Pocket ObGyn – Vaginal / Vulvar Cancer
See Abbreviations

Vaginal Cancer

Epidemiology

• 1–2% of all gynecologic Incid of VAIN: 0.2/100000 women
• Mean age: 70–90 84% are metastases from other sites.

Pathology (Curr Opin Obstet Gynecol 2005;17:71)

• VAIN is precursor Upper 3rd of vagina most common. A/w CIN. Risk of transformation to invasive vaginal carcinoma 9–10%.

•   Squamous cell carcinoma

85% of vaginal cancer. Superficial spread, then invasion to paravaginal tissue. Metastasis to liver/lung.

•   AdenoCa:

15% of cases. Metastasis to lung, supraclavicular & pelvic LNs. Metastasis from other sites is more common than primary vaginal adenoCa.

• Clear cell adenoCa: DES Coexists w/ vaginal adenosis.
• Melanoma: <1–3% of vaginal Pigmented or nonpigmented.
• Sarcoma botryoides: Multicentric; anter wall; grape More common in children.
• Adenosquamous carcinoma: 1–2% of vaginal Aggressive.
• Secondary carcinomas: Extension from cervix, endometrial metastasis, bowel/ bladder local extension, gestational trophoblastic

Etiology

• HPV 16 & 18 found in invasive cancer & DES exposure. Endometriosis linked w/ adenoCa. Radiation exposure.

Clinical Manifestations

• Vaginal bleeding or bloody discharge usually indicates advanced Urinary sx.

Diagnostic Workup

• Bx for tissue dx; view by colposcopy w/ Lugol’s solution (localized or skip lesions). Bx cervix & vulva as well.

Management

• VAIN I: Observation
• VAIN II or III: Wide local excision, partial or total vaginectomy, intravag 5-FU, trichloroacetic acid, 5% imiquimod, laser therapy (Journal of Lower Genital Tract Disease 2012;16:00)
• Stage I SCC: <5 cm thick: Intracavitary radiation, wide local excision, or total vaginectomy; >0.5 cm thick: Radical vaginectomy w/ pelvic LND & inguinal LND (if lower 3rd), radiation if lower 3rd to pelvic/inguinal LNs or poorly differentiated/ infiltrating.

 

• Stage I adenoCa: Total radical vaginectomy, hysterectomy, LND, vaginal reconstruction ± intracavitary/interstitial radiation
• Stage II SCC/adenoCa: Brachytherapy/EBRT or radical vaginectomy or pelvic exenteration ± radiation
• Stages III & IVA SCC/adenoCa: Interstitial, intracavitary, & EBRT
• Stage IVB SCC/adenoCa: Radiation ± chemo
• Melanoma: Wide local excision, radical excision w/ inguinofemoral LND, pelvic exenteration, radiation, chemo, or immunotherapy (Int J Gynecol Cancer 2004;14:687)
• Local recurrence: Pelvic exenteration or radiation

•   Distant recurrence: Chemo

• Prog: 70% 5-y survival for stage I; 50% survival for advanced stage

 

FIGO staging for vaginal cancer, 2009
stage i	Tumor limited to vaginal wall
stage ii	Tumor involves the subvaginal tissue; not extended to the pelvic sidewall
stage iii	Tumor extends to the pelvic sidewall
stage iv   iva ivB	Tumor extends beyond the true pelvis or has involved the mucosa of the bladder or rectum Tumor invades bladder &/or rectal mucosa &/or direct extension beyond pelvis Distant spread
From Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet. 2009;105(1):3–4.

Posttreatment Surveillance (Am J Obstet Gynecol 2011;204:466)

• Exam (if low risk) q6mo ´ 2 y then yearly ´ 2 y; (if high risk) q3mo ´ 2 y, then q6mo
• 2 y, then Pap smear yearly. CT or PET if recurrence.

Vulvar Cancer

Definitions and Epidemiology (Hematol Oncol Clin N Am 2012;26:45)

• VIN: Dysplasia confined to epithelium
• Vulvar carcinoma: Lesion invading through basement membrane
• Incid: Vulvar cancer 3/100000 women/y;VIN: 1.2–2.1/100000 women
• 4–7% of all gynecologic Median age at dx: 68 y.

• Lifetime risk: 27%

Pathology

• VIN usual type: Warty, basaloid, HPV related.
• VIN differentiated type: A/w lichen sclerosus, squamous cell NOT HPV related. Risk of developing keratinizing squamous cell carcinoma.
• SCC: 92% of vulvar cancer.Warty & basaloid type; keratinizing, nonkeratinizing, basaloid, verrucous, warty, & acantholytic type; invasive or superficial Most common sites: Labia majora (50%), labia minora (15–20%). HPV16 & 18; 40% of invasive cancers are HPV positive; 80% of VIN are HPV positive; vaccination may prevent.
• Basal cell carcinoma: 2–4% of vulvar Infiltrating tumor w/ basal cells of the epidermis. Labia majora is the most common site. Basosquamous or metatypical basal cell carcinoma: Malig squamous component, found in 3–5% of basal cell carcinomas (treat as squamous carcinoma).
• Bartholin’s gland carcinoma: 40% adenoCa; 40% squamous carcinoma; 15% adenoid cystic Bx any Bartholin’s gland abscess in woman >35 y.
• Sarcoma: 1–2% vulvar Leiomyosarcoma, liposarcoma, fibrosarcoma, neurofibrosarcoma, rhabdomyosarcoma, malig schwannoma, angiosarcoma, epithelioid sarcoma.
• Verrucous carcinoma: Cauliflower-like appearance. Slow growing & locally invasive (will even invade bone)
• Malig melanoma: 2nd most common vulvar Labia minora or clitoris most common sites. Arise de novo; pigmented lesion, asymptomatic.
• Paget’s dz of vulva: <1% of vulvar neoplasms. Concurrent w/ underlying adenoCa in 4–20%. 12% invasive; 35% recurrence Large pale cells (Paget cells). Raised, velvety appearance. A/w adenoCa of other location (breast/colon): 30%.

