1.DR. N. SRAVANTHIDR. NEHADR. S. C. SAHA 8/8/2012

2. Pre- treatment work up A thorough pre- operative evaluation for coexisting medicalproblems Routine investigations and Chest radiograph PAP smear and colposcopy of cervix and vagina. Imaging : CT and MRI may help to determine resectability andtreatment planning, and distant metastases Cystoscopy, intravenous pyelography, or proctoscopy (or all three) isindicated if it appears that locally advanced cancer 3. . SURGERY. RADIATION. CHEMOTHERAPY 4. Standard treatment in the past : Radical vulvectomy and enbloc groin dissection ( Taussig and Way) Involves radical removal of the entire vulva, the monspubis, the inguino-femoral lymph nodes, and often the pelviclymph nodes. 5. 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 6. During the past 20 years, a number of significant advances havebeen made in the management of vulvar cancer, reflecting aparadigm shift toward a more conservative surgical approachwithout compromised survival and with markedly decreasedphysical and psychological morbidity Individualization of treatment for all patients with invasive disease Vulvar conservation for patients with unifocal tumors and an otherwise normal vulva 7. Omission of the groin dissection for patients with T1 tumorsand, 80% POSITIVE90%. Choice of treatment depends on various tumor and patient factors.Micro-invasive lesions (2cm with 1 cm of urethra removed or any preoperative stress urinaryincontinence consider surgical anti-incontinence procedure. 21. Management of vulvar cancer with perianalinvolvement Difficult to obtain adequate surgical margin on resection Difficult to decide b/w radical excision and colostomy orpreoperative radiotherapy 22. Measures to minimize incontinence : ( rarely needed ) Sphincter approximation and levator muscle plication Bowel preparation, prophylactic antibiotics ,post-operative bowelmanagement Use of cutaneous rhomboid flaps in reconstruction of perineum andperianal areas 23. MANAGEMENT OF REGIONAL LYMPH NODES Appropriate groin dissection single most important factor indecreasing mortality in early vulvar cancer Virtually no risk of lymph node metastasis if stromal invasion < 1mm therefore one can omit groin dissection if invasion < 1mm ,nolympho-vascular space invasion and no clinically suspicious groinlymph node Depending on laterality of vulvar lesion- ipsilateral or bilaterallymphadenectomy becomes necessary Recurrence in undissected groin > 90% mortality 24. All patient whose tumors demonstrate more than >1mm of stromal invasion Or whose tumors are >2cm (T1b and above ) Require inguinal- femoral lymphadenectomy 25. If Groin dissection is indicated in patients with vulvar cancer, itshould 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 multiplemicroscopically positive ipsilateral lymph nodes should undergocontralateral inguinal femoral lymphadenectomy. Bilateral inguinal-femoral lymphadenectomy be performed for Midline lesions Those with in 2 cm from midline 26. If Pre-operative pelvic imaging reveals bulky pelviclymph nodes Resection via extra-peritoneal approach prior to radiation(limited ability of external beam radiation therapy tosterilize bulky positive pelvic nodes) 27. Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients withvulvar carcinoma.Gynecol Oncol. 2006 Apr;101(1):140-2. Epub 2005 Dec 20Dardarian 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 inguinallymphadenectomy 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 toclinical characteristics. All patients received closed suction drains and prophylactic antibiotics. Median number of nodesdissected 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 dissectionswhere 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-ligatedgroup 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 incidenceof wound cellulitis, wound breakdown, and chronic lymphedema. 28. 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 (P0.05). 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. 29. SENTINEL LYMPHNODE MAPPING 30. First draining lymph-node in the lymphatic basin that recieves primarylymph flow from the tumor. Use of comprehensive serial sectioning, Immunohistochemistry (IHC), andreverse transcription-polymerase chain reaction have been investigated aspotential methods to detect the earliest signs of metastatic disease. 31. PROCEDURE 1-2mlof isosulfan blue dye or 400mCi of technetium labeled sulfurcolloid injected circumferentially intradermally around thetumor, 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. 32. Intra operative gamma counter to identify for identification of thenodes and lymphatics. The removed SLNs sent to the pathologist separately. Ultrastaging consisted of performing serial sectioning and IHCanalysis with cytokeratins. 33. Studies in vulvar cancer in which SLN detection wasfollowed by a completion inguino-femoral lymphadenectomysuggest that the SLN procedure is highly accurate inidentifying lymph node metastases with an NPV approaching100% 34. STUDIESDetailsGROINSS-V 403patients 3% groin recurrences26% metastatic sentinel nodes GOG-173 452 women underwent the132 node-positive womenplanned procedures,11 (8.3%) with false-418 had at least one negative sentinel lymph 23% true positive detectedby IHCsensitivity was 91.7% False-negative predictivevalue 3.7%Sentinel lymph node biopsy is a reasonable alternative to inguinal femorallymphadenectomy inselected women with squamous cell carcinoma of the vulva. 