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Vulva Neoplasms and common benign lesions

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Presentation on theme: "Vulva Neoplasms and common benign lesions"— Presentation transcript:

1 Vulva Neoplasms and common benign lesions
Maria Horvat, MD, FACOG

2 Anatomy of the vulva

3 Lymphatic drainage of the vulva

4 Vulvar Cancer 5% of female genital malignancies
Usually occurs in the year old population Histology is necessary for diagnosis Occurs anywhere on vulva Surgically staged Most common type is squamous cell Melanoma is 2nd most common – but still <5% Associated with HPV

5 Vulvar Cancer Spreads by direct extension Embolizes to lymphatics
Hematogenous dissemination

6 Risks of vulvar cancer HPV Lichen sclerosis Long history of puritis
Lymph nodes are single most important prognostic factor

7 Vulvar Intraepithelial Neoplasms
VIN - preinvasive disease VIN 1 VIN 2 VIN3

8 Vulvar Intraepithelial Neoplasms
VIN 1 Abnormal cellular changes Confined to lower 1/3 Epithelium – no progressive vulvar cancer

9 Vulvar Intraepithelial Neoplasms
VIN 2 “moderate” 1/3-2/3 Epithelium involved

10 Vulvar Intraepithelial Neoplasms
VIN 3 “severe” 2/3 – all If untreated most go on to cancer If treated 4% go on to cancer Treat with wide local excision

11 Cancer In-Situ All epithelium involved

12 New Classification for VIN
Old System New System VIN 1 Flat condyloma or HPV effect VIN2,3 VIN, usual type VIN, warty type VIN, basaloid type VIN, mixed (warty/basaloid) type Differentiated VIN VIN, differentiated type

13 VIN 3

14 VIN 3

15 VIN 3

16 VIN - Treatment Local excision Local destruction

17 VIN 50% asymptomatic 25% hyperpigmented Typically: raised surface

18 VIN – Diagnosis 3% acetic acid Punch biopsy

19 Staging of Vulvar Carcinoma
Stage Characteristics Stage 0 Carcinoma in situ; intraepithelial neoplasia grade III Stage I Lesion <2 cm; confined to the vulva or perineum; no nodal metastasis Stage Ia Lesion <2 cm; confined to the vulva or perineum and with stromal invasion <1 mm; no nodal metastasis Stage Ib Lesion <2 cm; confined to the vulva or perineum and with stromal invasion >1mm; no nodal metastasis Stage II Tumor >2 cm in greatest dimension; confined to the vulva and/or perineum; no nodal metastasis Stage III Tumor of any size with adjacent spread to the lower urethra and/or vagina or anus and/or unilateral regional lymph node metastasis Stage Iva Tumor invasion of any of the following: upper urethra, bladder mucosa, rectal mucosa, and/or pelvic bone and/or bilateral regional node metastases Stage Ivb Any distant metastasis, including pelvic lymph nodes


21 Vulvar Cancer – prognostic factors
For nodal involvement Size Depth of invasion Lesion thickness Grade Vascular space involvement For survival Positive inguinal nodes Positive pelvic nodes

22 VIN - Treatment Cancer-in-situ Invasive Cancer
Excision with at least 1cm margins topical Invasive Cancer Inguinal-femoral lymph nodes Radical excision Radiation Pelvic exenteration

23 Melanoma Usually arises from nevi Blue/black Ulcerated
RX: wide excision with 2 cm free border If depth of invasion <1.5mm, 100%survival

24 Vulvar Melanoma

25 Vulvar Melanoma

26 Pagets Disease of the Vulva
Hyperemic tissue Cake icing effect Rx: wide local excision 30% will develop adenocarcinoma of the breast, colon, and rectum

27 Pagets Disease

28 Lichen Sclerosis Itching Diagnosed by biopsy
Can eventually become VIN or vulvar cancer 20% hypothyroid

29 Lichen Sclerosis

30 Remember! BIOPSY anything suspicious!

31 References The Female Patient; April 2008 Clinical Gynecology; Bieber

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