Transcript Cervical and Vulvar Carcinoma

GYNECOLOGIC
CARCINOMAS
CHRISTOPHER P. DESIMONE, M.D.
ASSOCIATE PROFESSOR
DIVISION OF GYNECOLOGIC ONCOLOGY
OUTLINE
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Endometrial Carcinoma
Ovarian Carcinoma
Cervical Carcinoma
Vulvar Carcinoma
• Epidemiology
• Clinical symptoms
• Risk factors
• Diagnosis
• Staging
• Treatment
ENDOMETRIAL CARCINOMA
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Most common gynecologic malignancy
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4th most common malignancy among women
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Estimated 52,630 new cases per year in the United States
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1 in 38 women will develop this cancer
7th most common cause of malignancy related deaths among
women
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8,590 deaths annual from endometrial cancer
Seigel et al. CA J Clin. 2014
CLINICAL TYPES OF ENDOMETRIAL
CANCER
• Type one occurs in obese women with hyper-estrogenism.
Tend to have diabetes, hypertension and hyperlipidemia
as co-morbid medical conditions
• Pathology tends to be well to moderately differentiated,
superficially invasive and has a good prognosis (85%
five year survival)
Bokhman, Gynecol Oncol. 1983
CLINICAL TYPES OF ENDOMETRIAL
CANCER
• Type two occurs in elderly thin women who have no signs
of hyper-estrogenism.
• No clear pathway causing carcinoma other than genetic
and cellular mutations
• Pathology tends to be poorly differentiated with deep
invasion, lymph node metastasis and poor prognosis
(58% five year survival)
Bokhman, Gynecol Oncol, 1983
SYMPTOMS
• Postmenopausal bleeding (90%)
• Back pain
• Vaginal discharge
• Unusual but can happen…
• SOB (multiple pulmonary metastases)
• CNS symptoms (isolated cranial metastasis)
RISK FACTORS
• Nulliparous
• Late menopause
• Diabetes
• HTN
• Obesity >30lbs
• Obesity >50lbs
• Unopposed estrogen
MacMahon, Gynecol Oncol 1974
2x
2.4x
2.8x
1.5x
3x
10x
9.5x
ESTROGEN STIMULATION
• Adipose converts androstenedione into estrone, a weak
estrogen
• Increased adipose correlates into increased estrone levels
• estrone causes proliferation of endometrial cells
• Prolonged estrone exposure causes endometrial
carcinoma
DIAGNOSIS
• Endometrial biopsy
• Dilatation and curettage (D&C)
• 90% accuracy in detecting endometrial cancer
• Vaginal ultrasound
• Endometrial thickness (ET) evaluated in 205 postmenopausal
women
• No cancers detected with an ET < 5 mm
• PPV 87%, Sensitivity 100%, Specificity 96%
Granberg et al. Am J Obstet Gynecol. 1991.
TREATMENT
• Surgery
• Hysterectomy, bilateral salpingo-oophorectomy, pelvic and para
aortic lymphadenectomy and pelvic washings
± adjuvant treatment
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Radiation
• Reserved for women who have an absolute contraindication to
surgery
• Hormonal
• Progestin therapy
• Best for women who want to preserve fertility
ENDOMETRIAL CANCER
SURGICAL STAGING
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IA
IB
tumor invasion < ½ myometrium
tumor invasion > ½ myometrium
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II
cervical involvement
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IIIA
IIIB
IIIC1
IIIC2
+ pelvic cytology, adnexa or uterine serosa
parametrial or vaginal involvement
pelvic lymph node involvement
para-aortic lymph node involvement
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IVA
IVB
rectal or bladder mucosa involvement
inguinal node involvement, intra abdominal disease
or distant metastasis
PROGNOSIS BY STAGE
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IA
IB
88%
75%
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II
69%
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IIIA
IIIB
IIIC
58%
50%
47%
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IVA
IVB
17%
15%
ACS Webpage 2013
LYMPH NODES
• Two schools of thought among GYN/Oncologists
regarding pelvic lymphadenectomy for endometrial
adenocarcinoma:
• Everyone receives a pelvic lymphadenectomy and para aortic
lymph node sampling or…
• Selective lymphadenectomy for high-risk patients
LYMPH NODES
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University of Kentucky is conducting a trial regarding lymphadenectomy
