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Vulvar Cancer

Vulvar Cancer. 부산 백병원 산부인과 조인호. Preview. Annually, 3800 new case, 800 deaths in US Uncommon, 3-5% in Gyn cancer 90% of vulvar cancer : Squamous cell ca. Incidence of VIN : 1970 년대 중반 -> 1980 년대 중반 ; 2 배 Invasive squamous cell ca. : stable.

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Vulvar Cancer

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  1. Vulvar Cancer 부산 백병원 산부인과 조인호

  2. Preview • Annually, 3800 new case, 800 deaths in US • Uncommon, 3-5% in Gyn cancer • 90% of vulvar cancer : Squamous cell ca. • Incidence of VIN : 1970년대 중반 -> 1980년대 중반 ; 2배 • Invasive squamous cell ca. : stable 부산백병원 산부인과

  3. Radical vulvectomy and en bloc groin dissection with or without pelvic lymphadenectomy • Changes in Tx. • Individualization of Tx. For Pt. • Vulvar conservationwith unifocal tumors • Omission of the groin dissection for Pt. with T1 tumors and <1mm of stromal invasion. • Elimination of routine pelvic lymphadenectomy • Separate incisions for the groin dissection to improve wound healing 부산백병원 산부인과

  4. Omission of the contralat. Groin dissection in Pt. with lat. T1 lesions and negative ipsilat. Node. • Preoperative radiation therapy • Postoperative radiation therapy 부산백병원 산부인과

  5. Etiology • Basaloid or warty types • Multifocal, younger, related to HPV infection, VIN, smoking • Keratinizing types • Unifocal, older, not related to HPV infection, adjacent to lichen sclerosus and squamous hyperplasia • VIN3 : potential precancerous lesion • VIN -> cancer ; difficult • VIN (10-20%) ; harbor an invasive component • 80% of VIN found adjacent to basaloid or warty vulvar squamous cell ca. 부산백병원 산부인과

  6. VIN3의 89%, warty or basaloid type carcinos의 86% : DNA of HPV • Itch-scratch cycle associated with lichen sclerosus and squamous hyperplasia, with atypical changes occurring in the repaired epithelium. • Demonstrate aneuploid DNA content, p53 overexpression, and monoclonal expansion of keratinocytes in lichen sclerosus and associated squamous hyperplasia 부산백병원 산부인과

  7. In past, • High risk factor : obese, HBP, DM, nulliparous, • In recent, • Unable to confirm 부산백병원 산부인과

  8. Type of Vulvar cancer • Table 33.1 부산백병원 산부인과

  9. Squamous cell cancer • 90-92% of vulvar cancer • Basaloid carcinoma, warty carcinoma, keratinizing squamous carcinoma • Keratinization • Microinvasive squamous carcinoma • <2cm in diameter /c <1mm stromal invasion • Invasion depth <1mm -> inguinal LN meta : extremely rare • Invasion depth >1mm -> LN meta risk ↑ 부산백병원 산부인과

  10. 부산백병원 산부인과

  11. Squamous cell caClinical Features • Mean age : 65세 (15%는 40세 이전) • Sx. • Vulvar pruritus, a lump, mass • Bleeding, ulcerative lesion, discharge, pain, dysuria • P/Ex. • Raised, fleshy, ulcerated, leukoplakic, warty • Labia majora and minora (60%), clitoris(15%), perineum(10%) • Groin LN examination, Pap smear, colposcopy 부산백병원 산부인과

  12. Squamous cell caDiagnosis • Wedge Bx. • Lesion is 1cm in diameter -> Excision Bx. • Any confluent warty lesion requires biopsy before medical or ablative therapy is initiated 부산백병원 산부인과

  13. Squamous cell caRoutes of Spread • Direct extension to involve adjacent structures • Lymphatic embolization to the regional inguinal and femoral LN • Hematogenous spread to distant sites (lungs, liver, bones) 부산백병원 산부인과

  14. Fig 33.3 부산백병원 산부인과

  15. Staging • Previously, • Clinical staging based on • tumor size • Location • Palpable regional LN • Limited search for distant metastasis • Now, -> Surgical Staging • 18-44% error in clinical staging compared with Surgical Staging 부산백병원 산부인과

