Vulval Cancer and Precancer Flashcards
Why is the incidence of vulval intraepithelial neoplasia increasing?
- Recognition of VIN
- HPV related diseases
What is the incidence of vulval intraepithelial neoplasia?
Uncommon vulval skin disorder
-1.4 cases per 100,000 women
What is vulval intraepithelial neoplasia?
A squamous intraepithelial lesion
Who is usually affected by lower genital tract intra-epithelial neoplasia?
Decreasing age at presentation
- Average 36 years
- Younger women more likely to be multi-focal and HPV positive
- Older women more likely to be uni-focal and HPV negative
How is the main goal in the management of vulva intra-epithelial neoplasia?
Prevention of invasive disease
- 4% risk of invasion in treated women
- 20-40% in untreated women
What are the risk factors for vulval intraepithelial neoplasia?
- Smoking
- Other genital intra-epithelial neoplasia
- Previous related malignancy
- Immunosuppression
What is the clinical appearance of VIN?
- Raised papular or plaques lesions
- Erosions, nodules, warty
- Keratotic roughened appearance
- Sharp border
- Differentiated VIN tends to be unifocal ulcer or plaque
- Discoloration (red/white/brown/pigemented)
How is VIN diagnosed?
Histological diagnosis via punch biopsy under local anaesthetic
Why is VIN managed?
- Prevent cancer
- Eliminate symptoms
- Preserve sexual function
- Preserve body image
How is VIN managed?
- Surveillance of lower genital tract and use of emollients
- Surgery
- Topical treatments
- Laser ablation
What topical treatments are available for VIN?
- Imiquimod
- Photodynmaic therapy
- 5FU, alpha-interferon, cidofivir
What are the features of topical treatments in VIN?
- Tissue preservation
- Multiple lesions
- Effect on sexual function not known
- Long term recurrence rates and risk of cancer are not known
What are the features of laser as a treatment in VIN?
- CO2 laser
- Improved cosmetic results
- Miss occult invasion (12%)
- 75% can be treated at one session
- Suitable for mucosal skin
- 40-70% recurrence rate
How is VIN followed up?
- Dedicated clinic
- Role of colposcopy (other LGT sites)
- Frequency of follow-up
- Duration of follow-up dependent if unifocal or multi-focal disease
What types of vulval cancer are there?
- Mostly squamous cell carcinoma (VIN, Lichen sclerosus)
- Also melanoma, basal cell carcinoma and Bartholin’s gland
What is the incidence of vulval cancer?
- Uncommon cancer in UK
- 3% of gynaecological cancers
- 97 cases per year in Scotland
- 3.7/100,000 women
Who is usually affected by vulval cancer?
- Average age 74 (27-97)
- 75% diagnosed over age 60
How does vulval cancer present?
- Pain
- Itch
- Bleeding
- Lump/ulcer
How is vulva cancer staged?
- Staging is surgical-pathological
- Stage 1a is micro-invasion <1mm
- Depends on size of lesion
- Depends on lymph node involvement (inguinal, upper femoral and pelvic)
What are the features of stage 1 vulval cancer?
- Size <2cm
- Survival 97%
What are the features of stage 2 vulval cancer?
- Size >2cm
- Survival 85%
What are the features of stage 3 vulval cancer?
- Local spread
- Unilateral nodes
- Survival 46%
What are the features of stage 4 vulval cancer?
- Distant or advanced local spread
- Pelvic nodes
- Survival 50%
How is vulval cancer treated?
- Surgery (individualised, radical local excision and unilateral/bilateral node dissection)
- Radiotherapy
- Chemotherapy
How is groin node dissection for vulval cancer performed?
- Inguinal and upper femoral nodes
- Separate node incisions
- Staging and remove nodal disease
- Associated with significant morbidity
Why is groin node dissection associated with significant morbidity?
- Wound infection
- Lymphocysts
- Nerve damage
