This document discusses cancer of the vulva, including its incidence, risk factors, types, diagnosis, staging, prognosis, and management. Some key points: - Vulvar cancer accounts for 1-4% of gynecological cancers and predominantly affects postmenopausal women. Risk factors include HPV infection, smoking, and history of other gynecological cancers. - Squamous cell carcinoma makes up 90% of cases. Diagnosis requires biopsy of any suspicious lesions. Staging is based on tumor size and spread to lymph nodes or distant sites. - Prognosis depends on lymph node involvement, with 5-year survival rates over 90% for stage I but under 50% if nodes are

1. Cancer vulva recapitulating the FACTS
Dr. Sunaina wadhwa
Dr. Pratima mittal
Department of obstetrics &
gynecology
Vmmc & sjh.

2. Objectives of this presentation
 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

3. Introduction
 Vulval cancer is uncommon & accounts for
approximately 1-4% of all gynecological cancer
 4th most common malignancy of the female
genital tract
 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.
 As the 6th , 7th decade of life and does increase
with increasing age.

4. - The incidence increases with age.
- Recently there was a rise in the incidence, due
to
 Longevity (Long standing preinvasive
stage)
 Increased HPV infections.
 Increased smoking habits

5. Risk factors for carcinoma of the vulva
1- Human papillomavirus infection.
Genital condylomas: these are detected in 5 %
of vulvar cancer.
Vulvar intraepithelial neoplasia (VIN) and also
CIN.
2- Medical history of:
Vulvar dystrophy.
Chronic vulvar pruritus.
3- Patients with a history of squamous cell ca of
cervix or vagina.
4- Chronic immunosuppression.
5- Smoking

6. 2 Types / Variants
(15%) (85%)

7. (90%)
(2-3%)
(5%)

8. 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 .

9. Essentials of Diagnosis
 Typically occurs in postmenopausal
women.
 Long history of vulvar irritation with pruritus,
local discomfort, and bloody discharge.
 Appearance of early lesions like that of
chronic vulvar dermatitis.
 Appearance of late lesions like that of a
large cauliflower, or a hard ulcerated area
in the vulva.
 Biopsy necessary for diagnosis.

10. 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

11. 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.

12. Diagnosis
1) Local examination of the relevant areas: early lesions appears as
chronic vulvar dermatitis.
2) Clinical assessment of the lymph nodes is to be performed in the
relevant regions.
3) Biopsy: 1- From the suspected lesions:
a) Dermal punch biopsy using a local anesthetic: Lesions
< 1 cm
b) Excisional biopsy under general anesthesia: Lesions >
1 cm:
2- From the lymph nodes in the relevant regions when
suspected for metastasis.
Differential diagnosis:
1- Venereal diseases: syphilis, chancroid, lymphogranuloma venereum,
granuloma inguinale.
2- VIN. An association between invasive and noninvasive lesions is a
possibility.
3- Condyloma acuminatum.

13. In order to make a diagnosis
 you need to get tissue, and wedge
biopsy, excisional biopsies,
colposcopy,
 It’s very important to remember that you
have to examine the remainder of the
genital tract looking for vaginal lesions and
also for cervical dysplasia or early invasive
cancer because often times these can be
metastatic from another site,

14. Squamous Cell carcinoma
 65% arises in labia majora and minora
 25% percent in clitoris or perineum
 Appearance varies from a large,
exophytic, cauliflowerlike lesion to a small
ulcer crater superimposed on a dystrophic
lesion of the vulvar skin
 primary determinant of nodal metastases
is tumor size.

15. SITES.
 The most frequent sites are on the labia
majus, followed by the labium minorum,
and then some patient’s will have
combined lesions about 15%.

16. SQUAMOUS CELL
CARCINOMAAre 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:

18. 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.
External Iliac Nodes Common Iliac Nodes
Para Aortic L.N Thoracic Duct

19. 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.

