What HPV subtypes are associated with vulvar cancer?
6, 16, 18, 33
Subsites of the vulva?
Labia majora Labia minora Mons pubis Clitoris Vaginal Vestibule Perineal body Posterior forschette
What elements of the history and physical do you need to know?
History: pruritis, discomfort pain, dysuria, bleeding, difficulty with defecation, duration, prior exams, pap smears, GYN cancers
Physical: Visulization of external genetalia, Speculum exam, Bimanual exam digitial rectal exam, inguinal nodal exam, pap smear
How is locally advanced vulvar cancer defined? What percentage of patients have it at diagnosis?
- Cancer that can not be resected without exenterative surgery
- 30%
What are the 1st, 2nd and 3rd echelon nodes?
- Superficial inguinofemoral
- Deep inguinofemoral and femoral
- External iliac
What are the predictors of nodal disease?
- Depth of invasion
2. Grade
What is the risk of nodes by depth of invasion?
- < 1 mm: 5 mm:34%
What are the common histologies?
- Squamous cell carcinoma: 80-90%
- Melanoma
- Basal cell carcinoma
- Merkel cell
- Sarcoma
- Adenocarcinomas of the bartholin’s gland
What is the treatment for vulvar CIS or VIN?
Superficial local excision
or
If the clitoris or labia minora are involved, laser ablation can be done
How to acquire a tissue diagnosis?
- Lesions < 1 cm: excisional biopsy with 1 cm margin
- Lesions > 1 cm: Wedge biopsy including surrounding skin taken from the edge of the lesion to include the interface between normal skin and the tumor to determine if there is invasion of surrounding skin
Also performed a EUA with colposcopy, and directed biopsy of the cervix, vagina, vulva to rule out primary cervical or vaginal cancer
What labs and imaging are needed for at work up?
Imaging: CT scan of the abdomen/pelvis, MRI of primary and CXR. +/- PET/CT scan.
Labs: UA to rule out infection, HIV, CBC
What special studies may be needed at diagnosis?
- Cystoscopy
- Proctoscopy
For locally advanced disease Stage II-IV
FIGO Stage I
IA: lesion 2 cm or less, confined to vulva or perineum with stromal invasion < 1 mm, no nodal mets
IB: Lesion > 2 cm or with stromal invasion > 1 mm, confined to vulva or perineum, no nodal mets
FIGO Stage II
Stage II: Any size lesion, invades lower 3rd of the urethra, vagina, or anus, no nodal mets
FIGO Stage III
A. 1 LN 5 mm or larger or 1-2 LNs < 5 mm
B. 2 LN or more 5 mm or larger, 3 LN or more and each < 5 mm
C. Nodes with ECE
FIGO Stage IVA1
- Lesion invades upper urethra and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone
FIGO Stage IVA2
Fixed or ulcerated inguinofemoral LNs
FIGO Stage IVB
Distant metastasis including pelvic nodes
Treatment options for pts with Stage III-IV disease
- Surgery (if negative margins can be achieved) + PORT
- Neoadjuvant CRT followed by surgery
- Definitive CRT
Indications for PORT to the primary site?
- Close or positive margins of WLE ( < 8mm in fixed specimen, < 1 cm by frozen)
- LVSI
- DOI > 5 mm
What are the acute toxicities?
- Dermatitis
- Nausea
- Vomiting
- Diarrhea
- Urethritis
- Cystitis
- Decreased blood counts
What are the late RT toxicities?
- Vaginal atrophy
- Itching
- Discharge
- SBO
- Femoral neck fracture
5 year OS estimates by Stage?
- Stage I: 90%
- Stage II: 81%
- Stage III: 68%
- Stage IV: 20%
What is the standard regimen for unresectable disease?
GOG 101
RT: 47.6 at 1.2 BID
Concurrent 5FU and cisplatin