  16. Table 33.4 부산백병원 산부인과

  17. Prognosis of survival • Factor • LN status : most important • Lesion size • Histologic grade, tumor thickness, depth of stromal invasion, lymph-vascular space involvement, tumor ploidy • 5-yr survival rate : LN(-) ;90% , LN(+) ;50% • 2-yrs survival rate : • LN meta 3개이상 :20% • N0,N1 : 78%, N2 : 52%, N3 : 33% 부산백병원 산부인과

  18. Table 33.5 부산백병원 산부인과

  19. Table 33.3 부산백병원 산부인과

  20. Treatment • En bloc radical vulvectomy and bilateral dissection of the groin and pelvic nodes • 지난 20년간의 변화 • Early stage (T1) : 50%이상 차지 • Hospitalization의 기간 연장 • Psychosexual consequence에 대한 인식의 증대 부산백병원 산부인과

  21. Early Vulvar Cancer (T1) • The modern approach to the management -> individualized • Microscopic tumor foci가 lymphatics에 남아 있더라도 en bloc resection은 고려하지 않는다. • Radical local excision > Radical vulvectomy • Recurrence, depth of invasion • 1-1.5cm grossly negative margin 부산백병원 산부인과

  22. Patient age -> Tx. 결정 인자 • Lat. or Post. aspects of vulva lesion • >Radical local excision • Clitoris를 침범한경우 -> • Small field of radiation Tx. • Sensitizing chemotherapy 부산백병원 산부인과

  23. T2 , T3 Vulvar cancer • Surgical margin of at least 1cm • More conservative resection • Involving the post. half of the vagina • Preservation of the clitoris and mons pubis • More advanced T2 and T3 • Radical vulvectomy and bilat. inguinal-femoral lymphadenectomy 부산백병원 산부인과

  24. Closure of Large Defects • An area may be left open to granulate, after 6-8 weeks • Full-thickness skin flaps • Rhomboid flap, - post. vulva • Mons pubis pedicle flap – lat. Defects • Myocutaneous flaps • Tensor fascia lata myocutaneous graft 부산백병원 산부인과

  25. Advanced DiseaseLarge T3 and T4 Primary Tumor • Radical vulvectomy and inguinal-femoral lymphadenectomy + pelvic exenteration • Chemoradiation ->90% response (initial) • Op후 chemoradiation 순서 • Radiation alone (/c or /s chemoTx.) • Residual tumor :1/2이상 -> 50-79% relapse • Combined radiation + surgery • 5 yr survival rate : as high as 76% 부산백병원 산부인과

  26. Management of the Lymph Nodes • Groin dissection -> • postop. wound infection • Breakdown • Chronic leg edema (major problem) • Invasion <1mm, no risk of LN metastasis • Recur in undissected groin -> 90% mortality • Lat. Vulvar lesion -> ipsilat. Bilat. Lymphadenectomy becomes necessary • Appropriate groin dissection is the single most important factor in decreasing the mortality 부산백병원 산부인과

  27. Microinvasive Carcinoma • Stromal invasion >1mm ; inguinal-femoral lymphadenectomy • Radiation cannot substitute for groin dissection • Primary lesion is unilateral and the ipsilateral LN are negative -> not necessary to perform a bilateral groin dissection • Groin node (-) -> pelvic node meta is rare • Sentinel LN studies : predict the presence or absence of reginal nodal metastasis 부산백병원 산부인과

  28. 부산백병원 산부인과

  29. 부산백병원 산부인과

  30. 부산백병원 산부인과

  31. 부산백병원 산부인과

  32. 부산백병원 산부인과

  33. 부산백병원 산부인과

  34. 부산백병원 산부인과

  35. 부산백병원 산부인과

  36. 부산백병원 산부인과

  37. 부산백병원 산부인과

  38. Postoperative Management • Inpast, • Bed Rest: 3-5days for immobilization • These days, • Separate incision -> POP 1-2day : ambulation시작 • DVT prevention • Subcutaneous heparin • pneumatic calf compression • Frequent dressing • Suction drainage of each side of the groin • Sitz bath or whirlpool therapy 부산백병원 산부인과

