Preinvasive

Preinvasive
Disease of the
Disease of the
Vagina and Vulva
Vagina and Vulva
Fred Ueland, MD Fred Ueland, MD
Division of Gynecologic Oncology Division of Gynecologic Oncology
University of Kentucky University of Kentucky
Juneau, Alaska
Examining
Examining
the External Genitalia
the External Genitalia
Dorsal lithotomy position Dorsal lithotomy position
Clitoris and frenulum Clitoris and frenulum
Urethra and anus Urethra and anus
Labia majora and minor Labia majora and minor
Introitus Introitus
Perineum Perineum
Vulva
Vulva
Conditions
Conditions
the Labia and Perineum
the Labia and Perineum
Infection Infection
HPV, HSV HPV, HSV
Chancroid, LGV, syphilis Chancroid, LGV, syphilis
Molluscum Molluscum contagiosum contagiosum
Dermatologic Dermatologic
Lichen sclerosus, hyperplasia Lichen sclerosus, hyperplasia
Vulvar HPV
Vulvar HPV
Non
Non
-
-
neoplastic Conditions
neoplastic Conditions
Syphilis Syphilis
Non
Non
-
-
neoplastic Conditions
neoplastic Conditions
Condyloma lata Condyloma lata
Non
Non
-
-
neoplastic Conditions
neoplastic Conditions
Molluscum Contagiosum Molluscum Contagiosum
Non
Non
-
-
neoplastic Conditions
neoplastic Conditions
Squamous hyperplasia Squamous hyperplasia
Lichen sclerosus Lichen sclerosus
Other Other dermatoses dermatoses
Psoriasis Psoriasis
Lichen simplex Lichen simplex chronicus chronicus
Lichen Lichen planus planus
Tinea Tinea
Non
Non
-
-
neoplastic Conditions
neoplastic Conditions
Lichen Sclerosus Lichen Sclerosus
Lichen Sclerosus
Lichen Sclerosus
Hyperkeratosis Hyperkeratosis
Flattened Flattened rete rete pegs pegs
Cytoplasmic vacuoles Cytoplasmic vacuoles
in basal layer in basal layer
Pink staining Pink staining
beneath epidermis beneath epidermis
Inflammatory infiltrate Inflammatory infiltrate
Hubbard Glacier
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
Same culprit, HPV Same culprit, HPV
50% asymptomatic 50% asymptomatic
Increasing incidence Increasing incidence
2 to 3 fold increase 2 to 3 fold increase
Declining age (mean = 40 years) Declining age (mean = 40 years)
Tripled in white Tripled in white under age 35 under age 35
Appearance Appearance
White, red, or pigmented White, red, or pigmented
Flat, raised, macular, papillary, solitary or Flat, raised, macular, papillary, solitary or multifocal multifocal
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
VIN
VIN
VIN 3
VIN 3
VIN
VIN
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
Vulvar Intraepithelial Neoplasia
VIN 3
VIN 3
Pigmented Lesion
Pigmented Lesion
Location of
Location of
Multifocal
Multifocal
CIS
CIS
92% 92%
70% 70%
45% 45%
40% 40%
20% 20%
60% 60%
30% 30%
Vulvar CIS
Vulvar CIS
Judson, Obstet Gynecol 2006 Judson, Obstet Gynecol 2006
13,176 women with CIS and cancer 13,176 women with CIS and cancer
Vulvar CIS increased 400% from 1973 to Vulvar CIS increased 400% from 1973 to
2000 2000
CIS increases with age until 50, then CIS increases with age until 50, then
CA increases with age, more rapidly > 50 CA increases with age, more rapidly > 50
Vulvar CIS
Vulvar CIS
Jones, Obstet Gynecol 2005 Jones, Obstet Gynecol 2005
Mean age CIS decreased from 50 before Mean age CIS decreased from 50 before
1980 to 39 today 1980 to 39 today
50% require 2 50% require 2
nd nd
treatment treatment
Synchronous cancer in 4% (vulvar, Synchronous cancer in 4% (vulvar, perianal perianal, ,
urethral) urethral)
Progression in untreated 1.1 Progression in untreated 1.1- -7.3 years 7.3 years
(mean = 3.9 years) (mean = 3.9 years)
Pagets Disease
Pagets Disease
Disease of the Disease of the apocrine apocrine glands glands
Arm pits, genital, anal regions Arm pits, genital, anal regions
Fat containing sweat, odor after bacterial digestion Fat containing sweat, odor after bacterial digestion
Excretions via hair follicle Excretions via hair follicle
Localized or diffuse Localized or diffuse
