1. DR. N. SRAVANTHI
DR. NEHA
DR. S. C. SAHA
8/8/2012

2. Pre- treatment work up
 A thorough pre- operative evaluation for coexisting medical
problems
 Routine investigations and Chest radiograph
 PAP smear and colposcopy of cervix and vagina.
 Imaging : CT and MRI may help to determine resectability and
treatment planning, and distant metastases
 Cystoscopy, intravenous pyelography, or proctoscopy (or all three) is
indicated if it appears that locally advanced cancer

3. .
• SURGERY
.
• RADIATION
.
• CHEMOTHERAPY

5.  Standard treatment in the past : Radical vulvectomy and en
bloc groin dissection ( Taussig and Way)
 Involves radical removal of the entire vulva, the mons
pubis, the inguino-femoral lymph nodes, and often the pelvic
lymph nodes.

8.  ISSUES OF CONCERNS :
 High rate and the severity of wound complications
 Psychosexual effects of radical removal of the vulvar tissues
 Urinary or fecal incontinence
 Vaginal relaxation,
 Overtreatment of early cancer,
 Inadequate treatment of more advanced disease

9.  During the past 20 years, a number of significant advances have
been made in the management of vulvar cancer, reflecting a
paradigm shift toward a more conservative surgical approach
without compromised survival and with markedly decreased
physical and psychological morbidity
 Individualization of treatment for all patients with
invasive disease
 Vulvar conservation for patients with unifocal tumors
and an otherwise normal vulva

10.  Omission of the groin dissection for patients with T1 tumors
and, <1 mm of stromal invasion .
 Elimination of routine pelvic lymphadenectomy.
 Investigation of role of sentinel lymph node procedure to
eliminate requirement for complete inguino-femoral
lymphadenectomy.
 The use of separate incisions for the groin dissection to
improve wound healing

11.  Omission of the contralateral groin dissection in patients
with lateral T1 lesions and negative ipsilateral nodes
 The use of preoperative radiation therapy to obviate the
need for exenteration in patients with advanced disease.
 The use of postoperative radiation therapy to decrease the
incidence of groin recurrence in patients with multiple
positive groin nodes

12. Prognostic factors
 Primary Tumor factors :
 depth of invasion or tumor thickness,
 tumor diameter,
 tumor differentiation,
 lymph-vascular space involvement, and
 Margin status : most powerful predictor of local recurrence
( At least 1cm grossly negative surgical margin)
( Closer than 0.8cm margins – almost 50% recurrence risk

13.  Status of the inguino-femoral lymph nodes- single most important
prognostic factor
NODAL STATUS 5 YEAR SURVIVAL RATE
NEGATIVE >80%
POSITIVE <50%
 No. Of Nodes:
No. of NODES Prognosis
Single microscopically +ve Similar as negative nodes
3 or more +ve nodes 2year survival of 20%

14.  Extra-capsular extension
 Clinical nodal status
 Size of the metastatic deposit inside the lymph node,
 Percentage of nodal replacement.

15. Modifications in Management of the Vulvar
Phase of Treatment
 Modified radical vulvectomy - generally refers to radical removal
of the portion of the vulva containing the tumor
 AIM: to obtain 2cm skin margins while sparing of as much normal vulvar
tissue as possible is less likely to produce sexual dysfunction and a sense of
disfigurement
 Chief concerns :
 possibility of an increased risk of local recurrence and
 later an increased risk of a second primary vulvar cancer

16. A comparative study of radical vulvectomy and modified radical vulvectomy for
the treatment of invasive squamous cell carcinoma of the vulva
SURGERY No. of Patients Local recurrence
Modified Radical 45 1 (2.2%)
Vulvectomy
Radical vulvectomy 45 2 (4.4%)
Hoffman MS, Roberts WS, Finan MA, Fiorica JV, Bryson SC, Ruffolo EH, Cavanagh D
Gynecol Oncol 1992 May;45(2):192-7

17. The evolution of surgical techniques in vulvar cancer. (A) Radical vulvectomy with en bloc dissection;
(B) radical vulvectomy with triple incision; (C) modified radical vulvectomy;
(D) clitoral-sparing modified radical vulvectomy

18. STAGE I Vulvar cancer
 Radical vulvectomy (5-year survival rates ) >90%.
 Choice of treatment depends on various tumor and patient factors.
Micro-invasive lesions (<1 mm Wide (5–10 mm) local excision
invasion)
Lesions >2cm with <5mm invasion “Radical local excision” with
and clinically negative nodes complete unilateral
lymphadenectomy
 “At least 1cm grossly negative margin, without putting the skin under tension, should
be obtained and extended to the level of inferior fascia of the urogenital diaphragm .”

