Vulval Cancer and Precancer Flashcards
What are the features of lower genital tract intra-epithelial neoplasia?
Stratified squamous epithelium - no transition zone, natural history from infection to neoplasia is longer than in CIN
Decreasing age at presentation - around 36 years
Younger women with multi-focal disease, HPV +ve, more susceptible to multi-zonal disease
Older women with uni-focal disease, HPV -ve
How many women are affected by vulva intraepithelial neoplasia?
1.4 cases per 100,000 women
What are the reasons for the increasing incidence of vulva intraepithelial neoplasia?
Recognition of VIN - people more aware and less likely to put up with symptoms for as long
HPV related diseases - increasing infection resulting in increasing vaginal, vulva and anal disease
What is the management of vulva intraepithelial neoplasia?
Prevent invasive disease Eliminate symptoms Preserve sexual function Preserve body image Surveillane - lower genital tract, emollients Surgery Topical treatments Laser ablation
What is the risk of invasive disease in vulva intraepithelial neoplasia?
4% risk of invasion in treated women
20-40% risk in untreated women
What are the risk factors for vulva intraepithelial neoplasia?
Smoking
Other genital intra-epithelial neoplasia
Previous related malignancy
Immunosuppression e.g. HIV +ve, autoimmune disease, immunosuppression for transplantation
What is the clinical appearance of vulva intraepithelial neoplasia?
Raised papular lesions or plaques - can be seen without colposcopy
Erosions, nodules, warts
Keratotic roughened appearance
Sharp border
Differentiated VIN tends to be uni-focal ulcer or plaque, generally seen in older women
Discolouration - red, white, brown, pigmented
How is VIN diagnosed?
Histological diagnosis
VIN/SIL
Punch biopsy under local anaesthetic
The pathology of VIN looks identical to CIN, how can you differentiate?
Biopsy site
What are the functions of topical treatments for VIN?
Tissue preservation
Multiple lesions
What are the topical treatments used for VIN?
Imiquimod Photodynamic therapy 5FU Alpha interferon Cidofivir
What is the effect of topical treatment on sexual function, long-term recurrence rates and risk of cancer?
Unknown
What are the features of laser ablation for treatment of VIN?
CO2 laser
Improved cosmetic results, more minor procedure
What percentage of laser ablation for VIN will miss occult invasion?
12%
What percentage of VIN can be treated in one session of laser ablation?
75%
What is the recurrence rate of VIN following laser ablation?
40-70%
What is the follow up for VIN?
Dedicated clinic
Role of colposcopy
Frequency and duration of follow up depend on uni-focal or multi-focal disease
What percentage of gynaecological cancers are accounted for by vulva cancer?
3%
How many cases per year of vulva cancer are there in Scotland?
130
How many women are affected by vulva cancer?
4.6/100,000 women
What are the histological types of vulva cancer?
Most commonly squamous cell carcinoma
Also basal cell carcinoma, melanoma and Bartholin’s gland adenocarcinoma
What is squamous cell carcinoma of the vulva related to?
VIN
Lichen sclerosus
At what age does vulva cancer typically occur?
Age 74
Range 27-97
What percentage of vulva cancer is diagnosed in women > 60 years?
75%
What is the presentation of vulva cancer?
Pain
Itching - may be related to VIN or lichen sclerosus
Bleeding
Lump/ulcer
How is vulva cancer staged?
Surgical-pathological staging
What factors are involved in staging vulva cancer?
Size of lesion
Lymph node involvement
Metastases
What is stage 1a of vulva cancer?
Micro-invasion < 1mm, no node involvement
What is stage 1 of vulva cancer?
< 2mm lesion
No node involvement
What is stage 2 of vulva cancer?
> 2mm lesion
No node involvement
What is stage 3 of vulva cancer?
Local spread
Unilateral node involvement
What is stage 4 of vulva cancer?
Distant or advanced local spread
Pelvic node involvement
What is the survival of stage 1 vulva cancer?
97%
What is the survival of stage 2 vulva cancer?
85%
What is the survival of stage 3 vulva cancer?
46%
What is the survival of stage 4 vulva cancer?
50%
What is the treatment of vulva cancer?
Surgery
- individualised for each patient, need to consider urinary, bowel and sexual function
- radical local excision
- unilateral or bilateral node dissection (bilateral if central tumour as it could metastasise to either side)
Radiotherapy
Cemotherapy
What is the process of groin node dissection?
Inguinal and upper femoral nodes dissected
Separate node incisions
Staging and removal of nodal disease
Groin node dissection is associated with significant morbidity, such as
Wound infection
Lymphocysts
Nerve damage
