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

2. 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

3. 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

4. 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

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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

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

19. 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

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

21. 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

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