This document discusses benign and malignant diseases of the vulva. It covers symptoms, general pathology, diagnosis of white, red and brown lesions. Nonneoplastic epithelial disorders like lichen sclerosis and squamous cell hyperplasia are examined. Malignant diseases like HPV, VIN, and carcinoma are addressed. Cancer epidemiology, management including staging, surgery, radiation and chemotherapy are summarized. Prognostic factors and recurrence are also reviewed. Key points emphasize inspection, biopsy, medical therapy for benign conditions and challenges in vulvar cancer treatment.

1. Benign and malignant
disease of the vulva
Khalid Sait ( FRCSC)
Gynecological Oncology
Professor
Faculty of Medicine
King Abdulaziz University

2. Symptoms of Vulvar
Disease
• Itching
• Burning
• Dyspareunia
• Discharge
• Bleeding

4. General Pathology Term.
• Epidermis
• Acanthosis
• Parakeratosis
• Hyperkeratosis

17. Vestibular
Micropapillomatosis

19. General Guide to
Diagnosis
• White Lesions
• Red Lesions
• Brown/Bluish Lesions

20. White Lesions
• Vitilligo
• Nonneoplastic epithelial disorders

22. Nonneoplastic Epithelial
Disorders - Vulva
• Squamous cell hyperplasia
• Lichen Sclerosis
• Other dermatosis
ISSVD 1987

25. Lichen Sclerosis
• Steroid
• Testesterone
• Progesterone

28. Squamous cell
hyperplasia
• Steroid

33. Red Lesions
• Infective
• Dermatitis
• Psoriasis
• Pagets
• VIN/Ca

41. HPV - Treatment
• Observation
• Podophyllin
• Trichloroacetic acid
• Interferon
• Imiquimod ( Aldara)
• Excision /Laser

51. Brownish/Bluish Lesions
• VIN
• Naevi/Melanoma
• Carcinoma

57. Malignant Disease Of The
Vulva

58. Female Genital Tract
Malignancy
• Uterus
• Ovary
• Cervix
• Vulva
• Vagina
• Fallopian Tubes.

59. Epidemiology
• Mean age at diagnosis is 65 years
• Etiology is unknown
• VIN is premalignant
• Lichen sclerosis is associated with vulva
cancer
• HPV found in 50 % of vulva cancer
• Alteration in p 53
• smoking

60. Malignancy Of The Vulva
• Squamous cell carcinoma 90 %
(Verrucous ca)
• Melanoma
• Bartholine gland adenocarcinoma
• sarcoma

65. Carcinoma Of The Vulva
• Preoperative workup
• History
• Physical Examination
• CBC, U/E and LFT
• CXR a-p/lat

66. Management
Staging: surgico - pathological
• Management of the vulva
• Management of the groin

68. Microinvasion
• Lesion less than 2 cm with depth of
less than 1 mm with noLVS inv. and
no clinical positive node
• Incidence of L.node mets is 0 %
• Treatment wide local excision down
to colles’ fascia

69. Lateral T1 lesion
• Radical local excision and groin unilateral
node dissection
• Send for frozen if positive do the other
side
• If negative unilat node only 10 % will have
positive contra lateral node usually in
lesion with risk factors
• 20-30 % of non suspicious node will have
mets

70. Lateral T2 lesion
• Unilateral hemivulvectomy and
bilateral node groin dissection

72. Prevalence of local invasive recurrence after radical
local excision and radical vulvectomy for early T1 lesion
procedure Pts number recurrence Dead of
disease
Radical local
excision
165 12(7.2%) 1(0.6%
Radical
vulvectomy
365 23(6.3%) 2(0.6%

73. T1 or T2 midline or
bilateral lesion
• Radical vulvectomy and bilateral groin
node dissection

74. Post operative adjuvant
therapy
• Close margin(< 8mm) re-excision
versus RT. to the vulva
• Poorly diff., large tumor, LVS
involvement and diffuse infiltrative
lesion :
Radiation to the vulva a lone and may
be to the medial groin area

75. Respectable vulva lesion with clinically positive groin
node
• Radical vulvectomy with bilateral
groin node dissection followed BY
radiation to groin and pelvis
• With multiple inguinal node 20 % risk
of pelvic node involvment
• 22 % of clinical positive groin node
will show no histology evidence of
mets

77. T3 Involvement of distal urethra , vagina or
anus
• Preoperative radiation and chemotherapy
to allow conservative surgery with
affecting sphencter followed by:
if residual disease radical vulvectomy and
groin lymph node dissection
If no residual disease do multiple vulval
biopsies and node dissection
• If bulky node remove bulky node initially if
not fixed or ulcerated

78. T4 Primary lesion with massive bladder and or rectum
involvement
• Selective Exenteration with radical
vulvectomy and groin node dissection
• Remove bulky nodes if not fixed or
ulcerated and give radiation to the
groin and pelvic nodes as well as
radiation to vulva with 5 FU followed
by debulking surgery or a modified
exentrative procedure

79. Chemotherapy
• 5 FU 1gm/m2/d 1-4 days over 2 4
hoyrs infusion 96 ml start 24 hours
before radiation and be given on day
29-32 of radiation

80. Radical Vulvectomy
• Radical en-bloc dissection
Taussig and Way 1949-1960
• Triple incision technique

97. Rhomboid flaps

100. Morbidity related to
treatment
• Wound breakdown
• Sepsis
• Venous thromboembolism
• Pressure sore
• Lymphaedema
• Lymphocyst
• Psychosexual problems
• Moist desquamation

101. Carcinoma Of The Vulva
stage 5 years survival
0 100 %
1 95 %
2 83%
3 36 %
4 29 %

102. Prognostic Factors
• Stage
• Histological
• Status of l.node an d number involved and
capsule
• Vascular invasion
• Tumor thickness
• Depth of invasion
• Amount of keratin
• performance status
• DNA polidy

103. Recurrence
• In vulva: excision with margin if
possible with 5 years survival up to
50 % or RT if not given before
• In groin: IF RT NO GIVEN
BEFORE---à RT IF RT GIVEN
BEFORE---à excision IF POSSIBLE
• In pelvis: radiation if not given
before
• Distal or after radiation:
chemotherapy

106. Verrucous Carcinoma

108. VERRUCOUS
CARCINOMA
• VARIAN OF SQUAMOUS Ca.
• Rare
• Florid cauliflower like lesion in labia
majora
• L. node mets is not reported
• Treatment wide local excision
• Very little atypia

112. MELANOMA
• 2-10 % of vulva malignancy
• 5 % of melanoma of white female occur in
vulva
• Mean age 63
• STAGE I
• STAGE II
• STAGE III
• STAGE IV
• Node resection need to be done for
prognostic or if found to be positive
clinically

119. Key Points
• Inspection/ Palpation
• Biopsy prior to treatment
• Medical therapy for majority of
benign lesions
• Vulvar cancer is uncommon.
Squamous cancer is the most
frequently recognized subtype

120. Key points
• At least two possible etiologies are considered. 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
• Vulval cancer is a challenging disease to treat. Its rarity has
mindered attempts to improve management through clinical
trials