Vulval Pre-cancer and Cancer: Diagnosis and Management Flashcards by Joseph Uche

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

3rd week

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Genital swellings form —

Labia majora

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Genital tubercle forms –

Clitoris

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Urethral folds form —

Labia minora

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The urogenital groove forms –

Vestible

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

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

F
Labia majora

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The labia minora split anteriorly to form the — and —

Prepuce and frenulum of the clitoris

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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

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2 pathways of VIN etiopathogenesis

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

Prior vulval lesions or non-HPV related: older women

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Concomitant lesions are seen in up to —% of cases

44%

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

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

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4 symptoms of VIN

May be asymptomatic
Vulval itching
Irritation
Burning
Dyspareunia

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5 specific investigations for VIN

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

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Mild. Dysplastic cells in lower third

VIN 1

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Moderate. Lower two – thirds

VIN 2

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Severe. Carcinoma – in – situ. Whole layer

VIN 3

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

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5 modes of treatment for VIN

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

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4 topical agents used in VIN

Interferon gel
retinyl acetate gel
5-fluoro-uracil
imiquimod

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One disadvantage of topical management for VIN

No specimen for histology

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

<40 years with no invasive lesion

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One disadvantage of CO2 laser treatment for VIN

No specimen for histology

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Depth of CO2 laser in the treatment of VIN

3 - 4mm

Treatment of choice in older women

Wide local excision

Wide local excision is curative in --% of cases

75% of cases if only VIN

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

In the treatment of VIN gross margins should be

0.5 – 1.0cm

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

% of missing invasive lesions in the treatment of VIN

18.8%

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

3 prognostic fate of VIN following treatment

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

% of VIN that recur after local excision

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

% of VIN that progress to VSCC

10%

4 markers of progression of VIN

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

How do you follow up VIN after treatment

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

6 modes of preventing VIN

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

Incidence of vulva cancer

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

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

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

3 risk factors for vulva cancer in young women

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

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

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

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

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

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

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

% of HPV prevalence in vulva cancer

20 40%

Which HPV subtype forms 75% of HPV dependent vulva cancer

HPV - 16

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

7 clinical features of vulva cancer

There may be no specific symptoms, leading to delay in treatment! Itching Dyspareunia Soreness Burning sensations Bleeding Lump Ulcer

10 specific investigations for vulva cancer

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

5 histological distribution of vulva cancer

VSCC - >90%. Keratinizing Basaloid Warty Verrucous

3 distribution sites of vulva cancer

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

Site with the highest distribution of vulva cancer

Labia - 80% Clitoris (10%), lower commissure (10%)

3 modes of spread of vulva cancer

Local invasion of adjacent tissues Embolization to regional lymph nodes (superficial, deep inguinal to pelvic nodes) Haematological to lungs, liver and bones

Vulva cancer stage 1 has how many substages

2 substages 1A and 1B

FIGO stage 1 vulva cancer

Tumor confined to the vulva

Stage 1A vulva cancer

Tumor size

Stage 1B vulva cancer

Tumor size >2cm or stromal invasion >1mm

FIGO stage 2 vulva cancer

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

FIGO stage 2 of vulva cancer has how many substaging

No substaging

FIGO stage 3 of vulva cancer has how many substaging

3 substaging lllA, lllB and lllC

FIGO stage 3 vulva cancer

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

FIGO stage lllB of vulva cancer

Regional lymph node metastases >5mm

FIGO stage lllC vulva cancer

Regional lymph node metastases with extracapsular spread

FIGO stage lllA vulva cancer

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

How many substages in FIGO stage 4 of vulva cancer

2 substages lVA and lVB

FIGO stage lV of vulva cancer

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

FIGO stage lVA vulva cancer

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

FIGO stage lVB vulva cancer

Distant metastases

Major form of therapy for vulva cancer

Surgery

2 aims of surgical treatment in terms of margins

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

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

50%

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

11 complications of vulva cancer treatment

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

% of chronic lymphedema complicating treatment of vulva cancer

30 - 70% Significant in 10%

Complications of adjuvant radiotherapy in the treatment of vulva cancer

Radiation dermatitis, fibrosis and ulceration - Vaginal stenosis

Neoadjuvant therapy in vulva cancer treatment

Chemoradiation

2 reasons for neoadjuvant chemoradiation in the treatment of vulva cancer

To shrink tumour To avoid injury to urethra, anus

% risk of transformation from VIN to VSCC

10% or 3% if VIN is treated

The most important prognostic factor in vulva cancer

Lymph node involvement

5-yr survival rate in FIGO stage l vulva cancer

79%

5-yr survival rate in FIGO stage lV vulva cancer

13%

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

59 and 43% respectively

2 modes of prevention of vulva cancer

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

Vulval Pre-cancer and Cancer: Diagnosis and Management Flashcards

(85 cards)