This document discusses pre-malignant and malignant conditions of the vulva. It begins by describing vulvar intraepithelial neoplasia (VIN), the pre-malignant condition where cellular changes are limited to the epithelium. VIN is graded based on the depth of atypical cells. Vulvar cancer most commonly presents as squamous cell carcinoma in older women. Risk factors include HPV infection, smoking, and immunosuppression. Examination may reveal irregular growths or ulcers. Biopsy is needed for diagnosis. Treatment options depend on the grade of the lesion and include local excision, laser ablation, or topical therapies. Follow up is important due to the risk of recurrence.

1. PRE-MALIGNANT AND
MALIGNANT CONDITIONS
OF VULVA
Dr. Ujjwal Khullar
Dr. Prachi Kushwaha(GUIDE)

2. • VIN (vulvar
intraepithelial
neoplasia) is the
premalignant condition of
the vulva where the
cellular changes are
limited to the epithelium
but do not extend beyond
the basement membrane.
• Also known as the
squamous
intraepithelial lesions
of the vulva
VIN

3. GRADING
• VIN 1 – atypical cells are found only in
deeper 1/3 of epithelium
• VIN 2 –intermediate state b/w 1 & 3
• VIN 3 – atypical epithelium is present
throughout the whole depth of
epithelium , k/a CARCINOMA in SITU.
 Basement membrane is intact in all.

4. • The vulva is the area
immediately external
to the vagina,
includes-
the mons pubis,
labia,
clitoris,
Bartholin glands,
perineum.

5.  Anatomically, the
vulva extends from-
• Anteriorly- Mons
pubis
• Laterally- Genito-
crural folds
• Posteriorly- Anus
The normal findings in
the vulva include-
• Micropapillomatosis,
• Sebaceous glands and
• Vestibular redness.
 It is important to be aware
of normal findings and not
mistake them for vulvar
lesions.

6. The anatomical structures in the vulva

7. CLASSIFICATION
• NON-NEOPLASTIC EPITHELIAL DISORDER OF SKIN AND MUCOSA
- Lichen sclerosis
- Squamous hyperplasia
- Other dermatosis
• MIXED NON-NEOPLASTIC AND NEOPLASTIC EPITHELIAL DISORDERS
• INTRAEPITHELIAL NEOPLASIA
-squamous intraepithelial neoplasia
 VIN 1
 VIN 2
 VIN 3
-non squamous intraepithelial neoplasia
paget`s disease
tumours of melanocytes, noninvasive

8. • High-grade squamous intraepithelial lesion
(HSIL) has replaced the term ‘VIN usual
type’ and includes the warty, basaloid and
mixed lesions.
• It is associated with high-risk HPV infection,
by HPV 16, 18 and 33.
• Other risk factors are smoking, HIV
infection and STDs.
• VIN usually associated with vulvar lichen
sclerosus and not associated with HPV and
occurring in older women.

9. PATHOLOGY
• Macroscopically-
the lesion may be a
warty, elevated plaque
that is white or red, an
ulcer or a nodular lesion
• The lesions may be
multifocal.
• Differentiated VIN is
usually associated with
lichen sclerosis and
squamous cell
hyperplasia.

10. Microscopically ,the
cells exhibit -
• Nuclear abnormalities
• Maturation
disturbance
• Increase in mitotic
activity
• Sometimes changes of
HPV infection.

11. DIAGNOSIS
Symptoms of VIN-
• Asymptomatic
• Pruritus vulva
• Ulcer
• Discomfort, pain
• Warty growth
• Bleeding, discharge

12. EXAMINATION
• VULVOSCOPY- with 3-
5% acetic acid is
helpful.
• Acetic acid enhances
– surface topography
and acetowhite areas.
• Helps to see – coarse
punctations
• LESSIONS SEEN ARE-
1. White hyperkeratotic
plaques
2. Hyper pigmented lesions
3. Areas of erythema
4. Raised / flat lesions
5. Bulky lesions
6. Condylomatous lesions
7. Multifocal lesions

13. In cases of DIFFERENTIATED VIN
(Dvin)-
• Lesion is single with
LICHEN SCLEROSES /
LICHEN SIMPLEX near
vulval skin.
• Lessions are-
- Ulcer
- Warty papule
- Hyperkeratotic
plaque

14. BIOPSY
• Which lessions to be
biopsied?
- Irregular
- Asymmetric
- Dark
- Large
- Elevated
- Rough
- Nodular
- Ulcerated lession with
induration
- Inguinal
lymphadenopathy
• KEYES PUNCH BIOPSY-
- Apply local anesthetic injection ,
apply acetic acid.
- Aceto-white area is biopsied.
- Alternatively biopsy can be taken
by cervical punch biopsy forceps /
knife
- About 6mm diameter
suspicious area is taken and
one or two haemostatic
sutures are taken with vicryl-
2-0.
- Lesions of CLITORIS – to be
done under GA.

