CPC vulval cancer

Question 1

vulva cancer - age

Answer 1

75% diagnosed >60y/o

mean age of presentation 74

can present at any age from 27-97

Question 2

presentation of vulval cancer

Answer 2

pain
itch
bleeding
lump/ulcer

Question 3

is vulval cancer common

Answer 3

no

much lower incidence than other gynae cancer

Question 4

risk factors for vulval cancer

Answer 4

• intraepithelial neoplasia or cancer at other lower genital tract site
• lichen sclerosus
• smoking
• immunosuppression

Question 5

what is lichen sclerosus

Answer 5

chronic dermatosis

1 in 300 women

believed to be AI in origin

unrelated to HPV

progression to cancer is a rare complication

Question 6

HPV related VIN and vulval cancer

Answer 6

usual type VIN

younger women

multifocal

multizonal

immunosuppression

past hx of intra-epithelial neoplasia

Question 7

non-HPV related VIN and vulval cancer

Answer 7

differentiated VIN

older women

lichen sclerosus

often presents as cancer at first diagnosis

Question 8

stage 1 vulval cancer - size, nodes, survival

Answer 8

<2cm

no nodal involvement

97%

Question 9

stage 2 vulval cancer - size, nodes, survival

Answer 9

>2cm

no nodal involvement

85%

Question 10

stage 3 vulval cancer - size, nodes, survival

Answer 10

local spread

unilateral nodes

46%

Question 11

stage 4 vulval cancer - size, nodes, survival

Answer 11

distant spread or advanced local spread

pelvic nodes

50%

Question 12

histopathology of vulval cancer

Answer 12

punch/excisional biopsy

consider other possible diagnoses

Question 13

possible diagnoses from histopathology

Answer 13

inflammatory incl. lichen slcerosus

dysplasia - VIN

malignant - squamous cell carcinoma

Question 14

what is vulvar intraepithelial neoplasia

Answer 14

abnormal proliferation of squamous epithelium

can progress to carcinoma

Question 15

what is usual type VIN

Answer 15

aka classical/warty

associated w/ HPV infection

low grade (VIN 1) or high grade (VIN 2 and 3)

Question 16

what is differentiated type VIN

Answer 16

older women

not HPV related

always high grade

usually associated w/ lichen sclerosus

Question 17

what is shown here

Answer 17

normal squamous epithelium

intact BM

cells move towards the top as they mature into a basket-weave appearance

Question 18

what is shown here

Answer 18

classical/warty VIN

overlying hyperkeratosis

cells are larger as they move towards the top

not organised arrangement of cells

koilocytosis

basal cells are all intact - no invasion

Question 19

what is shown here

Answer 19

differentiated VIN

squamous epithelium isn’t nicely arranged

thickened and variable thickness

overlying hyperkeratosis

sclerosis

but intact basal cells and no invasion

Question 20

squamous cell carcinoma - what is it

Answer 20

malignant tumour of squamous cells

ability to invade adjacent tissues and spread to distant sites

Question 21

how do we stage vulval cancer

Answer 21

FIGO staging

Question 22

what is very important to measure on biopsy

Answer 22

depth of invasion

Question 23

what is labelled in this image

what else can be seen

Answer 23

keratinisation

grossly abnormal

squamous cells invading into underlying connective tissues

keratinisation shouldn’t be deep within the tissue - raises suspicion of squamous cell carcinoma

Question 24

surgery for vulval cancer

Answer 24

individualised surgery

local excision

unilateral or bilateral node dissection.

Question 25

management of vulval cancer

Answer 25

surgery

RT

chemotherapy

Question 26

groin node dissection - which nodes

Answer 26

inguinal and upper femoral nodes

Question 27

how is groin node dissection done and why

Answer 27

separate node incisions i.e. not along with tumour removal

staging and remove nodal disease

Question 28

morbidity from groin node dissection

Answer 28

associated with significant morbidity

wound infection

lymphocysts

nerve damage