Vulvar and Vaginal lesions Dr F Behnamfar MD

Vulvar and Vaginal lesions Dr. F Behnamfar MD

Introduction n n Most usful means of generating differential diagnosis is by morphological findings rather than symptomatology Vulvar biopsy should be performed if the lesion is clinically suspicious or does not resolve after standard therapy

Vulvar Symptoms n Most often, primary vaginitis and secondary vulvitis n A number of skin conditions on other areas of the body

Neoplasia Vulvar intraepithelial neoplasia a precancerous lesion that may progress to invasive cancer n n Most are raised multifocal white (may be red or pink) and/or verrucous lesions n Cancer presents with unifocal vulvar plaque, ulcer or mass Lichen scerosus and erosive lichen planus predispose to cancer n

Genital warts n n n Caused by human papillomavirus Flat, filliform or verrucous, or giant Flesh colored or pigmented Biopsy is indicated if there is rapid growth, increased pigmentation, ulceration, pigmentation, fixation or poor response to therapy Treatment : trichloroacetic acid, podophyllum, Cryo, laser Not curative , merely speed clinical resolution

White patch n n Lichen sclerosus, well demarcated white finely wrinkled and atrophic patches Vulvar itching and typical findings Potent topical corticosteriod ointment Close follow up for risk of malignancy

Other vulvar conditions n folliculitis n Fox. fordiyce disease n Acanthosis nigricans n Extramammary pagets disease, intraepithelial adenocarcinoma

n n Herpes simplex Scabis

Vulvar cysts, tumors and masses n Condylomata accuminata n duct cysts, Skenes duct cysts n Vulvar Ulcers: Behcet disease, lichen planus

Vaginal Conditions Retained foreign body n Ulceration n Malignancy n

Vulvar Cancer 3870 new cases 2005 n 870 deaths n Approximately 5% of Gynecologic Cancers n American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

Vulvar Cancer 85% Squamous Cell Carcinoma n 5% Melanoma n 2% Sarcoma n 8% Others n

Vulvar Cancer n Biphasic Distribution , two distinct etiologies: – Age 70 – type, unifocal, – in areas adjacent to lichen sclerosus or squamous hyperplasia (Chronic inflammatory conditions) – 20% in patients UNDER 40 and appears to be increasing, – multifocal, – basaloid or warty types, – HPV related, smoking and VIN

Vulvar Cancer n Paget’s Disease of Vulva – 10% will be invasive – 4 -8% association with underlying Adenocarcinoma of the vulva

Symptoms Most patients are treated for “other” conditions n 12 month or greater time from symptoms to diagnosis n

Symptoms n n n n Pruritus Mass Pain Bleeding Ulceration Dysuria Discharge Groin Mass

Symptoms n May look like: – Raised – Erythematous – Ulcerated – Condylomatous – Nodular

Vulvar Cancer IF IT LOOKS ABNORMAL ON THE VULVA n BIOPSY! n

Tumor Spread Very Specific nodal spread pattern n Direct Spread n Hematogenous n

Staging n Based on TNM Surgical Staging – Tumor size – Node Status – Metastatic Disease

Staging n Stage I T 1 N 0 M 0 – Tumor ≤ 2 cm – IA – IB ≤ 1 mm depth of stromal Invasion 1 mm or more depth of invasion

Staging n Stage II T 2 N 0 M 0 – Tumor >2 cm – Confined to Vulva or Perineum

Staging n Stage III – T 3 N 0 M 0 – T 3 N 1 M 0 – T 1 N 1 M 0 – T 2 N 1 M 0 n Tumor any size involving lower urethra, vagina, anus OR unilateral positive nodes

Staging n Stage IVA – T 1 N 2 M 0 – T 2 N 2 M 0 – T 3 N 2 M 0 – T 4 N any M 0 n Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodes

Staging n Stage IVB – Any T Any N M 1 n Any distal mets including pelvic nodes

Treatment n Primarily Surgical – Wide Local Excision – Radical Vulvectomy with Inguinal Node Dissection n Unilateral n Bilateral n Possible Node Mapping, still investigational

Treatment Local advanced may be treated with Radiation plus Chemosensitizer n Positive Nodal Status n – 1 or 2 microscopic nodes < 5 mm can be observed – 3 or more or >5 mm post op radiation

New advances in treatment Individualization of treatment, vulvar conservation for unifocal tumors n Elimination of routine pelvic lymphadenectomy n Omission of groin dissection for T 1 tumors (<1 mm stromal invasion) n Separate incisions improve wound healing n

Treatment n Special Tumor – Verrucous Carcinoma n Indolent tumor with local disease, rare mets UNLESS given radiation, becomes Highly malignant and aggressive n Excision or Vulvectomy ONLY

Vulva 5 year survival Stage I n Stage III n Stage IV n 90 77 51 18 Hacker and Berek, Practical Gynecologic Oncology 4 th Edition, 2005

Recurrence n Local Recurrence in Vulva – Reexcision or radiation and good prognosis if not in original site of tumor – Poor prognosis if in original site

Recurrence n Distal or Metastatic – Very poor prognosis, active agents include Cisplatin, mitomycin C, bleomycin, methotrexate and cyclophosphamide

Melanoma 5% of Vulvar Cancers n Not UV related n Commonly periclitoral or labia minora n

Melanoma n Microstaged by one of 3 criteria – Clark’s Level – Chung’s Level – Breslow

Melanoma Treatment Wide local or Wide Radical excision with bilateral groin dissection n Interferon Alpha 2 -b n

Vaginal Carcinoma 2140 new cases projected 2005 n 810 deaths projected 2005 n Represents 2 -3% of Pelvic Cancers n American Cancer Society. Cancer Facts & Figures. 2004. Atlanta, GA; 2005

Vaginal Cancer n 84% of cancers in vaginal area are secondary – Cervical – Uterine – Colorectal – Ovary – Vagina Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2 nd ed. 2002

Vaginal Carcinoma Squamous Cell n Clear Cell n Sarcoma n Melanoma n 80 -85% 10% 3 -4% 2 -3%

Clear Cell Carcinoma n Associated with DES Exposure In Utero – DES used as anti abortifcant from 19491971 – 500+ cases confirmed by DES Registry – Usually occurred late teens

Vaginal Cancer Etiology n Mimics Cervical Carcinoma – HPV 16 and 18

Staging Stage I n Stage II n n Stage III Stage IVA n Stage IVB n Confined to Vaginal Wall Subvaginal tissue but not to pelvic sidewall Extended to pelvic sidewall Bowel or Bladder Distant mets

Treatment Surgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in Vagina n All others treated with radiation with chemosensitization n

5 year Survival Stage I n Stage III n Stage IV n 70% 51% 33% 17%