15. MEDICAL TREATMENT FOR VIN
• Topical steroid therapy
(TST)
• Topical 5-fluorouracil
(TFT)
• Alfa interferon (under
trial)
• Even with medical
treatment routine
biopsy is essential.
TOPICAL STEROID
THERAPY (TST)
 CLOBETASOL
PROPROIONATE cream
 FLUOCINOLONE oint.
 HALCINONIDE cream.
 5-FLUOROURACIL cream
DOSE- TDS for 3-4 weeks.
Above is not definative
treatment.

16. MANAGEMENT OF
VIN -
• Local excision is done for
vulvar HSIL and VIN
differentiated.
• Disease-free margin of 5 mm
should be obtained.
• Large, confluent lesions
require more extensive
excision and rotational flap
for skin grafting.
• Young women with VIN
may be treated by CO2 laser.
• Immune response
modulators such as
imiquimod are under trial.

17. TREATMENT OF HIGH GRADE SIL OF
VULVA / VIN 2 AND 3
• High grade VIN is treated.
• VIN on skin surface tend to be deeper involving
pilosebaceous units in 66% cases and is limited to
2.5mm depth from epidermal surface
• Mucosal surface lessions are more superficial.
• Extensive excision is needed.

18. WIDE LOCAL
EXCISION
• Treatment of
choice- large
advanced VIN in
which probability of
vulvar cancer can`t
be excluded.
• A surgical margin of
at least 5 mm is
prefered
• Recurrence rate –
20%
LASER ABLATION
• CO2 gives good cosmetic
results and depth of tissue
distruction can be
controlled
• ADVANTAGES-
- It is less disfiguring as
compared to excision
- Less bleeding
• DISADVANTAGES
- Prolonged painful healing
- No tissue specimen
- More reurrence – 25%

19. CAVITATIONAL
ULTRASONIC
SURGICAL ASPIRATION
(CUSA)
- Done on non- hairy skin
- Ultrasound is used to
cause cavitation and
disruption of affected
tissue.
- Less pain and scaring
- Tissue obtained is in
fragments
- Recurrence -35%
TOPICAL MEDICAL
THERAPY
- Topical Imiquimod
cream applied over the
affected area has lower
toxicity than 5-
Fluorouracil and
Cidofovir.
- Efficacy- 77% cure rate
- Recurrence- 20%
- PREVENTION- HPV
vaccine.
- FOLLOW UP- after 6
months and then yearly.

20. BOWEN’S DISEASE
• It’s intraepithelial
carcinoma of Vulva.
• CLINICAL FEATURES-
slowly growing hard red
indurated patch on vulva
with intense itching.
• EXAMINATION-
- Well demarcated reddish
indurated lesion on vulva
with eczematous dry
surface.
- BIOPSY- pickle cells / giant
cells (BOWEN CELLS)
- TREATMENT- vulvectomy
- Prognosis- good
- Metastasis- rare

21. PAGET’S DISEASE
• Extra mammary disease on
vulva simulating intraductal
breast carcinoma with
involvement of apocrine sweat
glands
• May have associated
ADENOCARCINOMA in apocrine
and Bartholin gland
• May involve perianal and anal
skin.
• CLINICAL FEATURES-
- Pruritis
- Vulvar discomfort
- Pain

22. EXAMINATION-
• Elevated white indurated
eczematous lesions.
• Vulval biopsy- typical paget
cells in the epidermis
• These cells are large pale
vaculated rounded cells with
pale cytoplasm and vesicular
nuclei.
• Secreats- mucous
• May be asso. With
adenocarcinoma of Bartholin
glands in 20% cases.

