This document discusses vulvar cancer, including its incidence, types, anatomy, etiology, clinical features, diagnosis, staging, treatment, prognosis, and complications. Some key points include:
- Vulvar cancer accounts for 0.6% of all malignancies and 4% of genital malignancies, with squamous cell carcinoma making up 90% of cases.
- Lymph node status is the single most important prognostic marker, with 5-year survival rates of 90% for node-negative patients and 50% for node-positive patients.
- Risk factors include HPV, VIN, smoking, immunosuppression, and history of other cancers.
- Diagnosis involves biopsy of any suspicious vulvar lesions.
7. Applied Anatomy
ī Single most prognostic marker â L N status
ī 5 yr survival rate
No LN - 90%
LN - 50%
ī Superficial Inguinal Lymph node â Sentinal Lymph
Node
8.
9. Etiology
ī HPV
ī VIN
ī CIN
ī Lichen sclerosis
ī Squamous hyperplasia
ī Immunodeficiency
ī History of genital warts
ī Smoking
ī Alcohol
ī Immunosuppression
ī H/O Cervical or Vaginal cancer
ī Northern Europe ancestry
11. Clinical features
ī Postmenopausal female
(Mean Age â 65 yrs)
ī VIN
ī Vulval Pruritis
ī Lump or mass
ī Rare â bleeding/ulcerative lesions, discharge
ī Pain or dysuria
ī Large metastatic mass in groin
ī Other malignancies â HPV and smoking associated
14. Staging
IA Tumor confined to the vulva or perineum, ⤠2cm in size
with stromal invasion ⤠1mm, negative nodes
IB Tumor confined to the vulva or perineum, > 2cm in size or with
stromal invasion > 1mm, negative nodes
II Tumor of any size with adjacent spread (1/3 lower
urethra, 1/3 lower vagina, anus), negative nodes
15. Staging
IIIA Tumor of any size with positive inguino-femoral lymph
nodes
(i) 1 lymph node metastasis âĨ 5 mm
(ii) 1-2 lymph node metastasis(es) < 5 mm
IIIB (i) 2 or more lymph nodes metastases âĨ 5 mm
(ii) 3 or more lymph nodes metastases < 5 mm
IIIC Positive node(s) with extracapsular spread
16. Staging
IVA (i) Tumor invades other regional structures (2/3
upper urethra, 2/3 upper vagina), bladder mucosa, rectal
mucosa, or fixed to pelvic bone
(ii) Fixed or ulcerated inguino-femoral lymph nodes
IVB Any distant metastasis including pelvic lymph
nodes
17. Prognosis
ī Lymph nodes status
ī Lesion size
ī Histologic grade, tumor thickness, depth of stromal invasion, lymph-
vascular space involvement, tumor ploidy
ī Stage I â 79%
ī Stage II â 59%
ī Stage III â 43%
ī Stage IV â 13%
21. ī Stage Ia â Microinvasive T1a
Wide Local excision â deep upto dermis
ī Stage Ib & II â Early vulval cancer
Radical local excision plus Ipsilateral groin node
dissection
- 1 cm negative margin
- Extending up to inferior fascia of urogenital diaphragm
- Separate incision technique
Treatment
22. Treatment
ī Midline lesions
Anterior â clitoris sparing surgery â 8mm margin
ī Periclitoral lesion in young pt â small field RT with
concomitant chemosensitization
ī small lesion â 5000 cGy external radiation
f/b biopsy
23. Treatment
ī Stage II involving adjacent srtucture
Radical vulvectomy or radical local excision Plus
LN Dissection
ī Advanced disease
Surgery plus RT
plus
concomitant chemo
28. Closure of large defects
ī Small defects â primary closure without tension
ī Large â left open to granulate
ī Full thickness skin flap â rhomboid or mons pubis flap
ī Myocutaneous flap â gracialis
ī Tensior fascia lata myocutaneous graft
29. Management of LN
ī > 2 cm diameter
ī > 1 mm invasion
