VulvaNeoplasms and common benign lesions

Maria Horvat, MD, FACOG

Anatomy of the vulva

Lymphatic drainage of the vulva

Vulvar Cancer

5% of female genital malignanciesUsually occurs in the 70-80 year old populationHistology is necessary for diagnosisOccurs anywhere on vulvaSurgically stagedMost common type is squamous cellMelanoma 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 1Abnormal 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 New System

VIN 1 Flat condyloma or HPV effect

VIN2,3 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 CharacteristicsStage 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 involvementSizeDepth of invasionLesion thicknessGradeVascular space involvement

For survivalPositive inguinal nodesPositive pelvic nodes

VIN - Treatment

Cancer-in-situExcision with at least 1cm margins

topical

Invasive CancerInguinal-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