Vulvar / Vaginal Neoplasia

Question 1

Preinvasive Vulvar Disease:

Answer 1

Either squamous (VIN) or nonsquamous (Paget / melanoma in situ)

Question 2

VIN:

Answer 2

Cellular atypia within epithelium.

VIN I/II/III based on depth of involvement.

Question 3

Risks for VIN

Answer 3

HPV 16/18 associated (if younger pt, HPV associated, faster / more aggressive; if older often not HPV-associated and slower moving), also smoking / immunocompromise.

Question 4

Diagnosis of VIN

Answer 4

Many asx & picked up on exam
Also pruritis / irritation / dysuria.
PE: flat or raised, red or white or pigmented, can be multifocal.
Need colpo to look for additional lesions

Question 5

Management of VIN

Answer 5

Get bx to look for invasion; if no invasion, wide local excision with split-thickness skin graft afterwards. Can also do laser vaporization - but bx first, since no tissue left behind.
If younger, can try 5-FU / imiquimod to preserve anatomy, but can’t be invasive and need to follow up closely (lower effectiveness)
If older, may chose vulvar vulvectomy
Close follow up (1/3 will recur) - colpo q6mo x 2y then annually

Question 6

Paget disease of vulva:

Answer 6

Rare, intrapithelial neoplasia a/w coexistent adenocarcinoma
a/w breast cancer (although not as much as paget disease of breast)
May be confused with lichen sclerosis, although paget disease has more hyperkeratotic appearance and doesn’t respond to steroids.

Question 7

Diagnosis of paget disease of vulva

Answer 7

Chronic inflammatory changes (hyperemia, well demarcated thickening / excoritation), often velvety red lesions → white plaques after chronic itching 2/2 pruritis.
Most common in pts > age 60 with vulvar pruritis / vulvodynia

Question 8

Treatment of paget disease of vulva

Answer 8

Tx: wide local excision but high recurrence rate; fatal if spreads to LNs

Question 9

Melanoma

Answer 9

Should be on DDx as well

Often p/w invasion

Question 10

Vulvar cancer

Answer 10

Most commonly squamous cell carcinoma, also melanoma / BCC / soft tissue sarcomas
Most lesions unifocal on labia majora, can have varied appearance.
Mostly older women (65 is avg age)
Spreads via lymphatics & direct extension

Question 11

Risk factors for vulvar cancer

Answer 11

Menopause, smoking, VIN/CIN, HPV, immunocompromise, hx cervical cancer

Question 12

Treatment for vulvar cancer

Answer 12

Tx if bx proven - need radical vulvectomy and bilateral inguinal lymph node dissection. If microinvasive (bx of small (<2 cm), well-differentiated lesion, with invasion <1.0 mm), then and only then can you consider wide local excision.
If metastatic, use pelvic radiation as adjunct.
If melanoma, don’t do lymphadenectomy (if metastasized, high mortality).

Question 13

Vaginal intra-epithelial neoplasia (VAIN)

Answer 13

VAIN is premalignant form of vaginal cancer; classified I-II-IIII (III = > ⅔ epithelium thickness)
A/w CIN, cervical cancer, condylomas, HPV, etc. (majority have neoplasia / Ca of vulva/cervix)

Question 14

Diagnosis of VAIN

Answer 14

Almost always asymptomatic but can have some spotting or discharge; picked up on Pap
Consider if persistent abnormal Pap but no neoplasia on cervical bx
Bx the lesions!

Question 15

Treatment of VAIN

Answer 15

Local excision.
If invasion ruled out, can try laser vaporization or 5-FU (esp if multiple lesions or immunocompromised)
Get close follow up with colpo

Question 16

Vaginal cancer

Answer 16

Mostly SCC; adenoCa / sarcoma / melanoma less common
Consider clear cell adenocarcinoma if hx of in utero DES exposure
Usually posterior wall, upper ⅓ vagina; spreads via lymphatics or hematogenous
Mostly older women > 60

Question 17

Diagnosis of vaginal cancer

Answer 17

Postmenopausal bleeding / postcoital spotting / watery or bloody discharge.
Often may be diagnosed on Pap
W/U and staging: CXR, cystoscopy, sigmoidoscopy, IVP for local invasion

Question 18

Treatment of vaginal cancer

Answer 18

Small in upper ⅓ vagina → surgical resection
Large (>2cm) or in lower ⅔ vagina or stage III/IV → radiation therapy alone
If adenocarcinoma, treat similarly.