35. 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 510 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 36. Reconstruction of surgical defects Gluteus maximus myocutaneous flaps Rectus abdominis myocutaneous flap 37. Tensor fascia lata myocutaneous graft for extensive defect in groin and vulva. 38. Rhomboid flap best suited for posterior vulva. 39. Mons pubis pedicle flap for lateral defects. Unilateral or bilateral Gracilis myocutaneous grafts - whenextensive resection done from mons to perianal region. 40. 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 avoidgroin seromas Heparin thrombo-prophylaxis until ambulatory Pneumatic calf compressions 41. A compression dressing (rolled gauze and an abdominal binder) ismaintained on the groins for an additional 24 to 48 hours to preventlymphocyst formation Foleys catheter till patient ambulatory ( may be required for prolongedperiods if significant peri-urethral swelling ) Bowel rest - depending on the degree of perineal or perianal resection 42. 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 43. Femoral nerve injury anesthesia of anterior thigh (resolves slowly) Urinary tract infection Seroma of femoral triangle DVT, Pulmonary embolism , hemorrhage, osteitis pubis 44. 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 operativecounselling 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 andpreserving the saphenous vein decreases the incidence of this problem 45. Use of graduated compression stockings after lymphadenectomy canhelp prevent lymphedemaMx : Intermittent limb elevation Manual lymphatic drainage(massage combined with bandaging ) moderate exercise program carefully fitting compression stockings pneumatic compression devices 46. 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 47. Survival Five Year Survival with Vulvar carcinomaFIGO Stage 5- Year survival ( % ) I79 II 59III 43IV13Modified from FIGO Annual report on the results of treatment in Gynecological Cancer using 1994 FIGO staging classification 48. RADIOTHERAPY Alone has a little role in the primary management, generallyindicated in conjunction with surgery PRE- OPERATIVELY : patients with advanced disease who wouldotherwise require pelvic exenteration or suffer loss of anal orurethral sphincteric function POST- OPERATIVELY : to treat the pelvic lymph nodes and groinof patients with two or more microscopically positive or one grosslypositive groin node. 49. Possible roles To prevent local recurrences in patients with involved or closesurgical margins Primary therapy for patients with small primary tumors, particularlyclitoral or peri-clitoral lesions in young and middle-aged women 50. The benefit of adjuvant postoperative radiotherapy is much moreevident 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) 51. 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 unresectabletumours as a postoperative adjuvant treatment either alone or concomitant toradiation for the management of relapsed disease. 52. Most extensively studied regimens : Bleomycin, methotrexate andcisplatin Others 5FU, mitomycin-C A trial from European Organization for Research and Treatment ofCancer (EORTC)in the late 1980s evaluated the use of lomustine(CCNU), methotrexate and bleomycin in locally advanced cases witha surprisingly high activity 53. RECURRENCES 15 40% have recurrences 70% have local component 55 90% isolated local recurrences Isolated local recurrences commonest with neg. lymph nodesin groins Recurrence site strongest predictor of outcome Groin recurrence occur sooner than vulvar recurrence ( mediantime : 6 months / 3 yrs ) 54. Margin status at the time of radical resection : most powerfulindicator of local recurrence ; however it doesnt predictsurvival The long-term survival rate after radical excision of a vulvarrecurrence has been reported as 50-60% Disease at sites other than the vulva and a short interval frominitial treatment to recurrence diminish the cure rate after localrecurrence . For a large recurrence, an exenterative procedure can beattempted 55. 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 recurrenceshould be attempted is if the groin node is an isolated recurrence andthe patient has not been previously irradiated 56. JUST TO SUMMARIZE Vulvar cancer is surgically staged. Imaging such as CT of the abdomen and pelvis should beperformed for women with tumors 2 cm or larger or to detectlymph node or other metastases. Staging should include evaluation of factors related toprognosis: tumor size, depth of invasion, lymph nodeinvolvement, and presence of distant metastases. 57. Inguino-femoral lymph node metastasis is the most importantpredictor of overall prognosis. Inguino-femoral lymphadenectomy or sentinel lymph nodeevaluation can be omitted for lesions 2 cm or smaller and depthof invasion less than 1 mm. Sentinel node biopsy seems to be a reliable means topathologically assess inguino-femoral lymph node metastasis 58. All tumors larger than 2 cm require pathologic inguino-femorallymph node evaluation. Radical local excision or modified radical vulvectomy isappropriate for most stage I and II lesions located on the lateralor posterior aspects of the vulva. A tumor-free surgical margin of at least 1 cm decreases the riskof local recurrence. Chemo-radiation therapy is the preferred approach for mostpatients with very advanced vulvar cancer