Cancer of The Vulva

					     Cancer
  of The Vulva

By Dr Emdalala Elasheg
Introduction
Vulval cancer is uncommon and accounts
for approximately 1-4% of all gynecological
cancer
incidence : 1.8 /100.000, It is predominantly
seen in postmenopausal and old women
(mean age 65 years ) ,and only 2% were
less than 30 years.
In countries such as south Africa where
sexually transmitted diseases are common,
the mean age of presentation is 59 years.
           Objectives
• To know the out lines of
  etiology,diagnosis and mangment of
  cancer vulva.

• To understand the importance of
  early dectection of cancer vulva to
  improve prognosis and survival rate
AETHIOLOGY:

Little is known
 A viral factor has been suggested by
 the detection of antigens induced by
 Herpes simplex virus type (HSV2)
 Type 16/18 human papilloma virus
 (HPV) , in vulval intraepithelial
 neoplasia.
PATHOLOGY
Primary Tumor
  90% of lesions are of squamous in origin.
  3-5 of lesions are melanoma.
  2% of lesions is basal cell carcinoma.
  Less than 1% is sarcoma.
Secondary Tumors
  It is occasionly found in vulva
 Most commonly the primary lesion is from
  the cervix or the endometrium .
SQUAMOUS CELL CARCINOMA
   Are usually seen in the anterior part of the
   vulva.
   2/3 of cases in the labia majora.
   1/3 of cases in the clitoris ,labia
   minora,fourchitte, and perineum.
Spread:-
1. LYMPHATIC > 50%
2. Direct spread occurs in 25% to the urethra,
   vagina and rectum
3. Hematogenous spread to bone or lung is rare
   The lymph nodes are arranged in 5 groups in
   each groin:
Superficial L.N:
1- Inguinal L.N:   Medial I.L.N ,lying inferior to S.I.ring.
                   Lateral I.L.N ,below the inguinal ligament.
2-Femoral L.N:     Medical F.L.N,lying medical to saph.vein
                   Lateral F.L.N, lying lateral to saph .vein
Deep L.N:
1. Deep inguinal L.N , lying in the inguinal channel
2. Deep femoral L.N (node of cloquet lying in the
   femoral channel
3. External iliac L.N:
                       Medial groups ,lying medial to EIV
                       Lateral groups,lying lateral to EIA
                       Anterior groups ,lying between EIV
                        and EIA
   External Iliac Nodes        Common Iliac Nodes

    Para Aortic L.N             Thoracic Duct
 Lt sided lesion will spread to the Lt groin Lymph node.
 Rt sided lesion will spread to the Rt Groin Lymph node.
 Bilateral nodes involvement is seen in 14% of cases.
 Contralateral node involvement without ipsilateral
 disease is seen in 5% of cases.
Never found pelvic nodes to be involved in the absence of
 inguinal nodes metastases.
   Clinical Features & Diagnosis
Most patients with invasive disease
complain of:
 Irritation or purities in 70% of cases
 Vulvar mass or ulcer in 55% of cases
 Bleeding in 28% of cases
 Discharge in 2-3% of cases
The major problem in invasive vulvar cancer is delay
between the first appearance of the symptoms and referral
to the gynecological opinion due to :

 1. The doctor fails to recognize the gravity
    of the lesion and prescribes topical
    therapy.
 2. Older women are often embarrassed and
    shy.
On Examination
1. Lesion can take any form from flat white lesion to
   large ulcer.the size of the tumor ,involvement of
   the urethra and anus should be noted
2. Inspection of the cervix and cervical cytology.
3. Needle aspiration of any suspicious groin node.
diagnosis is made on histology from full thickness
   generous biopsy.
STAGING:
FIGO suggest clinical staging in 1969 based
on TNM (Tumor node metastasis)
classification taking into consideration:
 The size of the local lesion.
 Groin node involvement.
 Metastases.
A new FIGO staging based on surgical
findings in 1988, it is more accurate
 as the involvement of groin nodes is
missed on clinical examination in up to
30% of cases and over diagnosis in 5%.
          NEW FIGO STAGING OF
           VULVA CARCINOMA
Stage 1   2 cm lesion    Confined to the vulva or perineum nodes
          size Or less   histo-Logically negative.
Stage 2 > 2cm lesion Confined to the vulva or perineum nodes
            size     histo-Logically negative.
Stage 3                  Tumor of any size spread to lower urethra
                         vagina anus +/- Unilateral metastasis
Stage 4        A         Involvement of :
                         Upper urethra
                         Bladder mucosa
                         Rectal mucosa
                         Pelvic bone
                         Bilateral L.N.metastasis
               B         Distant metastases and / or pelvic nodes
              PROGNOSIS

