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WACS > Vulval Pre-cancer and Cancer: Diagnosis and Management > Flashcards

Vulval Pre-cancer and Cancer: Diagnosis and Management Flashcards

1
Q

Mesenchymal cells from primitive streak form pair of cloacal folds in what week of intrauterine life

A

3rd week

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2
Q

Genital swellings form —

A

Labia majora

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3
Q

Genital tubercle forms –

A

Clitoris

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4
Q

Urethral folds form —

A

Labia minora

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5
Q

The urogenital groove forms –

A

Vestible

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6
Q

T/F: The subcutaneous layer of the labia majora has Camper’s and Colles’ fascia similar to abdominal wall

A

T

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7
Q

T/F: The anterior and posterior commissures are formed by the labia minora

A

F
Labia majora

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8
Q

The labia minora split anteriorly to form the — and —

A

Prepuce and frenulum of the clitoris

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9
Q

T/F: VIN is a disease of the elderly (7th decade) but younger women (third to fourth decades) are increasingly affected due to HIV/AIDS forming over 90% of cases

A

T

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10
Q

2 pathways of VIN etiopathogenesis

A

HPV related: 16, 18. Multifocal, in younger women,

Prior vulval lesions or non-HPV related: older women

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11
Q

Concomitant lesions are seen in up to —% of cases

A

44%

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12
Q

T/F: VIN is a part of ‘Field Carcinogenesis Phenomenon’ or ‘Field Effect’

A

T

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13
Q

T/F: Lichen sclerosus and autoimmune diseases are predisposing lesions of VIN

A

T

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14
Q

4 symptoms of VIN

A

May be asymptomatic
Vulval itching
Irritation
Burning
Dyspareunia

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15
Q

5 specific investigations for VIN

A
  1. Simple inspection using white light
  2. Acetic acid painting (3-5% acetic acid), with magnifying glass
  3. Pap smear
  4. Colposcopy
  5. Biopsy – colposcopically directed, using Keyes dermal punch
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16
Q

Mild. Dysplastic cells in lower third

A

VIN 1

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17
Q

Moderate. Lower two – thirds

A

VIN 2

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18
Q

Severe. Carcinoma – in – situ. Whole layer

A

VIN 3

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19
Q

T/F: VIN II and VIN III should be treated, and all women with HSIL, uVIN

A

T

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20
Q

5 modes of treatment for VIN

A

Topical
CO2 laser
Wide local excision
Simple vulvectomy
Skinning vulvectomy with split-thickness skin graft

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21
Q

4 topical agents used in VIN

A

Interferon gel
retinyl acetate gel
5-fluoro-uracil
imiquimod

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22
Q

One disadvantage of topical management for VIN

A

No specimen for histology

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23
Q

CO2 laser is ideal for which group of women in VIN management

A

<40 years with no invasive lesion

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24
Q

One disadvantage of CO2 laser treatment for VIN

A

No specimen for histology

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25
Q

Depth of CO2 laser in the treatment of VIN

A

3 - 4mm

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26
Q

Treatment of choice in older women

A

Wide local excision

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27
Q

Wide local excision is curative in –% of cases

A

75% of cases if only VIN

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28
Q

T/F: There is less distortion of anatomy with skinning vulvectomy with split-thickness skin graft.

A

T

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29
Q

In the treatment of VIN gross margins should be

A

0.5 – 1.0cm

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30
Q

T/F: In the treatment of VIN hair bearing areas have deeper involvement which can be easily missed

A

T

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31
Q

% of missing invasive lesions in the treatment of VIN

A

18.8%

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32
Q

T/F: In the treatment of VIN hair bearing areas have deeper involvement which can be easily missed

A

T

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33
Q

3 prognostic fate of VIN following treatment

A
  1. Spontaneous regression
  2. Recur after local exicion
  3. Progress to VSCC
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34
Q

% of VIN that recur after local excision

A
  1. If edges are free = 10%
  2. If edges are involved = 50%
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35
Q

% of VIN that progress to VSCC

A

10%

36
Q

4 markers of progression of VIN

A
  1. Increasing age
  2. Immunosuppression
  3. Smoking
  4. Raised lesions with irregular surface
37
Q

How do you follow up VIN after treatment

A

Long term follow-up is crucial
- yearly, using VIA (3 – 5% acetic acid) and magnifying glass / colposcope

38
Q

6 modes of preventing VIN

A

Vulval self examination

Education

Lifestyle adjustment. Smoking cessation

Protected sex – especially female condom which covers the vulva

Vaccination. 2 types (16, 18), 4 types (6, 11, 16, 18), 9 types (6, 11, 16, 18, 31, 33, 45, 52, 58)

Screening of high risk groups – hrHPV, smokers, immunocompromised, previous VIN, CIN, VAIN or perianal IN

39
Q

Incidence of vulva cancer

A

0 - 4.6/100,000.
Less than 5% of female genital tract cancers

40
Q

T/F: High income countries have higher rates of vulva cancer

A

T.
HICs have higher rates (65%) than Africa and Asia (35%)

41
Q

3 risk factors for vulva cancer in young women

A
  1. Smoking
  2. High number of sexual partners
  3. Compromised immune status
42
Q

Associated with HPV-d.
-Older women, p53 mutation, history of lichen sclerosus or chronic dermatosis with autoimmune diseases

A
42
Q

4 etiological risk factors of vulva cancer associated with HPV-d.

A
  1. Older women
  2. p53 mutation
  3. History of lichen sclerosus
  4. Chronic dermatosis with autoimmune diseases
43
Q

T/F: Vulval carcinoma can arise from normal skin.