Hyperemic, well Hyperemic, well- -demarcated, excoriated demarcated, excoriated
Prolonged, indolent course if intra Prolonged, indolent course if intra- -epithelial epithelial
Simultaneous adenocarcinoma in up to 20% Simultaneous adenocarcinoma in up to 20%
Simple, partial Simple, partial vulvectomy vulvectomy with FS margins with FS margins
Radiation can be successful, particularly when anal Radiation can be successful, particularly when anal
involvement involvement
Apocrine
Apocrine
glands
glands
Pagets Disease
Pagets Disease
Pagets Disease
Pagets Disease
Vulvar Cancer
Vulvar Cancer
Vulvar Cancer
Vulvar Cancer
Diagnosis
Diagnosis
Inspection Inspection
Vulvoscopy Vulvoscopy
Review outside pathology Review outside pathology
Biopsy Biopsy
Lidocaine Lidocaine
Combined diagnosis, treatment in OR Combined diagnosis, treatment in OR
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Keyes Punch Keyes Punch
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Vulvar Biopsy
Gold Rush
Gold Rush
Skagway, Alaska Skagway, Alaska
1898 1898
Population grew to 10,000 (now 862) Population grew to 10,000 (now 862)
Gateway to Klondike region of Gateway to Klondike region of
Canadas Yukon territory Canadas Yukon territory
The easy way The easy way
Sail to Skagway, Alaska Sail to Skagway, Alaska
Up White Pass, Dead horse trail Up White Pass, Dead horse trail
Hike to Canada and build raft Hike to Canada and build raft
Float Yukon River to Dawson City Float Yukon River to Dawson City
Gold Rush
Gold Rush
Travel Travel Challenges Challenges
Pack one ton of supplies (2200 lb) Pack one ton of supplies (2200 lb) - - Canadian Canadian
Mounties at summit Mounties at summit
Dead horse trail littered with abandoned gear, Dead horse trail littered with abandoned gear,
dead horses and mules: 20 miles, 3300 feet dead horses and mules: 20 miles, 3300 feet
Tram operator Tram operator
425 mile treacherous expedition to Dawson City 425 mile treacherous expedition to Dawson City
Examining
Examining
the Clitoris
the Clitoris
Vulvar intraepithelial neoplasia Vulvar intraepithelial neoplasia
70% may involve clitoris or 70% may involve clitoris or
frenulum frenulum
Tumors Tumors
Cancer Cancer
Squamous cell Squamous cell
Melanoma Melanoma
Clitoral Fibroma
Clitoral Fibroma
Examining
Examining
the Urethra
the Urethra
Caruncle Caruncle
Urethral diverticulum Urethral diverticulum
Urethritis Urethritis
Condyloma Condyloma
Cancer Cancer
Squamous, transitional cell, melanoma Squamous, transitional cell, melanoma
Urethral Carcinoma
Urethral Carcinoma
Examining
Examining
the Vagina
the Vagina
Atrophy Atrophy
Infection Infection
HSV, HPV HSV, HPV
Candidiasis Candidiasis
Bacterial vaginosis, trichomoniasis Bacterial vaginosis, trichomoniasis
Cancer Cancer
Squamous cell, melanoma Squamous cell, melanoma
Atrophic Vaginitis
Atrophic Vaginitis
Trichomonas
Trichomonas
VAIN
VAIN
Benedet Benedet, J. , J. Reprod Reprod Med, 1992 Med, 1992
Normal epithelium Normal epithelium
Epithelial thickness = 0.28 mm Epithelial thickness = 0.28 mm
Menopausal patients 33% thinner Menopausal patients 33% thinner
VAIN VAIN
Epithelial thickness = 0.46 mm Epithelial thickness = 0.46 mm
No difference for menopause No difference for menopause
Recommend treatment to 1.5 mm Recommend treatment to 1.5 mm
VAIN
VAIN
Appearance Appearance
Subtle, often Subtle, often multifocal multifocal
Punctate Punctate, possibly raised , possibly raised
Peau Peau dorange dorange
May show May show acetowhite acetowhite
changes but rarely the changes but rarely the
mosaicism mosaicism of CIN of CIN
VAIN
VAIN
Colposcopy Colposcopy
Largest speculum Largest speculum
Start at apex and move to Start at apex and move to introitus introitus
Aceitic Aceitic acid or acid or Lugols Lugols
Alligator biopsy forceps Alligator biopsy forceps
AgNO AgNO
3 3
