar melanoma?

Answer 14

controversial as it’s mostly prognostic

Question 15

best treatment for a 4 cm vulvar ulcer after radiation therapy?
a) hyperbaric oxygen
b) flap
c) resection

Answer 15

hyperbaric oxygen

Question 16

Vaginal cancer: 1cm posterior vaginal fornix, hx crohn’s, treatment?
a) radiation
b) radical local excision
c) partial resection +LND
d) rad hyst, LND, vaginectomy

Answer 16

d) Rad hyst, LND, vaginectomy

Upper 1/3 vagina–> external iliac nodes
Middle 1/3–> common and internal iliac nodes
Lower 1/3–> superficial inguinal nodes

Question 17

How often are hair bearing areas involved with VIN?

Answer 17

50%

Question 18

what has been associated with decreased infection in groin dissection?

Answer 18

Saphenous vein sparing

Question 19

Which vessel is not encountered during inguinal LND?
a) deep circumflex femoral artery
b) femoral artery
c) superficial circumflex iliac vein
d) superficial external pudendal
e) superficial epigastric vein
f) saphenous vein

Answer 19

a) deep circumflex femoral artery – NOT encountered
b) femoral artery
c) superficial circumflex iliac vein (lateral)
d) superficial external pudendal (medial)
e) superficial epigastric vein (superior)
f) saphenous vein

deep circumflex iliac artery (or deep iliac circumflex artery) is an artery in the pelvis that travels along the iliac crest of the pelvic bone

lateral circumflex femoral artery is a short branch of the deep femoral artery. The artery courses laterally separating the femoral nerve into anterior and posterior divisions in the femoral triangle.

medial circumflex femoral artery usually arises from the deep femoral artery

Question 20

What is best way to decrease wound infection after inguinal dissection?
a) prolonged prophylactic abx
b)tissel spray
c) sparing the saphenous

Answer 20

c) sparing the saphenous

Question 21

1 week s/p vulvectomy. Presents with hypotension, fevers, crepitus. Failed drainage. Next step?
a) ICU and abx
b) abx and ID consult
c) abx and CT scan
d) operative management

Answer 21

d) operative management

Question 22

What are the stages of vulvar cancer?

Answer 22

Question 23

What is a tumor marker for Melanoma?

Answer 23

Serum LDH

Melanomas express S-100 protein, HMB-45, and Melan-A on tumor tissue

Question 24

Micrometastasis in a sentinel inguinal LN - what is the next step in treatment?

Answer 24

Radiation - don’t need to do full LND since it is micromet and needs RT anyway. BULKY inguinal disease could be debulked first.