19. STAGE II Vulvar cancer
 Standard therapy : Modified radical vulvectomy with bilateral
inguinal and femoral lymphadenectomy
(Target : tumor free margins of at least 1 cm)
 Adjuvant local radiation therapy may be indicated for surgical
margins less than 8 mm, and particularly if the patient also has
positive nodes

20. STAGE III Vulvar cancer
 Modified radical vulvectomy with inguinal and femoral
node dissection.
 Radical vulvectomy with inguinal and femoral node
dissection
 followed by radiation therapy

21. STAGE IV Vulvar cancer
 Radical vulvectomy and pelvic exenteration (if resectable).

22. A phase II trial of radiation therapy and weekly cisplatin chemotherapy for
the treatment of locally-advanced squamous cell carcinoma of the vulva: a
gynecologic oncology group study.
Moore DH, Ali S, Koh WJ, Michael H, Barnes MN, McCourt CK, Homesley HD, Walker JL
Gynecol Oncol. 2012 Mar;124(3):529-33. Epub 2011 Nov 9
 OBJECTIVES:
 To determine the efficacy and toxicity of radiation therapy and concurrent weekly cisplatin chemotherapy in achieving a
complete clinical and pathologic response when used for the primary treatment of locally-advanced vulvar carcinoma.
 METHODS:
 Patients with locally-advanced (T3 or T4 tumors not amenable to surgical resection via radical vulvectomy), previously
untreated squamous cell carcinoma of the vulva were treated with radiation (1.8 Gy daily × 32 fractions=57.6 Gy) plus weekly
cisplatin (40 mg/m(2)) followed by surgical resection of residual tumor (or biopsy to confirm complete clinical response).
Management of the groin lymph nodes was standardized and was not a statistical endpoint. Primary endpoints were complete
clinical and pathologic response rates of the primary vulvar tumor.
 RESULTS:
 A planned interim analysis indicated sufficient activity to reopen the study to a second stage of accrual. Among 58 evaluable
patients, there were 40 (69%) who completed study treatment. Reasons for prematurely discontinuing treatment included:
patient refusal (N=4), toxicity (N=9), death (N=2), other (N=3). There were 37 patients with a complete clinical response (37/58;
64%). Among these women there were 34 who underwent surgical biopsy and 29 (78%) who also had a complete pathological
response. Common adverse effects included leukopenia, pain, radiation dermatitis, pain, or metabolic changes.
 CONCLUSIONS:
 This combination of radiation therapy plus weekly cisplatin successfully yielded high complete clinical and pathologic
response rates with acceptable toxicity

23. Management of vulvar cancer with peri-urethral
involvement
 Needs removal of outer urethra
 Foley’s catheter for one week postoperatively facilitate healing and
splinting of the urethra
 If >1 cm of urethra removed or any preoperative stress urinary
incontinence – consider surgical anti-incontinence procedure.

24. Management of vulvar cancer with perianal
involvement
 Difficult to obtain adequate surgical margin on resection
 Difficult to decide b/w radical excision and colostomy or
preoperative radiotherapy

25. Measures to minimize incontinence : ( rarely needed )
 Sphincter approximation and levator muscle plication
 Bowel preparation, prophylactic antibiotics ,post-operative bowel
management
 Use of cutaneous rhomboid flaps in reconstruction of perineum and
perianal areas

26. MANAGEMENT OF REGIONAL LYMPH NODES
 Appropriate groin dissection – single most important factor in
decreasing mortality in early vulvar cancer
 Virtually no risk of lymph node metastasis if stromal invasion < 1
mm therefore one can omit groin dissection if invasion < 1mm ,no
lympho-vascular space invasion and no clinically suspicious groin
lymph node
 Depending on laterality of vulvar lesion- ipsilateral or bilateral
lymphadenectomy becomes necessary
 Recurrence in undissected groin > 90% mortality

27.  All patient whose tumors demonstrate more than
 >1mm of stromal invasion
 Or whose tumors are >2cm (T1b and above )
Require inguinal- femoral lymphadenectomy

28.  If Groin dissection is indicated in patients with vulvar cancer, it
should be a thorough inguinal- femoral Lymphadenectomy.
 UNILATERAL GROIN DISSECTION:
 if the primary lesion is unilateral and
 ipsilateral nodes are negative.
 Recommended that patients with any bulky or multiple
microscopically positive ipsilateral lymph nodes should undergo
contralateral inguinal – femoral lymphadenectomy.
 Bilateral inguinal-femoral lymphadenectomy be performed for
 Midline lesions
 Those with in 2 cm from midline