ī Surgery â trt of choice
ī Bilateral dissection - midline lesions, clitoris, post forchet
- unilateral bulky LN / multiple microscopic
LN
ī Bulky LN â debulking
ī Fixed unresectable LN - chemoradiation
30. Sentinal Lymph node biopsy
Criteria
1) unifocal primary tumour of 4 cm or less in diameter with >
1 mm invasion
2) no obvious metastatic disease on physical
examination/imaging
31. Postop management
ī Ambulation on day 1 or 2
ī DVT prevention
ī Subcutaneous heparin
ī pneumatic calf compression
ī Frequent dressing
ī Suction drainage of each side of the groin
ī Sitz bath
32. Early Postoperative Complications
ī Groin wound infection, necrosis, breakdown
ī En bloc operation â 53-85%
ī Separate-incision approach â 44%
ī UTI
ī Lymphocyst
ī DVT
ī Pulmonary embolism
ī MI
ī Hemorrhage
33. Late Complications
ī Chronic lymphedema
ī Recurrent lymphagitis or cellulitis
ī Usually responds to oral antibiotics
ī SUI
ī Introital stenosis
ī Femoral hernia (uncommon)
ī Depression, altered body image and sexual dysfunction
ī Pubic osteomylitis
ī Fistula
34. Recurrent Vulvar cancer
ī âĨ 3 LN - 2/3 of vulvar cancer recur within first 2 years from initial
Tx.
ī Local recurrence
ī Margin status
ī Closer than 0.8cm -> 50% recur
ī Primary lesion larger than 4cm in diameter
ī Ipsilateral lymphovascular space invasion
ī Deep invasive tumour
ī Tx.
ī Additional surgery with myocutaneous graft
ī External beam therapy + interstitial needles
with chemotherapy
35. Regional and Distant Recurrence
ī Difficult
ī Poor prognosis
ī Radiation
ī Chemotherapy
ī Bleomycin and methotrexate & lomustine
ī Bleomycin and mitomycin C
ī Cisplatin, vincristine & paclitaxel
ī Response
ī Usually disappointing
ī Long-term survival is very uncommon
36. Role of Radiation Therapy
ī primary vulval ca.
ī Advanced disease
ī LN meta â microscopic, gross
ī Possible roles for RTx.
ī Involved or close surgical margin
ī Small primary tumor - primary Tx.,
ī Particularly clitoral or periclitoral lesion
37. Melanoma
ī Rare
ī Incidence : 0.1-0.19/100,000women
ī Second most common of vulvar malignancy
ī Postmenopausal white women
ī No symptoms (most)
ī Itching, bleeding, groin mass
ī Labia minora, clitoris
ī Vulvar nevi are junctional, precursor lesion to melanoma; thus,
should be removed
38. Histopathology
ī Mucosal lentiginous melanoma
ī Flat freckle, quite extensive, superficial
ī Superficial spreading melanoma
ī Most common, superficial
ī Nodular melanoma
ī Most aggressive, raised lesion
ī Penetrate deeply
ī Metastasize widely
ī Âŧ of cases of melanomas
ī Macroscopically amelanotic -> spread early
42. Bartholin Gland Carcinoma
ī Rare
ī Postmenopausal
ī Premenopausal
ī Honanâs criteria
ī The tumor is in the correct anatomic position
ī The tumor is located deep in the labium majus
ī The overlying skin is intact
ī There is some recognizable normal gland present
43. Bartholin Gland Carcinoma
ī Signs and Symptoms
ī Vulvar mass or perineal pain
ī 10% of patients may be mistaken for benign cysts or
abscesses
ī Treatment
ī Radical vulvectomy with bilateral groin and pelvic LN
dissection
ī Fixed, involves adjacent structures-> postop radiation
and chemotherapy is preferable
The FIGO staging used for squamous lesions is not applicable to melanomas
Because the lesions are usually much smaller,
and the prognosis is related to the depth of tumor invasion rather than to the diameter of the lesion