ONCOLOGY OF VULVA AND VAGINA

THE VULVA

INCIDENCE: OVER 400, OVER 200 DETHS (ANNUAL IN POLAND) 40-60% STAGE III and IV – FIGO – inolved lymph nodes

Risk factors low level of hygiene, HSV, HPV(40%), chlamydia trachomatis, cosmetics age – organism involution (i.e. metabolic abnormalities)

Prognosis 5-year survival I (FIGO) - 90% IV (FIGO) - 18% (all togother 35%)

VIN - vulvar intraepithelial neoplasia (SIL –squamos intraepithelial lesion)

VIN 1 (low grade dysplasia) – 1/3 lower part of epithelium VIN 2 (intermediary grade dysplasia) – 2/3 lower part of epithelium VIN 3 (high grade dysplasia) – 1/3 upper part of epithelium or whole epithelium - ca praeinvasivum or 1/3 lower part similar - ca planoepitheliale G1

Ca planoepitheliale - 90% Bartholin gland Ca - 5% other glandular – Paget disease sarcomas metastatic – breast, kidney, stomach, melanoma

Two types of vulvar cancer

1/3 papillar or basal cell ca relatively young women before ca – VIN and virus infection multifocal

2/3 planoepithelial keratodes in older age before no VIN lichen sclerosus planoepithelial hyperplasia virus infection rare monofocality

Symptoms. - no. - itching. - pain (clitoris). - abnormalities of Symptoms - no - itching - pain (clitoris) - abnormalities of defecation and miction - smell secretion

Ways of invasion - infiltration of neighbour structures (urethra, vagina, anus) - metastasis into regional lymph nodes

Diagnositic EVERY disease in region of vulva needs histioathological verification

If melanoma suspection: resection of the whole abnormal tissue with margin of normal tissue

in 20% of cases vulvar malignancy coexist with second malignancy of FGT

Stage O (carcinoma in situ, intraepithelial carcinoma) treatment simple resection of vulva local resection

Stage I (tumor infiltrating vulva or perineum; in largest diam max 2 cm; no metastasis to lymph nodes) vulvectomy with bilateral inguinal lymph nodes margin min.: 8 – 10 mm

If metastasis in lymph nodes – complementary radiation theraphy

In case of patient who does not agree for surgery – radical radiotheraphy

Stage II ((tumor infiltrating vulva or perineum; in largest diam over 2 cm; no metastasis to lymph nodes)

Radical vulvectomy (margin of inaffected tissues - min 10 mm) with bilateral inguinal lymph nodes

Complementary radiotheraphy - metastasis in inguinal lymph nodes Complementary radiotheraphy - metastasis in inguinal lymph nodes (2 or more without cossing the capsule of LN or 1 with cossing the capsule of LN or macroscopic invasion) - margin smaller than 8 mm - deph of invassion larger than 5 mm - lymph or capillary vassels invassion

Stopień III (tumor of any size infiltrating urethra, vagina, anus or/and unilateral metastasis to LN)

Deep radical vulvectomy with superficial and profundal inguinal LN, urethra resection, partial resection of anus

Radiotheraphy in patients who can not be qualified to surgery or do not agree

Stopień IV IV A – tu infiltration upper part of urethra, urinal cyst mucose, mucose of anus, pelvic bones, and/or bilateral inguinal LN IV B – distant metastasis including pelvic LN

1. Radical vulvectomy with involved organs (urethra, urinal cyst, anus), with regional LN complementary radiation 2. Radical radiotheraphy 3. Paliative radiation 4. Symptomatic treatment.

Chemotheraphy - as a part of radiochemotheraphy in preoperative radiation in stage III/IV - in recurence 5-fluorouracyl i cisplatin

SROM

SROM

The Vagina

Ca of vagina – primary - 1-2% of all FGT cancers Very rare 1-2% of all FGT cancers 80-90% secondary Planoepithelial ca - (85%) - in this 80% cervical ca, 17% vulva ca Glandular ca - – endometrium (32%), colon (26%), ovary (17%) kidney, breast, chorioncarcinoma

Ethiology of primary ca of vagina persistent leukorrhea ? mechanic contraceptives persistent leukorrhea leucoplakia vaginitis late menopause masturbation viral infection pessars lack of estrogenes

Location Most frequent - 1/3 – back-upper wall Less frequent - 1/3 low part Sporadic in the middle part of vagina

Contact bleeding, leukorrhea, urinal bladder, anus abnormalities Symptoms At the beginning – NO In advanced stages – Contact bleeding, leukorrhea, urinal bladder, anus abnormalities

Diagnosis - other cancer than planoepithelial - hist-pat verification of the tumor - colposcopy with biopsy - exclussion of cervical cancer (cervical tissue sections / abrasion) - other cancer than planoepithelial - Uteral cave abrassion, USG, mammography - cystoscopy + tissue sections ( front wall) - rectoscopy + tissue sections ( back wall)

chemotheraphy (advanced stages) (Cisplatyna, 5Fu, Mitomycyna) Treatment Surgery (partly!) radiotheraphy ! teleradiotheraphy brachyteraphy (chir + rtp) chemotheraphy (advanced stages) (Cisplatyna, 5Fu, Mitomycyna)

5-year survival average 35 % Iº - 70% - 80% IVº - 0% - 18%