for endometrial cancer
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Our division favors selective lymphadenectomy
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Both studies did show an increase in Stage III disease (~10%) which did
change post-operative treatment
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One of the studies showed significantly more early and late post
operative morbidity in patients undergoing lymphadenectomy (late
morbidity – lymph edema)
Two European randomized trial revealed no significant difference in OS
with pelvic lymphadenectomy
UNIVERSITY OF GYNECOLOGIC
ONCOLOGY POSITION ON PELVIC
LYMPHADENECTOMY
• No lymphadenectomy
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Small tumors < 2 cm and…
Grade 1 or 2 adenocarcinomas and…
Less than ½ myometrial invasion on frozen section
< 5% risk of positive lymph nodes
• Pelvic Lymphadenectomy and para aortic lymph node sampling
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Large tumors > 2cm and/or…
Grade 3 adenocarcinoma and/or…
Greater than ½ myometrial invasion
10-35% risk of positive lymph nodes
• Caveat: multiple studies evaluating preoperative imaging have failed to reliably predict
myometrial invasion
ILIAC LYMPH NODES
OBTURATOR LYMPH NODES
ADJUVANT TREATMENTS
• Pelvic radiation (brachytherapy and external beam) is used for
adjuvant therapy
• Use of adjuvant radiation is stratified according to the stage of the
patient.
• High risk groups (Stages: III, IV) are at an increased risk for local and
distal recurrences. Adjuvant pelvic radiation and chemotherapy is
universally recommended
• Intermediate risk groups (Stage IB, II) are treated with pelvic
radiation according to risk factors
• Age, grade, lymph vascular space invasion, depth of myometrial invasion
RADIATION
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Stages IB, II frequently receive adjuvant radiation
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Side effects include
XRT decreases significantly decreases pelvic recurrence
XRT does not change disease specific survival (it has little
impact on distal disease)
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Diarrhea
Pain
Vaginal stenosis
ADJUVANT CHEMOTHERAPY
• Used with Stage III, IV endometrial cancer.
• Carboplatin, Taxol ± Adriamycin are used
• Current trend is to incorporate pelvic radiation with
the chemotherapy
• Common side effects include
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Fatigue
Neuropathy
Myelosuppresion
Alopecia
RECURRENCES
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Vaginal recurrence is the most common, next pulmonary
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70% of patients with isolated vaginal recurrences can be
salvaged with XRT
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Isolated distal recurrences (pulmonary) can be surgically
managed
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Otherwise distal disease is uniformly fatal
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Combination chemotherapy can improve disease free interval
OVARIAN CANCER
• Epithelial ovarian cancer statistics
• 21,980 new cases a year in the United States
• 14,270 women will die each year
• 5th most common cause of cancer related mortality among
women
• Peak incidence at age 65-85
• Slowly decreasing in incidence since the mid 1980’s
Seigel et al. Ca J Clin. 2014
SYMPTOMS
• Nebulous, Vague and Insidious
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Abdominal swelling or fullness
Early satiety
Dyspepsia
Urinary frequency
• By the time these symptoms elicit an exam or radiologic evidence of
disease, 80% of women will be diagnosed with stage IIIC disease
RISK FACTORS
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Northern European descent/ Ashkenazi Jews
Nulliparous
Late menopause
Infertility
Talc
Hereditary (10% of all epithelial ovarian cancer)
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Birth control pills decrease the risk of ovarian carcinoma by
50%
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BRCA 1 & 2
HNPCC
DIAGNOSIS
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Excision and pathologic evaluation (gold standard)
Vaginal ultrasound
