vulval carcinoma

1. Dr Antima Rathore

2. Incidence
 0.6 % of all malignancies
 4 % of genital malignancies
 Squamous cell carcinoma – 90 %

3. Types of Vulvar cancer

4. Anatomy of the vulva

5. Lymphatic drainage of vulva

6. Lymphatic drainage of the vulva

7. Applied Anatomy
 Single most prognostic marker – L N status
 5 yr survival rate
No LN - 90%
LN - 50%
 Superficial Inguinal Lymph node – Sentinal Lymph
Node

9. Etiology
 HPV
 VIN
 CIN
 Lichen sclerosis
 Squamous hyperplasia
 Immunodeficiency
 History of genital warts
 Smoking
 Alcohol
 Immunosuppression
 H/O Cervical or Vaginal cancer
 Northern Europe ancestry

10. Squamous cell cancer
90 %
Basaliod
 Multifocal
 Younger pt
 HPV
 VIN
 Smoking
Keratinising
 Unifocal
 Older patient
 Lichen Sclerosis
 Sq. Hyperplasia
(>80% cases)
Itch Scratch Cycle

11. Clinical features
 Postmenopausal female
(Mean Age – 65 yrs)
 VIN
 Vulval Pruritis
 Lump or mass
 Rare – bleeding/ulcerative lesions, discharge
 Pain or dysuria
 Large metastatic mass in groin
 Other malignancies – HPV and smoking associated

12. Diagnosis
 Any vulval lesion warrants biopsy
 Punch biopsy
 Wedge biopsy
(include dermis)
 Colposcopy – cervix and vagina
 Labia majora & minora – 60%
 Clitoris – 15%
 Perineum – 10%
 Multifocal – 5%
 Extensive – 10%

13. Routes of Spread
 Direct extension
 Lymphatic
 Hematogenous

14. Staging
IA Tumor confined to the vulva or perineum, ≤ 2cm in size
with stromal invasion ≤ 1mm, negative nodes
IB Tumor confined to the vulva or perineum, > 2cm in size or with
stromal invasion > 1mm, negative nodes
II Tumor of any size with adjacent spread (1/3 lower
urethra, 1/3 lower vagina, anus), negative nodes

15. Staging
IIIA Tumor of any size with positive inguino-femoral lymph
nodes
(i) 1 lymph node metastasis ≥ 5 mm
(ii) 1-2 lymph node metastasis(es) < 5 mm
IIIB (i) 2 or more lymph nodes metastases ≥ 5 mm
(ii) 3 or more lymph nodes metastases < 5 mm
IIIC Positive node(s) with extracapsular spread

16. Staging
IVA (i) Tumor invades other regional structures (2/3
upper urethra, 2/3 upper vagina), bladder mucosa, rectal
mucosa, or fixed to pelvic bone
(ii) Fixed or ulcerated inguino-femoral lymph nodes
IVB Any distant metastasis including pelvic lymph
nodes

17. Prognosis
 Lymph nodes status
 Lesion size
 Histologic grade, tumor thickness, depth of stromal invasion, lymph-
vascular space involvement, tumor ploidy
 Stage I – 79%
 Stage II – 59%
 Stage III – 43%
 Stage IV – 13%

18. Treatment

19.  Table 33.4
부산백병원 산부인과

21.  Stage Ia – Microinvasive T1a
Wide Local excision – deep upto dermis
 Stage Ib & II – Early vulval cancer
Radical local excision plus Ipsilateral groin node
dissection
- 1 cm negative margin
- Extending up to inferior fascia of urogenital diaphragm
- Separate incision technique
Treatment

22. Treatment
 Midline lesions
Anterior – clitoris sparing surgery – 8mm margin
 Periclitoral lesion in young pt – small field RT with
concomitant chemosensitization
 small lesion – 5000 cGy external radiation
f/b biopsy

23. Treatment
 Stage II involving adjacent srtucture
Radical vulvectomy or radical local excision Plus
LN Dissection
 Advanced disease
Surgery plus RT
plus
concomitant chemo

24. Treatment
 Clinicaly advanced nodes – debulking of enlarged nodes
&/or chemoradiation
 Metastatic disease - palliation

25. 부산백병원 산부인과

26. 부산백병원 산부인과

27. 부산백병원 산부인과

28. Closure of large defects
 Small defects – primary closure without tension
 Large – left open to granulate
 Full thickness skin flap – rhomboid or mons pubis flap
 Myocutaneous flap – gracialis
 Tensior fascia lata myocutaneous graft

29. Management of LN
 > 2 cm diameter
 > 1 mm invasion
 Surgery – trt of choice
 Bilateral dissection - midline lesions, clitoris, post forchet
- unilateral bulky LN / multiple microscopic
LN
 Bulky LN – debulking
 Fixed unresectable LN - chemoradiation

