The document discusses the lymphatic drainage patterns of the vulva and vagina and describes vulval cancer. It notes that the vulva has dense lymphatic plexuses that drain to the superficial and deep inguinal lymph nodes and external iliac nodes. Vulval cancer is rare and usually occurs in postmenopausal women. Risk factors include conditions like lichen sclerosus. Diagnosis is by biopsy and treatment involves radical vulvectomy with bilateral lymph node dissection or radiotherapy depending on the stage of cancer. Prognosis depends on lymph node involvement, with 5-year survival rates ranging from 90-100% without node involvement to below 20% with positive pelvic nodes.

1. Vulval Lymphatics and Vulval
Cancer
DR. HEM NATH SUBEDI
RESIDENT ,OBGYN
COMSTH

2. LYMPHATICS OF THE VAGINA
The intrinsic plexuses are situated in the
mucosal and muscle layers.
(i) Upper two-thirds drain into the glands like
those of the cervix.
(ii) Lower one-third drains into inguinal and at
times into external iliac nodes.

3. LYMPHATICS OF THE VULVA
There are dense lymphatic plexuses in the dermis of the vulva, which
intercommunicate with those of subcutaneous tissue .
• ••The lymphatics of each side freely communicate with each of them.
• ••The lymphatics hardly cross beyond the labiocrural fold.
• ••The vulval lymphatics also anastomose with the lymphatics of the lower-
third of the vagina and drain into external iliac nodes
• ••Lymphatics from the deep tissues of the vulva accompany the internal
pudendal vessels to the internal iliac nodes
• ••Superficial inguinal lymph nodes are the primary lymph nodes that act as
the sentinel nodes of the vulva. Deep inguinal lymph nodes are
secondarily involved. It is unusual to find positive pelvic glands without
metastatic disease in the inguinal nodes
• ••Gland of Cloquet or Rosenmüller, which is the upper most deep femoral
nodes is absent in about 50 percent of cases.

5. Labia majora (anterior half)
• Lymphatics intercommunicate with the
opposite side in the region of mons veneris →
Superficial inguinal nodes.
• Thus, there is bilateral and contralateral
spread of metastasis in malignancy affecting
the areas.

6. Labia majora (posterior half)
• Drains into → Superficial inguinal → Deep inguinal→ External iliac.
Labia minora and prepuce of clitoris
• Intercommunicating with the lymphatics of the opposite side in the
vestibule and drains into superficial inguinal nodes.
Glans of clitoris:
• Drains directly into the deep inguinal and external iliac glands.
Bartholin’s glands:
• The lymphatics drain into superficial inguinal and anorectal nodes.

7. • Node of Cloquet
It was previously thought to be the main relay
node through which the efferents from the
superficial inguinal nodes pass to the external
iliac nodes. Recent study shows its insignificant
involvement in vulval malignancy, and thus, it is
not considered to be the relay node. The
efferents from the superficial inguinal may reach
the external iliac group bypassing the node of
Cloquet.

9. VULVAL CARCINOMA
Incidence
The lesion is rare, about 1.7 per 100,000 females. The distribution varies from 3-5 percent amongst
genital malignancies.
Etiology
• The etiology remains unclear. But the following factors are often related. Usually occurring in
postmenopausal women with a median age of 60.
• ™More common amongst whites. Increased association with obesity, hypertension, diabetes and
nulliparity.
• ™Associated vulval epithelial disorders (lichen sclerosus) specially of atypical type are the risk factors.
• ™Human papilloma virus (HPV) DNA (type 16, 18) has been detected in patients with invasive vulval
cancer.
• ™Vulval cancer may have a causal relation with condyloma accuminata (HPV 6, 11), syphilis and
lymphogranuloma venereum.
• ™Chronic pruritus usually preceds invasive vulval cancer.
• ™Chronic irritation of the vulva by chemical or physical trauma associated with poor hygiene may be a
predisposing factor.
• ™Other primary malignancies have been observed in about 20 percent of cases with vulval cancer.
• Cervix is most commonly affected; other sites are breast, skin or colon.

12. • ™Vulval cancer may have a causal relation with
condyloma accuminata (HPV 6, 11), syphilis and
lymphogranuloma venereum.
• ™Chronic pruritus usually preceds invasive vulval cancer.
• ™Chronic irritation of the vulva by chemical or physical
trauma associated with poor hygiene may be a
predisposing factor.
• ™Other primary malignancies have been observed in
about 20 percent of cases with vulval cancer.
• Cervix is most commonly affected; other sites are
breast, skin or colon.

13. Pathology
• Sites: The commonest site is labium majus followed
by clitoris and labium minus. Anterior two-third are
commonly affected. Malignant ulcer on the
contralateral side may be multifactorial.
Naked Eye
• Ulcerative: The features are raised everted edges,
sloughing base with surrounding induration. This is
common.
• Hypertrophic: The overlying skin may be intact or it
ulcerates sooner or later. This is rare.

