Vulval Cancer and Pre-Cancer Flashcards
Define vulva cancer
Malignancy of outer female genitalia (labia minor/majora, clitoris, Bartholins glands)
What is VIN?
Vulvar intraepithelial neoplasia
Precancerous lesion caused by dysplasia of the squamous cells
Intra-epithelial = abnormal cells contained within top layer of epidermis that covers the vulva
Neoplasia = the cells are abnormal
What is the mean age for VIN?
36y
What are the two types of VIN and how do they differ?
Younger females - HPV related & multifocal
Older females - related to lichen sclerosus, tends to be unifocal
What is lichen sclerosus?
Chronic inflammatory disease with characteristic white, atrophic plaques
What are the symptoms of VIN?
Can be asymptomatic Itching Pain Changes to vulval skin Discomfort/pain during sex/dysuria
What can be the appearance of a VIN?
Leukoplasia (white laques on mucosal surfaces as a result of overgrowth of keratin)
Can be v. red and ulcerated
Raised papular/plaque lesions
Nodules, warty
Keratotic roughened appearance
Sharp border
Differentiated VIN tends to be unifocal ulcer/plaque & tends to be discoloured (white, red, brown)
What does a VIN look like histologically?
Similar to normal vulval cells but there is keritanisation
What are risk factors for vulval cancer/VIN?
HPV infection Smoking Other genital intra-epithelial neoplasia (check anal canal too) Prev related malignancy Immunosupression
How do you diagnose VIN?
Speculum & colposcope to see inside vagina
Colposcope allows you to see abnormalities too small for the naked eye
Histological diagnosis (from punch biopsy taken under LA)
How do you categorise VIN?
VIN 1, 2, 3 based on how deeply the abnormal cells go into the dermis but now VIN 1 - not precancerous VIN 2/3 grouped together (VIN 2/3 = VIN = SIL)
How do you manage VIN?
Prevent cancer - surveillance & emollients
Surgery - wide, local excision, topical Rx, laser ablation
Eliminate symptoms (REMEMBER these woman have a severe, irretractable itch which is not helped by creams)
Preserve sexual function & body image)
What are the topical Rx for VIN?
Imiquimoid - topical cream that stimulates body to destroy HPV virus in hope cells will return to normal
Photodynamic therapy - lights/drugs to kill cancer
5FU, alpha-interferon, cidofivir
When would you use topical Rx for VIN?
Tissue preservation, if multiple lesiosn
When would you use laser Rx for VIN?
Suitable for mucosal skin
Improved cosmetic results
What kind of laser is used to Rx VIN?
CO2 laser
Burns abnormal cells away and re-epithelisation occurs within a few weeks
Can’t be done on hair baring skin!
What is involved in the follow up of VIN?
Dedicated clinical
Colposcopy used
Duration of follow up depends on unifocal vs multifocal dx
How common is vulval cancer?
Not very
What are the most common vulval cancers?
SCC (squamous cell carcinoma) developing from VIN/lichen sclerosus
What are the less common vulval cancers?
Basal cell carcinoma, melanoma, Bartholin’s gland
Why is vulval cancer incidence increasing?
People are living longer
At what rate does vulval cancer tend to progress?
Sowly
What chronic skin condition is associated with vulval cancer?
Lichen sclerosus
What is lichen sclerosus?
Skin condition that causes itchy white plaques on the genitals (mostly vulva) & anus of older women
What is the average age of presentation of vulval cancer?
74
Mostly over 60
What are the symptoms of vulval cancer?
Pain
Itch/burning
Bleeding
Lump/ulcer
What is the staging of vulval cancer?
1A - 2cm or less in size, only grow 1mm or less into skin/tissue underneath, no LN involvement
1B - >2cm in size, >1mm into skin/tissue underneath unlikely to have spread to LNs
2 - spread to nearby tissues (e.g. lower vagina, urethra, anus), no cancer in LNs
3A/B/C - any size, may have spread to nearby tissues, involves lymph nodes on one side
4A/B - distant spread or advanced local spread/spread to pelvic LNs
How do you Rx vulval cancer?
Surgery - radical local excision +/- unilateral/bilateral node dissection
Radiotherapy
Chemotherapy
What nodes may need to be resected in vulval cancer?
Inguinal & upper femoral
What are the complications of groin node dissection?
Wound infection
Lymphocysts (=accumulation of lymph fluid)
Nerve damage (e.g. damage to branch of femoral n)
What woman do we want to have surveillance for vulval cancer?
Those with lichen sclerosis & VIN
