Vulval cancer evolution of management

PROF.S.SUBBIAH et.al
Vulvar cancer – Evolution of
Management.!
Halstaedian Concept to Hamilton concept.!
Department of Surgical Oncology
Centre for Oncology
GRH,Royapettah

Most common organs causing Metastasis to Vulva

RAY’S river flow incision, AIIMS, Delhi

Anagram
CASPARS TRIANGLE
SCARPA’S TRIANGLE

ANAGRAM
Broadway persecutes

BASSET WAY procedure
Tausig and way

Introduction
• Predominantly a disease of postmenopausal women
• 4% of gynecologic cancers
• Associated with or preceded by vulvar intraepithelial neoplasia (VIN).
• A VIN lesion is more likely to be HPV positive than invasive cancer

Floor of the vulva
• Represented by the median perineal fascia or perineal membrane of
the urogenital diaphragm, which becomes the femoral fascia in the
thigh.
• Between the skin and the median perineal fascia of the urogenital
diaphragm is the fatty tissue, which is divided into a superficial
(hypodermal) and deep portion by the superficial fascia or Colle's
fascia

Lymphatic drainage
• A rich network of anastomosing lymphatics.
• Crosses midline
• Initial regional metastasis is to the inguinal lymph nodes (that are
medial to the common femoral and saphenous veins and superficial to
Camper fascia)
• Metastasize secondarily to deeper femoral lymph nodes, to the lateral
circumflex nodes, and to the pelvic lymph nodes

• Tumors of Clitoris can spread directly to the obturator nodes through
lymphatics that follow the dorsal vein of the clitoris.
• Spread to contralateral lymph nodes is uncommon in patients with
well-lateralized T1 lesions.
• The lungs are the most common sites of hematogenous metastasis

Lymphnodes of the groin
• Superficial inguinal nodes- along the tributaries of GSV.
• ANSON divided these nodes anatomically into five groups
• Superficial femoral lymph nodes lie vertically along the terminal
portion of the great saphenous vein before it enters the femoral vein,
at the fossa ovalis, superficial to the femoral fascia.
• other names superficial inguinal lower group or superficial subinguinal
lymph nodes

• Deep inguinofemoral lymph nodes , are always situated within the
fossa ovalis, beneath the level of the coplanar lamina cribrosa and
femoral fascia, medial to the femoral vein.
• No lymph nodes are located beneath the femoral fascia distal to the
lower margin of the fossa ovalis and lateral to the femoral artery

Cloquet Node- inconsistancy.
• Its presence has no particular surgical relevance and
• Today is considered an inconstant lymph node, being absent in
approximately 50% of the cases and, when present, unilateral in
approximately 30% of patients.

ISSVD Terminologies

Types of vulvectomy- based on depth
• Skinning or superficial - Removal of a lesion with only the
skin/mucosa, leaving in situ the underlying fatty tissue (hypodermal)
and fascial structures (superficial or Colle's fascia).
• Simple- Removal of the skin along with the superficial portion of the
fatty tissue (hypodermal) lying on the superficial fascia.
• Radical or deep- Removal of the skin along with all of the tissue
extending from the surface to the urogenital diaphragm or median
perineal fascia (perineal membrane)

Types of vulvectomy- based on extent
• Total vulvectomy- When the entire vulva is removed
• Partial vulvectomy. When the excision is limited in extension to a
portion of the vulva but is more than a biopsy.
sector or conservative vulvectomy, or vulvar sector excision or resection,
or wide vulvar local excision.

Early stage vulval cancer

• Most small lesions (approximately <4 cm) that do not involve the
urethra, anus, or other adjacent structures can be controlled locally
with a radical local excision.
• upto inferior fascia of the urogenital diaphragm.
• 1-cm margin of normal tissue.
• Small lesions that invade </=1 mm - local resection alone.
• >1 mm invasive tumors must have surgical or radiation treatment of
the inguinal nodes.