 

Clinical Manifestations

• Presentation: Vulvar itching & irritation, burning, pain, Pigmented lesions, ulcerations, papules, nodules, or scar-like lesions. Persistent condyloma (30% w/ VIN 3).

Diagnostic Workup

• Bx flat, elevated, or pigmented lesions; bx genital warts in postmenopausal women or women who fail topical Colposcopy.

Management

• VIN: Wide local excision (low risk of recurrence if negative margins); laser ablation if cancer not suspected (colposcopy to delineate margins); topical 5% imiquimod

•   Vulvar squamous carcinoma

Stage I: Wide local excision if microinvasive (<1 mm invasion), otherwise, radical local excision w/ complete unilateral LND (bilateral LND if lesion <1 cm from midline)

Stage II: Modified radical vulvectomy w/ bilateral inguinal LND & femoral LND: Radiation if margins <8 mm, lymphovascular invasion, or >5 mm thick

Stage III: Modified radical vulvectomy w/ bilateral inguinal/femoral LND w/ radiation

Stage IV: Radical vulvectomy followed by radiation

Recurrence: Depending on location & extent of recurrence, options

include wide local excision, radical vulvectomy, pelvic exenteration, radiation, chemo

• Basal cell carcinoma: Radical local excision
• Bartholin’s gland carcinoma: Radical local excision or hemivulvectomy, consider ipsilateral inguinal LND
• Sarcoma: Radical local excision
• Verrucous carcinoma: Radical local excision; radiation contraindicated (induces anaplastic transformation which may lead to metastasis)
• Malig melanoma: Radical local excision if <1 mm invasion; consider ipsilateral inguinal LND if >1 mm invasion
• Paget’s dz of vulva: Wide local excision; modified radical vulvectomy if underlying adenoCa
• Prog: 5-y survival 7%; based on stage at dx; ­ risk of metastasis if nodes positive, advanced stage, advanced age, increased stromal invasion, LVSI

Posttreatment Surveillance (Am J Obstet Gynecol 2011;204:466)

• Exam q3mo ´ 2 y, then q6mo ´ 3 y, then

CT &/or PET if recurrence suspected.VIN surveillance: q6mo for 1 y, then annually; recurrence high (30–50%).

 

Clark, Breslow, and Chung staging for melanoma See also chapter 1
	Clark	Breslow	Chung
i	Confined to epithelium	0.75 mm or less	Confined to epithelium
ii	Penetrate basement membrane; extend into papillary dermis	0.76–1.50 mm	Penetrates basement membrane; extends to 1 mm or less from granular layer
iii	Fills papillary dermis	1.51–2.25 mm	Penetrates btw 1.1 and 2 mm from granular layer
iv	Invades deep reticular dermis	2.26–3 mm	Invades beyond 2 mm from granular layer
v	Invades subcutaneous adipose tissue	>3 mm	Invades into subcutaneous adipose tissue
From Jahnke A, Makovitzky J, Briese V. Primary melanoma of the female genital system: A report of 10 cases and review of the literature. Anticancer Res. 2005;25(3A):1567–1574.

 

FIGO staging for vulvar cancer, 2009
stage i ia iB	Tumor limited to the vulva Lesion £2 cm in size, confined to the vulva or perineum & w/ stromal invasion £1 mm; no nodal metastasis Lesion >2 cm in size or w/ stromal invasion >1 mm; confined to perineum, w/ negative nodes
stage ii	Tumor of any size w/ extension to adj perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) w/ negative nodes
stage iii iiia iiiB iiic	Tumor of any size w/ or w/o extension to adj perineal structures w/ positive inguinofemoral LNs (i) 1 LN metastasis ³5 mm (ii)  1–2 LN metastases <5 mm (i) 2 or more LN metastases ³5 mm (ii)  3 or more LN metastases <5 mm Positive nodes w/ extracapsular spread
stage iv iva ivB	Tumor invades other regional structures (2/3 upper urethra, 2/3 upper vagina) or distant structures (i) Tumor invades urethral &/or vaginal mucosa &/or bladder mucosa &/or rectal mucosa; fixed to pelvic bone (ii)  Ulcerated or fixed inguinofemoral LNs Distant metastasis including pelvic LNs
From Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet. 2009;105(1):3–4.

See Abbreviations