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

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Presentation on theme: "Vulva Neoplasms and common benign lesions Maria Horvat, MD, FACOG."— 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 2 nd 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 SystemNew System VIN 1Flat condyloma or HPV effect VIN2,3VIN, usual type VIN, warty type VIN, basaloid type VIN, mixed (warty/basaloid) type Differentiated VINVIN, differentiated type

13 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 StageCharacteristics Stage 0Carcinoma in situ; intraepithelial neoplasia grade III Stage ILesion <2 cm; confined to the vulva or perineum; no nodal metastasis Stage IaLesion <2 cm; confined to the vulva or perineum and with stromal invasion <1 mm; no nodal metastasis Stage IbLesion 1mm; no nodal metastasis Stage IITumor >2 cm in greatest dimension; confined to the vulva and/or perineum; no nodal metastasis Stage IIITumor of any size with adjacent spread to the lower urethra and/or vagina or anus and/or unilateral regional lymph node metastasis Stage IvaTumor invasion of any of the following: upper urethra, bladder mucosa, rectal mucosa, and/or pelvic bone and/or bilateral regional node metastases Stage IvbAny 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 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


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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