Let's talk a little bit today about the treatment of cancer of the vulva. This is a class, as we call it here in Brazil, called Beans with Rice. It is very objective and very practical. So it's for you to see something and move on with the conduct. You can interrupt me in the middle of the way, there is no problem with that. My name is André Lopes, you already know me. Beans with rice cancer in the world is considered a rare disease. It corresponds to about 4% of all female genital tract tumors. But it is a rare pathology in the world. It is not something that is very common to be found. And the vast majority of the types of vulva cancer are of the scar cell carcinoma, which corresponds to about 90% of all cases. The remaining 10% is divided into other pathologies, such as vascular carcinoma, basaloid, melanoma, and so on. It is so rare that in Brazil it is not even among the main types of women's cancer. But for you who are an oncologist, you will receive these cases. So it is mandatory that you have knowledge about vulva cancer. For you to have an idea, in the IBCC we receive about 10 to 12 cases per year. So it is a considerable number, given the rarity. In Mozambique I looked for this data, I did not find it on the internet, but I was very curious, because I believe that this proportion should be greater in relation to the number of cases of vulva. In all the missions we went to, we always had 1 or 2 cases of vulva. Later you could tell me a little bit about it. So it's about 4% of all genital aneoplasia. In the United States, there are an estimated 6,000 new cases. In Brazil, we do not have this number of cases of vulva cancer. It is a predominantly elderly disease, but this in the world in general. In Mozambique, the reality is different. We operated on very young patients, mainly because of HIV, HIV and HIV infections. And as I said, 90% corresponds to the case of sclerosis, which is by far the most frequent, and today's class is more focused on this type. Remembering that the other subtypes, you have to individualize the treatment. For example, melanoma. You do not treat melanoma in the vulva like vulva cancer, you treat it like melanoma. So the treatment is a little different. So you have to individualize the treatment. If I were to put it on a pizza chart, so you don't forget, 90% of sclerosis. Its etiology, mainly, is known in two ways of development of aneoplasia in the vulva. Then Mila corrects me if I'm wrong. And they are classified as associated HPV or independent HPV or not associated HPV. That's how they usually call it. So these patients who are HIV-independent are older patients, with a unifocal tumor, inflammatory vascular disorders, such as leaking. So it is very associated with leaking and sclerosis. And when you have associated HPV, it is usually in those younger patients, which are normally multifocal tumors, which are associated with that classic level. And it is usually associated with other neoplasies of the lower genital tract, such as NIC, colorectal cancer, or even colorectal cancer. The associated HPV is mainly caused by HPV-16. So keep in mind that the vaccine could greatly reduce the number of these cases. The diagnosis is done by physical examination. You are examining the patient, and you see a suspected injury in the vulva. And what are you going to do with this suspected injury? Nothing more than a biopsy. It is to get a pathological anatomy, in some way. Most of the time you can do this in the office with local anesthesia. Or you will do an incisional biopsy, if it is a very small injury. Incisional corresponds to completely removing the tumor, if it is a small injury. If it is a major injury, you will do an incisional biopsy. So with a little local anesthesia, you can do that. The study we used is from Figo. And pay close attention, especially in study 1. You see what is there. Study 1, tumor smaller than 2, and infiltration of a stroma smaller than 1 mm. Gustavo can correct later if I'm wrong. The depth of this is measured in millimeters. So you see it all there. You see the depth of the stromal invasion. And the rest is according to the invasion of adjacent organs. Study 2 is when it invades the vagina, or a little urethra. And 3 is when it has lymph nodes. 4 and so on. This principle of pathology is important. Because you have to see the size of the infiltration of the stroma, which is measured in millimeters. This also has a prognostic factor. The lines of dissemination are local-regional, that is, by contiguity. The tumor can grow, invade the urethra, anus, vagina. A large line of dissemination is also lymphatic. That's why we always have to look at the inguinal region. So the tumor can have drainage to the inguinal region. And the distance, which is less common, but it is possible, which is to the lung, lung and triceps. The prognosis depends on the stage you are diagnosing this patient. The earlier, the better. So this is a survival curve. It's good that you get used to these curves. So you see, this line at the top is the 1A clinical status. That is, the more initial you discover, the better. And for the vulva, this is well defined. In the preoperative evaluation, you will need a torso tomography, abdomen and pelvis. And if possible, a pelvic magnetic resonance. Because you can assess the relation of the tumor with other organs. That is, local-regional invasion, if possible, is also interesting. The treatment of cases confined to the vulva, we start with surgery and do radical or partial vulvectomy. You will see that we have done less and less today. Radical vulvectomy, we have done