Anatomy & Management

1. CARCINOMA VAGINA

2. Anatomy

3. Lymphatic drainage

4. Epidemiology
• Rare malignancy
• 1-2% of all gynecological malignancies
• Diagnosis of exclusion
• Peak incidence- 6th and 7th decade
• Mean age- 65.7± 14.3 years

5. Vaginal intraepithelial neoplasia

6. Vaginal intraepithelial neoplasia
• Incidence- 0.2-0.3 cases per 1 lac population
• Peak incidence 40-60 years
• VAIN-1 and 2- common in younger age group than VAIN-3
Risk factors-
• Low sociocultural level
• H/O genital warts
• Prior history of hysterectomy
at any age
• H/O CIN
• Immunosuppression
• Smoking
• Exposure to DES
• H/O STDs or HPV infection
• Prior pelvic irradiation
(controversial)

7. Natural history of VAIN
Risk of invasive carcinoma increases with VAIN:-
• 4.5% had VAIN-1, progressed to stage I cancer in 5 years
• 4.5% had VAIN- 3, progressed to stage I cancer in 4 years
• Overall spontaneous regression rate- 78%, of which 78%
occurring in VAIN-1 and 2
Clinical presentation :-
Usually asymptomatic
Detected after cytologic evaluation in routine surveillance
Surveillance cytology recommended post hysterectomy

8. VAIN pathology
• Definition- squamous cell atypia without evidence of invasion
• Classified according to depth of invasion-
Superficial 1/3rd –VAIN-1
Superficial 2/3rd – VAIN-2
> 2/3rd – VAIN-3
CIS- encompasses full epithelial thickness - included in VAIN-3
• Most lesions are epidermoid;
• Superior 1/3rd vagina- most commonly involved
• Exhibit full thickness alterations with atypical mitoses
• Mostly multifocal
• Associated with HPV infection (92.6-100% cases)
HPV 16 or 18 – 9%, 7% and 67% of VAIN- 1, 2 and 3 respectively

9. VAIN- treatment options
• No consensus guideline available
• Treatment approaches are-
• Local excision
• Partial or total vaginectomy (52-100% success rate)
• Laser vaporization (48-100% success rate)
• Electrocoagulation
• Topical 5-FU (75-100% success rate)
• Radiotherapy (83-100% success rate)
Most patients with VAIN-1 close surveillance

10. Surgical and ablative therapies
• Surgical approaches include:-
Local excision
Partial vaginectomy- vaginal vault
- post hysterectomy recesses
Total vaginectomy- rarely done (for highly extensive disease)
• Mostly performed via transvaginal approach
• Local therapy-
Cold knife approach
Electrosurgical loop excision
Laser
Ultrasonic surgical aspiration
CO2 laser

11. Complications
• Post-operative pain
• Scarring
• Bleeding
Advantages
 Minimum impact on sexual
function
 Well tolerated procedure

12. Topical treatment
• Inclusion criteria-
Early stage lesions
Multifocal disease
Multiple comorbidities
Prior to surgery- reduces lesion size
- improves striping of neoplastic epithelial cells
• Agents available-
1. Topical 5-FU
 Response rate- 41-88%
2. 5% Imiquimod
 Response rate- 71-78%

13. Radiation therapy
•Control rate- 80-100%
•Techniques- LDR/ MDR/ HDR
•Reserved for patients –
Relapse after more conservative treatment
•Drawbacks-
Under-treatment of occult invasive disease
Risk of 2nd malignancy- no data available
Long term morbidity

14. Squamous cell carcinoma of vagina

15. Epidemiology
FIGO stage distribution-
• 26% stage I
• 37% stage II
• 24% stage III
• 13% stage IV

16. Risk factors
• HPV infection (80% with in situ disease and 60% with invasive disease)
• H/O CIN (10-50% cases develop disease after approx.14 years)
• Vulvar intraepithelial neoplasia
• Immunosuppression
• Early onset of intercourse
• Increased number of lifetime sexual partners
• Smoking
• Low socioeconomic status
• H/O genital warts
• Vaginal discharge/ irritation
• H/O abnormal cytology
• H/O prior irradiation- controversial
 Prior hysterectomy
 Use of vaginal pessary
 Vaginal trauma
 Alcoholism