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UK ovarian ultrasound experience (asymptomatic women)
89 cancers among 35,000 screenings
Sensitivity 86%, Specificity 70%, PPV 10%
CA 125
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Laughable
50% of stage I cancers do not have elevated CA 125’s
Endometriosis, PID, hepatitis, CHF all cause false positive results
TYPES OF OVARIAN CANCER
• Epithelial
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• 80-90% of all ovarian cancers
• Affects women 65-85
• Papillary serous histology most common
Germ Cell
• 10-15% of all ovarian cancers
• Affects women 10-30
• Highly curable
Sex-cord Stromal
• Rare
• Produce estrogen or testosterone
• Usually cured with surgery
TREATMENT
• Surgery followed by adjuvant chemotherapy
• Neoadjuvant therapy followed by interval debulking
• Surgery- Hyst/BSO, omentectomy, ± colon or bowel resection,
pelvic lymph nodes
• Aim to optimally debulk the patient leaving all remaining tumor
less than 1 cm
OVARIAN CANCER
OVARIAN CANCER
OVARIAN CANCER
OVARIAN CANCER
OVARIAN CANCER
STAGING
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I - limited to the ovary
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II - pelvic extension
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III – abdominal extension
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IV – distant metastasis
• IVA- malignant pleural effusion
• IVB- Hepatic or splenic parenchyma, distal spread outside the abdomen
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IA one ovary (capsule intact, no tumor on surface, negative cytology)
IB both ovaries
IC1 surgical spillage
IC2 spontaneous rupture, tumor on surface of ovary
IC3 positive cytology
IIA extension to uterus/tubes
IIB other pelvic intraperitoneal tissues (bladder/colon serosa)
IIIA1- positive retroperitoneal lymph nodes
IIIA2 - microscopic seeding of abdominal peritoneal surfaces
IIIB - abdominal implants < 2 cm
IIIC - abdominal implants > 2 cm
SURVIVAL BY STAGE – OLD
CLASSIFICATION
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IA
IB
IC
94%
90%
81%
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IIA
IIB
IIC
76%
67%
57%
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IIIA
IIIB
IIIC
45%
39%
35%
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IV
18%
ACS website 2013
FACTOIDS
• 80% of all epithelial ovarian cancers are diagnosed as
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stage IIIC
Occult stage I ovarian cancer is upstaged 30% of the
time to stage IIIC when lymph node sampling is
performed
Patients with microscopic residual disease do better than
patients with ≤ 2 cm residual disease than patients with >
2 cm of residual disease (4 year survival rates 60%,
35%, <20%)
CHEMOTHERAPY
• Gold standard following debulking surgery is Taxol and Carboplatin
• Response rate of 80%
• Tumors resistant to this combination are refractory to most other types
of chemotherapy
• Despite this therapy, 70% of patients with Stage III disease will recur
• 100% of patients who have recurrent ovarian cancer will die from
their disease
BETTER BULLET
• New combinations of chemotherapy (Carboplatin/Taxol
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and Avastin)
Intraperitoneal chemotherapy offers a survival
advantage for optimally debulked ovarian cancer
Dose Dense Chemotherapy (weekly Taxol) also has a
survival advantage over traditional therapy
Both IP and dose dense chemotherapy have higher
morbidity than standard therapy
New agents
RECURRENT DISEASE
• Chronic disease
• Salvage chemotherapy (Doxil, Gemzar, Taxotere, etc)
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most utilized
Most produce clinical responses, thereby, keep patients
alive longer
Women living on average 4 to 5 years with ovarian
cancer
Some live 8 to 9 years with the disease
Inevitably, the cancer becomes resistant to chemotherapy
and the patient dies of bowel obstruction and malnutrition
CERVICAL CANCER
• 3rd most common cancer among women world wide
• Estimated 475,000 new cases
• 250,000 deaths annually worldwide
• 12th most common cancer among women in the United
States
• Estimated 12,360 new cases each year
• 4,020 deaths annually from cervical cancer
Seigel et al. Ca J Clin, 2014.
WHO DEVELOPS CERVICAL CANCER?