  39. Early Postoperative Comlications • Groin wound infection, necrosis, breakdown • En bloc operation – 53-85% • Separate-incision approach – 44% • UTI • Seromas • DVT • Pulmonary embolism • MI • Hemorrhage 부산백병원 산부인과

  40. Late Complications • Chronic lymphedema (30%) • Recurrent lymphagitis or cellulitis (10%) • Usually responds to oral antibiotics • SUI (10%) • Femoral hernia (uncommon) • Depression, altered body image and sexual dysfunction 부산백병원 산부인과

  41. Role of Radiation Therapy • RTx : 점점 중요한 요소로 부각됨 • Local tissue tolerance : poor, vulvar necrosis • Ix. for RTx. with primary vulvar ca. • Advanced disease • Op.후 LN meta가 microscopic하게 2개 이상 (+), gross하게 1개이상 (+) • Possible roles for RTx. • Involved or close surgical margin인 경우 • Small primary tumor인 경우 primary Tx., • Particularly clitoral or periclitoral lesion • Op할 경우 Psychologic한 결과가 예상되는 경우 부산백병원 산부인과

  42. 1 microscopically positive groin node (+) -> No additional Tx. Recommended • Microscopic groin node 2개 이상 (+) -> recurrence risk ↑ • =>irradiation • The survival rate (1977, GOG positive groin (+)) 부산백병원 산부인과

  43. Recurrent Vulvar cancer • 2/3 of vulvar cancer recur within first 2years from initial Tx. • Positive groin nodes와 recurrence는 정비례 • Local recurrence • Margin status • Closer than 0.8cm -> 50% recur • Primary lesion larger than 4cm in diameter • Tx. • Additional surgery • RTx (External beam therapy + interstitial needles) • chemotherapy 부산백병원 산부인과

  44. Regional and Distant Recurrence • Difficult • Poor prognosis • Radiation • Chemotherapy • Bleomycin and methotrexate with or without cisplatin • Bleomycin and mitomycin C • Response • Usually disappointing • Long-term survival is very uncommon 부산백병원 산부인과

  45. Melanoma • Rare • Incidence : 0.1~0.19/100,000women • Second most common of vulvar malignancy • Postmenopausal white women • No symptoms (most) • Itching, bleeding, groin mass • Labia minora, clitoris • Vulvar nevi are junctional, precursor lesion to melanoma; thus, should be removed 부산백병원 산부인과

  46. Melanoma Histopathology • Mucosal lentiginous melanoma • Flat freckle, quite extensive, superficial • Superficial spreading melanoma • Most common, superficial • Nodular melanoma • Most aggressive, raised lesion • Penetrate deeply • Metastasize widely • ¼ of cases of melanomas • Macroscopically amelanotic -> spread early 부산백병원 산부인과

  47. Melanoma Staging • The FIGO staging used for squamous lesions is not applicable to melanomas • Because the lesions are usually much smaller, • and the prognosis is related to the depth of tumor invasion rather than to the diameter of the lesion 부산백병원 산부인과

  48. Melanoma Treatment (1) • Understanding of the prognostic significance of the microstage • Individualization • More conservative surgical management • Invasion 에 따른 Tx.방침 • (<1mm) : Radical local excsion alone • (>1mm) : en bloc resection of the primary tumor and regional groin node dissection recommended • 1cm이상 surgical margin (<0.76mm) • 2cm이상 surgical margin (1-4mm) 부산백병원 산부인과

  49. Melanoma Treatment (2) • 10-year survival rate • Lateral lesion (61%), medial lesion (37%) • Superfical lesion (Breslow tumor thickness <0.76mm ) • Lymphadenectomy not indicated • Intermediate-thickness (1-4mm) • Observation showed a 5-year survival advantage who underwent lymph node dissection • Deeply invasive cutaneous melanoma (>4mm) • Benefit from regional lymphadenectomy • Chemotherapy : interferon -a 부산백병원 산부인과

  50. Melanoma Prognosis 부산백병원 산부인과

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