Download Cervical/Vulvar Cancer

Vulvar and Vaginal
lesions
Dr.F Behnamfar MD
Introduction
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Most usful means of generating
differential diagnosis is by morphological
findings rather than symptomatology
Vulvar biopsy should be performed if
the lesion is clinically suspicious or does not
resolve after standard therapy
Vulvar Symptoms
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Most often,primary vaginitis and
secondary vulvitis
A number of skin conditions on other
areas of the body
Neoplasia
Vulvar intraepithelial neoplasia
a precancerous lesion that may progress to invasive
cancer
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Most are raised multifocal white (may be red or
pink) and/or verrucous lesions
Cancer presents with unifocal vulvar plaque,ulcer or
mass
Lichen scerosus and erosive lichen planus
predispose to cancer
Genital warts
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Caused by human papillomavirus
Flat,filliform or verrucous,or giant
Flesh colored or pigmented
Biopsy is indicated if there is rapid
growth,increased
pigmentation,ulceration,pigmentation,fixation or
poor response to therapy
Treatment : trichloroacetic acid,
podophyllum,Cryo,laser
Not curative ,merely speed clinical resolution
White patch
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Lichen sclerosus,well demarcated
white finely wrinkled and atrophic
patches
Vulvar itching and typical findings
Potent topical corticosteriod ointment
Close follow up for risk of malignancy
Other vulvar conditions
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folliculitis
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Fox.fordiyce disease
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Acanthosis nigricans
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Extramammary pagets
disease,intraepithelial adenocarcinoma
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Herpes simplex
Scabis
Vulvar cysts, tumors and
masses
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Condylomata accuminata
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duct cysts,Skenes duct cysts
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Vulvar Ulcers: Behcet disease,lichen
planus
Vaginal Conditions
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Retained foreign body
Ulceration
Malignancy
Vulvar Cancer
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3870 new cases 2005
870 deaths
Approximately 5% of Gynecologic
Cancers
American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005
Vulvar Cancer
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85% Squamous Cell Carcinoma
5% Melanoma
2% Sarcoma
8% Others
Vulvar Cancer
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Biphasic Distribution ,two distinct
etiologies:
– Age 70
– type, unifocal,
– in areas adjacent to lichen sclerosus or squamous
hyperplasia (Chronic inflammatory conditions)
– 20% in patients UNDER 40 and appears to be
increasing,
– multifocal,
– basaloid or warty types,
– HPV related,smoking and VIN
Vulvar Cancer
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Paget’s Disease of Vulva
– 10% will be invasive
– 4-8% association with underlying
Adenocarcinoma of the vulva
Symptoms
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Most patients are treated for “other”
conditions
12 month or greater time from
symptoms to diagnosis
Symptoms
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Pruritus
Mass
Pain
Bleeding
Ulceration
Dysuria
Discharge
Groin Mass
Symptoms
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May look like:
– Raised
– Erythematous
– Ulcerated
– Condylomatous
– Nodular
Vulvar Cancer
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IF IT LOOKS ABNORMAL ON THE
VULVA
BIOPSY!
BIOPSY!
BIOPSY!
Tumor Spread
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Very Specific nodal spread pattern
Direct Spread
Hematogenous
Staging
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Based on TNM Surgical Staging
– Tumor size
– Node Status
– Metastatic Disease
Staging
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Stage I T1 N0 M0
– Tumor ≤ 2cm
– IA
– IB
≤1 mm depth of stromal Invasion
1 mm or more depth of invasion
Staging
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Stage II T2 N0 M0
– Tumor >2 cm
– Confined to Vulva or Perineum
Staging
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Stage III
– T3
– T3
– T1
– T2
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N0
N1
N1
N1
M0
M0
M0
M0
Tumor any size involving lower urethra,
vagina, anus OR unilateral positive nodes
Staging
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Stage IVA
– T1
– T2
– T3
– T4
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N2 M0
N2 M0
N2 M0
N any M0
Tumor invading upper urethra, bladder,
rectum, pelvic bone or bilateral nodes
Staging
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Stage IVB
– Any T Any N M1
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Any distal mets including pelvic nodes
Treatment
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Primarily Surgical
– Wide Local Excision
– Radical Excision
– Radical Vulvectomy with Inguinal Node
Dissection
Unilateral
 Bilateral
 Possible Node Mapping, still investigational
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Treatment
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Local advanced may be treated with
Radiation plus Chemosensitizer
Positive Nodal Status
– 1 or 2 microscopic nodes < 5mm can be
observed
– 3 or more or >5mm post op radiation
New advances in
treatment
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Individualization of treatment,vulvar
conservation for unifocal tumors
Elimination of routine pelvic
lymphadenectomy
Omission of groin dissection for T1
tumors (<1mm stromal invasion)
Separate incisions improve wound
healing
Treatment
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Special Tumor
– Verrucous Carcinoma
Indolent tumor with local disease, rare mets
UNLESS given radiation, becomes Highly
malignant and aggressive
 Excision or Vulvectomy ONLY
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Vulva 5 year survival
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Stage
Stage
Stage
Stage
I
II
III
IV
90
77
51
18
Hacker and Berek, Practical Gynecologic Oncology 4th Edition,
2005
Recurrence
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Local Recurrence in Vulva
– Reexcision or radiation and good
prognosis if not in original site of tumor
– Poor prognosis if in original site
Recurrence
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Distal or Metastatic
– Very poor prognosis, active agents
include Cisplatin, mitomycin C, bleomycin,
methotrexate and cyclophosphamide
Melanoma
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5% of Vulvar Cancers
Not UV related
Commonly periclitoral or labia minora
Melanoma
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Microstaged by one of 3 criteria
– Clark’s Level
– Chung’s Level
– Breslow
Melanoma Treatment
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Wide local or Wide Radical excision
with bilateral groin dissection
Interferon Alpha 2-b
Vaginal Carcinoma
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2140 new cases projected 2005
810 deaths projected 2005
Represents 2-3% of Pelvic Cancers
American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005
Vaginal Cancer
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84% of cancers in vaginal area are
secondary
– Cervical
– Uterine
– Colorectal
– Ovary
– Vagina
Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2nd ed. 2002
Vaginal Carcinoma
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Squamous Cell
Clear Cell
Sarcoma
Melanoma
80-85%
10%
3-4%
2-3%
Clear Cell Carcinoma
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Associated with DES Exposure In
Utero
– DES used as anti abortifcant from 19491971
– 500+ cases confirmed by DES Registry
– Usually occurred late teens
Vaginal Cancer Etiology
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Mimics Cervical Carcinoma
– HPV 16 and 18
Staging
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Stage I
Stage II
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Stage III
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Stage IVA
Stage IVB
Confined to Vaginal Wall
Subvaginal tissue but not
to pelvic sidewall
Extended to pelvic
sidewall
Bowel or Bladder
Distant mets
Treatment
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Surgery with Radical Hysterectomy
and pelvic lymph dissection in selected
stage I tumors high in Vagina
All others treated with radiation with
chemosensitization
5 year Survival
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Stage
Stage
Stage
Stage
I
II
III
IV
70%
51%
33%
17%