vulva neoplasms and common benign lesions maria horvat, md, facog
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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
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