Friday, March 6, 2009

Vulvar Cancer

JP presents a case of Vulvar Cancer - 60 yo WF with vulvar pruritis x 1 year.  SCC 7mm diam, 1.5cm depth.  deep margin at resection was 2mm.  T1bNx.  Then underwent a bilateral inguinal node dissection - negative.

Questions what to treat if at all, nodes, primary?

Vulvar cancer 3-5% of gyn malignancies.  3500/year.  80-90% scc.  Occaisional bartholin glands Adenocarcinomas.  Most HPV related.  Smoking, Lichen Sclerosis.  

IA <=2cm primary <=1mm invasion
IB <=2cm primary >1mm invasion
II >2cm
III unilateral inguinal nodes, lower urethra, vagina, anus (N1)
IVA bilater inguinal, upper urethra/bladder, rectum, pubic bone (T4 or N2)
IVB pelvic nodes, DM

"single incision" - radical vulvectomy and bil inguinal dissection- 50% incidence breakdown, 10-15% extremity lymphedema
"triple incision" for excision of primary and for each LN sampling

local recurrence series: 
UCLA Heaps Gyn Onc 1990 - 135 pt with inv SCC of vulva.  (majority I or II)  margins >= 8mm was 0% LR, <8mm>
Also associated 9.1mm invasion, tumor thickness >1cm, keratinization >= 25%, mitosis >10/HPF

Pittsburg 1997 Faul IJROBP - 62 with close of postive margins (<8mm).>
close margins LR 33% obs vs 5% RT (SS)
pos margins LF 76% obs vs 32% RT (SS)

Case: Treated primary to 50Gy at 2Gy/fx  AP/PA. 

New Case:
35 yo with HIV/AIDS, vulvar mass for 3 weeks.  R mass extending to clitoris.  biopsy +SCC.  PET CT demonstrated activity in primary and bilateral nodes.  Rad Hemi- Vulvecomy with L inguinal Dissection.  4cm primary with 8mm invasion, margin was 2mm.  1/2 LN positive on the Left.  Staged as pT2N1 (though R not dissected).

Treating the Pelvis:
nodal risks
for tumors of >= 2cm, risk of inguinal nodes are dependent on depth of invasion: <1mm> 5mm 37.5%.

Cloquet's node: most superior deep inguinal node.

GOG 37: Homseley 1986. 
s/p radical vulvectomy & bil superficial and deep inguinal dissection found to have + inguinal LNs 
114 pts randomized to:
Pelvic node dissection - PLND (15/53 patients had + pelvic LNs)
RT (45-50 Gy to inguinal nodes and pelvic nodes BUT NOT vulvar region)
50% of patients were cN0 (PE not sensitive for groin node mets) 
Groin recurrence PLND 13/55 vs  RT 3/59 (p=0.02) 
OS (2) PLND 54% vs RT 68% (p=0.03) 
on subset analysis those with only 1 node positive did not benefit from RT.

GOG 88: Stehman 1992. 
Resectable vulvar SCC; Excluded T1 lesions unless LVI or >5mm invasion; s/p radical vulvectomy
58 pts randomized to 
Bilateral groin dissection, RT if positive
Bilateral groin irradiation 
50 Gy/ 25fx, with 50% of dose given with 12-13 MeV electrons; Rx'd to 3 cm 
5/25 patients had + nodes in Arm A and were treated with RT
OS (88% disection vs 66% RT) and DFS (92% disection vs 70% RT) were better in the dissected + selective RT arm, with a large portion of local failures of the RT arm were in the groin.

University of Washington Anatomic Study
Examined CT scan of 50 patients undergoing treatment for Gynecologic Cancer
Koh IJROBP 1993;27:969-974
demonstrates that in most of the patients in GOG 88 were probably undertreated as most nodal basins are much deeper than 3cm.

to be continued...

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