Management of carcinoma of Vulva

1. Planning Meet
VULVAR CANCER
Dr. Shreya Singh
JR-III
Department of Radiation Oncology
IMS, BHU
1

2. Epidemiology
• Vulvar cancer is a rare malignancy
• Represents < 1% of all the cancers diagnosed
in women and < 5% of all gynecologic
neoplasms
• More common with increasing age ; Median
age – 68 years
2

3. Risk Factors
• Older age
• Precancerous changes (dysplasia) in vulvar tissues
• Lichen sclerosus, which causes persistent itching and scarring of the
vulva
• Human papillomavirus (HPV) infection
• Cancer of the vagina or cervix
• Heavy cigarette smoking
• Chronic granulomatous disease (a hereditary disease that impairs the
immune system)
3

4. Pathogenesis
• Two primary mechanisms involved in the
carcinogenesis:
– Human papillomavirus (16, 18, and 33)
– Vulvar dystrophy, including lichen sclerosus (LS)
and squamous hyperplasia
• Usual-type VIN (uVIN) is often HPV driven and occurs
in younger women with HPV risk factors
• Differentiated-type VIN (dVIN) arises in the setting of
LS and other chronic inflammatory processes and is
associated with older age
4

5. Pathogenesis
• The differing precursor lesions may transform
into two distinct classifications of squamous
carcinoma:
 Keratinizing squamous carcinomas (KSCs) arising
from dVIN
 Basaloid squamous carcinomas (BSCs) arising
from uVIN
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6. Pattern of Spread
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7. Lymphatic Spread
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8. Distant Metastasis
• Hematogenous dissemination generally occurs
late in the natural history of the disease
• The most common sites are-
Lungs
Liver
Bones
• Overall survival is limited in these cases to a
median of approximately 6 months
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9. Staging of Vulvar Cancer
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10. Stage I Vulvar Cancer
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11. Stage II Vulvar Cancer
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12. Stage III Vulvar Cancer
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13. Stage IV Vulvar Cancer
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14. 5-Year Survival
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16. Evaluation
• Clinical history
• Examination of the vagina, cervix, perianal skin,
and anal canal - to delineate the extent of disease
and to identify synchronous lesions
• Examination of inguinofemoral basins for clinical
detection of lymphatic spread
• Complete blood cell count
• Blood chemistry
• Biopsy
16

17. Imaging
Imaging in locally advanced disease –
• Cystoscopy
• CECT - suspicious lymphadenopathy in the inguinofemoral,
pelvis, or para-aortic regions
• MRI - to delineate the primary lesion and evaluation of
inguinal lymph node
• PET - to evaluate the groin prior to surgical evaluation
Sensitivities of all imaging modalities available are
insufficient to omit surgical evaluation in women with
a high risk of nodal involvement
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18. Treatment
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22. Surgery
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23. Surgery
• In tumors clinically confined to the vulva or perineum, radical
local excision with a margin of at least 1 cm has replaced
radical vulvectomy
• Separate incision has replaced en bloc inguinal node
dissection
• Ipsilateral inguinal node dissection is preferred over bilateral
dissection for laterally localized tumors
• Lymph node dissection has been omitted in many cases by
employing Sentinel Lymph Node Biopsy
23

24. Surgery In Locally Advanced Cases
• Radical vulvectomy is reserved for patients with large
or multifocal lesions in whom preservation of normal
vulvar tissue is not possible or would not serve a
functional or reconstructive benefit
• When the anus, vagina, or urethra is involved by
malignancy, extended radical vulvectomy or pelvic
exenteration is required to clear the disease
surgically
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25. • Adjuvant Radiotherapy
• Definitive Radiotherapy
• Neo-adjuvant Radiotherapy
• Palliative Radiotherapy
Radiotherapy
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26. Adjuvant Radiotherapy
• In the setting of early invasive disease treated with wide local
excision, radiation to the tumor bed may be advised to
prevent local recurrence
• Indications for adjuvant RT to the primary site include-
 Lymphatic–vascular invasion (LVI)
Depth of invasion >5 mm
Margins <8 mm
Microscopically positive margins
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27. Adjuvant RT to Inguinal and Pelvic Nodes
• All women with ECE of tumor in the nodes or with residual
disease in the inguinal areas should receive postoperative RT
to the pelvis and inguinal areas
• There are consensus to support adjuvant radiation to the
pelvis and both groins for all patients with nodal involvement
27