17. Clinical presentation
• Irregular vaginal bleed (65% cases)- primary symptom
• Vaginal discharge (10-15% cases)- 2nd most common
symptom
• Presence of a mass
• Pain
• Urinary symptoms (Frequency/ Dysuria/ Hematuria)
• GI complaints (Tenesmus/ Constipation/ Malaena)

18. Clinical presentation Contd…
• Nodular/ ulcerated/ indurated/ exophytic/ endophytic lesion
• Well/ moderate/ poorly differentiated
• Keratinizing/ non-keratinizing/ basaloid/ warty/ verrucous
• Most common site- upper 1/3rd of vagina (50-83% cases)
• Middle and lower third equally involved or lower third > middle
third
• Posterior vaginal wall involvement ≥ anterior wall
• Verrucous carcinoma-
Histological variant
Well circumscribed, soft, cauliflower like mass
Well differentiated
Papillary growth pattern
Acanthotic epithelium
Less aggressive behavior
Rarely metastasizes

19. Clinical presentation
• Spreads along vaginal wall involves cervix/ vulva,
• Spreads radially
1. Into the lumen exophytic mass
2. Through the vaginal wall invades surrounding structures
• Anterior wall lesion vesicovaginal septum/ urethra
• Posterior wall lesion rectovaginal septum rectal mucosa
• Lateral extension parametrium and paracolpol tissue
Urogenital diaphragm, levator ani muscle or pelvic fascia
Pelvic side wall

20. Lymphatic spread
• Risk of nodal involvement-
Increases with stage
20% have clinically positive inguinal nodes at the time of diagnosis
Nodal failure- most common form of local recurrence
•Stage I- 0-14%
•Stage II- 21-32%
•Stage III- 78%
•Stage IV- 83%

21. Distant spread/ hematogenous spread
• Most common site- lung > liver and bone
• Stage wise incidence-
•Stage I- 16%
•Stage II- 31%
•Stage IIB- 46%
•Stage III- 62%
•Stage IV- 50%

22. Initial evaluation
• Complete history and thorough physical examination
• CBC, LFT and KFT
• EUA for complete assessment of tumor extent and vaginal walls
• Bimanual examination
• Biopsy of suspected lesion
• Colposcopy with acetic acid followed by lugol’s iodine- may be done
• Biopsy from cervix- to rule out cervical primary

23. Initial evaluation Contd…
Imaging
Chest x-ray
Cystoscopy and proctosigmoidoscopy- if indicated
CT scan- for local disease, lymphadenopathy and renal
parenchyma
CEMRI (superior to CT)
- Delineation of primary
- LN assessment
- 80% sensitive, 88% specific
USG guided FNAC of suspicious LNs
Whole body PET CT scan- 67% sensitive, 95% specific

24. T3
T1
T4
T2

25. AJCC staging FIGO staging

26. Prognostic factors
• Stage at the time of presentation- most important factor
• 5 year survival rate (NCDB and Shah et al)
• Lymph node involvement
• Size of initial lesion
5 year survival rate- (SEER database study and Tran et al)
•Stage 0- 96%
•Stage I- 73%
•Stage II- 58%
•Stage III and IV- 36%
•Size ≥ 4 cm- 65%
•Size < 4cm- 84%

27. Prognostic factors Contd…
• Tumor involving ≥ 2/3rd of vagina
• Tumor with circumferential growth
• Location of the lesion-
5 year survival rate- 60% -upper 1/3rd of vagina
- 37.5%- middle 1/3rd of vagina
- 37%- lower 1/3rd of vagina
Lesions of posterior vaginal wall- 10 year recurrence rate- 32% (vs.19% in
anterior wall)
• Histologic grade
• Age
• HPV- favorable in stage III onwards

28. Treatment
•Radiotherapy
•Surgery
•Chemotherapy

29. Treatment algorithm

30. Surgery
• Indications-
Early stage lesions
Previously irradiated patients
• WLE-
Carcinoma in situ
Small, superficially invasive, well demarcated lesions
• Radical hysterectomy, upper vaginectomy and bilateral pelvic
lymphadenectomy-
Extensive lesion in proximal vaginal canal  if positive margin,
then adjuvant radiation

