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Vulvar and Vaginal Vulvar and Vaginal lesionslesions
Dr.F Behnamfar MDDr.F Behnamfar MD
Introduction
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 SymptomsVulvar Symptoms
Most often,primary vaginitis and Most often,primary vaginitis and secondary vulvitissecondary vulvitis
A number of skin conditions on A number of skin conditions on other areas of the bodyother areas of the body
Neoplasia
Vulvar intraepithelial neoplasia a precancerous lesion that may progress to
invasive cancer
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
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
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 Other vulvar conditionsconditions folliculitisfolliculitis
Fox.fordiyce diseaseFox.fordiyce disease
Acanthosis nigricansAcanthosis nigricans
Extramammary pagets Extramammary pagets disease,intraepithelial adenocarcinomadisease,intraepithelial adenocarcinoma
Herpes simplex Scabis
Vulvar cysts, tumors Vulvar cysts, tumors and massesand masses Condylomata accuminataCondylomata accuminata
duct cysts,Skenes duct cystsduct cysts,Skenes duct cysts
Vulvar Ulcers: Behcet Vulvar Ulcers: Behcet disease,lichen planusdisease,lichen planus
Vaginal ConditionsVaginal Conditions
Retained foreign bodyRetained foreign body UlcerationUlceration MalignancyMalignancy
Vulvar CancerVulvar Cancer
3870 new cases 20053870 new cases 2005 870 deaths870 deaths Approximately 5% of Gynecologic Approximately 5% of Gynecologic
CancersCancers
American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005
Vulvar CancerVulvar Cancer
85% Squamous Cell Carcinoma85% Squamous Cell Carcinoma 5% Melanoma5% Melanoma 2% Sarcoma2% Sarcoma 8% Others8% Others
Vulvar CancerVulvar Cancer
Biphasic Distribution ,two distinct Biphasic Distribution ,two distinct etiologies:etiologies:
– Age 70 Age 70 – type, unifocal,type, unifocal,– in areas adjacent to lichen sclerosus or squamous in areas adjacent to lichen sclerosus or squamous
hyperplasia (Chronic inflammatory conditions)hyperplasia (Chronic inflammatory conditions)
– 20% in patients UNDER 40 and appears to be 20% in patients UNDER 40 and appears to be increasing,increasing,
– multifocal,multifocal,– basaloid or warty types,basaloid or warty types,– HPV related,smoking and VIN HPV related,smoking and VIN
Vulvar CancerVulvar Cancer
Paget’s Disease of VulvaPaget’s Disease of Vulva– 10% will be invasive10% will be invasive– 4-8% association with underlying 4-8% association with underlying
Adenocarcinoma of the vulvaAdenocarcinoma of the vulva
SymptomsSymptoms
Most patients are treated for Most patients are treated for “other” conditions“other” conditions
12 month or greater time from 12 month or greater time from symptoms to diagnosissymptoms to diagnosis
SymptomsSymptoms
PruritusPruritus MassMass PainPain BleedingBleeding UlcerationUlceration DysuriaDysuria DischargeDischarge Groin MassGroin Mass
SymptomsSymptoms
May look like:May look like:– RaisedRaised– ErythematousErythematous– UlceratedUlcerated– CondylomatousCondylomatous– NodularNodular
Vulvar CancerVulvar Cancer
IF IT LOOKS ABNORMAL ON THE IF IT LOOKS ABNORMAL ON THE VULVAVULVA
BIOPSY!BIOPSY! BIOPSY!BIOPSY! BIOPSY!BIOPSY!
Tumor SpreadTumor Spread
Very Specific nodal spread Very Specific nodal spread patternpattern
Direct SpreadDirect Spread HematogenousHematogenous
StagingStaging
Based on TNM Surgical Staging Based on TNM Surgical Staging – Tumor sizeTumor size– Node StatusNode Status– Metastatic DiseaseMetastatic Disease
StagingStaging
Stage I T1 N0 M0Stage I T1 N0 M0– Tumor ≤ 2cm Tumor ≤ 2cm
– IAIA ≤1 mm depth of stromal ≤1 mm depth of stromal InvasionInvasion
– IBIB 1 mm or more depth of 1 mm or more depth of invasioninvasion
StagingStaging
Stage II T2 N0 M0Stage II T2 N0 M0– Tumor >2 cmTumor >2 cm– Confined to Vulva or PerineumConfined to Vulva or Perineum
StagingStaging
Stage IIIStage III– T3 N0 M0T3 N0 M0– T3 N1 M0T3 N1 M0– T1 N1 M0T1 N1 M0– T2 N1 M0T2 N1 M0
Tumor any size involving lower urethra, Tumor any size involving lower urethra, vagina, anus OR unilateral positive vagina, anus OR unilateral positive nodesnodes
StagingStaging
Stage IVAStage IVA– T1 N2 M0T1 N2 M0– T2 N2 M0T2 N2 M0– T3 N2 M0T3 N2 M0– T4 N any M0T4 N any M0
Tumor invading upper urethra, bladder, Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodesrectum, pelvic bone or bilateral nodes
StagingStaging
Stage IVBStage IVB– Any T Any N M1Any T Any N M1
Any distal mets including pelvic nodesAny distal mets including pelvic nodes
TreatmentTreatment
Primarily SurgicalPrimarily Surgical– Wide Local ExcisionWide Local Excision– Radical ExcisionRadical Excision– Radical Vulvectomy with Inguinal Radical Vulvectomy with Inguinal