Advanced stage Vulval cancer

• Adequate surgical clearance can often be obtained only by sacrificing
organ function.
• Concept of close margin near vital structures
• <8mm margin - role of Post op RT
• more advanced involvement of vital structures- ULTRARADICAL
procedures( eg- pelvic exentrations)

1. Wide Radical Excision
• 75% of patients with disease limited to the vulva can be salvaged by
radical wide excision (partial deep vulvectomy)
• Goal- clear deep margin
• Primary closure of the vulvar defect – if difficult- reconstruction

2. Radical Vulvectomy
• The classic description of en bloc radical vulvectomy and bilateral
lymphadenectomy can be based on either a “butterfly” or
“longhorn” approach.
• The butterfly incisions use convex “wings” over the groin and around
the anus to facilitate closure of the defect .
• The longhorn incisions - limit skin resection over the groin (to reduce
wound breakdown).

Ref: Danforth Textbook of Obs and
Gynecology

Incision- Landmarks
• The arcing superior incision - from the lateral margins of the groin
dissection across the mons pubis.
• The lateral vulvar incisions are placed at the labiocrural folds (most
lateral location of the superficial vulvar lymphatics).
• The perianal incision is placed to allow resection of the perineal body.
• These incisions are taken to the level of the deep inguinal and
perineal fascia .

3. Pelvic Exenteration
• Curative resection may still be possible when vulvar recurrence
extends to the vagina, proximal urethra, or anus.
• Selected patients have achieved long-term survival after PE for such
recurrences

Groin nodes- Addressing surgically

Can we do a superficial inguinal dissection
alone?
• In the 1990s, “superficial” inguinal lymphadenectomy - early disease.
• Complications are avoided, but inguinal recurrence rates were higher
(7% to 16%) in patients who had negative dissections.
• Reason: Did not remove medial inguinal-femoral nodes!.
• For this reason, gynecologic oncologists generally recommend
removal of at least the superficial and medial inguinofemoral nodes.

SLNB- for whom? And How is it done?
• Dual dye technique (Mead et al)
• Only intradermal
• NPV approaching 100%
• Half life Tc 99 nanocolloid- 6 hours and vital blue dye- 45 minutes
• Both first and second echelon nodes are harvested for analysis
• Alternative to inguinofemoral lymphadenectomy in
• tumors ≤4 cm,
• with no suspicious LNs on physical examination or imaging and
• no prior groin surgery or radiation

Identify !

SPECT > conventional LSG

Pros and Cons
• LSG
• Determine the number and location of the SLNs preoperatively and
• to detect a SLN outside the nodal basin;
• Disadvantages- cost of equipment
• Blue dye
• the color becomes visible in the nodes and lymphatic channels, quickly
allowing for rapid SLN dissection.
• Less hypersensitivity reactions and
• Inexpensive.
• Disadvantage -rapidly passes through the lymphatics, and so it is possible to
miss the SLN.

How to Section SLN for HPE?
• Spacing must be one-half the diameter of the tumor to be detected.
• The LN or nodes are sliced in 1 to 2 mm slices.
• Cut at right angles to the long axis of the node.
• Embedded in the paraffin block, - three sections from each block.
• This second slide is held for additional H&E staining, or IHC, if the
first and last H&E sections have equivocal findings.

GROINSS-VII- Study
• Role of completion dissection Vs adjuvant RT alone in SLNB +ve cases.
• Interim analysis demonstrated a high rate of recurrences based on
the size of LN metastases (2.1% for LN ≤ 2 mm vs. 20% for LN > 2
mm).
• Protocol was modified - completion dissection and then possible
adjuvant RT for patients with macrometastases (defined as >2 mm).
• Suboptimal efficacy of RT for macrometastases

What does Recommendations have to say
finally? [NCCN 2021]
• Staging involves complete surgical resection of the primary vulvar
tumor(s) with at least 1-cm clinical gross margins and either a
unilateral or bilateral inguino-femoral lymphadenectomy or an SLN
biopsy in select patients.
• Inguinofemoral lymphadenectomy removes the LNs along the
inguinal ligament, within the proximal femoral triangle, and deep to
the cribriform fascia.

• The choice of vulvar tumor resection - partial or total vulvectomy, and the
depth of resection may be superficial/skinning, simple, or radical.
• The depth of the resection - urogenital diaphragm, or median perineal
fascia or periosteum of pubic bone.
• There are no prospective trials comparing the resection techniques above.
• Retrospective data suggest there is no difference in recurrence outcome
between radical partial vulvectomy compared with radical total
vulvectomy.

