Carcinoma Vulva & Vagina Subdivisi Onkologi Ginekologi Bagian Obgin FK USU
Vulvar Carcinoma. Definition: Cases should be classified as carsinoma of the vulva when the primary site growth is in the vulva Malignant melanoma should be reported and staged according to the system for cutaneous melanoma
Vulvar casinoma Eldery type: More common Unrelated to HPV Dystrophic lesion Lichen sclerosis Younger type Related to HPV Related to smoking Associated with VIN
Models of vulvar cancer Characteristic Age Cervical neoplasia Cofactors Histopathology of tumor Younger Type Younger ( 35 to 65 yo) High association Age, immune status, viral integration Intraepithelial-like like (basaloid), poorly diff. Elderly Type Older (55 to 85 yo) Low association Vulva atypia, possibly mutated host gene Keratinizing, squamous cell carcinoma, well diff HPV DNA Frequent (>60%) Seldom (<15%) Pre-existing existing lesion History of condyloma History of STD VIN Strong association Strong association Vulvar inflam, lichen- sclerosis, squamous cell hyperplasia Rare association Rare association Cigarette smoking High incidence Low incidence
Etiology No specific etiologic factor Relation to VIN : controversial VIN considered low malignant potential Related to infection with HPV HPV DNA : 20% 60%
Diagnosis No screening procedures Histopathologic Wedge biopsy Under local anesthesia Include some surrounding skin Include some underlying dermis / connective tissue Problem : delay diagnosis
Staging 1988 : clinical staging 1994 : surgical staging Regional lymph node (N): NX : regional node cannot be assessed N0 : no regional node metastasis N1 : unilateral node metastasis N2 : bilateral node metastasis Distant metastasis (M): MX : distant metastasis cannot be assessed M0 : no distant metastasis M1 : distant t metastasis t
FIGO stage Stage Primary tumor cannot be assessed No evidence of primary tumor 0 Carcinoma in situ (preinvasive carcinoma) TNM categories TX T0 Tis I IA IB Tumor confined to vulva and/or perineum, 2 cm in greatest dimension Tumor confined to vulva and/or perineum, 2 cm in greatest dimension and with stromal invasion 1 mm Tumor confined to vulva and/or perineum, 2 cm in greatest dimension and with stromal invasion > 1 mm T1 T1a T1b II Tumor confined to vulva and/or perineum, > 2 cm in greatest dimension T2 III IV IVA Tumor invades any the following :lower urethra, vagina, anus and/or unilateral regional node metastasis Tumor invades any the following: bladder mucosa, rectal mucosa, upper urethral mucosa, or is fixed to bone and/or bilateral regional node metastasis T3 T4 IVB Any distant metastasis including pelvic node
Carcinoma of the vulva Stage grouping g FIGO stage T N M 0 Tis IA IB II III IVA IVB T1A T1B T2 T1 T2 T3 T1 T2 T3 T4 Any T N0 N0 N0 N0 N1 N1 N1 N2 N2 N2 Any N Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1
Treatment VIN or carcinoma in situ Multiple biopsy to ensure the lesion entirely intra epithelial Local incision with 1 cm margin laterally Invasive carcinoma Individualized Primary lesion Groin lymph node Micro invasive (stage IA) Wide local excision No groin resection
Treatment Early stage (confined to the vulva without clinically suspicious lymph node) Less radical surgery (radical local excision) Lateral margin 1 cm Depth : inferior fascia urogenital Urethra may be resected Groin node dissection: Ipsilateral for T2 or T1 stromal invasion > 1 mm Bilateral dissection for midline tumor Adjuvant radiation if: Node positive, Ǿ > 1 cm 2 node positive 50 Gy in fractionation
Treatment Advanced stage ( T3/T4 or bulky groin node) Multimodality treatment Primary tumor : if possible resected Node : resected or not Radiation at
Vaginal Carcinoma Definition: Primary malignant from vaginal tissue The rarest gynecological neoplasm (<1%) Squamous cell carcinoma is the most common
Etiology The etiologic factor :? Prior pelvic radiation due to cervical carcinoma > 5 years ago Any new vaginal carcinoma developing at least 5 years after the cervical cancer should be considered as a new primary lesion Related to the administration i ti of DES for clear cells adenocarsinoma
Diagnose Screening : women with history cervical cancer 28% occult carcinoma found in VAIN Relation VAIN and carcinoma vagina :? Biopsy : under local anesthesia Histopathology
Staging Stage 0 Carcinoma in situ, intraepithelial neoplasia grade 3 Stage I Stage II Stage III Stage IV Stage IV A Stage IV B The carcinoma is limited to the vaginal wall The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall The carcinoma has extended to the pelvic wall The carcinoma has extended beyond the true pelvic or has involved the mucosa of bladder or rectum, bullous edema as such does not permit a case to be allotted to stage IV Tumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvic Spread to distance organs
Treatment Referred to tertiary referral unit Individualized Surgery : limited role Radiation : choice of treatment Tele & intra cavitary radiation