31. Surgery Contd…
Lesions extending to inferior vagina
Total vaginectomy with radical hysterectomy, pelvic lymphadenectomy ±
vulvovaginectomy and inguinofemoral lymphadenectomy
Vagina is in close proximity with rectum and urethra
Early involvement of these structures
Pelvic exenteration in 40-50% cases to obtain negative margins
•Anterior exenteration
For invasive anterior wall lesions
Removes-
1. Vagina
2. Urethra
3. Bladder
•Posterior exenteration
For invasive posterior wall lesions
Removes-
1. Vagina
2. Rectum
•Complete exenteration-
For deeply invasive,
circumferential lesions
•Radiotherapy is the treatment of choice

32. Surgery Contd…
• Select stage I disease-
Surgery may have excellent result
5 year survival rate- 56-100%
• Neoadjuvant chemotherapy followed by surgery-
Benedetti et al [5] -
1. 11 patients with stage II SCC vagina
2. 3 cycles of NACT (Paclitaxel+ Cisplatin)
3. 91% had pCR or CR, out of which 27% had CR
4. 100% had clear margin post surgery
5. 1 patient had positive LN
6. Median follow up time- 75 months

33. Radiotherapy
•External beam radiotherapy
•Brachytherapy

34. Stage I
• Stage I lesions- 0.5-1 cm in thickness
• Individualised management based on-
Size
Depth
Location
• May be treated with brachytherapy alone
• Local control rate- 67-100%
• Perez et al –
Stage I patients, treated with brachytherapy alone
Dose- 60-70 Gy, prescribed 5 mm beyond the plane of implant or
vaginal mucosa
Vaginal surface dose- 80-120 Gy
88% pelvic tumor control
Frank et al & Dancuart et al
Result- Pelvic relapse rate of
18% at 10 years in patients
treated with brachytherapy
alone

35. • Entire length of the vagina is treated to a mucosal dose of 60 to 65 Gy
• Additional mucosal dose of 20 to 30 Gy delivered to the area of tumor involvement
• LDR brachytherapy-
Treatment can be delivered in two applications
1st to treat the entire vaginal wall
2nd application to cover the tumor volume
Delivered with a shielded vaginal cylinder to treat the tumor with a 2-cm margin
• HDR brachytherapy-
To treat superficial lesions
Vaginal mucosa - dose of 21 to 25 Gy, prescribed to a depth of 5 mm, in weekly #s of
5 to 7 Gy each
Additional 21 to 25 Gy delivered to the tumor , prescribed to a depth of 5 mm, via
shielded vaginal cylinder, with weekly #s of 5 to 7 Gy
Total dose - 42 to 50 Gy

36. When the lesion is thicker than 5 mm!
• Combination of intracavitary and interstitial brachytherapy
• Vaginal cylinder delivers 45 Gy (LDR) or 21 to 25 Gy (HDR) to a
depth of 5 mm into the vaginal mucosa
• Subsequent therapy - via interstitial implant, to deliver an additional
dose of 25 to 35 Gy (LDR) to the tumor volume
For more extensive stage I lesions, with
greater infiltration or poor differentiation
 Combination of EBRT and brachytherapy is used

37. Stage II - Radiotherapy
Primary treatment
• EBRT + Brachytherapy
36% pelvic tumor control with brachytherapy alone
67% with EBRT + brachytherapy
• Dose- 45-50.4 Gy, 1.8 Gy/ #, with parametrial boost if-
Extensive primary infiltration
High suspicion of nodal disease
For lesions involving distal vaginal canal-
Inguinal LN are included in whole pelvic field
• Tumor volume should receive 75-80 Gy combining EBRT +
brachytherapy dosages

38. Stage III and IVA
EBRT with brachytherapy

39. • Minimum tumor dose- 75-80 Gy
• If extensive tumor infiltration
• Involvement of rectovaginal septum/ bladder
• Overall cure rate-
Stage III- 30-50%
Stage IV- worse prognosis
• 5 year actuarial survival rate-
Stage III- 25-58% and local failure rate- 30-75%
Stage IV- 0-40%
Shrinking field
technique/
IMRT is used

40. Role of chemotherapy and radiation
• No randomised controlled trials available comparing RT alone with
CTRT
• Cisplatin is used by extrapolating data of improved PFS and OS in
cervical carcinoma
• 5-FU and Mitomycin C- also used, but results were inferior
• Frank et al - retrospective series at MDACC
9 patients with stage II- IVA
RT alone and RT+ concurrent cisplatin chemotherapy
Median follow up time- 129 months
44% treated with CTRT were free of disease