• 50% of women diagnosed with cervical cancer have
not had a Pap test in 5 years
• 25% of all cervical cancers are diagnosed in women
older than 65
• In women older than 65, it is estimated that over
50% have not had a Pap test in the past 10 years
• Bottom Line – the majority of women with cervical
cancer fail to get annual Pap tests
SYMPTOMS
• Early stages
• Vaginal bleeding
• Post coital spotting
• Foul smelling, yellowish discharge
• Late stages
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Back pain
Lethargy
Nausea/vomiting
Most symptoms attributable to renal failure from ureteral
obstruction
CLASSIC RISK FACTORS FOR CERVICAL
CANCER
• Early first age of sexual contact
• Multiple sexual partners
• Smoking
• Multiple sexually transmitted diseases
• Immunocompromised
• Lower socio-economic class
• Family history is not a risk factor
MAIN RISK FACTORS FOR CERVICAL
CANCER
• Human papillomavirus (HPV) is the cause of cervical
cancer
• Estimated that 80% of men and women will have been
exposed to the virus by the age of 50
• Smoking is an important cofactor for malignant
transformation
HPV AND CERVICAL CANCER
• Bosch et al in 1995, accrued 932 cases of cervical
cancer from around the world
• Using polymerase chain reactions (PCR), his group
amplified HPV DNA from the tumor and recorded their
findings
• 93% of cervical carcinoma had HPV DNA
• Common types included 16, 18, 31, 33, 35, 39, 45, 51
(high risk HPV subtypes)
Bosch et al. J Natl Cancer Inst, 1995
HPV AND CERVICAL CANCER
• Walboomers et al. repeated Bosch’s experiment using
new PCR primers
• Those cancers that failed to test positive for HPV DNA
were retested with these new primers
• Results showed that 99.7% of Bosch’s original cases
tested positive for HPV DNA
Walboomers et al. J Pathol, 1999
INCIDENCE OF HPV
• 608 college aged women studied from 1992-1994
• Followed 3 years at 6 month intervals
• Incidence of infection 43%
• Median duration of any HPV infection, 8 months
• 70% cleared in one year, 90% in two years
Ho et al. NEJM 1998
RISK FACTORS FOR HPV
• African American and Hispanic races
(RR 4.4 and 2.1)
• Etoh consumption > 4 times a month
(RR 2)
• > 2-3 sexual partners in one year
(RR 3)
• > 6 sexual partners of main regular partner (RR 10.1)
Ho et al. NEJM 1998
HPV AND CERVICAL DYSPLASIA
• Persistent HPV more likely to progress to cervical
dysplasia
• High risk types take longer to clear (Median of 12 month)
• Women infected with high risk types documented at two 6
month visits were 38 times more likely to develop
dysplasia
Ho et al. NEJM 1998
HPV AND ONCOGENESIS
• Viral DNA E6 and E7 believed to be
crucial in stimulating cellular proliferation
• E6 acts by inhibiting p53 which is a crucial
cell protein involved in programmed cell
death (apoptosis)
• E7 acts by binding the retinoblastoma (Rb)
protein
• Once bound, Rb releases E2F transcription
factor which causes cellular proliferation
• Combined they inhibit the regulatory
mechanism for apoptosis while stimulating
the cell to proliferate
HPV AND SMOKING
SMOKING AND HPV
• Prior to understanding the role of HPV in cervical cancer,
studies which focused on smoking as a risk factor were
often contradictory
• Once stratified for HPV status, many recent studies have
shown that smokers with HPV are more likely to develop
cervical cancer and CIN 3
SMOKING AND ONCOGENESIS
• Two probable causes for oncogenesis
• Accumulation of carcinogens from tobacco smoke in cervical
mucous
• Decreased host immune system
•
Decreased T cells more likely to lead to uncontrolled cell growth
SMOKING AND CERVICAL CANCER
• Plummer et al. and the IARC performed a case-
control study to determine if smoking was a cofactor
for progression of HPV to cancer
• Included:
• 1463 squamous cell carcinomas
• 124 adenocarcinomas
• 211 CIN 3 cases
• 254 control women
• Only women positive for HPV DNA were included
Plummer et al. Cancer Causes Control, 2003
SMOKING AND CERVICAL CANCER
• Results:
• ever smoking and HPV had an OR 2.17 (95% CI 1.46-3.22)
• Stronger risk for squamous cell carcinomas OR 2.3 (95% CI
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1.31-4.04)
Ex-smokers also had an increased risk for developing squamous
