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: Younger type
More common Related to HPV
Unrelated to HPV Related to smoking
Dystrophic lesion Associated with VIN
Lichen sclerosis
 Models of vulvar cancer
Characteristic Younger Type Elderly Type

Age Younger ( 35 to 65 yo) Older (55 to 85 yo)

Cervical neoplasia High association Low association

Cofactors Age, immune status, viral Vulva atypia, possibly

integration mutated host gene
Histopathology of Intraepithelial-like Keratinizing, squamous
tumor (basaloid), poorly diff. cell carcinoma, well diff

HPV DNA Frequent (>60%) Seldom (<15%)

Pre-existing lesion VIN Vulvar inflam, lichen-
sclerosis, squamous cell
hyperplasia
History of condyloma Strong association Rare association
History of STD Strong 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 metastasis
 Stage
FIGO TNM
stage categories

Primary tumor cannot be assessed TX

No evidence of primary tumor T0

0 Carcinoma in situ (preinvasive carcinoma) Tis

I Tumor confined to vulva and/or perineum, 2 cm in greatest dimension T1

IA Tumor confined to vulva and/or perineum, 2 cm in greatest dimension and with T1a
stromal invasion 1 mm

IB Tumor confined to vulva and/or perineum, 2 cm in greatest dimension and with T1b
stromal invasion > 1 mm

II Tumor confined to vulva and/or perineum, > 2 cm in greatest dimension T2

III Tumor invades any the following :lower urethra, vagina, anus and/or unilateral regional T3
node metastasis

IV T4

IVA Tumor invades any the following: bladder mucosa, rectal mucosa, upper urethral
mucosa, or is fixed to bone and/or bilateral regional node metastasis

IVB Any distant metastasis including pelvic node

Carcinoma of the vulva
Stage grouping
FIGO stage T N M
0 Tis N0 M0
IA T1A N0 M0
IB T1B N0 M0
II T2 N0 M0
III T1 N1 M0
T2 N1 M0
T3 N1 M0
IVA T1 N2 M0
T2 N2 M0
T3 N2 M0
T4 Any N M0
IVB Any T Any N 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, > 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
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 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 The carcinoma is limited to the vaginal wall

Stage II The carcinoma has involved the subvaginal tissue but

has not extended to the pelvic wall
Stage III The carcinoma has extended to the pelvic wall

Stage IV 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
Stage IV A Tumor invades bladder and/or rectal mucosa and/or
direct extension beyond the true pelvic
Stage IV B Spread to distance organs
Treatment

Referred to tertiary referral unit

Individualized
Surgery : limited role
Radiation : choice of treatment
Tele & intra cavitary radiation