41. Radiotherapy techniques
• External Beam Radiotherapy
1. 2 D treatment planning
2. 3 D conformal treatment
3. IMRT
• Brachytherapy
1. LDR brachytherapy
2. HDR brachytherapy
3. Interstitial brachytherapy

42. External beam radiotherapy
• Radio opaque marker- used to delineate distal tumor margin
• CT simulation for contouring of vessels for LN localization
• Frog leg position- for inguinal LN treatment
• CECT preferred over NCCT for planning purpose
• Fusion of pelvic MRI or PET CT with planning CT, if available

43. 2 D treatment planning
• Opposed anterior and posterior fields (AP/PA)- most commonly used
• 4 field technique with small bowel blocks in lateral fields
• Avoid shielding of presacral, perirectal and anterior external iliac LNs
while shielding small bowel
• Target volume must cover-
Vagina
Common iliac nodes
External iliac nodes
Obturator nodes

44. 2 D treatment planning Contd…
• Borders-
Superior border- L5-S1 interspace (covering the retroperitoneal nodes)
- or 1-2 cm superior to inferior margin of SI joint
- If positive pelvic LN, then L4-5 interspace or higher
to include common iliac nodes
Inferior border- introitus or 4 cm distal to vaginal tumor
Lateral border- 1.5-2 cm lateral to pelvic brim
Lateral fields-
Anterior border- pubic symphysis
Posterior border- S2-3 interspace
•Mostly failures occur in vagina, paracolpos and parametria
•Regional nodes must be negative on imaging

45. How to minimize dose to femoral heads
while 2 D planning
• Electron boost to inguinal nodes
• Unequally weighted AP/ PA beams (2:1)
• Low and high energy photons
• Wide AP and narrow PA fields with boost to inguinal nodes

46. 3 D conformal radiotherapy
• GTV- gross disease+ palpable LN+ suspicious LN on imaging
• CTV-
GTV with 1-2 cm margin
Entire length of vagina
Paravaginal tissue up to pelvic side wall
Bilateral pelvic LNs
• Pelvic nodal CTV-
1-2 cm margin around blood vessel
Common iliac LN
External iliac LN
Internal iliac LN
For distal vaginal involvement- inguinal LN are included
Inferior border- ischial tuberosity or lesser trochanter
Obturator LN
Perirectal LN
Presacral LN

47. 3 D conformal radiotherapy
• PTV- CTV+ 1 cm
• Dose- 45-50.4 Gy/ 1.8 Gy per fraction ± Parametrial boost 50-65 Gy
• Elective nodal irradiation of inguinal nodes- 45-50 Gy
• Gross nodal disease- 60-65 Gy
• After EBRT, tumor of vaginal apex > 0.5 cm depth-
Interstitial brachytherapy/ EBRT boost
• Tumor < 0.5 cm depth-
Intracavitary brachytherapy
• Tumors of mid vagina or distal vagina-
Interstitial brachytherapy/ EBRT boost
• Anterior/ lateral tumors of mid vagina-
Interstitial brachytherapy

48. IMRT
• Must be done cautiously
Constant normal tissue changes
Rapid response with RT
Vaginal volume should be contoured with both bladder full and empty
Rectal filling must be taken care of
 Dose constraints (RTOG trial 0921)
 No > 30% of entire small and large bowel should receive > 40 Gy
 D2cc- maximum 55Gy
 At least 35% of bladder volume must receive ≤ 45 Gy with D2cc 90Gy
 At least 60% of rectosigmoid junction must receive ≤ 40 Gy with D2cc 70-
75 Gy maximum
 At least 15% of femoral head must receive ≤ 35Gy
 Plans must be optimized to minimize volume of PTV receiving > 110% of
prescribed dose

49. Brachytherapy
• Indications-
Superficial disease ≤ 5 mm in thickness intracavitary
Thickness > 5mm interstitial brachytherapy
• Intracavitary brachytherapy as monotherapy-
VAIN
Highly selected stage I patients with minimally invasive disease
• Used after EBRT as boost with small lesions < 5 mm thick
• Cumulative dose- 70-75 Gy

50. LDR intracavitary brachytherapy
• Most commonly performed with vaginal cylinder of Cs-137
• 2-3 Cesium sources are placed along the central tandem
• Most appropriate when thickness ≤ 5 mm, due to rapid fall of dose
• Labia are sutured close, to secure the implant in place