29.  If Pre-operative pelvic imaging reveals bulky pelvic
lymph nodes
 Resection via extra-peritoneal approach prior to radiation(
limited ability of external beam radiation therapy to
sterilize bulky positive pelvic nodes)

45. Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with
vulvar carcinoma.
Gynecol Oncol. 2006 Apr;101(1):140-2. Epub 2005 Dec 20
Dardarian TS, Gray HJ, Morgan MA, Rubin SC, Randall TC
 OBJECTIVES:
 To compare short- and long-term morbidity associated with saphenous vein sparing versus ligation during inguinal
lymphadenectomy for vulvar carcinoma.
 METHODS:
 A retrospective evaluation of patients with carcinoma of the vulva that underwent inguinal lymphadenectomy was performed.
Operative reports were evaluated and patients were divided into those who had sparing of the saphenous vein versus ligation.
Postoperative short- and long-term complications were compared between the two groups using Pearson chi squared analysis.
 RESULTS:
 There were a total of 49 inguinal lymphadenectomies performed on 29 patients. The saphenous vein was spared in 18 (37%)
groin dissections compared to 31(63%) in which the saphenous vein was ligated. The two groups were similar in regards to
clinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodes
dissected was similar. Cellulitis was more common in the vein-ligated group compared to the vein-spared group (45% vs. 0%;
P < 0.001). Wound breakdown occurred in 25% of dissections where the saphenous vein was ligated versus 0% in dissections
where the vein was spared (P = or < 0.02). Short-term edema (< or = 6 months) was similar between vein-ligated and vein-
spared groups (67% vs. 72%, P < 1.0). Subsequently, chronic lymphedema (> 6 months) persisted in 38% of the vein-ligated
group compared to 11% in the vein-spared group (P < 0.05). The incidence of recurrent disease was similar in both groups
(19.3 % vs. 22.2% P < 0.1).
 CONCLUSIONS:
 Routine preservation of the saphenous vein during inguinal lymphadenectomy for vulvar carcinoma may reduce the incidence
of wound cellulitis, wound breakdown, and chronic lymphedema.

46. Sparing of saphenous vein during inguinal lymphadenectomy for vulval malignancies.
Zhang X, Sheng X, Niu J, Li H, Li D, Tang L, Li Q, Li Q.
Gynecol Oncol. 2007 Jun;105(3):722-6. Epub 2007 Apr 3
 Abstract
 OBJECTIVE:
 This work was set out to investigate the effect of saphenous vein preservation during inguinal lymphadenectomy for patients with vulval malignancies.
 METHODS:
 64 patients with vulval malignancies were allocated into two groups depending on their clinical stages, with one of them (31 patients included) being
subjected to sparing of saphenous vein and the other to saphenous vein ligated surgery while treated with inguinal lymphadenectomy. The operative
time, blood loss, 5-year survival rate, short- and long-term postoperative complications, 5-year survival rate and groin recurrence were selected as the
monitored parameters, through which the above two groups were compared with each other using t test, chi2 and life table analysis.
 RESULTS:
 (1) The median operative time for bilateral inguinal lymphadenectomy was 155 min (130-170 min) in the sparing group, compared to 140 min (120-170
min) in the excision group (P>0.05). The median intraoperative blood loss was 295 mL (100-450 mL) in the sparing group, and 270 mL (150-390 mL)
in the excision group (P>0.05). (2) Short-term lower extremity lymphedema occurred with 27 patients (43.5%) in the sparing group and 44 patients
(66.7%) in the excision group (P<0.01). Still, short-term lower extremity phlebitis was observed with 7 patients (11.3%) in the sparing group while 17
developed phlebitis (25.8%) in the excision group (P<0.05). However, there was no statistical difference in postoperative fever, acute
cellulites, seroma, or lymphocyst formation. (3) Long-term complication occurrence rate decreased by about 50% in patients subjected to saphenous
vein sparing surgery compared with those to ligated surgery, while there was no remarkable difference between two groups in the occurrence rates of
phlebitis and deep venous thrombosis (P>0.05). (4) The overall 5-year survival rate was 67.3%, with 66.7% and 68.0% for the excision group and the
sparing group, respectively (P>0.05).
 CONCLUSION:
 The application of saphenous vein preservation technique during inguinal lymphadenectomy for patients with vulval malignancies could
significantly decrease the occurrence rate of postoperative complications without compromising outcomes and should be widely put into
clinical practice.