23. TREATMENT-
- Simple vulvectomy
- Treat like vulval cancer – radical vulvectomy
with inguino- femoral lymphadenectomy.
- Radiaotherapy for elderly unfit women.
- Topical BLEOMYCIN or 5- fluorouracil
- Recurrence- 20-25%

24. CARCINOMA VULVA
• Vulvar cancer accounts for about 4% of cancers of
the female genital system in India.
• Most common age group - >65-70 yrs
• Median age 68 yrs.
• Most common variety of vulval cancer –
SQUAMOUS CELL (90-92%) followed by
melanoma (2-4%).
• Most common SITE for vulval carcinoma- HARTS
LINE f/b labia minora and L. majora.

25. ANATOMY

26. Possible signs of vulvar cancer include
bleeding or itching.
• -A lump or growth on the vulva.
• Changes in the vulvar skin, such as color
changes or growths that look like a wart or
ulcer.
• Itching in the vulvar area, that does not go
away.
• Bleeding and Tenderness in the vulvar area.

27. HISTOLOGICAL SUBTYPES

28. Most Common Histological types
• Squamous: >90%
• Melanoma: 5-10%
• Basal Cell: 2%
• Sarcoma: 1-2%
• Paget: <1%
• Bartholin gland: rare

29. TYPES OF SQUAMOUS CELL
CARCINOMA
TYPE 1 WARTY /
BASALOID TYPE-
• Young women <50 yrs
• Multifocal
• Related to HPV infection
, vulval intraepithelial
neoplasia , smoking ,
STD ,
immunosuppresion.
• PROGNOSIS- good
TYPE 2 KERATINIZING ,
DIFFERENTIATED /
SIMPLEX TYPE
• Elderly
• Unifocal
• Related to vulval ds-=
like- lichen sclerosis ,
squamous hyperplasia
• GENE mutation
responsible – p53

30. ETIOLOGY
• Older age
• Precancerous changes (dysplasia) in vulvar tissues
• Lichen sclerosus, which causes persistent
• itching and scarring of the vulva
• Human papillomavirus (HPV) infection
• Cancer of the vagina or cervix
• Heavy cigarette smoking
• Chronic granulomatous disease (a hereditary
disease that impairs the immune system)

31. HUMAN PAPILLOMA VIRUS
INFECTION (HPV)-
HPV mainly 16 and 18 , 31 , 33 are responsible
• HPV DNA is detected in 90% cases of VIN and
only 50-70% cases of vulval carcinoma ,i.e., only
basaloid and warty types
• RISK FACTORS- smoking and HPV genital warts
• HPV VACCINE reduces incidence of vulval
carcinoma.

32. • HERPES SIMPLEX VIRUS- is weakly associated
, along with co-factors like smoking.
• CHRONIC IMMUNOSUPPRESSION- transplant
patients on immunosuppressive drugs , HIV
women especially in younger age
- Hence vulval biopsy must be done for any
suspicious lesions specially in
immunocompromised patients.
• VIN-2 and VIN 3 can develop
into carcinoma with in 4
years

33. CLINICAL PRESENTATION
SYMPTOMS-
• Asymptomatic
• Vulvar pruritis of long
duration ( commonest
symptom)
• Vulvar irritation
• Vulvar pain
• Vulvar mass (Warty
growth)
• Non healing vulvar ulcer
• Vulvar bleeding
• Vulvar discharge
• Dysuria and difficult
micturition (involvement
of urethra)
• Rectal bleeding and
painful defecation
(involvement of anal
canal)
• Inguinal mass ( metastatic
lymph nodes)

34. SIGNS
Vulvar examination may
reveal-
• Irregular fungating mass
• Irregular ulcer
• Warty growth
• Plaque like lesion
• Red or white
pigmentation on vulvar
lesion
• Tenderness over lesion
(may or may not be
present)
• Unilateral or bilateral
inguino-femoral
lymphadenopathy
Parts involved-
Labia Majora or minora (60%), Clitoris ( 10%),
Perineum ( 10%)

35. PARTS INVOLVED ARE-

36. HISTORY
• Careful history taking for symptoms and their
duration.
• Past history of sexually transmitted disease ,
any condylomata or vulval disease (lichen
sclerosis)
• HISTORY- smoking and immunosuppressive
drugs.

