Carcinoma of the

Carcinoma of the Carcinoma of the - Start

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Vulva. Epidemiology. 4% of gynecologic malignancy. The median age of patients with invasive . vulvar. cancer at diagnosis is about . 65 to 70 years. median age of women with . VIN. at diagnosis is . ID: 465893 Download Presentation

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Carcinoma of the




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Presentations text content in Carcinoma of the

Slide1

Carcinoma of the VulvaEpidemiology

4% of gynecologic malignancy

The median age of patients with invasive

vulvar

cancer at diagnosis is about

65 to 70 years

median age of women with

VIN

at diagnosis is

45 to 50 years

Slide2

The relatively stable incidence of invasive cancer despite a steady increase in patients diagnosed with VIN could suggest

etiologic factors are different

Dx improved

effective treatment of VIN has prevented a significant increase in the incidence of invasive disease.

Slide3

HPV

89 percent of VIN lesions

40% of invasive vulvar carcinomas

HPV vaccination

Slide4

Invasive SCC

associated with HPV infection

notassociated with HPV infection

Slide5

HPV-positive tumors

Basaloid or warty carcinomas with little keratin formation

often associated with VIN

frequently multifocal

in younger women (35 to 55 years)

more likely to have CIN

to have risk factors typically associated with cervical cancer

Slide6

HPV-negative tumors

In older women (55 to 85 years)

often associated with vulvar inflammation or lichen sclerosis (but rarely with VIN)

Unifocal

well differentiated

Higher incidence of p53 mutations

Slide7

Natural History and Pattern of Spread

Slide8

female external genitalia

mons pubis,

labia majora, labia minora

clitoris,

vestibular bulb,

vestibular glands (including Bartholin's glands

vestibule of the vagina.

Slide9

gynecologic perineum

The region between the posterior commissure of the labia and the anus is termed the gynecologic perineum.

Slide10

lymphatics

Even minimally invasive

superficial inguinal lymph nodes(lateralized lesions)

deeper femoral lymph nodes (secondarily )

pelvic lymph nodes (then)

medial femoral lymph nodes(more medial lesions)

obturator nodes(clitoris)

Slide11

Despite the extensive anastomosis of lymphatics in the region, metastasis of vulvar carcinoma to contralateral lymph nodes is uncommon in patients with well-lateralized T1 lesions.

Slide12

The lungs are the most common sites of hematogenous metastasis

Slide13

Pathology

Nonneoplastic epithelial disorders of the vulva

lichen sclerosis

squamous hyperplasia

dermatoses

Slide14

About 10% of these lesions have cellular atypia and are termed vulvar intraepithelial neoplasia

VIN lesions are assigned a grade from 1 to 3 according to their degree of maturation

Slide15

Paget's disease of the vulva

a rare intraepithelial lesion located in the epidermis and skin adnexa, accounts for 1% to 5% of vulvar neoplasms.

negative for HPV

in postmenopausal women

Slide16

SCC(More than 90% )

Most squamous carcinomas are well differentiated,

About 5% of vulvar cancers are anaplastic carcinomas

Slide17

Verrucous carcinoma

Rare

very well-differentiated

in the fifth or sixth decade

a large, locally invasive lesion.

Even with extensive local invasion, lymph node metastasis from verrucous carcinoma is very rare.

Slide18

primary mammary adenocarcinoma

basal cell carcinomas

sebaceous carcinomas

Malignant melanomas

Vulvar sarcomas

Slide19

Diagnosis, Clinical Evaluation, and Staging

Patients with VIN may complain of :

vulvar pruritus

irritation,

a mass

50% are asymptomatic

bleeding

tender

Slide20

new vulvar lesion

biopsy

Once the diagnosis of high-grade VIN has been established, the entire vulva, cervix, and vagina should be carefully examined because patients often have multifocal or multicentric involvement.

Slide21

Colposcopic examination

wedge biopsy

Excisional biopsy

is preferred for lesions smaller than 1 cm in diameter.

Slide22

a careful physical examination

chest radiography

biochemical profile

Cystoscopy and proctoscopy

skeletal radiography

CT or MRI scans

PET (poor sensitivity but high specificity in the prediction of lymph node metastases)

Slide23

(FIGO) Staging of Carcinoma of the Vulva

I Lesions 2 cm or less in size confined to the vulva or perineum. (T1) (N0)

IA Lesions 2 cm or less in size confined to the vulva or perineum and with stromal invasion no greater than 1.0 mm (No)

IB Lesions 2 cm or less in size confined to the vulva or perineum and with stromal invasion greater than 1.0 mm (No)

Slide24

II Tumor confined to the vulva and/or perineum or more than 2 cm in the greatest dimension. (T2) (N0)

III Tumor of any size with:

Adjacent spread to the

lower urethra

and/or the

vagina

, or the

anus

(T3) and/or

Unilateral regional node metastasis (N1)

Slide25

IVA Tumor invades any of the following: upper urethra, bladder mucosa, rectal mucosa, pelvic bone (T4) and/or

Bilateral regional node metastasis. (N2)

IVB Any distant metastasis including pelvic lymph nodes. (M1)

Slide26

Px

Clinical tumor diameter

depth of invasion

tumor thickness

presence or absence of LVSI

tumor grade?

More than 75% of patients with LVSI have positive inguinal nodes.

Slide27

Prognostic Factors

amount of keratin

the mitotic rate

the tumor growth pattern

Aneuploid tumors (not be an independent predictor of outcome)

HPV DNA ( a poorer prognosis)

age ?