47. SENTINEL LYMPHNODE MAPPING

48.  First draining lymph-node in the lymphatic basin that recieves primary
lymph flow from the tumor.
 Use of comprehensive serial sectioning, Immunohistochemistry (IHC), and
reverse transcription-polymerase chain reaction have been investigated as
potential methods to detect the earliest signs of metastatic disease.

49. PROCEDURE
 1-2mlof isosulfan blue dye or 400mCi of technetium labeled sulfur
colloid injected circumferentially intradermally around the
tumor, and lymphoscintigraphy was performed.
 The sites of the SLNs marked on the skin with a pencil.
 SLNs identified using a handheld probe and the dissection of blue-
stained lymph vessels and lymph nodes.

50.  Intra operative gamma counter to identify for identification of the
nodes and lymphatics.
 The removed SLNs sent to the pathologist separately.
 Ultrastaging consisted of performing serial sectioning and IHC
analysis with cytokeratins.

51. Studies in vulvar cancer in which SLN detection was
followed by a completion inguino-femoral lymphadenectomy
suggest that the SLN procedure is highly accurate in
identifying lymph node metastases with an NPV approaching
100%

52. STUDIES Details
GROINSS-V 403patients 3% groin recurrences
26% metastatic sentinel
nodes
GOG-173 452 women underwent the 132 node-positive women
planned procedures, 11 (8.3%) with false-
418 had at least one negative
sentinel lymph 23% true positive detected
by IHC
sensitivity was 91.7%
False-negative predictive
value 3.7%
Sentinel lymph node biopsy is a reasonable alternative to inguinal femoral
lymphadenectomy in
selected women with squamous cell carcinoma of the vulva.

53.  Reliance on the SLN is dependent on
 accurate injection of the blue dye and/or radioisotope,
 interpretation of the preoperative lymphoscintigraphy, and
 proper handling of the node by the pathologist, including serial sectioning and IHC analysis.
 Implementation in the routine treatment of early-stage vulvar cancer requires quality control
at each step of this multidisciplinary procedure.
 Learning curve associated with the SLN procedure
 Success of the procedure is surgeon dependent (requires a surgeon with successful experience
SLN procedure followed by full lymphadenectomy in at least 10 patients.) Finally, to keep the
experience at a high level, an exposure of at least 5–10 SLN procedures per year per surgeon
is likely necessary.
 In a rare tumor such as vulvar cancer, this requires centralization of early stage vulvar cancer
treatment in oncology centers

54. Reconstruction of surgical defects
 Gluteus maximus myocutaneous flaps
 Rectus abdominis myocutaneous flap

55.  Tensor fascia lata myocutaneous graft – for extensive
defect in groin and vulva.

56.  Rhomboid flap – best suited for posterior vulva.

57.  Mons pubis pedicle flap – for lateral defects.
 Unilateral or bilateral Gracilis myocutaneous grafts - when
extensive resection done from mons to perianal region.

58. Post-operative Management
 Prophylactic antibiotics for 24 hrs
 Ambulation delayed - If wounds are closed under tension
 Meticulous perineal hygiene
 Measures to keep the area dry and clean
 Continue suction drainage of groin till output is minimal to avoid
groin seromas
 Heparin thrombo-prophylaxis until ambulatory
 Pneumatic calf compressions

59.  A compression dressing (rolled gauze and an abdominal binder) is
maintained on the groins for an additional 24 to 48 hours to prevent
lymphocyst formation
 Foley’s catheter till patient ambulatory ( may be required for prolonged
periods if significant peri-urethral swelling )
 Bowel rest - depending on the degree of perineal or perianal resection

61. Early complications
 Wound infection
 Wound breakdown
 Major break down occurs in about 14% patients
 With separate incision approach – reduced to 44%
 Lymphocysts or groin seromas ( 10 – 15% cases)
 small and asymptomatic - be left alone
 Repeated aspirations until resolution is most commonly recommended

62.  Femoral nerve injury – anesthesia of anterior thigh (resolves slowly)
 Urinary tract infection
 Seroma of femoral triangle
 DVT, Pulmonary embolism , hemorrhage, osteitis pubis

63. Late complications
 Depression, altered body image, sexual dysfunction
 major long term treatment complication
 Associated with the extent of vulvar surgery
 RX : modification of radical extent of surgery and preoperative and post operative
counselling
 Chronic lymphedema (30%)
 reported in 10-20% of women after groin node dissection
 Can be a disabling problem
 More common if radiation is required after groin dissection
 Limiting groin node dissection in women with early cancers and
preserving the saphenous vein decreases the incidence of this problem