37. EXAMINATION
• Careful examination of
vulva should be done ,
look for –
 Size
 Location
 Extent of lesion
 Warty growth or
 Ulcerative growth
 Single / multifocal
 Association with lichen
sclerosis
 Involvement of vagina
Urethra
Base of bladder /
anus

38. • PER SPECULAM EXAMINATION- to
look for extension to vagina and cervix
• Per vaginal and per rectal examination is also
important.
• Any fixity of vulval lession to bone is looked.
• Inguinal regions should be palpated for
inguinofemoral lymph nodes , their enlargement
,size , number and fixity to skin.

39. DIAGNOSIS
• If the lesion is not visible we can go for
VULVOSCOPY with 3% Acetic acid to look for
aceto- white areas.
• DEFINATIVE DIAGNOSIS- BIOPSY

40. TYPES OF BIOPSY
• Keyes punch biopsy :-
– Done under local anesthesia.Skin over lesion is made taut
with left hand.
– The keyes punch is put against the lesion firmly and rotated
with a constant firm pressure clockwise and then counter
clockwise for penetration into skin and to reach
subcutaneous fat.
– The raised circular tissue is grasped and cut at base with
scissors .
• Wedge biopsy :-
– Taken with knife.
– 2-0 chromic catgut or vicryl suture is applied for hemostasis.

41. INVESTIGATIONS
• PAP smear for cervial and vaginal cytology.
• Colposcopy of cervix and vagina.
• Vulvoscopy for inspection of other lesions.
• Imaging modalities:-
– Ultrasonography pelvis
– CT or MRI to see extent of disease and metastasis.
– Cytourethroscopy to rule out involvement of urethra and
bladder.
– Proctosigmoidoscopy.
– Intravenous urogram.
• Lymphography to detect smaller lymph node
metastasis.

42. Routine preoperative workup:
PAP smear
Serology
Complete hemogram
Blood gp (rh typing)
Urine routine and microscopy
Urine culture
LFT
KFT
BT/CT
X-ray chest
ECG

43. DEPTH OF INVASION

44. • Tumor shows classic
diagnostic features
of invasive
squamous cell
carcinoma that
include-
• a squamoid
appearance
• intercellular bridges
• brightly eosinophilic
keratin pearls
• Nests of invasive
tumor are
surrounded by
chronic
inflammation.

45. STAGING OF CARCINOMA VULVA

48. MODE OF SPREAD
• Direct extension :- To adjacent structures (vagina,
urethra , anus , clitoris )
• Lymphatic spread :- It is common and occurs by
embolization to regional lymph nodes.
Superficial inguinal lymph nodes
Deep inguinal and femoral nodes
Pelvic lymph nodes.

49. INITIAL SPREAD-
INGUINAL L.N (b/w Camper`s fascia ant. fascia
lata)
CLOQUET’S L.N / ROSENMULLER NODES
(SENTINAL LYMPH NODE of carcinoma vulva)
These are deep femoral nodes situated beneath
round ligament medial to femoral vein.
• Hematogenous spread : - Occurs rarely in the
late stages.

50. NORMAL LYMPHATIC DRAINAGE
• From VULVA+ Dist.3ed of
VAGINA.
• Drains into superficial
inguinal nodes.
• Lymph travels through
DEEP FEMORAL
Lymphatics and node of
CLONQUET to pelvic L.N
• Lymph can directly also
drain into DEEP
FEMORAL nodes from
CLITORIS and UPPER
LABIA
All lessions within 2cm of
midline may spread via
lymphatics.

52. DIFFERENTIAL DIAGNOSIS
• Syphilitic ulcer
• Tubercular ulcer
• Lymphogranuloma
venereum
• Granuloma inguinal
• Chancroid
• Vulvar elephantiasis
• Lichen sclerosis

53. TREATMENT
• SURGICAL TREATMENT :-
– Main treatment modality.
– Need to have adequate resection margin of 1 cm
and groin node dissection.

54. WIDE LOCAL EXCISION/ SIMPLE
PARTIAL VULVECTOMY
• For micro-invasive tumor (stage IA).
• 2cm tumour free surgical margin is
to obtained around the lesion
• Deep surgical margin should also
be 1 cm which roughly corresponds
to colles fascia.
• Lymph nodes are not removed.

55. RADICAL PARTIAL VULVECTOMY
• Partial vulvectomy is typically reserved for unifocal
lesions that are clinically connected to the labia majora,
labia minora , mons , vestibule, and/or perineum and
that have limited involvement to the adjacent urethra,
vagina, and/or anus.
• Complete removal of tumor containing portion of the
vulva wherever it is situated with 1 cm skin margins and
excision to the pelvic membrane.
• Combined with ipsilateral inguinofemoral
lymphadenectomy .

