Dr. Jean Peiffer - Wide excision of vulva and perineum - Bilateral inguinal lymphadenectomy - Primary closure - Mortality <5% - Recurrence <10% - Standard treatment for >50 years - Morbidity high: wound breakdown, lymphedema, sexual dysfunction - Replaced by less radical surgery when LN status shown to be most important prognostic factor - Still indicated for large fixed tumors with close or positive margins - Adjuvant radiation reduces recurrence rates - Quality of life better with less radical surgery when oncologically sound - Basset’s operation established vulvar cancer surgery as a subspecial

1. Vulvar Cancer
with special guest
VIN
Professor Khalid Sait (FRCSC)
Chairman of Scientific chair of Prof. Basalamah for
gynecological cancer
Director of Gynecology oncology unit
Faculty of medicine
King Abdulaziz university
Jeddah, Saudi Arabia

2. Epidemiology
 4% of gential tract malignancies
 Mean age 65 is decreasing
 Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal

3. Epidemiology
 4% of gential tract malignancies
 Mean age 65 is decreasing
 Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal

4. Epidemiology
 4% of gential tract malignancies
 Mean age 65 is decreasing
 Two types:
VIN associated Vulvar dystrophy
Prevalence 20-30% 50-60%
Age Younger 30-35 Older 55-85
Histology Poorly diff./ non-keratinizing Well diff./ keratinizing
Lesions Multifocal Unifocal

5. Risk Factors
 Smoking
 Vulvar dystrophy
 VIN
 HPV 16 and 18
 Immunodeficiency
 Previous cervical cancer
 Northern European
 Radiation

6. Presentation
 Symptomatic
 Pruritis
 Soreness
 Dysparunia
 Lumps
 Asymptomatic
20%

7. Presentation
 Associations
 CIN
 PAIN in up to 30% of cases

8. Diagnosis
 Vulvoscopy
 Enhances examination
 Useful in selecting sites for biopsy
 Acetic acid
 Can enhance lesions
 Makes clinically unimportant HPV
obvious
 Toludine blue
 Not used clinically

9. Diagnosis: Biopsy
 Use local anaesthetic
 Xylocaine
 EMLA cream
 Punch biopsy
 Keyes punch
 Cervical biopsy forcep
 Haemostasis
 Apply AGNO3
 Apply monsels soln
 suture

10. 10
Marcaine
0.5 % w/o

11. Classification: 1989
 Intraepithelial neoplasia
 Squamous
 VIN 1
 VIN 2
 VIN 3
 Nonsquamous intraepithelial neoplasia
 Paget’s disease
 Tumours of the melanocytes, non invasive (melanoma in situ)
ISSVD Int J Gynecol Pathol 1989;8:83
VIN 3 replaces, Bowens disease, Erythroplasia of Queyrat,Carcinoma in situ
,Bowenoid papulosis

12. VIN
White plaques Pigmented: brown/ red Condyloma

13. ISVVD 2004
 VIN 1
 VIN 2, 3 = VIN
 VIN
 Usual type VIN ( warty, basaloid) HPV associated (type
16 in >80%)
 Differentiated type VIN
<2-5% of VIN
Older patient
Associated with squamous hyperplasia and/or lichen sclerosus
p53 mutation and/ or over-expression relatively common
Sideri M et al. J Reprod Med. 2005 Nov;50(11):807-10

14. Basiloid
 Thickened epithelium
 Flat, smooth surface
 Atypical small immature
parabasal type cells
 Numerous mitotic figures
 Enlarged hyperchromatic
nuclei.

15. Condylomatous
• Least common
• Papillary form: Undulating or
spiking surface
• Hyperkeratosis, parakeratosis
• Mitotic figures and abnormal
maturation
• Surface keratinocytes with
koilocytosis, binucleation or
multinucleation
Parakeratosis: nuclei in surface keratin, sign of high turnover
Koilocytosis: HPV effect, hyperchromatic/ “raisin” nuclei, vacuoles in cytoplasm

16. Differentiated (simplex) type
• Easy to miss
• Almost looks normal
• Full thickness but large abnormal cells
confined to the parabasal and basal
portion of the rete pegs with
eosinophilic cytoplasm
• Mild nuclear atypia
• Keratin pearl formation may be present

17. VIN 2
VIN 1
VIN 3
HPV only- not neoplastic
Untreated
Progresses to
Cancer
Variable rates
Women > 30 yrs
Treated
VIN Natural History
Spontaneous regression
Can occur
Women < 30 yrs
Risk of subsequent
malignancy 2.5-7%
Risk of invasion
at treatment 18-22%

18. Preinvasive neoplasia - VIN
“Early and effective treatment, elimination of smoking and
long-term follow-up of all patients with VIN is imperative.”
Local excision: local 0.5cm margin, epidermis and dermis
Skinning vulvectomy: multifocal, epidermis only
Laser ablation: multifocal 1-3mm depth
5FU: multifocal
Imiquimod:
Only AFTER appropriate biopsies to rule out
invasive disease

