Vulval cancer

Question 1

Define

Answer 1

Older woman with labial lump and inguinal lymphadenopathy → ?vulval carcinoma

90% of vulval cancers are SQUAMOUS CELL CARCINOMAS

Two types:

High risk HPV-associated

• Arise on background of multifocal high-grade vulval intraepithelial neoplasia (VIN 3)
• Often in younger women

Non-HPV associated

• Associated with pre-malignant vulval condition: lichen sclerosus
• Affecting older women

Remaining 10%:

• Malignant melanoma
• Basal cell carcinoma
• Adenocarcinoma
• Paget’s disease
• Bartholin gland tumours

Vulval tumours spread locally and metastasise first via inguinofemoral lymph nodes

Haematogenous spread to liver and lungs is a LATE event

 

Question 2

Premalignant conditions of the vulva

Answer 2

Question 3

Symptoms and Signs

Answer 3

Presenting Symptoms

• Lump or ulcer- sometimes associated with bleeding or discharge
• Painful/ painless lump
• Difficult to sit down
• Vulval itching, irritation or pain
• Present late due to embarrassment or reluctance to be examined

 

Signs O/E

• Well-demarcated raised or ulcerated lesion, often on the labium majora
• Hard + craggy, bleeds on touch

Pre-malignant change

• Younger women- VIN (white plaque-like and do not ulcerate)
• Older women- Lichen sclerosus

NOTE: When examining:

• Include assessment of size, position on vulva, proximity to important midline structures (particularly urethra and anus).
• Important to examine groin for lymph node metastases- hard, craggy, fixed subcutaneous lymph node swellings on palpation
• Vulval cancers spread locally and metastasise via the inguinofemoral lymph nodes before the pelvic nodes

Question 4

Investigations

Answer 4

FBC, LFTS

Tissue diagnosis – full thickness biopsy, sentinel node biopsy

Cervical smear – exclude CIN if VIN-associated

Imaging – CT or MRI to assess lymphadenopathy

Other – staging by cystoscopy, proctoscopy

Staging (FIGO staging)

I: tumour confined to vagina

II: tumour invades the subvaginal tissue

III: tumour invades the pelvic side wall

IV: tumour invades bladder or bowel mucosa or extends beyond true pelvis

Differential diagnosis: (ulcerated area of vulva)

Infection

Inherent skin conditions

▪ Eczema

▪ Lichen sclerosis

▪ Intra-epithelial neoplasia

▪ Malignancy

Vaginal carcinomas are rare

• Clear Cell adenocarcinoma
• Primary vaginal adenocarcinoma

Question 5

Management

Answer 5

Management – vulvectomy + bilateral inguinal lymphadenectomy

1a-> wide local excision ± neoadjuvant chemotherapy = radical surgical excision with 10mm clear margin

>1a -> radical vulvectomy + bilateral inguinal lymphadenectomy (15% are +ve for inguinal metastasis)

• A dye and radioactive nucleotide can be injected into the vulval tumour to identify the sentinel node
• If removed, groin lymphadenectomy is a very morbid procedure with complications including wound healing problems, infection, VTE and chronic lymphoedema

Unsuitable for surgery -> radiotherapy

Question 6

Complications

Answer 6

Groin lymphadenectomy

• Wound-healing problems
• Infection
• VTE
• Lymphocyst
• Chronic lymphoedema

Itraoital stenosis

Metastases

Relapse

Question 7

Prognosis

Answer 7

5-year survival in those with lesions < 2cm and no lymph node involvement is > 80%

This falls to < 50% if inguinal lymph nodes are involved

Falls to 10-15% if iliac or other pelvic lymph nodes are involved

Residual Lichen sclerosus is associated with recurrence of vulval cancer

Lymph node metastasis is the most important prognostic factor for recurrence and survival