Vulval cancer Flashcards
What type are most vulval cancers?
- SCCs (most common - 95%)
Others include:
- Malignant melanoma
- BCC
- Adenocarcinoma of the Bartholin gland
How common is vulval malignancy? Who is most affected?
Uncommon - 1000 diagnoses in UK every year
Usually affects older women but increasing rates seen in women in the 4th/5th/6th decades.
What are the risk factors for vulval malignancy?
- Often arises de novo
- VIN
- Lichen sclerosus
- Immunosuppresion
- Smoking
- Paget’s disease of the vulva
What is the aetiology of vulval cancer?
SCC has 2 aetiologies:
- High-risk HPV associated cancers - arising on a mackground of multifocal high-grade vulval intraepithelial neoplasia (VIN 3), often in younger women
- Non-HPV-associated tumours - affecting older women and associated with premalignant vulval condition lichen sclerosus
How do vulval cancers present?
- Usually a well-demarcated raised or ulcerated lesion that is hard and craggy and bleeds on touch
- Lump or ulcer
- Bleeding or discharge
- Painful or painless
- May present late due to embarassment
- Preexisting VIN or lichen sclerosus
What should be noted on examination of a vulval lesion?
Bleeding
Proximity to anus and urethra
Inguinofemoral lymph nodes - hard, craggy and fixed subcutaneous lymph node swelling
What investigations are required for suspected vulval malignancy?
Referral to specialist gynaecology oncology MDT - this is a rare condition managed by surgeons, oncologists, radiologists, histopathologists and clinical nurse specialists
Biopsy to confirm diagnosis
Clinical photograph
To assess fitness for surgery, a chest X-ray, ECG, FBC and U&E are required, as these patients are
usually elderly. Blood is cross-matched.
Imaging is unreliable in the detection of groin metastases but may be required if there is obvious groin node disease to assess extent of metastasis
What staging is used for vulval cancer?
FIGO staging
What are the treatment options for vulval cancer?
Vulval excision +/- neoadjuvant radiotherapy /chemotherapy - with clear margin of 10mm
Sentinel lymph node biopsy and groin lymphadenectomy - standard approach is a full inguinofemoral lymphadenectomy is done which has many complications. More commonly sentinel* node biopsies are done to prevent this.
Radiotherapy
- Adjuvant radiotherapy - after surgery if _>_2 groin lymph node metastases are found
- Neoadjuvant radiotherapy - given prior to surgery if tumour is large and involving the anus or urethra
- Radical radiotherapy - if patient not suitable for anaesthetic
- Chemoradiotherapy
*first node in the lymph node basin to receive lymphatid drainage from a tumour
What are the complications of groin lymphadenectomy?
Highly morbid procedure:
- wound healing problems,
- infection,
- VTE,
- prolonged hospital stay,
- lymphocyts
- chronic lymphoedema
Mets only found in 15% so often done unnecessarily.
How is sentinel node biopsy done in vulval malignancy?
Small vulval tumours (<4 cm) with greater than 1 mm depth of invasion are injected with radioactive nucleotide on the day before surgery
Intraoperative identification of the sentinel node is by gamma probe detection - facilitated by injection of blue dye into the tumour immediately preoperatively.
It is important to identify bilateral sentinel lymph nodes where tumours impinge on the midline
Full lymphadenectomy is done if the sentinel node is positive.
List 3 premalignant conditions of the vuvla and their aetiologies.
- VIN - high-risk HPV
- Lichen sclerosus - unknown
- Extramammary Paget’s disease of the vuvla - unknown
Describe the appearance of these premalignant vulval conditions:
- VIN
- Lichen sclerosus
- Paget’s disease of the vulva
- Multifocal leukoplakic, erythematous or pigmendted lesions
- Leukoplakia of the vuvlal skin in a ‘figure eight’ distribution, with loss of vulval architecture
- Well-demarcated erythematous lesion affecting the vulva with ‘cake icing’ effect
All can present with itch, irritation or be asymptomatic. Each carries ~10% risk of malignancy.
