vulval Flashcards
What information might be gained from an EUA for a vulval cancer
Size
Distance from midline
Fixity
Involvement of local structures - urethra, vagina, anal canal
What investigations should be done for a vulval cancer
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
What is the management of a stage 1A vulval cancer
Stage 1A = ≤2cm size and ≤1mm stromal invasion
Mx: WLE with 1cm margin
What is the management of a stage 1B vulval cancer
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
What is the management of a stage 2 vulval cancer
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
When is groin radiotherapy considered equivalent to groin nodal dissection
For sentinel node positive disease, but micrometastatic only.
Macromets seen in groin nodes should be treated with dissection .
How should stage 3 & 4a vulval disease be treated
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
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
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
When is adjuvant RT considered after surgery for a vulval cancer
When should chemoRT be considered
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
What should be included in an IMRT plan for adjuvant treatment to a vulvar cancer
What CTV-PTV margin should be applied
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
If only the vulva is being treated, what modality can be considered and what is the setup
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
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
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
What are the dose constraints for local OARs
Bladder - V50 <50%
Rectum - V50 <60%
Femoral head - V50 <50%
What systemic treatment options are available for a metastatic vulval SCC
1st line
Cisplatin/Carbo & 5FU or Weekly paclitaxel (if less fit)
2nd line
Cisplatin & Vinorelbine
What are the typical sites of recurrent disease
Recurrence tends to be local - 50%
Otherwise - inguinal nodes, pelvis, or distant mets