56. RADICAL PARTIAL VULVECTOMY
Its VARIATIONS are-
1. Right / left vulvectomy –
one side of L. majora and
minora.
2. Ant. Hemivulvectomy-
clitoris+ partial resection of
L. minora+ majora and mons
pubis
3. Post. Hemivulvectomy-
portion of L.majora ,
bartholin gland and upper
perineal body.

57. RADICAL TOTAL VULVECTOMY
• Removal of entire VULVA till
Perineal membrane + pubic
symphysis.
• Two elliptical incisions are made
on either sides of vulva.
• INNER INCISION- On vaginal
introitus and vestibule ant. To
urethral meatus post. to clitoris.
• OUTER INCISION- along
Labiocrural folds and Ant.across
mons pubis and post. Across the
perineal body.

58. • the en bloc incision,
also termed the
butterfly or longhorn
incision, made from one
ASIS to other.
• Its abandoned.
• Survival rates
equivalent to radical
complete vulvectomy
but carries signicantly
greater morbidity.
• After complete dissection ,
levator ani muscle are
approximated to prevent
RECTOCELE.
DISADVANTAGES-
 Complete loss of vulval
tissue with psychosexual
complications.
 Wound break down in 50%
 High rate of lymphedema
(65%)
NOT USED NOW A DAYS.

59. SENTINAL LYMPH NODE BIOPSY
• The FIRST LYMPH NODE to
receive tumour lymphatic
drainage is termed as
SENTINAL L.N
• If on biopsy sentinal node is
NEGATIVE , whole chain of
lymph nodes above it is also
likely to be NEGATIVE.
• NOT DONE – if groin
metastasis is suspected
• Done with
LYMPHOSCINTIGRAPHY with
Tc99m labelled nano colloid /
isosulphan blue injected into
skin around tumour.
• 5 mins late if TRACES of
dye +nt , excision under
microscope
INDICATIONS-
• Unifocal primary vulval
cancer
• <4cm diameter
• Tumour invasion <1mm
• Absence of obvious
metastasis on clinical
and radiology
• Absence of suspicious
inguino- femoral L.N

60. MANAGEMENT OF LYMPH NODES
 L.N DISECTION-
INGUINO-FEMORAL L.N
DISECTION
If carcinoma is within
2cm of midline
BILATERAL INGUINO-
FEMORAL LN DISECTION
If cancer is >2cm away
from midline
UNILATERAL INGUINO-
FEMORAL L.N DISECTION

61. APPROACH TO LYMPH NODE
DISECTION

66. 5 YEAR SURVIVAL RATE
• SINGLE most important
factor for PROGNOSIS is
INVOLVEMENT OF
LYMPH NODES.
L.N INVOLVED
5 YRS survival rate – 85%
L.N NOT involved
5 yrs survival rate -50%
DEPENDING ON
DEPTH OF INVASION-
1. <1MM – L.N not
involved , no
disection needed
PROGNOSIS- GOOD
2. >1MM – need
disection
PROGNOSIS- POOR

67. LYMPH NODE METASTASIS
• OVER ALL L.N metastasis- 25% cases of vulval
cancer.
STAGE LYMPH NODE
METASIS
1 10%
2 30%
3 75%
4 98-100%

68. ROLE OF RADIOTHERAPY
INDICATION-
• PREOPERATIVELY in pt
with advanced disease
with fixed L.N
• POSTOP- pts with positive
inguinal L.N
• POSTOP- pts with close
surgical margins of <5mm
, to prevent recurrence.
• In young patients , to
prevent severe
psychological effects of
radical surgery
• Recurrent disease
• Women unfit for surgery
/ anaesthesia.
TREATMENT- usually
teletherapy of 45-55GY.

69. ROLE OF CHEMOTHERAPY
• Limited role
• Mostly used as
neoadjuvant therapy
with radiotherapy in
advanced cases.
• Done where surgery is
not possible.
DRUGS USED ARE-
 CRISPLATIN
 5-FLUROURACIL
 BLEOMYCIN
 MITOMYCIN C

70. 5 YEAR SURVIVAL RATE
• STAGE 1 & 2 - 75-90%
• STAGE 3 – 54%
• STAGE 4B- 10%
• If INGUINAL lymph nodes are involved – 50%
FOLLOW-UP 6 monthly follow up after treatment is
completed and wound is healed till 5 yrs
• AIM- to detect recurrence , new primary lymph
node
• Patient should be looked for Ca vagina and cervix.

