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VWOG richtlijn vulvacarcinoom Herfst symposiumVVOG Kinepolis Brugge

VWOG richtlijn vulvacarcinoom Herfst symposiumVVOG Kinepolis Brugge. Frédéric Amant Namens VWOG bestuur. Tissue is the issue!. Vulvar intraepithelial disease Squamous cell carcinoma (90%) Verrucoid cancer Basal cell ca Adenocarcinoma Paget’s disease

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VWOG richtlijn vulvacarcinoom Herfst symposiumVVOG Kinepolis Brugge

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  1. VWOG richtlijn vulvacarcinoomHerfst symposiumVVOGKinepolis Brugge Frédéric Amant Namens VWOG bestuur

  2. Tissue is the issue! • Vulvar intraepithelial disease • Squamous cell carcinoma (90%) • Verrucoid cancer • Basal cell ca • Adenocarcinoma • Paget’s disease • Bartholin gland carcinoma (40% squamous) • Melanoma • Malignant mesenchymal tumors • Metastatic

  3. VIN III: Triad of three P’s: parakeratosis, pigment, papulae

  4. Vulvar Intraepithelial Neoplasia • Low grade VIN: subclinical HPV infection • High grade VIN: - moderate to severe dysplasia - undisputed malignant potential - 30-50% co-existence with vulvar ca - S/ no, pruritus, burning, pain, dysuria - R/ surgical excision (laser, cold knife)

  5. Diagnostic work-out • KO: operability & groin • Chest X-ray • CT abdomen, inclusive groin • SCC in blood • On indication: recto- en cystoscopy, CT-thorax

  6. Treatment modalities in vulvar cancer • Stage Ia(< 1mm depth of invasion  0% + inguin LN partial vulvectomy • Stage Ib-III (partial) vulvectomy inguinofemoral lymphadenectomy/ sentinel node procedure • Stage IVa exenteration/neoadjuvant CT/45-65Gy • Stage IVb palliation

  7. Total vulvectomy

  8. The price of less radical surgery • Surgical tumor-free margin • > 8 mm: no vulvar recurrence, n=91 • < 8 mm: 21/44 (48%) vulvar recurrence • Heaps et al., Gynecol Oncol 1990;38:309-14 • Surgical tumor-free margin • >8 mm: no vulvar recurrence, n=39 • < 8 mm: 9/40 (22.5%) vulvar recurrence • de Hullu et al., Cancer 2002;95:2331-8

  9. What is an adequate resection margin?Ibrahim et al., IGCS 2006, Santa Monica Abstract 36 • 15 consecutive patients • At least 10 mm clear margin macroscopically • Reduction of clear margin • 15% post resection • 15% tissue fixation • 15% microscopically • Totalling 45% reduction • 1 cm is insufficient as macroscopic margin

  10. Impact of partial (< 1.5 cm) urethral resectionde mooij et al., Int J Gynecol Cancer 2007;17:294-7

  11. M Pectineus m adductor longus M abdominis, sheet femoral artery and vein M sartorius

  12. Apex of the femoral triangle Femoral vein Sartorius muscle Femoral artery

  13. Ipsilateral superficial inguinal lymphadenectomyStehman et al., Obstet Gynecol 1992;79:490-7 • Prospective evaluation • N = 155 • 7.3% inguinal recurrence rate • Historical control: 0% inguinal recurrence rate Recurrence rate varies from 0-8.6%(Berman 1989; Stehman 1992; Burke 1995; Gordinier 2003; Kirby 2005) Number of recurrences attributable to decision to leave the femoral nodes

  14. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer: morbidityVan der Zee et al., JCO 2008;26:884-9

  15. Fig 2. (A) Cumulative proportion of groin recurrences in patients with unifocal vulvar cancer < 4 cm and negative sentinel node (dark blue line); 95% CIs are also given (light blue lines) 6/259 (2.3%) 97% 3y survival Van der Zee, A. G.J. et al. J Clin Oncol; 26:884-889 2008

  16. Sentinel node dissection is safe in the treatment of early-stage vulvar cancer: quality control at each stepVan der Zee et al., JCO 2008;26:884-9 • Injection of radioactive tracer • Interpretation of lymphoscintigram • Surgeon: 10 patients/year/surgeon • Pathology: experience with ultrastaging

  17. Patient met T1 of T2 (<4cm) vulvair carcinoom zonder verdachte liezen Metastase: volledige lymphadenectomie Radiologie (Ct of MR) om verdachte klieren te identificeren; zo verdacht echografie + fijne naald aspiratie Geen metastase Geen sentinel lymfeklier: technisch falen? Logistiek probleem? • Sentinel lymfeklier procedure met gecombineerde techniek (preoperatief lymphoscintigraphy met 99m Technetium gelabeld nanocolloid en patent blauw). • Verwijderde SLNs voor vriescoupe. • Intraoperatieve palpatie om vaste lymfeklieren te voelen. • Patholoog informeert gynaecoloog over aantal SLN’s. • Brede locale excisie. • In liezen met een positieve SLN bij vriescoupe een volledige inguinofemorale lymphadenectomie. • Bij problemen ter identificatie van de SLNs eerst verwijderen primaire tumor om radioactiviteit te verminderen en nadien de SLN’s • Definitieve pathologie: (micro) metastase in SLN(‘s): secundaire volledige lymphadenectomie. Ja: herhaal procedure Nee: volledige inguinofemorale lymphadenectomie Zo meer dan 1 intranodale metastase of extranodale groei: postoperatieve radiotherapie FOLLOW-UP Flow chart sentinelklierprocedurede Hullu et al., Gynecol Oncol 2004;94:10-5

  18. Vulvar > 4 cm Ø < 8 mm resection margin Significant lymfatic permeation Inguinofemoral Macrosc + nodes  2 microscopic nodes Indications for postop radiochemotherapy of the groin and ipsilateral hemipelvis

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