We are ready to go. Yes, we're ready to go. Okay, thank you very much. Well, I've got a notice here saying, have I got it or not? I don't know how I- It might be asking if it's okay for me to record. Right, okay. Right, well, all the cancer, as you know, represents about 4% of gynecological cancers and the average age of diagnosis is 65 years. 30 to 40% of the cases are HPV positive. This is the next slide, particularly HPV 16. There are two common types. As you know, those that occur in elderly women and are usually associated with lichen sclerosis and sometimes differentiated DIN and those that occur in younger women. And this group is increasing in Western countries. So HPV related, smoking related and quite often associated with warty or basaloid type of DIN. Next slide. And the next slide. Wait a minute, oh, sorry. I just gonna say, I'm gonna talk about the management of early primary cancers, late primary cancers, management of the lymph nodes and early and late vulva cancer and say some few words about non-swamish cancers. Next slide is, yes. Okay, so it used to be that everybody with vulva cancer got a radical vulvectomy and a bilateral groin dissection. But now, as we know, we need to independently assess the best treatment for the primary lesion and for the lymph nodes. And with respect to the primary lesion, I think it's important to try and perform a colposcopy of the cervix, vagina and vulva to determine the extent of any associated intraepithelial neoplasia because there may well be some associated disease anywhere in the lower genital tract. And then resect the local cancer, the primary cancer with a radical local excision. That means radical means a wide excision, at least one centimetre wide and a deep incision down to the deep fascia. These factors, the presence of multifocal cancer or the extent of any associated VIN may have to modify the treatment. Next slide, and you see this small primary cancer. The remainder of the vulva is completely normal. So there's nothing more to be done here than a radical local excision. Whereas the next slide, here's a large vulva cancer and this needs to be similarly excised with adequate one centimetre margins, but you can't close this primarily. So I think this VY flap, the Y when you close it is a good way to deal with lesions such as this. Next slide, basically shows a fairly extensive invasive cancer anteriorly and a degree of VIN posteriorly. So the anterior lesion needs to be radically excised. The posterior just superficially excised, but it's too extensive of course to close the defect. So using a split thickness skin graft is the best way I think to deal with that. Next slide. When you get to patients with locally advanced disease, the issue is really whether you can resect the tumour without a stoma. And I think at all costs, you need to avoid a stoma if possible. If you can get it without a stoma, then resect it preferably with one centimetre margins. Although if I can get clear margins, that is clear but close margins, I would usually prefer to resect it and then use radiation postoperatively. On the other hand, if it's going to require a stoma, then I think you've got to give preoperative radiation. Or I noticed, Detendra, that you used some anelogenin chemotherapy in the patient you had, and you've got a very good response. And I haven't had experience with that, although I've seen reports that that is also effective. I think you then do need to resect the tumour bed because it may appear to be completely eradicated, but there's often some microscopic residual there. This is a large primary cancer, which actually involved the distal urethra. Now, you can certainly resect the distal one, one and a half centimetres of urethra with impunity. You shouldn't be afraid to do that. The woman will remain continent. And a large tumour like this, it's perfectly reasonable to do a gracilis type of myocutaneous graft here to close that defect. Here's a lesion that's somewhat similar to the one that you actually had presented. Instead of an ulcerated lesion, this is a large exophytic tumour. Now, the main concern was not that it was anywhere near the urethra, but it was very close to the anus. But I elected to resect this initially. You can see here's the margin here. This skin margin is actually four millimetres, but it's clear. And I think by resecting the tumour and then giving a smaller field of radiation, you get the best result. This one, in fact, involves the anus. So there's no way that you can do anything surgically that won't necessitate a stoma. She had a very good result, but I would still like to resect the base of the cancer here. You don't need to resect this other normal side, but you certainly need to resect the base. This is another cancer demonstrating this problem of a patient we had more recently where we resected the normal looking skin here, but you can see this underlying focus, microscopic focus of invasive cancer. And if you don't get rid of that, then of course it's going to recur within a matter of months. Next slide. So adjuvant radiation, I think, is important in these patients. This was the study originally from Memorial Sloan Kettering back in the late 90s, but it showed with adjuvant radiation, you could decrease the incidence of local recurrence from about 58 to about 16%. Next slide. Now, so I was going to say, I put another slide in here, which you don't have, but there's been quite a bit written about the prognostic significance of margins in vulva cancer recently, and basically indicating that margins are not important. Now, I don't believe that if you divide them into those that have primary site recurrences and remote site recurrences, there's no question that you get more local recurrences if you don't have that one centimeter margin. We recently reported this paper, the prognostic role of surgical margins in squamous vulva cancer, a retrospective Australian study in cancers in 2020. And