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Have you heard about lichen? Anong alam nyong mga lichen? transitional cell carcinoma of the bladder or urethra, and (3) Paget disease as
Lichen simplex chronicus, ano pa? Ano pang mga lichen an extension of an associated adjacent primary cancer such as vulvar, anal, or
lichen? LICHEN SCLEROSUS is placed here because it is a pre- rectal cancers. The histologic differentiation of these Paget disease types is
malignant lesion. Other lichens are usually benign. Actually important because the specific diagnosis significantly influences treatment
benign naman ang lichen sclerosus but it is a predisposing selection.
factor.” Primary cutaneous vulvar Paget disease displays slow growth.
Since it has a premalignant potential, you have to remind them Diseased areas should be resected with a wide local excision. Positive
to follow-up and apply appropriate management after the margins occur frequently, and disease recurrence is common regardless of
diagnosis. the surgical margin status. If invasive disease is suspected, radical partial
vulvectomy is warranted by extending the deep margins to the perineal
membrane.
Keratinocytes affected by lichen sclerosus show a proliferative phenotype and
can exhibit markers of neoplastic progression.
o Suggests that lichen sclerosus may be a precursor lesion VULVAR ATYPIA: CLINICAL PRESENTATION
in some cases of invasive squamous vulvar cancer. Vulvar Variety of signs and symptoms
cancers that coexist with lichen sclerosus have been Irritation or itching is common
shown to develop in older women, predominate in near Diffuse whitish change to the vulvar skin which appears thin with
the clitoris, and lack association with VIN 3.
scarring and contracture
Areas of squamous hyperplasias (formerly called hyperplastic
C. VULVAR INTRAEPITHELIAL NEOPLASIA (VIN) dystrophy without atypia) also appear as whitish lesions in
VIN I – Mild dysplasia (lower third of the epithelium) general, but the tissues of the vulva usually appear thickened
VIN II – Moderate dysplasia (half to two-thirds of the epithelium) and the process tends to be more focal or multifocal than diffuse
VIN III – Severe atypia (more than two-thirds of the epithelium) & Fissuring of the skin is often present with excoriation
Carcinoma-in-situ (full thickness of the epithelium) May also appear as white, red, or pigmented areas on the vulva
>50%: Long-term pruritus or lump/mass on vulva- sometimes 10
o Atypical changes may appear in the vulvar epithelium. These years na yung pruritus
are usually marked by a loss of the maturation process usually Indolent, extends slowly, metastasizes fairly late
seen in squamous epithelium, as well as an increase in mitotic 70% arise on the labia (more commonly labia majora)
activity and nuclear/cytoplasmic ratio
o In addition, reddish nodules may also be foci of Paget disease the sweat glands of the vulva or Bartholin gland carcinoma may
as well as of carcinoma in situ. Paget disease often has a be present
reddish eczematoid appearance. It should be reemphasized Rule out presence of breast and GI malignancy
that these conditions cannot be accurately diagnosed from o Breast mammography, Stool occult blood
their clinical appearance, and biopsies are needed. Wide local excision
o remove the full thickness of the skin to the subcutaneous fat
o “You have to remove the complete thickness with an
appropriate margin”
Topical Imiquimod cream as a nonsurgical therapy
Surgical procedures for the treatment of invasive vulvar neoplasia include
wide local excision (WLE), radical partial vulvectomy, and radical complete
vulvectomy.
Vulvoscopy
o Vulva is soaked with 3-percent acetic acid for 5 minutes
to allow adequate penetration into the keratin layer this
aids identification of acetowhite areas and abnormal
vascular patterns, which are characteristics of vulvar SQUAMOUS CELL CARCINOMA
neoplasia. 90% of primary vulvar malignancies
o Lesions may be raised, ulcerated, pigmented, or warty, appear as raised, flat, ulcerated, plaque-like, or polypoid
and biopsies of the most suspicious appearing areas are masses on the vulva
obtained..
arising in a bed of lichen sclerosis
“If you will not perform biopsy, you may actually try na mag topical
steroids muna. You may use Fluticasone, then let your patient
come back maybe after 4 weeks.”
“Itching is a red flag, kasi minsan din a sila makatulog, ano nalang
ginagawa sa gabi? Nagkakamot nalang. You have to inform then
to use mild soap, yung type of panty, steroids can actually address
the itchiness pero pag sobrang severe, you may give also anti-
histamine.”
