1. Cancer of The Vulva
By Dr Emdalala Elasheg

2. Introduction
Vulval cancer is uncommon and accounts for approximately 1-4% of all gynecological cancer
incidence : 1.8 / , It is predominantly seen in postmenopausal and old women (mean age years ) ,and only 2% were less than 30 years.
In countries such as south Africa where sexually transmitted diseases are common, the mean age of presentation is 59 years.

3. Objectives
To know the out lines of etiology,diagnosis and mangment of cancer vulva.
To understand the importance of early dectection of cancer vulva to improve prognosis and survival rate

4. AETHIOLOGY: Little is known
A viral factor has been suggested by the detection of antigens induced by
Herpes simplex virus type (HSV2)
Type 16/18 human papilloma virus (HPV) , in vulval intraepithelial neoplasia.

5. PATHOLOGY Primary Tumor 90% of lesions are of squamous in origin.
3-5 of lesions are melanoma.
2% of lesions is basal cell carcinoma.
Less than 1% is sarcoma.
Secondary Tumors
It is occasionly found in vulva
Most commonly the primary lesion is from the cervix or the endometrium .

6. SQUAMOUS CELL CARCINOMA
Are usually seen in the anterior part of the vulva.
2/3 of cases in the labia majora.
1/3 of cases in the clitoris ,labia minora,fourchitte, and perineum.
Spread:-
LYMPHATIC > 50%
Direct spread occurs in 25% to the urethra, vagina and rectum
Hematogenous spread to bone or lung is rare
The lymph nodes are arranged in 5 groups in each groin:

7. Superficial L.N:
1- Inguinal L.N: Medial I.L.N ,lying inferior to S.I.ring.
Lateral I.L.N ,below the inguinal ligament.
2-Femoral L.N: Medical F.L.N,lying medical to saph.vein
Lateral F.L.N, lying lateral to saph .vein

8. Anterior groups ,lying between EIV and EIA
Deep L.N:
Deep inguinal L.N , lying in the inguinal channel
Deep femoral L.N (node of cloquet lying in the femoral channel
External iliac L.N:
Medial groups ,lying medial to EIV
Lateral groups,lying lateral to EIA
Anterior groups ,lying between EIV and EIA

10. Thoracic Duct Para Aortic L.N External Iliac Nodes Common Iliac Nodes
Lt sided lesion will spread to the Lt groin Lymph node.
Rt sided lesion will spread to the Rt Groin Lymph node.
Bilateral nodes involvement is seen in 14% of cases.
Contralateral node involvement without ipsilateral disease is seen in 5% of cases.
Never found pelvic nodes to be involved in the absence of inguinal nodes metastases.

11. Clinical Features & Diagnosis
Most patients with invasive disease complain of:
Irritation or purities in 70% of cases
Vulvar mass or ulcer in 55% of cases
Bleeding in 28% of cases
Discharge in 2-3% of cases

12. Older women are often embarrassed and shy.
The major problem in invasive vulvar cancer is delay between the first appearance of the symptoms and referral to the gynecological opinion due to :
The doctor fails to recognize the gravity of the lesion and prescribes topical therapy.
Older women are often embarrassed and shy.

13. On Examination
Lesion can take any form from flat white lesion to large ulcer.the size of the tumor ,involvement of the urethra and anus should be noted
Inspection of the cervix and cervical cytology.
Needle aspiration of any suspicious groin node.
diagnosis is made on histology from full thickness generous biopsy.

14. STAGING:
FIGO suggest clinical staging in 1969 based on TNM (Tumor node metastasis) classification taking into consideration:
The size of the local lesion.
Groin node involvement.
Metastases.

15. A new FIGO staging based on surgical findings in 1988, it is more accurate
as the involvement of groin nodes is missed on clinical examination in up to
30% of cases and over diagnosis in 5%.