64. Use of graduated compression stockings after lymphadenectomy can
help prevent lymphedema
Mx :
 Intermittent limb elevation
 Manual lymphatic drainage(massage combined with bandaging )
 moderate exercise program
 carefully fitting compression stockings
 pneumatic compression devices

65.  Recurrent lymphangitis and cellulitis of leg (10%)
 Dyspareunia – due to Introital stenosis
 Urinary stress incontinence (with or without genital prolapse)
 Femoral hernia
 Pubic osteomyelitis
 Recto vaginal or recto perineal fistulas

66. Survival
Five – Year Survival with Vulvar carcinoma
FIGO Stage 5- Year survival ( % )
I 79
II 59
III 43
IV 13
Modified from FIGO Annual report on the results of treatment in Gynecological
Cancer using 1994 FIGO staging classification

67. RADIOTHERAPY
 Alone has a little role in the primary management, generally
indicated in conjunction with surgery
 PRE- OPERATIVELY : patients with advanced disease who would
otherwise require pelvic exenteration or suffer loss of anal or
urethral sphincteric function
 POST- OPERATIVELY : to treat the pelvic lymph nodes and groin
of patients with two or more microscopically positive or one grossly
positive groin node.

68. Possible roles
 To prevent local recurrences in patients with involved or close
surgical margins
 Primary therapy for patients with small primary tumors, particularly
clitoral or peri-clitoral lesions in young and middle-aged women

69.  The benefit of adjuvant postoperative radiotherapy is much more
evident
 if there is gross replacement or extra-capsular involvement of a
lymph node, or
 involvement of three or more lymph nodes,
(the risk of groin recurrence and pelvic nodal metastases is substantial)

70. CHEMOTHERAPY
 The likely uses of chemotherapy in vulval cancer
 as a neo-adjuvant to shrink tumour initially considered unresectable
 as a concomitant to radiation for primary management of unresectable
tumours
 as a postoperative adjuvant treatment either alone or concomitant to
radiation for the management of relapsed disease.

71.  Most extensively studied regimens : Bleomycin, methotrexate and
cisplatin
 Others – 5FU, mitomycin-C
 A trial from European Organization for Research and Treatment of
Cancer (EORTC)in the late 1980s evaluated the use of lomustine
(CCNU), methotrexate and bleomycin in locally advanced cases with
a surprisingly high activity

72. RECURRENCES
 15 – 40% have recurrences
 70% have local component
 55 – 90% isolated local recurrences
 Isolated local recurrences commonest with neg. lymph nodes
in groins
 Recurrence site – strongest predictor of outcome
 Groin recurrence occur sooner than vulvar recurrence ( median
time : 6 months / 3 yrs )

73.  Margin status at the time of radical resection : most powerful
indicator of local recurrence ; however it doesn’t predict
survival
 The long-term survival rate after radical excision of a vulvar
recurrence has been reported as 50-60%
 Disease at sites other than the vulva and a short interval from
initial treatment to recurrence diminish the cure rate after local
recurrence .
 For a large recurrence, an exenterative procedure can be
attempted

74.  Resection of a groin recurrence is not usually recommended.
Often, this area heals slowly if radiation has already been used.
 The only situation in which resection of a groin node recurrence
should be attempted is if the groin node is an isolated recurrence and
the patient has not been previously irradiated

75. “JUST TO SUMMARIZE”
 Vulvar cancer is surgically staged.
 Imaging such as CT of the abdomen and pelvis should be
performed for women with tumors 2 cm or larger or to detect
lymph node or other metastases.
 Staging should include evaluation of factors related to
prognosis: tumor size, depth of invasion, lymph node
involvement, and presence of distant metastases.

76.  Inguino-femoral lymph node metastasis is the most important
predictor of overall prognosis.
 Inguino-femoral lymphadenectomy or sentinel lymph node
evaluation can be omitted for lesions 2 cm or smaller and depth
of invasion less than 1 mm.
 Sentinel node biopsy seems to be a reliable means to
pathologically assess inguino-femoral lymph node metastasis

77.  All tumors larger than 2 cm require pathologic inguino-femoral
lymph node evaluation.
 Radical local excision or modified radical vulvectomy is
appropriate for most stage I and II lesions located on the lateral
or posterior aspects of the vulva.
 A tumor-free surgical margin of at least 1 cm decreases the risk
of local recurrence.
 Chemo-radiation therapy is the preferred approach for most
patients with very advanced vulvar cancer