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Vulva Neoplasms and common benign lesions Maria Horvat, MD, FACOG Anatomy of the vulva Lymphatic drainage of the vulva Vulvar Cancer 5% of female genital malignancies Usually occurs in the 70-80 year old population Histology is necessary for diagnosis Occurs anywhere on vulva Surgically staged Most common type is squamous cell Melanoma is 2nd most common – but still <5% Associated with HPV Vulvar Cancer Spreads by direct extension Embolizes to lymphatics Hematogenous dissemination Risks of vulvar cancer HPV Lichen sclerosis Long history of puritis Lymph nodes are single most important prognostic factor Vulvar Intraepithelial Neoplasms VIN - preinvasive disease VIN 1 VIN 2 VIN3 Vulvar Intraepithelial Neoplasms VIN 1 Abnormal cellular changes Confined to lower 1/3 Epithelium – no progressive vulvar cancer Vulvar Intraepithelial Neoplasms VIN 2 “moderate” 1/3-2/3 Epithelium involved Vulvar Intraepithelial Neoplasms VIN 3 “severe” 2/3 – all If untreated most go on to cancer If treated 4% go on to cancer Treat with wide local excision Cancer In-Situ All epithelium involved New Classification for VIN Old System VIN 1 VIN2,3 New System Flat condyloma or HPV effect VIN, usual type VIN, warty type VIN, basaloid type VIN, mixed (warty/basaloid) type Differentiated VIN VIN, differentiated type VIN 3 VIN 3 VIN 3 VIN - Treatment Local excision Local destruction VIN 50% asymptomatic 25% hyperpigmented Typically: raised surface VIN – Diagnosis 3% acetic acid Punch biopsy Staging of Vulvar Carcinoma Stage Characteristics Stage 0 Carcinoma in situ; intraepithelial neoplasia grade III Stage I Lesion <2 cm; confined to the vulva or perineum; no nodal metastasis Stage Ia Lesion <2 cm; confined to the vulva or perineum and with stromal invasion <1 mm; no nodal metastasis Stage Ib Lesion <2 cm; confined to the vulva or perineum and with stromal invasion >1mm; no nodal metastasis Stage II Tumor >2 cm in greatest dimension; confined to the vulva and/or perineum; no nodal metastasis Stage III Tumor of any size with adjacent spread to the lower urethra and/or vagina or anus and/or unilateral regional lymph node metastasis Stage Iva Tumor invasion of any of the following: upper urethra, bladder mucosa, rectal mucosa, and/or pelvic bone and/or bilateral regional node metastases Stage Ivb Any distant metastasis, including pelvic lymph nodes Vulvar Cancer – prognostic factors For nodal involvement Size Depth of invasion Lesion thickness Grade Vascular space involvement For survival Positive inguinal nodes Positive pelvic nodes VIN - Treatment Cancer-in-situ Excision with at least 1cm margins topical Invasive Cancer Inguinal-femoral lymph nodes Radical excision Radiation Pelvic exenteration Melanoma Usually arises from nevi Blue/black Ulcerated RX: wide excision with 2 cm free border If depth of invasion <1.5mm, 100%survival Vulvar Melanoma Vulvar Melanoma Pagets Disease of the Vulva Hyperemic tissue Cake icing effect Rx: wide local excision 30% will develop adenocarcinoma of the breast, colon, and rectum Pagets Disease Lichen Sclerosis Itching Diagnosed by biopsy Can eventually become VIN or vulvar cancer 20% hypothyroid Lichen Sclerosis Remember! BIOPSY anything suspicious! References The Female Patient; April 2008 Clinical Gynecology; Bieber www.Images.MD