cell carcinoma, OR 1.8 (95% CI 0.95-3.44)
No increased risk for smoking and adenocarcinoma
STAGING OF CERVICAL CANCER
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Clinically staged (at least partially)
Stage I is confined to the cervix
• IA1 (microinvasive disease)
• Stromal invasion ≤ 3 mm and lateral spread ≤ 7 mm
• IA2
• Stromal invasion 3-5 mm and lateral spread < 7 mm lateral spread
• IB1
• Clinically visible lesion ≤ 4 cm
• IB2
• Clinically visible lesion > 4cm in greatest dimension
STAGING OF CERVICAL CANCER
• Stage IIA- Upper 2/3 of vagina
• IIA1- visible lesion ≤ 4 cm
• IIA2- visible lesion > 4cm
• Stage IIB
• Parametrial involvement
• Stage IIIA
• Lower 1/3 of vagina
• Stage IIIB
• Pelvic sidewall or hydronephrosis
• Stage IVA
• Rectal or bladder mucosa
• Stage IVB
• Distant disease
CERVICAL ANATOMY
CELL TYPES
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Squamous (90%)
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Large cell non-keratinizing
Adenocarcinoma (10%)
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Large cell keratinizing
Incidence is increasing ~30%
Adenosquamous
Small cell
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Neuroendocrine tumor
SURVIVAL RATES
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IA
93%
IB
80%
IIA
63%
IIB
58%
IIIA
35%
IIIB
32%
IVA
16%
IVB
15%
ACS website, 2013
STAGE IB1 CERVICAL CANCER
TREATMENT
• Surgery is reserved for early staged cervical cancer
• Stage IA1
• Cervical cone
• Hysterectomy
• Stage IA2, IB1 and IB2
• Radical hysterectomy
RADICAL HYSTERECTOMY
• Objective is to remove tissue adjacent to the uterus
• Parametrial tissue
• Complete pelvic lymphadenectomy (internal, external, common
iliac nodes and obturator nodes)
• Upper 2 cm of the vagina
• Higher morbidity than a simple hysterectomy
RADICAL HYSTERECTOMY ANATOMY
RADICAL HYSTERECTOMY ANATOMY
RADICAL HYSTERECTOMY ANATOMY
TREATMENT
• Stages II-IVB receive radiation (XRT) and chemotherapy
• XRT given in two phases
• 1st 5-6 weeks of external beam radiation
• Total dose 45 to 50 Gy
• Or 180 to 200 cGy each day
• Cisplatin 40 mg/m2 Q week
• 2nd Brachytherapy
• HDR or LDR
• Positions a radioactive implant adjacent to the carcinoma
CHEMORADIATION
Study
Stage
N
Treatment
GOG #85
Whitney et al
IIb-IVb
-PALN
177
EB+BT+ Cisplatin 50 mg/m2
5- FU 1000mg/m2
199
EB+BT+ Hydroxyurea 80mg/kg
2× week
176
EB+BT+ Cisplatin 40mg/m2
week
173
EB+BT+ Cisplatin 50 mg/m2
5-FU 1000mg/m2
Hydroxyurea 2gm/m2
177
EB+BT+ Hydroxyurea 3gm/m2
195
EB+BT+ Cisplatin 75 mg/m2 (D1) Q 3 weeks ×2
5-FU 1000 mg/m2 (D2-5)
193
EB+BT
183
EB+BT+ Cisplatin 40 mg/m2 week + hysterectomy
186
EB+BT+ hysterectomy
127
EB+ Cisplatin 70 mg/m2 (D1)
5-FU 1000 mg/m2 (D2-5)
116
EB
GOG #120
Rose et al
RTOG #9001
Morris et al
GOG #123
Keys et al
GOG #109
Peters et al
IIb-IVb
-PALN
Ib-IVa
Ib-IIa
Ia2-IIa
s/p
RAH
(D1, 29)
(D2-5 & D30-33)
Follow up
Median 3
year
Survival
(%)
Significance
8.7 years
67
OS p=0.018, RR 0.74
57
35 months
(D1, 22)
(D2-5 & D23-26)
2× week
2× week
65
OS p=0.004, RR 0.61
65
OS p=0.002, RR 0.58
47
43 months
75
OS p=0.004, RR 0.59
63
36 months
83
OS p=0.008, RR 0.54
74
Q 3 weeks ×2
42 months
87
77
OS p=0.01, RR 0.49
ADVANCED/ RECURRENT DISEASE
• Main stay is chemotherapy
• Advanced (IVA & IVB) palliative XRT and chemo
• Recurrent- chemotherapy
• Cisplatin/Taxol/Avastin
ACOG RECOMMENDATIONS FOR HPV
VACCINATION (CERVARIX OR GARDASIL)
• Target age 11-12 (Males and Females)- Cervarix is only approved for women
• Females as young as 9 may receive HPV vaccination
• Vacination is nearly 100% effective in preventing CIN2, CIN3, and VIN
• Prevelance
of vaccine-type HPV has decreased 56% among females aged 14-19 years
since 2006
• Vaccination
is recommended to females age 13-26 to catch up missed vaccine or to
complete the series
• Vaccination
is not currently recommended for women over the age of 26 or pregnant women
(Category B)
• Vaccination is acceptable for lactating women
• Sexually
active women or women with cervical dysplasia/genital condyloma can receive
vaccination
• Screening for cervical cancer should continue in both vaccinated and unvaccinated women
ACOG CO #588, 2014.
