vulval Flashcards

1
Q

What information might be gained from an EUA for a vulval cancer

A

Size
Distance from midline
Fixity
Involvement of local structures - urethra, vagina, anal canal

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2
Q

What investigations should be done for a vulval cancer

A

Bloods
EUA
Biopsy - punch or wedge
Imaging - US & biopsy of any possibly involved nodes
MRI pelvis & CTCAP

Cystoscopy and proctoscopy if suspicion of local invasion

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3
Q

What is the management of a stage 1A vulval cancer

A

Stage 1A = ≤2cm size and ≤1mm stromal invasion

Mx: WLE with 1cm margin

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4
Q

What is the management of a stage 1B vulval cancer

A

Stage 1B = >2cm or >1mm stromal invasion

WLE - 1-1.5cm margin
If <15mm margin, re-excise.
If not possible -> Adj RT

If no clinically suspicious nodes -> Sentinel node removal / LND
SLNB positive -> If >2mm - unilateral lymphadenectomy; if <2mm - groin RT
SLNB negative -> no groin directed tx necessary

If clinically suspicious nodes -> unilateral (if lateral) or bilateral (if midline) lymphadenectomy
If ≥2 micromets in LNs -> RT
ECS -> adj RT

If tumour >4cm -> Bilateral GD

If node +ve after unilateral dissection -> contralateral GD. If declines -> CRT

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5
Q

What is the management of a stage 2 vulval cancer

A

Stage 2 = node negative but involvement of adjacent structures - lower 1/3 of urethra, vagina, anus

Mx:
If tumour <4cm - vulvectomy and SLNB
If tumour >4cm - vulvectomy and bilateral groin dissection

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6
Q

When is groin radiotherapy considered equivalent to groin nodal dissection

A

For sentinel node positive disease, but micrometastatic only.
Macromets seen in groin nodes should be treated with dissection .

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7
Q

How should stage 3 & 4a vulval disease be treated

A

Stage 3 = regional node positive, extension to upper 2/3 of urethra, vagina or anus, bladder or rectal mucosa

Stage 4A = disease fixed to pelvic bone or ulcerated regional nodes

Mx:
-surgery followed by adjuvant chemoRT if positive or close margins, multiple nodes (≥2) or ECS
-Or primary CRT

For inoperable disease: primary CRT +/- surgery if residual disease

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8
Q

What is the adjuvant / post-op dose for RT, where there is ≥2 micromets in nodes, macromets in nodes, ECE or residual disease

What depth is treated

A

45Gy in 25# OR 50.4Gy in 28# (both 1.8Gy/#) if no previous hysterectomy as otherwise small bowel constraint will limit the dose possible
With boost to 60Gy for residual disease or positive margins, either sequentially (further 20Gy/10#) or as SIB (60Gy/25# to boost volume)

Treat to 3cm depth

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9
Q

When is adjuvant RT considered after surgery for a vulval cancer

When should chemoRT be considered

A

Absolute indications: residual disease or positive margins, ≥2 micromets present in nodes, any macromets, and any ECE

Consider if LVSI, G3, large primary tumour

Consider addition of chemotherapy if ECE - concurrent cisplatin

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10
Q

What should be included in an IMRT plan for adjuvant treatment to a vulvar cancer

What CTV-PTV margin should be applied

A

CTV P - Surgical scar + 1cm margin + remaining vulva
CTV N - Inguinal, Femoral, External & Internal iliac nodes – up to level of common iliacs

PTV P - CTV P + 1cm
PTV N - CTV N + 8mm

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11
Q

If only the vulva is being treated, what modality can be considered and what is the setup

A

Clinical markup and treat with electrons to 45-50Gy/25#

Single direct field, ‘frog leg’ position & consider bolus
Or legs together (to self bolus) - beware anterior mons pubis & posterior anus, these may need bolus

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12
Q

What should be included in an IMRT plan for primary RT to a vulval cancer
What is the GTV-CTV margin
What is the CTV-PTV margin

A

GTV-P - primary tumour, involved nodes on CT, MR and PET
CTV-P - GTV-P +7mm (SCC) or 5mm (BCC)
Also include within the CTV-P: remaining vulva, mons pubis (to top of symphysis pubis), 3cm of vagina above tumour, perineum

CTV-nodal elective - inguinal, femoral, int/ext iliac

CTV-PTV - 3mm

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13
Q

What are the dose constraints for local OARs

A

Bladder - V50 <50%
Rectum - V50 <60%
Femoral head - V50 <50%

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14
Q

What systemic treatment options are available for a metastatic vulval SCC

A

1st line
Cisplatin/Carbo & 5FU or Weekly paclitaxel (if less fit)

2nd line
Cisplatin & Vinorelbine

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15
Q

What are the typical sites of recurrent disease

A

Recurrence tends to be local - 50%
Otherwise - inguinal nodes, pelvis, or distant mets

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16
Q

What is the treatment for recurrent disease

A

Treatment depends on site of recurrence and previous treatment and disease free interval

Pelvic recurrence - consider systemic treatment with chemotherapy, CRT if they have only had surgery previously, or pelvic exenteration if further CRT is not suitable

Nodal recurrence - SABR for isolated recurrence, CRT if only previous surgery, and resection if amenable or previous CRT

Localised ulcerated disease - symptom support and. palliative RT - 20Gy/5# or 20Gy/10# if pelvic retreatment