Vulval and vaginal tumours

Question 1

Vulval intraepithelial neoplasia (VIN) - overview

Answer 1

1. VIN = dysplastic lesion of squamous epithelium
2. Associated with persistent infection with HPV in >90% of cases, esp. HPV 16. HPV infection may cause multifocal disease, and pts with VIN should be carefully screened for CIN
3. Smoking also associated with development of VIN
4. Can occur in any age group, but more common in post-menopausal women
5. Approximately 10% of women with VIN progress to vulval cancer over several years

Question 2

VIN - presentation

Answer 2

1. Primary symptom = itch
2. Pain
3. Ulceration
4. Lesions may be raised and warty or flat and erythematous, and are frequently found at multiple sites on the vulva
5. 20% asymptomatic

Question 3

VIN - dx

Answer 3

Punch or excision biopsy. Also need regular cervical smears

Question 4

VIN - mx

Answer 4

1. Surveillance - careful follow up. Suspicious lesions should be biopsied
2. Surgery - excision of painful/irritating lesions can be performed, but vulvectomy or laser ablation is rarely recommended bc high recurrence rate
3. Immunotherapy - imiquimod (apply cream 2-3x weekly for 12 weeks), most will relapse, side effects include soreness and burning
4. Vaccination (may help to prevent VIN but no role in tx existing VIN)
5. Do not use topical 5-fluorouracil (bc usually ineffective and badly tolerated)

Question 5

Vulval cancer - overview

Answer 5

1. Uncommon
2. 90% are SCC, 5% vulval melanomas
3. Rest are BCC, Bartholin’s gland carcinomas and sarcomas
4. Mostly in older women (median age at presentation 74y)
5. Commonly arise on a background of lichen sclerosus or VIN

Question 6

Vulval cancer - presentation

Answer 6

1. Lump
2. Pain, irritation
3. Bleeding
4. May be obvious ulcer present
5. May have palpable groin LN

Note - may be delay in presentation due to embarrassment

Question 7

Vulval cancer - ix (3)

Answer 7

1. FBE, UEC, LFTs
2. CXR (staging and preoperative
3. Biopsy of all suspicious vulval lesions. Small lesions -> excise, larger lesions -> take wedge biopsy
   Note - no role for imaging groins for lymph nodes

Question 8

Vulval cancer - mx

Answer 8

1. Surgery (mainstay of tx, both for curative intent and palliation)
2. Pts iwth disease >1mm invasion should have groin lymphadenectomy performed
3. Lateral disease - can have ipsilateral LN dissection; if +ve LN, bilateral groin LN dissection required
4. Central disease - requires bilateral groin LN dissection
5. Radiotherapy +/- chemotherapy
   - Can be used before surgery to shrink primary cancer
   - Used after surgery if positive groin LNs, to prevent regional recurrence. External beam radiotherapy to tx potentially +ve pelvic LN. Can combine with chemotherapy

Question 9

Vaginal cancer - overview (3)

Answer 9

1. Rare, accounting for only 1% of all gynaecological malignancies
2. Most are metastases from either above (cervical or uterine) or below (vulval)
3. Of the remaining true vaginal tumours, most are SCCs and present in older women

Question 10

Vaginal cancer - risk factors

Answer 10

1. Hx intraepithelial neoplasia (?)
   2 Hx invasive carcinoma of vulva, vagina or cervix
2. HPV infection
3. Pelvic radiotherapy
4. Long-term inflammation due to vaginal pessary or procidentia