Cancers of Vulva and Vagina

1. Cancers of Vulva & Vagina

2. Cancer of Vulva:
 Cancer of the vulva is a rare entity and accounts for 1%-5% of all genital tract
cancers.
 It can be classified into two types:
 1. Preinvasive lesions include:
1. Intraepithelial cancer usual type VIN & differentiated VIN.
2. Bowen disease.
3. Paget disease.
4. Microinvasive.
5. Melanoma in situ.

3.  2. Invasive lesions:
1. Squamous cell carcinoma (most common – 90%)
2. Melanoma 1-5%
3. Adenocarcinoma 1%
4. Sarcoma 2%
5. Rodent ulcer or basal cell carcinoma 1%

4. Pre-invasive lesions of the vulva:
 Incidence:
Intraepithelial Cancer often affects women younger than 40 years who are often
affected by sexually transmitted diseases and viral inflections such as HPV (70-80%)
and herpes simplex virus 2.
 Aetiology:
1. Chronic vulval irritation, immunosuppressive conditions such as pregnancy, HIV
infection and smoking suppress the immune system and predispose the patient to
VIN lesions.
2. Condyloma, sexually transmitted diseases and dystrophies are other risk factors.

5.  Clinical features:
1. Pruritus may be the only symptom in early stage.
2. Soreness, dysuria and dyspareunia develops later.
3. Pre-existing leucoplakia, condyloma and dystrophic areas may now show white or
red, flat warty or papular lesions, single or multiple with well defined edges.

6.  Investigations:
1. Application of K-Y jelly improves visualization of the vasculature of the vulval skin. Five percent
acetic acid causes white areas and staining the area with 1% toluidine blue marks abnormal areas
royal blue, thus enabling selective biopsies from the dark stained areas.
2. Excisional biopsy of a localised lesion picks up VIN.
3. Colposcopy and pap smear of the cervix are also required to rule out concomitant pre-invasive
cancer of the cervix.
4. Proctoscopy and anoscopy may be required if the perianal region is involved in the lesion. This will
show extension into the anal wall. Vaginal and pap smear become mandatory in diagnosis &
treatment of these multifocal lesions.
5. Human papilloma virus DNA detection combined with cytology improves the detection test to 95%.

7.  Management:
1. To relieve the symptoms of pruritus and
soreness.
2. To prevent cancer developing in the area. 5-
10% VIN progresses to invasive cancer
within 8 years.
3. To avoid mutilating surgery & sexual
dysfunction in young women; radical
vulvectomy is mutilating and causes genital
disfigurement and dyspareunia.

8.  Follow up:
Recurrence around the excised lesion or fresh recurrence occurs in 20-30% of cases.
Five to ten percent of cases progress to invasive cancer in 8 years, after which invasion
is less likely, unlike that in carcinoma in situ of the cervix which may take 10-15 years
to develop to invasion cancer.

9. Invasive carcinoma of the vulva:
 Epidemiology:
1. Vulval cancer accounts for 2-4% of all malignancies of the female genital tract.
2. The women are generally elderly, in the sixth or seventh decade of life.
3. Increasing number of lesions are now seen in younger women and most of them
suffer from sexually transmitted diseases such as HPV and HIV infection.
4. Smoking is also a risk factor in these young women.

10.  Aetiology:
The causes are same as that of in situ carcinoma. The lesion associated with VIN and atypical
dystrophy often progresses to invasive cancer.
 Clinical features:
1. Most common features include pruritus, vulval swelling, lump or an ulcer. The lump may be
papular, raised pigmented area. The ulcer has often an everted margin. The surrounding skin
may be fissured, cracked and indurated.
2. Leukoplakic or dystrophied area may be present, and these may be single or multifocal. The
lesion is more commonly encountered over the labia majora, but the clitoris and perianal area
may be involved.

11.  Differential diagnosis:
1. Tubular or syphilitic ulcer.
2. Elephantiasis vulva.
3. Soft sore.
4. Lymphogranuloma.
 Spread of the tumour:
1. Direct spread to adjacent
organs.
2. Lymphatic spread.
3. Haematogenous spread rare

12.  Investigations:
1. Punch or excision biopsy depending on the size of the lesion.
2. Cystoscopy of urethra is involved.
3. Anoscopy and proctoscopy if the perianal area is involved.
4. X-ray of chest and bones.
5. CT and MRI scans for lymph node metastasis.
6. Lymphography is superior to CT scan and can detect metastasis in the lymph
nodes 2-5mm in size whereas CT can pick up metastasis only if it is more than
1cm.

13.  Treatment:
1. Stage 1: Lateral lesions can be dealt with by simple partial vulvectomy with a
margin of at least 2 cm beyond the growth, or unilateral vulvectomy, accompanied
by ipsilateral inguinal node dissection.
2. Stage 2: Radical/ modified radical vulvectomy and bilateral inguinofemoral lymph
node dissection.
3. Stage 3: Megavoltage radiotherapy can cause shrinkage and sometimes total
disappearance. Local excision can then be performed.
4. Stage 4: It is treated by chemotherapy or radiotherapy. Commonly used agents are
5-FU and mitomycin-C.

14. Vaginal Cancer:
 Primary vaginal cancer is a rare cancer accounting for less than 0.2% of all cancers in
women. It occurs in elderly women often older than 70 years when sexual activity has
generally ceased.
 Clinical features:
1. Vaginal cancer is generally asymptomatic in its earlier stages.
2. The usual complaints are presence of watery discharge or postcoital bleeding, the lesions
may be diffuse, raised velvety patched bleeding in touch, a whitish patch or ulcer.
3. The Lesions are often multifocal and in the upper-third of the posterior wall. Schiller’s iodine
test/ colposcopy and biopsy help settle the diagnosis.

15.  Diagnosis:
Suspicious areas of plaque/white patch should be
subjected to Schiller’s test and colposcopic biopsy. All
gross lesions such as nodule, papule, ulcer or mole
should be biopsied. Local application of oestrogen in
old women enhances a colposcopic view. Colposcopy
is difficult on account of a large vaginal area, multiple
lesions and vaginal fo.lds

16.  Management:
1. VAIN: It is treated with local excision biopsy, CO2 laser and local application of 5-
fluorouracial cream. Electrocautery and cryotherapy are best avoided.
2. Invasion cancer is treated with local radiotherapy, Wertheim hysterectomy with
total colpectomy or exenteration operation for the advanced cases involving
bladder/bowel.
3. Creation of neovagina is required in young women.
 Prophylaxis:
Treating a decubitus ulcer & proper care of a ring pessary in a prolapse can avoid
cancer of vagina.

17. Thank you.