Vulval/Vaginal

Question 1

Management Paget’s disease of the vulva

Answer 1

Refer GONC
workup for synchronous neoplasms (breast, colon, bladder, cervix)
WLE usually; vulvectomy and skin graft for invasive disease
If invasion >1mm or stage 1b or greater, needs groin LN dissection
Recurrence can be associated with measured surgical margin (aim 15mm)
Can have chemo and RT
Need prolonged follow up (3-6 monthly)

Question 2

VAIN treatment

Answer 2

topical 5 FU or imiquimod

laser treatment

Question 3

Vaginal cancer treatements

Answer 3

Mainstay of treatment is RT (brachytherapy if <5mm thick) but also EBRT
Partial or radical vaginectomy +/- reconstruction
If in upper vagina - rad hyst, vaginectomy + B/L radical PLN removal
CT for stage II disease
Pelvic exteneration

Question 4

Treatment for vulval cancer <2cm and <1mm invasion (FIGO 1A)

Answer 4

WLE - margin 15mm

risk of groin mets <1%

Question 5

Treatment for >FIGO1A

Answer 5

groin lymphadenectomy
if >1cm from midline, can do ipsilateral side (if any nodes positive, do the other side
If in midline, need bilateral
if lesion <4cm and unifocal, could consider SLN biopsy

Question 6

Indication for adjuvant RT in vulval cancer

Answer 6

presence of extracapsular spread in involved groin LN

two or more positive groin nodes

Question 7

Management of advanced vulval cancer (Stage III or IV)

Answer 7

radical vulval excision with partial or total exenteration and groin lymphadenectomy) with plastic reconstruction. - significant physical and psychological morbidity and postoperative mortality rates of 0–20%.
2The use of preoperative radiotherapy and chemotherapy may shrink the tumour to allow less destructive surgery, in particular, preservation of sphincters and avoidance of stomas. Combination of chemoradiotherapy and surgery is associated with significantly more morbidity than either treatment on its own.
3Neoadjuvant chemotherapy with cisplatin and 5-FU followed by surgery or radiotherapy is an alternative treatment regimen, especially in those patients who have had perineal radiotherapy previously.
4Primary radiotherapy with or without chemotherapy in those patients who are medically unfit for surgery.
5Palliative treatment alone.

Question 8

recurrence rate vulval cancer

Answer 8

15-33%
most commonly on vulva
groin recurrences usually fatal
No role for surgery in pelvic recurrences

Question 9

Follow up after vulval cancer

Answer 9

3–4 monthly for the first 2 years
6-monthly for years 3 and 4
annually thereafter.