20. A new FIGO staging based on surgical
findings in 1988, which underwent
revision in 2009 to provide better
prognostic discrimination b/w stages
and less hetrogeneity
The main changes are:
While stage 1a remains unchanged as s
only group of patients with negligible
risk of ln involvment , former stage 1
and 11 have been combined to 1b

21.  The new stage 11 segregates pts whose
tumors involve the lower adjacent perineal
structure from those with positive ln
 For stages iii and iv the no. and
morphology of the involved nodes are
taken into account and the bilaterality of
lymphnodes is discounted

24. T N M STAGING
 T-0 pre-malignant change
 T-1
 A a cancer less than 2.0cm in diameter and less than 1.0mm in
depth of invasion
 B a cancer less than 2.0cm in diameter but greater than 1.0mm in
invasion
 T-2 greater than 2.0 centimeters in diameter
 T-3 involves vagina, urethra or anus
 T-4 involves bladder, rectum or pelvic bone N-0 no lymph
nodes involved
 N-1 lymph node metastases to one groin
N-2 lymph node metastases to both groins
 M-1 any distant metastases
 M-0 no distant metastases

25. Stage I and II Stage III
Stage IV

27. 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%.

28. 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.

29. 5.Depth of Invasion:
A-invasion of 1 mm no risk of nodal metastases.
B-invasion of 1-3 mm 6-8% incidence of metastases.
C-invasion of 5 mm 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.

30. Prophylaxis…A high index of suspicion
 Detection and management of VIN.
 Proper management of all cases with
pruiritus vulvae.
 All vulval lesions should be diagnosed
accurately especially those arising after
menopause.
 All pigmented vulvar lesions should be
removed for biopsy.

31. Management
Modalities
Surgical Treatment Radiotherapy Chemotherapy
Radical Vulvectomy
En Block Dissection
3-in one incision
Pre-operative Post-operative Radiation Sensitizer
Metastatic
Conditions

32. Advances in managment of
vulvar ca
 Individualization of treatment for all patients
with invasive disease
 Vulvar conservation for patients with unifocal
tumor and an otherwise normal vula
 Omission of groin dissection for patients with
microinvasive tumor(t1a<2cm diameter and
<1mm stromal invasion
 Elimination of routine pelvic lymphedenectomy
 Investigation of role of sentinal ln procedure to
eliminate complete inguinofemoral
lyphedenectomy

33.  Use of separate incision for groin dissection
to improve wound healing
 Omission of contralateral groin dissection in
pts with lateral t1 lesion and negative
ipsilateral lnodes
 Use of preoperative radiotherapy to obviate
the need for exenteration in pts with
advanced disease
 Use of post operative rt to decrese the
incidence of groin recurrence with multiple
groin nodes

34. 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.

35. 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.

36. Treatment Options by Stage
Treatment OptionStage
Partial Vulvectomy excision of the tumor, with a 1 cm safe margins. No need
for node removal.
Ia
Ib
Modified radical vulvectomy with either of the following:
1) Ipsilateral groin lymph node dissection: in cases of lateralized
lesion
2) Bilateral groin node dissection: in cases of centralized lesions
Modified radical vulvectomy with bilateral groin node dissection.
II
- Combined approach:
1- Preoperative external beam radiation therapy.
2- Chemotherapy (e.g. 5-fluorouracil, cisplatin).
3- Radical excision with bilateral inguinal & femoral node dissection.
4- Preoperative RT, then surgical excision of the tumor.
- Pelvic exenteration.
III
Individualized
IV

37. HISTORICAL.
 The surgical treatment, back in the early
1900s Basset from France who adopted
a Hallstedian concept to the treatment
of vulvar cancer very similar what Dr.
Hallstead had adopted for breast cancer,
felt that wide surgical excision was the
best.

38. The standard treatment
( Hallstedian concept )
 , was block radical vulvectomy with
bilateral inguinal femoral
lymphadenectomies and we did selective
pelvic lymphadenectomies through
separate extra peritoneal incisions and this
basically is what has been called the
butterfly incision or the Texas longhorn
incision.

