1. INVASIVE CANCER of THE VULVA
Rukset Attar, MD, PhD
Obstetrics and Gynecology Department

2. incidence has been increasing: 8 %
Usu at age years
Cases should be classified as carcinoma of the vulva when the primary site of the growth is in the vulva.
A carcinoma of the vulva that has extended to the vagina should be considered as a carcinoma of the vulva.
Malignant melanoma should be reported separately.

3. Risk factors DM
Obesity
HT-40% and atherosklerosis
Nulliparity
Premature menapause Sy
Abnormal PAP smear test
Age

4. Working at a laundry or dry cleaning
Vulvar dysthrophies
HPV infection
CIN
Cigarette smoking
Immun supression
Genital wart
VIN- 30%
P53, PTEN, Rb gen mutation

5. Incidence of vulvar neoplasms by histologic type
Tumor type Percent
Epidermoid
Melanoma
Sarcoma
Basal cell
Bartholin gland
squamous
adenocarcinoma
Adenocarcinoma
Undifferentiated

6. ETIOLOGY Human papilloma virus Type 16,18,31 Coal tar chemicals
Arsenic dermatitis- in laundry detergents
Vulvar irritation
Any chronic vulvitis
Herpetic vulvitis ?

7. In terms of etiology, pathogenesis, and clinical presentation, vulvar squamous cell carcinomas divided into two general groups
The first group
in younger patients
associated with cancer-related HPV and smoking
multicentric,
frequently coexists with or is preceded by a classic Vulvar Intraepithelial Neoplasia (VIN).
A variety of chromosome abnormalities are linked to invasive vulvar cancer, some of which may be specific for HPV-positive tumours.

8. The second group
In elderly parients
associated with squamous cell hyperplasia and lichen sclerosis.
The etiology of this group of carcinomas is unclear, infrequently associated with HPV:
genetic alterations arise in lichen sclerosus or hyperplasia, leading directly to invasion, or
atypia develops within hyperplasia or lichen sclerosis (differentiated VIN).
These tumours are associated with mutations in p53
significantly worse prognosis than HPV-positive tumours

9. SIGNS AND SYMPTOMS OF VULVAR CANCER
Signs and symptoms Percent
Pruritis
Mass
Pain
Bleeding
Ulceration
Dysuria
Discharge
Groin mass

10. Indications for excisional biopsy of vulvar nevi
Change in surface area of nevus
Change in elevation of a lesion – raised,thickened,or nodular
Change in color – especially brown to black
Change in surface – smooth to scaly or ulcerated
Change in sensation – itching or tingling

13. FIGO Staging of Vulva CA
Stage I Tumor confined to the vulva
IA Lesions ≤2 cm in size, confined to the vulva or perineum and with stromal invasion ≤1.0 mm, no nodal metastasis
IB Lesions ›2 cm in size or with stromal invasion › 1.0 mm, confined to the vulva or perineum, with negative nodes
Stage II Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with negative nodes

14. Stage III Tumor of any size with or without extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes
IIIA
(i) With 1 lymph node metastasis (≥5 mm), o
(ii) 1–2 lymph node metastasis(es) (‹5 mm)
IIIB
(i) With 2 or more lymph node metastases (≥5 mm), or
(ii) 3 or more lymph node metastases (‹5 mm)
IIIC With positive nodes with extracapsular spread

15. Stage IV Tumor invades other regional (2/3 upper urethra, 2/3 upper vagina), or distant structures
IVA Tumor invades any of the following:
(i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone, or
(ii) fixed or ulcerated inguino-femoral lymph nodes
IVB Any distant metastasis including pelvic lymph nodes
The depth of invasion is defined as the measurement of the tumor from the epithelial stromal junction of the adjacent most superficial dermal papilla to the deepest point of invasion.

16. Routes of Spread Direct extension Lymphatic embolization
vagina,urethra,anus
Lymphatic embolization
regional lymph nodes
Hematogenous spread
distant sites,lung,liver,bone

17. Risk of metastatic spread
size of tumour
depth of invasion
involvement of lymphatic vessels.
most commonly involved nodes:
inguinal, femoral, pelvic, iliac, and periaortic lymph nodes.
hematogenous dissemination involves the lungs, liver, and other internal organs

18. Therapy
Staging and treatment for stage I and II vulvar cancer is surgical
The primary treatment is complete surgical removal
Stage Ia: wide local excision (2 cm margin)
Stage Ib: radical local excision (3-4 cm margin) with lenfadenecytomy with adjuvant RT
Stage ≥II
pelvic egzenteration
Radical vulvectomy with lenfadenecytomy with or without preop chemoRT (cisplatin-5FU) or postop RT

19. INVASIVE CANCER of THE VAGINA
Rukset Attar, MD, PhD
Obstetrics and Gynecology Department

20. Age 60 years
More than 50% in posterior and 1/3 upper vaginal wall
May be due to chronic irritation
Symptoms as in cervix ca
Vaginal esp bloody discharge
Urinary symptoms
Pelvic pain

21. 85% are epidermoid cancers, and the remainder, in decreasing order of frequency, are adenocarcinomas, sarcomas, and melanomas.
A tumor should not be considered a primary vaginal cancer unless the cervix is uninvolved or only minimally involved by a tumor obviously arising in the vagina.
Any malignancy involving both cervix and vagina that is histologically compatible with the origin in either organ is classified as cervical cancer.

22. Secondary carcinoma of the vagina is seen more frequently than primary vaginal cancers.
Secondary, or metastatic, tumors may arise from cervical, endometrial, or ovarian cancer, gestational trophoblastic disease, colorectal cancer, or urogenital or vulvar cancer.
Extension of cervical cancer to the vagina is probably the most common malignancy involving the vagina.

23. Risk Factors HPV Pesser Vaginal prolapsus Chronic leukorrhea sy
early hysterectomy
prior radiation are possible
no specific etiologic agent has been identified

24. Local invasion Lymphatic spread Hematogeneus spread
Upper vaginal wall- obturatory, iliac and hypogastric and paraaortic- as in cervix
Lower vagina-inguinal, pelvic-as in vulva
Hematogeneus spread
Lung, liver, bone

25. FIGO staging of carcinoma of the vagina
Stage 0 Carcinoma in situ, intraepithelial carcinoma.
Stage I limited to the vaginal mucosa
Stage II involved the subvaginal tissue
A but not extended to real paracolpium
B involved real paracolpium but not extended to the pelvic wall
Stage III extended to the pelvic wall or symphsis involvement
Stage IV extended beyond the true pelvis or has involved the mucosa of the bladder or rectum.
A Spread of the growth to adjacent organs- the mucosa of the bladder or rectum
B Spread to distant organs.

26. Diagnosis is difficult
Abnormal PAP smear without lesion in vulva or cervix
Colposcopy
Biopsy
Clinical Staging

27. Therapy Upper vaginal wall ca Lower vaginal wall ca
Radical hysterectomy with vagenectomy RT
Surgery with RT
Lower vaginal wall ca
Radical vulvectomy with vagenectomy
Stage IVa- egzenteration