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Vulva disease

This document discusses benign and malignant diseases of the vulva. It covers symptoms, general pathology, diagnosis of white, red and brown lesions. Nonneoplastic epithelial disorders like lichen sclerosis and squamous cell hyperplasia are examined. Malignant diseases like HPV, VIN, and carcinoma are addressed. Cancer epidemiology, management including staging, surgery, radiation and chemotherapy are summarized. Prognostic factors and recurrence are also reviewed. Key points emphasize inspection, biopsy, medical therapy for benign conditions and challenges in vulvar cancer treatment.

Health & Medicine◦
Benign and malignant disease of the vulva Khalid Sait ( FRCSC) Gynecological Oncology Professor Faculty of Medicine King Abdulaziz University
Symptoms of Vulvar Disease •  Itching •  Burning •  Dyspareunia •  Discharge •  Bleeding
General Pathology Term. •  Epidermis •  Acanthosis •  Parakeratosis •  Hyperkeratosis
Vestibular Micropapillomatosis
General Guide to Diagnosis •  White Lesions •  Red Lesions •  Brown/Bluish Lesions
White Lesions •  Vitilligo •  Nonneoplastic epithelial disorders
Nonneoplastic Epithelial Disorders - Vulva •  Squamous cell hyperplasia •  Lichen Sclerosis •  Other dermatosis ISSVD 1987
Lichen Sclerosis •  Steroid •  Testesterone •  Progesterone
Squamous cell hyperplasia •  Steroid
Red Lesions •  Infective •  Dermatitis •  Psoriasis •  Pagets •  VIN/Ca
HPV - Treatment •  Observation •  Podophyllin •  Trichloroacetic acid •  Interferon •  Imiquimod ( Aldara) •  Excision /Laser
Brownish/Bluish Lesions •  VIN •  Naevi/Melanoma •  Carcinoma
Malignant Disease Of The Vulva
Female Genital Tract Malignancy •  Uterus •  Ovary •  Cervix •  Vulva •  Vagina •  Fallopian Tubes.
Epidemiology •  Mean age at diagnosis is 65 years •  Etiology is unknown •  VIN is premalignant •  Lichen sclerosis is associated with vulva cancer •  HPV found in 50 % of vulva cancer •  Alteration in p 53 •  smoking
Malignancy Of The Vulva •  Squamous cell carcinoma 90 % (Verrucous ca) •  Melanoma •  Bartholine gland adenocarcinoma •  sarcoma
Carcinoma Of The Vulva •  Preoperative workup •  History •  Physical Examination •  CBC, U/E and LFT •  CXR a-p/lat
Management Staging: surgico - pathological •  Management of the vulva •  Management of the groin
Microinvasion •  Lesion less than 2 cm with depth of less than 1 mm with noLVS inv. and no clinical positive node •  Incidence of L.node mets is 0 % •  Treatment wide local excision down to colles’ fascia
Lateral T1 lesion •  Radical local excision and groin unilateral node dissection •  Send for frozen if positive do the other side •  If negative unilat node only 10 % will have positive contra lateral node usually in lesion with risk factors •  20-30 % of non suspicious node will have mets
Lateral T2 lesion •  Unilateral hemivulvectomy and bilateral node groin dissection
Prevalence of local invasive recurrence after radical local excision and radical vulvectomy for early T1 lesion procedure Pts number recurrence Dead of disease Radical local excision 165 12(7.2%) 1(0.6% Radical vulvectomy 365 23(6.3%) 2(0.6%
T1 or T2 midline or bilateral lesion •  Radical vulvectomy and bilateral groin node dissection
Post operative adjuvant therapy •  Close margin(< 8mm) re-excision versus RT. to the vulva •  Poorly diff., large tumor, LVS involvement and diffuse infiltrative lesion : Radiation to the vulva a lone and may be to the medial groin area
Respectable vulva lesion with clinically positive groin node •  Radical vulvectomy with bilateral groin node dissection followed BY radiation to groin and pelvis •  With multiple inguinal node 20 % risk of pelvic node involvment •  22 % of clinical positive groin node will show no histology evidence of mets
T3 Involvement of distal urethra , vagina or anus •  Preoperative radiation and chemotherapy to allow conservative surgery with affecting sphencter followed by: if residual disease radical vulvectomy and groin lymph node dissection If no residual disease do multiple vulval biopsies and node dissection •  If bulky node remove bulky node initially if not fixed or ulcerated
T4 Primary lesion with massive bladder and or rectum involvement •  Selective Exenteration with radical vulvectomy and groin node dissection •  Remove bulky nodes if not fixed or ulcerated and give radiation to the groin and pelvic nodes as well as radiation to vulva with 5 FU followed by debulking surgery or a modified exentrative procedure
Chemotherapy •  5 FU 1gm/m2/d 1-4 days over 2 4 hoyrs infusion 96 ml start 24 hours before radiation and be given on day 29-32 of radiation
Radical Vulvectomy • Radical en-bloc dissection Taussig and Way 1949-1960 • Triple incision technique
Rhomboid flaps
Morbidity related to treatment •  Wound breakdown •  Sepsis •  Venous thromboembolism •  Pressure sore •  Lymphaedema •  Lymphocyst •  Psychosexual problems •  Moist desquamation