Vulvar and Cervical Cancer 3

Question 1

What are the two groups of people who have vulvar cancer?

Answer 1

• HPV Assoc → HSIL (VIN-2/3), Younger age (<55y/o), smoking, low SES, high-risk sexual behaviors, HIV
• Non-HPV Assoc → Chronic inflammatory disease-30% assoc. with Lichen Sclerosis

Question 2

What is the most important procedure if there is any question about vulvar lesion/pathologic process?

Answer 2

BIOPSY - full thickness, including underlying dermis

Question 3

What is the etiology, symptoms, PE, evaluation, and treatment of contact vulvar dermatitis?

Answer 3

• Etiology:
  
  • allergen that produces an immune response (delayed)
  • irritant that directly damages vulvar skin (immediate)
• Symptoms:
  
  • severe pruritus (most common), rawness, stinging, burning, and pain
• PE:
  
  • mild-to-severe erythema
  • scaling and fissures
  • excoriation
  • lichenification of the skin (simplex chronicus)
• Eval:
  
  • consider Biopsy
  • infection/STD
• Treatment:
  
  • behavioral modification: break itch/scratch cycle
  • eliminate offending allergen/irritant
  • consider topical steroid

Question 4

What is the etiology, symptoms, PE, evaluation, and treatment of lichen sclerosis?

Answer 4

• Etiology:
  
  • complex chronic inflammatory skin condition
  • exact etiology is unknown
  • considered an autoimmune disease
• Symptoms:
  
  • Severe pruritus (most common), vulvar irritation, pain, and dyspareunia
• PE:
  
  • porcelain white (hypopigmentation) papules and plaques, often with areas of ecchymosis, purpura, and excoriation.
  • shiny, waxy, thinned, whitened, and crinkling- “cigarette paper.”
  • changes in vulva: loss of the labial contours and fusion of the labia minora into the labial fat pad
• Eval:
  
  • consider biopsy
• Treatment:
  
  • ultrapotent steroids

Question 5

What is the treatment of vulvar/perianal condylomas?

Answer 5

Laser therapy if severe

Question 6

What are vulvar lymphatics and why are they important?

Answer 6

• Vulva & distal third of vagina to ipsilateral superficial inguinal groin
• Lymph channels then perforate cribiform fascia to deep inguinal/femoral LN
  
  • cloquet node: superiormost deep femoral LN
• Drainage from midline structures (urethra, clitoris, perineum) likely bilateral
• Lymph Node Dissection:
  
  • superficial borders:
    
    • sartorius,
    • adductor longus,
    • inguinal ligament
  • deep borders:
    
    • beneath cribiform fascia medial to femoral vein
    • beneath the borders of the fossa ovalis

Question 7

What are treatments for vulvar carcinoma?

Answer 7

• Current Surgical Management: Triple Incision Vulvectomy/Wide Local Excision
  
  • >1-2cm margin around primary lesion, separate incision for groin.
  • lymph node dissection: ipsilateral only, unless ≤2cm of midline
  • partial radical vulvectomy for lesions >2cm
• Radical vulvectomy: depth of the perineal membrane
• Previously: Radical Vulvectomy
  
  • butterfly vs. longhorn
• For advanced disease: Consider Neoadjuvant chemoradiation primary concern adequate XRT with minimal damage to femoral heads

Question 8

What is the basic structure of staging for carcinoma of the vulva?

Answer 8

• Stage I = tumor confined to the vulva
• Stage II = tumor of any sizes with extension to adjacent perineal structures with negative nodes
• Stage III = tumor of any size with or without extension to adjacent perineal structures with positive inguino-femoral lymph nodes
• Stage IV = tumor invades other regional or distant structures

Question 9

What is the treatment and most important prognostic factor for carcinoma of the vulva?

Answer 9

• Treatment = inguinofemoral LND performed for allstages except IA
• Positive LN is single most important prognostic factor
  
  • 5 year survival with positve LN is 50% of similar size with negative LN

Question 10

Describe the findings of melanoma of the female reproductive tract.

Answer 10

• 5-10% of vulvar CA, Mean age 55y/o
• Typical Presentation:
  
  • Caucasian with pigmented lesion or bleeding/painful mass
  • risk factors:
    
    • fair
    • sun
    • UV
    • fam Hx
    • atypical nevi (ABCDEs)
• Staging: Tumor Thickness/Depth of Invasion
• Breslow: Best predictor of outcome
• Spread: Groin Mets/Distant Metastasis Frequent
• Rx: Surgical RLE include B/L Groin LND
  
  • the thicker the tumor, the larger margin
  • recurrence: Consider XRT
• Nodular is worst subtype