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, 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
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