The overall 5 years survival rate for vulval
   cancer is 70% for all operable cases,
This depends on:
1. L.N Involvement:
   This is the most prognostic factor
   Metstatic involvement of groin nodes
   decreases the 5 years survival rate to below
   50% as opposed to the 90% when L.N are
   not involved.
   Once pelvic nodes are involved the 5 years
   survival rate is 15%.
2. The number of groin nodes involvement:
   microscopical involvement of N.regardless
   of stage has a good prognosis.
   2 or more positive nodes have a worse
   prognosis.
3. Stage:
   The 5 years survival rate decreases with
   advancing stage from >90% in stage 1 to <
   10% in stage 4.
4. Differentiation:
   A well diff.tumor has a better prognosis
   than poor diff.
5.Depth of Invasion:
A-invasion of 1 mm         no risk of nodal metastases.
B-invasion of 1-3 mm     6-8% incidence of metastases.
C-invasion of 5 mm     22-37% incidence of metastases.
6.Surgical Margin:
Surgical excision margin of more than 1 cm in all
diameters results in a low local recurrence rate.
              Treatment
The corner stone of treatment is surgery
The majority of FIGO stage 1 and 2 will be
cured by surgery alone.
Because most vulval cancers present at an
advanced stage in developing countries
other modalities such as chemotherapy and
radiotherapy may have to be used.
SURGURY:
 The standard surgery is enblock radical
 vulvectomy and bilateral groin nodes
 dissection as described by Taussing and
 way (three separate incision). This
 associated with:
 High incidence of morbidity (wound
 infection, necrosis and break down , pul.
 Embolism, and lymphoedema).
 Problems with body image and sexual
 function.
The recent trend in management is not to
cure patients but to preserve body image
and sexual function by performing less
radical surgery .The individualization of the
treatment depends on:
Size and position of tumor.
Depth of invasion.
The age and performance status of the
patient.
  Primary management in Carcinoma
           of The Vulva
Features of Carcinoma       Management
1)-< =2cm lesion size       Radical local excision only
-< =1mm depth invasion      (Excision with 2 cm margins,
-No lymph-vascular space    down to super,aponeurosis of
involvement.                The original diaph +/-pubic
-Well or mod.diff.          Periosteum)
2)>2 cm lesion size         Radical local excision and inguino
-Or > 1 mm depth invasion   femoral node dissection.
-Or lymph-vascular space    unilateral if lesion unilat not
Involvement                 Involving midline,bilat.if lesion
-Or poorly diff             midline
3)-Involves clitoral        -Anterior redical vulvectomy
                             (including removal of clitoris but
                            -preserving post.vulva).
                            -bilat inquinal –femoral N dissection
 Primary management in Carcinoma
          of The Vulva
Features of Carcinoma      Management
4)-Post. Vulva /perineum   -posterior radical vulvectomy
                            (preserving clitoris and anterior vulva).
                           -bilat inquinal-femoral N dissection
5)-Locally advanced        -pelvic exenteration(ant,post,total as
                           indicated by structures involved)
                           -anovalvetomy (for lesion
                           Involving anus /and vulva).
                           -Chemo-radiation followed by limited surgery
6)-Bone involvement        -chemo-radiation followed by limited
Fixed groin nodes          ` surgery if locally resectable
  Nowadays they found that pelvic node
  radiation is better than pelvic node
  dissection because:
PND (pelvic node dissection)   PNR (pelvic node radiation)
Survival rate 2 years 55%      significant improvement of
                               survival rate of 2 years 70%
           CONCLUSION
Any patient with persistence itching or vulval
lesion not responds to simple treatment , you
should take multiple biopsies from vulva to
exclude malignancy.
In management of cancer vulva, age group,
psychology of patient, and the appearance of
the vulva should be taken in account as this
will change the plan of management of
cancer.
Plastic surgery should play role in the future.
In future infrared , and laser therapy under
microscopy will play role in the management
of premalignant lesions.

				
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