VULVAL CARCINOMA

Introduction
Vulva contains a variety of tissues and hence all types of tumours can occur in the vulva. b Many types have been recorded, both benign and malignant. b Vulval malignancies account for about 4% - 5% of all genital malignancies
b

 1.7

per 1,00,000 females, the lesion is rare The distribution varies from 3.5 % amongst genital malignancy.

 Multi factorial Basaloid or warty types

Multifocal Younger women Related to HPV infection VIN( vulvar intraepithelial neoplasia) Smoking

Keratinizing types

related to HPV infection, Others Obesity, hypertension, diabetes, nulliparity Condylomata accuminata( HPV 6,11), HSV-2 Syphilis & lymphogranuloma venerum. Chronic irritation of vulva by chemical or physical trauma, cervical neoplasia Poor hygiene, immunosuppression

Unifocal, older post menopausal women , not

 Sites: common

is labia majora, clitoris, labia minora. Anterior 2/3rd commonly affected. Naked eye appearance Ulcerative: features are raised everted edges, sloughing base with surrounding induration. It is common Hypertrophic: overlying skin may be intact or ulcerates sooner or later. It is rare.

Squamous

cell cancer: Basaloid carcinoma, warty carcinoma, keratinizing types. Mitoses is noted in these malignancies Keratinization is seen

Microinvasive

squamous

carcinoma
2cm in diameter with 1mm

stromal invasion Invasion depth <1mm -inguinal LN metastasis : extremely rare Invasion depth >1mm - LN metastasis risk is more

 Direct

extension to involve adjacent structures

Lymphatic

embolization to the regional inguinal and femoral LN

spread to distant sites (lungs, liver, bones)

Hematogenous

 Older

women: absent Young women: present, 29 years Pruritis vulvae: present Swelling with offensive discharge & bleeding: present Difficulty in urination: present Backache : present Pain : present

 Vulval

inspection Fungating mass on vulva with sloughing base, irregular edges: present Foul smelling discharge, bleeds to touch: present PV: growth involves ant. & lateral vaginal wall PR: rectal mucosa free Inguinal lymph gland enlargement: left side lymphadenopathy.

 Wedge

biopsy Excisional biopsy: lesion<1 cm in diameter MRI CT

Condylomata

accuminata Syphilitic ulcer Tubercular ulcer Lymphogranuloma venerum

Uraemia Rupture

vessels sepsis

of femoral

Stage 0 (Carcinoma in Situ) Treatment of stage 0 may include the following: Wide local excision and/or laser therapy. Skinning vulvectomy with or without skin grafting. Simple vulvectomy. Topical chemotherapy.

 Wide

local excision. Radical local excision with removal of nearby lymph nodes. Radical vulvectomy and either removal of nearby lymph nodes or radiation therapy to the lymph nodes. Radiation therapy.

 Modified

radical vulvectomy and removal of nearby lymph nodes or radiation therapy to the lymph nodes. Radiation therapy to the area of surgery may also be given. Radiation therapy.

 Modified

radical vulvectomy and removal of nearby lymph nodes, with or without radiation therapy. Radical vulvectomy and removal of nearby lymph nodes, with or without radiation therapy. Radiation therapy followed by surgery. Radiation therapy with or without chemotherapy.

 Radical

vulvectomy and pelvic exenteration. Radical vulvectomy followed by radiation therapy. Radiation therapy followed by surgery, with or without chemotherapy. Radiation therapy with or without chemotherapy.

 Lymphoscintigraphy

locate nodes

is used to

 Inpast, Bed Rest: 3-5days for immobilization

These days, Separate incision -> POP 1-2day : ambulation DVT prevention Subcutaneous heparin pneumatic calf compression Frequent dressing Suction drainage of

each side of the groin Sitz bath or whirlpool therapy

Groin wound infection, necrosis, breakdown

En bloc operation 53-85% Separate-incision approach 44%

UTI Seromas DVT Pulmonary embolism MI Hemorrhage

 Chronic

lymphedema (30%) Recurrent lymphagitis or cellulitis (10%)

Usually responds to oral antibiotics
Femoral

hernia (uncommon)

Depression,

altered body image and sexual dysfunction

 Chronic

pain related to vulval growth, metastases Imbalancd nutrition less than body requirement related to less food intake Impaired urinary elimination related to closure of urethra by vulval growth Anxiety and fear related to outcome of the disease process

 Knowledge

deficit related to disease process, outcome and management Ineffective individual coping related to disease condition Interrupted family process related to hospitalization Decisional conflict related to treatment option Anticipatory grieving relatd to potential loss of life Risk for infection related to open vulval growth, poor nutritional status.

Sheth SS. Essentials of Gynecology. 1stedition. New Delhi: Jaypee bros;2005 Mukherjee GG. Current obstetrics and gynecology. 1st edition. New Delhi: Jaypee bros medical publishers.2007. Varney H, Kriebs JM , Gregor CL. Varneys textbook of midwifery . 4th edition. New Delhi: Elsevier; 2005 Padubidri V.G, Daftary SN. Hawkins and burns- Shaws text book of gynecology.14th edition. Noida: Elsevier;2008 Kumar P, Malhotra N. Jeffcoats principles of gynecology. 7th edition. New Delhi: Jaypee Bros Medical Publishers;2008 Dutta DC. Text book of gynecology.4th edition. Kolkata: New central book agency;2007 http://www.nlm.nih.gov/medlineplus/vulvarcancer.html