Carcinoma Vulva & Vagina Subdivisi Onkologi Ginekologi Bagian Obgin – FK USU

Vulvar Carcinoma. Definition: Cases should be classified as carsinoma of the vulva when the primary site growth is in the vulva Malignant melanoma should be reported and staged according to the system for cutaneous melanoma

Vulvar casinoma Eldery type: Younger type More common Unrelated to HPV Dystrophic lesion Lichen sclerosis Younger type Related to HPV Related to smoking Associated with VIN

Models of vulvar cancer Characteristic Younger Type Elderly Type Age Younger ( 35 to 65 yo) Older (55 to 85 yo) Cervical neoplasia High association Low association Cofactors Age, immune status, viral integration Vulva atypia, possibly mutated host gene Histopathology of tumor Intraepithelial-like (basaloid), poorly diff. Keratinizing, squamous cell carcinoma, well diff HPV DNA Frequent (>60%) Seldom (<15%) Pre-existing lesion VIN Vulvar inflam, lichen-sclerosis, squamous cell hyperplasia History of condyloma Strong association Rare association History of STD Cigarette smoking High incidence Low incidence

Etiology No specific etiologic factor Relation to VIN : controversial VIN considered low malignant potential Related to infection with HPV HPV DNA : 20% – 60%

Diagnosis No screening procedures Histopathologic Wedge biopsy Under local anesthesia Include some surrounding skin Include some underlying dermis / connective tissue Problem : delay diagnosis

Staging 1988 : clinical staging 1994 : surgical staging Regional lymph node (N): NX : regional node cannot be assessed N0 : no regional node metastasis N1 : unilateral node metastasis N2 : bilateral node metastasis Distant metastasis (M): MX : distant metastasis cannot be assessed M0 : no distant metastasis M1 : distant metastasis

Stage FIGO stage TNM categories Primary tumor cannot be assessed TX No evidence of primary tumor T0 Carcinoma in situ (preinvasive carcinoma) Tis I Tumor confined to vulva and/or perineum, ≤ 2 cm in greatest dimension T1 IA Tumor confined to vulva and/or perineum, ≤ 2 cm in greatest dimension and with stromal invasion ≤ 1 mm T1a IB Tumor confined to vulva and/or perineum, ≤ 2 cm in greatest dimension and with stromal invasion > 1 mm T1b II Tumor confined to vulva and/or perineum, > 2 cm in greatest dimension T2 III Tumor invades any the following :lower urethra, vagina, anus and/or unilateral regional node metastasis T3 IV T4 IVA Tumor invades any the following: bladder mucosa, rectal mucosa, upper urethral mucosa, or is fixed to bone and/or bilateral regional node metastasis IVB Any distant metastasis including pelvic node

Carcinoma of the vulva Stage grouping FIGO stage T N M Tis N0 M0 IA T1A IB T1B II T2 III T1 N1 T3 IVA N2 T4 Any N IVB Any T M1

Treatment VIN or carcinoma in situ Invasive carcinoma Multiple biopsy to ensure the lesion entirely intra epithelial Local incision with 1 cm margin laterally Invasive carcinoma Individualized Primary lesion Groin lymph node Micro invasive (stage IA) Wide local excision No groin resection

Treatment Early stage (confined to the vulva without clinically suspicious lymph node) Less radical surgery (radical local excision) Lateral margin ≥ 1 cm Depth : inferior fascia urogenital Urethra may be resected Groin node dissection: Ipsilateral for T2 or T1 stromal invasion > 1 mm Bilateral dissection for midline tumor Adjuvant radiation if: Node positive, Ǿ > 1 cm ≥ 2 node positive 50 Gy in fractionation

Treatment Advanced stage ( T3/T4 or bulky groin node) Multimodality treatment Primary tumor : if possible resected Node : resected or not Radiation

Vaginal Carcinoma Definition: Primary malignant from vaginal tissue The rarest gynecological neoplasm (<1%) Squamous cell carcinoma is the most common

Etiology The etiologic factor : ? Prior pelvic radiation due to cervical carcinoma > 5 years ago Any new vaginal carcinoma developing at least 5 years after the cervical cancer should be considered as a new primary lesion Related to the administration of DES for clear cells adenocarsinoma

Diagnose Screening : women with history cervical cancer 28% occult carcinoma found in VAIN Relation VAIN and carcinoma vagina : ? Biopsy : under local anesthesia Histopathology

Staging Stage 0 Carcinoma in situ, intraepithelial neoplasia grade 3 Stage I The carcinoma is limited to the vaginal wall Stage II The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall Stage III The carcinoma has extended to the pelvic wall Stage IV The carcinoma has extended beyond the true pelvic or has involved the mucosa of bladder or rectum, bullous edema as such does not permit a case to be allotted to stage IV Stage IV A Tumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvic Stage IV B Spread to distance organs

Treatment Referred to tertiary referral unit Individualized Surgery : limited role Radiation : choice of treatment Tele & intra cavitary radiation