we showed that if you had excision margins less than eight millimeters pathologically, that is one centimeter in the growth state, then re-excision or radiation of those margins significantly decreased the risk of recurrence. I can send that paper to you if you like. So I think that in general, conservative vulvar resection is the way to go. Patients rarely should die of a local recurrence, but you do have to follow these patients for a long time. You can't dismiss them after five years because many of the recurrences will occur several years later. I think self-inspection with a mirror, an early presentation is important because rarely will patients die with a local recurrence. The follow-up doesn't have to be done, of course, in the cancer center. It can be done by the local GP or local gynecologist, but it is important, I think, that someone, the patient is encouraged to see someone for that follow-up. Now, it's the mismanagement of the lymph nodes, of course, that is what kills the patient. The status of the lymph nodes is the single most important prognostic factor in vulvar cancer. And the only way to be sure of the status of the lymph nodes, in fact, is to dissect the inguinal femoral nodes. This is the way I like to do it, and I was pleased to see, just Hendra, that you did it exactly the same way, make an incision about a centimeter above the groin crease. And then the critical thing is to preserve the subcutaneous fat. If you don't, if you start cutting, undermining this fat here, you'll get skin necrosis and wound breakdown. You cut down onto the campus fascia here, and the lymph nodes are in that fatty tissue between campus fascia and the fascia lata. So. It looks like we lost him. Hold on just a second. Well, send him an email. I don't know if gender, you probably don't have his phone number do I have. Okay, yeah, if you want to call him because he may not even know that we lost him. Yeah, thank you. Thank you. Yeah, I think you have dropped off. She'll have to send you another link or you have the link on the email. No problem. I'll see in a minute if you start speaking then we will know. No, we are not able to hear. No. Is the... Can you can you hear me now? Yeah, yeah, we can hear now. Yep, you're back. Yeah, we can hear now. Okay, all right. Oh, it looks like, oops. Oh, I think we lost him again. We can make, well, we'll see if it's going to say we can go to the case presentation while I work with him on, um, but we'll see. Yeah, it looks like you're dropped off again. Okay, thanks. He's trying again. Okay, no problem. No problem. There it is. Hello, can you hear me? Yes, perfect. Okay, sorry about that. So what I was saying, if you do the groin dissection this way, you'll usually get primary skin healing, but you'll certainly not avoid lymphocysts and they'll occur in 30 or 40% of patients. And you just need to make a one centimeter or so incision over it and drain those lymphocysts early and they will settle down quite quickly. The only patients that you can completely avoid a lymph node dissection on are those that have two centimeter tumors less than a millimeter. They've got virtually zero risk of lymph node metastases, but you see with even one to two millimeters is about a 7% risk of having lymph node metastases. Now in recent years, of course, the sentinel node biopsy has come into vogue for cancers that are unifocal and four centimeters or less in diameter. Most studies report false negative rates of between five to 10%. And most patients don't want to take the risk of dying because death from an undissected groin is, as you know, very common. About 90% of patients will die in this original paper from Van Der Zee. Six out of the seven died, but in subsequent follow-up all seven who recurred with a false negative died of disease. But fortunately more recently, the same group published this paper in 2008, showing the efficacy of ultrasound in the follow-up after negative sentinel node biopsies in women with vulva cancer. Now, I had been doing this type of work for a number of years and have picked up three patients. In this study, they suggested that you do the ultrasound every three months for two years. I was doing it every three months for one year. I picked up three cases. I picked up two in this study. All five cases were picked up within eight months. So I don't think it's important to do it for two years. I think 12 months is enough, but I do think it needs to be every two months, not every three, because in their study and also in my as yet unpublished study, there was one patient in each that presented with a palpable node. And once you get a palpable node, then it's very difficult to cure the patient. So in advanced cases, whether you've got an advanced primary, again, you need to decide what's the best treatment for the lymph nodes as opposed to the primary lesion. And I think the decision about the lymph nodes needs to be made first. If you've got a large primary lesion, but no palpable nodes, then that patient should have a complete groin dissection. If you've got palpably enlarged nodes, then you need to get a CAT scan of the pelvis and abdomen to make sure that there's no enlarged nodes in the pelvis. Patients with no palpable nodes in the groin are not likely to have any palpable nodes in the pelvis. So I think you can avoid a CAT scan in such patients, but if you've got enlarged nodes here, you do need to check that because there may well be palpably enlarged nodes in the pelvis and I think all enlarged nodes need to be resected and then bilateral groin and pelvic radiation. Next slide. And I stress it should be bilateral because in the early days, we had a patient who had positive nodes on the left side, negative nodes on the right, there were bulky nodes here. We thought we would just give unilateral groin and pelvic radiation, but unfortunately she had this retrograde spread and got this horrible scenario of cutaneous metastases on