30. Sentinal Lymph node biopsy
Criteria
1) unifocal primary tumour of 4 cm or less in diameter with >
1 mm invasion
2) no obvious metastatic disease on physical
examination/imaging

31. Postop management
 Ambulation on day 1 or 2
 DVT prevention
 Subcutaneous heparin
 pneumatic calf compression
 Frequent dressing
 Suction drainage of each side of the groin
 Sitz bath

32. Early Postoperative Complications
 Groin wound infection, necrosis, breakdown
 En bloc operation – 53-85%
 Separate-incision approach – 44%
 UTI
 Lymphocyst
 DVT
 Pulmonary embolism
 MI
 Hemorrhage

33. Late Complications
 Chronic lymphedema
 Recurrent lymphagitis or cellulitis
 Usually responds to oral antibiotics
 SUI
 Introital stenosis
 Femoral hernia (uncommon)
 Depression, altered body image and sexual dysfunction
 Pubic osteomylitis
 Fistula

34. Recurrent Vulvar cancer
 ≥ 3 LN - 2/3 of vulvar cancer recur within first 2 years from initial
Tx.
 Local recurrence
 Margin status
 Closer than 0.8cm -> 50% recur
 Primary lesion larger than 4cm in diameter
 Ipsilateral lymphovascular space invasion
 Deep invasive tumour
 Tx.
 Additional surgery with myocutaneous graft
 External beam therapy + interstitial needles
with chemotherapy

35. Regional and Distant Recurrence
 Difficult
 Poor prognosis
 Radiation
 Chemotherapy
 Bleomycin and methotrexate & lomustine
 Bleomycin and mitomycin C
 Cisplatin, vincristine & paclitaxel
 Response
 Usually disappointing
 Long-term survival is very uncommon

36. Role of Radiation Therapy
 primary vulval ca.
 Advanced disease
 LN meta – microscopic, gross
 Possible roles for RTx.
 Involved or close surgical margin
 Small primary tumor - primary Tx.,
 Particularly clitoral or periclitoral lesion

37. Melanoma
 Rare
 Incidence : 0.1-0.19/100,000women
 Second most common of vulvar malignancy
 Postmenopausal white women
 No symptoms (most)
 Itching, bleeding, groin mass
 Labia minora, clitoris
 Vulvar nevi are junctional, precursor lesion to melanoma; thus,
should be removed

38. Histopathology
 Mucosal lentiginous melanoma
 Flat freckle, quite extensive, superficial
 Superficial spreading melanoma
 Most common, superficial
 Nodular melanoma
 Most aggressive, raised lesion
 Penetrate deeply
 Metastasize widely
 ¼ of cases of melanomas
 Macroscopically amelanotic -> spread early

39. Staging

40. Treatment
 More conservative surgical management
 Invasion
 (<1mm) : Radical local excision alone
 (>1mm) : en bloc resection of the primary tumor and
regional groin node dissection recommended
 1cm surgical margin (<0.76mm)
 2cm surgical margin (1-4mm)

41. Treatment
 10-year survival rate
 Lateral lesion (61%), medial lesion (37%)
 Superfical lesion (Breslow tumor thickness <0.76mm )
 Lymphadenectomy not indicated
 Intermediate-thickness (1-4mm)
 Observation showed a 5-year survival advantage who
underwent lymph node dissection
 Deeply invasive cutaneous melanoma (>4mm)
 Benefit from regional lymphadenectomy
 Chemotherapy : interferon – α , dacarbazine

42. Bartholin Gland Carcinoma
 Rare
 Postmenopausal
 Premenopausal
 Honan’s criteria
 The tumor is in the correct anatomic position
 The tumor is located deep in the labium majus
 The overlying skin is intact
 There is some recognizable normal gland present

43. Bartholin Gland Carcinoma
 Signs and Symptoms
 Vulvar mass or perineal pain
 10% of patients may be mistaken for benign cysts or
abscesses
 Treatment
 Radical vulvectomy with bilateral groin and pelvic LN
dissection
 Fixed, involves adjacent structures-> postop radiation
and chemotherapy is preferable

44. Bartholin Gland Carcinoma
 Adenoid Cystic Carcinoma of Bartholin Gland
 Other Adenocarcinomas
 Adenosquamous Carcinoma
 Basal cell carcinoma
 Verrucous Carcinoma
 Vulvar Sarcoma

45. Rare Vulvar Malignancies
 Lymphomas
 Endodermal Sinus Tumor
 Merkel Cell Carcinoma
 Dermatofibrosarcoma Protuberans
 Metastatic Tumors of the Vulva