19. •Surface epithelium
• only possible with laser
• Epidermis & papillary dermis
• Condylomata
• Epidermis & part of reticular
dermis
• VIN
• To fascia
• Malignancy
Principles of excision
4th plane

20. Surgery: Wide local excision
 Commonest surgical
modality
 Excise skin with 5mm
margins

21. Surgery: Wide local excision
 Free margins
 90% success rate
 Involved margins
 50% success rate

22. Surgery: Skinning vulvectomy
 Introduced 1968
 Rutledge and Sinclair
 Extensive often multifocal
lesions
 Especially in hair bearing
areas
 Removal of large area of
vulva skin
 5 mm margins
 Shallow layer of skin removed
 Split thickness skin graft
used to fill defect

23. Surgery: Skinning vulvectomy
 Problems
 Extensive surgery
 Sexual dysfunction post op
 Recurrence
 Up to 39 %
 Can occur in grafted areas
 Does provide a pathological specimen when
invasion is a concern
 Can be used in association with laser

24. Vulva-Laser
 Usually use “superpulse”
 Less thermal damage
 Less carbonization than lowering the energy and
using a continuous waveform

26. 26
LASER
Therapy 8 Weeks
Post
Laser

27. Other Treatments
 Photodynamic therapy
 using topically applied 5-aminolevulinic acid.
 Limited experience and availability
 Labour intensive
 5FU (Efudex cream)
 Painful –not recommended
 Imiquimod cream 5% (Aldara)
 promising
 5% cream applied 3X a week for 8 weeks or more,
continue 2 weeks after disappearance
27

28. Preinvasive neoplasia -
VIN
30% of women will have recurrence
Especially:
- high grade
- multifocal
- positive margins
Therefore long-term follow up is necessary

29. Paget’s Vulva
 Often multifocal erethematous-whithe plaques
 <10 % have an associated cancer, Colon, Bladder,
endomerium
 10-20% have associated invasive Pagets or vulvar Ca

30. Pagets

33. • acanthosis and elongated rete pegs
•Paget’s cells with large nucleus and prominent neucleolus, occur in
clusters
•Hyperplastic epithelium

34. Approach to Paget’s
 Investigations:
 Colonoscopy
 CT abdomen/ pelvis
 Urinalysis

35. Paget’s:Therapy
 Excision:
 Wide local excision, 2 cm into subcutaneous tissues
 Suspicion of invasion treated with radical excision
 Medical therapy:
 ? imiquimod

36. Vulvar Cancer Continued…

37.  Surgical staging is preferable because the inguinal
femoral lymph node status is the most important
predictor of over all prognosis

38.  Stage I: tumor confined to the vulva
 IA: lesions ≤ 2 cm in size, confined to the vulva or
perineum and with stromal invasion ≤ 1.0 mm with
negative node.
 IB: lesions > 2 cm in size or with stromal invasion >
1.0 mm, confined to the vulva or perineum with
negative node
FIGO 2010 staging of vulvar
cancers

39.  Stage II: Tumor of any size with extension to
adjacent perineal structures (1/3 lower urethra, 1/3
lower vagina and/or extension to the anus) with
negative nodes.

40. Stage III: tumor of any size with or without extension to the
adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive
inguino-femoral lymph nodes.
 IIIA: (i) 1 lymph node metastasis ≥ 5 mm
(ii) 1–2 lymph node metastasis(es) < 5 mm
 IIIB: (i) 2 or more lymph node metastases ≥ 5 mm
(ii) 3 or more lymph node metastases < 5 mm
 IIIC: Positive node(s) with extracapsular spread

41. Stage IV: tumor invades other regional (2/3 upper urethra or
vagina), or distant structures.
 IVA: cancer invades any of the following:
(i) upper urethral and/or vaginal mucosa, 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

42. Principles of treatment
 Treatment should be individualized for each
patient.
 A full pre-operative work-up, including colposcopy
of cervix, vagina and vulva, should be performed to
assess the extent of subclinical disease.
 Preinvasive disease should be removed with the
primary lesion, if feasible.

43. Principles of treatment
 Surgery attempts to
 1) Stage (i.e., assess the extent of
disease and hence the prognosis).
 2) Debulk a) Primary Tumor
b) Lymph Nodes
 Conservative surgery is preferred
over radical surgery as long as
prognosis is not adversely affected.

44. Principles of treatment
 Vulvar cancers spread by embolozation, not
permeation so tissue between tumor and LNs need
not be ressected (i.e., en bloc).
 When recurrence occurs locally, it reflects the
behaviour of the disease, not inadequate ressection.

45. Principles of treatment
 Positive margin need re-excision
 Positive groin node two or more microscopic , one or more
macroscopic, any extra-capsular spread need adjuvant
radiation.
 Elimination of routine pelvic lymphadenectomy in case of positive
groin node i.e. pelvic radiation( GOG).
 Adjuvant radiation required to the vulva in locally advanced
disease after excision.
 Chemotherapy may be useful in the treatment of locally
advanced disease( to avoid urostomy or if there is bone
involvement) /distant metastases and recurrent disease in
groin.