Unilateral vs bilateral Node dissection
• For a unifocal primary vulvar tumor that is <4 cm diameter,
• located 2 cm or more from the vulvar midline and
• clinically negative inguinofemoral LNs, a unilateral inguinofemoral
lymphadenectomy or SLN biopsy is appropriate
• For a primary vulvar tumor located within 2 cm from or crossing the
vulvar midline, a bilateral inguinofemoral lymphadenectomy or SLN
biopsy is recommended.

• Inguinofemoral lymphadenectomy or SLN biopsy can be omitted in
patients with stage IA primary disease with clinically negative groins
due to a <1% risk of lymphatic metastases.
• For patients with stage IB–II disease, inguinofemoral
lymphadenectomy is recommended due to a risk of >8% of lymphatic
metastases.
• A negative unilateral inguinofemoral lymphadenectomy is associated
with a <3% risk of contralateral metastases.

GOG 88
• Prophylactic RT
• Inguinal RT vs surgery for N0 groin
• Prematurely terminated with 58 patients when there was a higher
rate of groin recurrence in the RT arm (0% vs. 18.5%).

Prophylactic RT to Adjuvant RT - CHange over!
• Prophylactic RT in the undissected but high-risk groin remains
controversial.
• Adjuvant RT - improves regional tumor control and survival.
• Retrospective studies -
- increased risk of groin recurrence after radical
surgery, and therefore may benefit from RT.

GOG 37
• 114 patients
• Patients who had positive inguinal nodes were randomized intraop to
receive either pelvic node dissection or postoperative irradiation to the
pelvic and inguinal nodes.
• Closed Prematurely, based on interim analysis identifying a significant
survival benefit with RT (68% vs. 54%, p = 0.03)

Preoperative Radiotherapy
Advantages for patients with locally advanced vulvar carcinomas
1. Less radical resection of the vulva may be adequate
2. Allow the surgeon to obtain adequate tumor-free surgical
margins without sacrificing important pelvic structures
3. RT alone may be sufficient to sterilize microscopic regional
disease in N0 groin
4. Mobilize fixed and matted nodes, facilitating subsequent
surgical excision.

what is new?
• Role of preop CHEMORADIATION

Preop Concurrent CRT
• Two large prospective phase 2 trials performed by the GOG.
• Locally advanced T3 or T4 disease who were deemed not resectable by
standard radical vulvectomy underwent preoperative CRT
• GOG 101- Split course radiation(47Gy) with 5FU and cisplatin
• cCR- 47% and pCR 31%
• GOG 205- 57 Gy RT with weekly cisplatin(40mg/m2)
• cCR- 64% and pCR 50%
• GOG 279 - concurrent gemcitabine with cisplatin + IMRT, and dose escalation
to 64 Gy

Two questions addressed.!
• Can patients be observed after preop CRT?
• Management of nodes - Is Preop RT useful?

• The single most important prognostic factor for recurrence and OS in
women with vulvar cancer is metastasis to the inguinal LNs;
• Most recurrences happen within 2 years of primary treatment.

Recurrent Disease
• The site and volume of recurrent vulvar lesions dictate both
resectability and potential for cure.
• Categorized as local (vulvar), inguinal, or distant (pelvis, lower
extremity, or beyond).
• Curative or palliative role of surgery

Resection of Groin Recurrence
• RT > Surgery.
• A resection with negative margins usually requires the resection of
vessels or bone with plastic reconstruction.
• Isolated groin recurrence is a rare event, so the data to support the
efficacy of this treatment are anecdotal

Take home Message
• LN status is the most important determinant of survival
• Tumor margin is the most important factor in recurrence of SCC of
vulva
• Double or Triple incision is the Current norm

• The traditional treatment radical surgical excision of the primary tumor and
inguinofemoral lymphadenectomy.
• Experience has shown that survival is improved with the administration of
postoperative radiation therapy- for high risk patients.
• More recently, neoadjuvant radiotherapy (RT) with concomitant
radiosensitizing chemotherapy (CT) - for whom radical surgery would be
either too morbid or technically not feasible.
• Sentinel lymph node (SLN) biopsy - the promise of better outcomes for
patients with early disease.
• An individualized approach to vulvar cancer management - better cosmetic
results and sexual function, is now the norm.

Vulval cancer evolution of management

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