51. HDR intracavitary brachytherapy
• Iridium-192 is used
• Dose- 3-8 Gy per session for 1-6 sessions
• Mock et al –
Largest series of HDR brachytherapy, at Vienna
86 patients with stage 0-II
Intracavitary HDR brachytherapy alone
Dose per fraction- 5-8 Gy, mean dose 7 Gy, 2-6 sessions (median-5)
5 year recurrence free survival- 100%, 77% and 50% for stage 0, I and II

52. Interstitial brachytherapy
• Indications-
1. Paravaginal extension
2. Lesion thickness > 5 mm
3. Distal vaginal extension
4. Vagina unable to accommodate standard intracavitary applicators
Dose-
With gross residual disease- 70-90 Gy, with 60 Gy prescribed to entire
vaginal surface

53. Treatment algorithm- summary

54. CARCINOMA VULVA

55. Anatomy of vulva

56. Lymphatic drainage

57. Epidemiology
• <1% of all cancers diagnosed in women
• 3-4% of all gynecologic malignancy
• Incidence increases with age
• Median age 68 years
• Constitutes 0.4% new cancer cases in USA
• Estimated number of cases in 2018 in USA- 6190 with
1200 (0.2%) deaths due to vulvar Ca

58. Cancer vulva- facts
• Vulvar cancer has two peaks in age incidence
• Younger vulvar cancer patients-
1.More commonly smoke
2.Higher incidence of HPV infection
3.Associated with vulvar intraepithelial neoplasia (VIN)
• In elderly patients
1.HPV infection is less likely
2.Concurrent VIN less common
3.Background of lichen sclerosus is common
• Only 4% of patients with lichen sclerosus will develop clinically
apparent neoplasia

59. Histological classification
Common histologies
• Squamous (80-90%)
• Vestibular gland carcinoma-
Adenoid cystic carcinoma
Adenocarcinoma
30-50% have squamous
histology
Rare histologies
• Melanoma(10%)
• Basal cell carcinoma
• Merkel cell tumor
• Sarcoma
• Carcinoid
• Apocrine gland cancer
• Paget disease
• Metastatic lesions

60. Clinical features
•Vaginal pruritus- most common
•Vulvar lesion-
•Bleeding
•Pain
•Discharge
•Dysuria
•Rectal bleeding
•Enlarged groin lymph node
•Lower extremity edema
•Unifocal vulvar plaque
•Ulcer
•Mass
•Multifocal in 5% cases

61. Primary sites
•70% - labia majora and minora
•15% - clitoris
•5% perineum and fourchette
prepuce, Bartholin’s glands and urethra
•5% - too extensive at presentation to classify

62. Patterns of spread
•Direct
•Lymphatic
•Hematogenous

63. Lymphatic spread
•Most commonly seen in-
•Superficial inguinofemoral LN→ deep inguinofemoral nodes
•Contralateral LN involvement is unusual for well lateralized
disease
•Lesions of the clitoris or urethra can spread directly to pelvic
lymph nodes
•High grade tumors
•Spray growth pattern
•Lymphatic space invasion

64. Factors affecting LN involvement
• Tumor thickness
• Histologic grade
• Capillary like space involvement
• Depth of invasion
• Location of tumor
• Extension to other sites (also worsens the prognosis)
• Tumor size
• Clinical stage
• Positive inguinal nodes
• Positive margin at primary site
• PNI
•When ≤1 mm, LN involvement is ≤5%
•When it is ≥5mm, LN involvement increases to 33.3%
- Rowley et al, Gynecol Oncol, 1988
•Depth of invasion of 1,2 and 3 mm corresponds to
4.3, 7.8 and 17% incidence of LN involvement
- Rowley et al, Gynecol Oncol, 1988

65. Distant metastases/ hematogenous
• Typically occurs late in the course of disease
• Rare without inguinofemoral LN involvement
• Portends a very poor outlook
• Most common site- lungs > liver > bones
*
*Hacker NF, Berek JS, Lagasse LD, et al. Management of regional lymph nodes
and their prognostic influence in vulvar cancer. Obstet Gynecol 1983; 61:408.
No. of positive LNs Risk of hematogenous spread
≤3 4%
>3 66%

66. Prognostic factors
• Lymph node metastasis
• Tumor size
• LVI
•Most important prognostic factor
•Presence of inguinal LN ≈ 50% reduction in long term survival