28. Dose
• The elective volume (grossly uninvolved nodal basins) can be
treated to 45 to 50.4 Gy
• When microscopic disease in the primary tumor area is
suspected, a dose of 55 Gy is recommended
• When there is ECE of tumor in the lymph nodes, the dose to
the groins can be carried up to 60 Gy
• If there is gross residual disease post surgery, the dose to the
area should be brought to a minimum of 65 to 70 Gy, a dose
used for definitive therapy.
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29. Neo-Adjuvant Radiotherapy
• Given with the goals of decreasing the sequelae of radical
surgery and to maximize functional outcome
• After initial concurrent chemoradiation and healing of the
reaction, the response to the therapy at the primary site and
the lymph nodes is assessed
• If there is complete clinical regression of the disease,
resection may be omitted for negative biopsies from primary
site with groin dissection
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30. Dose
• Dose to primary and gross nodal disease-
 Upto 55.8 to 59.4 Gy with 1.8 Gy daily fraction
• Dose to elective nodal sites-
 45 to 50.4 Gy with 1.8 Gy daily fraction
• With or without concurrent chemotherapy
• Surgery is performed for any residual disease 6 to
8 weeks post treatment
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31. Definitive Radiotherapy
• In locally advanced disease with-
– Anorectal, urethral, or bladder involvement (in an effort to
avoid colostomy and urostomy)
– Disease that is fixed to the bone
– Gross inguinal or femoral node involvement (regardless of
whether a debulking lymphadenectomy was performed)
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32. Dose :
• With appropriate field reductions, radiation dose should be brought
up to 60 to 70 Gy
• Total dose to certain areas is dependent upon location and extent
of the disease, response to therapy, and estimated tolerance of the
area requiring the high radiation dose
• Often, tolerance of normal tissue limits the dose to ≤65 Gy
• Chemotherapy should be continued throughout the entire course
of radiation for radiosensitization
Weekly Cisplatin @ 40 mg/m2
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33. RT Planning
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34. CT Simulation
• Oral contrast
• Bladder protocol
• Frog leg position in a vacuum-
evacuated device
• Hands over chest
• Fiducials
• IV contrast
• Customised bolus of 0.5 cm
thickness for the vulvar region at
simulation
• Images taken from L2 to mid thigh
with slice thickness of 3 mm
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35. Contouring
Target Volume :
Entire Vulva / Post-op Bed
B/L Inguinofemoral nodes
Pelvic lymph nodes
Consensus recommendations for radiotherapy contouring and treatment
of vulvar carcinoma David K. Gaffney
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36. GTV + CTV Primary
• GTV :
All gross disease on physical examination and imaging (see above
regarding the importance of PET-CT and MRI)
• CTV Primary :
 GTV + 1 cm including the entire vulva; exclude uninvolved bone,
muscle, and adjacent organs
 Include entire vagina if vaginal involvement and generate ITV for full
and empty bladder if feasible
 Include 2 cm of urethra proximal to primary GTV for anterior
periurethral lesion or to the bladder neck if extensive urethral
involvement
 Include a 1–2 cm margin if anal verge is involved or the entire
mesorectum if anal canal involvement
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37. GTV + CTV Primary
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38. CTV Inguinal Node
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39. CTV Pelvic Node
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40. CTV Total
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41. CTV Total to PTV Total
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42. OARs
• Bladder
• Bowel Bag
• Rectum
• Head of femur
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43. 3D-CRT Planning
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44. Wide anterior and Wide Posterior Field
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45. Dmax Femoral Head = 56.17 Gy
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46. 3D-CRT Planning
• Solutions :
 Wide anterior field, narrow posterior field, anterior electron
field
 Narrow anterior and Narrow posterior field and anterior
electron field
 Wide anterior, Narrow posterior, and anterior inguinal
photon fields
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47. Wide Anterior Field, Narrow Posterior
Field, Anterior Electron Field
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48. Narrow Anterior and Narrow Posterior
Field and Anterior Electron Field
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49. Wide Anterior, Narrow Posterior, and
Anterior Inguinal Photon Fields
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50. Challenges with 3DCRT technique
• Abutting photon-electron fields at the groin result in
significant hotspots and dose inhomogeneity at the match
line, which contribute to patient morbidity
• The depth of inguinal node necessitates the use of high
energy electron that result in severe skin reaction
• The irradiation of large volumes of normal tissue, especially
small bowel exposes patients to treatment related toxicities
and limits the total deliverable dose
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51. IMRT
• Often used to treat the pelvis and inguinal nodes
• Careful quality assurance is required when using IMRT
• In particular, care should be placed to ensure that the surface
of the vulvar tumor receives adequate dose
• Virtual Flash –
 During treatment planning, the PTV is expanded out of the skin by 1 to
2 cm, with additional placement of virtual tissue equivalent to allow
for dose buildup
 This protects against underdosing the tumor surface if there is
displacement of the patient during treatment 51