Node DissectionNode Dissection UnilateralUnilateral BilateralBilateral Possible Node Mapping, still Possible Node Mapping, still
investigationalinvestigational
TreatmentTreatment
Local advanced may be treated Local advanced may be treated with Radiation plus with Radiation plus ChemosensitizerChemosensitizer
Positive Nodal StatusPositive Nodal Status– 1 or 2 microscopic nodes < 5mm 1 or 2 microscopic nodes < 5mm
can be observedcan be observed– 3 or more or >5mm post op 3 or more or >5mm post op
radiationradiation
New advances in New advances in treatmenttreatment Individualization of treatment,vulvar Individualization of treatment,vulvar
conservation for unifocal tumorsconservation for unifocal tumors Elimination of routine pelvic Elimination of routine pelvic
lymphadenectomy lymphadenectomy Omission of groin dissection for T1 Omission of groin dissection for T1
tumors (<1mm stromal invasion)tumors (<1mm stromal invasion) Separate incisions improve wound Separate incisions improve wound
healinghealing
TreatmentTreatment
Special TumorSpecial Tumor– Verrucous CarcinomaVerrucous Carcinoma
Indolent tumor with local disease, rare Indolent tumor with local disease, rare mets UNLESS given radiation, becomes mets UNLESS given radiation, becomes Highly malignant and aggressiveHighly malignant and aggressive
Excision or Vulvectomy ONLYExcision or Vulvectomy ONLY
Vulva 5 year survivalVulva 5 year survival
Stage IStage I 9090 Stage IIStage II 7777 Stage IIIStage III 5151 Stage IVStage IV 1818
Hacker and Berek, Practical Gynecologic Oncology 4th Edition, 2005
RecurrenceRecurrence
Local Recurrence in VulvaLocal Recurrence in Vulva– Reexcision or radiation and good Reexcision or radiation and good
prognosis if not in original site of prognosis if not in original site of tumortumor
– Poor prognosis if in original sitePoor prognosis if in original site
RecurrenceRecurrence
Distal or MetastaticDistal or Metastatic– Very poor prognosis, active agents Very poor prognosis, active agents
include Cisplatin, mitomycin C, include Cisplatin, mitomycin C, bleomycin, methotrexate and bleomycin, methotrexate and cyclophosphamide cyclophosphamide
MelanomaMelanoma
5% of Vulvar Cancers5% of Vulvar Cancers Not UV relatedNot UV related Commonly periclitoral or labia Commonly periclitoral or labia
minoraminora
MelanomaMelanoma
Microstaged by one of 3 criteriaMicrostaged by one of 3 criteria
– Clark’s LevelClark’s Level– Chung’s LevelChung’s Level– BreslowBreslow
Melanoma TreatmentMelanoma Treatment
Wide local or Wide Radical Wide local or Wide Radical excision with bilateral groin excision with bilateral groin dissectiondissection
Interferon Alpha 2-bInterferon Alpha 2-b
Vaginal CarcinomaVaginal Carcinoma
2140 new cases projected 20052140 new cases projected 2005
810 deaths projected 2005810 deaths projected 2005 Represents 2-3% of Pelvic Represents 2-3% of Pelvic
CancersCancers
American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005
Vaginal CancerVaginal Cancer
84% of cancers in vaginal area 84% of cancers in vaginal area are secondaryare secondary– CervicalCervical– UterineUterine– ColorectalColorectal– OvaryOvary– VaginaVagina
Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2nd ed. 2002
Vaginal CarcinomaVaginal Carcinoma
Squamous CellSquamous Cell 80-85%80-85% Clear CellClear Cell 10%10% SarcomaSarcoma 3-4%3-4% MelanomaMelanoma 2-3%2-3%
Clear Cell CarcinomaClear Cell Carcinoma
Associated with DES Exposure In Associated with DES Exposure In UteroUtero– DES used as anti abortifcant from DES used as anti abortifcant from
1949-19711949-1971– 500+ cases confirmed by DES 500+ cases confirmed by DES
RegistryRegistry– Usually occurred late teensUsually occurred late teens
Vaginal Cancer Vaginal Cancer EtiologyEtiology Mimics Cervical CarcinomaMimics Cervical Carcinoma
– HPV 16 and 18HPV 16 and 18
StagingStaging
Stage IStage I Confined to Vaginal Confined to Vaginal WallWall
Stage IIStage II Subvaginal tissue but Subvaginal tissue but not not to pelvic sidewallto pelvic sidewall
Stage IIIStage III Extended to pelvic Extended to pelvic sidewallsidewall
Stage IVAStage IVA Bowel or BladderBowel or Bladder Stage IVBStage IVB Distant metsDistant mets
TreatmentTreatment
Surgery with Radical Surgery with Radical Hysterectomy and pelvic lymph Hysterectomy and pelvic lymph dissection in selected stage I dissection in selected stage I tumors high in Vaginatumors high in Vagina
All others treated with radiation All others treated with radiation with chemosensitizationwith chemosensitization
5 year Survival5 year Survival
Stage IStage I 70%70% Stage IIStage II 51%51% Stage IIIStage III 33%33% Stage IVStage IV 17%17%