16. NEW FIGO STAGING OF VULVA CARCINOMA
Stage 1
2 cm lesion size Or less
Confined to the vulva or perineum nodes histo-Logically negative.
Stage 2
> 2cm lesion size
Stage 3
Tumor of any size spread to lower urethra vagina anus +/- Unilateral metastasis
Stage 4 A
Involvement of :
Upper urethra
Bladder mucosa
Rectal mucosa
Pelvic bone
Bilateral L.N.metastasis B
Distant metastases and / or pelvic nodes

17. PROGNOSIS
The overall 5 years survival rate for vulval cancer is 70% for all operable cases,
This depends on:
L.N Involvement:
This is the most prognostic factor
Metstatic involvement of groin nodes decreases the 5 years survival rate to below 50% as opposed to the 90% when L.N are not involved.
Once pelvic nodes are involved the 5 years survival rate is 15%.

18. The number of groin nodes involvement:
microscopical involvement of N.regardless of stage has a good prognosis.
2 or more positive nodes have a worse prognosis.
Stage:
The 5 years survival rate decreases with advancing stage from >90% in stage 1 to < 10% in stage 4.
Differentiation:
A well diff.tumor has a better prognosis than poor diff.

19. Depth of Invasion: Surgical Margin:
A-invasion of 1 mm no risk of nodal metastases.
B-invasion of 1-3 mm % incidence of metastases.
C-invasion of 5 mm % incidence of metastases.
Surgical Margin:
Surgical excision margin of more than 1 cm in all diameters results in a low local recurrence rate.

20. Treatment The corner stone of treatment is surgery
The majority of FIGO stage 1 and 2 will be cured by surgery alone.
Because most vulval cancers present at an advanced stage in developing countries other modalities such as chemotherapy and radiotherapy may have to be used.

21. SURGURY:
The standard surgery is enblock radical vulvectomy and bilateral groin nodes dissection as described by Taussing and way (three separate incision). This associated with:
High incidence of morbidity (wound infection, necrosis and break down , pul. Embolism, and lymphoedema).
Problems with body image and sexual function.

23. The recent trend in management is not to cure patients but to preserve body image and sexual function by performing less radical surgery .The individualization of the treatment depends on:
Size and position of tumor.
Depth of invasion.
The age and performance status of the patient.

24. Primary management in Carcinoma of The Vulva
Features of Carcinoma
Radical local excision only
(Excision with 2 cm margins,
down to super,aponeurosis of
The original diaph +/-pubic
Periosteum)
1)-< =2cm lesion size
-< =1mm depth invasion
-No lymph-vascular space
involvement.
-Well or mod.diff.
Radical local excision and inguino
femoral node dissection.
unilateral if lesion unilat not
Involving midline,bilat.if lesion
midline
2)>2 cm lesion size
-Or > 1 mm depth invasion
-Or lymph-vascular space
Involvement
-Or poorly diff
-Anterior redical vulvectomy
(including removal of clitoris but
-preserving post.vulva).
-bilat inquinal –femoral N dissection
3)-Involves clitoral

25. Primary management in Carcinoma of The Vulva
Features of Carcinoma
Management
4)-Post. Vulva /perineum
-posterior radical vulvectomy
(preserving clitoris and anterior vulva).
-bilat inquinal-femoral N dissection
5)-Locally advanced
-pelvic exenteration(ant,post,total as
indicated by structures involved)
-anovalvetomy (for lesion
Involving anus /and vulva).
-Chemo-radiation followed by limited surgery
6)-Bone involvement
Fixed groin nodes
-chemo-radiation followed by limited
` surgery if locally resectable

26. Nowadays they found that pelvic node radiation is better than pelvic node dissection because:
PND (pelvic node dissection) PNR (pelvic node radiation)
Survival rate 2 years 55% significant improvement of
survival rate of 2 years 70%

27. CONCLUSION
Any patient with persistence itching or vulval lesion not responds to simple treatment , you should take multiple biopsies from vulva to exclude malignancy.
In management of cancer vulva, age group, psychology of patient, and the appearance of the vulva should be taken in account as this will change the plan of management of cancer.
Plastic surgery should play role in the future.
In future infrared , and laser therapy under microscopy will play role in the management of premalignant lesions.