67. Initial evaluation
• Complete history and thorough physical examination
• CBC, LFT and KFT
• EUA, (cystoscopy and proctoscopy- if indicated)
• Imaging
May not be necessary in early lesions
CT scan- for lymphadenopathy
CEMRI
- Delineation of primary
- LN assessment
- 80% sensitive, 88% specific
USG guided FNAC of suspicious LNs
Whole body PET CT scan- 67% sensitive, 95% specific

69. Proximal 2/3rd
Distal 1/3rd
<2.0 cm >2.0 cm
<1.0 mm
>1.0 mm

70. Management

71. Challenges in the management
•Patients - older & have comorbidities
•Tumor easily involve adjacent organs
• The treatment can have major psychosexual impact
on patients

72. Treatment algorithm

73. Outline of management
Early invasive disease
• Surgery
• Radiation therapy
Advanced disease
• Multimodality approach
• CTRT as
Neoadjuvant or
Post operative adjuvant

74. Radiation therapy in early invasive disease
• Radiation to the tumor bed to prevent local recurrence
• Pathologic features associated with higher risk of LR
Lymphatic-vascular invasion (LVI)
Depth of invasion >5 mm
Margins <8 mm
Microscopically positive margins
• Patients with
Extracapsular extension (ECE) of tumor in the nodes
Residual disease in the inguinal areas
• Postoperative radiation should be given to-
Pelvis
Groins
Primary tumor bed area

75. GOG trial
• Patients underwent bilateral inguinal lymphadenectomy
• Inclusion criteria- positive groin nodes
• Arms- pelvic lymphadenectomy or radiation to the pelvis and bilateral groins
• Findings-
Radiation arm
Pelvic
lymphadenectomy
arm
Groin recurrence
rate
5.1% 23.6%
2 year survival
benefit
(p value= 0.03)
68% 54%
Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy versus pelvic node resection for
carcinoma of the vulva with positive groin nodes. Obstet Gynecol 1986;68:733–740

76. Surgery
•Primary tumor
•Inguinofemoral lymph nodes
•Pelvic lymph nodes

77. Evolution of surgical approach
Radical
vulvectomy
Wide local
excision
± CTRT

78. Radical vulvectomy
•Indications-
Large lesion
Multifocal disease
Anus/ vagina/ urethra are involved

79. Wide local excision
• Also known as-
Radical local excision or radical wide excision or
modified radical vulvectomy
Disease should not involve-
Anus
Vagina
Urethra
Depth of excision- deep perineal fascia
2 cm clear margin (at least 1cm)
If clitoris is involved or abutted, cannot be preserved

80. Inguinofemoral lymph node dissection
• Must be done cautiously
• Complications-
Wound breakdown
Lower extremity lymphoedema
• Indications-
Tumor size >2 cm
Depth of invasion- >1mm
Midline or clitoral lesion
Palpable inguinal lymph nodes

81. • Small (<2cm), lateralized lesions may be treated by u/l groin
dissection
• For midline and clitoral lesions & for those >2cm b/l groins
should be assessed
• For patients undergoing primary surgery, palpable inguinal
nodes should be removed
• Assessment of groin nodes can be done via full superficial
inguinal dissection or sentinel lymph node procedure

82. Pelvic lymph node
Clinically or pathologically positive groin nodes
Increased risk of contralateral groin and pelvic LN involvement
• GOG trial[1]
Pelvic node dissection vs. pelvic node radiation
Similar result in terms of control
Result- RT to the pelvic node is preferred over surgery
Reason- women in need of treatment to pelvis, also require RT to
primary and/ or inguinal nodes
1. Homesley HD, Bundy BN, Sedlis A, et al. Radiation therapy versus pelvic node resection
for carcinoma of the vulva with positive groin nodes. Obstet Gynecol 1986;68:733–740.

