Vulval Carcinoma

Question 1

Around 80% are what type of cancer?

Answer 1

Squamous cell carcinoma

Others: melanoma, basal cell, carcinoma of Bartholin’s glands

Question 2

Most cases occur in women over what age?

Answer 2

65

Question 3

Is it rare or common?

Answer 3

Relatively rare

Question 4

What risk factors are there?

Answer 4

Age
HPV infection 
HSV T2 
Vulval intraepithelial neoplasia (VIN) 
Immunosuppression 
Lichen sclerosis 
Chronic vulvular irritation 
Smoking

Question 5

How may it present?

Answer 5

As a lump
Indurated ulcer
Itching, irritation

May not notice lump/ ulcer unless it causes pain or bleeding - so often presents late (50% already have inguinal involvement)

Question 6

At presentation, what percentage already have inguinal LN involvement?

Answer 6

50%

Question 7

Where might it present?

Answer 7

Lesion in labia or clitoris

Question 8

What is vulval intraepithelial neoplasia (VIN)?

Answer 8

The pre invasive phase of vulval malignancy

Question 9

How may VIN appear?

Answer 9

White areas with surrounding inflammation

Question 10

How can VIN present?

Answer 10

Asymptomatic 
Itching 
Burning
Pain
Changes to vulval skin
Pain/ discomfort during sex

Question 11

What causes VIN?

Answer 11

Often HPV (especially 16) - 5% acetic acid stains affected area white

Question 12

What percentage have coexisting neoplasia elsewhere?

Answer 12

10% - most commonly cervical

Question 13

If VIN is found on biopsy, what should be examined?

Answer 13

Cervix
Anal canal if within 1.5cm
Natal cleft skin and breasts

Question 14

How is VIN treated?

Answer 14

Surveillance is key, with biopsy of suspicious lesions
Conservative - antihistamines
Medical - imiquimod
Surgery - wise local excision

Question 15

Is recurrence common with VIN?

Answer 15

Yes so follow up regularly

Question 16

How is vulval cancer treated?

Answer 16

Surgery
If tumour < 2cm wide and < 1mm deep lymph node excision not needed
If > 1mm deep do triple incision surgery = WLE plus ipsilateral groin node biopsy - if affected sample contralateral side as well
More advanced disease may need radical vulvectomy with inguinal gland removal and skin graft may be needed
RT may be needed pre op to shrink tumour if sphincters affected

Chemoradiotherapy if unsuitable for surgery, shrink large tumour preop and for relapse

Question 17

What is the 5 year survival rate?

Answer 17

> 80% if lesions <2cm with no node involvement

Otherwise <50%

Question 18

How does imiquimod work?

Answer 18

It stimulates the immune system to kill HPV
Applied to the area 3-4 times per week and can take up to 6 months to work
Inflammation of vulval skin is a common side effect