2. Vulvar and Vaginal lesions
Dr.F Behnamfar MD

3. Introduction
Most usful means of generating differential diagnosis is by morphological findings rather than symptomatology
Vulvar biopsy should be performed if the lesion is clinically suspicious or does not resolve after standard therapy

4. Vulvar Symptoms Most often,primary vaginitis and secondary vulvitis
A number of skin conditions on other areas of the body

5. Neoplasia Vulvar intraepithelial neoplasia
a precancerous lesion that may progress to invasive cancer
Most are raised multifocal white (may be red or pink) and/or verrucous lesions
Cancer presents with unifocal vulvar plaque,ulcer or mass
Lichen scerosus and erosive lichen planus predispose to cancer

6. Genital warts Caused by human papillomavirus
Flat,filliform or verrucous,or giant
Flesh colored or pigmented
Biopsy is indicated if there is rapid growth,increased pigmentation,ulceration,pigmentation,fixation or poor response to therapy
Treatment : trichloroacetic acid, podophyllum,Cryo,laser
Not curative ,merely speed clinical resolution

7. White patch
Lichen sclerosus,well demarcated white finely wrinkled and atrophic patches
Vulvar itching and typical findings
Potent topical corticosteriod ointment
Close follow up for risk of malignancy

8. Other vulvar conditions
folliculitis
Fox.fordiyce disease
Acanthosis nigricans
Extramammary pagets disease,intraepithelial adenocarcinoma

9. Herpes simplex
Scabis

10. Vulvar cysts, tumors and masses
Condylomata accuminata
duct cysts,Skenes duct cysts
Vulvar Ulcers: Behcet disease,lichen planus

11. Vaginal Conditions
Retained foreign body
Ulceration
Malignancy

12. Vulvar Cancer 3870 new cases 2005 870 deaths
Approximately 5% of Gynecologic Cancers
American Cancer Society. Cancer Facts & Figures Atlanta, GA; 2005

13. Vulvar Cancer 85% Squamous Cell Carcinoma 5% Melanoma 2% Sarcoma
8% Others

14. Vulvar Cancer Biphasic Distribution ,two distinct etiologies: Age 70
type, unifocal,
in areas adjacent to lichen sclerosus or squamous hyperplasia (Chronic inflammatory conditions)
20% in patients UNDER 40 and appears to be increasing,
multifocal,
basaloid or warty types,
HPV related,smoking and VIN

15. Vulvar Cancer Paget’s Disease of Vulva 10% will be invasive
4-8% association with underlying Adenocarcinoma of the vulva

18. Symptoms Most patients are treated for “other” conditions
12 month or greater time from symptoms to diagnosis

19. Symptoms Pruritus Mass Pain Bleeding Ulceration Dysuria Discharge
Groin Mass

20. Symptoms May look like: Raised Erythematous Ulcerated Condylomatous
Nodular

21. Vulvar Cancer
IF IT LOOKS ABNORMAL ON THE VULVA
BIOPSY!

22. Tumor Spread Very Specific nodal spread pattern Direct Spread
Hematogenous

23. Staging Based on TNM Surgical Staging Tumor size Node Status
Metastatic Disease

24. Staging Stage I T1 N0 M0 Tumor ≤ 2cm
IA ≤1 mm depth of stromal Invasion
IB 1 mm or more depth of invasion

25. Staging
Stage II T2 N0 M0
Tumor >2 cm
Confined to Vulva or Perineum

26. Staging Stage III T3 N0 M0 T3 N1 M0 T1 N1 M0 T2 N1 M0
Tumor any size involving lower urethra, vagina, anus OR unilateral positive nodes

27. Staging Stage IVA T1 N2 M0 T2 N2 M0 T3 N2 M0 T4 N any M0
Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodes

28. Staging Stage IVB Any T Any N M1
Any distal mets including pelvic nodes

29. Treatment Primarily Surgical Wide Local Excision Radical Excision
Radical Vulvectomy with Inguinal Node Dissection
Unilateral
Bilateral
Possible Node Mapping, still investigational

30. Treatment
Local advanced may be treated with Radiation plus Chemosensitizer
Positive Nodal Status
1 or 2 microscopic nodes < 5mm can be observed
3 or more or >5mm post op radiation

31. New advances in treatment
Individualization of treatment,vulvar conservation for unifocal tumors
Elimination of routine pelvic lymphadenectomy
Omission of groin dissection for T1 tumors (<1mm stromal invasion)
Separate incisions improve wound healing

32. Treatment Special Tumor Verrucous Carcinoma
Indolent tumor with local disease, rare mets UNLESS given radiation, becomes Highly malignant and aggressive
Excision or Vulvectomy ONLY

33. Vulva 5 year survival Stage I 90 Stage II 77 Stage III 51 Stage IV 18
Hacker and Berek, Practical Gynecologic Oncology 4th Edition, 2005

34. Recurrence Local Recurrence in Vulva
Reexcision or radiation and good prognosis if not in original site of tumor
Poor prognosis if in original site

35. Recurrence Distal or Metastatic
Very poor prognosis, active agents include Cisplatin, mitomycin C, bleomycin, methotrexate and cyclophosphamide

36. Melanoma 5% of Vulvar Cancers Not UV related
Commonly periclitoral or labia minora

37. Melanoma Microstaged by one of 3 criteria Clark’s Level Chung’s Level
Breslow

38. Melanoma Treatment
Wide local or Wide Radical excision with bilateral groin dissection
Interferon Alpha 2-b

39. Vaginal Carcinoma 2140 new cases projected 2005
810 deaths projected 2005
Represents 2-3% of Pelvic Cancers
American Cancer Society. Cancer Facts & Figures Atlanta, GA; 2005

40. Vaginal Cancer 84% of cancers in vaginal area are secondary Cervical
Uterine
Colorectal
Ovary
Vagina
Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2nd ed

41. Vaginal Carcinoma Squamous Cell 80-85% Clear Cell 10% Sarcoma 3-4%
Melanoma 2-3%

42. Clear Cell Carcinoma Associated with DES Exposure In Utero
DES used as anti abortifcant from
500+ cases confirmed by DES Registry
Usually occurred late teens

43. Vaginal Cancer Etiology
Mimics Cervical Carcinoma
HPV 16 and 18

44. Staging Stage I Confined to Vaginal Wall
Stage II Subvaginal tissue but not to pelvic sidewall
Stage III Extended to pelvic sidewall
Stage IVA Bowel or Bladder
Stage IVB Distant mets

45. Treatment
Surgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in Vagina
All others treated with radiation with chemosensitization

46. 5 year Survival
Stage I 70%
Stage II 51%
Stage III 33%
Stage IV 17%