1. Vulvar Cancer A. Gari MD.

2. Epidemiology The 4th common Gynecologic Cancer : - Uterine - Ovarian
- Cervical
5% (stable incidence).
Predominantly a disease of PM women with a mean age at diagnosis of 65 years.

3. Risk Factors
VIN is considered to have a low malignant potential with low potential of progress to invasive disease (Immunodeficiency/elderly).
The field effect in up to 22% of cases.
HPV DNA has been reported in up to 60% of patients with invasive vulvar cancer.

4. Multiple sexual partners. Vulvar dystrophy (L. Sclrosus).
Risk Factors cont’d
Multiple sexual partners.
Vulvar dystrophy (L. Sclrosus).
Immunodeficiency
History of genital warts.
Smoking.
H/O Cervical or Vaginal cancer.
Northern Europe ancestry.

5. CLINICAL MANIFESTATIONS
Pruritus is a common complaint.
Unifocal vulvar plaque.
Ulcer Lesion
Mass (fleshy, nodular, or warty) .
labia majora
labia minora Site
Perineum.
Clitoris.
Lesions are multifocal in 5 percent of cases.
A synchronous second malignancy, most commonly cervical neoplasia, is found in up to 22%.

6. DIAGNOSIS
Biopsy :
If multiple abnormal areas are present; then multiple biopsies should be taken.
If a lesion is not grossly evident but clinical suspicion is high, Colposcopy should be done.

7. HISTOLOGIC TYPES Squamous cell carcinomas (90%).
Melanoma (2ed most common).
Bartholin gland / Adenocarcinoma.
Sarcoma.
Basal cell carcinoma (rodent ulcer).
Verrucous carcinoma. 
Paget's disease.

8. Paget’s disease Adenocarcinoma in situ.
10 to 12% of patients have invasive vulvar Paget’s disease (background of Adeno).
Usually affects PM white women .
Pruritus and vulvar soreness.

9. Eczematoid appearance, it is well-demarcated and has slightly raised edges and a red background.
Paget’s disease usually extends well beyond the gross lesion.
Multi-focal lesions.
Positive surgical margins and frequent local recurrence are common.

11. MODE OF SPREAD
Direct extension to adjacent structures (eg, vagina, urethra, clitoris, anus).
Lymphatic embolization to regional lymph nodes.
Hematogenous

12. Lymph nodes involvement Clinical evaluation of the groin LN is inaccurate in approximately 30%

13. Lymph nodes involvement
Table 13.4

14. Staging
IA Tumor confined to the vulva or perineum, 2 cm in greatest dimension, negative nodes, stromal invasion no greater than 1.0 mm
IB Tumor confined to the vulva or perineum, 2 cm in greatest dimension, negative nodes, stromal invasion greater than 1.0 mm
II Tumor confined to the vulva and/or perineum, < 2 cm in greatest dimension, negative nodes
III Tumor of any size with adjacent spread to the lower urethra or anus and/or Unilateral regional lymph node metastasis
IV-A Tumor invades any of the following: upper urethra, bladder or rectal mucosa, pelvic bone, or Bilateral regional node metastasis
IV-B Any distant metastasis including pelvic lymph nodes

15. Management Wide local excision. (WLE) Radical local excision.
Skinning vulvectomy.
Simple vulvecomy.
Radical vulvectomy.
Hemi-vulvectomy.
Centralized vs. Lateralized lesion.
Free margin and close margin.

18. Management of early vulvar cancer stage (SCC)
I-A
Radical local excision with out LND (Lymph nodes dissection).
I-B
Radical local excision with LND (unilateral vs. bilateral ).

20. Management of early stage (I-B) Lymphatic mapping
(Tc99 lymphscintigraphy)
M Blue
Sentinel LN is the first node in the lymphatic basin that receives primary lymphatic flow from the suspect lesion and therefore should be the fist site of metastatic disease * if the sentinel LN is -ve ,the patient can be spared the morbidity of full groin dissection.

21. Management of early stage I-B
Positive groin nodes:
No additional treatment is recommended if 1 or 2 micrometastasis are found.
Patients with 3 or more micromets nodes / any evidence of extracapsular spread / one or more macromets / close & +ve margins should receive radiation.

22. Management of stage II or III
Radical vulvectomy and bilateral inguino- femoral lymphadenectomy.
If the disease involves the distal urethra or vagina , partial resection of these organs is required (partial exentration).
Pre-op RT or Chemo might be an option.

25. Recurrence
Perineal recurrences can be treated successfully by re-excision in up to 75%.
Inguinal recurrences are less amenable to surgical resection, radiation therapy may be added to surgery or chemotherapy

26. Verrucous carcinoma. Radical local excision.
Suspicious lymph nodes should be biopsied; if positive<< LND
RT is contraindicated because it can induce Anaplastic Transformation and increase the likelihood of metastases.
Recurrences are treated surgically.

27. Melanoma WLE and Radical local excision carries a similar rec. rates.
Melanomas <1 mm thick should be treated with 1 cm skin margins; margins should be 2 cm for melanomas 1 to 4 mm thick.
The depth should be at least 1 cm .
If clinically evident nodal disease <<LND.
LND is prognostic only (got no curative role).

28. Basal cell carcinoma Radical local excision with a wide base.
Rarely metastasize.
Inguinofemoral lymphadenectomy is not required.

29. Bartholin gland
Bartholin’s gland abscess in PM women should be biopsied.
Radical local excision.
Inguinofemoral lymphadenectomy (unilateral) is indicated.

30. Adenocarcinoma. Radical local excision.
LND (unilateral vs BL) is indicated.

31. Sarcoma WLE with out LND. Lymphatic metastases are uncommon.
Rhabdomyosarcomas:( children ) treated with primary chemotherapy followed by surgery as needed.

32. Paget's disease WLE with out LND.
Adenocarcinoma should be rolled out (5-15%).
Check for extra-vulvar pagets (20-30%)
Breast
Rectum
Bladder
Urethra
Cervix
Ovary

33. Complications of radical vulvectomy & groin dissection
Infection.
Thrombo-embolic disease.
Wound breakage.
Lymphocyst.
Bleeding.
Anesthesia conplications.
skin flaps necrosis.
Lymphangitis.
Chronic swelling of the leg (lymphedema).
Sexual dysfunction & Psychological concerns.

34. Thank you