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Vulvar and Vaginal lesions Dr.F Behnamfar MD Introduction Most usful means of generating differential diagnosis is by morphological findings rather than.

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Presentation on theme: "Vulvar and Vaginal lesions Dr.F Behnamfar MD Introduction Most usful means of generating differential diagnosis is by morphological findings rather than."— Presentation transcript:

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2 Vulvar and Vaginal lesions Dr.F Behnamfar MD

3 Introduction Most usful means of generating differential diagnosis is by morphological findings rather than symptomatology Vulvar biopsy should be performed if the lesion is clinically suspicious or does not resolve after standard therapy

4 Vulvar Symptoms Most often,primary vaginitis and secondary vulvitis Most often,primary vaginitis and secondary vulvitis A number of skin conditions on other areas of the body A number of skin conditions on other areas of the body

5 Neoplasia Vulvar intraepithelial neoplasia a precancerous lesion that may progress to invasive cancer Most are raised multifocal white (may be red or pink) and/or verrucous lesions Cancer presents with unifocal vulvar plaque,ulcer or mass Lichen scerosus and erosive lichen planus predispose to cancer

6 Genital warts Caused by human papillomavirus Flat,filliform or verrucous,or giant Flesh colored or pigmented Biopsy is indicated if there is rapid growth,increased pigmentation,ulceration,pigmentation,fixation or poor response to therapy Treatment : trichloroacetic acid, podophyllum,Cryo,laser Not curative,merely speed clinical resolution

7 White patch Lichen sclerosus,well demarcated white finely wrinkled and atrophic patches Vulvar itching and typical findings Potent topical corticosteriod ointment Close follow up for risk of malignancy

8 Other vulvar conditions folliculitis folliculitis Fox.fordiyce disease Fox.fordiyce disease Acanthosis nigricans Acanthosis nigricans Extramammary pagets disease,intraepithelial adenocarcinoma Extramammary pagets disease,intraepithelial adenocarcinoma

9 Herpes simplex Scabis

10 Vulvar cysts, tumors and masses Condylomata accuminata Condylomata accuminata duct cysts,Skenes duct cysts duct cysts,Skenes duct cysts Vulvar Ulcers: Behcet disease,lichen planus Vulvar Ulcers: Behcet disease,lichen planus

11 Vaginal Conditions Retained foreign body Retained foreign body Ulceration Ulceration Malignancy Malignancy

12 Vulvar Cancer 3870 new cases new cases deaths 870 deaths Approximately 5% of Gynecologic Cancers Approximately 5% of Gynecologic Cancers American Cancer Society. Cancer Facts & Figures Atlanta, GA; 2005

13 Vulvar Cancer 85% Squamous Cell Carcinoma 85% Squamous Cell Carcinoma 5% Melanoma 5% Melanoma 2% Sarcoma 2% Sarcoma 8% Others 8% Others

14 Vulvar Cancer Biphasic Distribution,two distinct etiologies: Biphasic Distribution,two distinct etiologies: – Age 70 –type, unifocal, –in areas adjacent to lichen sclerosus or squamous hyperplasia (Chronic inflammatory conditions) –20% in patients UNDER 40 and appears to be increasing, –multifocal, –basaloid or warty types, –HPV related,smoking and VIN

15 Vulvar Cancer Paget’s Disease of Vulva Paget’s Disease of Vulva –10% will be invasive –4-8% association with underlying Adenocarcinoma of the vulva

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18 Symptoms Most patients are treated for “other” conditions Most patients are treated for “other” conditions 12 month or greater time from symptoms to diagnosis 12 month or greater time from symptoms to diagnosis

19 Symptoms Pruritus Pruritus Mass Mass Pain Pain Bleeding Bleeding Ulceration Ulceration Dysuria Dysuria Discharge Discharge Groin Mass Groin Mass

20 Symptoms May look like: May look like: –Raised –Erythematous –Ulcerated –Condylomatous –Nodular

21 Vulvar Cancer IF IT LOOKS ABNORMAL ON THE VULVA IF IT LOOKS ABNORMAL ON THE VULVA BIOPSY! BIOPSY!

22 Tumor Spread Very Specific nodal spread pattern Very Specific nodal spread pattern Direct Spread Direct Spread Hematogenous Hematogenous

23 Staging Based on TNM Surgical Staging Based on TNM Surgical Staging –Tumor size –Node Status –Metastatic Disease

24 Staging Stage I T1 N0 M0 Stage I T1 N0 M0 –Tumor ≤ 2cm –IA≤1 mm depth of stromal Invasion –IB1 mm or more depth of invasion

