CH 47 Premalignant & Malignant Disorders of the Vulva & Vagina

Question 1

pre-invasive disease of the vulva

Answer 1

strong association between STDs and vulvar intraepithelial neoplasia, HPV and HIV.

Question 2

HPV types related to cancer

Answer 2

16, 18, and 31

Question 3

VIN treatment

Answer 3

treatment based on biopsy results, includes: wide local excision (for small foci), laser ablation (for multi foci dz), topical application of 5-fluoroucil or imiquimod (stimulates local cytokine release and enhances cell mediated immunity), or superficial vulvectomy with or without split thickness skin grafting.

Question 4

cancer of the vulva general considerations

Answer 4

typically occurs in postmenopausal women and 90% are squamous cell carcinoma. HPV (in younger women) and vulvar dystrophy and chronic inflammation (in older patients) are pathways to cancer. usually there is a 6-12 month delay in the report of the cancerous tumor by the patient. more common in poor and elderly (60-70 years old)

Question 5

cancer of the vulva patho

Answer 5

tumors spread by local extension and with few exceptions by lymphatic embolization. Route is via superficial inguinal, deep femoral, and external iliac lymph nodes.

Question 6

squamous cell carcinoma

Answer 6

most common type of tumor and most frequently involves the anterior half of the vulva, usually arises in the labia majora and minora. varies in appearance from large, exophytic, cauliflower like lesion to a small ulcer crater superimposed on a dystrophic lesion of the vulvar skin

Question 7

Ulcerative lesions of squamous cell carcinoma

Answer 7

begin as raised, flat, white area of hypertrophic skin that undergoes ulceration

Question 8

Exophytic lesions of squamous cell carcinoma

Answer 8

become extremely large, undergo necrosis, and become secondarily infected and malodorous

Question 9

squamous cell carcinoma grading

Answer 9

graded histologically from 1-3. Grade 1: well differentiated and form keratin pearls. Grade 2: moderately well differentiated. Grade 3: poorly differentiated cells

Question 10

verrucous carcinoma

Answer 10

locally invasive tumor that seldom metastasizes to regional lymph nodes. looks like a condylomatous growth, histopathology reveals papillary fronds without a central core. treat with vulvectomy

Question 11

Carcinoma of Bartholin’s gland

Answer 11

1% of vulvar CA. most common site for vulvar adenocarcinoma. 50% are squamous cell carcinoma. may impinge on rectum

Question 12

basal cell carcinoma

Answer 12

most are small elevated lesions with ulcerated center and rolled edges (rodent ulcers). some described as pigmented tumors, moles, or simply pruritic maculopapular eruptions. usually erupt on labia majora. derived from primordial cells. treat with wide local excision

Question 13

malignant melanoma

Answer 13

5% of vulver CAs. usually arise around labia minora and clitoris and there is tendency to spread toward urethra and vagina. Described as dark pigmented raised lesion at mucocutaneous region. Spreads through lymphatic channels and metastasizes early. remove with excision biopsy with 0.5-1 cm margin of normal skin

Question 14

clinical findings of vulvar cancers

Answer 14

usually has had infrequent medical exams. 10% are diabetic, 30-50% are obese or hypertensive or heart dz. usually occurs in 70s and 80s.

Question 15

signs and symptoms of vulvar cancers

Answer 15

vulvar pruritis and/or mass, bleeding, vulvar pain. important to do a biopsy

Question 16

vulvar cancer complications

Answer 16

wound breakdown from radical vulvectomy and dissection. seperate groin incision and careful handling of skin flaps have reduced incidence

Question 17

vulvar cancer treatment

Answer 17

complete surgical removal of all tumor. large tumor may require d&c and endometrial biopsy. Unifocal stage 1 lesion treated with wide radical local excision. with margins of 1-2cm. Stage 2 lesions or those crossing midline can be treated with bilat inguinal femoral lymphadenectomy. If there is a spread to lymph nodes, do adjunct radiation

Question 18

preinvasive disease of vagina general info

Answer 18

almost all lesions are aymptomatic. often accompany HPV infection (so pt may have warts) and abnormal pap. lesions usually found along vaginal ridges and may appear raised or have spicules.

Question 19

preinvasive disease of vagina diagnosis

Answer 19

made by colposcopic exam of vagina with directed biopsy. This can be difficult, especially if hysterctomy has already been done because lesions can lay in recesses of vaginal cuff. Do thorough exam of vagina because dz is usually multifocal

Question 20

preinvasive disease of vagina colposcopy exam findings

Answer 20

3-5% acetic acid is applied to vaginga. lesions may appear as white epithelium and may have mosaicism or punctuation. Lugol’s iodine can be added to help define borders.

Question 21

Cancers of vagina signs

Answer 21

usually patients are asymptomatic and found with abnormal vaginal cytology and confirmed with biopsy. early signs: painless bleeding from ulcerated tumor, late signs: bleeding, pain, weight loss, swelling.

Question 22

cancers of vagina risk factors

Answer 22

smoking, HPV infection, multiple sex partners, hx of lower genital tract neoplasia, utero DES exposure

Question 23

preinvasive carcinoma: stage 0

Answer 23

carcinoma in situ, intraepithelial carcinoma

Question 24

invasive carcinoma stage 1

Answer 24

carcinoma is limited to vaginal mucosa

Question 25

invasive carcinoma stage 2

Answer 25

carcinoma has involved subvaginal tissue but has not extended to pelvic wall

Question 26

invasive carcinoma stage 3

Answer 26

carcinoma has spread to pelvic wall

Question 27

invasive carcinoma stage 4

Answer 27

carcinoma has extended beyond true pelvis or has involved the mucosa of the bladder or rectum. bullous edema as such does not permit allotment of a case to stage 4

Question 28

invasive carcinoma stage 4a

Answer 28

spread of growth to adjacent organs

Question 29

invasive carcinoma stage 4b

Answer 29

spread to distant organs