Slide28

LN

presence and number of inguinal node metastases

bilateral node involvement

pelvic node metastases (as stage IV)

extracapsular extension

Slide29

surgical margins and tumor recurrence

1 cm or <8mm

Slide30

Treatment

Radical en bloc resection of the vulva, and inguinofemoral nodes until the early 1980s.

5-year survival rates of 60% to 70%,

the surgery caused significant physical and psychological complications,

patients with multiple positive nodes continued to have a poor prognosis.

Slide31

operating through separate vulvar and groin incisions

cure rates similar to vulvectomy.

role of radiotherapy in the curative management of locoregionally advanced disease.

Slide32

Preinvasive Disease (VIN)-

treatment of high-grade VIN (VIN 3) should be as conservative as possible

Focal lesions can be simply excised.

Multiple lesions can be excised separately or, if confluent, with a larger single excision.

This approach is generally well tolerated and provides material for histologic assessment.

more extensive high-grade VIN, with a CO

2

laser.

Slide33

Extensive, diffuse VIN 3

a wider excision, particularly if the lesion involves the perianal skin.

a partial vulvectomy of the superficial skin (skinning vulvectomy‌)

Slide34

VIN 3 often

recurs

VIN 3 can recur within the donor skin from split-thickness grafts

Slide35

T1 and T2 Tumors

Invasive vulvar tumors can usually be treated effectively without

en bloc radical vulvectomy and inguinal node dissection.

Today, most gynecologic oncologists advocate an individualized approach to early invasive vulvar carcinomas.

Slide36

Overall 5-year disease-specific survival rates for stage I (T1N0M0) and stage II (T2N0M0) disease are approximately 98% and 85%, respectively.

Slide37

T1 and selected T2 lesions

radical local excision.

A wide and deep excision of the lesion is performed, with the incision extended down to the inferior fascia of the urogenital diaphragm.

An effort should be made to remove the lesion with a

1-cm margin

of normal tissue in all directions unless this would require compromise of the anus or urethra.

Slide38

Small T1 lesions that invade 1 mm or less can be managed with local resection alone because the risk of regional spread is very small.

Slide39

Larger T2 lesions

:

modified

radical or radical vulvectomy

separate

vulvar and groin incisions.

Slide40

Acute complication

Wound seroma

(15

%

)

urinary tract infection

wound cellulitis

temporary anterior thigh anesthesia from femoral nerve injury

thrombophlebitis

pulmonary embolus.

Slide41

Chronic complication

leg edema

genital prolapse

urinary stress incontinence

temporary weakness of the quadriceps muscle

introital stenosis.

pubic osteomyelitis,

femoral hernia,

rectoperineal fistula

Slide42

T3 and T4 Tumors

T3 tumors

S +_RT

the vulva may be treated with opposed anterior and posterior photon fields (if the inguinal regions also require treatment) or with an appositional perineal electron beam. The vulva should receive a total dose of 50 to 65 Gy, depending on the proximity of disease to the surgical margin.

Slide43

preoperative chemoradiation in some patients with T3 and T4

These reports indicated that modest doses of radiation (45 to 55 Gy) produced dramatic tumor responses in some patients with T3 and T4 disease, permitting organ-sparing surgery without sacrifice of tumor control.

Investigators have emphasized the use of

concurrent chemoradiation

in this setting.

Slide44

Chemoradiation in Locally Advanced Disease

Most studies have used combinations of

cisplatin

,

5-FU,

and

mitomycin-C,

Treatment schedules usually include a 4- to 5-day infusion of 5-FU combined with one of the other two drugs, with this course repeated every 3 to 4 weeks

Slide45

CHRT

Impressive responses

Cisplatin

Slide46

neoadjuvant chemotherapy in the treatment of locally advanced vulvar cancer.

two to three cycles of cisplatin, bleomycin, and methotrexate followed by radical surgery.

Caution is warranted

Elderly (concurrent

medical

problems)

Slide47

Tx:

Small T1 lesions : local resection alone

T1 and selected T2 lesions: radical local excision

Larger T2 lesions: modified radical or radical vulvectomy

Locally

Advanced Disease: CHRT +

S

T3

: S+_RT

T4 Tumors:RT+_S+_CHT

Slide48

Treatment of Regional Disease

patients

who suffer inguinal recurrences are rarely

curable

primary

tumors that invade more than 1 mm must have their inguinal nodes treated

Slide49

compared pelvic lymphadenectomy with inguinal and pelvic irradiation in patients with inguinal node metastases from carcinoma of

the

vulva:

a

survival advantage for the radiotherapy arm

Slide50

postoperative radiotherapy became standard for most patients with inguinal node metastases.

Slide51

Complications of lymphadenectomy

Slide52

Complications

wound disruption

infection

chronic lymphedema

perioperative mortality

Slide53

غدد لنفاوی اینگواینال در عمق بیش از 5 تا 8 سانتی متری قرار دارد

Slide54

Neg

inguinal

nodes (by tomographic imaging)

with

radiotherapy

treatment planning rarely experience a regional recurrence after inguinal-pelvic irradiation to 40 to 50 Gy.

Slide55

extent of lymph node dissections

medial

inguinal-femoral nodes

may be the primary site of drainage of some vulvar cancers;

now recommend removal of at least the

superficial

and

medial

inguinofemoral nodes.

Slide56

The efficacy of sentinel lymph node evaluation in patients with T1 or T2 (less than 4 cm) vulvar cancers?

whether the sentinel node procedure can effectively supplant lymphadenectomy in the management of

stage I and II vulvar cancer

Slide57

Treatment of Metastatic Disease

chemotherapy ?

clinicians often use single agents and combination regimens that have had some activity in the treatment of cervical cancer.

Slide58

Slide59

Slide60

Slide61

Slide62

Slide63


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