ample resection, vulva resection. And always evaluating the inguinal region in search of what we call lymph nodal status, which is to know how the lymph nodes are. If these lymph nodes are affected or not. Because this will imply an adjuvant treatment and also in the patient's prognosis. In some cases, we can also do the Sentinel. Let's see for whom. So you do the surgery, see the pathological anatomical factors, risk factors and lymph nodal status. And then you will decide whether or not to do an adjuvant treatment with or without chemotherapy. There is not much data on chemotherapy, but people end up extrapolating it in relation to the colorectal tumor and end up doing chemo too. It's a point of discussion. If the patient has a positive lymph node, there is no need for chemotherapy. If the margin was compromised, it is also necessary. These are factors that you will observe for this. And in cases where it is not possible to do the surgery, read those cases that need an exoneration right at the beginning, the one that invades straight, invades anus, invades bladder. In these cases, you can do a radiotherapy with or without chemotherapy. And then you will do a surgery, that is, a neoadjuvant radiotherapy. It is very important for you to know anatomy, especially from the external region of the vulva. Big lips, small lips, clitoris, anus, vagina. All this you need to study before doing a surgery. And also study the anatomy of the inguinal region that you are going to operate on. So, some principles of surgery. The most important principle is the margin. You have to give a margin free of this disease, otherwise it comes back. This is a very important prognostic factor. It is a margin to the naked eye, which we call in surgery, of at least one centimeter of the tumor in all directions, that is, radially. There are some works that say it has to be an 8mm margin, but this 8mm margin, correct me Gustavo later, is a pathological margin, that is, it is in the surgical piece. There are those who question this whole margin, but the classic is this. And you will only do free margins less than 8mm, if necessary, in some more sensitive areas, such as the rectum or anus. Sometimes you can only give half a centimeter of margin in the urethra, but if you can preserve the urethra, it's worth it. You will not extend the margin to the urethra, because of a free margin that you already have, even if it is less than 8mm. These are important concepts. So, we used this partial ambovectomy. You have a very small injury, and you have drawn a centimeter of radial margin on the entire edge of the tumor. So, you can do this. These are large surgeries, you end up having to remove a considerable piece of tissue from these patients. So, that's what you need to do with the margin. You delimit the margin, and remove the skin and subcutaneous tissue, which is below the vulva. This, fortunately, is a very small tumor. You see that it is also far from the average line, at least 1.5 to 2 cm. This is also important. I'll talk about this later. So, you incise the skin, incise the subcutaneous tissue, and remove it, up to the muscle layer, the muscle face down there. So, you need to remove all this subcutaneous tissue that is below the vulva. So, radical vulvectomy is when you remove the entire vulva. There are some cases in Mozambique that we operated on. So, when you remove everything. And the other, when you remove less, is the partial vulve. For these cases, you see that the margin is very important. So, you have to remove the piece, the margin around it, the free margin. And you don't always manage to close this defect. And the big step, in addition to the surgery of the vulva, is the rotation of the reticles, so that you can close this defect. There are some reticles that you can use, which is the VY. I've already seen Ciro doing some. There are some rotation reticles, which is a type of lotus petal, or myoclutans, which are gluteus, gracilis, etc. But these details, you need to have some ideas when making these details. For example, you have to understand that you have to preserve the urinary function. In patient evacuations, you see that it is an area that needs a lot of care. You need to preserve the sexual function, which is often in younger patients. You have to understand this microenvironment. Because it is an area that the patient will use for urine, for feces. So you have to avoid, as much as possible, the problem of the essence of wounds. You have to think about this when you choose your reticle. Also in the morbidity of the place of pain, of the receptor of the reticle. You also have to be concerned about the movement of the inferior extremity, depending on where you remove this reticle. Maybe the patient has a little difficulty walking. And also see the aesthetic result of the patient's body image. Remember that many of these patients have new images that still worry a little about the self-image. So you have to take care of all this when you think about which reticle you will do. So you have several options. This is a rotation reticle. You see a smaller tumor that makes a reticle that literally rotates. So you have several options to do. Or advanced reticles, like this one, which is a patient from Mozambique. Remembering that this area that you are going to insert must be at least three times the length of the reticle. So if you have this area that needs to be covered, the reticle must have a length of at least two to three times this area. So this is how advanced reticles are made. And these are relatively good results that we achieve. This is a patient who