Vulvar and Vaginal lesions

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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 symptomatology - PowerPoint PPT Presentation

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<ul><li><p>Vulvar and Vaginal lesionsDr.F Behnamfar MD</p></li><li><p>IntroductionMost usful means of generating differential diagnosis is by morphological findings rather than symptomatology</p><p>Vulvar biopsy should be performed if the lesion is clinically suspicious or does not resolve after standard therapy</p></li><li><p>Vulvar SymptomsMost often,primary vaginitis and secondary vulvitis</p><p>A number of skin conditions on other areas of the body</p></li><li><p>NeoplasiaVulvar intraepithelial neoplasia a precancerous lesion that may progress to invasive cancer</p><p>Most are raised multifocal white (may be red or pink) and/or verrucous lesions</p><p>Cancer presents with unifocal vulvar plaque,ulcer or massLichen scerosus and erosive lichen planus predispose to cancer</p></li><li><p>Genital wartsCaused by human papillomavirusFlat,filliform or verrucous,or giantFlesh colored or pigmentedBiopsy is indicated if there is rapid growth,increased pigmentation,ulceration,pigmentation,fixation or poor response to therapyTreatment : trichloroacetic acid, podophyllum,Cryo,laserNot curative ,merely speed clinical resolution</p></li><li><p>White patchLichen sclerosus,well demarcated white finely wrinkled and atrophic patchesVulvar itching and typical findingsPotent topical corticosteriod ointmentClose follow up for risk of malignancy</p></li><li><p>Other vulvar conditionsfolliculitis</p><p>Fox.fordiyce disease</p><p>Acanthosis nigricans</p><p>Extramammary pagets disease,intraepithelial adenocarcinoma</p></li><li><p>Herpes simplexScabis</p></li><li><p>Vulvar cysts, tumors and massesCondylomata accuminata</p><p>duct cysts,Skenes duct cysts</p><p>Vulvar Ulcers: Behcet disease,lichen planus</p></li><li><p>Vaginal ConditionsRetained foreign bodyUlcerationMalignancy</p></li><li><p>Vulvar Cancer3870 new cases 2005870 deathsApproximately 5% of Gynecologic Cancers</p><p> American Cancer Society. Cancer Facts &amp; Figures. 2004. Atlanta, GA; 2005 </p></li><li><p>Vulvar Cancer85% Squamous Cell Carcinoma5% Melanoma2% Sarcoma8% Others</p></li><li><p>Vulvar CancerBiphasic Distribution ,two distinct etiologies: Age 70 type, unifocal,in areas adjacent to lichen sclerosus or squamous hyperplasia (Chronic inflammatory conditions)</p><p>20% in patients UNDER 40 and appears to be increasing,multifocal,basaloid or warty types,HPV related,smoking and VIN </p></li><li><p>Vulvar CancerPagets Disease of Vulva10% will be invasive4-8% association with underlying Adenocarcinoma of the vulva</p></li><li><p>SymptomsMost patients are treated for other conditions12 month or greater time from symptoms to diagnosis</p></li><li><p>SymptomsPruritusMassPainBleedingUlcerationDysuriaDischargeGroin Mass</p></li><li><p>SymptomsMay look like:RaisedErythematousUlceratedCondylomatousNodular</p></li><li><p>Vulvar CancerIF IT LOOKS ABNORMAL ON THE VULVABIOPSY!BIOPSY!BIOPSY!</p></li><li><p>Tumor SpreadVery Specific nodal spread patternDirect SpreadHematogenous</p></li><li><p>StagingBased on TNM Surgical Staging Tumor sizeNode StatusMetastatic Disease</p></li><li><p>StagingStage I T1 N0 M0Tumor 2cm </p><p>IA1 mm depth of stromal InvasionIB1 mm or more depth of invasion</p></li><li><p>StagingStage II T2 N0 M0Tumor &gt;2 cmConfined to Vulva or Perineum</p></li><li><p>StagingStage IIIT3 N0 M0T3 N1 M0T1 N1 M0T2 N1 M0Tumor any size involving lower urethra, vagina, anus OR unilateral positive nodes</p></li><li><p>StagingStage IVAT1 N2 M0T2 N2 M0T3 N2 M0T4 N any M0Tumor invading upper urethra, bladder, rectum, pelvic bone or bilateral nodes</p></li><li><p>StagingStage IVBAny T Any N M1Any distal mets including pelvic nodes</p></li><li><p>TreatmentPrimarily SurgicalWide Local ExcisionRadical ExcisionRadical Vulvectomy with Inguinal Node DissectionUnilateralBilateralPossible Node Mapping, still investigational</p></li><li><p>TreatmentLocal advanced may be treated with Radiation plus ChemosensitizerPositive Nodal Status1 or 2 microscopic nodes &lt; 5mm can be observed3 or more or &gt;5mm post op radiation</p></li><li>New advances in treatmentIndividualization of treatment,vulvar conservation for unifocal tumorsElimination of routine pelvic lymphadenectomy Omission of groin dissection for T1 tumors (</li><li><p>TreatmentSpecial TumorVerrucous CarcinomaIndolent tumor with local disease, rare mets UNLESS given radiation, becomes Highly malignant and aggressiveExcision or Vulvectomy ONLY</p></li><li><p>Vulva 5 year survivalStage I90Stage II77Stage III51Stage IV18Hacker and Berek, Practical Gynecologic Oncology 4th Edition, 2005</p></li><li><p>RecurrenceLocal Recurrence in VulvaReexcision or radiation and good prognosis if not in original site of tumorPoor prognosis if in original site</p></li><li><p>RecurrenceDistal or MetastaticVery poor prognosis, active agents include Cisplatin, mitomycin C, bleomycin, methotrexate and cyclophosphamide </p></li><li><p>Melanoma5% of Vulvar CancersNot UV relatedCommonly periclitoral or labia minora</p></li><li><p>MelanomaMicrostaged by one of 3 criteriaClarks LevelChungs LevelBreslow</p></li><li><p>Melanoma TreatmentWide local or Wide Radical excision with bilateral groin dissectionInterferon Alpha 2-b</p></li><li><p>Vaginal Carcinoma2140 new cases projected 2005810 deaths projected 2005Represents 2-3% of Pelvic Cancers American Cancer Society. Cancer Facts &amp; Figures. 2004. Atlanta, GA; 2005</p></li><li><p>Vaginal Cancer84% of cancers in vaginal area are secondaryCervicalUterineColorectalOvaryVagina</p><p>Fu YS, Pathology of the Uterine Cervix, Vagina and Vulva, 2nd ed. 2002</p></li><li><p>Vaginal CarcinomaSquamous Cell80-85%Clear Cell10%Sarcoma3-4%Melanoma2-3%</p></li><li><p>Clear Cell CarcinomaAssociated with DES Exposure In UteroDES used as anti abortifcant from 1949-1971500+ cases confirmed by DES RegistryUsually occurred late teens</p></li><li><p>Vaginal Cancer EtiologyMimics Cervical CarcinomaHPV 16 and 18</p></li><li><p>StagingStage IConfined to Vaginal WallStage IISubvaginal tissue but not to pelvic sidewallStage IIIExtended to pelvic sidewallStage IVABowel or BladderStage IVBDistant mets</p></li><li><p>TreatmentSurgery with Radical Hysterectomy and pelvic lymph dissection in selected stage I tumors high in VaginaAll others treated with radiation with chemosensitization</p></li><li><p>5 year SurvivalStage I70%Stage II51%Stage III33%Stage IV17%</p></li><li><p>*</p></li></ul>