46. Requirment for unilateral
LND
 UNIFOCAL
 Lateral more than 1 cm from the mid line
 Not located in the ant. Portion of the labia minora
 No palapable groin node in both side
 No l. node mets found at the time of the unilat LND

47. Treatment

48. Treatment
Surgery LN Radiation Chemotherapy
IA(T1)
<= 1 mm
invasion
Radical local
Excison
- - -
IB
(T1)
> 1 mm
invasion
Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
III (T3 –
late)
IV (T4)
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?

49. Treatment
Radical local excision:
• A wide (1-2 cm margins) and deep (to the inferior fascia of the urogenital diaphragm)
excision of the primary tumor
• Closure: primary two layers
Surgery LN Radiation Chemotherapy
IA(T1)
<= 1 mm
invasion
Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?

50. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB
(T1)
> 1 mm
invasion
Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop +
Recurrence Rexcison + +
Radical local excision:
Radical Vulvectomy
•
•

51. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
Radical Vulvectomy +/- myo-cutaneous flab
•

52. Surgical Challenges

53. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
II(T2)
III (T3 –
early)
¯
OR Radical
Vulvectomy
Bilateral Groin + -
III (T3 –
late)
IV (T4)
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop Cis or 5FU
Recurrence Rexcison ? ?
Exenteration:
• En bloc dissection from:
• the cardinal ligaments laterally
• the broad ligaments of the rectum
posteriorly
• the supralevator attachments of the
bladder, urethra & vagina anteriorly
• the perineum around vagina & anus
caudally
• Reconstruct vagina with gracilis myocutaneous
flap
• 10% operative mortality

54. •Surface epithelium
• only possible with laser
• Epidermis & papillary dermis
• Condylomata
• Epidermis & part of reticular
dermis
• VIN
• To fascia
• Malignancy
Principles of excision
4th plane

55. 1. Acetic Acid
2. Colposcopy
3. Outline incision
Principles of excision

56. 4. Select appropriate depth
Principles of excision

57. 5. Mobilize adjacent tissues
• Vagina
• Perineum
Principles of excision

58. 6. Primary Closure/ Graft
7. Post operative
• Analgesia
• Sitz baths
• Stool softner
• Bedrest
• DVT prophylaxis
• +/- Drains
Principles of excision

59. Radical Vulvectomy (
Basset’s operation)
Antoine Basset (1882-1951) Paris
First to publish 147 cases of vulval cancer which he called cancer of the clitoris
Rev Chir 1912
‘’ The evolution of the disease appears to be rather rapid without
surgical treatment, at least after the tumour is ulcerated, and the
prognosis is then always fatal. It is still very somber after
the mutilating operation, because of great frequency of local,
and above all nodal, recurrence. But this seems amenable to
improvement by early and systemic extirpation including all
the lymphatics and nodes that drain the clitoris ‘’

60. Treatment
Surgery LN Radiation Chemotherapy
IA Radical local
Excison
- - -
IB Ipsilateral/
Bilateral Groin
- -
T2
T3 – early
¯
OR Radical
Vulvectomy
Bilateral Groin + -
T3 – late
T4
Rad.
Vulvectomy/
Exenteration
N2/ N3 Groin
± Bilateral
Groin & Pelvic
Preop ?
Recurrence Rexcison + ?
Groin (Inguinal and Femoral)
LN Dissection:
• Linear incision medial 4/5ths
between ASIS and pubic tubercle
• Dissect between fascia lata and
superficial fascia, preserving tissue
above
• Tie off saphenous vein
• Inguinal: above fascia lata, 2cm
above inguinal ligament, medially by
adductor longus, laterally by sartorius
• Femoral: Below fascial lata, medial
to femoral vein at opening of the
femoral ring

61. Inguinal LN Dissection

62. Inguinal LN Dissection
 High perioperative morbidity:
 Requires 3-4 days of bed rest, wound breakdown 50%,
lymphocele, lymphedema, infection, bleeding, DVT
• Can some low-risk
women avoid full LN
dissection?
Sentinel Node Biopsy

63. Sentinel Node Biopsy
• Used in breast CA and melanoma
• Two methods:
– Radiolabelled human albumin and gamma-detecting probe
Possible 91-100% NPV: 100%
– Isosulfan blue dye Possible 56-75% NPV: 96-100%

64. Key Points
 VIN is a condition of increasing importance with multiple
methods of treatment
 At least two possible etiologies are considered for vulvar
cancer. One is related to infection with oncogenic HPV ,
other is related to maturation disorders
 Management must address local control and regional
( nodal ) disease
 The evolution of management has been driven by desire
to reduce morbidity whilst maintaining disease control
 Vulvar cancer is a challenging disease to treat. Its rarity
has mindered attempts to improve management through
clinical trials

65. Thank You!