had already done a previous radiotherapy. He ended up needing to run a GLUT. It is a much larger surgery. But these are surgeries that are possible to be done. In vulva, the problem is to close the defect. In relation to lymphadenectomy and gluten, there are two basic things that you have to understand in vulva. It is vulvectomy and lymphadenectomy. And why do I need to do lymphadenectomy? Because the answer is simple. If a patient recidivates in a region in the glute, and this region in the glute was not previously explored, this corresponds to the death of this patient. That is, a lymphadenectomy in vulva cancer is similar to death. And studies have shown that if you omit this lymphadenectomy, this ends up being a very important prognostic factor. That is, the patient will stop doing a treatment that she could have done, and if she recidivates, she will die, most likely. In the past, that incision was made in the aspergillus, which removed the lymph nodes and the vulva in a monoblock. Nowadays we don't do that anymore, we use separate incisions, even to have a better healing. Centinela can be used for tumors up to 4 cm. And remembering that lymphadenectomy is not necessary for T1 tumors. See what I said in the beginning of the class, that a tumor with up to 1 mm of invasion, this patient does not need to have a lymphadenectomy. So you will not have positive lymph nodes in the case of T1A, which are tumors up to 2 cm, and an invasion of trauma of 1 mm. And we can do a unilateral lymphadenectomy if the tumor is very lateral in the vulva, that is, if it is at least 2 cm from the middle line. If it is less than 2 cm from the middle line, you will need to explore the two regions and gynae. So a little bit of incision technique. This is a photo of Berek, but it's more or less what I use to do it here. You will make the incision using the public tubercle and the upper anterior crystalline. To match these two reference points, which correspond to the gynal ligament, around 2 cm below this imaginary line, you will make this incision. On the right or left side, or whatever you need. And remember that when you are deepening, you will find the camper face. So you will need to dry under the camper face. Why is this important? Because if you don't, you leave this rectum of the gynal region very thin, with little fat. So there may be necrosis of this rectum if you don't leave this rectum with some fat. So you have to be careful with that when you do the lymphadenectomy in the gynal. In the gynal lymph nodes, if there is a macroscopically coarse lymph node, palpable, or seen in the resonance, in the tomography, you will have to remove these bulk lymph nodes. And in relation to the sentinel, the concept of the sentinel does not apply to this type of lymph node, that is, you use the sentinel when you have normal lymph nodes. So what is the sentinel? It is defined as the first lymph node in a primary tumor drainage pathway. The hypothesis is that this is the most likely place to receive metastasis of the lymphatic chain, that is, it is the tumor that is the first, the guardian of the lymphatic drainage of the tumor. This is a photo of one that we used in the green of the oceanina, in the sentinel. This is available, but not always. The green is available in every corner. Currently, the most used are the green, the patent blue, which is not methylene blue, the patent blue has a greater tropism for the lymphatic vein, and the teckness. Sometimes we have used more teckness. So I use the blue one. The injection is done near the tumor. You can divide it into four 1mm or 1ml or 2ml sentinels, and you inject near the tumor and investigate it in the inguinal region. For the green, you will need a special equipment, which is expensive, even here in Brazil. Not even the Pataculani Hospital, they all have it here. It is better than the blue, but you will use what you have. Even in the IBCC, we use the blue. This is a photo of how it looks with the green of the oceanina in the equipment. This is the inguinal region of the tumor. The aesthetic results are very satisfactory for those who use the lymph node of the sentinel. You can see that the incision is very small. It was a central tumor, which unfortunately caught the clitoris. But the aesthetic result was satisfactory. So the type of surgery we do today is much smaller than it used to be. And be very careful when doing the lymphadenectomy, because patients can have lymphedema, which is an affliction for the rest of their lives. Finishing with the last slide, which are important considerations to have here in the vulva cancer. If you didn't pay attention, wake up. The important thing is that there is an individualization of the treatment. You can do a conservative surgery in the vulva. Lymphadenectomy in T1A tumors is not necessary, that is, those very initial tumors. It is also not necessary to do pelvic lymphadenectomy in the vulva cancer, pelvic lymphadenectomy is already considered half the distance. Unilateral lymphadenectomy in the vulva, in tumors that are more than 2 cm from the middle line, uses separate incisions. For those tumors that are irreversible, you can start a pre-operative radiotherapy, and you can also start a post-operative radiotherapy, which increases the chance of survival and decreases the chance of recidivism in those patients who have indication. And you can use the Centinella lymph node. So I'll stay here to answer the questions. I hope I haven't left the subject for too long.

cancer of the vulva

squamous cell carcinoma

vulvar cancer

diagnosis and treatment

surgical techniques