52. IMRT
Dose constraints :
o Small bowel : V45 < 195 cc
o Rectum : V50 < 50%
o Bladder : Dmax < 65 Gy
o Femoral heads : <15 % to
receive > 35 Gy
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53. Conventional Radiotherapy
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54. • AP-PA fields with the patient in the supine position are
recommended for the delivery of external beam
• Depending on whether the inguinofemoral lymph nodes
and/or pelvic lymph nodes are to be included in the radiation
volume, different field configurations may be used
• Although there are no data regarding scar recurrences, it is
common practice to include the inguinal node dissection scars
in the radiation field
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55. Superior Border-
 middle of the sacroiliac joints to cover the external and internal iliac
nodes
 If a patient has internal or external iliac node involvement, the
superior border should be extended to the L3/L4 interspace
Inferior Border –
 Should cover the entire vulva and the most superficial, inferior
inguinal nodes
Lateral Border -
 Posterior field : The pelvic field extends 2 cm laterally to the widest
point of the pelvic inlet
 Anterior field : The pelvic field extend laterally to lateral edge of lesser
trochnter
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56. Treatment borders demonstrating the wide anterior field (outer
border) and the narrow posterior field (shaded region)
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57. Portal for irradiation of pelvic and inguinofemoral lymph nodes
and vulvar area
A final boost to the positive inguinal lymph nodes may be given
with a reduced field
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58. Brachytherapy
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59. Brachytherapy
• Brachytherapy has been used for inoperable vulvar cancer,
disease recurrence and as a boost to the primary tumor
• Advocated for primary vulvar cancer if the patient refuses
surgery or if surgery is contraindicated
• Because of the significant risk of necrosis, the use of
brachytherapy should be limited to very selected cases and
performed by experienced practitioners
59

60. Procedure
• Patient hospitalized a day before the procedure for parts and
bowel preparation
• Procedure performed under spinal or general anesthesia with
patient placed in a lithotomy position
• After thorough clinical examination under anesthesia and
mapping of disease, radioopaque silver markers are implanted
to assist delineation of tumor on planning imaging
• BT procedure involves insertion of plastic catheters or bevel-
edged stainless-steel hollow rigid needles into the vulvar
tissues with safety margin
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61. Procedure
• Implantation techniques are guided by the Paris
system rules in terms of spacing and margins
accounting for the tumor size in all three
dimensions
• Usually, free-hand implant is done to treat the
superficial vulvar lesions while template-based
straight or curved needles are employed for
treatment of deep vulvar lesions extending into
vagina
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62. Interstitial Implant
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63. Treatment Planning
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64. • Organs at risk –
 Urethra
 Bladder
 Rectum
• Dose –
 Definitive :
o 3.5 to 4 Gy per fraction
o 10 to 13 fractions atleast 6 hours apart
o EQD2 of 30 to 40 Gy
 Boost :
o 3.5 to 4 Gy per fraction
o 4 to 5 fractions atleast 6 hours apart
o EQD2 of 16 to 20 Gy
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65. Sequelae of Treatment
ACUTE -
• Muco-cutaneous reaction
• Wound infection and hematoma
• Hematological toxicity
• Deep vein thrombosis
• Osteitis pubis
• Sensory loss in thigh (Femoral nerve injury)
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66. Sequelae of Treatment
CHRONIC –
• Avascular vulvar necrosis
• Edema of lower extremeties
• Chronic cellulitis of inguinal area
• Introitus stenosis
• Recto-vaginal or recto-perineal fistula
• Psycho-sexual dysfunction
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