A

T

44
Q

T/F: Low CD4 (<500/mm3) increases incidence of VIN 2 and 3

A

T

45
Q

T/F: The burden of hr-HPV infection is high among heterosexual men in sub-Saharan
Africa and most pronounced among the HIV-infected individuals

A

T

46
Q

% of HPV prevalence in vulva cancer

A

20 40%

47
Q

Which HPV subtype forms 75% of HPV dependent vulva cancer

A

HPV - 16

48
Q

T/F: DNA damage from pelvic irradiation can cause vulva cancer

A

T

49
Q

7 clinical features of vulva cancer

A

There may be no specific symptoms, leading to delay in treatment!

Itching
Dyspareunia
Soreness
Burning sensations
Bleeding
Lump
Ulcer

50
Q

10 specific investigations for vulva cancer

A
  1. Visual inspection after staining
  2. Vulvoscopy
  3. Colposcopy: Preceded by Pap smear because of ‘Field Effect’
  4. Anoscopy
  5. Cystoscopy
  6. Rectoscopy
  7. Radiology – Chest and bone Xray, IVU, CT Scan, MRI, PETScan
  8. Lymphography Blue dye and radioactive colloids injected peri-lesionally
  9. Lymphscintigraphy
  10. Near-infrared fluorescence optimal imaging
51
Q

5 histological distribution of vulva cancer

A

VSCC - >90%.
Keratinizing
Basaloid
Warty
Verrucous

52
Q

3 distribution sites of vulva cancer

A

Labia (80%)
Clitoris (10%)
Lower commissure (10%)

53
Q

Site with the highest distribution of vulva cancer

A

Labia - 80%

Clitoris (10%), lower commissure (10%)

54
Q

3 modes of spread of vulva cancer

A

Local invasion of adjacent tissues

Embolization to regional lymph nodes (superficial, deep inguinal to pelvic nodes)

Haematological to lungs, liver and bones

55
Q

Vulva cancer stage 1 has how many substages

A

2 substages
1A and 1B

56
Q

FIGO stage 1 vulva cancer

A

Tumor confined to the vulva

57
Q

Stage 1A vulva cancer

A

Tumor size </= 2cm and stromal invasion </= 1mm

58
Q

Stage 1B vulva cancer

A

Tumor size >2cm or stromal invasion >1mm

59
Q

FIGO stage 2 vulva cancer

A

Tumor of any size with extension to lower 1/3 of the urethra, lower 1/3 of the vagina, lower 1/3 of the anus with negative nodes

60
Q

FIGO stage 2 of vulva cancer has how many substaging

A

No substaging

61
Q

FIGO stage 3 of vulva cancer has how many substaging

A

3 substaging
lllA, lllB and lllC

62
Q

FIGO stage 3 vulva cancer

A

Tumor of any size with extension to upper part of adjacent perineal structures, or with any number of nonfixed, nonulcerated lymph node

63
Q

FIGO stage lllB of vulva cancer

A

Regional lymph node metastases >5mm

64
Q

FIGO stage lllC vulva cancer

A

Regional lymph node metastases with extracapsular spread

65
Q

FIGO stage lllA vulva cancer

A

Tumor of any size with disease extension to upper 2/3 of the urethra, upper 2/3 of vagina, bladder mucosa, rectal mucosa, or regional lymph node metastases </= 5mm

66
Q

How many substages in FIGO stage 4 of vulva cancer

A

2 substages
lVA and lVB

67
Q

FIGO stage lV of vulva cancer

A

Tumor of any size fixed to bone, or fixed, ulcerated lymph node metastases, or distant metastases

68
Q

FIGO stage lVA vulva cancer

A

Disease fixed to pelvic bone, or fixed or ulcerated regional lymph node metastases

69
Q

FIGO stage lVB vulva cancer

A

Distant metastases

70
Q

Major form of therapy for vulva cancer

A

Surgery

71
Q

2 aims of surgical treatment in terms of margins

A

1-2cm macroscopic margin
or
less than 0.8cm histologic tumour-free margin

72
Q

With surgical treatment of vulva cancer, what is recurrence rate if margins are less than 1cm

A

50%

73
Q

T/F: Distal 1/3 of urethra can be excised without loss of continence

A

T

74
Q

11 complications of vulva cancer treatment

A

Anaesthetic
Haemorrhage
Necrosis of skin flaps. Wound breakdown
Infection
DVT, pulmonary embolism
Pressure sores
Lymphocyst
Chronic lymphoedema of the lower limbs (30 – 70%), significant in 10%
Hernia, genital prolapse, urine/fecal incontinence
Vaginal stenosis and dyspareunia
Psychosexual problems

75
Q

% of chronic lymphedema complicating treatment of vulva cancer

A

30 - 70%
Significant in 10%

76
Q

Complications of adjuvant radiotherapy in the treatment of vulva cancer

A

Radiation dermatitis, fibrosis and ulceration
- Vaginal stenosis

77
Q

Neoadjuvant therapy in vulva cancer treatment

A

Chemoradiation

78
Q

2 reasons for neoadjuvant chemoradiation in the treatment of vulva cancer

A

To shrink tumour
To avoid injury to urethra, anus

79
Q

% risk of transformation from VIN to VSCC

A

10% or 3% if VIN is treated

80
Q

The most important prognostic factor in vulva cancer

A

Lymph node involvement

81
Q

5-yr survival rate in FIGO stage l vulva cancer

A

79%

82
Q

5-yr survival rate in FIGO stage lV vulva cancer

A

13%

83
Q

5-yr survival rate in FIGO ll and lll vulva cancer respectively

A

59 and 43% respectively

84
Q

2 modes of prevention of vulva cancer

A

Incidence of vulval cancer can be reduced by half using HPV vaccines 16 and 18 (Hampl M et al 2006), and others

Early biopsy of vulval lesions

WACS (19 decks)

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