Management of Carcinoma Vulva

Topics
Anatomy
Epidemiology
Etiology
Pathology
Immunohistochemistry
 VIN

Treatment is recommended for all women with vulvar HSIL (VIN usual type).
 Because of the potential for occult invasion, wide local excision should be performed if
cancer is suspected.
 When occult invasion is not a concern, vulvar HSIL (VIN usual type) can be treated with
excision, laser ablation, or topical imiquimod .
Vaccinating girls with HPV vaccine before their initial sexual contact has been claimed to
reduce incidence of VIN
Presentation
Investigations
 Prognosis
LN involvement – single most imp factor
 -ve LN – 91% 5 yr survival
 +ve LN – 52% 5 yr survival
 Extent (number)
 U/L vs B/L
 Volume of tumor in involved nodes
 Extracapsular extension
 Level of metastatic disease in the nodal chain

Tumor size < 4 cm

Depth of invasion (5-9 mm) –
Surgical margin
 < 8 mm – 43% LR

Growth pattern (infiltrative vs exophytic)

Vascular space invasion
Treatment
Early stage( I & II)
Surgery
SLNB
 Indications of Lymph node Dissection
IF LAD Tumor Size( cm) Stromal Invasion(mm)

No LAD reqd <= 2 cm <=1( LVSI –ve)

Ipsilateral LAD <=2cm <=1mm(LVSI +ve)

<=2cm >1mm

>2cm any

Bilateral LAD Midline Tumour<1cm

Involves Ant Labia Minora

+ve Ipsilateral LN ( lesion > 2cm and Depth more than 5

mm)
Radiotherapy
Large II and III stage
Pre Op Radiotherapy
Radiotherapy
Bolus
Contouring
Lesions involving Vagina
Lymph nodal Stations
Post operative
 2 D planning
Pelvis + groin + vulva
Sup. – absent pelvic N mid SI jt
(includes caudal Ext I N)
– pelvic N +ve/ N cephalad to ing
ligL3-L4 (includes Com. I N)
Lat – pelvis 2 cm lateral to boney
margin of pelvis
– groin  extend lateral upto ant
iliac crest
Inf – upper medial thigh/ 5cm below &
parallel to inguinal lig
– extensive skin involvement 
additional 5 cm of skin flap to be included
in target volume
Modifications
 IMRT
Advantages Disadvantages

Ability to protect skin outside the PTV Controversies about target delineation –
Groin,Skin bridge, Coverage of mons, Vaginal
Coverage
Protection of central pelvic bowel, Air gaps- issues with optimization

Ability to protect femoral heads even in

obese pts

Concurrent boosts
Brachytherapy
Side effects of radiotherapy
Follow up
Chemotherapy
Melanoma of vulva
Pagets disease
Review of literature
Our data show that the risk of non-sentinel-node metastases increases with size of
sentinel-node metastasis. No size cutoff seems to exist below which chances of
non-sentinel-node metastases are close to zero. Therefore, all patients with
sentinel-node metastases should have additional groin treatment. The prognosis
for patients with sentinel-node metastasis larger than 2 mm is poor, and novel
treatment regimens should be explored for these patients.
Pre op RT
QUESTIONS???