15. Spread
• Direct
• Lymphatics
• Hematogenous

17. Clinical features
Patient profile: The patients are usually postmenopausal, aged about
60 years often with obesity, hypertension and diabetes.
signs
• „Vulval inspection reveals an ulcer or a fungating mass on the vulva.
The ulcer has a sloughing base with raised, everted and irregular
edges and it bleeds to touch. Surrounding tissue may be edematous
and indurated.
• „Associated vulval lesions mentioned earlier may be present.
• Inguinal lymph nodes of one or both the sides may be enlarged and
palpable. The enlargement may also be due to infection.
• „Clinical examination of the pelvic organs, including the cervix,
vagina, urethra and rectum must be done. This is due to the
coexistance of other primary cancers in the genital tract.

19. Diagnosis
The diagnosis is confirmed by biopsy.
• When a definite growth is present, the biopsy
is to be taken from the margin.
• Cystourethroscopy, Proctoscopy CT/MRI scan
(for nodes) may be needed.
• In cases of vulval dystrophy, the sites are from
multiple areas usually from the persistent red
areas or from stained areas following toluidine
blue test.

20. DIFFERENTIAL DIAGNOSIS
The lesion needs differentiation from:
• Condyloma accuminata
• Syphilitic ulcer
• Tubercular ulcer
• Lymphogranuloma venereum
• Soft sore

22. CAUSES OF DEATH
• „Uremia—from ureteric obstruction due to
enlarged common iliac and paraaortic nodes.
• „Rupture of the femoral vessels by the
overlying involved inguinal lymph glands.
• „Sepsis.

23. MANAGEMENT
Prophylactic
• Adequate therapy for non-neoplastic epithelial
disorders of the vulva.
• Adequate therapy for persistent pruritus vulvae in
postmenopausal women.
• Frequent use of multiple biopsies in conservative
treatment of VIN.
• Liberal use of simple vulvectomy in postmenopausal
women with VIN where follow-up facilities are not
available.

24. DEFINITIVE TREATMENT
Microinvasive lesion
• There is increased incidence of lymph node involvement in
lesion of more than 1 mm invasion.
• It is thus prudent to perform radical vulvectomy with
bilateral groin node dissection in all cases of stromal
invasion more than 1 mm.
• However, if the invasion is less than 1 mm, wide local
excision with or without ipsilateral groin lymphadenectomy
may be done with follow up.
• Generally, there is no lymph gland involvement.Tumor free
surgical margin should be at least 1 cm to prevent local
recurrence.

25. Frank invasion
• Radical vulvectomy with bilateral inguinofemoral
lymphadenectomy is the ideal surgery.
• Three separate incision (one for radical vulvectomy and one
each for groin node dissection) approach is currently
preferred instead of en-block approach. Pelvic node
metastases are rare unless inguinofemoral nodes are
involved.
• Pelvic lymphadenectomy in cases of positive deep node
involvement is omitted in preference to external radiation
on the groin and pelvis—in the form of 4500 to 5000 cGy,
usually 4–6 weeks after surgery.

26. • Negative sentinel lymph node biopsy for
• Micrometastasis may avoid extensive
lymphadenectomy.
• Radical vulvectomy is often associated with
• Major long-term morbidity, sexual dysfunction and loss
of body image.
• Radical local excision of the vulva with wide margins
(1–3 cm) is considered to be an alternative to radical
vulvectomy with equal result.

27. If the general condition is poor and/or in presence of medical
diseases
The following principles may be adopted:
• Two stage operation is preferred. Total vulvectomy followed by at a
later date, bilateral inguinofemoral lymphadenectomy.
• Total vulvectomy followed by full pelvic and groin irradiation
(megavoltage therapy).
Neoadjuvant chemotherapy—chemotherapy followed by surgery,
radiotherapy or both.
Technically inoperable or recurrent lesion − Chemotherapy (cisplatin,
bleomycin, 5-FU) can be used as radiation sensitizer.
Chemoradiation therapy may be combined as primary therapy or
following surgical excision of the tumor.
Radiotherapy can be used as a primary therapy for advanced disease.

28. RESULTS
• With negative groin nodes, the 5 year
survival rate for invasive carcinoma ranges
from 90–100 percent.
• With positive groin nodes, the survival rate
falls to 20–55 percent. With positive pelvic
nodes, the survival rate falls even below 20
percent.

29. Prognostic factors for vulval
squamous cell carcinoma
• Clinical stage of the disease.
• Site of the tumor .
• Depth of stromal invasion.
• Lymph node involvement (inguinofemoral and
pelvic).
• Tumor diameter and differentiation.
• DNA ploidy status.

31. THANK YOU