, , Monsels Monsels solution solution
Treatment Options
Treatment Options
VIN and VAIN VIN and VAIN
Excision Excision
Not LEEP Not LEEP
CO CO
2 2
laser vaporization laser vaporization
Electrical vaporization (fulguration) Electrical vaporization (fulguration)
Topical therapy Topical therapy
5 5- -FU FU
Aldara Aldara
Surgical Excision
Surgical Excision
Laser Ablation
Laser Ablation
VAIN
VAIN
CO2 Laser Vaporization CO2 Laser Vaporization
Colposcopy Colposcopy- -assisted assisted
15 15- -20 watts, continuous 20 watts, continuous
General anesthesia General anesthesia
Destruction depth Destruction depth
1.0 to 1.5 mm 1.0 to 1.5 mm
Post Post- -treatment narcotics treatment narcotics
Medical Treatment VAIN
Medical Treatment VAIN
5 5- -Fluorouracil Fluorouracil
Not for intra Not for intra- -vaginal use vaginal use
Actinic keratosis, superficial basal cell Actinic keratosis, superficial basal cell
Daly et al. Obstet Gynecol, 1980 Daly et al. Obstet Gynecol, 1980
Post Post- -radiated VIN treated with 5 radiated VIN treated with 5- -FU FU
bid for 10 bid for 10- -14 days 14 days
NED for 2 NED for 2- -5 years 5 years
8% non 8% non- -healing ulcers at 6 months healing ulcers at 6 months
Pregnancy Category X Pregnancy Category X
Medical Treatment VAIN
Medical Treatment VAIN
Daily 5 Daily 5- -Fluorouracil Fluorouracil
Efudex 5% cream Efudex 5% cream
Disp Disp: 25 gram tube : 25 gram tube
Sig Sig: Use applicator (2 : Use applicator (2- -2.5 gm) in vagina 2.5 gm) in vagina
qHS qHS for 5 nights. Insert tampon and coat for 5 nights. Insert tampon and coat
vulva with Desitin. In morning, remove vulva with Desitin. In morning, remove
tampon and allow medicine to drain into tampon and allow medicine to drain into
commode. Gently cleanse vulva. commode. Gently cleanse vulva.
Medical Treatment VAIN
Medical Treatment VAIN
Weekly Weekly 5 5- -Fluorouracil Fluorouracil
Efudex 5% cream Efudex 5% cream
Disp Disp: 25 gram tube : 25 gram tube
Sig Sig: Use 1/3 applicator (1.5 gm) in vagina at : Use 1/3 applicator (1.5 gm) in vagina at
night night weekly weekly for up to 10 weeks. Insert for up to 10 weeks. Insert
tampon and coat vulva with Desitin. In tampon and coat vulva with Desitin. In
morning, remove tampon and allow morning, remove tampon and allow
medicine to drain into commode. Gently medicine to drain into commode. Gently
cleanse vulva. cleanse vulva.
Medical Treatment
Medical Treatment
Aldara Aldara
Immune modifier Immune modifier
Induces cytokines, interferon Induces cytokines, interferon- - , lymphocytes, , lymphocytes,
macrophages macrophages
Actinic keratosis, superficial basal cell, external Actinic keratosis, superficial basal cell, external
condylomata condylomata
Age 12 and older Age 12 and older
72% CR for condylomata 72% CR for condylomata
90% with vulvar discomfort, 15% with flu 90% with vulvar discomfort, 15% with flu- -like like
symptoms, 20% dont finish therapy. symptoms, 20% dont finish therapy.
Pregnancy Category C Pregnancy Category C
Medical Treatment
Medical Treatment
Aldara Aldara
Aldara 5% cream Aldara 5% cream
Disp Disp: 250 mg single use packets : 250 mg single use packets
Sig Sig: Use 1 packet 3 times weekly : Use 1 packet 3 times weekly qHS qHS. Leave . Leave
on for 6 on for 6- -10 hours and remove with mild 10 hours and remove with mild
soap and water. Use no longer than 16 soap and water. Use no longer than 16
weeks. weeks.
Surveillance
Surveillance
Colposcopy or Colposcopy or vulvoscopy vulvoscopy
Cytologic screening Cytologic screening
Cervicovaginal Cervicovaginal
Anal Anal
4 to 6 months 4 to 6 months
Smoking cessation Smoking cessation
Vaccination? Vaccination?
Parting Thoughts
Parting Thoughts
aratus simper disceri aratus simper disceri
Always prepared to learn Always prepared to learn
From a doorway arch in From a doorway arch in
the Vatican library the Vatican library