Vulval Malignancies

Question 1

HPV is a major risk factor for both vulval and cervical cancer. What age groups are these common in?

What exactly is VIN and CIN?

Answer 1

Median age is 71 for vulval cancer => post-menopausal women mostly
Cervical cancer can be at any age but the median age is much lower

Intraepithelial neoplasia means the pre-cancerous state

Question 2

Define VIN
What subtype is the most linked to VIN?

What are the RF of VIN?

How would a patient with VIN present?

What findings are expected on exam?

How will you diagnose?

Answer 2

Dysplastic lesion of squamous epithelium a/w with HPV with a 9% progression to vulval carcinoma.
HPV 16

RF:
1) HPV (not attending screening)
2) Smoking
3) Post-menopausal women
4) Immunosuppression

Sx: Pruritis and vulvodynia (burning, stinging, pain)

Exam: Raised, ulcerated warty or erythematous lesions at multiple sites (discoloured lesions)

Dx: Punch biopsy/excisional biopsy and send to lab

Question 3

What is the most common cancer of the vulva?

Answer 3

90% Squamous cell carcinoma. Why? The cell type present is keratinizing squamous epithelium.
Others include Melanomas and BCC cuz skin

Question 4

Give 5 RF of vulval carcinoma

Answer 4

!!!Lichen Sclerosis
+Those of VIN
1) HPV (not attending screening)
2) Smoking
3) Post-menopausal women
4) Immunosuppression

Question 5

Patients often present late due to embarrassment. What is the typical presentation of vulval carcinoma? (symptoms and examination)

Answer 5

Symptoms:
Pruritis and vulvodynia (burning, stinging, pain)
+ Bleeding (its a cancer)

Exam: Vulval lump, discoloured lesion,
+ Evidence of bleeding
+ Groin lymph nodes (metastasis)

Question 6

How will you diagnose vulval carcinoma? State the gold standard

Answer 6

1) Focused hx and examination
2) Histology via punch/excisional biopsy (Gold standard)
3) Lymph node mapping
4) Bloods: typical bloods
5) Imaging: CXR, CTTAP, MRI AP

Question 7

How is lymph node mapping performed

Answer 7

Injection of a dye or a radioactive substance to trace the path of cancer cells in the blood.

Question 8

What is the FIGO staging of Vulval carcinoma (modified for OSCE)

How would you treat a patient with vulval carcinoma?

Answer 8

Stage 0 = In situ
Stage 1 = <2cm confined to vulva/perineum
Stage 2 = >2cm confined to vulva/perineum
!Stage 3: Unilateral lymph node metastasis OR adjacent spread to lower urethra, vagina or anus
Stage 4 A: Bilateral Lymph node metastasis OR local spread to upper urethra, bladder, rectum
Stage 4 B: Distant metastasis including pelvic lymph nodes

Treatment:
1) Radiotherapy/chemotherapy to shrink tumour prior to surgery
2) Surgical excision of tumour
3) Lymphadenectomy
4) If stage >3 Adjuvant Chemoradiotherapy