25 Staging Stage II T2 N0 M0 Stage II T2 N0 M0 –Tumor >2 cm –Confined to Vulva or Perineum

26 Staging Stage III Stage III –T3 N0 M0 –T3 N1 M0 –T1 N1 M0 –T2 N1 M0 Tumor any size involving lower urethra, vagina, anus OR unilateral positive nodes Tumor any size involving lower urethra, vagina, anus OR unilateral positive nodes

27 Staging Stage IVA Stage IVA –T1 N2 M0 –T2 N2 M0 –T3 N2 M0 –T4 N any M0 Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodes Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodes

28 Staging Stage IVB Stage IVB –Any T Any N M1 Any distal mets including pelvic nodes Any distal mets including pelvic nodes

29 Treatment Primarily Surgical Primarily Surgical –Wide Local Excision –Radical Excision –Radical Vulvectomy with Inguinal Node Dissection Unilateral Unilateral Bilateral Bilateral Possible Node Mapping, still investigational Possible Node Mapping, still investigational

30 Treatment Local advanced may be treated with Radiation plus Chemosensitizer Local advanced may be treated with Radiation plus Chemosensitizer Positive Nodal Status Positive Nodal Status –1 or 2 microscopic nodes < 5mm can be observed –3 or more or >5mm post op radiation

31 New advances in treatment Individualization of treatment,vulvar conservation for unifocal tumors Individualization of treatment,vulvar conservation for unifocal tumors Elimination of routine pelvic lymphadenectomy Elimination of routine pelvic lymphadenectomy Omission of groin dissection for T1 tumors (<1mm stromal invasion) Omission of groin dissection for T1 tumors (<1mm stromal invasion) Separate incisions improve wound healing Separate incisions improve wound healing

32 Treatment Special Tumor Special Tumor –Verrucous Carcinoma Indolent tumor with local disease, rare mets UNLESS given radiation, becomes Highly malignant and aggressive Indolent tumor with local disease, rare mets UNLESS given radiation, becomes Highly malignant and aggressive Excision or Vulvectomy ONLY Excision or Vulvectomy ONLY

33 Vulva 5 year survival Stage I90 Stage I90 Stage II77 Stage II77 Stage III51 Stage III51 Stage IV18 Stage IV18 Hacker and Berek, Practical Gynecologic Oncology 4 th Edition, 2005

34 Recurrence Local Recurrence in Vulva Local Recurrence in Vulva –Reexcision or radiation and good prognosis if not in original site of tumor –Poor prognosis if in original site

35 Recurrence Distal or Metastatic Distal or Metastatic –Very poor prognosis, active agents include Cisplatin, mitomycin C, bleomycin, methotrexate and cyclophosphamide

36 Melanoma 5% of Vulvar Cancers 5% of Vulvar Cancers Not UV related Not UV related Commonly periclitoral or labia minora Commonly periclitoral or labia minora

37 Melanoma Microstaged by one of 3 criteria Microstaged by one of 3 criteria –Clark’s Level –Chung’s Level –Breslow

38 Melanoma Treatment Wide local or Wide Radical excision with bilateral groin dissection Wide local or Wide Radical excision with bilateral groin dissection Interferon Alpha 2-b Interferon Alpha 2-b

39 Vaginal Carcinoma 2140 new cases projected new cases projected deaths projected deaths projected 2005 Represents 2-3% of Pelvic Cancers Represents 2-3% of Pelvic Cancers American Cancer Society. Cancer Facts & Figures Atlanta, GA; 2005

40 Vaginal Cancer 84% of cancers in vaginal area are secondary 84% of cancers in vaginal area are secondary –Cervical –Uterine –Colorectal –Ovary –Vagina Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2 nd ed. 2002

41 Vaginal Carcinoma Squamous Cell80-85% Squamous Cell80-85% Clear Cell10% Clear Cell10% Sarcoma3-4% Sarcoma3-4% Melanoma2-3% Melanoma2-3%

42 Clear Cell Carcinoma Associated with DES Exposure In Utero Associated with DES Exposure In Utero –DES used as anti abortifcant from –500+ cases confirmed by DES Registry –Usually occurred late teens

43 Vaginal Cancer Etiology Mimics Cervical Carcinoma Mimics Cervical Carcinoma –HPV 16 and 18

44 Staging Stage IConfined to Vaginal Wall Stage IConfined to Vaginal Wall Stage IISubvaginal tissue but not to pelvic sidewall Stage IISubvaginal tissue but not to pelvic sidewall Stage IIIExtended to pelvic sidewall Stage IIIExtended to pelvic sidewall Stage IVABowel or Bladder Stage IVABowel or Bladder Stage IVBDistant mets Stage IVBDistant mets

45 Treatment Surgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in Vagina Surgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in Vagina All others treated with radiation with chemosensitization All others treated with radiation with chemosensitization

46 5 year Survival Stage I70% Stage I70% Stage II51% Stage II51% Stage III33% Stage III33% Stage IV17% Stage IV17%

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