17) Gynae-oncology: Vulval

Question 1

Lifetime risk of vulval cancer

Answer 1

1 in 250

Question 2

Incidence of vulval cancer

Answer 2

3.7/100,000 women

Question 3

Most common type of vulval cancer

Answer 3

Squamous cell cancers (90%)

Question 4

What type of VIN does lichen sclerosis give rise to?

Answer 4

Differentiated VIN

Question 5

What type of VIN does hrHPV give rise to?

Answer 5

Usual/classical/undifferentiated

Question 6

Risk of invasion with VIN?

Answer 6

4%

Question 7

How to diagnose vulval cancer?

Answer 7

Representative biopsy of tumour that includes area of epithelium where there is transition abnormal –> normal and >1mm depth.

Question 8

How does vulval cancer metastasise?

Answer 8

Direct extension
Embolisation to superficial inguinal and femoral nodes
Haematogenous spread

Question 9

5 year survival rates

Answer 9

> 80% if no LN involvement
<50% if inguinal nodes
10-15% if iliac or other pelvic LN involved

Question 10

Recurrence rate of vulval cancer

Answer 10

15-35%

Question 11

Treatment of vulval cancer

Answer 11

1A: WLE without node dissection
1B or more should have groin node dissection
Advanced disease - WLE/radical vulvectomy with consideration to primary or net-adjuvant radiotherapy if surgical approach risks sphincter damage.

Question 12

Size of WLE

Answer 12

Margins should be 10mm on fixed specimen (15mm on fresh specimen)

<8mm associated with 47% recurrence (0% if >8mm)

Question 13

Which lymph nodes should be removed?

Answer 13

Superficial inguinal and deep femoral.

If unifocal tumours <4cm with no clinical suspicion of LN involvement then can just do sentinel LN.

If lateral lesions (WLE would not impinge on midline) then can do just ipsilateral node dissection initially and if positive do contralateral ones.

Question 14

When to consider adjuvant radiotherapy?

Answer 14

If positive margins or 2 or more LN with microscopic disease or 1 or more LN with macroscopic disease.