Management of Vulvar Cancer: How to Handle Close Margins?
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1 Management of Vulvar Cancer: How to Handle Close Margins? Sven Mahner, MD Department of Gynecology and Obstetrics University of Munich AGO Study Group Munich, Germany
2 Surgical Resection of Vulvar Cancer Depending on the tumor localization, different resection and reconstruction strategies are necessary
3 Aims of Surgical Resection and Role of Plastic Reconstruction Tumor resection Preservation of sexual function and body image Plastic reconstruction of the vulva anatomy Plastic reconstruction of large defects Negative examples! Negative examples!
4 Aims of Surgical Resection and Role of Plastic Reconstruction Tumor resection Preservation of sexual function and body image Plastic reconstruction of the vulva anatomy Plastic reconstruction of large defects Negative examples! Negative examples!
5 Radical Local Resection/Partial Vulvectomy Organ Preservation and Plastic Reconstruction
6 Role of the Tumor-Free Resection Margin % of Patients Kum. Überleben R R1 P = disease free survival (n = 103) Woelber L, et al. Anticancer Res. 2009;29(2):
7 SO WE KNOW THAT WE NEED A FREE MARGIN BUT WHAT IS A CLOSE MARGIN?
8 Prognostic Role of Resection Margins Single Center Experience 102 pts. with primary vulvar cancer (1998 bis 2008) Median age 62 y (26-84) Median FU 31 months (1-105) Tumor stages pt1 56 (56%) pt1a 11 (11%) pt1b 45 (44%) pt2 39 (38%) pt3 7 (7%) pt4 2 (1%) Lymph node status pn0 62 (61%) pn1 20 (20%) pn2 9 (9%) pnx 11 (11%) 15.7 % (n=16) recurrences 65% at the vulva 17,6% deaths (crude) Pathologic resection margins all R0 Median 5mm (0.5-25mm) Location of minimal margin Basal 22 (21%) Lateral 49 (48%) Basal and lateral 8 (8%) Woelber L, et al. Ann Surg Oncol. 2011;18(13):
9 Prognostic Role of Resection Margins Resektionsrand < / 8mm p = n.s. (n = 102) Woelber L, et al. Ann Surg Oncol. 2011;18(13):
10 Prognostic Role of Resection Margins p = n.s. Resektionsrand <3 mm (blau) 3-8 mm (grün) >8 mm (grau) Woelber L, et al. Ann Surg Oncol. 2011;18(13):
11 Prognostic Role of Resection Margins Progressionsfreies Überleben Resektionsrand p = n.s. <3 mm (blau) 3-8 mm (grün) >8 mm (grau) Woelber L, et al. Ann Surg Oncol. 2011;18(13):
12 Prognostic Role of Resection Margins Progressionsfreies Überleben Resektionsrand p = n.s. <3 mm (blau) 3-8 mm (grün) >8 mm (grau) Woelber L, et al. Ann Surg Oncol. 2011;18(13):
13 Multicenter Study AGO CaRE Mahner S, et al. J Natl Cancer Inst. 2015;107(3): pii: dju426.
14 Subanalysis Resection Margin Woelber L, et al. Eur J Cancer. 2016;69:
15 Subanalysis Resection Margin 289 patients with surgical treatment only, R0 resection and known margin Median FU: 38,8 months Woelber L, et al. Eur J Cancer. 2016;69:
16 Recurrence Rates and Localizations Woelber L, et al. Eur J Cancer. 2016;69:
17 Recurrence and Margin Distance Woelber L, et al. Eur J Cancer. 2016;69:
18 SO WE KNOW THAT WE DON T KNOW THE "OPTIMAL" MARGIN BUT WHAT IS THE ROLE OF LOCAL RECURRENCE ANYWAY??
19 When Do Recurrences Occur? And What Is the Outcome After Recurrence? Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
20 CaRE-1 Outcome After Recurrence Patients 90% locally restricted tumors (1124/1249 pt1b/pt2) 82% R0 resection (1022/1249) 26% received adjuvant treatment (324/1249) Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
21 CaRE-1 Outcome After Recurrence Results Localization of Recurrence Localization of disease recurrence Total N- N+ (n=1249) (n=802) (n=447) 360 recurrences 169 recurrences Vulva (+/- other localizations) thereof vulva only Groins (+/- other localizations) thereof groins only Pelvis (+/- other localizations) thereof pelvis only Distant (+/- other localizations) recurrences N+ vs. N-: HR 2.47, 95%CI ( )] after a median of 17.1 months thereof distant only Unknown Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
22 CaRE-1 Outcome After Recurrence Results Risk Factors for Recurrence HR p-value 95% CI Age (per year) pt2 vs.pt1b 1.92 < pt3/pt4 vs. pt1b pt unknown vs. pt1b Depth of invasion in mm Grade 2 vs. Grade Grade 3 vs. Grade Grade unknown vs. Grade Resection margin in mm R0 vs. R Rx vs. R Adjuvant radiotherapy vulva yes vs. no Adjuvant radiotherapy vulva unknown vs. no Multivariate analyses of further variables influencing local recurrence (n= 1240, number of events= 193; HR hazard ratio; CI confidence interval) Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
23 CaRE-1 Outcome After Recurrence Results Treatment of Recurrence Treatment of vulvar recurrence: surgery only: 104 (53.9%) surgery and radiotherapy: 40 (20.7%) radio(chemo)therapy only: 14 (7.3%) No treatment: 19 (9.8%) Unknown: 16 (8.3%) Median follow-up after diagnosis of local recurrence: 11.5 months 1-year DFS rate after local recurrence was 58.5% 30.1% (58/193) developed second recurrence: 40 (20.7%) vulva, 15 (7.8%) groin, 7 (3.6%) pelvis, 12 (6.2%) distant, 2 (1.0%) unkown (multiple locations possible) Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
24 CaRE-1 Outcome After Recurrence Results Survival After Recurrence Overall survival with regard to local recurrence no recurrence vulvar recurrence only time (months) No recurrence N=889 Vulvar recurrence N=193 Events, n year survival 85.9 % 76.7 % 5-year survival 80.6 % 66.9 % Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
25 CaRE-1 Outcome After Recurrence Results Time of Recurrence Cumulative Incidence vulvar only groins only vulva and groins only including pelvis or distant unknown localization death before recurrence.1 Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract time (months) Cumulative incidence curves for primary recurrence at different sites and death before recurrence
26 Long-Term Follow-Up GROINSS-VI Local recurrence rate N+: 33.2% after 5 years and 46.4% after 10 years N-: 24.6% and 36.4%. Te Grootenhuis NC, et al. Gynecol Oncol. 2016;140(1):8-14.
27 CaRE-1 Outcome After Recurrence Interpretation Opposite to common believe, patients with isolated vulvar recurrence show impaired prognosis in the CaRE cohort A high percentage of the patients with local recurrence develop second recurrences Primary treatment has to improve with regard to prevention of local recurrence However, effective strategies are yet to be defined Woelber L, et al. J Clin Oncol. 2016;34(suppl): Abstract 5595.
28 DO WE GET HELP FROM GUIDELINES?
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31 Conclusion: How to Handle Close Margins Consider different aspects for your patient Organ preservation (clitoris!) Concomitant premalignant disease Availability of regular vulvoscopic follow up Biology of tumor and patient Grade Age Lymph node status
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