Transcript 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:
2-Femoral L.N:
Medial I.L.N ,lying inferior to S.I.ring.
Lateral I.L.N ,below the inguinal ligament.
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
Para Aortic L.N
Common Iliac Nodes
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
size Or less
Confined to the vulva or perineum nodes
histo-Logically negative.
Stage 2 > 2cm lesion Confined to the vulva or perineum nodes
size
histo-Logically negative.
Stage 3
Stage 4
Tumor of any size spread to lower urethra
vagina anus +/- Unilateral metastasis
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
B-invasion of 1-3 mm
C-invasion of 5 mm
no risk of nodal metastases.
6-8% incidence of metastases.
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
-< =1mm depth invasion
-No lymph-vascular space
involvement.
-Well or mod.diff.
Radical local excision only
(Excision with 2 cm margins,
down to super,aponeurosis of
The original diaph +/-pubic
Periosteum)
2)>2 cm lesion size
-Or > 1 mm depth invasion
-Or lymph-vascular space
Involvement
-Or poorly diff
Radical local excision and inguino
femoral node dissection.
unilateral if lesion unilat not
Involving midline,bilat.if lesion
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
Fixed groin nodes
-chemo-radiation followed by limited
` 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.