Background

Question 1

Appx how many pts are affected by vulvar cancer per yr in the United States? What is the incidence of vulvar cancer in the United States?

Answer 1

∼6,020 pts are estimated to be affected in 2017 by vulvar cancer in the United States. The incidence is 2.5/100,000 people.

Question 2

Vulvar cancer accounts for what % of gyn malignancies? What % of all malignancies in women are vulvar malignancies?

Answer 2

Vulvar cancer represents 3%–5% of all gyn malignancies. This comprises 1%–2% of all cancers in women.

Question 3

What are the risk factors for vulvar cancer?

Answer 3

Risk factors for vulvar cancer:

Increasing age
HPV
Vulvar intraepithelial neoplasia (VIN)
Bowen Dz (squamous cell CIS)
Paget Dz (lesions arising from Bartholin gland, urethra, or rectum)
Smoking
Immune deficiency
Lichen sclerosis

Question 4

What HPV subtypes are associated with vulvar cancer?

Answer 4

HPV subtypes associated with vulvar cancer include 6, 16, 18, and 33.

Question 5

What is the function of HPV-associated oncoproteins?

Answer 5

It is thought that HPV-associated oncoproteins bind and inactivate tumor suppressor proteins such as Rb, p53, and p21.

Question 6

What are the subsites of the vulva?

Answer 6

Subsites of the vulva:

Ant and post fourchette
Clitoris (clitoral hood and gland)
Labia minora and majora
Mons pubis
Perineal body
Urethral meatus
Vaginal orifice

Question 7

If a malignancy with the epicenter in the vagina involves the vulva, what is the primary?

Answer 7

Vulvar primary. Considering primary vaginal cancers are rare, any tumor within the vagina touching the vulva should be considered a vulvar primary.

Question 8

What histology constitutes the vast majority of vulvar cancers? Name other histologies of tumors found on the vulva.

Answer 8

The most common vulvar histology is squamous cell carcinoma (80%–90%). Verrucous is a less aggressive subtype of vulvar SCC with rare LN spread.

Other histologies include melanoma, basal cell, Merkel cell, sarcoma, and adenocarcinomas of the Bartholin glands.

Question 9

What are the most common presenting Sx of pts with vulvar cancer?

Answer 9

Common presenting Sx of vulvar cancer: pruritus, vulvar discomfort or pain, dysuria, oozing, or bleeding.

Question 10

In which subsites does vulvar cancer most commonly arise?

Answer 10

70% of vulvar cancers arise from the labia majora/minora.

Question 11

How is “locally advanced” vulvar cancer defined?

Answer 11

Locally advanced vulvar cancer is defined as T2 tumors >4 cm or extension into anus and/or vagina, or T3. Also defined as any burden that cannot be resected without exenterative Sg.

Question 12

What are the 1st-, 2nd-, and 3rd-echelon LN regions in vulvar cancer, and which subsite is associated with skip nodal mets?

Answer 12

LN regions in vulvar cancer:

1st echelon: superficial inguinofemoral

2nd echelon: deep inguinofemoral and femoral

3rd echelon: external iliac nodes

The clitoris can drain directly to the deep inguinofemoral or pelvic nodes.

Question 13

What is the strongest predictor of LN involvement in vulvar cancer?

Answer 13

The strongest predictor of LN involvement in vulvar cancer is DOI.

Question 14

Estimate the risk of inguinal LN involvement based on the DOI of a vulvar tumor: <1 mm, 1–3 mm, 3–5 mm, and >5 mm.

Answer 14

LN involvement by cervical tumor DOI:

≤1 mm: <5%

1–3 mm: 8%

3–5 mm: 27%

5 mm: 34%

(Hacker NF et al., Cancer 1993)

Question 15

What is the rate of pathologic inguinal positivity for cN0 pts?

Answer 15

25%–30%

Van Der Zee et al., GROINSS-V 2008

Question 16

If someone is found to have a positive inguinal LN, what is the rate of positive pelvic LNs and contralat inguinal LNs?

Answer 16

Pelvic LN+: 30%

Contralat inguinal LN+: 25%–30%

(Homesley HD et al., Obstet Gynecol 1986)