39. Why conservative surgery?
 The rationale for conservative surgery
is that most of the metastases occur by
embolization and the early advocates of
the more conservative procedures in
their series found no metastatic lesions
in the skin bridge between the vulva
and the groin,

40. Vulvectomy
 There are several operations in which part of the
vulva or all of the vulva is removed:
 A skinning vulvectomy means only the top layer of skin
affected by the cancer is removed. Although this is an
option for treating extensive VIN3, this operation is rarely
done.
 Simple vulvectomy, the entire vulva is removed.
 Radical vulvectomy can be complete or partial.
 When part of the vulva, including the deep tissue, is removed,
the operation is called a partial vulvectomy.
 In a complete radical vulvectomy, the entire vulva and deep
tissues, including the clitoris, are removed.
 An operation to remove the lymph nodes near the vulva
is called a en block dissection. It is important to
remove these lymph nodes if they contain cancer.

43. Skinning / Simple Vulvectomy

44. Radiotherapy
 Malignant diseases of the vulva are not commonly managed
by RT because of the intolerance of surrounding normal
tissues.
 Chemotherapy as radiation sensitizer can improve response of the
malignant tissues.
 Indications of RT in malignant diseases of the vulva:
 Preoperative RT in stage III and IV:
 The lesion shrunk and it limits the need for pelvic exenteration.
 It also improves surgical respectability of tumors.
 Postoperative RT: can reduce regional recurrences and inguinal
lymph node metastases.
 Multiple positive groin nodes: It decreases the incidence of recurrence.
 Positive surgical margins as seen on microscopic examination.
 Multiple focal recurrences.
 When the tumor size is > 4 cm

48. metastasis
 Primarily lymphatics to the superficial
inguinal lymph nodes
 Direct extension to vagina, urethra and
anus

50. Malignant Melanoma
 Accounts for 5% of vulvar cancers
 most commonly arises in the labia minora
and clitoris
 superficial spread toward the urethra and
vagina
 nonpigmented melanoma may closely
resembles squamous cell carcinoma
 darkly pigmented, raised lesion is a
characteristic finding

51. Colposcopy images after application of
acetowhite 5% and toluidine blue test

52. FACT: Current place of pelvic
lymphadenectomy?
 In the past pelvic lymphedenectomy was
routinely done now it has been
established that patients with negative
groin nodes rarely have positive pelvic
nodes.
 pts with >3 positive groin nodes are
prone to pelvic ln involvement

53. We omitted routine
pelvic lymphadenectomy,
 patient’s who have positive nodes, ,
end up getting radiation therapy to the
whole pelvis anywhay.

54. Role of adjuvent radiotherapy?
 Review of recurrence studies of in
Homesley,s study suggests that adjuvent
RT is more effective largely because groin
recurrences are reduced.

55. Should we do separate groin
incisions ?
 Understanding that the mode ofmetastatic
spread is embolic rather than by
contiguous grouth allowed for three-
incision technique..
 Less morbidity.
 No impact on survival.
(54% BREAKDOWN RATE WITH BUTTERFLY TECH.)

56. Is there a place for unilateral
inguinofemoral lymphadenectomy?
 May be indicated in well lateralised early
tumors.
 No lymph-capillary space involvement.
 Negative groin nodes by frozen section.

57. What is the place of superficial
inguinal lymphadenectomy?
 Above the cribriform fascia , mainly those
associated with great saphenous and
superficial epigastric veins.
 ONLY with low risk for LN metastasis.
 Tumors confined to labia majora.
 Negative superficial nodes on frozen
section.

58. Can we omit groin node dissection
in superficial diseases?
 Stage 1a have <1% for groin node
metastasis.
 we do give postoperative radiation for
groin nodal metastases

59. Is there a place for preoperative
radiotherapy?
 we give preop radiation therapy for
advanced disease.

60. Conclusions.
Now to run through management,
again
for stage I, it’s pretty much radical local
excision, and try to maintain at least a 1
cm margin and if it’s truly a small
lesion with less than a mm invasion, it
is felt that most of those patient’s do
not need to have lymph nodes removed.