71. RECURRENCE
• About 30% vulval
cancer recur.
• 50% recurrence- if
margin is <8mm.
VULVA 70%
GROIN 24%
PELVIS 15%
DISTANT ORGAN
18%
MANAGEMENT OF
RECURRENCE-
VULVA- radiotherapy +/-
wide local excision
GROIN- radiotherapy/
radical groin dissection.
PELVIS- palliative
radiotherapy with
chemotherapy
DISTANT ORGAN-
palliative chemo. , poor-
prognosis. (<1 yr)

72. VULVAL MELANOMA
• 2nd MOST COMMON
vulval cancer (2-5%)
• Elderly
• 5 yrs survival – 10-50%
• Arises from L. majora ,
minora and clitoris.
• Hyperpigmented nodule
on vulva
• DIAGNOSIS- biopsy
TREATMENT-
• Radical Partial
vulvectomy with
inguino-femoral
lymphadenectomy.
• Prognosis- poor
• Chemotherapy –
alpha interferon,
interleukin-2 (new).

73. VERRUCOUS CARCINOMA OF VULVA
• Rare type of Squamous
cell Ca. of vulva
• Incidence- <1%
• Associations has been
seen with HPV genome
• Clinical features-
vulval mass , pain and
pluritis
• On examination –
cauliflower like tender
growth.
TREATMENT-
• Wide local excision with 1cm
surgical margin
• Usually no lymph node
involvement
• If needed FNAC of inflammed/
suspected L.N can be sent
• RADIOTHERAPY is
CONTRAINDICATED as it may
stimulate anaplastic
transformation , making it
more aggressive.
• PROGNOSIS- POOR

74. BASAL CELL CARCINOMA / RODENT
ULCER OF VULVA
• 2% of all vulval cancers
in elderly women.
• Site- labis majora
• Features- rolled out
edges with central
ulcer + pain +pruritus +
bleeding
• Rarely metastatic
• Biopsy - confirmatory
TREATMENT-
• Radical partial
vulvectomy with at least
1cm surgical margin
• If lymph node
involvement- inguino-
femoral
lymphadenectomy

75. BARTHOLIN GLAND CARCINOMA
• RARE tumour
HISTOLOGICAL TYPES
 ADENOCARCINOMA
 Squamous cell
carcinoma
 Transitional cell
carcinoma
• Age- 60-65 yrs
Clinical features-
• RECURRENT
BARTHOLIN’S ABSCESS
• Dyspareunia
SOLID TUMOUR OF BARTHOLIN
GLAND
 FNAC
 SPREAD- solid tumours
infiltrating into vulva and
ischiorectal fossa.
 Lymphatic spread- to pelvic LN
 Haematogenous spread- seen
TREATMENT
• Early stage- radical partial
vulvectomy with inguino-
femoral lymphadenectomy
• If tumour is pressing RECTUM-
preOP chemotherapy + radical
partial vulvectomy + ipsilateral/
B/L I.F lymphadenectomy.

76. VULVAL SARCOMA
• RARE
TYPES-
 Leiomyosarcoma
(commonest)
 Fibrous histiocytoma
• Develops as isolated
lesion on vulva
• Prognosis- poor
• TREATMENT-
Radical vulvectomy +
inguinofemoral
lymphadenectomy
Adjuvany chemotherapy
and chemotherapy given
for large tumours.

77. MANAGEMENT DURING PREGNANCY
• Squamous cell cancer of the vulva is rarely diagnosed and
surgically treated during pregnancy
• Incidence - 1 per 20,000
• Radical complete or partial vulvectomy and inguino femoral
lymphadenectomy can be performed if needed in 1st and
2nd trimester.
• During the 3ed trimester, there is increased genital
vasculature can increase surgical morbidity. Only local
excision is done
• Final surgery is done 2-3 weeks after delivery.
• If diagnosed at delivery, definitive surgery is performed
typically 2 to 3 weeks postpartum.
• MODE OF DELIVERY- VAGINAL DELIVERY.
• C.S is only done for obs. Indication or if tumour size is big
enough to cause hindrance in deliver

78. THANK YOU