Transcript Vulva Neoplasms and common benign lesions

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