Vulvakarzinom State of the Art
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Vulvakarzinom State of the Art Elmar A. Joura Universitätsklinik für Frauenheilkunde Wien Obergurgl, 6.2.2017 Vulvakarzinom- Ätiologie } HSIL Vulväre Intraepitheliale Neoplasie (VIN) } Lichen sclerosus } dVIN LS - Morphologie HSIL/dVIN – p16/p53 HSIL– p16 Horn et al., 2011 differenzierte VIN – p53 Vulvar HSIL Trends in Vulvar Neoplasia HSIL (VIN 3) Austria Joura et al., J Reprod Med 2000 Trends in Vulvar Neoplasia SCC: bimodal age-distribution n Joura et al., J Reprod Med 2000 Epidemiologie Incidence of vaginal and vulvar cancers after CIN 3 Vaginal cancer Edgren G et al, Lancet Oncology 2007 Vulvar cancer HPV in Vulvakarzinomen Sanjose 2013 HPV in Vulvakarzinomen Sanjose 2013 HPV in Vulvakarzinomen Sanjose 2013 ICC n=429 VIN n=509 0,4 10,4 2,5 9,2 HPV 16 HPV 18 77,3 HPV 33 3,3 6,5 4,6 13,1 HPV 16 HPV 18 72,5 HPV 33 HPV 45 HPV 45 Sonstige Sonstige HPV und p16 positiv HPV status and favorable outcome in vulvar squamous cancer Wakeham K et al, November 2016 Primärprävention qHPV: Efficacy against vulvar/ vaginal precancers End of study results (4 years) PPEpopulation (PooledanalysisP007,013and 015,16-26ywomen,upto4y follow-up,N=18,150) Gardasil® n=9,075 n Placebo n=9,075 Prophylactic Efficacy (%) 95%CI Cases n Cases VIN2/3,VaIN 2/3orworse 7,900 0 7,902 23 100 82.6,100.0 VIN2/3 7,900 0 7,902 13 100 67.2,100.0 VaIN2/3 7,900 0 7,902 10 100 55.4,100.0 HPV6/11/16/18-related Joura,EAetal.Lancet2007,KjaerSetal.CancerPrevRes2009 15 HPV 31/33/45/52/58 Vaccine Efficacy Per-Protocol Efficacy Population- end of study Endpoint 9vHPV n qHPV n Vaccine Efficacy All CIN 2 / 5949 110 / 5943 98.2% (93.7, 99.7) > CIN2 1 / 5949 35 / 5943 97.1% (83.5, 99.9) > CIN3 0 / 5949 7 / 5,943 100% (39.4, 100) All VIN,VaIN 1 / 6009 18 / 6012 94.4% (67.7, 99.7) 3 / 6012 100.0% (-71.5, 100) > H- VIN,VaIN 0 / 6009 Joura et al, SGO 2015 Sekundärprävention Klinische Diagnostik Klinische Diagnostik VIN und Biopsie } 2%-iges Lidocain mit Epinephrin 1:100.000 } 4mm Stanzbiopsie } Diagnose nur durch Histologie } Forensischer Aspekt Operative Therapie des Vulvakarzinoms Vulvar Cancer Stage I Local radical Excision vs. Radical Vulvectomy OP n recurrence DOD 165 7.2% 0.6% Vulvectomy 365 6.3% 0.6% Excision P=0.85 Free margins >10mm are adequate! Hacker & Van der Velden, Cancer 1993 Lappenrekonstruktion } } Primär irradiiertes N. vulvae V-Y flap Nodal Status and Survival FIGO LN - LN+ n I&II 98% 44% 108 III 70% 27% 57 Total 92% 32% 165 Morley et al. 1976 AGO-CaRE-1: Nodal status- OS Mahner S et al, JNCI 2015 Ausmaß der Lymphonodektomie Role of tumour-free margin distance for locoregional control in vulvar cancer Wölber L et al, Eur J Cancer 2016 Ausmaß der Lymphonodektomie Sentinel Node Dissection is Safe in the Treatment of Early-Stage Vulvar Cancer } } } Multicenter observational study 2000-2006 } TC + blue dye, 623 groins of 403 assessable patients. } 259 patients: unifocal tumor + negative sentinel node } median follow-up time 35 months six groin recurrences (2.3%; 95% CI, 0.6% to 5%) 3-year survival 97% } wound breakdown groin: 11.7% v 34.0%; P<.0001 cellulitis: 4.5% v 21.3%; P<.0001. recurrent erysipelas: 0.4% v 16.2%; P<.0001 } lymphedema of the legs: 1.9% v 25.2%; P<.0001). } } Van der Zee et al., Journal of Clinical Oncology 26;2008:884-9 AGO-CaRE-1: Sentinel Klapdor 2016 Sentinel Node and Vulvar cancer Sentinel Tumor Sentinel Node ICG – Sentinel inguinal ICG – Sentinel inguinal ICG – Sentinel inguinal ICG – Sentinel inguinal ICG – Sentinel inguinal ICG – Sentinel inguinal Sentinel- Lymphonodektomie Adjuvante Radiotherapie Adjuvante Radiotherapie Adjuvante Radiotherapie AGO-CaRE-1: study population AGO-CaRE-1: Adjuvant treatment-N+ AGO-CaRE-1: PFS- nodal status Nachsorge Nachsorge Nachsorge Vulvakarzinom - Conclusio } Prävention } } } Prognose } } HPV- Impfung Management des Lichen sclerosus Abhängig vom Lymphknotenstatus Reduktion der Radikalität } } } } Sentinel Knappe Resektion Gleiche Sicherheit - Bessere Lebensqualität Sexuelle Funktion Herzlichen Dank für Ihre Aufmerksamkeit! Courbet: L‘origin du monde