VULVAR CANCER
• 4850 new cases each year in the United States
• 1030 deaths each year in the United States
• Commonly presents at age 70-80
• Most common cell types:
• Squamous (90%)
• Melanoma (6%)
• Basal Cell (3%)
Seigel et al. CA J Clin. 2014
SYMPTOMS
• Pruritis
• Mass
• Pain
• Bleeding
• Ulceration
45%
45%
23%
14%
14%
• Patients delay medical care by 8 to 12 months
• Physicians delay biopsy by 6 to 10 months
RISK FACTORS
• Multiple sexual partners
• Prior abnormal Pap tests
• Genital condyloma
• Poor socioeconomic class
• Smoking
• Human papillomavirus
• Associated with 60-70% of squamous vulvar carcinoma
Hording et al. Gynecol Oncol, 1994
STAGING
• Stage I
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Tumor confined to the vulva
Stage IA- lesions ≤ 2 cm in size with stromal invasion ≤ 1 mm
Stage IB- lesions > 2cm or with stromal invasion > 1 mm
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Stage II
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Stage III Tumor of any size with or without extension to adjacent structures (⅓ lower urethra, vagina, anus) and
with positive inguino-femoral lymph nodes
Tumor of any size with extension to adjacent structures (⅓ lower urethra, vagina, anus)
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Stage IIIA- 1 lymph node (≥ 5mm) or 1-2 lymph nodes (< 5mm)
Stage IIIB- 2 lymph nodes (≥ 5mm) or 3 lymph nodes (< 5mm)
Stage IIIC- with positive nodes with extracapsular spread
Stage IV Tumor invades other regional (⅔ upper urethra and vagina) or distant structures
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Stage IVA- tumor invades any of the following:
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(i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa or fixed to pelvic
bone
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(ii) fixed or ulcerated inguino-femoral lymph nodes
Stage IVB- any distant metastasis including pelvic lymph nodes
2010 FIGO Staging system
TREATMENT
• Surgical excision mainstay of therapy 95%
• Lateral lesions are removed (radical hemivulvectomy)
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along with the ipsilateral inguinal lymph nodes
Central lesions are removed (radical vulvectomy) with
bilateral superficial inguinal lymph nodes
Patients with positive inguinal lymph nodes receive EB
radiation to the groin (45 Gy)
RADICAL HEMIVULVECTOMY
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
VULVAR EXCISION FROM START TO
FINISH
LARGE VULVAR EXCISIONS
• Flap placement is often required to close large defects
• V to Y flaps
• Gracilis muscle flaps
• Rhomboid flaps
COMPLETE VULVECTOMY
COMPLETE VULVECTOMY
LARGE VULVAR EXCISIONS
LARGE VULVAR EXCISIONS
ADVANCED STAGES
• Exenteration
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Lengthy
Increased blood loss
Permanent colostomy
Plastic reconstruction
• Chemoradiation
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Studied by the GOG
Can spare morbid surgery and achieve reasonable
survival
RECURRENT DISEASE
• Local recurrence can be salvaged with local excision
• 50% 5-year survival
• Distant disease is lethal
• Chemotherapy
• Cisplatin
• Bleomycin
• Adriamycin
40% RR
30% RR
30% RR
SUMMARY
• Endometrial Cancer
• Postmenopausal bleeding must be evaluated with an ultrasound
or diagnostic biopsy
• 80% of patients are cured with surgery alone
• Ovarian Cancer
• Difficult to detect
• Obtain annual vaginal ultrasounds for your patients
• Poor prognosis if detected at an advanced stage
SUMMARY
• Cervical Cancer
• Obtain a Pap test
• Ask the patient when her last Pap test was performed
• With today's screening, few cancers should be diagnosed past
Stage II
• Vulvar Cancer
• “Biopsy first, medicine later”
• Excellent prognosis with surgery