the contralateral side. So I would say definitely do not do unilateral groin and pelvic radiation, do bilateral groin and pelvic radiation if radiation is required. Now, who requires it? Well, certainly anybody with extra capsular spread, extranodal spread should get groin and pelvic radiation. Certainly anybody with three or more micro metastases you should receive it. I have always given it for one macro metastasis, but we recently contributed to a patient that Covan de Belden reported, I think in Kansas, where there was no advantage to any body who had one micro or macro metastasis as long as there was no extra capsular spread. So I'd say it certainly should be given to anybody with extra capsular spread and anybody with two or more positive nodes. The resection of the bulky nodes simply requires that you open up beneath the campus fascia and you feel around and take out anything that's enlarged. We don't do a full groin dissection. We've published these data and I don't believe you need to do a full groin dissection, but you need to take anything that's palpably enlarged out of the groin and you can get to the pelvis through the same incision. You just cut through the abdominal wall muscles, strip the peritoneum immediately and you can get to any enlarged nodes in the pelvis. Now, just a couple of examples of non squamous carcinomas. The commonest of these, of course, is the melanoma. Typically occurs on the labia minus, as you see here. And again, this does not need anything more than a radical local excision with at least one centimeter margins. And I think if the stromal invasion is greater than one millimeter, you should also do a unilateral groin node dissection on that side. Paget's disease of the vulva is an interesting condition. There's two types, primary Paget's disease, as you know, which is usually intraepithelial on the vulva as opposed to the breast. But it can be in 20% of cases, so associated with stromal invasion. So you need to excise the disease and carefully section it to make sure there's no stromal invasion. And it's sometimes a manifestation of an underlying adenocarcinoma of a skin appendage or subcutaneous vulva gland. And then the secondary Paget's disease, this is very uncommon in my experience. I've seen it, but it's very uncommon. Most cases, the primary Paget's, but it can be secondary to an anorectal adenocarcinoma, a urethelial carcinoma, or occasionally a manifestation of another noncutaneous adenocarcinoma, particularly endocervical, endometrial, or rarely, which I've never seen, ovarian. The, all patients I think should be considered to be at risk for an associated malignancy and any symptoms investigated. I think they all should have a cervical cytology. And if it involves the anus, I think the patient should have a colonoscopy. If it involves the urethra, I think they should have a cystoscopy. This is a patient, the next slide, which was treated as psoriasis for quite a long time without a biopsy. And I think this is a good example of the need to biopsy anything at all suspicious on the vulva. It, you can't be sure what you're dealing with unless you biopsy it. When a biopsy was done, it showed classical Paget's disease. And you can see it was then referred and we had to widely excise it and reconstruct the vulva, mainly with a split thickness skin graft. But there was no underlying disease here, but nevertheless it had become quite extensive and quite a problem to resect. This is Barton's land carcinoma, uncommon carcinoma. You can see the bulbs there on the right side. This really just needs a radical local excision of the gland and a unilateral groin dissection. But I think you need to add local radiation, vulva radiation, because it's very difficult to get good margins on these Barton's land carcinomas. I think you need to start dissecting reasonably well anteriorly so that you can get around the cancer with clear margins. You don't want to cut through cancer, but it's very difficult to even measure margins when you're not talking about skin margins. So I think the right treatment for all except very small vulva cancers is to do a radical local excision, do a unilateral groin dissection and give some adjuvant vulva radiation. And this is a triple treat, if you like. It's a varicose carcinoma anteriorly, differentiated VIN and lichen sclerosis. It's very difficult to do much with that, I think, except a radical vulvectomy or more radical around the varicose cancer, less radical, of course, just superficially remove the lichen sclerosis and the VIN. But it's difficult to know here what you're dealing with. So certainly a radical excision of most of the vulva I think would be important. These varicose cancers rarely go to glands, so there's no need to do a groin dissection. So I think in summary then, surgery for vulva cancers should ideally be centralized and individualized. Conservative vulvar resection with one centimeter margins is appropriate. I don't believe the papers that are suggesting this is not appropriate. I believe this is appropriate for unifocal T1 and T2 lesions. Emission of the groin node dissection is appropriate only for patients with stage 1A disease. Sentinel node biopsy should be performed for unifocal cancers less than four centimeters in diameter and patients with a negative sentinel node should be followed by groin ultrasound every two months for 12 months. If resection of advanced cancer would necessitate a stoma, primary RT or neoadjuvant chemotherapy should be performed, followed, in my opinion, by excision of the tumor bed and bulky nodes should be resected without need for complete groin dissection prior to bilateral pelvic and groin radiation. Thank you very much. Alert. Thank you. Thank you. Yeah, that was wonderful. Thank you so much. I don't know if anyone has so many comments or questions.

vulvar cancer

colposcopy

radical local excision

lymph nodes

adjuvant radiation therapy

surgical approaches