83. Radiotherapy

84. Indications
•Small central lesion
•Lesions in close proximity to-
Urethra
Clitoris
Anus
•Usually used in combination with surgery/
chemotherapy

85. Treatment volume
• Target volume- vulva+ both groins+ lower pelvic nodes
• Use of midline block should be avoided- may increase the chance for local
recurrence
• Factors associated with increase in chances of vulvoperineal recurrence are-
Close or positive margin (<8 mm)
Primary tumor size > 4 cm
LVSI
Deep invasion (> 9 mm)
Tumor thickness >1 cm
Infiltrative growth pattern/ spray pattern
> 25% keratin in the tumor
High mitotic rate >10/10 hpf

86. Treatment field
• Superior border- middle of SI joint to
cover external and internal iliac nodes
• If external and internal iliac nodes are
positive – superior border extended to
L3/4 interspace to cover common iliac
nodes
• Inferior border- should cover entire
vulva and most superficial, inferior
inguinal nodes
• Lateral border- 2 cm lateral to the widest
point of pelvic inlet Position- Frog leg

87. • To reduce dose to femoral head while using AP field-
Narrow posterior field covering only the pelvis and sparing femoral
heads
Inguinal dose is supplemented with electron field matched with pelvic
field
• Bolus- to ensure adequate dose to superficial portion of groins
• 2nd method- wide AP field with narrow PA field, with partial
transmission block placed in central portion of AP field
• 3rd method- AP/PA field to include primary and pelvic nodes
- Groin with separate anterior electron fields

90. IMRT technique
• GTV- gross tumor/ post op tumor bed
• CTV- 1 cm margin around GTV
- 1-2 cm margin around B/l external iliac, internal iliac and inguinofemoral LNs for
pelvic nodal CTV
• PTV- 1 cm margin around CTV
• Dose- 43-48 Gy in pre op setting, 45-50.4 Gy for post op cases and 59.4-64.8 Gy for
unresectable disease,1.8 Gy/ fraction
• Post operative RT should be started within 6-8 weeks
• Large nodes may be boosted to a total dose of 70 Gy

91. Preoperative radiotherapy with
concurrent chemotherapy
• Dose- 45-55 Gy
• Chemotherapy regimen- 5-FU, Cisplatin and Mitomycin-C
CTRT
CR
Inguinal LN
dissection is
must

92. Definitive CTRT
• Indications-
Advanced unresectable disease
Medically inoperable
Clinically negative nodes
• Technique
Electron therapy
Photon therapy

93. Post operative radiotherapy
• Indications-
Limited surgery (for organ preservation)
Positive or close margin (<8 mm)
LVI
Depth of tumor invasion > 5mm
> 1 involved inguinal node
ECE
Gross residual nodal disease
• In positive or close margin, re-resection prior to RT can be done
• Field- same as earlier (AP/PA)
• Dose- 50 Gy (50-60 Gy if ECE present and 65-70 Gy for R2 resection)

94. Brachytherapy
• Radical ISBT-
Stage IA
• Boost ISBT (after EBRT)-
Stage IB, II and III
• Salvage ISBT-
Recurrent vulva (small size)
Indications

95. Brachytherapy Contd…
• Dose- 3-4 Gy times 4-6 sessions, 2 sessions per day,
prescribed at 3-4 mm from applicator surface, or
• 7-10 Gy, 3 sessions, once weekly, dose prescribed at 3-4 mm
at surface

96. Chemotherapy
• Chemotherapy alone is reserved for patients-
Advanced disease
Inoperable disease
Metastatic disease
Recurrent disease
• Evidence in support not available
• Associated with higher toxicity and poor response
• Biologic agents
EGFR inhibitors- (Erlotinib)

97. •Paclitaxel and Erlotinib- single agents showing
activity against advanced vulvar cancer in phase II
studies (only case reports are available)
•Combination chemotherapy regimens- Cisplatin and
5-FU

98. Recent NCCN guideline for systemic
therapy

99. Toxicities (post surgery)
• Lymphoedema (69%*)
• Wound infection (20-40%) and hematoma
• Seroma
• Hemorrhage
• DVT
• Pulmonary embolism
• Osteitis pubis
• Femoral nerve injury- loss of sensory perception in anterior aspect of thigh
Chronic cellulitis of inguinal areas
Stenosis of introitus
Femoral hernia
Rectovaginal and rectoperineal fistula

100. Toxicities (post RT or CTRT)
• Mucocutaneous reaction in vulva, perineum or inguinal folds
• Acute hematologic toxicity- (common after chemotherapy)
• Telangiectasias
• Atrophy of skin and mucosa of vulva
• Dryness of mucosa of vagina and vulva
• Narrowing of vaginal introitus
• Avascular necrosis of femoral head (very rare)
Psychosexual morbidity

101. Surveillance