pre-malignant lesions of female genital tract · pre-malignant lesions of female genital tract jed...
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Pre-malignant Lesions
of
Female Genital Tract
Jed Delmore, MD, FACS, FACOG
Professor, Obstetrics and Gynecology
University of Kansas School of Medicine, Wichita
Disclosure
Documented Premalignant Lesions
• Vulva: Yes
– VIN
• Vagina: Yes
– VAIN
• Cervix: Yes
– CIN
• Endometrium: Yes
– For Type I cancers, EIN
• Fallopian Tube: Yes
– STIC
• Ovary: Probably not, or No
Principles
• Rule out invasive disease
• Define extent of disease
• Do more good than harm
Treatment Selection
• Risk of progression if untreated?
• Success of treatment?
• Toxicity/complications of therapy?
• Extent or size of lesion?
• Presence or absence of symptoms?
Case #1
45 year old renal transplant patient, smokes 2
ppd. Complains of vulvar pruritis.
Exam demonstrates-
Diagnosis?
Diagnosis?
Vulvar Intraepithelial Neoplasia
• VIN I: does not exist
• VIN: Encompasses VIN 2 & 3
– VIN- Usual Type (warty, basaloid, mixed)
• Associated with invasive squamous carcinoma of
warty or basaloid type
– VIN-Differentiated type
• More common in older women, with lichen
sclerosus.
• Associated with keratinizing squamous carcinoma.
• Not HPV related
Sideri M, et al Squamous Vulvar Intraepithelial Neoplasia 2004 Modified Terminology, ISSVD Vulvar Oncology Subcommittee.J Reprod Med 2005;50:807-10.
Treatment Options
• Observation- In the face of repeated recurrences, or
something else will do her in first.
• Excision- Primary closure or skin graft
• Laser vaporization- Multiple lesions, large, or at the
introitus
• Topical therapy ( 5-FU), Imiquimod
Excision, laser or
combination
Laser or excision and graft
What if the biopsy showed this?
Diagnosis?
Case #1
45 year old renal transplant patient, smokes 2
ppd. Complains of vulvar pruritis.
Exam demonstrates- Hypo and hyper
pigmented vulvar lesions.
Bx = VIN/CIS with probable early invasion.
Treatment Options??
Case # 2
77 year old with vulvar pruritis and multiple
treatments for yeast infection.
Exam =
Diagnosis?
Diagnosis?
Case # 2
77 year old with vulvar pruritis and multiple
treatments for yeast infection.
Exam = Erythematous, excoriated epithelium
with “cake frosting” coating.
Vulvar Biopsy = Paget’s disease of the vulva
Workup and treatment??
Treatment Options
• Excision- Primary
• Laser vaporization- Poor choice due to
gland involvement
• Topical therapy ( 5-FU)-Rarely
Case # 3
38 year old G3P3, Reports a vaginal hysterectomy
for a precancerous condition three years ago.
Pap = HSIL
Colposcopy = Thickened, acetowhite epithelium at
the vaginal apex.
Now what??
VAIN II-III
Treatment Options?
Treatment Options
• Excision- I wouldn’t unless I suspected invasion.
• Laser vaporization- Yep
• Topical therapy ( 5-FU), Imiquimod- Last
resort
Case # 4
32 year old G2P2 with HSIL Pap.
Colposcopy = Acetowhite epithelium with
punctuation. Large transformation zone.
ECC and Cervical Biopsies performed.
What is a Transformation Zone??
Squamocolumnar Junction
Transformation Zone
Transformation Zone
Acetowhite Epithelium
Mosaicism
Punctation
Atypical Vasculature
Case # 4
32 year old G2P2 with HSIL Pap.
Colposcopy = Acetowhite epithelium with
punctuation. Large transformation zone.
ECC-neg, CxBx-CIN III
Treatment Options??
Treatment Options ??
• Observation ?
• Excision ?
• Laser vaporization, Cryotherapy ?
• Hysterectomy ?
Treatment of CIN 2,3
• LEEP, or conization may be used whenever
treatment is appropriate.
• Cryotherapy of Laser vaporization should be used
only after rigorously excluding invasive cancer.
• Hysterectomy is unacceptable as primary therapy
for CIN 2+
ACOG Practice Bulletin 140, December, 2013
Case # 4
32 year old G2P2 with HSIL Pap.
Colposcopy = Acetowhite epithelium with
punctuation. Large transformation zone.
What if the biopsy had shown
adenocarcinoma in situ of the cervix?
The End
Pretend the cervix is gone.
Diagnosis?
Diagnosis?
Slide # 1
Slide #2
Diagnosis ?
VAIN Treatment Outcome
VIN Therapy