A. Treatment – VIN
Once the diagnosis of VIN has been established by biopsy,
therapy is performed to eradicate the area containing the
neoplasia
VIN may spontaneously regress
Local excision In the clinical staging system, lymph node status was assessed
o Laser therapy of the atypical area may be used for younger clinically and incorporated into the stage. Enlarged or clinically
patients who do not have raised lesions suspicious lymph nodes were assigned a higher stage, regardless
HPV Vaccination – explored for treatment of VIN III of disease status documented at surgery. Clinically negative
“What’s the HPV type??? Type 16 and 18” nodes were assigned an earlier stage, which was upheld even if
they were found to harbor metastasis after surgical removal and
B. Treatment – PAGET’S DISEASE pathologic examination.
The major importance of Paget disease of the vulva is the
frequent association with other invasive carcinomas. Squamous ”Remember pala, Cervical cancer- clinically staged,
cell carcinoma of the vulva or cervix or an adenocarcinoma of Treatment: Chemoradiation.”
C. VERRUCOUS CARCINOMA
A special variant of squamous cell cancer
Appear as a large condylomatous mass on the vulva
OTHER VULVAR MALIGNANCIES Treatment: Wide local excision and tumor-free margins
Radiotherapy is contraindicated
Bartholin Gland Carcinoma
Basal Cell Carcinoma
Verrucous Carcinoma
Melanoma
D. MELANOMA
The most frequent non-squamous cell malignancy of the vulva Malignant vulvar melanoma will most commonly arise from the labia minora,
Second most common malignant neoplasm of vulva labia majora, or clitoris.
5% of vulvar carcinomas Three histologic subtypes of vulvar melanoma have been described:
superficial spreading melanoma (SS), nodular melanoma (NM), and acral
Arises from a lesion containing a junctional or a compound
lentiginous melanoma (AL).
nevus
Pigmented and raised, may be ulcerated
Pruritus, bleeding, enlargement of pigmented are E. SARCOMA
Most occur on the labia minora or clitoris “so where is the most less than 3% of vulvar cancers ”it is very rare”
common area for melanoma? Clitoris or labia. Remember that” Leiomyosarcomas are the most common histologic subtype
Radical local excision with a margin of 2 cm for thin lesions (up found
to 7 mm) and 3 to 4 cm for thicker lesions for well-circumscribed Surgical removal of the primary tumor is the treatment of choice
melanomas Chemotherapeutic considerations
o Clark level I or II – wide local excision
Lymphadenectomy is prognostic than therapeutic
F. GRANULAR CELL MYOBLASTOMAS
Often misdiagnosed as undifferentiated squamous cell cancers
(especially when amelanotic) extremely rare tumor that is almost invariably benign but
morphologically shows pleomorphism
tumor appears as a solitary, firm, non-tender, slowly growing
nodule in the subcutaneous tissue of the vulva
Local excision is generally sufficient therapy
MANAGEMENT – VAIN
Principles of management: rule out and prevent invasive disease
and preserve vaginal function
VAIN can be treated by excision, laser, 5-FU, or Imiquimod
o Excision is often used for VAIN-3
o Laser treatment is generally used for discrete lesions once
invasion has been ruled out
o 5-FU and Imiquimod cream are used to treat diffuse,
multicentric, low-grade disease
Median interval between cervical disease and development of o Upper 3rd – common iliac, presacral, hypogastric nodes
vaginal cancer – 14 years
o 16% had history of prior radiation
Screening
Examine lateral “horns” of upper vaginal vault in patients with
history of hysterectomy “usually diba pag ni-IE mo, you will feel
a donut, yung cervix. Pero pag nag post-hysterectomy na, SLIT-
CUT lng mafeel mo”
Pap smear
o Continued in women with history of cervical dysplasia/cancer
(increased risk) whether or not they may have had a
hysterectomy
Development of vaginal cancer is possible even in women with
a history of hysterectomy for a benign disease
Management
Local therapy for small, stage I clear cell adenocarcinoma
o If the tumor is smaller than 2 cm in diameter
o invades less than 3 mm
Patterns of Spread o predominantly of the tubulocystic histologic type
Metastasizes by direct extension, lymphatic dissemination, Pelvic nodes should be sampled and be free of tumor
hematogenous spread “because the vagina is very vascular Overall 5-year survival rate of treated patients is 80%
diba?”
Lymphatic drainage of vagina:
o Lower 3rd – drain into femoral and external iliac nodes MALIGNANT MELANOMA
o Middle 3rd – hypogastric nodes Rare and highly malignant
REFERENCES
Comprehensive Gynecology
Trans batch 2018