218. Cervical and Vulvar Malignancy

Question 1

Cervical Cancer

• Epi
• RFs (3 groups)
• guidelines for Pap Smear

Terminology
NILM
ASC-US
LSIL
HSIL
ASC-H
AGC

Answer 1

Epi: 4th most common W cancer, 7th leading cause of cancer death W

RF:

1. Demographics: Age (location of transition zone), Race, low SES/education
2. Behavior: # sex partners, early age at sex, cigarette smoking, long term OCP use, diet low in folate
3. Medical: HR HPV INFECTION, early age 1st pregnancy, lack of routine cytologic screening!, multiparity

Pap smear: start age 21 q3 years, co-test HPV at age 30 q5 years (when HPV cant be easily sloughed off)

NILM: no intraepithelial lesions or malignancy
ASC-US: atypical squamous cells - unknown significance (most common abnormal result)
LSIL: low grade squamous intraepithelial lesion
HSIL: high grade squamous intraepithelial lesion
ASC-H: atypical squamous cells - cannot EXCLUDE high grade lesion (significant pre-cancer)
AGC: atypical glandular cells

Question 2

Indications for Conization (4)

Staging for cervical cancer (I-IV)

Tx: for low grade, high grade, cervical ca

Answer 2

1. HGSIL initial tx
2. Persistent CIN1 - 2 years
3. CIN 2/3 on biopsy vs. hysterectomy
4. Pos. Margins s/p LEEP

Staging
I: confined to cervix (IA microscopy, IB visible)
II: beyond uterus
III: to pelvic wall
IV: to adjacent/distant organs

LGSIL: surveillance
HGSIL: surgery (conization or hysterectomy)
Cercival Ca: small - surgery; local advanced - radiation/chemo, distant - chemo (no surgery if advanced)

Question 3

Vulvar Cancer

• epi
• demographics
• groups
• 2nd group etiology: sx, PE, tx

Answer 3

Epi: 4th most common GYN CA
Demo: mean age 65 yo (post mp)
1. HPV Assoc: HSIL, younger age <55, smoking, low SES, high risk sexual behavior, HIV
2. Non-HPV Assoc: Chronic inflammatory disease, assoc with Lichen Sclerosis

Lichen Sclerosis

• complex chronic inflammatory skin disease, autoimmune
• sx: SEVERE PRURITIS, vulvar irritation, pain, dyspareunia
• PE: porcelain white hypopigmented cigarette paper papules/plaques with areas of ecchymosis
• tx: ultrapotent STEROIDS (prevent vulvar cancer)

Question 4

Vulvar Cancer

• tx
• staging
• outcomes: most important prognostic factor, sites of mets

Pagets Disease

• demographic
• PE
• what it is
• tx

Answer 4

Tx: surgery (triple incision vulvectomy - removes groin LNs; or radical vulvectomy), if advanced add neoadjuvant chemoradiation

Staging: I (vulva), II (perineal adjacent structures), III (positive inguino-femoral LNs), IV (regional/distant structures)

Prognostic factor: +LN (halves survival rate)
Mets: lung, bone, brain, liver (universally fatal if recur to groin)

Paget’s Disease

• demo: post-mp caucasian women
• PE: eczematoid red, weeping area on vulva
• may represent underlying colon/urothelial cancer
• 20-30% develop later metastatic dz
• tx: WLE (wide local excision), if recur repeat WLE