Vulval Cancer

Question 1

Risk factors and aetiology

Answer 1

• Smoking
• HPV
• Altered immune system
• Squamous metaplasia
• Chronic skin lesions (i.e. lichen sclerosus)
• VIN

Question 2

Incidence

Answer 2

• Increases with age - peak around 80-85 years

Question 3

Types of vulval cancer

Answer 3

• SCC (most common - 90%)
• Adenocarcinoma
• Melanoma
• BCC
• Sarcoma
• Metastatic

Question 4

Vulval Intraepithelial Neplasia (VIN)

Answer 4

• VIN 1 - nor precursor of VIN 2,3
• VIN 2,3 - differentiated, warty/basaloid/usual
• Appearance is variable - red/white plaques, papular, polypoid, verruciform.
• 9% progress to cancer

Question 5

Pathology of VIN

Answer 5

1. Usual type, thickened, keratinocytes disorganised, high nuclear:cytoplasmic ratio
2. Warty, papillary configuration, multinucleate cells, koliocytes and dyskeratotic cells
3. Basaloid, flat suface, less differentiated cells with high nuclear:cytoplasmic ratio
4. Differentiated, not well documented, thickened epidermis, surface parakeratosis, elongated rete ridges, enlarged keratinocytes

Question 6

Presentation of VIN

Answer 6

• Pruritis
• Pain
• Ulceration
• Leukoplakia
• Lump/wart
• Can be asymptomatic

Question 7

Commonest sites of VIN

Answer 7

• Labia majora
• Labia minora
• Posterior fourchette
• Mons pubis
• Perineal
• Clitoris
• Perianal

Question 8

Diagnosis of VIN

Answer 8

• Biopsy
  
  • Incisional
  • Excisional

Question 9

Management of VIN

Answer 9

• Observation
• Excision
• Ablation
  
  • Chemical (Imiquimod, topical 5-FU, steroids, retinoids, IG alpha)
  • Laser
  • Photodynamic therapy

Question 10

Presentation of vulval cancer

Answer 10

• Lump
• Pain
• Bleeding
• Discharge
• Swollen leg
• Colour changes
• Elevation and irregularity of surface
• Inguinal lymphadenopathy
• Lower limb lymphadenopathy

Question 11

Diagnosis and further investigation of vulval cancer

Answer 11

• Biopsy
• USS
• CT
• MRI
• Sentinal lymph node bipopsy also used

Question 12

Staging

Answer 12

• FIGO
  
  • 1) 80% 5 year survival
  • 2) 60% 5 year survival
  • 3) 40% 5 year survival
  • 4) 15% 5 year survival

Question 13

Management of vulval cancer

Answer 13

• Surgical
  
  • WLE (traditional butterfl or triple excision)
  • Vulvectomy +/- inguinal lymphadenectomy
  • Reconstruction using grafts of flaps (i.e. lotus petal flaps)
• Chemotherapy

Question 14

Prognostic factors

Answer 14

• Depth of involvement
• Involvement of other structures
• Histological subtype
• LVSI
• Excision margins
• Nodes