61. CONCLUSIONS.
For large stage II lesions, again,
depending on where it’s located, we do
a radical vulvectomy and bilateral
inguinal femoral lymphadenectomy, if
there are more than two lymph nodes
positive, the patient’s will get
postoperative whole pelvic radiation.

62.  For stage III tumors, it depends on what’s
involved, you can do a radical excision which
often times becomes extended and you have
to take the distal vagina and even sometimes
the distal urethra and if you are going to treat
it surgically it needs to be combined with the
bilateral inguinal femoral lymphadenectomy
and again, if there is lymph node
involvement POST OPERATIVE
RADIOTHERAPY.

63. Conclusions.
 For advanced disease, again you have to
individualize, add up with surgical clearance
for disease sometimes involves the anus,
rectum, proximal urethra and requires an
exenterative procedure with radical vulvectomy
and bilateral groin nodes and that particular
circumstance is very important that patient’s
are evaluated either with MRI, CAT scans and
possibly even a PET scan for metastatic
disease prior to undertaking such a large
procedure. The operative mortality is about 5 to
10%.

64. Conclusions.
 Survival is also determined whether or
not the nodes are positive or negative,
and by which nodes are involved.
 If patient’s have negative groin nodes,
the five year survival is 90% and that’s
for stage I and stage II.
 If they have positive groin nodes,
survival drops about 57%.

65.  If they have positive pelvic lymph nodes, it
drops to 20%. Unilateral positive groin
nodes is about 70% five year survival,
bilateral positive groin nodes, however,
drops down to 25% five year survival, and
then the increasing number of positive
nodes.


66. CONCLUSIONS.
 and also the tumor diameter affects nodal
involvement, lymphatic vascular space
involvement and then overall survival.

67. Conclusions.
 .
 Less extensive surgery for vulvar cancer appears safe and
limits mutilation
 Vulvar cancer is rare, affecting mainly older women. Until the
1980s, affected women underwent extensive, mutilating surgery.
Groin nodes on both sides as well as all vulvar tissue were
removed. Recently surgeons have carried out a smaller
operation, leaving as much vulvar tissue as possible behind. No
randomized controlled trials have been conducted on the safety
of this reduced surgery, but from the available evidence it
appears to be safe to perform this smaller operation in most
patients.
The Cochrane Database of Systematic Reviews 2006 Issue 1
Copyright © 2006 The Cochrane Collaboration. Published by John Wiley & Sons, LtdSurgical interventions
for early squamous cell carcinoma of the vulva
Ansink A, van der Velden J, Collingwood M

68. What is the place of modified
radical vulvectomy?
 main morbidity of radical vulvectomy is
sexual dysfunction and compromised
function of the anus and urethra.
 The main fear of about the modified
operation is the multicentricity of the
tumor.(20-30%).
 So reservethe operation to well localised
tumors,with 2 cm free margin.

69. How should we treat vulvar
carcinoma with perianal
involvement?
 The main problem in these cases is to do
adequate resection with maintaining
sphincteric function.sometimes
 we may need to do more radical resection
and colostomy or
 preoperative radiotherapy.

70. what is the place of ultraradical
surgery?
 Only in patients with clearly resectable
lesions and negative or one or two
microscopicaly positive nodes.

71. what is the place of neoadjuvent
chemotherapy?
Resuts are not encouraging for time being.

72. CONCLUSION
1.Standard radical vulvectomy and bilateral
lymphadenectomy(Hallstedian concept.)has
compromised the life of many women with
cancer vulva.
2.In many well selected patients wide excision
with 2 cm margin with or without node
selection may suffice.
3.modified radical vulvectomy with bilateral
groin node dissection will give equaly good
results in the majority of cases

73. 4.Pelvic lymphadenectomy should be
abondoned except in a minority of selected
cases.
5.Radiotherapy should be given to the groins
and pelvis postoperatively only if
more than one groin nodesis positive for
metestatic disease.
6.ultraradical surgery selective
7.In situ stage is almost 100% curable.and
FIGO stage 1 disease is 90% curable and 5
year survival rate.

74. Take home message
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.