Proposed All Wales Vulval Cancer Guidelines. Dr Amanda Tristram

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1 Proposed All Wales Vulval Cancer Guidelines Dr Amanda Tristram

2 Previous FIGO staging FIGO Stage Features TNM Ia Lesion confined to vulva with <1mm invasion, T 1 N 0 M 0 superficially invasive vulval carcinoma. Ib All lesions confined to the vulval with a T 1 N 1 M 0 diameter <2cm and no clinically suspicious groin lymph nodes. II All lesions confined to the vulva with a T 2 N 0 M 0 maximum diameter >2 cm and no suspicious groin nodes III Lesions extending beyond the vulva but without grossly positive groin nodes. T 3 N 0 M 0 T 3 N 1 M 0 T 3 N 2 M 0 Lesions of any size confined to the vulva and T 1 N 2 M 0 IV having suspicious nodes. Lesions with grossly positive groin nodes regardless of the extent of the primary. Lesions involving mucosa of rectum, bladder, urethra, or involving bone. T 2 N 2 M 0 T 1 N 3 M 0 T 2 N 3 M 0 T 3 N 3 M 0 T 4 N 3 M 0 T 4 N 0 M 0 T 4 N 1 M 0 All cases with pelvic or distant metastases T 4 N 2 M 0 M 1 A M 1 B

3 Revised FIGO Staging Stage I Tumor confined to the vulva IA Lesions 2 cm in size, confined to the vulva or perineum and with stromal invasion 1.0 mm, no nodal metastasis IB Lesions >2 cm in size or with stromal invasion >1.0 mm, confined to the vulva or perineum, with negative nodes Stage II Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes

4 Stage III Tumor of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes IIIA (i) With 1 lymph node metastasis ( 5 mm), or (ii) 1 2 lymph node metastasis(es) (>5 mm) IIIB (i) With 2 or more lymph node metastases ( 5 mm), or (ii) 3 or more lymph node metastases (>5 mm) IIIC With positive nodes with extracapsular spread

5 Stage IV Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures IVA Tumor invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or (ii) fixed or ulcerated inguino-femoral lymph nodes IVB Any distant metastasis including pelvic lymph nodes

6 Referral Pathways/Networks General Practitioner If cancer of the vulva is suspected then referral should be to acancer Centre which has appropriately trained personnel. In this instance, referral will be to a gynaecologist who has additional training in oncology.

7 Referral Pathways/Networks General Practitioner If cancer of the vulva is suspected then referral should be to acancer Centre which has appropriately trained personnel. In this instance, referral will be to a gynaecologist who has additional training in oncology. Non-oncological gynaecologists If a patient with vulval cancer is seen by a gynaecologist who has had no additional training in oncology, then referral should be made to the Cancer Centre (C). The rarity of the cancer, the variety of possible management techniques and the additionalskills required mandate that this cancer should be managed by specialist teams. Referral should include sending all relevant histopathological material to the specialist gynaecological pathologist in the gynaecological cancer centre.

8 Referral Pathways/Networks General Practitioner If cancer of the vulva is suspected then referral should be to acancer Centre which has appropriately trained personnel. In this instance, referral will be to a gynaecologist who has additional training in oncology. Non-oncological gynaecologists If a patient with vulval cancer is seen by a gynaecologist who has had no additional training in oncology, then referral should be made to the Cancer Centre (C). The rarity of the cancer, the variety of possible management techniques and the additionalskills required mandate that this cancer should be managed by specialist teams. Referral should include sending all relevant histopathological material to the specialist gynaecological pathologist in the gynaecological cancer centre. Cancer Centre The patient should be seen within two weeks of referral and definitive treatment should be undertaken within six weeks of diagnosis. All new cases of vulval cancer should be discussed at the cancer centre multidisciplinary team meeting and the histopathological material reviewed by a specialist gynaecological pathologist, prior to radical surgery.

9 Cancer Centre The patient should be seen within two weeks of referral and definitive treatment should be undertaken within six weeks of diagnosis.

10 Cancer Centre All new cases of vulval cancer should be discussed at the cancer centre multidisciplinary team meeting and the histopathological material reviewed by a specialist gynaecological pathologist, prior to radical surgery.

11 Pre-operative investigations for women with vulval cancer. Vulval biopsy. Chest X-ray. Cervical smear (if not done and cervix in situ.) Biochemical profile, liver function tests. Abdominal and pelvic CT scan or MRI scan (for concurrent pelvic pathology and retroperitoneal nodes. Biopsy of any grossly involved nodes or other metastases. 2 unit cross match. MSU. ECG if over 50 years. NB This list is not exhaustive or proscriptive.

12 Postoperative radiotherapy Postoperative radiotherapy to the loco-regional nodes should be considered when: two or more lymph nodes are involved with metastatic disease or when there is complete replacement or extra capsular spread in any node.

13 Postoperative radiotherapy (cont) Although both lymphovascular invasion and infiltrative growth patterns are associated with a worse prognosis, currently, adjuvant radiotherapy is not recommended in these situations, in the absence of other risk factors.

14 Chemotherapy?

15 Sentinel node biopsy Dye studies and lymphoscintigraphy may be of value in the detection of sentinel nodes [5-7], although the outcome of this type of intervention is awaiting the outcome of controlled clinical evaluation. Surgery confined to sentinel node dissection should only be undertaken as part of a clinical trial.

16 Primary groin radiotherapy Morbidity after surgical treatment and groin node dissection is considerable. Primary radiotherapy to the groin is expected to result in less morbidity, however studies to date on the efficacy of primary radiotherapy to the groins in terms of groin recurrences and survival show conflicting results, surgery is still the cornerstone of therapy.

17 Questions?

18 Agree guidelines

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